2013 Update: Bleach-free Disinfection and Sanitizing for ... · Care Health Project; outreach to client agencies providing child care to low-income families in San Francisco ... BLEACH-FREE

2013 Update: Bleach-free Disinfection and Sanitizing for Child Care

January 2013www.sfgov.org/asthma

S a n F r a n c i S c o

Acknowledgements

Report research and lead writer

• LuzAgana,MPH,Asthma Task Force Consultant, Project Coordinator

Project support and staffing

• AsthmaTaskForceviafiscalagentAsthmaResourceCenterofSanFrancisco,Inc.• SanFranciscoDepartmentofPublicHealth,Children’sEnvironmentalHealthPromotionProgram

Project field support

• SanFranciscoDepartmentofPublicHealth,Maternal,ChildandAdolescentHealthSection,ChildCareHealthProject

• SanFranciscoUnifiedSchoolDistrictToolsforSchoolCoordinator• SanFranciscoQualityConnectionsatWestEd• CompassFamilyServices,AccessibleChildCareExpeditedfortheShelterSystemSanFrancisco(ACCESS)• GatewaytoQualityChildCareAssessmentTeam

Project technical support

• CaliforniaDepartmentofPublicHealth,OccupationalHealthBranch,OccupationalHealthSurveillanceandEvaluationProgram’sWork-RelatedAsthmaProject

• PattiTenBrook,a United States Environmental Protection Agency Region 9, Pesticides Office • SanFranciscoDepartmentoftheEnvironmentanditsconsultants:

KellyD.Moran,TDC Environmental PresidentAliciaCulver,Responsible Purchasing Network Executive Director

Project policy-making support

• MonayLawrenceandNancyLunardi,bCalifornia Department of Social Services, Child Care Policy and Advocacy • LucyChaidez,California Emergency Medical Services Authority• RegionalAsthmaManagementandPrevention• BreatheCalifornia,GoldenGatePublicHealthPartnership• CaliforniaChildCareHealthProgram

Project fiscal support

• HumanServicesAgencyofSanFrancisco• SanFranciscoDepartmentofChildren,Youth&TheirFamilies• First5SanFranciscoChildren&FamiliesCommission• SanFranciscoDepartmentofPublicHealth

a. TheviewsexpressedinthisreportarethoseoftheauthorsanddonotnecessarilyreflecttheviewsorpoliciesoftheU.S.EnvironmentalProtectionAgency.Mentionoftradenamesorcommercialproductsdoesnotconstituteendorsementorrecommendationforuse.

b. TheviewsexpressedinthisreportarethoseoftheauthorsanddonotnecessarilyreflecttheviewsoftheCaliforniaDepartmentofSocialServices.Mentionoftrade names or commercial products does not constitute endorsement or recommendation for use.

Acknowledgements (continued)

• RegionalAsthmaManagementandPrevention• SanFranciscoPublicHealthFoundation• SanFranciscoDepartmentoftheEnvironment• NeilGendel,Director of Healthy Children Organizing Project • SanFranciscoFoundation

Grant coordination

• SanFranciscoDepartmentofPublicHealth,Children’sEnvironmentalHealthPromotionProgram• AsthmaResourceCenterofSanFrancisco,Inc.• BreatheCalifornia,GoldenGatePublicHealthPartnership

These individuals provided invaluable support for preparing this 2013 Update report:

• KarenCohn,Program Manager; San Francisco Department of Public Health (SFDPH), Children’s Environmental Health Promotion Program; Project Supervision

• DavidLoandCynthiaMelgoza,Health Educators; SFDPH Children’s Environmental Health Promotion Program; trainers and translators for dissemination to Cantonese and Spanish-speaking child care operators

• JaneEvans,Program Manager; SFDPH Child Care Health Project; supervision and coordination of outreach to child care serving low-income families in San Francisco

• JaleilaKing/IvySteverson/CarolThrailkill/PeterVaernet/YanOiWong:Public Health Nurses; SFDPH, Child Care Health Project; outreach to client agencies providing child care to low-income families in San Francisco

• JustineWeinberg,Research Scientist; California Department of Public Health, Occupational Health Branch Work-Related Asthma Prevention Program; industrial hygiene consultation for reviewing exposure issues of sanitizers and disinfectants

• JenniferFlattery,Epidemiologist; California Department of Public Health, Occupational Health Branch Work-Related Asthma Prevention Program; work-related asthma data

• ChrisGeiger,Manager; San Francisco Department of the Environment, Municipal Green Purchasing & Integrated Pest Management Programs; product selection and troubleshooting

• JacquelineChan,Industrial Hygienist; SFDPH, Occupational Safety & Health Section and Coordinator of San Francisco Unified School District (SFUSD), Tools for Schools; industrial hygiene

• MartinEscalanteandWillieGreen,General Services Managers; SFUSD, Custodial Services Department; procurement and implementation

• GeorgeDuran,Nutrition Manager; SFUSD, Early Education Program; procurement and implementation

Executive Summary

Quick Guide to Using this Report

Introduction

Section I. Site Implementation

Section II. Large-Scale Replication

Section III. Communicable Disease Outbreaks

Endnotes

Websites

Appendices A-I

Table1:Glossaryofterms

Table2:CommunityCareLicensingDivision’sTitle22Regulationsfordisinfectingandsanitizinginchildcare

Table3:TaskForcerecommendedbleach-freedisinfectantsandsanitizer

Table4:Alpha-HP®Multi-SurfaceDisinfectantCleanerandAlpha-HP®Multi-SurfaceCleanerlabels

Table5:Examplesofmodesoftransmissionofinfectiousdiseasesinchildcare

Table6:DisinfectantsregisteredwiththeUSEPAaseffectiveagainstCoxsackievirus

Table7:Communicablediseasesofconcerninchildcareandinfectioncontrolrecommendations

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Contents

ListofTables

1B l e a c h e x p o S u r e i n c h i l d c a r e S e t t i n g S

Required infection control for child care

Childcarecentersandfamilychildcarehomeshavespecificdisinfectingandsanitizingrequirementsforthetwoagegroupstheyserve,infants(0-2yearsold)andpreschoolers(2-5yearsold).See Tables 1 and 2 on following page.

CaliforniaDepartmentofSocialServices,CommunityCareLicensingDivision’s(CCL)Title22Regulationsspecificallymentionbleachastheproductthatmeetsthecode’sdisinfectingandsanitizingrequirements,anditalsogivestheamountofbleachconcentratetousewhenmakinggallondilutions.Formanyyears,childcareworkershaveonlyusedbleachsolutions,oftendilutedwithquestionableaccuracy,tomeettheserequirements,sincebleachisrelativelyinexpensiveandoffersantimicrobialresultsafterareasonablecontactdwelltimeonhardsurfaces.

Manychildcareprovidershadexperiencedbreathingdifficultiesfromtheuseofbleach,aswellascorrosiveburnstoskinandclothing,andwishedtofindalternativesthatwouldbeincompliancewithCCLregulations.Occupationalhealthevidenceindicatedthatbleachexposurecausedasthmaexacerbationsandwasaprobablecauseofnewasthma.Forthesereasons,theSanFranciscoAsthmaTaskForcetookonthechallengeoffindingbleach-freedisinfectantsandsanitizers,issuedpreliminaryrecommendationsin2011,andisnowupdatingthoserecommendations in this 2013 report.

Distinguishing cleaning from infection control

Itisimportanttobecomefamiliarwithcommonwordsthatinthiscontextareusedinapreciseregulatorysense.AlldisinfectantsandsanitizersmustberegisteredwiththeUnitedStatesEnvironmentalProtectionAgency(USEPA)asantimicrobialpesticidesduetotheirabilityto“reduce,ormitigategrowthordevelopmentofmicrobiologicalorganisms.” 1,2TheUSEPAauthorizesintendedandproperuseduringtheregistrationprocessasstatedonaproduct’slabelandissuesaUSEPAregistrationnumber(“EPAReg#”).3Forproperinfectioncontrol,refertothedefinitionslistedonthefollowingpage.

ExecutiveSummary

2 b l e a c h - f r e e d i s i n f e c t i o n a n d s a n i t i z i n g f o r c h i l d c a r e

Table 1. Glossary of terms

Table 2. Community Care Licensing Division’s Title 22 Regulations for disinfecting and sanitizing in child care10

Term Definition

CleanTheprocessofphysicallyremovingdebrisfromasurfaceorareabyscrubbing,washing,andrinsing.Sanitizersanddisinfectants cannot work on dirty or greasy surfaces.4Therefore,cleaningorpre-cleaningthesurfaceisanecessaryfirststep.

SanitizeToreduce,butnotnecessarilyeliminate,bacteriafromtheinanimateenvironmenttolevelsconsideredsafeasdeterminedbypublichealthcodesorregulations.Afoodcontactsurfacesanitizer,termedsanitizing rinsebytheUSEPA,mustkillatleast99.999%ofthetwospecifiedbacteria(Staphylococcus aureus and Escherichia coli)within30seconds.1,2,5,6

Disinfect

Todestroyorirreversiblyinactivateinfectiousfungiandbacteriabutnotnecessarilytheirspores,intheinanimateenvironment.TheUSEPAregistersthreetypesofdisinfectantsbasedonthetypeofefficacydatasubmitted.Foreachtype,thedisinfectantmustkillon59of60carriersforeachofthreeproductsamplestestedagainstthebacteriaspecifiedbelow:

•Limiteddisinfectant–effectiveagainstonlyaspecificmajorgroupofmicroorganisms,suchasgram-positiveorgram-negativebacteria.cForexample,alimiteddisinfectantmustkillon59of60carriersforeachofthreeproductsamplesofeithera)gram-positiveStaphylococcus aureusorb)gram-negativeSalmonella enterica.

•General/Broad-spectrumdisinfectant–effectiveagainstbothgram-positiveandgram-negativebacteria.Abroad-spectrumorgeneraldisinfectantmustkillon59of60carriersforeachofthreeproductsamplestestedagainsttwospecifiedbacteria:Salmonella enterica and Staphylococcus aureus.

•Hospitaldisinfectant–disinfectantproductsrecommendedforuseinhospitals,clinics,dentaloffices,nursinghomes,sickrooms,oranyotherhealthcare-relatedfacility.Ahospital-leveldisinfectantmustkillon59of60carriersforeachofthreebatchestestedagainstStaphylococcus aureus and Pseudomonas aeruginosa.1,2,7,8,9

Requirement Surface (Section #) How Often

DISINFECT

Infant/Toddlerclassrooms:•Diaperchangingareas*(101428)•Pottytrainingchairs*(101428)•Nappingequipment****/**(101239.1,101439.1) *Aftereachuse

**Aftereachuseifsoiled***Daily****Weekly

Infant/Toddler/Classroomswithmildlyillchildren:•Sinks**(101438.1,101638.1)•Floors***/**(101438.1,101638.1)•Walls/Partitions****/**(101438.1,101638.1)•Mouthedobjects(includingtoys)***(101438.1,101638.1)

SANITIZE^

All classrooms: •Dishes/Utensils,Cups*(101227) *Aftereachuse

***DailyInfant/Toddlerclassrooms:•Disposablediapercontainers***(101428,101628)

DevelopedbytheSanFranciscoAsthmaTaskForce,derivedfromTitle22Regulations.

^ Consideringnationalguidelinesforchildcarehealthandsafety,theTaskForcerecommendsthatallclassroomsSANITIZEmeal/snacktablesandhighchairtablesbeforeandaftereachuse.

c. Gram-positivebacteriaisnormallyfoundontheskin(e.g.,Staphylococcus aureus);andgram-negativebacteriacanbeantibioticresistantandcancauseinfectionssuchasbloodstreamorwoundinfections,pneumonia,andmeningitis(e.g.,Acineobacter, Klebsiella, and Escherichia coli).DepartmentofHealthandHumanServices,CentersforDiseaseControlandPrevention(www.cdc.gov/bloodsafety/bbp/diseases_organisms)

3b l e a c h - f r e e d i s i n f e c t i o n a n d s a n i t i z i n g f o r c h i l d c a r e

Need for this 2013 Update Report

ThisreportreflectschangesinTaskForcerecommendationssincetheMarch2011report.ThemostsignificantchangeisthattheTaskForcehaseliminatedrecommendationsforsaferbleachdilutionmethods.ThefollowingareTaskForcerationaleforeliminatingsaferbleachpractices:1)theportion-controlledpumps,usedforsaferdispensingofbleachconcentrateandmoreaccuratepreparationofbleachdilutions,couldnotwithstandbleachcorrosionandbecameunreliable;and2)bleachiscurrentlydesignatedasanasthma-causingsubstance,termedasthmagen,bytheAssociationofOccupationalandEnvironmentalClinics.11Additionally,theTaskForceabandonedrecommendingtheIonatorEXP™forthefollowingreasons:1)lackofsufficientevidencetosupportsanitizingclaims;and2)labanalysisfromtheSanFranciscoDepartmentfortheEnvironmentrevealedthattheoneIonatorEXP™devicetestedreleasedchromiumandhexavalentchromium,categorizedasahumancarcinogenandreproductivehazard,12 in the ionized water sprayed. See the Update Letters from 2012 for more details; accessible at the Task Force website (www.sfgov.org/asthma).

Summation of Task Force recommendations

TheTaskForcestronglyrecommendsaprecautionaryapproach,wherechildcareproviderstransitionassoonaspossibletobleach-freesanitizersanddisinfectantsthatarealsosafeforasthma.Bleachexposureshouldbelimitedasmuchaspossibleandprovidersshouldavoidbleachexceeding6.15%sodiumhypochlorite(theactiveingredientforbleach).Severalmanufacturersarecurrentlyselling“RegularBleach”–brandnameandgeneric–thatcontains8.25%sodiumhypochlorite;andifcentersareusingvendorsthatdistributejanitorialsupplies(orprocuringproductsfromstoresthatcarryjanitorialsupplies),thecentermayinadvertentlypurchaseindustrialstrengthbleach(e.g.,12.5%sodiumhypochlorite).Therefore,providersshouldusecautionwhenpurchasing.Additionally,theuseofsanitizingdevicesshouldbeavoided.

TheTaskForcecurrentlyrecommendsthefollowingUSEPA-registeredbleach-freedisinfectantsandsanitizerwithhydrogenperoxideastheactiveingredient:

•Oxivir® Tb,adisinfectantusedbyclassroomstaff•SaniDate®,afoodcontactsanitizerusedbyclassroomstaff,and•Alpha-HP® Multi-Surface Disinfectant Cleaner,adisinfectantusedbycustodialstaff.


Table 3. Task Force recommended USEPA-registered bleach-free disinfectants and sanitizer

Product Use Surface

Oxivir® Tb

Disinfecthardnonporous,non-foodcontactsurfaces

•Diaperchangingtables•Pottytrainingchairs•Cots/cribs•Mouthedobjects(includingtoys)•Sinks•Walls/partitions

SaniDate®

Sanitize food contact surfaces and non-food contact surfaces

Food contact surfaces•Snack/mealtables•Highchairtables

Non-food contact surfaces•Non-mouthedtoys

Alpha-HP® Multi-Surface Disinfectant

Disinfecthardnonporous,non-foodcontactsurfaces Floors(infant/toddlerrooms)


Section I

Ifyouwouldliketoconvertachildcaresitetoableach-freeenvironment,SectionIprovidesastep-by-stepprocessdescribingexactlyhowyoucanmakethatchangeregardlessofwhereyourcenterislocated.Forthishow-toguide,go directly to page 11.

Section II

IfyouwouldliketoreplicatetheTaskForceprojectonalargerscaleforyourcommunity(e.g.,consortiaofcenter-basedchildcare,schooldistrictEarlyEducationDepartmentcenters),SectionIIprovidesrecommendationsonreplicatingthisintervention.Foradviceonimplementation,gotopage21.

Section III

Ifyouwouldliketolearnhowtoprepareyourcenterforcontrollingexposuretospecificcommunicablediseasecasesoroutbreaks,SectionIIIprovidesinformationaboutdisinfectionpracticesapprovedforcertaindiseases.Forguidanceoncommunicablediseaseoutbreaks,gotopage30.

UsingthisReport


A. BackgroundHealth rationale: Evidence linking bleach and asthma

Bleachexposureisknowntoexacerbateasthmasymptoms in those who already have asthma and hasrecentlybeenconfirmedascausingnewasthmaforthoseexposedtobleachatwork.See Appendix H for related documentation from the California Department of Public Health, Work-Related Asthma Prevention Program.

Asfurtherproofofbleach’simpactonrespiratoryhealth,inMay2012,theAssociationofOccupationalandEnvironmentalClinics(AOEC),designatedbleach(sodiumhypochlorite)asanasthmagen,thetermusedforanasthma-causingsubstance.11TheAOECmustcarefullyreviewmandatedreportingofwork-relatedasthma(WRA)aswellaspublishedtoxicologyandepidemiologypeer-reviewedresearchpriortoassigninganytoxicitydesignationtoasubstance.See Appendix H of this report for the research basis of AOEC’s action.

TheSanFranciscoAsthmaTaskForce(TaskForce)initiatedthisprojecttodecreasetheenvironmentalrisksforasthmafacedbychildcareworkersandthechildrenintheircare.TheTaskForcefocusedoneliminatingorreducingbleachexposurebecauseSanFranciscochildcare providers already had access to training programs that taught howtoreduceotherindoorasthmatriggerssuchaspets,dustandtobaccosmoke.

All licensed child care facilities in California must comply with infection controlrequirementsoftheCaliforniaDepartmentofSocialServices,

CommunityCareLicensingDivision’s(CCL)Title22Regulations.10By2008,agoodnumberofSanFranciscochildcareprovidersservinglow-incomefamiliesexpressedadesiretoreplacebleachastheirprimarydisinfectantandsanitizer,duetotheirconcernsaboutthecorrosiveandirritantpropertiesasexperiencedbystaff;andbreathingdifficultiesexperiencedbystaffaswellaschildrenwithasthmaintheircare.SomechildcareproviderswereawarethattheState’spublichealthagencywasalsoaccumulatingwork-relatedasthmadatathatimplicatedbleachasbeingabletocausenewonsetasthma.

Work-Related Asthma (WRA) Studies

WRA associated with exposure to bleachStatewide:60%arenew-onsetasthma

WRA associated with exposure to cleaning productsStatewide:10%ofWRAcasesNationwie:72%arenew-onsetasthma

In educational settingsCleaning staff are at the highest riskTeachersandteachers’aides

A 2011 study provides more evidenceAirwayresponsetoinhalingbleach

In 2012 bleach designated as an asthmagen

Introduction


TheTaskForcebeganitspilotprojectin2008tohelpresolvethedilemmafacedbylocalchildcareproviders,publichealthnurseswiththeSanFranciscoDepartmentofPublicHealthChildCareHealthProject(aimedatimprovinghealthandsafetyoutcomesofSanFranciscochildreninchildcare)andchildcarequalityassessorswithGatewaytoQuality(aninitiativeaimedatensuringqualitychildcareinSanFrancisco),whoallwantedtopromoteoptimalinfectioncontrolwithoutcompromisinghealth.AstheTaskForceanditsadvisorygroupbegantheinvestigationtofindbleach-freeantimicrobialagentsthatcompliedwithCCLrequirements,theTaskForcealsoemphasizedfindingproductsandmethodsthatchildcareworkerswouldreadilyaccept for their ease of use and lack of irritating scent.

Health equity rationale: Occupational health risk reduction

TheTaskForceandRegionalAsthmaManagementandPrevention(RAMP),anon-profitasthmaprogramthatsupportedaspectsofthisproject,considerthisefforttoreduceoreliminatebleachexposurestochildcareworkersahealthequityissuebecausethemajorityofchildcareworkersinSanFranciscoarewomenofcolorwithlowearningpotentialandloweducationalattainment,ascomparedtothemedianwageandeducationofthecity’sadultworkingpopulation.13-15Childcareworkershavebeenlowwageearnerswithlimitedhealthbenefits,traditionallylackingtheknowledgetoconnectnewonsetasthmawiththeirworkenvironment,andmanymayfearreportingexposure-relatedhealthsymptomsorconcernsforfearoflosingtheirjob,beingreportedtoimmigrationauthoritiesorotherconsequences.Additionally,manychildrenincarecomefromlow-incomefamilieswithlimitedaccesstohealthyhousing,andthusareexposedtomanyotherasthma-causingandasthma-exacerbatinghousingconditions.

B.MilestonesPilot project and first report (2011)

From2008to2010,theTaskForceandpartnersresearchedalternativestobleachthatwereUSEPA-registeredasantimicrobialdisinfectantsandsanitizers,andonewater-ionizingdeviceforwhichthemanufacturerpresenteddataestablishingantimicrobialsanitizingpropertiesappropriateforfoodcontactsurfaces.Thepilotprojectenrolled20childcaresitesthatwouldrepresentdiversedistricts,ethniccommunities,andcompliancewithinfectioncontrolrequirements.PersonnelateachsitegavetheTaskForcefeedbackonthealternativeantimicrobialsintroduced,aswell as on the customized training and reinforcement tools provided to the site:

• Soapywater(non-antibacterial)forpre-cleaningpriortodisinfectingorsanitizing• Timersforassuring1-minutedwelltimeonsurfaces• Trilingualplacardsillustratingpilotprojectuseinstructions,and• Two-hourinteractivePowerPointtrainingprogram,providedinEnglish,SpanishorCantonese.

Thepilotprojectfocusedonfindingwaystobothreduceandeliminateexposuretobleach.TheTaskForcerecognizedthatsomecenterswerenotreadytoconverttobleach-freedisinfectionandsanitizing,orcouldnotaffordtodoso.


Forthataudience,theTaskForceproposedmethodsandtoolsthatwouldimprovesafetyduringbleachdilutionsandreduceoveruseofbleachfrominaccuratedilution,includingthefollowing:

• Portion-controlled(calibrated)pumpstodispenseconcentrate

• Recommendationof5.25%unscentedbleachconcentrate,and

• Safetyglasses,glovesandeyewashstationsforhandlingcorrosives.

