7.2.0.1: Immunization Documentation

Child care facilities should require that all parents/guardians of children enrolled in child care provide written documentation of receipt of immunizations appropriate for each child’s age. Infants, children, and adolescents should be immunized as specified in the “Recommended Immunization Schedules for Persons Aged 0 Through 18 Years – United States” developed by the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC), the American Academy of Pediatrics (AAP), and the American Academy of Family Physicians (AAFP). Children whose immunizations are not up-to-date or have not been administered according to the recommended schedule should receive the required immunizations, unless contraindicated or for legal exemptions (1,2).

An updated immunization schedule is published annually in the AAP’s Pediatrics and in the CDC’s MMWR and should be consulted for current information. In addition to print versions of the recommended immunization schedules, the current child, adolescent, and catch-up schedules are posted on the Websites of the CDC at http://www.cdc.gov/vaccines/ and the AAP at http://www.aap.org/
immunization/.

RATIONALE

Routine immunizations at the appropriate age are the best means of protecting children against vaccine-preventable diseases. Legal requirements for age-appropriate immunizations of children attending licensed facilities exist in almost all states (see http://www.immunize.org/laws/). Parents/guardians of children who attend unregulated child care facilities should be encouraged to comply with the most recent “Recommended Immunization Schedules” (2).

Immunization is particularly important for children in child care because preschool-aged children have the highest age-specific incidence or are at high risk of complications from many vaccine-preventable diseases (specifically, measles, pertussis, rubella, influenza, varicella [chickenpox], rotavirus, and diseases due to Haemophilus influenzae type b (Hib) and pneumococcus) (3).

COMMENTS

Early education and child care settings present unique challenges for infection control due to the highly vulnerable population, close interpersonal contact, shared toys and other objects, and limited ability of young children to understand or practice good respiratory etiquette and hand hygiene. Parents/guardians, early childhood caregivers/teachers, and public health officials should be aware that, even under the best of circumstances, transmission of infectious diseases cannot be completely prevented in early childhood or other settings. No policy can keep everyone who is potentially infectious out of these settings (4).

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

REFERENCES

1. American Academy of Pediatrics, Committee on Infectious Diseases. 2011. Policy statement: Recommended childhood and adolescent immunization schedules – United States, 2011. Pediatrics 127:387-88.
2. Fiene, R. 2002. 13 indicators of quality child care: Research update. Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/basic-report/13-indicators-quality-child-care.
3. Centers for Disease Control and Prevention (CDC). 2009. CDC guidance on helping child care and early childhood programs respond to influenza during the 2009–2010 influenza season. Atlanta: CDC. http://www.cdc.gov/h1n1flu/childcare/pdf/guidance.pdf.
4. Centers for Disease Control and Prevention. 2015. Recommended immunization schedules for persons aged 0-18 years – United States, 2015. http://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html

7.2.0.2: Unimmunized/Underimmunized Children

Immunizations are effective in preventing the spread of infectious diseases in early care and education programs. Children may not receive all age-appropriate immunizations due to medical, religious, or personal exemptions, or delays in getting recommended vaccines. Programs should work with families to get vaccine records and keep required documentation for the following situations:

• Medical exemptions: Some children cannot receive certain vaccines due to medical conditions. Children with a medical exemption should have a statement from a healthcare provider documenting what vaccines are exempt and the reason for exemption.¹ 
• Religious and personal exemptions: Some states allow parents/guardians to refuse some or all vaccines for their children based on religious or personal beliefs. Programs should keep any program, state-specific, health department, or other required documentation on file.¹ 
• Delayed immunizations: Children who have not received all recommended age-appropriate vaccines should receive missing vaccines as soon as possible. Families should work with their healthcare provider to make a plan that follows the recommended immunization schedules (see Appendix G). Letting children who are unimmunized (not vaccinated) or underimmunized (partially vaccinated) attend a program can put other children, program staff, and close contacts at risk. Attendance for children who are unimmunized or underimmunized should depend on state, local, tribal, or territorial public health guidance, including how to handle the risk and if parents of other enrolled children should be informed about the risks.²
  

If a vaccine-preventable disease occurs in a program, the program should temporarily exclude all unimmunized and underimmunized children for the duration of the possible exposure or until they are fully vaccinated.² Contact state, local, tribal, or territorial public health authorities for guidance. 

