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Appendix A
Contributed Manuscripts

A1
TECHNICAL REPORT FOR STATE AND LOCAL PUBLIC HEALTH OFFICIALS AND SCHOOL ADMINISTRATORS ON CDC GUIDANCE FOR SCHOOL (K-12) RESPONSES TO INFLUENZA DURING THE 2009-2010 SCHOOL YEAR1

CDC Community Mitigation Task Force


CDC is releasing new guidance2 to help decrease the spread of flu among students and school staff during the 2009-2010 school year. The guidance expands upon earlier school guidance documents by providing a menu of tools that school and health officials can choose from based on conditions in their area. It recommends actions to take this school year, suggests strategies to consider if CDC finds that the flu starts causing more severe disease than during the spring 2009 outbreak, and provides a checklist for making decisions at the local level. Based on the severity of 2009 H1N1 flu-related illness thus far, this guidance also recommends that students and staff with influenza-like illness remain home until 24 hours after resolution of fever without the use of fever-reducing medications. For the purpose of this document, “schools” will refer to both public and private institutions providing grades K-12 education to children and adolescents in group



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Appendix A Contributed Manuscripts A1 TECHNICAL REPORT FOR STATE AND LOCAL PUBLIC HEALTH OFFICIALS AND SCHOOL ADMINISTRATORS ON CDC GUIDANCE FOR SCHOOL (K-12) RESPONSES TO INFLUENZA DURING THE 2009-2010 SCHOOL YEAR1 CDC Community Mitigation Task Force CDC is releasing new guidance2 to help decrease the spread of flu among students and school staff during the 2009-2010 school year. The guidance expands upon earlier school guidance documents by providing a menu of tools that school and health officials can choose from based on conditions in their area. It recom- mends actions to take this school year, suggests strategies to consider if CDC finds that the flu starts causing more severe disease than during the spring 2009 outbreak, and provides a checklist for making decisions at the local level. Based on the severity of 2009 H1N1 flu-related illness thus far, this guidance also rec- ommends that students and staff with influenza-like illness remain home until 24 hours after resolution of fever without the use of fever-reducing medications. For the purpose of this document, “schools” will refer to both public and private institutions providing grades K-12 education to children and adolescents in group 1 Reprinted from http://www.cdc.gov/h1n1flu/schools/technicalreport.htm (accessed November 10, 2009). 2 See http://www.cdc.gov/h1n1flu/schools/schoolguidance.htm. 95

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96 IMPACTS OF THE 2009-H1N1 INFLUENZA A PANDEMIC settings. The guidance applies to such schools in their entirety, even if they pro- vide services for younger or older students. Guidance for child care settings and institutions of higher education will be addressed in separate documents. This Technical Report includes detailed information on the reasons for the strategies presented in the CDC Guidance for School (K-12) Responses to Influ- enza During the 2009-2010 School Year3 and suggestions on how to use them. The guidance is designed to decrease exposure to regular seasonal flu and 2009 H1N1 flu while limiting the disruption of day-to-day activities and the vital learn- ing that goes on in schools. CDC will continue to monitor the situation and update the current guidance as more information is obtained on 2009 H1N1. About 55 million students and 7 million staff attend the more than 130,000 public and private schools in the United States each day. By implementing these recommendations, schools and health officials can help protect one-fifth of the country’s population from flu. In addition to their central mission of educat- ing children and adolescents, schools meet other basic needs: feeding students and providing needed child care, health and mental health services, and safe and stable routines. It is crucial not to interrupt the learning process without due cause. Although illness may be such a cause, schools and their communities have a responsibility to balance the risks of illness among students and staff with the benefits of keeping students in school. The decision to dismiss students should be made locally and should bal- ance the goal of reducing the number of people who become seriously ill or die from influenza with the goal of minimizing social disruption and safety risks to children sometimes associated with school dismissal. Based on the experience and knowledge gained in jurisdictions that had large outbreaks in spring 2009, the potential benefits of preemptively dismissing students from school are often outweighed by negative consequences, including students being left home alone, health workers missing shifts when they must stay home with their children, students missing meals, and interruption of students’ education. Still, although the situation in fall 2009 is unpredictable, more communities may be affected, reflecting wider transmission. The overall impact of 2009 H1N1 should be greater than in the spring, and school dismissals may be warranted, depending on the disease burden and other conditions. CDC is continually monitoring the spread of flu, the severity of the illness it is causing (including hospitalizations and deaths), and whether the virus is changing; CDC will provide periodic updates of these assessments. If this infor- mation indicates that flu is causing more severe disease than during the spring 2009 outbreak, or if other developments might require more aggressive mitigation measures, CDC might recommend preemptive, or early, school dismissals. 3 See http://www.cdc.gov/h1n1flu/schools/schoolguidance.htm.

