Monday, August 10, 2009

H1N1 Flu CDC Guidelines: School Responses...

CDC Guidance for State and Local Public Health Officials and School Administrators for School (K-12) Responses to Influenza during the 2009-2010 School Year

Physician First Watch Summary (by David G. Fairchild, MD, MPH, Editor-in-Chief):

If H1N1 severity is the same as during the spring outbreak, the CDC advises that:

  • ill students and staff should remain at home for 24 hours after they are free of fever (without use of fever-lowering drugs);
  • those who are sick at school should be separated from others until they can be sent home.

If the virus shows increased severity compared with the spring outbreak:

  • students and staff should be screened on arrival at school and sent home if ill;
  • people at high risk for complications or with ill household members should stay home;
  • sick people should stay home for at least 7 days, even if they become asymptomatic.

This document provides guidance to help decrease the spread of flu among students and school staff during the 2009-2010 school year. This document 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 and suggests strategies to use if CDC finds that the flu starts causing more severe disease. The guidance also provides a checklist for making decisions at the local level.

Detailed information on the reasons for these strategies and suggestions on how to use them is included in the Technical Report.

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 guidance, “schools” will refer to both public and private institutions providing grades K-12 education to children and adolescents in group settings. The guidance applies to such schools in their entirety, even if they provide services for younger or older students. Guidance for child care settings and institutions of higher education will be addressed in separate documents.

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 learning 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.

  • Collaboration is essential: CDC, the U.S. Department of Education, state and local public health and education agencies, schools, students, staff, families, businesses, and communities all have active roles to play.

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 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. (See the Technical Report for discussion of the kinds of circumstances that might warrant preemptive school dismissals.)

Recommended school responses for the 2009-2010 school year

Under conditions with similar severity as in spring 2009

  • Stay home when sick: Those with flu-like illness should stay home for at least 24 hours after they no longer have a fever, or signs of a fever, without the use of fever-reducing medicines. They should stay home even if they are using antiviral drugs. (For more information, visit
  • Separate ill students and staff: Students and staff who appear to have flu-like illness should be sent to a room separate from others until they can be sent home. CDC recommends that they wear a surgical mask, if possible, and that those who care for ill students and staff wear protective gear such as a mask.
  • Hand hygiene and respiratory etiquette: The new recommendations emphasize the importance of the basic foundations of influenza prevention: stay home when sick, wash hands frequently with soap and water when possible, and cover noses and mouths with a tissue when coughing or sneezing (or a shirt sleeve or elbow if no tissue is available).
  • Routine cleaning: School staff should routinely clean areas that students and staff touch often with the cleaners they typically use. Special cleaning with bleach and other non-detergent-based cleaners is not necessary.
  • Early treatment of 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. People at high risk include those who are pregnant, have asthma or diabetes, have compromised immune systems, or have neuromuscular diseases.
  • Consideration of selective school dismissal: Although there are not many schools where all or most students are at high risk (for example, schools for medically fragile children or for pregnant students) a community might decide to dismiss such a school to better protect these high-risk students.

Under conditions of increased severity compared with spring 2009

CDC may recommend additional measures to help protect students and staff if global and national assessments indicate that influenza is causing more severe disease.

In addition, local health and education officials may elect to implement some of these additional measures. Except for school dismissals, these 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: Schools should check students and staff for fever and other symptoms of flu when they get to school in the morning, separate those who are ill, and send them home as soon as possible. Throughout the day, staff should be vigilant in identifying students and other staff who appear ill.
  • High-risk students and staff members stay home: People at high-risk of flu complications should talk to their doctor about staying home from school when a lot of flu is circulating in the community. Schools should plan now for ways to continue educating students who stay home through instructional phone calls, homework packets, internet lessons, and other approaches.
  • Students with ill household members stay home: Students who have an ill household member should stay home for five days from the day the first household member got sick. This is the time period they are most likely to get sick themselves.
  • Increase distance between people at schools: CDC encourages schools to try innovative ways of separating students. These can be as simple as moving desks farther apart or canceling classes that bring together children from different classrooms.
  • Extend the period for ill persons to stay home: If influenza severity increases, people with flu-like illness should stay home for at least 7 days, even if they have no more symptoms. If people are still sick, they should stay home until 24 hours after they have no symptoms.
  • School dismissals: School and health officials should work closely to balance the risks of flu in their community with the disruption dismissals will cause in both education and the wider community. The length of time schools should be dismissed will vary depending on the type of dismissal as well as the severity and extent of illness. Schools that dismiss students should do so for five to seven calendar days and should reassess whether or not to resume classes after that period. Schools that dismiss students should remain open to teachers and staff so they can continue to provide instruction through other means.

    Reactive dismissals might be appropriate when schools are not able to maintain normal functioning for example, when a significant number and proportion of students have documented fever while at school despite recommendations to keep ill children home.

    Preemptive dismissals can be used proactively to decrease the spread of flu. CDC may recommend preemptive school dismissals if the flu starts to cause severe disease in a significantly larger proportion of those affected.

Deciding on a course of action

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 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.


In the CDC technical report the details are very similar to what we have been advocating:

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 illness 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. Implementing 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);
  • 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.

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