Forbothbleach-freeandsaferbleachusingsites,theTaskForcestafffirstobservedcurrentpractices,thenprovidedcustomizedinteractivetraininginthreelanguagesonsite.Followingtraining,TaskForcestaffvisitedeachsiteforaweektoobserveandtoensurethatchildcarestaffcompleteddailyandend-of-weekquestionnaires.Thequestionnairesprovidefeedbackonworkereaseofuseandtheoverallacceptabilityofallnewly-introducedproductsandmethods.Afteranalyzingpilotprojectfindingswithanadvisorygroup,andpresentingfindingstoSanFrancisco’sChildcarePlanningandAdvisoryCouncil,theTaskForceissueditsrecommendationsinaMarch2011report.

Support from California Community Care Licensing

TheTaskForceanditspartnerRAMPapproachedCCLtorequestthatCCLinformtheirregulatedcommunitythatTaskForce-recommendedbleachsubstitutesandmethodswereacceptableforCCLinfectioncontrolrequirements.Inagreement,CCLfeaturedtheSanFranciscoTaskForceprojectandreferredtoreportrecommendationsinitsSpring-2012 Child Care Update.16,AppendixGCCLalsoconnectedtheTaskForcewiththeCaliforniaEmergencyMedicalServicesAuthority(EMSA),theState’sagencythatprovidesthemandatorypreventivehealthtrainingfornewchildcareproviders.Asaresult,EMSAmayuseTaskForceworkandresearchasareferenceforproviders.

Compliance with Cal/OSHA Blood-Borne Pathogen regulation

CaliforniaOccupationalSafetyandHealthAdministration(Cal/OSHA)istheState’sprogramthatenforceslawsprotectingworkersfromsafetyhazardsintheworkplace.Cal/OSHArequirestraininginUniversalPrecautionsforworkerspotentiallyexposedtoblood-bornepathogens.AUniversalPrecautionsapproachassumesthatallhumanbloodandbodyfluidsmaytransmitcommunicablediseases,suchasHIV,HepatitisBandHepatitisC.Thisisrelevanttochildcareworkersbecausetheymustfrequentlyrespondtobodyfluidspills,suchasbloodandvomit,andthereforemustuseUniversalPrecautions.TheTaskForceresourcematerialshelpprovidersmeetthisrequirementforresponsetobodyfluidspillsbyemployingOxivir®TbwhichisaUSEPA-registereddisinfectantforuseagainstHIV,HepatitisBandHepatitisC.See Appendix E for body fluid spills placard, and Table 7 that describes Oxivir® Tb-approved uses against specific disease agents.

Regulatory oversight of food contact surface sanitization in child care ends

Statewide,EnvironmentalHealthinspectorsineachcountyinspectfood-servingretailestablishmentsforfoodsanitizationrequirements.AsofAugust2012,childcaresettingsarenolongerconsideredfoodfacilitiesintheStateof California.17Therefore,childcareoperationsareexemptfromfoodhandlinginspectionsbylocalenvironmentalhealth agencies.

Regulatory oversight of Oxivir® Tb against communicable disease agents of concern

Childcareprovidershaveexpressedconcernthatbleach-freedisinfectantsmayleadtogreatersusceptibilityforcommunicablediseaseoutbreaks,meaningthatagreaternumberofcasesthanexpectedofacertaindiseasewill


bediagnosed.Forthisreason,theTaskForceresearchedandincludedinSectionIIIofthisreportinfectioncontrolprotocolsforthreecommunicablediseases(bothreportableandnon-reportable)thathavebeenreportedasaffectingSanFranciscochildrenfouryearsofageandyounger.Inaddition,Table7ofthisreportcomparesUSEPAregistrationlabelsforOxivir®Tband6.15%bleachastotheirtestedeffectivenessagainstmultiplecommunicablediseaseagentsthat may occur in child care settings.

Bringing the project to scale

Subsequently,theTaskForceexecutedatrainingprogramtoimplementreportrecommendationsforabroadergroupoftargetsites.Priorityforoutreachwasfocusedon121center-basedand100home-basedchildcareproviders,basedontheguidanceofpublichealthnurseswithintheSanFranciscoDepartmentofPublicHealthChildCareHealthProject,GatewaytoQualityassessorsandtheSanFranciscoHumanServicesAgency,whichadministersvouchered,subsidizedchildcaretoeligiblefamilies.Forexample,outreachprioritiesincludedcenter-basedchildcaresitesservingCalWORKsandotherlow-incomefamilies,andahome-basedprovidernetworkservingfamiliesthathavebeenhomelessorlivingindomesticviolenceshelters.

C.OutcomesDissemination and adoption of bleach-free practices (as of November 2012)

Number of target sites that have received training on bleach-free practices:

• 67of121center-basedtargetsites(55%oftarget)trained;3pendingsitesareexpectedtoadoptbleach-freerecommendations;25targetsitesdidnotrespondand26declinedtrainingorhadmanagementtransitionsthatprohibitedtheirparticipation

• 62of100home-basedtargetsites(62%oftarget)trained;38sitesarependingtrainingduetoatransitionoftheir network coordination contract.

Number of target sites adopting specific bleach-free practices:

of 67 center-based child care trainees:

• 29centers(43%oftrainedsites)adoptedbothbleach-freedisinfectionandsanitizingpractices

• 16centers(24%oftrainedsites)beganconversionbyimplementingthebleach-freesanitizeralone

• Basedonthecostsofpurchasingbleach-freeproducts,22centers(33%oftrainedsites),havechosento retainbleach-basedinfectioncontrol.

of 62 home-based child care trainees:

• 3sites(5%oftrainedsites)adoptedbothbleach-freedisinfectionandsanitizingpractices

• Basedonthecostsofpurchasingbleach-freedisinfectants,59sites(95%oftrainedsites)haveadoptedonlybleach-freesanitizing,usingTaskForce-subsidizedSaniDate® product.

TheTaskForcewillbeseekingtocompletetrainingforallSanFranciscotargetgroupsbyJune2013.


2011 San Francisco Board of Education policy enlarges target group

OnJune28,2011throughconcertedadvocacybytheTaskForce,ledbymemberagencyBreatheCaliforniaGoldenGatePublicHealthPartnership(anon-profitorganizationaimedatworkingtoreducetheimpactoflungdisease),theSanFranciscoBoardofEducationadoptedResolution 116-14A3: In Support of Green Cleaning throughout the San Francisco Unified School District,18introducedbyBoardmemberJillWynns.TheResolutionstatesthattheSanFranciscoUnifiedSchoolDistrict(SFUSD)willpurchaseonlyapprovedgreencleaningproductsverifiedbytheSanFranciscoDepartmentofEnvironmentforuseinEarlyEducation,StudentNutrition,SpecialEducation,officesandclassroomcleaningforallschoolsintheDistrict.Furthermore,thispolicymandatesthatthe31EarlyEducationDepartment(EED)centersoftheSFUSDeliminatebleachandadopttheTaskForcebleach-freerecommendationsforsanitizinganddisinfecting.ThirteenEEDsitesreceivedfirstprioritybecausetheyarestand-alonecenters,ratherthanbeingco-locatedatK-12sites.Ofthe13sitestrained,100%haveimplementedbleach-freesanitizing;andsixcenters(46%ofsitestrained)havecompletelytransitionedtobothrecommendedsanitizinganddisinfectingproducts.

2013 Regional Asthma Management and Prevention initiates project expansion to East Bay

RAMPiscurrentlyconductingoutreachtobringSanFranciscoAsthmaTaskForcerecommendationsandprotocolstoEastBaychildcarenetworksviaestablishmentofatrain-the-trainerprogram.

Review of where child care operations must employ disinfectants vs. sanitizers:

• Disinfectingisrequiredinchildcaresettings on hard surfaces where diapering ortoiletactivitiesarelocated,andonmouthedtoysandobjects;

• Sanitizingisrequiredinchildcaresettingsonhardsurfaceswherefoodiseaten,termed food contact surfaces,suchaslunchtablesandhighchairtrays,andonnon-mouthed toys.

25%

58%

17%

lBleach-freesanitizer&disinfectant

l Bleach-free sanitizer only

l Bleach

Percentage of trained sites adopting bleach-free practices post-training


Duringthepilotprojectsiteobservationphase,TaskForcestafflearnedofthemanydemandsplacedonchildcareworkersandhowinfectioncontrolspracticesmaysuffer.Staffmayknowofbarrierstoeffectiveinfectioncontrol,buthaveinsufficientcommunicationmechanismsforreportingthosebarrierstomanagement.Atthesametime,theTaskForceencounteredsitemanagerswho,duetotheirowndemands,werenotawareoftheday-to-dayroutinesforinfectioncontrolattheirsitesandwhetherornotthoseroutinesmetCCLrequirements.

Qualityassessmentisanadditionalfactorinfluencingattentiontoinfectioncontrol.Basedontheirevaluation,qualityassessors provide information to funders and key stakeholders on the strengths and needs of a child care program. Therefore,theinformationprovidedbyqualityassessorsimpactsthesubsidiesreceivedbychildcaresites.Somechildcaresiteschoosetofocusonimprovingtheirscoresonchilddevelopmentbestpracticesaspriorityovertheirscoresforhealthandsafetybestpractices.

TheTaskForcerecommendsthatsitemanagersfirstspendtimeobservingday-to-dayroutinesforinfectioncontrolinordertobetterunderstandthebaselineknowledgeandbeliefsoftheirstaffaswellascurrentbarrierstomeetinginfectioncontrolrequirements.Inthismanner,sitetrainingforimplementationofbleach-freeinfectioncontrolcanbecustomizedtocreategreaterstaffbuy-inforthenewprotocols.Thefollowingtipsmayhelpmanagersbecomeeffective agents of change as well as provide support for staff with the transition to new practices.

Tip #1Observeday-to-dayworkpracticesObserve current infection control practices

Duringsitevisits,TaskForcestaffobservedthatmanychildcareworkersusedinfectioncontrolpracticesthatcreatedhazardstothemselvesandtochildrenincare.Someoftheobservedhazardouspracticesincludedmixingtwodifferentdisinfectants,inconsistentuseofpersonalprotectiveequipment,recyclingspraybottlesfromothercleaningproductstouseforbleachsolutions,usingaspraybottleclosetotheirbreathingzone,sprayingstrongbleachsolutionsonlunchtableswhilechildrenweresleepingjustbelowthetableontheircots,andleavingsurfaceswithawetresidueofstrongbleachsolutionthatchildrencouldaccess.

Get in touch with the baseline knowledge, skills, beliefs and attitudes that supervisors and staff have about current infection control practices

TheTaskForcestaffobservedthatinfectioncontrolpracticesvariedwidely,evenwithinthesameclassroom.Eachindividualhastheirownphilosophyofwhatcleanisandwhattheprocessisforcleaning.Infectioncontrolgoesbeyondcleaning,butbuildsonthosephilosophies.Managersshouldobservecurrentsanitizinganddisinfectingpracticesintheclassroominordertolearnthebeliefsandattitudesoftheirstaff.Thiswouldhelpcustomizeatrainingthateffectivelyaddressesbaselineinfectioncontrolpractices.ThisisimportantnotonlytoaddressCCL

SectionI.SiteImplementation


requirementsthatarenotbeingmet,orpracticesthatareunsafe,inconsistent,orincorrect,butalsotofacilitatebehaviorchangenecessarytotransformcurrentpractices.Havingaclassroompresenceandbecomingmoreawareofhow the employees are using products would inform training needswithregardstohealthandsafety,andmeetingCCLrequirements. See Appendix B for sample site observation checklist.

Tip #2GetyourhouseinorderTake inventory of current cleaning and antimicrobial products at your center

Thisstartsbymanagersbecomingawareofproductsintheclassrooms,custodialcloset,storageareas,bathrooms,offices,andkitchens. See Appendix B for sample inventory checklist.

Purge the center of products that are not necessary

Ifthereisanoverabundanceofproducts,communicationwithemployeesiskeytounderstandingwhopurchased/donatedtheproducts,whythoseproductsareinthecenterandwhythestaffthinktheyarenecessary.Thiscould

help initiate dialogue with staff regarding harmful chemicals that couldnegativelyimpacttheirhealthandthechildren’shealth,andcanidentifythepotentialneedsofstaff(e.g.,training,policiesinplace,materialandtools).

Properlydisposeofunnecessarydisinfectingproducts(forinformationonhowtoproperlydisposeofcleaningproducts,contactyourlocalhouseholdhazardouswastefacility).Eliminate

thepurchaseordonationofaerosolsprays,deodorizingsprays,airfreshenersincludingplug-ins,solids,anddiffusersastheyirritatetherespiratorysystemandmaycauseorexacerbateasthma.Staffshouldnotusesuchproductsinhallwaysorareasdesignatedforadults,suchasbreakrooms,officesandadultbathrooms.Theseproductscanadverselyaffectstaffandthe volatized chemicals can readily disperse into hallways used for children to reach their classrooms or get into the ventilation system to bespreadthroughoutthebuilding.

Perceptions can impact infection control. Below are examples of comments made by child care workers expressing experiences that might affect work practices.

“Mymother/grandmother/guardianusedbleachregularlytocleananddisinfect.Ilikebleachbecauseitwhitenssurfacesandkillseverything.”Theseworkersmaybeskepticaloftheeffectivenessofbleach-freedisinfection;additionally,theymaythinkthatover-sprayingismore effective.

“Iusescentedcleaningproductsathome.SometimesIuseproductswithastrongscentbecauseitmakesmyhousesmellclean.”Theseworkersmaybeundertheimpressionthatscentisan indicator of cleanliness or product effectiveness.

“Ineedtouseairfreshenersatworkbecauseitsmellsbadwhenmyco-workersorthechildrenusethebathroom.”Theseworkersmaynotunderstand the hazards of using aerosol sprays andairfresheners.Theymaynotunderstandtheneedtoidentifythesourceoftheodors,andtheharm in covering or masking them.

“After our training we eliminated the use of any sprays within the classroom as we learned they can easily trigger asthma.”

inFant/toddler center manager


Tip #3Learnhowtoimplementbleach-freedisinfectionand sanitizingA. Procurement and product use

Ifyourcenterhasdecidedtotransitiontoableach-freeenvironmentbasedontheTaskForcerecommendations,yourinventoryneedsonlytheproductslistedbelowtobecompliantwithCCLrequirements.See Appendix A for ordering information and cost.

B. Procure triclosan-free or triclocarban-free (non-antibacterial) soap for the pre-clean step

Someantibacterialsoapscontaintheingredienttriclosanortriclocarbanwhichhavebeenassociatedwithnegativehealthimpacts,andstudiesshowthattherearenoadditionalbenefitsusingantibacterialsoapcontainingtriclosan.See Appendix F for more information.Forthesereasons,theTaskForcerecommendsusingnon-antibacterial(i.e.,triclosan-freeortriclocarban-free)soapforthepre-cleanstep,andforhandwashing.

Sanitizinganddisinfectingisusuallyatwo-stepprocess.Thefirststepremovesthedebristhatmayactasashieldforthevirusesandbacteria.Ifperformedproperly,withthoroughwipingorscrubbing,thepre-cleanstepwillremovemostofthevirusesandbacteriafromthesurface.

C. Procure Task Force-recommended products for disinfecting diaper changing and toileting surfaces, sanitizing food contact surfaces, and disinfecting floors (infant/toddler rooms only)

(1) Oxivir® Tb, EPA Reg# 70627-563a

Oxivir®Tbisaready-to-use disinfectantwithhydrogenperoxideastheactiveingredient.Oxivir®Tbrequiresasurfacecontactdwell time of one minute for routine disinfection of hard nonporous surfacessuchasdiaperchangingareas,toilets,pottytrainingseats,sinks,nappingequipment,andmouthedobjects.TheTaskForcerecommendsthatstaffusesafepracticeswhendisinfecting.See Tip #4 for recommendations on safe work practices.

Oxivir®Tbisalsoregisteredforuseagainstbacteriaandvirusesthatcauseinfectiousdiseasessuchassalmonellosis,shigellosis,HIV,HepatitisB,HepatitisC,andnorovirus.See Section III, Table 7, for more information regarding the efficacy of Oxivir® Tb against certain communicable diseases.Therequiredsurfacecontactdwelltimeforthesesituationswillvary,refertothelabelontheproductforthisinformation,orrefertoTable7forthecontactdwelltimesasspecifiedinthe2012USEPAregistrationforOxivir®Tb.Whenrespondingtosuchsituations,gloves,safetygoggles,anapron/smock,andafacemaskarerecommendedforusewhenappropriate(e.g.,fordisinfectingsurfacessoiledwithbloodorotherpotentiallyinfectiousbodyfluids).


(2.) SaniDate®, EPA Reg# 70299-93b

SaniDate® is a ready-to-use food contact sanitizer with hydrogenperoxideastheactiveingredient.SaniDate® requiresasurfacecontactdwelltimeofoneminuteforsanitizingmeal/snacktables,highchairtables,andnon-mouthed toys. Although this sanitizer is not as hazardous asadisinfectantorbleach,staffshouldcontinuetousesafe work practices. See Tip #4 for recommendations on safe work practices.

(3) Alpha-HP® Multi-Surface Disinfectant, if caring for infants 2 years of age and younger; EPA Reg# 70627-623c

Alpha-HP®Multi-SurfaceDisinfectant(called“Alpha-HP®Multi-SurfaceDisinfectant Cleaner”)isaconcentrated ready-to-dilute (RTD) product with the following dilutions and uses:

• 1:64foruseasadisinfectant(10minutessurfacecontactdwelltime)

• 1:128foruseasasanitizer(3minutessurfacecontactdwelltime),and

• 1:256foruseasageneralcleaner(nosurfacecontactdwelltimerequired).

Alpha-HP®Multi-SurfaceDisinfectantisaUSEPA-registereddisinfectantwithhydrogenperoxideastheactiveingredient.UseofAlpha-HP®requiresautilitysinkfordilutionsincetheproductusesaclosedsystemtodiluteproductintospraybottles(whichhasashelflifeoftwoweeks)orintoamopbucket.Alpha-HP® Multi-SurfaceDisinfectantisusedbycustodialstafftodisinfectfloorsininfant/toddlerroomswhichisrequiredbyCCL;10 and is alsousedonhardnonporoussurfacessuchaswalls/partitions,sinks,andtoilets.Pre-cleaningisnotrequiredwiththeuseofAlpha-HP®unlessthesurfaceis“heavilysoiled”.3cUseofmicrofibermopsisrecommendedformoreeffectivemoppingoffloorsandtoreducecost(usingcottonstringmopsrequiresmoreproductandisthereforemoreexpensive).

Alpha-HP®Multi-SurfaceDisinfectantisaconcentratedproduct,andpriortodilution,ismorehazardousthantheready-to-usedisinfectantandsanitizermentionedabove.Safeuseofthissystemrequirespropertrainingofstaff.See Tip #4 for more information on safe work practices.

Thesamedisinfectingregulationsforfloorsdonotapplyifcaringonlyforchildrenwhoarepreschoolage.Therefore,insteadofusingtheAlpha-HP®disinfectant,theTaskForcerecommendsusingthelesscorrosive,lessacidic,GreenSeal™andEcoLogo™certifiedAlpha-HP®Cleanerlistedasrecommendation(4).Notethatthepackagingandlabelsfor the disinfectant and the cleaner are similar.


Table 4. Alpha-HP® Multi-Surface Disinfectant Cleaner and Alpha-HP® Multi-Surface Cleaner labels

Name Product Product Label

3) Alpha-HP® Multi-Surface

Disinfectant Cleaner

4) Alpha-HP® Multi-Surface Cleaner

(4) Alpha-HP® Multi-Surface Cleaner, Green Seal™ and EcoLogo™ certified,19 can be used if caring only for children who are preschool age

Alpha-HP®Multi-SurfaceCleanerisadifferentproductfromthedisinfectantspecifiedabove.Alpha-HP®Multi-SurfaceCleanerisGreenSeal™andEcoLogo™certified,19andisnotregisteredwiththeUSEPAasadisinfectant(i.e.,isnotreviewedbytheUSEPAandisnotissuedanEPAReg#).Alpha-HP®isusedbycustodialstaffasageneralcleaneronly,andisnotintendedtosanitizeordisinfect.SinceAlpha-HP®Multi-SurfaceCleanerisnotaUSEPA-registereddisinfectant,thiscleanerwillnotdisinfectsurfacessoiledwithbodyfluidssuchasblood,vomit,feces,ortissuedischarge.Therefore,ifthecenterhasacommunicablediseaseoutbreak,Alpha-HP®Multi-SurfaceCleanerisnotsufficienttocontrolexposure.

Alpha-HP®Multi-SurfaceCleanerisaconcentrated ready-to-dilute (RTD) product with the following dilutions and uses:

• 1:64foruseasaheavy-dutyspraycleanerforcarpetsorbathrooms

• 1:128foruseasamedium-dutyspraycleaneronsurfacessuchasglass,and

• 1:256foruseonfloors.

Alpha-HP®Multi-SurfaceCleanercontainstheactiveingredienthydrogenperoxide.UseofAlpha-HP®requiresautilitysinkfordilutionsincetheproductusesaclosedsystemtodiluteproductintospraybottlesorintoamopbucket.Alpha-HP®Multi-SurfaceCleanerisaconcentratedproductpriortodilution,andsafeuseofthissystemrequirespropertrainingofstaff.See Tip #4 for more information on safe work practices.Alpha-HP®canbeusedonsurfacessuchasfloors,walls/partitions,sinks,toiletsandcarpet.Pre-cleaningandsurfacecontactdwelltimearenotrequiredforAlpha-HP®Multi-SurfaceCleaner.


