10.5.0.1: State and Local Health Department Role

State and local health departments should play an important role in the identification, prevention and control of injuries, injury risk, and infectious disease in child care settings as well as in using the child care setting to promote health and safety. This role includes the following activities to be conducted in collaboration with the child care licensing agency:

1. Assisting in the planning of a comprehensive health and safety program for children and child care providers, including promoting and ensuring maintenance of a system of child care health consultation;
2. Monitoring the occurrence of serious injury events and outbreaks involving children or providers;
3. Alerting the responsible child care administrators about identified or potential injury hazards and infectious disease risks in the child care setting;
4. Controlling outbreaks, identifying and reporting infectious diseases in child care settings including:
   1. Methods for notifying parents/guardians, caregivers/teachers, and health care providers of the problem;
   2. Providing appropriate actions for the child care provider to take;
   3. Providing policies for exclusion or isolation of infected children;
   4. Arranging a source and method for the administration of needed medication;
   5. Providing a list of reportable diseases, including descriptions of these diseases. The list should specify where diseases are to be reported and what information is to be provided by the child care provider to the health department and to parents/guardians;
   6. Requiring that all facilities, regardless of licensure status, and all health care providers report certain infectious diseases to the responsible local or state public health authority. The child care licensing authority should require such reporting under its regulatory jurisdiction and should collaborate fully with the health department when the latter is engaged in an enforcement action with a licensed facility;
   7. Determining whether a disease represents a potential health risk to children in out-of-home child care;
   8. Conducting the epidemiological investigation necessary to initiate public health and safety interventions;
   9. Recommending a disease prevention or control strategy that is based on sound public health and clinical practices (such as the use of vaccine, immunoglobulin, or antibiotics taken to prevent an infection);
   10. Verifying reports of infectious diseases received from facilities with the assessment and diagnosis of the disease made by a health care provider and, or the local or state health department;
5. Designing systems and forms for use by facilities for the care of children who are ill to document the surveillance of cared for illnesses and problems that arise in the care of children in such child care settings;
6. Assisting in the development of orientation and annual training programs for caregivers/teachers. Such training should include specialized education for staff of facilities that include child who are ill, as well as those in special facilities that serve only children who are ill. Specialized training for staff who care for children who are ill should focus on the recognition and management of childhood illnesses, as well as the care of children with infectious diseases;
7. Assisting the licensing authority in the periodic review of facility performance related to caring for children who are ill by:
   1. Reviewing written policies developed by facilities regarding inclusion, exclusion, dismissal criteria and plans for health care, urgent and emergency care, and reporting and managing children with infectious disease;
   2. Assisting with periodic compliance reviews for those rules relating to inclusion, exclusion, dismissal, daily health care, urgent and emergency care, and reporting and management of children with infectious disease;
8. Collaborating in the planning and implementation of appropriate training and educational programs related to health and safety in child care facilities. Such training should include education of parents/guardians, primary care providers, public health and safety workers, licensing inspectors, and employers about how to prevent injury and disease as well as promote health and safety of children and their caregivers/teachers;
9. Promoting that health care personnel, such as qualified public health nurses, pediatric and family nurse practitioners, and pediatricians serve as child care health consultants;
10. Ensuring child care programs are included and represented in local and state disaster preparedness and pandemic flu planning.

RATIONALE

A number of studies have described the incidence of injuries in the child care setting (7-10). Although the injuries described have not been serious, these occur frequently, and may require medical or emergency attention. Child care programs need the assistance of local and state health agencies in planning of the safety program that will minimize the risk for serious injury (11). This would include planning for such significant emergencies as fire, flood, tornado, or earthquake (11-13). A community health agency can collect information that can promptly identify an injury risk or hazard and provide an early notice about the risk or hazard (14). An example is the recent identification of un-powered scooters as a significant injury risk for preschool children (15). Once the injury risk is identified, appropriate channels of communication are required to alert the child care administrators and to provide training and educational activities.

