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
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
Pandemic does not reflect severity of disease—only the spread of the infection geographically.

5. Novel H1N1 influenza: Background information

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 Infection Seasonal 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 Safety (known for seasonal vaccine) Timing
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 Novel H1N1 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?
Target Groups
High Priority Groups
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
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
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
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.
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.

24. Swine Flu Spreads Across D.C. Region
Washington Post
Washington Post
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
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.

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
National
School
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.
The word came so late in the school day yesterday that officials couldn't send a letter to parents, so they resorted to s and phone calls: A student at Folger McKinsey Elementary School in Severna Park was one of six probable cases of swine flu in Maryland.

28. CDC Guidance School & Health Department CDC
In conformity with CDC guidance, School and Health Department close school.
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).

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.

34. School response to Novel H1N1 Virus, Fall 2009: CDC Guidance—Scalable Responses
Conditions with similar severity as in Spring 2009:
Recommendation:
Stay home when sick
Separate ill students and staff
Hand hygiene and respiratory etiquette
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
(Continued)

35. School response to Novel H1N1 Virus, Fall 2009: CDC Guidance—Scalable Responses
Conditions with similar severity as in Spring 2009:
(continued)
Recommendation:
Routine cleaning
Early treatment of high-risk students and staff
Consideration of selective school dismissal
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. ( )
The EPA provides a list of EPA-registered products effective against flu:

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
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)
Recommendation:
Increase distance between people at schools
Extend the period for ill persons to stay home
School dismissals
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

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)
Generally:
Collaboration with School Health staff during design phase
Health Room:
Location
Size
Equipment
Communications/support systems (intranet, internet, phone, fax)
Supplies
Storage
Staffing
National Clearinghouse for Educational Facilities (National Institute of Building Sciences), Resource List for School-Based Health Facilities--
The Center for Health and Health Care in Schools--

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:
Use:
Alternate Care Site (e.g., for local hospital during disaster)
Mass immunization site
Point-of-distribution (POD) for medications
Facilities issues:
Location/Proximity to “index”
facility
Ingress/Egress
Building systems (HVAC, electrical, IT)
Location/Proximity to Population
Traffic Flow
Storage (e.g., refrigeration)
Same

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?