Controlling Communicable Diseases in Child Care Facilities

Deborah W. Harris, R.N.

Why the Concern for Diseases in Child Care?

Continued need for child care – 70 percent of NC mothers with children less

than 6 years of age work outside the home--highest in the nation (NC Partnership for Children)

Children in child care centers are 30 percent more likely to contract diarrheal illnesses than children at home.

Infection Control Concerns in Child Care

Crowded conditions and close contact Personal hygiene Limited immunity Mobility Spread frequency often occurs prior to

recognition

The Cost of Illnesses in Child Care

Costs businesses between $2-$12 billion per year due to work days missed

– Parents of children in child care centers miss an average of 1 to 4 weeks of work each year to care for their sick children (Davis et al., 1994)

Problems with Controlling Outbreaks in Child Care Centers Ease of person-to-person transmission

among young children High secondary attack rates

– as high as 40 percent for shigellosis Extended duration of outbreaks Multiple points of exposure

Who to Contact When You Get the Call

– EPI team leader – Environmental Health Supervisor – Regional Environmental Health Specialist – Division of Child Development – Communicable Disease Control Nurse – Laboratory Personnel – Other State Personnel (e.g., Communicable Disease

Control Section) – Local pediatricians and hospital

Controlling Communicable Diseases in Child Care

Visiting, Inspecting, and Contacting Handwashing: Instructing and Monitoring Testing, Exclusion, and Cohorting Informing and Educating Review of Specific Diseases in Child Care

Settings

Visiting, Inspecting, and Contacting

Containing Cases

Exclude new admissions Prevent transfer of children to other child care

centers – Call area child care centers to inform them of the

outbreak and instruct them not to accept children from the infected center

Contact area pediatric practices, ERs, clinics, and other health care providers for prompt reporting of additional cases

Containing Cases

Local EHS should visit the center with the communicable disease control nurse – conduct interviews – gather information

In addition, visit and/or inform child care centers and child care homes in the immediate outbreak area

Diapering Procedures

Diapering procedures posted/followed? – Is the caregiver washing both their hands and the

child’s hands? – Are gloves being used properly? – Cloth diapers – Are diapers being placed in a plastic-lined, covered

container? Flies can transmit Shigella to water and food.

Diapering Procedures

Is the diapering surface smooth, nonabsorbent, & easily cleanable?

Toileting and Diapering Procedures

Are they using a solution of soap/water prior to sanitizing?

Is the disinfecting concentration adequate? Is the contact time appropriate for the

disinfectant being used? Are toilets being cleaned and disinfected? Adequate amounts of toilet paper? Proper supervision of the children?

Mouth Contact Surfaces

Are sanitizing procedures being followed?

Are the toys easily cleanable?

Discourage sharing of personal articles or toys

Fecal Contamination in Child Care Center Classrooms

Most important sources of contamination: – Hands, toys, sinks, and faucets

High levels of fecal coliforms were more likely to occur on sinks and faucets than on other classroom surfaces.

Classrooms for infants were more often contaminated than classrooms for toddlers.

Laborde et al., 1995

Fecal Contamination in Child Care Center Classrooms

Greater levels of contamination on staff member’s hands in classrooms for infants. – Could result from greater diapering activity. Laborde et al., 1995

Recommendations to Reduce Fecal Contamination

Disposable Gloves Waterless hand sanitizers Frequent disinfection of sinks and toys

throughout the day. Knee- or foot pedal-controlled sinks All diapering activities conducted by one

individual per room. Laborde et al., 1995

Food Protection

Staff who prepare or serve food should not change diapers and staff who change diapers should not prepare food. – The odds of having an increased rate of diarrhea in a

center where the food preparer changed diapers is 18 times that compared to centers where the food preparer did not change diapers (Mohle-Boetani et al., 1995).

Thoroughly wash all vegetables Proper protection and temperatures maintained

Banning Activities

No water play activities

No family-style food service

Hand-washing: Instructing and Monitoring

Hand-washing is the single most important line of defense in preventing the transmission of disease-causing organisms.

Handwashing

Ensure that tempered water, soap, and disposable towels are available in child care centers, schools, and other places frequented by young children

Parents and teachers should instruct students/attendees on proper handwashing and monitor children for symptoms of shigellosis/HAV

Handwashing

Proper handwashing – An organized effort to promote careful handwashing

with soap and water is the single most important control measure to decrease transmission rates

– Handwashing procedures posted? – Are they adhering to the .2800 Rules?

Rubbing hands for 15 seconds Rinsing for 10 seconds Turning off the faucet with a paper towel or other method

without recontaminating hands.

Testing, Exclusion, and Cohorting

Testing Contacts

Obtain specimens immediately Based on available information, conduct the

most appropriate test – Stool specimens – Serologic testing – Etc...