Tip #4Providestafftrainingoninfectioncontrolbestpractices and safe practicesA. Establish Task-Force recommended safe work practices for sanitizing and disinfecting

For all recommended products:

• Completethepre-cleanstepproperlyaccordingtoinstructionsonthelabel

• Usepersonalprotectiveequipment,alsoknownas“PPE”(refertotheUSEPAproductregistrationorthematerialsafetydatasheets,“MSDS,”forrecommendedPPE)

• Ensureincreasedventilationbyopeningwindowsanddoorsifsafetodoso

• Ensurethatthechildrenareinanotherareawhendiluting,sanitizingordisinfecting

• Avoidsprayingsanitizeronmeal/snacktablesifchildrenarenappingoncotsnexttothetable

• Avoidsprayingsanitizersanddisinfectantsonverticalsurfaces(suchaswindows,mirrors,andpartitions)closeto the face

• Spraythesanitizerordisinfectantonthesurfacewhileholdingthespraybottleawayfromthebreathingzone(noseandmouth)atasafedistance

• Avoidover-sprayingthatresultsinpoolsorpuddlesofsanitizerordisinfectantonthesurface

• Wipesurfacesdryaftertherequiredcontactdwelltimehaslapsed,and

• Ensurethatsurfacesaredrywhenthechildrenreturntothearea.

For Alpha-HP®, which requires dilution, additional precautions should be taken:

• UsethefollowingPPE:gloves,safetygoggles(i.e.,protectiveeyewear),smockorapron

• DiluteAlpha-HP®whileholdingthebottleofconcentrateatasafedistancefromtheface

• HoldtheAlpha-HP®concentratebottlefirmlywhiledilutingintoamopbucketorspraybottle

• Avoidmoppingthefloorinthesameareawherechildrenarenappingoncots

• StoreAlpha-HP®inthe“Off”positionbysettingthedialto:

B. Provide infection control training

1) Rethink your center’s in-service training process, methods and materials

TheTaskForcestaffrecognizedearlyintheprojectthatasinglelecture-stylein-servicewasnotaneffectivetrainingmethod.Therefore,atrainingprocesswasestablishedthatincludedimplementationoforientationformanagerspriortostafftraining,trilingualparticipatorytrainingforstaffwithprovisionoftoolkitsthatincludedinstructionalplacardsandsafetymaterials,andcontinuedonsitesupportforstaff.Thistypeoftrainingwillallowmanagersandstafftounderstandareasneedingre-enforcementforhealthandsafety,identifywhatmaterialsandtoolsareneeded,identifybarrierstomeetinginfectioncontrolrequirements,andpromoteconsistencyofpracticesamongstaff.See Appendix C for an example of the recommended training outline.


2) Review your center’s written infection control policies and procedures

Whenassessingyourexistingsystemforinfectioncontrol,thisistheidealtimetoreviewyourcenter’spoliciesandprocedureswithregardtoinfectioncontrol,exposurecontrol,immunizations,healthscreenings,andtrainingrequirementsornotificationsregardinghealth-relatedissues.RefertotheAmericanAcademyofPediatricsfortheirrecommendations on written policies and procedures.20

3) Establish an exposure control plan or policy for dealing with disease outbreak situations

CaliforniaCodeofRegulations,(Vol.22),Title17(Section20),PublicHealthdefinesadiseaseoutbreak situation as:

“theoccurrenceofcasesofadisease(illness)abovetheexpectedorbaselinelevel,usuallyoveragivenperiodoftime,inageographicareaorfacility,orinaspecificpopulationgroup.Thenumberofcasesindicatingthepresenceofanoutbreakwillvaryaccordingtothediseaseagent,sizeandtypeofpopulationexposed,previousexposuretotheagent,andthetimeandplaceofoccurrence.Thus,thedesignationofanoutbreakisrelativetotheusualfrequencyofthediseaseinthesamefacilityorcommunity,amongthespecifiedpopulation,overacomparableperiodoftime.Asinglecaseofacommunicablediseaselongabsentfromapopulationorthefirstinvasionbyadiseasenotpreviouslyrecognizedrequiresimmediatereportingandepidemiologicinvestigation.”21

Anexposurecontrolplanorpolicyisimportantforhavingaprocedureforaddressingdiseaseoutbreaksituations.Theplanshouldspecifywhotocontact(i.e.,parents/guardians,yourcity’scommunicablediseaseprogram),inclusion/exclusionguidelines,signsandsymptomsforearlydetection,proceduresforareasneedingimmediateinfectioncontrol,andproceduresforpersonalprotectionandhygiene.Theplanshouldbelinguisticallyappropriateandsharedwithallstaff–teachers,helpers,volunteers,students,foodhandlers–andmanagerialstaffshouldreviewtheplanannuallyandwitheachnewhire.Forrecommendationsonexclusion,standardprecautions,age-appropriatevaccinations,anddetailedinformationoninfectiousdiseases,refertothe“ChildreninOut-of-HomeChildCare”sectionintheAmericanAcademyofPediatricsRedBook.20 See Section III and Table 7 for further infection control recommendations; and see Websites section for more information on exposure control.

4) Provide Hazard Communication training

Thereisanobviousneedformanagerstounderstandtherisksofthesite’schemicalproductsinordertopreventinjuryandillnessamongstaffandthechildrenintheircare.Cal/OSHAlawrequiresallemployerstoprovidetheiremployeesHazardCommunicationtraining,includingproductsafetyinformationforchemicalproductsinuse.Thislawappliestotheuseofcleaners,sanitizers,anddisinfectantsaswellasotherchemicalproductsandmanagersshouldimplementHazardCommunicationtrainingfortheirstaff.Formalistofapprovedproductsforyourcenter,andprohibitproductsthatarenotonyourlist.Abinderdedicatedtoinfectioncontrolshouldincludethelistofproducts,orderinginformation,MSDS,trainingmaterial,andCCLandEnvironmentalRatingScalesrequirements.See Websites section for information on Hazard Communication.

observation of infection control practices

orientation training for managers

interactive training for staff

Follow-up and on-site support


Tip #5Anticipatequestionsandconcernsyourstaffmayhavewhenimplementingbleach-freesanitizersand disinfectantsWhenmanagersbecomewellinformedofCCL-requiredinfectioncontrolpracticesandhownewproductprotocolsmeetthoserequirements,theywillbebetterequippedtoaddressconcernsoftheirstaff.

Myth 1: We will get “dinged” by our quality assessors for using bleach-free products, as we are mandated to only use bleach.

Fact: AlternativestobleachareacceptableintheStateofCaliforniaaccordingtoCommunityCareLicensing’sTitle22Regulations.Section101438.1(f)ofArticle7(PhysicalEnvironment:InfantCareGeneralSanitation)statesthat“Commercial disinfecting solutions, including one-step cleaning/disinfecting solutions, may be used in accordance with label directions.”10

Additionally,bleach-freeUSEPA-registeredsanitizersanddisinfectantsareacceptableforqualityassessorsusingtheEarlyChildhoodEnvironmentRatingScale(ECERS),Infant/ToddlerEnvironmentRatingScale(ITERS)andFamilyChildCareEnvironmentRatingScale(FCCERS).TheEnvironmentRatingScalesInstitute,theorganizationthathasdevelopedthescales,hasissuedupdatedclarificationregardingcleaning,sanitizing,anddisinfectingintheirAdditionalNotesforClarificationforECERS-R/ITERS-R/FCCERS-R.See References for links to notes, accessible online. TheyhavestatedthatUSEPA-approvedsanitizersanddisinfectantscanbeusedintheplaceofbleach,andmustbeusedaccordingtotheirlabel.22-22c

Myth 2: The new products don’t smell, they must not clean very well, I have to spray a lot to get the same effect as bleach.

Fact: Astrongscentisnotnecessaryinorderforsanitizersanddisinfectantstobeeffective.SanitizersanddisinfectantsareheldtothesameUSEPAstandards,andshouldbecomparableregardlessofscent/lackofscent.Additionally,ifthesurfaceiscleanedthoroughlywithsoapywaterandwipedadequatelytoremovealldebris,thiswill remove most of the germs from the surface. Sanitizers and disinfectants will then remove any residual germs thatremain.Toobtainthedesiredeffectiveness,sanitizersordisinfectantsshouldbesprayedonlytovisiblywetthesurface.Over-sprayingsuchthatwetpuddlesarevisibleonthesurfaceonlyleadstohigheruseandincreasedcost.

Myth 3: Using two products instead of one will create more work for me and will take longer.

Fact:Thesanitizeranddisinfectantrecommendedforclassroomuseareready-to-useandhaveashorterdwelltimethanbleach(oneminutevs.twominutesforbleach).Therefore,theprocessforusingthebleach-freesanitizeranddisinfectantwilltakelesstimethanbleach.

“Since we started using the new products, some of the staff said it was easy to use because it was replacing bleach and water mixture at the beginning of the day. Since they don’t have to mix the bleach anymore there are no accidents from usage of these products. .” center SuperviSor


Myth 4: The bleach-free products are completely safe; therefore, I do not need to use PPE or take pre-cautions that I do when using bleach.

Fact:Inordertoreduceordestroymicroorganisms,bleach-freeproductscontainchemicals.Staffshouldstilltakeprecautionswhensanitizinganddisinfecting.Refertotheproduct-specificUSEPAregistrationortheMSDSforrecommendedPPE.See Tip #4 of this report for recommended safe work practices.

Myth 5, Part 1: The bleach-free products have not been well-studied and are not as effective as bleach.

Fact: Allsanitizersanddisinfectantsare“publichealth”antimicrobialpesticideproductsandrequireregistrationwiththeUSEPA.Assuch,“Registrantsofpublichealthantimicrobialpesticideproductsmustsubmitefficacydatatosupporttheirapplicationforregistrationoramendmentstoaddpublichealthclaims.”Therefore,manufacturersofsanitizersarerequiredtosubmitdatashowingthatthesanitizer“reducesthebacterialpopulationintheinanimateenvironmentbysignificantnumbers,(e.g.,3log10reduction)ormore,butdoesnotdestroyoreliminateallbacteria.”1

Likewise,manufacturersofdisinfectantsarerequiredtosubmitdatashowingthatthedisinfectant“destroysorirreversiblyinactivatesbacteria,fungiandviruses,butnotnecessarilybacterialspores,intheinanimateenvironment.”Efficacydatasubmittedisbasedonthetypeofdisinfectant–limited,general(orbroad-spectrum),andhospital.1

Myth 5, Part 2: If we have an outbreak, I need to go back to using bleach.

Fact: Manufacturersofantimicrobialdisinfectants,includingOxivir®Tb,voluntarilysubmitadditionaltestsforregistrationagainstcertainhumanpublichealthbacteriaandviruses.Ifyoursitehasanoutbreakofacommunicabledisease,youmaybetoldtogobacktousingbleach.However,Oxivir®TbisUSEPA-registeredforkillingallofthesamecommunicablediseaseagentsas6.15%bleach,withtheexceptionofHepatitisA.See Section III and Table 7 for more information.

Myth 6: Since the Task Force is recommending hydrogen peroxide products, any product with hydrogen peroxide that I find in stores should meet our needs.

Fact: OnlyUSEPA-registeredhydrogenperoxide-baseddisinfectantsandsanitizersmeetinfectioncontrolrequirementsinchildcare.Hydrogenperoxide(3-3.5%)thatisusedasaskinantisepticisregulatedbytheUnitedStatesFoodandDrugAdministration(FDA)nottheUSEPA,anddoesnotmeetinfectioncontrolrequirements.

Fact: Notallhydrogenperoxide-baseddisinfectantsarethesame.USEPA-registereddisinfectantsarecomposedofamixtureofchemicals,andsomenewwidelyavailablehydrogenperoxide-baseddisinfectantscontainsyntheticfragrances.Therefore,notallnewhydrogenperoxide-baseddisinfectantsaresaferforasthma.Additionally,theyhavevarioussurfacecontactdwelltimesandmaynotworkinareasonableamountoftime.See Tip #8 for information on how to choose a safer disinfectant.

“I’ve noticed less flu and illness over the last 4-5 months since we started using the bleach-free sanitizer. My staff are more willing to clean surfaces they normally wouldn’t clean- furniture, mirrors, flat surfaces. My classrooms are definitely getting more attention than they used to.”

center program coordinator

“I noticed since we’ve gone bleach-free that my staff is cleaning and disinfecting more often, and there is no more irritating bleach odor in the center.”

center SuperviSor


Tip #6Sustainingstaffbuy-inforthenewproductsandpracticesrequiresanongoingeffortInorderforemployeestotransformexistingpractices,onsiteguidanceandregularevaluationarerecommendedtofacilitatebehaviorchange.Sustainingbestpracticesandmaintainingasafeenvironmentareongoingprocesses.Ifthemanagerisnotregularlyaccessibletostaff,thecentercanappointanotherperson(i.e.,healthadvocateorhealthmanager)whoislinguisticallycompatibleandreadilyavailableinthecenterandclassroomforthefollowing:

• Toserveasamentorforteachingstaff

• Tohelpimplementproperuseofdifferentproducts

• Tohelptailorcurrentpracticesandsetuptheclassroomenvironmentthatisbestformaintainingsafeuseofproducts,and

• Tohelpencourageteambuildingindevelopingefficientprocesses to maintain infection control.

Postingscanbeausefulwaytoshareupdatedinstructionalmaterialthatiseasilyaccessibleandlinguistically-appropriate.Thisinformationcanpromotestandardizedbestpracticesforstaffandvolunteerparents,students,floaters,volunteersandhelpersparticularlyaroundtheissueofdisinfectingandsanitizing.Somesuggestionstocommunicate these important guidelines in a way that might minimize confusion include:

• DisplayinginformationthatiscompliantwithregulatingbodiessuchasCCLandtheUSEPA

• Establishinginstructionsthataresimple,explicit,andeasytofollow

• Displayingplacardsrelatedtothesanitizersordisinfectantsinthespecificareaofuse

• Clearingthepostingspaceofextraneousflyersandothermaterials,and

• Reviewingthepostings/placardsperiodicallytoensurethattheinstructionsarecorrectandupdated.

Observationisanotherwaytoencouragesafeandbestpractices.Informalobservationwhenvisiting/checkinginwiththeclassroomsallowsmanagerialstaffevaluationofregularinfectioncontrolpractices.Inadditiontoobservingproperproductsandprocedures,keepinmindsafepracticessuchaslocationofchildrenandhowstaffsprayantimicrobials(i.e.,over-spraying,sprayingclosetothebreathingzone/face).Toestablishmaximumairflow,observeifstaffopenwindowsanddoors,ifsafetodoso,whensanitizinganddisinfecting;andverifyroutinemaintenanceandserviceofyourcenter’sHeating,Ventilating,andAirConditioning(HVAC)Systems.Theseobservationsareessentialbecausesanitizersanddisinfectantssprayedfrequentlythroughoutthedayaffectindoorairquality.Ensuringincreasedairflowandhavingwell-maintainedHVACsystemsareimportantsinceventilationinchildcaresettingsisofteninadequate.Furtherresearchiswarrantedregardingairchangeratesinthesesettings.

Finally,addingaquestiontoyouragendaatstaffmeetings,in-services,ortrainingsessionsthatengagesthestaffwithregardstoCCLrequirementsandproductsusedisawaytogatherinformationon:

• Trainingneeds •Concernsofstaff,and

• Needformaterial •Concernsexpressedbyparentstostaff

“We are putting on our agenda to address how to roll out a monitoring system to be effective [to monitor best practices]. The new products are less prep-time for staff, healthier products, and there are less allergic break-outs.” center manager

“When we went bleach-free, it was challenging to get into practice using the new products, but now it’s gotten much easier… After training the supervisors came to check up and make sure products are still being used properly.” center toddler teacher


Tip #7EstablishabroadcoalitionofadvisorypartnersIn order to be successful, your partners should be key informants about the following sets of knowledge:

• Regulatoryrequirementsforinfectioncontrolatlicensedchildcaresites

• Innerworkingsandbarrierstoadoptionofnewpracticesatthechildcaretargetsites

• Qualityassurance(QA)evaluationstandardsandQAassessmentpracticesinthefield

• AntimicrobialefficacyandlabelspecificationforUSEPA-registeredbleach-freedisinfectantsandsanitizers,and

• Dataestablishingwork-relatedasthmaduetobleachandotherdisinfectantsandsanitizers.

PartnerstoAsthmaTaskForce

San Francisco department of public health child care health project

gateway to Quality

caifornia dph occupational health Branch,Work-related asthma prevention program

San Francisco department of the environment

regional asthma management and preventionBreathe california

SFdph children’s environmental health promotion programhuman Services agency of San Francisco

First 5 San FranciscoSan Francisco department of children, Youth & their Families

San Francisco unified School district

identification of target Sites

identification of Sanitizers & disinfectants

policy initiatives

project implementation and adoption of recommendations

SectionII.Large-ScaleReplication


Tip #8 Be aware of the rapidly-changing market and choose new sanitizers and disinfectants carefullySanitizersanddisinfectantsareregulatedasantimicrobialpesticidesbytheUSEPA.“Antimicrobialpesticidesaresubstancesormixturesofsubstancesusedtodestroyorsuppressthegrowthofharmfulmicroorganismswhetherbacteria,viruses,orfungioninanimateobjectsandsurfaces.”2Therefore,bylawtheyrequireregistrationwiththeUSEPAandtheCaliforniaDepartmentofPesticideRegulation.Additionally,theUSEPAmustapproveaproduct’slabelforintendedandproperusepriortoauthorizingregistration.TheUSEPAisstillimprovingtheirregistrationprocesstoprovidebetterreviewofthedatasubmittedvalidatingmanufacturerdisinfectingandsanitizingclaims.

A. Task Force criteria for choosing new products

The Task Force Advisory Group used the following criteria in product selection:

(1) Bleach-freeUSEPA-registereddisinfectantsandsanitizerswerechosenthatdidnothaveingredientsknowntocauseorexacerbateasthma;morespecifically,theactiveingredientswerenotknownbytheAOECtobeassociated with work-related asthma.

(2) Productswerechosenthatwerenotassociatedwithothernegativehealthorsafetyimpacts,suchasrespiratoryirritationfromodororscents.Forexample,theTaskForcehasnotendorsedanythymol-baseddisinfectantsorsanitizerstodateprimarilybecauseoffeedbackobtainedfrom115childcareworkersatelevenchildcarecenterswhofield-testedathymol-basedfoodcontactsanitizerovera1-2weekperiodduringthepilotproject.

Ofthe115respondents,62(54%)reportedthescentasbeingbothersomeandwhentheyansweredthequestion:“Whatdoyoulikeleastabouttheproduct?”69(60%)oftheworkersindicatedodor,scentorsmell.Additionally,40(35%)indicatedthattheywouldnotrecommendthattheircenterpurchasethesanitizerduetothescent.Thirty-fiveindividualworkers(30%)reportedthatusingthesanitizerresultedinatleastoneofthefollowingadversehealtheffects:headache(19);nausea(8);irritationskin(6),respiratory(5),eye(4);feelingallergic(2);anddizziness(2).

(3) Productswerechosenthathadconvenientsurfacecontactdwelltimes,asspecifiedbytheproduct’sUSEPAregistrationlabel,basedonawarenessthatoperatoracceptanceandcompliancewouldberelatedtotheproduct’seaseofuse.

Productchoicesmustbefeasibleforthedemandsofthechildcaresetting,ortheproductsmaynotbewidelyacceptedbychildcarestaff.Alpha-HP®andSeventhGeneration™Multi-SurfaceCleaner,athymol-basedproduct,wereruledoutforuseatdiaperchangingtablesbecausetherequired10-minutesurfacecontactdwelltimefordisinfectingwastoolongfortheworkpaceneededatdiaperchangingtables.

(4) ProductswerechosenthatwouldbeincompliancewithCCLregulationsandanationalguidanceforchildcarehealth and safety.

Giventhesecriteria,oneofthebarriersfortheTaskForcewasthelimitedselectionofUSEPA-registeredsanitizersanddisinfectantswithoutasthmarisksorotherknownnegativehealthimpacts.Furthermore,sanitizersthatwillbeusedonsnackandmealtablesmustberegisteredwiththeUSEPAforuseonfoodcontactsurfaces.Thenumberofbleach-freeasthma-safesanitizersalsoregisteredforuseonfoodcontactsurfacesisverylimited.


Themanufacturingworldisjustcatchingupwiththemarketdemandforbleachalternatives,andthus,productlinesareconstantlychanging.Thoughnewantimicrobialproductsarebecomingwidelyavailable,thisproductmarketisever-evolvingandtotallyoutoftheconsumer’scontrol.Forexample,althoughtheactiveingredient“thymol”wasclassifiedasanasthmagenbytheAOECatthetimeofthe2011report,theAOEChassinceremovedthisdesignationforthymol.Atthesametime,apopularwater-ionizingsanitizingdevicemanufacturerhasgoneoutofbusinesswhilethevalidityofthedevice’ssanitizingclaimswasbeingquestionedbyUSEPAandothers.

Inconclusion,theselectionofantimicrobialproductsthataresaferforasthmaisimprovingbutstilllimitedatthistime.

B. Tips to help you choose new products

ThefollowingtipsmayhelpyouidentifywhethertheproductsyoufindinthestorearesaferandmeetCCLrequirements.

(1) Read the label

Itisimportanttoreadaproduct’slabelforseveralreasons:

a. TodetermineiftheproductisUSEPA-registered

b. Tofindtheactiveingredient

c. Tousetheproductproperlyandsafely,and

d. Toidentifytherequiredsurfacecontactdwelltime(i.e.,theamountoftimeasanitizerordisinfectanthasto remainonasurfaceinordertoreduceorkillmicrobialorganisms).

