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

October 21, 2009 5:00 PM ET

CDC is releasing new guidance to help decrease the spread of 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 flu severity is increasing compared with the spring/summer 2009 outbreak, 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 influenza-like illness remain home until 24 hours after resolution of fever without the use of fever-reducing medications. For the purpose of this document, IHE is used to 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 be useful for residential (boarding) schools providing primary and secondary education, with adaptations as needed for their younger population. This guidance represents the 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.

This Technical Report includes detailed explanations of the strategies presented in the CDC Guidance for Responses to Influenza for Institutions of Higher Education during the 2009-2010 Academic Year and suggestions on how to use them. The guidance is designed to decrease exposure to regular seasonal flu and 2009 H1N1 flu while limiting the disruption of day-to-day activities and the vital academic activities that go on in Institutions of Higher Education (IHE). CDC will continue to monitor the situation and update the current guidance as more information is obtained on 2009 H1N1.

More than 17 million students attend the 4,300 degree-granting post-secondary institutions in the United States and more than 3 million people work as faculty and staff. An additional 2,222 non-degree-granting institutions offer vocational post-secondary education. IHEs are extremely varied and include:

• Public and private institutions
• Residential and nonresidential institutions
• Degree-granting and non-degree-granting institutions
• Educational or training programs that last from a few weeks to 4 or more years
• Student population sizes ranging from fewer than one hundred to tens of thousands
• Community colleges and vocational education and training programs that serve their local communities
• Colleges and universities with students from across the country and around the world

Institutions will need to tailor the guidelines to their own unique circumstances, taking into account the size, diversity and mobility of their student body, faculty, and staff; their location and physical facilities; programs; and student and employee health services.

Decisions about which strategies to implement should balance the goal of reducing the number of people who become seriously ill or die from influenza with the goal of minimizing educational and social disruption.

IHEs should examine and revise, as necessary, their current crisis or pandemic plans and procedures, including updating contact information for students, their families, faculty, and staff. Communication plans should be shared with students, their families, faculty, and staff before an outbreak so that they know how the IHE will contact them and what types of information to expect. Establishing mechanisms to contact students’ families in the event of a flu outbreak on campus, or to notify them that their student is ill, may decrease the number of inquiries coming into the IHE and therefore the burden on IHE staff.

IHEs also should communicate with vendors who supply critical products or services to plan for continuation of those services throughout the flu season. Critical services may include food service, hygiene supplies, security, and personal protective equipment for staff. This planning is especially important when suppliers may be small businesses in the local area that could also be affected by a flu outbreak. Visit School Planning for the Colleges and Universities Pandemic Influenza Planning Checklist.

Although the situation during the fall and winter 2009-2010 is unpredictable, more communities may be affected by 2009 H1N1, and the impact could be more severe, than in spring/summer 2009. In addition, seasonal influenza viruses may cause illness at the same time as 2009 H1N1. CDC is continually monitoring the spread of flu, the severity of the illness it is causing (including hospitalizations and deaths), and for possible changes in flu viruses; CDC will provide periodic updates of these assessments. If the information CDC gathers indicates that flu is causing more severe disease than during the spring/summer 2009 H1N1 outbreak, or if other developments indicate more aggressive mitigation measures should be taken, CDC may recommend additional strategies.

Preparing for the Flu: A Communication Toolkit for Institutions of Higher Education

Recommended responses to influenza for the 2009–2010 academic year

The most important things IHEs can do are to encourage and facilitate use of hand hygiene and respiratory etiquette measures by students, faculty, and staff; encourage influenza vaccination for those recommended for vaccination; and to separate ill and well people as soon as possible. There are many ways to employ these strategies; not all can be described in this document. The following recommendations provide a framework to determine the most appropriate and feasible strategies for each IHE.

Although isolating ill people is not typically recommended for seasonal flu, it is a critical strategy for addressing 2009 H1N1 for three reasons: (1) while a vaccine for seasonal flu will be available early in the flu season, a vaccine for 2009 H1N1 is not yet available; (2) 2009 H1N1 may result in more serious complications for people in high-risk groups and these measures help protect high-risk people (see list of high-risk groups below); and (3) a widespread pandemic may result in many more hospitalizations and medical care visits than usually associated with seasonal flu. Measures to limit the spread of influenza, if effective, may reduce demand on the health care system. Other measures, such as suspending classes, are recommended for conditions of increased influenza severity, but might be necessary during period of increased influenza activity in the community, on a case-by-case basis, if the IHE is not able to maintain normal functioning.

