Prevention of Swine Influenza A (H1N1) in the Dental Healthcare Setting

The Centers for Disease Control and Prevention provides important and up-to-date information to the public and healthcare providers on the recent outbreak of swine influenza in humans. Interim CDC Guidance for Clinicians & Public Health Professionals regarding case identification, Infection Control for Care of Patients with Confirmed or Suspected Swine Influenza A (H1N1) Virus Infection in a Healthcare Setting, mask and respirator use, and other topics pertinent to dental healthcare providers can be found by going to the main CDC swine flu Web site at http://www.cdc.gov/swineflu/ in the section titled Guidance for Professionals. This information will be updated regularly and may change on a daily basis; check the Web site frequently.

Dental healthcare providers are urged to view the main CDC swine flu Web site for the latest updates, but Frequently Asked Questions from dental providers have been:

1. What to do if a patient presents for routine treatment and has acute respiratory symptoms with or without fever?

2. What to do if a patient with acute respiratory symptoms requires urgent dental care?

3. What to do if staff report to work with acute respiratory symptoms?

Overview

Prevention of Disease Transmission in the Dental Healthcare Setting

Patients with an acute respiratory illness may present for dental treatment at outpatient dental settings. The primary infection control goal is to prevent transmission of disease. Early detection of a suspected or confirmed case of swine influenza and prompt isolation from susceptible persons will reduce the risk of transmission. To prevent the transmission of respiratory infections in healthcare settings, including influenza, respiratory hygiene/cough etiquette infection control measures should be implemented at the first point of contact with a potentially infected person (http://www.cdc.gov/flu/professionals/infectioncontrol/resphygiene.htm).

Infection control issues during patient assessment:

· Patients with an acute respiratory illness should be identified at check-in and placed in a single-patient room with the door kept closed.

· Offer a disposable surgical mask to persons who are coughing, or provide tissues and no-touch receptacles for used tissue disposal.

· The ill person should wear a surgical mask when outside the patient room.

· Dental healthcare personnel assessing a patient with influenza-like illness should wear disposable surgical facemask*, non-sterile gloves, gown, and eye protection (e.g., goggles) to prevent direct skin and conjunctival exposure. These recommendations may change as additional information becomes available. Check the CDC swine flu Web site for updates at http://www.cdc.gov/swineflu/guidelines_infection_control.htm.

· Patient and dental healthcare workers should perform hand hygiene (e.g., hand washing with non-antimicrobial soap and water, alcohol-based hand rub, or antiseptic handwash) after having contact with respiratory secretions and contaminated objects/materials.

· Routine cleaning and disinfection strategies used during influenza seasons can be applied to the environmental management of swine influenza. More information can be found at http://www.cdc.gov/ncidod/dhqp/gl_environinfection.html.

*Until additional specific information is available regarding the behavior of swine influenza A (H1N1), the guidance provided in the October 2006 “Interim Guidance on Planning for the Use of Surgical Masks and Respirators in Healthcare Settings during an Influenza Pandemic” http://www.pandemicflu.gov/plan/healthcare/maskguidancehc.html is being recommended at this time, and is reflected in the above recommendations. These interim recommendations will be updated as additional information becomes available.

Frequently Asked Questions

Frequently Asked Questions

1) What to do if a patient presents for routine treatment and has acute respiratory symptoms with or without fever?

If the dentist suspects the illness could be due to swine influenza (symptoms include fever, body aches, runny nose, sore throat, nausea, or vomiting or diarrhea), elective dental treatment should be deferred and the patient should be advised to contact their general health care provider. The health care provider will determine whether influenza testing or treatment is needed. Refer to http://www.cdc.gov/swineflu/guidelines_infection_control.htm for case definition and other information.

2) What to do if a patient with acute respiratory symptoms requires urgent dental care?

If urgent dental care is required and swine influenza A (H1N1) has either been confirmed or is suspected, the care should be provided in a facility (e.g., hospital with dental care capabilities) that provides airborne infection isolation (i.e., airborne infection isolation room with negative pressure air handling with 6 to 12 air changes per hour).

For aerosol-generating procedures, use a procedure room with negative pressure air handling. Personnel providing direct patient care for suspected or confirmed swine influenza A (H1N1) cases should wear a fit-tested disposable N95 respirator when entering the patient room and when performing dental procedures. Respirator use should be in the context of a complete respiratory protection program in accordance with Occupational Safety and Health Administration (OSHA) regulations. Information on respiratory protection programs and fit test procedures can be accessed at www.osha.gov/SLTC/etools/respiratory.

