Caring for Our Children: Chapter 6 - Infectious Diseases Chapter 6: Infectious Diseases 6.1 RESPIRATORY TRACT INFECTIONS Please note that if a staff member has no contact with the children, or with anything with which the children come in contact, the staff requirements in these standards do not apply to that staff member. HAEMOPHILUS INFLUENZAE TYPE B (Hib) STANDARD 6.001 immunization for haemophilus influenzae type b All children in child care shall have received age-appropriate immunizations with an H. influenzae type b (Hib) conjugate vaccine (1). Children in child care, who are not immunized or not age-appropriately immunized, shall be excluded from care immediately if the child care facility has been notified of a documented case of an invasive Hib infection. These children shall be allowed to return when the risk of infection is no longer present, as determined by the health department. RATIONALE: Appropriate immunization of children with an H. influenzae type b conjugate vaccine prevents the occurrence of disease and decreases the rate of carriage of this organism, thereby decreasing the risk of transmission to others (2, 3). COMMENTS: Transmission of H. influenzae type b may occur among unimmunized young children in group child care, especially children younger than 24 months of age. For additional regarding Hib disease, consult the Red Book from the American Academy of Pediatrics (AAP). Contact information for the AAP is located in Appendix BB. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 6.002 informing parents of hib exposure If a child with invasive H. influenzae type b (Hib) infection has been in care, the facility shall inform parents of other children who attend the facility, after consultation with the health department, that their children may have been exposed to the Hib bacteria and may have greater risk of developing serious Hib disease if their child is unimmunized or incompletely immunized. The facility shall recommend that parents contact their child's health care provider. RATIONALE: The risk of secondary cases of Hib disease occurring among child care contacts does not seem to be uniform. Studies of child care contacts of children with Hib disease have varied in identification of an increased risk of Hib disease in this setting (4, 5, 6, 7). In general, the risk of secondary Hib disease is probably lower for child care contacts than it is for household contacts. The risk of secondary cases of Hib disease occurring among child care attendees is greatest among, and may be limited to, children younger than 2 years of age who are not immunized (6). In settings with more than one classroom, increased risk has been shown only for children in the classroom of the infected child (6, 7). COMMENTS: Sample letters of notification to parents that their child may have been exposed to an infectious disease are contained in the (National Academy for the Education of Young Children (NAEYC) publication, Healthy Young Children . Contact information is located in Appendix BB. For information about health education for children, staff, and parents, see STANDARD 2.060 through STANDARD 2.067. For additional information regarding Hib disease, consult the Red Book from the American Academy of Pediatrics (AAP). Contact information for the AAP is located in Appendix BB. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 6.003 informing public health authorities of hib cases Local and/or state public health authorities shall be notified immediately about cases of H. influenzae type b (Hib) infections involving children or child care providers in the child care setting. Facilities shall cooperate with their health department in notifying parents of children who attend the facility about exposure to children with Hib disease. This may include providing local health officials with the names and telephone numbers of parents of children in classrooms or facilities involved. The health department may recommend rifampin, an antibiotic taken to prevent infection, for chil-dren in care and staff members, to prevent secondary spread of Hib disease in the facility. Antibiotic prophylaxis is not recommended for pregnant women because the effect of rifampin on the fetus has not been established. RATIONALE: Because the risk of secondary cases of Hib disease seems to be variable among child care contacts of children with Hib disease, opinions differ as to the most appropriate guidelines for the use of rifampin to prevent infection in the child care setting. Rifampin treatment of children exposed to a child with Hib disease can reduce the prevalence of Hib respiratory tract colonization in treated children and reduce the subsequent risk of invasive Hib infection, particularly in children under 2 years of age (6). Prophylaxis should be initiated as soon as possible, when 2 or more cases of invasive disease have occurred within 60 days and when unimmunized or incompletely immunized children attend the child care facility. In addition, children who are not immunized or are not age-appropriately immunized should receive a dose of vaccine and should be scheduled for completion of the Recommended Childhood Immunization Schedule from the American Academy of Pediatrics (AAP) (1, 8). See Appendix G. COMMENTS: For additional information regarding Hib disease, consult the Red Book from the American Academy of Pediatrics (AAP). Contact information for the AAP is located in Appendix BB. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STREPTOCOCCUS PNEUMONIAE STANDARD 6.004 immunization with s. pneumoniae conjugate vaccine All children less than 23 months of age in child care shall have received age-appropriate immunizations with S. pneumoniae conjugate vaccine. Children age 24 to 59 months of age at high risk of invasive disease caused by S. pneumoniae (including sickle cell disease, asplenia, HIV, chronic illness or immunocompromised) shall be recommended to receive S. pneumoniae conjugate vaccine. All other children 24-59 months of age shall be encouraged to be protected against invasive S. pneumoniae disease through immunization, especially children who attend out-of-home child care and children of American Indian, Alaska Native, and African-American descent (9, 10, 11). RATIONALE: Pneumococcal disease among children in out-of-home child care has been reported more frequently over the last decade in the U.S. and other developed countries. In the U.S., the risk for contracting an invasive pneumococcal infection in out-of-home child care (as defined as child care greater than 4 hours/week outside the home) increases by 2 to 3 times in children less than 60 months of age. Appropriate immunization of children with S. pneumoniae conjugate vaccine prevents the occurrence of disease and decreases transmission to others. The risk for invasive disease is greatest in children who attend out-of-home child care and children of American Indian, Alaska Native, and African-American descent (10, 11). COMMENTS: For additional information regarding S. pneumoniae disease, consult the Red Book from the American Academy of Pediatrics (AAP). See also Appendix G. Contact information for the AAP is located in Appendix BB. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 6.005 informing public health authorities of invasive S. pneumoniae Local and/or state public health authorities shall be notified immediately about cases of invasive S. pneumoniae infections involving children or child care providers in the child care setting. Facilities shall cooperate with their health department in notifying parents of children who attend the facility about exposure to children with invasive S. pneumoniae disease. This may include providing local health officials with the names and telephone numbers of parents of children in classrooms or facilities involved. RATIONALE: Secondary spread of S. pneumoniae in child care has been reported, but the degree of risk of secondary spread in child care facilities is unknown (12). Prophylaxis of contacts after the occurrence of a single case of invasive S. pneumoniae disease is not recommended. In addition, children who are not immunized or are not age-appropriately immunized should receive a dose of vaccine and should be scheduled for completion of the Recommended Childhood Immunization Schedule from the American Academy of Pediatrics (AAP) (9). See Appendix G. COMMENTS: For additional information regarding S. pneumoniae disease, consult the Red Book from the American Academy of Pediatrics (AAP). Contact information for the AAP is located in Appendix BB. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home NEISSERIA MENINGITIDIS (MENINGOCOCCUS) STANDARD 6.006 informing public health authorities of meningococcal infections Local and/or state public health authorities shall be notified immediately about cases of meningococcal infections involving children or child care providers in the child care setting. Facilities shall cooperate with their local health department officials in notifying parents of children who attend the facility about exposures to children with meningococcal infections. This may include providing local health officials with the names and telephone numbers of parents of children in involved classrooms or facilities. RATIONALE: Neisseria meningitidis is an important cause of bacterial meningitis in childhood. The infection is spread from person to person by direct contact with respiratory tract secretions (including large droplets) that contain N. meningiditis organisms. COMMENTS: Sample letters of notification to parents that their child may have been exposed to an infectious disease are contained in the National Academy for the Education of Young Children (NAEYC) publication, Healthy Young Children . Contact information is located in Appendix BB. For information about health education for children, staff, and parents, see STANDARD 2.060 through STANDARD 2.067. For additional information regarding meningococcal disease, consult the Red Book from the American Academy of Pediatrics (AAP). Contact information for the AAP is located in Appendix BB. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 6.007 health department recommendations on antibiotics When the health department recommends administering an antibiotic to prevent secondary infection of meningococcal disease within the facility, an antibiotic to prevent an infection shall be administered to staff members and children, with parental permission (13, 14, 15). RATIONALE: Children and staff exposed, by close contact for an extended period to the child first infected with meningococcal disease, are at risk for contracting invasive meningococcal disease (13). The attack rate of meningococcal disease for this population is more than 300 times higher than rates in the general population (14). Because outbreaks may occur in child care settings, chemoprophylaxis with rifampin or ceftriaxone is indicated for exposed child care contacts. Children in child care who are exposed to a child or an adult with meningococcal infection should receive rifampin or ceftriaxone as soon as possible to prevent an infection, preferably within 24 hours of diagnosis of the primary case (14, 15). In contacts over 18 years of age, ciprofloxacin is effective. Rifampin and ciprofloxacin are not recommended for pregnant women. COMMENTS: For additional information regarding meningococcal disease, consult the Red Book from the American Academy of Pediatrics (AAP). Contact information for the AAP is located in Appendix BB. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 6.008 protective measures for meningococcal infection When an antibiotic to prevent an infection with Neisseria meningitidis (meningococcal infection) is indicated for child care contacts, all children and staff members, for whom prophylaxis has been recommended, shall be excluded from attending the facility until these measures have begun. Any exposed individual who develops a febrile illness (one accompanied by a fever) shall receive prompt medical evaluation. New entry children shall not be enrolled in a child care facility in which a case of invasive N. meningitidis has been documented until 2 months has elapsed since the diagnosis was made. RATIONALE: Children and staff exposed, by close contact for an extended period to the child first infected with meningococcal disease, are at risk for contracting invasive meningococcal disease (13). The attack rate of meningococcal disease for this population is more than 300 times higher than rates in the general population (14). Because outbreaks may occur in child care settings, chemoprophylaxis with rifampin or ceftriaxone is indicated for exposed child care contacts. Children in child care who are exposed to a child or an adult with meningococcal infection should receive rifampin or ceftriaxone as soon as possible to prevent an infection, preferably within 24 hours of diagnosis of the primary case (14, 15). In contacts over 18 years of age, ciprofloxacin is effective. Rifampin and ciprofloxacin are not recommended for pregnant women. COMMENTS: For additional information regarding meningococcal disease, consult the Red Book from the American Academy of Pediatrics (AAP). Contact information for the AAP is located in Appendix BB. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home PERTUSSIS STANDARD 6.009 informing public health authorities of pertussis cases Local and/or state public health authorities shall be notified immediately about cases of pertussis involving children or child care providers in the child care setting. Facilities shall cooperate with their local health department officials in notifying parents of children who attend the facility about exposures to children with pertussis. This may include providing the health department officials with the names and telephone numbers of parents of children in the classrooms or facilities involved. Guidelines for use of antibiotics and immunization for prevention of pertussis in individuals who have been in contact with children who have pertussis shall be implemented in cooperation with officials of the health department. Children and staff who have been exposed to pertussis, especially those who are incompletely immunized, shall be observed for respiratory tract symptoms for 20 days after the last contact with the infected person. RATIONALE: Notification of health department officials when pertussis occurs in a child or staff member in a child care center will help ensure the following (16, 17): All children have received age-appropriate immunization; Erythromycin prophylaxis (or other recommended antibiotic therapy, if erythromycin is not tolerated) is provided to those exposed to the child first infected with pertussis; Children and adults are observed for respiratory tract symptoms. COMMENTS: Sample letters of notification to parents that their child may have been exposed to an infectious disease are contained in the National Academy for the Education of Young Children (NAEYC) publication, Healthy Young Children . Contact information for the NAEYC is located in Appendix BB. For information about health education for children, staff, and parents, see STANDARD 2.060 through STANDARD 2.067. For additional information regarding pertussis, consult the Red Book from the American Academy of Pediatrics (AAP). Contact information for the AAP is located in Appendix BB. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 6.010 prophylactic treatment for pertussis When there is a known or suspected occurrence of pertussis in a child care facility, all staff members and children in care shall initiate the appropriate prophylactic treatment (usually administration of erythromycin or another appropriate antibiotic) and any additional treatment deemed medically necessary by a health care provider before they are allowed to return to the facility. Adults and children who have been in contact with a person infected with pertussis shall be monitored closely for respiratory tract symptoms for 20 days after the last contact with the infected person. RATIONALE: Even if outbreaks of pertussis in child care facilities have not been reported, children and staff who attend out-of-home child care occasionally contract pertussis. The spread of infection to contacts who are incompletely immunized can be reduced by treating the primary case and susceptible contacts with prophylactic antibiotics, usually erythromycin (16, 17). COMMENTS: For additional information regarding pertussis, consult the Red Book from the American Academy of Pediatrics (AAP). Contact information for the AAP is located in Appendix BB. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 6.011 exclusion for pertussis Children and staff members with characteristic symptoms (primarily cough) of pertussis shall be excluded from child care pending evaluation by a health care provider. The child or staff member may not return to the facility until: a) Five days after initiation of a 10-14 day course of erythromycin or other recommended antibiotic therapy; b) Three to four weeks after the onset of the cough; c) The medical condition allows. RATIONALE: Even if outbreaks of pertussis in child care facilities have not been reported, children and staff who attend out-of-home child care occasionally contract pertussis. The spread of infection to contacts who are incompletely immunized can be reduced by treating the primary case and susceptible contacts with prophylactic antibiotics, usually erythromycin (16, 17). COMMENTS: For additional information regarding pertussis, consult the Red Book from the American Academy of Pediatrics (AAP). Contact information for the AAP is located in Appendix BB. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home GROUP A STREPTOCOCCAL (GAS) INFECTION STANDARD 6.012 exclusion for group A streptococcal infections Children with group A streptococcal (GAS) respiratory tract, skin, or ear infections shall be excluded from child care until 24 hours after antibiotic treatment has been initiated and until the child has no fever for 24 hours. RATIONALE: Streptococcal respiratory tract infections and scarlet fever resulting from GAS have been reported in children in child care, but are not a major problem (18, 19). Group A streptococcal respiratory tract infections may resolve without treatment; however, GAS respiratory tract infections can be complicated by pneumonia, arthritis, rheumatic fever, and glomerulonephritis (20). Early identification and treatment of GAS infection in children and adults are important in reducing transmission and subsequent occurrence of disease. Consultation with the health department is advised when high rates of streptococcal infection occur in child care facilities. Parents of children exposed to a child with documented GAS infection should be notified of the exposure. COMMENTS: For additional information regarding group A streptococcal respiratory tract infection, consult the Red Book from the American Academy of Pediatrics (AAP). Contact information for the AAP is located in Appendix BB. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 6.013 informing caregivers of group A STREPTOCOCCAL infection Parents who become aware that their child is infected with group A streptocci (GAS), has strep throat, or has scarlet fever, shall inform caregivers within 24 hours. When exposure to GAS infection occurs, care-givers, in cooperation with health department officials, shall inform the parents of other children who attend the facility, that their children may have been exposed. RATIONALE: Periodically, the incidence of rheumatic fever seems to increase (20). Identification and treatment of streptococcal infections of the respiratory tract are central to preventing rheumatic fever. Therefore, awareness of the occurrence of streptococcal infection in child care is important. Adult child care staff members are not immune to streptococcal infections and may be carriers of organisms that cause disease in children. When outbreaks of streptococcal disease occur, interventions are available to limit transmission of streptococcal infection. Consultation with the health department is advised when high rates of streptococcal infection occur in child care facilities. This information could be useful to the exposed child's health care provider if the exposed child deve-lops illness. COMMENTS: Sample letters of notification to parents that their child may have been exposed to an infectious disease are contained in the (National Academy for the Education of Young Children (NAEYC) publication, Healthy Young Children . Contact information is located in Appendix BB. For information about health education for children, staff, and parents, see STANDARD 2.060 throughSTANDARD 2.067. For additional information regarding group A streptococcal infections, consult the Red Book from the American Academy of Pediatrics (AAP). Contact information for the AAP is located in Appendix BB. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home TUBERCULOSIS STANDARD 6.014 MEASURES FOR DETECTION AND CONTROL OF tuberculosis Local and/or state public health authorities shall be notified immediately about suspected cases of tuberculosis disease involving children or child care providers in the child care setting. Facilities shall cooperate with their local health department officials in notifying parents of children who attend the facility about exposures to children or staff with tuberculosis disease. This may include providing the health department officials with the names and telephone numbers of parents of children in the classrooms or facilities involved. Tuberculosis transmission shall be controlled by requiring regular and substitute staff members and volunteers to have their tuberculosis status assessed with a one-step or two-step Mantoux intradermal skin test prior to beginning employment unless they produce documentation of the following: a) A positive Mantoux intradermal skin test result in the past, or b) Tuberculosis disease that has been treated appropriately in the past. The one-step Mantoux intradermal tuberculin test shall suffice except that for individuals over 60 years of age or those who have a medical condition that reduces their immune response, the use of the two-step method is required. Individuals with a positive Mantoux intradermal skin test or tuberculosis disease in the past shall be evaluated with chest radiographs and shall be cleared for work by their physician or a health department official. Review of the health status of any staff member with a positive Mantoux intradermal skin test or tuberculosis disease in the past shall be part of the routine annual staff health appraisal (21). In large and small family child care homes, this requirement applies to all adolescents and adults who are present while the children are in care. Tuberculosis screening by Mantoux intradermal skin testing, using the one-step procedure, of staff members with previously negative skin tests shall not be repeated on a regular basis unless required by the local or state health department. Anyone who develops an illness consistent with tuberculosis shall be evaluated promptly by a physician. Staff members with previously positive skin tests shall be under the care of a physician who, annually, will document the risk of contagion related to the person's tuberculosis status by performing a symptom review including asking about chronic cough, unintentional weight, unexplained fever and other potential risk factors. RATIONALE: Young children acquire tuberculosis infection from infected adults or occasionally, infected adolescents (21). Tuberculosis organisms are spread by inhalation of a small particle aerosol produced by coughing or sneezing by an adult or adolescent with contagious (active) pulmonary tuberculosis. Transmission usually occurs in an indoor environment. Tuberculosis is not spread through objects such as clothes, dishes, floors, and furniture. The one-step Mantoux method of intradermal PPD skin testing involves injecting the material known as PPD into the skin so that a bleb is raised as the material is injected. For most healthy individuals, the one-step test is sufficient to detect latent TB or active TB disease. TB testing depends on cell-mediated immunity and the anemnestic or memory response where the body recalls a previous encounter with the antigen and reacts to it. In older individuals and those who have one of a group of specific conditions that reduce immune response, the first Mantoux test can produce a false negative response to a first test. In these individuals, the two-step method is recommended, involving repeating the Mantoux test procedure with an interval of at least one week to get an accurate result. Anamestic memory for most antigens occurs within one week after stimulation with the substance -thus a second test may be positive when a first is negative and indicate that an individual has latent TB or TB disease. The need for a two-step test for individuals under 60 years of age should be determined by the clinician performing the test or by the local department of health. COMMENTS: The two stages of tuberculosis are: Latent tuberculosis infection, when the tuberculosis germ is in the body and causes a positive Mantoux intradermal skin test but does not cause sickness; Active tuberculosis (tuberculosis disease), when the tuberculosis germ is in the body and causes sickness. Virtually all tuberculosis is transmitted from adults and adolescents with tuberculosis disease. Infants and young children with tuberculosis are not likely to transmit the infection to other children or adults because they generally do not produce sputum and are unable to forcefully cough out large numbers of organisms into the air. Only Mantoux intradermal skin test, containing 5 tuberculin units of purified protein derivative administered intradermally, should be used for skin testing. Multiple puncture tests should no longer be used because several problems severely limit their use. Problems include a lack of antigen standardization, false-positive and false negative results, and variable sensitivity and specificity. For additional information regarding tuberculosis, consult the Red Book from the American Academy of Pediatrics (AAP). Contact information for the AAP is located in Appendix BB. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 6.015 attendance of children with tuberculosis infection Children with tuberculosis infection or disease can attend child care if they are receiving appropriate therapy. RATIONALE: Children can return to regular activities as soon as effective therapy has been instituted, adherence to therapy has been documented, and clinical symptoms have disappeared. If approved by local health officials, children may attend out-of-home child care once they are considered non-infectious to others. COMMENTS: For additional information regarding tuberculosis, consult the Red Book from the American Academy of Pediatrics (AAP). Contact information for the AAP is located in Appendix BB. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home PARVOVIRUS B19 STANDARD 6.016 attendance of children with erythema infectiosum (EI) Children who develop erythema infectiosum (EI), also known as fifth disease, following infection with parvovirus B19, shall be allowed to attend child care because they are no longer contagious when signs and symptoms appear. RATIONALE: EI is caused by parvovirus B19. EI begins with a fever, headache, and muscle aches, and is followed by a rash, which is intensely red with a "slapped cheek" appearance. A lace-like rash appears on the rest of the body. Isolation or exclusion of an immunocompetent person with parvovirus B19 infection in the child care setting is not necessary because little to no virus is present in the respiratory tract secretions at the time of occurrence of the rash (22). COMMENTS: For additional information regarding parvovirus B19, consult the Red Book from the American Academy of Pediatrics (AAP). Contact information for the AAP is located in Appendix BB. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home UNSPECIFIED RESPIRATORY TRACT INFECTION STANDARD 6.017 attendance of children with unspecified respiratory tract infection Children without fever who have mild symptoms associated with the common cold, sore throat, croup, bronchitis, rhinitis (runny nose), or otitis media (ear infection) shall not be denied admission to child care, sent home from child care, or separated from other children in the facility unless their illness is characterized by one or more of the following conditions: a) The illness has a specified cause that requires exclusion, as determined by other specific performance standards in Child Inclusion/Exclusion/Dismissal, STANDARD 3.065 through STANDARD 3.068; b) The illness limits the child's comfortable participation in child care activities; c) The illness results in a need for more care than the staff can provide without compromising the health and safety of other children. Treatment with antibiotics shall not be required or otherwise encouraged as a condition for attendance of children with mild respiratory tract infections unless directed by local health authorities. RATIONALE: The incidence of acute diseases of the respiratory tract, including the common cold, croup, bronchitis, pneumonia, and otitis media, is high in infants and young children, whether they are cared for at home or attend out-of-home facilities (23). Studies suggest that children who attend child care facilities have a significantly higher risk of upper and lower respiratory tract infections compared to children who are cared for at home and that infants and young children in child care have a higher incidence of these infections when they first begin to attend child care (24, 25, 26). Children, 3 years of age and younger, experience an average of 5 to 10 respiratory tract infections each year, most of which are not severe and are caused by viruses that infect the respiratory tract (27). There is no evidence that the incidence of most acute diseases of the respiratory tract can be reduced among children in child care by any specific intervention other than routine sanitation and personal hygiene. Exclusion of ill children from the facility has not been found of value in preventing common respiratory infections. When compliance with environmental infection control practices is high in child care settings, a reduction in episodes of colds is possible (28). Most children with viral respiratory tract infections remain infectious for at least 5 to 8 days. Frequently, infected children are shedding viruses before they are obviously ill, and some infected children never become overtly ill. Therefore, excluding children with respiratory tract disease from child care is not likely to limit transmission of respiratory tract infections in the child care setting. The inappropriate use of antibiotics is a serious public health problem leading to development of antibiotic resistance (29, 30). Inappropriate antibiotic use in child care for mild respiratory tract infections is common even though these infections are often caused by viruses. Parents may attempt to pressure physicians into prescribing antibiotics for infections because they falsely believe that antibiotics will shorten the time when their children are excluded from child care. COMMENTS: Uncontrolled coughing, difficult or rapid breathing, and wheezing (if associated with difficult breathing or if the child has no history of asthma) may represent severe illness or even a life-threatening condition. Exclusion in these cases is for the child's safety. The child should receive medical care before being allowed to return to the facility. For additional information regarding unspecified respiratory tract infections, consult the Red Book from the American Academy of Pediatrics (AAP). Contact information for the AAP is located in Appendix BB. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home 6.2 HERPES VIRUSES Please note that if a staff member has no contact with the children, or with anything with which the children come in contact, the staff requirements in these standards do not apply to that staff member. HERPES SIMPLEX STANDARD 6.018 DISEASE RECOGNITION AND CONTROL OF HERPES SIMPLEX VIRUS Children with herpetic gingivostomatitis, an infection of the mouth caused by the herpes simplex virus, who do not have control of oral secretions shall be excluded from child care. In selected situations, children with mild disease who are in control of their mouth secretions may not have to be excluded. The facility's health consultant or health department officials shall be consulted. Child care providers with herpetic gingivostomatitis, cold sores, or herpes labialis shall do the following: a) Refrain from kissing and nuzzling children; b) Refrain from sharing food and drinks with children and other caregivers; c) Avoid touching the lesions; d) Wash their hands frequently; e) Cover any skin lesion with a bandage, clothing, or an appropriate dressing. Child care providers shall be instructed in the importance of and technique for handwashing and other measures aimed at limiting the transfer of infected material, such as saliva, tissue fluid, or fluid from a skin sore. RATIONALE: Initial herpes simplex virus disease in children often produces a sudden illness of short duration characterized by fever and sores around and within the mouth. Illness and viral excretion may persist for a week or more; severe open skin sores may prevent oral intake and necessitate hospitalization (31). Recurrent oral herpes is manifested as small, fluid-filled blisters on the lips and entails a much shorter period of virus shedding from sores. Adults and children also can shed the virus in oral secretions in the absence of identifiable sores. Although the risk of transmission of herpes simplex virus in the child care setting has not been documented, spread of infection within families has been reported and is thought to require direct contact with infected secretions (31). Transmission of herpes simplex in child care is uncommon (32). COMMENTS: For additional information on policies, staff education, on recognizing and controlling herpes simplex and varicella-zoster (chickenpox) viruses, see Training STANDARD 1.023 through STANDARD 1.033; Hygiene STANDARD 3.012 through STANDARD 3.027, Child Inclusion/Exclusion/Dismissal, STANDARD 3.065 through STANDARD 3.068; and Notification of Parents, STANDARD 3.084 and STANDARD 3.085. For additional information regarding herpes simplex, consult the Red Book from the American Academy of Pediatrics (AAP). Contact information for the AAP is located in Appendix BB. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home VARICELLA-ZOSTER (CHICKENPOX) VIRUS STANDARD 6.019 STAFF AND PARENT NOTIFICATION ABOUT VARICELLA-ZOSTER (CHICKENPOX) VIRUS The child care facility shall notify all staff members and parents when a case of chickenpox occurs, informing them of the greater likelihood of serious infection in susceptible adults, the potential for fetal damage if infection occurs during pregnancy, and the risk of severe varicella in children or adults whose immune systems are impaired for any reason including HIV infection, steroid use, cancer chemotherapy, or organ transplantation (33). RATIONALE: About 5 to 10 percent of adults will be susceptible to varicella-zoster virus. Susceptible child care staff members who are pregnant and are exposed to children with chickenpox should be referred to physicians or other health professionals who are knowledgeable in the area of varicella infection during pregnancy within 24 hours after the exposure is recognized. The Centers for Disease Control and Prevention (CDC) and the American Academy of Pediatrics (AAP) recommend the use of varicella vaccine in non-pregnant susceptible persons 12 months of age and older within 72 hours after exposure to varicella (33, 34). COMMENTS: Sample letters of notification to parents that their child may have been exposed to an infectious disease are contained in the National Academy for the Education of Young Children (NAEYC) publication, Healthy Young Children . Contact information is located in Appendix BB. For information about health education for children, staff, and parents, see STANDARD 2.060 through STANDARD 2.067. For additional information regarding varicella, consult the Red Book from the American Academy of Pediatrics (AAP). Contact information for the AAP is located in Appendix BB. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 6.020 EXCLUSION OF CHILDREN WITH VARICELLA-ZOSTER (CHICKENPOX) VIRUS Children who develop chickenpox shall be excluded until all sores have dried and crusted (usually 6 days). Staff members or children with shingles (herpes zoster) shall keep sores covered by clothing or a dressing until sores have crusted. The need for excluding an infected person shall be decided based on the recommendations of the person's health care provider. If a conflict or question about return to the child care facility arises, the facility shall consult personnel at the health department. Until the conflict is resolved, readmission shall be delayed. RATIONALE: Exclusion of children infected with varicella-zoster virus may not control illness in child care, but exclusion may help control disease caused by this virus in some individuals (such as adults, children and adults who have a compromised immune system, and newborn infants). The chickenpox virus seems to be present in respiratory tract secretions and to be shed from the mouth and throat as well as from skin lesions. Spread from oral or respiratory tract secretions to susceptible contacts is likely. With shingles, the virus is present in small, fluid-filled blisters, and is spread by direct contact. Sores that are covered seem to pose little risk to susceptible persons. Older children and staff members with herpes zoster should be instructed to wash their hands if they touch potentially infectious lesions. About 5 to 10 percent of adults will be susceptible to varicella-zoster virus. Susceptible child care staff members who are pregnant and are exposed to children with chickenpox should be referred to physicians or other health care professionals who are knowledgeable in the area of varicella infection during pregnancy within 24 hours after the exposure is recognized. COMMENTS: Initial viral infection with varicella-zoster virus produces an acute fever and the appearance of chickenpox blisters; reactivation of the virus results in shingles (herpes zoster). See STANDARD 6.023, for more information on shingles. Routine use of varicella vaccine as recommended by the American Academy of Pediatrics (AAP) and the Centers for Disease Control and Prevention (CDC) will reduce the likelihood of transmission of wild type strains of varicella virus (33, 34, 35). In mild cases with only a few sores and rapid recovery, an otherwise healthy child may be able to return to child care sooner once the lesions are crusted. Children whose immune system does not function properly and children with more severe cases of chickenpox shall be excluded from child care until lesions are crusted. For additional information regarding varicella, consult the Red Book from the AAP. Contact information for the AAP is located in Appendix BB. For information about health education for children, staff, and parents, see STANDARD 2.060 through STANDARD 2.067. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home CYTOMEGALOVIRUS (CMV) STANDARD 6.021 STAFF EDUCATION AND POLICIES ON CYTOMEGALOVIRUS (CMV) Facilities that employ women of childbearing age shall educate these workers with regard to the following: a) The increased probability of exposure to cytomegalovirus (CMV) in the child care setting; b) The potential for fetal damage when CMV is acquired during pregnancy; c) Hygiene measures (especially handwashing and avoiding contact with urine, saliva, and nasal secretions) aimed at reducing the acquisition of CMV; d) The availability of counseling and testing for serum antibody to CMV to determine the child care provider's immune status. Female employees of childbearing age shall be referred to their personal health care providers or to the health department authority for counseling about their risk of cytomegalovirus (CMV) infection. This counseling may include testing for serum antibodies to CMV to determine the employee's immunity against CMV infection. RATIONALE: CMV is the leading cause of congenital infection in the United States, with approximately 1% of live born infants infected prenatally (36). While most infected fetuses escape resulting illness or disability, 10 to 20 percent will have hearing loss, mental retardation, cerebral palsy, or vision disturbances. Although maternal immunity does not prevent congenital CMV infection, evidence indicates that initial acquisition of CMV during pregnancy (primary maternal infection) carries the greatest risk for resulting illness or disability of the fetus (36). Children enrolled in child care facilities are more likely to acquire CMV than are children cared for at home. Epidemiologic data, as well as laboratory testing of viral strains, has provided evidence for child-to-child transmission of CMV in the child care setting (36). Rates of CMV excretion have varied among facilities and even between class groups within a facility. Children between 1 and 3 years of age have the highest rates of excretion; published studies report rates between 20 to 80 percent in this age group. Children who acquire CMV from a maternal source or in a facility may continue to excrete the virus for years (37). Thus, it is reasonable to conclude that child care staff members are more likely to come into contact