RATIONALE

Immunizations at the appropriate age are the best ways to protect children from vaccine-preventable diseases. All states have mandates for age-appropriate immunization of children in early care and education programs.1 Some children and adults cannot receive certain vaccines because of a medical condition. Some states allow parents to refuse some or all vaccines for their children because of the parents’ religious or personal beliefs. Enrolling children whose parents refuse some or all vaccines, or allowing an underimmunized adult to work in a group care setting, increases the risk of spreading certain infectious diseases.³ Underimmunized children and adults increase their risk of getting a vaccine-preventable illness. When they do become sick from a vaccine-preventable infection, they  risk infecting others who have valid medical reasons for being unable to receive a specific vaccine or who are too young to have received enough doses of a vaccine to be protected.³ If they are exposed to a vaccine-preventable disease they will be excluded from child care or work for a long time.³

Allowing attendance of children or adults who do not have a medical reason to forego vaccines may result in legal liability for programs if refusal results in a preventable illness. Immunization laws and regulations differ between states, counties, and cities. Compliance with local legal immunization requirements may not meet national immunization recommendations. All early care and education programs must meet state licensing and federal Child Care Development Fund requirements for documentation of up-to-date immunization of children in their care.³

More information on state requirements and mandates can be found at: https://www.immunize.org/laws/laws-exemptions.asp 

More information about vaccines is available from the Centers for Disease Control and Prevention (CDC):

• https://www.cdc.gov/vaccines/
• https://www.cdc.gov/vaccines/parents/records/schools.html
• https://www.healthychildren.org/English/safety-prevention/immunizations/Pages/default.aspx

 

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

Appendix G: Recommended Childhood Immunization Schedule

REFERENCES

1. Immunize.org. State exemptions. State mandates on immunization and vaccine-preventable diseases. Immunize.org Web site. Last updated February 24, 2020. Accessed May 2 2022. https://www.immunize.org/laws/laws-exemptions.asp
2. American Academy of Pediatrics. Section 2: Recommendation for care of children in special circumstances; children in group childcare and schools. In: Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH, eds. Red Book: 2021 Report of the Committee on Infectious Diseases. Elk Grove Village, IL: American Academy of Pediatrics; 2021:122123. 
3. American Academy of Pediatrics. Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide. Aronson SS, Shope TR, eds. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2022.

NOTES

Standard was last updated 09/27/2022.

7.2.0.3: Immunization of Staff

To protect children and staff from vaccine-preventable diseases, early care and education staff should be up to date on all recommended immunizations, including annual immunizations (i.e., influenza). Programs should encourage staff members to work with their primary health care providers to ensure that they receive all program-required vaccines and other recommended vaccines based on their health status. Exclusion may be required for the duration of possible exposure or until they complete appropriate immunizations. Programs should require and maintain documentation of staff immunization records. Programs should require staff members who are not appropriately immunized for medical, religious, or philosophical reasons to provide written documentation of the reason.

• All early care and education adult staff members should receive all vaccines routinely recommended for adults, in consultation with their primary health care provider, including:1
  • Annual influenza
  • Tdap/Td (tetanus, diphtheria, pertussis)
  • Varicella (chickenpox)
  • MMR (measles, mumps, and rubella)
  • Human papillomaviruses (HPV)
  • Zoster recombinant (shingles)
  • COVID-19
• Other vaccines recommended, in consultation with their primary health care provider, if a specific risk factor is present:
  • Pneumococcal
  • Hepatitis A
  • Hepatitis B
  • Meningococcal
  • Haemophilus influenzae type B
• Other vaccines as determined by the Centers for Disease Control and Prevention (CDC), the Advisory Committee on Immunization Practices (ACIP), and state and local public health authorities as new vaccines are developed or in response to unexpected emergence of other diseases (e.g., the 2020 COVID-19 pandemic).^1,2
  
• Programs should seek health department guidance on temporary exclusion of unimmunized adults who are susceptible to a vaccine-preventable disease outbreak in a program.
  

