Nov 13 2009 Guidance for School nurses on H1N1 - Massachusetts Nurses Association

The Commonwealth of Massachusetts Executive Office of Health and Human Services Department of Public Health

2009-2010 Guidance for Schools Facing High Absenteeism due to Influenza-Like-Illness (ILI)

Updated November 13, 2009

Massachusetts is currently experiencing rates of ILI that exceed the rates typically seen during the peak of flu season. Many schools are experiencing higher than expected student and faculty absenteeism due to ILI. This guidance provides information to consider during this challenging situation. Our goal remains limiting transmission in schools in order to keep schools open and functioning.School officials are urged to work closely with DPH and local boards of public health to respond to high rates of ILI. DPH epidemiologists and senior clinicians are available for consultation by calling 617-983-6800.

Guidance is provided to schools in 4 areas:

Infection control measures
Decisions about school closing
Approaches to reopening schools
Communicating with parents and the community

INFECTION CONTROL MEASURES

Make sure all school officials and school health personnel are familiar with the 2009 Influenza Guidance, jointly issued by the Departments of Elementary and Secondary Education and Public Health.

Continue to monitor absenteeism due to ILI, as well as the number of students and faculty who are sent home during the day.

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 must be prepared to stay home as long as it takes to become fever-free for 24 hours.

Avoid any incentives for students or staff to come to school when sick. Review school policies, such as attendance awards, grading policy and timing of school events. Consider ways to assist students in making up tests and assignments to facilitate them staying home when sick. Consider not requiring a physician note for students absent due to ILI.

Engage in active screening of students to identify those with signs of ILI at the beginning of the school day. Immediately separate these students (ask them to wear masks when they are able) and make arrangements for them to be sent home. The Flu Symptom Checklist (attached at the end of this document and available on the DPH website, www.mass.gov/flu) is a useful tool that can be used by non-clinical staff to screen children and identify those who may need further evaluation by school health personnel.

Institute social distancing measures, such as moving desks farther apart, having classes remain together and rotating teachers, postponing school assemblies, field trips or other activities in which students are in close contact.

Communicate with parents about the importance of their role in maintaining a healthy school environment by keeping sick students home. Let them know that students will be actively screened for symptoms each morning using The Flu Symptom Checklist and children who are not well enough to be in school will be promptly dismissed. (See section below on Communication with Parents and the Community.) Make sure families have the checklist to use at home. Consider sharing data on the number of children sent home sick to convey how effective the active screening approach is.

Do not require that students absent due to influenza-like-illness provide a doctor’s note to excuse their absence. Requiring all individuals who get the flu to obtain a doctor’s note would overwhelm health care providers and interfere with their ability to care for those who really do need medical care. The CDC and DPH recommend that people not go to emergency rooms or to their doctors’ offices if they are experience mild symptoms. However, people with underlying chronic medical conditions like asthma, diabetes or conditions of their immune system, should call their providers to discuss if they need to be treated.

Emphasize the importance of proper hand washing and cough etiquette in preventing the spread of diseases with students and staff. Provide 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. Educational materials and posters are available on the DPH website, www.mass.govflu. Send hand washing or other flu control educational materials home to parents and ask for their assistance in reinforcing these messages with their children.

Remind students not to share eating utensils, cups or water bottles. This is especially important for students on sports teams who may be accustomed to this. Sharing these items can transmit flu viruses.

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.

DECISIONS ABOUT SCHOOL CLOSING

DPH recognizes that, on a case-by-case basis, some schools may need to consider the 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 should 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.

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 absenteeism continues to rise
4. Large numbers of students being sent home from school due to influenza-like- illness
5. Inability to function due to high absenteeism among students and/or staff

If after instituting the control measures described in Section 1, absenteeism is increasing and the school is not able to function, a decision to dismiss school should be considered in consultation with the local board of health and/or DPH. Once a decision to close a school has been reached, schools and local boards of health should consider the following recommendations:

Cancellation of all school-related gatherings, including after school programs, sports events, etc.

Strongly encourage parents to prevent students from congregating outside of school. Remind them that the school closure period is not a time for parties, sleepovers, etc., since those activities will allow continued transmission of the flu among students.

The duration of closings for school and childcare facilities should be for 5-7 days. This length of time is to take into account the incubation and likely symptomatic periods of students and faculty who were exposed but not ill at the time of closure.

School authorities should consult with their local board of health and DPH for guidance on reopening. This allows for schools to plan for measures to have in place to limit transmission when schools reopen.

All school closures must be reported to DPH and DESE. 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 (available at www.mass.gov/flu) to the DPH Office of Integrated Surveillance and Informatics Services by fax at 617-983-6220.

3. APPROACH TO REOPENING SCHOOLS
Keep in mind that the flu will likely still be circulating, and there will be the potential for additional cases when your school re-opens. Be prepared to institute all of the necessary surveillance and control measures at that time.

Prepare parents, faculty and students that there will likely be some continued cases of ILI in the school because it is so widespread in the community. (See below).
Before school reopens, communicate with parents about the following

4. COMMUNICATION WITH PARENTS AND THE COMMUNITY
Because the number of H1N1 illnesses continue to increase and as the H1N1 vaccine supply is, for now, only being distributed in limited quantities across the state, DPH would like to provide you with some basic talking points to refer to when speaking with concerned parents in your community. Please see the attached memo, H1N1 Influenza – Communicating With Parents, for suggestions on how to communicate what can be complicated information to parents and the broader community.

