title: Variability in school closure decisions in response to 2009 H1N1: a qualitative systems improvement analysis.
abstract: BACKGROUND
  School closure was employed as a non-pharmaceutical intervention against pandemic 2009 H1N1, particularly during the first wave. More than 700 schools in the United States were closed. However, closure decisions reflected significant variation in rationales, decision triggers, and authority for closure. This variability presents the opportunity for improved efficiency and decision-making.
  
  
  METHODS
  We identified media reports relating to school closure as a response to 2009 H1N1 by monitoring high-profile sources and searching Lexis-Nexis and Google news alerts, and reviewed reports for key themes. News stories were supplemented by observing conference calls and meetings with health department and school officials, and by discussions with decision-makers and community members.
  
  
  RESULTS
  There was significant variation in the stated goal of closure decision, including limiting community spread of the virus, protecting particularly vulnerable students, and responding to staff shortages or student absenteeism. Because the goal of closure is relevant to its timing, nature, and duration, unclear rationales for closure can challenge its effectiveness. There was also significant variation in the decision-making authority to close schools in different jurisdictions, which, in some instances, was reflected in open disagreement between school and public health officials. Finally, decision-makers did not appear to expect the level of scientific uncertainty encountered early in the pandemic, and they often expressed significant frustration over changing CDC guidance.
  
  
  CONCLUSIONS
  The use of school closure as a public health response to epidemic disease can be improved by ensuring that officials clarify the goals of closure and tailor closure decisions to those goals. Additionally, authority to close schools should be clarified in advance, and decision-makers should expect to encounter uncertainty disease emergencies unfold and plan accordingly.
authors.affiliation: Jefferson University School of Population Health, 105 Walnut Street, Philadelphia, Pennsylvania 19107, USA.
authors.forename: Tamar
authors.initials: T
authors.lastname: Klaiman
authors.forename: John D
authors.initials: JD
authors.lastname: Kraemer
authors.forename: Michael A
authors.initials: MA
authors.lastname: Stoto
mesh_terms: D003140:Communicable Disease Control / Q000379:methods; D003657:Decision Making; D004196:Disease Outbreaks / Q000517:prevention & control*; D006801:Humans; D053118:Influenza A Virus, H1N1 Subtype; D007251:Influenza, Human / Q000453:epidemiology*; D008402:Mass Media; D011640:Public Policy; D012574:Schools / Q000458:organization & administration*; D014481:United States / Q000453:epidemiology