# Presentation: 231008

## Pandemic Influenza:Preparing and Responding to a School Crisis

**Diane Allensworth, PhD, RN**
**Associate Director, Education Sector**
**Division of Private and Public Partnerships, Centers for Disease Control**

## "As a former superintendent of the nation's seventh largest school district, I know the importance of emergency planning.  The midst of a crisis is not the time to start figuring out who ought to do what.  At that moment, everyone involved - from top to bottom - should know the drill and know each other."	  Former Secretary of Education, Rod Paige

**Notes:**
The Former Secretary of the Department of Education, has said that.... (read slide).

"Families trust schools to keep their children safe during the day.  Thanks to the efforts of millions of teachers, principals and staff across America, the majority of school remain a safe haven for our nation's youth.  The unfortunate reality is however, that school districts in this county may be touched either directly or indirectly by a crisis of some kind at any time."

Department of Education, Office of Safe and Drug Free Schools.  Practical Information on Crisis Planning: A Guide for Schools and communities. Washington, D.C., 2003, page 1-1.

## Natural Disasters

-  Tornadoes
-  Floods
-  Hurricanes
-  Earthquakes
-  Landslides

**Notes:**
As a former school nurse in the mid-west, I remember crisis/disaster planning  as planning that revolved around plans to implement in case of a fire and/or a weather emergency, such as a tornado.

## School Shootings

**Notes:**
The list of events that constitutes a crisis has expanded with the events at Columbine.  Unfortunately, this type of crisis is much too prevalent.  

##       Infectious Diseases

- 	Colds
- Pertussis
- Viral Meningitis
- Lice/Scabies
- Ringworm
- Chickenpox
- Seasonal Influenza

**Notes:**
A major category of events that can cause a crisis in school are those resulting from infectious disease.  There are several infectious diseases and conditions that are common in school setting. They are spread from person to person. This presentation focuses on a potentially emerging disease pandemic influenza.   Before I mention pandemic influenza, I I want to talk a minute about seasonal influenza - just to put a pandemic in perspective.
Seasonal influenza is a contagious respiratory illness caused by influenza viruses and occurs every year. (CDC Pandemic Influenza Update 12/07/06 Page 1).

##  Infectious Diseases

- Seasonal Influenza

**Notes:**
" Students lose more than 120 million school days each year because of illness caused by bacteria, viruses or other infectious agents.  Acute respiratory conditions, such as the common cold and flu, cause the majority of lost days."  (Page 3 ASHA)

"What the difference between a cold and the flu?   In general, the flu is worse than the common cold.  Colds generally do not cause fever or muscle aches, nor result in serious health problems, such as pneumonia or bacterial infections.  People with colds are likely to have a runny or stuffy nose." (Page 7 ASHA)

"Seasonal influenza can cause mild to severe illness.  It is responsible for about 36,000 deaths each year in the United states, mostly among persons 65 years of age and older.  The best protection against seasonal flu is vaccination." (CDC Pandemic Influenza Update 12/07/06 Page 1).

"The bad news for schools is that while seasonal influenza does not usually cause deaths students, it continues to impact schools.  Influenza alone leads to approximately 53 million lost school days each year.    Infectious diseases of the respiratory system, such as colds and influenza, usually spread from person to person in respiratory droplets, released through coughs and sneezes: the droplets move through the air and land on the mouth or nose of someone nearby.  Germs also spread when a person touches infected respiratory droplets on a surface like a desk or door handle and then touches food or their own mouth or nose before washing their hands.  Some viruses and bacteria can live 2 hours on such surfaces."

Health In Action: Preventing the flu and other infectious diseases can improve school attendance.  Kent, Ohio: American School Health Association. 2004;4(2) p. 3    

## Avian Influenza

- Avian influenza or "bird flu" is an infection in birds caused by a variety of subtype viruses.
- One such subtype is H5N1.
- Some strains of H5N1 are highly pathogenic.
- The severe strain of H5N1 is killing birds in Asia and parts of Europe.

**Notes:**
"Avian influenza or "bird flu" is an infection in birds caused by a variety of subtype viruses. 
One such subtype is H5N1.
Some strains of H5N1 are highly pathogenic.  In other words, they make birds seriously ill and die.
The severe strain of H5N1 is currently killing birds in Asia and parts of Europe. Sometimes a bird flu strain will change so that it can also make people or others animals very sick or die." (CDC Pandemic Influenza Update 12/07/06 Page 1).

## Avian Influenza cont....

- The H5N1 strain has sickened about 142 people in Asia who came in contact with the sick birds - 74 people died.

