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 Table of Contents  
Year : 2020  |  Volume : 22  |  Issue : 2  |  Page : 266-268

Best practices with optimal outcomes during COVID-19 pandemic – A swiss cheese model experiment in the naval training command

1 Radiodiagnosis, DNB (Radiation Oncology), Command Medical Officer, HQ Southern Naval Command, Naval base, Kochi, Kerala, India
2 NeuroAnesthesia, HOD, Department of Anesthesiology and Critical Care, INHS Sanjivani, Naval Base, Kochi, Kerala, India
3 Community Medicine, Officer-in-charge Station Health Organisation, Kochi, Kerala, India
4 Dermatology, HOD, Department of Dermatology, INHS Sanjivani, Naval base, Kochi, Kerala, India

Date of Submission09-Dec-2020
Date of Decision18-Dec-2020
Date of Acceptance25-Dec-2020
Date of Web Publication18-Jan-2021

Correspondence Address:
Surg Cdr Manish Khandare
Department of Dermatology, INHS Sanjivani, Naval Base,Kochi - 682 004, Kerala
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jmms.jmms_184_20

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How to cite this article:
Sarin A, Bhatnagar V, Neelakantan A, Khandare M. Best practices with optimal outcomes during COVID-19 pandemic – A swiss cheese model experiment in the naval training command. J Mar Med Soc 2020;22:266-8

How to cite this URL:
Sarin A, Bhatnagar V, Neelakantan A, Khandare M. Best practices with optimal outcomes during COVID-19 pandemic – A swiss cheese model experiment in the naval training command. J Mar Med Soc [serial online] 2020 [cited 2021 Apr 23];22:266-8. Available from: https://www.marinemedicalsociety.in/text.asp?2020/22/2/266/307332

This year commenced with China witnessing a serious COVID-19 infection epidemic, which progressed to be declared as a pandemic by March 2020.[1]

Historically, militaries around the world have sustained far more casualties from disease outbreaks than that from combat. Communal nature of living, premium personal space, and factors unique to military way of life predispose troops to higher risk of contracting infectious diseases compared to other communities.[2],[3]

COVID-19 has been extracting a heavy toll on Armed Forces of world powers, with many military exercises and operations canceled or postponed. Military training works on the integral principle of “the more you sweat in peace the less you bleed in war,” whether combat or medical, training is an integral and imperative component. With the introduction of virus which transmits through close contact, droplets, and fomites, the challenge to maintain training standards in Armed Forces and ensuring high level of skill imparting was paramount. Training became a trial during the initial days of pandemic, and the danger of spreading the infection put it on a halt for some time. The mission was taken head on, and few strategies formulated about how to start training with the new normal. Thus, the objective was to evaluate strategies employed and reflect the ones with optimal outcomes.

A Naval Training Command entails training a large number of recruits, cadets, and other trainees in multiple units and training schools. With progress of COVID-19 pandemic, a fair amount of knowledge was freely available;[4] however, there existed gaps in Knowledge–Attitude–Practices among the various subsets in the Naval Training settings. Thus, interventions to plug gaps were developed using readily available resources and keeping the basic principles of control of a highly infectious disease and implemented by modalities befitting each of the subsets.

First and foremost, it was projected at each level that multiple layers increase the level of protection. As Swiss Cheese Model of Pandemic defense states, one single intervention may not be perfect for prevention of spread of the disease agent[5] [Figure 1]. However, if multiple interventions are used, chances are that breaking the chain may become effective, thereby decreasing the spread.
Figure 1: Swiss cheese model to break the chain in COVID-19 pandemic one single intervention may not be perfect for prevention of spread of the disease agent. Multiple interventions such as avoiding crowded areas, social distancing, environmental sanitization, ventilation, avoidance of air-conditioning, correct usage of mask and avoidance of touching face, nose and eyes, hand hygiene, contact tracing, quarantine and isolation, and correct personal protective equipment can help to break the chain

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Hence, various interventions that were projected significantly were avoiding crowded areas, social distancing, environmental sanitization, ventilation, avoidance of air-conditioning, correct usage of mask and usage of correct mask, avoidance of touching face, nose, and eyes, hand hygiene, surveillance and contact tracing, quarantine and isolation, hand hygiene again, and correct personal protective equipment (PPE). These awareness and knowledge about these interventions were disseminated at regular intervals.

