Pandemic Influenza and Schools: Preparing to Respond

1
Pandemic Influenzaand Schools Preparing to
Respond
2
Learning Objectives

• Understand the history and current status of
  avian influenza and the potential for pandemic
  influenza
• Describe the issues and efforts surrounding
  preparations for pandemic influenza
• Identify components to be included in your
  district's crisis management and/or pandemic
  influenza plan
• Describe steps districts can take to develop
  their pandemic influenza plan

3
Outline

• Background
• Planning for Pandemic Influenza
• How Can Schools Prepare?
• Developing Your Plan
• Questions and Discussion
• Evaluation

4
Background

5
Influenza-Speak

• Seasonal flu
• Avian flu
• Pandemic flu
• What do they mean? How are they different?

6
Seasonal Flu

• Illness in humans caused every year by influenza
  viruses
• e.g. H1N1, H1N2, H3N2 influenza A viruses,
  influenza B viruses
• 5-20 of the U.S. population gets the flu every
  year
• Estimated 36,000 annual deaths in U.S.

Adapted from CDC Influenza (Flu) Key Facts
7
Seasonal Flu

• Spread by respiratory droplets (coughing and
  sneezing)
• Usually person-to-person can infect others from
  1 day before getting sick to 5 days after
  becoming sick
• Sometimes from touching infected surfaces
• Vaccine offers effective protection
• Vaccines are developed to match the viral strains
  expected to circulate each year

Adapted from CDC Influenza (Flu) Key Facts
8
Avian (Bird) Flu

• Illness in birds caused by avian influenza
  viruses
• Low pathogenic types
• Highly pathogenic types (e.g. H5N1)
• Illness in humans caused by avian influenza
  viruses
• Spread by direct or close contact with infected
  poultry or contaminated surfaces
• No vaccine currently commercially available

Adapted from CDC Influenza (Flu) Key Facts
9
Pandemic Flu

• Increased and sustained transmission of influenza
  in the general population
• Generally caused by a new influenza virus to
  which few, if any, people have immunity
• New viruses result from new combinations on viral
  proteins i.e. a major change in influenza A
  virus (antigenic shift)
• Results in viruses that can spread easily from
  person to person and can cause serious illness
  due to low levels of immunity in a population

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Pandemics in the Past 100 Years

• 1918-1919 H1N1 influenza A virus
• 500,000 U.S. deaths
• 20-50 million worldwide deaths
• H1N1 still in circulation today
• 1957-58 H2N2 influenza A virus
• 70,000 U.S. deaths
• 1968-1969 H3N2
• 32,000 U.S. deaths
• H3N2 still in circulation today

Adapted from CDC Influenza (Flu) Key Facts
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WHO Pandemic Phases

• Inter-Pandemic Period
• Phase 1 No new influenza virus subtypes have
  been detected in humans. An influenza virus
  subtype that has caused human infection may be
  present in animals. If present in humans, the
  risk of human infection or disease is considered
  low
• Phase 2 No new influenza virus subtypes have
  been detected in humans. However, a circulating
  animal influenza virus subtype poses a
  substantial risk of human disease

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WHO Pandemic Phases

• Pandemic Alert Period
• Phase 3 Human infection(s) with a new subtype,
  but no human-to-human spread, or at most rare
  instances of spread to a close contact
• Phase 4 Small cluster(s) with limited
  human-to-human transmission but spread is highly
  localized, suggesting that the virus is not well
  adapted to humans

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WHO Pandemic Phases

• Pandemic Alert Period
• Phase 5 Larger cluster(s) but human-to-human
  spread still localized, suggesting that the virus
  is becoming increasingly better adapted to
  humans, but may not yet be fully transmissible
  (substantial pandemic risk)
• Pandemic Period
• Phase 6 Pandemic occurring increased and
  sustained transmission in the general population

14
Current Status

• Through February 2007, there have been 273
  laboratory-confirmed cases of avian influenza
  A/H5N1 among humans reported to WHO
• 167 deaths
• 11 countries far and middle east, Indonesia,
  northern Africa
• Avian influenza A/H5N1 has been confirmed in
  poultry and/or wild birds in these areas as well
  as India, Russia and Europe

