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Impact of Seasonal Influenza-Related School Closures on Families --- Southeastern Kentucky, February 2008

During influenza epidemics, little is known about how influenza-related school closures affect families (1--6). Many children meet nutritional needs through school food programs (7), and schools provide child care both during and after school. Moreover, schools rely on student attendance to meet federal and state funding and educational requirements. To assess the impact of school closings on families, the Kentucky Department for Public Health (KDPH) conducted a telephone survey of randomly sampled households whose children attended schools in two adjacent school districts that had been closed because of high absenteeism during an outbreak of seasonal influenza in the community in February 2008. This report summarizes the results of that survey, which indicated that 97.0% of respondents agreed with the decision to close schools. In 29.1% of households, an adult had to miss work to provide child care, and in 15.7% of households, at least one adult lost pay because of missed work. Although the schools closed because of high absenteeism affecting school operations and funding, this was not fully communicated to families; 64.4% of respondents believed the closures would "keep people from getting ill," and 90.8% thought it was "extremely or very important" to disinfect schools while closed to reduce community spread of influenza. School districts and health departments should provide families with specific information about the reason for school closings and provide recommendations for reducing the spread of influenza while students are dismissed from school.

School closures can be triggered by illness-related absenteeism during periods of peak influenza activity (1), primarily when local officials decide that high absenteeism compromises the school's ability to function normally. On February 4, 2008, officials in two school districts (school districts A and B) in rural, southeastern Kentucky closed all schools for 3 (district A) or 4 school days (district B) because of high absenteeism related to a community outbreak of seasonal influenza. In 2008, the two districts enrolled approximately 7,300 students in grades K--12. Districts did not differ on grade distribution of students. School officials informed the community that schools were closing because of "high absenteeism due to illness" in the community via radio announcements and information sent home with students. The information sent home by school district A included a CDC handout that described ways of lowering the risk for influenza.

As of the 2000 census, the racial/ethnic composition of the population was approximately 98% white in both districts. School district A is in a rural, farming area with some manufacturing and coal mining. District A schools are located mainly in two cities that have a combined population of 7,884 covering one county with a population of 35,865. School district B is located in a city with a population of 7,742 that is legally incorporated into two counties with 17,558 persons living in the surrounding suburban developments. It is at the epicenter of three county seats with a cumulative population of approximately 100,000. The area was built on the rail industry, the major employers are in manufacturing, and the area is home to the regional medical referral center for southeastern Kentucky. In this rural, mountainous setting, school closures caused by weather conditions are common; therefore, the community has a heightened level of logistical preparedness.

To examine the effects of school closure on families, KDPH asked CDC to help conduct a telephone survey approximately 3 weeks after the closing, during Wednesday, February 27, through Monday, March 3, 2008, in a random sample of households. Telephone numbers for all households were obtained for all 14 schools in districts A and B, and a random sample of 602 households (11%) was selected. Of the 602 telephone numbers dialed, 282 (46.8%) did not result in contact, and 58 (9.6%) reached households in which a person either hung up or refused to participate in the survey. For each household, interviews were conducted with one adult parent or guardian of a school-aged child. Of the 320 households reached by telephone, a total of 262 surveys (81.9%) were completed; one respondent was not an adult member of the household, and that household was excluded from the analyses. Thus, the response rate, based on Council of American Survey and Research Organizations (CASRO) guidelines, was 43.3% (261 of 602 households). Surveys were conducted by staff members of KDPH, the local county health department, and CDC, mainly during 4:00--8:00 p.m., with follow-up calls conducted at times requested by respondents. All statistical tests of proportions were conducted using chi-square tests.

A total of 480 children lived in the 261 surveyed households (1.8 per household). Of the 480 children, 327 (69.3%) attended school district A, and 145 (30.7%) attended school district B; for eight children, the school district was unknown. In 112 (42.9%) households, at least one child was enrolled in a school meal program (the National School Lunch Program or the School Breakfast Program). School district A has a lower socioeconomic status than school district B; school district B households were significantly less likely to have children participating in the school meal programs than were school district A households (p<0.05), and school district B households had significantly higher annual household income and education levels than school district A households (p<0.05) (Table 1). In 11 (10.0%) households with children enrolled in the school meal programs (4.2% of all households surveyed), the school closure caused difficulty for their family because of the loss of these meals.*

The survey inquired into what places in the community children visited during the school closures, and in what activities they participated (Table 2). Children in school district B were more likely to have attended religious services while schools were closed than children in school district A (p<0.05), and although not statistically significant, children in school district B also more frequently visited restaurants, a friend, sporting events, and social gatherings. Of note, some parents expressed concern that school athletic events such as practices and games were still held on the days when schools were otherwise closed. The most frequent activities for both districts were visiting strip malls or Wal-Mart (the only large store in the area) (113 [43.3%]) or visiting family (112 [42.9%]) while schools were closed.

