Canada's monthly school health report from the Canadian Association for School Health
Volume 5, Issue 3 (November, 2010)
Featuring: SARS, H1N1 and Influenza: Strengthening the School’s Role before the Big One
The topics for the feature article for this month is a faint echo of what was dominating school health promotion last
year; H1N1 and influenza. In this article, we draw from an 18-month tracking project undertaken by the International
School Health Network that monitors over 150 research journals, over 75 media outlets and over 50 social media
sources every week and month. The article provides a fact-based argument for a comprehensive, school-based and
school-linked approach to the prevention of influenza and infections and the promotion of hygiene and immunization in
Canadian School Health Knowledge Network News Canadian Media Reports for November 2010
CASH Conference Planned for November 2011 in Montreal
Our annual conference, which normally is held in the Spring of News Story (Nov 30-10) No HPV vaccine for P.E.I. boys
each year, will be organized instead for late November in http://is.gd/iilpL
Montreal. We are pleased to be partnering with the Institute for
Public Health in Quebec, as part of their Journeés annuelles de la News Story (Nov 29-100 Children's eating disorders jump in
santé publique (JASP). Other partners in the event include the U.S., Canadian Stats http://is.gd/iie26
International Union for Health Promotion and Education (IUHPE)
and the International School Health Network. CASH will be News Release (Nov 29-10) Canada Funds Child & Maternal
represented on the international planning committee by Health in Bolivia http://is.gd/iia68
Carol,MacDougal and Fran Perkins of the Ontario Healthy Schools
Coalition. News Release (Nov 29-10) Harper Government Takes Action
to Protect Children from Lead Exposure http://is.gd/ii9Bs
CASH Leads PHAC Discussions on Knowledge Exchange
Executive Director Doug McCall has been active in providing News Story (Nov 29-10) Ottawa sets new lead limits
advice to the Canadian Best Practices Portal and Initiative. PHAC http://is.gd/ii9fk
is funding CASH to map out the web-based KE activities of many
national organizations, federal departments and agencies and News Story (Nov 28-10) French immersion demand creating
universities. A wiki-based web site has been developed to assist in two solitudes in Ottawa schools http://is.gd/ioCzw
the project at: www.exchangeknowledge.ca
News Story (Nov 26-10) HPV vaccine studied for N.B. boys
Call for Local Programs in School Mental Health http://is.gd/hXKH2
CASH is part of a consortium project funded by the Mental Health
Commission. Project staff are building a list of Canadian News Story (Nov 25-10) 24 Vancouver elementary schools
programs. We invite you to nominate a SBMHSA face loss of aging playgrounds http://is.gd/ioykA
program(s)/model(s) or initiative(s) that you feel is worth
examining in our environmental scan of Canadian SBMHSA News Story (Nov 25-10) Kids' exercise boosted by team
programs. The goal is to develop a national list of SBMHSA ethic http://is.gd/hXK7Q
programs/models/initiatives across Canada and to invite those
responsible for the implementation or coordination of SBMHSA News Story (Nov 23-10) Boys, as well as girls, need HPV
programs or models to participate in a semi structured telephone vaccine, medical group says http://is.gd/hXISp
interview.To nominate a program, go to:
http://sbmhsa.smartsimple.biz/Forms/fm_forms.jsp?token=Hwo News Release (Nov 24-10) CIDA Call for Proposals:
OSxkGYFxaRxJa Maternal, NewBorn & Child Health) Partnership Program
School Mental Health Implementation Summaries & Webinars News Release (Nov 23-10) The Impact of the H1N1
As part of this same project, CASH will be working with the Pandemic on Canadian Hospitals http://is.gd/hXHy4
International School Health Network to develop wiki-based
summaries and webinars/web meetings on five key Report Aboriginal children’s health:Leaving no child behind
implementation issues. These include: http://is.gd/hXHdf
- coordinated inter-ministry policy
- inter-agency cooperation On Liine Petition UNICEF Canada Call for Canadian
- maintaining fidelity dilemmas and issues Children's Commissioner http://is.gd/hXGPR
- evidence-based implementation planning
- system and organizational capacities and capacity-building News Story (Oct 26-10) Illegal cigarettes lure Ontario high
Watch for more news about this project at our School Mental schoolers http://is.gd/hXGoW
Health Community of Practice web pages.