**Notes:**
"The H5N1 strain has sickened about 142 people in Asia who came in contact with the sick birds - 74 people (52%) died." (CDC Pandemic Influenza Update 1/05/06 Page 5).

At this time the H5N1 strain is not transmitted from human to human.  It is transmitted to humans by contact with sick birds. (e.g., handling of sick or dead birds). 

## Pandemic Influenza = Global Outbreak

- Conditions Supporting Pandemic Influenza
- New influenza type emerges
- Causes serious human illness
- Spreads easily from person to person

**Notes:**
If H5N1 were to change (mutate) and become easily transferred from human to human (instead of the sick bird to human), there is the possibility of a pandemic influenza.

"Pandemic flu or pandemic influenza is a global outbreak of disease that occurs when three conditions are met:
New influenza type emerges
Causes serious human illness
Spreads easily from person to person
(CDC Pandemic Influenza Update 12/07/06 Page 1).

## Currently there is no pandemic influenza in the world.

- Scientists can not predict if and when the H5N1 virus might start a pandemic.

**Notes:**
Currently there is no pandemic influenza in the world.
"Remember, the H5N1 avian influenza or "bird flu" covered in the news has not qualified as a pandemic strain of influenza.  Importantly, scientists can not predict if and when the H5N1 virus (0r any other virus) might mutate and become easily spread from person to person.
(CDC Pandemic Influenza Update 12/07/06 Page 2).

## Public Health Prepares for a Possible Pandemic...

- CDC

- Issues:
-  An Influenza pandemic may
-     emerge with little warning.
-  A vaccine will not yet be
-     available.
-  The supply of anti-viral drugs
-     will be limited.

**Notes:**
"An influenza pandemic may emerge with little warning, affecting a large number of people within a short space of time.  During the first wave of the pandemic, outbreaks may occur simultaneously in many locations throughout the nation - requiring each locality to depend I large measure on its own resources to respond.  A vaccine will not yet be available, and the supply of antiviral drugs will be limited.  Local outbreaks may last for weeks or months and widespread illness in a particular community could lead to shortages in the health care sector as well as in essential services".
(CDC Pandemic Influenza Update 12/07/06 Page 2).

##  1918-19 Pandemic Influenza  (Type A H1N1)

- More than 500,000 deaths in the US.
- Up to 50 million may have died world wide.

**Notes:**
To put Avian Influenza in perspective...
"In 1918 -19 the Influenza type A (H1N1) caused the highest number of known influenza deaths: 
	More than 500,000 deaths in the US.
	Up to 50 million may have died world wide.
The 1957-58 pandemic, influenza type a H2N2, caused about 70,000 deaths in the United States.  

Sometimes a novel strain of influenza virus emerges in humans, but unexpectedly causes relatively few cases of serious illness or death.  The 1976 swine flu disease in this country was such an example.

(CDC Pandemic Influenza Update 12/07/06 Page 1).

## CDC Recommends...

- CDC

- Begin planning for a potential
-    pandemic
- Draft key documents identifying
- 	* legal authority for action
- 	* quarantine and isolation
- 		orders
- 	* opening and closing schools

**Notes:**

Read slide
(CDC Pandemic Influenza Update 12/07/06 Page 1).

## CDC Resources:1)  www.pandemicflu.gov 2)  District Planning Checklist: School District (K-12) Pandemic Influenza Planning Checklist

**Notes:**
CDC, in conjunction with HHS has developed a web site that contains our best information on planning for pandemic influenza.  It can be seen at  www.pandemicflu.gov 
With the assistance of the Department of Education, CDC has also developed a beginning planning check list which has been distributed to you.  There is a need to follow this checklist with additional specific  guidance for local schools from the Department of Education as well as from CDC.

## US Department of Education'sPractical Information on Crisis Planning

**Notes:**
To begin planning for any crisis, I would recommend securing a copy of the US Department of Education's
: 'Practical Information on Crisis Planning. 
This book takes one through the basic steps of crisis planning:. Every crisis that could occur in schools can and should be handled with guidelines revolving around these four steps.

"Crisis planning may seem overwhelming.  It takes time and effort, but it is manageable".
My guess is that most of you have already done that and are far along on your crisis management plans.

## Crisis Planning: The Basic Steps		

- Prevention
- Preparedness
- Response
- Recovery

**Notes:**
As you know,
"Crisis management is a continuous process in which all phases of the plan are continually being revised.  Good plans are never finished.  They can always be updated based on experience, research and changing vulnerabilities" (US Dept of Education. Practical Information on Crisis Planning p1-6).

