Daniel LaHart, CIH Environmental Issues Program Manager Operations Division

1. Impact of H1N1 on School Facilities: An Outlook for the Future Daniel LaHart, CIH Environmental Issues Program Manager Operations Division Anne Arundel County Public Schools 410-360-0138 Edward L. Van Oeveren, M.D., M.P.H. Health Officer, Anne Arundel County Department of Health

2. Outline • Novel H1N1 influenza: Background information • H1N1 outbreak in Anne Arundel County Public Schools, Spring 2009 • School response to Novel H1N1 Virus, Fall 2009: • Current • Contingency plans • Potential school design elements to facilitate response to communicable diseases • Summary • Questions

3. Novel H1N1 influenza: Background information

4. What is influenza? A type of virus that causes respiratory infection with systemic S/S Two types of influenza viruses cause epidemic human disease: Influenza A: Categorized into subtypes on the basis of 2 surface antigens: Hemagglutinin Neuraminidase Influenza B: Two distinct genetic lineages: Yamagata and Victoria Not categorized into subtypes Seasonal vs. pandemic influenza Seasonal Virus changes slightly most years (antigenic drift) Season usually October through May ~200,000 persons hospitalized ~36,000 deaths Pandemic Influenza virus to which most of population lacks immunity Spread to at least two regions in the world

5. Novel H1N1 influenza: Background information H N

6. What is H1N1 influenza? Antigenically and genetically distinct from other human influenza A (H1N1) viruses in circulation since 1977 Inappropriately referred to as “swine” flu because the virus is related to influenza viruses that affect pigs. The most affected group of persons is under age 24 years. Has spread to all regions of the globe—pandemic declared in June 2009.

8. How is influenza spread?Seasonal and Novel H1N1 Respiratory droplets from an infectious individual—coughing and sneezing Can travel up to 3 feet in the air Contaminates another person close by Lands on surfaces (fomites), e.g., doorknobs, computer keyboards, faucet handles Infection begins when the virus is introduced to the nose or mouth (mucous membranes)

9. How are people affected?Seasonal and Novel H1N1 Respiratory illness with systemic signs & symptoms: Fever (100°F or greater), cough, sore throat Nasal congestion, muscle aches, headache, chills, fatigue Diarrhea, vomiting (seen with novel H1N1) Usually abrupt onset Typical time to recover is 4 days to one week in healthy people

10. Risk Factors for Severe Disease Immune system disorders HIV, transplant, chemotherapy, etc. Elderly, infants, pregnant women Other medical problems: Lung disease Diabetes Kidney disease

11. Treatment of InfectionSeasonal and Novel H1N1 Rest Drink plenty of liquids Avoid drinking alcohol or smoking Use over-the-counter medications Labeled “cold and flu” remedies Not aspirin In some situations, use antivirals Oseltamivir (Tamiflu), zanamivir (Relenza) Prescription medications Initiate within 48 to 72 hours of first symptoms for optimal effectiveness

12. Preventing the flu Seasonal and Novel H1N1 Clean hands often Soap and water Alcohol-based hand sanitizers Cover your cough/sneeze Use a tissue or your sleeve Avoid close contact with sick people Practice healthy behaviors Don’t smoke, eat a healthy diet, exercise Use antiviral medication if prescribed

13. Novel H1N1 influenza: Background information

14. Preventing the flu Influenza Vaccine

15. Flu Vaccines Two types Trivalent inactivated influenza vaccine (TIV) (injectable) Live, attenuated influenza vaccine (LAIV) (nasal spray) Safety (known for seasonal vaccine) Shot: arm soreness, redness, swelling, low grade fever, mild muscle aches, fatigue Nasal spray: low grade fever, runny nose, headache, sore throat, fatigue DOES NOT CAUSE THE FLU!! Timing Protection takes at least 10 days

16. Flu Vaccines Seasonal vaccine Still important this year Available now Novel H1N1 vaccine First shipments anticipated ~mid-October Target and priority groups initially If available, everyone for whom medically appropriate may be vaccinated over the next 6 months Not mandatory

17. Who will get the H1N1 vaccine? Pregnant women Health care and emergency medical workers People who live with or care for children <6 months old Persons 6 months through 24 years Adults 24 through 64 years with high risk health conditions Pregnant women Health care workers with direct patient contact People who live with or care for children <6 months old Children 6 months through 4 years People 5 through 18 years with high risk health conditions Target Groups High Priority Groups CDC. MMWR Early Release. 2009;58 (August 21, 2009).