News Story (Nov 24-10) Greater Victoria schools probe Wi-
School Nutrition National Meeting Fi safety http://is.gd/iovJG
Congratulations to Mary McKenna, Chair of our CoP on Nutrition,
for organizing a national meeting on school nutrition last Spring. News Story (Nov 16-10) Gambling a problem for 29,000
Mary was able to persuade Health Canada to sponsor the Ontario students http://is.gd/hXGfK
meeting and we look forward to Mary's continued leadership this
year. News Release (Nov 19-10) Children's Rights Champion,
Marv Bernstein, Joins UNICEF Canada as Chief Advisor,
CASH CoP Chairs Lead School Administrator Session Advocacy http://is.gd/hXFDz
Gloria Wells and Michelle Forge, Co-Chairs of the CASH CoP on
Mental Health were instrumental in organizing and delivering a News Release (Nov 22-10) Childhood Obesity Foundation
workshop at the July annual conference of the Canadian applauds federal government for taking action on childhood
Association of School Administrators. obesity. http://is.gd/hXFi6
CASH-CACE Community of Practice Sparks International News Story (Nov 12-10) Canada endorses UN stance on
Discussion on Social Determinants, Disparities and Disadvantage indigenous rights http://is.gd/hXAXx
Delphine Melchert, Coordinator of of national CoP partner, the
Canadian Association for Community Education, will be organizing News Story (Nov 21-10) Aboriginal children's health below
a session at their upcoming national conference this Spring. national averages: UNICEF http://is.gd/hXAsK
Dwayne Provo, our other co-chair of this CoP, brought the results
of our work and the consensus statement developed at the April News Story (Nov 22-10) Children of divorce more prone to
2010 CASH Conference to the international School health strokes as adults: Study http://is.gd/hXAmj
symposium in Geneva. The statement will be the basis for a series
of webinars, web meetings and wiki-based summaries of the News Story (Nov 22-10) New plan to help schools fight drug
evidence and experience in the coming months. use http://is.gd/ioxQA
Revived CoP on Sexual Health? News Story (Nov 22-10) Child asthma rate down in Canada
We are hopeful that we will be able to revive our Community of with less smoking http://is.gd/hXA28
Practice on School Sexual Health Promotion which was drmant
last year. Our thanks to Rozelle Paulsen of the Sexuality Education News Story (Nov 18-10) Schools offering lessons in
Resource Centre in Manitoba for her leadership in setting up this emotions, social development http://is.gd/iovg3
News Story (Nov 17-10) Boys-only classrooms gain favour
Aboriginal School Health CoP Framework Goes International http://is.gd/ioDwO
The hard work from our aboriginal CoP members and its chair
Shirley Tagalik has been recognized internationally. Shirley News Story (Nov 15-10) Text talk problematic in schools,
keynoted the recent international School Health Symposium in academic work http://is.gd/ioyI5
Geneva, presented at the American School Health Association
and organized workshops in Australia. News Story (Nov 16-10) Use photo radar at schools and
construction sites: MPP http://is.gd/ioyaq
Toot Your Horn by Tweeting! Do you have SH news you want to
share with 2500 other Canadian SH practitioners. Then feel free News Story (Nov 15-10) Fast food near schools linked to
to post your news on the shared "CSH Tweets" account on obesity http://is.gd/iovAh
Twitter. Simply go to www.twitter.com/cshtweets, sign in as user News Story (Nov 15-10) Gay teens 'terrorized' in Canada's
"cshtweets`, password `cash-aces and post your news. Those schools http://is.gd/ioAdw
tweets and other items are subsequently posted on the CSH web
site through posting updates directly onto our School Health Blog News Story (Nov 11-10) Closing the aboriginal achievement
and will also be included in this monthly emailing to over 2500 gap at B.C.'s schools http://is.gd/iozXk
people. This “self-serve” process is starting to work, with three
recent postings coming directly from other organizations into the News Story (Nov 12-10) Fear of gunman leads to two school
School Health Blog. lockdowns in London, ON http://is.gd/iozz6
New Features on www.canadianschoolhealth.ca News Story (Nov 11-10) Junk-food ads aimed at kids come
In our continuing effort to use technology effectively, we have under fire http://is.gd/iozqz
added a couple of features to the web site. These include:
o Enabling the chairs of our Communities of Practice to News Release (Nov 10-10) Federal Health Minister
communicate with CoP members through designated Announces Drug Prevention Projects in Edmonton and BC
“friends” lists within the membership of the web site http://is.gd/gUAry
o Adding Instant Message boxes onto a “Drop-In - Office
Hours” page in the web site. During next school year, we News Story (Nov 6-10) School head lice checks lack medical
will designate times, topics and resource people that will backing http://is.gd/iou0i
be available to answer questions through private or
public IM messages or to drop into an informal “web News Story (Nov 5-10) Gay teens told it gets better, stats
meeting” using our webinar platform. And, yes, we will reveal crisis in our schools http://is.gd/ioAK5
also be available by telephone during those “office
hours”. Indeed, the page also includes links to a VOIP- News Story (Nov 4-10) Ottawa students asked about sexual
based telephone system where anyone can call us free orientation http://is.gd/gT22V
from anywhere in Canada.
