Strategy On Flu Under Revision
U.S. Officials to Put Less Emphasis on School Closings

By Spencer S. Hsu
Washington Post Staff Writer
Tuesday, August 4, 2009

The Obama administration is finalizing guidelines that would scale back when the federal government recommends closing schools in response to the swine flu pandemic, several people involved in the deliberations said Monday.

More targeted guidance would mark a change in the government's approach from this spring, when health officials suggested that schools shut down at the first sign of the H1N1 virus. They later relaxed that advice.

This fall, federal authorities would recommend closures only under "extenuating circumstances," such as if a campus has many children with underlying medical conditions, a senior U.S. health official involved in the talks said. The official added that discussions are continuing and that no decision has been made.

Schools also might be advised to close if many students or staff members are already sick or otherwise absent, officials said.

"The framework is to try to keep schools open to the extent possible," the senior health official said, speaking on condition of anonymity because the White House has not completed its review of the issue.

School closings this past spring raised questions about whether closings slow the spread of H1N1 and are worth the educational and economic cost. The federal government's decision could have a far-reaching effect on tens of millions of Americans, the economy and other countries wrestling with similar choices.

President Obama's top scientific advisers, Cabinet members and national security aides are racing to update the government's flu strategy before the school year begins this month, when infections are expected to surge -- particularly among young people.

Decisions on school closings will be made locally because the flu's severity varies geographically and because local and state governments have authority over school and public health matters, officials said. Federal guidance could change if the virus becomes more virulent or lethal, officials said.

John O. Brennan, the deputy national security adviser who chaired two Cabinet-level meetings in the White House last week to coordinate H1N1 planning, said the internal debate is intended to "think through all the angles" and avoid "knee-jerk" decisions. He said it is too soon to predict the outcome.

"There will be circumstances where it makes sense to close schools, but what we are trying to do is refine" those instances, he said.

U.S. authorities will release within days other "community-mitigation" measures, intended to help keep businesses operating, help hospitals avoid being overwhelmed and guide local authorities in deciding whether to cancel public events, officials said.

Experts say such decisions are timely because of the quickly approaching fall flu season.

The H1N1 virus does not appear to be more lethal than seasonal flu, but it might be two or three times as infectious and is expected to hit young, healthy people and schools especially hard.

On average, about 36,000 Americans a year die of seasonal flu, and more than 200,000 are hospitalized, most of them elderly or already ill. By contrast, most H1N1 cases involve people younger than 18, and children are more infectious than adults, the British medical journal Lancet reported last month.

Advocates of school closings say it is among the best options to slow a pandemic -- and thus reduce deaths and the strain on hospitals.

Following a pandemic plan that the U.S. Centers for Disease Control and Prevention published in early 2007, Obama on April 29 urged U.S. schools with confirmed or suspected flu cases to strongly consider closing for as much as two weeks. The advice came amid a spiraling H1N1 outbreak in Mexico.

More than 700 schools nationwide dismissed nearly a half-million students within days.

But the CDC stepped back May 4, noting that the disease did not appear as lethal as feared and recommending that sick students and staff members stay home for seven days. U.S. officials agreed to revisit the issue by fall.

Education officials said they felt bound to respect what federal officials were telling them, but they decried the effect of the closures, particularly the lost instruction time.

Federal officials proposed school closings after studying the outbreaks of severe acute respiratory syndrome (SARS) and avian flu in Asia earlier this decade, examining the 1918 and 1957 flu pandemics and using new computer models.

But opponents of school closings said that the research relied on unrealistic assumptions and overlooked real-world factors.

Schools would have to stay shut for the duration of a pandemic for closings to work, they say, which could have serious economic consequences. Parents staying home to tend their children would cause widespread financial losses.

Critics of school closings also note the tension between the main objectives of the government's flu response: to minimize illness and death and to limit social disruption.

The Lancet study reported that school closings could help slow the pandemic, but a 12-week closure in the United States or United Kingdom could cost 1 percent to 6 percent of gross domestic product.

Brennan said U.S. authorities are acting now with a "better understanding" of the virus, based on cases here and in the Southern Hemisphere, where flu season is in full swing. Earlier plans were premised on containing a deadlier outbreak that spread from Asia, not a milder form that began, and is already widespread, in North America, officials said.

Neil M. Ferguson, a leading CDC modeler, said the public might be the final decider. He said that people won't accept mass disruption unless the flu is severe and that then they may demand it.

The trouble with waiting is that school closings, to be effective, should be applied before an outbreak peaks, not when it is at its worst.

"Clearly there's some level of flu where it's worth closing the schools and some level of flu where it's not," Marc Lipsitch, a professor at the Harvard School of Public Health, who sits on an external board that is advising the CDC. "The problem here is it's not obvious to everyone which situation we're in."

If health officials see a change in the pandemic, the government will need to alter course again, he said. "It won't necessarily be smooth, but it will have to happen."

Staff writer Martin Weil and staff researcher Madonna Lebling contributed to this report.

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