1. Influenza & Early Childhood Education
The purpose of this presentation is to educate early care and education providers on disaster preparedness with respect to pandemic flu. The presentation will provide health information and guidance to child care programs and schools on creating pandemic influenza action plans. The health information presented will assist early care and education programs in effectively communicating suggested practices to prevent, prepare, detect, and respond to influenza.
Potential stakeholders include: school district personnel; local child care resource and referral agencies; private for profit and nonprofit child care providers including: child care centers, family child care homes, and preschools; local health departments, local hospitals and community clinics; parent organizations and groups; faith based organizations; Colorado Department of Public Health and Environment; Colorado Department of Education; and the Colorado Department of Human Services.
Influenza & Early Childhood Education
Ashante Butcher
PUBH: Environmental Health
Instructor Dr. Shana Morrell

2. Learning Goals Review universal precautions.
Review procedures that prevent illness and promote children’s health in early care and learning environments.
Identification of resources for effective activities that promote health.
Overview of regulatory systems which guide Colorado’s early childhood programs.
Procedure for planning, developing, and evaluating health practices in an early childhood program.
Today we will review universal precautions that can be applied in early care and education environments. We will review procedures that prevent illness and promote children’s health in early care and learning environments. Resources that can promote health awareness and activities in early care and learning will be discussed. In addition we will learn about two regulatory systems in Colorado that guide early childhood programs, and we will discuss procedures for planning, developing, and evaluating health practices in early childhood programs.
Colorado Office of Professional Development. (2008). Colorado core knowledge and standards: A guide for early childhood professional development. Denver, CO.

3. Learning Outcomes
Awareness of health practices that can be promoted in early care and education environments.
Examination of recommendations for routine cleaning, sterilizing, and maintaining learning materials and equipment.
Procedures to formulate a training plan for pandemic flu prevention and preparedness.
Essential safety management procedures, including a plan for tracking pandemic flu.
Intended learning outcomes are to increase awareness of health practices that can be promoted in early care and education environments. Additionally, we will examine recommendations for routine cleaning, sterilizing, and maintaining learning materials and equipment. Procedures to formulate a training plan, prevention and preparedness practices, and tracking methodologies will be reviewed.
Colorado Office of Professional Development. (2008). Colorado core knowledge and standards: A guide for early childhood professional development. Denver, CO.

4. Pandemic Influenza
A pandemic is a disease that occurs over a wide geographic area and affects an exceptionally high proportion of the population. This presentation will provide information on pandemic influenza. If you are caring for a young child or loved one during a pandemic, it’s important to take steps to protect yourself and others.
Merriam-Webseter. Definition of pandemic. Retrieved from

5. Flu Terms Defined
Seasonal (or common) flu - is a respiratory illness that can be transmitted person to person.
The seasonal flu, also known as the common flu is a respiratory illness that can be transmitted person to person. Most people have some immunity, and a vaccine is available. Seasonal outbreaks of the flu are caused by viruses that are already among people. Seasonal outbreaks of the flu are caused by viruses that are already among people.
U.S. Department of Health and Human Services (2006). Pandemic influenza pre-event message maps. Retrieved from

6. Flu Terms Defined
Pandemic Influenza – a global outbreak caused by a new influenza virus.
The virus may spread easily, possibly causing serious illness and death.
Because so many people are at risk, serious consequences are possible.
Historically, pandemic influenza has caused widespread harm and death.
Pandemic influenza is a global outbreak caused by a new influenza virus. This year, H1N1 influenza has reached pandemic status. Because so many people are at risk, serious consequences may result from pandemic influenza. Historically, pandemic influenza has caused widespread harm and death.
U.S. Department of Health and Human Services (2006). Pandemic influenza pre-event message maps. Retrieved from

