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Medical and Public Health Responsibilities

The federal and state governments use schools as the vehicle to enforce various public health laws directed at children. States have customarily required proof of immunization for childhood diseases for school admission. Some states are mandating that schools screen children for personal health problems. State laws also provide schools with the authority to screen and exclude students to prevent the spread of communicable diseases. The controversies over school children with HIV have sensitized the public to communicable diseases in schools. While HIV in young school children is diminishing (most HIV babies die before school age), HIV is an increasing problem in adolescents. This will force school physicians to become a front line force in community disease control.

A variety of screening programs are carried out in schools. Some of these, such as scoliosis screening, are of questionable medical importance. Others, such as vision and hearing testing, are very important but overinclusive. These programs must be combined with reliable follow-up systems for all positive findings. The follow-up examination may be done by the school physician, but it is preferable to refer the child to a personal physician or clinic that can oversee treatment and continued evaluation.

Physicians who receive these referrals should make a careful evaluation of any abnormalities detected on screening and notify the school physician of the disposition of the referral unless the child's parents object. School physicians must ensure that the child keeps the referral appointment and is properly evaluated. The school physician has a duty to ensure adequate care for problems detected on school screenings just as for problems he or she detects personally in private office.

All states require that physicians report communicable diseases to the public health department. Most also require reporting of outbreaks of any disease that may be caused by infection, infestation, or environmental hazards, particularly if they occur in a school. School physicians have personal responsibility for seeing that the reports are made. Normally, the school nurses will do the actual tallying and reporting of routine cases such as influenza or chicken pox. They should report unusual disease problems to the school physician immediately.

Every school needs a detailed, written policy on the management of students with communicable diseases. Schools have the right and duty to screen and restrict students infected with diseases that pose a risk to other students, but they cannot use this power to remove students who pose a political problem rather than a communicable disease problem. For example, a student with asymptomatic HIV infection does not pose a risk to other students. This student must be allowed to stay in school without restrictions unless the student is violent due to dementia, or has infectious tuberculosis. (See Chapter 21.)

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