Exclusion Criteria

In general, remove cases from child care until past infectivity period and asymptomatic

Cohorting

Helps control the spread frequency Protects the community

Cohorting--Shigellosis

Once diarrhea ceases, cases are kept in a group isolated from others

The room or area should have: – a bathroom reserved for this group’s use – assigned caregivers

Released from the cohort only after 2 negative stool cultures 24 hours apart and at least 48 hours after ending antibiotic treatment

Informing and Educating

Informing and Educating

Provide information about the specific infection and their prevention to: – parents and families of patients – child care centers, schools/pre-schools – restaurants – churches – news media – WIC, immunization, and community clinics – hospital emergency rooms

Educate Caregivers and Parents

Do not leave the child care center without leaving educational materials

Brochures, Books, Videotapes, etc. – Hygiene practices – Modes of Transmission – Signs/Symptoms

Before an Outbreak

Discuss what to do if…with the child care operator – The Division of Child Development requires

that they post the number of the fire department, police, etc., next to the telephone Make sure your number is up there too

After the Outbreak

Send a report to… – Communicable Disease Control section – Child Care Center – State Offices (Children’s Environmental Health

Branch, DCD) – Health Director – Board of Health – Etc…..

Review investigation

Reporting

§ 130A-136 Child Care Operators Required to Report – Child care facility directors and school

principles must report communicable diseases § 130A-142 Immunity of Persons Who

Report

15A NCAC 18A .2836 MILDLY ILL CHILDREN

Review of Specific Diseases in Child Care Settings

Transmission

Airborne – Pertussis, H. Influenza, Varicella

Fecal-oral – Shigella, Salmonella, Hepatitis A,

Enteroviruses Personal contact

– Varicella, Pediculosis

Parvovirus B19 – Fifth’s Disease

Mild rash illness--typically a slapped cheek appearance and lacy red rash on the trunk and limbs

Low grade fever, malaise or cold for a few days before rash breaks out

Rash resolves in 7-10 days Found in respiratory tract prior to onset of

rash

Parvovirus B-19 Fifth’s Disease

May become ill 4-14 days and up to 20 days after exposure

Usually not serious, but may cause serious illness in persons with sickle-cell disease or similar types of chronic anemia

Persons with compromised immune systems may develop chronic anemia

Parvovirus B-19 Fifth’s Disease

No vaccine or medication for prevention Frequent handwashing recommended Not necessary to exclude from work, child

care – Contagious before rash appears

Pertussis

Highly communicable, vaccine-preventable disease

Occurs through direct contact with discharges from respiratory mucous membranes of infected persons

Paroxysmal spasms of severe coughing, whooping and posttussive vomiting

Pertussis

Major complications: hypoxia, apnea, pneumonia, seizures, encephalopathy and malnutrition

Death – 13 children died in the US in 2003 – Most deaths occur among unvaccinated

children or children too young to be vaccinated

Pertussis

Immunize children appropriately For outbreaks, Erythromycin is the drug of

choice for contacts Exclude from child care until 5 days after

initiation of 10-14 day antibiotic regimen

Haemophilus Influenzae--Hib

Vaccine-preventable disease Meningitis with fever, headache and stiff

neck Leading cause of bacterial pneumonia Children not vaccinated or age

appropriately vaccinated should be excluded from child care

Varicella-Zoster

Virus, known as Chicken-pox Blister-like rash, itching, tiredness & fever Rash begins on trunk of body--Contagious

before rash appears Highly infectious and spreads from person-

to-person Airborne-usually from coughing & sneezing Vaccine now available

Shigellosis

Caused by bacteria called Shigella – S. sonnei most common type

Diarrhea, fever, stomach cramps beginning 1-2 days after exposure

Diarrhea is often bloody Fecal-oral route and contaminated food

Shigellosis

Treated with antibiotics--Ampicillin, Bactrim/Septra

Thorough handwashing after changing diapers or cleaning after bowel movement

Safe food handling Remove child from child care setting until

diarrhea has resolved plus two negative stool samples

Ringworm

Skin and scalp disease caused by fungi Skin--reddish, ring shaped rash Scalp--bald patch Rash can be dry and scaly or wet and crusty Transmitted by direct contact (people or animals) Anti-fungal creams work effectively on skin For scalp, need Rx from doctor

Scabies

Microscopic mite Sarcoptes scabei Infestation common, affects all races &

social classes Spreads rapidly under close, crowded

conditions where skin-to-skin contact is likely such as hospitals, institutions, child care facilities, & nursing homes

Scabies Pimple-like irritations, burrows or rash of the skin Symptoms may appear 4-6 weeks after infestation

or within days if previous infection Usually linear in appearance Intense itching, usually at night Prolonged contact Infestation may occur by sharing clothing, towels

and bedding Itching may continue for 2-3 weeks after

treatment. No new burrows should appear 24-48 hours after effective treatment

Respiratory infections

Colds, bronchitis, pneumonia and otitis media No evidence that the incidence can be reduced

among children in child care by any specific intervention other than by sanitation and personal hygiene

Exclusion of ill children from the facility has not been found of value in preventing common respiratory infections

Online Resources Investigating Foodborne Disease Outbreaks www.cdc.gov/foodborneoutbreaks/info_healthprofessional.htm To conduct an online outbreak investigation, “Botulism in

Argentina,” visit: www.phppo.cdc.gov/phtn/casestudies/ computerbased/default.htm To explore an historical outbreak investigation, visit the

online UNC John Snow Case Study at: www.sph.unc.edu/courses/Course_support/

Case_studies/John FOCUS on Field Epidemiology, UNC-SPH www.sph.unc.edu/nccphp

Helpful Resources

Donowitz, L.G. (1996). Infection Control in the Child Care Center and Preschool – (800) 638-0672

Chin, J. (2000) Control of Communicable Diseases Manual

American Academy of Pediatrics Red Book