Policies in the US on closing schools in a flu pandemic

So, as I am understanding, the level of decision-making (US, particular state, region, city, school, parents) may vary and will be more or less effective on that particular level if there is more or less adequate information about the pandemic. Also the goals may differ; closing a school may be the first thing to do in order to prevent any spreading of viral infection by children, even when there are no symptoms. But when the school is thinking about education, the level of absenteism may be a criterium.
The first thing to coordinate would be IMHO to make a list of possible goals and the second thing to put the goals of survival and prevention (of contamination) as a priority.
A surveillance system could deliver the information needed to take decisions concerted at all levels as quickly as possible.
In the Netherlands we have a common flu surveillance system. It's not perfect and it's voluntarily, and the reports are made by laymen; but physicians could join it as they are having their own network to share necessary (professional and laboratory) information. At this moment the professional network cannot be accessed by layman.
In case of a pandemic it could be worth thinking of.
I am wondering if any network like this one does exist in the US? The European EISS link has been posted at EM already.
Here's the Netherlands (and Belgium) link:
http://www.degrotegriepmeting.nl/public/index.php?vraag=alles&datum=200…

Click on the picture and the choices will emerge.
Total number of reports, staying home, cold, fever, probably flu (as concluded from reported symptoms) every day. It's all in Dutch.
There has been published about this surveillance system. If it's in English, I'll give that link also.

Yes, it's in English.
Here is the link:
http://www.biomedcentral.com/1471-2458/6/242

The issue of school closure during a pandemic has been debated very vigorously in the past few months, not least because the Feds are getting ready to roll out interim guidance for state and local public health authorities due this month.

These have been the subject of ongoing discussion at the Flu Wiki forum, with the case for early school closure made as part of a more comprehensive set of community mitigation strategies proposed by various modelers.

The consultation process culminated in a 2 day stakeholders' meeting in December, also discussed here in which some interesting revelations emerged about how policymakers who were having difficulties making recommendations had no doubts how they themselves would behave as parents - none of them would consider sending their children to school in a pandemic.

That, of course, is not something that is going to go down well with parents who would naturally feel very betrayed if they find out the double standards employed, especially when they find out the current peak fatality for young people for H5N1 infections is at 60+%.

In a recent presentation, even the HSC is admitting that a pandemic with a 2% CFR ie a 1918-like scenario, would result in deaths for those aged 1-19 that would be the equivalent of 20+ years of normal mortality for those age groups currently, all happening within one season. Plus of course, the 1918 scenario is by no means the worst case scenario.

Irrespective of that, to the extent that parents are the ultimate legal decision makers as to whether a particular child ought to go to school during a disease outbreak, barring the exercise of mandatory powers by the state, the education and involvement of parents and parental organizations such as PTA's in pandemic preparedness and planning is one policy gap that needs to be filled asap. If anything, they would likely be the most motivated at the local level to make this process work.

anon_22: Many thanks for the very helpful links. The Flu Wiki is certainly in the vanguard.

Too bad only some might consider it unethical
not to be planning to close schools
and shelter families at first sign of a deadly pandemic,
given how H5N1 has been looking all this time, as to ages and cfr.

Want to bet how the parents will feel about it;
if something we have no immunity to
and a high death rate -even when hospital treatment is available, and it can't be, and the govt warned it won't be, not in the numbers a pandemic would present,
starts mowing down an unwarned community or state next week or so?
Don't underestimate parental outrage.

They trusted their childrens' lives to these school officials, and most of the parents don't even know what "worst case" really is.
"Snow day" doesn't tell them to prep for surviving a pandemic influenza year or so.

"Two weeks" of "schools closed" and "panflu non-hospital centers open"
is verging on negligant homicide,
if any people shown only a few pieces of the picture mistakenly think things can really be back to normal after two weeks, since that is the way officials are spinning it.

Silence = death.

Govt took the taxes, and tries to lie to the public;
so much for transparency and honesty and public participation being vital for pandemic preparedness,
and forget "consent of the governed" and "post-pandemic economic recovery",
if panflu refuses to auto-magically turn into a mild seasonal flu season the status quo, powers that be, can handle without having woken up the public.