7. Historical Overview 1918: H1N1 “Spanish Flu” 1957: H2N2 “Asian Flu”
1968: H3N2 “Hong Kong Flu”
History suggests that influenza pandemics have probably happened during at least the last four centuries. During the 20th century, three pandemics and several "pandemic scares" occurred.
The Spanish Influenza pandemic is the catastrophe against which all modern pandemics are measured. It is estimated that approximately 20 to 40 percent of the worldwide population became ill and approximately 50 million people died. Between September 1918 and April 1919, approximately 500,000 deaths from the flu occurred in the U.S. alone. Many people died from this very quickly. Some people who felt well in the morning became sick by noon, and were dead by nightfall. Those who did not succumb to the disease within the first few days often died of complications from the flu, such as pneumonia which is caused by bacteria.
In February 1957, the Asian influenza pandemic was first identified in the Far East. Immunity to this strain was rare in people less than 65 years of age, and a pandemic was predicted. The 1957 pandemic virus was quickly identified, due to advances in scientific technology. Vaccine was available in limited supply by August The virus came to the U.S. quietly, with a series of small outbreaks over the summer of When U.S. children went back to school in the fall, they spread the disease in classrooms and brought it home to their families. Infection rates were highest among school children, young adults, and pregnant women in October During January and February 1958, there was another wave of illness among the elderly; referred to as a "second wave”, such infections can develop during a pandemic. The disease infects one group of people first, infections appear to decrease and then infections increase in a different part of the population. Although the Asian flu pandemic was not as devastating as the Spanish flu, about 69,800 people in the U.S. died.
In early 1968, the Hong Kong influenza pandemic was first detected in Hong Kong, China. The first cases in the U.S. were detected as early as September of that year, but illness did not become widespread in the U.S. until December. Those over the age of 65 were most likely to die. The number of deaths between September 1968 and March 1969 for this pandemic was 33,800, making it the mildest pandemic in the 20th century.
Taubenberger, J.K., & Morens, D.M., (2006) influenza: The mother of all pandemics. Emerging Infectious Diseases, 12, 1, 15 – 22.
U. S. Department of Health and Human Services. Pandemic Influenza. Retrieved from:

8. Pandemics Do Happen! *Avian (or Bird) Flu
Pandemics have naturally occurred throughout the 20th century
H9*
1998
1999
H5*
2003
Historical analysis can assist in effective planning for a pandemic
1997
H7*
1980
1996
2002 H1 H3 H2 H1
Pandemics do happen and several influenza pandemics naturally occurred throughout the 20th century. By way of historical analysis, communities/nations can effectively plan for a pandemic. This timeline outlines the major pandemics of the 20th century including Spanish influenza, Asian flu, and Hong Kong flu that were reviewed on the last slide.
1977
1915
1925
1935
1945
1955
1965
1975
1985
1995
2005
1918
Spanish
Influenza
H1N1
1957
Asian
Influenza
H2N2
1968
Hong Kong
Influenza H3N2
*Avian (or Bird) Flu
U.S. Department of Health and Human Services (2006). Pandemic influenza pre-event message maps. Retrieved from

9. History - Influenza Pandemics
Historical records since the 16th century suggest that new influenza pandemics may appear at any time of the year.
All influenza A pandemics have been caused by descendants of the 1918 virus, including “drifted” H1N1 viruses and reassorted H2N2 and H3N2 viruses.
Before and after 1918, most influenza pandemics developed in Asia and spread from there to the rest of the world.
1918 virus was novel to humans in 1918 and was not a reassortment virus produced from old existing strains, such as those causing the 1957 and 1968 pandemics.
Historical records since the 16th century suggest that new influenza pandemics may appear at any time of the year, not necessarily in the familiar annual winter patterns of interpandemic years. This is because newly shifted influenza viruses have behaved differently than when they find a universal or highly susceptible human population.
All influenza A pandemics have been caused by descendants of the 1918 virus, including “drifted” H1N1 viruses and reassorted H2N2 and H3N2 viruses. Before and after 1918, most influenza pandemics developed in Asia and spread from there to the rest of the world. Viral sequence data now suggest that the entire 1918 virus was novel to humans in 1918 and was not a reassortment virus produced from old existing strains that acquired 1 or more new genes, such as those causing the 1957 and 1968 pandemics.
Taubenberger, J. K., & Morens, D. M., (2006) Influenza: the mother of all pandemics. Emerging Infectious Diseases, 12, 1, 15 – 22.