3) What to do if staff report to work with acute respiratory symptoms?

· Staff experiencing influenza-like-illness (ILI) (fever with either cough or sore throat, muscle aches) should not report to work.

· Staff who experience ILI and wish to seek medical care should contact their health care providers to report illness (by telephone or other remote means) before seeking care at a clinic, physician’s office, or hospital.

· Staff who were not using appropriate personal protective equipment during close contact with a confirmed, probable, or suspect case of swine influenza A (H1N1) virus infection during the case’s infectious period should receive chemoprophylaxis according to CDC guidance (http://www.cdc.gov/swineflu/recommendations.htm).

· Staff who have difficulty breathing or shortness of breath, or are believed to be severely ill, should seek immediate medical attention.

Summary

Respiratory hygiene/cough etiquette infection control measures along with contact precautions are currently recommended for preventing transmission of swine influenza in a dental healthcare setting. CDC is working very closely with officials in states where human cases of swine influenza A (H1N1) have been identified, as well as with health officials in Mexico, Canada, and the World Health Organization. This is a rapidly evolving situation and CDC will provide updated guidance and new information as it becomes available.

I have a question you haven’t answered. How can I ask it?

SHARING INFORMATION

Q: What sort of information should school leaders share regarding this flu outbreak with

parents as well as teachers?

A: Many parents have already heard of the potential for H1N1 flu outbreaks through the media,

and as with many sensitive issues, misinformation is always a potential problem. School leaders

are trusted figures in a community and should continue to provide accurate, yet not inflammatory,

information about the spread of this virus, effects in the school community, and as well as

encourage students or staff to stay home if they are sick.

Q: Are school districts permitted to disclose information on affected students to local,

State, and Federal authorities in the case of a severe pandemic?

A: Balancing an individual’s privacy with public health is important, but there are provisions for

sharing such information appropriately between health and education authorities in the event of

an emergency. The Family Educational Rights and Privacy Act (FERPA) permits school officials

to disclose, without consent, education records, or personally identifiable information from

education records, to appropriate parties in connection with an emergency, if knowledge of that

information is necessary to protect the health or safety of the student or other individuals. ED

provides additional guidance on FERPA and emergencies flu-related emergencies at

http://www.ed.gov/admins/lead/safety/emergencyplan/pandemic/guidance/pan-flu-guidance.pdf.

School officials may contact ED’s Family Policy Compliance Office with any questions by calling

(202) 260-3887 or by e-mailing FERPA@ed.gov.

Q: I have a question you haven’t answered. How can I ask it?

A: E-mail ED’s Office of Safe and Drug Free Schools at flu@ed.gov. We will do our best to get

you an answer, and we will share the question and response here if we think there would be

broad interest. Don’t forget, though, that the best guidance on health questions comes from

physicians, health agencies and other experts. The Department of Education has relied on their

guidance to compile the information we’re providing here.

ONLINE RESOURCES FOR SCHOOLS REGARDING FLU and PUBLIC HEALTH

Centers for Disease Control and Prevention:

• H1N1 Flu updates: www.cdc.gov/swineflu

• Recommendations for affected schools and communities:

http://www.cdc.gov/swineflu/mitigation.htm

• Information on disease prevention and mitigation: http://www.cdc.gov/flu/school/

• The Centers for Disease Control and Prevention (CDC) Hotline (1-800-CDC-INFO) is

available in English and Spanish, 24 hours a day, seven days a week.

Pandemic Flu.Gov: www.pandemicflu.gov

• State pandemic influenza plans: http://www.pandemicflu.gov/plan/states/index.html

• Checklists for schools, communities, and individuals and families:

http://www.pandemicflu.gov/plan/checklists.html

Department of Education:

• Emergency planning for schools: www.ed.gov/emergencyplan

• Pandemic-specific planning information:

http://www.ed.gov/admins/lead/safety/emergencyplan/pandemic/index.htm

• Readiness and Emergency Management for Schools’ Technical Assistance Center:

http://rems.ed.gov

• Resources for teaching and learning online: http://www.free.ed.gov

• General information about WHO actions: http://www.who.int

Q: When should an infected child (or adult) be allowed to return to school?

that child should be sent home and advised to stay

home for seven days or 24 hours after symptoms subside if longer than seven days.

