Public Health Guidance for Post Secondary and Boarding Schools regarding the Prevention and Management of Influenza-like-illness (ILI), Including the Pandemic (H1N1) 2009 influenza Virus

19 August 2009

This guidance document is being provided for public health officials by the Public Health Agency of Canada in response to the pandemic (H1N1) 2009 influenza virus outbreak.  This guidance is based on currently available scientific evidence about this emerging disease and is subject to review and change as new information becomes available.  It should be noted that this document has been developed based on the Canadian situation and therefore may differ somewhat from other guidance documents developed by other countries.

The following guidance document should be read in conjunction with relevant provincial and territorial guidance documents.  The Public Health Agency of Canada will be posting regular updates and related documents at www.phac-aspc.gc.ca.

This guidance document provides information regarding:

Post secondary / Vocational / Adult Learning Settings: For the purpose of this guidance document, these settings include public and private colleges, universities and vocational/technical schools. School populations are comprised of young adults who live in on-campus housing, private accommodation off campus or in the family home.

Residential/boarding schools: For the purpose of this guidance document, these settings include those where students reside at the school and return home on holidays and vacations.

Introduction

The pandemic (H1N1) 2009 influenza virus has rapidly spread across the world. While influenza activity would normally be expected to wane during the summer months, the pandemic (H1N1) 2009 influenza virus has not done this and surveillance data suggest that community spread has continued.

To date, infection with the pandemic (H1N1) 2009 influenza virus has resulted in influenza-like-illness (ILI) similar to seasonal influenza.

• ILI is defined as the acute onset of respiratory symptoms with fever and cough and one or more of the following symptoms: sore throat, muscle aches, joint pain, or weakness. Gastrointestinal symptoms may also be present and fever may not be prominent.

This pandemic (H1N1) 2009 influenza virus is thought to be spread from person to person in the same way as seasonal influenza where transmission occurs predominantly through coughing or sneezing. Indirect transmission can also occur through self-inoculation after contact with surfaces and objects contaminated with the virus from infected persons.

Like seasonal influenza, the pandemic (H1N1) 2009 influenza infection in humans can vary in severity from mild to severe, with the most severe disease occurring mainly in known and emerging risk groups such as the immuno-compromised and pregnant women.  People with underlying medical conditions may also be at greater risk of severe illness or complications.  Most illness from the pandemic (H1N1) 2009 influenza virus (especially in children) has to date been relatively mild and self-limiting with most cases recovering quickly. 

The incubation period for pandemic (H1N1) influenza virus is understood to be up to 4 days and the period of communicability up to 7 days from onset of symptoms in uncomplicated cases.  This may be longer (up to 10 days) in individuals with severe illness and children in whom symptoms and virus shedding may persist.  Consistent with seasonal flu, transmission of the pandemic (H1N1) influenza virus is most likely during the initial days of infection when the individual is symptomatic and has a high viral load.

Although illness among school-aged children/young adults and transmission within schools, including residential and boarding schools, has occurred in various provinces and territories in Canada, in light of the current situation of community spread of this illness, widespread school closures are not recommended at this time.  Decisions about individual school closures lie at the discretion of appropriate local authorities and would typically be based on considerations such as local public health concerns, school community or local community concerns, the impact of school absenteeism and/or staffing shortages on school operations and potential negative consequences resulting from the school closure.

Recommendations Regarding Infection Prevention Measures

General Information

Communication programs that educate parents/guardians, students, children, faculty and staff play an important role in the control of the transmission of pandemic (H1N1) 2009 influenza virus in boarding schools and post secondary settings. 

At this time, the most important factors in the control of the spread of the pandemic (H1N1) 2009 influenza virus in post secondary and boarding schools settings are;

• Early identification of ill students, staff and faculty exhibiting symptoms of ILI,
• Exclusion/isolation from the setting of anyone ill with symptoms of ILI and,
• Practising cough/sneeze etiquette and frequent hand cleaning.

Public health officials may consider sharing these key messages when communicating with boarding school or post secondary administrations.

Post secondary and boarding schools should develop communication programs that meet the needs of parents/guardians, students, faculty and staff.  Information that can be included in these education programs is outlined below.

Self Care

• Practise cough and sneeze etiquette.
• Use the correct hand washing technique.
• Practise frequent hand cleaning (i.e., after sneezing or coughing, before and after eating, after recreational activities, after going to the washroom, after riding on public transit, etc.)
• Take care of themselves when caring for someone who is ill.
  
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Monitoring

• Provide basic information on how to recognize symptoms of ILI to all parents/guardians, students, faculty and staff.
• Encourage students, faculty and staff to monitor their health daily for symptoms of ILI.
• Teachers, faculty and staff should observe students for any signs of ILI and encourage students who are ill to self isolate.

Reporting

• Post secondary and boarding schools should establish mechanisms to monitor pandemic (H1N1) 2009 influenza virus activity in their setting and processes for reporting staff and student/child illness above normal expected absenteeism levels to local public health officials as required; and
• To facilitate reporting, institutions may consider establishing a dedicated phone line and/or web-based method of receiving illness reports from students, staff and faculty.

Isolation

• Students/staff/faculty who become ill with ILI at home or in their dormitory or residence should be encouraged to self isolate until their symptoms resolve and they are feeling well and able to fully participate in all normal day to day school activities (including intra/extramural activities). To help prevent transmission, good respiratory and hand hygiene practices are recommended, as well as, to the extent possible, having ill individuals stay two meters away from others.
• Students/staff/faculty who become ill while attending classes or other school activities should isolate themselves by returning to their room or home until they are symptom free and are feeling well and able to fully participate in all normal day to day school activities (i.e., intra/extramural activities).
• Post secondary institutions and residential/boarding schools may wish to consider developing plans to group students with ILI in one dorm area as a measure to contain the spread of the virus for on-campus residences and boarding schools.  This may facilitate monitoring of ill students and prevention of transmission of the virus to others.
• In considering the school setting where people are not typically trained in the proper use of masks and considering the potential risk of infection associated with improper mask use, the use of masks in the school setting is not recommended.