We know that....
Prevention is the phase in which schools and districts address what they can do to reduce or eliminate risk to life and property.  The checklist provides some instruction on the need to reinforce hygienic habits long before a pandemic is upon us.  But preventing a pandemic is basically out of the control of an LEA.
Preparedness focuses on the process of planning for the worst case scenario.  How can learning continue it the school is shut down for 8 or more weeks?  What do we do for the vulnerable students who depend on the school cafeteria for two meals a day?
Response is the phase devoted to implementing the identified steps to take during a crisis.  Who has the authority to close and reopen  the schools in your area?
Recovery deals with how to restore the learning and teaching environment after a crisis.  Given there will be a number of fatalities, how will students cope?  How with the school cope with the loss of critical staff?

The checklist developed by the  Department of Education and the Centers for Disease Control and Prevention is a beginning for LEAs to use as they think through the issues in preparing for a pandemic. 

Let me just identify some of the highlights of the check list.  Although you have a copy, it has not been released and still is embargoed waiting the release by HHS and DoE.  Consider yourself a part of a large focus group.  If you see glaring omissions or errors, please let me know so that we can make sure that the final version provides the best possible guidance.

Department of Education, Office of Safe and Drug Free Schools.  Practical Information on Crisis Planning: A Guide for Schools and communities. Washington, D.C., 2003, page 1-8.

## Prevention

- 	*Reducing and/or eliminating risk to life and property of a particular environment. *
- Implement prevention programs
- Institute policies to reduce impact

**Notes:**
I am briefly going to review the required steps and provide examples of issues to think about early in the planning...
As I said earlier, prevention is the process in which school staff try to reduce and/or eliminate risk or harm to life (students, teachers, staff) and their property in the school environment. 
While there is not a lot that the local district can do to prevent the development of a pandemic, they do have the opportunity to promote ways of curtailing the dissemination of infectious disease and these should be standard practices within all schools well before an pandemic strikes.

## Is The School Environment Conducive to Good Hygiene?

- Accessible soap, paper towels &
-   sinks
- Breaks for hand hygiene
- Incentives for hand hygiene
- Sanitary, health & safety inspections
-   of the school
- Healthy Schools, Healthy People: It's a Snap program www.itsasnap.org

**Notes:**
In order to prevent an infectious disease outbreak, all schools should assess the degree to which the environment is conducive to good hygiene:
" Are soap, paper towels and working sinks available at accessible locations?  Are they unlocked during the day?  Are bathroom locations convenient?  Are students given enough time during their breaks to take advantage of hand sinks?   Is there a place for students to wash their hands before eating?....An available hand sink at the beginning of the lunch line in the cafeteria would encourage hand washing prior to eating.  Food service workers are required to wash their hands frequently to prevent disease....shouldn't schools ask the same of their students and staff? (page 13).

.

A great resource is: Healthy Schools, Healthy People: It's a Snap program www.itsasnap.org
While it is designed for middle school students, it can be adapted for elementary or secondary schools. (page 19)

Health In Action: Preventing the flu and other infectious diseases can improve school attendance.  Kent, Ohio: American School Health Association. 2004;4(2) p. 13,19

## Infectious Diseases Policies

- _Written Policies Needed by Schools_
- Environmental hygiene
- Inclusion & exclusion for students/staff  illnesses
- Notification of local health authorities of certain communicable diseases
- American Academy of Pediatrics. *Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide*.* *2005;13

**Notes:**
"All child schools should have written policies that describe environmental hygiene,inclusion and exclusion for children and staff illnesses, families' responsibility to share information about illnesses in children, the need to notify local health authorities of certain communicable diseases involving children or staff..."
Accurate record keeping and tracking for immunizations and other routine preventive health care services and the need to identify the child's source of routine, comprehensive health care, known as the medical home." (Page 13)

American Academy of Pediatrics. Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide. 2005, page 13

## Preparedness

- Constructing a plan to properly handle a situation prior to its occurrence.
- 			* District level
- 			* School level

**Notes:**
Let's move to the next major steps in planning: Preparedness.
Proper planning will facilitate systematic, prompt, and efficient response to a crisis.
"Despite everyone's best efforts at crisis prevention, a pandemic may occur and it will affect schools.  Good planning will facilitate a rapid, coordinated effective response when a crisis occurs.  Being well prepared involves an investment of time and resources - but the potential to reduce injury and save lives is well worth the effort.  
Every District needs a crisis plan that is tailored to its unique characteristics.  Within a school district, however, it is necessary the plans at the respective schools to have certain commonalities.  Also, it is impractical for all schools to work individually with emergency responders and other local agencies, although school staff should meet the people who will respond to a crisis before one happens.  It is important to find the right balance and to assign district and school roles early."  A pandemic probably will not require a school specific response.

