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Flu Strategists See Schools on Front Line
Children Key to Infection-Prevention Dynamic

By Nelson Hernandez and David Brown
Washington Post Staff Writers
Monday, August 24, 2009

One of the main battlegrounds in the fight against an expected resurgence of swine flu this fall will be the schoolyard, a place where the disease could, well, go viral.

People between 6 months and 24 years old appear to be particularly vulnerable to the swine flu virus, known as H1N1. And there are several reasons to think that schools could be hotbeds of infection:

Large groups of children and young adults? Check.

In close proximity? Check.

Lax sanitary standards? Check.

And with schools expected to remain open unless the virus becomes more severe, there's little standing in the way of H1N1's spread.

At the same time, schools are likely to serve as centers for mass immunizations, which could sharply reduce H1N1's reach, according to the Centers for Disease Control and Prevention and state and local authorities. So far, the swine flu does not appear to be more dangerous than the typical seasonal flu. But medical authorities are concerned that it could infect many more people -- thereby increasing the potential number of deaths -- because so few people have immunity against it.

The mass immunization program, likely to be the largest of its kind since the polio vaccine was given to about 100 million Americans in the 1960s, will play out with some differences between states and local jurisdictions. For instance, still waiting to be resolved are questions about who gets the vaccine, whether schools are used as vaccination sites, whether parents are present when children are vaccinated and whether the vaccine is administered by injection or nasal spray.

Health officials in Virginia, Maryland and the District said that at least some school campuses will be used as vaccination sites. Schools reopen today in the District and in parts of suburban Maryland.

"There's considerable interest out there from the local health departments and school districts to do it in the schools," said Jim Farrell, director of the immunization division of the Virginia Department of Health.

Elsewhere, officials suspect that schools will be used less.

"Our school health system . . . is not very well-funded," said David Fleming, public health director and health officer for Seattle and King County, Wash. "We don't have the staff in the schools to do it. There's also the cumbersome process of getting parental permission. So doing it during school hours may not make a lot of sense."

In Cuyahoga County, Ohio, officials expect that schools will be used at nights and on weekends so parents can be present.

"Parents are going to want to be there to support their kids for vaccination," said Terry Allan, the county health commissioner.

Maryland has more experience than most states in preparing to fight flu. In the 2006-07 flu season, it was the first state to offer vaccinations in all public elementary schools, partly because of a large donation of nasal-spray vaccine by MedImmune, a biotech company in Gaithersburg. Several other states now offer or require statewide seasonal flu immunizations for children.

Virginia and the District have no such program, although Virginia officials said some jurisdictions in the state's rural southwest had offered school-based vaccinations. Dena Iverson, a spokeswoman for the D.C. Department of Health, said there were "a number of programs in place that serve as mechanisms to get vaccine" to children.

In the Maryland initiative, about 80,000 5- to 11-year-olds were immunized, out of 490,000 children in that age group in the state. Participation varied widely, from about 10 percent in Baltimore City to 58 percent in St. Mary's County. In the next two years, when local governments had to buy the vaccine, only seven of Maryland's 24 major jurisdictions continued the program.

This year, Maryland is using some of its federal economic stimulus money to again offer seasonal flu vaccine in elementary schools. The state will also offer swine flu vaccine, said Greg Reed, manager of the Center for Immunization at Maryland's health department.

The swine flu vaccine will probably arrive after the seasonal vaccine and will target a much larger group of students -- everyone through 12th grade. How and where it will be offered -- and how to reach students in private and home schools -- is the subject of intense planning, Reed said.

Diane Helentjaris, director of Virginia's H1N1 office, said the vaccine is expected to be available by mid-October, but officials don't know in what quantity.

Research shows that school-based vaccination can measurably reduce illness.

A study published last summer compared school absentee rates in Carroll County, where 44 percent of elementary students got flu vaccine in 2005, with the rates in neighboring Frederick County, where there was no such program. Frederick absenteeism went up from 2 percent to almost 4 percent during flu season; in Carroll, it rose much less, from about 2.5 percent to 3 percent.

A relatively small increase in absenteeism was also seen in high schools, although they held no immunization programs. That suggests, as does much other research, that young children are a major force in spreading flu.

The ability of schools to track sick students might also prove crucial to understanding the spread of swine flu. Health officials nationally are developing a questionnaire that would provide a useful snapshot without burdening local health departments. Information on the amount of illness in schools will be essential, said Jack Herrmann, a specialist in preparedness at the National Association of County and City Health Officials.

"It is no secret that the school dismissal issue is foremost in the minds of everybody, from the White House on down," Herrmann said. "Clearly, some idea of what is going on in schools is going to be of great interest."

Teachers and principals across the region are being briefed on what to do about swine flu. About 200 Fairfax County principals received advice on hand washing and other anti-flu measures from health officials one day this month, and they left the meeting room with a pamphlet that declared, "Schools Are the Front Lines in Flu Prevention."

"It's a natural occurrence in nature that we have these," said Fred Ellis, the Fairfax school system's director of safety and security. "It's going to come. The best thing we can do is try to mitigate these outcomes."

The briefing ranged over various subjects, including what to do with children who go to school sick (they are to be given surgical masks and placed in an isolation room until their parents pick them up) and how to maintain an online site to allow students to keep up with assignments while they are sick at home. The principals asked about what cleaning products worked best and about what to clean and how often, prompting Ellis to tease them about being "germaphobes."

But cleanliness is important. Apart from a vaccine, the best way to prevent the disease's spread is for people to wash their hands regularly with soap and water.

Some officials recommend singing a song to make sure that hands are being washed long enough.

In a letter to parents, D.C. Schools Chancellor Michelle A. Rhee and D.C. Health Department Director Pierre Vigilance suggested: "A good way to make sure your children are scrubbing their hands for the right amount of time is to sing the Happy Birthday or Row, Row, Row Your Boat songs twice."

Staff writer Rob Stein contributed to this report.

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