Objective: During the COVID-19 pandemic in the United States, mitigation measures were implemented on a state-by-state basis. Governors were responsible for establishing interventions appropriate for their states and the timing of implementation. This paper evaluated the association between the presence and timing of a mask mandate and the severity of the COVID-19 epidemic by state. Methods: The states were divided into 3 categories based on when the governors of each state implemented a mask mandate: Early (mask mandate implemented between March 2020 and June 2020), Late (July 2020-December 2020), and Never (no mask mandate implemented). The rates of hospitalizations and mortality (per 100 000) were assessed at the different time points during the pandemic across these categories from March to December 2020. Results: The mortality rates across all 3 groups were observed to be highest in the beginning and toward the end of the pandemic in 2020 with the peak observed in the Early group between April and May 2020. Also, the rates of hospitalization increased steadily across all groups. The Early mask group was comprised of 86.7% and 13.3% states with Democratic and Republican governors respectively, and no states in the Never category had Democratic governors. Conclusion: These results support the benefit of implementing a mask mandate to minimize the impact of the COVID-19 pandemic and the role of political affiliation of governors on that impact.

Context: Public health professionals around the country faced significant challenges responding to the COVID-19 pandemic. Reflecting on their experience is an essential element in making sense of their experience and learning from it. Objective: The objective of this qualitative study was to (1) describe the lived experiences of public health professionals working during the COVID-19 pandemic, (2) discuss the effectiveness of a guided reflection exercise to help public health professionals process these experiences, and (3) provide lessons learned and best practices to inform preparation for a future infectious disease pandemic. Design: Qualitative focus group study design. Setting: This activity was conducted at a Midwestern state public health professional meeting. Participants: Forty-eight public health professionals self-selected to participate in this study. Results: Five themes were elicited in this analysis, including Communication, Leadership and Collaboration, Data Management, Community Relationships, and Resources and Planning. In addition, public health professionals reported numerous lessons learned, including the need for more leadership from the state government, the conflicted response of their communities, and the benefits of community solidarity where it was present. Conclusions: This article provides a detailed account of public health workers' experiences during the COVID-19 pandemic. It also provides lessons learned that will help public health workers lead more effectively in the future. Guided reflection on a traumatic professional experience can assist participating individuals in making sense of their experience and learning important lessons from it.

Context: COVID-19 exerted severe challenges on skilled nursing facility (SNF) residents and staff. A combination of internal and external factors predisposed SNFs to an increased propensity of COVID-19 spread. Objective:The purpose of this paper is to examine which facility characteristics may have contributed to COVID-19 outbreaks within urban and rural North Dakota skilled nursing facilities.Methods: A 23-question survey regarding facility characteristics was developed and distributed to all 78 North Dakota skilled nursing facilities (SNF).Findings: Of the North Dakota SNF, 40 out of 78 total facilities (51.2%) participated in the survey. Of those participating, 38 of 40 (95%) were in counties with populations under 50,000, with the smallest county population being 1,876. A Spearman's rank test suggested a relationship between the community spread of COVID-19 and the COVID-19 positivity of SNF residents. Spearman's rank also suggested a positive association between the SNF resident COVID-19 positivity in relation to staff positivity (p-value 0.042) and county rates (p-value 0.045).Limitations: While this is a comprehensive survey with a very good response rate, two key limitations are identified. First, the survey relies on self-reported data from SNF staff. Second, it is not clear what data would have been received from non-responding SNFs.Implications: Substantial lessons have been learned, which may not only aid future pandemic preparedness but improve the quality of care for nursing home residents during a pandemic or other respiratory disease outbreaks. Proactively knowing susceptibilities and vulnerabilities ahead of time will allow local and state leaders to plan and allocate resources. Future state and local pandemic emergency plans need to be reviewed with the prioritization of skilled nursing facilities as front line facilities during a pandemic, rather than placing their "traditional" emphasis of emergency preparedness on hospitals.