(2) Choose USEPA-registered sanitizers and disinfectants

AntimicrobialsthatarecompliantwithCCLregulationsaredisinfectantsandsanitizersthatareregisteredwiththeUSEPA.Iftheproduct’slabeldoesnothavean“EPAReg#”thenthatproductisonlyacleaner,andisnotcompliantwithCCLregulationsforsanitizinganddisinfecting.

(3) If your center is in California, verify that product registration with the California Department of Pesticide Regulation (CDPR) is active

InadditiontoUSEPAregistration,allsanitizersanddisinfectantssoldandusedinthestateofCaliforniaaremandatedtohaveanactiveregistrationwithCDPR.Todeterminethestatusofaproduct’sregistration,visittheCDPRwebsite.See Websites section for more information.

(4) Avoid active ingredients that have been designated as AOEC asthmagens, or chemicals that are associated with other negative health impacts

TheAOEClistofasthmagenscanbefoundbyaccessingtheAssociation’sExposureCodeLookup.11 Asthmagen designationsintheExposureCodeListarereviewedandupdatedonaregularbasis.Whenyouarechoosinganewsanitizerordisinfectant,usetheAOECasthmagenlistasaguidetokeepyouup-to-dateonactiveingredientsassociated with asthma risks.

Additionally,avoidingthechemicalslistedinAppendixFwillhelpeliminatesanitizersanddisinfectantsthatcontainasthmagens or that could potentially negatively impact the health of child care providers and the children they serve.


(5) Avoid purchasing scented or fragranced antimicrobials

Fragranced(i.e.,scented)antimicrobialscanirritatetherespiratorysystem,cancauseorexacerbateasthma,andare associated with other negative health impacts. See Appendix F for more information. Althoughhydrogenperoxideissaferforasthma,therearesomenew,widelyavailablehydrogenperoxide-baseddisinfectantsandsanitizersthatcontainfragrances.Avoidpurchasingfragrancedantimicrobialseveniftheactiveingredientmaybesaferforasthma.

(6) Be aware of contact dwell times specified on the label

Readingthelabeltofindtherequiredsurfacecontactdwelltimewillhelpyoudetermineifaproductwillbeconvenientforyourcenter.Forexample,somenewhydrogenperoxide-baseddisinfectantsandsanitizershaveacontactdwelltimeof10minutesthatmaynotbereasonableforyourstaff.TheTaskForcerecommendeddisinfectantsandsanitizershaveasurfacecontactdwelltimethatislessthanthetwominutesrequiredforroutinedisinfectingusingbleach.

(7) Read the MSDS for the pH of food contact sanitizers

ChoosefoodcontactsanitizersthathaveapHvaluethatiscloserto7(i.e.,neutral)sincetheywillbesafertouseonmeal/snacktablesincloseproximitytonappingchildren.Somefoodcontactsanitizersaretooacidicforuseontablesincloseproximitytochildrennappingontheircots.TheTaskForcerecommendationistoavoidsprayingsanitizersonmeal/snacktablesifchildrenarenappingoncotsnexttothetable.

ThepHscalerangesfrom0-14whereapHvalueof7isneutral,andpHvaluesbelow7areacidic.YoursanitizerwillbemoreacidicthecloserthepHvalueisto0.TheMSDSprovidesthepHfortheproduct.Forexample,SaniDate® ready-to-useproductispH3.6,andanotherproductbasedoncitricacidispH2.4.ThereforetheSaniDate® is preferable.

(8) Avoid sanitizers and disinfectants that require a rinse step on food contact surfaces

SanitizersusedonmealtablesmustberegisteredwiththeUSEPAas“foodcontactsanitizers”.Ifthelabelofaproduct(canbedisinfectantsorsanitizers)specifiesthatitcanbeusedasasanitizer,butrequiresarinsestepwithpotablewateraftersanitizing,theproductmaynotberegisteredforuseonsurfaceswheremealsareserved.Avoidingsuchproductswilleliminatetheextrastepofensuringthattherinsestephasbeenperformedproperlyandno residue of sanitizer or disinfectant is left on the surface.

(9) Avoid purchasing devices with antimicrobial claims

TheUSEPAdoesnothavetheauthoritytoregulateantimicrobialdevices,astheydoforchemicalantimicrobialpesticidessuchasthosecurrentlyrecommendedbytheTaskForce.23Therefore,manufacturersofdevicesarenotrequiredtosubmitdatatotheUSEPAverifyingtheirantimicrobialclaims,anddevicesarenotissuedUSEPAregistrationnumbersorlabels.Additionally,sinceantimicrobialdevicesarenewtothemarket,theymaynothavebeencompletelytestedforsafety.Therefore,avoidingdevicesaltogetherisprudentuntiltheyareregulated.


Tip #9Taketimetounderstandthelimitationsofinfection control regulations and guidelines Oversightagenciesmayhaveincompatiblehealthandsafetyassuranceprotocols,oruseincorrectinformationtosettheirstandards.Bepreparedtodothecollaborativeworkthatwillwinovertheseagenciesasprojectallies.

Environment Rating Scales not in accordance with USEPA product registration

Widely-usedEnvironmentRatingScalescriteriaarenotinaccordancewithUSEPAproductregistrationlabelsforbleach,althoughtheirrevisionisbeingconsidered.TheEnvironmentRatingScalesusedatthebeginningoftheTaskForceprojectincorrectlytoldqualityassessorstouse10secondsasthebenchmarkforeffectivedisinfectingandsanitizingofrequiredsurfaceswithbleach.Thiscontradictedthemuchlongersurfacecontactdwelltimesrequiredbybleachmanufacturers’USEPAregistrationlabels.AftercontactingtheUniversityofNorthCarolinaacademicswhopublishseveralinternationallyusedEnvironmentRatingScales,theTaskForcewasinformedthattheywouldchangethisrecommendationtoreflecttherequireddwelltimeforbleach.Beforethatchangehappens,theEnvironmentRatingScalesInstitutemayaddressthisissueinupcomingAdditionalNotesforClarification.Additionally,inSeptember,theyhadstatedthatUSEPA-approvedsanitizersanddisinfectantscanbeusedintheplaceofbleach,andmustbeusedaccordingtotheirlabel.22-22c

IndependentqualityassessmentorganizationsusinganyofthepublishedEnvironmentRatingScales[EarlyChildhoodEnvironmentRatingScale(ECERS),Infant/ToddlerEnvironmentRatingScale(ITERS),andFamilyChildCareEnvironmentRatingScale(FCCERS)]shouldprovidetrainingfortheiranalysts,observers,andcoachesinordertodisseminatethecorrectinformationwhenprovidingon-sitecoaching,training,orfeedbackforchildcareworkers.

CCL disseminates information not in accordance with Title 22 Regulations

Theroleofacounty’s“Evaluator”mayincludeprovidingtrainingfororientingproviders(centerandhome-based),answeringproviders’questionswhenassignedtothesupportdesk,andperformingonsiteevaluations.Duringproviderorientation,TaskForcestaffobservedthatevaluatorsprovidedincorrectinformationwithregardtomandateddisinfectants,properdilutionofbleach,andareastosanitizeanddisinfect.AccordingtoCommunityCareLicensingDivision’sTitle22Regulations,“Commercial disinfecting solutions, including one-step cleaning/disinfecting solutions, may be used in accordance with label directions.”10Therefore,theuseofawebinarorsupplementalguideforevaluatorscontaininginformationonareastosanitizeanddisinfectaswellasalternative,bleach-freeproductsmaybeuseful.Additionally,sincetheCCLregulationsspecifytheuseofbleach,thesupplementalguideshouldhighlighttheproperwaytodiluteandusebleachinordertopreventaccidentsormisuseofbleachthatcanbehazardoustothe workers and children served.

Lack of USEPA oversight for antimicrobial devices

BecausetheIonatorEXP™isadeviceratherthananantimicrobialpesticide,itsefficacyclaimsarenotregulatedbytheUSEPA.DevicemanufacturersarerequiredonlytohaveanestablishmentnumberfromtheUSEPAindicatingtheplaceorfacilitywherethedeviceisproduced,andtomakeonlyantimicrobialclaimsthatarenot“falseormisleading”(i.e.,claimstheycansubstantiate).RefertotheUSEPA’sPesticideRegistrationManual:Chapter13–Devices,section40CFR156.10(a)(5).22


USEPA Antimicrobial Testing Program evaluation occurs post-registration

TheUSEPAregistrationprocessforantimicrobialpesticidesincludes,butisnotlimitedto,thesubmittalofproduct-specificeffectivenessdatabythemanufacturertotheUSEPA.TheAgencythenreviewsallrequirementsfortheproduct’sregistrationandifthoserequirementsaremet,theUSEPAissuesanEPAregistrationnumber(“EPAReg#”).3

Afterproductregistration,theUSEPA’sAntimicrobialTestingProgram(ATP)testsonlyhospital-leveldisinfectantstoensurethatefficacystandardsaremet.TheUSEPA’sATPevaluatesantimicrobialeffectivenessbywayoftheUSEPA,ratherthanthemanufacturer,testingtheefficacyofregisteredhospital-leveldisinfectantsagainstthefollowingbacteria:Staphylococcus aureus and Pseudomonas aeruginos, and Mycobacterium bovisBCG(iftheproductisregisteredaseffectiveagainsttuberculosis).Atthistime,theprogramdoesnottesttovalidateotherbacteriathanthosespecifiedabove,andtheprogramdoesnottesttovalidatevirucidalclaims.24

OnMay9,2012,theUSEPApostedanATPstatustableofapproximately800EPA-registeredhospital-leveldisinfectantsand150tuberculocidesthathavebeentested.Ifaproductdoesnotmeetpost-registrationefficacystandardsundertheATP,theUSEPAmaytakeanyofthefollowingactions:requestthatthemanufacturerrelabeltheirproduct,askthemanufacturertovoluntarycancelproductregistration,orinitiate“removaloftheproductfromthemarketplace(e.g.,stopsaleorders)”.Fordisinfectantswiththestatus“AgencyTakingAction”,theAgencyisconsideringthebestcourseofactionandwhetherthedisinfectantrequiresfurthertestingorreview,ortheAgency’sinitiation of regulatory/enforcement action.25

TheAgencyisintheprocessofupdatingtheATPwebsiteandanticipateshavingtheupdatedversionofthestatustableavailabletothepublicin2013.Additionally,theAgencyiscurrentlyconductingapilotprogramthatisfocusedon food contact sanitizers.26


Tip #10PreparetosolvebarrierstoimplementationInthecourseofdissemination,projectstaffrealizedthatthevarioustypesofchildcarefacilitieshavedistinctsupportneedswhenimplementingbleach-freedisinfectionandencouragingsustainabilityofbestpractices.Inordertoprovidetheappropriatesupportforlargecenter-basedchildcare,consortiaofcenter-basedchildcare,schooldistrictEarlyEducationDepartmentcenters,andhome-basedfamilychildcareproviders,theTaskForcesuggestsconsideringcreatingaprogramplanorstrategytohelpaddresspotentialobstaclesinadvance.

Center-based child care

Justification of cost for governing boards

Largecenter-basedchildcare,orcentersthatarepartofaconsortium,havetheinfrastructureinplacetoprovideon-sitesupportforstaff.However,thesecentersmayhaveaBoardthatreviewsthecenter’sbudget.TheBoardmayaskforjustificationoftheincreasedannualcost.TheTaskForceaskedtheDirectorofthePediatricEnvironmentalHealthSpecialtyUnitoftheUniversityofCalifornia,SanFranciscotowritealetterinsupportofreducingbleachinchildcare.Additionally,centersmayusestudiestheAOECreviewedtosupporttheclassificationofbleachasanasthmagen.27-29,AppendixH

Cost planning

StateandCitysubsidizedcenter-basedchildcareconsortiamayviewtheupfrontcostofpurchasingasupplyofsanitizeranddisinfectantforthewholeconsortiumasabarriertoimplementation.Asexperiencedduringdissemination,consortiatypicallywouldnotbuyintotheincreasedcost,andwouldchoosetocontinuebleachuse.However,centersthatwereindependentlyabletotransitiontoableach-freeconsortium,includingtheSanFranciscoUnifiedSchoolDistrict(SFUSD)EarlyEducationDepartment(EED)Program,reviewedandutilizedexistingfundsattheendofthefiscalyeartopurchaseastartersupplyofsanitizersanddisinfectants.Basedontheamountofproductusedfromthestartersupply,theyeithercreatedafinancialplanthatallocatedfundstowardsthenewsanitizer/disinfectantinthenewfiscalyear,ortheyplacedlargebulkordersintendedtolastoneyear.

Group purchasing

Grouppurchasingororderinginbulkwillbemorecost-effective.Anothercosttokeepinmindwhenpurchasingordersisshipping,whichisoftenfreeorreducedwithlargeorders.Whenplacinglargerorders,havingaplanforstorageanddistributionwouldallowforamoreefficientsystemaswellasamethodtotrackproductuse.Thiswillhelpcenter/schoolstaffwithprocuringproducts,andthiswouldbenefitmanagerialstaffinbudgetingforthenextyearorthenextorder.

Home-based family child care providers

On-site support

Home-basedfamilychildcareprovidersoftenhadthemotivationandthemeanstobuy-intothebleach-freesystem.Sincetheprovidersworkintheirhomes,theyareinvestedinmaintainingasafework/homeenvironment.Home-basedprovidershavethebenefitoflessconfinedspacesandincreasedairflowcomparedtocenter-basedfacilities.Implementationandsustainabilityofbestpracticesincreasesinahome-basedsettingduetothesmallernumbers


ofstaff,lessturnover,andthementoringsystemthatprovidersuseforsupportandcoaching.However,provisionofon-sitesupportforprojectstaffwasmorechallengingsincemostprovidersattendedtraininginalargergroupsettingand rely on their support networks rather than outside trainers.

Communication

Communicationwasanotherchallengeforprojectstaffsincemosthome-basedprovidersweremonolingualinSpanishorCantonese.Theirpreferredformofcommunicationwasbywordofmouthwithinneighborhoodnetworksorwithinethnicgroups.Thisposedachallengeforoutreachpriortotraining.Outreachcapacityimprovedupondistributionoflinguisticallyappropriateoutreachflyerswithspecificinformationstatinga)thebleach-freesanitizerisacceptablebybothCCLandQualityAssessors,andb)astartersupplyofthesanitizerwouldbeprovidedasadonationtotheirchildcareforhavingattendedtraining.Outreachalsoexpandedbyfindingamentor/leaderinaneighborhoodnetworkorethnicgroup,whohadalreadyattendedaninitialtraining,andapproachingthemforhelp.

Duringtraining,monolingualprovidersexpressedhesitationtoorderonlinefromdifferentvendorsorhavingtoorderoverthetelephone.Projectstaffencouragedgrouppurchasing(seebelow)todecreasecost,andtoidentifyandencourageproviderswhofeltmorecomfortableorderingonline/overthetelephoneonbehalfofthegroup.

Group purchasing

Giventheneighborhoodnetworksorethnicgroupsupportsystemsforfamilychildcareproviders,thereispotentialtodrive down the cost with group purchasing. Coordination is the key to group purchasing which involves coordinating severalproviders,collectingfees,orderingfromdifferentvendors,determiningalocationofdeliveryandinterimstorage,andinformingthegrouptopickuptheirproducts.

School district-based Early Education Department centers

Program plan

Asanexampleofhowprojectimplementationcouldbeintegratedwithaschooldistrict-basedearlyeducationprogram,hereisadescriptionoftheTaskForce’scollaborationwiththeSFUSD.TheSFUSDEEDcentersalreadyhadthespace,facilities,andpersonneltosupporttheconversiontoableach-freeprogram(i.e.,custodialclosetwiththecorrectfaucetthreadingforAlpha-HP®,morestorage,staffassignedforcleaning,buildingsandgrounds).However,thefragmentationoftheorganizationonalargerscaleposedasachallengeforinformingcentersoftheResolution,coordinatingpurchasingandtraining,definingpurchasingresponsibilities,andsupplyingthecenterswiththeappropriateproducts,tools,andsupport.

Havingawell-definedprogramplanthatincludesaflowcharttoillustratethestrategyishighlyrecommended.Theprogramplanshouldincludepersonnelresponsibilities,purchasing,timeline,andevaluationatregularintervals(todetermineifunapprovedproductsareinuse,tomonitorpracticesleadingtoproductoveruse,andtoevaluateifbestpracticesaresustainable).TheTaskForcealsorecommendsdesignatingpersonneltoprovideonsitecoachingtoensurethatunapprovedproductsarenotinuse,andtoensurebestpractices.Thiswouldhelpprovidetheessentialsupporttohumanresourcesnecessaryforimplementationandsustainability.


Centralize purchasing

Creatingacentralizedpurchasinganddistributionsystemhelpedstandardizeindividualstand-alonecentersintheSFUSDEEDProgram.PriortoimplementationoftheResolution,eachstand-alonecenterpurchasedtheirownsuppliesfromvariousvendorswiththeirownfunds.Centralizingpurchasingcanhelpreducecost,createsaneasiersystemforprocuringproducts,andcreatesamethodfortrackingexpenditures.

Support Special Education classrooms

InCalifornia,CCLdoesnotlicenseSpecialEducationclassroomsintheEEDDepartmentProgram.SpecialEducationclassroomsfallunderthejurisdictionoftheCaliforniaDepartmentofEducation.Therefore,althoughtheneedforinfectioncontrolissimilarorhigherinSpecialEducationclassrooms,theymaynotreceivethesameservicesorsuppliesasgeneraleducationclassroomsinthesameschool.SpecialEducationteachersmaydisinfectmoreoftenthangeneraleducationteachers;andsinceteachersareatahigherriskfordevelopingasthmaineducationalsettings,30theremaybeagreaterneedinSpecialEducationclassroomsfordisinfectantsthataresaferforasthma.

IncollaborationwiththeSFUSDSpecialEducationnurse,theAssistantSuperintendentofSpecialEducationServiceswasinformedoftheResolutionandtheassociatedneedforprovisionofbleach-freedisinfectants.AsaresultoftheSuperintendent’sadvocacy,theCustodialServicesDepartmentprovidedbleach-freedisinfectantsforallSpecialEducationclassroomsandarrangedcentralizedpurchasing


Tip #11Learnhowearlychildhoodcommunicablediseases are transmitted Achildincaremaybediagnosedwithacommunicabledisease,andthechild’sparents,guardiansortreatingphysicianmayreportthisoccurrencetothecareprovider.Ifthediseaseaffectsenoughchildrenorcareproviders,thismightbeconsideredanoutbreaksituation.Inordertocontrolexposure,infectioncontrolstepswilldifferfromdailyroutines.Ifyoursitehasanoutbreakofacommunicabledisease,youmaybetoldtogobacktousingbleach.However,Oxivir®TbisUSEPA-registeredforkillingallofthesameagentsthatcausesomediseasesofconcerninchildcare(listedinTable7)as6.15%bleach,withtheexceptionofHepatitisA.Table7givesthesurfacecontactdwelltimerequiredbyOxivir®Tbandby6.15%bleachforeachofthesecommunicablediseases.

Eachcommunicablediseaseandinfectionhasawell-establishedmodeoftransmissionfromoneindividualtoanother;seeTable5below.Exposurecontrolinvolvesvariouspractices.Frequenthandwashingthatisperformedproperly is one of the most important ways to stop the spread of infection.31 See Appendix E for hand washing placard. Forexample,properhandwashingcanhelpstopthespreadofinfectionsthataretransmittedviathefecal-oralroute,suchasnorovirus.Thefecal-oralrouteisthe“spreadofmicroorganismsfromtheinfectedstoolofoneperson into the mouth of another”.32Thismayoccurbyingestionoffoodordrinkthathavebeencontaminatedbyfecalmatterorbyhand-to-mouthtransmissionaftercontactwithitemscontaminatedwithinfectiousfecalmatter.

Otherpracticesthathelpcontrolexposureincludespatialseparation,limitingperson-to-personcontact,andpracticingcoughandsneezeetiquette.Additionally,properfoodhandling(pertheCaliforniaHealthandSafetyCode:Part7–CaliforniaRetailFoodCode33),propersanitizingoffoodcontactsurfacesandproperdisinfectinghelpcontrolindirect transmission.

Asstatedabove,duringanoutbreak,hardnonporoussurfacesrequiredisinfectionthatisdifferentfromroutinedisinfecting.Dependingontheproduct,disinfectionmayrequirelongersurfacecontactdwelltimeorstrongerdilutionsinordertoeffectivelycontrolthespreadofdiseasesthatoccurthroughindirecttransmission(i.e.,skin-to-surfacecontact).Thistypeoftransmissionoccursbytouchinginanimatesurfacessuchastoys,tables,foodcontactsurfaces,soiledclothesorbedding,oreatingutensilsthathavebeencontaminatedwithinfectiousbodyfluids.Adisinfectant’slabelindicatestheproperinstructionsiftheproductisregisteredwiththeUSEPAaseffectiveagainstthe disease of concern.

Diseasetransmissionpathwaysforthreeearlychildhoodcommunicablediseasesofconcern,Pertussis(WhoopingCough),NorovirusandHand,Foot,andMouthDisease,areillustratedinthissection.SanFrancisco2010diseasestatistics are provided as a reference as how likely these diseases may occur in the child care-age population.

SectionIII.GuidanceforCommunicableDiseaseOutbreaks


Table 5. Examples of modes of transmission of infectious diseases in child care d,20, 34

Transmission Mode How does transmission happen?