Of the 261 households surveyed, in only 39 (14.9%) did any adult have the option to work from home. A total of 104 (39.8%) households had a "nonworking adult household member or homemaker" provide child care during the closure, and 157 (60.1%) households had to make alternative arrangements to provide child care for at least one child in the household. In 76 (29.1%) households, a "working adult household member" provided child care during the closure, and in 41 (15.7%) households, at least one adult missed work and lost pay, and all 41 adults took care of a child who was not ill. No statistically significant differences were observed between school districts for provision of child care or work missed.

A total of 233 (89.3%) household respondents stated that they knew ways to lower the risk for acquiring influenza, and 200 (76.6%) stated that they did (or told their children to do) something to lower their risk.§ A total of 171 (65.5%) household respondents reported that they washed their hands to lower their risk for becoming ill or told their children to do so, and 73 (28.0%) household respondents reported telling their children to cover coughs and sneezes or did so themselves as a way to reduce risk for influenza (Table 3).

A total of 252 household respondents (96.6%) agreed with the decision to close schools. When asked why they agreed, 168 (64.4%) said that it would keep more persons from becoming ill, 97 (37.2%) specifically mentioned that it would keep their children from becoming ill, and 237 (90.8%) households stated that it was either "extremely important or very important" to disinfect the schools while they were closed.**††

Reported by: CG Timperio, Whitley County Health Dept; K Humbaugh, MD, Kentucky Dept for Public Health. M Riggs, PhD, D Thoroughman, PhD, Career Epidemiology Field Officer Program, Office of Public Health Preparedness and Response; L Barrios, DrPH, D Copeland, MD, A Waller, MPH, M Denniston, MSPH, Div of Adolescent and School Health, National Center for Chronic Disease Prevention and Health Promotion; S Beavers, MD, C Broussard, PhD, EIS Officers, CDC.

Editorial Note:

During seasonal influenza epidemics, decisions about school closure are made by state and local authorities. However, little is known about the impact of school closures on families with respect to work time lost, provision of child care, and loss of school meals. A principle of such school closures is that they must balance the potential negative consequences of school closure with the reasons for closing the school (1). Communities generally are supportive of school closures during large community outbreaks to reduce risk for children getting ill (3), but without accurate public health messages, the spread of communicable illness might not be mitigated (6). In this report, schools were closed because of influenza-related absenteeism >15%, which affected school funding and operation. Parents were told that the schools were closing because of "high absenteeism due to illness," and they inferred that the closing was to disinfect the schools and reduce transmission. Despite this, the children who attended the closed schools gathered in many social activities during the closure.

For the 3--4 day school closure described in this report, provision of child care in the home was available for approximately two thirds of households, but adults missed work in nearly one quarter of households, and only a small percentage of households had an adult who could work from home. When schools are closed for longer periods, parents might need alternative means of child care to avoid missing work beyond what is described in this report. Findings from a recent public deliberation indicated that participants were concerned about job security and economic strain on families in the event of prolonged school closures (9). During the short school closures described in this report, substantial socioeconomic differences between school district A and school district B appeared to influence several of the children's activities and sites visited during the closure but did not influence child care arrangements, workplace absenteeism, or use of risk-reduction methods. However, whether this lack of difference by socioeconomic variables would be maintained during a longer school closure period is unknown.

The findings in this report are subject to at least three limitations. First, telephone numbers (for landline and cellular telephones) were randomly sampled from school district rosters available at the time of survey administration. Student households without a telephone were not eligible to be sampled. Second, the response rate among households successfully contacted was high (81.9%); however, a substantial proportion of telephone numbers originally sampled were unreachable (e.g., no answer, phone disconnected, or not accepting calls), which might have introduced response bias. Finally, because household respondents were surveyed retrospectively on events occurring approximately 3 weeks before, recall bias might have reduced the accuracy of responses.

