Last fall, school and city public health officials in Laredo, Texas, noticed a steep increase in the number of children presenting with flu-like symptoms in one of the city's elementary schools. Officials reacted to the data like it was a fire alarm.
School health administrators immediately took aggressive steps to safeguard the student population, including frequent scrubbing of high-touch areas and active screenings in classes where students with likely "influenza-like illness" (ILI) had been seen by the nurse.In the following week, the school's reported cases of ILI were cut nearly in half, school officials reported. They attributed the quick alert in part to an online reporting platform called Argus1 that provides data entry, analysis and clinical decision support for the surveillance of ILI symptoms.
Laredo school health services director Patricia Keck said the electronic system enabled city health and school officials to act in real-time. This was a vast improvement over a paper-based system that was updated weekly on each campus, and which took several more days to compile and fax to the city's public health department.
"By then, the window of opportunity for identifying hot spots and intervention is over," said Keck. Laredo is just one example of K-12 school health planners using Web-based and IT-driven systems to help manage health crises. When it comes to diseases like influenza, children are an especially volatile population that requires improved disease-tracking technology and crisis management tools.
"Children are not only more susceptible to this flu, they spread it more easily because they shed the virus longer than adults do," said Matthew Reynolds, a spokesman for the Centers for Disease Control and Prevention (CDC) in Atlanta. "Schools are really the ground zero of this virus, and so it's important for communities to know exactly what's happening."
For its part, CDC last year created a Web-based school closure form in response to the H1N1 pandemic. In more than 75 percent of nationwide school closures during the crisis, the CDC has been alerted via the electronic form.
Using such tools, school district health planners and federal public health coordinators are building the infrastructure needed to manage the H1N1 outbreak as well as future pandemics, public health officials say. "Any time we can get real-time data on a virus, the more quickly we can understand what's going on and get an accurate picture of the disease and how it's affecting specific communities," Reynolds said.
Fear and ignorance
Schools are tackling two fronts in their use of technology: disease surveillance and communications. The latter, said Linda Sharp, project director for the Consortium on School Networking, is important because schools need to successfully combat rumors and fear among parents and get their cooperation, to cope with an outbreak effectively.
"You're talking about kids, so there's a lot of emotion involved," Sharp said. "For this reason, schools really need to make sure that parents have accurate information about preventative measures, policies, and critically, how many H1N1 cases they're actually seeing in the school. That way, parents will trust that the school is being straight with them and be more willing to cooperate and do what is necessary to help slow the spread of the virus."
In Louisiana, the Calcasieu Parish Public Schools turned to technology to improve communications after being barraged daily with phone calls from worried parents acting on hearsay and innuendo. In response, Sheryl Abshire, chief technology officer for the school district, set up a special H1N1 page on the district's Web site to post the exact number of daily confirmed H1N1 cases. The effort has drastically cut the number of calls to the school. The Chicago public school system, meanwhile, relies on online forms and robo-calling to ensure that officials had accurate contact information for parents in case a student exhibits flu-like symptoms. If a parent is required to come take their child home or there is a sudden decision to close a school, there can't be any delays because of a wrong phone number.
The school is also contacting parents of absent students to find out how many are actually showing flu symptoms and then relaying that information to the local department of health. "The idea is to see trends and minimize the spread of the disease so they don't have to shut down the schools," said Sharp. "The goal is to keep the schools open."
School surveillance tools
While tools to manage public and response team communications during a public-health crisis are critical, good surveillance of the school systems is key to containing the threat, according to public health experts.
The Argus1 tool used in the Laredo school system was developed by Argus One Systems in Rosenberg, Texas. The system features a pull-down user interface that breaks down data to the individual school and case level as well as clinical decision information for each selected condition.Argus1 was originally developed for combating bioterrorism, said Dr. Vincent Friedewald, Argus One systems medical director. The platform used in the Laredo schools was picked by the Department of Homeland Security (DHS) for a bio-surveillance test that ran from 2003-2005. DHS officials thought Laredo's status as a large inland port of entry made it especially vulnerable to a potential bio-terror attack.
The emergence of H1N1 last spring spurred school health services director Keck and Friedewald to plan for expanding the system to include the expected flu surge at the opening of the 2009-2010 school year. Keck said the system is now in place in all city schools and is used by 36 nurses on 30 campuses.
Texas is pioneering Web-based surveillance systems elsewhere in the state. In the Dallas-Fort Worth metroplex region of Tarrant County, public health IT experts at the Southwest Center for Advanced Public Health Practice (APC) began developing an open-source surveillance system for the county's school nurses in 2007.
The initial uptake of the system was gradual, but the H1N1 outbreak raised its profile significantly. In the first weeks of the 2009-10 school year, school nurses contributed more than 1,400 reports to its database, according to Dean Lampman, regional surveillance coordinator for the Tarrant County Public Health Department.
The Tarrant County system allows nurses in each of the county's schools to upload a form that includes the number of students absent, the number of students absent with ILI symptoms, the number of students who visited the nurse's office and the number of office visits due to ILI. It also asks nurses to rate their perception of increasing, decreasing or stable ILI activity. The data is entered daily and analyzed weekly by the county health department.
"The school nurses were more concerned about the quality and frequency of data at the end of the last school year, in the spring when H1N1 first emerged," Lampman said. "And that has carried over to the beginning of this school year. We have seen a dramatic increase in the frequency of reporting."
Coordinating unfamiliar teams
While new Web-based surveillance technology proved itself useful in a public health crisis, the tools can expose community fault lines that can stifle efficient pandemic management. The tools are only as good as the coordination of teams that must work together to resolve a crisis, experts said.
Coordinating information sharing between school nurses and attendance clerks about causes of absences can be problematic, for instance. This is especially true where parental reporting of flu symptoms as the reason for absence is not mandatory and where attendance software has no easy way to i