Airborne Inhalationofmicrobialaerosols(i.e.,infectiousparticles)

Person-to-personproximityandproximityofthebreathingzone

Direct Contact(skin-to-skin)

•Contactwithinfectiousbodyfluids-throughbreaksintheskinsuchasopencuts,sores,rashes-throughmucusmembranes(locatedintheeyes,nose,andmouth);includesdropletsprayfromsneezing,coughing,speaking,spitting

•Inchildcare,riskfactorsincludebiting,frequentscratching,generalizeddermatitis,andpersonswithbleedingproblems(notethatstaffwithbloodborneinfections,especiallythosewithopenwoundsorlesions,shouldseekmedicaladviceonwhenitissafetoreturntowork)

Ingestion(foodborne) Eatinginfectedfood

Indirect

Contact(skin-to-skin)Touchinginanimatesurfaces(e.g.,toys,tables,soiledclothesorbedding,eatingutensilsorfoodcontactsurfaces)contaminatedwithinfectiousbodyfluids

Fecal-oral•Hand-to-mouthactivityaftercontactwithitemscontaminatedwith

infectious fecal matter•Ingestionoffoodordrinkcontaminatedwithinfectiousfecalmatter

Disease transmission illustrated by three early childhood communicable diseases of concern: Pertussis (Whooping Cough), Norovirus and Hand, Foot, and Mouth Disease

(San Francisco 2010 statistics used as example)

A. Pertussis (“Whooping Cough”): 23 cases children four years of age or younger in SF in 2010.

All adults working in infant care settings should receive a pertussis vaccination in order to protecttheinfantsintheircare(alsoknownas“cocooning”).e

BetweenJan.–Oct.2010,therewasanepidemicofpertussiswhere9,156caseswithonsetin2010werereportedinthestateofCalifornia.Thiswasthehighestnumberofreportedcasesinover60years.Ofthesecases,455infantsundertheageofthreemonthswerehospitalizedand10infantsdied.Asaresult,theStateHealthDepartmentpartneredwithlocalhealthdepartmentsandproviderstoimplementdiseasecontrolstrategies,releaseinformationalalerts,andofferfreevaccination.Sincethattime,theratesofpertussishavedeclinedand289knownhospitalizedinfantsunderthreemonthswithnodeathshaveoccurred.35

Infantssixmonthsoldoryoungerhaveimmatureimmunesystemsandareatthegreatestriskforbecominginfectedwithpertussis.Theyhavemoreseverecomplicationsfromtheillness,includingdeath.PertussisisahighlycontagiousrespiratoryillnesscausedbyinfectionwiththebacteriaBordetella pertussis that causes cold-likesymptoms.Symptomsmayincludearunnynose,low-gradefever,mildorseverecoughingwhichcanlastfor

Source: Centers for Disease Control and Prevention

d. TheAAPrecommendspracticingstandardprecautionstohelppreventtransmission.StandardprecautionsasdescribedbytheAAPincludethefollowing:PPEuse(especiallytheuseofglovestocleanupaccidentsinvolvingbodyfluids),absorbbloodorbodyfluidscontainingbloodwithdisposablepapertowels,disinfectwithbleachorappropriateUSEPA-approveddisinfectant,avoidcontactwithbreaksintheskin,handhygiene,andproperdisposalofcontaminatedmaterial.

e. Whenworkersarevaccinated,theyarelessliketospreadWhoopingcoughtoinfantsincare.Instead,theysurroundthebabywitha“cocoon”ofprotectionuntiltheinfantsreceivealloftheirvaccinations.ImmunizationActionCoalitionhttp://www.immunize.org/catg.d/p4039.pdf


weeks(thecoughingsymptomsmayvarydependingontheageofthechild),coughingfitsfollowedbya“whooping”soundasthechildtriestoinhale,andapnea(apauseinbreathingpatterns)ininfants.Infectedpersonsmightalsoexperiencevomitingandlethargyasaresultofseverecoughing.Seriouscomplicationsmayoccurininfantsandyoungchildren,especiallychildrenwhohavenotbeenfullyvaccinated;theyincludepneumonia,convulsions,encephalopathy,anddeath.36-38

Pertussisistransmittedbyclosecontactwithapersonwhohasbeeninfected.Apersoncanbecomeinfectedthroughinhalationofthebacteriathatiscontainedinthe“wetdrops”releaseduponcoughing,sneezing,ortalking(person-to-persontransmission).39Avoidingclosecontact,monitoringcontactbetweenchildren,ensuringspatialseparationofcotsorbeds(atleastthreefeetapart),exclusionofchildrenorchildcareworkerssuspectedofhavingpertussis,notificationofparentsregardingthesituation(ifnecessary),andmedicalexamination(ofchildrenandworkerssuspectedofhavingpertussis)arerecommended.20,40

Neither6.15%bleachnorOxivir®TbhasprovidedtestingdatatotheUSEPAtoaddBordetella pertussis,thebacteriathatcausespertussis,toitsregistrationlabel.

B. Norovirus: Two suspected outbreaks and one confirmed outbreak in San Francisco child care in 2010 (116 cases children four years of age or younger were reported)

TherehasbeenoneoccurrenceofanorovirusoutbreakataSFhighschool(St.IgnatiusCollegePreparatoryHighSchool)inthelastyear.IllnessonsetsbeganonJanuary30,2012andwithinfourdays,thevirushadaffectedmorethan400studentsand30teachers.TheoutbreakwasinvestigatedbytheSanFranciscoDepartmentofPublicHealthCommunicableDiseaseControl&Prevention(SFDPHCDCP).Theschoolwasclosedforoneweekandwasdisinfectedwithbleach.41

In2010,twosuspectednorovirusoutbreaksoccurredinpreschooltypesettingsandoneoccurredinadaycaresetting.42Altogether,116childrenwerereportedtohavebeenaffectedbynorovirusatthattime.Althoughnorovirusisnotonthelistofreportableinfectiousdiseases,norovirusisaconcerninchildcaresettingssinceitcanspreadquicklyandisaseriousillnessforyoungchildren.Therefore,whenchildrenorstaffexperiencevomitingand/ordiarrhea,infectioncontrolmeasuresshouldbeinitiatedimmediatelyinordertolimittransmission.Norovirusillnessisaviralinfectionthatcausesinflammationofthestomachand/orintestines(alsoknownas“acutegastroenteritis”),whichleadstostomachpain,nausea,diarrhea,andvomiting.Thevirusesthatcausenorovirusincludenorwalk-likeviruses,caliciviruses,andsmallroundstructuredviruses.42,43

Norovirusishighlycontagiousandistransmittedthroughcontactwithinfectedpersons,inhalationofwetdropletsfromvomiting,ingestionoffoodorwatercontaminatedwithnorovirus,ortouchingsurfacescontaminatedwithvomitorstool(fecal-oral)followedbyputtinghandsorfingersinthemouth.42 Since norovirus can live on inanimate surfacesforuptoapproximatelysevendays,44,45bodyfluidspillsinvolvingvomitanddiarrhearequirepre-cleaningand disinfecting.

Inadditiontofrequenthandwashing,centersshouldlimitperson-to-personcontact,ensurespatialseparationofcotsorbeds(atleastthreefeetapart),20usepersonalprotectiveequipment,anddisinfectcontaminatedsurfacestohelppreventthespreadofinfection.Bleach(6.15%)oraUSEPA-approveddisinfectant(i.e.,Oxivir®Tb)fornorovirusshouldbeusedduringanoutbreak(refertotheUSEPA’sOfficeofPesticidePrograms“ListG:EPA’sRegisteredAntimicrobialProductsEffectiveAgainstNorovirus(Norwalk-likevirus)”January9,2009).46

Oxivir® Tband6.15%bleachhavebothprovidedtestingdatatotheUSEPAtoaddthevirusthatcausesNorovirustotheirproductlabel.Oxivir® Tbrequiresaone-minutesurfacecontactdwelltimewhereasadilutionusing6.15%


bleachrequiresadwelltimeoffiveminutes.However,atthistime,theSanFranciscoDepartmentofPublicHealthCommunicableDiseaseControlandPreventionsectionisnotwillingtoacceptotherdisinfectantsthanbleachinresponsetonorovirus.Notethat5.25%and6.0%bleacharenotregisteredwiththeUSEPAaseffectiveagainstnorovirus.PertheUSEPAregistrationfor6.15%bleach,acenterwouldusethefollowinginstructionstodisinfectsurfaces contaminated with norovirus:

• UsingtheappropriatePPE,dilute6.15%bleach:2oz.(4Tablespoons)ofbleachtoonequart(32oz.)ofwater(1:16dilution)

• Pre-cleanthesurfaceusingsoapywater

• Spraythedilutedbleachonthesurface

• Leavethesurfacewetwithbleachsolutionfor5minutes,and

• Rinsethesurface.

Forthemostup-to-dateinformationaboutdisinfectingrecommendationspleasevisityourcity’scommunicablediseaseprogram.

C. Hand, Foot, and Mouth Disease (has been known to occur in SF child care settings)

Hand,Foot,andMouthDisease(HFMD)isanotherdiseasethatisofconcerninchildcare settings since it affects mostly infants and young children and is very contagious. HFMDisaviralillnesscausedbyaclassofvirusescalledenteroviruses;morespecially,CoxsackievirusA16(themostcommoncauseofHFMD)andEnterovirus71(thetypeassociatedwithHFMDoutbreaks).

HFMDcausesfever,lossofappetite,lethargy,sorethroat,soresinthebackofthemouth,insideofcheeks,gumsandtonguethatmaybecomeblisters,andskinrashwithraisedorflatspotscommonlyfoundonthepalmsofhandsandsolesoffeet(butmayaffectotherareasofthebodysuchasknees,elbows,buttocksorgenitalarea).Onveryrareoccasions,HFMDcomplicationsmayincludetemporaryfingernailandtoenailloss,viralmeningitis(headache,stiffneck,andfever),orencephalitis(swellingofthebrain)thatmaybecomefatalifsevere.47

HFMDistransmittedbytouchingcontaminatedsurfacesorthroughdirectcontactwithsaliva,sputum,nasalmucus,fluidfromblisters,andstoolofinfectedpersons.Althoughaninfectedpersonismostcontagiousduringthefirstweek,theviruscanremaininaperson’sbodyforweeksaftersymptomshavegoneaway.Therefore,apersonisstillinfectioustoothersforweeksaftertheyareasymptomatic.SinceCoxsackieviruscanliveoninanimatesurfacesfordays,48 similar precautionstakenfornorovirusincludingfrequenthandwashing,limitingperson-to-personcontact,usingpersonalprotectiveequipment,anddisinfectingcontaminatedsurfaces(includingtoys)helppreventthespreadofinfection.34 Exclusionofinfectedchildrenisrecommended,untiltheynolongerhaveafeverandtheirmouthsoreshavehealed.47

Neither6.15%bleachnorOxivir®TbhasprovidedtestingdatatotheUSEPAtoaddtheCoxsackievirus(thatcausesHFMD)toitsregistrationlabel.Atthistime,only14disinfectantsareregisteredwiththeUSEPAaseffectiveagainstCoxsackievirus.See Table 6 on the following page.

Eachofthese14registereddisinfectantsapprovedforCoxsackieviruscontainanactiveingredientthatisconsideredarespiratoryirritantorthatcausesasthma.Therefore,theTaskForceisnotabletorecommendoneoftheseproductsasbeingsaferforasthma.See Websites section on page 46 for information on accessing this list.

Source: Centers for Disease Control and Prevention


Table 6. Disinfectants registered with the USEPA as effective against Coxsackie virus

EPA Reg# Name of product (note that the name listed may be the USEPA registered product name) Active ingredient of concern for asthma

777-99 ProfessionalLysol®BrandIIIDisinfectantSpray Quaternaryammoniumcompound

777-105 Lysol®BrandIVI.C.Disinfectant Quaternaryammoniumcompound

1677-216 ExsporBaseConcentrate Bleach

5813-21 Clorox®Clean-UpCleanerwithBleach-OldProduct Bleach

5813-97 Brac Quaternaryammoniumcompound

67619-17 CloroxCommercialSolutions®Clorox® Clean-Up® Disinfectant Cleaner with Bleach

Bleach

67619-21 CloroxCommercialSolutions®Clorox® Disinfecting Spray

Quaternaryammoniumcompound

6659-3 SprayNineMulti-PurposeCleaner/Degreaser Quaternaryammoniumcompound

9804-1 BioVex® BioCide Bleach

10088-105 DecidentDisposableDisinfectantSleeve Phenylphenol

55195-3 Coldcide0.25% Phenylphenol,glutaraldehyde

55195-4 Coldcide0.25%DisinfectingWipes Phenylphenol,glutaraldehyde

56392-2 Citrace®HospitalGermicide Phenylphenol

70369-1 Microstat2Disinfectant Releaseschlorine


Tip #12Compare6.15%bleachandOxivir®TbeffectivenessagainstspecificcommunicablediseasesSearching USEPA antimicrobial website

Manufacturersofantimicrobialdisinfectantssubmitmandatorytestdata,forspecificbacteria,totheUSEPAforproductregistration.ThepubliccanuseUSEPA’swebsitetoaccesseachindividualproduct’slabellistingthesubstantiatedclaims.

Inaddition,manufacturersofantimicrobialdisinfectantsvoluntarilysubmitadditionaltestsforregistrationagainstcertainhumanpublichealthbacteriaandviruses.TheUSEPAhasprovidedapubliclook-upwebsiteforselectedcommunicablediseaseagents,showingwhichproductshavetestedeffectiveagainstthatdiseaseagent.See Websites section for more information.Antimicrobialsshouldbeusedaccordingtotheproductlabelinordertodisinfect effectively since surface contact dwell time will vary from routine use. See Table 7 for more information on USEPA-registered disinfectants approved for specific communicable diseases.

Mandatory Communicable Disease reporting

AllhealthcareprovidersinthestateofCaliforniaaremandatedbyTitle17,CaliforniaCodeofRegulationstoreportto their local health authority49theoccurrenceofspecificdiseasesandotherconditions(suchasthosecharacterizedbylapsesofconsciousnessandpesticide-relatedillnessorinjury).50Thisallowsforpublichealthagenciestoidentify,prevent,andcontrolinfectiousdiseasesinatimelymanner;andtoplanandevaluatediseasepreventionandcontrolprograms.Tothisend,nationwide(UnitedStatesDepartmentofHealthandHumanServices,CentersforDiseaseControlandPrevention,CDC)andstatewide(CaliforniaDepartmentofPublicHealth’sDivisionofCommunicableDiseaseControl)agencies51provideinformationforcommunicable,infectious,andchronicdiseases.Informationincludessignsandsymptoms,transmission,diagnosisandtreatment,prevention,andotherresources.Formoreinformationonreportablediseasesandconditions,visitthecommunicablediseasecontrolwebsiteofyourlocaljurisdiction.Althoughadiseaseorconditionmaynotbespecifiedonacounty’slistofreportablediseases,thismeansthatindividualcasesarenotreportable,butoutbreaksofanydiseasearereportable.

InSanFrancisco,treatingcliniciansaremandatedtoreporttheoccurrenceofspecificinfectiousdiseasesandconditionstotheDepartmentofPublicHealthCommunicableDiseaseControlandPrevention(SFDPHCDCP).Table 7 onthefollowingpagecitesdatacapturedbySFDPHCDCPforchildrenfouryearsofageoryoungerasanexampleofdiseasefrequency,andcomparestheeffectivenessof6.15%bleachandOxivir®Tbinthefollowingcategories:

• Reportablecommunicablediseases

• Non-reportable communicablediseases,and

• Reportable diseases not typically reported for this demographic.


Table 7. Communicable diseases of concern in child care and the comparison of Oxivir® Tb and 6.15% bleach USEPA registration labels (EPA Reg# 70627-563a and EPA Reg# 67619-83d, respectively) for effectiveness against the associated microbial organisms.

Communicablediseasesinchildcarewiththeassociatedmodesoftransmission,symptomstoobserve,andrecommendationsforcontrollingexposure.PurpleshadingindicatesthediseasewhereOxivir®Tband6.15%bleachdifferinwhethertheyareUSEPA-registeredaseffectiveinkillingthemicroorganismassociatedwiththatdisease.Forthiscomparison,6.15%bleachisusedsince5.25%and6.0%bleacharenotregisteredaseffectiveagainstnorovirus,HepatitisBandHepatitisC.

A=American Academy of Pediatrics, B=Centers for Disease Control and Prevention, C= California Department of Public Health, D= SFDPH CDCP

A) Reportable diseases affecting children 4 years of

age or younger

# Cases (SF 2010)D

Modes of transmission & viability on hard

surfacesSymptoms

USEPA label indicates is effective against specific

microbe & required contact time on surface

Infection control recommendations

Oxivir® Tb 6.15% Bleach

1. Campylo-bacteriosis (Foodborne

bacteria)

33

•Ingestionofcontaminatedfood or drinks

•Cross-contaminationofsurfaces or other food from raw meat

•Diarrhea•Vomiting•Fever•Abdominalpain•Nausea

No No•Frequenthand-washing•Excludestaffwithdiarrhea

from handling foodA

2. Salmonellosis (Foodborne

bacteria)33

•Fecal-oral•Ingestionofcontaminated

food or drinks•Handlinganimals

•Diarrhea•Vomiting(some

cases)•Fever•Abdominal

cramps•Dehydration

Yes (1 minute)

Yes(5 minutes followed by rinse step)

•Frequenthand-washing•Oxivir®Tbor •6.15%Bleach:2oz.

(4Tablespoons)ofbleachtoonequart(32oz.)water(1:16dilution)

•Excludechildwithdiarrheaor vomitingA

3. Pertussisalso known as

“Whooping Cough”(Airborne bacteria)

23

•Person-to-personcontact via inhalation of infected droplets released fromtalking,sneezing,coughing

•Cold-likesymptoms

•Runnynose•Low-gradefever•Mildorsevere

long lasting cough•Coughingfits

followedbya“whooping”sound

•Vomitingandlethargy(asaresult of incessant coughing)

No No

•Frequenthand-washing•Vaccinationofstaff•Excludechild/staffa)Ifpersonisreceiving

treatment,excludeuntilafter5daysofantibiotictreatment, or

b)Ifpersonisnotreceivingtreatment,excludefor21days after cough onsetA,C

•Spatialseparationofcotsorbeds(atleastthreefeetapart)A

4. Giardiasis(Parasite) 14


food or water

•Diarrhea•Abdominalcramps•Nausea•Bloatingandgas•Lethargy•Weightloss•Dehydration

No No

•Frequenthand-washing•Excludechild/staffwith

diarrhea•Somechildcarecenters

requireexclusionuntilperson’sstoolcultureisnegative for GiardiaC


A) Reportable diseases affecting children 4 years of

age or younger

# Cases (SF 2010)D


surfacesSymptoms





5. Amebiasis (Parasite) 2


food or water

•Loosestool•Stomachpain•Cramping

No No •Frequenthand-washing•Maintainpersonalhygiene

6. Shigellosis (Foodborne

bacteria)2


food or water•Person-to-personcontact

•Diarrhea(oftenbloody)

•Fever•Dehydration•Abdominal

cramps•Mayexperience

very few symptoms

Yes(1 minute)

Yes (5 minutes followed by rinse step)

•Frequenthand-washing•Oxivir®Tbor•6.15%Bleach:2oz.


•Excludechild/staffwithdiarrhea until

a)Atleast24hoursormoreafter diarrhea stopsA

b)Insomestates,excludeuntil two stool cultures are negative for Shigella

•EliminatesharedwaterplayA

Table 7. (continued)


B) Non-Reportable diseases affecting children 4 years

of age or younger

# Cases (SF 2010)D


surfacesSymptoms





1. Norovirus(Norwalk virus)

116(two

suspected outbreaksand one

confirmedoutbreak)

•Contactwithsurfacescontaminated with vomit orstool(fecal-oral)followedbyputtinghandsorfingersinthemouth

•Inhalationofairborneinfected droplets from vomit

•Ingestionofcontaminatedfood or drinks

•Person-to-personcontact(includescaringforanillchild/adult,sharingeatingutensils,orsharingfood)

•Noroviruscanliveoninanimate surfaces for up toapproximatelysevendays46,47

•Diarrhea•Vomiting•Stomachpain•Nausea

Yes(1 minute)



(4Tablespoons)ofbleachtoonequart(32oz.)ofwater(1:16dilution)

•Excludechild/staffwithdiarrhea or vomiting





B) Non-Reportable diseases affecting children 4 years

of age or younger

# Cases (SF 2010)D


surfacesSymptoms





2. Hand, Foot & Mouth Disease

(Coxsackie virus)

•Directcontactwithsaliva,sputum,nasalmucus,fluidfromblisters,andstool of infected persons

•Contactwithsurfacescontaminatedwithbodyfluidsofinfectedpersons

•Coxsackieviruscanliveon inanimate surfaces for days50

•Soresinthebackofthemouth,insideofcheeks,gums

•Sorethroat•Skinrashwith

raisedorflatspotscommonly found on palms of hands and soles of feet butcanappearonother areas of the body

•Fever•Lossofappetite•Lethargy

No No

•Frequenthand-washing•Excludechilda)Withfever,andb)Untilmouthsoreshave

healedC

3. Methicillin-Resistant

Staphylococcus Aureus also

known as “MRSA” (Bacteria: Staphylococcus

aureus, also known as “staph”)

•Skin-to-skincontact•Contactwithaninanimate

objectorsurfacethathasbeencontaminatedbypusdrainagefromwounds or lesions of an infected person

•MRSAisnotpassedthrough the air

•MRSAcansurviveformonthsonadry,inanimate surface48

•Redness•Warmth•Swelling,and•Tendernessof

the skin•Possiblefever

and/or chills•Boils,blisters,

pustules or abscessesmaydevelop

Yes(1 minute)


•Frequenthand-washing• Oxivir®Tbor• 6.15%Bleach:2oz.


