The boy in the Germ Stopper poster is friendly, vigorous and positive, and as he looks you confidently in the eye he shares the familiar can-do pose of the superhero. But what’s that he brandishes in his right hand? Yes, it’s a box of tissues.
His message is simple. You too can be as strong and cool as he is if you use tissues when you sneeze and cough. You should wash your hands carefully, too — make sure you wash for long enough to sing the Happy Birthday song twice while you do it — and you will help to stop germs spreading, and to stop colds and flu.
For four years Germ Stopper has encouraged American children to adopt good basic hygiene habits. And now that avian flu is regarded as a potential threat, the Centre for Disease Control and Prevention is about to launch a programme designed to combat it. The advice, to be published on March 1, means that should bird flu start to mutate to affect human beings, the spread among American children will be controlled because viruses are passed by sneezing and coughing and contact, and children do a lot of that. The evidence lies in the 1957 flu pandemic in Britain, in which half of those affected were children: although some cases occurred that June, the pandemic was not triggered until children returned to school in September.
In residential schools attack rates reached 90 per cent, often affecting a whole school within two weeks.This month 60 schools in the Midlands reported outbreaks of both the norovirus (winter vomiting bug) and influenza B, and more than 20 schools in Birmingham, Sandwell and Dudley closed when children and staff became ill. Specialist cleaning teams were called in to two schools in Gloucestershire to tackle the virus.
Further evidence that children are key in the spread of disease lies in Japan, the only country that has initiated a flu-control policy based on the vaccination of children. The policy began in 1962, eased in 1987 and ended in 1994 amid doubts about its effectiveness and concerns about side-effects of the vaccine. But between 1970 and 1990 deaths from pneumonia and flu decreased by 10,000 to 12,000 a year — showing, according to a report in The New England Journal of Medicine, that controlling the spread of flu in children protects the whole population, including the elderly.
So let’s put these facts together and ask a question. One, it is well known that good hygiene can control the spread of viruses. Two, it is well known that viruses can spread rapidly in schools, or, as the Department of Health’s contingency plan on avian flu states specifically: “Influenza will spread rapidly in schools.” So why has the Department of Health failed to pass on to schools the information about hygiene that could, should bird flu affect humans in Britain, significantly restrict its spread?
“If a flu pandemic emerges we don’t know which groups will be vulnerable,” says a DH spokeswoman who seems to be unaware of the statement quoted above. “In terms of schools our pandemic plan talks about different sorts of public health measures. Included is whether we would have to consider closing schools to try to stop the spread. We would take a decision at the time as to whether children were specifically vulnerable.”
The Department for Education and Skills had a similar answer: “There are measures being discussed but there is no guidance being issued.”
Why not? During the 1940s and 1950s the Government recognised the importance of good hygiene practice: it issued pamphlets recommending it. In 2006 DH guidelines on avian flu stress the need for good hygiene in hospitals: “It is important to educate children and their families to adopt good hygiene measures to minimise potential transmission, including the use of disposable tissues for wiping noses, covering nose and mouth when coughing, sneezing or using tissues, and keeping hands away from the mucous membranes of the eyes and mouth.”
The information is there — so why not join up the thoughts and extend the advice to schools? It doesn’t require extra staff or expensive resources, it’s common sense, and it is precisely what virologists such as Professor John Oxford of St Bartholomew’s and the Royal London Hospital recommend.
Last year Professor Oxford published a study that found hand-washing to be more effective than products such as antiviral tissues in preventing the transmission of respiratory viruses. By washing hands frequently and not touching your face, you can reduce the incidence of respiratory disease by about half, he says, and he applauds the US practice: “It’s a splendid idea. If children are educated about hygiene it can help to break the chain because normally it’s children who bring these viruses home to their parents.
“Children get close to each other and there will be a relatively high attack rate in schools. Their parents might be sitting at home with their grandparents and get the virus from the child. If the child is educated in cross-infection it will reduce the chances of transmission.”
The main lines of attack on avian flu will be new antiviral drugs and vaccines, Professor Oxford says. But this does not dilute the importance of hygiene: “The main thing would be to supervise hand-washing: soap, fairly hot water, rubbing, drying — that rigmarole has been forgotten. It’s not just about flu. The projectile vomiting/diarrhoea virus that’s roaring through schools at the moment could be controlled by good hygiene.