Q: We have a school trip to Mexico planned, and students and their families are planning

to travel to Mexico once school lets out for the summer. Should we cancel?

A: The CDC advises Americans to postpone and avoid all non-essential travel to Mexico until

further notice. More information: http://wwwn.cdc.gov/travel/contentSwineFluMexico.aspx.

Q: For schools in areas where migrant or seasonal workers are employed, are there

additional precautions that should be taken, particularly if those workers are from Mexico?

A: It’s important to remember—and to remind students, parents, and staff—that by their very

nature, viruses are indiscriminate and equal opportunity. No one has immunity to this particular

strain of influenza, so everyone is equally at risk of getting sick. Isolating, blaming, discriminating

against or otherwise singling out individuals or sub-groups of a school’s population is not helpful;

using common sense to prevent flu and monitoring for any symptoms is. School leaders should

be vigilant about preventing bullying and harassment in schools. Additional information on

bullying prevention can be found at: http://www.stopbullyingnow.org.

At any school, with any population, school health officials should assess risk and take action

appropriately. Schools should continue to maintain clean environments and encourage common-

sense preventive measures: wash hands, cover mouths when coughing, and avoid close contact.

School closure should be strongly considered where there is a confirmed case of H1N1 flu and

may be considered when there is an outbreak in the community

ISOLATING CONFIRMED FLU CASES

Q: When should an infected child (or adult) be allowed to return to school?

A: Students may come back to school after seven days or, if symptoms persist after seven days,

they should stay home for 24 hours after symptoms have been gone.

Q: Should special attention be made to cleaning our schools, in light of this outbreak?

A: School leaders should always uphold a high standard of cleanliness in their school buildings.

Schools should continue to clean frequently touched surfaces, such as desks, doorknobs, or

pencil sharpeners or, for younger children, toys or classroom manipulatives. Schools can use

standard products according to directions on the product label. It is not necessary to do extensive

cleaning of surfaces where it is not likely that children have touched, such as walls or the insides

of lockers, since it is not likely that children will spread germs from these surfaces.

Information about products shown to kill influenza A viruses can be found at:

http://www.epa.gov/oppad001/influenza-disinfectants.html.

Schools and parents should continue to promote careful hand- washing and covering one’s

mouth when coughing or sneezing.

Q: Should we hand out masks at school in the future?

A: If someone is coughing and sneezing and is suspected of being infected with H1N1 mask use

should be considered. But masks don’t entirely prevent the spread of viruses, particularly if they

are not fitted to the person wearing it. Students and staff with flu-like symptoms or confirmed

cases of the flu should isolate themselves at home, not put on a mask and continue to come to

school.

School nurses or those caring for sick students may want to consider wearing OSHA-approved

masks (also known as “respirators”). Guidance for health care workers can be found at:

http://www.pandemicflu.gov.

Are there resources available to help us start developing partnerships with community entities?

Frequently Asked Questions:

Q: When a school closes and students are dismissed, how long should the school remain

closed, and what exactly does that mean?

A: According to the CDC’s May 5th guidance, schools that have been closed can reopen.

Q: Why do experts think that reopening schools is the right step at this time, particularly

because the news reports more and more cases of H1N1 flu?

A: Initial cases in the United States were associated with travel to Mexico and many initial cases

occurred among school-aged students and were associated with school-based outbreaks. Based

on this initial information, CDC recommended school closure to lessen the risk of infection with

this novel influenza virus and protect members of the school community from a potentially severe

disease.

New information on disease severity led scientists to review the school closure guidance. The

majority of U.S. cases have been less severe than initially reported from Mexico with fewer

hospitalizations and deaths. CDC and local and state health officials will continue to closely

monitor the severity and spread of this novel H1N1 influenza outbreak.

CDC recommends as this time that the focus of school-based efforts should be on early

identification of ill students and staff, recommendation to stay home when ill, and good cough and

hand hygiene etiquette as the primary means to reduce spread of influenza in schools. Decisions

about school closure should be at the discretion of local authorities based on local considerations,

including public concern, the impact of school absenteeism, and staffing shortages.

Q: Are there resources to help me figure out how to discuss this situation with my

children?