IHEs should review, and revise if necessary, their sick leave policies to remove barriers to faculty and staff staying home while ill or to care for an ill family member. For students, IHEs may consider altering policies on missed classes and examinations and late assignments so that students’ academic concerns do not prevent them from staying home when ill or prompt them to return to class or take examinations while still symptomatic and potentially infectious. Do not require a doctor’s note for students, faculty, or staff to validate their illness or to return to work, as doctor’s offices and medical facilities may be extremely busy and may not be able to provide such documentation in a timely way. Distance learning or web-based learning may also help students maintain self-isolation. IHEs should determine quantities of supplies and space needed to facilitate self-isolation for example, hygiene supplies, masks and other personal protective equipment.

IHEs should take opportunities at the beginning of events to remind attendees about the importance of self-isolation when ill; early evaluation by a health care provider for those who become ill, especially for people at higher risk for influenza complications; hand hygiene; and respiratory etiquette. Orientation activities can provide one such opportunity as the academic year begins. Educational materials such as posters and flyers to enhance compliance with recommendations should be visible throughout the campus. Information and links to credible sources should be posted on the IHE website. Examples of these materials are available at 2009 H1N1 Flu .

The recommendations that follow are divided into two groups: 1) recommendations to use now, during this academic year, assuming a similar severity to the spring/summer H1N1 flu outbreak, and 2) recommendations to consider adding if the flu begins to cause more severe disease. 

Recommended strategies to use now, undercurrent flu conditions
(similar severity as in spring/summer 2009)

Facilitate self-isolation of residential students with influenza-like illness in their residence halls, dormitory rooms, the campus health service, or other locations, and help them stay away from others for the full recommended period.

CDC recommends that individuals with influenza-like illness remain at home and away from other people until at least 24 hours after they are free of fever (100° F [37.8° C] or greater), or signs of a fever, without the use of fever-reducing medications.  Influenza-like illness is defined as a fever plus cough and/or sore throat. If possible, residential students, faculty, or staff members who live relatively close to the campus should return to their home to keep from making others sick. Those leaving the IHE to go to a private home to recuperate 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.

While the campus infirmary would be an ideal location for ill people, few schools have them and such facilities could be rapidly overwhelmed during an influenza outbreak. Students with single rooms and private bathrooms should stay in their rooms. Students living in suite-type living quarters should remain in their own rooms and receive care and meals from a single person, if possible. Students could be asked to establish a “flu buddy scheme” in which students pair up as the identified caregiver if one or the other becomes ill. Ill students should limit their contact with others and, to the extent possible, maintain a distance of 6 feet from people with whom they share living space. Shared bathrooms should be avoided or receive frequent cleaning. If close contact cannot be avoided, the ill student should be asked to wear a surgical mask during the period of contact. Visit: Interim Recommendations for Facemask and Respirator Use to Reduce 2009 Influenza A (H1N1) Virus Transmission or Flu.gov for more information on personal protective equipment.

Close contact, for the purposes of this document, is defined as caring for or living with a person with influenza-like illness or being in a setting with a high likelihood of contact with respiratory droplets and/or body fluids of such a person. Close contact typically does not include activities such as walking by an infected person or sitting across from a symptomatic patient in a waiting room or office.

For those who cannot leave campus, and who do not have a private room, IHEs may consider providing temporary, alternate housing where those who are ill can stay until 24 hours after they are free of fever. Because ill students do not need to stay away from other ill students, some IHEs are considering temporarily converting a gym or other large space to housing for ill people. Local emergency management agencies might be able to assist with planning and arranging for necessary equipment, such as sleeping cots. Locations should have good access to bathrooms (which ideally should not be shared with well people) and security services; meals and medications (if indicated) should be provided. Internet access might allow students to continue their class work when feeling better but still self-isolating. Some IHEs have explored pre-arranging contracts with hotels or local landlords for temporary use of off-campus space. 

