City of Cincinnati H1N1 Update

October 13, 2009

Re: H1N1 (swine) flu important information

Dear Child Care Provider,

There has been much recent concern about the novel H1N1 flu virus (sometimes referred to as “swine flu”). We would like to take this opportunity to introduce several resources that may be useful to you that are available and regularly updated on the internet. We would also like to highlight some information about best practices that may be especially valuable to you.

1. The best “one-stop-shop” for the latest Centers for Disease Control (CDC) recommendations for H1N1 (swine) flu management and precautions that are available on the website www.flu.gov. This site is regularly updated, and has options that can be tailored to different populations (for example, parents, child-care providers).

2. Information about H1N1 that is specifically tailored for child-care settings can be found at http://www.flu.gov/professional/school/childguidance.html.

3. A toolkit with materials for both child-care providers and parents, including guidance for parents on what to do when their child is sick can be found at:
http://www.flu.gov/professional/school/childtoolkit.html.

What can you do to prevent the spread of H1N1 (swine) flu in your child-care facility?
The CDC websites listed above are updated regularly and list many ideas. Highlights from these websites include:

• Get vaccinated against the flu: The best way to protect against the flu – seasonal or 2009 H1N1 – is to get vaccinated. A vaccine will be available this year, as it is each year, to protect against seasonal influenza. Vaccine to protect against the 2009 H1N1 flu virus is currently in production, and initial doses are expected to become available later in the fall.

• Wash hands frequently with soap and water when possible; keep hands away from your nose, mouth, and eyes; and cover noses and mouths with a tissue when coughing or sneezing (or a shirt sleeve or elbow if no tissue is available). For children with emerging self-care skills, parents and caregivers should closely monitor their respiratory etiquette and hand hygiene and remind children not to share cups or eating utensils. Visit: www.cdc.gov/cleanhands for more information on hand hygiene and http://www.cdc.gov/flu/protect/covercough.htm for more information on respiratory etiquette.

• Perform routine environmental cleaning: Areas and items that are visibly soiled should be cleaned immediately, and all areas should be regularly cleaned – with a particular focus on items that are more likely to have frequent contact with the hands, mouths, and bodily fluids of young children (for example, toys and play areas). CDC does not believe any additional disinfection of environmental surfaces beyond routine cleaning is required. Visit http://nrckids.org for more information on cleaning in early childhood settings.

• Conduct daily health checks: Early childhood providers conducting daily health checks should observe all children and staff and talk with each child’s parent or guardian and each child. He or she should look for changes in the child’s behavior, a report of illness or recent visit to a health care provider, and any signs or symptoms of illness. During the day, staff also should identify children and other staff who may be ill. Ill children and staff should be further screened by taking their temperature and inquiring about symptoms. An example of how to perform daily health checks can be found at: http://www.bmcc.edu/Headstart/Trngds/Diseases/pg91-108.htm.

• Separate ill children and staff: Children and staff who develop symptoms of flu-like illness while at the early childhood program should promptly be separated from others until they can be sent home. While this may be challenging for some home-based providers, they should provide a space where the child can be comfortable and supervised at all times.

• Stay home when sick: This point cannot be emphasized enough. Children and caregivers with flu-like illness should remain at home and away from others until at least 24 hours after they are free of fever.

Many child-care providers have questions about exclusion and readmission criteria for H1N1—who needs medical evaluation, who needs treatment, who needs a doctor’s excuse, and when can children return to child-care. Relevant CDC recommendations are listed in the websites above. Highlights are listed below:

• Symptoms: Symptoms of H1N1 include both fever (defined as greater than 100.4°F when measured orally) AND cough or sore throat. Other symptoms may include runny nose, body aches, chills a headache, tiredness, diarrhea, or vomiting.
• Course: Fevers associated with H1N1 typically last 2 to 4 days.
• Who should seek medical evaluation? Any child or adult whose symptoms are more severe than those outlined above should contact their doctor. Concerning symptoms include: fast breathing, trouble breathing, bluish or gray skin color, not drinking enough fluids, not urinating as much as usual, severe or persistent vomiting, not waking up or interacting as usual, being so irritable that the child does not want to be held, or fever returns after being absent for a day, or a significant change in the fever pattern occurs (e.g., it was 101°F for several days then becomes 103°F).
• Need for diagnosis: The CDC does not recommend routine testing for the H1N1 strain of the flu. Testing is only recommended for pregnant women and hospitalized patients. According to CDC guidelines, testing cannot be offered for the sole purpose of diagnosis, or for obtaining this information so that it can be posted in child-care settings.
• Need for treatment: Most children and adults infected with H1N1 recover on their own and do not need any treatment. The antivirals that are available for treatment are in short supply, and the CDC has strongly encouraged medical providers to reserve these medicines for the sickest patients (i.e., those who are hospitalized) or those at the highest risk for complications.
• Readmission criteria/infection control guidelines: Children (and staff) with a fever (>100.4°F) should be kept at home until they have gone without fever for 24 hours, without using any fever-reducing medicines such as Tylenol or ibuprofen (Motrin or Advil). This exclusion period is recommended regardless of whether antiviral medications are used. Because the fevers associated with H1N1 typically last 2 to 4 days, this period of confinement should typically last 3 to 5 days. In order to prevent further spread of the infection to others, it is very important for sick children and adults to remain at home, and not to go to public places such as schools, workplaces, shopping centers/grocery stores, libraries, and parks. If a child or staff member has recovered from the flu and fully satisfied the exclusion criteria (24 hours fever-free) s/he may return to work/school. According to CDC guidelines, it is NOT necessary to obtain a doctor’s note or excuse in order to be readmitted to child-care settings.
  

If you have any questions about this letter, please consult the websites listed in this letter. If you have additional questions, you may call 513-357-7499.

Sincerely,
Lawrence Holditch, M.D.
Medical Director, Cincinnati Health Department