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97 APPENDIX A Recommended School Responses to Influenza for the 2009–2010 School Year Basic foundations of infection control in school settings should always be promoted and facilitated, not only during an influenza pandemic. During flu season, schools should be particularly vigilant about keeping sick students and staff home. Schools should be proactive, develop contingency plans to cover key positions (for example, school nurses) when staff are home ill, and regularly remind parents and staff of the exclusion recommendations. Plans should focus on protecting people at high risk for influenza complications as these groups are frequently found in schools. For example, asthma alone affects nearly one in ten school-aged youth. For a list of groups at high risk for influenza complications, see Novel H1N1 Flu and You.4 For general guidance on infection control in schools, see the American Academy of Pediatrics’ Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide, 2nd Edition5 (2009). Recommended Responses Under Conditions with Similar Severity as in Spring 2009 Stay Home When Sick CDC recommends that individuals with influenza-like illness remain at home until at least 24 hours after they are free of fever (100° F [37.8° C] or greater), or signs of a fever, without the use of fever-reducing medications. This recommendation is based on epidemiologic data about the overall risk of severe illness and death and attempts to balance the risks of severe illness from influenza and the potential benefits of decreasing transmission through the exclu- sion of ill persons with the goal of minimizing social disruption. Decisions about extending the exclusion period should be made at the com- munity level, in conjunction with local and state health officials. More stringent guidelines and longer periods of exclusion – for example, until complete resolu- tion of symptoms – may be considered for people returning to settings where high numbers of high-risk people may be exposed. Epidemiologic data collected during spring 2009 found that most people with 2009 H1N1 flu who were not hospitalized had a fever that lasted 2 to 4 days; this would require an exclusion period of 3 to 5 days in most cases. Those with more severe illness are likely to have fever for longer periods of time. Although fever is a component of the case definition of influenza-like ill- ness, the epidemiologic data collected during spring 2009 found that a minority 4 See http://www.cdc.gov/h1n1flu/qa.htm. 5 See http://aapredbook.aappublications.org/resources/midsheets.dtl.

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98 IMPACTS OF THE 2009-H1N1 INFLUENZA A PANDEMIC of patients infected with 2009 H1N1 flu with respiratory symptoms did not have a fever. Sick individuals should stay at home until the end of the exclusion period, to the extent possible, except when necessary to seek required medical care. Sick individuals should avoid contact with others. Keeping people with a fever at home may reduce the number of people who get infected since elevated temperature is associated with increased shedding of influenza virus. CDC recommends this exclusion period whether or not antiviral medications are used. People on antiviral treatment may shed influenza viruses that are resistant to antiviral medications. Many people with influenza illness will continue shedding influenza virus 24 hours after their fevers go away, but at lower levels than during their fever. Shedding of influenza virus, as detected in laboratory tests, can be detected for 10 days or more in some cases. Therefore, when people who have had influenza- like illness return to school they should continue to practice good respiratory etiquette and hand hygiene when they return to school and avoid close contact with people they know to be at increased risk of influenza-related complications. Because some people may shed influenza virus before they feel ill, and because some people with influenza will not have a fever, it is important that all people cover their cough and wash hands often. To lessen the chance of spread- ing influenza viruses that are resistant to antiviral medications, adherence to good respiratory etiquette and hand hygiene is as important for people taking antiviral medications as it is for others. Fever-reducing medications, that is, medications containing acetaminophen or ibuprofen, are appropriate for use in individuals with influenza-like illness. Aspirin (acetylsalicylic acid) should not be given to children or teenagers who have influenza; this can cause a rare but serious illness called Reye’s syndrome. The determination of readiness to return to school should be made when at least 24 hours have passed since the ill person’s temperature first remained normal without the use of these medications. For more information on caring for sick persons in the home, see Taking Care of a Sick Person in Your Home.6 Separate Ill Students and Staff Sick students and staff should always be required to stay home. CDC rec- ommends that students and staff who appear to have an influenza-like illness at arrival or become ill during the day be promptly separated from other students and staff and sent home. Schools should regularly update contact information for parents so that they can be contacted more easily if they need to pick up their ill child. Recognizing that space is often in short supply, early planning on the loca- tion for a sick room is essential. This room should not be one commonly used for 6 See http://www.cdc.gov/h1n1flu/guidance_homecare.htm.

