Public Health Considerations in Child Care Settings

1. Public Health Considerations in Child Care Settings Elizabeth Lowery, MPH Epidemiologist Rappahannock Area Health District

2. True or False • Children in out-of-home child care centers experience a higher incidence of common infectious diseases than children reared exclusively in their own home. True! • 60% of employee absenteeism is attributable to unmet child care needs. True! • Parents miss 1-4 weeks per year to care for sick children. True!

3. On May 23… RAHD received a physician report of meningococcal infection in a toddler attending a day care center in Stafford County. The District Director and District Epidemiologist coordinated with the day care center director and the child’s physicians to coordinate prophylaxis of the entire class and family contacts. Actions included: • Arranging with a pharmacy close to the center to provide antibiotics for the students • Sending a letter home instructing parents how to pick up prescriptions • Following up on reports of similar illness in students for the next week • Notifying the hospital of the situation, to heighten their awareness of meningococcal infection

5. Immunizations • Daily check for immunizations required for age • If not immunized: • Letter from provider • Waiver signed by parents • Evidence of scheduled appointment • Will be excluded if VPD occurs in facility

6. Immunizations • Staff should have: • TD boosters every 10 yrs • MMR • Polio • Chickenpox (or evidence of disease) • Hepatitis B

7. Hygiene – hand washing • Upon arrival • Moving from one child care group to another • Before and after: eating, handling food, feeding children, giving meds, playing in water shared by others

8. Hygiene – hand washing • After: • Diapering • Using bathroom • Handling bodily fluids • Handling uncooked food • Handling pets • Playing in sandbox • Cleaning or handling garbage

9. Vaccine Preventable Diseases: Streptococcus pneumoniae Neisseria meningitidis Pertussis Haemophilus influenzae, Type B Measles Mumps Rubella Influenza Chickenpox Hepatitis A Hepatitis B Rotavirus Enteric Diseases: Shigellosis Salmonellosis E. coli Norovirus C. difficile Other Diseases: RSV Adenovirus Group A Strep Parvovirus B19 CMV Staphylococcus aureus Infectious diseases documented in out-of-home child care centers

10. Patterns of disease occurrence • Infects children, child care staff, and family members (shigella) • Infection not apparent in children, but is present in staff and family members (hep A) • Infection in children but not adults or older siblings (HIB) • Infection mild in children, staff and family members, but poses risk to pregnant staff (CMV)

11. Modes of Transmission • Direct • Contact – touching, biting, kissing • Projection – droplet spray to eyes, nose, mouth while sneezing, coughing, spitting, singing, talking • Person to person - lesser extent person to object to person Examples: head lice, impetigo, pinkeye, ringworm, some GI

12. Modes of Transmission • Indirect • Vehicle-borne – from an inanimate object to a person • Vector-borne – insect carried Examples: some GI – salmonella, Hepatitis A

13. Modes of Transmission • Airborne • particles that remain suspended for longer period – droplet nuclei, dust Examples: cold, flu, pertussis (whooping cough), norovirus

14. Shigellosis • Bacteria • ~14,000 cases reported/year in US • ~470 reported cases in VA/year in the last 10 years • Principle reservoir: Humans

15. Shigellosis distribution by Age-2000

16. Shigellosis • Transmission mode: direct-ingestion • Food/water • Person to person • 10 bacteria to infect • Incubation period: 1-3 days • Fatality can range from 5-15% depending on strain

17. Shigellosis • Cases may continue to excrete Shigella organisms for 1-4 weeks after diarrhea ceases • Long-term carriage is rare

18. Shigellosis • When diarrhea stops, child may return to day care, but handwashing must be strictly monitored until stool cultures are negative. • 2 negative stools, 24 hours apart, at least 48 hours after beginning antibiotics

19. Shigellosis- Public Health • Under normal conditions, poor hygiene is most common cause • Handwashing • Diapering hygiene

20. E. coli O157:H7 • 73,000 cases reported in US/yr • ~70 cases reported in VA each year • Reportable since 1999

21. E. coli O157:H7 • E. coli found in intestines of all animals and humans • O157:H7 is a type found in cattle that produces a toxin • Thought that 10 bacteria can infect

22. E. coli O157:H7 • Transmission mode: direct-ingestion • Bloody diarrhea, stomach cramps • Lasts ~1 week • Potential complications especially for children under 5 • Hemolytic uremic syndrome (HUS-kidney failure)

23. E. coli O157:H7 • Single case in a day care? • Contact day care operator to determine if other children or staff have had diarrhea. • Handwashing guideline review • If possible, family to arrange for care of the child in an individualized setting

24. E. coli O157:H7 • If individual child care arrangements cannot be made, the child may return to the facility after diarrhea has ceased, but handwashing must be strictly monitored.

