1.Pandemic Influenza and 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

Illnessin humanscaused 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 othersfrom 1 day before getting sickto 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

Illnessin birdscaused byavian influenza viruses

• Low pathogenic types

• Highly pathogenic types (e.g. H5N1)

Illnessin humanscaused byavian 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

Generallycaused by a new influenza virusto 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

10. 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 11. 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

12. 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

13. 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 (substantialpandemic 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

15. Planning for Pandemic Influenza 16. Planning Goals

Prevent/minimize morbidity and mortality

• Limit disease spread

• Mitigate disease, suffering and death

Minimize social disruption

Minimize economic effects

17. Reducing Morbidity and Mortality

Primary strategies for combating pandemic flu

• Vaccination

• Antiviral medications

• Community control measures

18. 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

19. 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

21. 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

22. Primary Strategies Community Control Measures CDC, 2007 Pandemic outbreak:no intervention Daily cases Pandemic outbreak:With intervention Days since first case 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 StatesFirst 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 thatclosing 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 26. 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 27. Who will implement these strategies? 28. Public Health Officials

Federal, state and localpublic healthagencies 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)

29. Public Healths Authority

Chapter 81 of the Texas Health and Safety Code establishes the role of thehealth 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

30. Public Healths Authority

The authority to compel disease control measures is derived from the states inherentpolice 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

31. 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

• (713) 767-3000

32. Public Health and Pandemic Planning 33. 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

34. 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

35. 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

36. 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

37. Surveillance

In addition to conducting year-round monitoring of influenza in the health-care sector, DSHS collaborates withschoolsto track reports of influenza-like illness among students

• Participating schools submit weekly reports of influenza-like illness activity to via fax

38. Prevention/Containment

Discusses local plans for the three strategies of pandemic prevention and containment:

• Vaccines

• Antivirals

• Community Control Measures

39. Vaccines and Antivirals

DSHS will coordinate decision-making regardingvaccineandantiviralallocation

• Oncevaccinesare available, DSHS 6/5S will implement itsMass Vaccination Planto provide flu vaccine to the public

• Onceantiviralsare widely available, DSHS 6/5S will implement itsMass Dispensing Planto provide public sector distribution of antivirals

40. 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

41. Whats Your Plan?

Contact DSHS Region 6/5S to obtain your areas pandemic influenza plan

• (713) 767-3000

42. How Can Schools Prepare? 43. 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)

45. School Planning

The U.S. Department of EducationsPractical Information on Crisis Planning:A Guide for Schools and Communitiesis a useful tool for developing and enhancing EOPs

• www.ed.gov/emergencyplan

46. School Planning

Four domainsmust 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

47. 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

48. 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 ISDdescribes the role of HCPHES, references the HCPHES pandemic influenza plan and lists HCPHES contact information

49. 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

50. 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

51. 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

52. 2. Infection Control

Infection control refers to:

• Decreasing the probability that contact will result in infection

• Decreasing contact between infected and uninfected individuals

53. 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

54. 2. Infection Control

Sample policy language from theHCPHES 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

55. 2. Infection Control

HoustonsGrace Schoolhas permanently posted handwashing and cough etiquette signs in each restroom and classroom

• The school nurse provides classroom instruction on proper handwashing techniques

56. 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/media/pressrel/fs021025.htm

• • CDC Germstopper campaign

• • www.cdc.gov/germstopper

• • CDC Cover Your Cough campaign -www.cdc.gov/flu/protect/covercough.htm

57. 2. Infection Control

At this time, the benefit of wearing disposablesurgical masksby 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

58. 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

59. 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

60. 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

61. 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 Schoolamended its policies to require that an employee or student must be fever-free for24 hours without the use of fever-reducing medicineprior to returning to school

• Establish policies for transporting ill students and staff

62. 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

63. 2. Infection Control

Key activities:

• Ensure that school-based health facilities follow national infection control guidelines

• • Seewww.hhs.gov/pandemicflu/plan/pdf/S03.pdffor specific guidance regarding infection control procedures for healthcare facilities during a pandemic

64. 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

65. 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 atwww.ready.gov

66. 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

67. 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

68. 3. Continuity of Operations and Instruction

Tomball ISDsplan 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

69. 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 ISDplans to use its website and homework hotlines to disseminate lesson plans, with tutorials conducted through its website, emails and instant messaging

• • Grace Schoolwill extend the school year

70. 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

71. 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

72. 4. Communications

Key activities:

• Develop and test any methods for communicating to staff, students and families during a pandemic

• • Tomball ISDhas developed templates for press releases, letters to parents and talking points for school officials in English and Spanish

• • Grace Schoolhas 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

74. 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

75. 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 ISDhas developed templates of letters to parents about family preparedness, caring for ill persons at home and stress/crisis management

76. 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

77. Developing Your Plan:Next Steps 78. 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

• 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

Who will assist with preparing, responding and recovering from an event? 80. 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

81. Pandemic Influenza Planning Tool

Assess financial impact of alternate scheduling or 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

Develop communications plan for possible school closures

April 2, 2007 Stakeholders will outline further areas for development.

EOP

Suggested Pan Flu policies and procedures

All key stakeholder stakeholders

Determine if any additional policies/procedures need to be in place

April 2, 2007 Stakeholders to review additional needs re: Pan Flu planning for their department. EOP developed last year with an existing communicable disease plan. Director of Risk Management & other key stakeholders

Review district emergency response and communicable disease policies and procedure

March 14, 2007 Identify and contact district stakeholders and schedule a time to meet. EOP Strategic Planning Work Group developed EOP last year. Example:Jim (Director of Risk Management)

Identify or create district committee to provide guidance to school sites regarding pandemic flu preparations

Timeline Next Steps Existing Resources Responsible Person(s) Task Mitigation and Prevention 82. Resources

School District Pandemic Influenza Planning Checklist - www.pandemicflu.gov/plan/school/schoolchecklist.html

Pandemic Influenza Community Mitigation Interim Planning Guide for Elementary and Secondary Schools (see p. 87) -www.pandemicflu.gov/plan/community/community_mitigation.pdf

Pandemic Flu:A Planning Guide for Educators -www.ed.gov/admins/lead/safety/emergencyplan/pandemic/planning-guide/index.html

Practical Information for Crisis Planning: A Guide for Schools and Communities -www.ed.gov/admins/lead/safety/emergencyplan/crisisplanning.pdf

83. Resources

Contra Costa Health Services Pandemic Flu School Action Kit www.cchealth.org/topics/pandemic_flu/school_action_kit /

Texas A&M 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/pandemicplan.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

[email_address]