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Planning for Pandemic Influenza

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Planning Goals

• Prevent/minimize morbidity and mortality
• Limit disease spread
• Mitigate disease, suffering and death
• Minimize social disruption
• Minimize economic effects

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Reducing Morbidity and Mortality

• Primary strategies for combating pandemic flu
• Vaccination
• Antiviral medications
• Community control measures

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Primary Strategies - Vaccination

• Vaccination would be the single most effective
  intervention, BUT
• Unlikely that a well-matched vaccine will be
  available when a pandemic begins
• Current technology would require 4-6 months for
  vaccine development after the pandemic begins
• Once developed, production capacity would limit
  availability

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Primary Strategies - Antivirals

• Antivirals could be used for both treatment and
  prophylaxis, BUT
• Effectiveness of current antivirals against a
  future pandemic strain is unknown
• Quantities are limited

20
Primary Strategies Community Control Measures

• Two approaches
• Decrease the probability that contact will result
  in infection
• Cough etiquette, hand hygiene, infection control
• Decrease contact between infected and uninfected
  individuals
• Isolation, quarantine, travel advisories,
  cancellation of mass gatherings, social
  distancing, school closures

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Primary Strategies Community Control Measures

• These nonpharmaceutical interventions will
• Help buy time for production and distribution of
  vaccine
• Reduce the total number of cases, thus reducing
  community morbidity and mortality

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Primary Strategies Community Control Measures
CDC, 2007
23
Primary Strategies Community Control Measures
Collins SD, Frost WH, Gover M, Sydenstricker E
Mortality from influenza and pneumonia in the 50
largest cities of the United States First
Edition Washington U.S. Government Printing
Office 1930.
24
Primary Strategies Community Control Measures
Mayor closes theaters, moving picture shows,
schools, pool and billiard halls, Sunday schools,
cabarets, lodges, societies, public funerals,
open air meetings, dance halls and conventions
until further notice
Closing order withdrawn
Levins, H. What he knew in 1918 could save
millions of lives. St. Louis Post-Dispatch Jul.
08 2006.
25
Primary Strategies Community Control Measures

• Mathematical modeling has shown that closing
  schools at the outset of a pandemic could
  decrease attack rates in a community by about 33
• Compared to the attack rate when not implementing
  any control measures
• School closures would likely occur in concert
  with other control measures

National Academy of Sciences, 2006
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Primary Strategies Community Control Measures

• Recommendations for closing schools will depend
  upon the severity of the pandemic. For example
• Category 1 no closure
• Category 2 3 short-term closure (4 weeks)
• Category 4 5 longer-term closure (12 weeks)

CDC, 2007
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Who will implement these strategies?

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Public Health Officials

• Federal, state and local public health agencies
  maintain the lead role in preparing for and
  responding to pandemic influenza
• Examples
• Federal Centers for Disease Control and
  Prevention (CDC)
• State Texas Department of State Health Services
  (TDSHS)
• Local Harris County Public Health
  Environmental Services (HCPHES)

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Public Healths Authority

• Chapter 81 of the Texas Health and Safety Code
  establishes the role of the health authority, a
  physician appointed to administer laws related to
  public health within their jurisdiction
• Including laws related to community control
  measures
• Such measures include isolation, quarantine,
  immunization, detention, restriction,
  disinfection, decontamination, disinfestation,
  chemoprophylaxis, preventive therapy, prevention
  and education

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Public Healths Authority

• The authority to compel disease control measures
  is derived from the states inherent police
  powers
• Police powers refer to the authority of a state
  government to enact laws and promote regulations
  to safeguard the health, safety and welfare of
  its citizens

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Public Healths Authority

• There are 172 local health authorities in Texas,
  many affiliated with local health departments
• Areas without local health authorities are
  covered by TDSHS regional health authorities
• Contact TDSHS Region 6/5S for your local health
  authority
• [phone]

