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Why the Concern for Diseases in Child Care?
Continued need for child care – 70 percent of NC mothers with children less
than 6 years of age work outside the home--highest in the nation (NC Partnership for Children)
Children in child care centers are 30 percent more likely to contract diarrheal illnesses than children at home.
Infection Control Concerns in Child Care
Crowded conditions and close contact Personal hygiene Limited immunity Mobility Spread frequency often occurs prior to
recognition
The Cost of Illnesses in Child Care
Costs businesses between $2-$12 billion per year due to work days missed
– Parents of children in child care centers miss an average of 1 to 4 weeks of work each year to care for their sick children (Davis et al., 1994)
Problems with Controlling Outbreaks in Child Care Centers Ease of person-to-person transmission
among young children High secondary attack rates
– as high as 40 percent for shigellosis Extended duration of outbreaks Multiple points of exposure
Who to Contact When You Get the Call
– EPI team leader – Environmental Health Supervisor – Regional Environmental Health Specialist – Division of Child Development – Communicable Disease Control Nurse – Laboratory Personnel – Other State Personnel (e.g., Communicable Disease
Control Section) – Local pediatricians and hospital
Controlling Communicable Diseases in Child Care
Visiting, Inspecting, and Contacting Handwashing: Instructing and Monitoring Testing, Exclusion, and Cohorting Informing and Educating Review of Specific Diseases in Child Care
Settings
Containing Cases
Exclude new admissions Prevent transfer of children to other child care
centers – Call area child care centers to inform them of the
outbreak and instruct them not to accept children from the infected center
Contact area pediatric practices, ERs, clinics, and other health care providers for prompt reporting of additional cases
Containing Cases
Local EHS should visit the center with the communicable disease control nurse – conduct interviews – gather information
In addition, visit and/or inform child care centers and child care homes in the immediate outbreak area
Diapering Procedures
Diapering procedures posted/followed? – Is the caregiver washing both their hands and the
child’s hands? – Are gloves being used properly? – Cloth diapers – Are diapers being placed in a plastic-lined, covered
container? Flies can transmit Shigella to water and food.
Toileting and Diapering Procedures
Are they using a solution of soap/water prior to sanitizing?
Is the disinfecting concentration adequate? Is the contact time appropriate for the
disinfectant being used? Are toilets being cleaned and disinfected? Adequate amounts of toilet paper? Proper supervision of the children?
Mouth Contact Surfaces
Are sanitizing procedures being followed?
Are the toys easily cleanable?
Discourage sharing of personal articles or toys
Fecal Contamination in Child Care Center Classrooms
Most important sources of contamination: – Hands, toys, sinks, and faucets
High levels of fecal coliforms were more likely to occur on sinks and faucets than on other classroom surfaces.
Classrooms for infants were more often contaminated than classrooms for toddlers.
Laborde et al., 1995
Fecal Contamination in Child Care Center Classrooms
Greater levels of contamination on staff member’s hands in classrooms for infants. – Could result from greater diapering activity. Laborde et al., 1995
Recommendations to Reduce Fecal Contamination
Disposable Gloves Waterless hand sanitizers Frequent disinfection of sinks and toys
throughout the day. Knee- or foot pedal-controlled sinks All diapering activities conducted by one
individual per room. Laborde et al., 1995
Food Protection
Staff who prepare or serve food should not change diapers and staff who change diapers should not prepare food. – The odds of having an increased rate of diarrhea in a
center where the food preparer changed diapers is 18 times that compared to centers where the food preparer did not change diapers (Mohle-Boetani et al., 1995).
Thoroughly wash all vegetables Proper protection and temperatures maintained
Hand-washing: Instructing and Monitoring
Hand-washing is the single most important line of defense in preventing the transmission of disease-causing organisms.
Handwashing
Ensure that tempered water, soap, and disposable towels are available in child care centers, schools, and other places frequented by young children
Parents and teachers should instruct students/attendees on proper handwashing and monitor children for symptoms of shigellosis/HAV
Handwashing
Proper handwashing – An organized effort to promote careful handwashing
with soap and water is the single most important control measure to decrease transmission rates
– Handwashing procedures posted? – Are they adhering to the .2800 Rules?
Rubbing hands for 15 seconds Rinsing for 10 seconds Turning off the faucet with a paper towel or other method
without recontaminating hands.
Testing Contacts
Obtain specimens immediately Based on available information, conduct the
most appropriate test – Stool specimens – Serologic testing – Etc...