10. History - Influenza Pandemics
Most pandemic influenza cases in 1918 (>95% in most locales in industrialized nations) were mild and essentially indistinguishable from influenza cases today.
High death rates appear to be the result of several factors including higher proportion of severe and complicated infections of the respiratory tract.
Protective immunity to influenza?
During influenza pandemics, high death rates appear to be the result of several factors including higher proportion of severe and complicated infections of the respiratory tract, rather than involvement of organ systems outside the normal range of the influenza virus. Most pandemic influenza cases in 1918 (>95% in most locales in industrialized nations) were mild and essentially indistinguishable from influenza cases today.
Deaths during the 1918 pandemic were concentrated in an unusually young age group. In 1917, the 5 – to 15-year age group accounted for 11% of total influenza cases. But in 1918 cases in the 5 to 15-year-old age group jumped to 25% of influenza cases. Findings suggest that older individuals may have acquired protective immunity caused by a closely related viral protein to which older persons had one been exposed.
Taubenberger, J. K., & Morens, D. M., (2006) Influenza: the mother of all pandemics. Emerging Infectious Diseases, 12, 1, 15 – 22.

11. History - Influenza Pandemics
Even with modern antiviral and antibacterial drugs, vaccines, and prevention knowledge, the return of a pandemic virus equivalent in pathogenicity to the virus of 1918 would likely kill > 100 million people worldwide.
Even with modern antiviral and antibacterial drugs, vaccines, and prevention knowledge, the return of a pandemic virus equivalent in pathogenicity to the virus of 1918 would likely kill > 100 million people worldwide. Understanding influenza pandemics in general requires understanding of the 1918 pandemic in historical, epidemiologic, and biologic aspects. This overview is intended to provide a basic understanding of the impact of pandemics in modern times. Now we will shift to discussing the influenza and how it impacts young children and explore aspects of the H1N1 pandemic of 2009.
Taubenberger, J. K., & Morens, D. M., (2006) Influenza: the mother of all pandemics. Emerging Infectious Diseases, 12, 1, 15 – 22.

12. Young Children and the Flu
Influenza threatens the health of young children year round! This graph shows hospitalization rates for young children up to age four at two week intervals throughout the 2007 – 2008 flu season. According to the Centers for Disease Control and Prevention, annual hospitalization rates among children birth through age four typically increase around November and continue at high rates through March. In order to decrease the number of children who are hospitalized due to Influenza at higher rates, not only during the winter months, but year round, children, families, and caretakers must be familiar with recommended actions to take to lessen the impact of influenza in communities.
Centers for Disease Control and Prevention – 2008 U.S. Influenza Summary. Retrieved from

13. Influenza in Mountain States
This graph represents the incidence of influenza (virologic) activity and the percentage of hospital visits for influenza like illness (ILI) in the U. S. mountain region. The mountain region includes: Colorado, Montana, North Dakota, South Dakota, Utah, and Wyoming. In the mountain region, incidence of influenza follows national trends where higher rates typically exist from November through March.
Centers for Disease Control and Prevention – 2008 U.S. Influenza Summary. Retrieved from

14. Prepare for flu 2009 H1N1 in the United States – as of August 6, 2009:
6506 hospitalized cases
436 deaths
Higher rates of pandemic influenza when schools are open and children congregate.
Influenza in Colorado.
As of August 6, 2009, the Centers for Disease Control and Prevention reported 6506 hospitalized cases and 436 deaths from pandemic H1N1 flu virus since the first US cases were reported in April 2009 (CDC, 2009). It is very likely that we will experience higher rates of pandemic influenza when schools are open and children congregate (Campos-Outcalt, 2009). As of October 17, 2009, a total of 20 influenza associated deaths (6 pediatric deaths and 14 adult deaths) has been reported in Colorado (CDPHE, 2009c)
Campos-Outcalt, D. (2009). Pandemic and seasonal flu: What you need to know. The Journal of Family Practice, 58, 9, 481 – 484.
Centers for Disease Control and Prevention (CDC). (2009). Novel H1N1 flu situation update: August 6, Retrieved from
Colorado Department of Public Health and Environment (CDPHE). Disease Control and Environmental Epidemiology Division. (2009c). Colorado weekly flu report for the week ending October 17, Retrieved from

15. What Can You Do to Protect Yourself During a Pandemic Influenza Event?
There are many considerations to keep in mind during a pandemic influenza event.

