Control Of Influenza Outbreaks Research Articles

Epidemiologic characteristics and influencing factors of influenza outbreaks in Guangdong Province, 2015-2022

Objective: To grasp the epidemiological characteristics of influenza outbreaks in Guangdong Province by analyzing the outbreaks of influenza-like cases reported in Guangdong Province from January 2015 to the end of August 2022. Methods: In response to the outbreak of epidemics in Guangdong Province from 2015 to 2022, information on on-site epidemic control was collected, and epidemiological analysis was conducted to describe the characteristics of the epidemics. The factors that influence the intensity and duration of the outbreak were determined through a logistic regression model. Results: A total of 1 901 influenza outbreaks were reported in Guangdong Province, with an overall incidence of 2.05%. Most outbreak reports occurred from November to January of the following year (50.24%, 955/1 901) and from April to June (29.88%, 568/1 901). A total of 59.23% (1 126/1 901) of the outbreaks were reported in the Pearl River Delta region, and primary and secondary schools were the main places where outbreaks occurred (88.01%, 1 673/1 901). Outbreaks with 10-29 cases were the most common (66.18%, 1 258/1 901), and most outbreaks lasted less than seven days (50.93%,906/1 779). The size of the outbreak was related to the nursery school (aOR=0.38, 95%CI:0.15-0.93), the Pearl River Delta region (aOR=0.60, 95%CI:0.44-0.83), the time interval between the onset of the first case and the time of report (>7 days compared with ≤3 days: aOR=3.01, 95%CI:1.84-4.90), the influenza A(H1N1) (aOR=2.02, 95%CI:1.15-3.55) and the influenza B (Yamagata) (aOR=2.94, 95%CI: 1.50-5.76). The duration of outbreaks was related to school closures (aOR=0.65, 95%CI: 0.47-0.89), the Pearl River Delta region (aOR=0.65, 95%CI: 0.50-0.83) and the time interval between the onset of the first case and the time of report (>7 days compared with ≤3 days: aOR=13.33, 95%CI: 8.80-20.19; 4-7 days compared with ≤3 days: aOR=2.56, 95%CI: 1.81-3.61). Conclusions: An influenza outbreak in Guangdong Province exhibits two peaks, one in the winter and spring seasons and the other in the summer. Primary and secondary schools are high-risk areas, and early reporting of outbreaks is critical for controlling influenza outbreaks in schools. Furthermore, comprehensive measures should be taken to prevent the spread of the epidemic.

IRF7-deficient MDCK cell based on CRISPR/Cas9 technology for enhancing influenza virus replication and improving vaccine production.

The influenza virus is a cause of seasonal epidemic disease and enormous economic injury. The best way to control influenza outbreaks is through vaccination. The Madin-Darby canine kidney cell line (MDCK) is currently approved to manufacture influenza vaccines. However, the viral load from cell-based production is limited by host interferons (IFN). Interferon regulating factor 7 (IRF7) is a transcription factor for type-I IFN that plays an important role in regulating the anti-viral mechanism and eliminating viruses. We developed IRF7 knock-out MDCK cells (IRF7−/ − MDCK) using CRISPR/Cas9 technology. The RNA expression levels of IRF7 in the IRF7−/ − MDCK cells were reduced by 94.76% and 95.22% under the uninfected and infected conditions, respectively. Furthermore, the IRF7 protein level was also significantly lower in IRF7−/ − MDCK cells for both uninfected (54.85% reduction) and viral infected conditions (32.27% reduction) compared to WT MDCK. The differential expression analysis of IFN-related genes demonstrated that the IRF7−/ − MDCK cell had a lower interferon response than wildtype MDCK under the influenza-infected condition. Gene ontology revealed down-regulation of the defense response against virus and IFN-gamma production in IRF7−/ − MDCK. The evaluation of influenza viral titers by RT-qPCR and hemagglutination assay (HA) revealed IRF7−/ − MDCK cells had higher viral titers in cell supernatant, including A/pH1N1 (4 to 5-fold) and B/Yamagata (2-fold). Therefore, the IRF7−/ − MDCK cells could be applied to cell-based influenza vaccine production with higher capacity and efficiency.