What part of "the fed. and state govt. don't have enough to help every community; it is local responsibility to meet the needs of their citizens during a pandemic year", and "H5N1 could go pandemic at current cfr" don't they understand?

They'd rather risk everyone and their childrens' lives,
than risk being "wrong" to warn the public about a panflu year?
Too late to send them back to school.
Officials might survive the beginning of panflu, and it might have been wrong to not warn the public about pandemic then what will they do?
What if a couple of generations of young people are lost, besides all the adults and elders dependant on modern medical care, normal staffing, and imported meds, and the power grid? We know they did so have an idea "it could be so bad".

crfullmoon, good writing! ;-)

I agree with most of your sentiments. However, this is a work in progress, so let's see what comes out of that process in the next few weeks.

For those who have not followed the discussions closely, we are in a interesting situation where the Feds might actually be more on the same page as our opinion on the flu blogs, while those in charge of implementation at the local and state level are at varying degrees of understanding or willingness to be open.

There's a lot more that needs to be done, so thank you for continuing to raise awareness all round.

crfullmoon, your outrage is understandable, and you're right, parents will indeed go apeshit if school administrators behave that way during a pandemic. I feel some sympathy for them, though until and unless they receive more expert guidance/government guidelines, they are the ones who will be asked to make the tough calls, and are guaranteed to be criticized no matter what.

Even if they happen to luck out, as much as one can, and pull the trigger at exactly the right time, there will be people second guessing that. If one child from a school district dies who is suspected to have caught it at school (likely in a med-high CFR pandemic, unless all schools shut as soon as it's in the country), then someone (whom I also symapathize with) will be asking why their little Lee or Aisha died, if they might have been saved if the schools had closed earlier.

They are also going to be the focus of questions of what working parents are supposed to do with children too young to be at home unsupervised. If the kids leave school and go to the mall, as happened in Hong Kong (I think) during SARS, they will be blamed for that too.

And no matter what, assuming these people care for the children under their charge, the prospect of a pandemic flu is horrifying to contemplate. Many probably don't want to face or accept the possibilities; many probably can't bear to imagine them. They're not health care workers, who deal with sickness and death all the time; they're not epidemiologists who have the backgrounds to assess the appropriate course of action. They're mostly former teachers with advanced degrees in things like education... they may know they'd be out of their depth. So even if they have been informed properly, they avoid or deny or downplay the risk.

So do we all, sometimes. If not with panflu, something else. We also balance and prioritize risks. Even when we're right on the numbers, we might happen to be wrong. That's just how it goes.

Just as a side note, someone who is a parent in the Palo Alto, CA school system informed me that there was a large pertussis outbreak there just before the holidays.

Pertussis? Good old whooping cough? Er, is that not kept in check by the standard DPT triple immunization combo? An immunization which should have been well-nigh universal among privately insured kids from affluent families with excellent healthcare access?

Aye, there's the rub. This outbreak *would* have been kept in check, *if* the yuppie parents in question had made sure that their kids got their shots. It's certainly not due to a lack of attention. These parents are ruthlessly focussed on the very smallest curricular and extracurricular details of their kids' schools.

But, apparently because of autism fears, a lot of these prosperous and professional parents deliberately opted to keep their children unvaccinated. It has happened before in other places. There was a mumps boom in Southern California recently, with precisely the same root cause: Mom and Dad wanted to "protect" their offspring from the dreaded MMR shot.

I don't think that these parents are opting to take the kids for flu shots, either. And if one credits the idea earlier aired here, that routine flu immunization may give a survival edge in an avian flu pandemic, then the conclusion is hard to avoid that some of the worst youth mortality may be in some of society's most well-off communities. How's that for an unanticipated second-order effect?

I've been teaching and active in the decision making boards of public schools long enough to be certain of one thing: The decision absolutely positively must be made at the state level.

At local levels, schools are very much afraid to make independent decisions on such things as long term school closures. They are okay with closing for a day or two due to weather, but even that is done reluctantly with one eye over the shoulder. The reason is that public schools have mandates about how many hours (even to the minute) of education children are to receive each week, month and year. They also have mandates regarding how many hours and minutes the school employees (in particular salaried teachers) are to put in. Missed time has to be made up.