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Public Health and Pandemic Planning

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Roles and Responsibilities

• Federal Agencies (CDC, etc.)
• Supporting the establishment of stockpiles of
  vaccines and antivirals
• Facilitating (and funding) state and local
  planning
• Providing guidance to the private sector
• Overall domestic incident management
• TDSHS
• Developing and exercising preparedness and
  response plans
• Managing federal pandemic preparedness grant
  funding to local agencies
• Maintaining state-purchased stockpiles of
  medications

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Roles and Responsibilities

• Local Health Departments
• Developing and exercising preparedness and
  response plans
• Integrating non-health entities in pandemic
  planning
• Providing education to the public and other key
  stakeholders on pandemic influenza
• Monitoring local disease status
• Providing local incident management
• In Texas, decision-making regarding pandemic
  influenza will be made at the local level

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Assumptions

• 30 of population may become ill
• 15 of population will seek outpatient care
• 0.3 to 3 of population will be hospitalized
• 0.07 to 0.64 of population may die

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Assumptions

• The duration of illness for an uncomplicated case
  of influenza is five days
• Medical care services may be severely taxed or
  overwhelmed
• Illness rates may be up to 40 among school-aged
  children and 20 among working adults
• 30 or more of the workforce may be out of work
  due to illness at the peak of a major pandemic
  influenza wave.
• This includes work loss while caring for oneself
  or for ill family members

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Surveillance

• In addition to conducting year-round monitoring
  of influenza in the health-care sector, DSHS
  collaborates with schools to track reports of
  influenza-like illness among students
• Participating schools submit weekly reports of
  influenza-like illness activity to via fax

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Prevention/Containment

• Discusses local plans for the three strategies of
  pandemic prevention and containment
• Vaccines
• Antivirals
• Community Control Measures

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Vaccines and Antivirals

• DSHS will coordinate decision-making regarding
  vaccine and antiviral allocation
• Once vaccines are available, DSHS 6/5S will
  implement its Mass Vaccination Plan to provide
  flu vaccine to the public
• Once antivirals are widely available, DSHS 6/5S
  will implement its Mass Dispensing Plan to
  provide public sector distribution of antivirals

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Community Control Measures

• DSHS in coordination with local health
  authorities will develop and enact control
  measures within jurisdictions. Examples
• Isolation and quarantine
• Social distancing
• Cancelling mass gatherings
• Closing schools
• The types of measures implemented will depend
  upon the location of cases, size of clusters,
  availability of vaccine, pandemic severity, etc.
• Measures will be undertaken in coordination with
  other local, state and federal officials

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Whats Your Plan?

• Contact DSHS Region 6/5S to obtain your areas
  pandemic influenza plan
• [phone]

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How Can Schools Prepare?

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School Planning

• Schools face several unique challenges
• Planning assumptions estimate that in the absence
  of intervention, illness rates would be highest
  among school-aged children (40)
• Children may be more likely to spread influenza
  than adults
• Unlike many sectors, schools must focus upon
  protecting their workforce AND their students
• Schools must address continuity of instruction

44
School Planning

• Every Independent School District (or the
  equivalent) should ensure plans to protect the
  health and safety of their staff and students
  during a pandemic
• Plans should build upon existing Emergency
  Operations Plans (EOPs)

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School Planning

• The U.S. Department of Educations Practical
  Information on Crisis Planning A Guide for
  Schools and Communities is a useful tool for
  developing and enhancing EOPs
• www.ed.gov/emergencyplan

46
School Planning

• Four domains must be considered when developing
  plans to prepare for and respond to pandemic
  influenza
• Planning and Coordination
• Infection Control Policies and Procedures
• Continuity of Core Operations and Student
  Instruction
• Communications

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1. Planning and Coordination

• Planning and coordination refers to
• Determining who is responsible for making
  decisions related to the response to a pandemic
• Carrying out activities before, during and after
  a pandemic
• Developing and maintaining the response plan

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1. Planning and Coordination