Specific therapy and emergency prevention of flu

Influenza A and B epidemics, occasionally pandemics, are characterized by high morbidity and mortality rates. In most cases, an uncomplicated disease ends with recovery, but unfavorable outcomes, up to lethal, are possible, especially in premature, low birth weight, infants and young children, old people, pregnant and postpartum women, with chronic diseases, immunocompromised, receiving salicylates and anticoagulants. The use of modern diagnostic methods allows early detection of patients with influenza, distinguishing them from the total number of patients with respiratory infections. This allows you to optimize the timing of the examination, avoid unnecessary prescription of antibiotics, and timely prescribe specific chemotherapy and chemoprophylaxis. During epidemics, in the presence of an epidemiological history, the conclusion of the clinician is decisive for the diagnosis. Vaccination is an excellent method of preventing or relieving the flu. However, in case of an unfavorable course of the disease, in risk groups, in closed groups, it is recommended to use chemotherapy, pre-exposure or post-exposure chemoprophylaxis. Numerous studies have proven the effectiveness of the use of the drug oseltamivir, a specific blocker of the virus neuraminidase. As a result, its replication stops. The drug does not complicate the vaccination, it can be used in vaccinated people, in all age groups, is available in different dosages, and can be used with food. Treatment for uncomplicated influenza lasts 5 days. In certain situations, chemoprophylaxis and chemotherapy with the specific antiviral drug oseltamivir can help control influenza outbreaks in certain populations.

Influenza A (H1N1)pdm09 outbreak of unknown source in a Ghanaian senior high school

BackgroundInfluenza is an acute viral respiratory tract infection caused by influenza virus and transmitted from person to person. Though usually seasonal in temperate climates, influenza occurs throughout the year in the tropics with outbreaks occurring at irregular intervals. On February 6, 2018, a number of students from a Senior High School (SHS) in Accra reported to a district hospital with cough, fever and other respiratory symptoms. An influenza-like illness (ILI) outbreak was suspected. We investigated to determine the magnitude and source of the outbreak and implement control and preventive measures.MethodsWe interviewed health workers, staff and students of the school as well as case-patients and reviewed health records to collect data on demographic characteristics, signs and symptoms, date of illness onset and outcome. We defined ILI case as “any person in the SHS with fever (measured axillary temperature of ≥ 37.5 °C or history of fever) and cough with or without sore throat or runny nose from January 21 to February 26, 2018”. We conducted active case search to identify more cases and took oropharyngeal samples for laboratory testing. We performed descriptive and inferential analysis by calculating attack rate ratios (ARR) and their exact 95% confidence intervals (CI).ResultsOf the 3160 students, 104 case-patients were recorded from January 25, 2018 to February 13, 2018 (overall attack rate of 3.3%). Mean age of case-patients was 16.1 (±2.3) years with males constituting 71.2% (74/104). Sex specific attack rates were 5.6% (74/1331) and 1.6% (30/1829) for males and females respectively. Compared to females, males were 3.4 times as likely to be ill [ARR =3.4, 95%CI = (2.23–5.15)]. Nine oropharyngeal samples from 17 suspected case-patients tested positive for influenza A (H1N1)pdm09.ConclusionOutbreak of influenza A (H1N1)pdm09 occurred in a SHS in Accra from January to February, 2018. Even though source of the outbreak could not be determined, prompt case management and health education on hand and personal hygiene as non-pharmacological factors probably contributed to the outbreak control. The outbreak ended with a scheduled mid-term break. This underscores the need for more evidence on the effect of school closure in influenza outbreak control.

Humidity as a non-pharmaceutical intervention for influenza A

Influenza is a global problem infecting 5–10% of adults and 20–30% of children annually. Non-pharmaceutical interventions (NPIs) are attractive approaches to complement vaccination in the prevention and reduction of influenza. Strong cyclical reduction of absolute humidity has been associated with influenza outbreaks in temperate climates. This study tested the hypothesis that raising absolute humidity above seasonal lows would impact influenza virus survival and transmission in a key source of influenza virus distribution, a community school. Air samples and objects handled by students (e.g. blocks and markers) were collected from preschool classrooms. All samples were processed and PCR used to determine the presence of influenza virus and its amount. Additionally samples were tested for their ability to infect cells in cultures. We observed a significant reduction (p < 0.05) in the total number of influenza A virus positive samples (air and fomite) and viral genome copies upon humidification as compared to control rooms. This suggests the future potential of artificial humidification as a possible strategy to control influenza outbreaks in temperate climates. There were 2.3 times as many ILI cases in the control rooms compared to the humidified rooms, and whether there is a causal relationship, and its direction between the number of cases and levels of influenza virus in the rooms is not known. Additional research is required, but this is the first prospective study suggesting that exogenous humidification could serve as a scalable NPI for influenza or other viral outbreaks.