If you receive media inquiries, DPH encourages you to coordinate messaging with us before responding. If you do not feel comfortable responding to such inquiries, DPH would be happy to assist you. It is important to note, that the Department will never confirm or discuss activities occurring in any school without your express consent. If you receive media inquiries and would like to reach the Department for assistance, please contact Jennifer Manley at 617-624-5006.

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/.

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.

TO: Massachusetts School Administrators, School Nurses, and Educators

FROM: John Auerbach, Commissioner of Public Health

RE: H1N1 Influenza – Communicating With Parents

The number of H1N1 illnesses continue to increase and as the H1N1 vaccine supply is, for now, only being distributed in limited quantities across the state, DPH would like to provide you with some basic talking points to refer to when speaking with concerned parents in your community.

General Information

The flu virus is circulating widely throughout our communities, not just in schools, so we all need to use basic prevention steps everywhere.
- Cover your mouth when you cough or sneeze with a tissue or the bend of your elbow
- Wash your hands often with soap and warm water or an alcohol-based hand sanitizer
- Get both a seasonal and H1N1 flu shot, when available

This flu season we’re dealing with two different strains of the flu; seasonal flu and H1N1 (swine) flu.

We see seasonal flu every winter so over time we build up some resistance to it.

However, a new strain of flu has emerged called H1N1 (swine) flu. Since we’ve never seen it before our bodies can’t fight it off as well, which is why so many people may get sick. In general, it doesn’t appear more severe than the seasonal flu, but because children in particular have not been exposed to it before, they are much more likely to become ill from it.

We know parents are concerned about protecting their child from getting the flu and you may feel that knowing who is sick will help you do that. However, we can’t know everyone who is sick because this illness is widespread in our communities. This illness is not like the measles or another very rare illness, where there might be a few cases in the community and knowing who is sick can help track exposure. Instead, in the case of the flu which is circulating widely in our communities, we have to focus on keeping our children healthy wherever they are in the community because they could be exposed to the flu anywhere.

What the School Is Doing

We are actively taking specific steps to stop the spread of the virus by screening all students for flu-like symptoms. This means we will be using the Flu Symptom Checklist that we have sent home to you, to make sure that students are well enough to be in school.

If a child comes to school sick, they will be sent home. Please do not send your child to school if they are not feeling well. If your child has a fever, do not give them fever reducing medication and then send to school. This exposes other students to illness and leads to more students getting sick and higher absentee rates.

Both students and staff that come to school with flu-like illness, or develop symptoms during the day, will be sent to a separate room until they can be sent home. They will be asked to wear a surgical mask if possible, and those caring for them will also wear masks in order to reduce the spread of infection.

We are carefully monitoring absenteeism in both students and staff and may follow up with you if you child is absent to better understand his/her symptoms.

School nurses and student health centers will report higher than normal absenteeism or clusters due to influenza-like-illness to the local health department and to the Massachusetts Department of Public Health.

It is important to note that we are not providing specific information about whether or not students have confirmed cases of H1N1. The vast majority of people with flu-like symptoms do not get tested, so relying on confirmed cases is not an accurate indication of flu activity in the school. Also, if there is flu present in the school, this means that there is also flu present in elsewhere in our community- in the grocery store, at church and on the playground. We all need to take the same precautions to protect ourselves everyday, regardless of where we are.

School Closing Information

When considering a possible school closing, we follow the recommendations and guidelines set by the Massachusetts Department of Public Health (DPH).

The goal of both DPH and < school/town name> is to keep our school open and functioning as usual.

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 most infectious to others. For most people, this will be about 4 days.

DPH recognizes that, on a case-by-case basis, some schools may need to consider closing. This option will take several factors into account including the extent to which the flu has impaired the school’s ability to perform its educational functions. Thus, a higher than usual absentee rate does not necessarily mean that a school should close.

We must discuss our situation with the local board of health and/or DPH prior to making any decisions. There are factors we need to take into account when considering closing our school. They are:
- Absenteeism that is substantially higher than expected for the facility at this time of year
- Confirmation that the absenteeism is due to influenza-like-illness
- Indication that the already high absenteeism is rising rather than falling
- Inability to function due to high absenteeism among students and/or staff

Please keep in mind that flu will likely still be circulating when the school re-opens, so there will be the potential for more cases. We will have surveillance and control measures in place at that time. This will include actively screening students as they come to school each day to make sure they are well enough to be in school.

What Parents Should Do If Their Child Is Sick

Keep your child home if they are sick. It is very important that your child does not go to school or any other places where they could spread the flu virus to other people, such as after school programs, the mall, or sporting events.
- Flu-like symptoms include: fever (over 100.4 degrees F), with cough and/or sore throat. Additional symptoms of H1N1 flu may include: runny nose, stuffy nose, headache, body aches, feeling very tired, and sometimes vomiting or diarrhea.
- Most children will need to stay home about 4 days. They must stay home until they are fever-free for at least 24 hours after their last dose of fever reducing medicine, like Tylenol, Advil or Motrin.

Be sure to call your doctor’s office and let them know your child’s symptoms and history. Your doctor will advise you whether you should come to the office. It is best to call ahead before bringing your child in so that the office is prepared to receive your child in a way that will help prevent spreading illness to others.

Remember that DPH discourages the use of the hospital emergency rooms for treatment of flu symptoms unless directed by a health care provider.

What Parents Should Do If Their Child Is Healthy

Continue to send your child to school if they are not sick.

Consistently reinforce prevention measures with them including frequent hand washing, as well as covering coughs and sneezes with a tissue or their inner elbow.

If there is flu present in your school, this means that there is also flu in your community. Keeping your healthy child away from school will not help better protect them from the virus.

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