o Designated Twitter account tracking a topic. In News Story (Nov 4-10) NDP in Canada pressing for national
cooperation with the International School Health suicide prevention plan http://is.gd/gT1O1
Network, we have established a web page within the
Mental Health CoP section of the web site that posts the News Story (Nov 9-10) Texting, social networking linked to
very latest research on schools & mental health. If you booze, drugs and sex: Survey http://is.gd/ioCde
would like to access the information more frequently
than that, you can follow the ISHN Twitter Newsfeed on Editorial (Nov 8-10) Schools can't solve the dropout crisis
School Mental Health from your own Twitter account. alone http://is.gd/iozN9
o Search for Canadian SH news using our Google
customized search engine for Canadian newspapers News Story (Nov 8-10) Measles exposure warning issued in
Sign Up & Sign In: We are continuing to transfer the email
contacts lists over to our professional networking web site at News Story (Nov 8-10) 2nd H1N1 wave in Canada was larger
www.canadianschoolhealth.ca Agencies, organizations and than 1st http://is.gd/gSZRr
individuals will be able to control the email they receive from this
wiki-based web site through their own profiles. (This occurs by News Story (Nov 4-10) North York shooting sends four
"watching" or "unwatching" selected pages). As well, they will be schools into lockdown http://is.gd/ioCoj
able to use the tools on the web site to interact with others and
receive RSS feeds from the daily blog of SH news. News Story (Nov 2-10) Oral sex often a prelude to
intercourse for teens http://is.gd/ioDHf
Canadian Research, Reports & Resources from the September School Health Blog Postings
Our blog also tracks Canadian research studies, reports and new planning/educational resources announcements. Here are the ones
posted for November 2010:
Articles in the Nov-Dec 2010 Issue of Canadian Public Health Journal
A public policy up in smoke
Health Inequalities, Deprivation, Immigration and Aboriginality in Canada: A Geographic Perspective
Estimates of the Number of Prevalent and Incident Human Immunodeficiency Virus (HIV) Infections in Canada, 2008
A Multilevel Examination of School and Student Characteristics Associated With Moderate and High Levels of Physical
Activity Among Elementary School Students (Ontario, Canada)
Sorry Doctor, I Can’t Afford the Root Canal, I Have a Job: Canadian Dental Care Policy and the Working Poor
Canada’s Health Promotion Survey as a Milestone in Public Health Research
Tools for Thoughtful Action: The Role of Ecosystem Approaches to Health in Enhancing Public Health
Influenza Pandemic Planning and Performance in Canada, 2009
The Inevitable Health System(s) Reform: An Opportune Time to Reflect on Systems Thinking in Public Health in Canada
Canadian infants and children Articles in the Nov 23 2010 Issue of the Canadian Medical Association Journal
Global tuberculosis partnership says industrialized world must do more
Mental disorders seek space at the global health table
Panel says less-is-more when it comes to nutrition ratings on packaged foods
Canadian restaurant industry opposes calorie content disclosure
Prevalence of seroprotection against the pandemic (H1N1) virus after the 2009 pandemic
Pandemic (H1N1) 2009: assessing the response
Articles in the Nov 9 2010 Issue of the Canadian Medical Association Journal
China’s "left behind" children often suffer health consequences
Polio immunity in Ontario
Articles in the November 2010 Issue of Paediatrics & Child Health
Using path analysis to understand parents' perceptions of their children's weight, physical activity and eating habits in the
Champlain region of Ontario
Ed Resource Quiz on Radon Canadian Lung Association http://is.gd/iih
Feature Article: SARS, H1N1 and Influenza: Strengthening the School’s Role before the Big One
By Doug McCall, Executive Director, Canadian Association for School Health
This commentary suggests that schools should play a more significant role in national and state/provincial plans and
programs to prevent and respond to pandemics such as SARS, H1N1 and other influenza outbreaks as part of a wider
effort to prevent infections and immunize school-age children. The article is based on a year-long tracking project of
news, research and reports for over a year done by The School Health Insider, the information service provided to
members of the International School Health Network. (ISHN tracks emerging and ongoing issues as part of its weekly
tracking of over 150 journals, over 75 media outlets, over 50 social media sources and regular searchers of the Internet).
Note: The ISHN information service will be accessible only to ISHN members early in 2011, so we have provided a link to
a sample page on the public version of the site.
H1N1 – It’s Not Over
Last year at this time, schools in Canada and in many other countries were in the midst of responding to the threat of a
new form of influenza, the H1N1 strain. As Andre Picard, the public health reporter for one of Canada’s major
newspapers wrote just prior to the start of school in 2011:
Paradoxically, this “normal” flu season will likely prove far more deadly than the pandemic. About 18,000 people
worldwide died of H1N1 (including 428 in Canada). But the seasonal flu kills somewhere between 250,000 and
500,000 people each and every year. H1N1 has returned with a vengeance to parts of Europe. In the past week,
the number of cases of influenza has soared by 40 per cent in Britain and Ireland, and 36 deaths have been
In the Southern Hemisphere, flu season is over and their experience can also be indicative of what to expect in
the Northern Hemisphere. In Australia in 2010, the flu season was unusually mild but in December – when the
season is usually over – there was a significant upsurge of H1N1 infections. There is also a major out-of-season
outbreak of H1N1 flu in Sri Lanka currently. This could serve as a warning to Canada that its flu season may not
follow traditional patterns.
The ISHN tracking of H1N1 and other influenza stories has also noted that other countries are still responding to H1N1,
with New Zealand experiencing significant H1N1 outbreaks, and an article in the Journal of the American Medical
Association reporting that the H1N1 virus was already mutating in the swine population where it started.
But this article is not about the transmission and vaccination aspects of H1N1 or other forms of influenza. Nor is it
another effort at second guessing about the predictions and manufacturing of vaccines which are also part of the
extensive number of news stories that ISHN has followed. Instead, this article is about the important and vital role that
schools should be playing in the delivery of vaccinations as well as in prevention of influenza and other similar diseases.
Canada was one of the world “leaders” in managing to vaccinate about 40% of its population, with some experts saying
that the “second wave” had already passed by the time the vaccine was truly available for the majority of its population.
If the Canadian experience is being deemed as a good result for a developed country, then we will have a majority of our
population exposed to the next virus. Obviously, we need to consider using schools more effectively.
The Vital Role of Schools in Influenza Prevention, Pandemic Response and Immunization
Despite the fact that schools can be either a place incubating a disease or in rapidly providing vaccinations, despite that
fact that school-based vaccinations are more effective and cost less, despite the fact that schools can be a vital part of a
immunization strategy and despite the fact that schools can be a key delivery point for universal immunization, almost
all of the reports, media coverage and post-H1N1 assessments have ignored the vital role of the school. In our tracking
of the reports over the past 18 months, we located only one report (Como-Sabetti et al, 2010) that examined the school-
related experiences during the H1N1 pandemic.
