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Communicable and Zoonotic Disease Control Safe & Effective Cleaning May 2010 Pacific NW Association of Independent Schools. DOH School Environmental Health and Safety Program. Provide technical support & training, develop resources Local Health Jurisdictions (LHJs)

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Communicable and Zoonotic Disease Control

Safe & Effective Cleaning

May 2010

Pacific NW Association of Independent Schools


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DOH School Environmental Health and Safety Program

Provide technical support & training, develop resources

Local Health Jurisdictions (LHJs)

Schools: K – 12th grade

IAQ

Best Practices Manual

Asthma Plan implementation - reducing triggers in schools

Investigations

“Green Cleaning”

Rehab the Lab / Hazardous Chemicals

Integrated Pest Management (IPM)

Healthy High Performing Schools

Work with organizations and agencies concerned with SEH&S

Website and List Serve

DOH Fall 2010 SHE&S Workshops - Free

Nov. 2 – Dec. 2, 8:30-3:30

Dave Waddell – 12:30-3:30


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Communicable

(Infectious)

Diseases

In

Schools


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Infectious Diseases in the US

  • Every year, schools close due to infectious disease outbreaks

  • Infectious diseases are illnesses that are transmitted from one person to another via various routes

  • OSPI/DOH Infectious Disease Guide for School Staff, April 2004

    http://www.k12.wa.us/healthservices/pubdocs/InfectiousDiseaseControlGuide3-11-04.pdf


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Common Routes of Transmission

  • Person-to-Person

  • Contaminated surfaces

  • Foodborne

  • Waterborne


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Infectious Diseases and Children

  • Children and youth are particularly efficient vectors for disease transmission.

  • Children have less developed immune systems than adults.

  • Children may not be fully immunized against vaccine-preventable diseases (or require boosters).

  • Schools tend to be densely packed environments.

  • School environments may not be routinely cleaned and disinfected in a manner that reduces possibilities for disease transmission (i.e. playgrounds).


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Consequences of Infectious Diseases for Schools

Students and staff may be affected by illnesses.

If handled poorly, community trust in schools is shaken.

Depending on the disease, may cause high rates of illness, potentially some deaths in the school community.

Absences may cause schools to close for days or weeks – Continuity of Operations plans may need to be enacted.


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Some Common Infectious Diseases That Affect Schools

  • Viral Infections

    • Gastroenteritis – Noroviruses

    • Influenza

    • Varicella (Chicken Pox)

    • Meningitis

  • Bacterial Infections

    • E. Coli

    • MRSA

    • Strep throat

    • Meningitis

  • Fungal Infections

    • Ringworm


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MRSA Case

  • In Fall 2007, the death of a high school football player in Virginia focused the nation on MRSA in Schools

  • Within a month or two, several more MRSA outbreaks were reported across the nation, closing several schools and triggering cleaning efforts


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MRSA

(Methicillin-Resistant Staphylococcus aureus)

  • Type of “staph” infection

  • Often causes skin infections

  • Resistant to (not killed by) penicillin

  • Treatable with appropriate antibiotic

  • Lives on surfaces for days – at least 70!


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MRSA in High School Athletic Facilities

  • Journal of EH, Jan/Feb 2010

    • 10 high school athletic training facilities

    • 90% - 2 or more positive surfaces for MRSA

    • ~50% of surfaces tested positive

      • Water coolers – 80%

      • Treatment/taping tables – 70%

      • Sink faucet handles – 60%

      • Shower handles – 50%

      • Ice Machine – 30%

    • 9 high school wrestling facilities

      • Wrestling mats – 89%

      • Locker room benches – 78%

      • Treatment table – 56%

      • Doorknob – 44%


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What does MRSA look like?

  • Spider bite

  • Turf burn

  • Impetigo

  • Boil

  • Abscess

Source: LA County Health Department

Source: Mark Grubb, MD

Source: CDC

Source: CDC

Source: CDC


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How is MRSA spread?

  • Skin to Skin Contact

    • Touching MRSA infected skin

    • Touching drainage from MRSA skin infection

  • Surface to Skin Contact

    • Sharing personal items (skin ointments, razors, bar soap, towels)

    • Touching unclean sports equipment (weights & benches) and practice surfaces (wrestling mats)


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What increases the risk of MRSA infection?

