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The CDC posts influenza prevention and response guidelines for schools and school nurses, for each educational level. The CDC’s latest K-12 recommendations for situations with severity similar to that of the spring 2009 outbreak include:

Staying home when sick. Any student or staff member who comes down with flu-like illness should be sent home and stay at home for at least 24 hours after they no longer have a fever, or signs of a fever, without the use of fever-reducing medicines. They should stay home even if they are taking antiviral drugs. The most common signs of influenza are fever (temperature > 100 degrees F), sore throat, and coughing. Headache and weakness have also been reported.

Using hand hygiene and respiratory etiquette. These are the first lines of defense against influenza. Everyone should wash hands frequently with soap and running water when possible, and cover noses and mouths with a tissue when coughing or sneezing (or a shirt sleeve or elbow if no tissue is available). Hand sanitizer should be widely available, especially in areas where there is no running water.

Separating ill students and staff. Students who appear to have flu-like illness should wait in a room separate from healthy students until they can be sent home. The CDC recommends that the ill student wear a surgical mask and be placed in a separate room. School nurses and health room attendants should wear protective gear, such as a mask, when in contact with a sick child or staff member.

Initiating early treatment of high-risk students and staff. Students or staff at high risk for influenza complications who present with influenza-like illness should contact their healthcare provider as soon as possible. Early treatment with antiviral medications is very important for people at high risk because it can prevent hospitalizations and deaths. People at high risk include those who are pregnant, have asthma or diabetes, have compromised immune systems, or have neuromuscular diseases.

Routine cleaning. School staff should routinely clean areas that students and staff touch often with the cleaners they typically use. The CDC does not believe that any additional disinfection of environmental surfaces beyond the recommended routine cleaning is required.

Considering school dismissal. School dismissal might be necessary for select schools. For example, a community might decide to dismiss a school that has a large population of high-risk students to better protect the high-risk students.

These recommendations could change if we encounter influenza conditions with increased severity compared with spring of 2009. Supplementary measures might include active screening of students, telling high-risk staff and students to stay home (even if they are not symptomatic), telling students with ill household members to stay home for 5 days after the first person became ill, increasing the distance between students, and extending the period for ill students to stay home to 7 days. If a school closure is necessary, the school should remain open to staff so that they can continue to provide instruction by other means.

School closure has a ripple effect throughout the community. The benefits of reducing illness and complications of influenza can be rapidly outweighed by negative consequences, including students being left home alone, healthcare workers missing shifts when they must stay home with their children, students missing meals, and interruption of students’ education.

“School closure will be a local decision, unless the pattern of illness increases in severity,” explains Delack. “Right now, the only reason to close a school is if you have so many staff home sick that you can’t staff the school.” She also contends that if schools are closed, students need to stay home, acknowledging that this poses problems for parents who are working. Delack recommends telling parents at the beginning of the school year that they need to make contingency plans for childcare should the schools close or their children become ill.

If conditions are more severe than they were last spring, there is a greater chance that school closure will occur as schools find themselves unable to maintain normal functioning (a reactive dismissal). Alternatively, preemptive dismissals could be recommended if the flu is causing more severe disease than expected. If a decision is made to close one or more schools, this must be reported to the CDC via the Novel Influenza A (H1N1) — Related School Dismissal Reporting system. An online reporting form is available.

The H1N1 Vaccine
Current projections of vaccine supply indicate that, at least initially, 5 specific groups will be targeted for vaccination when the vaccine becomes available. These are

• Pregnant women;
• Persons who live with or provide care for infants age < 6 months (eg, parents, siblings, and daycare providers);
• Healthcare and emergency medical services personnel;
• Persons age 6 months to 24 years; and
• Persons age 25-64 years who have medical conditions that put them at higher risk for influenza-related complications.

If the vaccine supply is even more limited than expected, the most vulnerable of these 5 groups (eg, pregnant women, persons with medical conditions that connote high risk) will be vaccinated first. Therefore, in a setting of extremely limited availability of vaccine, school-age children (age 5-18 years) who are otherwise healthy would not be among the first recipients of the vaccine. All children, however, should receive the seasonal influenza vaccination as soon as it becomes available.

The news is full of reports that the US government and many state departments of health are gearing up for mass vaccinations of students within the schools, much like the mass polio vaccinations of students in the 1960s. Although no definitive decisions regarding dissemination of the vaccine to students have yet been made, Delack believes that schools are the “logical choice” to serve as vaccination clinics. In any case, mass vaccinations of healthy, low-risk students and staff may be a long way off according to other reports suggesting that only about one third of the needed supply of vaccine will be available in October 2009.

Conclusion
In their issue brief, “Role of the School Nurse,” the NASN notes that in 1902, the earliest function of school nurses was “to reduce absenteeism by intervening with students and families regarding health care needs related to communicable diseases.” Although in subsequent years the role of the school nurse has expanded far beyond this responsibility, it seems that in 2009 we have come full circle. The school nurse must assume a leadership role in the prevention of a pandemic influenza, a role that involves education, collaboration, planning, decision-making, and many other functions. Schools that have nurses should consider themselves very lucky in the days and weeks to come.

About the NASN. The NASN is the leader in advocacy for student health and professional development of school nurses. The Association supports the health and educational success of children and youth by developing and providing leadership to advance school nursing practice by specialized registered nurses. Every child deserves a school nurse.