with CMV-excreting children than are individuals in any other known situation or occupation. Epidemiologic data and study of CMV strains have shown that premature newborn infants who acquire CMV in the nursery can transmit the virus to their parents (38). Moreover, parents of children attending centers have a higher rate of development of antibodies to CMV than parents of children kept at home (39). Parental infection with CMV is related to the child's CMV excretion (38, 39, 40). With regard to child-to-staff transmission, studies have shown a high rate of infection with CMV among child care workers with annual rates ranging from 14 to 20 percent (41, 42, 43). Therefore, exposure to CMV with the higher rate of acquisition that occurs in child care staff will most likely lead to a higher rate of gestational CMV infection in staff members without antibodies to CMV and an increased rate of congenital CMV infection in their offspring (36). Women who have antibodies to CMV can be reassured that their risk of having an infant damaged by congenital CMV infection is low. With current knowledge on the risk of CMV infection in child care staff members and the potential consequences of gestational CMV infection, child care staff members should receive counseling in regard to the risks. COMMENTS: Assays for measuring antibody to CMV are available commercially and seem to perform well when used by qualified laboratories. They are accepted for screening blood products, transfusion recipients, and organ donors and recipients. For additional information regarding CMV, consult the Red Book from the American Academy of Pediatrics (AAP). Contact information for the AAP is located in Appendix BB. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 6.022 attendance and testing of children with cmv Testing children to detect CMV excretion or excluding children known to be CMV infected is not recommended. All infants and toddlers shall be assumed to be infected with CMV. RATIONALE: Testing of urine and saliva for CMV excretion in children is expensive and is likely to be misleading, since excretion of CMV by children in child care is intermittent and common (39, 40). COMMENTS: For additional information regarding CMV, consult the Red Book from the American Academy of Pediatrics (AAP). Contact information for the AAP is located in Appendix BB. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home 6.3 ENTERIC (DIARRHEAL) AND HEPATITIS A VIRUS (HAV) INFECTIONS Please note that if a staff member has no contact with the children, or with anything with which the children come in contact, the staff requirements in these standards do not apply to that staff member. STANDARD 6.023 CONTROL OF ENTERIC (DIARRHEAL) AND HEPATITIS A VIRUS INFECTIONS Facilities shall employ the following procedures, in addition to those stated in Inclusion/Exclusion/Dismissal, STANDARD 3.065 through STANDARD 3.068, to prevent and control infections of the gastrointestinal tract (including diarrhea) or liver: a) Children who cannot use a toilet for all bowel movements while attending the facility and who develop diarrhea shall be removed from the facility by their parent or legal guardian. Pending arrival of the parent or legal guardian, the child shall not be permitted to have contact with other children or be placed in areas used by adults who have contact with children in the facility. This shall be accomplished by removing the ill child to a separate area of the child care center or, if not possible, to a separate area of the child's room. The area shall be one where the child is supervised by an adult known to the child, and where the toys, equipment, and surfaces will not be used by other children or adults until after the ill child leaves and after the surfaces have been disinfected. When moving a child to a separate area of the facility creates problems with supervision of the other children, as in small family child care homes, the ill child shall be kept as comfortable as possible, with minimal contact between ill and well children, until the parent or legal guardian arrives. The child who requires separation because of diarrhea shall be separated from the group upon the onset of the diarrhea. Caregivers with diarrhea as defined in STANDARD 3.069 shall be excluded. Separation and exclusion of children or caregivers shall not be deferred pending health assessment or laboratory testing to identify an enteric pathogen. b) A child who develops jaundice (when skin and white parts of the eye are yellow) while attending child care shall be separated from other children and the child's parent or legal guardian shall be called to remove the child. The child shall remain separated from the other children as described above until the parent or legal guardian arrives and removes the child from the facility. c) Exclusion for acute diarrhea shall continue until either the diarrhea stops or the continued loose stools are deemed not to be infectious by a licensed health care professional. Exclusion for hepatitis A virus (HAV) as specified in item b) above shall continue for one week after onset of illness or until immune globulin has been administered to appropriate children and staff at the facility. See also STANDARD 3.065, on inclusion/exclusion/dismissal of children with diarrhea. d) Alternate care for children with diarrhea or hepatitis A in special facilities for ill children shall be provided only in facilities that can provide separate care for children with infections of the gastrointestinal tract (including diarrhea) or liver. See also STANDARD 3.070 through STANDARD 3.080, on caring for ill children. e) Children and caregivers who excrete intestinal pathogens but no longer have diarrhea generally may be allowed to return to child care once the diarrhea resolves, except for the case of infections with Shigella , E. coli 0157:H7 or Salmonella typhi. For Shigella and E.coli 0157:H7 two negative stool cultures are required for readmission, unless state requirements differ. For Salmonella typhi , three negative cultures are required. For Salmonella species other that S.typhi stool cultures are not required from asymptomatic individuals. f) The local health department shall be informed within 24 hours of the occurrence of hepatitis A virus infection or an increased frequency of diarrheal illness in children or staff in a child care facility. g) In addition to the recommended postexposure prophylaxis, hepatitis A immunization shall be considered in child care settings with ongoing or recurrent outbreaks, especially in communities where routine immunization of children for hepatitis A is recommended (44). In the absence of ongoing outbreaks, immunization in child care centers shall be used to implement routine hepatitis A immunization, particularly in communities where cases in the child care facility contribute substantially to the total number of hepatitis A cases and seem play a role in sustaining community-wide outbreaks. h) If there has been an exposure to a case of hepatitis A or diarrhea in the child care facility, caregivers shall inform parents of other children in the facility, in cooperation with the health department, that their children may have been exposed to children with hepatitis A virus (HAV) infection or diarrheal illness. i) These procedures shall be implemented in addition to those stated in STANDARD 3.065 through STANDARD 3.068. RATIONALE: Intestinal organisms, including hepatitis A virus, cause disease in children, child care providers, and close family members (45, 46, 47, 48). The primary age groups involved are children younger than 3 years of age who wear diapers. Disease has occurred in outbreaks within centers and as sporadic episodes. Although many intestinal agents can cause diarrhea in children in child care, rotavirus, other enteric viruses, Giardia lamblia , Shigella , and Cryptosporidium have been the main organisms implicated in outbreaks. In addition, excretion of intestinal agents, particularly Giardia lamblia and rotavirus, has been shown to occur in children who show no symptoms (49, 50). The significance of this phenomenon in transmission is unknown. Child care providers should observe children for signs of disease to permit early detection and implementation of control measures. Facilities should consult the local health department to determine whether the increased frequency of diarrheal illness requires public health intervention. The most important characteristic of child care facilities associated with increased frequencies of diarrhea or hepatitis A is the presence of young children who are not toilet-trained (47, 51). Contamination of hands, communal toys, and other classroom objects is common and plays a role in the transmission of enteric pathogens in child care facilities. Studies commonly find that fecal contamination of the environment is frequent in centers and is highest in infant and toddler areas where diarrhea or hepatitis A are known to occur most often (52, 53). Studies indicate that the risk of diarrhea is significantly higher for children in centers than in age-matched children cared for at home or in small family child care homes (8). The spread of infection from children who are not toilet-trained to other children in child care facilities or to their families is common, particularly when Shigella , rotavirus and other enteric viruses, Giardia lamblia, Cryptosporidium , or hepatitis A virus (HAV) is the causal agent (45). To decrease diarrheal disease in child care, the staff and parents must be educated about modes of transmission as well as practical methods of prevention and control. Staff training in handwashing and hygiene, combined with close monitoring of staff compliance, is associated with a significant decrease in infant and toddler diarrhea (54, 55). Staff training on a single occasion, without close staff monitoring, however, does not result in a decrease in diarrhea rates; this finding emphasizes the importance of monitoring as well as education (54,55). Therefore, appropriate hygienic practices, hygiene monitoring, and education are important in limiting infections of the intestines or liver in child care. The Centers for Disease Control and Prevention (CDC) recommends excluding children with diarrhea (for any reason) from child care until diarrhea has resolved. This standard is more lenient than the CDC recommendation by allowing children whose feces are contained by use of a toilet to remain in care. Because outbreaks are rare in groups of toilet-trained children, a more lenient approach may be taken in this age group. COMMENTS: See also the environmental and personal hygiene standards given in the following standards to prevent and control infections of the gastrointestinal tract (including diarrhea) or liver: STANDARD 3.070 through STANDARD 3.080, on caring for ill children; STANDARD 3.012 through STANDARD 3.019, on toileting and diapering, STANDARD 3.020 throughSTANDARD 3.024, on handwashing; STANDARD 3.028 through STANDARD 3.040, on sanitation, disinfection, and maintenance; STANDARD 4.050 through STANDARD 4.060, on food safety; STANDARD 3.042 through STANDARD 3.044, on animals; STANDARD 8.046 through STANDARD 8.052, on child records; STANDARD 5.219 through STANDARD 5.225, on interior maintenance; STANDARD 8.035 and STANDARD 8.036, on food handling, feeding, and nutrition policies. Sample letters of notification to parents that their child may have been exposed to an infectious disease are contained in the (National Academy for the Education of Young Children (NAEYC) publication, Healthy Young Children . Contact information is located in Appendix BB. For information about health education for children, staff, and parents, see STANDARD 2.060 through STANDARD 2.067. For additional information regarding enteric (diarrheal) and hepatitis A virus (HAV) infections, consult the Red Book from the American Academy of Pediatrics (AAP). Contact information for the AAP is located in Appendix BB. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 6.024 STAFF EDUCATION AND POLICIES ON ENTERIC (DIARRHEAL) AND HAV INFECTIONS Facilities shall adhere to the following staff educational policies to prevent and control infections of the gastrointestinal tract (mainly diarrhea) or liver: a) The facility shall conduct ongoing continuing education for staff members, to include the following: 1) Methods of transmission of pathogens that cause diarrhea and hepatitis A virus; 2) Recognition and prevention of diarrhea and disease associated with hepatitis A virus infection; b) All caregivers, food handlers, and maintenance staff shall receive ongoing education and monitoring concerning handwashing and cleaning of environmental surfaces as specified in the facility's plan. See STANDARD 3.020 through STANDARD 3.023, on handwashing; and STANDARD 3.028 through STANDARD 3.040, on sanitation, disinfection, and maintenance; c) At least annually, the director shall review all procedures related to preventing diarrhea and hepatitis A virus infections. Each caregiver, food handler, and maintenance person shall review a written copy of these procedures or view a video, which shall include age-specific criteria for inclusion and exclusion of children who have a diarrheal illness or hepatitis A virus infection and infection control procedures. See Child Inclusion/Exclusion/Dismissal, STANDARD 3.065 through STANDARD 3.068; d) Guidelines for administration of immune globulin and immunization against hepatitis A virus shall be enforced to prevent infection in contacts of children with hepatitis A disease (44, 56). RATIONALE: Staff training in hygiene and monitoring of staff compliance have been shown to reduce the spread of diarrhea (51, 54, 55, 57). These studies suggest that training combined with outside monitoring of child care practices can modify staff behavior as well as the occurrence of disease. Child care providers should observe children for signs of disease to permit early detection and implementation of control measures. Facilities should consult the local health department to determine whether the increased frequency of diarrheal illness requires public health intervention. COMMENTS: For additional information regarding enteric (diarrheal) and hepatitis A virus (HAV) infections, consult the Red Book from the American Academy of Pediatrics (AAP). Contact information for the AAP is located in Appendix BB. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 6.025 DISEASE SURVEILLANCE OF ENTERIC (DIARRHEAL) AND HAV INFECTIONS The child care facility shall cooperate with local health authorities in notifying all staff and parents of other children who attend the facility of possible exposure to hepatitis A, and diarrheal agents such as E. coli: 0157:H7 , Shigella, rotavirus and other enteric viruses, Salmonella, Campylobacter, Giardia lamblia , and Cryptosporidium . RATIONALE: Intestinal organisms, including hepatitis A virus, cause disease in children, child care providers, and close family members (45, 46, 47, 48). Disease has occurred in outbreaks within centers and as sporadic episodes (45, 49, 58). Although many intestinal agents can cause diarrhea in children in child care, rotavirus, other enteric viruses , Giardia lamblia , Shigella , and Cryptosporidium have been the main organisms implicated in outbreaks. Child care providers should observe children for signs of disease to permit early detection and implementation of control measures. Facilities should consult the local health department to determine whether the increased frequency of diarrheal illness requires public health intervention. COMMENTS: Sample letters of notification to parents that their child may have been exposed to an infectious disease are contained in the (National Academy for the Education of Young Children (NAEYC) publication, Healthy Young Children . Contact information is located in Appendix BB. For information about health education for children, staff, and parents, see STANDARD 2.060 through STANDARD 2.067. For additional information on enteric (diarrheal) and hepatitis A virus infections, see Training, STANDARD 1.023 through STANDARD 1.033; and Notification of Parents, STANDARD 3.084 and STANDARD 3.085. Also, consult the Red Book from the American Academy of Pediatrics (AAP). Contact information for the AAP is located in Appendix BB. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 6.026 maintenance of records on incidents of diarrhea The facility shall maintain a record of children and caregivers who have diarrhea while at home or at the facility. This record shall include: a) The child or caregiver's name; b) Dates the child or caregiver is ill; c) Reason for diarrhea, if known; d) Whether the child or caregiver was in attendance at the child care facility during the diarrhea episode; e) Any leakage of feces from the diaper while the child was in attendance at the child care facility. The facility shall notify the local health department authorities whenever there have been two or more children with diarrhea in a given classroom or three or more unrelated children (not siblings) within the facility within a 2-week period. RATIONALE: Disease surveillance and reporting to the local health department authorities are critical in preventing and controlling diseases in the child care setting. A major purpose of surveillance is to allow early detection of disease and prompt implementation of control measures. Ascertaining whether a child who attends a facility is ill is important when evaluating childhood illnesses; ascertaining whether an adult who works in a facility or is a parent of a child attending a facility is ill is important when considering a diagnosis of hepatitis A and other diseases transmitted by the fecal-oral route. Causes of these infections in household contacts may require questioning about illness in the child attending child care and testing the child for infection. Information concerning communicable disease in a child care attendee, staff member, or household contact should be communicated to public health authorities, to the child care director, to all staff and to all parents with children in the facility. COMMENTS: For more information on reporting requirements for communicable disease, see STANDARD 3.086 and STANDARD 3.087. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home 6.4 BLOODBORNE INFECTIONS Hepatitis B virus, HIV, and hepatitis C virus are bloodborne pathogens. Although the risk of contact with blood containing one of these viruses is low in the child care setting, appropriate infection control practices will prevent transmission of bloodborne pathogens if exposure occurs (59, 60, 61, 62). Please note that if a staff member has no contact with the children, or with anything with which the children come in contact, these standards do not apply to that staff member. HEPATITIS B VIRUS (HBV) STANDARD 6.027 DISEASE RECOGNITION AND CONTROL OF HBV INFECTION Facilities shall have written policies for inclusion and exclusion of children known to be infected with hepatitis B virus (HBV) and immunization of children with hepatitis B vaccine as part of their routine immunization schedule. When a child who is an HBV carrier is admitted to a facility, the facility director or the caregiver usually responsible for the child shall be informed. Children who carry HBV chronically and who have no behavioral or medical risk factors, such as aggressive behavior (biting and frequent scratching), generalized dermatitis (weeping skin lesions), or bleeding problems shall be admitted to the facility without restrictions. Testing of children for HBV shall not be a prerequisite for admission to facilities. With regard to infection control measures, every person shall be assumed to be an HBV carrier. Child care personnel shall adopt standard pre- cautions, as outlined in Prevention of Exposure to Blood, STANDARD 3.026 and STANDARD 3.027. Toys and objects that young children (infants and toddlers) mouth shall be cleaned and sanitized, as stated in STANDARD 3.036 through STANDARD 3.038. Toothbrushes shall be individually labeled so that the children do not share toothbrushes, as specified in STANDARD 5.095. RATIONALE: Transmission of HBV in the child care setting is of concern to public health authorities. Children who are HBV carriers (particularly children born in countries highly endemic for HBV) can be expected to require child care (62, 63, 64, 65, 66). The risk of transmitting the disease in child care is theoretically small, though, because blood or infected body fluid must get inside another body for it to transmit HBV infection and because immunization of infants as part of the routine childhood immunization schedule has decreased the number of susceptible children. Immunization not only will reduce the potential for transmission but also will allay anxiety about transmission from children and staff in the child care