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Volume 15, Number 1—January 2009

School Closure to Reduce Influenza Transmission

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To the Editor

Cowling et al. reported on the effects of school closure in Hong Kong, People’s Republic of China, during March 2008 in response to influenza-related deaths of children (1). The influenza epidemic started in January 2008 and peaked in late February, but the 2-week school closure did not begin until March 12. Consequently, the school-based epidemic was on the decline by the time officials closed schools. Other studies have suggested that early school closures can help reduce influenza illness in the community and among school children, especially during a pandemic (26). However, surveillance systems that rely on school absenteeism or deaths would likely provide information too late during the outbreak for school closure to effectively reduce influenza transmission.

The Centers for Disease Control and Prevention (CDC) has recommended early closure of schools as a community mitigation measure in the event of a severe pandemic (7). Specifically, CDC recommends rapidly initiating activities such as advising sick persons to stay home, dismissing children from schools, closing childcare facilities, and initiating further social distancing measures within a state or a community at the beginning of the upslope of a pandemic wave (acceleration interval), i.e., when cases are initially identified and community transmission begins to occur (8). We concur with the authors that the 2007–08 influenza season was already waning by the time the decision was made to close schools (deceleration interval).

School closure used as a single pandemic control measure is predicted to be less effective than early, concurrent use of multiple measures. Socially disruptive measures like early school closure and keeping children from congregating in the community would likely reduce community transmission of pandemic disease, but would also create secondary challenges (9,10). Therefore, to ensure maximal benefit for reducing disease transmission, interventions should be implemented early and concomitantly with other nonpharmaceutical and pharmaceutical measures, accompanied by public education, and used judiciously based on pandemic severity.


Lisa M. KooninComments to Author  and Martin S. Cetron

Author affiliations: Centers for Disease Control and Prevention, Atlanta, Georgia, USA



  1. Cowling  BJ, Lau  EH, Lam  CL, Cheng  CK, Kovar  J, Chan  KH, Effects of school closures, 2008 winter influenza season, Hong Kong. Emerg Infect Dis. 2008;14:16602. DOIPubMed
  2. Heymann  A, Chodick  G, Reichman  B, Kokia  E, Laufer  J. Influence of school closure on the incidence of viral respiratory diseases among children and on health care utilization. Pediatr Infect Dis J. 2004;23:6757. DOIPubMed
  3. Ferguson  NM, Cummings  DA, Fraser  C, Cajka  JC, Cooley  PC, Burke  DS. Strategies for mitigating an influenza pandemic. Nature. 2006;442:44852. DOIPubMed
  4. Glass  RJ, Glass  LM, Beyeler  WE, Min  HJ. Targeted social distancing design for pandemic influenza. Emerg Infect Dis. 2006;12:167181.PubMed
  5. Markel  H, Lipman  HB, Navarro  JA, Sloan  A, Michalsen  JR, Stern  AM, Nonpharmaceutical interventions implemented by US cities during the 1918–1919 influenza pandemic. JAMA. 2007;298:64454. DOIPubMed
  6. Hatchett  RJ, Mecher  CE, Lipsitch  M. Public health interventions and epidemic intensity during the 1989 influenza pandemic. Proc Natl Acad Sci U S A. 2007;104:75827. Epub 2007 April 6. DOIPubMed
  7. Centers for Disease Control and Prevention. Interim pre-pandemic planning guidance: community strategy for pandemic influenza mitigation in the United States—early, targeted, layered use of nonpharmaceutical interventions. Atlanta: The Centers; 2007.
  8. Federal guidance to assist states in improving state-level pandemic influenza operating plans. March 11, 2008 [cited 2008 Nov 26]. Available from
  9. Johnson  AJ, Moore  ZS, Edelson  PJ, Kinnane  L, Davies  M, Shay  DK, Household responses to school closure resulting from outbreak of influenza B, North Carolina. Emerg Infect Dis. 2008;14:102430. DOIPubMed
  10. Blendon  RJ, Koonin  LM, Benson  JM, Cetron  MS, Pollard  WE, Mitchell  EW, Public response to community mitigation measures for pandemic influenza. Emerg Infect Dis. 2008;14:77886. DOIPubMed


Cite This Article

DOI: 10.3201/eid1501.081289

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Table of Contents – Volume 15, Number 1—January 2009


Please use the form below to submit correspondence to the authors or contact them at the following address:

Lisa M. Koonin, Centers for Disease Control and Prevention, 1600 Clifton Rd NE, Mailstop A20, Atlanta, GA 30333, USA;

Benjamin J. Cowling, School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, 21 Sassoon Rd, Pokfulam, Hong Kong, People’s Republic of China;

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Page created: December 06, 2010
Page updated: December 06, 2010
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The conclusions, findings, and opinions expressed by authors contributing to this journal do not necessarily reflect the official position of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors' affiliated institutions. Use of trade names is for identification only and does not imply endorsement by any of the groups named above.