RATIONALE

Routine immunization is the best means of preventing vaccine-preventable diseases in children and adults. Vaccines, which are safe and effective in preventing these diseases, need to be used in adults to minimize disease and to eliminate potential sources of transmission.^1–3 Because vaccine preventable diseases can be transmitted to children, staff members who do not receive recommended immunizations put at risk themselves, other staff, and children in their care. Immunization with Tdap that protects against pertussis (whooping cough) is especially important because adults often spread pertussis to vulnerable infants and young children. Staff members who receive an annual influenza (flu) vaccine help protect infants who are too young to receive the vaccine. Staff previously vaccinated for, or infected with, some infectious diseases (e.g., COVID-19, influenza, pertussis) can become reinfected and spread the illness to staff and children and may require additional vaccines. Although immunization for hepatitis A is not a routine recommendation, the disease may spread to staff in early care and education programs. Unless requested, vaccines for hepatitis A and B, pneumococcal, and meningococcal are recommended only for adults with high-risk conditions or who work in high-risk settings. 

COMMENTS

For more information and up-to-date adult vaccine recommendations, visit the CDC website on immunizations and vaccines at http://www.cdc.gov/vaccines/ and Vaccine Information for Adults: What Vaccines are Recommended for You, at https://www.cdc.gov/vaccines/adults/rec-vac/.^3,4 The CDC also has useful educational resources including fact sheets on adult immunization that may be shared with staff, at https://www.cdc.gov/vaccines/hcp/adults/for-patients/adults-all.html#handouts.⁵

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

7.3.3.1 Influenza Immunizations for Children and Staff
7.3.3.2 Influenza Control
7.3.3.3 Influenza Prevention Education

REFERENCES

1. Centers for Disease Control and Prevention. Recommended adult immunization schedule for ages 19 year and older: United States 2021. CDC.gov Web site. Last reviewed February 11, 2021. Accessed November 3, 2021. 

2. Kroger A, Bahta L, Hunter P. General best practice guidelines for immunization. Best practices guidance of the Advisory Committee on Immunization Practices (ACIP) CDC.gov Web site. Updated May 4, 2021. Accessed November 3, 2021. https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/index.html

3. Centers for Disease Control and Prevention. Vaccines & immunizations. CDC.gov Web site. Updated February 16, 2021. Accessed November 3, 2021. http://www.cdc.gov/vaccines/

4. Centers for Disease Control and Prevention. What vaccines are recommended for you. CDC.gov Web site. Updated November 21, 2019. Accessed November 3, 2021. https://www.cdc.gov/vaccines/adults/rec-vac/

5. Centers for Disease Control and Prevention. Educating adult patients: Vaccination resources. CDC.gov Web site. Updated April 21, 2020. Accessed November 3, 2021. https://www.cdc.gov/vaccines/hcp/adults/for-patients/adults-all.html#handouts

NOTES

Content in the STANDARD was modified on 02/25/2022.

7.3.1.1: Exclusion for Group A Streptococcal (GAS) Infections

Children or staff with group A streptococcal (GAS) infection (strep throat or skin infection) should be temporarily excluded from the early care and education program until they have been treated with an appropriate antibiotic for 12 hours. Children may return once they are treated with an appropriate antibiotic and are able to fully participate in activities.^1–2 Children or staff who have GAS skin infections do not need to be sent home early and should have the area washed with soap and water and covered with a bandage.³

Parents/guardians and staff exposed to a child with a GAS infection should be told of the exposure and watch for symptoms.³ Children and staff who develop symptoms should be examined by a health care provider.

