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Wednesday, August 12

Dealing with H1N1 swine flu outbreaks in U.S. schools: CDC advice about non-medical strategies and what's wrong with it

On Friday the U.S. departments of homeland security, education, heath and human services (HHS), and the CDC (Centers for Disease Control and Prevention), issued a joint announcement on the updated guidelines regarding whether U.S. schools should remain open during an outbreak of swine flu.

As I detailed in my Monday post the guidelines were spun two ways: one way for the unwashed masses and another way for education and public health authorities at the state/local levels.

The message to the public, delivered via a phone presser for the news media and a joint televised press conference, emphasized that schools should remain open in the event of a swine flu outbreak in the school, and by implication that schools should open on time this year.

The recommendation was qualified by the observation that if so many students and staff were sick from swine flu, or if parents of sick children kept sending them to school, schools should close in the those events. However, Thomas Frieden, the CDC director, spelled out for the public the government's overriding message: “It’s now clear that closure of schools is rarely indicated, even if H1N1 is in the school.” (1)

The published version of the guidelines, which is directed at state and local education officials via the CDC and HHS web sites, is neutral on the question of whether schools should open on time this year and close during a swine flu outbreak in a school. (For readers outside the USA: local authorities, not the federal government, have jurisdiction on the matter of school closings.)

However, the guidelines include a handful of non-medical strategies (or 'non-pharmacological interventions' - NPIs -- as they're called in the trade) that school officials could deploy to mitigate the effects of a swine flu outbreak among students while keeping the school open.

The strategies are extensively supplemented in the CDC's handbook, 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. A version of the federal guidelines and handbook will be published on August 23 for colleges and offices.

If it seems the CDC advice is coming a little late in the day, it's coming four months late in the day, to be precise -- almost four months to the day the government got around to announcing the swine flu outbreak. If one really wanted to nitpick, the advice is coming four years late in the day; that would be four years after the government issued their vague and incomplete pandemic planning manual. But there I go again, harping on details.

Be happy that the CDC is now a veritable fountainhead of advice on how schools can deal with a pandemic virus while remaining open. The catch is that much of the advice ranges from inadequate to pretty damn strange.

In truth the CDC remains firmly wedded to their belief that vaccination is the "best way" to prevent the spread of swine influenza.(1) Those impertinent enough to ask them, 'Wouldn't deploying NPIs until the vaccine is distributed actually be the best way?' are looked at as if they've farted.

Nonetheless, in what could be a token gesture to Americans such as Pundita, who keep pestering them with annoying questions (How come Mainland China's death toll from swine flu is zero and America's is 436? Huh? Huh? How come America doesn't have a pandemic-fighting plan like China's, huh? huh? When are we going to get airport screening measures like Mainland China's, huh?), the CDC has graciously included the suggestion in their handbook that schools deploy screening measures in the event that the swine flu outbreak becomes "severe." Under the sub-header "Active screening for illness" the CDC writes:
If influenza 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 symptoms such as fever, cough, runny nose, and sore throat during the previous 24 hours. Some persons with laboratory-confirmed influenza do not have a fever (between 10% and 40% of people). Therefore, absence of fever does not indicate absence of infection.

In a higher severity situation, schools should send home persons with symptoms of acute respiratory infection (that is, any two of the following: sore throat, cough, runny nose [new and unexplained by allergies], or fever). 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 ill. These students and staff should be further screened by the school nurse, or other school-based health care 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 sent home. When possible and if the sick person can tolerate it, he or she should wear a surgical mask until sent home.
Straight out of the gate we come to a snag. I forget which of the two ferret studies (Netherlands, CDC) that were published a couple months ago mentioned a finding about the attack range of the swine flu virus. But physician DocJim posted the information in one of my comment sections with a note on the attack range, which if I recall correctly is two meters.

That's just for infection that can be transmitted through normal breathing; for sneezes and coughs the CDC handbook recommends keeping a distance of six feet -- and indeed it cites the six-foot distance as the safe one for avoiding contamination from infected people under all circumstances.

That presents a problem for health workers who would be tasked with taking students' temperatures during a swine flu outbreak in the school.