  • Close skin contact w/ someone who has MRSA

  • Skin disease or injury

  • Lack of good hygiene

  • Sharing personal items

  • Sharing sports equipment

  • Overcrowded living conditions

  • Lack access to healthcare

  • Incorrect use or overuse of antibiotics


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Controlling MRSA

  • Washing hands frequently!!

  • Do not touch other people’s skin lesions.

  • Report potential skin infections to the coach / nurse.

  • Use a towel between skin and gym equipment.

  • Do not share clothes, towels, water bottles, or personal hygiene items. No body cosmetic shaving.

  • Soap shower right after all practices and competitions.

  • Wash uniforms with soap/hot water, dry in a hot dryer after each use.

  • Use alcohol-based hand sanitizer when soap and water are not available.


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Cleaning for MRSA

  • Athletic areas are critical, including PE.

  • Maintaining equipment in good repair.

  • Developing & following routine schedules for cleaning & disinfecting sports equipment.

  • Clean and disinfect all hard surfaces that may contact skin at least daily with an EPA-approved disinfectant, including benches, weights, workout machines, floor and wall mats, etc. Before and after use is preferred.

  • Clean locker rooms and shower areas daily.

  • Keep soap dispensers full – fragrance free, NOT antibiotic soap.

  • Have separate cleaning mops (preferably micro-fiber) and buckets for athletic areas.


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MRSA Resources

Tacoma-Pierce County Health Department

www.tpchd.org/mrsa

Washington State Department of Health

http://www.doh.wa.gov/Topics/Antibiotics/MRSA.htm

Centers for Disease Control and Prevention

www.cdc.gov/ncidod/dhqp/ar_mrsa_ca.htm


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Noroviruses

  • Noroviruses are a group of single-stranded RNA, nonenveloped viruses that cause acute gastroenteritis in humans.

  • CDC estimates that 50% of all foodborne outbreaks of gastroenteritis can be attributed to noroviruses

  • Noroviruses are transmitted through the fecal-oral route, by consumption of fecally contaminated food or water, direct person-to-person spread, or environmental and fomite contamination.

  • Quaternary compounds are NOT effective against Noroviruses


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    Norovirus

    • 24-48 hour incubation period

    • Sudden onset vomiting, diarrhea, cramping

    • Low-grade fever

    • Symptoms last 1-2 days

    • Viruses in stool and vomit

    • Can shed virus for days to 2 weeks after symptom free

    • Highly contagious (10 viruses can cause illness)

    • Lives for days on surfaces, where it can be “picked up” by others – at least 7!


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    Animals

    In

    Schools


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    ZoonoticDiseases

    • Salmonella

      • Reptiles

      • Chicks

      • Owl Pellets

    • Psittacosis (parrot fever)

    • Rabies

    • West Nile Virus

    • Hanta Virus

    • Lice

    • Classroom Pets

    • DOH Zoonotic Disease http://www.doh.wa.gov/ehp/ts/ZOO.HTM

    http://www.nasphv.org/documentsCompendiaAnimals.html


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    Guidelines for Animals in Schools

    • Health and Safety Guide K-12 Schools in Washington, Second Edition

    • Section O: Animals in Schools

    • Appendix F: Animals in the Classroom

    • NASPHV Compendium of Measures to Prevent Disease Associated with Animals in Public Settings, 2009 -

    • Appendix D: Guidelines for Animals in School and Childcare Settings

    • Animals are effective and valuable teaching aids, but safeguards are required to reduce the risk for infection and injury.

    • www.nasphv.org/Documents/AnimalsInPublicSettings.pdf


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    Public contact with animals should occur in settings where measures are in place to:

    • Reduce the potential for injuries

    • Reduce disease transmission

    • Increase the probability that incidents / problems identified with animal contact settings will be

    • 1) reported

    • 2) documented

    • 3) handled appropriately


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    • Injuries measures are in place to:

    • Injuries associated with animals in public settings:

    • Bites

    • Kicks

    • Falls

    • Scratches

    • Stings

    • Crushing of the hands or feet

    • Being pinned between the animal and a fixed object.

