Guidance for School Administrators to Help Reduce the Spread of Seasonal Influenza in K-12 Schools

This document from the Centers for Disease Control and Prevention (CDC), an agency of the U.S. Department of Health and Human Services, provides guidance to help reduce the spread of seasonal influenza (flu) among students and staff in K-12 schools. Recommendations are based on CDC’s current knowledge of flu in the United States. CDC will continue to monitor flu activity and update this guidance as needed.

For the purpose of this guidance, “schools” will refer to both public and private institutions providing grades K-12 education to children and adolescents in group settings.

Supplemental Interim Guidance for School Administrators Associated with Possible Outbreaks of H3N2 Variant Influenza Virus ("H3N2v")

Background

Flu seasons are unpredictable in a number of ways. Although widespread influenza activity occurs every year, the timing, severity, and duration of it depend on many factors, including which flu viruses are spreading, the number of people who are susceptible to the circulating flu viruses, and how well the flu vaccine is matched to the flu viruses that are causing illness. The timing of flu can vary from season to season. In the United States, seasonal flu activity most commonly peaks in January or February, but flu viruses can cause illness from early October to late May. Flu viruses are thought to spread mainly from person to person through coughs and sneezes of infected individuals. People may also become infected by touching something with flu virus on it and then touching their mouth, nose, or eyes.

Many respiratory infections spread from person to person and cause symptoms similar to those of flu. Therefore, the nonpharmaceutical recommendations in this document might help reduce the spread of not only flu, but also respiratory syncytial virus (RSV), rhinovirus, and other viruses and bacteria that can cause illness.

Each day, about 55 million students and 7 million staff attend the more than 130,000 public and private schools in the United States. By implementing the recommendations in this document, schools can help protect one-fifth of the country's population from flu. Collaboration is essential; CDC, the U.S. Department of Education, state/local public health and education agencies, schools, staff, students, families, businesses, and communities should work together to reduce the spread of flu and other respiratory infections.

See Current Flu Season Information and Key Facts about Influenza (Flu) and Flu Vaccine.

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High-Risk Groups

People of all ages get sick with flu. School-aged children are the group with the highest rates of flu illness. Groups at highest risk for severe flu-related illness, including being hospitalized or dying from flu, include:

• Children younger than 5 years of age, but especially children younger than 2 years of age
• Adults 65 years of age and older
• Pregnant women
• American Indians/Alaskan Natives
• People younger than 19 years of age who are receiving long-term aspirin therapy
• People who have certain medical conditions, including:
  
  • Asthma
  • Other chronic lung diseases (such as chronic obstructive pulmonary disease [COPD] and cystic fibrosis)
  • Neurological and neurodevelopmental conditions (including disorders of the brain, spinal cord, peripheral nerve, and muscle, such as cerebral palsy, epilepsy [seizure disorders], stroke, intellectual disability [mental retardation], moderate to severe developmental delay, muscular dystrophy, and spinal cord injury).
  • Heart disease (such as congenital heart disease, congestive heart failure, and coronary artery disease)
  • Blood disorders (such as sickle cell disease)
  • Endocrine disorders (such as diabetes mellitus)
  • Kidney disorders
  • Liver disorders
  • Metabolic disorders (such as inherited metabolic disorders and mitochondrial disorders)
  • Weakened immune systems due to disease or medication (such as HIV/AIDS, cancer, and chronic use of steroids)
  • Morbid obesity (body mass index [BMI] of 40 or greater)

See People at High Risk of Developing Flu-Related Complications.

