CDC to College Students: Smooch With Surgical Masks to Curb Swine Flu
Health Officals Offer Unusual Advice to Ill Students
By DAN CHILDS and MAXINE PARK
Aug. 21, 2009
When it comes to swine flu, John Genovese of Scottsdale, Ariz., said he's not taking any chances as he settles in the dorm for his freshman year at Arizona State University.
Newlyweds Heidi Montag and Spencer Pratt attempt some sort of display of public affection while honeymooning in Mexico in April. A new CDC recommendation for ill college students to abstain from certain activities, including kissing, unless they are wearing a surgical mask has some students and infectious disease experts alike scratching their heads. Collapse
"Swine flu is a pretty serious thing, so I'd adhere to whatever the CDC advises," Genovese, 18, said.
But even Genovese said that a new piece of advice issued Thursday by the U.S. Centers for Disease Control and Prevention in Atlanta seems a bit strange. It's a recommendation suggesting that if college students are ill, they should refrain from kissing but, if they must, wear a surgical mask while doing the deed.
"I studied abroad in Costa Rica when swine flu broke out over there and we had to wear masks for a while," he said. "But I don't think I'd kiss with a surgical mask."
At least one of Genovese's classmates said he would, although he did add that he imagined kissing with a surgical mask wouldn't be comfortable.
"It just seems a little crazy and weird," said 18-year-old freshman Jordan Wilhelmi of Rosemont, Minn. "But I'd wear a mask if someone asked me to."
The recommendation is just one of several that federal health officials posted online in a document titled "CDC Guidance for Responses to Influenza for Institutions of Higher Education during the 2009-2010 Academic Year."
The tips are aimed at dorm-residing college students and, for the most part, they are the same well-worn guidelines that the agency has promoted in light of the swine flu pandemic, mainly involving social distancing and proper hand-washing technique.
But one of the "recommended strategies under current flu conditions" has raised eyebrows.
"If close contact with others cannot be avoided, the ill student should be asked to wear a surgical mask during the period of contact," the recommendation reads. "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."
CDC spokesperson Tom Skinner acknowledged that the language of the recommendation was confusing and that the agency would "look at rewording" the guidance.
"We're not telling them to wear a mask when they kiss," Skinner said. "What we're trying to do is give examples of 'close contact.'"
Some infectious disease experts agreed that despite the seemingly odd piece of advice, the overall intent of the guidelines is reasonable.
Mask Advice Is Strange, Doctors Say
"I believe the intent of the writer was to avoid close contact, including the examples cited, and to wear a surgical mask if close contact cannot be prevented such as when [you're in a] in room coughing and hacking with your roommate," said Dr. Christopher Ohl, associate professor of medicine at the Wake Forest University School of Medicine's Section on Infectious Diseases, in Winston-Salem, N.C. "Obviously, kissing with a surgical mask on is a bit technically difficult. I don't think the writer was insinuating that 'If you have to kiss, put on a mask.' The verbiage could have been clearer."
But others said the guidance, regardless of intention or verbiage, is simply unrealistic.
"It falls into that category of, 'It's the right advice, but impractical and hence not going to be followed,'" said Dr. Gregory Poland, director of the Mayo Vaccine Research Group at the Mayo Clinic in Rochester, Minn. "I think telling two college students in love not to kiss is neither practical nor informed about human behavior -- don't tell my grad student daughter I said the latter -- and therefore less helpful than explaining the virus is transmitted by the respiratory route: sneezing, coughing, oral contact, etc."
Dr. Pascal Imperato, dean of the SUNY Downstate Medical Center School of Public Health in Brooklyn, N.Y., was less charitable.
"Implying that kissing through a mask is fine probably refers to kissing on the cheek, not the sort of kissing college students usually have in mind when they think of kissing," Imperato said, adding that in his view, even a kiss on the cheek through a mask would not be wise.
"I suspect that whoever drafted the wording for this recommendation may never have kissed while in college, nor anywhere else for that matter," he said. "They really need to revise this statement."
Meanwhile, Philip Alcabes, author of "Dread: How Fear And Fantasy Have Fueled Epidemics From The Black Death To Avian Flu" and associate professor of Urban Public Health at Hunter College of The City University of New York, said that the recommendations will likely do little to curb the spread of the flu -- and much more to spread fear.
"Of course, it isn't crazy to tell people that kissing could spread flu virus," he said. "But [Thursday's] CDC guidance -- with masked kissing, flu buddy schemes, and shirt-sleeve sneezing -- is further evidence that panic has set in among officials.
"Probably, our officials are well meaning and concerned with the public's health. But it often seems like their overriding concern isn't real programs to stop disease, it's that they'll be criticized for doing too little. And since there's nothing to be done right now, they just say something. Anything. 'Masks.'"
Can Masks Cut the Spread of Swine Flu on Campus?
It's not just the kissing guidelines that may pose a problem, SUNY's Imperato said. Specifically, sharing of utensils is something that should never be done with an ill friend -- regardless of whether they happen to be wearing a mask or not.
"What is additionally odd is that it implies that such students can share eating and drinking utensils with well contacts, provided that they, the ones ill with the flu, wear a mask," Imperato said. "The bottom line here is that students ill with the flu should not be kissing other people nor sharing eating and drinking utensils with them."
"I guess a mask is better than duct tape," noted Charles Gerba, a microbiologist at the University of Arizona whose work on microbes has earned him the nickname "Dr. Germ."
"Some barrier is better than [none] at all, but I would just avoid kissing altogether and sharing utensils, or at least wash them," he said. "I was trying to figure out how you drink or eat with a face mask on. I think they must mean if you are in a room where someone is eating or drinking."
Eating and drinking aside, at least one student -- a nursing major no less -- appeared to agree wholeheartedly with Gerba's advice.
"I'm a bit germaphobic in general, so I'd definitely wear a surgical mask, but not for kissing." said Anna Salinas, 19, from Goodyear, Ariz. "It's better to wait until you're better."
CDC Guidance for Responses to Influenza for Institutions of Higher Education during the 2009-2010 Academic Year
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).
* 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.
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