• Key activities
• Identify the authorities responsible for
  executing community response plans and
  activities, including case identification,
  isolation, quarantine and community control
  measures
• On Page 1 of its Pandemic Influenza Plan, Tomball
  ISD describes the role of HCPHES, references the
  HCPHES pandemic influenza plan and lists HCPHES
  contact information

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1. Planning and Coordination

• Key activities
• Identify the authority responsible for activating
  the districts pandemic influenza plan
• Provide the contact information for this
  person(s) to the public health authority so that
  information regarding community control measures
  can be communicated efficiently

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1. Planning and Coordination

• Key activities
• Address pandemic influenza preparedness as part
  of your districts crisis management plan
• Involve all relevant stakeholders
• Delineate accountability and responsibility
• Coordinate with other relevant response plans
• Establish an organizational structure to manage
  the execution of the plan, such as an Incident
  Command Structure see page 6-19 of the DOE
  guide

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1. Planning and Coordination

• Key activities
• Test your pandemic plan
• Implement an internal exercise/drill
• Participate in exercises of the communitys plan
• Periodically revise your plan

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2. Infection Control

• Infection control refers to
• Decreasing the probability that contact will
  result in infection
• Decreasing contact between infected and
  uninfected individuals

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2. Infection Control

• Key activities
• Implement policies and procedures that can limit
  the spread of influenza at school
• Promote of hand hygiene and cough etiquette
• Ensure appropriate supplies are available soap,
  tissues, hand sanitizer, waste baskets
• Limit face-to-face contact, when possible
• Making good hygiene a habit now can help protect
  children from many infectious diseases, including
  flu

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2. Infection Control

• Sample policy language from the HCPHES
  Occupational Health and Safety Manual
• Following Centers for Disease Control and
  Prevention (CDC) hand hygiene guidelines, all
  HCPHES staff will maintain hand hygiene
  including, but not limited to, hand washing. 
  HCPHES will ensure that hand hygiene facilities
  and supplies are readily accessible

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2. Infection Control

• Houstons Grace School has permanently posted
  handwashing and cough etiquette signs in each
  restroom and classroom
• The school nurse provides classroom instruction
  on proper handwashing techniques

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2. Infection Control

• Hand hygiene and cough etiquette resources
• CDC/DHHS hand hygiene materials targeted to
  schools - www.itsasnap.org
• CDC hand hygiene guidelines - www.cdc.gov/od/oc/me
  dia/pressrel/fs021025.htm
• CDC Germstopper campaign
• www.cdc.gov/germstopper
• CDC Cover Your Cough campaign -
  www.cdc.gov/flu/protect/covercough.htm

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2. Infection Control

• At this time, the benefit of wearing disposable
  surgical masks by asymptomatic persons in a
  community setting (such as a school) has not been
  demonstrated to decrease infections during a
  community outbreak
• However, you may anticipate that persons at risk
  may choose to obtain and wear such masks

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2. Infection Control

• Key activities
• Establish special policies and procedures
  regarding absenteeism that may be unique to a
  pandemic situation
• Non-punitive absenteeism policies for students
• Relaxed and/or enhanced sick leave and
  absenteeism policies for employees

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2. Infection Control

• Sample policy language
• During times of a declared public health
  emergency and/or large-scale disease outbreak,
  the district may suspend district policies that
  penalize students for excessive student
  absenteeism
• During times of a declared public health
  emergency and/or large-scale disease outbreak,
  the district may suspend district programs
  regarding perfect attendance achievement

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2. Infection Control

• Sample policy language
• During times of a declared public health
  emergency and/or large-scale disease outbreak and
  school remains in session, the district may
  suspend district policies or temporarily adopt
  alternate policies regarding staff sick leave and
  absenteeism
• Example - Harris County has a policy that allows
  24 hours of sick leave per year to be used to
  care for ill family members. This type of policy
  could be waived or expanded during a pandemic

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2. Infection Control

• Key activities
• Establish special policies and procedures for
  staff and students suspected to be ill or who
  become ill at school, including policies for
  returning to school
• Grace School amended its policies to require that
  an employee or student must be fever-free for 24
  hours without the use of fever-reducing medicine
  prior to returning to school
• Establish policies for transporting ill students
  and staff

