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

February 17, 2010 1:00 PM ET

How does CDC’s new flu guidance for schools differ from the previous school guidance documents?

The new guidance applies to any flu virus circulating during the 2009-2010 school year, not only 2009 H1N1 flu. The new guidance recognizes the need to balance the risks of illness among students and staff with the benefits of keeping students in school. It offers specific steps for school staff, parents, and students to take given the current flu conditions as well as for more severe flu conditions. The new guidance also provides information for making decisions at the community level about when to use these strategies aimed at schools.
In addition, this guidance recommends that, based on current flu conditions, students and staff with flu-like illness stay home until at least 24 hours after they no longer have a fever or signs of a fever. This should be determined without the use of fever-reducing medicines (any medicine that contains ibuprofen or acetaminophen). This is a shorter time period from the previous guidance which recommended that sick students and staff stay home 7 days after symptoms begin. The 7 day period away from school for sick students and staff would still be recommended under more severe flu conditions.  In addition, this longer period should be used in healthcare settings and in any place where a high number of high-risk people may be exposed, such as childcare facilities for children younger than 5 years of age.

Why should we be concerned about the spread of flu in schools?

Students can get sick with flu and schools may act as a point of spread, where students can easily spread flu to other students and their families. So far, with 2009 H1N1 flu, the largest number of cases has been in people between the ages of 5 and 24-years-old.

Which students and staff are at higher risk for complications from flu?

Anyone can get the flu (even healthy people), and serious problems from the flu can happen at any age. However, 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 system due to disease or medication; and people younger than 19 years of age who are receiving long-term aspirin therapy are more likely to get complications from the flu. See CDC's information on people at higher risk for flu complications.

How will schools and communities decide what steps to take?

CDC and other public health agencies will be monitoring national data on the number of people who seek care for flu-like illness, as well as the number of hospitalizations and deaths. CDC will also look at the geographic spread of flu-like illness and will look for changes in the characteristics of the virus. By comparing data on a weekly basis with seasonal flu trends and trends from the 2009 H1N1 flu from April through December 2009, CDC will be able to provide advice to state and local agencies on appropriate steps to take. States and local communities can expect the impact of flu in their communities to be different from that seen in other parts of the country. States, communities, and schools should consider:

• who needs to be involved in the decision-making process and include those people in regular communications,
• the severity of flu and the impact in the community and in the schools, and
• the goals, feasibility, and community’s acceptability of the action steps being considered.

What can families, students, and school personnel do to keep from getting sick and spreading flu?

Families, students, and school staff can keep from getting sick with flu in three ways:

• Practicing good hand hygiene. Students and staff members should wash their hands often with soap and water, especially after coughing or sneezing. Alcohol-based hand rubs are also useful.
• Cover your mouth and nose when you cough or sneeze.  The main way that the flu spreads is from person to person in the droplets produced by coughs and sneezes, so it’s important to cover your mouth and nose with a tissue when you cough or sneeze.  If you don’t have a tissue, cough or sneeze into your elbow or shoulder, not into your hands.
• Staying home if you’re sick. Keeping sick students at home means that they keep their viruses to themselves rather than sharing them with others.

Students, staff, and their families must take personal responsibility for helping to slow the spread of the virus by practicing these steps to keep from getting sick with flu and protecting others from getting the flu.

What is the best way to practice good hand hygiene?

• Washing your hands with soap and water for at least 20 seconds (the time it takes to sing “Happy Birthday” twice) is the best way to keep your hands from spreading the virus.
• Alcohol-based hand rubs containing at least 60% alcohol are also useful.
• If soap and water are not available and alcohol-based products are not allowed in the school, other hand rubs that do not contain alcohol may be useful for cleaning hands. However, they may not be as useful as alcohol-based rubs.

What steps can schools take to keep students and staff from getting sick?

Schools should take the following steps to help keep students and staff from getting sick with flu. These steps should be followed ALL the time, and not only during a flu pandemic.

