As the 2009-2010 school year begins, the Massachusetts Department of Public Health (DPH) is providing updated guidance for schools concerning H1N1 influenza, seasonal influenza, and influenza-like illness (ILI).  MDPH expects that both seasonal and H1N1 influenza will be circulating in the fall and is preparing for increased number of cases.  The main changes in the guidance since the spring of 2009 are: 1) the importance of early seasonal flu vaccination; 2) the availability of H1N1 influenza vaccine; and 3) the shorter isolation period for those with influenza-like illness (ILI).  The information provided is based on the most recent guidance from the Centers for Disease Control and Prevention (CDC).  Our goal for the new school season is limiting transmission in schools in order to keep schools open and functioning as usual. 

1. Seasonal Influenza Vaccination
As was the case last year, annual seasonal influenza vaccination is recommended for all children aged 6 months through 18 years.  Schools should work closely with local boards of health, community vaccinators, parents, students and healthcare providers to ensure that students are vaccinated.  Seasonal influenza vaccine became available in Massachusetts communities in August of 2009.  It is recommended that communities begin seasonal influenza vaccination as soon as possible after vaccine becomes available.  For more information concerning seasonal influenza vaccination please go to mass.gov/flu and click on “Seasonal Flu.”

2. H1N1 Influenza Vaccination
H1N1 vaccine is expected to be available in October.  Schools will need to work closely with local boards of health, community vaccinators, parents, students and healthcare providers to ensure that students are vaccinated.  While vaccination is recommended for everyone, initial target groups are:

• pregnant women
• household contacts and caregivers of infants less than 6 months of age
• persons aged 6 months – 24 years old
• persons aged 25 – 64 years old with certain health problems that can put them at increased risk for complications (such as heart disease, asthma, diabetes, weakened immune systems, certain muscle and nerve disorders that can lead to breathing or swallowing problems)
• healthcare providers and emergency medical services staff

Most people will need two doses, spaced approximately 3 weeks apart.  The CDC and state health departments will be monitoring very closely for any signs that the H1N1 vaccine is causing unexpected adverse events, and the Vaccine Adverse Event Report System (VAERS) system is in place to report suspect events and investigate rapidly.  More detailed information regarding target groups, allocation and administration of H1N1 vaccine will be distributed widely when the vaccine is available. 

A federal law known as the PREP Act provides protection from liability for anyone involved in any part of a vaccination campaign against H1N1 flu.

3. Control and Surveillance Measures for ALL Schools
The following recommendations are designed to help prevent the spread of ILI in schools and should be followed all the time, not only during a flu outbreak. If the CDC or DPH determine that flu conditions are more severe than the spring 2009 outbreak, additional guidance will be issued.

• Promptly isolate and send home all students or staff who become sick at school with influenza-like illness. 

• Students and staff with flu-like illness should be sent to a separate room, if possible, until they can be sent home.  The ill individuals should wear surgical masks, if possible, and those caring for them should wear masks too.

• All sick students and staff should stay home for at least 24 hours after they no longer have a fever.  This fever-free period must be without the use of fever-reducing medicines, like Motrin (ibuprofen) or Tylenol (acetaminophen).  They should stay home until at least 24 hours after they no longer have a fever even if they are taking antiviral medicines.  Many people can expect to stay home for about 4 days: about 3 days with fever and one more day with no fever and no fever reducing medicines. However, the fever with influenza can last 2-5 days or more, so students and staff should be prepared to stay home as long as it takes to become fever-free for 24 hours.

• Make sure that sick students, teachers and staff stay home.  Inform parents that they should assess children for symptoms of influenza before sending them to school.  ILI symptoms include fever plus cough and/or sore throat.  It may also include other symptoms, such as vomiting or diarrhea.  Distribute the Flu Symptom Checklist to families and ask that parents use it if they are unsure if their child is well enough to go to school.  Distribute it to staff as well. Keeping people with a fever at home will reduce the number of people who get infected.

• Encourage early medical evaluation of high-risk students and staff who have conditions that put them at increased risk of complications from the flu (heart disease, asthma, diabetes, pregnancy, weakened immune systems, and certain muscle and nerve disorders that can lead to breathing or swallowing problems).  Try to identify these individuals now, so they can be promptly referred if they become ill. 

• Monitor absenteeism in students and staff.  School nurses and student health centers should report higher than normal absenteeism or clusters due to influenza-like-illness to your local health department and to the DPH Immunization Program at 617-983-6800.  An epidemiologist is available to provide further guidance on surveillance and outbreak control.

• Otherwise healthy students and staff experiencing mild ILI do not need to seek medical care since this would place a difficult burden on the health care system. Therefore, if a child is out with ILI and has stayed home according to the guidelines above, they do not need a note from their doctor or to have had a flu test in order to return to school. 

• A negative rapid influenza test result can occur even when someone does have influenza (a “false negative”).  Rapid influenza tests, used in some medical offices and emergency rooms, can help in the diagnosis and management of patients with signs and symptoms of influenza.  If they are positive, the likelihood that the patient has influenza is very high.  However, if they are negative, the patient can still have influenza. Therefore, a negative rapid test can not be used to shorten the exclusion period.

• A health care provider’s note recommending a child with ILI return to school does not supersede the public health exclusion guidance. 

