By Greg Toppo, USA TODAY
Taken from USA Today online

It didn't take long for swine flu to show up at Vista del Lago High School in California's Sacramento County: About 10 a.m. on Aug. 10, two hours into the first school day, administrators got a call with news that a freshman who had stayed home that morning had a confirmed case.

"I was hoping we'd make it until at least 11 o'clock," says Mary Ann Delleney, who oversees health for Folsom Cordova Unified School District.

By Day 2 it was up to eight cases, and by week's end the number of confirmed cases at the school rose to 14 — a reminder that for many schools and colleges this fall, swine flu, or H1N1, may be a fact of life.

As millions of students and teachers head back to class this month and next, schools are preparing for the return of the new flu strain, which first appeared almost simultaneously last April in Mexico and the USA. But seasonal flu also is making its annual return this fall — a combination that is creating uncertainty and anxiety as medical personnel prepare for both strains.

Schools are waiting on a promised H1N1 vaccine — due in mid-October — but are moving ahead regardless to prepare for major challenges given that young people are particularly vulnerable to the new strain.

Some schools are preparing to turn their gyms and cafeterias into vaccination clinics, and trying to identify spaces that could serve as isolation rooms for the sick. Many school systems are devising ways to quickly identify infection patterns in daily absentee reports, and on Monday federal officials advised systems to come up with alternate ways to deliver lessons to infected students stuck at home.

Meanwhile, school systems also are pushing to control both the new strain and the seasonal flu with widespread and aggressive campaigns that urge students to wash and sanitize their hands throughout the day, cover their coughs and sneezes, limit unnecessary exposure to classmates and, by all means, stay home if they're feeling the least bit ill.

Such efforts took on new urgency Monday with a report from the President's Council of Advisors on Science and Technology that warned that up to half the U.S. population could be infected by swine flu.

Across the USA this fall, educators and school nurses say, anyone who shows up to school with a fever and any one of a mix of mild symptoms such as a headache, sore throat, cough or muscle aches probably will be asked to head home for a few days.

So far, at least, parents seem to be getting the message.

"I don't have parents who argue," says Britt Stanley, a registered nurse at Putnam City North High School in Oklahoma City, which has not seen any H1N1 cases. "They understand the importance of sending them home."

At Putnam City, as elsewhere, teachers now wipe down desks regularly, keep large bottles of hand sanitizer in classrooms and urge students to use them.

"They're concerned but they're not overly concerned, and they know that, working in the school, these illnesses kind of come with the territory," Stanley says.

"I think they feel like it's just a fact of life and they're preparing for it."

Health officials say schools were likely ground zero for much of the rapid but short-lived spread of H1N1 last spring. It was over so quickly, they say, because it began so late in the school year.

"The reason it ended in Boston was schools closed," says Barbara Ferrer, executive director of the city's health commission.

The outbreak was responsible for 522 deaths and 7,963 hospitalizations in the USA, according to the federal Centers for Disease Control and Prevention (CDC).

In all, it forced about 700 schools to close temporarily, prompting U.S. Rep. George Miller, D-Calif., to say last May, "It's a delicate balancing act between taking necessary safety precautions without overreacting or igniting panic."

Dealing with fear

This fall, schools are preparing for the worst while trying to prevent panic.

So it didn't help that at Vista del Lago the other day, television news trucks pulled up to the school to report on the first-day outbreak. A local 51-year-old nurse died from swine flu in July, and that put people on edge, Delleney says.

"The issue of fear is really an important one," she says.

And though the outbreak emerged quickly at the school, she says, "right now, the reality is that it is being managed."

At Hixon Middle School in St. Louis, students must disinfect their hands with antimicrobial foam each day on the way to lunch.

Registered nurse Linda Neumann hopes the routine cuts down on all illnesses — not just H1N1. "I think we're going to make it through this year all right," she says.

Like many other nurses, she has been getting constant updates on H1N1 the past few weeks from the CDC as well as state and local health departments. Asked whether H1N1 keeps her up at night, Neumann says, "No, but it keeps me reading e-mails at all hours."

School closings discouraged

After hundreds of school closures last spring, the CDC revised its guidelines: It now discourages schools from closing even if H1N1 strikes.

Homeland Security Secretary Janet Napolitano said this month that only schools with "high numbers of high-risk students" who show flu symptoms should consider closing. She pointed out that shutting down a school, even temporarily, "causes a very significant ripple effect" in the community, forcing schools to reschedule classes and extracurricular activities, while parents must find child care and rearrange work schedules.

The new guidelines say ill students should be kept out of school for 24 hours after their fever subsides without medication.

In schools where students show symptoms, U.S. Education Secretary Arne Duncan says, educators should set aside a room to isolate students — "a safe place for them to stay" until they're picked up to go home.

