Should U.S. schools close during a swine flu outbreak? The CDC's answer is a mixed message.

WASHINGTON, August 7 (Wall Street Journal)

New Federal H1N1 Guidelines Recommend Keeping Schools Open

Top federal officials said Friday that schools should only close in "rare" cases if students and staff become sick with the H1N1 flu. [...]

"What we are seeing looks very much like seasonal flu so far," said Health and Human Services Secretary Kathleen Sebelius.[...]

HOUSTON, August 6 (Xinhua)

Florida A/H1N1 flu deaths double to 41 in 2 weeks

[...]

If state health projections hold true, some 160 Lee County residents and 5,000 Floridians will die from the A/H1N1 flu in the next 18 months to two years, the average life cycle of a pandemic, said Jennifer James-Mesloh, the Lee County Health Department spokeswoman.

That's twice as many deaths as Lee County sees in a typical flu season, she added.

[...]

The rapid increase of fatalities from the A/H1N1 virus seems unpredicted by the health officials and local citizens in the state.

The U.S. federal government sent different messages on Friday on the matter of whether schools should close during a swine flu outbreak.

They sent one message in a CDC phone presser for the news media on Friday morning and followed this with a joint news conference at HHS that included Kathleen Sebelius and the heads of Homeland Security, Education and the CDC.

The message: Based on CDC guidance, the federal government advises against school closings even if there is an outbreak of swine flu in the school.

All the major press outlets dutifully passed along the message to the public, which was also broadcast on the nightly TV news on Friday. The message was unequivocal:

"It's now clear closure of schools is rarely indicated," said Thomas R. Frieden, the director of the Centers for Disease Control and Prevention.

And as I noted above HHS Secretary Kathleen Sebelius chimed in with, "What we are seeing looks very much like seasonal flu so far."

However, the HHS and CDC web sites had a different message. The identical press releases posted at the sites on Friday made no mention of any federal advice to keep schools open during a swine flu outbreak or to open schools on time even in the face of an epidemic. From the first paragraph of the press release, which is titled:

Updated Federal Guidelines for 2009 H1N1 Influenza in Schools Offer Many Options

Updated federal guidelines offer state and local public health and school officials a range of options for responding to 2009 H1N1 influenza in schools, depending on how severe the flu may be in their communities. The guidance says officials should balance the risk of flu in their communities with the disruption that school dismissals will cause in education and the wider community.

The press release continues in that vein, with Education Secretary Arne Duncan chipping in, “We can all work to keep our children healthy now by practicing prevention, close monitoring, and using common sense. We hope no schools have to close. But if they do, we need to make sure that children keep learning."

Offering a range of options is a far cry from issuing a guideline that schools should stay open even during a swine flu outbreak.

Now why did the CDC-HHS send a different message on their web sites than the one they projected at press conferences?

The answer would be matter of conjecture.

The message at the CDC - HHS web sites, which is an official federal update, gets emailed to state and local health and education authorities.

From that, I'd say it's likely the first message was directed at the public, whereas the message on the web sites was directed at school and public health administrators.

The feds have no jurisdiction in the matter of school closings, even though state and local health/education officials take their guidance from CDC scientists when it comes to infectious disease control at school. The most the feds can do is make their opinion known to the school administrators.

So why didn't their written update contain a strongly-worded recommendation that schools remain open even when experiencing an outbreak of swine flu?

Again, the answer would speculative. The education department and HHS clearly want the schools to remain open and to open on time. Setting aside their rationale that closing schools and delaying their opening would be socially disruptive, there is a logistical reason for their decision:

Earlier in the year the CDC and HHS flogged the vaccine manufacturers to have their regular seasonal influenza ready in record time so the companies could start work on the swine flu vaccine.

The CDC's plan was to get schoolchildren vaccinated with the seasonal flu vaccine in August-September through a vaccination program at the schools. However, at that time the CDC was assuming swine flu would act like the regular seasonal flu and leave the Northern Hemisphere for a few months. That didn't happen.

So now there are millions of doses of seasonal flu vaccine ready for distribution at the schools as soon as the schools open. But because the swine flu outbreak is going full tilt in several U.S. states, as soon as millions of kids show up at school, this is expected to touch off large swine flu outbreaks. That situation has already happened at one school that is open this early in the year. It might have been a school in North Carolina although don't hold me to the name of the state. In any event the school had to close immediately.

Without shutting the schools, the projected outbreaks this autumn would quickly spread to the larger community. But because the CDC has also ordered up millions of doses of swine flu for distribution to begin at schools in mid-October, by gum they want to get the kids vaccinated first with the regular seasonal influenza shots.