18. The Good News… Majority of those affected do not require hospitalization and recover without complications. So far, H1N1 flu appears similar to seasonal flu except for different high-risk groups. Antivirals still generally effective. Vaccine is developed, studies ongoing. Prevention measures work!

19. What else can you do? • Stay home if you or your children are sick! • Do not go to work, school or daycare until 24 hours after the fever has resolved • Recovery takes 3-5 days for most people • Healthcare workers: Stay home for 7 days after symptom onset or until S/S resolve • Make a family plan • Back-up plans for childcare • Look into teleworking with your employer • Food & water supplies • Be flexible

20. H1N1 outbreak in Anne Arundel County Public Schools, Spring 2009

21. Spring 2009: Elementary School – 375 students and staff What occurred What’s going on simultaneously Family member ill (flu symptoms) Recently returned from Mexico Children exposed @ home Children come to school School notified, etc Health Department directs school system “Pandemic” flu announced Media news bites clips focus on people wearing protective masks H1N1Vaccine not ready yet Worst is yet to come Anxiety - probably Panic – not yet but….

22. School System Response School With Teachers and Admin. Facilities With Custodial Staff In consultation w/HD who, in turn, are following CDC: Family children sent home Meet w/teachers and staff Explain situation Advise cleaning protocols Promote good hygiene in classroom & home Letter sent home School will stay open School custodial staff backed up with extra volunteers to clean & disinfect classroom Provided training on virus, disinfection cleaning techniques, overview of disinfectant, and MSDS Provided gloves, masks, rags, spray bottles, pump sprayers Team cleaning approach Disinfectant sprayed on Wipe and rinse

23. Then what….. At school Facility Management Parents swamp phone lines Some kids stay home Rumors Many are sick Another child suspected of H1N1 School to close 5-7 days per H.D. News helicopters, TV reporters & cameras, etc. Gear up for full school disinfection; desks, chairs, hallways. Lockers, basically all surfaces, handles, sinks, knobs etc. TV Crews see inside school to see crews with masks, etc. National news show same scenario in a NY high school.

24. SwineFlu Spreads Across D.C. Region Washington Post Washington Post A federal agent who traveled to Mexico with President Obama this month probably contracted swine flu and infected several members of his family in Anne Arundel County, prompting assurances yesterday from the White House that the President was safe. Parents and government officials are debating whether to close schools where suspected cases of swine flu have been discovered. What should officials do? Keep schools open. Schools should be cleaned and sick children kept home, but closings go too far.39% Close schools. School officials should take every step possible to protect children from the flu.57% Other solution. Write your answer in the comments below.2% Total Votes: 2,648

25. Community/parents alarm • Folger McKinsey Elementary School in Anne Arundel County has a student that has been tested for the swine flu. The results have not come back yet. School and county officials were on hand for the opening of school Thursday morning.

27. Parents Debate Sending Children to School as Officials Urge Caution School National The word came so late in the school day yesterday that officials couldn't send a letter to parents, so they resorted to e-mails and phone calls: A student at Folger McKinsey Elementary School in Severna Park was one of six probable cases of swine flu in Maryland. At a news conference last night, President Obama recommended that schools with suspected cases of swine flu strongly consider closing. But a spokesman for Gov. O'Malley said afterward that Maryland schools would remain open. "At this point it doesn't appear that it's necessary given the probable cases in Maryland," spokesman Shaun Adamec said.

28. CDC Guidance CDC School & Health Department On a national conference call, CDC states that any school with even a single case of H1N1 influenza should close for 5-7 days (possibly as long as 14 days). In conformity with CDC guidance, School and Health Department close school.

