Class Dismissal in Europe During Pandemics – Scientific and Public Health Issues”   

Angus Nicoll Influenza Coordinator ECDC based on contributions by

Simon Cauchemez (Imperial College), Anders Tegnell (Board of Health & Welfare, Sweden), Guillaume Saour (Ministry of Health, France), Jean-Pierre Bayeux

(Ministry of Education, France), John Edmunds (HPA/LSHTM) and Ben Duncan

(ECDC)

From the French Presidency Eurogrippe

Seminar Angers, France

3-5 september 2008

Content Introduction Potential impact on health outcomes Potential secondary effects of school

closures – class dismissal Mitigation of secondary effects Communication aspects Formulation

3

Definitions

School Closure – School closed and teachers and administration go home

Class Dismissal – School remains open with administrative staff but children told to stay home.

Community Mitigation (Public Health Measures) in a Pandemic – The Objectives

1. Delay and flatten outbreak peak2. Reduce peak burden on healthcare system and allow

better fit of services to cases 3. Reduce number of cases4. Buy (a little) time

DailyCases

#1

#2

#3

Days since First Case

No intervention

With interventions

ECDC Menu of Public Health Measures

http://ecdc.europa.eu/Health_topics/Pandemic_Influenza/phm.html Travel Measures - Restrictions on

international travel Travel advice Entry screening Border closures

Personal protective measures Regular hand-washing Respiratory hygiene General mask wearing outside the

home Mask-wearing in health-care

settings Mask wearing in high-risk situations Mask-wearing by people with

respiratory infections Early self-isolation of ill people Quarantine measures

Antivirals – Early Treatment All those with symptoms Health care or exposed key workers

Antivirals - Prophylaxis following a case

Family Family and other social contacts Family and geographical contacts

Antivirals – Continuous prophylaxis Health care and key workers

Vaccines - Human H5 vaccines for the whole population for children for health care workers

Vaccines – Specific pandemic vaccine

Specific pandemic vaccines

ECDC Menu of Public Health Measureshttp://ecdc.europa.eu/Health_topics/Pandemic_Influenza/phm.html

Social distancing measures Internal travel restrictions Reactive school closures Proactive school closures Reactive workplace closures Home working and reducing

meetings Cancelling public gathering,

international events etc

School Closures Vs Class Dismissal

“for every complex, difficult problem there is frequently a simple and attractive solution”

“for every complex, difficult problem there is frequently a simple and attractive solution”

– that doesn’t workHL Mencken

“for every complex, difficult problem there is frequently a simple and attractive solution”

Glass RJ, Glass LM, Beyeler WE, Min HJ. Targeted social distancing design for pandemic influenza. Emerg Infect Dis

[serial on the Internet]. v [cited http://www.cdc.gov/ncidod/EID/vol12no11/06-0255.htm

From ECDC/WHO/EC National Self Assessments Why are some countries

planning to close schools?

Because they can Because they do

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Questions for the workshop Do you plan to close schools or dismiss classes If so

A central decision or local? Any day care measures planned? Measures to continue schooling? What should freed-up teaching staff do?

Should the decision be shared by Member States

What should be the communication strategy

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What would be the potential health benefits of school closures

in a pandemic?

From Simon Cauchemez (UK-France)

Cauchemez Conclusions

•No clear message from modellers – look closely at the assumptions

•Analysis of what actually happens when schools close with seasonal flu – this gives a relatively consistent message.

• Optimistic scenario (i.e. proactive school closure: same impact as holidays):

Limited impact on the cumulated number of cases. Could prevent - 1 in 7 cases (15%);

No ‘magic bullet’ but still 15% is a lot of people

When children die … and its presumed they were infected in school

More significant reductions in peak attack rates (~40%)

Modelling – why such differences?

• Results of models depend on assumptions that are made. For example:

Assumption in model Conclusion re school closure

50% of transmissions occur in schools huge impact on spread

15% of transmissions occur in schools marginal impact on spread

• It is not possible to “guess” which scenario is the most likely. We need to learn from past outbreaks!

• For results of modelling to be predictive, it is critical to “feed” models with observations from past outbreaks!

School closure in Hong Kong, March 2008 (1)[Cowling et al., EID, in press]

School closure

Important reduction observed after the peak – But in a flu outbreak, that is what you expect to see, even without intervention…

School closure in 2008

Cowling et al detect no substantial effect of school closure on transmission

School closure in Hong Kong, March 2008 (2)[Cowling et al., EID, in press]

Figure from Glass RJ, Glass LM, Beyeler WE, Min HJ. Targeted social distancing design for pandemic influenza. Emerg Infect Dis [serial on the Internet]. v [cited http://www.cdc.gov/ncidod/EID/vol12no11/06-0255.htm

0

10

20

30

40

50

60

0 10 20 30 40 50 60 70 80

Age

Att

ack

rate

(%

)

1957 (from Chin et al)

1968 (from Davis et al 1970)

1918 (from Glezen 1996)Base Case 50% attack rate

Pandemics are not Standard

Cauchemez conclusion

•No clear message from modellers – look closely at the assumptions

•Analysis of what actually happens when schools close with seasonal flu – this gives a relatively consistent message.