Exclusion Criteria
In general, remove cases from child care until past infectivity period and asymptomatic
Cohorting--Shigellosis
Once diarrhea ceases, cases are kept in a group isolated from others
The room or area should have: – a bathroom reserved for this group’s use – assigned caregivers
Released from the cohort only after 2 negative stool cultures 24 hours apart and at least 48 hours after ending antibiotic treatment
Informing and Educating
Provide information about the specific infection and their prevention to: – parents and families of patients – child care centers, schools/pre-schools – restaurants – churches – news media – WIC, immunization, and community clinics – hospital emergency rooms
Educate Caregivers and Parents
Do not leave the child care center without leaving educational materials
Brochures, Books, Videotapes, etc. – Hygiene practices – Modes of Transmission – Signs/Symptoms
Before an Outbreak
Discuss what to do if…with the child care operator – The Division of Child Development requires
that they post the number of the fire department, police, etc., next to the telephone Make sure your number is up there too
After the Outbreak
Send a report to… – Communicable Disease Control section – Child Care Center – State Offices (Children’s Environmental Health
Branch, DCD) – Health Director – Board of Health – Etc…..
Review investigation
Reporting
§ 130A-136 Child Care Operators Required to Report – Child care facility directors and school
principles must report communicable diseases § 130A-142 Immunity of Persons Who
Report
Transmission
Airborne – Pertussis, H. Influenza, Varicella
Fecal-oral – Shigella, Salmonella, Hepatitis A,
Enteroviruses Personal contact
– Varicella, Pediculosis
Parvovirus B19 – Fifth’s Disease
Mild rash illness--typically a slapped cheek appearance and lacy red rash on the trunk and limbs
Low grade fever, malaise or cold for a few days before rash breaks out
Rash resolves in 7-10 days Found in respiratory tract prior to onset of
rash
Parvovirus B-19 Fifth’s Disease
May become ill 4-14 days and up to 20 days after exposure
Usually not serious, but may cause serious illness in persons with sickle-cell disease or similar types of chronic anemia
Persons with compromised immune systems may develop chronic anemia
Parvovirus B-19 Fifth’s Disease
No vaccine or medication for prevention Frequent handwashing recommended Not necessary to exclude from work, child
care – Contagious before rash appears
Pertussis
Highly communicable, vaccine-preventable disease
Occurs through direct contact with discharges from respiratory mucous membranes of infected persons
Paroxysmal spasms of severe coughing, whooping and posttussive vomiting
Pertussis
Major complications: hypoxia, apnea, pneumonia, seizures, encephalopathy and malnutrition
Death – 13 children died in the US in 2003 – Most deaths occur among unvaccinated
children or children too young to be vaccinated
Pertussis
Immunize children appropriately For outbreaks, Erythromycin is the drug of
choice for contacts Exclude from child care until 5 days after
initiation of 10-14 day antibiotic regimen
Haemophilus Influenzae--Hib
Vaccine-preventable disease Meningitis with fever, headache and stiff
neck Leading cause of bacterial pneumonia Children not vaccinated or age
appropriately vaccinated should be excluded from child care
Varicella-Zoster
Virus, known as Chicken-pox Blister-like rash, itching, tiredness & fever Rash begins on trunk of body--Contagious
before rash appears Highly infectious and spreads from person-
to-person Airborne-usually from coughing & sneezing Vaccine now available
Shigellosis
Caused by bacteria called Shigella – S. sonnei most common type
Diarrhea, fever, stomach cramps beginning 1-2 days after exposure
Diarrhea is often bloody Fecal-oral route and contaminated food
Shigellosis
Treated with antibiotics--Ampicillin, Bactrim/Septra
Thorough handwashing after changing diapers or cleaning after bowel movement
Safe food handling Remove child from child care setting until
diarrhea has resolved plus two negative stool samples
Ringworm
Skin and scalp disease caused by fungi Skin--reddish, ring shaped rash Scalp--bald patch Rash can be dry and scaly or wet and crusty Transmitted by direct contact (people or animals) Anti-fungal creams work effectively on skin For scalp, need Rx from doctor
Scabies
Microscopic mite Sarcoptes scabei Infestation common, affects all races &
social classes Spreads rapidly under close, crowded
conditions where skin-to-skin contact is likely such as hospitals, institutions, child care facilities, & nursing homes
Scabies Pimple-like irritations, burrows or rash of the skin Symptoms may appear 4-6 weeks after infestation
or within days if previous infection Usually linear in appearance Intense itching, usually at night Prolonged contact Infestation may occur by sharing clothing, towels
and bedding Itching may continue for 2-3 weeks after
treatment. No new burrows should appear 24-48 hours after effective treatment
Respiratory infections
Colds, bronchitis, pneumonia and otitis media No evidence that the incidence can be reduced
among children in child care by any specific intervention other than by sanitation and personal hygiene
Exclusion of ill children from the facility has not been found of value in preventing common respiratory infections
Online Resources Investigating Foodborne Disease Outbreaks www.cdc.gov/foodborneoutbreaks/info_healthprofessional.htm To conduct an online outbreak investigation, “Botulism in
Argentina,” visit: www.phppo.cdc.gov/phtn/casestudies/ computerbased/default.htm To explore an historical outbreak investigation, visit the
online UNC John Snow Case Study at: www.sph.unc.edu/courses/Course_support/
Case_studies/John FOCUS on Field Epidemiology, UNC-SPH www.sph.unc.edu/nccphp