Support

• Post-secondary and residential schools may want to consider providing support for those students (residing on or off-campus) who are ill and do not have other support available. This may include providing in-room meals and care.   
• Students/staff/faculty and parents should be given information on how to take care of themselves if ill.
• Students should also be provided information on how to access healthcare for assessment of their medical condition if needed.

Considerations Prior to Travel

• Schools should communicate with individuals who are traveling from other parts of the country or other countries in advance of their travel and advise them not to travel while ill.
• Schools should develop plans in case of the temporary closure of study abroad programs and to support both ill and healthy individuals affected in the event they cannot return home.
• While not currently recommended in Canada, individuals who are travelling should be warned of the possibility that quarantine or other public health measures may be applied at international borders.

Environmental Cleaning

Influenza viruses can survive on some surfaces for several hours to days but are rapidly destroyed by cleaning. Cleaning of objects and surfaces that are frequently touched by multiple students or staff, high touch surfaces such as doorknobs, faucet handles, computer keyboards, telephones, etc., will help to prevent the transmission of the influenza virus from person to person through contaminated hands.

It is recommended that high touch surfaces in post secondary and boarding schools be cleaned at least twice daily.  No special disinfectants or waste handling practices are required for influenza; regular household or commercially available cleaning products are sufficient for this purpose, and waste handling would be according to usual standards.

Post secondary and boarding schools are advised to increase the frequency of cleaning during school hours as well as monitoring hand cleaning supplies.  All sinks in washrooms, kitchens and classrooms should be well stocked with hand washing supplies at all times (i.e., soap and paper towels).  Consider the use of alcohol-based hand rubs (with 60-90% alcohol) in classrooms without hand washing sinks.

Hand Hygiene and Respiratory Etiquette

Hand hygiene and covering coughs and sneezes with one’s sleeve are important means of preventing the transmission of pandemic H1N1 influenza virus.

Consideration should be given to providing increased numbers of hand wash stations (or alcohol based hand rub stations) as well as tissues and waste receptacles throughout post secondary and boarding schools.  It is recommended that additional tissue supplies and waste receptacles be kept in supervised areas (i.e. classrooms).  If alcohol based hand rubs are provided to supplement hand washing facilities, locked dispensers that are permanently attached to a wall are recommended and should be located in supervised areas.

It should be noted that hand washing with plain soap and water is the preferred method of hand hygiene in schools as the mechanical action is effective at removing visible soil as well as microbes.  In instances where hand washing sinks are not available, use of alcohol based hand rubs may be considered.  If hands are visibly soiled, alcohol based hand rubs may not be effective at eliminating the influenza virus.

Outbreak Recommendations

Post secondary and boarding schools should develop programs for monitoring of student/staff and faculty illness and develop a strategy to recognize an outbreak of pandemic (H1N1) 2009 influenza virus and/or other triggers that warrant consultation with local public health officials.  Prompt action will help to ensure appropriate measures can be implemented to mitigate the impact and spread of the illness to both students and staff.

Realizing that consultation with public health officials may occur for any number of reasons, it is especially recommended that notification and consultation occur in outbreaks or unusual situations. Examples of such situations would be when absenteeism of students/staff is greater than what would normally be expected on any day or when unusual or more severe illness is observed.

Post Secondary/Boarding School Closure

The decision to close schools, either proactively (in anticipation of disease or outbreaks), or more typically reactively (in response to disease or outbreaks), lies at the discretion of appropriate local authorities and would typically be based on considerations such as local public health concerns, school community or local community concerns, the impact of school absenteeism and/or staffing shortages on school operations and potential negative consequences resulting from the school closure.

Proactive closure-The Public Health Agency of Canada does not recommend widespread proactive closures of boarding schools and universities at this time during the pandemic.  While some modelling studies have shown the potential for reduced transmission or blunting of peak epidemic waves from widespread and sustained proactive school closures, this potential benefit must be weighed against high economic and social costs, ethical issues including undue burden on specific populations and the possible disruption of key services such as healthcare.  Currently, the virus is known to be easily spread from human to human and has been detected throughout Canada.  An increasing number of community level outbreaks are occurring with the virus causing primarily mild illness in Canada.  It is not felt that widespread proactive school closures at this point in the pandemic in Canada would be of sufficient benefit to warrant the many costs this measure would entail.  If the epidemiology of the disease changes and the virus were to become highly virulent in children for example, these recommendations will be reconsidered along with other social distancing strategies as the likeliness of students to congregate elsewhere in less controlled environments cannot be discounted, thus reducing the intended benefits of school closures. 

Reactive closure-The decision about individual reactive post secondary or boarding school closures (as opposed to widespread proactive closures) remains at the discretion of appropriate local authorities in accordance with provincial/territorial legislation.  Such decisions should be based on considerations such as the impact of school absenteeism and/or staff shortages on safe school operations. 

It is important to note that there are many protective factors present in post secondary and boarding school settings that must be considered especially during a time of disruption such as a pandemic.  Such settings are excellent places to:

• educate, inform and communicate with students, their families, staff and faculty in an efficient and timely manor,
• support the economic and social elements of the community by continuing to operate,
• provide a structured environment able to support efficient and effective administration of vaccines.