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99 APPENDIX A other purposes for example, the lunchroom during non-meal times. Nor should it be a space through which others regularly pass. It is not necessary for this room to have a separate air supply (HVAC) system. Ill persons should be placed in well ventilated areas and placed in areas where at least 6 feet of distance can be maintained between the ill person and others. A limited number of staff should be designated to care for ill persons until they can be sent home. When possible, these should be people with limited inter- actions with other students and staff and therefore decreased risk of spreading influenza. These persons should not be at increased risk of influenza complica- tions (for example, pregnant women) and they should be familiar with infection control recommendations to prevent spread of influenza. When possible and if the sick person can tolerate it, he or she should wear a surgical mask when near other persons. School nurses, and other staff who act in this capacity, are likely to come into close contact with students and staff with influenza-like illness. CDC recommends that staff who provide care for persons with known, probable or suspected influ- enza or influenza-like illness use appropriate personal protective equipment. For more information on caring for sick persons in the home, see Taking Care of a Sick Person in Your Home.7 See Interim Recommendations for Facemask and Respirator Use to Reduce Novel Influenza A (H1N1) Virus Transmission8 or www.flu.gov for more informa- tion on personal protective equipment and how to recommend it to employees. Hand Hygiene Influenza may spread via contaminated hands or inanimate objects that become contaminated with influenza viruses. CDC recommends that students and staff be encouraged to wash their hands often with soap and water, especially after coughing or sneezing. Alcohol-based hand cleaners are also effective at killing flu germs, but may not be allowed in all schools. If soap and water are not available, and alcohol-based products are not allowed in the school, other hand sanitizers that do not contain alcohol may be useful however, there is less evidence on their effectiveness compared to that on hand washing and alcohol- based sanitizers. Schools should provide the time needed for all students and staff to wash their hands whenever necessary, especially after coughing or sneezing into hands, before eating, and after using the restroom. Soap, paper towels and sanitizers are critical for proper hand hygiene and should be readily available in schools. If it is necessary to provide supervision to students as they wash hands in rest rooms, schools should consider timing and staffing as they plan for the fall. Schools also 7 See http://www.cdc.gov/h1n1flu/guidance_homecare.htm. 8 See http://www.cdc.gov/h1n1flu/masks.htm.

