This document provides guidance to help decrease the spread of flu among students, faculty, and staff of institutions of higher education (IHE) and post-secondary educational institutions during the 2009-2010 academic year. The guidance expands upon earlier guidance for these settings by providing a menu of tools that IHE and health officials can choose from based on conditions in their area. It recommends actions to take now (during this academic year), suggests strategies to consider if the flu starts causing more severe disease than during the spring/summer 2009 H1N1 outbreak, and provides a checklist for making decisions. Detailed information on the reasons for these strategies and suggestions on how to use them is included in the Technical Report. Based on the severity of 2009 H1N1 flu-related illness thus far, this guidance also recommends that students, faculty, and staff with flu-like illness remain home until 24 hours after resolution of fever without the use of fever-reducing medications. For the purpose of this guidance, IHE will refer to public and private, residential and nonresidential, degree-granting and non-degree-granting institutions providing post-secondary education in group settings regardless of the age of their students. Portions of this guidance pertaining to dormitories and residence halls may serve as a useful supplement to residential (boarding) schools providing primary and secondary education, with adaptations as needed for their younger population. This guidance represents the CDC’s current thinking on this topic. It does not create or confer any rights for or on any person or operate to bind the public.

IHEs should tailor the guidance to account for the size, diversity, and mobility of their students, faculty, and staff; their location and physical facilities; programs; and student and employee health services. Decisions about strategies should balance the goal of reducing the number of people who become seriously ill or die from flu with the goal of minimizing educational and social disruption.

Although the severity of flu outbreaks during the fall and winter of 2009-10 is unpredictable, more communities may be affected than were affected in spring/summer 2009, reflecting wider transmission and possibly greater impact. CDC is working with state and local health departments to continually monitor the spread of flu, the severity of the illness it is causing, and changes to the virus. If this information indicates that flu is causing more severe disease than during the spring/summer 2009 H1N1 outbreak, or if other developments require more aggressive mitigation measures, CDC may recommend additional strategies. Since severity may vary from community to community, IHEs should also look to their state and local health officials for information and guidance specific to their location.

The recommendations below are divided into two groups: 1) recommendations to use now, during this academic year, assuming a similar severity to the spring/summer H1N1 flu outbreak, and 2) recommendations to consider adding if the flu begins to cause more severe disease. 

Recommended responses to influenza for the 2009 – 2010 academic year

Recommended strategies under current flu conditions
(similar severity as in Spring/Summer 2009)

Facilitate self-isolation of residential students with flu-like illness

• Those with flu-like illness should stay away from classes and limit interactions with other people (called “self-isolation”), except to seek medical care, for at least 24 hours after they no longer have a fever, or signs of a fever, without the use of fever-reducing medicines. Some people with influenza will not have fever; therefore, absence of fever does not mean absence of infection. They should stay away from others during this time period even if they are taking antiviral drugs for treatment of the flu. (For more information, visit http://www.cdc.gov/h1n1flu/guidance/exclusion.htm .)
• Review and revise, as needed, policies, such as student absenteeism policies and sick leave policies for faculty and staff, that make it difficult for students, faculty, and staff to stay home when they are ill or to care for an ill family member,. Do not require a doctor’s note to confirm illness or recovery. Doctor’s offices may be very busy and may not be able to provide such documentation in a timely way.
• If possible, residential students with flu-like illness who live relatively close to the campus should return to their home to keep from making others sick. These students should be instructed to do so in a way that limits contact with others as much as possible. For example, travel by private car or taxi would be preferable over use of public transportation.
• Students with a private room should remain in their room and receive care and meals from a single person. Students can establish a “flu buddy scheme” in which students pair up to care for each other if one or the other becomes ill. Additionally, staff can make daily contact by e-mail, text messaging, phone calls, or other methods with each student who is in self-isolation.
• If close contact with others cannot be avoided, the ill student should be asked to wear a surgical mask during the period of contact. Examples of close contact include kissing, sharing eating or drinking utensils, or having any other contact between persons likely to result in exposure to respiratory droplets.
• For those who cannot leave campus, and who do not have a private room, IHEs may consider providing temporary, alternate housing for ill students until 24 hours after they are free of fever.
• Instruct students with flu-like illness to promptly seek medical attention if they have a medical condition that puts them at increased risk of severe illness from flu, are concerned about their illness, or develop severe symptoms such as increased fever, shortness of breath, chest pain or pressure, or rapid breathing.