Effective control and prevention of infectious diseases in child care settings depends on affirmative relationships among parents/guardians, caregivers/teachers, public health authorities, regulatory agencies, and primary health care providers. The major barriers to productive working relationships between caregivers/teachers and health care providers are inadequate channels of communication and uncertainty of role definition (4). Public health authorities can play a major role in improving the relationship between caregivers/teachers and primary care providers by disseminating information regarding disease reporting laws, prescribed measures for control and prevention of diseases and injuries, and resources that are available for these activities (11). Child care health consultant networks have proven to be effective in improving the health and safety of children in child care settings (16-18).

State and local health departments are legally required to control certain infectious diseases within their jurisdictions (20). All states have laws that grant extraordinary powers to public health departments during outbreaks of infectious diseases (1,11,12). Since infectious disease is likely to occur in child care settings, a plan for the control of infectious diseases in these settings is essential and often legally required. Early recognition and prompt intervention will reduce the spread of infection. Outbreaks of infectious disease in child care settings can have great implications for the general community (2). Programs administered by local health departments have been more successful in controlling outbreaks of hepatitis A than those that rely primarily on private physicians. Programs coordinated by the local health department also provide reassurance to caregivers/teachers, staff, and parents/guardians, and thereby promote cooperation with other disease control policies (3). Infectious diseases in child care settings pose new epidemiological considerations. Only in recent decades has it been so common for very young children to spend most of their days together in groups. Public health authorities should expand their role in studying this situation and designing new preventive health measures (4,5).

Collaboration is necessary to use limited resources most effectively. In small states, a state level task force that includes the Department of Health might be sufficient. In larger or more populous states, local task forces in addition to coordination at the state level may be needed. The collaboration should focus on establishing the role of each agency in ensuring that necessary services and systems exist to prevent and control injuries and infectious diseases in facilities (6,19).

Health departments generally have or should develop the expertise to provide leadership and technical assistance to licensing authorities, caregivers/teachers, parents/guardians, and primary care providers in the development of licensing requirements and guidelines for the management of children who are ill. The heavy reliance on the expertise of local and state health departments in the establishment of facilities to care for children who are ill has fostered a partnership in many states among health departments, licensing authorities, caregivers/teachers, and parents/guardians for the adequate care of children who are ill in child care settings (16-18).

RELATED STANDARDS

3.6.2.5 Caregiver/Teacher Qualifications for Facilities That Care for Children Who Are Ill
3.6.2.7 Child Care Health Consultants for Facilities That Care for Children Who Are Ill
3.6.4.3 Notification of the Facility About Infectious Disease or Other Problems by Parents/Guardians
3.6.4.4 List of Excludable and Reportable Conditions for Parents/Guardians

REFERENCES

1. Grad, F. P. 2004. The public health law manual. 3rd ed. Washington, DC: American Public Health Association.
2. Brady, M. T. 2005. Infectious disease in pediatric out-of-home child care. Am J Infect Control 33:276-85.
3. Heymann, D. L. 2008. Control of communicable diseases manual. 19th ed. Washington, DC: American Public Health Association.
4. Ginter, P. M., Wingate, M. S., A. C. Rucks, R. D. Vasconez, L. C. McCormick, S. Baldwin, C. A. Fargason. 2006. Creating a regional pediatric medical disaster preparedness network: Imperative and issues. Maternal Child Health J 10:391-96.
5. Buttross, S. 2006. Caring for children of caretakers during a disaster. Pediatrics 117: S446-47.
6. Wilson, S. A., B. J. Temple, M. E. Milliron, C. Vazquez, M. D. Packard, B. S. Rudy. 2008. The lack of disaster preparedness by the public and it’s affect on communities. Internet J Rescue Disaster Med 7 (2): 1.
7. Murray, J. S. 2009. Disaster care: Public health emergencies and children. Am J Nursing 109: 28-29, 31.
8. Vollman, D., R. Witsaman, D. R. Comstock, G. A. Smith. 2009. Epidemiology of playground equipment-related injuries to children in the United States, 1996-2005. Clinical Pediatrics 48:66-71.
9. Gordon, R. A., R. Kaestner, S. Korenman. 2007. The effects of maternal employment on child injuries and infectious disease. Demography 44:307-33.
10. Jansson, B., A. P. De Leon, N. Ahmed, V. Jansson. 2006. Why does Sweden have the lowest childhood mortality in the world? The role of architecture and public pre-school services. J Public Health Policy 27:146-65.
11. Gaines, S. K., J. M. Leary. 2004. Public health emergency preparedness in the setting of child care. Family and Comm Health 27:260-65.
12. American Academy of Pediatrics, Committee on Pediatric Emergency Medicine, Task Force on Terrorism. 2006. Policy statement: The pediatrician and disaster preparedness. Pediatrics 117:560-65.
13. National Association of Child Care Resource and Referral Agencies. Helping families and children cope with trauma in the aftermath of disaster. http://www.naccrra.org/for_parents/coping/trauma.php.
14. Samet, J. M. 2004. Risk assessment and child health. Pediatrics 113:952-56.
15. Kubiak, R., T. Slongo. 2003. Unpowered scooter injuries in children. Acta Paediatrics 92:50-54.
16. Crowley, A. A. and Kulikowich, J. M. 2009. Impact of training on child care health consultant knowledge and practice. Pediatric Nurs 35:93-100.
17. Dellert, J. C., D. Gasalberti, K. Sternas, P. Lucarelli, J. Hall. 2006. Outcomes of child care health consultation services for child care providers in New Jersey: A pilot study. Pediatric Nursing 32:530-37. 
18. Alkon, A., J. Bernzweig, K. To, M. Wolff, J. F. Mackie. 2009. Child care health consultation improves health and safety policies and practices. Academic Pediatrics 9:366-70.
19. Garrett, A. L., R. Grant, P. Madrid, A. Brito, D. Abramson, I. Redlener. 2007. Children and megadisasters: Lessons learned in the new millennium. Advances Pediatrics 54:189-214.
20. National Child Care Information and Technical Assistance Center. State and territory emergency preparedness plans. http://nccic.acf.hhs.gov/poptopics/disasterprep.html.