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100 IMPACTS OF THE 2009-H1N1 INFLUENZA A PANDEMIC should educate families, students and staff about the importance of good hand hygiene and proper methods for cleaning hands. Visit Clean Hands Save Lives9 for more information on hand hygiene. Respiratory Etiquette Influenza viruses are thought to spread mainly from person to person in respiratory droplets of coughs and sneezes. This can happen when droplets from a cough or sneeze of an infected person are propelled through the air and deposited on the mouth or nose or are inhaled by people nearby. CDC recommends covering the nose and mouth with a tissue when coughing or sneezing and throwing the tissue in the trash after use. Wash hands promptly after coughing or sneezing. If a tissue is not immediately available, coughing or sneezing into one’s arm or sleeve (not into one’s hand) is recommended. To encourage respiratory etiquette, students and staff should have access to tissues and must be educated about the importance of respiratory etiquette, including keeping hands away from the face. Visit Cover Your Cough10 for more information on respiratory etiquette. Routine Cleaning The American Academy of Pediatrics provides guidance for school clean- ing and sanitizing which is appropriate for influenza. Schools should regularly clean all areas and items that are more likely to have frequent hand contact (for example, keyboards or desks) and also clean these areas immediately when vis- ibly soiled. Use the cleaning agents that are usually used in these areas. Some states and localities have laws and regulations mandating specific cleaning products be used in schools. School officials should contact their state health department or department of environmental protection for additional guid- ance. Schools should ensure that custodial staff and others (such as classroom teachers) who use cleaners or disinfectants read and understand all instruction labels and understand safe and appropriate use. Instructional materials and train- ing should be provided in languages other than English as locally appropriate . CDC does not believe any additional disinfection of environmental surfaces beyond the recommended routine cleaning is required. See the American Academy of Pediatrics’ Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide, 2nd Edition (2009)11 for guidance on cleaning and sanitizing in schools. The EPA provides a list of EPA-registered products effective against flu. 12 9 See http://www.cdc.gov/cleanhands/. 10 See http://www.cdc.gov/flu/protect/covercough.htm. 11 See http://aapredbook.aappublications.org/resources/midsheets.dtl. 12 See http://www.epa.gov/oppad001/influenza-disinfectants.html.

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101 APPENDIX A Early Treatment for High-Risk Students and Staff People at high risk for influenza complications who become ill with influenza- like illness should speak with their health care provider as soon as possible. Early treatment with antiviral medications is very important for people at high risk because it can prevent hospitalizations and deaths. CDC recommends that schools encourage ill staff and parents of ill students at higher risk of complications from influenza to seek early treatment. High-risk students and staff who have had close contact with others who are sick with an influenza-like illness should contact their health care provider to discuss whether they may need to take influenza antiviral medications that require a prescription in the U.S. People on antiviral treatment may still shed influenza viruses and therefore may still transmit the virus to others. These influenza viruses may develop resis- tance to antiviral medications. To lessen the chance of spreading influenza viruses that are resistant to antiviral medications, adherence to good respiratory etiquette and hand hygiene is as important for people taking antiviral medications as it is for others. For more information on antiviral medications, see Interim Guidance on Antiviral Recommendations for Patients with Novel Influenza A (H1N1) Virus Infection and Their Close Contacts.13 Selective School Dismissals Selective school dismissals may be considered based on the population of an individual school. Although there are not many schools where all or most students are at high risk (for example, a school for medically fragile children or for pregnant students) a community might decide to dismiss such a school to better protect these high-risk children. The decision to selectively dismiss a school should be made locally and should balance the risks of keeping the students in school with the social disruption that school dismissal can cause. School officials should work closely and directly with their local and state public health officials when deciding whether or not to selectively dismiss a school or schools. Selective school dismissals are not likely to have a significant effect on community-wide transmission: Instead, this strategy aims to protect students and staff at high risk of severe illness and death. Information on reactive and preemptive school dismissals is provided in the next section. 13 See http://www.cdc.gov/h1n1flu/recommendations.htm.