A: Parents should first ask their children what they’ve heard and what they already know to help

address specific concerns and clarify or correct misinformation. It is important for parents to be

calm and reassuring and provide as much factually information is developmentally appropriate.

Additional FAQs for parents, as well as information about how to talk to your child about this

situation, can be found at: http://www.cdc.gov/h1n1flu/talkingtokids.htm and

http://www.nasponline.org/resources/Talking_With_Children_About_Flu_FINAL.pdf.

Q: What should schools do if standardized testing is planned but they have suspected

cases of H1N1 flu?

A: CDC does not recommend widespread school closure based on available scientific

information. However, if there is a sufficient number of students absent, the school may want to

consider pushing back testing, if at all possible.

Q: If this happens again and we have to close schools and dismiss students, should we

plan to continue educating students?

A: Many state and local educational agencies have been working on plans to consider educating

students in the event of a prolonged school closure. State pandemic plans may include

information about this, as may local plans. Educational resources are also available at

www.ed.gov.

Q: Are there resources available to help us start developing partnerships with community

entities?

A: Information on developing community resources to support youth can be found at

www.findyouthinfo.gov.

EXPOSURE TO MEXICO

Q: If a student took a vacation in Mexico recently, should the student be kept at home?

A: There is no reason to exclude a student from school merely because he or she has recently

visited Mexico. If, however, that student shows symptoms of influenza (fever above 37.8oC or

U.S. Department of Education

When should we send a student or staff member to the doctor?

Q: When should we send a student or staff member to the doctor?

A: Any individual with flu-like symptoms—fever above 37.8oC or 100oF accompanied by cough or

sore throat—should stay home or be sent home if they become ill at school. They may be

referred to a health professional if their symptoms worsen.

Q: What should we do if we have no cases in our community?

A: CDC recommends that schools and childcare facilities in unaffected areas begin developing or

reviewing their all-hazards plans, which should include considerations of infectious disease

outbreaks, including a potential future resurgence of H1N1 or other viruses. Many districts have

developed pandemic plans as part of their all-hazards planning efforts and are encouraged to

review those plans. If plans have not been developed, information on getting started can be found

at: http://www.ed.gov/admins/lead/safety/emergencyplan/pandemic/index.html,

http://rems.ed.gov, and www.pandemicflu.gov.

Schools and IHEs should always promote good hand-washing and hygiene practices, including

cough and sneezing etiquette and ensuring that tissues are disposed of after usage. Schools

should also regularly be sure to clean and disinfect any frequently touched surfaces, following

directions on manufacturer’s labels, particularly if students or faculty become ill at school. More

information on preventing the spread of influenza can be found at: http://www.cdc.gov/flu/school/.

Q: What steps should school leadership take when there is a confirmed or probable case

of H1N1 flu among students or staff on campus?

A: School leadership need not close schools for a suspected or probable case of H1N1.

However, schools should continue good health and hygiene practices around cleaning and

disinfecting frequently touched surfaces in the school environment, encouraging sick student and

staff to stay home, and actively encouraging good hand washing practices. It is also important to

communicate with your faculty, students, and families.

Q: What should school leaders do if a sibling of one of their students has a confirmed

case of the H1N1 flu (specifically, a sibling that attends another school)?

A: The current CDC guidance recommends that schools need not close to prevent the spread of

disease.

Q: Should we call this H1N1 flu or “swine flu”?

A: H1N1 is the name of this particular strain of influenza. Influenza strains often originate with

animals and get transmitted to humans. At this point in the progression of this strain, though,

transmission appears to be entirely from human to human. Although it appears to have originated

with pigs, then to have passed to humans working around pigs, the virus has combined with

components of other types of influenza, including avian and human strains of the virus, to create

this particular strain that appears to be easily passed from human to human, which is a concern.

The H1N1 virus is not transmitted by food. You cannot get this influenza from eating pork or pork

products. Eating properly handled and cooked pork and pork products is safe.

Q: Should we buy special products, like antibacterial soap or hand sanitizer?

A: Schools should always maintain adequate stock of personal hygiene products, including soap.

There is no need to purchase special anti-bacterial soap, as regular soap and warm water are

sufficient cleansers. Schools may consider purchasing alcohol-based hand gel, which can be

used if there is no visible dirt on hands, as long as the gel is alcohol-based. Schools should

consider the necessity of providing students adequate time to wash hands during the day,

particularly before mealtimes.

