NYTIMES: No Guidance on How to Rein In the Flu

May 19, 2009
NYTIMES: No Guidance on How to Rein In the Flu
By DONALD G. McNEIL Jr.
As schools shut down because of the flu — with a dozen closed in New York and hundreds in Texas and Japan — health officials are asking a question for which there is little guidance, even in pandemic plans: what is the best way to stop an epidemic that spreads mostly in schools rather than in nursing homes?

Many school officials have shut the doors and had the custodians disinfect the empty buildings.

But that leaves parents confused and frustrated. Those whose schools remain open may fear that their children are in danger, and those with healthy children whose schools close may feel that officials have overreacted, burdening them with day-care costs and denying their young ones an education.

Even guidance from the top is ambivalent.

On May 4, the acting director of the Centers for Disease Control and Prevention, Dr. Richard E. Besser, said “closing schools is not effective” at halting the spread. Previously, the centers had advised schools to shut for up to two weeks if a confirmed case was found.

On Monday, New York City closed four more Queens schools after outbreaks of flu symptoms, bringing the total to 16 ordered shut since last week. In Texas, hundreds have been closed at various times.

“There’s no right answer,” Mayor Michael R. Bloomberg said at a news conference. “I’ve asked the question, ‘What would you do, Dr. Frieden, if you wanted to prevent the spread of flu around the entire student population?’ And the answer is, ‘Closing the schools for a month, prohibit all interaction among kids outside of school, and even then there’s no guarantee that you can do that.’ The bottom line is, case-by-case basis is probably the right thing.”

(Mr. Bloomberg was referring to Dr. Thomas R. Frieden, the city’s health commissioner, who has just been nominated to be chief of the C.D.C.)

Many parents and teachers have been calling local lawmakers wondering if their schools would be closed, said Eric Gioia, a City Council member from Queens who wants parents to be given the results of flu tests at their local schools and daily attendance figures.

“The lack of definitive information is causing great stress on families,” Mr. Gioia said. “If a school is safe, then the city needs to not only say it is but give parents all the information they need.”

Before closing one, Dr. Frieden said, officials look at documented fevers in students and how fast they are increasing. They also call families to see if children are really sick, not just staying home out of fear.

One thing is clear, infection control experts say: disinfecting closed schools is pointless. Flu viruses are believed to live on objects for perhaps two to eight hours, so a week’s closing will kill them. But when students return, if a few are sick, every cafeteria table, desk, lab beaker, doorknob, bathroom tap and basketball will soon be recontaminated.

Washing schools “is done for looks,” said Michael Olesen, a Minnesota infection control specialist. “It’s not a rational approach.”

The C.D.C.’s swine flu Web sitehas infection-control guidelines for many settings: hospitals, nursing homes, day-care centers and even dialysis clinics. But it has nothing specific to the core of this outbreak: schools full of teenagers.

Teenagers, experts say, are different from the victims of seasonal influenza. The bed-ridden, the very ill and infants can be forced to practice good hygiene, or isolated or sent home if they won’t.

But teenagers resist tedious advice to wash their hands for 20 seconds, cover every cough with a tissue or sleeve and stay away from other teenagers. If school is closed, they are likely to get together at the park or the mall.

Keeping sick students out of school is the most crucial step, said Dr. Yoko Furuya, an infection control specialist at NewYork-Presbyterian/Columbia hospital.

But that can be impractical. And students can shed virus for a day before they are sick.

“I’d lean toward getting surgical masks on them and trying to get to the end of the school year,” said Mr. Olesen, who is reluctant to see schools shut. “The masks capture all those droplets at the point of release.”

And how, he was asked, could students be made to do that?

“I don’t know how, but they make them do other things,” he said.

Amy D. Nichols, chief of infection control for the University of California at San Francisco Medical Center, said she would like to see “schools just as awash in alcohol hand rubs as hospitals are, so it’s easy and quick to clean one’s hands.”

Ms. Nichols favors making students disinfect their hands before entering each class, the gym or the cafeteria.

“In junior high, you want to be like everyone else,” she said. “So schools should have wall-mounted push dispensers. That way it becomes part of the culture of the schools. The more people push the handle, the more everybody else does.”

She also favors cleaning surfaces as often as is practical, because other risks like antibiotic-resistant bacteria persist longer than flu.

What to do with sick students whose working parents cannot afford babysitters is another problem.

Asked if schools could set up cots in a gym for ill students, Mr. Olesen demurred.

“I don’t know,” he said. “Cots for kids in puberty with their hormones raging? That’s a whole other public health problem.”

Even if schools make it to summer break, hot weather may slow, but not solve the problem, the C.D.C. said Monday.

“We’d love to see a decrease in cases, but in the past there have been outbreaks of seasonal influenza even in summer camps,” said Dr. Anne Schuchat, the agency’s interim deputy director for public health.

Confirming anecdotal observations that this flu concentrates in young people, Dr. Schuchat said preliminary studies of family transmission showed that when one member gets infected, the most likely to follow are those under 18, not parents or grandparents. .

In Geneva, swine flu topped the agenda of the annual assembly of world’s health ministers. Britain, Japan and other countries with many cases argued that World Health Organization pandemic alerts should measure a virus’s severity, not just its spread. Dr. Margaret Chan, the health organization’s director-general, said she would consider keeping the alert level at 5, and warned that the virus’s initial mildness had “handed the world a grace period.”

“I strongly urge you to look closely at anything and everything we can do, collectively, to protect developing countries from once again bearing the brunt of a global contagion,” Dr. Chan said.

Reporting was contributed by Anemona Hartocollis, David Chen and Sharon Otterman.

http://www.nytimes.com/2009/05/19/health/policy/19guidance.html?_r=1&ref=nyregion