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CDC Guidance on Helping Child Care and Early Childhood Programs Respond to Influenza during the 2009–2010 Influenza Season

February 22, 2010, 3:00 PM ET

This document provides guidance to help decrease the spread of influenza (flu) among children in early childhood programs and among early childhood providers during the 2009-2010 flu season. The guidance expands upon earlier guidance documents by providing a menu of tools that health officials, Head Start, and other early childhood and child care providers can choose from based on conditions in their area. It recommends actions to take now, during the 2009-2010 flu season, suggests strategies to consider if CDC determines that the flu is becoming more severe, and provides a checklist for decision-making at the local level. Based on the severity of 2009 H1N1 flu-related illness thus far, this guidance recommends that children and early childhood providers with flu-like illness remain home until 24 hours after resolution of fever without the use of fever-reducing medicines. For the purpose of this document, “early childhood programs” will refer to center-based and home-based early childhood programs, Head Start programs, and other early childhood programs providing care for children in group settings.The guidance applies to all early childhood programs, even if they provide services for older children. This guidance represents CDC’s current thinking on this topic. It does not create or confer any rights for or on any person or operate to bind the public.

A more in depth explanation of the strategies and suggestions presented in this CDC Guidance may be found in the Technical Report for State and Local Public Health Officials and Child Care and Early Childhood Providers on CDC Guidance on Helping Child Care and Early Childhood Programs Respond to Influenza during the 2009–2010 Influenza Season.

BACKGROUND

Children less than 5 years of age are at higher risk for flu complications and the risk is greater among children less than 2 years old. Importantly, infants less than 6 months of age represent a particularly vulnerable group because they are too young to receive vaccines against seasonal or 2009 H1N1 flu viruses; as a result, individuals responsible for caring for these children constitute a primary target group for early vaccination. Flu vaccination is the primary means of preventing flu. Additionally, infection control measures are recommended to reduce the spread of flu. Early childhood settings present unique challenges for infection control due to the highly vulnerable population, close interpersonal contact, shared toys and other objects, and limited ability of young children to understand or practice good respiratory etiquette and hand hygiene. Thus, parents, early childhood providers, and public health officials should be aware that, even under the best of circumstances, transmission of infectious diseases such as flu cannot be completely prevented in early childhood or other settings. No policy can keep everyone who is potentially infectious out of these settings.

The purpose of this document is to provide updated guidance for reducing the spread of flu in early childhood programs. We provide recommendations for the 2009-2010 flu season, assuming that severity of illness during the 2009 H1N1 flu outbreak has been similar to what occurred during April through December 2009, as well as recommendations that could be added if the severity of illness worsens. Flu is unpredictable, and CDC will provide periodic updates of these assessments and may recommend additional strategies if they are needed. Also, because conditions may vary from community to community, early childhood providers should also look to their state and local health officials for information and guidance specific to their location.

Flu Symptoms, Transmission, and Risk:

Symptoms of flu can include fever, cough, sore throat, runny or stuffy nose, body aches, headache, chills, and fatigue, and sometimes diarrhea and vomiting. People may be infected with the flu, including 2009 H1N1 flu and have respiratory symptoms without a fever. Like seasonal flu, 2009 H1N1 flu infection in humans can vary in severity from mild to severe. Visit http://www.cdc.gov/H1N1flu/qa.htm for more information on flu symptoms.

Like seasonal flu, the 2009 H1N1 flu virus is spread mainly from person to person through coughs or sneezes of infected individuals. People may also become infected by touching something – such as a surface or object – with flu virus on it and then touching their mouth, nose, or eyes.

Some people are at higher risk than others for serious complications from flu.

These people include:

• children younger than 5 years old, but especially children younger than 2 years old
• people aged 65 years or older
• pregnant women
• adults and children who have:
• asthma
• neurological and neurodevelopmental conditions
• chronic lung disease
• heart disease
• blood disorders
• endocrine disorders (such as diabetes)
• kidney, liver, and metabolic disorders
• weakened immune systems due to disease or medication
• people younger than 19 years of age who are receiving long-term aspirin therapy

For more information on people at high risk for flu complications, visit http://www.cdc.gov/h1n1flu/highrisk.htm.