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2. Infection Control

• Sample policy language
• Staff and students with a known or suspected
  communicable disease should not remain at school
  and should return only after symptoms resolve and
  they are physically ready. Certification of
  fitness for duty by a medical professional may be
  required
• Consider allowing for modification during a
  pandemic to encourage home quarantine if a family
  member is ill

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2. Infection Control

• Key activities
• Ensure that school-based health facilities follow
  national infection control guidelines
• See www.hhs.gov/pandemicflu/plan/pdf/S03.pdf for
  specific guidance regarding infection control
  procedures for healthcare facilities during a
  pandemic

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3. Continuity of Operations and Instruction

• Continuity of operations refers to ensuring that
  the capability exists to continue essential
  agency functions when faced with high absenteeism
  or temporary school closure
• Continuity of instruction refers to minimizing
  the potential disruption to student learning

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3. Continuity of Operations and Instruction

• Key activities
• Develop a continuity of operations plan (COOP)
  for essential central office functions
• Payroll
• Communication with staff, students and parents
• The basic elements of a COOP can be found at
  www.ready.gov

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3. Continuity of Operations and Instruction

• Key activities
• Develop scenarios describing the potential impact
  of a pandemic on student learning, school
  closings and extracurricular activities
• Based on various levels of illness and
  absenteeism, and different mandates from public
  health authorities
• Brainstorm possible alternatives and solutions
  for each scenario

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3. Continuity of Operations and Instruction

• Possible scenarios
• Your public health authority recommends
  heightening adherence to hand hygiene and cough
  etiquette and limiting face-to-face contact
• Your public health authority recommends
  cancellation of large group gatherings
• Your district is experiencing a 15 absenteeism
  rate among staff and 20 among students
• Your public health authority recommends school
  closures for twelve weeks

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3. Continuity of Operations and Instruction

• Tomball ISDs plan contains a flow chart
  describing action steps for each of the following
  scenarios
• Less than 10 of students absent
• Letter to parents, heightened surveillance,
  heightened infection control, etc.
• 10-29 of students absent
• 30 or more of students absent

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3. Continuity of Operations and Instruction

• Key activities
• Brainstorm alternate methods to provide
  instruction to students in the event of high
  absenteeism or temporary school closure
• Tomball ISD plans to use its website and
  homework hotlines to disseminate lesson plans,
  with tutorials conducted through its website,
  emails and instant messaging
• Grace School will extend the school year

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4. Communications

• Communications planning refers to ensuring
  accurate and timely information regarding the
  impact of the pandemic on your operations
• Also refers to assisting public health
  authorities with disseminating messages to the
  public
• Schools are a trusted source of information
  within their communities

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4. Communications

• Key activities
• Develop a plan to disseminate information to
  staff, students and families
• Designate a lead spokesperson
• Incorporate links to other communication networks
• Ensure language, culture and reading level
  appropriateness

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4. Communications

• Key activities
• Develop and test any methods for communicating to
  staff, students and families during a pandemic
• Tomball ISD has developed templates for press
  releases, letters to parents and talking points
  for school officials in English and Spanish
• Grace School has developed templates for email
  blast alerts and canned answering machine
  messages

73
4. Communications

• Key activities
• Maintain updated communication contacts of key
  public health and education stakeholders
• Provide updated status information to these
  contacts during a pandemic as necessary,
  including absenteeism rates due to influenza

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4. Communications

• Key activities
• Inform staff, students and families where they
  can find up-to-date and reliable pandemic
  information
• State website - www.dshs.state.tx.us
• Federal website - www.pandemicflu.gov

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4. Communications

• Key activities
• Disseminate information from public health
  sources about important pandemic topics
• Infection control (hand hygiene, cough etiquette)
• Disease basics (signs and symptoms, modes of
  transmission)
• Personal and family protection strategies (family
  preparedness, at-home care of ill family members)
• Tomball ISD has developed templates of letters to
  parents about family preparedness, caring for ill
  persons at home and stress/crisis management

