Questions and Answers about CDC’s Guidance on Helping Child Care and Early Childhood Programs Respond to Flu during the 2009-2010 Flu Season

February 17, 2009 1:00 PM ET

About the Guidance for Child Care and Early Childhood Programs

How does CDC’s new guidance differ from the previous guidance for early childhood programs?
This new guidance applies to any flu virus circulating during the 2009-2010 flu season, including seasonal and 2009 H1N1 flu. It recognizes the need to balance the risks of illness among children and early childhood program staff in center- and home-based early childhood programs, Head Start programs, and other early childhood programs with the benefits of keeping children in early childhood programs.  It offers specific steps for early childhood program providers and parents to take given the current flu conditions as well as for more severe flu conditions. The new guidance also provides information for making decisions at the community level about when to use these strategies aimed at early childhood programs.

In addition, this guidance recommends that, based on current flu conditions, early childhood program staff and children with flu-like illness stay home until at least 24 hours after they no longer have a fever (100 degrees Fahrenheit or 37.8 degrees Celsius measured by mouth) or signs of a fever (have chills, feel very warm, have a flushed appearance, or are sweating). This should be determined without the use of fever-reducing medicines (any medicine that contains ibuprofen or acetaminophen). This is a shorter time period from the previous guidance which recommended that sick early childhood program providers and children stay home 7 days after symptoms begin. The 7 day period away from early childhood programs for sick children and early childhood program providers would still be recommended under more severe flu conditions. 

How is the term “early childhood program” used in this guidance?
For the purpose of this guidance, “early childhood program” refers to any setting that involves care for a group of young children, such as center- or home-based early childhood programs, Head Start programs, and other early childhood programs. This guidance applies to the whole early childhood program including services for older children.

Why should early childhood programs be concerned about the flu?
Children under the age of 5 are at higher risk for complications from flu, and severe flu complications are most common in children younger than 2 years old. Infants younger than 6 months old are a particularly vulnerable group because they are too young to get the seasonal flu or 2009 H1N1 flu vaccine.

So far, with 2009 H1N1 flu, the highest number of cases has been in people between the ages of 5 and 24 years old. Some early childhood programs provide after school programs to children in this age group. The second highest number of cases of 2009 H1N1 flu has been in children younger than 5 years old. 

How will CDC help early childhood programs and communities decide what steps to take?
CDC and other public health agencies will be monitoring national data on the number of people seeking care for flu-like illness. CDC will also look at the geographic spread of flu-like illness and changes in the virus. By comparing data with historical seasonal flu trends and trends during the H1N1 flu conditions from April through December 2009, CDC will be able to provide advice to state and local agencies on appropriate steps to take. Since the impact of flu in fall and winter 2009-2010 will likely vary from community to community, early childhood program providers should check with state and local health officials for information and guidance specific to their location.

State and local public health officials will work with community partners to consider:

• who needs to be involved in the decision-making process, and include those people in regular communications,
• severity of the flu and its impact in the community and early childhood programs,
• capacity of the healthcare system to respond to local outbreaks, and
• the goals, feasibility, and community’s acceptability of action steps being considered.

Steps for Early Childhood Programs to Help Prevent the Spread of Flu during Current Flu Conditions

What steps can early childhood programs take to keep children and program staff healthy?

• Encourage all early childhood program staff to get vaccinated for seasonal flu and 2009 H1N1 flu according to CDC recommendations. Most staff who work in early childhood program settings are in the primary target group for vaccination. Also encourage parents to get their children vaccinated. For more information about primary target groups for vaccination, visit www.cdc.gov/h1n1flu/vaccination/acip.htm and www.cdc.gov/flu/protect/keyfacts.htm.

• Encourage early childhood program staff to stay at home if they are sick with flu-like illness. Ask parents to keep children home if they are sick. Staff and children should stay home until they are free of fever (100 degrees Fahrenheit or 37.8 degrees Celsius measured by mouth) for at least 24 hours, without the use of fever-reducing medicines.
• Conduct a daily health check of children and staff. Watch children and staff for signs of illness. If they are sick, take their temperatures and ask about symptoms.
• Move children and staff who become sick at the early childhood program to a separate, supervised, space which separates them from others by at least 6 feet until they can be sent home. Limit the number of staff who take care of the sick person and provide a surgical mask to sick staff members to wear if they can tolerate it. Visit www.cdc.gov/h1n1flu/guidance_homecare.htm for more information on caring for someone who is sick.
• Encourage respiratory etiquette by providing staff and children
• education and reminders about covering coughs and sneezes, and
• easy access to tissues and trash cans.
• Remind staff and children to practice good hand hygiene and provide the time and supplies (such as running water, soap, and paper towels) for children and staff to wash their hands.
• Routinely clean surfaces and items that children frequently touch with their hands or mouths, or that come in contact with their body fluids. Wipe these surfaces with a household disinfectant that is usually used, following the directions on the product label. Additional disinfection of these surfaces beyond routine cleaning is not recommended.
• Communicate and instruct staff and parents of children in early childhood programs to get medical care for themselves or for their children immediately if they get sick and are at higher risk of flu complications, are concerned about their illness, or develop severe symptoms. Early treatment with flu antiviral medicines can decrease the risk of severe illness from flu.
• Consider closing the early childhood program if flu transmission is high in the community. Work closely with local public health officials to decide if the early childhood program should be closed temporarily.

