Technical Report for State and Local Public Health Officials and Child Care and Early Childhood Providers on CDC Guidance on Helping Child Care and Early Childhood Programs Respond to Influenza during the 2009–2010 Influenza Season

February 22, 2010, 10:00 AM

CDC has released guidance to help decrease the spread of influenza (flu) among children in early childhood programs and early childhood providers during the 2009–2010 flu season. The new guidance expands upon earlier guidance documents by providing a menu of tools that health officials and early childhood providers can choose from based on conditions in their area. The new guidance recommends actions to take now, during the 2009–2010 flu season; suggests additional strategies to consider if CDC determines that flu is becoming more severe; and provides a checklist for decision-making at the local level. Based on the severity of 2009 H1N1 flu-related illness thus far, this guidance recommends that children and early childhood providers with flu-like illness remain home until 24 hours after resolution of fever without the use of  fever-reducing medicines. For the purpose of this document, “early childhood” will refer to both center-based and home-based early childhood programs, Head Start programs, and other early childhood programs providing care for children in group settings. The guidance applies to all early childhood programs, even if they provide services for older children. This guidance represents CDC’s current thinking on this topic. It does not create or confer any rights for or on any person or operate to bind the public.

This Technical Report provides a more in depth explanation of the strategies presented in the CDC Guidance on Helping Child Care and Early Childhood Programs Respond to Influenza during the 2009–2010 Influenza Season and gives suggestions on how to use these strategies. The guidance is designed to decrease exposure to seasonal flu and 2009 H1N1 flu and limit the disruption of the essential service early childhood provides to families.  

BACKGROUND

According to the National Association of Child Care Resource and Referral Agencies (NACCRA), there were 119,174 child care centers and 238,103 home-based child care programs in the United States in 2008 (http://www.naccrra.org/randd/docs/2008_Child_Care_Capacity.pdf). Of the 9,660,666 (39.5%) children 0 through 4 years of age in (non-relative) child care for at least 10 hours each week identified in the 2007 National Survey of Children’s Health, 10.6% were in child care in their own home, 21.7% were in child care in someone else’s home, and 72.0% were in center-based child care.

Flu vaccination is the primary means of preventing flu but infection control measures also can reduce the spread of flu. Early childhood settings present unique challenges for infection control because of the close interpersonal contact, shared toys and other objects, and limited ability of young children to understand or practice good respiratory etiquette and hand hygiene. Thus, parents, early childhood providers, and public health officials should be aware that, even under the best of circumstances, transmission of infectious diseases such as flu cannot be completely prevented in early childhood or other settings. No policy can keep everyone who is potentially infectious out of these settings.

The purpose of this document is to provide updated guidance for reducing the spread of flu in early childhood programs. We provide recommendations for the 2009-2010 flu season, assuming that severity of illness is similar to what was seen during April through December 2009 of the 2009 H1N1 flu outbreak, as well as recommendations that could be added if the severity of illness worsens. Flu is unpredictable, and CDC will provide periodic updates of these assessments and may recommend additional strategies if they are needed. Also, because conditions may vary from community to community, early childhood providers should also look to their state and local health officials for information and guidance specific to their location.

Flu Symptoms, Transmission, and Risk:

Symptoms of flu can include fever, cough, sore throat, runny or stuffy nose, body aches, headache, chills, and fatigue, and sometimes diarrhea and vomiting. People may be infected with the flu, including 2009 H1N1 flu and have respiratory symptoms without a fever. Young children with flu may be cranky, less playful, or not eat well. Infants with flu may have fever and lethargy without cough or respiratory symptoms. For more information, visit http://www.cdc.gov/h1n1flu/childrentreatment.htm. Like seasonal flu, 2009 H1N1 flu infection in humans can vary in severity from mild to severe. Visit http://www.cdc.gov/H1N1flu/qa.htm for more information on flu symptoms.

Like seasonal flu, the 2009 H1N1 flu virus is spread mainly from person to person through coughs or sneezes of infected individuals. People may also become infected by touching something – such as a surface or object – with flu virus on it and then touching their mouth, nose, or eyes.

