Infection Control In Daycare

Infection Control in Day Care I. Hepatitis A Infection A. Infectious diseases that adults are likely to acquire from children who attend day care centers include the following: 1. Hepatitis A: Fecal oral transmission 2. Cytomegalovirus: Transmission by contact with saliva, urine; risk to fetus if pregnant day care provider develops infection (primary infection in particular) 3. Parvovirus B 19-respiratory transmission, risk to fetus in pregnant day care provider who becomes infected 4. Children are at risk of acquiring tuberculosis from infected adults who care for them B. Classification of Child Care 1. Because enteric pathogens are much more easily spread among diapered children 2. Home care (small family child-care home) 5-6 children, no licensing 3. Day care home (large family child-care home) 7-12 children, variable licensing requirements 4. Day care centers > 13 children, licensed C. Enteric pathogens spread in child care 1. Viruses a. Hepatitis A b. Rotavirus c. Astrovirus d. Enteric adenovirus e. Calicivirus f. Enteroviruses 2. Bacteria a. Salmonella b. Shigella-small inocula infection, highly contagious-exclude until treated c. E. coli O157:H7 d. Campylobacter e. Clostridium difficile 3. Parasites and Fungi a. Cryptosporidium b. Giardia lamblia c. Enterobius vermicularis (1) Day care attendees with vomiting and diarrhea should generally be excluded until symptoms have resolved (they need ill care, which daycare centers usually cannot provide; it is more difficult to contain secretions in this situation) 4. Hepatitis A -Epidemiology/Clinical Features a. Common infection in children and particularly in day care centers with diapered attendees b. Infection in young children is usually asymptomatic or mildly symptomatic only, but infection in adults is symptomatic 75-100% of the time D:\FILES\Review Courses\Peds ID\Peds ID 1\Infection in daycare.wpd

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c. Jaundice occurs in less than 10% of infected children under age 6 years d. Infection in children is often only identified when an adult contact develops jaundice e. The diagnosis is confirmed by detection of hepatitis A IgM. Maternal testing is diagnostic f. Hepatitis A IgM persists for about 5 months after infection will run on the infant should be tested if the mother has hepatitis A--it will still be positive if he recently had Hepatitis A 5. Control of Spread of Hepatitis A a. Passive immunization with gammaglobulin b. Household and sexual contacts of a case should receive immune globulin by injection c. Dose is 0.02 ml/kg of body weight d. In day care centers, aggressive use of immune globulin recommended if: (1) A case is diagnosed in a child or adult in the center. (2) Two or more families with children in the center experience hepatitis A infection in a 6 week period All children and adults should receive gammaglobulin if there are diapered children in the facility. If no diapered children, give only to classroom contacts of infected child. Observe closely for additional cases over next 6 weeks (health dept assistance). If outbreak persists, may need to give immune globulin to household contacts of diapered children. Parents should not transfer their child to another day care center during an outbreak. If child develops hepatitis A with symptoms, exclude until asymptomatic. e. Hepatitis A vaccine (1) If outbreak widespread and/or persistent, consideration should be given to use of hepatitis A vaccine, in consultation with local health department. 6. Hepatitis A Vaccine a. Recommended for: (1) International travelers (2) Individuals at high risk of infection: Alaskan Native, American Indian (3) IV drug users (4) Persons with clotting factor disorders (5) Homosexual men (6) Patients with chronic liver disease (7) Children who reside in communities with high rates of hepatitis A and periodic hepatitis A outbreaks (8) Control of an outbreak in certain situations 7. Hepatitis B infection a. Not highly transmissible in day care setting because it usually requires contact with blood b. Avoid sharing toothbrushes, use appropriate precautions for handling cuts/blood spills c. Other pathogens potentially transmissible by blood: Cytomegalovirus, Hepatitis C, HIV 8. Recommendations for handwashing, food preparation, and diapering in day care centers D:\FILES\Review Courses\Peds ID\Peds ID 1\Infection in daycare.wpd