4.   Prevention and Education
Schools can act as a point of spread of flu cases, and students can easily spread flu to other students and their families. The primary steps for prevention and decreasing transmission of flu cases are listed below: 
• Make sure all school aged children are vaccinated against both types of flu. 
o Children and staff can get a seasonal flu shot as soon as possible, starting in early September
o Children will be able to get an H1N1 flu shot in October.  The H1N1 flu shot is recommended for everyone, especially:
• pregnant women
• household contacts and caregivers of infants less than 6 months of age
• people aged 6 months to 24 years old
• persons aged 25 – 64 years old with certain health problems that can put them at increased risk for complications (such as heart disease, asthma, diabetes, weakened immune systems, certain muscle and nerve disorders that can lead to breathing or swallowing problems)
• healthcare providers and emergency medical services staff

• Emphasize and remind students and staff about the importance of proper hand washing and cough etiquette in preventing the spread of diseases.  Provide the time and supplies for students and staff to wash their hands when needed. Place hand sanitizer in each classroom to facilitate regular hand hygiene.  Place boxes of tissues in each room.

• Ask teachers or school nurses to demonstrate and teach proper hand washing and cough etiquette in each class, and to explain why it’s important.  Educational materials, posters, etc., are available on the DPH website, www.mass.gov/dph/swineflu. Send hand washing or other flu control educational materials home to parents and ask for their assistance in reinforcing these messages with their children.

• Clean surfaces and items that are more likely to have frequent hand contact (“high touch surfaces”) with your normal cleaning agents according to your routine schedule.  Once respiratory secretions containing the virus dry out, the virus is no longer effectively infectious. Reassure parents and staff that there is no need for special disinfection or decontamination efforts and that the main focus should be on hand washing and cough and respiratory etiquette.

5.   Planning for the Flu Season
• Try to set up a separate room for care of sick students or staff until they can go home.
• Purchase personal protective equipment such as surgical masks for nurses and other staff providing care for sick people at home and train staff about basic infection control.
• Update student and staff contact information as well as emergency contact lists.
• Identify and establish a point of contact with your local board of health.
• Develop a plan to cover key positions, such as the school nurse, when staff stay home when they are sick.
• Review school policies, such as attendance awards criteria, to avoid any incentives for students or staff to go to school when sick and to encourage social distancing.
 
6. Decisions about School Dismissal or Closing
In order to limit the spread of influenza, DPH has recommended a policy focused on keeping all students and staff with symptoms of influenza out of school and related school activities during their period of illness and recuperation, when they are infectious to others.  The goal is to keep schools open and functioning as usual.

However, DPH recognizes that, on a case-by-case basis, some schools may need to consider the dismissal or closure of a facility if the extent of influenza-like illness has impaired the school’s ability to perform its educational functions, or it is a facility where most of the students are pregnant or medically fragile*.  School officials must discuss their situation with their local board of health and/or DPH prior to making this determination.  Schools should prepare for the possibility of school dismissal or closure before facing this decision.  This includes asking teachers, parents, and officials in charge of critical school-associated programs (such as meal services) to make contingency plans.

* A medically fragile child is one who needs intensive life sustaining medical assistance with daily living, for example, a child who uses an oxygen tank, needs suctioning, is on a ventilator, is fed through a tube or has trouble moving.

Factors to consider in school closure decisions: 

1.  Absenteeism that is substantially higher than expected for the facility at this time of year
2.  Confirmation that the absenteeism is due to influenza-like-illness
3.  Indication that the already high absenteeism is rising rather than falling
4.  Inability to function due to high absenteeism among students and/or staff

If a decision to dismiss or close a facility is made in consultation with the local board of health and/or DPH, the following should be considered:

• Cancellation of all school-related gatherings and discouraging parents and students from congregating outside of the school. 
• Duration of closing: The duration of closings for school and childcare facilities should be for 5-7 days.  School authorities should consult with their local board of health and DPH for guidance on reopening. 
• Steps to take after reopening:  Keep in mind that flu will likely still be circulating, and there will be the potential for more cases when your facility re-opens.  Be prepared to institute all of the necessary surveillance and control measures at that time.
• Reporting to DPH:  If a decision is made to close a school, the school should notify DPH by calling the Immunization Program at 617-983-6800 and ask to speak to an epidemiologist.  The school should also submit a School Closure Reporting Form to the DPH Office of Integrated Surveillance and Informatics Services by fax at 617-983-6220.  The form is available at: www.mass.gov/Eeohhs2/docs/dph/cdc/flu/swine_school_closure_form.pdf. 

Additional Information and Resources
For the most up-to-date information concerning H1N1 and seasonal influenza, please check the MDPH flu web site at www.mass.gov/ flu.

CDC has developed Preparing for the Flu: A Communication Toolkit for Schools (Grades K – 12 which contains helpful detailed information.  Included are questions and answers, fact sheets, template letters and educational materials.  This Toolkit should be considered an additional resource for you and is available at: http://www.flu.gov/plan/school/.

Attachments:

File	Description	File size
H1N1 FAQ	H1N1 FAQ	532 Kb
Fever Factsheet	Fever Factsheet	48 Kb
H1N1 Flu Vaccine Survey	H1N1 Flu Vaccine Survey	25 Kb
Inst. for those who are sick	Inst. for those who are sick	111 Kb
H1N1 Symptoms	H1N1 Symptoms	577 Kb
Vaccine Safety	Vaccine Safety	25 Kb