• Encourage respiratory etiquette by providing staff and students
• education and reminders about covering coughs and sneezes, and
• easy access to tissues and running water and soap or alcohol-based hand rubs.
• Remind staff and students to practice good handwashing and provide the time and supplies for students and staff to wash their hands when needed.
• Send sick students and staff home. Advise students, staff, and families that sick people should stay at home until at least 24 hours after they no longer have a fever or signs of a fever. This should be determined without the use of fever-reducing medicines (any medicine that contains ibuprofen or acetaminophen). They should stay home until at least 24 hours after they no longer have a fever even if they are using antiviral medicines.  Schools should revise their policies and incentives to avoid unknowingly penalizing students who stay home when they are sick (e.g., perfect attendance awards).
• Clean surfaces and items that are more likely to have frequent hand contact with cleaning agents that are usually used in these areas. Additional disinfection beyond routine cleaning is not recommended. Some states and localities have laws about specific cleaning products used in schools.  School officials should contact their state health department and department of environmental protection for additional guidance.
• Move students and staff who become sick at school to a separate room until they can be sent home. Limit the number of staff who take care of the sick person and provide a surgical mask for the sick person to wear if they can tolerate it.
• Have Personal Protective Equipment (PPE) such as masks available and ensure it is worn by school nurses and other staff caring for sick people at school.
• Encourage sick students and staff at higher risk of complications from flu to get a medical evaluation as soon as possible. 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 the 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.
• Consider dismissing students if a large proportion of staff are at higher risk of flu-related complications.  This strategy would be applicable to very few schools nationwide.  Settings where this strategy might be appropriate are in schools for pregnant women and schools with many medically fragile children.

What should I do if I’m pregnant and I work or attend a K-12 school?

Pregnant women working in or attending schools should follow the same guidance as the general public about staying home when sick, handwashing, cover your mouth or nose when you cough or sneeze, and routine cleaning.  Pregnant women are at higher risk of complications from flu and should speak with their health care provider as soon as possible if they develop a flu-like illness to find out whether they should take antiviral flu medicines. Any person at high risk for flu complications should do the same. Early treatment with antiviral flu medicines is recommended for pregnant women who have the flu. Pregnant women and their health care providers should know that they are part of the first priority group to receive the 2009 H1N1 flu vaccine.

What are fever-reducing medicines and when would I stop giving them to my child?

Fever-reducing medicines are medicines that contain acetaminophen (such as Tylenol) or ibuprofen (such as Motrin). These medicines can be given to people who are sick with flu to help bring their fever down and relieve their pain. 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.
A sick student can return to school after 24 hours have passed with a normal temperature (98.6 degrees Fahrenheit or 37 degrees Celsius) without the use of fever-reducing medicines. As the sick person begins to feel better you may decide to stop giving fever-reducing medicines. Continue to monitor their temperature until the temperature has been normal for 24 hours.

Can the virus live on surfaces, such as computer keyboards?

• Yes, flu viruses may be spread when a person touches droplets left by coughs and sneezes on hard surfaces (such as desks or door knobs) or objects (such as keyboards or pens) and then touches his or her mouth or nose. However, it is not necessary to disinfect these surfaces beyond routine cleaning.
• Clean surfaces and items that are more likely to have frequent hand contact with cleaning agents that are usually used in these areas. Some states and localities have laws about specific cleaning products used in schools.  School officials should contact their state health department and department of environmental protection for additional guidance.

How do I recognize a fever or signs of a fever?

A fever is a temperature taken with a thermometer that is equal to or greater than 100 degrees Fahrenheit (37.8 degrees Celsius). If you are not able to measure a temperature, the sick person might have a fever if he or she

• feels warm,
• has a flushed appearance, or
• is sweating or shivering.
  

How long should a sick student or staff member be kept home?

In the current flu conditions, students and staff with symptoms of flu should stay home for at least 24 hours after they no longer have fever or do not feel feverish, without the use of fever-reducing medicines.  If the flu conditions become more severe, CDC recommends that a sick person stay home for 7 days. A person who is still sick after 7 days should stay home until 24 hours after the symptoms have gone away.  In addition, this longer period should be used in healthcare settings and in any place where a high number of high-risk people may be exposed, such as childcare facilities for children less than 5 years of age.
Sick people should stay at home, except to go to the health care provider’s office, and should avoid contact with others. Keeping people with a fever at home may reduce the number of people who get infected. Because high temperatures are linked with higher amounts of virus, people with a fever may be more contagious.

Should our K-12 school require a note from a health care provider to allow children who have been ill to return to the class?

No, a note from a doctor’s office or health care provider should not be required. Health care facilities may be very busy during flu season and it will be hard to provide these notes. Under current flu conditions, if a child has symptoms of flu they should stay home until they are free of fever (100 degrees Fahrenheit or 37.8 degrees Celsius measured by mouth) for at least 24 hours, without use of fever-reducing medicines. This is usually about 3 to 5 days.

Why didn’t my school send home a letter that there was a case of H1N1?

The CDC does not recommend notifying parents or sending home a letter when one or more children in a school have H1N1. Though we recognize this is something many parents want to know, unless this is something that a school does routinely every flu season, there is no reason to do so now. 
Schools in communities experiencing a flu outbreak should, in coordination with their state or local health and education agencies, send home information on the importance of staying home when sick and ways to reduce the spread of flu. The "Preparing for the Flu: A Communication Toolkit for Schools (Grades K-12)" includes fact sheets on actions parents can take to help protect their child from the flu as well as template letters schools can send to parents regarding steps schools are taking during current or more severe flu conditions.