10.5.0.2: Written Plans for the Health Department Role

The health department’s role defined in Standard 10.5.0.1 should be described in written plans that assign the responsibilities of community agencies and organizations involved in the prevention and control of injury, injury risk, and infectious disease in facilities. The plan should identify child care related risks and diseases as well as provide guidance for risk reduction, disease prevention and control. The health department should develop these written plans in collaboration with the licensing agency (if other than the health department), health care providers, caregivers/teachers, and parents/guardians to ensure the availability of sufficient community resources for successful implementation. In addition, the health department should provide assistance to the licensing agency (if other than the health department) for the promulgation and enforcement of child care facility standards. These services should be in addition to the health agency’s assigned responsibilities for enforcement of the state’s immunization and other health laws and regulations.

In addition to Caring for Our Children (CFOC) and Stepping Stones, the following resources should be consulted in the development of the health department plan:

1. Guidelines from the American Academy of Pediatrics (AAP), including current editions of Red Book, Managing Infectious Diseases in Child Care and Schools, Managing Chronic Health Needs in Child Care and Schools, and the many other relevant technical manuals on such topics as environment and nutrition;
2. Guidelines from the American Public Health Association (APHA), including Control of Communicable Diseases Manual;
3. Guidelines provided by the Centers for Disease Control and Prevention (CDC);
4. Guidelines from the U.S. Public Health Service’s Advisory Committee on Immunization Practices, as reported periodically in Morbidity and Mortality Weekly Report (MMWR);
5. State and local regulations and guidelines regarding infectious diseases in facilities;
6. Bright Futures - Guidelines for Health Supervision of Infants, Children, and Adolescents;
7. Current early childhood nutrition guidelines such as Preventing Childhood Obesity and Making Food Healthy and Safe for Children.
8. Current early childhood physical activity resources, such as Active Start: A Statement of Physical Activity Guidelines for Children From Birth to Age 5, 2nd Edition; Moving with a Purpose: Developing Programs for Preschoolers of All Abilities; and Purposeful Play: Early Childhood Movement Activities on a Budget.

RATIONALE

Written plans help define delegation and accountability, providing the continuity of purpose that helps to institutionalize performance.

RELATED STANDARDS

10.5.0.4 Use of Fact Sheets on Common Illnesses Associated with Child Care

10.5.0.3: Requirements for Facilities to Report to Health Department

The child care licensing authority should require all facilities under its regulatory jurisdiction to report outbreaks to the health department and comply with state and local rules and regulations intended to prevent infectious disease that apply to child care facilities.