16. What You Can Do… Be Prepared Maintain Hand Hygiene & Personal Health
Prepare Work Environments
Respond
Key considerations during a pandemic influenza event include: being prepared for the potential to contract the disease; maintenance of hand hygiene and personal health practices; the ongoing maintenance and preparation of child care, home, and other environments to prevent the spread of the influenza virus; and knowing the symptoms of flu so the virus can be readily recognized, those who may become ill can receive proper medical attention and be treated, and precautionary measures can be exercised to prevent further spread of influenza germs.

17. Pandemic Influenza – Prevention
Examples of educational materials and posters are available at: m
We must take preventative measures to control the spread of influenza. These healthy habits will help keep you and others from getting and passing on the virus:
Cover your mouth and nose with a tissue when you cough or sneeze and clean your hands afterward. Put used tissues in a wastebasket.
Cough or sneeze into your upper sleeve if you don’t have a tissue.
Clean your hands often with soap and water or alcohol-based hand sanitizer.
Keep your hands away from your eyes, nose and mouth to prevent germs from entering your body.
Early childhood providers should frequently remind children, their families, and staff about the importance of staying home when ill; early treatment for people at higher risk for flu complications; hand hygiene; and respiratory etiquette. Educational materials (for example, posters) to enhance compliance with recommendations should be visible in the child care setting. Examples of these materials are available at: (CDC, 2009).
Centers for Disease Control and Prevention. Cover your cough. Retrieved from

18. Vaccination Live attenuated influenza vaccine (LAIV): Runny nose
Recommendations for Children and Adolescents at High Risk for Complications:
Aged 6 months to 4 years
Those who have chronic diseases
Those with any respiratory condition
Those receiving long term aspirin therapy
Those in chronic-care facilities
Live attenuated influenza vaccine (LAIV):
Runny nose
Nasal congestion
Headache
Fever
Recommendations for Adults:
Persons aged ≥ 50 years
Pregnant women
Health care personnel
Care givers of children or those with medical conditions
Those who have chronic diseases
Those with any respiratory condition
Vaccination is an ideal response to an influenza epidemic (Barnett, 2006). Signs and symptoms often reported after receiving an influenza vaccine are mild and often include the following: runny nose, nasal congestion, headache, and fever.
Nonetheless, vaccination is recommended for persons of specific groups and specific ages, for persons who are, or are contacts of, persons at higher risk for influenza complications. Recommendations for Children and Adolescents at High Risk for Complications are as follows: aged 6 months to 4 years; those who have chronic diseases; those with any respiratory condition; those receiving long term aspirin therapy; and those in chronic-care facilities. Recommendations for Adults are as follows: persons aged ≥ 50 years; pregnant women; health care personnel; care givers of children or those with medical conditions; those who have chronic diseases; and those with any respiratory condition.
In addition to good hygiene, high risk individuals (i.e., young children, some adults, the elderly, and individuals with compromised immunity) should receive annual flu shots to prevent the spread of pandemic flu.
Centers for Disease Control and Prevention. (2008, July 17). Prevention and control of influenza: Recommendations of the advisory committee on immunization practices (ACIP). Morbidity and Mortality Weekly Report, 57, 1 – 60.