Simulation of key interventions for seasonal influenza outbreak control at school in Changsha, China.

ObjectiveTo use a mathematical model to simulate an influenza outbreak in a school in order to assess the effectiveness of isolation (Iso), antiviral therapeutics, antiviral prophylactics (P), vaccination prior to the outbreak, and school closure (for 1 [S1w], 2 or 3 weeks).MethodsThis study developed a susceptible–exposed–infectious/asymptomatic–recovered model to estimate the effectiveness of commonly used interventions for seasonal influenza outbreaks in school.ResultsThe most effective single-intervention strategy was isolation with a total attack rate of 1.99% and an outbreak duration of 30 days. The additional effectiveness of antiviral therapeutics and prophylactics and vaccination (prior to the outbreak) strategies were not obvious. Although Iso+P, P+Iso+S1w, four-, and five-combined intervention strategies had commendable effectiveness, total attack rate decreased only slightly, and outbreak duration was shortened by 9 days maximum, compared with the single-intervention isolation strategy. School closure for 1, 2 or 3 weeks was futile or even counterproductive.ConclusionIsolation, as a single intervention, was the most effective in terms of reducing the total attack rate and the duration of the outbreak.

Newcastle disease virus-based H5 influenza vaccine protects chickens from lethal challenge with a highly pathogenic H5N2 avian influenza virus

Since December 2014, Eurasian-origin, highly pathogenic avian influenza H5 viruses including H5N1, H5N2, and H5N8 subtypes (called H5Nx viruses), which belong to the H5 clade 2.3.4.4, have been detected in U.S. wild birds. Subsequently, highly pathogenic H5N2 and H5N8 viruses have caused outbreaks in U.S. domestic poultry. Vaccination is one of the most effective ways to control influenza outbreaks and protect animal and public health. Newcastle disease virus (NDV)-based influenza vaccines have been demonstrated to be efficacious and safe in poultry. Herein, we developed an NDV-based H5 vaccine (NDV-H5) that expresses a codon-optimized ectodomain of the hemagglutinin from the A/chicken/Iowa/04-20/2015 (H5N2) virus and evaluated its efficacy in chickens. Results showed that both live and inactivated NDV-H5 vaccines induced hemagglutinin inhibition antibody titers against the H5N2 virus in immunized chickens after prime and booster, and both NDV-H5 vaccines completely protected chickens from lethal challenge with the highly pathogenic H5N2 A/turkey/Minnesota/9845-4/2015 virus. No clinical signs and only minimal virus shedding was observed in both vaccinated groups. In contrast, all mock-vaccinated, H5N2-infected chickens shed virus and died within 5 days post challenge. Furthermore, one dose of the live NDV-H5 vaccine also provided protection of 90% chickens immunized by coarse spraying; after exposure to H5N2 challenge, sera from vaccinated surviving chickens neutralized both highly pathogenic H5N1 and H5N8 viruses. Taken together, our results suggest that the NDV-based H5 vaccine is able to protect chickens against intercontinental highly pathogenic H5Nx viruses and can be used by mass application to protect the poultry industry.

Outbreak detection and evaluation of a school-based influenza-like-illness syndromic surveillance in Tianjin, China.

School-based influenza-like-illness (ILI) syndromic surveillance can be an important part of influenza community surveillance by providing early warnings for outbreaks and leading to a fast response. From September 2012 to December 2014, syndromic surveillance of ILI was carried out in 4 county-level schools. The cumulative sum methods(CUSUM) was used to detect abnormal signals. A susceptible-exposed-infectious/asymptomatic-recovered (SEIAR) model was fit to the influenza outbreak without control measures and compared with the actual influenza outbreak to evaluate the effectiveness of early control efforts. The ILI incidence rates in 2014 (14.51%) was higher than the incidence in 2013 (5.27%) and 2012 (3.59%). Ten school influenza outbreaks were detected by CUSUM. Each outbreak had high transmissibility with a median Runc of 4.62. The interventions in each outbreak had high effectiveness and all Rcon were 0. The early intervention had high effectiveness within the school-based ILI syndromic surveillance. Syndromic surveillance within schools can play an important role in controlling influenza outbreaks.

