The purpose of the teleconference was to share experiences and early lessons learnt from recent outbreaks of new influenza A (H1N1) virus infection in communities or closed settings. As of 27 May 2009, >13 000 laboratory-confirmed cases of human infection with new influenza A (H1N1) virus had been officially reported to WHO.(3)
School settings
Countries in which laboratory-confirmed, albeit mild, cases of influenza A (H1N1) virus infection had occurred provided specific examples of outbreaks among schoolchildren or in academic settings, as well as the detailed measures taken to mitigate the spread of infection within schools and among communities. In most cases, decisions to suspend attendance at school had been taken by local rather than national authorities. The exception was Mexico, in which nationwide school closures had been mandated for 2 weeks in May 2009.
All countries agreed that school suspensions had been effective in mitigating the spread of influenza A (H1N1) virus infection; however, such measures were often prohibitively expensive.(4) School closures during the early phases of an outbreak had reduced transmission within schools, but had not always been effective (or their measurable effect) in reducing levels of community transmission.
The legal aspects of school closures and non-discrimination should be closely monitored. Epidemiological considerations should take precedence over racial or ethnic stereotypes, while at the same time recognizing that special provisions may be necessary for schools in countries or areas containing poor populations. While school closures may reduce transmission within school settings, such measures may not affect transmission in community settings. Care therefore needs to be taken when evaluating how school closures will impact transmission.
Mass gatherings
Countries reporting to WHO, with the exception of Mexico, had not instituted restrictions on mass gatherings and were maintaining vigilance for any upcoming events in their respective countries. In Mexico, public participation in mass gatherings during national football matches had been banned in May 2009.
Community-level social distancing measures and use of masks
The Government of Mexico has encouraged its citizens to use masks, particularly when in contact with cases of influenza A (H1N1) virus infection. In Japan, efforts to enact social distancing have included encouraging commuters, in particular, to wear masks. Additional guidelines established in Mexico for mitigating the spread of illness include recommendations on hygiene and implementation of hygiene measures, particularly in schools, as well as guidelines for social distancing in restaurants, stadiums and enclosed areas.
Recommendations
The WHO technical consultation made the following recommendations:
- When considering school suspensions and/or restrictions on mass gatherings, authorities should ask “what is the legal authority and what are the legal processes” for such suspensions and/or restrictions? Decisions should be consistent and well-documented, and be taken within the parameters of each country’s individual sovereignty and existing laws. Care should be taken to avoid discrimination based on nationality, ethnic origin, religion, gender and disability, etc. Furthermore, any decision that results in social isolation, restrictions on the right to travel and assemble, or impacts that commerce, trade and economic stability should be avoided.
- When considering mitigating the spread of influenza A (H1N1) virus infection in school settings, full school closures may not be warranted but class suspensions may be.
- Strategies regarding personal hygiene should be evaluated relative to the type of school (nursery/day care, elementary, junior, or senior high school) and their effectiveness in reducing transmission.
- Good communication is vital as situations surrounding this pandemic are fluid and change daily. Public health officials should convey strong, consistent, easily-understood and actionable messages to the general public and health-care providers. Messaging should encourage people to be aware of the potential for illness, to engage in conscientious public hygiene measures (for example, hand hygiene and cough etiquette) and to seek medical attention as needed. At the same time, public health announcements should reconcile the potential for indifference and the under-allocation of resources versus that of panic and over-allocation of resources.
(1) Canada, Japan, Mexico, Spain, the United Kingdom and the United States.
(2) Representatives from the Johns Hopkins Bloomberg School of Public Health; the European Centre for Disease Control and Prevention; the Department of Health of Hong Kong SAR; and an independent consultant.
(3) Latest figures of laboratory-confirmed cases of new influenza A (H1N1) as officially reported to WHO by States Parties to the International Health Regulations (2005) are available at http://www.who.int/csr/don/en/ .
(4) For additional information on cost analysis of school suspensions and/or closures, see: Cauchemez S, et al [unpublished article]. Closing schools during an influenza pandemic: a review; Cauchemez S et al. Estimating the impact of school closure on influenza transmission from Sentinel data. Nature, 2008, 452(7188):750–U6; Cowling BJ et al. Effects of school closures, 2008 winter influenza season, Hong Kong. Emerging Infectious Diseases, 2008, 14(10):1660–1662; Heymann A et al. Influence of school closure on the incidence of viral respiratory diseases among children and on health care utilization. Pediatric Infectious Disease Journal, 2004, 23:675–677; Sadique MZ, Adams EJ, Edmunds WJ. Estimating the costs of school closure for mitigating an influenza pandemic. Public Health, 2008, 8:135; Vynnycky E, Edmunds WJ. Analyses of the 1957 (Asian) influenza pandemic in the United Kingdom and the impact of school closures. Epidemiology and Infection, 2008, 136(2):166–179.
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