Effect of short-term school closures on the H1N1 pandemic in Japan: a comparative case study

Decisions and Influential Factors Regarding Class-Specific School Closures Against Seasonal Influenza Outbreak

Background One of the characteristics of school closure in Japan is class-specific school closure, which involves a reactive, short-term closure in the event of an infectious disease outbreak. These closures are implemented at each school in reaction to the annual seasonal influenza outbreaks. Very little research has addressed the formation of class-specific school closures to combat infectious diseases in elementary schools. We carried out a survey on factors involved in the decision to close classes and the determination of the timing and duration of class closures in elementary schools in Japan. Methods A mail-based questionnaire survey of elementary schools from four prefectures in western Japan was conducted between August and September 2021. The questions addressed the criteria for school closures (the timing and duration of class closure), various considerations, and confusion regarding class closures, with answers analyzed using descriptive statistical methods. Results In total, 714 elementary schools responded to the survey (37.9%). Furthermore, 398 (55.7%) schools established criteria for class closures during seasonal influenza. Class closure was most frequently initiated in schools with criteria when either 20% or 30% of class pupils were absent; the most common duration was three days. The duration of class closures was decided upon depending on the outbreak in some schools (69.8%), depending on the circumstances of the outbreak. Regarding class closure decisions, schools viewed school physicians' opinions as a priority, followed by school events, adjustments for Saturdays and Sundays, and Yogo teachers' opinions. Schools answering "no criteria for class closure" or "adjustments for Saturdays and Sundays" had difficulty determining class closure duration. Conclusion To guarantee the continuation of children's education and improve the effectiveness of preventive efforts against seasonal influenza, the following were considered important and helpful in class closure decision-making in elementary schools: scientific evidence, the school physician's opinion, and Yogo teachers' analysis of children's health information.

Taiwan's Response to Influenza: A Seroepidemiological Evaluation of Policies and Implications for Pandemic Preparedness

OBJECTIVES

To evaluate class suspension and mass vaccination implemented among Taipei schoolchildren during the 2009 influenza pandemic and investigate factors affecting antibody responses.

METHODS

We conducted 2 cohort studies on: (1) 972 schoolchildren from November 2009-March 2010 to evaluate pandemic policies and (2) 935 schoolchildren from November 2011-March 2012 to verify factors in antibody waning. Anti-influenza H1N1pdm09 hemagglutination inhibition antibodies (HI-Ab) were measured from serum samples collected before vaccination, and at 1 and 4 months after vaccination. Factors affecting HI-Ab responses were investigated through logistic regression and generalized estimating equation.

RESULTS

Seroprevalence of H1N1pdm09 before vaccination was significantly higher among schoolchildren who experienced class suspensions than those who did not (59.6% vs 47.5%, p<0.05). Participating in after-school activities (adjusted odds ratio [aOR]=2.47, p=0.047) and having ≥3 hours per week of exercise (aOR=2.86, p=0.019) were significantly correlated with H1N1pdm09 infection. Two doses of the H1N1pdm09 vaccine demonstrated significantly better antibody persistence than 1 dose (HI-Ab geometric mean titer: 132.5 vs 88.6, p=0.047). Vaccine effectiveness after controlling for preexisting immunity was 86% (32%-97%). Exercise ≥3 hours per week and preexisting immunity were significantly associated with antibody waning/maintenance.

CONCLUSIONS

This study is the first to show that exercise and preexisting immunity may affect antibody waning. Further investigation is needed to identify immune correlates of protection.

Allocation of scarce resources in a pandemic: rapid systematic review update of strategies for policymakers

OBJECTIVE

In pandemics like COVID-19, the need for medical resources quickly outpaces available supply. policymakers need strategies to inform decisions about allocating scarce resources.

STUDY DESIGN AND SETTING

We updated a systematic review on evidence-based approaches and searched databases through May 2020 for evaluation of strategies for policymakers.

RESULTS

The 201 identified studies evaluated reducing demand for healthcare, optimizing existing resources, augmenting resources, and adopting crisis standards of care. Most research exists to reduce demand (n = 149); 39 higher quality studies reported benefits of contact tracing, school closures, travel restrictions, and mass vaccination. Of 28 strategies to augment resources, 6 higher quality studies reported effectiveness of establishing temporary facilities, use of volunteers, and decision support software. Of 23 strategies to optimize existing resources, 12 higher quality studies reported successful scope of work expansions and building on existing interagency agreements. Of 15 COVID-19 studies, 5 higher quality studies reported on combinations of policies and benefits of community-wide mask policies.

CONCLUSION

Despite the volume, the evidence base is limited; few strategies were empirically tested in robust study designs. The review provides a comprehensive overview of the effects of strategies to allocate resources and provides critical appraisal to identify the best available evidence.

Experiences With COVID-19 Stressors and Parents' Use of Neglectful, Harsh, and Positive Parenting Practices in the Northeastern United States

OBJECTIVES

To estimate household exposure to COVID-19 related stress and the association with parent report of neglectful, harsh, and positive discipline practices.