When a vaccine becomes available, Duncan says, schools are natural locations for mass vaccinations: "It's where our students are."

Public health officials also are pushing schools to pay closer attention to attendance statistics.

In Chicago, where about 430,000 students attend school, each afternoon the school district forwards daily attendance figures, broken down by individual classrooms and student ID numbers, to the city's Department of Public Health, where analysts compare them with data going back two years. They're hoping to examine absence patterns, down to the classroom level, to warn schools and families if an outbreak could be imminent.

In Boston, health officials say the 24-hour rule is not enough: They're requiring students to stay out of school for a minimum of four days. Ferrer notes that schools were "the main place" where kids got H1N1 last spring and she's pushing to isolate ill kids.

Boston Mayor Thomas Menino has asked local businesses to modify their employee leave policies to accommodate parents who may have to stay home with a sick child for several days.

He also has asked religious groups to identify members who could be tapped to provide in-home child care.

Like many other cities, Boston is trying an aggressive education campaign, with Facebook pages, automated calls and Twitter feeds. A local hospital even produced a YouTube video urging people to wash their hands. One lyric: "When you go and give a little handshake, a little squirt is all it takes/Boom boom chicka chick Cal Stat." (Cal Stat is a brand of hand sanitizer.)

On Monday, Duncan said schools should be ready with hard-copy packets and online lessons to keep learning going even if H1N1 sickens large numbers of students.

New federal guidance advises schools to distribute recorded classes on podcasts and DVDs; create take-home packets with up to 12 weeks of printed class material; and hold live classes via conference calls or Internet seminars.

New federal guidance to the nation's colleges has a similar tone to it. The guidelines, issued Thursday, advise colleges to sequester ill students in dorm rooms or send them home if families live nearby. They say that students who can't avoid close contact should wear surgical masks and that ill students should identify a "flu buddy" to deliver meals and notes from class and provide rudimentary care.

Colleges also may consider moving students away from roommates into special temporary housing, federal officials say. But schools should not demand a doctor's note to prove someone is sick or recovering because doctors may be inundated.

In Wyoming's Laramie County School District No. 1., which has about 13,000 students, Chris Bartholomew supervises 21 nurses. Her biggest concern is trying to get up to four doses of vaccine for her youngest students — two each for seasonal flu (at least in those 9 and younger who have never had a flu shot) and H1N1 — out to as many as possible. The two sets of vaccines are expected to arrive about a month apart, and she says her nurses may have to "do some creative juggling," such as postponing complete checks of students' routine immunization records, to get as many children immunized as possible.

When students at a private high school in Queens, N.Y., began complaining of high fevers and sore throats one morning last April, nurse Mary Pappas called the New York City Health Department and ignited a flurry of activity that ultimately identified New York City's first H1N1 cases.

Pappas remembers the first few hours that Thursday morning as "a little overwhelming and chaotic," but soon she and two aides at St. Francis Preparatory School had enlisted other staffers to help shuttle ailing students from her cramped office (and the crowded hallway outside) to parents' waiting cars.

Her efforts made Pappas a folk hero among nurses, but she says it could have been worse without help from her colleagues.

This summer, she bought a pair of high-tech digital thermometers that can quickly scan a patient's forehead for a temperature. As students get their schedules, she's lecturing them about infection control. (Her trademark line: "If it's wet and it's not yours, don't touch it.")

Educators and public health officials also worry about H1N1 because, so far at least, it has targeted young, otherwise healthy people. Seasonal flu typically is most dangerous for infants, the elderly and those with other health problems.

H1N1 also appears more contagious than seasonal flu, according to the World Health Organization, though most of the cases have been mild. But that could change, experts say.

Boston health officials also found that H1N1 hit minority students harder than it did white students, probably because many had underlying health conditions or because their parents had more difficulty getting off work and quickly picking them up from school, Ferrer says.

Most Boston public schools are predominantly attended by low-income, minority students — most upper-class white students attend private schools. Ferrer and others say the parents of many low-income families also had difficulties keeping students at home, a precaution that would have isolated more ill children from well classmates.

Further, there's concern the H1N1 virus may be more dangerous to obese children. The CDC stops short of calling obesity a risk factor but says obese people often have other underlying diseases, such as asthma, diabetes and heart disease, that put them at risk for flu complications.

Pediatrician Neal Hoffman of Montefiore Medical Center in New York City, which runs health centers in 16 Bronx public schools, says he's concerned about obesity problems in the schools but is more worried "that we've got a much higher incidence of asthma in Bronx public schools" than elsewhere in the nation. These students should get the H1N1 vaccine, he says.

But, he says, "in general nationwide, we have a hard time even immunizing the highest-risk patients."

Contributing: The Associated Press