    • *Extreme example: a Kansas teenager was killed while posing for her senior year photo with a tiger being restrained by its handler at an

    • animal sanctuary


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    Health Risks Associated with Animal Contact measures are in place to:

    • Enteric diseases

    • Allergies

    • Injuries

    • Rabies exposures

    • Infections


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    Classroom pets measures are in place to:

    Animal visits

    Dissection

    owl pellets

    road kill

    Habitat projects

    reptiles

    amphibians

    fish

    What’s happening in class?


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    Classroom “dissections” measures are in place to:

    Owlpellets

    Road Kill

    Where’s the gloves?

    Biohazard protections?


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    Playground measures are in place to:visitors


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    Chicks and Ducklings measures are in place to:

    • Chicks and ducklings are inappropriate in schools due to high risk of salmonellosis and campylobacteriosis


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    Reptiles and Amphibians measures are in place to:

    • All reptiles and amphibians can carry salmonella

    • Students under 12 should be prohibited from handling reptiles and amphibians

    • No turtles under 4 inches in length are allowed in schools

    • Discourage children from “kissing” or having them in close contact with their faces

    • Instruct any child handling them to wash their hands immediately afterwards


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    Parrots, Parakeets, Cockatiels measures are in place to:, and MacawsPsittacosis (Parrot Fever)

    • Infection that can cause pneumonia and other serious health problems

    • Inhalation of dust from dried droppings andsecretions, and dust from feathers

    • Pet birds should never

      • Brought to school showing signs of illness

      • Be allowed to fly free in a classroom

      • Be handled by children

      • Their waste must be contained in their clean cages

    • Birds permanently housed on school property in cages

      should be treated prophylactically for psittacosis for

      45 days prior to entering the premises.


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    School Guidelines measures are in place to:

    PROPER HAND WASHING!!

    • Educate students of all ages in proper hand washing techniques after handling animals.

    • Have a school policy and

      procedures on animals.


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    Rabies measures are in place to:

    • Contact with rabid mammals can expose persons to rabies virus through:

    • bites

    • contamination of mucous membranes

    • (splashes, rubbing eyes, etc.)

    • scratches, wounds contaminated with

    • infected saliva or nervous tissue.

    • * Note:

    • Although no human rabies deaths caused by animal contact in public exhibits have been recorded, multiple rabies exposures have occurred, requiring extensive public health investigation and medical follow-up ($$$$ and worry and pain – Montana elementary school and the dead bat.)


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    Rabies measures are in place to:School Guidelines

    • Stray animals should never be brought onto school campuses because the health and vaccination status of these animals is seldom known.

    • Verified rabies vaccination is required for all dogs, cats, and ferrets which are brought onto school property for instructional purposes.

    • Puppies and kittens under 3 months and not vaccinated against rabies should not be handled by children or at school.


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    Bugs at School ? measures are in place to:

    • Head lice

    • Stinging insects

    • Ticks

    • Poisonous spiders


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    Head Lice measures are in place to:

    • Parasitic insect adapted to living mainly on the scalp and neck hairs.

    • Not a health hazard or responsible for the spread of any disease.

    • Not a sign of uncleanliness.

    • Transmitted by direct contact with live louse through head-to-head contact (mostly) or through contact with personal articles such as hats or combs.

    • “No Nit” policies – not recommended.


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    Stinging Insects measures are in place to:Wasps and Hornets

    • Beneficial insects – eat insects that damage shade trees and crops and house flies

    • Nests can be in trees, on buildings or underground, depending on species

    • Attracted to sugary fluids & drinks (sodas) at picnics or in garbage cans


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    Ticks measures are in place to:

    • Hard Ticks: Lyme Disease, Rocky Mountain Spotted Fever

      • Open forest, sagebrush, grasslands, woodland edges

    • Soft Ticks: Tick-borne relapsing fever – most common tick-borne disease in WA.

    • Avoid getting bitten

      • Wear long pants and a long-sleeved shirt. Tuck your pant legs into socks or boots and shirt into pants

      • Use tick repellent when necessary, and carefully follow instructions on the label

      • Buddy Checks


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    Spiders measures are in place to:

    • Black Widow

    • Common in eastern WA, some on the western side.

    • Undisturbed piles of wood, outbuildings,

    • rock piles, hay bales, crawl spaces.