SCHOOL CLOSURE

U.S. Department of Education

GENERAL GUIDANCE FOR SCHOOL LEADERS

GENERAL GUIDANCE FOR SCHOOL LEADERS

Q: What should schools be doing now? Should we close our schools?

A: On May 5, 2009, the CDC changed its guidance to recommend to schools that school closures

are not warranted at this time. Schools that have cases do not need to close, and schools that

have closed can begin procedures to reopen. Students or staff sick with a suspected or confirmed

case of H1N1 should stay home for seven days, even if symptoms subside sooner than that. If

someone is sick longer than seven days, that person should stay home for 24 hours after

symptoms subside.

This guidance is based on the understanding of the current situation. It is important to check the

CDC Web site (http://www.cdc.gov) daily to check for updated guidance during this ongoing

situation.

Schools should continue developing relationships with their health departments and consider

implementing systems to track and potentially follow up on students who are absent from school

to determine if absences illness-related. These systems can sometimes provide a clue to school

and health officials that there may be high rates of illness in a community. These systems are

important not just for this specific situation, but for other outbreaks as well.

Flu symptoms include acute respiratory illness, such as fever greater than 37.8oC or 100oF, plus

cough or sore throat. Other possible symptoms are runny nose, feeling very lethargic, loss of

appetite, and in some cases, nausea, vomiting, and diarrhea. Most cases in the U.S. have

recovered, but at least one death has occurred.

States and local educational agencies can also use this opportunity to identify their authorities for

school closures if they do not already know them. Accordingly, local educational agencies, non-

public schools, and institutions of higher education (IHEs) should consult their state's pandemic

influenza plan for more information about these authorities, state-level planning, and coordination.

Information about state pandemic planning efforts can be found at:

http://www.pandemicflu.gov/plan/states/index.html.

If students are dismissed from schools or day care centers, schools should cancel all school-

related gatherings and encourage parents and students to avoid gathering outside of school,

including at malls, movies theaters, public libraries or friends’ houses in large groups.

Q: Should colleges and universities close if there is a suspected or confirmed case on

campus?

A: The CDC does not recommend widespread school closure at this time. However, institutions

of higher education (IHEs) should consult their all-hazards plans for decisions about how to

protect student health and safety. State-run IHEs should consult their state pandemic influenza

plans, which are posted at http://www.pandemicflu.gov/plan/states/index.html. The American

College Health Association has also created guidance on pandemic planning.

Q: We have students or staff in Mexico now, or who have been there recently. Should we

send them home?

A: There is no reason to exclude anyone from school merely because he or she has recently

visited Mexico. If, however, an individual shows symptoms of influenza (fever above 37.8oC or

100oF, accompanied by cough or sore throat), they should stay home for 7 days, or 24 hours

after symptoms subside, if longer than seven days. See below for more information about

exposure to Mexico.

U.S. Department of Education

H1N1 Flu & U.S. Schools: Answers to Frequently Asked Questions

The U.S. Department of Education last updated these FAQs

on May 5, 2009, at 6:00 PM ET.

Guidance is subject to change as the flu situation develops.

Check www.ED.gov for updates.

BACKGROUND

Starting almost two weeks ago, scientists became increasingly concerned about a new and

potentially severe form of influenza known as H1N1. Over the last week, H1N1 has spread widely

through the United States and the world. The outbreak of H1N1 has prompted school closures

and cancellation of school-related events over the last few weeks. As the flu spreads, the

Department of Education (ED) encourages school leaders, parents and students to know how to

take action to reduce the spread of the virus and report illness.

Surveying the country, the overall impact of H1N1 flu on schools in the United States has been

relatively small, so far. On Tuesday, May 5, 2009, more than 700 schools were closed for health

reasons. It is important to remember that there are 15,000 school districts and approximately

100,000 schools in the United States.

UPDATED GUIDANCE

Initial cases in the United States were associated with travel to Mexico, and many initial cases

occurred among school-aged students and were associated with school-based outbreaks. Based

on this initial information, the Centers for Disease Control and Prevention (CDC) recommended

school closure as an option to lessen the risk of infection with this novel influenza virus in order to

protect students, staff, parents and other caregivers from a potentially severe disease.

New information on disease severity prompted health experts to revise the school closure

guidance. The majority of U.S. cases have been less severe than initially reported from Mexico

with fewer hospitalizations and deaths. CDC and local and state health officials will continue to

closely monitor the severity and spread of this novel H1N1 influenza outbreak.