29. Outcomes School Facilities Reopened in 3-4 days No outbreak School returns to routine Vast expenditure of manpower and equipment Lots of overtime

30. Lessons Learned from Spring 2009 • Use of Incident Command System (ICS) • Consistent, uniform messages from key leaders: • Joint Information Center (JIC) • Joint Press Conference • Manage expectations; pro-actively stress need for flexibility in response to a dynamic situation. • Frequent updates in understandable language: • Public/parents/children: • Phone bank • Automated phone call-out system • Websites • Written materials (letters home, posters in schools) • Staff (Schools, Health Department) • Collaboration between Schools and Health Department: • Planning (Schools/Health Department MOU; exercises) • Implementation • Communications (Continued)

31. Lessons Learned from Spring 2009(continued) • After-action analysis/assessment and follow-up action • Needs identified: • Formal school-based surveillance system • School attendance policies • Staff sick leave policies • Identification of personnel and equipment shared between schools (e.g., buses and bus drivers, itinerant staff) • Identification of, and planning for, “higher-order effects” of closure (e.g., free/subsidized meals, after-school activities, athletics) • Tracking costs/expenditures • Personal Protective Equipment (supplies, fit testing) • Isolation rooms • Handwashing stations

32. School response to Novel H1N1 Virus, Fall 2009

33. School response to Novel H1N1 Virus, Fall 2009: CDC Guidance--Philosophy Decision to dismiss students should: Be made locally Balance the goals of: Morbidity and mortality from influenza with Minimizing social disruption and safety risks to children sometimes associated with school dismissal. Based on the experience and knowledge gained in jurisdictions that had large outbreaks in spring 2009, the potential benefits of preemptively dismissing students are often outweighed by negative consequences, including: Students being left home alone Health workers missing shifts when they must stay home with their children Students missing meals, and Interruption of students’ education. http://pandemicflu.gov/professional/school/

34. School response to Novel H1N1 Virus, Fall 2009: CDC Guidance—Scalable Responses • Conditions with similar severity as in Spring 2009: • Facilities Issues: • Location for screening upon return • Instruction (study or teaching)while at home • Isolation rooms (students, staff) • Staffing • Storage of masks (surgical masks for ill; N-95’s for healthcare personnel) • Soap & towels, hand sanitizer, tissues: • Supplies • Locations, dispensers • Refill, maintenance, security • Waste receptacles Recommendation: • Stay home when sick • Separate ill students and staff • Hand hygiene and respiratory etiquette (Continued)

35. School response to Novel H1N1 Virus, Fall 2009: CDC Guidance—Scalable Responses • Conditions with similar severity as in Spring 2009: • (continued) • Facilities Issues: • Supplies & equipment (gloves, masks, pump and hand sprayers)* • Staffing • Compliance with medication regimen • Dispensing and storage of anti-viral Rx’s • Co-location of high-risk and normal-risk facilities *American Academy of Pediatrics’ Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide, 2nd Edition (2009) for guidance on cleaning and sanitizing in schools. (http://aapredbook.aappublications.org/resources/midsheets.dtl) The EPA provides a list of EPA-registered products effective against flu: http://www.epa.gov/oppad001/influenza-disinfectants.html Recommendation: • Routine cleaning • Early treatment of high-risk students and staff • Consideration of selective school dismissal

36. School response to Novel H1N1 Virus, Fall 2009: CDC Guidance—Scalable Responses • Conditions of increased severity compared with Spring 2009: • Facilities Issues: • Location for screening • Equipment/supplies (e.g., thermometers) • Staffing • Identification of high-risk persons: • Staff • Location • Communication with high-risk persons • Study/work from home: • Equipment, supplies • Staff • Same as above for affected students Recommendation: • Active screening • High-risk students and staff members stay home • Students with ill household members stay home (Continued)

37. School response to Novel H1N1 Virus, Fall 2009: CDC Guidance—Scalable Responses • Conditions of increased severity compared with Spring 2009: • (continued) • Facilities Issues: • Space limitations • Scheduling • Longer duration of above issues • Identification of appropriate schools • Impact on co-located facilities (e.g., schools, libraries, recreation centers) • Instructional staff facilities & resources • Security Recommendation: • Increase distance between people at schools • Extend the period for ill persons to stay home • School dismissals

38. Potential School Design Elements to Facilitate Response to Communicable Diseases

39. Potential School Design Elements to Facilitate Response to Communicable Diseases(Slide 1 of 9) National Clearinghouse for Educational Facilities (National Institute of Building Sciences), Resource List for School-Based Health Facilities--http://www.edfacilities.org/rl/health_centers.cfm The Center for Health and Health Care in Schools--http://www.healthinschools.org/static/states/MD-guidelines.aspx http://www.maclearinghouse.com/schoolhealthmanual/PDF/Chapters/Chapter02_D.pdf • Generally: • Collaboration with School Health staff during design phase • Health Room: • Location • Size • Equipment • Communications/support systems (intranet, internet, phone, fax) • Supplies • Storage • Staffing