Vaccinations work if the transmission of the disease can be halted to a sufficient degree so that the “herd” is protected
and the infection dies out due to a lack of new victims. Recent research from Canada and other countries show that the
herd is protected if vaccinations are done quickly through schools (Loeb et al, 2010; Glezen et al, 2010; Talbot et al,
2009). Conversely, studies have shown that schools and children can be a primary place for the transmission of
infectious diseases (Longini et al, 1982). For example, the waves of the recent H1N1 outbreak came in waves related to
the school year.
Canadian research (Guay et al, 2003; Sadoway et al, 1990) as well as studies from other parts of the world clearly
(Deuson et al, 1999; Jeuland et al, 2009) show that vaccinations delivered through schools are more effective in
participation rates (over 90% in schools vs 75% in community clinics) as well as significantly less costly. It almost goes
without saying that vaccinations are more cost-beneficial than treatment (Ryan et al, 2006; Salo et al, 2006; White et al,
1999; Wilson et al, 2000). A 2000 study done in Ontario (Mercer, 2000) reported that with careful time/staff
management and controlled conditions such as no overtime, a flu clinic could deliver vaccinations for $5.00 per shot.
During the H1N1 outbreak in 2009, Ontario promised a $10 per shot budget to health authorities that included
substantive overtime and extra costs which would be less necessary in school-based clinics. The Guay et al study
calculated the “societal cost” (wages/productivity etc) and found that school-based vaccinations cost $40 per shot vs
$63 in community clinics or physicians’ offices.
Immunization registries provide an effective and efficient way to track individual child vaccinations as well as provide
valuable planning and assessment data to decision-makers. School requirements for vaccinations at age of school entry
and in secondary school provide an excellent compliment to these registries (which form part of the immunization
planning suggested by many public health organizations in Canada.
As well, schools must be part of any universal immunization plan or goal for the reasons noted above.
Progress since SARS
On June 19, 2003, the Canadian Association for School Health was the lead among several organizations who responded
to a request from the US Department of Education to organize a debriefing session on the SARS outbreak in Ontario to
assist in the preparation of US guidelines about such outbreaks. The issues identified by the participants in that session
Coordination of responses between
- School Board and SARS teams
- School Board and Public Health
- Public Health and Hospitals
- Operation Centres
Closing a School/ Keeping it Open
Maintaining the support and involvement of staff
- work refusals
- union involvement
- support for staff
Emergency Procedures and Communications
Student/Teacher/Parent Travel (outside Toronto to SARS-affected areas)
Extra-curricular/Co-Curricular Activities for Students
The debriefing session identified huge gaps in inter-agency communications, disagreements about who decides re
school closings, misinformed parents sending their children to school despite public health efforts and more.
Here is a listing of program, policy and research questions that emerged from the SARS outbreak in Toronto. The
following summary outlines some immediate and long-term questions associated with SARS, other similar outbreaks and
diseases and the role of schools as well as public health agencies that work with schools.
SARS, Similar Outbreaks, Other Viral Infections and Schools
Program related Questions
1. Any background on what schools were doing about SARS BEFORE they had a suspect/probably case? (e.g.
reviews of infectious disease policies, school closure policies. updating staff about infectious disease policies,
educating staff, students about SARS or other infections etc)
2. Notification that school's student/staff member is a suspect/probable case (who provided the information,
who initially received the information (school, district, board, etc.), was there stigma/discrimination issues
for individuals or groups?, how did schools deal with rumours and/or misinformation?
3. Decision to close the school/not close the school (Who was involved in making the decision?, Was there
consultation with health officials?, Usefulness of existing infectious disease policies?, How long after #1 did
decision occur? Was there pressure to close/stay open?, What was the length of closure?, Did schools
receive feedback about decision to stay open?
4. Communicating the decision (Who were direct recipients of the communication? Who made the
communication on school's behalf (school principal, district superintendent, board, etc.), What worked/didn't
work?, What types of content were included in the communication?, How content was communicated (letter,
email, website, etc.), How were interactions with the media managed?)
5. Communications while school is closed (Was there a decision to change length of school closure?, How were
updates about students/staff of concern provided?, Were there community meetings (at school or
elsewhere)? Are there examples of any health or other instructions to students and staff?
6. Reopening the school (Were there concerns about coming back to school? Attendance issues? Any special
events on day of reopening? For students and staff? For parents? For other community members ? Any
special communications day of reopening? Media issues? review/revision of infectious disease policies,
school closure policies? stigma/discrimination issues for individuals or groups? ongoing partnerships with
public health officials, community leaders, etc?.
8. After school is reopened (Any ongoing concerns about attending school? Any stigma/discrimination issues
for individuals or groups?, Any SARS-specific educational programs, communication? Any general infectious
disease prevention efforts (hand washing, food safety, etc.)? Any environmental/sanitation efforts?
9. Applicability to other infectious diseases? (Lessons learned?, dos and don'ts, advice for other schools?)
1. Are current policies, directives, guidelines and procedures regarding such outbreaks and the sanitation of
2. Are staff directly related to these procedures adequately trained in emergency and preventive procedures?
3. Is there sufficient communication and coordination between schools and public health agencies to respond
to parental or public concerns as well as emergency situations?
