Daniel LaHart, CIH Environmental Issues Program Manager Operations Division Anne Arundel County Public Schools 410-360-0138 Edward L. Van Oeveren, M.D.,

Daniel LaHart, CIHEnvironmental Issues Program Manager

Operations DivisionAnne Arundel County Public Schools

410-360-0138

Edward L. Van Oeveren, M.D., M.P.H.Health Officer, Anne Arundel County Department of Health

Impact of H1N1 on School Facilities: An Outlook for the Future

2

Novel H1N1 influenza: Background informationH1N1 outbreak in Anne Arundel County Public

Schools, Spring 2009School response to Novel H1N1 Virus, Fall 2009:

CurrentContingency plans

Potential school design elements to facilitate response to communicable diseases

SummaryQuestions

Outline

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

5


N

H

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.

7

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 airContaminates another person close byLands on surfaces (fomites), e.g., doorknobs,

computer keyboards, faucet handlesInfection 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 throatNasal congestion, muscle aches, headache,

chills, fatigueDiarrhea, vomiting (seen with novel H1N1)Usually abrupt onsetTypical time to recover is 4 days to one week in

healthy people

10

Risk Factors for Severe Disease

Immune system disordersHIV, transplant, chemotherapy, etc.

Elderly, infants, pregnant womenOther medical problems:

Lung diseaseDiabetesKidney disease

11

Treatment of InfectionSeasonal and Novel H1N1

Rest Drink plenty of liquids Avoid drinking alcohol or smoking Use over-the-counter medications

Labeled “cold and flu” remediesNot aspirin

In some situations, use antivirals Oseltamivir (Tamiflu), zanamivir (Relenza)Prescription medicationsInitiate within 48 to 72 hours of first

symptoms for optimal effectiveness

12

Preventing the flu Seasonal and Novel H1N1

Clean hands oftenSoap and waterAlcohol-based hand sanitizers

Cover your cough/sneezeUse 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


Sleeves.wmv

C:\Program Files\Windows Media Player\mplayer2.exe

14

Preventing the flu Influenza Vaccine

15

Flu Vaccines Two types

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, fatigueNasal spray: low grade fever, runny nose,

headache, sore throat, fatigueDOES NOT CAUSE THE FLU!!

Timing Protection takes at least 10 days

16

Flu Vaccines

Seasonal vaccineStill important this yearAvailable now

Novel H1N1 vaccineFirst shipments anticipated ~mid-OctoberTarget and priority groups initiallyIf available, everyone for whom medically

appropriate may be vaccinated over the next 6 months

Not mandatory

17

Who will get the H1N1 vaccine?

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

Target Groups High Priority Groups

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 occurredWhat’s going on simultaneously

Family member ill (flu symptoms)

Recently returned from Mexico

Children exposed @ home

Children come to schoolSchool notified, etcHealth 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 comeAnxiety - probablyPanic – not yet but….

22

School System Response

SchoolWith Teachers and Admin.

FacilitiesWith Custodial Staff

In consultation w/HD who, in turn, are following CDC:Family children sent homeMeet w/teachers and staff

Explain situation Advise cleaning protocols Promote good hygiene in

classroom & home Letter sent homeSchool 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

Parents swamp phone linesSome kids stay home

RumorsMany are sick

Another child suspected of H1N1

School to close 5-7 days per H.D.

News helicopters, TV reporters & cameras, etc.

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.

24

Swine Flu Spreads Across D.C. Region

Washington Post Washington Post 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.

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

http://www.twiigs.com/poll/Health/30872






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.

26

27

Parents Debate Sending Children to School as Officials Urge Caution

School National The word came so late in

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

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.

28

CDC Guidance

CDCSchool & Health Department

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).

In conformity with CDC guidance, School and Health Department close school.

29

Outcomes

School FacilitiesReopened in 3-4

daysNo outbreakSchool returns to

routine

Vast expenditure of manpower and equipmentLots 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) ImplementationCommunications

(Continued)

31

Lessons Learned from Spring 2009 (continued)

After-action analysis/assessment and follow-up action Needs identified:

Formal school-based surveillance systemSchool attendance policiesStaff 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/expendituresPersonal Protective Equipment (supplies, fit testing) Isolation roomsHandwashing 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 aloneHealth workers missing shifts when they must stay home with their

childrenStudents missing meals, and Interruption of students’ education.

http://pandemicflu.gov/professional/school/

34

School response to Novel H1N1 Virus, Fall 2009: CDC Guidance—Scalable Responses

Recommendation:Stay home when sick

Separate ill students and staff

Hand hygiene and respiratory etiquette

• Conditions with similar severity as in Spring 2009:

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:

SuppliesLocations, dispensersRefill, maintenance, securityWaste receptacles

(Continued)

35


Recommendation:Routine cleaning

Early treatment of high-risk students and staff

Consideration of selective school dismissal

• Conditions with similar severity as in Spring 2009:

(continued)

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. (http://aapredbook.aappublications.org/resources/midsheets.dtl )

The EPA provides a list of EPA-registered products effective against flu: http://www.epa.gov/oppad001/influenza-disinfectants.html

http://aapredbook.aappublications.org/resources/midsheets.dtl








http://pandemicflu.gov/exlinkdisclaimer.html

http://www.epa.gov/oppad001/influenza-disinfectants.html





36


Recommendation:Active screening

High-risk students and staff members stay home

Students with ill household members stay home

• 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 Staff

Same as above for affected students

(Continued)

37


Recommendation: Increase distance between

people at schoolsExtend the period for ill

persons to stay homeSchool dismissals

• Conditions of increased severity compared with Spring 2009:

(continued)

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


(Slide 1 of 9)

Generally:Collaboration with School Health staff during design phase

Health Room:LocationSizeEquipmentCommunications/support systems (intranet, internet,

phone, fax)SuppliesStorageStaffing

National Clearinghouse for Educational Facilities (National Institute of Building Sciences), Resource List for School-Based Health Facilities--http://www.edfacilities.org/rl/health_centers.cfm

The Center for Health and Health Care in Schools--http://www.healthinschools.org/static/states/MD-guidelines.aspx

http://www.maclearinghouse.com/schoolhealthmanual/PDF/Chapters/Chapter02_D.pdf

40


(Slide 2 of 9)

Screening Points:Potential uses:

Active screeningReturn from illness

Considerations:Traffic flowLocation:

Ingress/egress to exterior of buildingProximity to:

Health RoomIsolation facilities

Staffing/monitoringFurnishingsEquipmentSupport systems (intranet, internet, telephone, fax)

41


(Slide 3 of 9)

Isolation capability:“Isolation” vs. “quarantine”Considerations:

CapacityLocation:

Proximity to:Health RoomScreening Points

Ingress/egress to exterior of buildingStaffing/monitoringFurnishingsEquipmentSupport systems (intranet, internet, telephone, fax)

42


(Slide 4 of 9)

Potential for fomite transmission:Factors affecting infection potentialEnvironmental 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):

o Initialo Maintenanceo Replacement

Durability Esthetics Special characteristics (e.g., non-slip flooring)

43


(Slide 5 of 9)

Hygiene resources/facilities:Rest Rooms:

SoapTowelsSupply storageWaste/refuse disposalFomite infection risk:

Environmental surfacesFaucet handles

MaintenanceHand hygiene:

Free-standing hand-washing stationsHand sanitizer stations:

LocationsRefilling & MaintenanceSafety & Security

44


(Slide 6 of 9)

Environmental Control Systems:TemperatureHumidityParticulates (especially allergens)Gases and vaporsAir exchangeDesign easy to change and readily accessible air filtersDesign for adequate ventilation: Solution to Pollution is Dilution Design schools with systems that require no-touch to operate via sensors

Room lightingDrinking fountainsToiletsHand sinks

4545


(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

46


(Slide 8 of 9)

Use:Alternate Care Site (e.g., for

local hospital during disaster)

Mass immunization site

Point-of-distribution (POD) for medications

Alternate uses of facility:

Facilities issues:Location/Proximity to

“index” facilityIngress/EgressBuilding systems (HVAC,

electrical, IT)Location/Proximity to

PopulationIngress/EgressTraffic FlowBuilding systems (HVAC,

electrical, IT)Storage (e.g., refrigeration)Same

47


(Slide 9 of 9)

Co-located facilities:Examples:

Other schools (e.g., pod of high school, middle school, and elementary school)LibraryRecreation/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 closureShared 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 learnedSchool response to Novel H1N1 Virus, Fall 2009:

CurrentContingency plans

Potential school design elements to facilitate response to communicable diseases

49

Questions?

Daniel LaHart, CIH Environmental Issues Program Manager Operations Division Anne Arundel County Public Schools 410-360-0138 Edward L. Van Oeveren, M.D.,

Documents

novel h1n1 influenza

flu influenza vaccine

novel h1n1 vaccine

novel h1n1 virus

influenza spread

h1n1 viruses

human influenza

days slide