Evaluation of the use of oseltamivir prophylaxis in the control of influenza outbreaks in long-term care facilities in Alberta, Canada: a retrospective provincial database analysis

ObjectivesTo evaluate the impact of oseltamivir prophylaxis in the management and control of influenza outbreaks in long-term care facilities in Alberta, Canada.Setting and participantsLong-term care facilities where 127 influenza outbreaks...

Baculovirus Displaying Hemagglutinin Elicits Broad Cross-Protection against Influenza in Mice.

The widespread influenza virus infection further emphasizes the need for novel vaccine strategies that effectively reduce the impact of epidemic as well as pandemic influenza. Conventional influenza vaccines generally induce virus neutralizing antibody responses which are specific for a few antigenically related strains within the same subtype. However, antibodies directed against the conserved stalk domain of HA could neutralize multiple subtypes of influenza virus and thus provide broad-spectrum protection. In this study, we designed and constructed a recombinant baculovirus-based vaccine, rBac-HA virus, that expresses full-length HA of pandemic H1N1 influenza virus (A/California/04/09) on the viral envelope. We demonstrated that repeated intranasal immunizations with rBac-HA virus induced HA stalk-specific antibody responses and protective immunity against homologous as well as heterosubtypic virus challenge. The adoptive transfer experiment shows that the cross-protection is conferred by the immune sera which contain HA stalk-specific antibodies. These results warrant further development of rBac-HA virus as a broad-protective vaccine against influenza. The vaccine induced protection against infection with the same subtype as well as different subtype, promising a potential universal vaccine for broad protection against different subtypes to control influenza outbreaks including pandemic.

Influenza virus vaccine for neglected hosts: horses and dogs.

This study provides information regarding vaccine research and the epidemiology of influenza virus in neglected hosts (horses and dogs). Equine influenza virus (EIV) causes a highly contagious disease in horses and other equids, and outbreaks have occurred worldwide. EIV has resulted in costly damage to the horse industry and has the ability of cross the host species barrier from horses to dogs. Canine influenza is a virus of equine or avian origin and infects companion animals that live in close contact with humans; this results in possible exposure to the seasonal epizootic influenza virus. There have been case reports of genetic reassortment between human and canine influenza viruses, which results in high virulence and the ability of transmission to ferrets. This emphasizes the need for vaccine research on neglected hosts to update knowledge on current strains and to advance technology for controlling influenza outbreaks for public health.

Keys to Control Influenza Outbreaks in Long-Term Care Facilities

Keys to Control Influenza Outbreaks in Long-Term Care Facilities

Characterization of T cell responses induced by Flu SAM(NP)® and SAM(M1)® vaccines (VAC5P.1124)

Abstract Vaccination remains the most cost-effective way to control Influenza outbreaks. However, current Influenza vaccines do not provide efficacious heterosubtypic immunity. Therefore, the development of a successful universal vaccination strategy is urgently needed. To achieve this goal, one approach is focused on the induction of a T cell based response versus more conserved flu antigens, such as the Nucleoprotein (NP) and the Matrix protein 1 (M1). The aim of this study was to evaluate the immunogenicity and protective efficacy conferred by conserved NP and M1 antigens expressed by a self-amplifying RNA-based vaccine (SAM(NP)® and SAM(M1)®). We demonstrate that SAM(NP)® and SAM(M1)® are immunogenic in Balb/c mice. SAM(NP)® formulation induced IFNγ+ and LAMP1+ NP-specific cytotoxic CD8+ T cells as well as multifunctional NP-specific CD4+ T cells. SAM(M1) ® elicited a robust polyfunctional CD4 T helper 1 response. Moreover, we show that SAM(NP)® and SAM(M1)® formulations, when administered separately or in combination, provided differential levels of protection against a lethal challenge with mouse-adapted A/PR/8/1934 (H1N1) Influenza virus. SAM(NP)® and SAM(M1)® formulation induced T cell immune responses, potent mediator of heterosubtypic immunity, therefore, they are promising antigens in the design of a cross-protective flu vaccine. Since the SAM® vaccine technology offers several advantages , it could potentially speed up the development of universal flu vaccine candidates.