IHEs should establish a method for maintaining contact with students who are in self-isolation. If resources permit, student affairs, housing staff, or health care providers (for example, nurses or physician’s assistants) could be assigned to make daily contact with each student who is in self-isolation for influenza-like illness in a dormitory or other university residential setting. For some IHEs, residential advisors also may serve this function. Possible contact methods include e-mail, text messaging, phone calls, or room visits. Ill students should be provided guidance that reinforces hygiene and self-isolation. Some IHEs may choose to also check on roommates, suitemates, and others who come in close contact with the ill person to determine if they have also fallen ill. 

Students should be instructed to promptly seek medical attention if they have a medical condition that places them at increased risk of influenza-related complications, are concerned about their illness, or develop severe symptoms.  Severe symptoms include increased fever, shortness of breath, chest pain or pressure, rapid respirations, cyanosis (bluish skin color), vomiting, dizziness, or confusion. Campus health services can communicate to the IHE community about these symptoms, how to contact health services, and groups of people at high risk for complications from influenza.

Guidance for caring for influenza patients in the home can be applied in the dormitory or residence hall as well. Visit: Interim Guidance for 2009 H1N1 Flu (Swine Flu): Taking Care of a Sick Person in Your Home for more information on caring for sick people in the home.

Students, faculty, and staff should be vigilant in identifying people who appear to be ill. These individuals should be encouraged by anyone who encounters them to self-isolate and to talk with a health care provider about whether they have influenza, appropriate treatment, and actions to take if they experience severe symptoms.

Promote self-isolation at home by non-resident students, faculty, and staff

CDC recommends that individuals with influenza-like illness remain at home until at least 24 hours after they are free of fever (100° F [37.8° C] or greater), or signs of a fever, without the use of fever-reducing medications.  If possible, students, faculty, and staff with influenza-like illness should be asked to stay at home or at a friend or family member’s home and avoid contact with other people until at least 24 hours after they are free of fever. Students leaving the IHE to go to a private home to recuperate 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. If he or she can tolerate it, the ill person should wear a mask while in close contact with others.

Visit CDC Recommendations for the Amount of Time Persons with Influenza-Like Illness Should be Away from Others for more information on staying home while ill.

Considerations for high-risk students and staff

Influenza can cause serious complications, including bacterial pneumonia and dehydration, and can worsen chronic medical conditions, such as congestive heart failure, asthma or diabetes. Every student, faculty, and staff member should know before an outbreak begins if they are or are not in a high-risk group. Students, faculty, and staff should be encouraged to talk with their health care provider to determine if they are at higher risk for influenza complications. Groups that are at increased risk of complications from influenza if they get sick (i.e., high-risk groups) include: children younger than 5 years old; people aged 65 years or older; children and adolescents (younger than 18 years) who are receiving long-term aspirin therapy and who might be at risk for experiencing Reye’s syndrome after influenza virus infection; pregnant women; adults and children who have asthma, other chronic pulmonary, cardiovascular, hepatic, hematological, neurologic, neuromuscular, or metabolic disorders such as diabetes; and adults and children with immunosuppression (including immunosuppression caused by medications or by HIV). People 65 years and older, however, appear to be at lower risk of 2009 H1N1 infection compared to younger people. But, if older adults do get sick from influenza, they are at increased risk of having a severe illness.

People at high risk for influenza complications who become ill with influenza-like illness should call their health care provider as soon as possible to determine if they need antiviral treatment. Early treatment with antiviral medications often can prevent hospitalizations and deaths. CDC recommends that IHEs encourage ill students, faculty, and staff at higher risk for influenza complications to seek early treatment. People on antiviral treatment may still shed influenza viruses and transmit the virus to others. In addition, people taking antiviral medications can develop infection with antiviral resistant virus strains. To lessen the chance of spreading influenza viruses that are resistant to antiviral medications, people on antiviral treatment should remain in self-isolation according to the current recommendations and adhere to good respiratory etiquette and hand hygiene. Visit: Updated Interim Recommendations for the Use of Antiviral Medications in the Treatment and Prevention of Influenza for the 2009-2010 Season for more information on antiviral medications.

One of the best ways to protect against the flu is to get vaccinated each year. As always, a vaccine will be available this year to protect against seasonal influenza. Everyone 6 months through age 18, people age 18 through 49 with medical conditions that put them at increased risk of complications from influenza, household contacts and caregivers of people less than age 5, and all people age 50 and older should be vaccinated against seasonal influenza. Seasonal influenza vaccine usually becomes available early in the fall.