Don't expect any but the most maverick and fearless of school principals to make any independent decisions when it comes to closing schools for extended periods due to pandemic threat. Even among those, most won't unless the epidemic is proven to be upon them, with high enough absenteeism that they feel they can justify their actions to the state Depts of Education. By allowing local school boards to decide when to close, it won't happen until after - as revere said - "the chain of transmission is established." A few kids may still avoid getting sick by this closure, but it won't do anything to help slow the pandemic.

On the other hand, trying to mandate what constitutes grounds for school closures at a federal level is just too far removed from individual states' situations to be workable, IMO. If, for example, this flu outbreak in Alabama were to be deemed a possible start of a pandemic, would the Governors and DOE's of places like Alaska and Hawaii feel that it was prudent to close their schools immediately? (It might be, but you would have a hard time convincing them of that.)

I absolutely agree with crfullmoon that parents, however, should be fully informed AS SOON AS POSSIBLE of the potentially lethal effects of this virus on school age children. They should have the right to make the decision to home school their children at the first sign of a pandemic, and should be given the textbooks and materials they need to do so until the threat passes. Regardless of what the states decide as to when to 'pull the plug' and close the schools officially, parents should have the right to pull their kids out as soon as they feel the threat is enough to warrant it, without any penalty or repercussions

Also, children who are homeschooled using school prepared lessons and texts should continue to be counted as enrolled. (and thus schools funded for them...otherwise you get into other problems with loss of revenues, jobs etc that might make states and local schools less willing to allow and support this homeschooling option.)

I personally have been pushing the county school system here for a standard to be developed but no one can give them the real skinny on how long its infectious. They closed a school system in SC just before Xmas because the flu was running amok down there.

So I asked my immunologist friend. He said that we should close it the minute there is a case of diagnosed H5N1 in high path and keep it closed and do a daily call list to see if there is anyone in home or work that has it. Then he said the day after the last reported case is in home with nothing else out there start a 21 day count down. If there are no cases then restart school and close it AGAIN if there are any secondary cases that pop up and restart after the last case is reported. I said that could in a single wave cause them to be out for upwards of six months. Uh-huh he said. The alternative to it is that many of those smart cookie adults that would want to start it back up too soon would be on the casualty reports along with your kids.

He caveated this with two things and I think Revere could appreciate them. He said herald waves would have less of a case fatality rate so High Path today might mean extremely High Path for tommorow. It only took me 1/2 of a bottle of vodka to get the cheap info on. The second was that if they stop school too late, it will be a death sentence for a lot of the seed corn for our future.

It could mutate into a mildly pathogenic version and due to genetics, previous flu's etc. it might not be so bad in parts of the country, and absolutely terrible in others. His bottom line was that until it emerges and he is of the mind that it will, that the schools above all others need to prepare. Sending a kid home from school could also kill a family. So there's a lot to consider.

Marquer there might be some excess mortality among the unvacccinated children, but I doubt it'd even be discernable amongst all the other factors. First of all, the protective effect of previous exposure to a different flu was observed in mice (IIRC), and "you can prove anything in mice." Second, I'm not even sure if this year's flu shot has as much in common with H5N1 as the strain they used to prep the animals. (I thought it did, but when Revere started discussing the strains recently, it sounded wrong. Nonetheless, I dutifully got my flu shot last week.)

Regardless, the lack of protection of parents who choose not to get flu shots for their kids (isn't it only recommended up to age five anyway?) would probably be balanced by the uninsured parents who couldn't afford the doctor's visit, or even the $25 vaccination at the local pharmacy, or couldn't afford the time off to take their kids.

And kids in low income households are at other disadvantages: unlike parents in white collar jobs, theirs may not be able to work at home, even so long as the power/internet stays up; the tighter money is, the less likely their parents will be able to afford not to go in to work, and the less likely they are to have even two weeks worth of food put by. Single parent households, which are more likely to be low income, will be at a disadvantage when it comes to the multiple responsibilties parents will have to provide and to provide care.

Etc.

Mary I agree about parents being able to keep their kids home without repercussions. I knew kids in high school who were highly focused on their futures and getting into good colleges. Those kids would resist staying home if it would mean failing required exams, losing credit for required classes, low or failing grades, or being held back.

The very diligence and studiousness we should respect could very well cost kids their lives if there aren't policies put in place, ahead of time, to make allowances.

