From the French Presidency Eurogrippe Seminar Angers, France 3-5 september 2008

1. Class Dismissal in Europe During Pandemics – Scientific and Public Health Issues”   Angus Nicoll Influenza Coordinator ECDCbased 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

2. Content Introduction Potential impact on health outcomes Potential secondary effects of school closures – class dismissal Mitigation of secondary effects Communication aspects Formulation

3. Definitions School Closure – School closed and teachers and administration go home Class Dismissal – School remains open with administrative staff but children told to stay home. 3

4. Community Mitigation (Public Health Measures) in a Pandemic – The Objectives #1 No intervention #2 Daily Cases With interventions #3 Days since First Case • 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

5. ECDC Menu of Public Health Measureshttp://ecdc.europa.eu/Health_topics/Pandemic_Influenza/phm.html Travel Measures - Restrictions on international travel Travel advice Entry screening Border closures Personal protective measures Regular hand-washing Respiratory hygiene General mask wearing outside the home Mask-wearing in health-care settings Mask wearing in high-risk situations Mask-wearing by people with respiratory infections Early self-isolation of ill people Quarantine measures Antivirals – Early Treatment All those with symptoms Health care or exposed key workers Antivirals - Prophylaxis following a case Family Family and other social contacts Family and geographical contacts Antivirals – Continuous prophylaxis Health care and key workers Vaccines - Human H5 vaccines for the whole population for children for health care workers Vaccines – Specific pandemic vaccine Specific pandemic vaccines

6. ECDC Menu of Public Health Measureshttp://ecdc.europa.eu/Health_topics/Pandemic_Influenza/phm.html Social distancing measures Internal travel restrictions Reactive school closures Proactive school closures Reactive workplace closures Home working and reducing meetings Cancelling public gathering, international events etc School Closures Vs Class Dismissal

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

8. “for every complex, difficult problem there is frequently a simple and attractive solution” – that doesn’t work HL Mencken

9. “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

10. From ECDC/WHO/EC National Self Assessments Why are some countries planning to close schools? Because they can Because they do

11. Questions for the workshop • Do you plan to close schools or dismiss classes • If so • A central decision or local? • Any day care measures planned? • Measures to continue schooling? • What should freed-up teaching staff do? • Should the decision be shared by Member States • What should be the communication strategy

12. What would be the potential health benefits of school closures in a pandemic?From Simon Cauchemez (UK-France) 12

13. 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%)

14. Modelling – why such differences? • Results of models depend on assumptions that are made. For example: Assumption in modelConclusion 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!

15. 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…

16. 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

17. Pandemics are not Standard 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

18. 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%)

19. 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

20. Modelling – why such differences? • Results of models depend on assumptions that are made. For example: Assumption in modelConclusion 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!

21. 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…

22. 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

23. What could be the social impact of closing schools?Anders Tegnell (Sweden) 23

24. Does it make sense? • Threat of unknown impact • Use a measure of uncertain efficiency • A measure with likely considerable negative effects • A measure which might send a message that the threat is bigger than it actually is

25. Impact on the work force if suddenly have to care for children • Major impact on the health and social care sector in Sweden • Could ‘lose’ up to 50% of health care workers • Impact on health care would be massive • Significant economic costs • Sadique MZ, Adams E, Edmunds J Estimating the costs of school closure BMC Public Health April 24th 2008

26. School closures : status of the French plan Guillaume Saour and Jean-Pierre Bayeux 26

27. Historical analysis of the 1957 pandemic Idea that closing schools would provoke panic and create the crisis Decisions came too late, only after 50-75% of children got ill (ministerial instructions) Complex instructions for education professionals Local decisions, lack of national consistency Overall inefficiency due to mentioned above conditions of application of 1957 27

28. The school closure in the French plan : Education continuity Continuity of the Education Administration Business Continuity Plans of each school to ensure essential activities (logistics, finances, communication networks) Pedagogic continuity 1/2 teachers in charge of maintaining the link between pupils/students and other teachers in each school. Mainly by phone Use of internet, TV and Radio for 3 months 28

29. Theoretical resources for alternative childcare in France Students: about 2 millions Grandparents – immediate neighbours 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

30. Lack of clarity of the measure The triggers for closure and re-opening are not clearly defined yet Age groups concerned? Room for inconsistency : Zonal, Regional planning assuming long/total school closures (use of facilities, etc…) vs planning more flexible Planning vs Population expectations; communication issue 30

31. Main issues Definition of triggers to implement and to cease the measure Definition of measures to maintain childcare and pedagogical continuity Definition of communication strategy Interoperability 31

32. Work in France • Much work in progress in France • National approach with local control • Part of the central plan with inter-ministerial coordination – DILGA • Work on continuing education in a pandemic • Work on alternative child-care when schools close

33. Communication AspectsBen Duncan ECDC 33

34. 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

35. Discussion DiscussionFormulation and Recommendations for future European work 35

36. Points from discussion - 1 • Children are important to society and their health & safety cause high emotions • Member states are different in social structure • Many things to be learnt from how some member states have done issues already • Can states plan reinbursement of parents for lost wages? • See this as a BCP issue?

37. Points from discussion - 2 • Education is locally controlled in many MS • Education sector highly complex and not easily organised • Vulnerable families and special children who rely on schools • Could be perverse effects of children being cared for by grand-parents • Learning from the experience with H5 in Hong Kong in 1997

38. Points from discussion – 3 • Cross-border issues. • May not even be legal powers if its not planned for. • Some countries have already done a lot on this – others could benefit from this thinking.

39. Conclusion of the Conclusions • C’est difficile

40. Conclusion of the Conclusions • C’est difficile • Mais c’est tres important!

41. Recommendation • Needs thought and work in every member state • Cannot be dealt with by ‘health’ alone – multi-sectoral approach • Decisions in one region or one member state will affect others – interoperability • An interministerial EU workshop specifically on this in 2009 for ‘health’, ‘education’ and ‘interministerial authorities’