  Determinants for Success of Training in Times of Covid-19 Pandemic Top

Information education communication

Information education communication activities in local languages as e-handouts are developed to sensitize different subgroups of target audience. Audio clips about social distancing, mask usage, hand hygiene, and environmental disinfection and video clips demonstrating various types of masks and correct usage help in creating awareness. Videos demonstrating effective environmental disinfection and correct method of donning and doffing of PPE too are necessary for awareness and enhancement of knowledge. The most important three points: hand hygiene, social distance, and a correct mask need to be stressed time and again and actual enforcement for all three have to be implemented.[6]

  Screening Centers Top

Influenza-like illness screening centers at vantage points can be established for early symptomatic diagnosis of COVID, and standard operating procedure (SOP) for implementing the same is to be formulated for each step. Extensive screening at the entry gates and other unauthorized entries and bio-bubbles can thus be created for smooth functioning of various important activities.

  Preparedness of Health System Top

Early diagnosis

Facilities for early diagnosis of cases need to be set up at the Medical Inspection room, at ships, and at the hospital. Rapid field antigen testing helps in easy conduct of the test at the point of care and is recommended to be used extensively.[6]

Truenat, which is a chip-based, portable reverse transcription polymerase chain reaction investigation, also has been utilized extensively in the hospital setting for early diagnosis and management.

Management of cases

Fever clinics established in early stages of pandemic by zonal hospital premises, creation of SOPs, and extensive training of healthcare workers (HCWs) in donning and doffing of PPE are the preliminary tasks. In the mixed COVID hospital, an interface was established between patient and clinic personnel by two-way audio communication system for history-taking. Examination kiosk became the interface during collection of oropharyngeal/nasopharyngeal swab. Establishment of widespread screening, extensive contact tracing, and thoughtful testing are paramount.[7]

Surveillance and quarantine

Quarantining is practiced in control of air-borne diseases (Refer The Recent CDC Quarantine Leaflet). Judicious setting-up of quarantine center at in-living blocks was another intervention applied for prevention and screening.[7],[8]

  Creating Force Multipliers Top

When the need for force multipliers to aid medical authorities during surge of pandemic was envisioned, empowerment through education performed by COVID training of Battle Field Nursing Assistants (BFNAs), with material, was developed using resources available at Zonal Hospital.[9] This COVID BFNA training envisaged equipping key nonmedical personnel with knowledge of the virus, its transmission, important warning signs and symptoms, and key prevention and control measures. The training employed involved cognitive, psychomotor, and affective domains by utilizing audio-visual–assisted lecture-demonstration, “hands-on” and simulation-assisted training, and allaying apprehensions regarding the newly introduced virus. Instructional CD was also created for follow-up and revision.

In addition to physical aspects of health, the social and mental health issues of all serving personnel, medical, and nonmedical were also considered.[10]

  Stress Coping Mechanisms Top

Mental health

These are the times full of anxiety and apprehension, more so for the HCWs who have worked uncompromisingly since the advent of this pandemic. COVID care helpline number was established to provide telephonic counseling for mental wellness of HCWs involved in patient care during pandemic. COVID care, from distress to de-stress, was operationalized jointly by Zonal Hospital and Station Mental Health Center under SHO. A separate helpline for nonmedical naval personnel was also developed, to share information on the disease, to avoid panic, and to clarify related FAQs on a 24 × 7 basis.

  Hospital Preparedness Top

Mixed COVID hospital

A fully prepared separate wing with separate entry–exit points, definite protocols for handling of COVID-19 patients, accessibility of advance monitoring and delivery of oxygen by various methods (including invasive and noninvasive ventilators), and incorporation of innovations after requisite functional testing and training of HCWs was established. Multidisciplinary teams constituted for field surveillance monitoring, hospital admissions record maintenance for both COVID and non-COVID patients, logistics, and administration. A horde of new, need-based innovations was developed and pilot-tested in zonal hospital. Salient among these were “examination kiosk, transparent barrier consultation chamber, intubation cubicle, multiple oxygen port manifold.” Such equipment were deemed safe and suitable for preventing cross infection between health care workers and patients, hence were employed. HCWs trained in adequate use of PPE, nontouch methods while providing patient care, ensuring adequate patient care while on video consultation and teleconsultation proved to be useful in long run. Aimed at minimizing exposure of routine nonemergency patients to hospital environment, noncontact clinical management using teleconsultation facility was established early into the pandemic, at family clinic under aegis of the SHO, and for select outpatient departments in zonal hospital.[11] The mixed COVID scenario entailed strict compliance to protocols so as to avoid even one single HCW contracting the disease or being instrumental in spreading it. The importance of hand hygiene, social distance, and adequate use of PPE has been implemented without fail.


