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 Year

February 22, 2010 3:00 PM EDT

CDC has released guidance to help decrease the spread of influenza (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 April through December 2009 of the 2009 H1N1  flu  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 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, “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 are addressed in separate documents. 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 includes a more in depth explanation of the strategies presented in the CDC Guidance for School (K-12) Responses to Influenza During the 2009-2010 School Year and gives 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 learning that goes on in schools.

BACKGROUND

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 educating 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 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. Education agencies and schools may dismiss students for reasons not related to public health goals, for example, when they are not able to maintain normal functioning because of very high student or staff absenteeism. Still, although flu is unpredictable, more communities may be affected, reflecting wider transmission. The overall impact of 2009 H1N1 should be greater during April through December 2009 and school dismissals may be warranted, depending on the disease burden and other conditions.

The purpose of this document is to provide updated guidance for reducing the spread of flu in schools. 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. CDC will continue to monitor the spread of flu, the severity of the illness it is causing, and whether the virus is changing; CDC will provide periodic updates of these assessments. If this information indicates that flu is causing more severe disease than during April through December 2009 of the 2009 H1N1 flu outbreak, or if other developments might require more aggressive mitigation measures, CDC might recommend preemptive or early school dismissals.

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 SCHOOL (K-12) RESPONSE TO FLU FOR THE 2009–2010 SCHOOL YEAR

The most important things schools can do to reduce the risk of flu is to encourage flu vaccination for all students and those staff who are recommended for vaccination; suggest early treatment for people at higher risk for flu complications; facilitate use of respiratory etiquette and hand hygiene by students and staff; ensure that sick students and adults do not come to the facility; and separate sick and well people as soon as possible. School administrators should frequently remind students, their families, and staff about the importance of these. Educational materials (for example, posters) to enhance compliance with recommendations should be visible in the school setting. Examples of these materials are available at http://www.cdc.h1n1flu/flyers.htm.  Furthermore, Preparing for the Flu: A Communication Toolkit for Schools (K-12) provides many materials for use. 

School administrators should examine and revise, as necessary, their current crisis or pandemic plans and procedures; develop contingency plans to cover key positions when staff are absent from work; update contact information for families and staff; and share their plans with families, staff, and the community. School administrators should review and revise, if necessary, their sick leave policies to remove barriers to staff staying home while sick or to care for a sick family member. A healthcare provider’s note should not be required for students or staff to validate their illness or to return to the school setting.

The recommendations that follow are divided into two groups: 1) recommendations to use now, during this academic year, assuming a similar severity to 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 severity similar 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 initial 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.

All students and some staff will fall within these groups and should be among the first to receive the 2009 H1N1 flu vaccine. Visit http://www.cdc.gov/h1n1flu/vaccination for more information.

• Advise the sick to stay home:

CDC recommends that individuals with flu-like illness remain at home for at least 24 hours after they no longer have a  fever (100° F [37.8° C] or greater when measured orally), or signs of a fever, without the use of fever-reducing medicines.

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 flu and the potential benefits of decreasing transmission through the exclusion of sick people with the goal of minimizing social disruption.

Decisions about extending the exclusion period should be made at the community level, in conjunction with local and state health officials. More stringent guidelines and longer periods of exclusion – for example, until complete resolution of symptoms – may be considered for people returning to settings where high numbers of people at higher risk for flu complications 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. However, people may be infected with the flu, including 2009 H1N1 flu and have respiratory symptoms without 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 flu virus. CDC recommends this exclusion period whether or not antiviral medicines are used. People on antiviral treatment may shed flu viruses that are resistant to antiviral medicines.  

Many people with flu illness will continue shedding flu virus 24 hours after their fevers go away, but at lower levels than during their fever. Shedding of flu virus, as detected in laboratory tests, can be detected for 10 days or more in some cases. Therefore, when people who have had flu-like illness return to school they should continue to practice good respiratory etiquette and hand hygiene and avoid close contact with people they know to be at higher risk for flu complications.

Because some people may shed flu virus before they feel sick, and because some people with flu will not have a fever, it is important that all people cover their cough and wash hands often. To lessen the chance of spreading flu viruses that are resistant to antiviral medicines, adherence to good respiratory etiquette and hand hygiene is as important for people taking antiviral medicines as it is for others.

Fever-reducing medicines, that is, medicines containing acetaminophen or ibuprofen, are appropriate for use in individuals with flu-like illness. Aspirin (acetylsalicylic acid) should not be given to children or teenagers who have flu; 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 sick person’s temperature first remained normal without the use of these medicines.