RECOMMENDATIONS FOR EARLY CHILDHOOD PROGRAMS FOR THE 2009–2010 FLU SEASON

Early childhood providers should examine and revise, as necessary, their current crisis or pandemic plans and procedures; develop contingency plans to cover key positions when staff are absent from work; update contact information for families and staff; and share their plans with families, staff, and the community. Early childhood providers should review and revise, if necessary, their sick leave policies to remove barriers to staff staying home while sick or to care for a sick family member. A healthcare provider’s note should not be required for children or staff to validate their illness or to return to the early childhood setting.

Early childhood providers should frequently remind children, their families, and staff about the importance of staying home when sick; early treatment for people at higher risk for flu complications; respiratory etiquette; and hand hygiene. Educational materials (for example, posters) to enhance compliance with recommendations should be visible in the child care setting. Examples of these materials are available at http://www.cdc.h1n1flu/flyers.htm.  Furthermore, Preparing for the Flu: A Communication Toolkit for Child Care and Early Childhood Programs also provides many materials for use. 

The recommendations that follow are divided into two groups: 1) recommendations to use now, during the 2009-2010 flu season, assuming a similar severity to the flu outbreak seen during April through December 2009 of the 2009 H1N1 flu outbreak, and 2) recommendations to consider adding if a more severe flu season occurs.

Recommended strategies to use now, for flu conditions with severity similar to April through December 2009 of the 2009 H1N1 flu outbreak

• Encourage vaccination against the flu: The best way to protect against the flu – seasonal and 2009 H1N1 – is to get vaccinated.
• The five primary target groups for vaccination against 2009 H1N1 flu include pregnant women, people who live with or care for children younger than 6 months of age, healthcare and emergency medical services personnel, people age 6 months through 24 years, and people age 25 through 64 years who have underlying medical conditions that put them at higher risk for flu complications. Due to increased vaccine availability, everyone, including those over age 65 years, can now be vaccinated.
• All children and staff should be encouraged to receive the 2009 H1N1 flu vaccine. Visit http://www.cdc.gov/h1n1flu/vaccination for more information.
• Advise the sick to stay home: Those with flu-like illness should remain at home and away from others until at least 24 hours after they are free of fever, or signs of a fever, without the use of fever-reducing medicines.  They should stay home even if they are using antiviral medicines. (For more information, visit http://www.cdc.gov/h1n1flu/guidance/exclusion.htm.)
• Conduct daily health checks: Early childhood providers conducting daily health checks should observe all children and staff and talk with each child’s parent or guardian and each child.
• He or she should look for changes in the child’s behavior, a report of illness or recent visit to a healthcare provider, and any signs or symptoms of illness.
• During the day, staff also should identify children and other staff who may be sick.
• Sick children and staff should be further screened by taking their temperature and inquiring about symptoms.
• An early childhood program’s health consultant may provide additional assistance. Visit http://nrckids.org for more information on health consultants or contact your State Child Care Administrator or local child care resource and referral agency to find out if there are early childhood health consultants in your state or local area. 
• Separate sick children and staff: Children and staff who develop symptoms of flu-like illness while at the early childhood program should promptly be separated from others.
• While this may be challenging for some home-based providers, they should provide a space where the child can be comfortable and supervised at all times.
• A parent or guardian should be called and asked to take his or her child home.
• Staff with flu-like illness should also be asked to go home immediately. A staff member who develops illness while at work should wear a facemask when near other people when possible until he or she can go home.