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4. Communications

• Remember to anticipate the potential fear, stress
  and anxiety of staff, students and families
• If possible, minimize rumors and the circulation
  of misinformation
• Share your plan with all stakeholders BEFORE a
  pandemic situation

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Developing Your Plan Next Steps

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Developing Your Plan Next Steps

• Identify and engage stakeholders (internal/
  external) to be included in planning
• Determine areas of overlap with EOP
• Develop action plan and timelines for new items
• Share draft plan with your public health
  department for feedback (if desired)
• Present completed plan to School Board for
  approval
• Communicate plan to others

79
Identify and Engage Stakeholders
Who will assist with preparing, responding and
recovering from an event?

• Director of Risk Management
• Superintendent
• Director of Health Services
• Director of Human Resources
• Director of Curriculum Instruction
• Principals (elementary, middle, high school)
• Teachers
• Counselors/Mental Health professionals

• Director of Administrative Services
• Director of Transportation
• Public Health
• Director of Child Nutrition
• Director of Maintenance
• Office of Public Information
• Local Emergency Response
• Local Law Enforcement
• Director of Technology
• Parent representatives

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Develop Action Plan Timeline

• Key activities
• Delineate roles and responsibilities for key
  stakeholders engaged in planning and executing
  specific components of the plan.
• Develop Action Plan using the Pandemic Influenza
  Planning Tool
• Ensure timelines are determined
• Completion by the beginning of the 07-08 school
  year is recommended

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Pandemic Influenza Planning Tool
Mitigation and Prevention Mitigation and Prevention Mitigation and Prevention Mitigation and Prevention Mitigation and Prevention
Task Responsible Person(s) Existing Resources Next Steps Timeline
Identify or create district committee to provide guidance to school sites regarding pandemic flu preparations Example Jim (Director of Risk Management) EOP Strategic Planning Work Group developed EOP last year. Identify and contact district stakeholders and schedule a time to meet. March 14, 2007
Review district emergency response and communicable disease policies and procedure Director of Risk Management other key stakeholders EOP developed last year with an existing communicable disease plan. Stakeholders to review additional needs re Pan Flu planning for their department. April 2, 2007
Determine if any additional policies/procedures need to be in place All key stakeholder stakeholders EOP Suggested Pan Flu policies and procedures Stakeholders will outline further areas for development. April 2, 2007
Develop communications plan for possible school closures
Work with Human Resources regarding schools functioning with 30 of work force absent. Look at alternatives such as staggered school times, changes in bussing, and telecommunications
Assess financial impact of alternate scheduling or school closures
82
Resources

• School District Pandemic Influenza Planning
  Checklist -www.pandemicflu.gov/plan/school/schoolc
  hecklist.html
• Pandemic Influenza Community Mitigation Interim
  Planning Guide for Elementary and Secondary
  Schools (see p. 87) - www.pandemicflu.gov/plan/com
  munity/community_mitigation.pdf
• Pandemic Flu A Planning Guide for Educators -
  www.ed.gov/admins/lead/safety/emergencyplan/pandem
  ic/planning-guide/index.html
• Practical Information for Crisis Planning A
  Guide for Schools and Communities -
  www.ed.gov/admins/lead/safety/emergencyplan/crisis
  planning.pdf

83
Resources

• Contra Costa Health Services Pandemic Flu School
  Action Kit www.cchealth.org/topics/pandemic_flu/s
  chool_action_kit/
• Texas AM Center for Rural Public Health
  Preparedness Pandemic Flu Toolkit Training CD
  provided at registration table
• HCPHES School Pandemic Flu Preparedness
  PowerPoint Template http//www.hcphes.org/pandem
  icplan.htm

84
Recognition

• Special thanks to Harris County Department of
  Public Health and Environmental Services for the
  use of this presentation.

85
Questions?

• Brian Winegar, MPH
• Public Health Preparedness Program
• 713-767-3034
• Brian.winegar_at_dshs.state.tx.us