Some people are at higher risk than others for serious complications from flu.

These people include:

• children younger than 5 years old, but especially children younger than 2 years old
• people aged 65 years or older
• pregnant women
• adults and children who have:
• asthma
• neurological and neurodevelopmental conditions
• chronic lung disease
• heart disease
• blood disorders
• endocrine disorders (such as diabetes)
• kidney, liver, and metabolic disorders
• weakened immune systems due to disease or medication
• people younger than 19 years of age who are receiving long-term aspirin therapy

For more information on people at high risk for flu complications, visit http://www.cdc.gov/h1n1flu/highrisk.htm.

RECOMMENDATIONS FOR EARLY CHILDHOOD PROGRAMS FOR THE 2009–2010 FLU SEASON

The most important things early childhood providers can do to reduce the risk of flu in the early childhood setting are to encourage flu vaccination for those recommended for vaccination; suggest early treatment for people at higher risk for flu complications; facilitate use of respiratory etiquette and hand hygiene by children and staff; ensure that sick children and adults do not come to the facility; and separate sick and well people as soon as possible. Childhood providers should frequently remind students, their families, and staff about the importance of these. The following recommendations provide a framework to determine the most appropriate and feasible strategies for each early childhood setting.

Early childhood providers should examine and revise, as necessary, their current crisis or pandemic plans and procedures, including updating contact information for families and staff. Plans should be shared with families, staff, and the community before an outbreak so that they know how and when they will be contacted and what types of information to expect. Early childhood providers should be proactive, develop contingency plans to cover for staff who are absent from work, and regularly remind parents and staff of exclusion policies. Early childhood providers should review – and revise, if necessary – their sick leave policies to remove barriers to staff staying home while sick or to care for a family member. A healthcare provider’s note should not be required for children or staff to validate their illness or to return to the early childhood setting. Healthcare provider offices and medical facilities may be extremely busy and unable to provide such documentation in a timely way during a flu outbreak. Planning should also include determining quantities of supplies and space needed to facilitate respiratory etiquette and hand hygiene (for example, tissues, soap, and paper towels).

Early childhood providers should frequently remind children, their families, and staff about the importance of staying home when sick; early treatment for people at higher risk for flu complications; respiratory etiquette; and hand hygiene. Educational materials (for example, posters) to enhance compliance with recommendations should be visible throughout the early childhood setting. Examples of these materials are available at http://www.cdc.gov/h1n1flu/flyers.htm. Furthermore, Preparing for the Flu: A Communication Toolkit for Child Care and Early Childhood Programs also provides many materials for use. 

The recommendations that follow are divided into two groups: 1) recommendations to use now, during the 2009–2010 flu season, assuming a similar severity to the flu outbreak as seen during April through December 2009 of the 2009 H1N1 flu outbreak, and 2) recommendations to consider adding if a more severe flu season occurs. 

Recommended strategies to use now, for flu conditions with similar severity to April through December 2009 of the 2009 H1N1 flu outbreak

• Encourage vaccination against the flu:

The best way to protect against the flu is to get vaccinated. The vaccine for seasonal flu is produced every year. Groups that should be vaccinated against seasonal flu include: everyone 6 months through 18 years of age; all people 50 years of age and older; women who will be pregnant during flu season; people age 18 through 49 with certain medical conditions that put them at higher risk for flu complications; healthcare workers; and household contacts and caregivers of people who are at increased risk of severe illness from flu, including children less than 5 years of age, pregnant women, people 65 and older, and anyone with certain medical conditions.

Vaccination to protect against the 2009 H1N1 flu virus should be encouraged. CDC’s Advisory Committee on Immunization Practices (ACIP) has recommended that doses of the 2009 H1N1 flu vaccine be prioritized for 5 primary target groups: pregnant women, people who live with or care for children younger than 6 months of age, healthcare and emergency medical services personnel, people age 6 months through 24 years, and people age 25 through 64 years who have certain medical conditions that put them at higher risk for flu complications. Due to increased vaccine availability, everyone, including those over age 65 years, can now be vaccinated.

