The swine flu outbreak of the last two weeks gave states' pandemic preparation plans their biggest test yet, and by most accounts, response was good. But officials now anticipate tweaking their plans, particularly in dealing with when to close schools and how to control the spread of the disease by undocumented and migrant workers.
States last updated their pandemic response plans in anticipation of an avian flu outbreak from Asia. The proximity of the swine flu outbreak in Mexico and its quick jump into the U.S. gave officials less time to assess the situation and react to the illness, said Paul Jarris, executive director of the Association of State and Territorial Health Officials.
The suddenness led state and federal health authorities to stress caution when the disease first appeared, he said. But Jarris also credited authorities for honestly telling the public about what they did and did not know.
The federal Centers for Disease Control and Prevention (CDC) said there were 1,105 probable or confirmed cases of swine flu in 44 states. That number soon could increase significantly, as states begin clearing the backlog of cases awaiting confirmation. The first swine flu fatality in the United States was a Mexican toddler in Texas; the second, announced Tuesday, was a woman in Texas.
On Tuesday (May 5), the CDC advised schools to stay open even if one or more of their students had been diagnosed with swine flu. That's a reversal from its earlier stance, when it suggested schools close for at least a week to prevent the illness from spreading. Schools in several states were shut down. Richard Besser, acting director of the CDC, said the agency changed course when it became clear that swine flu appeared far less dangerous than scientists originally feared.
State policies regarding who decides whether to shut schools vary by state, although it's largely up to school officials.
Texas school boards, for instance, decided to close more than 800 schools there, affecting 491,000 students, according to the Texas Education Agency.
In Maryland, the secretary of health and mental hygiene decides whether to keep schools open. That policy was established to address worries about anthrax and smallpox outbreaks following the 2001 terrorist attacks, a department spokesman said.
The state closed seven schools, including a 1,300-student high school in suburban Washington, D.C. Rockville High School remained shut for three days, and school officials worked to find new locations for SAT and Advanced Placement tests that had been scheduled in the school. Montgomery County Schools Superintendent Jerry Weast Tuesday objected to the ongoing closures.
If more students were found with swine flu, the school could be shut indefinitely at the "most critical time of the school year," said Steve Simon, a district spokesman. Simon also pointed out that schools were being closed, but other large gathering places were not. Still, he said communication among state, county and school officials had been very good.
Maryland officials said Rockville High will reopen on Wednesday, because of the new CDC guidelines.
New Jersey Education Secretary Lucile Davy told lawmakers Monday (May 4) that state education officials wanted to help local schools decide whether to close schools. But she said the decision should ultimately be made at the local level.
"We really feel strongly that, first of all, we are not medical experts and that health officials should be doing this in consultation with the local district folks. They know the local community issues," she told the Assembly's Health and Senior Services Committee.
Schools are a natural place to target for closure because they are "a petri dish for the spread of a bacteria or virus," said Dr. Martha Bergren, director of research for the National Association of School Nurses.
Kids have worse hygiene habits and more contact with each other than adults, and they're almost always in tight spaces with each other during school hours, Bergren said. The initial closure of schools made sense, because health officials didn't know how severe the flu was, she said.
A homeland security advisor drove the point home in a conference call last week ( PDF) in recalling accounts of the 1918 pandemic flu outbreak, Bregren said.
Dr. Richard Hatchett of the Homeland Security Council said researchers discovered that the flu was much more severe in cities that delayed closing schools. Philadelphia waited 16 days before closing schools, and 1 percent of the city's population died. St. Louis suspended classes two days after the first flu case was identified, and its fatality rate was only one-eighth of Philadelphia's.
Besides students, others that states should focus on for extra attention in a flu outbreak are uninsured and undocumented residents, according to Jarris, the executive director of the state health officials' group. Jarris said treating those who don't have access to health care is important from both a compassionate and practical standpoint to slow the spread of the disease. "These children are going to your kids' and my kids' schools," he said.State officials also should consider how to deal with migrant farm workers who might have the disease and travel from state to state, he said.
Authorities should also consider how to reduce the stigma attached to a disease outbreak, which led to hostility against Asians and Asian-Americans after the SARS ( Severe Acute Respiratory Syndrome) scare and against Latinos during the swine flu outbreak. Such stigmas could prevent people from getting treatment quickly, he said.
Jarris said the federal government needs to step up funding for more antivirals, better protections for health workers and more disaster planning to ensure states are prepared. He made a similar point to a U.S. Senate panel last week, the same day President Obama requested $1.5 billion in additional public health funding to cover the flu outbreak's costs.