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102 IMPACTS OF THE 2009-H1N1 INFLUENZA A PANDEMIC Recommended Additional Responses During Times of Increased Influenza Severity CDC will continue to assess the severity of illness caused by 2009 H1N1 flu and disseminate the results of these ongoing assessments. If global or national risk assessments indicate an increased level of severity compared with the spring 2009 H1N1 flu outbreak, CDC will consider the need to recommend additional strategies including preemptive school dismissals. Decisions to add strategies should be based on information on the severity of illness reported in national and global assessments, local goals, epidemiology, health care system capacity, and feasibility and acceptability of the strategies under consideration. The strategies which follow use a variety of methods for increasing social distance, while attempting to maintain operability of most schools. Feasibility and acceptability of these strategies will vary considerably across communities. Except for school dismissals, the following strategies have not been scientifically tested. But CDC wants communities to have tools to use that may be the right measures for their community and circumstances. Active Screening for Illness If influenza severity increases, schools should consider instituting active fever and respiratory infection symptom screening of students and staff when they arrive at school. At the beginning of the school day, all students and staff should be asked about suggestive symptoms such as fever, cough, runny nose, and sore throat during the previous 24 hours. Some persons with laboratory-confirmed influenza do not have a fever (between 10% and 40% of people). Therefore, absence of fever does not indicate absence of infection. In a higher severity situa- tion, schools should send home persons with symptoms of acute respiratory infec- tion (that is, any two of the following: sore throat, cough, runny nose [new and unexplained by allergies], or fever). As always, parents should be aware of their child’s health status and monitor them for illness every morning before school. Throughout the day, staff should be vigilant in identifying students and other staff who appear ill. These students and staff should be further screened by the school nurse, or other school-based health care worker, by taking their tem- perature and inquiring further about symptoms. Students and staff who develop symptoms of acute respiratory infection at school should be separated from others until sent home. When possible and if the sick person can tolerate it, he or she should wear a surgical mask until sent home. Permit High-Risk Students and Staff to Stay Home If influenza severity increases, students and staff at high risk for influenza complications may consider staying home from school while influenza transmis-

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103 APPENDIX A sion is high in their community if they, or their families, are concerned about their ability to avoid influenza at school. The decision about whether to stay home should be made in consultation with their health care provider. People who elect to stay home from school should also attempt to decrease their exposure in other ways for example, by avoiding large public gatherings. Well students should be expected to continue their education while at home as much as possible. Schools should prepare for discussions with parents about school safety and should consult with school boards and legal counsel about policy accommoda- tions that might be necessary to allow students and staff at high risk for influenza complications to stay home. Local and state laws and policies also might need to be reviewed for applicability. Policies to be reviewed may be official or unofficial, such as school principals’ awards for students with perfect attendance. Schools should plan now for ways to continue educating students who stay home through methods such as instructional telephone calls, homework packets, internet-based lessons, and other distance-based learning approaches. Students With Ill Household Members Stay Home If influenza severity increases, school-aged children who live with people with influenza-like illness should remain home for 5 days from the day the first household member got sick. This is the time period they are most likely to get sick themselves. The greatest risk of transmission is during the first 5 days of ill- ness of the first ill household member (about 90%), with the largest transmission risk by Day 1 of this person’s illness (about 40%). Keeping all the children in the household at home during this time period may also keep the flu virus from being spread to others outside the home. If a household member develops an acute respiratory illness during this time, the recommendations for exclusion of persons with influenza-like illness should be implemented. The five-day period does not need to start again for other well children in the household. Increase Social Distances Within the School Environment If influenza severity increases, schools should explore innovative methods for increasing social distances within the school environment. The goal should be to keep distance between people at most times or to cluster students in small, consistent groups. This is not a simple or easy strategy for most schools. Imple- menting any of the following options would require considerable flexibility and willingness to change among students, staff, and families. Some possible options to increase the amount of space between students or to keep consistent groups of students include: • rotate teachers between classrooms while keeping the same group of students in one classroom (in middle and high school);

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104 IMPACTS OF THE 2009-H1N1 INFLUENZA A PANDEMIC • cancel classes that bring students together from multiple classrooms (in elementary school); • postpone class trips that bring students together from multiple classrooms or schools in large, densely-packed groups; • hold classes outdoors; • discourage use of school buses and public transit; • divide classes into smaller groups; • move desks farther apart; and • move classes to larger spaces, when available, to allow more space between students. Extended Exclusion Period If influenza severity increases, individuals with influenza-like illness should remain at home for at least 7 days, even if symptoms resolve sooner. Individuals who are still sick 7 days after they become ill should continue to stay home until at least 24 hours after symptoms have resolved. This recommendation is based on viral shedding information. Influenza virus shedding general occurs for 5 to 7 days for seasonal influenza infection. This period may be longer for persons with 2009 H1N1 flu and among young children and people who are immunocompromised. Longer periods of exclusion also may be considered based on setting- and population-specific characteristics. Schools also might prefer a longer period so that students and staff feel able to fully function at school after recovery from their illness. Sick individuals should stay at home until the end of the exclusion period, to the extent possible, except when necessary to seek required medical care. Sick individuals should avoid contact with others. CDC recommends this exclusion period whether or not antiviral medications are used. People on antiviral treat- ment may shed influenza viruses that are resistant to antiviral medications. When people who have had influenza-like illness return to school they should continue to practice good respiratory etiquette and hand hygiene and avoid close contact with people likely to be at increased risk of influenza-related complica- tions. To lessen the chance of spreading influenza viruses that are resistant to antiviral medications, adherence to good respiratory etiquette and hand hygiene is as important for people taking antiviral medications as it is for others. For more information on caring for sick persons in the home, see Taking Care of a Sick Person in Your Home.14 14 See http://www.cdc.gov/h1n1flu/guidance_homecare.htm.