RATIONALE

State and local health departments are legally required to control certain infectious diseases within their jurisdictions. All states have laws that grant extraordinary powers to public health departments during outbreaks or epidemics of infectious disease or bioterrorism attacks. Since infectious disease is likely to occur in child care settings, a plan for the control of infectious diseases in these settings is essential and often legally required. Early recognition and prompt intervention will reduce the spread of infection (1,2).

Outbreaks of infectious disease in child care settings can have great implications for the general community (1,2). Programs coordinated by the local health department also provide reassurance to caregivers/teachers, staff, and parents/guardians, and thereby promote cooperation with other disease and safety control policies (1). Infectious diseases in child care settings pose epidemiological considerations. Public health authorities should expand their role in studying this situation and designing new preventive health and safety measures.

RELATED STANDARDS

3.6.1.1 Inclusion/Exclusion/Dismissal of Ill Children
3.6.1.2 Staff Exclusion for Illness

REFERENCES

1. Aronson, S. S., T. R. Shope, eds. 2017. Managing infectious diseases in child care and schools: A quick reference guide, pp. 43-48. 4^th Edition. Elk Grove Village, IL: American Academy of Pediatrics.
   

2. American Academy of Pediatrics. Out-of-home child care In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2018 Report of the Committee on Infectious Diseases. 31st Edition. Itasca, IL:  American Academy of Pediatrics; 2018: 122-123

3. American Academy of Pediatrics. School Health In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2018 Report of the Committee on Infectious Diseases. 31st Edition. Itasca, IL:  American Academy of Pediatrics; 2018: 138-146

   
   

10.5.0.4: Use of Fact Sheets on Common Illnesses Associated with Child Care

Health departments should help child care providers use prepared prototype parent and staff fact sheets on common illnesses associated with child care. These fact sheets should:

1. Be provided to parents/guardians when their child is first admitted to the facility, to staff at the time of employment and to both parents/guardians and staff when infectious disease notification is recommended;
2. Contain the following information:
3. Disease (case or outbreak) to which the child was exposed;
4. Signs and symptoms of the disease that the parents/guardians and caregivers/teachers should watch for in the child;
5. Mode of transmission of the disease;
6. Period of communicability;
7. Disease prevention measures recommended by the public health department (if appropriate);
8. Emphasize modes of transmission of respiratory disease and infections of the intestines (often with diarrhea) and liver, common methods of infection control (such as hand hygiene).

RATIONALE

Education is a primary method for providing information to primary care providers and parents/guardians about the incidence of infectious diseases in child care settings (1). Education of child care staff and parents/guardians on the recognition and transmission of various infectious diseases is important to any infection control policy (1). Training of child care staff has improved the quality of their health related behaviors and practices. Training should be available to all parties involved, including caregivers/teachers, public health workers, health care providers, parents/guardians, and children. Good quality training, with imaginative and accessible methods of presentation supported by well-designed materials, will facilitate learning. The number of studies evaluating the importance of education of child care staff in the prevention of disease is limited.

The provision of fact sheets on infectious childhood diseases at the time their child is admitted to a facility helps educate parents/guardians as to the early signs and symptoms of these illnesses and the need to inform caregivers/teachers of their existence. Illness information sheets can be assembled in a convenient booklet for this purpose. Health departments may consult or use nationally accepted fact sheets on common illnesses available from such agencies as the American Academy of Pediatrics (AAP) in its current edition of Managing Infectious Diseases in Child Care and Schools (1) and Red Book (2), and the Centers for Disease Control and Prevention (CDC). 

RELATED STANDARDS

3.2.1.1 Type of Diapers Worn
3.2.1.2 Handling Cloth Diapers
3.2.1.3 Checking For the Need to Change Diapers
3.2.1.4 Diaper Changing Procedure

REFERENCES

1. Aronson, S. S., T. R. Shope, eds. 2017. Managing infectious diseases in child care and schools: A quick reference guide, 4^th Edition. Elk Grove Village, IL: American Academy of Pediatrics.
2. Kimberlin, D.W., Brady, M.T., Jackson, M.A., Long, S.S., eds. 2015. Red book: 2015 report to the committee of infectious diseases. 30^th Ed. Elk Grove Village, IL: American Academy of Pediatrics.