    • Shy, bite reluctantly – usually when provoked.

    • Hobo Spider

    • Mature spiders common from mid-summer

    • through fall

    • Uncommon above basements or ground level

    • Build funnel-shaped webs in dark, moist areas,

    • wood piles, crawl spaces, perimeters of homes

    • Bite

      • Painless

      • Blister in 15-35 hours

      • Tissue necrosis

      • Seek medical care


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    West Nile Virus measures are in place to:


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    Mosquito Control measures are in place to:

    Eliminate mosquito larval habitats

    • For lined or contained water bodies

      • Remove or circulate the water

      • Larvae eating fish

      • Mosquito “dunks” or “bits” – larvicide Bacillus thuringiensis israelensis (Bti) – follow directions

    • For water bodies that can reach other water bodies

      • Retention pond with outlet, ditches, pond with stream

      • Licensed pesticide applicator needed to apply larvicides

      • May need an NPDES permit

      • Contact DOH Zoonotic Disease Program at

        (360) 236-3385 or

        [email protected] for more information


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    Eliminate Standing Water measures are in place to:


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    Online Dead Bird Reporting System measures are in place to:

    • Report any dead crows, jays, or raptors to the WA DOH’s online dead bird reporting website

    http://www.doh.wa.gov/ehp/ts/Zoo/WNV/reportdeadbird.html


    Hanta virus l.jpg
    Hanta Virus measures are in place to:

    • Sin Nombre virus, Hantavirus Pulmonary Syndrome

    • Deer mice in North America

      • WA ST: ~14% of 1,100 tested deer mice

      • ~6 inches nose to tail, grayish to light brown on top

      • Large ears, white belly, furry tail

    • Virus in urine, saliva, droppings

    • Exposure through inhaling contaminated dust, droppings, dried urine

    • Pets, snakes, predators not infected, can’t spread

    • No evidence for person-to-person spread

    • Average 1-5 cases/year in WA ST

    • Suspect all rodent contaminated areas


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    Cleaning up Rodent Infested Areas measures are in place to:

    • Wear rubber, latex, vinyl, or nitrile gloves.

    • Do not stir up dust by vacuuming, sweeping, etc.

    • Thoroughly wet contaminated areas with 10% bleach.

    • Soak for 10 minutes, remove soaked materials.

    • Mop/sponge area with bleach solution.

    • Steam clean/shampoo upholstered materials/carpet.

    • Soak dead rodents with bleach solution, double bag with all cleaning materials, dispose.

    • Clean/Disinfect gloves before removal.

    • Wash hands thoroughly after removing gloves.


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    Safe measures are in place to:

    And

    Effective

    Cleaning


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    Why consider “green cleaning”? measures are in place to:

    • Better for student health

    • Better for custodial health

    • Better for the environment

    • “Green” products “reduce the health and environmental impacts compared to similar products and services used for the same purpose.” Executive Order 13423


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    Asthma & respiratory ailments measures are in place to:

    Quats

    Bleach

    Fragrances

    Eye, nose, throat, and skin irritation

    Fatigue

    Reproductive disorders

    Burns

    Major organ damage

    Cancer

    Dizziness/Headaches

    Hazardous for Human Health


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    Cleaning Supplies Study measures are in place to:

    • 13 large CA school districts

    • “Airborne brew of chemicals”

    • 21 cleaners tested – released

      • 6 chemicals known to cause asthma

      • 11 contaminants known, probable, or possible cancer-causing in humans

      • hundreds of compounds with little or no hazard information

    • Green cleaners released a lower overall number of measurable air contaminants, particularly lower levels of VOCs

    • Environmental Working Group, School Cleaning Supplies, November 2009

      http://www.ewg.org/files/2009/10/school-cleaners/EWGschoolcleaningsupplies.pdf


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    Elements of a Cleaning Program measures are in place to:

    • Understand the unique requirements of your buildings.

    • Continuously examine the entire cleaning process and identifying areas needing improvement.

    • Program should be designed to have a positive impact on cleanliness and the health and performance of occupants.


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    Review and update cleaning and sanitizing policies measures are in place to:

    • Clean and disinfect regularly touched surfaces regularly.

    • Use EPA registered cleaner/disinfectants for influenza.