CDC policies for school closures during the current pandemic of influenza A (H1N1) (8) have been used to guide state and local officials, who must weigh public perception, the need to reduce spread of illness, severity of the illness, and protection of high-risk students and staff, in addition to considerations of the impact on children and families and whether high absenteeism compromises the school's ability to function normally. If school closure is necessary, school districts and health departments should work together to explain to parents their reasons for closing schools and appropriate actions to take (e.g., staying home if ill) while students are dismissed from school.

Acknowledgments

This report is based, in part, on contributions by V Lawson, T Johnson, C Parks, S Damron, S Richardson, S Walden, K Croley, M Whitman, T McKinney, G Young, D McNaughton, Whitley County Health Dept; W Hacker, MD, S Robeson, MPH, Kentucky Dept for Public Health; P Edelson, MD, H Hastings, MPH, V Moody, MHA, Div of Global Migration and Quarantine, National Center for Preparedness, Detection, and Control of Infectious Diseases; P Casteel, MPH, K Nicholson, MPH, Div of Adolescent and School Health, National Center for Chronic Disease Prevention and Health Promotion; C Dao, MPH, Influenza Div, National Center for Immunization and Respiratory Diseases, CDC.

References

  1. Cauchemez S, Ferguson NM, Wachtel C, et al. Closure of schools during an influenza pandemic. Lancet Infect Dis 2009;9:473--81.
  2. Inglesby TV, Nuzzo JB, O'Toole T, Henderson DA. Disease mitigation measures in the control of pandemic influenza. Biosecur Bioterror 2006;4:366--75.
  3. Johnson AJ, Moore ZS, Edelson PJ. Household responses to school closure resulting from outbreak of influenza B, North Carolina. Emerg Infect Dis 2008;14:1024--30.
  4. Koonin LM, Cetron MS. School dismissal to reduce influenza transmission [letter]. Emerg Infect Dis 2009;15(1).
  5. Cowling BJ, Lau EHY, Lam CLH, et al. Effects of school closures, 2008 winter influenza season, Hong Kong. Emerg Infect Dis 2008;14(10).
  6. Luckhaupt S, Hastings H, Hunter D, et al. Social distancing during a school closure due to communicable disease---Rhode Island, 2007. In: Late breaking reports of the 56th Annual Epidemic Intelligence Service Conference (April 17--20, 2007). Atlanta, GA: US Department of Health and Human Services, CDC; 2007. Available at http://www.cdc.gov/eis/downloads/2007.latebreakingreports.pdf. Accessed December 21, 2009.
  7. Clark MA, Fox MK. Nutritional quality of the diets of US public school children and the role of the school meal programs. J Am Diet Assoc 2009;109(2 Suppl):S44--56.
  8. CDC. CDC guidance for state and local public health officials and school administrators for school (K--12) responses to influenza during the 2009--2010 school year. Available at http://www.cdc.gov/h1n1flu/schools/schoolguidance.htm. Accessed December 21, 2009.
  9. Baum NM, Jacobson PD, Goold SD. "Listen to the people": public deliberation about social distancing measures in a pandemic. Am J Bioeth 2009;9:4--14.

* Based on a "yes" response to the survey question, "Did the school closure cause difficulty for your family because of the loss of these meals?"

Based on a "yes" response to the survey question, "Is there usually an adult capable of providing child care at home during the day?"

§ Based on responses to the survey questions "Did you do (or did you tell your child or children to do) any of these things to lower their risk of getting sick?" and "If yes, what did you do or tell them to do?"

Based on a "yes" response to the survey question, "Did you agree with the decision to close the schools?"

** Based on response to the survey question, "How important do you think it is for schools to be disinfected while the school is closed to prevent the spread of illness?"

†† School staff members should routinely clean areas that students and staff touch often with the cleaners they typically use. CDC does not believe any additional disinfection of environmental surfaces beyond the recommended routine cleaning is required (8).

What is already known on this topic?

Public health and education officials base their recommendation to close schools during influenza outbreaks on local circumstances, such as attendance rates, prevalence of illness in their community, severity of the illness, and the community's acceptability of the actions of officials.

What is added by this report?

This report indicates that despite parental concerns about reducing risk for illness during a seasonal influenza epidemic in 2008, nearly 40% of children gathered for social activities during a school closure, and parents' perceptions about the reasons for the closure often were inaccurate; in 15.7% of households, at least one adult lost pay because of missed work during the closings.

What are the implications for public health practice?

When school closures are necessary, school districts and health departments should enumerate the reasons and recommend measures to reduce the transmission of influenza during the closures.