“Schools should also concentrate on keeping doorknobs clean. During the Sars outbreak in Hong Kong it was shown that pressing buttons in lifts and all these everyday events were significant in transmission, and hand-washing has been shown to be effective in controlling MRSA in hospitals. It’s ordinary things that matter.
“These messages are not getting across clearly. The message is either panic mode, or nothing is happening.”
It is true that good hygiene is part of the British national curriculum but many parents doubt the consistency of the message reaching their children, talking of the four-year-old who wipes his nose on his sleeve or the six-year-old who has to be pestered to wash his hands before eating. No matter how often parents remind their children at home, they say, small children often fail to respond unless the message is also repeated constantly at school.
This is the strength of the American response. The Atlanta-based Centre for Disease Control — a division of the US Department of Heath and Human Services — has received questions from schools about how best to prepare for and prevent avian flu, so it has repackaged and supplemented the guidance it has issued about preventing infection in recent years. Whether or not individual states and school districts take up the advice, it is available to all schools and is, without doubt, an attractive, imaginative and child-friendly package.
Websites explain how flu spreads and exactly when and how children should wash their hands and use tissues. But what distinguishes the guidance from similar information issued by British government sources is that it relates specifically to children, taking into account their conventional reluctance to pay attention to such matters. Rather than just giving teaching staff the message they need to pass on, the CDC has come up with strategies that will engage children, and which therefore stand a chance of being successful.
For younger children there is a gallery of villains including Influenza Enzo, “the godfather of all viruses” who will “make you a fever you can’t refuse”. He is “Wanted”, as a poster puts it: “For causing sniffles, sneezes and headaches. If you come into contact with him, do wash your hands right away . . . Send the flu bug up the river to sink-sink. Reward: a happier, healthier you!”
There are computer games, too, that reinforce the hand-washing message, and songs instructing children on precisely how they should wash their hands. The greater challenge, says Dave Daigle of the CDC, “has not been to convince the five-year-old to wash his hands, but the middle-school-aged child that hand-washing is an important, sensible strategy for preventing illness.”
This has been done in conjunction with the CDC’s Division of Adolescent and School Health — and the Soap and Detergent Association — through a programme that provides information but relies on pupils to convince themselves, their peers and their families that hand-washing matters. Schools are encouraged to run hand-hygiene campaigns and the best entry wins a trip to Washington. One group of pupils cultured bacteria lifted from frequently touched surfaces such as the water fountain and toilets.
“The students were so disgusted by what they found — the toilets were cleaner than the water fountains they drank from — that they decided for themselves that hand-washing was essential,” says Daigle.
What impact does he think this would have should avian flu mutate as feared? “The important point is that frequent, proper hand-washing is cheap, easy and a first line of defence against infection,” he says.
Back in Britain the information remains buried in websites that are not aimed at schools. As the head teacher of one Inner London secondary school puts it: “There has been no specific advice relating to the possible arrival of avian flu. The emphasis in the Healthy Schools promotion is on exercise and healthy eating.”
Or, as David Tuck, head teacher of Dallow Primary School in Luton, says: “We know that viruses spread quickly in schools and it’s an area where we can be proactive. Schools need advice on avian flu now.”
Advice to US schools on preventing the spread of germs
Take care to:
- Clean your hands often
- Cover your mouth and nose when coughing or sneezing
- Cough or sneeze into a tissue, then throw it away. Cover your cough or sneeze if you do not have a tissue. Then clean your hands, and do so every time you cough or sneeze.
- Wash your hands — with soap and warm water — for 15 to 20 seconds. That’s about the time it takes to sing the “Happy Birthday” song twice.
- Alcohol-based hand wipes and gel sanitisers work, too. If you are using gel, rub your hands until the gel is dry. The gel doesn’t need water to work — the alcohol in it kills the germs on your hands.
ADDITIONAL REPORTING BY FRASER NEWHAM
www.cdc.gov/flu/school/
www.timesonline.co.uk/birdflu
