Children's health: Schools' swine-flu scepticism to confine UK to sick bed?

4th September 2009 at 01:00
Health and education officials around the globe are gearing up for the return of the H1N1 virus, while the attitude at home appears increasingly cynical. But is there a risk of complacency? Helen Ward examines the prospects for a new autumnal outbreak

Original paper headline: Will schools' swine-flu scepticism confine the UK to its sick bed?

What would you expect to get on your first day at university? A timetable? A book list? Or perhaps a thermometer - just in case you get swine flu?

Welcome to Northeastern University, Boston, Massachusetts. It may be gimmicky, but Madeline Estabrook, director of health services, has certainly got her message across. She wants students to take swine flu seriously, and her concerns are not that unusual.

The H1N1 virus has swept the world. Now, as pupils return to schools across the northern hemisphere, authorities from the United States to India have called for teachers to instruct pupils in handwashing, while caretakers tour the corridors putting up hand-sanitising spray.

But in England, heads and teachers have received only an email from Schools Secretary Ed Balls, encouraging everyone to follow basic hygiene practices, while heads largely back the Government's low-key "keep calm and carry on" attitude.

"It's another thing to think about, but I don't think heads are losing sleep," said Mick Brookes, general secretary of the National Association of Head Teachers. "It is part of what they are paid for - dealing with the unexpected."

But the reopening of more than 23,000 schools in England and the mingling of eight million pupils who may have been exposed to the virus, whether they were in Slough or Santiago during the summer holidays, is being very closely scrutinised by health officials and academics. Their aim is not only to cope with the current situation, but to predict the future course of the disease.

Medical opinion is that there is likely to be a second wave of cases as children socialise again and the cold weather brings the usual rise in seasonal flu. But few think the second wave will be more virulent. New Scientist magazine asked 60 experts whether they thought the virus would mutate - none thought it was very likely, and only five thought it likely.

In most cases, the H1N1 virus causes a mild illness. It is unpleasant, with symptoms including fever, aching limbs and possibly vomiting, but most people recover within a week with relatively little medical intervention. But it can be far more serious. By the end of August, 57 people had died in England after contracting it, and 218 were treated in hospital.

Rapid spread

When the virus first emerged in Mexico at the beginning of April, it was not known how deadly the new strain would be. So on April 27, with more than 100 deaths being investigated, the Mexican government announced that all schools would be closed for a week to combat the spread. By the time schools reopened, the virus had been confirmed in 23 countries including the United States, Canada, France, Spain, South Korea, New Zealand, El Salvador, Guatemala and, of course, the UK.

Parts of the media predicted dozens of deaths a day and interest was running high. When the virus was detected in schools in England, journalists turned up en masse.

Chris Smith, head of Welford Primary School in Birmingham, where 44 cases were confirmed in a single day, described it as "a degree of hysteria". Jane English, principal of Paignton Community and Sports College, Devon, the first in England to close because of swine flu, said some of the coverage, particularly asking people to pose wearing face masks, was irresponsible.

Similarly, in Australia the virus escalated quickly. Mary Bluett, president of the Victoria branch of the Australian Education Union, said that, as in England, the first cases in schools led to them being shut for a week. Then, as it became clear that containment was no longer an option and that the virus was mild, only sick pupils stayed away.

"A Melbourne school was the centre of the first confirmed swine flu case," said Ms Bluett. "The media coverage was intense and intrusive for the families and the schools. It generated fear and, in hindsight, it was clear it was over the top. The media was sensationalist and unhelpful for schools, students and families dealing with an `unknown' disease. It created unnecessary fear in the community."


On June 11, the World Health Organization (WHO) announced that the situation was now a pandemic. As the virus became widespread, school closures were stopped. By now, everyone knew someone who had had the virus and it was the jokes that went viral - "I knew I had swine flu because I came out in rashers."

In England, the first wave of the virus peaked at the end of July, when in a single week 110,000 people were estimated to have caught it. In contrast, the last week of August saw only 5,000 new cases. Last term, the Daily Mail reported fears that there would be dozens of deaths a day in August, but when August came, so did the backlash. The paper of Middle England now reckoned the swine flu guidelines were becoming a "skivers' charter".

The backlash may be an understandable reaction to some overly melodramatic headlines, but there may be risks in becoming too sceptical.

The WHO found that winter in the southern hemisphere brought a rapid rise in pandemic influenza. At the end of August, Brazil's health ministry said Latin America's largest country had the world's highest swine flu death toll - 557 deaths, some 35 more than in the United States. Argentina, where the virus has killed 465 people, has the third-highest death toll.

As we draw nearer to winter, Sir Liam Donaldson, the chief medical officer, has said it is "virtually impossible" to predict accurately when a second wave will hit.

While school closures in England were halted as a preventative measure in May, they may have a role in reducing pressure on the health service in the coming months.

Dr Simon Cauchemez, of Imperial College London, is joint author of a paper on the effect of school closures, which appeared in the Lancet Infectious Diseases journal at the start of the summer break. The research found the main benefit of school closures was to reduce the number of people infected at the peak of the outbreak.

"We have a disease that may be mild, but because it is a new strain, a relatively substantial proportion of people do get infected," he said. "The key quantity here is not the proportion of cases that get sick, but the pressure on the healthcare system.

"There are some severe cases that need to be treated in hospital. If that number rises during the course of the pandemic to a point where a hospital finds it difficult to treat so many cases, that is where (pre-emptive) school closures might be useful."

Research fast-tracked

But these school closures will only work if children are kept apart while they are outside school. The Department of Health has fast-tracked research on whether this is likely.

Dr Ken Eames, of the London School of Hygiene and Tropical Medicine, has been given almost pound;70,000 for a two-part project to investigate what effect closing schools has on contact between children, and what, in turn, being ill has on contact between the patient and others. It could be that closing a school means the number of contacts - and potential infections - falls dramatically. But keeping children apart would need the cooperation of increasingly sceptical parents.

Dr Cauchemez said: "If people do not believe school closures will make any difference, they won't really care about isolating their children. If they do not believe, school closures will not have a significant impact."

Mr Brookes agrees. "Heads have to have the trust and confidence of their parents," he said. "You can't win them all, but you can make sure the rationale is open, well thought out and well communicated."

As schools in Scotland began their autumn term, all primaries were sent a hand-hygiene pack with activities for three- to six-year-olds, including a DVD cartoon, stickers and ideas for building the message into activities such as making soap.

One lesson from around the world is clear: combating swine flu will mean more than crossing your fingers.

Swine flu goes global


The virus originated in Mexico but the number of cases there has fallen. At the height of the crisis, restaurants, schools, businesses and public institutions were closed.


Schools, universities, cinemas, theatres and gymnasiums were closed. Pregnant women were told that they could take two weeks off work to avoid contracting the virus.


The outbreak is said to be putting strain on the health system. In some hospitals, elective surgery has been cancelled to reserve beds for swine flu cases.


Screening and medical checks at airports and rail stations are being used. Schools with infected pupils have been shut. Cinemas in Mumbai were temporarily closed. There has been some criticism of media coverage causing panic.

Pueblo City, Colorado, US

A perfect-attendance rewards programme in which students have the chance to win a car is being adjusted to ensure that those who contract the H1N1 virus are encouraged to stay at home and not spread the disease.

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