• Coverskininfections• Avoidsharingpersonal

items with the infected staff or child

• Iflesionscannotbecovered,excludestaffor child from activities involving skin-to-skin contact

a)Untillesionsarehealed,or b)UntillesionscanbecoveredandcontainedadequatelyD

c)Untilreturntoactivitiesisapprovedbyschoolofficialor the treating medical personneD,C




B) Reportable diseases not

typically reported for children 4

years of age or younger

# Cases (SF 2010)D


surfacesSymptoms





1. Human immunodeficiency virus also known as “HIV” (Virus)

•Person-to-personcontact(throughabreakintheskin/mucusmembranes)

•Directcontactwithbloodorotherbodyfluids

•HIVcannotliveoutsideofthehumanbody,transmission does not occurfromtoilets,phonesor water fountainsD

•Immunestatusverifiedbybloodtesting

Yes(1 minute)




•StandardprecautionsA

2. Hepatitis A(Virus: Foodborne)

•Fecal-oral•Person-to-personcontact•Ingestionofcontaminated

food or drinks

•Diarrhea•Jaundice•Fever•Dark-coloredurine•Light-colored

stool•Fatigue•Abdominalpain•Lossofappetite•Nausea•Maybe

asymptomatic

No


•Frequenthand-washing•6.15%Bleach:2oz.


•Excludechildforsevendays after illness onsetA

•Excludestafffortwoweeks after illness onsetD

3. Hepatitis B (Virus)

•Person-to-personcontact•Directcontactwithblood

orotherbodyfluids•HepatitisBviruscan

survive on inanimate surfaces(andcancauseinfection)foratleast7daysB



asymptomatic

Yes(1 minute)

Yes(5 Minutes followed by rinse step)



•Limitpotentialsalivacontamination of surfaces


4. Hepatitis C (Virus)

•Person-to-personcontact•Directcontactwithblood

orotherbodyfluids•HepatitisCviruscan

survive on inanimate surfaces(andcancauseinfection)foratleast16hours and no longer than 4daysB



asymptomatic

Yes(1 minute)








B) Reportable diseases not

typically reported for children 4

years of age or younger

# Cases (SF 2010)D


surfacesSymptoms





5. Tuberculosis also known as “TB”

(Bacteria: Mycobacterium

tuberculosis)

•Person-to-personcontactvia inhalation of infected airbornedropletsreleasedfromtalking,sneezing,coughing

•TBcansurviveintheair for several hours depending on the environmentB

•Badcoughlastingthree weeks or longer

•Fever•Coughingup

bloodorsputum•Chestpain•Lethargy•Weightloss•Lossofappetite•Chills•Nightsweat

Yes(5 minutes)


•Frequenthand-washing•ForactiveTB,exclude

child/staff until determined tobenon-infectiousbymedicalorhealthdepartment personnel

•Oxivir®Tbor•6.15%Bleach:3oz.

(6Tablespoons)ofbleachtoonequart(32oz.)water(~1:10dilution)



1 UnitedStatesEnvironmentalProtectionAgency.Pesticide Registration Manual: Chapter 4 - Additional Considerations for Antimicrobial Products.PagelastupdatedAugust15,2012.Retrievedat www.epa.gov/pesticides/bluebook/chapter4.html

2 Mainwebpage:UnitedStatesEnvironmentalProtectionAgency.Pesticides: Regulating Pesticides, Regulating Antimicrobial Pesticides. PagelastupdatedAugust01,2012.Retrievedatwww.epa.gov/oppad001/UnitedStatesEnvironmentalProtectionAgency.Pesticides: Regulating Pesticides, What Are Antimicrobial Pesticides.PagelastupdatedMay09,2012.Retrievedatwww.epa.gov/oppad001/ad_info.htm

3 UnitedStatesEnvironmentalProtectionAgency.Pesticide Product Labeling System (PPLS). Accessibleathttp://iaspub.epa.gov/apex/pesticides/f?p=PPLS:1

3a UnitedStatesEnvironmentalProtectionAgency.Pesticide Product Labeling System (PPLS): Oxivir TB, EPA Reg# 70627-56.Accessibleathttp://iaspub.epa.gov/apex/pesticides/f?p=PPLS:8:749813487945001::NO::P8_PUID:479145

3b UnitedStatesEnvironmentalProtectionAgency.Pesticide Product Labeling System (PPLS): SaniDate Ready-to-Use, EPA Reg# 70299-9.Accessibleathttp://iaspub.epa.gov/apex/pesticides/f?p=PPLS:102:::NO::P102_REG_NUM:70299-9

3c UnitedStatesEnvironmentalProtectionAgency.Pesticide Product Labeling System (PPLS): Alpha-HP Multi-Surface Disinfectant Cleaner, registered under the name Phato 1:64 Disinfectant Cleaner, EPA Reg# 70627-62. Accessibleathttp://iaspub.epa.gov/apex/pesticides/f?p=PPLS:102:::NO::P102_REG_NUM:70627-62

3d UnitedStatesEnvironmentalProtectionAgency.Pesticide Product Labeling System (PPLS): Clorox commercial Solutions, Ultra Clorox, Germicidal Bleach I: Clorox Liquid Bleach, EPA Reg# 67619-8. Accessibleathttp://iaspub.epa.gov/apex/pesticides/f?p=PPLS:8:749813487945001::NO::P8_PUID,P8_RINUM:38687,67619-8

4 Rutala,W.A.,D.J.Weber,theHealthcareInfectionControlPracticesAdvisoryCommittee(HICPAC).2008.Guideline for disinfection and sterilization in healthcare facilities, 2008.Atlanta,GA:CentersforDiseaseControlandPrevention,NationalCenterforPreparedness,Detection,andControlofInfectiousDiseases,DivisionofHealthcareQualityPromotion.www.cdc.gov/hicpac/pdf/guidelines/Disinfection_Nov_2008.pdf

5 UnitedStatesEnvironmentalProtectionAgency.Pesticides: Science and Policy. Sanitizing Rinses (for previously cleaned food contact surfaces). LastupdatedonWednesday,May09,2012.Retrievedfrom www.epa.gov/oppad001/dis_tss_docs/dis-04.htm

6 UnitedStatesEnvironmentalProtectionAgency.OfficeofChemicalSafetyandPollutionPrevention(7510P).Product Performance Test Guidelines, OCSPP 810.2300: Sanitizers for Use on Hard Surfaces – Efficacy Data Recommendations. EPA 712-C-07-091, September4,2012.Retrievedfrom http://www.regulations.gov/#!documentDetail;D=EPA-HQ-OPPT-2009-0150-0022

Endnotes


7 UnitedStatesEnvironmentalProtectionAgency.Disinfectants for Use on Hard Surfaces. PagelastupdatedApr.6,2012.Retrievedfromwww.epa.gov/oppad001/dis_tss_docs/dis-01.htm

8 UnitedStatesEnvironmentalProtectionAgency:DIS/TSS-1 Jan 22, 1982 EFFICACY DATA REQUIREMENTS Disinfectants for Use on Hard Surfaces. LastupdatedApr.6,2012;referstotheAOACGermicidalSprayProductsTest(AOAC961.02).Retrievedfromwww.epa.gov/oppad001/dis_tss_docs/dis-01.htm

9 UnitedStatesEnvironmentalProtectionAgency:OfficeofChemicalSafetyandPollutionPrevention(7510P).Product Performance Test Guidelines, OCSPP 810.2200: Disinfectants for Use on Hard Surfaces – Efficacy Data Recommendations. EPA 712-C-07-074, September4,2012.Retrievedfrom http://www.regulations.gov/#!documentDetail;D=EPA-HQ-OPPT-2009-0150-0021

10 State of California: Department of Social Services. Manual of Policies and Procedures. Community Care Licensing Division. Child Care Center. Title 22, Division 12. Effective11/1/98.January2004.

11 AssociationofOccupationalandEnvironmentalClinics.Revised Protocol: Criteria for Designating Substances as Occupational Asthmagens on the AOEC List of Exposure Codes.RevisedSeptember2008.Retrievedatwww.aoec.org/content/Asthmagen_Protocol_9_15_08.pdf

AOEC Exposure Code List, Display All Asthmagens. Accessibleatwww.aoecdata.org/ExpCodeLookup.aspx

12 AgencyforToxicSubstancesandDiseaseRegistry:DivisionofToxicologyandEnvironmentalMedicineToxFAQs™.Chromium CAS#7440-47-3.September2008.Retrievedatwww.atsdr.cdc.gov/tfacts7.pdf

13 CaliforniaEmploymentDevelopmentDepartment.Occupational Employment and Wages Data. Wagesdatabasedon2005,1stQuarter.Wagesdefinedfor“childcareworker.”

14 TheCenterfortheChildCareWorkforce,TheCaliforniaChildCareResourceandReferralNetwork,andtheCenterfortheStudyofChildCareEmployment.The California Child Care Workforce Study: Center-based Child Care Staff in San Francisco, 2001.

15 WuYeeChildren’sServices.SFCARES.Data,EducationalAttainment,2005.

16 StateofCalifornia,HealthandHumanServicesAgencyDepartmentofSocialServices.Community Care Licensing Division. Child Care Update, Spring 2012.Accessibleathttp://ccld.ca.gov/res/pdf/CCUpdateSpring2012.pdf

17 BillNumber:AB2297,PassedtheSenateAugust29,2012,IntroducedbyAssemblyMemberHayashi.Accessibleathttp://sacramento.networkofcare.org/mh/legislate/state-bill-text.aspx?id=209852&bill=AB%202297&sessionid=2011000

18 SanFranciscoUnifiedSchoolDistrict.Resolution 116-14A3: In Support of Green Cleaning throughout the San Francisco Unified School District. June 28, 2011.Accessibleatwww.sfusd.edu/en/assets/sfusd-staff/about-SFUSD/files/resolutions/Wynns%20SFUSD%20Green%20Cleaning%206%2014%202011.pdf

19 GreenSeal:www.greenseal.org/Home.aspxEcologoCCD-146:HardsurfaceCleaners: www.ecologo.org/en/seeourcriteria/details.asp?ccd_id=371

20 AmericanAcademyofPediatrics.PickeringLK,BakerCJ,KimberlinDW,LongSSeds.Red Book 2009: Report of the Committee on Infectious Diseases, 28thed.ElkGroveVillage,Ill,AmericanAcademyofPediatrics,2009.


21 State of California. California Code of Regulations, (Vol. 22), Title 17 (Section 20), Public Health, April 1, 1990. Accessibleathttp://archive.org/details/gov.ca.ccr.17

22 EnvironmentRatingScalesInstitute.http://ers.fpg.unc.edu/

22aEnvironmentRatingScalesInstitute.Additional Notes for Clarification for the ITERS-R. 09/2012.Accessibleatwww.ersi.info/PDF/NotesforClarification/ITERS-R%20Additional%20Notes%2009-12.pdf)

22bEnvironmentRatingScalesInstitute.Additional Notes for Clarification for the ECERS-R. 09/2012.Accessibleatwww.ersi.info/PDF/NotesforClarification/ECERSR%20Additional%20Notes%2009-12.pdf

22cEnvironmentRatingScalesInstitute.Additional Notes for Clarification for the FCCERS-R. 09/2012. Accessibleatwww.ersi.info/PDF/NotesforClarification/FCCERS-R%20Additional%20Notes%209-12.pdf

23 UnitedStatesEnvironmentalProtectionAgency.Pesticide Registration Manual: Chapter 13 – Devices, section 40 CFR 156.10(a)(5).ElectronicCodeofFederalRegulations.CurrentasofSeptember27,2012.Retrievedathttp://ecfr.gpoaccess.gov/cgi/t/text/text-idx?c=ecfr&sid=4f63742302577774698092538d20b84d&rgn=div5&view=text&node=40:24.0.1.1.7&idno=40#40:24.0.1.1.7.1.1.1

24 UnitedStatesEnvironmentalProtectionAgency.Pesticides: Regulating Pesticides, Antimicrobial Testing Program. PagelastupdatedMay11,2012.Retrievedatwww.epa.gov/oppad001/antimicrobial-testing-program.html

25 UnitedStatesEnvironmentalProtectionAgency.Antimicrobial Testing Program (ATP) Status as of 5/9/2012. May09,2012.Retrievedatwww.epa.gov/oppad001/atp-summary-05-09-12.pdf

26 UnitedStatesEnvironmentalProtectionAgency:AntimicrobialsDivision.Inquiry submitted to the Antimicrobial Division. Answers provided by Ibrahim Laniyan, Microbiologist, Product Science Branch. October23,2012.

27 D’AlessandroA,KuschnerW,WongH,BousheyHA,BlancPD.Exaggerated responses to chlorine inhalation among persons with nonspecific airway hyperreactivity. Chest1996;109:331-337.

28 SastreJ,MaderoMF,Fernandez-NietoM,SastreB,delPozoV,Garcia-delPotroM,QuirceS.Airway response to chlorine inhalation(bleach) among cleaning workers with and without bronchial hyperresponsiveness.AmJIndMed2011;54:293-299.

29 ArifAA,DelclosGL.Association between cleaning-related chemicals and work-related asthma and asthma symptoms among healthcare professionals.OccupEnvironMed2012;69:35-40.

30 JacekM.Mazurek,MargaretFilios,RuthWillis,KennethD.Rosenman,MD,2MaryJoReilly,MS,2KatharineMcGreevy,DavidValiante,ElisePechter,LetitiaDavis,JenniferFlattery,RobertHarrison. Work-Related Asthma in the Educational Services Industry: California, Massachusetts, Michigan, and New Jersey, 1993–2000. AMERICANJOURNALOFINDUSTRIALMEDICINE51:47–59(2008).

31 UnitedStatesDepartmentofHealthandHumanServices,CentersforDiseaseControlandPrevention.Handwashing:CleanHandsSaveLives.www.cdc.gov/handwashing/

32 UnitedStatesDepartmentofHealthandHumanServices,CentersforDiseaseControlandPrevention.Fecal-oralroute.http://www2a.cdc.gov/nip/isd/ycts/mod1/scripts/glossary.asp?item=fecal-oral%20route

33 StateofCaliforniaHealthandSafetyCode:Part 7 - California Retail Food Code.EffectiveJanuary1,2012.Retrievedfromwww.cdph.ca.gov/services/Documents/fdbRFC.pdf


34 AmericanPublicHealthAssociation.BenensonASed.Control of Communicable Diseases in Man,15thed.Washington,DC,AmericanPublicHealthAssociation,1990.

35 CaliforniaDepartmentofPublicHealth.Pertussis Report, April 24, 2012.Accessibleatwww.cdph.ca.gov/programs/immunize/Documents/PertussisReport2012-04-24.pdf

36 StateofCalifornia,HealthandHumanServicesAgency,CaliforniaDepartmentofPublicHealthTitle 17, California Code of Regulations (CCR) §2500, §2593, §2641.5-2643.20, and §2800-2812 Reportable Diseases and Conditions.Accessibleathttp://www.cdph.ca.gov/HealthInfo/Documents/Reportable_Diseases_Conditions.pdf

37 UnitedStatesDepartmentofHealthandHumanServices,CentersforDiseaseControlandPrevention.http://www.cdc.gov/DiseasesConditions/

38 CaliforniaDepartmentofPublicHealth(CDPH):DivisionofCommunicableDiseaseControl http://www.cdph.ca.gov/programs/dcdc/Pages/default.aspx

39 UnitedStatesDepartmentofHealthandHumanServices,CentersforDiseaseControlandPrevention.Pertussis (Whooping Cough).Pagelastupdated:June11,2012.Retrievedfromwww.cdc.gov/pertussis/about/causes-transmission.html

40 CaliforniaDepartmentofPublicHealth. Pertussis (Whooping Cough) www.cdph.ca.gov/HealthInfo/discond/Pages/Pertussis.aspx Pertussis Quicksheet www.cdph.ca.gov/HealthInfo/discond/Documents/CDPHPertussisQuicksheet(3)201010.pdf

41 SanFranciscoDepartmentofPublicHealth.Director’s Report for Health Commission Meeting of February 7, 2012. Accessibleathttp://www.sfdph.org/dph/files/hc/HCAgen/HCAgen2012/feb%207/feb%207%20DR02_07_12.pdf

42 SanFranciscoDepartmentofPublicHealth:CommunicableDiseaseControlandPrevention,415-554-2830.Norovirus www.sfcdcp.com/norovirus.html SFDPH School Control Recommendation Checklist for Viral Gastroenteritis www.sfcdcp.com/giresources.html

43 CaliforniaDepartmentofPublicHealth. Norovirus (Norwalk Virus) www.cdph.ca.gov/healthinfo/discond/Pages/Norovirus.aspx NOROVIRUS, previously NORWALK VIRUS or NORWALK-LIKE or CALICIVIRUS INFECTIONS. Quicksheet http://www.cdph.ca.gov/HealthInfo/discond/Documents/norovirus.pdf

44 d’SouzaDH,WilliamsK,JeanJ,SairA,JaykusL:Persistence of Norwalk virus on environmental surfaces and its transfer to food,Washington,D.C.AmericanSocietyforMicrobiology;2003.

45 ClayS,MaherchandaniS,MalikYS,GoyalSM:Survivalonuncommonfomitesoffelinecalicivirus,asurrogateofnoroviruses. American Journal of Infection Control2006.

46 UnitedStatesEnvironmentalProtectionAgency,OfficeofPesticidePrograms“List G: EPA’s Registered Antimicrobial Products Effective Against Norovirus (Norwalk-like virus)” January9,2009,Accessibleatwww.epa.gov/oppad001/list_g_norovirus.pdf

47 CaliforniaDepartmentofPublicHealth.Hand, Foot, and Mouth Disease www.cdph.ca.gov/HealthInfo/discond/Pages/Hand_Foot_and_Mouth_Disease.aspx Factsheet:http://www.cdph.ca.gov/HealthInfo/discond/Documents/HFMD.pdf


48 KramerA,SchwebkeI,KampfG.How long do nosocomial pathogens persist on inanimate surfaces? A systematic review. BMCInfectiousDiseases,16August2006.

49 CaliforniaDepartmentofPublicHealthCalifornia Local Health Department (LHD) Contact Information for Health Care Providers/Labs to Report Communicable Diseases and Submit Confidential Morbidity Report (CMR) forms http://www.cdph.ca.gov/HealthInfo/Documents/LHD_CD_Contact_Info.pdf

50 Title17,CaliforniaCodeofRegulations(CCR)§2500,§2593,§2641.5-2643.20,and§2800-2812ReportableDiseasesandConditions.Accessibleathttp://www.cdph.ca.gov/HealthInfo/Documents/Reportable_Diseases_Conditions.pdf

51 UnitedStatesDepartmentofHealthandHumanServices,CentersforDiseaseControlandPreventionhttp://www.cdc.gov/DiseasesConditions/CaliforniaDepartmentofPublicHealth(CDPH):DivisionofCommunicableDiseaseControlhttp://www.cdph.ca.gov/programs/dcdc/Pages/default.aspx


Project report and associated material

SanFranciscoAsthmaTaskForcesite:www.sfgov.org/asthma RegionalAsthmaManagementandPreventionsite:www.rampasthma.org

United States Environmental Protection Agency pesticide registrations

1) Performance test guidelines

ToaccesstheUnitedStatesEnvironmentalProtectionAgency’s(USEPA)OfficeofChemicalSafetyandPollutionPrevention’sProductperformancetestguidelinesforsanitizersanddisinfectants,visit: http://www.epa.gov/ocspp/pubs/frs/publications/Test_Guidelines/series810.htm

2) Product registrations

ToaccesstheUnitedStatesEnvironmentalProtectionAgency’santimicrobialregistrations,visittheUnitedStatesEnvironmentalProtectionAgency’sPesticide Product Labeling System (PPLS),andsearchbyUSEPAregistrationnumber(“EPAReg#”);see table below for EPA Reg#s http://iaspub.epa.gov/apex/pesticides/f?p=PPLS:1

3) Disinfectants registered against certain public health bacteria and viruses

ToaccesstheUnitedStatesEnvironmentalProtectionAgency’slistsofSelected EPA-registered Disinfectants : EPA’s Registered Sterilizers, Tuberculocides, and Antimicrobial Products Against Certain Human Public Health Bacteria and Viruses, visit: http://www.epa.gov/oppad001/chemregindex.htm

California Department of Pesticide Regulation pesticide registrations

ToaccesstheCaliforniaDepartmentofPesticideRegulations’(CDPR)antimicrobialregistrationinformation,visitthePesticideProductsbyCaliforniaRegistrationNumber:PesticideProductsbyCaliforniaRegistrationNumber,andsearchbyEPAReg#;see table above for EPA Reg#s. http://www.cdpr.ca.gov/docs/label/epanum.htm

United States Environmental Protection Agency and California Department of Pesticide Regulation registration numbers for Task Force recommended sanitizers and disinfectants

Name of antimicrobial EPA Reg# CDPR Registration Number

Oxivir® Tb 70627-56 70627-56-AA

SaniDate® 70299-9 70299-9-AA

Alpha-HP® Multi-Surface Disinfectant Cleaner 70627-62 70627-62-AA

Websites

http://www.sfgov.org/asthma

http://www.rampasthma.org

http://www.epa.gov/ocspp/pubs/frs/publications/Test_Guidelines/series810.htm

http://iaspub.epa.gov/apex/pesticides/f?p=PPLS:1

http://www.epa.gov/oppad001/chemregindex.htm

http://www.cdpr.ca.gov/docs/label/epanum.htm


California Occupational Safety & Health Administration (Cal/OSHA)

ToaccessinformationfromtheCaliforniaDepartmentofIndustrialRelations–DivisionofOccupationalSafetyandHealth–onHazardsCommunicationtraining,seethe“GuidetotheCaliforniaHazardCommunicationRegulation”athttp://www.dir.ca.gov/dosh/dosh_publications/HazCom.pdf

ToaccessinformationfromtheCaliforniaDepartmentofIndustrialRelations–DivisionofOccupationalSafetyandHealth–onexposurecontrol,seethe“ExposureControlPlanforBloodbornePathogens”athttp://www.dir.ca.gov/dosh/dosh_publications/expplan2.pdf

Occupational Safety & Health Administration’s factsheets

ToaccesstheUnitedStatesDepartmentofLabor,OccupationalSafety&HealthAdministration’s(OSHA)factsheetsandquickguides,visithttp://www.osha.gov/pls/publications/publication.htmlFactsheetsfor“CleaningChemicals:ProtectYourself–CleaningChemicalsandYourHealthPoster”andBloodbornePathogensareavailable.