Visit: http://www.cdc.gov/h1n1flu/guidance_homecare.htm for more information on caring for sick people in the home.

• Separate sick students and staff:

Sick students and staff should always be required to stay home. CDC recommends that students and staff who appear to have a flu-like illness at arrival or become sick during the day be promptly separated from other students and staff and asked to go home immediately. Schools should regularly update contact information for parents so that they can be contacted more easily if they need to pick up their sick child. Recognizing that space is often in short supply, early planning on the location for a sick room is essential. This room should not be one commonly used for 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. Sick people should be placed in well ventilated areas and placed in areas where at least 6 feet of distance can be maintained between the sick person and others.

CDC recommends people with known, probable, or suspected flu or flu-like illness to use a facemask if available and tolerable, or otherwise to cover their noses and mouths with a tissue when coughing or sneezing (or an elbow or shoulder if no tissue is available). A limited number of staff should be designated to care for sick people until they are able to go home. When possible, these should be people with limited interactions with other students and staff and therefore decreased risk of spreading flu. These people should not be at higher risk for flu complications (for example, pregnant women) and they should be familiar with infection control recommendations to prevent spread of flu. School nurses, and other staff who act in this capacity, are likely to come into close contact with students and staff with flu-like illness. CDC recommends that staff who provide care for people with known, probable or suspected flu or flu-like illness use appropriate personal protective equipment.
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.

• Discourage attendance at school events by sick people:

Events such as school assemblies and sporting events that bring large groups together may pose a high risk of exposure and transmission of flu. Use a variety of communication methods such as sending a letter home with students or email to discourage those with flu-like illness who may come to watch these events, such as family friends or relatives, from attending these events until they have been free of fever for at least 24 hours without the use of fever-reducing medicines. Explore ways to modify events to reduce close contact and increase distances between participants. Schools may need to consider cancelling or postponing some events if modification is not possible and there is a high level of flu activity in the community.

• Emphasize respiratory etiquette:

Flu 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 mouth and nose 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 elbow or shoulder (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: http://www.cdc.gov/flu/protect/covercough.htm for more information on respiratory etiquette.

• Promote hand hygiene:

Flu may spread via contaminated hands or inanimate objects that become contaminated with flu viruses. CDC recommends that students and staff be encouraged to wash their hands often with soap and water, especially after coughing or sneezing. 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.

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 and paper towels are critical for proper handwashing and should be readily available in schools. If it is necessary to provide supervision to students as they wash hands in restrooms, schools should consider timing and staffing. Schools also should educate families, students and staff about the importance of good hand hygiene and proper methods for cleaning hands.

Visit: www.cdc.gov/cleanhands for more information on hand hygiene.

• Perform routine environmental cleaning:

Schools should regularly clean all areas and items that are more likely to have frequent hand contact and also clean these areas immediately when visibly soiled. Use the cleaning agents that are usually used in these areas. CDC does not believe any additional disinfection of environmental surfaces beyond the recommended routine cleaning is required.

Promote routine cleaning of frequently touched surfaces, and ensure adequate supplies of soap and paper towels. Provide no-touch wastebaskets and empty them frequently. Establish regular schedules for frequent cleaning of high-touch surfaces:

• Doorknobs and handrails
• Desks, tables, chairs
• Counters and surfaces in cafeterias, meeting rooms, and offices

Provide disposable wipes so that commonly used surfaces (for example, keyboards and headphones) can be wiped down by students before each use.

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 guidance. 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 training 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.

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

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

People at higher risk for flu complications who become sick with flu-like illness should speak with 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. Other people may also be treated with antiviral drugs by their doctor this season. CDC recommends that schools encourage sick staff and parents of sick students at higher risk for flu complications to seek early treatment.

Students and staff at higher risk for flu complications who have had close contact with others who are sick with a flu-like illness should contact their healthcare provider to discuss whether they may need to take antiviral medicines.

People on antiviral treatment may still shed flu viruses and therefore may still transmit the virus to others. These flu viruses may develop resistance to antiviral medicines. 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 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 higher risk for flu complications (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 students. 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 higher risk for flu complications. Information on reactive and preemptive school dismissals is provided in the next section.

Recommended strategies to add in the event of increased flu severity compared to April through December 2009 of the 2009 H1N1 flu outbreak

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 April through December 2009 of the 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, healthcare system capacity, and feasibility and acceptability of the strategies under consideration. The strategies that 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. However, CDC would like communities to have tools to use that may be the right measures for their community and circumstances. 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.