What can an early childhood program do to prepare for flu response during the 2009-2010 flu season?

• Examine and revise, as needed, current flu (or crisis) response plans.
• Update contact information for parents so they can be easily contacted if they need to pick up their sick child.
• Be aware if a child in their care has an underlying health condition that would put the child at particularly high risk of flu complications.
• Develop contingency plans to cover key positions when staff are sick or caring for family members at home.
• Identify and establish a point of contact with the local public health agency.
• Set up a separate space for care of sick students or staff which will separate them from others by at least 6 feet until they can be sent home.
• Display and distribute educational materials to encourage hand hygiene and respiratory etiquette. See tools available at www.flu.gov.
• Help families and communities understand the important roles they can play in reducing the spread of flu.
• Encourage parents to plan for alternate child care in case the early childhood program closes. 

What is a daily health check?
Early childhood programs should perform a daily health check for all children and staff upon or soon after arriving at the facility. The purpose of the daily health check is to observe and assess the child’s overall health. Trained and experienced early childhood program providers can be a valuable resource to parents, especially new parents who may not recognize their child is sick and should be examined by a pediatric health care provider. Young children may not be able to communicate that they are not feeling well.
The daily health check should consist of watching the child and talking with parent and child.
During the daily health check the early childhood program provider should look for:

• a change in the child’s behavior (crankiness, unusual crying, decreased appetite, or a lack of interest in playing),
• a report of illness in the child or family member,
• a report of a recent visit to a health care provider by the child or family member, and
• any signs or symptoms of flu: feeling warm to the touch, fever, cough, sore throat, runny or stuffy nose, body aches, headache, chills and tiredness. Some people may also have vomiting and diarrhea. People may be infected with the flu, including 2009 H1N1 flu, and have respiratory symptoms without a fever. 

An example of how to perform daily health checks can be found at: www.bmcc.edu/Headstart/Trngds/Diseases/pg91-108.htm

What can early childhood program providers and parents do to help young children wash their hands?
Early childhood program providers should

• provide enough time for all children and staff to wash their hands whenever needed;
• have soap, running water, paper towels, and a trash can that is easy to reach; and
• educate families, children, and staff about the importance of and proper methods for cleaning hands. 

Parents and early childhood program providers must wash the hands of children who cannot yet wash themselves, and closely monitor children who have not yet mastered proper hand hygiene.
For example, when teaching young children how to wash their hands:

• turn on the water;
• wet their hands;
• apply a good amount of soap and lather up;
• focus on having them wash their hands for about 20 seconds—about the time it takes to sing "Happy Birthday" twice;
• wash the front of the hands, the back, in between the fingers, around the nails, and then rinse everything off; and
• wipe their hands dry—preferably with something disposable such as a paper towel, and then use that to turn off the tap.

Visit www.cdc.gov/cleanhands for more information on hand hygiene.

What steps should be followed in early childhood program settings when soap and running water are not available?
When soap and running water are not available (such as during a field trip) use an alcohol-based hand rub.
However, some places may not allow alcohol-based hand rubs in early childhood program settings because they can be toxic if swallowed. If alcohol-based hand rubs are used, they should be kept in a location that children cannot reach, but adults can access when they need to dispense it.

Can the virus live on surfaces, such as toys, cots, or playground equipment?

• Yes, flu viruses may be spread when a child touches droplets left by coughs and sneezes on hard surfaces (such as doorknobs or tables) or objects (such as toys or markers) and then touches his or her mouth or nose. However, it is not necessary to disinfect these surfaces beyond routine cleaning.
• Clean surfaces and items that are more likely to have frequent hand or mouth contact with cleaning agents that are usually used in these areas. Some states and localities have laws about specific cleaning products used in early childhood programs. Early childhood program providers should contact their state health department and department of environmental protection for additional guidance.