METHODS

Cross sectional survey data was collected from 2,068 parents in the Northeastern US. Parents reported personal and household experiences of COVID-19 stressors, their level of distress, and use of neglectful parenting and discipline practices for a randomly selected child in their home. Analyses estimated rates of COVID-19 related stress and parenting practices. Logistic regression was used to assess the relation of COVID-19 stress to parenting behaviors.

RESULTS

Individual and household stressor level, as well as distress were each positively associated with likelihood of neglect. Personal exposure to stressors was minimally related to discipline, but household stressor level and parents' distress were positively associated with harsh and positive discipline.

DISCUSSION

Indicators of COVID-19 stress (e.g., exposure to stressors and distress) each uniquely predicted parents' use of neglect, particularly physical and family-based sub-types, and use of harsh and positive discipline practices. Results suggest that parents may require additional support to provide appropriate care for their children while coping with the increased rates of stress associated with the pandemic and the resulting public health response.

School closure in response to epidemic outbreaks: Systems-based logic model of downstream impacts

Background: School closures have been a recommended non-pharmaceutical intervention in pandemic response owing to the potential to reduce transmission of infection between children, school staff and those that they contact. However, given the many roles that schools play in society, closure for any extended period is likely to have additional impacts. Literature reviews of research exploring school closure to date have focused upon epidemiological effects; there is an unmet need for research that considers the multiplicity of potential impacts of school closures. Methods: We used systematic searching, coding and synthesis techniques to develop a systems-based logic model. We included literature related to school closure planned in response to epidemics large and small, spanning the 1918-19 'flu pandemic through to the emerging literature on the 2019 novel coronavirus. We used over 170 research studies and a number of policy documents to inform our model. Results: The model organises the concepts used by authors into seven higher level domains: children's health and wellbeing, children's education, impacts on teachers and other school staff, the school organisation, considerations for parents and families, public health considerations, and broader economic impacts. The model also collates ideas about potential moderating factors and ethical considerations. While dependent upon the nature of epidemics experienced to date, we aim for the model to provide a starting point for theorising about school closures in general, and as part of a wider system that is influenced by contextual and population factors. Conclusions: The model highlights that the impacts of school closures are much broader than those related solely to health, and demonstrates that there is a need for further concerted work in this area. The publication of this logic model should help to frame future research in this area and aid decision-makers when considering future school closure policy and possible mitigation strategies.

The Effect of School Closure on Hand, Foot, and Mouth Disease Transmission in Singapore: A Modeling Approach

Singapore implements a school closure policy for institutional hand, foot, and mouth disease (HFMD) outbreaks, but there is a lack of empirical evidence on the effect of closure on HFMD transmission. We conducted a retrospective analysis of 197,207 cases of HFMD over the period 2003–2012 at the national level and of 57,502 cases in 10,080 institutional outbreaks over the period 2011–2016 in Singapore. The effects of school closure due to 1) institutional outbreaks, 2) public holidays, and 3) school vacations were assessed using a Bayesian time series modeling approach. School closure was associated with a reduction in HFMD transmission rate. During public holidays, average numbers of secondary cases having onset the week after dropped by 53% (95% credible interval 44–62%), and during school vacations, the number of secondary cases dropped by 7% (95% credible interval 3–10%). Schools being temporarily closed in response to an institutional outbreak reduced the average number of new cases by 1,204 (95% credible interval 1,140–1,297). Despite the positive effect in reducing transmission, the effect of school closure is relatively small and may not justify the routine use of this measure.

The impact of hand, foot and mouth disease control policies in Singapore: A qualitative analysis of public perceptions

Hand foot and mouth disease (HFMD) is a widespread pediatric disease in Asia. Most cases are relatively mild and caused by Coxsackie viruses, but in epidemics caused by Enterovirus 71, severe complications can occur. In response to the deaths of dozens of children in a 1997 outbreak (Podin in BMC Public Health 6:180,1 Abubakar in Virus Res 61(1):1-9,2 WHO in3), Singapore practices childcare centre surveillance, case-isolation, and short-term closure of centres. We conducted 44 in-depth interviews with teachers, principals, and parents at four childcare centres in Singapore to better understand experiences with current control policies. We used applied thematic analysis to identify recurrent and unique themes. Participants were conflicted by perceiving HFMD as a severe illness and reported a sense of helplessness when hygiene and social-isolation efforts failed. They perceived that severity of HFMD influenced Singapore's choice of existing policies despite a lack of evidence of their effectiveness. Documenting stakeholders' perspectives clarifies the impact of control measures and how to communicate policy changes.