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a. Handwashing is the single most important measure to reduce pathogen transmission Soap dispensers, disposable paper towels, and use paper towel to turn off faucet is recommended. b. Sinks of appropriate height and adjacent to diapering and toileting areas Dirty utility sinks-not used for handwashing. Food preparation sinks are separate. Sinks should be routinely disinfected. 9. Diapering a. Excretions should be contained and contamination of environment and hands should be avoided. Change diapers on disposable covering, placed on smooth nonabsorbent, easily cleaned surface. b. Dirty disposable diapers and table coverings should be placed in plastic-bag-lined, foot operated cans (cans should be inaccessible to toddlers). Soiled clothing or nondisposable diapers should be placed immediately into ziplock bags labeled with child's name for laundering outside the center Infants and toddlers in diapers should have clothing covering diapers at all times. c. Changing areas should be separate from food preparation and serving. Child size toilets are useful (at least 1 toilet per 15 children). Disinfection of toilets should be done frequently. Diaper changing areas should be disinfected after each use, and providers should wear gloves/wash hands (inexpensive sanitizing solution is made by adding 1/4 cup household bleach to one gallon of water). Handwashing by child and care provider should be done after each diapering/toilet use. 10. Food preparation a. Proper food preparation, storage, handling should be assured b. No food handling by staff who are infected or ill c. Staff caring for diapered children should avoid food preparation and handling d. Handwashing prior to handling food II. Pediculosis (Head Lice) Infestation A. Characteristics of Organism 1. 2-4 mm long, flattened, wingless insects 2. Obtains nourishment by sucking blood from scalp 3. Female lice survives for 40 days and lays 100-300 eggs 4. Egg cases are attached to hair shaft near scalp 5. Can survive for 2-3 days off the host B. Clinical/epidemiologic Features of Infection 1. Children in urban communities are more commonly infected 2. Females and whites more commonly infected 3. Not related to poor hygiene 4. Usually, itching is the only symptom 5. Nits are easy to see, are opalescent white (can use magnifying glass), mature louse difficult to see (examine with bright light; louse may be seen scurrying away) 6. Nits must be distinguished from scale and hair casts (generally are non-fixed, sliding up and down hair shaft) "pseudo-nits" 7. Excoriations and secondary infections occasionally occur C. Treatment D:\FILES\Review Courses\Peds ID\Peds ID 1\Infection in daycare.wpd

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1. 1% permethrin creme rinse (NIX) is the treatment of choice (nonprescription) a. Applied to hair and scalp for 15 minutes and then rinsed (don't shampoo hair again for 24 hrs) b. Both pediculocidal and ovicidal; one treatment is usually adequate c. A second treatment may be repeated 7-14 days later d. Kwell no longer commonly used because more potential toxicity (neurotoxicity, which was usually from overuse or ingestion) 2. After treatment, nits should be removed with fine tooth comb, wetting hair in a solution of 1:1 white vinegar to water will loosen nits from shaft prior to combing 3. Clothing and bedding should be washed and dried at hot temperature (128EF) or dry clean 4. Combs and brushes are soaked in alcohol for 1 hour, then cleaned in hot water, or boiled for 20 min or soak in NIX 5. Hair bows, personal hair items: either wash as for clothing and bedding, or can microwave nonmetal items for 60 sec, or place in a sealed plastic bag for 4-10 days 6. Vacuum floors, play areas to remove hairs that may carry live nits 7. Treat child and all household members D. Interrupting Transmission 1. All day care attendees and family members should be examined for lice (ie, alert families to presence of infection in the center). Information should be provided to families in appropriate language 2. Treatment of all infested individuals 3. Spread may be by direct contact or fomite spread 4. Each child hang up coats, hats on separate hook in individual compartments. The practice of piling up coats and hats of all children together facilitates spread of infection. 5. Avoid sharing towels, and pillows, at nap time f. Avoid sharing of combs, brushes or other hair items among attendees and within families g. Treatment of all day care contacts generally not recommended unless infection is present; it is recommended that all family members of infected child be treated h. If crowding cannot be avoided, more widespread treatment may be recommended in select situations i. infected child can return to the center after appropriate treatment-treatment can be performed the day of diagnosis and child will not need to be excluded at all. j. No role for "fumigation" with general insecticides by pest control industry k. If one family a continued source of infection, a public health nurse visit to home may be able to detect which instructions were not understood or carried out. III. Varicella-zoster Virus Infection A. Varicella zoster infection 1. Incubation period: 10 days to 21 days (28 days if VZIG is given) 2. Period of contagiousness: 2 days before rash begins until all lesions crusted (usually day 5=7). 3. VZIG is given to varicella susceptible high risk children, such as immunocompromised (HIV, cancer). Not indicated for healthy child, unless a high-risk child is present in the D:\FILES\Review Courses\Peds ID\Peds ID 1\Infection in daycare.wpd