4. Are schools adequately sanitary and equipped to be sanitary?
5. If diseases and viruses such as SARS, West Nile Virus, Monkeypox are becoming more prevalent is there a
need to educate students, inform parents and staff more effectively about such diseases and how they can
be prevented or contained?
6. If widespread, emergency immunization and vaccination procedures are necessary, can schools be a more
cost-effective means for the delivery of such services?
7. What are the viruses and disease similar to SARS and are they an increasing burden on schools? (West Nile,
Monkeypox, meningitis, Head Lice, skin rashes, influenza, food bacteria, etc)
8. Are universal hygiene precautions understood and followed in schools? Do public health inspectors make
regular inspections? Are staff aware of and follow precautionary procedures?
9. Are food safety policies and procedures adequate and implemented?
10. Are there are adequate procedures and inspections for keeping school equipment, cafeterias, bathrooms,
gymnasia and facilities sanitary?
1. How sanitary are schools today? (with elimination of soap in bathrooms, reduction in public health nurse
time in schools for screening and examinations, difficulties in supervising students, increased numbers of
students from recently arrived families, etc)
2. Are universal hygiene precautions truly followed in schools? Are they adequate for the emerging virus and
more resilient bacteria?
3. What are the current knowledge, attitudes and behaviours of young people and adults related to such
diseases and virus? as well as other determinants influencing such KAB? Is the health status of children and
youth relative to such diseases increasingly threatened (prevalence of such disease)
4. Are the curricula in schools adequate for ensuring a basic knowledge and learned hygiene practice
5. What is a realistic role for schools to play on these issues in cooperation with other agencies and health
6. Can we describe and promote a comprehensive school health approach to these issues that engages all
relevant aspects of the school (teaching, safety, food services, parents, public health, physicians etc) can we
prepare guidelines for such issues similar to the CDC guidelines on physical activity, tobacco, safety and
nutrition? How can we encourage effective and sustainable cooperation among the agencies concerned?
7. Are parents adequately informed about these issues on a regular basis and are there convenient sources of
advice and help for them that can be promoted through schools?
8. Are there reliable, regular and meaningful data sources that can be used to monitor the incidence of serious
as well as less serious diseases and the impact they are having on schools as well as the status of relevant
policies and programs?
The news reports over the past 18 months indicate that some of those problems have been addressed. Several meetings
between public health and senior education officials were reported in August 2009. Most jurisdictions issued guidelines
specifically for schools. The procedure for school closing was addressed, albeit differently in different places. However,
these guidelines were not really tested during the tempest of an outbreak of a deadly disease like SARS. Public concern
was not immediate and the fear factor, compared to SARS, was minimal. Even then, much, if not all of the public health
staff who are normally assigned to schools were re-assigned to vaccination and other duties during the H1N1 outbreak.
The Minnesota review of their experience with schools during the 2009-10 H1N1 outbreak also identified a number of
issues that should be addressed now, rather than later. They conclude:
Whether to close schools immediately; the CDC and Minnesota advisories changed as the relatively minor
severity of the H1N1 strain became apparent. Since the strain emerged on the North American continent, the
time lag anticipated from the disease coming from Asia was not available. The USA guidelines initially suggested
that schools be closed quite quickly in the event of students or staff becoming sick and then shifted to excluding
those who were sick for at least seven days. What is best for the next time?
How can we ensure that there is effective and close school-based surveillance of outbreaks so that decisions
can be made in a timely and forthright manner?
How can we use technology effectively to keep school staff, parents, public health officials and more informed
as quickly as possible?
What is the best way to manage vaccinations and other precautionary steps for pregnant staff and medically
School-age children were among the priority groups for vaccination as of December 2009. Is this the best timing
for children (see above discussion re “heard protection)?
Minnesota used school-based vaccination clinics as a priority during the 2009-10 outbreak. Over 900 school
clinics were operated in Minnesota schools. Over 44% of children from six months to 17 years were vaccinated
in Minnesota, compared to a national average of 37%.
Should there be different sets of school guidelines for different types of outbreaks (mild, moderate, severe,
controlled, widespread etc)?
These specific issues and problems in relation to preventing influenza outbreaks through schools is complicated by
several contextual factors. The first is that Canadian school systems are among the very few in the world that can rely on
health personnel being present in the school to deliver health services. Most of Europe, the United States and countries
such as Australia all have school health nurses, school health centres and even part-time or full-time physicians assigned
to schools. The second factor is the absence of a national immunization strategy in Canada. The recent call for such a
strategy from several groups such as the Canadian Public Health Association may help to create a more stable policy
context for influenza prevention, in general, and within schools, in particular. A third factor is the strong division of
labour and structures in public health organizations that have separated infectious and non-communicable diseases
personnel. In schools, nursing personnel are often divided between clinical and health promotion roles and there is a
kind of competition between these two branches for the attention of school personnel. In a similar way, the absence of
a multi-setting approach in Canada to the prevention of infectious diseases, other infections and the promotion of
hygiene in general. In a 2008 international hygiene survey, 80% of Canadian thought that schools and day-care facilities
posed the greatest threat for coming into contact with harmful germs. The fifth and final factor complicating the
prevention of influenza through schools is the piece-meal thinking, often encouraged by a medical focus and scientific
specificity, that has made it difficult to link various infectious diseases, good hygiene, clean water, hand-washing
programs, sanitation, vaccinations for HPV and hepatitis, influenza prevention and pandemic planning into a
comprehensive, school-based approach.