Children and many staff in early childhood settings fall within these groups and should be among the first to receive the 2009 H1N1 flu vaccine. For more information on the ACIP recommendations, visit http://www.cdc.gov/mmwr/pdf/rr/rr58e0821.pdf.

• Advise the sick to stay home:

CDC recommends that children and caregivers with flu-like illness remain at home and away from others until at least 24 hours after they are free of fever (100° F [37.8° C] or greater when measured orally), or any signs of a fever, without the use of fever-reducing medicines. Epidemiologic data collected during April through 2009 found that most people with 2009 H1N1 flu who were not hospitalized had a fever that lasted 2 to 4 days; this would result in an exclusion period of 3 to 5 days in most cases. Early childhood programs, parents, or state and local officials may elect to require longer exclusion periods. Parental or community concerns and preferences also should be considered when evaluating if a more stringent exclusion policy is appropriate. Early childhood programs are encouraged to work with their local health department to establish exclusion policies.

• Conduct daily health checks: Early childhood providers should perform a daily health check of children and staff. Providers should have a policy and process for performing a daily health check of all children upon or soon after arriving at the program. The purpose of the health check is to observe and briefly assess the child’s overall health. This health check should consist of direct observation of the child and talking with the parent or guardian and the child. During the day, staff also should identify children and other staff who may become sick. Sick children and staff should be further assessed by taking their temperature and inquiring about symptoms. An aexample of how to perform daily health checks can be found at: http://www.bmcc.edu/Headstart/Trngds/Diseases/pg91-108.htm.

Early childhood providers should regularly update parent contact information so that parents can be reached quickly if they need to pick up their sick child. Caring for Our Children: National Health and Safety Performance Standards: Guidelines for Out-Of-Home Child Care provides more information on health checks.

An early childhood program’s health consultant may provide additional assistance. Some center- and home-based early childhood programs have access to a health consultant who is qualified to provide advice on child care. Early childhood programs should contact their State Child Care Administrator or local child care resource and referral agency for information on the availability of early childhood health consultants in their local area. Visit http://nrckids.org for more information on health consultants.

• Separate sick children and staff:

Children and staff who develop symptoms of flu-like illness while at the early childhood program should promptly be separated from others.  While this may be challenging for some home-based providers, they should provide a space where the child can be comfortable and supervised at all times. A parent or guardian should be called and asked to take his or her child home immediately.  Staff with flu-like illness should also be asked to go home immediately.

Early childhood providers who care for people with known, probable, or suspected flu or flu-like illness should wear appropriate personal protective equipment. When caring for a sick infant or young child, the caregiver should try to position the child’s head to minimize the child’s coughing directly into the faces of others, if possible. Visit: http://www.cdc.gov/h1n1flu/masks.htm or www.flu.gov for more information on personal protective equipment and how to recommend it to employees.

Sick people should be placed in well-ventilated areas where at least 6 feet of distance can be maintained between the sick person and others. Early childhood programs should designate such an area in advance. This area should not be one commonly used for other purposes, such as the playroom or a space through which others regularly pass. This area should be child-proofed and children should receive appropriate and safe supervision there. A limited number of staff should be designated to care for sick children until their parents arrive. These people should not be at high risk for flu complications.

Staff who develop symptoms of flu-like illness while at the early childhood program should be separated from children and other staff and promptly asked to go home. A staff member who develops flu-like illness while at work should wear a facemask when near other people when possible until he or she can go home.  Visit: http://www.cdc.gov/h1n1flu/guidance_homecare.htm for information on caring for a sick person.

• Emphasize respiratory etiquette:

Cover the nose and mouth with a tissue when coughing or sneezing and throw the tissue in the trash after use. Flu viruses are thought to spread mainly from person to person in respiratory droplets, which are often distributed by coughs and sneezes. Hands should be cleaned promptly after coughing or sneezing. Children should be taught developmentally appropriate respiratory etiquette (for example, coughing or sneezing into an elbow or shoulder if they are not able to retrieve tissues in sufficient time). To encourage respiratory etiquette, children, and staff should have easy access to tissues and trash receptacles and be educated about the importance of respiratory etiquette, including keeping hands away from the face. Visit: http://www.cdc.gov/flu/protect/covercough.htm for more information on respiratory etiquette.

