Conversations Concluded: H1N1
Editor’s Note: In the November+December 2009 issue of the Talking Stick we asked members to discuss how they are addressing H1N1 on their campus. As you would expect, they had plenty to say on the subject; so much that their ideas overflowed the magazine pages and onto this blog. So much that we’re even breaking it into three separate posts (read part 1 here and part 2 here). Participating in the Conversation is Mike Krenz, assistant manager for risk management at Texas A & M University in College Station; Gary McLaughlin, business manager for housing at Flinders University of South Australia in Adelaide; Steve Palmer, director of residence life at Western Michigan University in Kalamazoo; Robert Tattershall, director of housing and conference services at Washington State University in Pullman; Dima Utgoff , director of residence services at the University of Alberta in Edmonton, Canada; Joe Gonzalez, associate dean of residential life at Duke University in Durham, North Carolina; Sean Duggan, managing director of university student housing at Texas Tech University in Lubbock; and Bes Liebenberg, coordinator for student support residences at the University of Pretoria in Gauteng, South Africa.
Question: Under what circumstances, if any, would you not isolate students that have H1N1 or are suspected of having H1N1?
Tattershal: We chose self-isolation this time, so in this wave of H1N1 we chose not to isolate. Some time ago, during SARS and H5N1, helping the university understand that true isolation was virtually impossible in a high occupancy residence hall system (over 80 percent of our residents live with a roommate and have to leave their rooms to go to the bathroom and most have to leave at some time to get food), made quite a bit of difference in the current H1N1 discussion. We were successful in getting the committee to think not only of the first few cases of H1N1, so as not to tailor our response just for the beginning of the epidemic on our campus, but for the epidemic after a few weeks, when the numbers would be much larger and overwhelm any attempt to isolate people in the handful of empty spaces we had.
In our situation, we had one case during sorority recruitment, the week before school started. That one case, because of her contact with other students, and their contact with many more, became hundreds of suspected cases of influenza-like illness before we could have implemented an isolation program. Our health professionals stopped testing after the first few cases of H1N1 because of the time lag and cost, and the CDC statements that 98 percent of all influenza A illnesses were H1N1 at this time, which meant that we only knew people were sick, and it was probably H1N1. Therefore, isolation for us would have meant isolating hundreds of residents that had influenza-like illness, and doing so within days of the initial awareness that an outbreak was already here.
We knew last spring, that unless H1N1 mutated very quickly, and became much more lethal and the symptoms were much more severe, our response to H1N1 would be very different compared to what we were planning to do if SARS or H5N1 ever made it within 100 miles of our campus; i.e., recommending to our leadership to close the university. Interestingly, of course, closing the university doesn’t necessarily mean that we could close the halls, as several hundred of our residents simply wouldn’t be able to go home in the face of a infectious disease with high virulence and mortality.
McLaughlin: We did not specifically isolate any residents because by the time a resident was diagnosed they would have infected close contacts (if they were to be infected)anyway. In addition we do not have shared rooms so each resident was in their own room and that made it much easier to keep them away from others. By using the common area specifically set up plus having meals delivered, the infected residents were isolated but were not forbidden going to other areas of the complex.
Duggan: We suggest that students go home if that is an option, or self isolate to their res hall room.
Liebenberg: Only if the diagnoses are not confirmed. Out of a possible 8,000 residents we had only 12 confirmed cases reported and they all went home. I’m convinced that a severe outbreak would necessitate alternative measures.
Question: Besides isolation of residents, do your plans assume that residents who can go home will go home as the first line of defense in stopping the spread of H1N1 in your halls?
Duggan: Over 50 percent of our students come from 300 miles or farther. Going home is not a reality for most of our students. We are suggesting people to hunker down and take care of themselves and others when needed while protecting their health. I think some of the panic from last year has dissipated and people are treating this like a common illness. Two of my children had it last week, and the symptoms were very mild. As a family, we stepped up the cleaning and hand washing etc. Only two out of seven in my house got it this round.
Tattershal: We didn’t, but we knew that lots of residents would go home if they could. The CDC suggests this as an option, and to some degree it makes sense, but in our Pandemic Committee’s opinion, requiring that a lot of sick students go home just spreads the disease to other places. If we felt that the disease was more virulent and lethal, the primary method to prevent the spread of H1N1 in our halls is to close, but if we chose to close after we had a virulent H1N1 on campus then spreading the disease to other places is all the more relevant. In our case less than half our residents brought cars to school and 75 percent of them live 250 miles from here, so getting them home takes on a different dimension than it might at other universities.
Gonzalez: No, this is not part of our plan. Only about one-third of our students live in the vicinity of the university.
Krenz: Yes. Our first line of defense is to request that students return home.
McLauglin: It was entirely up to the residents and their families to decide if returning home was appropriate or desirable. Returning home however could have a detrimental effect in that it could spread H1N1 to other locations where it may not have spread had the resident remained at Flinders.
Question: Do you plan to isolate residents when seasonal flu hits your campus this year? If not, why not?
Tattershal: No, we do not plan to isolate residents who have seasonal flu. Our messages on sanitation, etc. will be the same, but I doubt we will be keeping a log at the front desk like we have been for H1N1, unless H1N1 is the primary version of Influenza A in circulation at the time. We will do so then because of the heightened awareness and fear generated by H1N1 publicity. If H1N1 turns deadly in the 2nd or 3rd wave, I expect our response will be much more like our plans were for SARS and H5N1.