Caia and Marquer another thing to consider is that this flu shot is likely going to knock you on your ass for several days. I cant take flu shots. They just lay me down no matter what year it is or what version is floating around. I actually in the last 3 years of the military career had a flu shot waiver because I started sending them the bills for the post "treatment".

As for the flu vaccine when it comes, dont worry about single moms and families getting it Caia. There will be only enough in the first six months for 5% of the population. That would be the necessary types such as docs, nurses, government workers. That'll about do the flu vaccine production for us for a year.

KRUGER-- You said " As for the flu vaccine when it comes, dont worry about single moms and families getting it Caia. There will be only enough in the first six months for 5% of the population. That would be the necessary types such as docs, nurses, government workers."
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No vaccine for this can be made until the Human-human-human strain actually emerges. It has proven already, to mutate even between human to human jumps. How can they make a vaccine for a constantly mutating virus !!!

We are hearing that even with the correct strain to work on; that, that 5% of available vaccine will NOT be ready for the "first List" for 6 to 9 MONTHS AFTER the pandemic starts !

As for closing the schools; I think the decision for that needs to be in the hands of the County Coronor. They have had training that school officials have not. THEY are listening to the government warnings; unlike the average "Joe Blow" sitting at home with the kids.

People are NOT listening to the warnings. They are complacent. They are ignorant of the facts that are out there. As a parent; I will NOT send my children to school, to the mall, or anywhere else once this starts.

The government and the other Powers That Be; have said REPEATEDLY; "We will not be able to help you....you must PREPARE to help yourselves and those you love."

Didn't Katrina teach the majority ANYTHING ?????

I'm waiting that the revere will address the
more controversial questions of quarantine and
isolating the sick/suspected.
I feel that school closure is just a preparation to
finally be able to talk about those issues without
too much crying out.
Most people agree on school closure, so this is
discussed first.

Actually avoiding these other critical subjects
still seems to be the politically best strategy.
But it might result in dangerous delays of
reasonable preparation and planning.

anon: I've discussed this several times. Isolating the sick makes sense. Quarantine doesn't.

There are only two issues here really. The first is that if you close schools the kids are going to hang out together some place else. Think this is Haber's work at Emory if I remember correctly. So unless you can keep the kids at home or get them to understand social distancing, it won't help a lot. Second, a multiwave pandemic could last 1-2 years. Are you going to keep schools closed that long?

Marissa, those are the tough questions. The answer isn't clear, but we're talking about 8-12 weeks closure during a typical wave. And maybe,

That means they can't go to the mall. It means planning on sheltering in place in some sense for that long. But it means also that in between waves, school goes on.

The necessity to close school systems rapidly and keep them closed long enough is apparent.
I would advocate for those educators who are "looking over their shoulders" to put their energies into devising ways to remain functional, albeit while the students stay home. Long distance learning already exists, and new technologies just enhance it. The teachers can still teach, they always have, one way or another. They want to get paid, after all.
Believe me, whoever does the caregiving during extended times of pandemic waves would love any structure that a school system can pass on to them. I can see it now, "Read Effect Measure's material on the following topic, and e-mail me a 500 word essay by Friday."

On the issue of pulling the trigger at the right time, in a pandemic with an R0 close to 2, and a generation time of 2-3 days, you are looking at the number of cases doubling every 3 day, approximately. Now, when the first case is identified in any community, chances are there are already 2-3 generations of cases.

Computer models suggest school closure and other NPI's work only when the number of cases within a community is less than 1%.

In a known pandemic, ie the virus is already efficiently transmitting h2h in other places eg overseas, the time interval between the identification of the first case and the threshold of 1% won't be more than 1-2 weeks. If you pull the trigger 'too early' all you are looking at is closing schools for a couple of weeks more than is necessary in a long pandemic. This is minor IMO compared to the downside of mass fatalities.

One way to think of the 1% threshold is using the analogy of a housefire. You can use the fire extinguisher in your kitchen but you know that over a certain point, it's not going to do the job. Do you wait to find out? Or do you call the fire department asap?