• Promote hand hygiene:

Children and staff should be encouraged to wash their hands often with soap and water, especially after coughing or sneezing. Because it will never be possible to identify everyone who is potentially infectious, hand hygiene is of critical importance. If soap and water are not available, alcohol-based hand rubs can also be used. However, hand rubs should not be used when hands are visibly soiled.

Early childhood providers should provide adequate time for all children and staff to wash their hands. Parents and early childhood providers should wash the hands of children who cannot yet wash themselves and closely monitor children who have not mastered proper hand hygiene. This could include children with special physical or developmental needs, particularly those with limitations or developmental delays in self-care skills. Soap, water, and paper towels are critical for proper hand hygiene and should be readily available. In addition, early childhood providers also should educate families, children, and staff about the importance of good hand hygiene and proper methods for hand hygiene. Visit: www.cdc.gov/cleanhands for more information on hand hygiene.

• Perform routine environmental cleaning:

Early childhood providers should regularly clean all areas with a particular focus on items that are more likely to have frequent contact with the hands, mouths, and bodily fluids of young children (for example, toys and play areas). These areas and items also should be cleaned immediately when they are visibly soiled. Provide disposable wipes so that commonly used surfaces can be wiped down by staff before each use. CDC does not believe any additional disinfection of environmental surfaces beyond the recommended routine cleaning is required.

Some states and localities have laws and regulations mandating that specific cleaning products be used in early childhood settings. Early childhood providers can contact their state or local health department or department of environmental protection for additional guidance. Early childhood providers should ensure that custodial staff and others in the early childhood setting who use cleaners or disinfectants read and understand all instruction labels and understand safe and appropriate use. Instructional materials and training should be provided in languages other than English as locally appropriate.

The EPA provides a list of EPA-registered products effective against flu: http://www.epa.gov/oppad001/influenza-disinfectants.html .

• Promote early treatment for children and staff at higher risk for flu complications

Flu can cause serious complications, including bacterial pneumonia and dehydration, and can worsen chronic medical conditions, such as asthma, heart disease, or diabetes. People should know before an outbreak begins if they or a member of their family are at higher risk for flu complications. Parents and staff should be encouraged to talk with their healthcare provider to determine if they or a member of their family are at higher risk for flu complications. For more information on people at high risk for flu complications, visit http://www.cdc.gov/h1n1flu/highrisk.htm .

Parents of children under age 5 and staff at higher risk for flu complications who develop flu-like illness should call their healthcare provider as soon as possible to determine if they need antiviral treatment. It’s very important that antiviral drugs be used early to treat flu in people who are very sick (for example people who are in the hospital) and people who are sick with flu and have a greater chance of getting serious flu complications. Early treatment should be considered for people with suspected or confirmed flu who are at higher risk for complications including children younger than 2 years old. Children 2 years to 4 years old are more likely to require hospitalization or urgent medical evaluation for flu compared with older children, although the risk is much lower than for children younger than 2 years old. Children aged 2 years to 4 years without medical conditions that put them at high risk conditions and with mild illness do not necessarily require antiviral treatment.

CDC recommends that early childhood providers encourage sick staff at high risk for flu complications and the families of sick children to seek early treatment. People on antiviral treatment may still shed flu viruses and transmit them to others. If for any reason there is a concern about a child, parent or staff person continuing to take the medicine, they should discuss this with their healthcare provider before making the decision to stop medicine for their child or for themselves. To lessen the chance of spreading flu viruses that are resistant to antiviral medicines, people on antiviral treatment should stay at home and away from others as recommended and practice good respiratory etiquette and hand hygiene even after their fever has resolved.

Visit: http://www.cdc.gov/h1n1flu/recommendations.htm for more information on antiviral medicines.

• Consider selective early childhood program closures:

Consider selectively closing early childhood programs if flu transmission is high in the community.  Because children less than 5 years of age are a group at higher risk for flu complications, some communities may consider temporarily closing some early childhood programs with the goal of reducing the spread of flu among these children. The decision to selectively close an early childhood program or part of a program (for example, the infant room) should be made locally and should balance the risks of keeping the children in the program with the social and economic disruption that can result from closing early childhood programs. Early childhood officials should work closely with their local and state public health officials when deciding whether or not to selectively close an early childhood program or part of a program. Additional considerations about early childhood program closures are provided in the next section.