What can families do to keep their children and others from getting sick and spreading flu?
Families can keep from getting sick with flu in four ways:

• Getting children from 6 months-5 years of age vaccinated for seasonal flu and 2009 H1N1 flu. People who care for a child younger than 6 months old also should be vaccinated. Vaccines should be considered for anyone who is at higher risk for complications from seasonal flu or 2009 H1N1 flu. For more information about primary target groups for vaccination, visit www.cdc.gov/h1n1flu/vaccination/acip.htm and www.cdc.gov/flu/protect/keyfacts.htm
• Practicing good hand hygiene. Wash your hands often with soap and water, especially after coughing or sneezing. Help your children wash their hands.
• Practicing respiratory etiquette.  The main way that the flu is thought to spread is from person to person in the droplets produced by coughs and sneezes, so it’s important to cover your mouth and nose with a tissue when you cough or sneeze.  If you don’t have a tissue, cough or sneeze into your elbow or shoulder, not into your hands. Teach your children how to do this.
• Staying home if you’re sick. Keeping sick children at home means that they keep their viruses to themselves rather than sharing them with others.

Families must take personal responsibility for helping to slow the spread of the virus by practicing these steps to keep from getting sick with flu and protecting others from getting the flu.

Should our early childhood program require a note from a health care provider to allow children who have been sick to return to the program?
No, a note from a health care provider’s office or health care provider should not be required. Health care facilities may be very busy during flu season and it will be hard to provide these notes. Under current flu conditions, if a child has symptoms of flu they should stay home until they are free of fever (100 degrees Fahrenheit or 37.8 degrees Celsius measured by mouth) for at least 24 hours, without the use of fever-reducing medicines. This is usually about 3 to 5 days.
Under more severe flu conditions, children with symptoms of flu should stay home for at least 7 days, even if symptoms go away sooner. People who are still sick after 7 days should continue to stay home until at least 24 hours after symptoms have gone away.

Does a staff member need a note from their health care provider to prove that they are sick and need to stay home or that they are healthy and can return to the early childhood program?
No, a note from a health care provider’s office or health care provider should not be required. Health care facilities may be very busy during flu season and it will be hard to provide these notes. Under current flu conditions, if a staff member has symptoms of flu they should stay home until they are free of fever (100 degrees Fahrenheit or 37.8 degrees Celsius measured by mouth) for at least 24 hours, without the use of fever-reducing medicines. This will usually be about 3 to 5 days.
Under more severe flu conditions, staff with symptoms of flu should stay home for at least 7 days, even if symptoms go away sooner. People who are still sick after 7 days should continue to stay home until at least 24 hours after symptoms have gone away.

What should parents do if there is a case of 2009 H1N1 flu in their early childhood program?
Early childhood programs can be challenging places to prevent the spread of flu. Young children are vulnerable to infections and are at higher risk for complications from flu. Children are in constant contact with one another, sharing toys and other items. It is also hard for children to understand and practice good hand washing and covering of coughs and sneezes. It is not possible to completely prevent the spread of infectious diseases, like flu, in early childhood program settings. No policy can keep everyone who is infectious out of these settings. Parents should watch their children carefully for signs and symptoms of flu and keep them home if they become sick.

Adults and Children at Higher Risk for Complications

Which children and staff are at higher risk for complications from flu?
Anyone (even healthy people) can get the flu (seasonal and 2009 H1N1), and anyone can have serious problems from the flu.  Some groups are at higher risk for complications from the flu. These include children younger than 5 years of age (children in early childhood programs are usually in this age group), pregnant women, people of any age with chronic health conditions (such as asthma, diabetes, or heart disease) and people 65 years of age and older. Among children younger than 5 years old, the risk for severe complications from flu is highest among children younger than 2 years old.

Who should receive a flu vaccination?
As always, vaccines will be available this year to protect against seasonal flu. Children 6 months through 18 years of age, people of any age with certain chronic medical conditions (such as asthma, heart disease, or diabetes), and everyone age 50 and older should be vaccinated against seasonal flu as early as possible. Information about seasonal flu vaccine can be found at: www.cdc.gov/flu/protect/keyfacts.htm.