My sense about the trigger is this: once kids start dying in any part of the country, parents will start pulling kids out of school in other communities, and schools will close. Except that it will be messy, haphazard, there will be recriminations all round, no one will be properly prepared. That is, you will have all the downside of school closure, and not necessarily the upside if it's not done properly eg with massive publicity about keeping kids from public places, support for homeschooling, support for those on school meals, and all the other interventions that still need to be worked out to support a proper school closure policy.

CC you are completely right about that 5% and six months. Thats if there is anyone around to make it. My kids, well I have told them that their school life will end the day that it goes high path anywhere on the planet with more than 100 uncontained and spreading cases. Sooner if it happens in the US first. For me, it will be like doing a little last minute shopping. Calling for fuel loads for the tanks, spare parts for the solar panels to generate hydrogen, fresh ammo, refresher courses in survival training for the kids and wife. It will be a hard day and months for all of us and I agree that NO ONE is paying attention. The worst part is that its the kids that will take the biggest hit, and then really their parents too because they are in the baby making years.

Will I make it? Likely not. Its not in my nature to sit back and watch something happen. Oh, I'll be suited up and masked and have a PAPR for taking people to the hospital and the such. But somewhere, somehow I will likely get i. I'll forget something, someone will honk on me and maybe touch something thats contaminated. But likely will. Making it to the 13th round will be fine with me if I do. At least I will be able to say I tried and man I beez trying right now.

I am being a royal pain in the ass to my electeds right now about this stuff. They grimace when they see me coming... almost as much as Revere ....GOOOOD!

Some very good points above:

- The need for transparency re the goals guiding decision-makers: as a parent, I need to understand that my child's health may not be the only, or even the most important goal behind a decision to keep schools open.
- The need to plan ahead: provide guidelines in advance so that principals don't feel pressured to stay open; have advance discussion with PTAs and staff to develop contingency plans to help with homeschooling and alternative child care, etc. If we're all expecting it, there's a better chance that parents will be able to cope (less work-related absenteeism/supply chain disruption/teens hanging at the mall instead/unhelpful fights over whether and when to close etc.)

Planning needs to distinguish between households where kids can be left alone vs. those that need supervision, and between younger ones who won't go far vs. teens mobile enough to end up at the mall, etc. Older kids can babysit younger relatives and neighbours. Advance education can mitigate but won't eliminate risky behaviour among teens; so can anticipating and accommodating their needs (e.g. Internet chat & webcams for virtual socializing, online school, shopping, etc.). Which communities/households will need help from social services and community groups re child minding? All these things won't entirely eliminate risks or downsides of school closures, but they can significantly reduce them.

Finally, mortality rates are an important factor - planners must consider how higher/lower mortality risks would influence public and institutional reactions. The idea of shifting mortality rates over time and between regions will therefore complicate things, especially as there would probably be a reporting lag time.

Bottom line - the worst case scenario would be to leave all these decisions to individual school administrators and school boards to make in the heat of crisis. Govts, parents, industry and education folks need to think this all through well ahead of time.

...oh, and another small point.

Schools close for at least two months every summer. Supply chains keep rolling and everyone copes. Re-scheduling the summer break to halt the spread of a pandemic and save lives is entirely doable with a little forethough.

Randy and Smith: I think you misunderstood, I wasn't talking about a potential pandemic vaccine; Marquer wasn't either. We were talking about any cross-protection from a regular seasonal vaccination to a later "challenge" from a pandemic virus. This idea that got some slight credence when they found such an effect with another strain and H5N1 in some small mammal.

I am well aware that there would be no pandemic vaccine for most of a pandemic, and not for most people for all of a pandemic.

Sorry, not strain, subtype.

Wish you could try persuading the MA honchos, M.R.K.

revere, I know you don't really know, but, what is going on in North Korea?

On top of the N.American kids on life support, Egypt, Indonesia, bar-headed geese, African having so many problems, our President being insane, ect, I am really feeling a chill.

School PTO chairs, principals, school nurses, school districts still do not want pandemic prepareness on the public radar, either. Just publically planning their happy little fundraisers, and suburban little projects.
If they really cared about the students, they way they say they do, they would not be keeping silent. So what, it doesn't say the "P" word in their job description? (Does't say "you can't tell" in their job description either, does it??)

(I'm to the point I'd like to sic M.R.K. on all of 'em... think he'd get results. And, he's way better able to defend his back than I am.)