Recommended strategies to add in the event of increased severity compared to April through December 2009 of the 2009 H1N1 flu outbreak CDC may recommend additional strategies to help decrease the spread of flu if global, national, or regional assessments indicate that flu is causing more severe disease. In addition, state and local health officials may choose to use additional strategies. Although the following strategies have not been scientifically tested in early childhood settings, they are grounded on basic principles of infection control. Implementation of these strategies is likely to be more difficult and to have more disruptive effects than the previously described strategies. These strategies should be considered if flu severity increases and are meant for use in addition to the strategies outlined above.

• Permit staff at higher risk for flu complications to stay home:

If flu severity increases, staff at higher risk for flu complications (for example, pregnant women or people with medical conditions that put them at high risk for flu complications) may consider staying home while flu transmission is high in their community. Such people should make this decision after consulting with their healthcare provider. People who elect to stay home should also attempt to decrease their exposure in other ways – for example, by avoiding large public gatherings.

Pregnant women are at higher risk for flu complications from 2009 H1N1 flu and may choose to withdraw their children from early childhood programs or to refrain from working as early childhood providers if flu severity increases. In addition, early childhood program staff with family members who are at higher risk for flu complications should consult with their healthcare providers about whether they should refrain from working as early childhood providers during this period.   

• Increase social distances between children in the early childhood environment:

If flu severity increases, early childhood providers should explore innovative methods for increasing social distances or separating children into small groups (without allowing the children to mix between groups) within the early childhood environment. This is not a simple or easy strategy for many early childhood programs, especially home-based programs. Implementing any of the following options would require considerable flexibility. Early childhood programs may wish to consider the following options:

• Avoiding bringing groups of children from different classes together.
• Keeping caregivers with their same class and minimize reassignments so teachers and children are kept as a cohort and to reduce contact between classes.
• Postponing trips that bring children together from multiple classrooms in large, densely packed groups.
• Conducting activities outdoors.
• Dividing classes into smaller groups for example, group with 6 or fewer children.
• Moving indoor play areas farther apart.
• Moving groups to larger spaces, when available, to allow more space between children.

• Advise children with sick household members to stay home:

If flu severity increases, children who live with people with flu-like illness should remain home for 5 days from the day the first household member became 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 sick 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 flu-like illness during the first 5 days of illness of the first sick household member, the recommendations for exclusion of people with flu-like illness should be implemented for this person. However, the 5-day period does not need to start again for other well children in the household.

• Extend the exclusion period:

If flu severity increases, people with flu-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 sick should continue to stay home until at least 24 hours after symptoms have resolved. This recommendation is based on data for seasonal flu infection indicating that flu virus shedding generally lasts for 5 to 7 days after symptom onset, but can be longer in young children or among people with weakened immune systems. A longer period of exclusion also may be considered on the basis of setting and population-specific characteristics. Visit: http://www.cdc.gov/h1n1flu/guidance_homecare.htm for more information on caring for sick people in the home.

• Consider early childhood program closures:

If flu severity increases, CDC recommends that communities review and prepare to implement their early childhood program closure plans according to the guidelines outlined below. Early childhood and health officials should balance the risks for flu transmission in their community with the disruption that early childhood program closures would cause. Early childhood providers should work closely and directly with their local and state public health officials to make sound decisions on the basis of local conditions, and to implement strategies in a coordinated manner.

When communities choose to close early childhood programs, early childhood and public health officials should clearly tell parents and their communities the reason for closing these programs.

Reactive closure might be appropriate for the following reasons: when early childhood programs are experiencing excessive absenteeism among children or staff; when a large number of sick children are being sent home each day; or for other reasons that decrease the ability of the early childhood program to function. Early childhood programs provided by few providers will be more susceptible to reactive closures because illness in a single provider could make the early childhood program inoperable. 