Promote self-isolation at home by non-resident students, faculty, and staff

• Non-residential students, faculty, and staff with flu-like illness should be asked to self-isolate at home or at a friend’s or family member’s home until at least 24 hours after they are free of fever, or signs of a fever, without the use of fever-reducing medicines.
• Review, and revise if needed, sick leave policies to remove barriers to faculty and staff staying home when they are ill or caring for an ill family member. For students, consider altering policies on missed classes and examinations and late assignments so that students’ academic concerns do not prevent them from staying home when ill or prompt them to return to class or take examinations while still symptomatic and potentially infectious.
• Do not require a doctor’s note for students, faculty, or staff to validate their illness or to return to work, as doctor’s offices and medical facilities may be extremely busy and may not be able to provide such documentation in a timely way.  
• Distance learning or web-based learning may help students maintain self-isolation.  
• Visit http://www.cdc.gov/h1n1flu/guidance/exclusion.htm for more information on staying home while sick.

Considerations for high-risk students and staff

• People at high risk for flu complications who become ill with flu-like illness should speak with their health care provider as soon as possible. Early treatment with antiviral medications often can prevent hospitalizations and deaths. Groups that are at higher risk of complications from flu if they get sick include: children younger than age 5; people age 65 or older; children and adolescents (younger than age 18) who are receiving long-term aspirin therapy and who might be at risk for experiencing Reye’s syndrome after flu virus infection; pregnant women; adults and children who have asthma, other chronic pulmonary, cardiovascular, hepatic, hematological, neurologic, neuromuscular, or metabolic disorders such as diabetes; and adults and children with immunosuppression (including immunosuppression caused by medications or by HIV). People age 65 and older, however, appear to be at lower risk of 2009 H1N1 infection compared to younger people. But, if older adults do get sick from flu, they are at increased risk of having a severe illness.
• One of the best ways to protect against the flu is to get vaccinated against the flu. People under age 25 are one of the key groups recommended by CDC’s Advisory Committee on Immunization Practices (ACIP) to be among the first to receive the 2009 H1N1 flu vaccine. For more information, visit http://www.cdc.gov/h1n1flu/vaccination.
• Communicate with local health officials to determine where vaccine will be administered and to discuss the possibility of a vaccination clinic at the IHE.

Discourage campus visits by ill persons: Use a variety of communication methods such as e-mail, posters, flyers, and media coverage to discourage people with flu-like illness from visiting the campus or attending IHE events such as football games or concerts until they have been free of fever for at least 24 hours.

Encourage hand hygiene and respiratory etiquette of both people who are well and those that have any symptoms of flu:  Emphasize the importance of the basic foundations of flu prevention: stay home when sick, wash hands frequently with soap and water when possible, and cover noses and mouths with a tissue when coughing or sneezing (or a shirt sleeve or elbow if no tissue is available).

Routine cleaning

• Establish regular schedules for frequent cleaning of high-touch surfaces (for example, bathrooms, doorknobs, elevator buttons, and tables).
• Provide disposable wipes so that commonly used surfaces (for example, doorknobs, keyboards, remote controls, desks) can be wiped down by students before each use.
• Encourage students to frequently clean their living quarters, including high-touch surfaces.

Considerations for specific student populations

• Review policies for study abroad programs, including accessing health services abroad and reporting illness to the IHE.
• Communicate plans, policies, and strategies to partner K-12 schools regarding “early/middle college” students, prospective student tours, and other K-12 students regularly on campus.
• Determine if special communication strategies are needed to meet the needs of students with disabilities.
• Remind health-care profession students to follow infection control guidance for health-care workers. Visit http://www.cdc.gov/h1n1flu/clinicians for guidance for health care settings.

Under conditions with increased severity compared to spring/summer 2009

CDC may recommend additional strategies to help protect IHE students, faculty, and staff if global, national, or regional assessments indicate that flu is causing more severe disease. In addition, local health or IHE officials may choose to use additional strategies. Although the following strategies have not been scientifically tested in the IHE setting, they are grounded on basic principles of infection control. Implementing these strategies is likely to be more difficult and to have more disruptive effects than the previously described strategies. These strategies should be considered if influenza severity increases and are meant for use in addition to the strategies outlined above.

Permit high-risk students, faculty, and staff to stay home when flu is spreading in the community

• If flu severity increases, people at high risk of flu complications may consider staying home while a lot of flu is circulating in their community. Such people should make this decision after consulting with their doctor. 
• IHEs should plan now for ways to continue educating students who stay home through distance learning methods. IHEs should also examine policy accommodations that might be necessary such as allowing high-risk students to withdraw for the semester, tailoring sick leave policies to address the needs of faculty and staff, or modifying work responsibilities and locations.