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105 APPENDIX A School Dismissals: Reactive and Preemptive In case influenza severity increases, CDC recommends that communities review and prepare to implement their school dismissal plans according to the guidelines outlined below. School and health officials should balance the risks of influenza in their community with the disruption dismissals will cause in both edu- cation and the wider community. School officials should work closely and directly with their local and state public health officials to make sound decisions, based on local conditions, and to implement strategies in a coordinated manner. When communities choose to use school dismissal, education and public health officials should clearly state to parents and their communities the reason for dismissing students and the type of school dismissal they are implementing. There are three types of school dismissals: selective (described above), reactive, and preemptive. Reactive dismissals might be appropriate when schools are experiencing excessive absenteeism among students or staff, a large number of children are vis- iting the school health office or being sent home from school during the school day with documented fever, the school is not able to keep potentially infectious people out, or for other reasons that decrease the ability to maintain school functioning. Reactive dismissals might reduce the burden on the local health care system. As with selective dismissals, the decision to dismiss students should be made locally and should balance the goal of reducing the number of people who become seriously ill or die from influenza with the goal of minimizing social disruption. School officials are encouraged to work collaboratively and commu- nicate with neighboring districts or schools to keep others in the region aware of actions that are taken. Officials might decide to dismiss or not dismiss students from their own schools based on the experiences of their neighbors. The risk to students and staff from an ongoing school-based outbreak if potentially infectious individuals cannot be excluded from school may also lead some jurisdictions to decide to close schools. In this case, school-related mass gatherings also should be cancelled or postponed. Preemptive dismissals can be used to decrease the spread of influenza virus or to reduce demand on the health care system. If global or national risk assess- ments indicate an increased level of severity compared with the spring 2009 H1N1 influenza outbreak, CDC might recommend preemptive school dismissals. If schools are dismissed, school-related mass gatherings should be cancelled or postponed. This would include sporting events, school dances, performances, rallies, commencement ceremonies, and other events that bring large groups of people into close proximity with one another. School dismissal is likely to be more effective in decreasing the spread of influenza virus in the community when used early in relation to the appearance of the virus in the community and when used in conjunction with other strategies (for example, cancellation of community sporting events and other mass gather-

