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CDC Guidance for Responses to Influenza for Institutions of Higher Education during the 2009-2010 Academic Year

February 22, 2010 11:00 AM ET

This document provides guidance to help decrease the spread of influenza (flu) among students, faculty, and staff of institutions of higher education (IHE) and post-secondary educational institutions during the 2009-2010 academic year. The guidance expands upon earlier guidance for these settings by providing a menu of tools that IHE and health officials can choose from based on conditions in their area. It recommends actions to take now (during this academic year), suggests strategies to consider if the flu starts causing more severe disease than during the April through December 2009 outbreak of  2009 H1N1 flu, and provides a checklist for making decisions. Based on the severity of 2009 H1N1 flu-related illness thus far, this guidance also recommends that students, faculty, and staff 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 guidance, IHE will refer to public and private, residential and nonresidential, degree-granting and non-degree-granting institutions providing post-secondary education in group settings regardless of the age of their students. Portions of this guidance pertaining to dormitories and residence halls may serve as a useful supplement to residential (boarding) schools providing primary and secondary education, with adaptations as needed for their younger population. 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 on CDC Guidance for Responses to Influenza for Institutions of Higher Education during the 2009–2010 Academic Year.

BACKGROUND

The purpose of this document is to provide updated guidance for reducing the spread of flu in IHEs.  We provide recommendations assuming that severity of illness is similar to what was seen during April through December 2009 of the 2009 H1N1flu outbreak, as well as recommendations that could be added if the severity of illness worsens. Flu is unpredictable. CDC is working with state and local health departments to continue to monitor the spread of flu, the severity of the illness it is causing, and changes to the virus. If this information indicates that flu is causing more severe disease than during April through December 2009 of the 2009 H1N1 flu outbreak, or if other developments require more aggressive mitigation measures, CDC may recommend additional strategies. Since severity may vary from community to community, IHEs should also look to their state and local health officials for information and guidance specific to their location.

The guidance is designed to decrease exposure to regular seasonal flu and 2009 H1N1 flu at IHEs. CDC will continue to monitor the conditions and update the current guidance as more information is obtained on 2009 H1N1 flu.

IHEs should tailor the guidance to account for the size, diversity, and mobility of their students, faculty, and staff; their location and physical facilities; programs; and student and employee health services. Decisions about strategies should balance the goal of reducing the number of people who become seriously sick or die from flu with the goal of minimizing educational and social disruption.

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 IHES FOR THE 2009–2010 ACADEMIC YEAR

IHEs 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 emergency contacts and staff; and share their plans with families, staff, and the community.  IHEs 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 students or staff to validate their illness or to return to the IHE or classroom.

IHEs should frequently remind students, 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 IHE. Examples of these materials are available at http://www.cdc.h1n1flu/flyers.htm.  Furthermore, Preparing for the Flu: A Communication Toolkit for Institutions of Higher Education also provides many materials for use. 