Error-prone pcr-based mutagenesis strategy for rapidly generating high-yield influenza vaccine candidates

Vaccination is the primary strategy for the prevention and control of influenza outbreaks. However, the manufacture of influenza vaccine requires a high-yield seed strain, and the conventional methods for generating such strains are time consuming. In this study, we developed a novel method to rapidly generate high-yield candidate vaccine strains by integrating error-prone PCR, site-directed mutagenesis strategies, and reverse genetics. We used this method to generate seed strains for the influenza A(H1N1)pdm09 virus and produced six high-yield candidate strains. We used a mouse model to assess the efficacy of two of the six candidate strains as a vaccine seed virus: both strains provided complete protection in mice against lethal challenge, thus validating our method. Results confirmed that the efficacy of these candidate vaccine seed strains was not affected by the yield-optimization procedure.

Guidance for practitioners on the use of antiviral drugs to control influenza outbreaks in long-term care facilities in Canada, 2014-2015 season.

The AMMI Canada Guidelines document 'The use of antiviral drugs for influenza: A foundation document for practitioners', published in the Autumn 2013 issue of the Journal, outlines the recommendations for the use of antiviral drugs to treat influenza. This article, which represents the first of two updates to these guidelines published in the current issue of the Journal, aims to inform health care professionals of the increased risk for influenza in long-term care facilities due to a documented mismatch between the components chosen for this season's vaccine and currently circulating influenza strains. Adjusted recommendations for the use of antiviral drugs for influenza in long-term care facilities for this season are provided.

Intranasal adenovirus-vectored vaccine for induction of long-lasting humoral immunity-mediated broad protection against influenza in mice.

Influenza vaccines aimed at inducing antibody (Ab) responses against viral surface hemagglutinin (HA) and neuraminidase (NA) provide sterile immunity to infection with the same subtypes. Vaccines targeting viral conserved determinants shared by the influenza A viruses (IAV) offer heterosubtypic immunity (HSI), a broad protection against different subtypes. We proposed that vaccines targeting both HA and the conserved ectodomain of matrix protein 2 (M2e) would provide protection against infection with the same subtype and also HSI against other subtypes. We report here that single intranasal immunization with a recombinant adenovirus (rAd) vector encoding both HA of H5 virus and M2e (rAdH5/M2e) induced significant HA- and M2e-specific Ab responses, along with protection against heterosubtypic challenge in mice. The protection is superior compared to that induced by rAd vector encoding either HA (rAdH5), or M2e (rAdM2e). While protection against homotypic H5 virus is primarily mediated by virus-neutralizing Abs, the cross-protection is associated with Abs directed to conserved stalk HA and M2e that seem to have an additive effect. Consistently, adoptive transfer of antisera induced by rAdH5/M2e provided the best protection against heterosubtypic challenge compared to that provided by antisera derived from mice immunized with rAdH5 or rAdM2e. These results support the development of rAd-vectored vaccines encoding both H5 and M2e as universal vaccines against different IAV subtypes. Current licensed influenza vaccines provide protection limited to the infection with same virus strains; therefore, the composition of influenza vaccines has to be revised every year. We have developed a new universal influenza vaccine that is highly efficient in induction of long-lasting cross-protection against different influenza virus strains. The cross-protection is associated with a high level of vaccine-induced antibodies against the conserved stalk domain of influenza virus hemagglutinin and the ectodomain of matrix protein. The vaccine could be used to stimulate cross-protective antibodies for the prevention and treatment of influenza with immediate effect for individuals who fail to respond to or receive the vaccine in due time. The vaccine offers a new tool to control influenza outbreaks, including pandemics.

Mechanisms of action and efficacy of statins against influenza.

The influenza virus (IV) is known to be a resistant virus with frequent mutations, causing severe respiratory diseases in the upper respiratory system. Public health concerns about clinical efficacy of all conventional drugs are ambiguous; therefore, finding additional therapeutic agents is critical to prevent and control influenza outbreaks. Influenza is associated with the induction of proinflammatory cytokines. Scientists have reported that anti-inflammatory drugs, with pleiotropic effects, reduce the burden of severe influenza diseases. Therefore, statins, which are cardioprotective drugs with anti-inflammatory and immunomodulatory effects, may help patients suffering from influenza virus (IV). This review delineates the potential use of statins as an alternative therapy in treating influenza related illness.