There is no vaccine available right now to protect against the 2009 H1N1 flu virus. However, a vaccine is currently in production, and initial doses of this vaccine are expected to become available for the public later in the fall. CDC’s Advisory Committee on Immunization Practices (ACIP) has recommended that certain groups of the population receive the 2009 H1N1 flu vaccine when it first becomes available. These initial target groups 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 influenza. Most IHE students are included in these initial target groups and should be among the first to receive the 2009 H1N1 flu vaccine. IHEs should contact their local health officials to determine where vaccine will be administered and to discuss the possibility of a vaccination clinic at the IHE.

Discourage visitors, students, faculty, and staff with influenza-like illness from attending IHE events until they have been free of fever for at least 24 hours

IHE events that draw the public and other visitors, such as football games or concerts, may pose a high risk of exposure and transmission of influenza. IHEs should use a variety of communication methods such as e-mail, posters, flyers, and media coverage to discourage people with influenza-like illness from attending these events until they have been free of fever for at least 24 hours and to encourage adherence to hand hygiene and respiratory etiquette. Materials should be made available in the language(s) spoken by the IHE community, including those for whom English is not their primary language. IHEs can also look for ways to modify these events to reduce close contact and increase distances between participants. IHEs may need to consider canceling some events if modification is not possible and there is a high level of influenza activity in the community.

Hand Hygiene

Influenza may spread via contaminated hands or inanimate objects that become contaminated with influenza viruses. CDC recommends that students, faculty, and staff be encouraged to wash their hands often with soap and water, especially after coughing or sneezing. Alcohol-based hand cleaners may also be effective, but may not be allowed in all settings. If soap and water are not available, and alcohol-based products are not allowed, other hand sanitizers that do not contain alcohol may be useful; however, there is less evidence on their effectiveness compared to that on hand washing and alcohol-based sanitizers.

Soap, paper towels and sanitizers are critical for proper hand hygiene and should be readily available throughout the campus. IHEs should educate all students, faculty, and staff about good hand hygiene through direct education as well as posting and disseminating communications materials such as signs, posters, and flyers.

Visit: Clean Hands Save Lives! for more information on hand hygiene.

Respiratory Etiquette

Influenza viruses are thought to spread mainly from person to person in respiratory droplets of coughs and sneezes. This can happen when droplets from a cough or sneeze of an infected person are propelled through the air and deposited on the mouth or nose or are inhaled by people nearby. CDC recommends covering the nose and mouth with a tissue when coughing or sneezing and throwing the tissue in the trash after use. Wash hands promptly after coughing or sneezing. If a tissue is not immediately available, coughing or sneezing into one’s arm or sleeve (not into one’s hand) is recommended. IHEs can encourage respiratory etiquette by providing tissues, through direct education, and by posting and disseminating communications materials such as signs and posters.
Visit: Cover Your Cough for more information on respiratory etiquette.

Routine cleaning

Promote frequent cleaning of bathrooms and other frequently used areas, and ensure adequate supplies of soap and paper towels. Provide no-touch wastebaskets and empty them frequently. Establish regular schedules for frequent cleaning of high-touch surfaces:

• Doorknobs, handrails, elevator buttons
• Desks, tables, chairs
• Counters and surfaces in cafeterias, meeting rooms, and offices

Provide disposable wipes so that commonly used surfaces can be wiped down by students before each use. High-use surfaces include:

• Chairs, desks, study carrels
• Remote controls
• Keyboards shared by students
• Headphones shared in language laboratories
• Telephone receivers and touch-tone pads in common areas

Encourage students to frequently clean their living quarters. Students living together should regularly clean frequently used surfaces such as doorknobs, refrigerator handles, remote controls, computer keyboards, countertops, faucet handles, and bathroom areas.

Considerations for specific student populations

Students studying abroad. IHEs should review their policies for study abroad programs, including how students can access health services abroad, how illness will be reported to the IHE, resources for students abroad who are unable to travel back to the U.S., and any legal liability issues. Visit Travelers' Health for more information on considerations for travel.