The recommendations that follow are divided into two groups: 1) recommendations to use now, during this academic year, assuming a similar severity to the flu outbreak seen during April through December 2009, 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 of complications from flu. Due to increased vaccine availability, everyone, including those over age 65 years, can now be vaccinated.
• Some students and staff will fall within these groups and should be among the first to receive the 2009 H1N1 flu vaccine. Visit http://www.cdc.gov/h1n1flu/vaccination for more information.
• Facilitate self-isolation of residential students with flu-like illness: Those with flu-like illness should stay away from classes and limit interactions with other people (called “self-isolation”), except to seek medical care, for at least 24 hours after they no longer have a fever, or signs of a fever, without the use of fever-reducing medicines. They should stay away from others during this time period even if they are taking antiviral medicines for treatment of the flu. (For more information, visit http://www.cdc.gov/h1n1flu/guidance/exclusion.htm.) 
• Review and revise, as needed, policies, such as student absenteeism policies and sick leave policies for faculty and staff, that make it difficult for students, faculty, and staff to stay home when they are sick or to care for a sick family member. Do not require a healthcare provider’s note to confirm illness or recovery.
• If possible, residential students with flu-like illness who live relatively close to the campus should return to their home to keep from making others sick. These students should be instructed to do so in a way that limits contact with others as much as possible. For example, travel by private car or taxi would be preferable over use of public transportation.
• Students with a private room should remain in their room and receive care and meals from a single person. Students can establish a “flu buddy scheme” in which students pair up to care for each other if one or the other becomes sick. Additionally, staff can make daily contact by e-mail, text messaging, phone calls, or other methods with each student who is in self-isolation.
• If close contact with others cannot be avoided, CDC recommends people with known, probable, or suspected flu or flu-like illness to use a facemask if available and tolerable, or otherwise to cover their noses and mouths with a tissue when coughing or sneezing (or an elbow or shoulder if no tissue is available). Close contact includes caring for or living with the sick person. For those caring for people with flu-like illness, CDC has recommendations for use of personal protective equipment. Visit http://www.cdc.gov/h1n1flu/masks.htm for information on appropriate personal protective equipment.
• For those who cannot leave campus, and who do not have a private room, IHEs may consider providing temporary, alternate housing for sick students until 24 hours after they are free of fever, or signs of a fever, without use of fever-reducing medicines.
• Instruct students with flu-like illness to seek medical attention promptly if they have a medical condition that puts them at higher risk for flu complications, are concerned about their illness, or develop severe symptoms such as increased fever, shortness of breath, chest pain or pressure, or rapid breathing.
• Promote self-isolation at home by non-resident students, faculty, and staff:
• Non-residential students, faculty, and staff with flu-like illness should be asked to self-isolate at home or at a friend’s or family member’s home until at least 24 hours after they are free of fever, or signs of a fever, without the use of fever-reducing medicines.
• Review, and revise if needed, sick leave policies to remove barriers to faculty and staff staying home when they are sick or caring for a sick family member. For students, consider altering policies on missed classes and examinations and late assignments so that students’ academic concerns do not prevent them from staying home when sick or prompt them to return to class or take examinations while still symptomatic and potentially infectious.
• Do not require a healthcare provider’s note for students, faculty, or staff to validate their illness or to return to work.  
• Distance learning or web-based learning may help students maintain self-isolation. 
• Visit http://www.cdc.gov/h1n1flu/guidance/exclusion.htm for more information on staying home while sick.
• Emphasize respiratory etiquette and hand hygiene by both people who are well and those who have any symptoms of flu:
• Encourage students and staff to cover their noses and mouths with a tissue when coughing or sneezing (or an elbow or shoulder if no tissue is available) and to wash their hands frequently with soap and water when possible; students and staff should keep hands away from their noses, mouths, 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:
• School staff should routinely clean frequently touched surfaces with the cleaners they typically use.
• Provide disposable wipes so that commonly used surfaces can be wiped down by students before each use.
• CDC does not believe any additional disinfection of environmental surfaces beyond the recommended routine cleaning is required. 
• Promote early treatment of students and staff at higher risk for flu complications:
• People at higher risk for flu complications who become sick with flu-like illness should speak with 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. Other people may also be treated with antiviral drugs by their doctor this season.  
• Discourage attendance at campus events by sick people: Events such as football games or concerts that bring large groups together may pose a high risk of exposure and transmission of flu.
• Use a variety of communication methods such as e-mail, posters, flyers, and media coverage to discourage people with flu-like illness from attending these events until they have been free of fever, or signs of fever, for at least 24 hours without use of fever-reducing medicines and to encourage respiratory etiquette and hand hygiene.
• Explore ways to modify events to reduce close contact and increase distances between participants. IHEs may need to consider cancelling some events if modification is not possible and there is a high level of flu activity in the community.
• Consider specific student populations:
• Review policies for study abroad programs, including accessing health services abroad and reporting illness to the IHE.
• Communicate plans, policies, and strategies to partner K-12 schools regarding “early/middle college” students, prospective student tours, and other K-12 students regularly on campus.
• Determine if special communication strategies are needed to meet the needs of students with disabilities.
• Review policies for sports teams, bands, and other large groups of students who spend a lot of time together in close quarters. IHE may need to consider cancelling travel to off-campus activities.
• Remind healthcare profession students to follow infection control guidance for healthcare workers. Visit http://www.cdc.gov/h1n1flu/clinicians for guidance for healthcare settings.