Should family members of sick students stay home too?

Not unless the flu conditions are determined to be more severe. If flu conditions are more severe, school-aged children should also stay home for 5 days from the time someone in their home became sick. It is possible that family members could already be sick with flu and not be showing symptoms yet. The 5-day period provides enough time to know if anyone else is sick with flu. Parents should continue to monitor their health and the health of the sick child, as well as the health of their other children.

What additional steps should schools and families take to keep students and staff from getting sick in the event that the flu is more severe?

In addition to the steps that schools should be taking all the time, if flu conditions become more severe, schools and families should consider adding the following steps.

• Extend the time sick students or staff stay home to at least 7 days, even if they feel better sooner. People who are still sick after 7 days should continue to stay home until at least 24 hours after symptoms have gone away.
• Schools should allow high risk students and staff to stay home.  These students and staff should make this decision in consultation with their health care provider.
• Schools should conduct active symptom screening of students and staff upon arrival at school. Any sick students or staff should be separated from others, offered a surgical mask, and sent home.
• If a household member is sick, parents should keep any school-aged children home for 5 days from the time the first person in the home became sick. Parents should monitor the health of their other children for fever and other symptoms of the flu.
• Schools should find ways to increase social distances (the space between people) at school if possible.
• Schools should work closely with their county and state public health officials to decide how and when to dismiss students. If the decision is made to dismiss students, schools should notify public health and education agencies by submitting a report about the dismissal. Students should be dismissed for 5 to 7 days and near the end of this period, communities should reassess to determine if students can return to school.

What can schools do to increase social distance during a more severe flu outbreak?

School officials should think creatively about ways to increase the space between people, but still keep students in school. Not everything will be feasible for all communities, but it is important to consider some options for social distancing if schools are going to remain open. Some options are―

• rotating teachers between classrooms while keeping the same group of students in one classroom,
• canceling classes that bring students together from multiple classrooms,
• holding classes outdoors,
• postponing class trips,
• discouraging use of school buses and public transit,
• dividing classes into smaller groups,
• moving desks farther apart, and
• moving classes to larger spaces to allow more space between students.

What is the difference between a school dismissal and school closure?

A school closure means closing the school and sending all the students and staff home. In a school dismissal, the school may stay open for staff while the children stay home.

Keeping school facilities open allows teachers to develop and deliver lessons and materials and other staff to continue to provide important services.

What are the different types of school dismissals?

There are three types of school dismissals:

• Selective dismissal is used when all or most students in the school are at higher risk for complications once infected with flu. For example, a school for medically fragile children or for pregnant students may decide to close based on the local conditions while other schools in the community may remain open.
• Reactive dismissal is used when many students and staff are sick and are not attending school, or many students and staff are arriving at school sick and are being sent home.
• Preemptive dismissal is used early during a flu response in a community to decrease the spread of the flu before many students and staff get sick. This is based on information about the spread of severe flu in the region. This dismissal is most effective at decreasing flu spread and burden on the healthcare system when done early in relation to the amount of flu activity in the area.

No matter what type of school dismissal is chosen, all school-related mass gatherings should be canceled or postponed in order to decrease the spread of flu among students, their families and staff. This includes sporting events, school dances, performances, rallies, commencement ceremonies, and other events that bring large groups of people into close contact with one another.

What is a medically fragile child?

For this guidance, a medically fragile child is a child who needs intensive, life sustaining medical assistance or therapy, and needs assistance with daily living (for example, a child who uses an oxygen tank, has trouble moving, is fed through a tube, needs suctioning, or is on a ventilator).  Many of these children need skilled nursing care and special medical equipment.  These medically fragile children may have chronic lung disease, severe cerebral palsy, muscular dystrophy, immunodeficiency, or problems with their metabolism.

How will the decision be made to dismiss schools?

The decision to dismiss students will be made at the community level. School officials should work closely with their local and state public health and government officials to make sound decisions, based on local conditions. The decision should consider

• the number and severity of cases in an outbreak (looking at national, regional, and local data),
• the risks of flu spread and benefits of dismissal,
• the problems that school dismissal can cause for families and communities, and
• different types of dismissal (selective, reactive, and preemptive).

CDC may recommend preemptive dismissals based on information that the outbreak is becoming more severe.  An increase in flu spread without an impact on disease outcomes will not lead to the use of preemptive dismissals in most cases.

How will communities know if the flu is more severe and that they need to consider taking additional action steps?

CDC and other public health agencies will be monitoring national data on the number of people who seek care for flu-like illness, as well as the number of hospitalizations and deaths. CDC will also look at the geographic spread of flu-like illness and will look for changes in the virus.  In addition, CDC will compare data on a weekly basis with seasonal flu trends from other years and with data collected during the from April through December 2009 outbreak. State and local health departments will also be on the lookout for increases in severe illness in their areas.

