Medical Professionals Online

Lessons From 1918 On Influenza-related School Closure Planning

September 06, 2017

During last spring's influenza A/H1N1 pandemic, closing schools was a common and often contested strategy for curbing spread of the virus. This debate likely will persist if the flu pandemic continues or worsens in the United States this fall. Researchers from the University of Michigan and the Centers for Disease Control and Prevention conducted a qualitative analysis of 43 U.S. cities and their public school systems during the 1918-1919 influenza pandemic to uncover lessons applicable to today's communities when dealing with the issue of school closure this fall.

In examining these large U.S. cities, the researchers found that school closure orders were almost always issued with community-wide measures known as nonpharmaceutical interventions (NPIs), such as quarantine, isolation and public gathering bans. They found a connection between smooth implementation of all such measures - not just school closures - with clear lines of authority among municipal and government agencies, and transparent communication between health officials and the public.

Their findings are published by Health Affairs online today as a Web exclusive.

"The recently issued CDC guidance for grades K-12 school dismissal provides a framework for communities to make decisions based on local factors and considerations, much like what we saw for cities in 1918. Then and now, there are parallels in the social, political and organizational factors influencing the smooth implementation of school closure," says author Alexandra Minna Stern, Ph.D., the Zina Pitcher Collegiate Professor in the History of Medicine and associate director of the UM Center for the History of Medicine.

The analysis reviewed scientific, medical and educational literature of 1918-1919 and examined newspaper articles and editorials, municipal reports and meeting minutes to explore community experiences with closure in public schools grades K-12. Cities were divided into these categories: high, medium or low interagency conflict and community compliance with community measures. The fourth category delineated a handful of cities that chose to keep schools open.

"Cities showing the greatest acceptance of and compliance with school closures and other community measures invariably exhibited established lines of trust and communication in government and the community that pre-existed the pandemic," says author Howard Markel, M.D., Ph.D., director of the UM Center for the History of Medicine and the George E. Wantz Distinguished Professor of the History of Medicine. "Their experiences present insights for contemporary pandemic preparedness and community mitigation planning."

Among high conflict cities, school and health officials were often at odds, with school boards occasionally closing schools preemptively against the advice of city health departments. Nine cities fell into this category and also experienced myriad difficulties with community members' acceptance of NPIs.

A significant number of cities were placed in the intermediate category because they experienced a mix of interagency cooperation and conflict, and sporadic compliance with NPIs. Yet many of the 11 cities in this category also experienced relatively smooth communication at the local level, including community engagement for relief efforts. For example, teachers often volunteered for community service and sometimes took on special assignments like canvassing for unreported cases.

Twenty of the cities that shuttered schools had little or no inter-agency conflict and also experienced smooth communication and community compliance with NPIs. Here, too, teachers often volunteered in the community. Characteristics generally shared by this group included a history of effective local leadership and good coordination at all applicable levels of the state, city and community, resulting in no apparent infighting to hinder relief efforts.

Chicago, New Haven and New York kept schools open, relying on sound public health infrastructures to closely monitor children's health in school. New York in particular stood out because it supplied follow up monitoring and services for any children identified as ill and sent home.

All this is not to say that cities with high degrees of cooperation avoided high absenteeism. This problem - the result of both fear and infection - plagued cities regardless of other circumstances for managing the pandemic, and sometimes led to creative ways for providing uninterrupted learning. In the case of Los Angeles, public educators established a system of mail-in correspondence courses for students in the higher grades.

This historical snapshot of 43 U.S. cities mirrors many of the dynamics found in communities today.

"This study clearly illustrates the value of transparent communication between health officials and the public and underscores the importance of health and school officials working together during a pandemic," says author Martin S. Cetron, M.D., director of CDC's Division of Global Migration and Quarantine. "As the current pandemic continues, schools and health officials can take the lessons we learned from 1918 to protect the public's health now."

For more information on CDC's guidance for schools with grades K-12, visit cdc/h1n1flu/schools/schoolguidance.htm.

University of Michigan Health System