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 protect IHE students, faculty, and staff if global, national, or regional assessments indicate that flu is causing more severe disease. In addition, local health or IHE officials may choose to use additional strategies. Although the following strategies have not been scientifically tested in the IHE setting, 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 students, faculty, and 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 while a lot of flu is circulating in their community. Such people should make this decision after consulting with their healthcare provider. 
• IHEs should plan now for ways to continue educating students who stay home through distance learning methods. IHEs should also examine policy accommodations that might be necessary, such as allowing students at higher risk for flu complications to withdraw for the semester, tailoring sick leave policies to address the needs of faculty and staff, or modifying work responsibilities and locations.
• Increase social distances: Explore innovative ways to increase the distances between students (for example, moving desks apart or using distance learning methods). Ideally, there should be at least 6 feet between people at most times.
• Consider postponing campus events: Consider whether to suspend or modify public events such as films, sporting events, or commencement ceremonies.
• Extend the self-isolation period: 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 24 hours after they have no symptoms. See information above for self-isolation in different types of housing.
• Consider suspending classes:
• IHE and health officials should work closely to balance the risks of flu in their community with the disruption that suspending classes will cause in both education and the wider community.
• Use multiple channels to communicate a clear message about the reasons for suspending classes and the implications for students, faculty, staff, and the community.
• Reactive class suspension might be needed when IHEs cannot maintain normal functioning, for example when a significant number and proportion of students have documented fever.
• To decrease the spread of flu, CDC may recommend preemptive class suspension if the flu starts to cause severe disease in a significantly larger proportion of those affected than occurred during April through December 2009 of the 2009 H1N1 flu outbreak.
• If classes are suspended, large gatherings (for example, sporting events, dances, commencement ceremonies) should be cancelled or postponed.
• IHEs should consider whether they can allow faculty and staff to continue use of their facilities while classes are not being held. This may allow faculty to develop lessons and materials and engage in other essential activities.
• IHEs with residential students should plan for ways to continue essential services such as meals, custodial services, security, and other basic operations for students who remain on campus. When possible, dismiss students who can get home – or to the home of a relative, friend of the family, or host family – by private car or taxi. International students and others without easy access to alternative housing should stay on campus, but increase the distance between people as much as possible.
• The length of time classes should be suspended will vary depending on the goal of class suspension as well as the severity and extent of illness. IHEs that suspend classes should do so for at least 5 to 7 calendar days. Before the end of this period, the IHE, in collaboration with public health officials, should reassess the epidemiology of the disease and the benefits and consequences of continuing the suspension or resuming classes. 

DECIDING ON A COURSE OF ACTION

CDC recommends a combination of strategies applied early and simultaneously. Strategies should be selected a) based on trends in the severity of disease, virus characteristics, feasibility, and acceptability and b) through collaborative decision-making with public health agencies, IHE faculty and staff, students, students’ 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. However, states and local communities can expect to see a lot of differences in disease patterns from community to community.

Every IHE has to balance a variety of objectives to determine the best course of action to help decrease the spread of flu. 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 in students, faculty, and staff; and (c) protecting people at higher risk for flu complications. Some strategies can have negative consequences in addition to their potential benefits. In the particular case of IHE class suspension, decision-makers also must consider and balance additional factors: (a) how to ensure students continue to learn; (2) how to provide an emotionally and physically safe place for students; and (3) how to reduce demands on local healthcare services.  The following questions can help begin discussions and lead to decisions.

Decision-Makers and Stakeholders

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

• Local and state health, education, and homeland security agencies
• Campus health services and mental health services
• Campus emergency managers and security staff
• Student affairs and residential life staff
• Communications staff
• Physical plant staff
• Food services staff
• Students
• Faculty
• Community representatives
• Students’ families

Information Collection and Sharing

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

• Numbers of and trends in outpatient visits, hospitalizations, and deaths from flu-like illness
• Percent of hospitalized patients requiring admission to intensive care units (ICUs)
• Groups being disproportionately affected
• Ability of local healthcare providers and emergency departments to meet increased demand
• Availability of antiviral medicines, hospital beds, staff, ICU space, and ventilators for flu patients

What does the IHE know about the following?

• Student, faculty, and staff absenteeism rates
• Number of visits to the campus health service
• Bed availability for student self-isolation
• Severity of illness among affected staff and/or students

Feasibility

Do you have the resources to implement the strategies being considered?

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

Acceptability

Have you determined how to address the following challenges to implementing the strategies?

• Public concern about flu
• People who do not feel empowered to protect themselves
• Lack of public support for the strategy
• Secondary effects of strategies (for example, job security, financial support, health service access, and educational progress)