• Optimistic scenario (i.e. proactive school closure: same impact as holidays):

Limited impact on the cumulated number of cases. Could prevent - 1 in 7 cases (15%);

No ‘magic bullet’ but still 15% is a lot of people

When children die … and its presumed they were infected in school

More significant reductions in peak attack rates (~40%)

Cauchemez Conclusions

But impact might be much smaller if it is difficult to maintain low contact rates among children for prolonged periods.

Pandemics are not standard – in some children more affected and important transmitters than others

• Late reactive closures would do little though may seem to do a lot

Modelling – why such differences?

• Results of models depend on assumptions that are made. For example:

Assumption in model Conclusion re school closure

50% of transmissions occur in schools huge impact on spread

20% of transmissions occur in schools marginal impact on spread

• It is not possible to “guess” which scenario is the most likely. We need to learn from past outbreaks!

School closure in Hong Kong, March 2008 (1)[Cowling et al., EID, in press]

School closure

Important reduction observed after the peak – But in a flu outbreak, that is what you expect to see, even without intervention…

School closure in 2008

Cowling et al detect no substantial effect of school closure on transmission

School closure in Hong Kong, March 2008 (2)[Cowling et al., EID, in press]

2323

What could be the social impact of closing schools?

Anders Tegnell (Sweden)

Does it make sense? Threat of unknown impact Use a measure of uncertain efficiency A measure with likely considerable

negative effects A measure which might send a

message that the threat is bigger than it actually is

Impact on the work force if suddenly have to care for children

Major impact on the health and social care sector in Sweden

Could ‘lose’ up to 50% of health care workers Impact on health care would be massive Significant economic costs

Sadique MZ, Adams E, Edmunds J Estimating the costs of school closure BMC Public Health April 24th 2008

2626

School closures : status of the French plan

Guillaume Saour and Jean-Pierre Bayeux

27

Historical analysis of the 1957 pandemic Idea that closing schools would provoke panic and

create the crisis Decisions came too late, only after 50-75% of

children got ill (ministerial instructions)

Complex instructions for education professionals Local decisions, lack of national consistency Overall inefficiency due to mentioned above

conditions of application of 1957

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The school closure in the French plan : Education continuity

Continuity of the Education Administration Business Continuity Plans of each school to

ensure essential activities (logistics, finances, communication networks)

Pedagogic continuity 1/2 teachers in charge of maintaining the link

between pupils/students and other teachers in each school. Mainly by phone

Use of internet, TV and Radio for 3 months

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Theoretical resources for alternative childcare in France

Students: about 2 millions

High school students: More than 10 years old

About 6 millions

Grandparents –

immediate neighbours

About 7 millions

between 65 and 80

8 millions of children under 10 need childcare

Other resources(retired, housewives,

but excludes unemployed people)

25-54 years old

2,6 millions women

0,7 million men

Teachers

About 1 million

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Lack of clarity of the measure The triggers for closure and re-opening

are not clearly defined yet Age groups concerned? Room for inconsistency :

Zonal, Regional planning assuming long/total school closures (use of facilities, etc…) vs planning more flexible

Planning vs Population expectations; communication issue

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Main issues Definition of triggers to implement and

to cease the measure Definition of measures to maintain

childcare and pedagogical continuity Definition of communication strategy Interoperability

Work in France Much work in progress in France National approach with local control Part of the central plan with inter-

ministerial coordination – DILGA Work on continuing education in a

pandemic Work on alternative child-care when

schools close

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Communication Aspects

Ben Duncan ECDC

Its difficult to know how this will appear

in the media – but it will It is inevitable that this issue will arise A must-do for preparation and flexibility Schools are likely to close – better to do

in an orderly manner

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Discussion DiscussionFormulation and

Recommendations for future European work

Points from discussion - 1

Children are important to society and their health & safety cause high emotions

Member states are different in social structure

Many things to be learnt from how some member states have done issues already

Can states plan reinbursement of parents for lost wages?

See this as a BCP issue?

Points from discussion - 2

Education is locally controlled in many MS Education sector highly complex and not

easily organised Vulnerable families and special children who

rely on schools Could be perverse effects of children being

cared for by grand-parents Learning from the experience with H5 in Hong

Kong in 1997

Points from discussion – 3

Cross-border issues. May not even be legal powers if its not

planned for. Some countries have already done a lot

on this – others could benefit from this thinking.

Conclusion of the Conclusions

C’est difficile

Conclusion of the Conclusions

C’est difficileMais c’est tres important!

Recommendation Needs thought and work in every member

state Cannot be dealt with by ‘health’ alone – multi-

sectoral approach Decisions in one region or one member state

will affect others – interoperability An interministerial EU workshop specifically

on this in 2009 for ‘health’, ‘education’ and ‘interministerial authorities’