The ISHN tracking of research, reports and news stories has identified some research articles (Painter et al, 2010;
Kwoung et al, 2010; Lindley et al, 2008)and planning resources (HHS School Flu Prevention Planning, that have started to
build this comprehensive approach.
ISHN is starting to catalogue and transfer the research and reports found from its searches as part of its members’
information service into its World School Health Encyclopedia program (that includes toolboxes of research, reports and
planning/educational tools. Go to this web page to see the first rough draft on Schools and Influenza that has over 100
The materials, research and reports being collected in this Influenza and Schools toolbox/bibliography are organized in
this outlines used by ISHN for all health issues:
A. Understanding the Problem: (This includes prevalence data/reports, articles, tools and reports the that explain
nature, aspects of the problem and behaviour theories that explain it).
B. Impact, Role of the School on the Problem (This includes a description of the influence of the physical and social
environment, role of school in preventing and models describing school approaches)
C. Effects of Comprehensive Approaches (Multi-issue, multi-level, multi-system programs) Coordinated Programs
and Services (School-Agency Programs and Whole School Only Programs) (This includes effects on the problem,
specific aspects of the problem, effects on educational achievement etc)
D. Effects of Individual Evidence-based Interventions
Policy ( This includes surveillance, school closing procedures, requiring vaccinations for school entry, mandatory
hand washing in schools, adequate time for hand washing in school day and inter-ministry coordination re
universal vaccination programs)
Instruction (This includes education to teach hand washing skills, overcome misunderstandings about vaccine
safety, hygiene and infections)
Services (This includes vaccinations, emergency procedures, coordinated information to parents, school-based
clinics, youth-friendly and school-linked clinics and the role of the school health nurse.)
Social Support (This includes staff awareness and support, parent education and parent-friendly service delivery,
and staff occupational health & safety issues, particularly for pregnant staff).
Physical Environment (This includes the provision of hand gel machines in schools, universal
precautions/cleansing of surfaces, adequate soap and conditions in bathrooms and school sanitation)
E. Implementation and Sustainability (This includes implementation planning and issues, use of diffusion or
system change theories, capacity-building and strategic consideration of system, agency, and school
F. Consideration of Local Community Contexts (This includes services and programs in rural, religious and
G. Consideration of and Integration within the Constraints and Educational Mandate of the School
H. Questions related to Future and Current Research (This includes research methods, links to educational
outcomes, cost-effectiveness etc)
Here are some of the promising and problematic items from the growing list in that toolbox.
First, and as noted above, it would appear that researchers are leading the way towards a more “comprehensive
approach” that includes a multi-system (health & education), multi-level (provincial, agency and school actions) and
multi-issue (influenza, other infectious diseases, hygiene, immunization) plan. “Coordinated agency-school programs”
on single broad issues like immunization and school hygiene have emerged in developing countries but less so in
developed countries. School-based influenza prevention based on vaccinations and hand washing interventions but
there does not appear to be a “whole school strategies” that involve all educators, parents and students in areas such as
education about infections and immunization, parent education about risk factors and school staff awareness.
Secondly, it appears that simple policy changes can make a big difference. This article has already cited controlled trials,
including Canadian studies that show that school-based vaccinations are more effective and less costly than clinic based
programs. The growing ISHN collection of studies and reviews has identified several successful examples.
However, more research needs to be done. Briss et al (2000) reviewed the different ways of increasing participation in
vaccinations for the Community Guide research review program in the USA. They reviewed three types of interventions;
increasing consumer demand (including schools requiring vaccinations), changing delivery methods (including using
schools as the delivery site) and persuading health care providers to change their delivery methods. (Single and multi-
component interventions were reviewed.) They concluded that having schools require vaccinations for entry was
effective in increasing participation rates. They also concluded that there was insufficient evidence (based on reviewing
only four studies and missing a 1990 Canadian comparative study) that school-based delivery would make a significant
difference in participation rates.
However, the ISHN tracking and minimal follow up on selected references published after 2000 has already found
several case studies reporting that school-based delivery is more effective and less costly. A systematic review, similar
to that done by CDC in 2000, is warranted.
Other simple policy changes would likely yield similarly better results. For example, within schools, a simple policy
change requiring students to wash their hands at scheduled times during the day can significantly reduce the spread of
infections (Nandrup-Busi, 2009; Master, 1997).
The gains from a comprehensive approach to influenza prevention would not only be higher vaccination rates and less
disease. There would also be reductions in student and staff absenteeism, thereby increasing educational achievement
and reducing costs for schools. The ISHN has located several studies that show vaccinations, hand washing and hand
sanitizers programs have positive effects on student absenteeism (Davis et al, 2008; Nettleman et al, 2001; Hull et al,
2010; Guinan et al, 2008; Hammond et al, 2000).
The reports, planning tools and research identified by the ISHN this far also indicates that there is a growing body of
evidence and experience on how to implement and maintain school-based vaccination programs. A systematic review
done by Cawley et al (2010) has summarized what can be found in the several case studies o9n the growing ISHN list.
They suggest that strategies such as incentives, education, the design of the consent form, and follow-up can increase
parental consent and number of returned forms. Minimizing out-of-pocket cost, offering both the intramuscular (shot)
and intranasal (nasal spray) vaccination, and using reminders can increase vaccination coverage among those whose
parents consented. Finally, organization, communication, and planning can minimize the logistical challenges. Included
in the list of studies identified by ISHN are reports on physician, parent, teacher and student perceptions of such
Kuehnert et al (2010), in their review of the recent H1N1 experience, suggest strongly that now is the time to build
capacity in school and public health systems. This is not only for the next emergency but also in moving towards a
universal immunization strategy.