(Department of Education, Office of Safe and Drug Free Schools.  Practical Information on Crisis Planning: A Guide for Schools and communities. Washington, D.C., 2003, page 3-1,2).
In contrast to most other crisis, a pandemic will not be school specific but probably affect the entire district.

## Preparedness

- 1. Identify _district-level teams _to develop the management plan
- Identify the authority for declaring  a public health emergency
- Coordinate the local/state health department/ emergency responders ensuring compatibility

**CDC**

**Notes:**
At the district level, all of the stakeholders (Superintendent/Principals, Security director, City/County Emergency Planners & Responders/ Health Department, Nurses, counselors, Food service director, and Families)  that should be assembled to develop a crisis management plan.  Stakeholders provide input on the section of the plan that pertains to them.  In some cases, school districts might want to sign MOAs with community agencies specifying expectations, roles and responsibilities.

Working with the local health department, as well as the state health department and state education agencies is recommended. Establishing who has the authority to close and open the schools is needed.  Also assuring that the plan established by the district is compatible with the communities plan.

The school has a variety of resources that may be useful to the county/city plan: school nurses, school counselors and psychologists, facilities that may be designated as contingency hospitals or schools may be needed to feed vulnerable populations.

## Preparedness

- Identify process and procedures for:
- Continuity of student learning
- Core operations
- Communication

**Notes:**
Given that at a minimum there probably will be at least two pandemic disease waves of about 6-8 weeks each over several months, schools will need to identify process for assuring:
	* Continuity of student learning 
	* Core operations
Continuity of student learning may be continued via web-based distance instruction, telephone trees, mailed lessons and assignments, instruction via local radio or television stations in even of school closures.

Core operations of the school such as payroll, maintenance of facilities and communications with staff and students will need to be maintained.

"...Create a communication system. During the planning process, both individuals and backups should be assigned to fill roles: School commander, liaison to emergency responders, student caregivers, security officers, medical staff, and spokesperson."  
It will be necessary to communicate 

( Department of Education, Office of Safe and Drug Free Schools.  Practical Information on Crisis Planning: A Guide for Schools and communities. Washington, D.C., 2003, Page 3-5)

## Preparedness

-  Create  and test an effective means of communication with staff, students, families and the media
- Determine a mechanism on how to instruct students and staff on what to do
- Determine means of communication
- Cell phones, radios, intercoms, e-mails etc
- Develop partnerships with media, community agencies and law enforcement

**Notes:**
Information is given to students, parents, staff and the media through communication and it is essential that it is correct and effective. 
"It is critical that schools and emergency responders use the same definitions for the same terms. Don't create more confusion because terms do not mean the same to everyone involved in responding to the crisis." 

( Department of Education, Office of Safe and Drug Free Schools.  Practical Information on Crisis Planning: A Guide for Schools and communities. Washington, D.C., 2003, Page 3-6)

In other words, use plain language rather than codes.

## Response

- Executing the plan that was produced prior to the crisis.

**Notes:**
Activating the plan is crucial during a crisis. It provides all the steps that are need to handle the crisis. This is especially significant when the crisis puts people in a state of panic, because everything they need to know or do is provided.
 It is important to follow the plan step-by-step and not to create a new plan on the spot
Creating a new plan may  cause confusion and add  chaos to the situation.

Maintaining links to credible public health reports will be critical, given that initially there will not be any vaccines, nor sufficient anti-virals for all.

## Recovery

- To return the environment back to its normal conditions, as early as possible

**Notes:**
"The goal of recovery is to return to learning and restore the infrastructure of the school as quickly as possible.  Focus on students and the physical plant, and to take as much time as needed for recovery.  School staff can be trained to deal with the emotional impact of the crisis, as well as to initially assess the emotional needs of students, staff and responders.  One of the major goals of recovery is to provide a caring and supportive school environment." "Experts agree that the first order of business following a crisis is to return students to learning as quickly as possible."  

( Department of Education, Office of Safe and Drug Free Schools.  Practical Information on Crisis Planning: A Guide for Schools and communities. Washington, D.C., 2003, page Page 5-2,3)

Getting the students back in the mode of learning will allow them to understand that just because a crisis has happened doesn't mean life is on hold or over. Some students will not cope with being separated from their classmates well.  
Given that at this time the death rate for avian flu is over 50%, we can anticipate the need for grief counseling,  The district also will need to consider alternate staffing mechanisms.

- 			     Questions?