How long will schools have to stay dismissed?

The length of time school should be dismissed will vary depending on how severe the flu is and how many people are sick. Near the end of this period, communities should reassess the severity and impact of the flu, the benefits of keeping students home, and the consequences of doing so.  Based on this reassessment, communities can decide whether to extend the school dismissal for another week or to reopen the school.  However, if a flu outbreak is determined to be severe, a longer time period may be recommended.

Why would one school dismiss students and another school continue to remain open?

School action steps should vary based on the severity of the pandemic and the impact it is having in the school. Decisions for school dismissal will be made at the community level, based on the number and severity of cases in the school and community. Because the impact of flu on a community will differ from location to location, the steps that are taken will also be different.
Also, certain schools may have a large number of students who are at high risk for complications from the flu (such as a school for pregnant teens). These schools may decide to close based on the local conditions while other schools in the community remain open. 

What can a parent do to prepare for flu during the 2009-2010 school year?

• Plan for child care at home if your child gets sick or their school is dismissed (for a minimum of 5 school days).
• Plan to monitor the health of the sick child and any other children by checking for fever and other symptoms of flu.
• Update emergency contact lists.
• Identify a separate room in the house for care of sick family members. Consider designating a single person as the main caregiver for anyone who gets sick.
• Pull together games, books, DVDs and other items to keep your family entertained while at home.
• Talk to your school about their flu pandemic or emergency plan.
• Get your family vaccinated for seasonal flu and 2009 H1N1 flu.

What can a school do to prepare for flu response during the 2009-2010 school year?

• Review and revise existing pandemic plans and focus on protecting high risk students and staff.
• Update student and staff contact information as well as emergency contact lists.
• Identify and establish a point of contact with the local public health agency.
• Develop a plan to cover key positions, such as the school nurse, when staff stay home because they are sick.
• Set up a separate room (a sick room) for care of sick students or staff until they can be sent home.
• Purchase Personal Protective Equipment (PPE) such as masks for nurses and other staff providing care for sick people at school. Provide training for this staff about basic infection control and the use of PPE.
• Develop an education campaign to encourage hand hygiene and respiratory etiquette.
• Develop communication tools (e.g., letters to parents) that can be used to send sick students home, dismiss students, help families identify students who are at high-risk of complications from flu, help staff members self-identify who is at high risk of complications from flu, or cancel mass gatherings. Remind parents and staff how long sick students and staff should remain at home.
• Identify ways to increase social distance (the space between people).
• Review school policies and awards to encourage social distancing and avoiding any incentives for people or staff to go to school when they are sick (e.g., cancel perfect attendance awards).
• Develop a school dismissal plan and options for how school work can be continued at home (e.g., homework packets, web-based lessons, phone calls), if school is dismissed or students are sent home when sick. Communicate this plan to all community members who would be affected.
• Collaborate with the local health department, community organizations, local businesses, and social services on a plan for response.
• Help families and communities understand the important roles they can play in reducing the spread of flu in schools.

What can local businesses do to help families and schools during a flu response?

Local business support is essential. If employees are not able to stay home when a child is sick without losing pay or losing their job, it will be even more difficult for families and schools to follow these school-based public health steps and ensure appropriate care for their children at home.  Businesses and employers should offer flexible leave policies that support public health steps to decrease the spread of flu.  Employers should explore telework alternatives when possible given the nature of the business.  Telework refers to activity of working away from the usual workplace (often at home) through telecommunications or other remote access means (e.g., computer, telephone).

What can community- and faith-based organizations do to help families and schools during a flu response?

Community-based and faith-based service organizations can help teach their members about how to stay healthy. They also can offer support to families by providing meals, transportation, and other services to make it easier to stay home if a family member is sick or school is dismissed.

How does CDC’s Guidance for School Response apply to my child at boarding school?

This guidance only applies to nonresidential K-12 schools.  If you would like to learn more about what to do if your child lives away at school, please see CDC’s Guidance on Day and Residential Camps. More information about residential students is available in the Guidance for Institutions of Higher Education. Continue to monitor CDC’s website for information about flu. CDC will continue to update the website and guidance recommendations as more is learned about the 2009 H1N1 flu or flu conditions change.

How does CDC’s Guidance for School Response apply to my child at college?

This guidance only applies to K-12 schools.  If you would like to learn more about what to do if your child is in a college or university, please visit the Guidance for Institutions of Higher Education. Continue to monitor CDC’s website for information about flu. CDC will continue to update the website and guidance recommendations as more is learned about the 2009 H1N1 flu or flu conditions change.