Association of Occupational and Environmental Clinics: Exposure Code List

TheAssociationofOccupationalandEnvironmentalClinics(AOEC)maintainsanExposureCodeListofchemicalsubstances,materials,andphysicalhazards.TheAOEChasanasthmagendesignationforasthma-causingsubstancesandmaterials.Thislistofasthmagens(AOECExposureCodeList,DisplayAllAsthmagens),whichisupdatedonaregularbasis,canbefoundbyaccessingtheirExposureCodeLookupatwww.aoecdata.org/ExpCodeLookup.aspx

Communicable diseases

SanFranciscoDepartmentofPublicHealth,CommunicableDiseaseControlandPrevention Mainwebpage: www.sfcdcp.org AnnualreportsofcommunicablediseasesinSanFrancisco:www.sfcdcp.org/publications.html

CaliforniaDepartmentofPublicHealth,DivisionofCommunicableDiseaseControl Diseaseindex: www.cdph.ca.gov/HealthInfo/discond/Pages/default.aspx

UnitedStatesDepartmentofHealthandHumanServices,CentersforDiseaseControlandPrevention Diseases and conditions: www.cdc.gov/DiseasesConditions

Disinfectants registered with the United States Environmental Protection Agency as effective against Coxsackie virus (the virus that causes Hand, Foot, and Mouth Disease)

PesticideActionNetwork(PAN)PesticideDatabase(maintainedbyPesticideActionNetworkNorthAmerica)PesticideProductSearchpage:http://pesticideinfo.org/Search_Products.jsp Type“coxsackie”inthe“Pest”boxatthebottomofthepage

http://www.dir.ca.gov/dosh/dosh_publications/HazCom.pdf

http://www.dir.ca.gov/dosh/dosh_publications/expplan2.pdf

http://www.dir.ca.gov/dosh/dosh_publications/expplan2.pdf

http://www.osha.gov/pls/publications/publication.html

http://www.aoecdata.org/ExpCodeLookup.aspx

http://www.aoecdata.org/ExpCodeLookup.aspx

http://www.sfcdcp.org

http://www.sfcdcp.org/publications.html

http://www.cdph.ca.gov/HealthInfo/discond/Pages/default.aspx

http://www.cdc.gov/DiseasesConditions

http://pesticideinfo.org/Search_Products.jsp


49 A.VendorsandCosts

50 B.InventoryandSiteObservationChecklists

55 C.TrainingOutline

57 D.HandWashingPlacard

58 E.BodyFluidSpillPlacard

59 F.ChemicalProductstoAvoid

61 G.CaliforniaDepartmentofSocialServices,CommunityCareLicensing Division,Child Care Update, Spring – 2012

64 H.ReferencesforDesignatingBleachasanAsthmagen

Appendices


AppendixA.VendorsandCosts(Sept.2012pricequotes)

Product Predominant UseApproximate

Quantity Used per Monthf

Ordering Informationg

Product Number(Item #)

Bottles perCase

Cost per Case ($)Maynot

includeS&H

Cost per Qt ($)

Oxivir® TBSoldas946mL/

1USQt Classroom Use•DiaperChanging

Tables•Sinks•Toilets•ActivityTables

2Qt.Oxivir®Tb

per infant/toddler room per month

Quill.comwww.quill.com

1-800-982-3400901-4277285 12x1Qt. 54 4.50

OfficeMaxwww.officemax.com

1-800-283-767423380707 12x1Qt. 56 4.67

WaxieSanitarySupp.www.waxie.com

1-800-995-44664277285 12x1Qt. 80 6.67

SaniDate® RTU Hard Surface

SanitizerSoldas946mL/

1USQt

Classroom Use•FoodContact

Surfaces•Non-mouthed

Toys

1-2.5Qt.SaniDate®

per month

EnviroSelects,LLCwww.enviroselects.com

1-877-358-1299

2018-32 12x1Qt

90 7.50

Palletsh Partial72

Full67

Palletsh

Partial6.00Full5.58

SaniDate® RTU Hard Surface

Sanitizer, RefillsSoldas1Gal

1-1.5Gal.per month

2017-1 4x1Gal.

96 6.00

Palletsh

Partial71Full63

Palletsh

Partial4.44Full3.94

Alpha-HP® Multi-Surface Disinfectant Cleaner, RTD

Soldas1.5L

Custodial Use Infant/ToddlerRooms•Floors•Sinks•Toilets

1.5LAlpha-HP®

producesi •25diluted

gallonsat1:64•50diluted

gallonsat1:128•75diluted

gallonsat1:256

www.waxie.com1-800-995-4466

328077

2x1.5L

830.83

Using1:64dilution

Alpha-HP® Multi-Surface Cleaner, RTD

Soldas1.5L328121 81

0.28Using 1:256dilution

f. ThevolumesofproductsusedareapproximationsbasedonmeasurementstakenbyTaskForcestaff.Usemayvarydependingsurfacesize,numberofchildrenserved(i.e.,childrenusingdiapers),and#hours/weekthesiteisoperating.

g. ThevendorslistedservetheSanFranciscoBayArea,andmaynotapplytoalllocations.h. Reducedcostforpurchasingpallets:Partial pallet–2casesspraybottles($72/eaor$6/Qt),3casesrefills($71/eaor$4.44/Qt),total=$355(includesS&H);

Full pallet–8casesspraybottles($67/eaor$5.58/Qt),24casesrefills($63/eaor$3.94/Qt),total=$2030(includesS&H).Pricesaresubjecttochange.i. Theaveragecustodialmopbucketandwringersystem(onwheels)holdsbetween6.5-8.75Gallons.


AppendixB.InventoryandSiteObservationChecklists

Inventory Checklist

Aresanitizersanddisinfectantsstoredoutofthereachofchildren? qYesqNo

Wherearethesanitizersanddisinfectantsstored? q Closet q Kitchen q Bathroom qOfficeq Classroom

Howmanysanitizersanddisinfectantsareusedinthecenter?

Wheninstorage,arethedisinfectantscappedproperly? qYesqNo

Arethedisinfectantsstackedontopofeachother? qYesqNo

Arethedisinfectantsstoredinsecondarycontainment? qYesqNo

Aremorethanonesanitizerandonedisinfectantusedintheclassrooms?Why? qYesqNo

Istherealistofspecifiedproductsforuseinthecenter? qYesqNo

Aredifferentproductsusedindifferentclassrooms? qYesqNo

Dothesanitizer/disinfectantsorotherproductsusedbythecentercontainanyofthefollowingingredients?

qQuaternaryammoniumcompoundsIncludingalkyldimethylbenzylammoniumchlorideanddidecyldimethylbenzylammoniumchloridesorhavenamessoundinglike:q Benzalkonium chlorideqBenzyl-C10-16-alkyldimethyl,chloridesqDodecyl-dimethyl-benzylammoniumchlorideqLauryldimethylbenzylammoniumchlorideqBenzyl-C12-18-alkyldimethyl,chloridesqBenzyl-C12-16-alkyldimethyl,chloridesqBenzyl-C16-18-alkyldimethyl,chlorides

qEthyleneglycolbutylether(2-butoxyethanol)qTriclosan/triclocarban

Doesthecenterhaveanyofthefollowing?

q Air freshenerq Deodorizing spraysqPlug-insqOildiffusersq Solid air fresheners

qPesticides(ant/roachsprays)qAntibacterialsoapqAdditionalgeneralcleanersbesidessoapywater

Notes:

Doesthesanitizer/disinfectantrequiredilution? qYesqNo

Isdilutionrequireddaily? qYesqNo

Ifnot,whatistheshelf-lifeofdilutedproduct?

Howdothestaffmembersknowwhentoreplacethedilutedproduct?


AppendixB.InventoryandSiteObservationChecklists(continued)

Inventory Checklist (continued)

IsdilutionperformedwithPPEandaccordingtoinstructions? qYesqNo

Notes:

IsthereastockofPersonalProtectiveEquipment(PPE)? qYesqNo

WhatPPEisused? qGlovesqEyeprotectionqMaskq Apron

DoesthecenterhaveanEmergencyeyewashstation? qYesqNo

Istheinfectioncontrolmaterialcontainedinonebinderinaknownlocation? qYesqNo

Doesthecenterhaveanexposurecontrolplanforoutbreaksituations? qYesqNo

Notes:

Arethespraybottlesold? qYesqNo

Dothenozzlessprayproperly? qYesqNo

Doesthecenterneedtoreplacethespraybottlescurrentlyinuse? qYesqNo

Aredistinctbottlesdesignatedforcleaning,sanitizing,disinfectingvs.thoseusedforwaterplay?

Sanitizing qYesqNoDisinfecting qYesqNo

Ifusingdifferentproducts,doesthecenterrecyclespraybottlestousewithbothproducts? qYesqNo

Arethebottleslabelsappropriately(i.e.withalabelstatingthecontents)? qYesqNo

Notes:

Istheairflowinthebathroom/classroomadequate? qYesqNo

Arewindowsanddoorsopenwhencleaningifsafetodoso? qYesqNo

IstheHVACsystemmaintained? qYesqNo

Aretherelingeringodorsintheair? qYesqNo


Site Observation Checklist

Doesthestaffdiluteormixproducts? qYesqNo

Wherearethechildrenwithrespecttoareasbeingsanitized/disinfected? qYesqNo

Isapre-cleanstepperformed? qYesqNo

Arethesanitizersanddisinfectantsusedaccordingtotheirlabel? qYesqNo

ArestaffwearingtheappropriatePPE? qYesqNo

Arestaffkeepingasafedistancewhilediluting/sprayingproducts?(i.e.,arethestaffsprayingateyelevelorclosetotheirface?)

qYesqNo

Isthesurfacewetwithsanitizer/disinfectantasspecifiedonthelabel? qYesqNo

Isthesurfacecompletelydrywhenthechildrenentertheroom? qYesqNo

Whatsystemisusedtoproperlydiluteconcentratedproducttosanitizinglevel?

q Closed dilution system qTablespoon/TeaspoonqMeasuringcupq“Eyeball”method

Notes:

IstheMSDSforeachsanitizeranddisinfectantinaknownlocation? qYesqNo

Arestaffknowledgeableaboutthehazardsassociatedwiththeproductsinuse?

qYesqNo

Does the center have instructional placards for sanitizing and disinfecting in the areaofuse?

qYesqNo

Aretheretoomanyinstructionalplacardsonthewall? qYesqNo

Istheinformationontheplacardsoutdated? qYesqNo

Aretheinstructionalplacardseasytounderstand? qYesqNo

Dotheplacardssupportthelanguagesspokenbythestaff? qYesqNo

Werethechildreninanotherareawhenthedisinfectingprocesswasperformed?

qYesqNo

Areas disinfected: qDiaperchangingtableqPottytrainingchairsqToiletsq Sinks qActivitytablesqToysqOther

Wasthesurfacepre-cleaned? qYesqNo



Site Observation Checklist (continued)

Wasthesolutionsprayedawayfromthebreathingzone? qYesqNo

Did the surface remain wet with disinfecting solution for the correct dwell time specifiedonthelabel?

qYesqNo

Howwasdwelltimemeasured? q Digital timer qWallclockqWatchqOther

Wasthesurfacerinsed? qYesqNo

Whatwasusedtowipethesurface? qRag/towelqPapertowelqWipesq Air dry

Werethesurfaceswipeddrywhenchildrencameincontactwiththem? qYesqNo

Werethechildreninanotherareawhenthedisinfectingprocesswasperformed?

qYesqNo

Areas disinfected: qDiaperchangingtableqPottytrainingchairsqToiletsq Sinks qActivitytablesqToysqOther

Wasthesurfacepre-cleaned? qYesqNo

Wasthesolutionsprayedawayfromthebreathingzone? qYesqNo

Did the surface remain wet with disinfecting solution for the correct dwell time specifiedonthelabel?

qYesqNo

Howwasdwelltimemeasured? q Digital timer qWallclockqWatchqOther

Wasthesurfacerinsed? qYesqNo

Whatwasusedtowipethesurface? qRag/towelqPapertowelqWipesq Air dry

Werethesurfaceswipeddrywhenchildrencameincontactwiththem? qYesqNo

Notes:

Howoftenwerethemeal/snacktablessanitized? q Before every meal q After every meal q After activities

Howoftenwasthediaperchangingtabledisinfected? q After every child qOther:

Howoftenwasthetrainingchairdisinfected? q After every child qOther:

Howoftenwasthetoiletdisinfected? q After every child qOther:



Site Observation Checklist (continued)

Howoftenwasthesinkdisinfected? qAftertooth-brushingq After toileting qOther:

Othersurfaces:MouthedtoyswithhardsurfacesActivitytables

Disinfectingfrequency:q Daily qWeeklyqMonthlyq Daily qWeeklyqMonthly

Soft toys Cots

q Daily qWeeklyqMonthlyq Daily qWeeklyqMonthly

Notes:

Wasdisposablepaperusedonthediaperchangingtable? qYesqNo

Wasthediaperchangingtabledisinfectedeventhoughdisposablepaperwasused?qYesqNo

Wasthetoiletingprocessmonitoredtodetectbodilyfluidspillsthatrequiredisinfecting? qYesqNo

Weremouthedtoysseparatedandplacedinadesignatedlabeledcontainerbeforedisinfecting? qYesqNo

Notes:

Wereinfectioncontrolpracticesstandardizedwithinaclassroom? qYesqNo

Wereinfectioncontrolpracticesstandardizedamongclassrooms? qYesqNo

Ifapplicable,areinfectioncontrolpracticesstandardizedamongthefollowing:ParentsInterns/studentsVolunteers?

qYesqNoqYesqNoqYesqNo

Notes:



AppendixC.TrainingOutlineAlltrainingmaterialcanbefoundinthetoolkit–accessibleatthewebsitesfortheSanFranciscoAsthmaTaskForceandRegionalAsthmaManagementandPrevention.

I. Asthma

A.Work-relatedasthma

B. Childhood asthma

C.Asthmabasics

1)Definitionofasthma

2)Asthmatriggers

3)Signsofasthma

II. Infection control

A.Importanceofinfectioncontrol

B.Productsusedforinfectioncontrolinchildcare(andhealthimpacts)

C.Cleaning,sanitizinganddisinfecting

1)Definitions

2)CCLregulationsforsanitizinganddisinfecting

III. Ways to reduce exposure to sanitizers and disinfectants

A.InformationonantimicrobialproductsandHazardsCommunication

1)Productlabel

2)MaterialSafetyDataSheets(MSDS)

3)RequiredPersonalProtectiveEquipment(PPE)

B.Hazardscommunicationandsafeworkpractices

1)Possiblehazardsassociatedwithproductsinuse

2)Productsafetyinformationforchemicalproductsinuse

3)See Tip#4 for safe work practices for recommended products

C. Sanitizers and disinfectants

1)Areaofuseforeachproduct

2)Howtouseeachproductproperly(routineuse)

3)AddresspotentialobstaclestomeetingCCLrequirements


D.Whattodoincaseofanoutbreak(exposurecontrol)

1)Whatdisinfectanttouseforcertaindiseases

2)RequiredPPE

3)Properdisinfectionprocessforeachdisease

4)Recommendationsforcontrollingexposuresuchasfrequenthandwashing,limiting

person-to-personcontact,limitingsharingofitems,ensuringspatialseparation,etc.

5)Whotocontactincaseofadiseaseoccurrence(localhealthdepartment,medicalpersonnel,parents,etc.)

IV. Demonstration of materials (toolkit)

A.Instructionalmaterial

1)Placards

2)MSDS

3)Trainingmaterialandresources

B.Tools

1)Digitaltimers

2)Properlylabeledspraybottlesforsoapywater(vs.bottlesusedforwaterplay)

C.Safetyequipment

1)Gloves

2)Protectiveeyewear

3)Eyewashstations

4)Aprons,smocks

D. Sanitizers and disinfectants: demonstration

1)Areaofuseforeachproduct

2)Howtouseeachproductsafelyandproperlyusingthetoolsabove


AlltrainingmaterialcanbefoundinthetoolkitaccessibleatthewebsitesfortheSanFrancisco

AsthmaTaskForceandRegionalAsthmaManagementandPrevention.

AppendixD.HandWashingPlacardProper Hand Washing Helps Stop the Spread of Infection

Wet hands with warm water

Apply non-antibacterial soap

Scrub backs of hands, wrists,

between fingers and under

fingernails for at least 20 seconds

Continue to scrub while rinsing hands

with warm water until the soap and soil are

washed away

Dry hands with a clean paper towel

CAREGIVERS SHOULD WASH THEIR HANDS

Upon arriving at work, and

BEFORE & AFTER

• Handlingfood (Includeseatingandfeedingchildren)• Givingmedication

AFTER

• Usingthebathroom• Changingadiaperorassistingintoileting• Wipingtheirnoseorachild’snose,sneezing,

orcoughing;assistingillchildren• Handlinganimals• Takingoutthegarbage• Contactwithbodyfluids• Cleaning,sanitizing,anddisinfecting• Removinggloves

OR IF VISIBLY SOILED

ENSURE THAT CHILDREN WASH THEIR HANDS

Upon arriving at child care, and

BEFORE & AFTER

• Handlingfood (Includeseating)

AFTER

• Usingthebathroomorhavingdiaperschanged

• Wipingtheirnose,sneezing,orcoughing• Handlinganimals• Beingcleanedupafteranaccident• Waterplayorsandplay• Playingoutdoors

OR IF VISIBLY SOILED


AppendixE.BodyFluidSpillPlacard

Leave

surface wet for

1 Minute

(5 Minutes for

tuberculosis)

Wipe dry with a clean paper towel

Spray the

surface with

OXIVIR® Tb

Pre-Clean

Remove excess waste then clean the surface with soapy water

DISINFECTING Body Fluid Spills with Oxivir® Tb*

Body Fluid Spills

Blood Vomit

Diarrhea Tissue Discharge

For outbreak situations, please refer your county’s communicable disease program. *Oxivir® Tb is registered with the United States Environmental Protection Agency (USEPA) as effective against norovirus, HIV, Hepatitis B, and Hepatitis C after the surface remains wet with Oxivir® Tb for one minute; and tuberculosis (TB) after the surface remains wet with Oxivir® Tb for five minutes.

讓 OXIVIR® Tb 停留於物件的

表面上1 分鐘

（消除肺结核病毒則需

5 分鐘）

使用清潔的紙巾拭乾

噴OXIVIR® Tb

於物件的表面上

先清潔物件的表面

先清除過量從身體內濺出的排洩污垢，

然後用肥皂水清潔物件的表面

身體內濺出的液體

血

嘔吐物腹瀉

組織的排放

關於出現疫情爆發，請參考閣下縣或市的傳染性疾病計劃的指引。 *Oxivir® Tb於美國環境保護署註冊為有效抵抗諾沃克、愛滋、及乙和丙型肝炎等病毒（如應用時間為一分鐘）；以及肺结核病毒（如應用時間為五分鐘）。

Dejar la superficie mojada por 1 Minuto

(5 Minutos

para tuberculosis)

Secar con una toalla limpia de

papel

Rociar la

superficie con

OXIVIR® Tb

Pre-Limpiar

Remover el exceso de desechos y

luego limpie la superficie con agua jabonosa

Fluidos del Cuerpo

Sangre Vomito Diarrea

Deshechos Humanos

En la situación de un brote de enfermedades, por favor consulte el programa de enfermedades transmisibles de su condado. *Oxivir® Tb esta registrado con la Agencia de Protección Ambiental de Estados Unidos (USEPA) como eficaz contra el norovirus, HIV, Hepatitis B, y Hepatitis C después de que la superficie se mantenga mojada con Oxivir® Tb por un minuto; y tuberculosis (TB) después de que la superficie se mantenga mojada con Oxivir® Tb por cinco minutos.

San Francisco Asthma Task Force, Dec. 2012, www.sfgov.org/asthma

使用 Oxivir® Tb* 消毒受身體內濺出的液體所污染的物件

DESINFECTANDO Derrames de Fluidos del Cuerpo Con Oxivir® Tb*

Personal Protection:

個人保護:

Protección Personal:


AppendixF.ChemicalProductstoAvoidOnereasonwhyreadinglabelsisimportantistobecomefamiliarwiththeingredientsinyourproducts.Avoidproductsthatdonotlisttheiractiveingredientsortheconcentrationoftheactiveingredients(especiallyiftheproductrequiresdilution).Whenlookingatproducts,considerallingredientsifpossible,notjusttheactiveingredientsincesomemanufacturersaremergingtheircleaningproducts(e.g.,thereareproductsthatare“poweredby/containbleach”)oraddingpopularfragrancesormaskingdeodorizers.Usecautionwhenpurchasing–justbecausetheactiveingredientmaybesaferforasthma,doesn’tmeantheproductasawholeissafer.