Evidence compendium and advice on social distancing and other related measures for response to an influenza pandemic

The role of social distancing measures in mitigating pandemic influenza is not precisely understood. To this end, we have conducted a systematised review, particularly in light of the 2009 pandemic influenza, to better inform the role of social distancing measures against pandemic influenza. Articles were identified from relevant databases and the data were synthesised to provide evidence on the role of school or work place-based interventions, case-based distancing (self-isolation, quarantine), and restriction of mobility and mass gatherings. School closure, whether proactive or reactive, appears to be moderately effective and acceptable in reducing the transmission of influenza and in delaying the peak of an epidemic but is associated with very high secondary costs. Voluntary home isolation and quarantine are also effective and acceptable measures but there is an increased risk of intra-household transmission from index cases to contacts. Work place-related interventions like work closure and home working are also modestly effective and are acceptable, but likely to be economically disruptive. Internal mobility restriction is effective only if prohibitively high (50% of travel) restrictions are applied and mass gatherings occurring within 10 days before the epidemic peak are likely to increase the risk of transmission of influenza.

Role of household factors in parental attitudes to pandemic influenza-related school closure in Japan: a cross-sectional study

Background

To investigate how household background factors affect parental behavior during pandemic influenza-related school closures, we determined associations between such factors and three parental attitudes: “caring for the child”, “taking leave from work”, and “permitting out-of-home activities”.

Methods

A hypothetical pandemic influenza situation was presented and a questionnaire survey among households of 2146 schoolchildren from 6 schools was conducted. Odds ratios of background factors were estimated using univariate and multivariate logistic regression models.

Results

Responses pertaining to 1510 children indicated that junior high school (OR = 0.11), both parents working (OR = 0.03), and family including grandparent(s) or other relatives (OR = 7.50) were factors associated with “caring for the child”, and elementary school (OR = 2.28), special education school (OR = 3.18), and both parents working (OR = 5.74) were associated with “taking leave from work”. Having an older sibling (OR = 0.74) and awareness of the technical term for school closure (OR = 0.73) were factors associated with “permitting out-of-home activities”.

Conclusion

Not only work status but also other household factors may be associated with parental behaviors during pandemic influenza-related school closures.

Evaluation of the spread of pandemic influenza A/H1N1 2009 among Japanese university students

The pandemic influenza A/H1N1 2009 virus is commonly known to affect younger individuals. Several epidemiological studies have clarified the epidemic features of university students in Japan. In this study, we reviewed these studies in Japan in comparison with reports from other countries. The average cumulative incidence rate among university students was 9.6 %, with the major symptoms being cough, sore throat, and rhinorrhea. These epidemiological features were similar between Japan and other countries. Attitudes and behaviors toward pandemic influenza control measures were different before and improved during and after the epidemic. These features were also similar to those in other countries. On the other hand, the epidemic spread through club activities or social events, and transmission was attenuated after temporary closure of such groups in Japan. This transmission pattern was inconsistent among countries, which may have been due to differences in lifestyle and cultural habits. Based on these results, infection control measures of pandemic influenza for university organizations in Japan should be considered.

Evaluation of factors affecting variations in influenza A/H1N1 history in university students, Japan

Although the natural history of H1N1 has been found to vary among patients, little is known about the factors that affect these variations. Infected patients with an extended infection history may shed virus longer and spread infection. To further clarify these variations, we evaluated the natural history of H1N1 infection in 324 university students using a descriptive epidemiological method and analyzed factors affecting the natural history of infection. The median times from infection to fever development and from fever development to cure were 2 days (range 0-8 days) and 5 days (range 1-12 days), respectively, and the median time not attending classes was 5 days (range, 1-13 days). Variations in H1N1 natural history were associated with both environmental and individual factors, including route of infection, grade, gender, epidemic period, respiratory and gastrointestinal symptoms and headache. Steps affecting these factors may help control variations in H1N1 natural history and may enhance infection control measures.

[Effects of school closure during influenza A/H1N1 pandemic in 2009 in Japan]

Schools were closed worldwide during the 2009 influenza A/H1N1 pandemic to prevent the viral spread; however, to date, there has been insufficient evidence to conclude that the closures were beneficial. Therefore, in the present review, we evaluated the effects of school closure during the 2009 influenza A/H1N1 pandemic in Japan. A search of PubMed and Japanese journals identified 24 articles that evaluated the effects of school closure using the following methods: descriptive epidemiology, changes in absenteeism rate, a simulation model, and reproductive number. Almost all of the retrieved studies showed that school closure effectively reduced the number of new infections and thus subsequently suppressed the epidemic. On the other hand, two major sets of confounding variables were identified. First, the effect of school closure was confounded by the methods used to measure, viral infectivity, subject characteristics, increased immunization rates, nonpharmaceutical interventions, antiviral administration, student contact patterns during school closure, and individual household environments. Secondly, school closure implementation was affected by differences between proactive and reactive closures, differences between seasonal and pandemic influenza, decision factors regarding school closure, socioeconomic cost, and ethics of imposing restrictions on individuals. Therefore, a comprehensive, longitudinal study is necessary to clarify the effects of school closure during viral pandemics.