Early/Middle College students. IHE plans and policies should consider high school students taking college classes for credit; students and families touring the IHE; and other K-12 students who regularly come to campus. IHEs should communicate with their partner K-12 schools about their plans, policies, and strategies they are implementing.

Students with disabilities. More than 11% of undergraduates reported some type of disability in 2003-2004; 7.5% of these students reported a specific learning disability. IHEs should determine if they need to use special communication strategies for these students.

Sports teams, bands, and other large student groups. IHEs should review their policies for sports teams, bands, and other large groups of students who spend a great deal of time together in close proximity. IHEs may need to consider canceling travel to off-campus events if there is a high level of influenza activity in the community.

Health-care profession students. IHEs that train health care professionals such as physicians, dentists, and nurses represent environments with the potential for greater exposure and to amplify transmission to populations at high risk for influenza complications. Students in the heath care professions who spend any time in a clinical setting should be reminded to self-monitor for symptoms of influenza-like illness, practice good hand hygiene and respiratory etiquette, and use appropriate personal protective equipment. Visit H1N1 Information for Health Care Providers for guidance for health care settings.

Under conditions with increased severity compared to spring/summer 2009

CDC will work with state and local health departments to continue to assess the severity of illness caused by 2009 H1N1 flu and disseminate the results of these ongoing assessments. If global, national, or regional risk assessments indicate an increased level of severity compared with the spring/summer 2009 H1N1 flu outbreak, CDC will consider the need to recommend additional strategies.

Decisions to add strategies should be based on information on the severity of illness reported in global, national, and regional assessments, local goals, epidemiology, and health care system capacity, bearing in mind the feasibility and acceptability of the strategies being considered. The following strategies use a variety of methods for increasing social distance, while attempting to maintain operability of most IHEs. Feasibility and acceptability of these strategies will vary considerably. Although the following strategies have not been scientifically tested in the IHE setting, they are grounded on basic principles of infection control. Implementing 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 influenza severity increases and are meant for use in addition to the strategies outlined above.

Permit high-risk students, faculty, and staff to stay home

If influenza severity increases, students, faculty, and staff at high risk for influenza complications may consider staying home while influenza transmission is high in their community. Such people should make this decision after consulting with their health care provider. People who elect to stay home should also attempt to decrease their exposure in other ways -- for example, by avoiding large public gatherings.

IHEs should consult with their boards and legal counsel about policy accommodations that might be necessary. For example, IHEs might be able to make provisions for distance learning methods such as conference calls and internet-based lessons or students at high risk for influenza complications might be allowed to withdraw for the semester without penalty. Sick leave policies might be tailored to address the needs of faculty and staff at high risk for influenza complications. Work responsibilities and locations potentially could be modified to keep people at high risk from coming into contact with potentially ill individuals. To the extent possible, telecommuting and distance learning could be made more widely available.

Increase social distances

If influenza severity increases, IHEs should explore innovative methods for increasing social distances while continuing to meet their educational mission. The goal should be for there to be at least 6 feet of distance between people at most times. This is not a simple or easy strategy and would typically require considerable flexibility. Possible options to increase the amount of space between students include moving desks farther apart, leaving vacant seats between students, holding classes outdoors, and using distance learning methods.

Campus events

At an increased level of severity, IHEs should consider whether to suspend or modify public events such as lectures, films, concerts, sporting events, worship services, and commencement or baccalaureate ceremonies. IHEs could also discourage large gatherings that are not sponsored by the IHE, such as fraternity parties.

Extend the self-isolation period

If influenza severity increases, individuals with influenza-like illness should self-isolate at home for at least 7 days after symptom onset, even if symptoms resolve sooner. Individuals who are still sick 7 days after they become ill should continue to self-isolate until at least 24 hours after symptoms have resolved.

This recommendation is based on viral shedding information. Influenza virus shedding generally occurs for 5 to 7 days for seasonal influenza infection. This period may be longer for people with 2009 H1N1 flu, for young children, or for people who are immune-compromised. Longer periods of exclusion of people who have influenza symptoms also may be considered based on setting- and population-specific characteristics.

See information above for self-isolation for residential and non-residential students.  

Visit CDC Recommendations for the Amount of Time Persons with Influenza-Like Illness Should be Away from Others for more information about staying home while sick.

