H1N1 flu and school closures: Lessons from 1918

NOW that the H1N1 virus has made its way through 168 countries, infecting some 162,000 people and killing more than a thousand, health officials are warning us about its second wave this fall, just in time for the new school year

While the virus, earlier called the swine flu, has not mutated into a more lethal strain and thus far threatens more of a pinch than a punch, we would all do well to remember — a la Spanish influenza in 1918 — things can turn south in a New York minute. In fact, some epidemiologists have been issuing dire forecasts because H1N1 is a new virus, meaning transmission could accelerate especially quickly due to the susceptibility of the population.

The one thing that is not new about this virus is the dilemma it poses for those who must decide when and for how long to close schools during an outbreak of infectious disease.

During the first week of October in 1918, Seattle health officials waited for the inevitable — the arrival of influenza in Puget Sound.

After being brought back to the United States by returning Navy sailors at Boston's Commonwealth Pier in late August, the second wave of Spanish influenza started moving westward via railcar. Within 48 hours of the first reported death in Puget Sound, health officials quickly responded with a number of restrictions, such as a ban on public and private dances and the enforcement of an anti-spitting ordinance. Shortly thereafter they went one step further and closed all places of indoor assembly — including the public schools.

School leaders were slightly less than enthusiastic about this turn of events. After all, they had not been consulted and felt somewhat put out by the usurpation of their jurisdiction. Veteran school Superintendent Frank Cooper called the decision "unwise" and a "senseless thing to do." The president of the School Board questioned whether health officials actually had the authority to close the schools, especially without advance notice. But eventually they agreed to comply with the missive and some 40,000 students stayed home for 28 days.

Nearly a century later, a similar scenario is unfolding. And deciding when to close schools remains an imperfect science.

School closures often have been thought of as a barometer for how serious an epidemic is within a given community. If kids are kept home, it must be bad!

But in many places, school-closure policy requires only a few students to have contracted the virus before the doors are ordered shut.

This past spring, some 700 schools — including three in Seattle — were closed due to H1N1. However, health officials are now changing course, cognizant that a decision to close schools inevitably engenders a host of secondary problems as parents scramble to find and pay for child care and poor kids lose out on breakfast and lunch programs. Paradoxically, the effectiveness of school closure is also lessened as the number of cases increase.

Thus, officials at the Centers for Disease Control and Prevention (CDC) took notice when Public Health-King County & Seattle leaders revised their school-closure policy in the beginning of May. Instead of closing the schools, health officials are now asking parents to assess their children each day and keep them home if they have flu-like symptoms. The feds have since followed suit, even going so far as to recommend that sick students be allowed to return 24 hours after their fever has subsided — compared with the former policy of waiting two weeks.

The CDC now recommends schools be closed only when there are many special-needs or medically fragile students on site, when high numbers of students and teachers are sick, or when parents disregard the protocol and send their fever-ridden children to school.

Knowing when schools should be left open or closed during an outbreak of infectious disease remains an imperfect science but recent policy shifts suggests we're better informed the second time around.