Influenza outbreak control practices and the effectiveness of interventions in long‐term care facilities: a systematic review

BackgroundEvaluation of influenza control measures frequently focuses on the efficacy of chemoprophylaxis and vaccination, while the effectiveness of non-pharmaceutical interventions (NPI) receives less emphasis. While influenza control measures are frequently reported for individual outbreaks, there have been few efforts to characterize the real-world effectiveness of these interventions across outbreaks.ObjectivesTo characterize influenza case and outbreak definitions and control measures reported by long-term care facilities (LTCFs) of elderly adults and estimate the reduction in influenza-like illness (ILI) attack rates due to chemoprophylaxis and NPI.MethodsWe conducted a literature search in PubMed including English-language studies reporting influenza outbreaks among elderly individuals in LTCFs. A Bayesian hierarchical logistic regression model estimated the effects of control measures on ILI attack rates.ResultsOf 654 articles identified in the literature review, 37 articles describing 60 influenza outbreaks met the inclusion criteria. Individuals in facilities where chemoprophylaxis was used were significantly less likely to develop influenza A or B than those in facilities with no interventions [odds ratio (OR) 0·48, 95% CI: 0·28, 0·84]. Considered by drug class, adamantanes significantly reduced infection risk (OR 0·22, 95% CI: 0·12, 0·42), while neuraminidase inhibitors did not show a significant effect. Although NPI showed no significant effect, the results suggest that personal protective equipment may produce modest protective effects.ConclusionsOur results indicate pharmaceutical control measures have the clearest reported protective effect in LTCFs. Non-pharmaceutical approaches may be useful; however, most data were from observational studies and standardized reporting or well-conducted clinical trials of NPI are needed to more precisely measure these effects.

Effective School Actions for Mitigating Seasonal Influenza Outbreaks in Niigata, Japan

BackgroundJapan has implemented various school actions during seasonal influenza outbreaks since the 1950's under the School Health Law. However, the effective duration, extent, and timing of closures remain unresolved.Materials and MethodsWe conducted a retrospective study on the relationship between elementary class closures and influenza outbreak control during four consecutive influenza seasons from the 2004-2005 to 2007-2008 school years in Joetsu, Niigata, Japan. Among a total of 1,061 classes of 72 schools, 624 cases of influenza outbreaks were documented among 61 schools.ResultsClass closures were carried out in a total of 62 cases in response to influenza outbreak, which was defined as a student absentee rate of greater than 10% due to influenza or influenza-like illness. Of these cases, two-day class closures were conducted the day after reaching a 10% student absentee rate in 28 cases and other types of closures were initiated in 34 cases. A markedly higher number of outbreak cases ended within one week for two-day class closures compared to the other types of closures (82.1% vs. 20.6%, respectively). The significant association between two-day class closures and interruption of an outbreak within one week was confirmed using a multivariable model adjusted for the season, grade, day of the week of an outbreak start, and absentee rate on the day of an outbreak start (OR, 3.18; 95% CI, 1.12–9.07; p = 0.030).ConclusionsOur results suggest that a two-day class closure carried out the day after reaching a 10% absentee rate is an effective approach for mitigating influenza outbreaks in elementary schools.

Knowledge, Attitudes, and Practices of School Personnel Regarding Influenza, Vaccinations, and School Outbreaks

School personnel are important for communicating with parents about school vaccination programs and recognizing influenza outbreaks. This study examined knowledge, attitudes, and practices of school personnel regarding seasonal and 2009 H1N1 influenza, vaccinations, and school outbreak investigations. Data were analyzed from survey interviews of 58 elementary and middle school personnel in 2010. Principals, assistant principals, and nurses have higher knowledge than front office clerks regarding seasonal (odds ratio [OR]: 2.50, 95% confidence interval [CI]: 1.15-5.42) and 2009 H1N1 influenza (OR: 2.04, 95% CI: 1.19-3.71). During 2009-2010, 63.8 and 19.0% of school personnel received seasonal and 2009 H1N1 influenza vaccine, respectively. Personnel were more likely to be vaccinated against seasonal influenza if they believed the vaccine was safe (OR: 2.26, 95% CI: 1.21-4.19). Of those unvaccinated against 2009 H1N1, 48.9% also cited safety concerns. While every principal, assistant principal, and nurse received both infectious diseases and outbreak trainings, only 42.5 and 27.5% of clerks received these trainings, respectively (p < .001), and 30% of clerks believed outbreak recognition was not their responsibility. The level of knowledge regarding influenza illness, vaccination, and outbreaks among subjects was low overall. Education of school personnel may improve school vaccination programs and control of influenza outbreaks.