• Early childhood providers who care for people with known, probable, or suspected flu or flu-like illness should use appropriate personal protective equipment. Visit http://www.cdc.gov/h1n1flu/masks.htm for information on personal protective equipment and how to recommend it to employees.
• Emphasize respiratory etiquette and hand hygiene by both people who are well and those who have any symptoms of flu:
• For children with emerging self-care skills, parents and caregivers should closely monitor their respiratory etiquette and hand hygiene and remind children not to share cups or eating utensils.  
• Cover noses and mouths with a tissue when coughing or sneezing (or an elbow or shoulder if no tissue is available) and wash hands often with soap and water when possible; keep hands away from the nose, mouth, and eyes.
• If soap and water are not available, alcohol-based hand rubs can also be used.  However, hand rubs should not be used when hands are visibly soiled.
• Visit: http://www.cdc.gov/flu/protect/covercough.htm for more information on respiratory etiquette and www.cdc.gov/cleanhands for more information on hand hygiene.
• Perform routine environmental cleaning:
• Areas and items that are visibly soiled should be cleaned immediately and all areas should be regularly cleaned – with a particular focus on items that are more likely to have frequent contact with the hands, mouths, and bodily fluids of young children (for example, toys and play areas).
• Provide disposable wipes so that commonly used surfaces can be wiped down by staff before each use.
• CDC does not believe any additional disinfection of environmental surfaces beyond routine cleaning is required. Visit http://nrckids.org for more information on cleaning in early childhood settings.
• Promote early treatment for children and staff at higher risk for flu complications:
• Parents and staff should be encouraged to talk with their healthcare provider to determine if they or a member of their family are at higher risk for flu complications. Staff at higher risk for flu complications and parents of children under age 5 who become sick with flu-like illness should call their healthcare provider as soon as possible to determine if they need antiviral treatment.
• It’s very important that antiviral drugs be used early to treat flu in people who are very sick (for example people who are in the hospital) and people who are sick with flu and have a greater chance of getting serious flu complications. Early treatment should be considered for persons with suspected or confirmed flu who are at higher risk for flu complications including children younger than 2 years old. Children 2 year to 4 years old are more likely to require hospitalization or urgent medical evaluation for flu compared with older children, although the risk is much lower than for children younger than 2 years old. 
• CDC recommends that early childhood providers encourage sick staff at high risk for flu complications and the families of sick children to seek early treatment. People on antiviral treatment may still shed flu viruses and transmit the virus to others. If for any reason there is a concern about a child, parent or staff person continuing to take the medicine, they should discuss this with their healthcare provider before making the decision to stop medicine for their child or for themselves.To lessen the chance of spreading flu viruses that are resistant to antiviral medicines, people on antiviral treatment should stay at home and away from others as recommended and practice good respiratory etiquette and hand hygiene even after their fever has resolved.
• Visit: http://www.cdc.gov/h1n1flu/recommendations.htm for more information on antiviral medicines.
• Consider selective early childhood program closures: If flu transmission is high, some communities or early childhood programs may consider temporary closures with the goal of decreasing the spread of flu among children less than 5 years of age.
• The decision to selectively close should be made locally in partnership with public health officials and should balance the risks of keeping the children in early childhood programs with the social and economic disruption that can result from closing these programs.