Consider suspending classes

CDC recommends that IHEs review and revise, as necessary, pandemic flu plans that can be readily implemented if influenza severity increases. Officials should balance the risks of influenza in their community with the disruption suspending classes will cause in both education and the wider community. IHE officials should work closely and directly with their local and state public health officials to revise their plans, to make sound decisions based on local conditions, and to implement strategies in a coordinated manner. When IHEs suspend classes, they should use multiple channels to communicate a clear message about their reasons for doing so and the implications for the students, faculty, staff, and the community.

Reactive class suspension. Suspending classes might be appropriate when IHEs are experiencing high rates of absenteeism due to influenza-like illness among students, faculty, or staff, when a large number of students are visiting campus health services for influenza-like illness, or when the IHE is not able to maintain normal functioning due to severe influenza conditions in the community.

Preemptive class suspension. IHEs might be asked to suspend classes to decrease the spread of influenza virus if global, national, or regional risk assessments indicate an increased level of severity compared with the spring/summer 2009 H1N1 influenza outbreak. Suspending classes is likely to be more effective in decreasing the spread of influenza virus in the community when used early in relation to the appearance of the virus in the community and when used in conjunction with other strategies.

A vaccine for 2009 H1N1 flu will likely become available in fall 2009. Protective immunity likely will require 2 doses of vaccine, separated by at least 3 weeks and an additional 2 weeks for the immune response to develop (that is, approximately 5 weeks after the first vaccination). If an increase in community-wide transmission occurs shortly before vaccine-induced immunity is anticipated, or before a scheduled break, some IHEs may consider suspending classes temporarily.

Large gatherings. If classes are suspended preemptively, other large gatherings should be cancelled or postponed. This would include sporting events, dances, performances, commencement ceremonies, and other events that bring large groups of people into close proximity with one another. Large gatherings might also need to be cancelled, postponed, or modified during a reactive class-suspension period.

Nonresidential students. IHEs with only nonresidential students should consider whether they can allow faculty and staff to continue to use their facilities while classes are not being held. Keeping facilities open may allow faculty to develop lessons and materials, to continue teaching through distance learning methods, to advise students using methods such as telephone calls and e-mail, and to engage in other essential activities, such as research projects.

Residential students. 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, faculty, and staff who can drive home or who can go to the nearby home of a relative, close friend of the family, or an international student’s host family. Students leaving the IHE 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. International students and others who do not have easy access to alternative housing should stay on campus, but increase the distance between people and minimize crowding to decrease the likelihood of influenza transmission. For example, if multiple roommates remain on campus, one might be able to move to a friend’s vacant room for this time period. Additionally, IHEs can explore distance-based learning methods to facilitate continued education both for students who remain on campus and those who leave. Faculty and staff should be allowed continued use of their facilities while classes are not being held.

Resuming classes. The length of time classes should be suspended will vary depending on the reason for suspending classes as well as the severity and extent of illness. When the decision is made to suspend classes, CDC recommends doing 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. Based on this reassessment, the IHE may decide either to extend the period for which classes are suspended (and reassess again) or to resume classes. In the event that global, national, and regional risk assessments indicate a much higher severity than that seen in the spring/summer 2009 H1N1 outbreak, IHEs should plan for more prolonged periods of class suspension. Complete closing of the campus (which would include suspension of research activities) is not possible or desirable for most IHEs and is unlikely to be recommended. However, IHEs should plan for ways to care for animals and maintain critical research activities while minimizing contact between people.

Roles

Collaboration is essential: many different stakeholders have important roles to play in the decision-making process, implementing strategies, and ensuring their effectiveness.