Finally, we are pleased to note that the ISHN list has also located several studies which report that school-based
approaches and programs can also be effective in reaching students in low income or isolated communities and those
facing higher health risks (Federico et al, 2010; Zimmerman et al, 2006; Foty et al, 2010; Britto et al, 2007; Painter et al,
Moving Forward in Canada
Canada is fortunate in several ways in regards to preventing influenza and promoting better hygiene and universal
immunization through schools.
First, we have survived not only the recent and relatively mild H1N1 pandemic but also a more deadly SARS outbreak.
Consequently, our Canadian public health systems have built capacity and experience. It is the next one that we should
be worrying about and it is obvious that schools will be part of the solution (doing vaccinations, hand washing
campaigns, maintaining hygiene and more) or they will be a big part of the problem (in regards to continuing to be a
primary transmission point for disease in the population).
Second, Canada now has an intergovernmental structure to facilitate policy and program coordination on health issues.
The influenza outbreak management guidelines for schools and day care centres issued by the Public Health Agency of
Canada on August 19, 2009 were adequate in respect to the pandemic and were essentially copied or repeated by
similar guidelines issued by the provinces and territories. However, these guidelines are not adequate in regard to
developing an overall prevention-based approach and policy/program/practice response.
The Joint Consortium for School Health was established exactly for this type of issue and can play a much stronger
leadership role in the future. The JCSH was established as part of the reaction to the SARS outbreak (The idea of jointly
named SH coordinators came from the Toronto SARS debriefing session.) and was established as part of the 2004 Health
Care Accord which is now being re-negotiated between the federal and provincial/territorial governments. Instead of
doing literature reviews and sponsored journal supplements which can be done by other organizations, the JCSH can
identify and develop inter-governmental, inter-ministry and inter-agency agreements and assist provinces in their
Further, a number of professional associations, led by the Canadian Public Health Association and supported by
government agencies, has called for a national immunization strategy as part of the renewal of the 2004 Health Care
Accord. An October 2009 invitational conference also called for national leadership in immunization. The Canadian
Coalition for Immunization Awareness and Promotion is ready and able to help with professional and public awareness.
All of these professional and non-governmental organizations can and should include schools as a major part of their
A similar capacity exists within the school health community. The Canadian Association for School health has developed
an expertise in cost-effective and national knowledge exchange through its Communities of Practice, webinars and other
web-based tools. Similarly, the International School Health Network, based at Simon Fraser University and part of a
WHO Collaborating Centre, is well placed to draw upon expertise and experience from other countries through its
information service and its encyclopedia/KE program.
School boards and health authorities now have more than enough research and planning tools to jointly implement
annual and ongoing programs such as hand washing, improved hygiene in classrooms and washrooms, cooperative
procedures in influenza surveillance, parent education about vaccinations and more. Teacher unions and school boards
should be updating their collective agreements and occupational health and safety provisions.
SARS, H1N1… what we call the next one? And, will we all be ready for it?
Briss PA, Rodewald LE, Hinman AR, et al.(2000) Reviews of evidence regarding interventions to improve vaccination
coverage in children, adolescents, and adults. Am J Prev Med 2000;18(1S):97-140
Britto MT, Schoettker PJ, Pandzik GM, Weiland J, Mandel KE (2007) Improving influenza immunisation for high-risk
children and adolescents Qual Saf Health Care. 2007 Oct;16(5):363-8
Cawley, J., Hull, H. F. and Rousculp, M. D. (2010), Strategies for Implementing School-Located Influenza Vaccination of
Children: A Systematic Literature Review. Journal of School Health, 80: 167–175.
Como-Sabetti K, Livingston F, Gahr P, Nagle K, Martin K, Morin G, Parilla E (2010) The 2009 H1N1 Influenza Pandemic
and Minnesota’s K-12 Schools Minnesota Medicine, Sep, 2010
Davis MM, King JC Jr, Moag L, Cummings G, Magder LS (2008) Countywide school-based influenza immunization: direct
and indirect impact on student absenteeism. Pediatrics. 2008 Jul;122(1):e260-5
Deuson RR, Hoekstra EJ, Sedjo R, Bakker G, Melinkovich P, Daeke D, Hammer AL, Goldsman D, Judson FN. The Denver
school-based adolescent hepatitis B vaccination program: a cost analysis with risk simulation Am J Public Health. 1999
Federico SG, , Lisa Abrams, Rachel M. Everhart, Paul Melinkovich, and Simon J. Hambidge (2010) Addressing Adolescent
Immunization Disparities: A Retrospective Analysis of School-Based Health Center Immunization Delivery September
2010, Vol 100, No. 9 | American Journal of Public Health 1630-1634
Foty RG, Guttmann A, Kwong JC, Maaten S, Manuel D, Stieb DM, Dell SD (2010) Predictors of universal influenza
vaccination uptake in grades 1 and 2 Toronto school children: effective vaccination strategies should not end with at risk
children. Vaccine. 2010 Sep 7;28(39):6518-22
Glezen WP Gaglani MJ, Kozinetz CA, Piedra PA (2010) Direct and Indirect Effectiveness of Influenza Vaccination Delivered
to Children at School Preceding an Epidemic Caused by 3 New Influenza Virus Variants J Infect Dis. (2010) 202 (11): 1626-
Guay M, Clouâtre AM, Blackburn M, Baron G, De Wals P, Roy C, Desrochers J, Milord F. (2003) Effectiveness and cost
comparison of two strategies for hepatitis B vaccination of schoolchildren. Can J Public Health. 2003 Jan-Feb;94(1):64-7.