Recommended strategies to add in the event of increased flu severity compared to April through December 2009 of the 2009 H1N1 flu outbreak

CDC may recommend additional strategies to help decrease the spread of flu if global, national, or regional assessments indicate that flu is causing more severe disease. In addition, state and local health officials may choose to use additional strategies. Although the following strategies have not been scientifically tested in early childhood settings, they are grounded on basic principles of infection control. Implementation of these strategies is likely to be more difficult and to have more disruptive effects than the previously described strategies. These strategies should be considered if flu severity increases and are meant for use in addition to the strategies outlined above.

• Permit staff at higher risk for flu complications to stay home: If flu severity increases, people at higher risk for flu complications may consider staying home from work while a lot of flu is circulating in their community. Such people should make this decision after consulting with their healthcare provider. Early childhood providers should review their leave policies to remove barriers to staff staying home if necessary.
• Increase social distances between children: Explore innovative ways to increase the distances between people or to separate children into small groups for example, groups with 6 or fewer children (without allowing the children to mix between groups). This is not a simple or easy strategy for many early childhood facilities and would require considerable flexibility.
• Advise children with sick household members to stay home: If flu severity increases, children who live with people with flu-like illness should remain home for 5 days from the day the first household member gets sick.
• Extend the time that sick people stay home: If flu severity increases, people with flu-like illness should stay home for at least 7 days after the onset of their symptoms, even if they have no more symptoms. If people are still sick after 7 days, they should stay home until at least 24 hours after they have no symptoms.
• Consider early childhood program closures: Early childhood and health officials should work closely to balance the risks of flu in their community with the disruption that closing early childhood programs would cause and should clearly state the reason for closing early childhood programs.
• Reactive closures might be needed when early childhood programs cannot maintain normal functioning, for example, due to high staff absenteeism or when a significant number or proportion of children have documented fever while at early childhood programs despite recommendations to keep sick children home.  
• Preemptive closures can be used proactively to decrease the spread of flu. CDC may recommend preemptive closures if the flu starts to cause severe disease in a significantly larger proportion of those affected.
• The length of time early childhood programs should be closed will vary depending on the reason for closing as well as the severity and extent of illness. Early childhood programs that close should do so for at least 5 to 7 calendar days. Before the end of this period, the community should reassess the epidemiology of the disease and the benefits and consequences of keeping children home.
• Visit http://www.cdc.gov/h1n1flu/vaccination for more information on the 2009 H1N1 flu vaccination. If transmission in the community occurs before vaccine-induced immunity, communities whose goal is to substantially reduce flu transmission among children in early childhood may consider temporarily closing early childhood programs. Infant rooms may need to close longer, as infants under age 6 months cannot receive flu vaccine.
• CDC does not believe any additional disinfection of environmental surfaces beyond routine cleaning is required while an early childhood program is closed.
• Parents should be encouraged to develop alternate child care plans in case the early childhood program closes (for example, individual or small group care by relatives or neighbors or changes to work schedules or locations).
• Communities should plan to address possible secondary effects of early childhood program closure. Closing early childhood programs could affect: critical infrastructure; parents’ job security and income; income and sustainability of early childhood programs; program quality; child nutrition; and child safety.

DETERMINING COMMUNITY APPROACHES TO PROTECTING CHILDREN AND STAFF IN EARLY CHILDHOOD PROGRAMS

CDC recommends a combination of strategies applied early and simultaneously. Communities and states should select strategies a) based on trends in the severity of disease, virus characteristics, feasibility, and acceptability, and b) through collaborative decision-making involving public health agencies, early childhood and education agencies, and representatives of early childhood programs, families, and the wider community. CDC and its partners will continuously look for changes in the severity of flu-like illness and will share what is learned with state and local agencies. States and local communities can expect to see a lot of differences in disease patterns from community to community.

Every community has to balance a variety of objectives to determine their best course of action. State and local community decision-makers should identify and communicate their objectives, which might be one or more of the following: a) protecting overall public health by reducing community transmission; b) reducing transmission within early childhood settings; and c) protecting people at higher risk for flu complications. Some strategies can have negative consequences in addition to their potential benefits. The following questions can help begin discussions and lead to decisions at the state and local level.

Decision-Makers and Stakeholders

Are all of the right decision-makers and stakeholders involved?

• State and/or local health officials
• State and/or local education officials
• State and/or local homeland security officials
• State and/or local early childhood licensing agencies, Child Care Administrators, and Head Start Collaboration Directors
• State and/or local governing officials (for example, governors, mayors)
• Family representatives
• Representatives of local businesses, the faith community, and community organizations
• Corporate early childhood program officers, center-based and home-based program owners and operators, early childhood staff
• Healthcare providers, including mental and behavioral healthcare providers, and hospitals
• Local resource and referral agencies

Information Collection and Sharing

Can local or state health officials determine and share information about the following?

• Outpatient visits for flu-like illness
• Hospitalizations for flu-like illness
• Trends in the numbers of hospitalizations or deaths
• Percent hospitalized patients who require admission to intensive care units (ICU)
• Deaths from flu
• Groups becoming sick disproportionately
• Ability of local healthcare providers and emergency departments to meet increased demand
• Availability of hospital bed, ICU space, and ventilators for flu patients
• Availability of hospital staff
• Availability of antiviral medicines

Can early childhood programs determine and share about the following?

• Child and staff absenteeism rates
• Number of children with flu-like illness sent home from the program

Feasibility

Does the state or community have the resources to implement the strategies being considered?

• Funds
• Personnel
• Equipment
• Space
• Time
• Legal authority or policy requirements

Acceptability

Has the state or community determined how to address the following challenges to implementing the strategies?

• Public concern about flu
• Lack of public support for the intervention
• People who do not feel empowered to protect themselves
• Secondary effects of strategies (for example, closing early childhood programs could affect child nutrition, job security, and financial support)