• Conduct active screening for illness:

If flu 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 flu-like symptoms during the previous 24 hours. Some people with laboratory-confirmed flu do not have a fever. Therefore, absence of fever does not indicate absence of infection. In instances of higher severity, schools should ask people with symptoms of acute respiratory infection (that is, any two of the following: sore throat, cough, runny nose [new and not due to allergies], or fever) to go home. 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 sick. These students and staff should be further screened by the school nurse, or other school-based healthcare worker, by taking their temperature and inquiring further about symptoms. Students and staff who develop symptoms of acute respiratory infection at school should be separated from others until able to go home. When possible and if the sick person can tolerate it, he or she should wear a facemask until able to go home.

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

If flu severity increases, students and staff at higher risk for flu complications may consider staying home from school while flu transmission is high in their community if they, or their families, are concerned about their ability to avoid flu at school. The decision about whether to stay home should be made in consultation with their healthcare 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 accommodations that might be necessary to allow students and staff at higher risk for flu 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.

• Increase social distances within the school environment:

If flu 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 (weather permitting);
• 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.

• Advise students with sick household members stay home:

If flu severity increases, school-aged 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 five-day period does not need to start again for other well children in the household.

• Extend the exclusion period:

If flu severity increases, individuals 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 viral shedding information. flu virus shedding general occurs for 5 to 7 days for seasonal flu infection. This period may be longer for people with 2009 H1N1 flu and among young children and people who are immune-compromised. 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 medicines are used. People on antiviral treatment may shed flu viruses that are resistant to antiviral medicines.

When people who have had flu-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 higher risk for flu complications. To lessen the chance of spreading flu viruses that are resistant to antiviral medicines, adherence to good respiratory etiquette and hand hygiene is as important for people taking antiviral medicines as it is for others.

Visit: http://www.cdc.gov/h1n1flu/guidance_homecare.htm for more information on caring for sick people in the home.

• Consider school dismissals:

In case flu 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 flu in their community with the disruption dismissals will cause in both education 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.

Reactive dismissals might be appropriate when schools are experiencing excessive absenteeism among students or staff, a large number of children are visiting 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 healthcare system.
The decision to dismiss students should be made locally and should balance the goal of reducing the number of people who become seriously sick or die from flu with the goal of minimizing social disruption. School officials are encouraged to work collaboratively and communicate 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 flu virus or to reduce demand on the healthcare system. 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 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 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 of event organizers, local public health officials and other government agencies and should be part of a coordinated community process.

• Resuming classes after a dismissal:

The length of time students should be dismissed from school will vary depending 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 higher risk for flu complications) and preemptive dismissals (to decrease the spread of flu 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 suggested 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 by school dismissal. These might include effects on critical infrastructure, parents’ 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 participation in school dismissal. Parents should plan in advance 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 teleconference 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 www.cdc.gov/FluSchoolDismissal.

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 flu illness, monitor for changes in circulating flu viruses that may confer increased severity of disease, identify promising methods for reducing morbidity and mortality, assist state and local health and education agencies to implement those methods and evaluate their effectiveness, and provide timely updates on new scientific findings as well as additional guidance as the conditions warrant.
• 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.
• 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 protective equipment for staff. This planning is especially important when suppliers 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 community or, where feasible, by providing direct assistance. Schools can communicate with families and the community about what they will do to decrease spreading flu illness; and help families and communities understand the important roles they can play in reducing the spread of flu and keeping schools open.
• Students, staff, and their families must take personal responsibility for staying home when sick, practicing respiratory etiquette and hand hygiene, 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 a sick 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 support to families by educating community members about the importance of staying home when sick, respiratory etiquette, and hand hygiene. 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 flu 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 flu-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 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 in students and school staff; and (c) protecting people at higher risk for flu complications.

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 healthcare 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 business and faith community representatives, teachers, healthcare 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 education 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 flu-like illness? What is the local hospitalization rate 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 being disproportionately affected?
• 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 to treat sick patients at higher risk for flu complications?

Can local education agencies or schools determine and share information about the following?

• What are school absenteeism rates for both students and staff? How many visits are being made to school health offices daily?  How many students and employees with flu-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 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, students, individuals and families need to take and the reasons for recommendations?

Acceptability

Have you 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 (for example, 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 buy-in?