Transcript Transfert Eurogrippe Informelle

Class Dismissal in Europe During Pandemics –
Scientific and Public Health Issues”
Angus Nicoll Influenza Coordinator ECDC
based on contributions by
Simon Cauchemez (Imperial College), Anders Tegnell (Board of Health & Welfare,
Sweden), Guillaume Saour (Ministry of Health, France), Jean-Pierre Bayeux
(Ministry of Education, France), John Edmunds (HPA/LSHTM) and Ben Duncan
(ECDC)
From the French
Presidency Eurogrippe
Seminar
Angers, France
3-5 september 2008
Content
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Introduction
Potential impact on health outcomes
Potential secondary effects of school
closures – class dismissal
Mitigation of secondary effects
Communication aspects
Formulation
Definitions

School Closure – School closed and
teachers and administration go home

Class Dismissal – School remains
open with administrative staff but
children told to stay home.
3
Community Mitigation (Public Health
Measures) in a Pandemic – The Objectives
1.
2.
3.
4.
Delay and flatten outbreak peak
Reduce peak burden on healthcare system and allow
better fit of services to cases
Reduce number of cases
Buy (a little) time
#1
No intervention
#2
Daily
Cases
With interventions
#3
Days since First Case
ECDC Menu of Public Health Measures
http://ecdc.europa.eu/Health_topics/Pandemic_Influenza/phm.html
Travel Measures - Restrictions on
international travel

Travel advice

Entry screening

Border closures
Personal protective measures

Regular hand-washing

Respiratory hygiene

General mask wearing outside the
home

Mask-wearing in health-care
settings

Mask wearing in high-risk situations
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Mask-wearing by people with
respiratory infections

Early self-isolation of ill people
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Quarantine measures
Antivirals – Early Treatment

All those with symptoms

Health care or exposed key workers
Antivirals - Prophylaxis following a
case
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Family
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Family and other social contacts
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Family and geographical contacts
Antivirals – Continuous prophylaxis
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Health care and key workers
Vaccines - Human H5 vaccines

for the whole population

for children

for health care workers
Vaccines – Specific pandemic
vaccine

Specific pandemic vaccines
ECDC Menu of Public Health Measures
http://ecdc.europa.eu/Health_topics/Pandemic_Influenza/phm.html
Social distancing measures
 Internal travel restrictions
 Reactive school closures
 Proactive school closures
 Reactive workplace closures
 Home working and reducing
meetings
 Cancelling public gathering,
international events etc
School Closures Vs Class
Dismissal
“for every complex, difficult
problem there is frequently a
simple and attractive solution”
“for every complex, difficult
problem there is frequently a
simple and attractive solution”
– that doesn’t work
HL Mencken
“for every complex, difficult
problem there is frequently a
simple and attractive solution”
Glass RJ, Glass LM, Beyeler WE, Min HJ. Targeted social
distancing design for pandemic influenza. Emerg Infect Dis
[serial on the Internet]. v [cited
http://www.cdc.gov/ncidod/EID/vol12no11/06-0255.htm
From ECDC/WHO/EC National Self
Assessments Why are some countries
planning to close schools?
Because they can
Because they do
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Questions for the workshop
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Do you plan to close schools or dismiss classes
If so
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A central decision or local?
Any day care measures planned?
Measures to continue schooling?
What should freed-up teaching staff do?
Should the decision be shared by Member States
What should be the communication strategy
11
What would be the potential
health benefits of school closures
in a pandemic?
From Simon Cauchemez (UK-France)
12
Cauchemez Conclusions
•No clear message from modellers – look closely at the assumptions
•Analysis of what actually happens when schools close with seasonal flu
– this gives a relatively consistent message.
• Optimistic scenario (i.e. proactive school closure: same impact as
holidays):
 Limited impact on the cumulated number of cases. Could prevent
- 1 in 7 cases (15%);
No ‘magic bullet’ but still 15% is a lot of people
When children die … and its presumed they were infected in school
 More significant reductions in peak attack rates (~40%)
Modelling – why such differences?
• Results of models depend on assumptions that are made. For example:
Assumption in model
Conclusion re school closure
50% of transmissions occur in schools
huge impact on spread
15% of transmissions occur in schools
marginal impact on spread
• It is not possible to “guess” which scenario is the most likely. We need to learn from
past outbreaks!
• For results of modelling to be predictive, it is critical to “feed” models with observations
from past outbreaks!
School closure in Hong Kong, March 2008 (1)
[Cowling et al., EID, in press]
School closure
Important reduction observed after the peak – But in a flu outbreak, that is
what you expect to see, even without intervention…
School closure in Hong Kong, March 2008 (2)
[Cowling et al., EID, in press]
School closure in 2008
Cowling et al detect no substantial effect of school closure on transmission
Pandemics are not Standard
60
1957 (from Chin et al)
1968 (from Davis et al 1970)
1918 (from Glezen 1996)
Base Case 50% attack rate
50
Attack rate (%)
40
30
20
10
0
0
10
20
30
40
50
60
70
80
Age
Figure from Glass RJ, Glass LM, Beyeler WE, Min HJ.
Targeted social distancing design for pandemic influenza. Emerg Infect Dis [serial on the Internet].
v [cited http://www.cdc.gov/ncidod/EID/vol12no11/06-0255.htm
Cauchemez conclusion
•No clear message from modellers – look closely at the assumptions
•Analysis of what actually happens when schools close with seasonal flu
– this gives a relatively consistent message.
• Optimistic scenario (i.e. proactive school closure: same impact as
holidays):
 Limited impact on the cumulated number of cases. Could prevent
- 1 in 7 cases (15%);
No ‘magic bullet’ but still 15% is a lot of people
When children die … and its presumed they were infected in school
 More significant reductions in peak attack rates (~40%)
Cauchemez Conclusions
But impact might be much smaller if it is difficult to
maintain low contact rates among children for
prolonged periods.
Pandemics are not standard – in some children more
affected and important transmitters than others
• Late reactive closures would do little though may seem to
do a lot
Modelling – why such differences?
• Results of models depend on assumptions that are made. For example:
Assumption in model
Conclusion re school closure
50% of transmissions occur in schools
huge impact on spread
20% of transmissions occur in schools
marginal impact on spread
• It is not possible to “guess” which scenario is the most likely. We need to learn from
past outbreaks!
School closure in Hong Kong, March 2008 (1)
[Cowling et al., EID, in press]
School closure
Important reduction observed after the peak – But in a flu outbreak, that is
what you expect to see, even without intervention…
School closure in Hong Kong, March 2008 (2)
[Cowling et al., EID, in press]
School closure in 2008
Cowling et al detect no substantial effect of school closure on transmission
What could be the social impact
of closing schools?
Anders Tegnell (Sweden)
23
Does it make sense?
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Threat of unknown impact
Use a measure of uncertain efficiency
A measure with likely considerable
negative effects
A measure which might send a
message that the threat is bigger than it
actually is
Impact on the work force if suddenly
have to care for children
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Major impact on the health and social care
sector in Sweden
Could ‘lose’ up to 50% of health care workers
Impact on health care would be massive
Significant economic costs