TABLE 1. Socioeconomic characteristics of households in two adjacent school districts --- southeastern Kentucky, February 2008

Characteristic

Total households (N = 261)*

Households in district A (n = 172)

Households in district B (n = 86)

No.

(%)

No.

(%)

No.

(%)

Annual household income

<$20,000

49

(19.1)

42

(24.6)

7

(8.1)

$20,000--$29,999

37

(14.4)

32

(18.7)

5

(5.8)

$30,000--$49,999

50

(19.5)

33

(19.3)

17

(19.8)

$50,000--$74,999

39

(15.2)

20

(11.7)

19

(22.1)

$75,000--$99,999

24

(9.3)

15

(8.8)

9

(10.5)

≥$100,000

18

(7.0)

5

(2.9)

13

(15.1)

Prefer not to answer

40

(15.6)

24

(14.0)

16

(18.6)

Highest education level§

Less than grade 12

29

(11.3)

28

(16.4)

1

(1.2)

High school graduate or GED

103

(40.2)

72

(42.1)

31

(36.5)

1--3 yrs of college

49

(19.1)

33

(19.3)

16

(18.8)

≥4 yrs of college

48

(18.8)

23

(13.5)

25

(29.4)

Graduate or professional school

22

(8.6)

12

(7.0)

10

(11.8)

Prefer not to answer

5

(2.0)

3

(1.8)

2

(2.4)

At least one child participates in free or reduced breakfast or lunch program**

112

(42.9)

92

(53.8)

19

(22.1)

* Data on school district missing for three households.

Excludes four households; p<0.05 by chi-square test of overall difference between districts.

§ Excludes five households; p<0.05 by chi-square test of overall difference between districts.

General Education Development certificate.

** Excludes four households; p<0.05 by chi-square test of difference between districts.


TABLE 2. Community sites visited and activities engaged in by children in two adjacent school districts while schools were closed --- southeastern Kentucky, February 2008

Total households (N = 261)*

Households in district A (n = 172)

Households in district B (n = 86)

Sites and activities

No.

(%)

No.

(%)

No.

(%)

Strip malls or Wal-Mart

113

(43.3)

75

(43.6)

36

(41.9)

Visit family

112

(42.9)

76

(44.2)

35

(40.7)

Grocery shopping

101

(38.7)

64

(37.2)

35

(40.7)

Restaurants

85

(32.6)

49

(28.6)

34

(39.5)

Friends' houses or friends visiting their house

79

(30.3)

46

(26.7)

31

(36.1)

Religious services§

76

(29.1)

40

(23.3)

34

(39.5)

Sports activities (e.g., practices, games, events, roller rink, or four-wheeling)

62

(23.8)

34

(19.8)

28

(32.6)

Public gatherings (e.g., concerts, movies, or festivals)

46

(17.6)

25

(14.5)

20

(23.3)

Part-time job

22

(8.4)

14

(8.1)

7

(8.1)

* Data on school district missing for three households.

Excludes households with missing data and when questions did not apply. Categories are not mutually exclusive.

§ p<0.05 by chi-square test of difference between districts.


TABLE 3. Behaviors respondents thought could reduce the risk for becoming ill from influenza and frequency of use of those behaviors by households in two adjacent school districts (N = 261) --- southeastern Kentucky, February 2008

Thought behavior could reduce risk for influenza

Engaged in or told child to engage in the behavior

Behavior*

No.

(%)

No.

(%)

Wash hands

196

(75.0)

171

(65.5)

Cover cough or sneeze

79

(30.3)

73

(28.0)

Avoid sharing drinks and utensils

54

(20.7)

69

(26.4)

Stay home

38

(14.6)

25

(9.6)

Avoid crowds

44

(16.9)

23

(8.8)

Use hand sanitizer

11

(4.2)

16

(6.1)

Eat right

16

(6.1)

13

(5.0)

Vaccination ("flu shot")

55

(21.1)

10

(3.8)

Get enough sleep

10

(3.8)

9

(3.5)

Take vitamins

13

(5.0)

9

(3.5)

Stay warm

9

(3.4)

7

(2.7)

Clean surfaces

12

(4.6)

5

(1.9)

Keep child out of school (beyond the school closure)

9

(3.4)

4

(1.5)

Keep hands away from mouth

3

(1.2)

3

(1.2)

* Categories are not mutually exclusive.

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Date last reviewed: 12/23/2009

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