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

This guidance 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 may 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 almost entirely during the summer months, the pandemic (H1N1) 2009 influenza virus continued to circulate at low levels in Canada and a resurgence has been seen this fall.

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 illness with fever and cough and with one or more of the following symptoms: sore throat, muscle aches, joint pain, or weakness which could be due to the influenza virus. In children under 5, gastrointestinal symptoms may also be present. In patients under 5 or 65 and older, fever may not be prominent.

It has been observed with the pandemic (H1N1) 2009 influenza virus that gastrointestinal symptoms have been present in at least one third of the cases and a wider age range of individuals may not experience fever.

The clinical case definition for ILI for treatment or isolation purposes in a given setting should be adapted to ensure appropriate sensitivity and specificity for post secondary and boarding school settings.

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.

The incubation period for pandemic (H1N1) 2009 influenza virus is understood to be approximately four days with a range of one to seven days. The period of communicability seven days in uncomplicated cases; however, it may be longer in children (up to ten days) and other individuals in whom symptoms and virus shedding may persist (i.e. those who are immunocompromised or severely ill). Consistent with seasonal influenza, 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. 

Like seasonal influenza, the pandemic influenza (H1N1) 2009 influenza infection in humans can vary in severity from mild to severe, with approximately two-thirds of hospitalized cases to date occurring in individuals with known risk factors for complications from influenza such as chronic illness, immunosuppression or pregnancy. This virus also appears to result in more severe disease in the 5-64 year old age group than does seasonal influenza; however, most individuals with pandemic (H1N1) 2009 influenza have not required hospitalization and have recovered in the community.

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

General Information

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

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;

• Immunization against the pandemic (H1N1) 2009 influenza virus,
• 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.

It is recommended that post secondary and boarding schools develop communication programs that meet the needs of parents/guardians, students, faculty and staff. Communication materials may need to be adapted to accommodate language and literacy levels as appropriate.

The following sections contain recommendations and information that can be shared by public health officials when communicating with school administrators.

Monitoring

It is recommended that:

• Basic information on how to recognize symptoms of ILI is made available to all parents/guardians, students, faculty and staff.
• Students, faculty and staff are encouraged to monitor their health daily for symptoms of ILI.
• Teachers, faculty and staff observe students for any signs of ILI and encourage students who are ill to self isolate.

Isolation

It is recommended that:

• Students/staff/faculty who become ill with ILI at home or in their dormitory or residence self isolate until 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 metres away from others.
• Student/staff/faculty who become ill while attending classes or other school activities isolate themselves by returning to their room or home until they are feeling well and able to fully participate in all normal day to day school activities (e.g., intra/extramural activities).
• Post secondary institutions and residential/boarding schools 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 prevent transmission of the virus to others.

In considering the school setting where people are not 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.

Self Care

It is recommended that students/staff/faculty are taught and encouraged to:

• 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.

Hand Hygiene and Respiratory Etiquette

Hand hygiene and covering coughs and sneezes are an important means of preventing the transmission of the pandemic H1N1 influenza virus. Information on hand hygiene and cough etiquette can be found at: http://www.phac-aspc.gc.ca/alert-alerte/h1n1/index-eng.php.

Respiratory etiquette involves coughing and sneezing into a disposable tissue, discarding the tissue immediately and cleaning one’s hands afterwards or coughing/sneezing into one’s elbow or sleeve rather than one’s bare hands, if tissues are unavailable.

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 (e.g., classrooms). If alcohol based hand rubs are provided to supplement hand washing facilities, secured alcohol based hand rub dispensers located in supervised areas are recommended. Material Safety Data Sheets and the product labels provide additional information regarding placement, storage and warnings associated with the product.

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.

Environmental Cleaning

Influenza viruses can survive on some surfaces for several hours to days but are rapidly destroyed by cleaning. Cleaning and disinfecting objects and surfaces that are frequently touched by multiple students or staff (e.g., high touch surfaces such as doorknobs, faucet handles, computer keyboards, and telephones) 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 and disinfected at least twice daily. Typically, no special disinfectants or waste handling practices are required for influenza. Waste handling would be according to usual standards and many readily available household or commercial disinfectant cleaning products are effective against influenza viruses. Product specific information, including its effectiveness against the H1N1 influenza virus, may be found on the cleaning product label and/or the manufacturer’s web site.¹ If household or commercial disinfectant cleaning products are not readily available, hard surfaces can be cleaned using a mixture of 1 part bleach and 9 parts water. Always use caution when using bleach as undiluted bleach is corrosive and could damage the skin, fabrics and others surfaces.

Increased monitoring of hand cleaning supplies is also recommended. All sinks in washrooms, kitchens and classrooms should be well stocked with hand washing supplies at all times (i.e., soap and paper towels). Supervised use of alcohol-based hand rubs (with 60-90% alcohol) in classrooms without hand washing sinks can be considered.

Boarding schools and post secondary institutions should also consider other cleaning needs and practices that may be relevant to their settings and activities. For example, it is recommended that water bottles used by sports teams not be shared among the team players. Another example would be the mouthpieces on musical instruments, especially on those used by more than one student; these should be cleaned and disinfected as per standard practices recommended for the instrument. Encouraging students to have their own mouthpieces may be advisable. Because there may be many and varied activities that should be considered, school and childcare officials are encouraged to review existing activities and practices within their settings to help determine where enhancements or increased cleaning frequencies may be recommended.

Reporting

It is recommended that post secondary and boarding schools establish mechanisms to monitor ILI activity in their settings. In order to facilitate reporting by students, staff and faculty, institutions may consider establishing a dedicated phone line and/or web-based method to receive illness reports.

It is also recommended that post secondary and boarding schools develop a strategy to recognize a cluster of cases of ILI 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 Closures

The decision to close schools/post secondary institutions, either proactively (in anticipation of illness or outbreaks), or reactively (in response to illness or outbreaks), lies at the discretion of appropriate local and/or provincial/territorial authorities, in accordance with applicable legislation and other requirements. Such decisions may take into account 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. 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. The pandemic (H1N1) 2009 influenza virus is known to be easily spread from human to human and detected throughout Canada. In light of the current situation of community spread and of primarily mild illness, it is not felt that widespread proactive school closures would be of sufficient benefit to warrant the many costs this measure would entail. If the epidemiology of the disease changes and the virus becomes highly virulent, these recommendations will be reconsidered along with other social distancing strategies as the likelihood of students to congregate elsewhere in less controlled environments cannot be discounted, thus reducing the intended benefits of school closures.

Should reactive closure(s) be considered at the local level, it is anticipated that public health officials and school administrators may take into account considerations such as the impact of school absenteeism and/or staff shortages on safe school operations while balancing these factors against the goal of minimizing disruption and student safety.

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 manner,
• 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.

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 can be given information on how to take care of themselves if ill.http://www.phac-aspc.gc.ca/alert-alerte/h1n1/guidance-orientation-05-03-eng.php
• Students should be provided information on how to access healthcare for assessment of their medical condition if needed.

Considerations Prior to Travel

• It is recommended that schools consider communicating 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.
• It is recommended that schools consider developing 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, it is advised that individuals who are travelling be warned of the possibility that quarantine or other public health measures may be applied at international borders or within other countries.