Germ Fighters Student Illness Prevention Program

State: IA Type: Model Practice Year: 2005

The 2003-2004 flu season had the potential to cause severe morbidity and mortality due to cases seen early in the fall, widespread vaccine shortage, and antigenic drift between the vaccine strain and circulating strain. In response to the potential for a severe fu season, a pilot fu prevention program called Germ Fighter was initiated in a Johnson County elementary school. The school participated in disease prevention educational activities, and began using ethanol based hand sanitizer. Rates of absence due to communicable illness were recorded at the school conducting the intervention and then compared to the rates of absence due to illness at a school with similar characteristics. The interventions used in this study were successful in reducing the incidence of student absence due to illness at the pilot school. The elements of this program may be replicated in any elementary school setting, and may even be appropriate for preschool and secondary school levels.
For more than a decade, the influenza vaccine has been promoted as the best defense against influenza. The vaccine is most effective in preventing influenza illness when the vaccine strains are the same as strains circulating among the general population. However, widespread morbidity and mortality may result when vaccine is in short supply, the strain circulating does not match the vaccine, and/or influenza cases are seen in early fall. The 2003-2004 flu season met all of the criteria for an especially severe flu year. Influenza can have a significant impact on school-age children. Rates of student absenteeism during flu outbreaks are usually high and are used in the State of Iowa as a way to determine the level of flu activity in the state. The intervention used in this study involved traditional methods of disease prevention: education, proper hand sanitizing technique and timing, and disease awareness. A key component of this intervention was the use of ethanol based hand sanitizers in the classroom. This intervention is innovative because the use of alcohol based hand sanitizer has not been widely promoted for use in the classroom setting. However, antimicrobial effects of alcohol have been documented for over a century. In recent years, alcohol-based hand sanitizers have become part of standard hospital disinfections practices. Several studies have documented antimicrobial activity of alcohol against gram positive, gram-negative, and even multi-drug resistant pathogens. Many viruses are also susceptible to alcohol including herpes simplex, human immunodeficiency virus (HIV), influenza, respiratory syncytial virus, vaccine, hepatitis B, hepatitis C, rotavirus, adenovirus, and rhinovirus. Studies have also shown that preparations with alcohol concentrations of 60-90% are most effective. Hospital-based studies have shown that alcohol-based solutions have a greater reduction of bacterial contamination when compared to simple hand washing. However, alcohol-based solutions have limited lasting efficacy and cannot adequately cleanse visibly soiled hands. For these reasons, we believed the use of alcohol based hand gel in this intervention program would be beneficial.
Agency Community RolesJohnson County Public Health (JCPH) coordinated the development, implementation, and analysis of the program. The agency created partnerships with local retailers, schools, corporations, and county residents to acquire the tangible elements and implement the program. The partners in this practice had varying degrees of involvement in planning and implementation. The local retailers simply donated supplies. Schools and the corporation donating the hand sanitizer met with JCPH to outline the program duration and process of implementation. All entities were interested in results detailing the impact of the program on influenza-like illness and non influenza-like illness. The school was willing to give ongoing feedback about program materials and sanitizer use. The hand sanitizer corporation worked out the details of provision directly with the school. Once established, the school and sanitizer corporation developed a continuing relationship. The school's parent-teacher organization now provides funding for hand sanitizer throughout the school year. The sanitizer company uses the results of this program in addition to referrals from the school to promote its product to other schools in the area. The company has also continued to donate materials to JCPH.  Costs and ExpendituresCosts vary according to school size and duration of the program. Johnson County Public Health recently received a grant to replicate program materials. A packet of program materials including a CD was provided to every elementary principal in Johnson County. We also purchased materials to created Glo-GermTM kits for use in the local school districts, daycares, and preschools. Hand sanitizer was purchased in small amounts for several schools for use in the remainder of the school year. Other funding sources have included the donation of sanitizer for trial use from a local company, materials donations from local retailers, and the sponsorship of a parent-teacher organization (PTO). The most significant cost associated with this program is the hand sanitizer. Providing sanitizer for a school of 400 for one year may cost more than $1000 or approximately $3 per student. It has been our experience that schools may solicit donations of sanitizer from parents, put the item on their school supply list, or request the product be provided by their PTO.  