This morning I got a call from one of the leading people working in the dengue outbreak operation center, asking for my opinion regarding closure of the schools. Request and pressure for school closure from parents and the community as well as the school management is a common happening in the Maldives and perhaps other parts of the world during disease outbreaks. Ministries of Education and Health find themselves in a difficult position in taking a decision on it. This is an issue related to an effective and timely risk communication.
Closure of school is in fact one of the strategies in minimizing disease transmission during some outbreaks, where there is a role of social distancing in minimizing transmission. Examples of these include recent H1N1 outbreak and SARS. Even during such outbreaks, school closure at the peak or during the downward slope of the epidemic curve may not have much beneficial effect from a public health perspective, as community wide transmission of the virus would have already taken place and school closure might not have much beneficial effect on reducing further transmission.
There is no direct role of such social distancing measures in dengue prevention, and hence it usually is not a public health advice to close down schools during dengue outbreaks. Dengue prevention depends on mosquito control and bite prevention. Moreover, during the peak biting times of the Aedes mosquito (dawn and dusk) students are at home or in the community. As Aedes is usually a day biter, and considering the fact that Aedes mosquito is abundantly seen in most of the houses in the Maldives (due to poor individual efforts to control mosquito), the time spend in school could provide better protection than staying home, if appropriate measures are taken like eliminating breeding sources in and around the school (including neighbouring buildings and houses), killing adult mosquitoes within school premises and bite protection. This however, is a general statement, as some of the students would have come from families where stringent measures and care is being taken to protect from mosquitoes.
The other issue that needs to be considered seriously is, how and where students spend their day when school is closed. Taking a scenario where they stay indoor or home, there would be no protection if there were mosquitoes in around home. This becomes even more important when there is a family member or a neighbour having dengue fever. The higher risk is due to the high possibility of mosquitoes carrying the virus from the sick individual and transmitting to healthy people. Taking a different scenario where students get together in the neighbourhood or play grounds or any other place, the whole purpose of school closure during any outbreak would be defeated. In case of dengue, presence of mosquitoes in such places put students in additional risk.
Hence, there is no public health justification to recommend school closure during the current dengue outbreak. The decision whether to close or not, should be purely a managerial decision. If there is a large percentage of either students or teachers having the disease and the high absenteeism carries no meaning in continuing the school, then on that ground, the management could close the school.
My view is that there is an opportunity during this outbreak to strengthen health education and mosquito control measures rather than closing the schools, as students and teachers would be more alert and aware of the disease. Students should be taught on measures they can take as individuals on bite prevention as well as their role and responsibility at home and community on mosquito control efforts. They could be effectively used as positive behavioural change ambassadors. This would help build their self-esteem, as they will get the satisfaction of contributing to the family, community and the nation during an emergency.