Preemptive closures may be considered to decrease the spread of flu virus among children and early childhood program staff, and in the larger community. If global or national risk assessments indicate an increased level of severity compared with April through December 2009 of the 2009 H1N1 flu outbreak, CDC might recommend closing early childhood programs. CDC does not believe any additional disinfection of environmental surfaces beyond routine cleaning is required while an early childhood program is closed.

Early childhood program closure is likely to be more effective at decreasing the spread of flu 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 gatherings). Cancellation or postponement of community events is a decision for event organizers, local public health officials and other government agencies to make and should be part of a coordinated community process.

Visit http://www.cdc.gov/h1n1flu/vaccination for more information on the 2009 H1N1 flu vaccination. If transmission in the community occurs before vaccine-induced immunity, communities whose goal is to substantially reduce flu transmission among children in early childhood may consider temporarily closing early childhood programs. Infant rooms may need to close longer, as infants under age 6 months cannot receive flu vaccine.

• Resuming early childhood programs after closure:

The length of time an early childhood program should be closed will vary depending on the type of early childhood program closure and the severity and extent of illness. When the decision is made to close an early childhood program, CDC recommends doing so for 5–7 calendar days. Reactive early childhood program closures are likely to be of shorter duration than selective or preemptive closures.

On a regular basis (for example, weekly), public health authorities in jurisdictions where early childhood programs have closed should reassess the epidemiology of the disease, the benefits of keeping children home, and the societal repercussions of closing these programs. On the basis of this reassessment, public health authorities, in consultation with early childhood providers, may decide to extend the early childhood program closure or to reopen them. In the event that CDC recommends preemptive early childhood program closure, this recommendation also might include a modification to the suggested length of closure, on the basis of the severity observed across the nation and globally. Therefore, early childhood providers may have to plan for more prolonged periods of closure.

• Reducing adverse effects from early childhood program closure:

As part of a community planning process, early childhood program closure plans should address possible secondary effects on the community. Plans should be developed and communicated to all community members affected by early childhood program closure. Preparing to address these secondary effects may increase acceptability and participation in early childhood program closure.

Early childhood program closure may:
• Affect critical infrastructure
• Adversely affect parents’ job security
• Cause income loss for parents and early childhood providers
• Cause long-term loss of early childhood programs
• Reduce early childhood program quality by forcing experienced staff into other jobs
• Cause deterioration in child nutrition from the loss of access to the meals program in early childhood programs
• Decrease educational progress of the children enrolled in early childhood programs, and
• Decrease child safety from possibly increased use of unregulated and marginal child care by parents unable to find or afford quality care

Parents should start thinking about options for alternate child care in case their usual programs are closed because these closure decisions may be made very quickly. Alternate arrangements include care by relatives, neighbors, co-workers, friends, or making accommodations to work settings to allow for parents to work from home, if possible, or to have different working hours to allow for parents to care for the children at home.

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.

• Early childhood programs should:
• Work with state and local public health and education agencies to decide which strategies to implement and when, to collect and share data on absenteeism, and to disseminate emerging guidance.
• Encourage the routine use of a qualified early childhood health consultant – a licensed health professional such as a nurse with experience working on health issues in out-of-home child care.
• Encourage vaccination against seasonal flu and the 2009 H1N1 flu.
• Examine and revise as necessary current crisis or pandemic plans and procedures, including updating parental contact information and communicating plans to parents.
• Examine and revise as necessary the current sick leave policy for staff to allow them to stay home when sick.
• Encourage parents to develop backup alternate child care plans if a severe flu outbreak causes dismissal of the early childhood program.  
• Serve as a resource for families to help them understand:
• The signs and symptoms of flu.
• The risks associated with flu and the strategies they can use to decrease their risk.
• What families can do to decrease the spread of the flu virus and their role in keeping early childhood programs open.
• Other resources in their community that might be able to provide assistance in addressing the secondary effects of early childhood program closures.
• Who should receive the seasonal flu and 2009 H1N1 flu vaccines and how to get them.
• It is important for parents to be responsible for keeping sick children at home, practicing respiratory etiquette and hand hygiene, teaching and monitoring children’s respiratory etiquette and hand hygiene, and planning in advance for alternate child care placement in the event that their usual program must close or limit the number of children.
• Early childhood program staff should stay at home when sick, practice respiratory etiquette and hand hygiene, and teach and monitor children’s respiratory etiquette and hand hygiene when possible.
• Early childhood program administrators need to establish alternate staffing plans to provide care while staff are absent from work.
• Private sector support is essential for working parents and guardians who need to stay home to care for a sick child or to find alternate child care if their usual early childhood program closes, even temporarily. The economic impact of early childhood program closure can have serious effects throughout the community and local economy. 
• Community-based organizations can provide crucial support to families by providing meals, transportation, and possibly alternate child care sites for small groups of children (for example, groups of 6 or fewer children). They may also be able to provide other services to ease the burden of early childhood program closure.

