SH Report Vol 5, No 3 November 2010 by SHInsider


									                   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   
     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
     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
     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
    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
     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
     the project at:
                                                                           News Story (Nov 26-10) HPV vaccine studied for N.B. boys
    Call for Local Programs in School Mental Health             
     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
     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
     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
     interview.To nominate a program, go to:            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
    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:                       
    - coordinated inter-ministry policy
    - inter-agency cooperation                                            On Liine Petition UNICEF Canada Call for Canadian
    - maintaining fidelity dilemmas and issues                            Children's Commissioner
    - 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
    Health Community of Practice web pages.
                                                                          News Story (Nov 24-10) Greater Victoria schools probe Wi-
   School Nutrition National Meeting                                     Fi safety
    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
    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
    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.

   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
    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
    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
    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

   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
    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
                                                                          News Story (Nov 17-10) Boys-only classrooms gain favour
   Aboriginal School Health CoP Framework Goes International   
    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
    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
   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

    Twitter. Simply go to, 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
    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
    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

   New Features on                            News Story (Nov 11-10) Junk-food ads aimed at kids come
    In our continuing effort to use technology effectively, we have        under fire
    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
         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
             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
             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
             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
             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
             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
         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 Agencies, organizations and                than 1st
    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
    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

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

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
   Managing misunderstanding/fear/hysteria
   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
   Joint policy-making/procedures/protocols
   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?)

Policy Issues

      1.        Are current policies, directives, guidelines and procedures regarding such outbreaks and the sanitation of
                schools adequate?

      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?

Research Questions

      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
         fragile students?
     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
web-linked documents.

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
       aboriginal communities.)
    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
vaccination programs.

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?


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