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Novel Influenza A (H1N1): Impact on Schools, Spring, 2009

Novel Influenza A (H1N1): Impact on Schools, Spring, 2009. 30 July 2009 Francisco Averhoff MD, MPH Community Measures Task Force Division of Global Migration and Quarantine Centers for Disease Control and Prevention. 2. Basis for Recommendations: Non-Pharmaceutical Interventions (NPIs).

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Novel Influenza A (H1N1): Impact on Schools, Spring, 2009

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  1. Novel Influenza A (H1N1): Impact on Schools, Spring, 2009 30 July 2009 Francisco Averhoff MD, MPH Community Measures Task Force Division of Global Migration and Quarantine Centers for Disease Control and Prevention

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  3. Basis for Recommendations: Non-Pharmaceutical Interventions (NPIs) • Evidence from 1918 pandemic • Epidemiologic studies • Modeling • Common Sense

  4. Non-Pharmaceutical Interventions (NPIs)* • Isolation and treatment of ill persons • Voluntary home quarantine of household contacts • Dismissal of students from school and social distancing and daycare closure • Workplace/community social distancing * Targeted Layered Containment (TLC): The sum likely to be greater than the parts…

  5. Factors that Impact Transmission and Reproductive Rate (Ro)* • Infectiousness of the infected • Susceptibility of uninfected • Interactions, contact and behaviors of the population- target of interventions * Goal is Ro < 1, results in decreasing epi curve and end of outbreak/epidemic

  6. Effect of R on Hypothetical Epidemic Curves

  7. #1 Pandemic outbreak: No intervention #2 Daily Cases Pandemic outbreak: With intervention #3 Days since First Case Community-Based Non Pharmaceutical Interventions (NPIs) 1. Delay disease transmission and outbreak peak 2. Decompress peak burden on healthcare infrastructure 3. Diminish overall cases and health impacts 11

  8. 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. 16

  9. Summary NPIs • Nonpharmaceutical interventions (NPIs) likely to be effective in mitigating influenza pandemic • Effectiveness unknown, will depend on implementation and compliance with interventions • Multiple, early, interventions started early (targeted, layered containment) likely more effective than single intervention • May be the only interventions available early in pandemic • Consequences of interventions need to be considered • Additional research needed

  10. Challenges, Spring, 2009 • April, 2009: Early emergence of H1N1 in US, lack of data on severity (suggestion from Mexico early of “moderate-high” severity) resulted in: • Need for national school closure surveillance system • Need to develop/implement NPI policies with insufficient data • School closure guidance/policies that deviated from USG planning and required modifications with additional data • Need to develop other/unanticipated NPI guidance: Public/mass gatherings, Post-Secondary Schools, Correctional Facilities, Summer Camp, Child Care, Other

  11. School Closure Surveillance, Spring 2009 • Methods • Definition • Public/private, K-12 • Dismissal/Closure >= 1 day • Attributed/associated novel influenza A or ILI • April 27 – June 12, 2009 • Media + state/local education website reviews • Direct reports to CDC, DOEd • Confirmation with district

  12. School Closures, Spring 2009 • Results: April 27 – June 12 • 35 States and DC >= 1 school • 1351 (1%) schools dismissed/closed >= 1 day • Mean 3.8 days (range 1 – 9 days) • 5137 total days of school lost • 824,000 students affected (3,170,000 student-days school lost)

  13. Number of school and student dismissals related to novel influenza A (H1N1), United States, April 27 – June 12, 2009 May 5 - School dismissal not recommended May 1 - School dismissal recommended for 14 days Apr 27 - School dismissal recommended for 7 days June 17 – Ended school dismissal surveillance Source: ED and CDC Confirmed School Closing Reports released each weekday at 2:00pm

  14. Observations • Schools Responsive to CDC Recommendations • Pre-emptive dismissal/closure rarely employed • Sporadic • Impact on disease? • Severity: Pandemic Severity Index (PSI): 2 or less • High Risk Persons at risk for hospitalization and death (eg Asthma) • Transmission: < seasonal influenza • Highest in school age • Maybe some protection with older age • Predominant modes: contact vs. droplet vs. air?

  15. ESSENCE: Total ILI and ILI among 5-17 year olds, Counties A and B, 2009 H1N1 school closure Winter break Spring break (County A) * Influenza-like illness, chief complaint of emergency department visits reported to ESSENCE

  16. 5 – 17 year olds Other Ages School Closed 25% 75% School Open 50% 50% Proportion of 5-17 year olds with ILI: comparison when schools open or closed, Counties A and B, Jan – June 2009 RR= 0.5 95% CI: [0.47, 0.53] p=.0001

  17. Ongoing NPI Studies (CDC) • School Closure/Dismissal & Other • Effectiveness • KAB including Adherence to Recommendations • Ill students/teachers stay home • Quarantine • Re-congregation • Hygiene • Consequences of School Closure • economic and other • Other & Community NPIs • Social Distancing

  18. Next Steps • Goals of interventions • Reduce Morbidity and Mortality • Minimize Social Disruption • Effectiveness of School Closure/Dismissal (Spring and Summer) • Review Spring experience (descriptive epidemiology) • Summer Camp experience • International experience • Establish Surveillance & Monitoring for Fall • School dismissal/closure • Other • Real-time evaluation and feedback • Effectiveness of NPIs • Isolation, Quarantine, Social Distancing (including School Closure/Dismissal), Hygiene, PPE

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