19. Influenza: Prevention & Preparedness
Application
5.25 Percent Chlorine
6.00 Percent Chlorine
Bleach Per Gallon of Water
Diapering areas & other surfaces contaminated with bodily secretions and excretions (disinfecting)
¼ cup
3 ½ tablespoons
Food contact surfaces & other areas not contaminated with bodily secretions and excretions (sanitizing)
1 tablespoon
2 ½ teaspoons
The flu virus is spread when contaminated droplets exit the mouth and nose of an infected person and the virus comes in contact with others. So, follow these tips to protect yourself and others in you child care settings and at home:
Keep everyone’s personal items separate.
All household members / child care providers should avoid sharing computers, pens, papers, clothes, towels, sheets, blankets, food or eating utensils.
Disinfect door knobs, switches, handles, toys and other surfaces that are commonly touched around the home or workplace.
Wash your hands after handling dirty laundry.
Wear disposable gloves when in contact with or cleaning up body fluids.
One person should be the caregiver - he or she may benefit by wearing a mask when giving care.
Use the following guidelines when preparing sanitizing and disinfecting solutions in child care centers. To prepare a 5.25% disinfecting solution add ¼ cup of bleach to 1 gallon of water. For a 6% disinfecting solution, add 3.5 tablespoons of bleach to 1 gallon of water. To prepare a 5.25% sanitizing solution add 1 tablespoon of bleach to 1 gallon of water. For a 6% sanitizing solution, add 2.5 tablespoons \of bleach to 1 gallon of water.
Remember to prepare disinfecting and sanitizing solutions daily, clean dirty surfaces with detergent and water prior to treating with disinfecting or sanitizing solutions, and let surfaces air dry for at least two minutes prior to use.
Colorado Department of Public Health and Environment. Consumer Protection Division. Guidelines for the use of sanitizers and disinfectants in child care centers. Retrieved from
International Child Resource Institute. Healthy Child Care: Clean and Sanitize. Retrieved from

20. Symptoms of Flu Seasonal Flu H1N1 Pandemic Flu
All types of flu can cause:
Fever
Coughing and/or sore throat
Runny or stuffy nose
Headaches and/or body aches
Chills
Fatigue
Same as seasonal flu, but symptoms may be more severe.
Fever
Coughing and/or sore throat
Runny or stuffy nose
Headaches and/or body aches
Chills
Fatigue
In addition to the above symptoms, a number of H1N1 cases reported:
Vomiting
Diarrhea
Know the symptoms of seasonal and pandemic flu.
All types of flu can cause:
Fever
Coughing and/or sore throat
Runny or stuffy nose
Headaches and/or body aches
Chills
Fatigue
The symptoms of H1N1 pandemic flu are the same as seasonal flu, however symptoms may be more severe.
In addition to the above symptoms, a number of H1N1 cases reported:
Vomiting
Diarrhea
U.S. Department of Health and Human Services (2009). Flu.gov. Retrieved from

21. Recommendations for Tracking & Surveillance
Influenza Like Illness Tracking
Name
Age
Sex
Staff or Child
Onset Date/Time
Degree of temperature
Symptoms (e.g., cough, sore throat, vomiting, fever, headache, chills, muscle aches, nausea, other)
Symptom Duration
Treatment/Action
Colorado Department of Public Health and Environment - Consumer Protection Division or Colorado Department of Human Services – Division of Child Care or
Early care and education facilities should have a data collection procedure in place to collect data when an illness such as influenza is suspected or occurring. Tracking may include the following information: individuals name; age; sex; distinction as to whether the individual was a staff member or child; the onset date and time of symptoms; a recording of the individuals temperature; the symptoms exhibited (e.g., cough, sore throat, vomiting, fever, headache, chills, muscle aches, nausea, etc; the duration of any symptoms, and anecdotal notes of treatments given and records of actions taken.
Please follow guidance recommended by your local health and human service departments and contact agencies directly for additional information.
Contact the Colorado Department of Public Health and Environment’s Consumer Protection Division. The Consumer Protection Division protects Colorado residents and visitors by preventing an array of health hazards and monitors child care centers.
The Colorado Department of Human Services, Division of Child Care, is the State’s lead agency in planning and implementing public child care policy.  The Division of Child Care is responsible for the licensing and monitoring of child care facilities.
Colorado Department of Public Health and Environment. Consumer Protection Division. Gastrointestinal illness in children’s resident camps: Outbreak prevention and control measures. Retrieved from