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center (that child only would receive VZIG). 4. Varicella vaccine should be routinely given to children at 12-18 months of age. Vaccination is indicated for susceptible children in the center who are at least 12 months of age. B. Pathogens acquired by respiratory route at day care 1. Bacteria Bordetella pertussis Haemophilus influenza type b Mycobacterium tuberculosis Neisseria meningitidis (particularly an issue if a case of meningitis occurs in the center-rifampin prophylaxis may be indicated) Streptococcus pneumoniae (including penicillin-resistant strains) Pertussis should be excluded until 5-7 days after initiation of effective therapy 2. Viruses Adenovirus Influenza Measles Parainfluenza Parvovirus B 19 RSV Rhinovirus Rubella Varicella Isolation or exclusion of children with common respiratory illnesses has not proven to be practical or effective in preventing spread of airborne diseases; handwashing remains the most effective means to control such spread. Varicella should be excluded until lesions are dry and crusted. Children with severe respiratory illness with fever, tachycardia should attend day care center. Measles should be excluded until 5 days from the appearance of the rash. Patients with bacterial conjunctivitis should be excluded until 24 hours after antimicrobial therapy, viral conjunctivitis until symptoms resolve. C. Pathogens acquired by skin/mucous membrane contact at day care 1. Bacteria Group A streptococcus Staphylococcus aureus For group A streptococcal pharyngitis, exclude until 24 hours of effective therapy For impetigo, exclude until 48 hours of effective therapy 2. Viruses Herpes simplex: if severe gingivostomatitis, exclude until lesions dry and crusted 3. Parasites and fungi Pediculosis Scabies Tinea capitis Tinea corporis D. Vaccines for day care attendees D:\FILES\Review Courses\Peds ID\Peds ID 1\Infection in daycare.wpd

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DPT, polio HIB (Haemophilus influenzae type b) Hepatitis NB MMR Varicella if susceptible (Influenza) (Hepatitis A) Immunization should be required for entry, records should be periodically checked to assure that age-appropriate vaccines are given in a timely fashion. E. Vaccines for day care staff dT, polio Hepatitis B MMR Varicella if susceptible (Influenza) (Hepatitis A) PPD testing prior to employment, repeat q 1-2 years F. Control of other herpesvirus infections 1. Herpes simplex (oral lesions) Commonly shed in oral secretions by symptomatic and asymptomatic children Avoid contact with lesions, good handwashing should avoid spread Toys and items handled by children with cold sores should be cleaned with sanitizing solution. Stuffed animals are difficult to clean and should not be allowed in day care centers 2. Cytomegalovirus May be spread from saliva or urine of child to day care employee. This is off particular concern to pregnant day care workers. Exclusion of children with congenital CMV not justified since many children, particularly those ages 2-4, have CMV in the urine. Good handwashing when contact with saliva or urine occurs, avoiding kissing should be advised.

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