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Symptoms and Emergency Warning Signs

The symptoms of flu can include:

• Fever (although not everyone with flu has a fever)
• Cough
• Sore throat
• Runny or stuffy nose
• Body aches
• Headache
• Chills
• Tiredness
• Sometimes diarrhea and vomiting

Emergency warning signs that indicate a person should get medical care right away include:

• In children:
  • Fast breathing or trouble breathing
  • Bluish skin color
  • Not drinking enough fluids
  • Not waking up or not interacting
  • Being so irritable that the child does not want to be held
  • Flu-like symptoms that improve but then return with fever and worse cough
  • Fever with rash
• In addition to the signs above, get medical help right away for any infant who has any of these signs:
  • Being unable to eat
  • Has trouble breathing
  • Has no tears when crying
  • Has significantly fewer wet diapers than normal
• In adults:
  • Difficulty breathing or shortness of breath
  • Pain or pressure in the chest or abdomen
  • Sudden dizziness
  • Confusion
  • Severe or persistent vomiting
  • Flu-like symptoms that improve but then return with fever and worse cough

See The Flu: What to Do If You Get Sick.

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Recommendations

Below are recommendations to help reduce the spread of flu in schools.

• Encourage students, parents, and staff to get a yearly flu vaccine.
  • Teach students, parents, and staff that the single best way to protect against the flu is to get vaccinated each year. See Key Facts About Seasonal Flu Vaccine.
    • Seasonal flu vaccination is recommended for everyone 6 months of age and older unless they have a specific contraindication to flu vaccine. See Persons Who Should Not Be Vaccinated.
    • The seasonal flu vaccine protects against three influenza viruses that research indicates will be most common during the upcoming season. The viruses in the vaccine change each year based on international surveillance and scientists’ estimations about which types and strains of viruses will circulate in a given year.
    • There are two types of seasonal flu vaccines.
      • One type is the “flu shot” (sometimes called TIV for “trivalent inactivated influenza vaccine”), an inactivated vaccine containing killed virus that is given with a needle, usually in the arm. The flu shot is approved for use in people 6 months of age and older, including healthy people, pregnant women, and people with chronic medical conditions.
      • The second type is the nasal spray vaccine (sometimes called LAIV for “live attenuated influenza vaccine”), a vaccine made with live, weakened flu viruses that do not cause flu. This vaccine is approved for use in people 2-49 years of age who are not pregnant and who do not have health problems.
    • Flu vaccines have a very good safety record. Over the years, hundreds of millions of Americans have received seasonal flu vaccines. The most common side effects following flu vaccinations are mild, such as soreness, redness, tenderness, or swelling where the shot was given. See Adverse Events after Receipt of TIV (Flu Shot) and Adverse Events after Receipt of LAIV (Nasal Spray Vaccine).
    • Vaccination efforts can start as soon as vaccination becomes available (usually in September) and should continue as long as flu viruses are spreading and causing illness in the community (usually until May).
  • Consider offering seasonal flu vaccination to students at school. School vaccination clinics, which are often led by local public health department staff in partnership with schools, are an option for vaccinating school-aged children against flu. Vaccination of other groups (e.g., staff, home-schooled students, students attending nearby schools, family members, and other community members) may also be considered. Contact your local public health department for more information. See Influenza School-Located Vaccination (SLV): Information for Planners.

See Preventing Seasonal Flu with Vaccination.