On May 5, 2009, CDC updated its guidance to reflect a more developed understanding of the

H1N1 virus. Based on this information, CDC changed its recommendation to focus school-based

efforts on early identification of ill students and staff, a recommendation to stay home when ill,

and good cough and hand hygiene etiquette as the primary means to reduce spread of influenza

in schools. Decisions about school closure should be at the discretion of local authorities based

on local considerations, including public concern, the impact of school absenteeism, and staffing

shortages.

But it is still essential that we all prepare and plan—especially at our schools. Do what is

appropriate for the health of your communities, your schools and your students, and rely on

guidance from the CDC. Even as this potential threat subsides, schools must be prepared for a

range of threats and hazards and develop “all-hazards” plans that address a variety of situations.

ED, in consultation with CDC and other federal public health experts, has attempted to answer

here some common questions about H1N1 that are circulating among members of the education

community. Remember that the best guidance on health questions comes from physicians, public

health agencies and other health experts. ED has relied on CDC guidance to compile the

information we are providing here, and we have provided Web links to their sites at the end of this

What is H1N1 influenza?

Massachusetts Department of Public Health, 250 Washington Street, Boston, MA 02108

What is H1N1 influenza?

H1N1 flu, also known as “swine flu,” is a respiratory disease caused by a type of influenza virus. There are several

different types of the “H1N1” flu virus. One type causes illness in pigs. Another type causes illness in people.

(Occasionally, the H1N1 virus from pigs can cause illness in humans and the H1N1 virus from pigs can cause

disease in humans.) Recently, a new type of H1N1 flu has been found to cause illness in people. Since March 2009,

there have been many cases of this new type of H1N1 flu in the United States and around the world.

What are the symptoms of the new H1N1 flu in people?

The new H1N1 flu causes symptoms very similar to seasonal flu. Just like seasonal flu, the most common symptoms

are fever, cough, and sore throat. They can also include body aches, headache, chills and feeling very tired. Some

people also have diarrhea and vomiting.

How would I know if I have the new H1N1 flu?

If you have symptoms of influenza, contact your healthcare provider. He or she will decide what type of testing

(if any) and treatment is right for you. Most people who are otherwise healthy, and who have mild illness, do

not need to be tested. Your healthcare provider may recommend testing if you are very ill or have a high risk of

complications with influenza (for example if you are over 65, immunosuppressed, or chronically ill). If you

think you might have H1N1 or seasonal flu and you need to see your health care provider, you should call ahead

and let them know you might have the flu. That way, precautions can be taken to avoid the spread of flu to

others.

How is the new H1N1 flu treated?

People sick with any type of flu should make sure to drink enough fluids, get plenty of rest, eat healthy foods,

wash hands frequently and stay home to avoid spreading the flu to other people. Drugs used to treat seasonal

flu, called antivirals, can also be used to treat the new H1N1 flu. A few influenza viruses, including H1N1, have

been resistant to some, but not all, of these drugs. Healthcare providers may recommend that people who are

sick with a flu-like illness receive an antiviral medication.

What if I live in or have recently been to an area where the new H1N1 flu in humans has been found?

If you live in or have recently traveled to an area affected by H1N1 flu, be watchful for any flu-like symptoms.

If you are experiencing any symptoms, stay home to avoid exposing others. Contact your healthcare provider

and he or she will decide what type of testing (if any) and treatment is right for you.

Is there a vaccine for the new H1N1 flu?

Right now there is no vaccine to protect against H1N1 influenza. According to U.S. Centers for Disease Control

and Prevention (CDC), it is unlikely that the vaccine for seasonal flu will prevent the new H1N1 flu. However,

the federal government is working with vaccine manufacturers to develop a vaccine that is expected to be

available in several months.

How can I protect myself and others from the new H1N1 flu?

You can protect yourself and others from the new H1N1 flu the same way that you protect yourself from

seasonal flu. Avoid holding, hugging, kissing, or shaking hands with anyone who has a cold or the flu. Wash

your hands often with soap and warm water, or use an alcohol-based hand sanitizer. Avoid touching your nose,

mouth or eyes. Clean things that are touched often like door handles, telephones, faucets, etc. If you get sick

with a flu-like illness stay home from work and school and avoid contact with others so the virus does not

spread.