ImplementationThe overall objective of the program is to reduce student absence due to communicable illness. Specific tasks enabling the success of the program included several things. First, educators, administrators, and parents were familiarized with the program elements through the use of guides for parents, educators, and administrators. These guides emphasized the symptoms, treatment, and isolation for common childhood ailments. The purpose was to create awareness of symptoms of communicable illness and to advise parents to keep ill students at home. The educators were encouraged to screen students for illness described in the guide and sent those meeting certain illness criteria to the school nurse for evaluation. The guide for educators and administrators also emphasized techniques for reducing contagion in the classroom. The educators and administrators were advised to limit group activities and assemblies when school absenteeism was 10% or greater. Second, students were part of a multifaceted education program with three components: lesson, hands on activity, and paper assignment. The students were verbally reminded of proper hand washing techniques and of the availability of hand sanitizer within the classroom. They were also introduced to basic disease concepts such as the routes of transmission for common bacterium and viruses. Then the students participated in a hands-on activity mimicking the spread of germs in the classroom. The students used GloGermTM invisible germs to demonstrate the spread of germs and whether they were able to wash their hands properly after being exposed to germs. The germs became visible using a black light bulb. Lastly, students completed a paper assignment reiterating the lessons taught in the verbal instruction and hands-on activity. The paper assignments were grade-specific and several different assignments were available for use throughout the school-year as a reminder of the initial lesson. Third, hand sanitizer was made available for students in the classroom. The purpose was to allow students the opportunity to cleanse their hands without leaving the classroom and in a non-disruptive manner. Careful use of the sanitizer was emphasized to prevent the emergence of resistant organisms. With respect to a timeline for carrying out tasks, first the educators, administrators, and parents were notified of the program. Then the students participated in the lessons. The hand sanitizer was made available at all times. This program may work best being implemented in early fall when respiratory communicable disease increases nationally, but will still likely be effective if started at the beginning of the school year. The program may be continued through the remainder of the school year.
To determine the efficacy of the tasks outlined in the Implementation section, a pilot program was conducted in 2004. Two schools participated in the program, one implemented the program in its entirety and another did no additional disease prevention activities. Rates of absence due to communicable illness were recorded at the school conducting the intervention and then compared to the rates of absence due to illness at the school with no intervention. The schools were similar in size, grade distribution, and demographic composition. The pilot program revealed that the interventions were successful in reducing the incidence of student absence due to illness at the pilot school. Very few challenges were encountered while carrying out the tasks of the program. Administrators were concerned about adverse reactions to hand sanitizer and potential dryness of hands due to overuse. Not one single instance of skin irritation was reported by the school widely using hand sanitizer. Possible explanations may be that the sanitizer used in the pilot program did not contain dyes or scents. Students did not complain of dry hands. Aloe in the sanitizer may have prevented that complication. Educators were concerned that the hand sanitizer would be a distraction in the classroom. Students were fairly enamored with it at first, but then fell into patterns of regular use.
SustainabilityThere is sufficient stakeholder commitment to perpetuate the practice. Schools desire to reduce the number of students absent from school. Sometimes school funding is based on attendance so a program improving attendance would definitely be advantageous. Parents are usually supportive of any practice that might prevent their child from missing school or becoming ill. An indirect incentive would include not missing work due to a child's illness. Lastly, students may realize the long-term incentive of learning appropriate disease prevention techniques to prevent illness. Many may adopt the concepts without realizing the true health benefits. However, making the program interesting and interactive hopefully promotes continued interest in the program. Sustaining the practice over time will simply require the reuse of existing materials. As students advance grade levels the program will be new to incoming students and may be continued for an unlimited number of years. Lessons LearnedThere were several lessons learned about the procedures and tasks in implementing the practice. Educators found it helpful to explain the use of hand sanitizer to prevent improper use. They also believed that adding these materials to their educational units on the human body worked well. Other lessons helpful to agencies seeking to adapt or replicate this practice include timing, community partnerships, and flexibility and creativity. With regard to timing, this program will have the greatest impact on student illness when student illness is at a peak. These periods include late fall through winter break and late January-early spring. It is helpful to introduce the program to school administrators before student illness peaks and to help schools outline their implementation of the program so that it may be started quickly in response to rising absenteeism. Community partnerships are vital to accomplishing the goals of this program. Local retailers may be able to donate supplies for Glo-Germ TM kits or hand sanitizer for classrooms. Schools willing to participate set the example for others to join. Parents may be able to help sponsor the program through parent-teacher organizations. Soliciting products and support were fruitful for us. Local retailers and corporations were very generous. Their donations even extended into the next year when the program was expanded to include every school in Johnson County.