Public Health Guidance for Child Care Programs and Schools (K to Grade 12) Regarding the Prevention and Management of Influenza-Like-Illness (ILI), including the Pandemic (H1N1) 2009 Influenza Virus

 

This guidance provides information regarding:

• Child care settings: For the purpose of this guidance document, child care settings will refer to both licensed and unlicensed child care programs providing family home or centre-based child care in group settings. These settings provide care and education to children from infants and toddlers to preschool age as well as providing before and after school care for school age children. Some child care programs are located in schools.   
  
• Schools: For the purpose of this guidance document, schools will refer to both public and private institutions providing Kindergarten to Grade 12 education programs (K to 12) to children and adolescents in group settings. Other school activities include sports, music and field trips into the community or to other schools and some schools provide meal programs for the children (breakfast and lunch). The school population may include children who require assistance with hygiene. Schools may also include populations such as international students that require special communication materials.

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: sore throat, muscle aches, joint pain, or weakness which could be due to 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 school and childcare 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 is seven days in uncomplicated cases; however, 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) 2009 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 and transmission within schools has occurred in all 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

School and child care settings are known settings for amplification of influenza transmission, including the pandemic (H1N1) 2009 influenza virus.  Children are also important vectors of transmission of the influenza virus at home and in the community;  however, schools and child care settings are very controlled environments and could identify potential influenza activity and implement measures to limit transmission of influenza. 

It is recommended that schools and child care centres develop systems to identify individuals with ILI and to implement measures to limit transmission of illness.

The most important factors in the prevention and control of the pandemic (H1N1) 2009 influenza virus in schools and child care settings are:

• Immunization against the pandemic (H1N1) 2009 influenza virus,
• Early identification of ill students, staff and children exhibiting symptoms of ILI,
• Exclusion from the setting of anyone ill with symptoms of ILI and,
• Practising cough/sneeze etiquette and frequent hand cleaning.

Communication and age appropriate education programs for parents/guardians, students, children and staff play an important role in the control of the transmission of the pandemic (H1N1) 2009 influenza virus in school and child care settings.

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

Monitoring

It is recommended that:

• Parents/guardians, students, children and staff are provided with basic information on how to recognize symptoms of ILI. (http://www.fightflu.ca/sym-eng.html)
• Parents/guardians are encouraged to monitor the health of their children daily for symptoms of ILI.
• Teachers and child care program staff observe children for any signs of ILI.
• Cases of ILI are identified when illness reports are received from parents/guardians and reports of ILI are recorded.

Isolation

It is recommended that:

• Schools and child care programs are prepared to promptly isolate students/children who become ill with ILI while in school or child care settings in a room/area separate from others with adequate supervision until they can go home. To help prevent transmission, good respiratory and hand hygiene practices are recommended, as well as, to the extent possible, having the ill children stay two metres away for others.
• Schools and child care programs have protocols in place to notify parents/guardians if their child becomes ill with ILI while at school/child care.
• Children who become ill with ILI while at school or child care are sent home with their parent or guardian and not travel on school buses. If there is no other option and the child must ride a school bus, it is recommended that the child sits on a seat by him/herself and is able to cover his/her mouth and nose with a tissue when coughing or sneezing.
• Students/staff/children who become ill at home with ILI stay at home until they are feeling well and able to fully participate in all normal day to day school activities (e.g., intra/extramural activities and school trips).
• Children and staff are excluded from child care settings if they are exhibiting symptoms of ILI and only return once they are able to fully participate in daily programs.
• Children excluded from one child care program for ILI not be placed into another group child care program.
• In settings where a large proportion of individuals have underlying illness that puts them at risk for severe illness or complications from the pandemic (H1N1) 2009 influenza virus, consideration be given to having symptomatic individuals remain in isolation for seven days after symptom onset or until all symptoms have resolved, whichever is longer.
• Given the potential for more severe illness or complications from influenza infection, schools and child care centres educate parents/guardians about the need for rapid medical assessment of high risk children and of all children in whom severe symptoms develop.

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/daycare setting is not recommended.

Self Care

It is recommended that parents/guardians, students, children and staff 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 recreation/play times, after going to the washroom etc.) and,
• 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 pandemic (H1N1) 2009 influenza virus. Information on hand hygiene and cough etiquette can be found at: http://www.fightflu.ca/prot-eng.html

Respiratory etiquette involves coughing and sneezing into a disposable tissue, discarding 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 schools and child care centres. 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 and child care centres as the mechanical action is effective at removing visible soil as well as microbes. In instances where hand washing sinks are not available, supervised 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 from several hours up to several 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, toys, computer keyboards, telephones, and school bus hand rails, 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 schools and child care centres 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.

School and childcare settings should also consider other cleaning needs and practices that may be relevant to their settings and activities. For example, as per standard procedures, it is recommended that childcare programs have toys that are easily cleaned and disinfected. It may be prudent to increase the frequency of the cleaning schedule for these items, especially when illness is circulating in the setting or the local community or if symptomatic children may have been playing with the toys. The following examples may be more relevant to school settings. It is recommended that water bottles used by sports teams not be shared among the team players.  Mouthpieces on musical instruments, especially on those used by more than one student, 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 school and child care settings implement programs for monitoring student/child and staff illness and develop a strategy to recognize clusters 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/children and staff.

It is recommended that notification and consultation with public health officials 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.

School Closures

The decision to close school or child care settings, 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 closures - The Public Health Agency of Canada does not recommend widespread proactive school closures 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 has been 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.

This guidance document has proposed measures to help mitigate the spread of influenza, including the pandemic (H1N1) 2009 influenza virus, in school and child care settings. Widespread proactive school closures as a control measure have the potential of coming at high economic and social costs since school closures would impact the many families that have one or both parents working outside of the home. Increases in workplace absenteeism could possibly lead to societal disruption and may lead to a less optimal pandemic response if significant absenteeism occurs among workers critical to the response. Consideration also needs to be given to the likeliness of students to congregate elsewhere in less controlled environments, 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/child care administrators may take into account considerations such as the impact of school absenteeism and/or staff shortages on safe school or child care operations while balancing these factors against the goal of minimizing social disruption and child safety. If schools close reactively, consideration should be given to whether some programs (e.g., school meal programs) can continue in order to mitigate the effect of the closure.

It is important to note that there are many protective factors present in school and child care 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 children and their families in an efficient and timely manner,
• support the economic and social elements of the community by allowing parents to continue to work and volunteer and,
• provide a structured environment able to support efficient and effective administration of vaccines to an important sub-group of the community.

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