setting who may be carriers of hepatitis B. The risk of disease transmission from an HBV-carrier child or staff member with no behavioral risk factors and without generalized dermatitis or bleeding problems is considered very low. This extremely low risk does not justify exclusion of an HBV-carrier child from out-of-home care, nor does it justify the routine screening of children as possible HBV carriers prior to admission to child care. HBV transmission in a child care setting is most likely to occur through direct exposure via bites or scratches that break the skin and introduce blood or body secretions from the HBV carrier into the victim. Indirect transmission via blood or saliva through environmental contamination may be possible but has not been documented. Saliva contains much less virus (1/1000) than blood; therefore, the potential infection from saliva is lower. In gibbons and chimpanzees, saliva has been shown to be infectious only when inoculated through the skin; it has not caused infection when administered by aerosol through the nose or mouth, by ingestion through the mouth, or by toothbrush on the gums (62). No data are available to indicate the risk of transmission if a susceptible person bites an HBV carrier. When the HBV statuses of both the biting child and the victim are unknown, the risk of HBV transmission would be extremely low because of the expected low incidence of HBV carriage by children of preschool-age and the low efficiency of disease transmission by bite exposure. Because a bite in this situation is extremely unlikely to involve an HBV-carrier child, screening is not warranted, particularly in children who are immunized appropriately against HBV (62). COMMENTS: Parents are not required to share information about their child's HBV status, but they should be encouraged to do so. For additional information regarding HBV , consult the Red Book from the American Academy of Pediatrics (AAP). Contact information for the AAP is located in Appendix BB. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 6.028 observation and follow-up of a child who is an HBV carrier The primary caregiver shall observe a child who is a known hepatitis B virus (HBV) carrier and the other children in the group for development of aggressive behavior (such as biting or frequent scratching) that might facilitate transmission of HBV. When this type of behavior occurs, the child's health care provider or the health department shall evaluate the need for immediate disease prevention measures with hepatitis B immune globulin and shall reevaluate the child's continuing attendance in the facility. RATIONALE: Regular assessment of behavioral risk factors and medical conditions of enrolled children who are HBV carriers is important. It is helpful if the center director and primary caregivers are informed that a known HBV-carrier child is in care. However, parents are not required to share this information. Most children in child care facilities have been immunized against hepatitis B as part of their routine immunization schedule, minimizing the risk of transmission (62). COMMENTS: For additional information regarding HBV infections, consult the Red Book from the American Academy of Pediatrics (AAP). Contact information for the AAP is located in Appendix BB. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 6.029 Staff education on prevention of bloodborne diseases All caregivers shall receive regular training on how to prevent transmission of bloodborne diseases, including hepatitis B virus (HBV). RATIONALE: Efforts to reduce the risk of transmitting diseases in child care through hygienic and environmental standards in general should focus primarily on blood precautions and ensuring that children are appropriately immunized against hepatitis B virus. COMMENTS: For additional information regarding HBV infections, consult the Red Book from the American Academy of Pediatrics (AAP). Contact information for the AAP is located in Appendix BB. also Continuing Education, STANDARD 1.029 through STANDARD 1.033. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 6.030 informing public health authorities of hbv cases Staff members known to have acute or chronic hepatitis B virus (HBV) shall not be restricted from work but shall receive training on how to prevent transmission of bloodborne diseases. Cases of acute HBV in any child or employee of a facility shall be reported to the health department for a determination of the need for further investigation or preventive measures. RATIONALE: The risk of disease transmission from a HBV carrier child or staff member with normal behavior and without generalized dermatitis or bleeding problems is considered very low. This extremely low risk does not justify exclusion of an HBV-carrier staff member from providing child care, nor does it justify the routine screening of staff as possible HBV carriers prior to admission to child care. COMMENTS: For additional information regarding HBV infections, consult the Red Book from the American Academy of Pediatrics (AAP). Contact information for the AAP is located in Appendix BB. See also Continuing Education, STANDARD 1.029 through STANDARD 1.033; Prevention of Exposure to Blood, STANDARD 3.026 and STANDARD 3.027; Reporting Illness, STANDARD 3.086 and STANDARD 3.087. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home HYGIENE FOR HEPATITIS B VIRUS (HBV) INFECTION STANDARD 6.031 handling of injuries to a HBV carrier Injuries that lead to bleeding by a hepatitis B virus (HBV) carrier child or adult shall be handled promptly in the manner recommended for any such injury in any child or adult using standard precautions. RATIONALE: Efforts to reduce the risk of transmitting diseases in child care through hygienic and environmental standards in general should focus primarily on blood precautions and ensuring appropriate immunization against hepatitis B virus. COMMENTS: For additional information regarding HBV infections, consult the Red Book from the American Academy of Pediatrics (AAP). Contact information for the AAP is located in Appendix BB. See STANDARD 3.026 and STANDARD 3.027, on the prevention of exposure to blood. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home HEPATITIS C VIRUS (HCV) STANDARD 6.032 infection control measures with HCV Standard precautions, as outlined in STANDARD 3.026, shall be followed to prevent infection with hepatitis C virus (HCV) infection. Children with HCV infection shall not be excluded from out-of-home child care. RATIONALE: Transmission risks of HCV infection in a child care setting are unknown. The general risk of HCV infection from percutaneous exposure to infected blood is estimated to be 10 times greater than that of HIV but lower than that of hepatitis B virus (HBV) (61). Transmission of HCV via contamination of mucous membranes or broken skin probably has an intermediate risk between that for blood infected with HIV and HBV. COMMENTS: For additional information regarding HCV infections, consult the Red Book from the American Academy of Pediatrics (AAP). Contact information for the AAP is located in Appendix BB. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home HUMAN IMMUNODEFICIENCY VIRUS (HIV) ADMINISTRATIVE POLICIES ON HIV INFECTIONS STANDARD 6.033 attendance of children with HIV Children infected with human immunodeficiency virus (HIV) shall be admitted to child care provided that their health, neurological development, behavior, and immune status are acceptable, as determined on a case-by-case basis by persons knowledgeable in the area of HIV infection, including the child's health care provider. These individuals must be able to evaluate whether the child will receive optimal care in the specific facility being considered and whether an HIV-infected child poses a potential threat to others. RATIONALE: No reported cases of HIV infection are known to have resulted from transmission in out-of-home child care. Although the risk of transmission of HIV infection to children in the child care setting seems to be extremely low, data does not exist that directly addresses this issue. Guidelines can most reasonably provide methods to reduce the risk of transmission of HIV infection to caregivers in out-of-home child care (59). COMMENTS: For additional information regarding HIV, consult the Red Book from the American Academy of Pediatrics (AAP). Contact information for the AAP is located in Appendix BB. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 6.034 PROTECTING HIV-INFECTED CHILDREN AND ADULTS IN CHILD CARE Parents of all children, including human immunodeficiency virus (HIV) infected children, shall be notified immediately if the child has been exposed to chickenpox, tuberculosis, fifth disease (parvovirus B19), diarrheal disease, measles, or other infectious diseases through other children in the facility. Children whose immune systems do not function properly to prevent infection and who are exposed to measles or chickenpox shall be referred immediately to their health care provider to receive the appropriate preventive measure (immune globulin or immunization) following exposure and decision about readmission to the child care facility (33, 67). Caregivers known to be HIV-infected shall be notified immediately if they have been exposed to chickenpox, fifth disease, tuberculosis, diarrheal disease, or measles through children in the facility. If they have been exposed to measles or chickenpox, they shall receive an appropriate preventive measure (immune globulin or immunization) after exposure (33, 67). Their return to work after exposure shall be determined jointly by the director of the center (or, in the cases of large family child care homes and small family child care homes, the primary caregiver) and the health care provider for the HIV-infected caregiver. Information regarding a child whose immune system does not function properly to prevent infection, whatever the cause, shall be available to caregivers who need to know so they can reduce the likelihood of transmission of infection to the child. Accordingly, infections in other children and staff members in the facility shall be brought to the prompt attention of the parent of the child whose immune system does not function properly. The parent may elect to seek medical advice regarding the child's continued participation in the facility. Injuries that lead to bleeding by a child with human immunodeficiency virus (HIV) shall be handled promptly in the manner recommended for any such injury in any child using standard precautions. RATIONALE: The immune system of children and adults who are infected with HIV often does not function properly to prevent infections. Children and adults with immunosuppression for multiple other reasons are at greater risk for severe complications from several infections including chickenpox, CMV, tuberculosis, Cryptosporidium , Salmonella , and measles virus (68). Available data indicate that infection with measles is a more serious illness in HIV-infected children than in children who are not HIV-infected. The first deaths from measles in the United States reported to the Centers for Disease Control and Prevention (CDC) after 1985 were in HIV-infected children (67). Caregivers should know about a child's special health needs so they can offer protection for that child. Care-givers' need to know does not require knowledge of a child's HIV status, because children whose immune system does not function properly because of other acquired and congenital causes may be in the facility. Standard precautions should be adopted in caring for all adults and all children in out-of-home child care when blood or blood-containing body fluids are handled to minimize the possibility of transmission of any bloodborne disease (59). COMMENTS: Staff should have training on standard precautions for bloodborne pathogens, HIV and other causes of immune deficiency, confidentiality and implications of suspicions about HIV status. All caregivers should be taught the basic principles of individuals' rights to confidentiality. See STANDARD 8.054 and STANDARD 8.055. For additional information on administrative policies on HIV infection, see Confidentiality and Access to Records, STANDARD 8.053 through STANDARD 8.057. See STANDARD 3.026 and STANDARD 3.027, on prevention of exposure to blood. Also consult the Red Book from the American Academy of Pediatrics (AAP). Contact information for the AAP is located in Appendix BB. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home PREVENTING TRANSMISSION OF HIV INFECTION STANDARD 6.035 STAFF education about preventing transmission of hiv infection Caregivers shall be knowledgeable about routes of transmission and about prevention of transmission of bloodborne pathogens, including human immunodeficiency virus (HIV) and shall practice measures recommended by the U.S. Public Health Service for prevention of transmission of these infections. RATIONALE: Unwarranted fear about HIV transmission in child care should be dispelled. Studies examining transmission of HIV support the concept that HIV is not a highly infectious agent (64). The major routes of transmission are through sexual contact, through contact with blood or body fluids containing blood, and from mother to child during the birth process. Several studies have shown that HIV-infected persons do not spread the HIV virus to other members of their households except through sexual contact. HIV has been isolated in low volumes in saliva, urine, and human milk. Transmission of HIV through saliva seems to be uncommon. Cases suggest that contact with blood from an HIV-infected individual is a possible mode of transmission through contact between broken skin and blood or blood-containing fluids. Theoretically, biting is a possible mode of transmission of bloodborne illness, such as HIV infection. However, the risk of such transmission is believed to be rare. If a bite results in blood exposure to either person involved, the U.S. Public Health Service recommends postexposure follow-up, including consideration of postexposure prophylaxis (69). COMMENTS: For additional information regarding HIV, consult the Red Book from the American Academy of Pediatrics (AAP). Contact information for the AAP is located in Appendix BB. See STANDARD 1.029 through STANDARD 1.033, on Continuing Education and STANDARD 3.026 and STANDARD 3.027, on the prevention of exposure to blood. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 6.036 ability OF CAREGIVERS WITH HIV INFECTION to care for children Human immunodeficiency virus (HIV) infected adults with no symptoms of illness may care for children in facilities provided they do not have open skin sores or other conditions that would allow contact of their body fluids with children or other adults. RATIONALE: Based on available data, there is no reason to believe that HIV-infected adults will transmit HIV in the course of their normal child care duties. Therefore, HIV-infected adults who do not have open skin sores that cannot be covered or other conditions that would allow contact with their body fluids may care for children in facilities. Immunosuppressed adults with acquired immunodeficiency syndrome (AIDS) may be more likely to acquire infectious agents from children and should consult with their own health care providers regarding the advisability of their continuing to work in a facility (68). COMMENTS: For additional information regarding HIV, consult the Red Book from the American Aca-demy of Pediatrics (AAP). Contact information for the AAP is located in Appendix BB. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home 6.5 SKIN INFECTIONS SCABIES STANDARD 6.037 Attendance of children with scabies Children with scabies shall be removed from the child care facility until appropriate treatment has been administered. Children shall be allowed to return to child care after treatment has been completed. RATIONALE: Scabies is caused by a mite which is associated with an intensely itchy, red rash. Transmission usually occurs through prolonged close personal contact. Epidemics and localized outbreaks may require stringent and consistent measures to treat contacts. Caregivers who have had prolonged skin-to-skin contact with infested persons may benefit from prophylactic treatment. Environmental disinfestation is unnecessary and unwarranted. Bedding and clothing that is worn next to the skin before treatment should be washed. COMMENTS: For additional information regarding scabies, consult the Red Book from the American Academy of Pediatrics (AAP). Contact information for the AAP is located in Appendix BB. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home PEDICULOSIS CAPITIS (HEAD LICE) STANDARD 6.038 attendance of children with head lice Children shall not be excluded immediately or sent home early from child care because of head lice. Parents of affected children shall be notified and informed that their child must be treated properly before returning to the child care facility the next day. Children and staff who have been in close contact with an affected child shall be examined and treated if infested. Infestation shall be identified by the presence of adult lice or nits (eggs) on a hair shaft 3 to 4 mm from the scalp (69). RATIONALE: Head lice infestation in children attending child care is common in the U.S. and is not a sign of poor hygiene. Head lice are not a health hazard because they are not responsible for spread of any disease. After proper application of an appropriate pediculicide, reinfestation of children from an untreated infested person is more common than treatment failure. COMMENTS: Differentiation of nits from benign hair casts (a layer of cells that easily slides off the hair shaft), plugs of skin cells, and debris can be difficult (69). For additional information regarding head lice, consult the Red Book from the American Academy of Pediatrics (AAP). Contact information for the AAP is located in Appendix BB. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home RINGWORM STANDARD 6.039 Attendance of children with ringworm Children with ringworm of the scalp or body shall receive appropriate treatment. Children receiving treatment shall not be excluded from child care. Children and staff in close contact with an affected child shall receive periodic inspections for early lesions and receive prompt therapy. RATIONALE: Ringworm infection results from a fungus that is transmitted by contact with an infected person (scalp and body) and by contact with infected animals (body). Treatment of ringworm of the scalp with oral medicine for 4 to 6 weeks and of ringworm of the body with topical medicine for 4 weeks is effective. COMMENTS: Ribbons, combs, and hairbrushes should not be shared among children and staff. For additional information regarding ringworm, consult the Red Book from the American Academy of Pediatrics (AAP). Contact information for the AAP is located in Appendix BB. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home READER'S NOTE ON JUDICIOUS USE OF ANTIBIOTICS The spread of antimicrobial resistance is an issue of concern to patients and parents as well as to health care professionals. Children treated with antibiotics are at increased risk of becoming carriers of resistant bacteria and if they develop an illness from resistant bacteria, they are more likely to fail antimicrobial therapy. For several conditions, such as acute otitis media, sinusitis, and pharyngitis due to group A streptococcal organisms, antibiotic therapy is indicated, but for other conditions such as the common cold and nonspecific cough illness/bronchitis, therapy is not indicated. Principles of judicious use of antimicrobial agents with detailed supporting evidence were published by the American Academy of Pediatrics (AAP), the American Academy of Family Practice (AAFP), and the Centers for Disease Control and Prevention (CDC) to identify areas where antimicrobial therapy might be curtailed without compromising patient care (30). REFERENCES 1. American Academy of Pediatrics, Committee on Infectious Disease. Recommended childhood immunization schedule - United States, January - December 2001. Pediatrics. 2001;107:202-204. 2. Adams WG, Deaver KA, Cochi SL, et al. Decline of childhood Haemophilus influenzae type b (Hib) disease in the Hib vaccine era. JAMA . 1993;269:246. 3. Murphy TV, White KE, Pastor P, et al. Declining incidence of Haemophilus influenzae type b disease since introduction of vaccination. JAMA. 1993;269:246. 4. Osterholm MT, Pierson LM, White KE, et al. 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Red book 2000: Report of the committee on infectious diseases. Elk Grove Village, Ill: American Academy of Pediatrics; 2000. Caring for Our Children, 2nd ed. Copyright 2002. National Resource Center for Health and Safety in Child Care 1-800-598-KIDS(5437) info@nrckids.org