The success of teleconsultation within few days of launch led to expansion of teleconsultation and video consultation facilities to all departments in hospital. Patients took prior telephonic appointment for teleconsultation which took place through video call. Doctor shared the medical advice and the e-prescription generated and patients collected medicines from packets kept in a tray at dispensary. Catch-up vaccination campaign for routine and booster dose cover was established for continuity of vaccination that was temporarily disrupted due to lockdown.

Naval training

Training, being the backbone of Armed Forces, can never take a back seat even in times of pandemic. However, to combat the challenge, new ways need to be designed to keep individuals combat ready; both for enemy or disease virus. Attempts were made in the Command to adhere to the new normal where hand hygiene, physical distance, and correct usage of mask are paramount to avoid exposure to disease causing virus. However, by utilizing advantages of virtual world as in simulation and social media as in creation and dissemination of knowledge capsules, conception of bio-bubbles (as in sports industry) training in military setting could be kick-started to a large extent.

Scenarios change and so do the need for new protocols, guidelines, and SOPs. Promulgation of best-of-fit models based on felt needs produce appreciable outcomes and hence can be applied at different places in civil as well as in military during similar situations. Concurrent impact evaluation is still being recorded and definitely will be an aid to improve practices promulgated, to weed out those practices with suboptimal outcomes, to sustain those with optimal outcomes, and to build upon the ones with supra-optimal outcomes. A new era emerged at the advent of the year 2020 which tested our spirit and resilience but strengthened our resolve to continue with our motto of Fighting Fit and Combat Ready, in face of enemy or disease. The strategies, thus developed and employed which presented with optimal and supra-optimal functions, have been recruited and successfully utilized and can be utilized later in other pandemics which result from air-borne diseases.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Li Q, Guan X, Wu P, Wang X, Zhou L, Tong Y, et al. Early Transmission Dynamics in Wuhan, China, of Novel Coronavirus-Infected Pneumonia. N Engl J Med 2020;382:1199-207.  Back to cited text no. 1
Ho ZJ, Hwang YF, Lee JM. Emerging and re-emerging infectious diseases: Challenges and opportunities for militaries. Mil Med Res 2014;1:21.  Back to cited text no. 2
Papagrigorakis MJ, Synodinos PN, Stathi A, Skevaki CL, Zachariadou L. The plague of Athens: An ancient act of bioterrorism? Biosecur Bioterror 2013;11:228-9.  Back to cited text no. 3
Contini C, Di Nuzzo M, Barp N, Bonazza A, De Giorgio R, Tognon M, et al. The novel zoonotic COVID-19 pandemic: An expected global health concern. J Infect Dev Ctries 2020;14:254-64.  Back to cited text no. 4
Joon JY, Jin YS, Seong Hee GY, JooKim JC. Safe hospital preparedness in the ra of COVID-19: The Swiss cheese model. Int J Infect Dis 2020;98: 294-6.  Back to cited text no. 5
Momanyi GO, Adoyo MA, Mwangi EM, Mokua DO. Value of training on motivation among health workers in Narok County, Kenya. Pan Afr Med J 2016;23:261.  Back to cited text no. 6
Rahim AA, Chacko TV. Replicating the Kerals state's succesful COVID-19 containment model: Insights on what worked. Indian J Community Med 2020;45:261-5.  Back to cited text no. 7
  [Full text]  
Mohfw.gov.in. 2020. Available from: https://www.mohfw.gov.in/pdf/90542653311584546120quartineguidelines.pdf. [Last accessed on 2020 Nov 08].  Back to cited text no. 8
Gambhir R, Agrawal A. Training in trauma management. Med J Armed Forces India 2010;66:354-6.  Back to cited text no. 9
Lurie N, Carr BG. The role of telehealth in the medical response to disasters. JAMA Intern Med 2018;178:745-6.  Back to cited text no. 10
Mehrotra A, Jena AB, Busch AB, Souza J, Uscher-Pines L, Landon BE. Utilization of telemedicine among rural medicare beneficiaries. JAMA 2016;315:2015-6.  Back to cited text no. 11


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