22. Pandemic (H1N1) 2009
The pandemic (H1N1) 2009 virus lives in some people for at least eight days after symptoms develop.
Individuals working with vulnerable populations (e.g., health care workers, those caring for young children, etc.) should stay home until the risk of transmission has passed.
Members of the general public should consider whether they are still coughing and sneezing and could spread the virus easily.
In Quebec, Canada, members of 65 families who contracted the virus from May through July 2009 were tested for the pandemic H1N1 flu virus. A team of researchers determined that the virus remains alive on the eighth day in 8% - 13% of people after they develop flu symptoms. These findings are critical when considering how to reduce the spread of the flu. The results of the study indicate that a large number of people with pandemic H1N1 are still contagious after their fever breaks and some may be able to transmit the virus to others for up to two days longer than those who have seasonal influenza.
Individuals working with vulnerable populations (e.g., health care workers, those caring for young children, etc.) should stay home until the risk of transmission has passed. In addition to staying home from work, school or running errands, all social contact with others should be avoided.
Members of the general public should consider whether they are still coughing and sneezing and could spread the virus easily. When social contact can not be avoided, a person with signs of the flu should consider wearing a surgical mask to reduce the risk of spreading germs and disease.
Eggerston, L. (2009). Pandemic (H1N1) 2009 lives in some people for at least eight days after symptoms develop. Canadian Medical Association Journal, 181,9, E203.

23. Pandemic Influenza
When influenza is suspected or occurring, there are three important things to remember!
Always follow the most current advice of the U.S. Department of Health & Human Services and your local health department.
Additionally, early childhood providers should conduct daily health checks to observe all children and staff in order to identify those that may be ill (CDC, 2009).
A recent study investigated whether hand hygiene and use of face masks prevents the spread of influenza transmission. Hand hygiene and facemasks seemed to prevent household transmission of influenza virus when implemented within 36 hours of patient symptom onset. The findings of the study suggest that nonpharmaceutical interventions are important for mitigation of pandemic and interpandemic influenza (Cowling et al., 2009).
Centers for Disease Control and Prevention (CDC). (2009). CDC Guidance on helping child care and early childhood programs respond to influenza during the 2009 – 2010 influenza season. Retrieved from
Cowling, B. J., Chan, K, Fang, V., Cheng, C., Fung, R. O., Wai, W., Sin, J., Seto, W. H. (2009). Facemasks and hand hygiene to prevent influenza transmission in households. Annals of Internal Medicine, 151, 7, 437 – 446.

24. Community strategies
Community strategies may delay or reduce the impact of pandemic influenza and reduce the spread of disease.
Business (child care provider) plans should consider the following recommendations:
Identify a workplace coordinator
Examine policies for leave and employee compensation
Share pandemic plans with employees and clearly communicate expectations
Prepare business continuity plans
Establish an emergency communication plan
Community strategies may delay or reduce the impact of pandemic influenza and reduce the spread of disease.
Having a plan for pandemic flu is a recommended community preparedness strategy.
Identify a workplace coordinator who will be responsible for dealing with flu issues and their impact at the workplace, including contacting local health department and health care providers in advance and developing and implementing protocols for response to ill individuals.
Examine policies for leave and employee compensation – leave policies should be flexible, non-punitive, and well-communicated. They should allow workers who have the flu to stay home and away from co-workers.
Share pandemic plans with employees and clearly communicate expectations. It is important to let employees know plans and expectations when flu or H1N1 outbreaks occur in communities. Consider ways to communicate with employees to who not speak English or those with disabilities.
Prepare business continuity plans so that if there is significant absenteeism or changes in the way you need to conduct business in the workplace during an outbreak, operations can be maintained. Health officials may advice that workplaces take multiple steps to increase the space between people, also known as “social distancing” to reduce the spread of illness during a severe outbreak. School dismissals and child care provider closures may increase absenteeism in the workplace.
Establish an emergency communication plan. This plan should include identification of key contacts (with back ups), chain of communications, and processes for tacking and communicating business and employee status.
U. S. Department of Homeland Security. (2009). Planning for 2009 H1N1 influenza: A preparedness guide for small business. Retrieved from

25. URL: http://www.flu.gov/ URL: http://www.cdc.gov/flu/
Training and Resources:
Educational materials and recommendations for personal and family preparedness should be disseminated to promote healthy habits to prevent getting and passing on the influenza virus. All early care and education facilities should have a plan for providing training to employees and staff members. Once a plan is developed, exercises should take place to provide additional training to employees prior to and throughout the “flu season”.
The Centers for Disease Control and Prevention (CDC) and the U.S. Department of Health and Human Services have resources available that provide general information, educational materials, and recommendations for individuals and families. Please visit the the following URLs for additional information.
URL:
URL:

26. Suggested Reading:
American Lung Association’s Influenza Prevention Program. URL:
American Red Cross. Pandemic Flu.
Butler, J. (2009). Flu still spreading in US, CDC says. Clinical Infectious Diseases, 49,8, i.
Centers for Disease Control and Prevention (CDCa). CDC’s Advisory Committee Recommends Influenza Vaccination for Children 6 months through 18 years of age [press release]. URL:
Centers for Disease Control and Prevention (CDCb). Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP). URL:
Centers for Disease Control and Prevention (CDC). (2009). CDC Guidance on helping child care and early childhood programs respond to influenza during the 2009 – 2010 influenza season. Retrieved from

27. Suggested Reading:
Campos-Outcalt, D. Pandemic and seasonal flu: What you need to know. Journal of Family Practice, 58, 9,
Eggerston, L. (2009). Pandemic (H1N1) 2009 lives in some people for at least eight days after symptoms develop. Canadian Medical Association Journal, 181,9, E203.
Flu.gov: What to do about the Flu. URL:
Glass, R., Glass, L., Beyeler, W., & Min, H. (2006). Targeted social distancing design for pandemic influenza. Emerging Infectious Diseases, 12, 11,
Petit, D. A., and Bailie, J (2008). A cruel wind: Pandemic flu in America, – Murfreesboro, TN: Timberlane Books.
Sick days could cost employers $10 billion [press release]. URL:
Taubenberger, J.K., & Morens, D.M., (2006) influenza: The mother of all pandemics. Emerging Infectious Diseases, 12, 1, Retrieved from

28. References:
Barnett, D. J., (2006 September - October). Disasters are always local. The Futurist, 57.
Campos-Outcalt, D. (2009). Pandemic and seasonal flu: What you need to know. The Journal of Family Practice, 58, 9, 481 – 484.
Centers for Disease Control and Prevention – 2008 U.S. Influenza Summary. Retrieved from 08summary.htm.
Centers for Disease Control and Prevention. Cover your cough. Retrieved from
Centers for Disease Control and Prevention (CDC). (2009). CDC Guidance on helping child care and early childhood programs respond to influenza during the 2009 – influenza season. Retrieved from  
Centers for Disease Control and Prevention. (2009). Novel H1N1 flu situation update: August 6, Retrieved from
Centers for Disease Control and Prevention. (2008, July 17). Prevention and control of influenza: Recommendations of the advisory committee on immunization practices (ACIP). Morbidity and Mortality Weekly Report, 57, 1 – 60.

29. References:
Colorado Department of Public Health and Environment. Consumer Protection Division. (2009a). Gastrointestinal illness in children’s resident camps: Outbreak prevention and control measures. Retrieved from
Colorado Department of Public Health and Environment. Consumer Protection Division. (2009b). Guidelines for the use of sanitizers and disinfectants in child care centers. Retrieved from
Colorado Department of Public Health and Environment. Disease Control and Environmental Epidemiology Division. (2009c). Colorado weekly flu report for the week ending October 17, Retrieved from
Colorado Office of Professional Development. (2008). Colorado core knowledge and standards: A guide for early childhood professional development. Denver, CO.
Cowling, B. J., Chan, K, Fang, V., Cheng, C., Fung, R. O., Wai, W., Sin, J., Seto, W. H. (2009). Facemasks and hand hygiene to prevent influenza transmission in households. Annals of Internal Medicine, 151, 7, 437 – 446.
Eggerston, L. (2009). Pandemic (H1N1) 2009 lives in some people for at least eight days after symptoms develop. Canadian Medical Association Journal, 181,9, E203.
International Child Resource Institute. Healthy Child Care: Clean and Sanitize. Retrieved from

30. References:
Taubenberger, J. K., & Morens, D. M., (2006) Influenza: the mother of all pandemics. Emerging Infectious Diseases, 12, 1, 15 – 22.
U.S. Department of Health and Human Services (2009). Flu.gov. Retrieved from
U.S. Department of Health and Human Services (2006). Pandemic influenza pre-event message maps. Retrieved from
U. S. Department of Homeland Security. (2009). Planning for 2009 H1N1 influenza: A preparedness guide for small business. Retrieved from

31. Ashante Butcher ashante.butcher@waldenu.edu