Remember the photographs of Chinese health workers garbed in biosafety suits while they were taking temperatures of arriving international passengers? Those aren't hazmat suits with their own air supply but the disposable uniforms cover the worker head to toe, and are finished off with safety goggles and respirator-style face masks.

That get-up is the only certain way to avoid exposure to the highly infectious airborne swine flu virus if you're standing closer than six feet to an infected person. Just slapping on an ordinary, ill-fitting surgical paper mask -- none of which are designed to stop a virus, anyhow -- is a token gesture, particularly if goggles aren't worn.

Note the CDC advice does not mention biosafety suits or goggles, and it leaves unaddressed the vexing problem of how to take a student's temperature from a distance of six feet. Maybe the infrared temperature guns will work at that distance, although I wouldn't bank on it and in any case I doubt many U.S. schools are equipped with them.

In any event, the CDC handbook does not provide a discussion of how the school health worker avoids infection while taking the temperature of a student who seems ill with swine flu.

Nor does the handbook admit to the obvious, which is that taking temperatures of students after they enter the school is another token gesture that undercuts the rationale for screening.

Not to keep throwing China in the CDC's face, but in Mainland China many corporations have chosen to make their contribution to battling swine flu by lining up their employees and taking their temperature before they enter the office for the work day.

No, the employees don't mind; they're proud of their contribution to keeping China's swine flu cases low. Amazing but true good citizens rather enjoy chipping in during a national crisis without waiting on government to tell them what to do. We saw that in the USA on 9/11 and the weeks that followed, and again during Hurricane Katrina's aftermath.

However, it would be a logistical nightmare to line up students outside, in a large school, to have their temperatures taken before they entered the building at the start of the school day. Of course there are workarounds; e.g., staggered student arrival times.

But in short if you want to do school screenings right, and not just make them a token gesture, it takes more planning and effort than the CDC handbook indicates.

Moving downhill from there, schools are looking at another logistical nightmare if they follow the CDC's advice to send infected children home. And their municipalities are facing the possibility of a large number of law suits, if sick children who are sent home without adult supervision become seriously ill or die.(2)

One of the government's biggest rationales for keeping schools open during a swine flu outbreak is that many working parents can't afford day care while their children are kept out of school. This is a particular concern for single working mothers at the lowest end of the economic scale.

Okay, but the snag is that if there's an outbreak in the school and children have to be sent home in droves, or the outbreak is so large the school has to close, this will mean parents having to take off work with no notice and stay at home to look after their sick children for what could be several days.

The CDC handbook's attempted workaround is another snag. They suggest that schools set up a "quarantine" or isolation room, where sick children can wait for their parents to pick them up.

But if the student is ill enough to require medical attention his waiting for hours in an isolation room, until a parent can get to the school to pick him up, could mean a critical delay in medical intervention. Many U.S. public schools don't even have a nurse on duty, much less a physician.

And realize that during a large swine flu outbreak in a school's region, the emergency rooms there are going to be swamped. This is a huge concern right now for U.S. medical authorities, who are bracing for a renewed onslaught of swine flu in the autumn.

Yes, delaying the opening of schools until the swine flu vaccine can be administered, or closing schools during an outbreak, is a hardship for parents who depend on the schools to babysit.

But if HHS had warned parents at the beginning of the pandemic that they should expect school openings to be delayed in the autumn by as much as two months, parents would have had four months to work out a plan to deal with the problem.

That would have given them time to contact relatives and ask for their help in looking after their children during parental work hours. It would have given religious organizations, community leaders, and the schools time to help parents deal with the problem.

Yet now, at the Eleventh Hour, there's little time for planning. And parents must face the prospect of unannounced school closings due to a large outbreak in their children's school.

Moving further downhill in the CDC's handbook of NPI suggestions -- but I think that's enough bad news for one day. I'll pick up from here in the next post, which will be on Friday at 7:00 AM EDT.

1) The New York Times: Swine Flu Should Not Close Most Schools, Federal Officials Say ; Denise Grady; August 7, 2009

2) The New York Times: First Flu Victim’s Family Intends to Sue City; ANEMONA HARTOCOLLIS; August 12, 2009
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