25. E. coli O157:H7 • Prefer to exclude until 2 negative stools • Because of the potential very serious complications of this infection, a more strict approach is taken, especially in an outbreak.

26. E. coli -Public Health • Avoiding cross contamination • Thoroughly cooking all foods • Handwashing • Diapering hygiene

27. Norovirus • “Stomach” flu • Not reportable in VA • ~181,000 cases estimated to occur annually in the US • Humans only known reservoir

28. Norovirus • Clinical signs: Vomiting Nausea Diarrhea • Usually self-limiting • Fatality rate: <1%

29. Norovirus • Mode of transmission: direct-ingestion • Incubation period: 24-48 hours • Infective dose probably low • Incubation period: 12-48 hours

30. Norovirus • More vomiting in children • More diarrhea in adults • Relatively mild, short duration

31. Norovirus • Highly infectious • (<100 particles) • Spread via person-to-person and foodborne • droplets • fecal contamination

32. Norovirus Management • Hand hygiene • Exclusion of symptomatic children • Diapering hygiene

33. Meningococcal Meningitis • Transmission from asymptomatic carrier by respiratory tract droplets • ONE case must be acted upon immediately

34. Meningococcal Meningitis • Abrupt onset fever, malaise, headache, stiff neck, sometimes rash • Disease most often occurs in children <5 yrs. (peak incidence in 3-5 mo.)

35. Management • Chemoprophylaxis of child care contacts • Determine if individual classroom or entire center requires antibiotic • No exclusion

36. Management • Arrange for bacterial isolates to be sent to DCLS for serogrouping • Consider vaccine if >2 cases. Depends on: age of children, serogroup

37. Haemophilus influenzae type b • Requirements for children to have HIB • Children not vaccinated are excluded if a case of invasive Hib is documented in center • Rifampin may be recommended if children in center are < 2 yrs • Secondary cases are variable

38. Pertussis • Bacterial disease • Upper respiratory infection that leads to coughing • 6-10 week duration • Transmission via droplets • Contagious for 2 weeks after cough onset

39. Pertussis • Report to HD immediately!! • Exclude until MD exam/5 days of antibiotic therapy for case • Check vaccine status of children <7 • Contacts may receive vaccine, depending on status, and antibiotics • Monitor staff

40. Chickenpox • Period of Communicability • Usually 1-2 days before the rash and for 5 days after the first vesicles appear • Transmission • Contact: Direct or indirect

41. Chickenpox • Rash characteristics: • Lesions in various stages of evolution at any one time • Lesions have a tendency to be seen on head and trunk first and then spread

42. Chickenpox • Exclude for at least 5 days after rash first appears or until ALL lesions are dry.

43. Herpes simplex • Children with herpes simplex gingivostomatits who do not have control of oral secretions should be excluded from child care. • Child care providers with hs gingivostomatits must not: nuzzle children, share food/drink, touch lessions, and must cover lesion.

44. CMV • CMV remains dormant over long period. • Shed in bodily fluids of any previously infected person, may be found in urine, saliva, blood, tears, semen, and breast milk. • Hygiene important! • Leading cause of congenital infection • Testing children and excluding those positive for CMV is not recommended. All infants and toddlers are assumed positive

45. Conjunctivitis • White part of eye becomes pink, tears and discharge • Direct contact • HANDWASHING

47. Hand, foot and mouth disease • Viral illness • Common illness of children • Mild fever, poor appetite, sore throat and rash • Moderately contagious • More frequent in summer and fall

48. Hand, foot and mouth disease • No specific treatment • Hand and general hygiene • No specific guidelines, but may exclude during the first few days of illness

49. Fifth Disease • Parvovirus B19 • “Slapped cheek” rash, mild fever • Mild illness

50. Fifth Disease • Contagious during early illness • Spread via direct contact with secretions • Control measures: • Handwashing • Exclusion not thought to be helpful