Certain groups are at higher risk for flu-related complications and are recommended to get the 2009 H1N1 vaccination. These people include: children younger than 5 years old, but especially children younger than 2 years old; people aged 65 years or older; pregnant women; adults and children who have asthma, neurological and neurodevelopmental conditions; chronic lung disease; heart disease; blood disorders; endocrine disorders, such as diabetes; kidney, liver, and metabolic disorders; weakened immune system due to disease or medication; and people younger than 19 years of age who are receiving long-term aspirin therapy. Due to increased vaccine availability, everyone, including those over 65 years, can now be vaccinated. For more information on people at higher risk for flu complications, visit http://www.cdc.gov/h1n1flu/highrisk.htm.

What actions should pregnant staff take to protect themselves from the flu?
Pregnant women should follow the same guidance as the general public related to staying home when sick, hand hygiene, respiratory etiquette, and routine cleaning. 
Pregnant women should know that they are a primary target group to receive the 2009 H1N1 flu vaccine. Seasonal flu vaccine is also recommended for pregnant women and can be given at any time during pregnancy.
Pregnant women are at higher risk of complications from flu and, like all people at higher risk, should speak with their health care providers as soon as possible if they develop flu-like symptoms. Early treatment with antiviral flu medicines is recommended for pregnant women who have the flu; these medicines are most effective when started within the first 48 hours of feeling sick.

If the flu conditions become more severe, pregnant women may want to withdraw their children from early childhood programs or stop working temporarily if they are an early childhood program provider.

Flu Symptoms

What are the symptoms of seasonal flu and the 2009 H1N1 flu?
The symptoms of seasonal and 2009 H1N1 flu virus include fever, cough, sore throat, runny or stuffy nose, body aches, headache, chills and tiredness. Some people may also have vomiting and diarrhea. People may be infected with the flu, including 2009 H1N1 flu, and have respiratory symptoms without a fever.

How do I recognize a fever or signs of a fever?
A fever is a temperature measured by mouth with a thermometer that is equal to or greater than 100 degrees Fahrenheit (37.8 degrees Celsius). Look for these possible signs of fever: if he or she feels very warm, has a flushed appearance, or is sweating or shivering.

Q. What should I do if I have a fever? 
Fever can be one of the symptoms of a flu-like illness for many people. A fever is an oral temperature of at least 100 degrees Fahrenheit (37.8 degrees Celsius). Signs of a fever include chills, a flushed appearance, feeling very warm, or sweating. 

Fever-reducing medicines typically contain acetaminophen (such as Tylenol) or ibuprofen (such as Motrin). These medicines can both help bring fever down and relieve pain. Aspirin (acetylsalicylic acid) should not be given to children or teenagers (anyone aged 18 years and younger) who have flu; this can cause a rare but serious illness called Reye’s syndrome.

To help avoid spreading the flu, if you have a fever, stay at home for at least 24 hours after you no longer have a fever or signs of a fever. However, if you're taking fever-reducing medicines, you cannot tell if your fever is truly gone. Therefore, when you start to feel better, increase the interval between doses of fever-reducing medicines and continue to monitor your temperature to make sure your fever does not return.

How do I know if a child has 2009 H1N1 flu or seasonal flu?
It will be very hard to tell if someone, including a child, is sick with 2009 H1N1 flu or seasonal flu. Public health officials and medical authorities will not be recommending laboratory tests. Anyone who has the symptoms of flu-like illness should stay home and not go to work.

Some children may not be able to tell you about their symptoms, which can result in a delay in responding to their illness. It is important to watch carefully for the signs and symptoms of flu or unusual behavior that may be a sign your child is sick. Symptoms of flu include fever, cough, sore throat, runny or stuffy nose, body aches, headache, chills and tiredness. Some people may also have vomiting and diarrhea. People may be infected with the flu, including 2009 H1N1, and have respiratory symptoms without a fever.

What fever-reducing medicines can children and staff take when sick?
Fever-reducing medicines are medicines that contain acetaminophen (such as Tylenol®) or ibuprofen (such as Motrin®). These medicines can be given to people who are sick with flu to help bring their fever down and relieve their pain. Aspirin (acetylsalicylic acid) should not be given to anyone younger than 18 years of age who has the flu; this can cause a rare but serious illness called Reye’s syndrome.

Early childhood programs should not give a child any medicines without a parent’s approval. Training should be provided to any staff who provide medicines to children.