• CDC will continue to work with state and local partners to monitor the spread and severity of influenza illness, monitor for changes in circulating influenza viruses that may confer increased severity of disease, identify promising methods for reducing morbidity and mortality, assist state and local health and education agencies to implement those methods and evaluate their effectiveness, and provide timely updates on new scientific findings as well as additional guidance as the situation warrants.
• The U.S. Department of Education (ED) will collaborate with federal, state, and local agencies as well as non-governmental entities to disseminate new guidance, provide support to state education agencies, and work with states to provide flexibility in regulations around funding.
• IHEs should:
• Work with state and local public health and education agencies to decide which strategies to implement and when, collect and share data, and disseminate emerging guidance.
• Establish collaborative relationships with local schools of medicine, hospitals, urgent care centers, and emergency departments.
• Assure campus health services have established plans for triage, treatment, vaccination, and education of students.
• Examine and revise, as necessary, their current crisis or pandemic plans and procedures.
• Examine and revise, as necessary, sick leave policies for faculty and staff to allow them to stay home when ill and policies on missed classes and examinations and late assignments so that students’ academic concerns do not prevent them from staying home when ill.
• Serve as resources for their students, parents, faculty, staff, visitors, and wider communities by providing education about ways to reduce the spread of influenza.
• Students, faculty, and staff must take personal responsibility for staying home when ill and practicing hand hygiene and respiratory etiquette.

Deciding on a course of action

To decrease exposure of students, faculty, and staff to the influenza virus, CDC recommends a combination of targeted, layered strategies applied early and simultaneously as the best means to reduce spread of influenza. The selection of strategies should be based on trends in the severity of the disease, characteristics of the virus, feasibility, and acceptability. A course of action should be determined through collaborative decision-making involving 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 influenza and will share what is learned with state and local agencies, the public, and other stakeholders. 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 influenza. Decision-makers should explicitly 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 among students, faculty, and staff; and (c) protecting people with high-risk conditions. Some strategies can have negative consequences in addition to their potential benefits. The following questions can help begin discussions and lead to decisions.

Decision-Makers and Stakeholders

Are all the right people involved in the decision-making process?

• Identify the decision-makers. In some communities, local and state health, education, and homeland security agencies may have relevant decision-making responsibilities. Public IHEs will have different types of decision-makers than private institutions.
• Identify the stakeholders. Stakeholders will vary between IHEs, but may include: staff from campus health services and mental health services, emergency management, student affairs, residential life, security, communications, physical plant operations, and food service; students; faculty; other staff; community representatives; and students’ families.

What is the process for working together?

• Do you have a process for regular input and collaboration on decisions?
• Are there strong, open communication channels between decision-makers and stakeholders? Does this include frequent information sharing?
• Do you regularly review your crisis and pandemic plans? Do you revise as needed?

Information Collection and Sharing

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

• What is the severity and extent of spread of the disease in the state or locality? How many people are making outpatient visits for influenza-like illness? How many people are being hospitalized for influenza-like illness? Are the numbers of hospitalizations or deaths increasing? What percent of these hospitalized patients require admission to intensive care units? How many influenza deaths have occurred in the community? Are some groups being disproportionately affected?
• How busy are local health care providers and emergency departments? How many visits are they getting for influenza-like illness? Are they able to meet the increased demand for care from people with influenza-like illness? Are local health care providers or emergency departments becoming overburdened?
• Are the hospital and intensive care unit (ICU) beds full with influenza patients? Is there available space in the ICUs? Are there enough ventilators?
• Do the hospitals have enough staff to provide care? Is there increasing absenteeism in health care workers due to influenza-like illness in themselves or their family members?
• Is there enough antiviral medication in the community to treat ill patients at high risk for complications?
• What are the plans for seasonal and 2009 H1N1 vaccination clinics?

What does the IHE know about the following?

• What are student absenteeism rates? Rates for faculty? Staff?
• How busy is the campus health service? How many visits are they getting for influenza-like illness? Are they able to meet the increased demand for care from people with influenza-like illness? Are beds available for students who need to self-isolate?

Feasibility

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

• What resources are available? Do you have access to the funds, personnel, equipment, and space needed?
• How long will the strategies take to implement? How long can the strategies be sustained?
• Are changes to policy needed? How feasible are these changes?
• How can you most clearly communicate with the IHE community about steps students, faculty, staff, and students’ families need to take and the reasons for recommendations?

Acceptability

• Have you determined how to address the following challenges to implementing the strategies?
• How are public concerns affecting the community? Are rumors circulating about the flu? About the strategies you are considering? What can you do to counter false rumors?
• What can you do to empower personal responsibility for protective actions? What can you do to increase buy-in?
• Will the community support the strategies under consideration? What can you do to increase support?

What secondary effects (for example, job security, financial support, health service access, and educational progress) might result from the strategies under consideration? Can these secondary effects be mitigated?