    • Review safe chemical management policies.

    • Ensure that products are being used as directed on the label by trained professionals.


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    Selecting Products measures are in place to:

    • Preferred products

      • Disinfectants - EPA approved for the intended purpose

      • Third Party Certified

        • Green Seal

      • Neutral pH

      • No phosphates, dye, fragrance, butyl cellusolve, nonylphenol ethoxylate

      • Meets or exceeds the California VOC requirements

      • Low hazard rating

      • Use only when and where needed

      • Concentrated (reduce packaging)


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    Less-toxic Ingredients measures are in place to:

    Use these: Instead of these:

    • Alcohol ethoxylates Nonylphenol ethoxylates or

      and/or polyglucosides alkylphenol ethoxylates

    • Hydrogen peroxide Harsh acids/alkali builders

    • Corn based esters Petroleum distillates

    • Vegetable derived Petroleum derived surfactants

      surfactants

    • Fruit derived solvents Petroleum solvents or harsh and acids acids

    Copyright 2008, Healthy Schools Network Inc.


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    Products of Most Concern measures are in place to:

    • Aerosol Sprays

    • Acid Toilet Cleaner

    • Degreasers/Solvents

    • Disinfectants

    • Metal Polish

    • Graffiti/Paint Removers

    • Floor Strippers


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    Special Concerns measures are in place to:

    • Cake toilet deodorizers – paradicholorobenzene

      • Teratogen, Carcinogen, 100% volatile

    • D-Limonene: Citrus & Terpene Solvents

      • Sensitizer, Neurotoxin, Irritant

    • Nano Technology (nano-silver)

    • “Air Fresheners”

    • Anti-microbial soaps

      • Triclosan / Triclocarban

        • Possible endocrine disrupters

        • Bacterial resistance

        • Killing good bacteria

        • What about the viruses?

        • Ubiquitous in the environment


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    Good Cleaning Practices measures are in place to:

    • Prevention

      • Walk-off mats

    • High efficient vacuum filters

    • No chemicals brought in by staff/parents

    • Automatic dilution

    • Avoid aerosols

    • Spray into cloths

    • Read the MSDS

    • No upholstered furniture

    • Clutter control

    • Control food in classrooms – including snack storage

    • Nitrile or vinyl gloves, not latex

    • Microfiber cloths


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    Infection Control measures are in place to:


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    Infection Control measures are in place to:

    • Persons with flu symptoms should stay home from the first sign of symptoms until fever free for 24 hours without fever reducing medication.

    • Cover nose and mouth when coughing or sneezing.

    • Wash hands with soap and water. Use alcohol-based hand sanitizers if you can’t wash.

    • Try to maintain spatial separation of at least 3 feet from others, if possible.


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    Flu viruses measures are in place to:on surfaces

    • Flu types A & B survive up to 48 hours on hard, nonporous surfaces – stainless steel, plastic.

    • Survive less than 12 hours on porous surfaces – cloth, paper, tissues.

    • Up to 72 hours on wet surfaces.

    • Flu virus survives for about 5 minutes on the hands after transfer from an environmental surface.


    Epa design for the environments dfe pilot project for disinfectants l.jpg
    EPA measures are in place to:Design for the Environments (DfE) pilot project for disinfectants

    DfE logo on an EPA-authorized antimicrobial pesticide label:

    • Least-hazardous classes

    • Unlikely carcinogenic or endocrine disruptor properties

    • Unlikely to cause developmental, reproductive, mutagenic, or neurotoxicity issues

    • Mixtures, including inert ingredients, have been reviewed and are accepted by EPA

    • Does not require the use of Agency-mandated personal protective equipment

    • No unresolved or unreasonable adverse effects reported

    • No unresolved efficacy


    Cleaning and disinfecting l.jpg
    Cleaning and Disinfecting measures are in place to:

    When surfaces are not visibly dirty

    • Clean the surface with a commercial product that is both a detergent (cleans) and a disinfectant (kills germs). These products can be used when surfaces are not visibly dirty.

      When surfaces are visibly dirty

    • Wash the surface with a general household cleaner (soap or detergent), rinse with water and follow with a disinfectant. This method should be used for visibly dirty surfaces.