Sadique MZ, Adams E, Edmunds J Estimating the costs of
school closure BMC Public Health April 24th 2008
School closures : status of the
French plan
Guillaume Saour and Jean-Pierre Bayeux
26
Historical analysis of the 1957
pandemic
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Idea that closing schools would provoke panic and
create the crisis
Decisions came too late, only after 50-75% of
children got ill (ministerial instructions)
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Complex instructions for education professionals
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Local decisions, lack of national consistency
Overall inefficiency due to mentioned above
conditions of application of 1957
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27
The school closure in the French
plan : Education continuity
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Continuity of the Education
Administration
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Business Continuity Plans of each school to
ensure essential activities (logistics, finances,
communication networks)
Pedagogic continuity
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1/2 teachers in charge of maintaining the link
between pupils/students and other teachers in
each school. Mainly by phone
Use of internet, TV and Radio for 3 months
28
Theoretical resources for
alternative childcare in France
Grandparents –
immediate neighbours
Students:
about 2 millions
About
7 millions
between
65 and 80
Teachers
About 1 million
High school students:
More than 10 years old
About
6 millions
Other resources
(retired, housewives,
but excludes
unemployed people)
25-54 years old
2,6 millions women
0,7 million men
8 millions of children under 10 need childcare
29
Lack of clarity of the measure
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The triggers for closure and re-opening
are not clearly defined yet
Age groups concerned?
Room for inconsistency :
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Zonal, Regional planning assuming
long/total school closures (use of facilities,
etc…) vs planning more flexible
Planning vs Population expectations;
communication issue
30
Main issues
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Definition of triggers to implement and
to cease the measure
Definition of measures to maintain
childcare and pedagogical continuity
Definition of communication strategy
Interoperability
31
Work in France
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Much work in progress in France
National approach with local control
Part of the central plan with interministerial coordination – DILGA
Work on continuing education in a
pandemic
Work on alternative child-care when
schools close
Communication Aspects
Ben Duncan ECDC
33
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Its difficult to know how this will appear
in the media – but it will
It is inevitable that this issue will arise
A must-do for preparation and flexibility
Schools are likely to close – better to do
in an orderly manner
Discussion Discussion
Formulation and
Recommendations for future
European work
35
Points from discussion - 1
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Children are important to society and their
health & safety cause high emotions
Member states are different in social
structure
Many things to be learnt from how some
member states have done issues already
Can states plan reinbursement of parents
for lost wages?
See this as a BCP issue?
Points from discussion - 2
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Education is locally controlled in many MS
Education sector highly complex and not
easily organised
Vulnerable families and special children who
rely on schools
Could be perverse effects of children being
cared for by grand-parents
Learning from the experience with H5 in
Hong Kong in 1997
Points from discussion – 3
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Cross-border issues.
May not even be legal powers if its not
planned for.
Some countries have already done a lot
on this – others could benefit from this
thinking.
Conclusion of the Conclusions
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C’est difficile
Conclusion of the Conclusions
C’est difficile
Mais c’est tres
important!
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Recommendation
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Needs thought and work in every member
state
Cannot be dealt with by ‘health’ alone – multisectoral approach
Decisions in one region or one member state
will affect others – interoperability
An interministerial EU workshop specifically
on this in 2009 for ‘health’, ‘education’ and
‘interministerial authorities’