We would close the campus for a period of time, preferably before a more virulent and lethal H1N1 gets here, to prevent the halls from being a focal point for the spread of a lethal disease.
Gonzalez: No, we do not plan to do this nor have we done it previously. In part this supported the approach we ultimately took with H1N1. Many questioned the sense of taking additional steps (like isolation) for a flu that in many ways is less virulent than the seasonal flu we annually deal with.
Krenz: We plan to have set aside “isolation” rooms for the seasonal flu time of the year. However, this is normal as we made a decision last year to always have rooms set aside for isolation in case of any type of infectious disease that the student health services recommends isolation for. For example, last year we had some students with MRSA who asked to be isolated after returning from student health services (they lived in a building with public area bathrooms). We used our pre-determined isolation rooms for this.
Palmer: No. However, with some of the symptoms overlapping, it could end up being challenging to differentiate.
McLaughlin: No we have not done it before and can see no reason to do it now. Vaccinations are available to our entire population for both the normal seasonal flu and H1N1.
Duggan: No we will just continue our current efforts. We are also highly recommending both types of flu shots. We will probably keep our ill student log going from now on, just so staff can track and touch base with students. This has been one positive outcome and will help us in the future. We have had students notify us they have chicken pox and staph infections so the communication channels have been established and crossed illnesses. We will be following up with all staff regarding confidentiality of shared information etc.
Liebenberg: No. Seasonal flu is quite common with the change of the season and is not regarded as an epidemic disease. We do emphasize personal health and will keep on with awareness campaigns regarding the prevention and spreading of H1N1. If H1N1 fatalities are occurring then surely residences might be closed, isolated of evacuated, depending on the severity of the occurrence.
Question: Any final comments?
Krenz: I am curious how some of the schools reported in the news know how many cases of H1N1 they have on their campus. Therefore, this leads me to a 3-in-1 question. Is your school tracking H1N1 cases? Is your student health services tracking H1N1 cases? Is your housing/residence life department tracking H1N1 cases?
Tattershal: We were a leading H1N1 school in the media, which is probably why I was included in this conversation. We don’t know how many cases of H1N1 we have, or I should say we have officially had three. The test to verify it is somewhat costly and takes 72 hours, and by the time we could confirm someone had H1N1, they were over it. In an epidemic, in Washington, the county health officer is God, and made the call not to test any more cases because the CDC was saying that 98 percent of the cases in which someone had Influenza A had H1N1. So, our Health and Wellness Services (HWS) triaged people at the clinic, and only saw people that were at high risk of complications. Anyone not at high risk, but with symptoms that indicated influenza, was told they probably had H1N1 and sent off to self-isolation. HWS is counting contacts, and our halls are counting contacts if students tell us.
You may have read that WSU had “2500 cases of H1N1″, and that was an estimate based on the triage HWS did by phone and in person. However, a key issue was, and is, that our HWS message was that students really don’t need to go to HWS, but instead take care of themselves in self-isolation. Going to HWS doesn’t mean student were going to get Tamiflu, because only high risk people will be getting flu medicine. HWS tried to balance the message that students were welcome to come to HWS, and no one would be turned away. But for most people there was no point. It was a tough thing to balance but we think they did a pretty good job. All a way of saying, HWS was counting, and they estimated 2500 students had flu-like symptoms, but there is no way to know for sure because not everyone called or contacted HWS.
As a side note, I currently have symptoms that are probably indicative of H1N1, but I’m not going to see a doctor. I’m not in a high risk category, and I have heard doctors say that the last thing we need is everyone going to medical centers and clogging up the system. Doing so results in doctors not having time to focus on the high risk cases. One other issue making WSU’s number seem so high is that we live in a small town and virtually all students go to HWS. In a big city, students have so many other options that big city university health clinics won’t see, and therefore count all the students that have flu-like symptoms. Plus, we started school about as early as it is possible to start the fall semester, and we are the only state school in Washington on a semester schedule, meaning our state news media picked up our story, and then all of yours did, making us look like H1N1 central. In addition, we were reporting cases according to the ACHA guidelines, and a lot of schools weren’t at the time and still aren’t. We think we “know” that our students have H1N1 more so than a lot of other schools for the reasons above, but every other school will be getting it just as much as we did, but reporting may be different, and it will be old news for most media outlets when all other schools have the same counts we have had, and certainly will when flu season starts in earnest here in a bit.
Krenz: Excellent answer. Thanks for all of the detail. The only thing I can say is … Ditto, ditto, ditto. Everything you have explained below sounds exactly like Texas A&M University, except our Student Health Services has been estimating “several hundred” cases of “flu-like symptoms”. In the residence halls, we have only been asked to report up the chain if the number of students and staff with flu-like symptoms becomes “disruptive to normal operations”.
Utgoff: Here is my answer to the question: Is your StudentHealth Services tracking H1N1 cases? It is but routine testing is not done for the reasons some members of our discussion group have already identified so it is still difficult to determine exact numbers. In response to: Is your Housing/Residence Life department tracking H1N1 cases? No, we have decided that any tracking that is done should be done by the University Health Centre.
Duggan: Our student health is tracking numbers, but they always have regarding the illnesses they are treating etc. They are seeing upwards of 250 patients a day. The highest number of flu-like symptoms for a day has been 20, with about 200 flu-like symptoms so far this year. I think lots of students are not even going to the doctor based on what they have seen in the news etc. No telling how many are just staying home and getting better. We have not had any large amount of press regarding the issue on campus.