How do I know when a child needs to be seen by a health care provider?
Watch for emergency warning signs that need urgent medical attention. These warning signs include one or more of the following:

• fast breathing, trouble breathing, shortness of breath, or stopping breathing;
• bluish, purplish, or gray skin color especially around the lips and the inside of the mouth, or around the nails;
• not drinking enough fluids, refusing to drink;
• not urinating, decreased number of wet diapers, or no tears when crying;
• severe or persistent vomiting;
• not waking up or not interacting (e.g., unusually quiet and inactive, no interest in playing, no interest in favorite toy);
• being so irritable that the child does not want to be held, or cannot be consoled;
• pain or pressure in the chest or stomach;
• sudden dizziness;
• confusion; and
• flu-like symptoms improve but then return with fever and worse cough

Steps Early childhood Programs Can Take to Prevent the Spread of Flu under More Severe Flu Conditions

How will early childhood programs know if the flu is more severe and they should consider taking additional action steps?
CDC, state and local health departments, and other public health partners will continue to monitor the spread of flu, the severity of the illness it’s causing, and whether the virus is changing. State and local health departments will also be on the lookout for increases in severe illness in their areas and will provide guidance to their communities. Early childhood programs should work closely with state and local public health officials to guide their flu response. Public health agencies will communicate changes in severity and the extent of flu-like illness to ensure that early childhood programs have the information they need to choose the right steps to reduce the impact of flu.

What additional steps should early childhood programs take to keep students and staff from getting sick in the event that the flu becomes more severe?
If flu conditions become more severe, CDC may recommend the following additional strategies and actions for early childhood programs:

• Permit children and staff at higher risk of complications from flu to stay home while there is a lot of flu in the community. Staff and parents should talk with their healthcare providers before making this decision.
• Explore innovative ways to increase social distances between children. For example, dividing classes into smaller groups (for example, groups of 6 or fewer children) and keeping them with a consistent early childhood program provider.
• Request that children who live with people who have flu-like illness stay home for 5 days from the day the first household member got sick.
• Let staff and parents of children who are sick know that if they are sick, they should stay home for at least 7 days, even if symptoms go away sooner. People who are still sick after 7 days should continue to stay home until at least 24 hours after symptoms have gone away.
• Consider closing the early childhood program. Early childhood programs should work closely with their local and state public health officials when deciding whether or not to close the program. If the decision is made to close the early childhood program, CDC recommends doing so for at least 5–7 calendar days.

What can early childhood programs do to increase social distance during a more severe flu outbreak?

Early childhood program providers should think creatively about ways to increase the space between children. Not every method will be feasible for all early childhood programs. However, it is important to consider options for social distancing if early childhood programs remain open.

Options include:

• avoiding bringing groups of children from different classes together,
• keeping children with the same small group and same provider(s),
• postponing trips that bring children together from multiple classrooms in large, densely-packed groups,
• holding activities outdoors,
• dividing classes into smaller groups (for example, groups of 6 or fewer children),
• moving play areas farther apart, and
• moving groups of children to larger spaces, when available, to allow more space between children.

What are the different types of early childhood program closures?
Early childhood programs should work closely with local public health officials to decide if the early childhood program should be closed temporarily. There are three types of early childhood program closures:

• Selective closure is used when flu conditions are similar to April through December 2009 and flu transmission is high. Some communities or early childhood programs may consider temporary closures to help decrease the spread of flu among children less than 5 years of age.
• Reactive closure is used when flu conditions are more severe compared to April through December 2009 and many staff and children are sick and are not coming to the early childhood program, or many children and staff are arriving at the early childhood program sick and are being sent home. The early childhood program may close because it is unable to operate under these conditions. Smaller home-based programs will be more likely than center-based programs to have a reactive closure because they have fewer staff available if some become sick.
• Preemptive closure is used early during a flu response in a community when flu conditions are more severe compared to April through December 2009. The goal is to decrease the spread of the flu before many children and staff get sick. This is based on information about the spread of severe flu in the region. This type of closure is most effective at decreasing flu spread and burden on the healthcare system when done early in relation to the amount of flu activity in the area.

What steps are recommended to resume early childhood programs after closure?
The length of time an early childhood program should be closed will vary depending on the type of closure that is selected and the severity and extent of illness. When the decision is made to close early childhood programs, CDC recommends doing so for 5 to 7 calendar days.

On a regular basis (for example, weekly) local health officials should reassess the spread of the disease, the benefits of keeping children home, and the impact of early childhood program closure. This information will help inform the decision to extend the closure or to reopen early childhood programs.

What options exist for parents if an early childhood program is closed?
Parents should make plans for alternate child care in case their usual early childhood programs are closed. Alternate child care may include care by relatives, neighbors, co-workers or friends. Parents should check with their employers to find out if they can be allowed to work from home or to have different work hours to be able to stay home and take care of their children. Temporary alternate child care should keep the child in small groups (for example, groups with 6 or fewer children). Parents should check with community groups on ways they can support emergency child care needs and plans if early childhood programs close during a severe flu outbreak.