• Encourage students, parents, and staff to take everyday preventive actions to stop the spread of germs.
  • Encourage respiratory etiquette among students and staff through education and the provision of supplies. See Cover Your Cough.
    • Teach students and staff to cover coughs and sneezes with a tissue or their arm. If they use a tissue, they should put the used tissue in a trash can and wash their hands.
    • Provide adequate supplies within easy reach, including tissues and no-touch trash cans.
  • Encourage hand hygiene among students and staff through education, scheduled time for handwashing, and the provision of supplies. See Handwashing: Clean Hands Save Lives.
    • Teach students and staff to wash hands often with soap and water for 20 seconds, dry hands with a paper towel, and use the paper towel to turn off the faucet. If soap and water are not available and hands are not visibly dirty, an alcohol-based hand sanitizer containing at least 60% alcohol may be used.
    • Include handwashing time in student schedules.
    • Provide adequate supplies, including clean and functional handwashing stations, soap, paper towels, and alcohol-based hand sanitizer.
  • Encourage students and staff to keep their hands away from their nose, mouth, and eyes.
  • Encourage routine surface cleaning through education, policy, and the provision of supplies. See How To Clean and Disinfect Schools To Help Slow the Spread of Flu.
    • Routinely clean surfaces and objects that are touched often, such as desks, countertops, doorknobs, computer keyboards, hands-on learning items, faucet handles, and phones. Empty trash cans as needed.
    • Use general cleaning products that you normally use. Always follow product label directions. Additional disinfection beyond routine cleaning is not recommended.
    • Provide adequate supplies, such as general EPA-registered cleaning products, gloves, disinfecting wipes, and no-touch trash cans.
    • Match your cleaning activities to the types of germs you want to remove or kill.
      • Flu viruses are relatively fragile, so standard practices, such as cleaning with soap and water, can help remove and kill them.
      • Most studies have shown that the flu virus can live and potentially infect a person for only 2 to 8 hours after being deposited on a surface. Therefore, special sanitizing processes beyond routine cleaning, including closing schools to clean every surface in the building, are not necessary or recommended to slow the spread of flu, even during a flu outbreak.
      • Some schools may include other cleaning and disinfecting practices in their standard procedures to address germs that are not removed or killed by soap and water alone.
  • Encourage students and staff to stay home when sick through education and policy.
    • Teach students, parents, and staff the importance of staying home when sick until at least 24 hours after they no longer have a fever (100 degrees Fahrenheit or 37.8 degrees Celsius, measured by mouth) or signs of a fever (chills, feeling very warm, flushed appearance, or sweating) without the use of fever-reducing medicine.
    • Review school policies, and consider revising those that make it difficult for students and staff to stay home when sick or when caring for others who are sick.
      • Implement flexible sick leave policies for students and staff.
      • Avoid the use of perfect attendance awards.
      • Cross-train staff so that others can cover for co-workers who need to stay home.

  See Good Health Habits for Preventing Seasonal Flu and
  Everyday Preventive Actions That Can Help Fight Germs, Like Flu [1.5 MB, 2 pages, 8 ½” x 11”] .

• Educate students, parents, and staff on what to do if someone gets sick.
  • Teach students, parents, and staff the signs and symptoms of flu, emergency warning signs, and high-risk groups. See lists at the beginning of this document.
    • Those who get flu-like symptoms at school should go home and stay home until at least 24 hours after they no longer have a fever or signs of a fever without the use of fever-reducing medicine. Those who have emergency warning signs should get immediate medical care. See The Flu: What To Do If You Get Sick.
    • Those who get flu-like symptoms and are at high risk of severe flu illness should ask a healthcare provider if they should be examined. See People at High Risk of Developing Flu–Related Complications.
  • Separate sick students and staff from others until they can be picked up to go home. When feasible, identify a “sick room” through which others do not regularly pass. The sick room should be separated from areas used by well students for routine health activities, such as picking up medications. Sick room staff should be limited in number and should not be at high risk for severe illness if they get sick.
  • Encourage students, parents, and staff to take antiviral drugs if their healthcare provider prescribes them. See Treatment - Antiviral Drugs.
    • Antiviral drugs, called Relenza® and Tamiflu®, are drugs that can be prescribed by healthcare providers to treat the flu. These drugs can reduce the number of days that a person is sick, but not everyone needs to be treated.
    • Antiviral drugs work best when started within the first 2 days of illness, but they may also help reduce the risk of severe illness even if started 2 or more days after onset of illness for persons who are hospitalized.
    • Although most people will recover from flu without treatment, antiviral drugs are recommended for people with influenza who have an illness requiring being in the hospital; have a progressive, severe, or complicated illness; or are at high risk of severe flu because of an underlying medical condition or their age.
• Establish relationships with state and local health officials for ongoing communication.
  • Follow your local flu situation through close communication with state and local health officials.
  • Update emergency plans so that they are in place before an outbreak occurs.

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