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106 IMPACTS OF THE 2009-H1N1 INFLUENZA A PANDEMIC ings). Cancellation or postponement of community events is a decision of event organizers, local public health officials and other government agencies and should be part of a coordinated community process. A vaccine for 2009 H1N1 flu will likely become available in fall 2009. For children, at least, protective immunity will require 2 doses of vaccine, separated by at least 3 weeks and an additional 2 weeks for the immune response to develop (that is, approximately 5 weeks after the first vaccination). If an increase in community-wide transmission occurs shortly before vaccine-induced immunity is anticipated, or before a scheduled vacation, some jurisdictions may consider preemptive dismissals. Resuming Classes After the Dismissal The length of time students should be dismissed from school will vary depend- ing on the type of school dismissal as well as the severity and extent of illness. When the decision is made to dismiss students, CDC recommends doing so for 5 to 7 calendar days. Reactive school dismissals are likely to be of shorter duration than selective or preemptive dismissals. Because the goals of selective dismissals (to protect students and staff at high risk of severe illness or death) and preemptive dis- missals (to decrease the spread of influenza virus) are usually different from those of reactive dismissals, the length of time schools are dismissed might be longer. On a regular basis (for example, weekly) communities that have dismissed students from school should reassess the epidemiology of the disease, the benefits of keeping students home, and the societal repercussions of doing so. Based on this reassessment, communities may decide either to extend the school dismissal or to reopen schools. In the event that CDC recommends preemptive school dismissals, this recommendation also might include a modification to the sug- gested length of dismissal, based on the severity observed across the nation and globally. Therefore, schools and school boards should plan for more prolonged periods of school dismissal. If schools attempt to continue educational services to all students during a lengthy school dismissal, students with disabilities should receive comparable access to education. The authority for decision-making regarding school dismissal may reside in multiple sectors of state and local government; these entities must work in a coordinated manner. National, regional, or local data, and the decision-making guidance included in this document, may be useful for determining whether to dismiss schools. Reducing Adverse Effects from School Dismissal As part of a community planning process, school dismissal plans should address possible secondary effects on the community. The planning process should include communicating these plans with all community members affected

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107 APPENDIX A by school dismissal. These might include effects on critical infrastructure, par- ents’ job security and income loss, school funding due to funding calculations based on attendance, child nutrition due to the loss of access to the school meals program, loss of access to health services, educational progress, and child safety due to possibly increased unsupervised time. Communities should prepare to address these secondary effects so as to increase the acceptability of and partici- pation in school dismissal. Parents should plan for child care while schools are dismissed, as these decisions may be made very quickly. Communities should also plan to allow school staff to use school facilities while students are dismissed. Keeping school facilities open may allow teachers to develop and deliver lessons and materials (for example, by using school tele- conference lines or other distance-based education delivery systems) and other staff to provide essential services (such as preparation of meals) keeping in mind basic infection control practices. If school is dismissed, let CDC, the U.S. Department of Education, and your state health and education agencies know by submitting a simple report at ww.cdc.gov/FluSchoolDismissal.15 Roles Collaboration is essential: many different stakeholders have important roles to play in the decision-making process, implementing strategies, and ensuring their effectiveness. To be most effective, these activities must be coordinated at the federal, state, and local levels. • CDC will continue to monitor the spread and severity of influenza ill - ness, monitor for changes in circulating influenza viruses that may confer increased severity of disease, identify promising methods for reducing morbidity and mortality, assist state and local health and education agen- cies to implement those methods and evaluate their effectiveness, and provide timely updates on new scientific findings as well as additional guidance as the situation warrants. • The U.S. Department of Education (ED) will collaborate with federal, state, and local agencies as well as non-governmental entities to disseminate new guidance, provide support to state and local education agencies, and work with states to provide flexibility in regulations around funding. • ED, state public health and education agencies, and CDC will monitor school dismissals and other related issues. • State and local public health and education agencies should work together to decide which strategies to implement and when, collect and share data, and disseminate emerging guidance. 15 See http://www.cdc.gov/h1n1flu/schools/dismissal_form/.