Increase social distances:

• Explore innovative ways to increase the distances between students (for example, moving desks apart or using distance learning methods). Ideally, there should be at least 6 feet between people at most times. 
• Consider whether to suspend or modify public events such as films, sporting events, or commencement ceremonies.

Extend the self-isolation period: If flu severity increases, people with flu-like illness should stay home for at least 7 days after the onset of their symptoms, even if they have no more symptoms. If people are still sick after 7 days, they should stay home until 24 hours after they have no symptoms. See information above for self-isolation in different types of housing.

Consider suspending classes

• IHE and health officials should work closely to balance the risks of flu in their community with the disruption that suspending classes will cause in both education and the wider community.
• Use multiple channels to communicate a clear message about the reasons for suspending classes and the implications for students, faculty, staff, and the community.
• Reactive class suspension might be needed when IHEs cannot maintain normal functioning.
• To decrease the spread of flu, CDC may recommend preemptive class suspension if the flu starts to cause severe disease in a significantly larger proportion of those affected than occurred during the spring/summer 2009 outbreak.
• If classes are suspended preemptively, large gatherings (for example, sporting events, dances, commencement ceremonies) should be cancelled or postponed.
• IHEs with only nonresidential students should consider whether they can allow faculty and staff to continue use of their facilities while classes are not being held. This may allow faculty to develop lessons and materials and engage in other essential activities.
• IHEs with residential students should plan for ways to continue essential services such as meals, custodial services, security, and other basic operations for students who remain on campus. When possible, dismiss students who can get home – or to the home of a relative, friend of the family, or host family – by private car or taxi. International students and others without easy access to alternative housing should stay on campus, but increase the distance between people as much as possible.
• The length of time classes should be suspended will vary depending on the goal of class suspension as well as the severity and extent of illness. IHEs that suspend classes should do so for at least five to seven calendar days. Before the end of this period, the IHE, in collaboration with public health officials, should reassess the epidemiology of the disease and the benefits and consequences of continuing the suspension or resuming classes.  

Deciding on a course of action
CDC recommends a combination of strategies applied early and simultaneously. Strategies should be selected a) based on trends in the severity of disease, virus characteristics, feasibility, and acceptability and b) through collaborative decision-making with public health agencies, IHE faculty and staff, students, students’ families, and the wider community. CDC and its partners will continuously look for changes in the severity of flu-like illness and will share what is learned with state and local agencies. However, states and local communities can expect to see a lot of differences in disease patterns from community to community.

Every IHE has to balance a variety of objectives to determine the best course of action to help decrease the spread of flu. Decision-makers should identify and communicate their objectives, which might be one or more of the following: (a) protecting overall public health by reducing community transmission; (b) reducing transmission in students, faculty, and staff; and (c) protecting people with high-risk conditions. Some strategies can have negative consequences in addition to their potential benefits. The following questions can help begin discussions and lead to decisions.

Decision-Makers and Stakeholders
Are all of the right decision-makers and stakeholders involved?

• Local and state health, education, and homeland security agencies
• Campus health services and mental health services
• Campus emergency managers and security staff
• Student affairs and residential life staff
• Communications staff
• Physical plant staff
• Food services staff
• Students
• Faculty
• Community representatives
• Students’ families

Information Collection and Sharing
Can local or state health officials determine and share information about the following?

• Numbers of and trends in outpatient visits, hospitalizations, and deaths for flu-like illness
• Percent of hospitalized patients requiring admission to intensive care units (ICUs)
• Groups being disproportionately affected
• Ability of local health care providers and emergency departments to meet increased demand
• Availability of antiviral drugs, hospital beds, staff, ICU space, and ventilators for flu patients

What does the IHE know about the following?

• Student, faculty, and staff absenteeism rates
• Number of visits to the campus health service
• Bed availability for student self-isolation
• Severity of illness among affected staff and/or students

Feasibility
Do you have the resources to implement the strategies being considered?

• Funds
• Personnel
• Equipment
• Space
• Time
• Legal authority or policy requirements
• Communication channels

Acceptability
Have you determined how to address the following challenges to implementing the strategies?

• Public concern about flu
• People who do not feel empowered to protect themselves
• Lack of public support for the strategy
• Secondary effects of strategies (for example, job security, financial support, health service access, and educational progress)