That's because the swine flu vaccine is somewhere between a completely new vaccine and a regular seasonal influenza one. So while unexpected side effects might not be as drastic as for a completely new type of vaccine, the 2009 swine flu vaccine needs particularly careful monitoring.

The doses prepared for the NIH clinical tests on humans have already been tested on animals and will be given limited testing for human safety during the trials, which are just getting underway. But the major focus of the trials is to learn whether one or two doses, or more, will be needed to provide people with adequate antibodies against the swine flu virus.

The plan is to administer one shot to the volunteers, then review for any immediate side effects after eight days, then administer a second shot within 21 days of the first shot, then test again for antibodies. (See the CNN report at the link I provided for more details on the vaccine trials.)

So I'd surmise that the CDC and HHS want the schools open on time so that the first round of vaccinations, with the regular seasonal influenza vaccine, will have time to 'take' before the next round of shots with the new swine flu vaccine gets underway. It's hoped this will prevent any severe 'crossover' side effects from the seasonal vaccine and the swine flu one being given close together.

Although it's likely that the swine flu vaccination program will go ahead, the CDC - HHS have not yet given the green light. They're going to have to wait for the NIH clinical trials to wrap up and for the FDA to give final approval for the swine flu vaccines.

But adhering to the schedule of vaccinations at the schools for seasonal influenza, followed by swine flu vaccinations approximately six weeks later, would be especially important, given that more than one company will be providing the swine flu vaccine. That means there'll be minor variations in the swine flu vaccine lots, some of which might interact poorly with the seasonal influenza shot. Spacing the shots cuts down on this possibility no matter how remote it might be.

There's another angle. If the big swine flu outbreak in New York City this Spring is any indication, I'd say that parents of school-age children are sharply divided on the matter of school closings.

During the outbreak many New York parents demanded that their child's school be shut when an outbreak occurred there. Other parents demanded that the school stay open. This situation was repeated in other cities including Washington, DC.

The CDC got caught in the crossfire. They'd originally recommended that schools with an outbreak shut down. That touched off protests from working parents who couldn't afford day care for their children and/or who depended on the public school system to feed their children one square meal daily.

So the CDC back-tracked after a few days and told the schools to make decisions on a case-by-case basis.

That seems to be the same message the CDC and HHS sent to school authorities on Friday: decide on an individual basis whether to open or close schools. At the same time the HHS and the education department wanted to assure parents that a decision to open the schools on schedule, and keep them open during a swine flu outbreak, had the CDC's Stamp of Science, and was best for all concerned.

In this way they would be greasing the wheels of the seasonal flu vaccination program at the schools. And they'd be providing backup to parents who wanted to keep the schools open.

In summary, I'd guess that the mixed message reflects the government's attempt to thread the needle.

That exhausts my crystal ball gazing. The next question is whether it's indeed best for all concerned to open the schools on time, and keep them open even during a swine flu outbreak.

The answer is patently obvious if one studies the handy swine flu maps that Wikipedia publishes. (1) The maps show the exact location of swine flu outbreaks in a U.S. state.

Some states are reporting no swine flu activity, which means no regions within the state have an outbreak.

Ergo, if your region shows no outbreak activity a week before school is scheduled to reopen, school systems in the region can risk opening on time.

Schools in regions where there's a widespread swine flu outbreak should delay opening until the outbreak dies down.

Otherwise they could be looking at a logistical nightmare that would cause as much or more social disruption as delaying the school openings.

Part of the nightmare is that the non-pharmacological interventions (NPIs) the CDC recommends to help schools mitigate the effect of a swine outbreak are for the most part unrealistic or inadequate. See the updated guidelines at the CDC website for details but in my next post I'll list the recommended NPIs and highlight their flaws, some of which are quite serious.

I've saved the hardest question for last: Will there be enough swine flu vaccine doses available to vaccinate all the nation's schoolchildren in mid-October? Hopes are running high but we'll just have to cross that bridge when we come to it.

That might be another reason the federal government wants schools to open on time: it's possible there won't be enough vaccine until November or even later in the year.

The worst-case scenario in the event vaccine availability is very limited: the choice would be pretty much between keeping schools closed for almost half the school year or preparing to deal with cascading outbreaks of swine flu infections in the schools that will in turn engulf entire communities.

Best-case scenario: the virus will suddenly fizzle out of its own accord or mutate into something that's no worse than a summer cold.

We can't predict which scenario is more likely. That's because right now a microbe is running humanity's show.

For background on the federal government's thinking about school closures, see Spencer S. Hsu's August 4 report for The Washington Post titled Strategy On Flu Under Revision: Federal Officials to Put Less Emphasis on School Closing

1) Wikipedia: 2009 Flu Pandemic in the United States by State