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108 IMPACTS OF THE 2009-H1N1 INFLUENZA A PANDEMIC • Schools should examine and revise, as necessary, their current crisis or pandemic plans and procedures, including updating contact information, and communicate with vendors who supply critical products or services to plan for continuation of those services throughout the flu season. Critical services may include food service, hygiene supplies, and personal protec- tive equipment for staff. This planning is especially important when sup- pliers may be small businesses in the local area that could also be affected by a flu outbreak. • Schools should be a resource for families to help mitigate the secondary effects of school dismissals by referring them to assistance in the com- munity or, where feasible, by providing direct assistance. Schools can communicate with families and the community about what they will do to decrease spreading influenza illness; and help families and communi- ties understand the important roles they can play in reducing the spread of influenza and keeping schools open. • Students, staff, and their families must take personal responsibility for stay- ing home when ill, practicing hand hygiene and respiratory etiquette, and planning in advance for child care in the event of a school dismissal. • Private sector support is essential for working parents and guardians who need to stay home to care for an ill child or find alternate child care in the event of a school dismissal. The economic impact of a school dismissal can have ripple-effects throughout the community and local economy. Flexible leave and workplace policies can keep parents from losing pay or even their jobs. • Community-based and faith-based organizations can provide crucial sup - port to families by educating community members about the importance of staying home when ill, hand hygiene, and respiratory etiquette. Often, they also can provide meals, alternative child care sites, transportation, and other services to ease the burden of staying home. Deciding on a Course of Action To decrease exposure of students and school staff to the influenza virus, CDC recommends a combination of targeted, layered strategies applied early and simultaneously based on trends in the severity of the disease, characteristics of the virus, expected impact, feasibility, and acceptability. These issues should be determined through collaborative decision-making involving education and public health agencies, parents, and the community. CDC and its partners will continuously look for changes in the severity of influenza-like illness and will share what is learned with state and local agencies. However, states and local communities can expect to see a lot of differences in disease burden across the country. Every state and community has to balance a variety of objectives to determine

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109 APPENDIX A their best course of action to help decrease the spread of influenza. Decision- makers should explicitly identify and communicate their objectives which might be one or more of the following: (a) protecting overall public health by reducing community transmission; (b) reducing transmission in students and school staff; and (c) protecting people with high-risk conditions. Some strategies can have negative consequences in addition to their potential benefits. In the particular case of school dismissals, decision-makers also must consider and balance additional factors: (a) how to ensure students continue to learn; (2) how to provide an emotionally and physically safe place for students; and (3) how to reduce demands on local health care services. The following questions can help begin discussions and lead to decisions at the state and local levels. Decision-Makers and Stakeholders Are all the Right Decision-Makers and Stakeholders Involved in the Decision-Making Process? • Identify the decision-makers. In different jurisdictions, local and state health, education, and homeland security agencies may have relevant decision-making responsibilities. Direct involvement of governors, mayors, public health officials, or school superintendents may be needed. • Identify the stakeholders. Stakeholders will vary from community to community but may include parent representatives, students, local busi- ness and faith community representatives, teachers, health care providers, hospitals, community organizations, school nurses, school food service directors, and vendors that supply schools. What is the Process for Working Together? • Do you have a process for regular input and collaboration on decisions? • Are there strong, open communication channels between health and edu - cation officials? Does this include frequent information sharing? • Do you regularly review your crisis and pandemic plans? Do you revise as needed? Information Collection and Sharing Can Local or State Health Officials Determine and Share Information About the Following? • What is the severity and extent of spread of the disease in the state or locality? What is the rate of outpatient visits for influenza-like illness? What is the local hospitalization rate for influenza-like illness? Are the

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110 IMPACTS OF THE 2009-H1N1 INFLUENZA A PANDEMIC numbers of hospitalizations or deaths increasing? What percent of these hospitalized patients require admission to intensive care units? How many influenza deaths have occurred in the community? Are some groups being disproportionately affected? • How busy are local health care providers and emergency departments? How many visits are they getting for influenza-like illness? Are they able to meet the increased demand for care from persons with influenza-like illness? Are local health care providers or emergency departments becom- ing overburdened? • Are the hospital and intensive care unit (ICU) beds full with influ- enza patients? Is there available space in the ICUs? Are there enough ventilators? • Do the hospitals have enough staff to provide care? Is there increasing absenteeism in health care workers due to influenza-like illness in them- selves or their family members? • Is there enough antiviral medication to treat sick patients at high risk for complications? Can Local Education Agencies or Schools Determine and Share Information About the Following? • What are school absenteeism rates? How many visits are being made to school health offices daily? How many students with influenza-like illness are being sent home during the school day? Feasibility Do You Have the Resources to Implement the Strategies Being Considered? • What resources are available? Do you have access to the funds, personnel, equipment, and space needed? • How long will the strategies take to implement? How long can the strate - gies be sustained? • Are changes to legal authority or policy needed? How feasible are these changes? • How can you most clearly communicate with the community about steps parents, students, individuals and families need to take and the reasons for recommendations?