40. Potential School Design Elements to Facilitate Response to Communicable Diseases(Slide 2 of 9) • Screening Points: • Potential uses: • Active screening • Return from illness • Considerations: • Traffic flow • Location: • Ingress/egress to exterior of building • Proximity to: • Health Room • Isolation facilities • Staffing/monitoring • Furnishings • Equipment • Support systems (intranet, internet, telephone, fax)

41. Potential School Design Elements to Facilitate Response to Communicable Diseases(Slide 3 of 9) • Isolation capability: • “Isolation” vs. “quarantine” • Considerations: • Capacity • Location: • Proximity to: • Health Room • Screening Points • Ingress/egress to exterior of building • Staffing/monitoring • Furnishings • Equipment • Support systems (intranet, internet, telephone, fax)

42. Potential School Design Elements to Facilitate Response to Communicable Diseases(Slide 4 of 9) • Potential for fomite transmission: • Factors affecting infection potential • Environmental surfaces: • Floors • Handles/knobs • Walls • Furnishings (e.g., desks, counters) • Equipment (e.g., keyboards [membrane covers?]) • Considerations: • Infection potential • Cleanability/potential to disinfect • Costs (total lifetime cost): • Initial • Maintenance • Replacement • Durability • Esthetics • Special characteristics (e.g., non-slip flooring)

43. Potential School Design Elements to Facilitate Response to Communicable Diseases(Slide 5 of 9) • Hygiene resources/facilities: • Rest Rooms: • Soap • Towels • Supply storage • Waste/refuse disposal • Fomite infection risk: • Environmental surfaces • Faucet handles • Maintenance • Hand hygiene: • Free-standing hand-washing stations • Hand sanitizer stations: • Locations • Refilling & Maintenance • Safety & Security

44. Potential School Design Elements to Facilitate Response to Communicable Diseases(Slide 6 of 9) • Environmental Control Systems: • Temperature • Humidity • Particulates (especially allergens) • Gases and vapors • Air exchange • Design easy to change and readily accessible air filters • Design for adequate ventilation: Solution to Pollution is Dilution • Design schools with systems that require no-touch to operate via sensors • Room lighting • Drinking fountains • Toilets • Hand sinks

45. Potential School Design Elements to Facilitate Response to Communicable Diseases(Slide 7 of 9 ) • Storage: • Cleaning & maintenance supplies (e.g., disinfectant) • Equipment (e.g., sprayers) • Health Room: • Equipment • Supplies (e.g., masks, gloves, thermometer covers) • Refrigerated storage: • Capacity • Temperature Tolerance 45

46. Potential School Design Elements to Facilitate Response to Communicable Diseases(Slide 8 of 9) • Alternate uses of facility: Facilities issues: • Location/Proximity to “index” facility • Ingress/Egress • Building systems (HVAC, electrical, IT) • Location/Proximity to Population • Ingress/Egress • Traffic Flow • Building systems (HVAC, electrical, IT) • Storage (e.g., refrigeration) • Same Use: • Alternate Care Site (e.g., for local hospital during disaster) • Mass immunization site • Point-of-distribution (POD) for medications

47. Potential School Design Elements to Facilitate Response to Communicable Diseases(Slide 9 of 9) • Co-located facilities: • Examples: • Other schools (e.g., pod of high school, middle school, and elementary school) • Library • Recreation/Community/Social Center • Potential issues: • Infection/cross-contamination (directly, or by shared/common population) • Facility closure (does closure of one necessitate closure of all) • Futility of selective/partial closure • Shared infrastructure/building systems: • Possible or cost-effective to partially shut down) • Effects on health risks/environmental control/comfort (e.g., HVAC)

48. Summary • Novel H1N1 influenza: • Information relevant to educational facility planners • H1N1 outbreak in Anne Arundel County Public Schools, Spring 2009: • Lessons learned • School response to Novel H1N1 Virus, Fall 2009: • Current • Contingency plans • Potential school design elements to facilitate response to communicable diseases

49. Questions?