Guinan M, McGuckin M, AliAm Y (2008) The effect of a comprehensive handwashing program on absenteeism in
elementary schools. J Infect Control. 2002 Jun ;30 (4):217-20
Hammond, Ali Y, Fendler E, Dolan M, Donovan S, (2000) Effect of hand sanitizer use on elementary school absenteeism
Am J Infect Control. 2000 Oct ;28 (5):340-6
Hull HF, Ambrose CS (2010) The Impact of School-Located Influenza Vaccination Programs on Student Absenteeism: A
Review of the U.S. Literature.
J Sch Nurs. 2010 Nov 15
Jeuland M, Cook J, Poulos C, Clemens J, Whittington D; DOMI Cholera Economics Study Group. (2009) Cost-effectiveness
of new-generation oral cholera vaccines: a multisite analysis. Value Health. 2009 Sep;12(6):899-908
Kuehnert P. (2010) Now more than ever: building and sustaining capacity for school-located vaccination initiatives. J Sch
Nurs. 2010 Aug;26(4 Suppl):27S-29S
Kwong JC, Ge H, Rosella LC, Guan J, Maaten S, Moran K, Johansen H, Guttmann A. (2010) School-based influenza vaccine
delivery, vaccination rates, and healthcare use in the context of a universal influenza immunization program: an
ecological study. Vaccine. 2010 Mar 24;28(15):2722-9
Lindley MC, Boyer-Chu L, Fishbein DB, Kolasa M, Middleman AB, Wilson T, Wolicki J, Wooley S; Working Group on the
Role of Schools in Delivery of Adolescent Vaccinations (2008) The role of schools in strengthening delivery of new
adolescent vaccinations. Pediatrics. 2008 Jan;121 Suppl 1:S46-54
Loeb M, Russell, ML, Moss L et al, (2010) Effect of Influenza Vaccination of Children on Infection Rates in Hutterite
Communities, JAMA. 2010;303(10):943-950
Longini IM, Koopman JS, Monto AS, Fox JP. (1982) Estimating household and community transmission parameters for
influenza. Am J Epidemiol. 1982;115:736-51.
Master D, Hess Longe SH, Dickson H. (1997) Scheduled hand washing in an elementary school population. Fam Med.
Nandrup-Bus I. (2009) Mandatory handwashing in elementary schools reduces absenteeism due to infectious illness
among pupils: a pilot intervention study. Am J Infect Control. 2009 Dec;37 (10):820-6
Nettleman MD, White T, Lavoie S, Chafin C (2001) School absenteeism, parental work loss, and acceptance of childhood
influenza vaccination. Am J Med Sci. 2001 Mar;321(3):178-80
Painter JE, Sales JM, Pazol K, Grimes T, Wingood GM, DiClemente RJ (2010) Development, theoretical framework, and
lessons learned from implementation of a school-based influenza vaccination intervention. Health Promot Pract. 2010
Painter JE, Sales JM, Pazol K, Wingood GM, Windle M, Orenstein WA, DiClemente RJ (2010) Psychosocial correlates of
intention to receive an influenza vaccination among rural adolescents. Health Educ Res. 2010 Oct;25(5):853-64
Ryan J, Zoellner Y, Gradl B, Palache B, Medema J (2006) Establishing the health and economic impact of influenza
vaccination within the European Union 25 countries. Vaccine. 2006 Nov 17;24 (47-48) :6812-22
Sadoway DT, Plain RH, Soskoline L (1990) Infant and preschool immunization delivery in Alberta and Ontario. A partial
cost-minimization analysis. Can J of Public Health. 81 (2): 146-51
Salo H, Kilpi T, Sintonen H, Linna M, Peltola V, Heikkinen T (2006) Cost-effectiveness of influenza vaccination of healthy
children. Vaccine. 2006 Jun 5;24(23):4934-41
Schmier J, Li S, King JC Jr, Nichol K, Mahadevia PJ. (2008) Benefits and costs of immunizing children against influenza at
school: an economic analysis based on a large-cluster controlled clinical trial. Health Aff (Millwood). 2008 Mar-
Talbot HK, Poehling KA, Williams JV, Zhu Y, Chen Q, McNabb P, Edwards KM, Griffin MR (2009) Influenza in older adults:
impact of vaccination of school children. Vaccine. 2009 Mar 18;27(13):1923-7
White T, Lavoie S, Nettleman MD (1999) Potential cost savings attributable to influenza vaccination of school-aged
children. Pediatrics. 1999 Jun;103(6):e73
Wilson T. (2000) Economic evaluation of a metropolitan-wide, school-based hepatitis B vaccination program. 1: Public
Health Nurs. 2000 May-Jun;17(3):222-7.
Zimmerman RK, Hoberman A, Nowalk MP, Lin CJ, Greenberg DP, Weinberg ST, Ko FS, Fox DE. (2006) Improving influenza
vaccination rates of high-risk inner-city children over 2 intervention years Ann Fam Med. 2006 Nov-Dec;4(6):534-40