Determining community approaches to protecting children and staff in early childhood programs

To decrease exposure of children and early childhood providers to the flu virus, CDC recommends a combination of targeted, layered strategies applied early and simultaneously on the basis of 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 early childhood and public health agencies, parents, healthcare providers, and the community.

CDC and its partners will continuously look for changes in the severity of flu and will share what is learned with state and local agencies. States and local communities can expect to see significant variability in disease burden across the country.

Every community has to balance a variety of objectives to determine the best course of action to help decrease the spread of flu. 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 among children and staff in early childhood programs; and (c) protecting people with higher risk conditions. Some strategies can have negative consequences in addition to their potential benefits. The following questions can help begin discussions and lead to decisions at the community or state level.

Decision-makers and stakeholders

In your community, 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. States and localities also have early childhood licensing agencies, Child Care Administrators, and Head Start Collaboration Directors. Direct involvement of governors, mayors, public health officials, education administrators, and early childhood business owners and administrators may be needed.
• Identify the stakeholders. Stakeholders will vary from community to community but may include parent representatives, local businesses, corporate early childhood program officers, center-based and home-based program owners and operators, early childhood staff, healthcare providers, hospitals, community organizations, and local resource and referral agencies.

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 public health officials, healthcare providers, and early childhood administrators? Does this include frequent information sharing?
• Do you regularly review your crisis and pandemic plans? Do you revise them as needed?
• Are community members engaged in making decisions regarding health and safety?

Information collection and sharing

Can local or state health officials determine, interpret, and share information with other local or state decision-makers about the following?

• Does the local or state government have a designated early childhood health consultant who can coordinate communication about flu?
• What is the severity and extent of spread of the disease in the state or locality? How many people are making outpatient visits for flu-like illness? How many people are being hospitalized for flu-like illness? Are the numbers of hospitalizations or deaths increasing? What percent of these hospitalized patients require admission to intensive care units? How many flu deaths have occurred in the community? Are some groups becoming sick, or more severely sick, than others?
• How busy are local healthcare providers and emergency departments? How many visits are they getting for flu-like illness? Are they able to meet the increased demand for care from people with flu-like illness? Are local healthcare providers or emergency departments becoming overburdened?
• Are the hospital and intensive care unit (ICU) beds full with flu 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 healthcare workers due to flu-like illness in themselves or their family members?
• Is there enough antiviral medicine in the community to treat sick patients at higher risk for flu complications?

Can early childhood program providers collect and share information with state or local decision makers about the following?

• How many children and staff are absent due to flu-like illness?
• How many children with flu-like illness symptoms are being sent home every day?

Feasibility

Does the state or community 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 strategies 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, children, and families need to take and the reasons for recommendations?

Acceptability

Has the state or community determined how to address the following challenges to implementing the strategies?

• How are public concerns affecting the community? What can you do to empower personal responsibility for protective actions?
• Will the community support the strategies under consideration? What can you do to increase support?
• What secondary effects (e.g., impaired child nutrition, job security, financial support, health service access, and educational progress) might result from the strategies under consideration? Can you get the message out to businesses and employers that they need to have flexible leave policies that align with public health recommendations?
• Can these secondary effects be mitigated? Which community entities and organizations can help reduce the secondary effects?
• What can be done to increase community acceptance?