Active ingredient Examples of Products with these Ingredients Potential Health Risks

Sodium hypochlorite (also known as “Bleach”)

•Bleach•Clorox® Clean-Up® Cleaner with Bleach•Lysol®All-PurposeCleanerwithBleach

SodiumhypochloriteisclassifiedasanasthmagenbytheAssociationofOccupationalandEnvironmentalClinics(AOEC).Thismeansthatbleachisconsideredanasthma-causingsubstance.j

Quaternary ammonium compounds (also known as “Quats”)Thesecompoundsincludealkyldimethylbenzylammoniumchlorideanddidecyldimethylbenzylammoniumchlorides.Therearemanysynonymsforthisclassofchemicals.Themostcommonlyusedsynonyms include the following:•Benzalkoniumchloride•Benzyl-C10-16-alkyldimethyl,chlorides•Dodecyl-dimethyl-benzylammoniumchloride•Lauryldimethylbenzylammoniumchloride•Benzyl-C12-18-alkyldimethyl,chlorides•Benzyl-C12-16-alkyldimethyl,chlorides•Benzyl-C16-18-alkyldimethyl,chlorides

•Lysol® Disinfectant Spray•Clorox® DisinfectingWipes,Bleach-Free•Lysol®BrandDualActionDisinfectingWipes•Fantastik®AntibacterialAll-PurposeCleaner•Formula409®KitchenAntibacterialAllPurpose

Cleaner•ClingFree®FabricSoftener,StaticStopping

Sheets

QuaternaryammoniumcompoundsareclassifiedasasthmagensbytheAOEC.j

Animalstudiessuggestthatexposuretoquatsmayhave negative reproductive effects.k

Ethylene glycol butyl ether (2-butoxyethanol, butyl cellosolve)

•DampRidMildewStainRemoverPlusBlocker•SimpleGreen®All-PurposeCleaner•Windex®GlassCleanerPowerizedFormula

(institutional)

Ethyleneglycolbutyletherisapossiblecarcinogen.Additionally,animalstudieshaveassociated2-butoxyethanolwith:•liverdamage/cancer•redbloodcelldamagecausinganemia•impairedfertility,and•reproductiveanddevelopmentaltoxicity.l

Ammonia

•Ammonia•Windex®FoamingGlassCleaner•Windex®MiniConcentratedGlassandSurface

Cleaner

AmmoniaisclassifiedasanasthmagenbytheAOEC.j Asastrongirritant,ammoniacancause•skinburnsand•eyedamage.m

Ammonia also poses as a concern in child care since whenmixedwithbleach,hazardouschlorinegasisreleased into the air.

Pine oils

•Pine-Sol®

•Hexol®PineOilGeneralPurposeCleaner&Deodorant

•GenuineJoePineOilCleaner

Pineoilscontainterpeneswhichcanreactwithtracelevelsofozoneintheair,andcanindirectlyform formaldehyde which is carcinogenic and an asthmagen.n

NOTE:AsreportedbytheEnvironmentalWorkingGroup,thecarcinogenformaldehyde(anindooraircontaminantreleasedbycleaningproducts),wasdetectedinthefollowing commonly used products in childcare: Comet®,DisinfectantPowderCleanser,Pine-Sol®,SimpleGreen®ConcentratedCleaner/Degreaser/Deodorizer,Nov2009,www.ewg.org/schoolcleaningsupplies.


AppendixF.ChemicalProductstoAvoid(continued)

Active ingredient Examples of Products with these Ingredients Potential Health Risks

Triclosan and triclocarban

•UltraDawnDishwashingLiquidandAntibacterialHandSoap

•Dial®AntibacterialLiquidHandSoap•Softsoap®2in1AntibacterialHandSoapPlus

MoisturizingLotion•Softsoap®AquariumAntibacterialLiquidHand

Soap

Studiesshowtherearenoadditionalbenefitsusingantibacterialsoap containing triclosan.

ThisingredientiscurrentlyunderreviewbytheFDAasanadditive.TheFDAconsiderstriclosanacategory3product:“insufficientinformationonthesafetyandeffectiveness”.

Animalstudiessuggesttriclosanmayenablethespreadofantibiotic-resistantbacteria,andmaymimichormonesresultinginpossiblehealthriskssuchas:•reproductiveharmand•developmentaleffectsonthenervousandendocrinesystems.o

Fragrances/scents/deodorizers

•Glade®Sense&Spray®AutomaticFreshener•Lysol®NeutraAir®Freshmatic®

•AirWick®FreshmaticUltraAutomaticSpray•Febreze®AirEffects® Spray•Febreze®NoticeablesScentedOilPlugIn

Asinglefragranceinaproductcancontainamixtureofhundreds of chemicals.

Commonchemicalsusedinscentedproductshavebeenassociated with the following:•asthma•cancer•respiratoryillness•skinconditions•neurologicproblemsincludingseizures,and•irritation.p

j. AssociationofOccupationalandEnvironmentalClinics(AOEC).Revised Protocol: Criteria for Designating Substances as Occupational Asthmagens on the AOEC List of Exposure Codes.RevisedSeptember2008.Retrievedathttp://www.aoec.org/content/Asthmagen_Protocol_9_15_08.pdf

AOEC.ExposureCodesList.Accessibleathttp://www.aoecdata.org/ExpCodeLookup.aspxk. Hunt,PA(2008).Cleanlinessandinfertility:Newconcernsaboutreproductiveeffectsofquaternaryammoniumdisinfectants.BiologyofReproduction,78,abstract

757.Retrievedfromwww.biolreprod.org/cgi/content/meeting_abstract/78/1_MeetingAbstracts/232-aMaher,Brendan.(2008,June18)Labdisinfectantharmsmousefertility.Nature,453,964.Retrievedfromwww.nature.com/news/2008/080618/full/453964a.html

l. GiftJS.U.S.EPA’sIRISassessment of 2-butoxyethanol: The relationship of noncancer to cancer effects. ToxicolLett2005Mar28;156(1):163-78. KamendulisLM,CorthalsSM,KlaunigJE.Kupffer cells participate in 2-butoxyethanol-induced liver hemangiosarcomas.Toxicology2010Apr11;270(2-3):131-6. LaifenfeldD,GilchristA,DrubinD,JorgeM,EddySF,FrushourBP,LaddB,ObertLA,GosinkMM,CookJC,CriswellK,SompsCJ,Koza-TaylorP,EllistonKO,Lawton

MP.Theroleofhypoxiain2-butoxyethanol-inducedhemangiosarcoma.ToxicolSci2010Jan;113(1):254-66. NTP (National Toxicology Program), NTP Toxicology and Carcinogenesis Studies 2-Butoxyethanol (CAS NO. 111-76-2) in F344/N Rats and B6C3F1 Mice (Inhalation

Studies).NatlToxicolProgramTechRepSer,2000.484:p.1-290.m. AgencyforToxicSubstancesandDiseaseRegistry(ATSDR).ToxicologicalProfileforAmmonia.Atlanta,GA:U.S.DepartmentofHealthandHumanServices,Public

HealthService.2004. Fedoruk,M.et.al.Ammoniaexposureandhazardassessmentforselectedhouseholdcleaningproductuses.JournalofExposureAnalysisandEnvironmental

Epidemiology.Vol15,No.6pp.534-544.(2005).n. Wolkoff,P.,Clausen,P.A.,Wilkins,C.K.andNielsen,G.D.Formationofstrongairwayirritantsinterpene/ozonemixtures,IndoorAir,10,82–91.2000. CaliforniaAirResourcesBoard(CARB).CleaningProductsandIndoorAirQuality:Actionsyoucantaketoreduceexposures.Sacramento,CA.2008.

http://www.arb.ca.gov/research/indoor/cleaning_products_fact_sheet-10-2008.pdf EnvironmentalWorkingGroup.GreenerSchoolCleaningSupplies=FreshAir+HealthierKids:NewResearchLinksSchoolAirQualitytoSchoolCleaningSupplies.

Nov2009,www.ewg.org/schoolcleaningsupplieso. USFoodandDrugAdministration:Triclosan:WhatConsumersShouldKnow http://www.fda.gov/forconsumers/consumerupdates/ucm205999.htm U.S.Food&DrugAdministrationDepartmentofHealthandHumanServices.NominationProfileTriclosan[CAS3380-34-5]:SupportingInformationforToxicological

EvaluationbytheNationalToxicologyProgram,July2008. AielloAE,LarsonEL,LevySB,AielloAE,LarsonE.Consumerantibacterialsoaps:Effectiveorjustrisky?;antibacterialcleaningandhygieneproductsasanemerging

riskfactorforantibioticresistanceinthecommunity.LancetInfectDis2003Aug;45Suppl2;3(8):S137;501,47;506. GeeRH,CharlesA,TaylorN,DarbrePD.Oestrogenicandandrogenicactivityoftriclosaninbreastcancercells.JApplToxicol2008Jan;28(1):78-91. KumarV,ChakrabortyA,KuralMR,RoyP.Alterationoftesticularsteroidogenesisandhistopathologyofreproductivesysteminmaleratstreatedwithtriclosan.Reprod

Toxicol2009Apr;27(2):177-85. StokerTE,GibsonEK,ZorrillaLM.Triclosanexposuremodulatesestrogen-dependentresponsesinthefemalewistarrat.ToxicolSci2010Jun18. AhnKC,ZhaoB,ChenJ,CherednichenkoG,SanmartiE,DenisonMS,LasleyB,PessahIN,KultzD,ChangDP,GeeSJ,HammockBD.Invitrobiologicactivitiesofthe

antimicrobialstriclocarban,itsanalogs,andtriclosaninbioassayscreens:Receptor-basedbioassayscreens.EnvironHealthPerspect2008Sep;116(9):1203-10. ZorrillaLM,GibsonEK,JeffaySC,CroftonKM,SetzerWR,CooperRL,StokerTE.Theeffectsoftriclosanonpubertyandthyroidhormonesinmalewistarrats.Toxicol

Sci2009Jan;107(1):56-64.p. Potera,Carol.ScentedProductsEmitaBouquetofVOCs.EnvironmentalHealthPerspectives,volume119,number1.January2011. CaliforniaDepartmentofPublicHealth,OccupationalHealthBranch,Work-RelatedAsthmaPreventionProgram.


AppendixG.CaliforniaDepartmentofSocialServices,CommunityCareLicensingDivision,Child Care Update, Spring – 2012In2012,CaliforniaDepartmentofSocialServices,CommunityCareLicensingDivisioninvitedtheSanFranciscoAsthmaTaskForcetowriteanarticlefortheirSpringQuarterlyUpdatetotheChildCareCommunityannouncingthatalternativestobleachmeetinfectioncontrolrequirementsinchildcaresettings.Belowisthearticlethatwaspublished.Theoriginalarticlecanbefoundonthebottomofpage9oftheUpdatewhichispostedontheCaliforniaDepartmentofSocialServiceswebsite,accessibleathttp://www.ccld.ca.gov/res/pdf/CCUpdateSpring2012.pdf

Meeting California Child Care Infection Control Requirements: Allowable Alternatives to Bleach

InCalifornia,childcarecentersmustcomplywithCaliforniaChildCareLicensingregulationsforsanitizingand disinfecting in order to maintain infection control. Bleach is cost-effective and widely used to meet those requirements.However,contactwithbleachcanburntheskinandeyes,andbreathingbleachfumescancauseasthmasymptoms,andirritationinthethroatandlungs.AccordingtotheState’sWork-RelatedAsthmaProgram,exposuretobleachhasalsobeenassociatedwithnewasthmacases.Whilecontrollingthespreadofinfectioninchildcareisimportant,theuseofsaferproductstoprotectthehealthofchildcareworkersandchildrenfromasthmaisalsocritical.Forthesereasons,theSanFranciscoAsthmaTaskForcelookedforwaystoreduceoreliminatebleachexposureinchildcaresettings,andpublishedtheirrecommendationsinaMarch2011report.

Thisarticleisintendedtogiveyou,asworkersinlicensedcenters,informationaboutalternativestobleachthatmeettheState’srequirements.Bleachisnottheonlyproductthatmeetstherequirements.Licensingregulations,Title22,Section101438.1(f)statesthat,“Commercialdisinfectingsolutions,includingone-stepcleaning/disinfectingsolutions,maybeusedinaccordancewithlabeldirections.”

COMMUNITY CARE LICENSING DIVISION

CHILD CARE UPDATE

SPRING- 2012

To the Child Care Community We have reached the 20th year of our efforts to keep the child care community informed about licensing programs and services. The Updates continue to be an important method for sharing information. We appreciate your support in sharing these Updates with those in your organization and others interested in child care issues. You may find the topic of your choice in each Update without having to scroll down. Just put your cursor over the blue highlighted subject heading that you wish to review, hold down the control and shift buttons at the same time, and you will be taken to that area of the Update.


Recommendations for Disinfecting and Sanitizing without Bleach

TheSanFranciscoAsthmaTaskForceisrecommendingtheuseofdisinfectantsandsanitizersthataresaferforasthma.Therecommendedproductsdonotcontainbleach,andmeettheStaterequirementsfordisinfectingandsanitizinginyourchildcarecenter.Thefollowinglistprovidesabasicoverviewoftheproducts.Moredetailedinformationabouttheproductsthatweretestedforthisprojectisavailableinthefullreport(See “Resources” for how to access the report).

• Fordisinfectinghard,non-poroussurfacessuchasdiaperchangingtables,therecommendedalternativeisaready-to-usedisinfectantwithacceleratedhydrogenperoxideastheactiveingredient.

• Forsanitizingfoodcontactsurfacessuchassnackandmealtables,therecommendedalternativeisalsoready-to-useandbleach-free.

• TheTaskForceisalsorecommendingafloorcleanerwithacceleratedhydrogenperoxideastheactiveingredient.

10 | P a g e

In California, child care centers must comply with California Child Care Licensing regulations for sanitizing and disinfecting in order to maintain infection control. Bleach is cost-effective and widely used to meet those requirements. However, contact with bleach can burn the skin and eyes, and breathing bleach fumes can cause asthma symptoms, and irritation in the throat and lungs. According to the State's Work-Related Asthma Program, exposure to bleach has also been associated with new asthma cases. While controlling the spread of infection in child care is important, the use of safer products to protect the health of child care workers and children from asthma is also critical. For these reasons, the San Francisco Asthma Task Force looked for ways to reduce or eliminate bleach exposure in child care settings, and published their recommendations in a March 2011 report. This article is intended to give you, as workers in licensed centers, information about alternatives to bleach that meet the State’s requirements. Bleach is not the only product that meets the requirements. Licensing regulations, Title 22, Section 101438.1 (f) states that, ―Commercial disinfecting solutions, including one-step cleaning/disinfecting solutions, may be used in accordance with label directions.‖

California Child Care Licensing Requirements for Sanitizing and Disinfecting

Requirement Surface (Regulation code) How Often

DISINFECT

Infant/Toddler Classrooms: Diaper Changing Areas -- 101428 (7) After each use

Potty Training Chairs -- 101428 (e) After each use Napping Equipment: 101239.1 (b)(4)

Weekly, or if soiled or wet

Napping Equipment—Infants: 101439.1 (B)

Daily, or if soiled/wet

Infant/Toddler/Classrooms with Mildly Ill Children: Sinks -- 101438.1 (c) (5), 101638.1 (e)(5)

After each use

Floors -- 101438.1 (c)(1), 101638.1 (e)(1)

At least daily, or more often if necessary

Walls/Partitions -- 101438.1 (c)(3), 101638.1(e)

(1)

At least weekly, or more often if necessary

Mouthed Objects (Including Toys) -- 101438.1 (d), 101638.1(f)

At least daily, or more often if necessary

SANITIZE

All Classrooms: Dishes/Utensils, Cups -- 101227 (a)(21)

After each use

Infant/Toddler Classrooms: Disposable Diaper Containers -- 101428

(d)(3)(a), 101628 (d)(2)

Daily

NOTE:TheTaskForcerecommendssanitizingsnack/mealtablesandhighchairtablesaftereachuse.


Recommendations for Reducing Bleach Exposure (if continuing to use bleach)

Ifyourchildcarecentercontinuestousebleachforsanitizinganddisinfecting,theTaskForcerecommendsseveralmethodsandtoolstoreduceexposuretobleachandcreateasaferenvironment.MaterialsinEnglish,SpanishandChinesehavebeendevelopedonhowtousebleachcorrectly.Therecommendationsregardingsaferuseofbleachincludesimpletoolsthatreduceexposure,suchas:

• pumpsthatputtheexactamountofbleachintoyourspraybottle(withoutmetalpartsthatcanrust)

• funnelsthatreducebleachspillsandsplashes

• quart-size(32ounces)spraybottleswithready-madelabelstoensuretherightbleach/watermixture

• digitaltimerstoensurethesurfaceremainswetwithbleach/watermixturefortwominutes

• protectiveequipmentsuchaseyewear(forexample,gogglesorglasses),gloves,andaprons.

Resources

TheSFAsthmaTaskForcereportalsoprovidesrecommendationsandguidelinesforspecifictrainingneedsofmanagement,staff,andparents.Thegoaloftheserecommendationsistoencouragethesustainabilityofbestpractices while protecting the health of child care workers and the children served.

Resources available as a result of this project include:

• productswithoutbleach–costandhowtoorder

• toolstoreduceexposuretobleach(ifyourcentercontinuestousebleach)

• instructionalsignsandlabelsinEnglish,Spanish,andChineseforproductswithoutbleachandforusingbleach/watermixtures.

To access the full project report and supplemental material, please visit either website:

• SanFranciscoAsthmaTaskForce,http://www.sfgov3.org/index.aspx?page=721

• RegionalAsthmaManagementandPrevention,www.rampasthma.org

TheSanFranciscoAsthmaTaskForceconductedthisgrant-funded*pilotprojecttoidentifymethodsforinfectioncontrolpracticesthateliminateorreducechildcareoperatorexposuretobleachandpublisheditsreportinMarchof2011.

*FundingwasprovidedbySanFranciscoFoundation,RegionalAsthmaManagement&Prevention,aprivatedonor,andtheSanFranciscoPublicHealthFoundation.


AppendixH.ReferencesforDesignatingBleachasan AsthmagenNationwide and statewide work-related asthma data

Newonsetwork-relatedasthma(WRA)casefindingandtheexacerbationofasthmaintheworkplacesubstantiatetheconcernsofstakeholders.Ongoingstatewidesurveillancefrom1993tothepresentlinksbleachtowork-relatedasthma(77WRAcasesof4417).qFortypercentoftheWRAcaseshadpre-existingasthmathatwasexacerbatedbybleachexposure,while60%werecasesofnewonsetasthma.NationwidesurveillanceofWRAconductedfrom1993-1997foundthat12%ofreportedWRAcases(236outof1915)wereassociatedwithexposuretocleaningproducts.Californiacontributed92ofthe236WRAcaseswith72%ofthecasesbeingnewonsetasthma.r Such data validatetheneedtopromoteasthma-safedisinfectantsandsanitizersandconsistentuseofprotectiveequipment.

Additionally,surveillancedatacollectedfrom1993-2000ineducationalsettingsservingchildrenoverfiveyearsof age show that cleaning staff in these settings are at the greatest risk for developing asthma in the workplace.s

Cleaningstaffhadthehighestproportionofnewonsetasthma,withbleachbeingamongthemostcommonlyreportedexposures.Sincestaffmembersinchildcaresettingsarecontinuallysprayingbleachthroughouttheday,someoftheirexposurescanbethoughtofassimilartocleaningstaff.However,WRAforstaffinchildcaresettingsisunlikelytomakeitintoreportingsystemsforseveralreasons:limitedhealthcareaccessaslowwageearners,lackofknowledgeconnectingnewonsetasthmawiththeirworkenvironment,andlackofreportingtoemployersforfearoflosingtheirjob,deportation,orotherconsequences.

Websites

CentersforDiseaseControlandPrevention:NationalInstituteforOccupationalSafetyandHealth(NIOSH).WorkplaceSafety&HealthTopics:AsthmaandAllergies.Accessibleathttp://www.cdc.gov/niosh/topics/asthma/

CaliforniaDepartmentofPublicHealth:OccupationalHealthBranch.TrackingWork-RelatedAsthma.Accessibleathttp://www.cdph.ca.gov/programs/ohsep/Pages/Asthma.aspx

AOEC references for designating bleach an asthmagen

TheAssociationofOccupationalandEnvironmentalClinics(AOEC)developedanExposureCodeListforitsmembersinorderto“systematicallyidentifybothexistingandemergingoccupationalandenvironmentalhealthconcerns”.TheAOECupdatesthislistregularlytoreflectthefindingsoftheirreviews.Inordertoclassifysubstancesasasthmagens,thetermusedforasthma-causingsubstances,theAOECcarefullyreviewsmandatedreportingofwork-relatedasthma(WRA)aswellaspublishedtoxicologyandepidemiologypeer-reviewedresearch.InMay2012,theAOECdesignatedbleach(sodiumhypochlorite)asanasthmagen. See the references below that were used by the AOEC for this designation.

q. UnpublishedData,1993-present,CaliforniaDepartmentofPublicHealth,OccupationalHealthBranch,Work-relatedAsthmaPreventionProgram.

r. RosenmanKD,etal.Cleaningproductsandwork-relatedasthma.JOccupEnvironMed2003May;45(5):556-63.

s. MazurekJM,etal.Work-RelatedAsthmaintheEducationalServicesIndustry:California,Massachusetts,Michigan,andNewJersey,1993–2000.AMERICANJOURNALOFINDUSTRIALMEDICINE51:47–59(2008).


AssociationofOccupationalandEnvironmentalClinics.RevisedProtocol:CriteriaforDesignatingSubstancesasOccupationalAsthmagensontheAOECListofExposureCodes.RevisedSeptember2008.Retrievedat http://www.aoec.org/content/Asthmagen_Protocol_9_15_08.pdf

AOECExposureCodeList,DisplayAllAsthmagens.Accessibleathttp://www.aoecdata.org/ExpCodeLookup.aspx

D’AlessandroA,KuschnerW,WongH,BousheyHA,BlancPD.Exaggeratedresponsestochlorineinhalationamongpersonswithnonspecificairwayhyperreactivity.Chest1996;109:331-337.

SastreJ,MaderoMF,Fernandez-NietoM,SastreB,delPozoV,Garcia-delPotroM,QuirceS.Airwayresponsetochlorineinhalation(bleach)amongcleaningworkerswithandwithoutbronchialhyperresponsiveness.AmJIndMed2011;54:293-299.

ArifAA,DelclosGL.Associationbetweencleaning-relatedchemicalsandwork-relatedasthmaandasthmasymptomsamonghealthcareprofessionals.OccupEnvironMed2012;69:35-40.

S a n F r a n c i S c o

January 2013