    Cleaning and disinfecting62 l.jpg
    Cleaning and Disinfecting measures are in place to:

    • Keep hard surfaces like countertops, tabletops, desktops and bathroom surfaces clean and disinfected daily.

    • Use disposable sanitizer cloths to wipe electronic items that are touched often.


    Cleaning and disinfecting63 l.jpg
    Cleaning and Disinfecting measures are in place to:

    • Keep surfaces touched by more than one person clean and disinfected daily.

      • Door handles

      • Faucets

      • Keyboards

      • Railings

      • Phones

    • Clean and disinfect surfaces where someone has been ill – coughing and sneezing.


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    Restrooms measures are in place to:

    • Clean and disinfect bathroom surfaces at least daily.

    • Keep soap and paper towel dispensers full.

    • IPC (2006) 416.5: “Tempered (85o-110oF) water shall be delivered from public hand-washing facilities through an approved water temperature limiting device that conforms to ASSE 1070.”

    • WAC 246-366-060: “Adequate, conveniently located toilet and handwashing facilities shall be provided for students and employees.

      • Hot water at a maximum of 120oF.

      • Hand-operated, self-closing faucets must deliver at least 10 seconds of water at a time, (15 seconds in food service).


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    Bleach measures are in place to:

    • Disinfectant, NOT a cleaner.

    • Always clean with soap/detergent first.

    • Make a fresh solution daily.

    • Disinfecting:

      • General: 1 T / quart water

      • Food contact surfaces: ~1t / quart of water

      • 3-5 minutes wet contact time

      • Noro virus/vomit: 10% bleach solution (after cleaning!)

      • 10 minute wet contact time

    • Never mix with ammonia or acid products

    • Use gloves, ventilation, eye protection


    Microfiber mop systems l.jpg
    Microfiber Mop Systems measures are in place to:

    • Reduce chemical use (~50 – 75%)

    • Cut water use (~ 90%) ~100,000 gallons/year

    • Reduce injuries (chemical exposure, back strain, accidents)

    • Effective (reduce dirt, avoid cross-contamination)


    Fragrance free soap l.jpg
    Fragrance Free Soap measures are in place to:

    • Mild Chemically

    • Biodegradable

    • Green Seal Certified

    • Fragrances have no hygienic function

    • Dispensers in all UW campus bathrooms

    • Avoid antibacterial soaps


    Hand sanitizers l.jpg
    Hand Sanitizers measures are in place to:

    • Not a substitute for hand washing

    • Not effective on dirty hands

    • At least 60% alcohol (70%+ more effective)

    • Fragrance free

    • We do NOT recommend Benzalkonium chloride or triclosan based hand sanitizers.

    • Supervision required:

      • Flammable – fire department requirements

      • Alcohol poisoning

      • Do we need it on every desk? High VOC levels

      • Read the label – are kids/teachers bringing in the appropriate kind?

      • No children < 1 year old

      • Hands should stay wet for 10-15 seconds


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    Resources measures are in place to:

    • The Quick & Easy Guide to Green Cleaning in Schools

      http://www.healthyschoolscampaign.org/programs/gcs/thankssu.php

    • Cleaning For Healthy Schools Toolkit

      http://www.cleaningforhealthyschools.org/

    • Cleaning Supplies Can Contaminate Classroom Air

      http://www.ewg.org/schoolcleaningsupplies/overview

    • Guide to Green Cleaning: Healthier Cleaning & Maintenance, Practices and Products for Schools

      www.healthyschools.org

    • Informed Green Solutions

      http://www.informedgreensolutions.org/publications/Asthmagens_in_Institutional_Cleaning.html

    • Characteristics of Selected Disinfectants

      http://www.cfsph.iastate.edu/BRM/resources/Disinfectants/CharacteristicsSelectedDisinfectants.pdf


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    Join my list serve for timely information! measures are in place to:

    www.doh.wa.gov/ehp/ts/school

    Resources available on my web site.

    Nancy P. Bernard, MPH

    Program Manager, IAQ / School EH&S

    Office of Environmental Health, Safety, & Toxicology

    Washington State Department of Health

    PO Box 47825, Olympia, WA 98504-7825

    (360) 236-3072, fax (360) 236-2261

    [email protected]


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