RATIONALE

Strep throat can occur in any age but is less common in children under three years old.³ Close contact in early care and education programs is a risk factor for spread for both children and adults.³ Children and adults who have been treated with appropriate antibiotics for 12 hours are not at risk for spreading this infection to others. Early diagnosis and treatment of a GAS infection in children and adults can help reduce the likelihood of complications of the infection and spreading the disease to others.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

7.3.1.2 Informing Caregivers/Teachers of Group A Streptococcal (GAS) Infection

REFERENCES

1. American Academy of Pediatrics. Section 3: Summaries of infectious disease, Group A streptococcal infections. In: Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH, eds. Red Book: 2021 Report of the Committee on Infectious Diseases. Elk Grove Village, IL: American Academy of Pediatrics; 2021:706

2. American Academy of Pediatrics. Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide. Aronson SS, Shope TR, eds. 5th ed. Itasca, IL: American Academy of Pediatrics; 2020

3. Centers for Disease Control and Prevention. Group A streptococcal (GAS) disease. Pharyngitis (strep throat). CDC.gov Web site. Last reviewed November 1, 2018. Accessed March 1, 2022. https://www.cdc.gov/groupastrep/diseases-hcp/strep-throat.htm

NOTES

Content in the STANDARD was modified on 8/9/2017 and 7/05/2022.

7.3.1.2: Informing Caregivers/Teachers of Group A Streptococcal (GAS) Infection

 

Anyone in an early care and education program infected with group A streptococcal (GAS), such as strep throat or scarlet fever, should inform program staff as soon as possible. Staff should follow recommended actions for infected individuals and alert exposed families and staff to watch for symptoms.¹

 

RATIONALE

Both children and adults can become infected with GAS; close contact, which is typical in early care and education programs, can cause GAS to spread. Awareness of infection in a program, temporarily excluding infected children or staff, and seeking medical care if symptoms develop can help reduce spread of GAS.²

COMMENTS

Sample letters of notification to parents/guardians that their child may have been exposed to an infectious disease are in the current edition of the publication of the American Academy of Pediatrics (AAP), Managing Infectious Diseases in Child Care and Schools.¹ 

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

7.3.1.1 Exclusion for Group A Streptococcal (GAS) Infections

REFERENCES

1. American Academy of Pediatrics. Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide. Aronson SS, Shope TR, eds. 5th ed. Itasca, IL: American Academy of Pediatrics; 2020

2. Centers for Disease Control and Prevention. Group A streptococcal (GAS) disease. Pharyngitis (strep throat). CDC.gov Web site. Last reviewed November 1, 2018. Accessed March 1, 2022. https://www.cdc.gov/groupastrep/diseases-hcp/strep-throat.htm

NOTES

Content in the standard was modified on 7/05/2022.

7.3.2.1: Immunization for Haemophilus Influenzae Type B (HIB)

All children in a child care facility should have received age-appropriate immunizations with a Haemophilus influenzae type b (Hib) conjugate containing vaccine (1). Staff and children in child care who are not immunized or not age-appropriately immunized (those under the age of 4 years) against invasive Hib disease do not need to be excluded from the child care setting unless there is another reason for exclusion (2). Please reference Standard 3.6.1.1: Inclusion/Exclusion/Dismissal of Children for a comprehensive list of exclusion criteria. 

RATIONALE

Appropriate immunization of children with a Hib conjugate-containing vaccine prevents the occurrence of disease and decreases the rate of spread of this organism, thereby decreasing the risk of transmission to others (3). 

COMMENTS

Transmission of Hib may occur among unimmunized young children in group child care, especially children younger than twenty-four months of age. Hib causes pneumonia, meningitis, joint and bone infection, heart infection, and epiglottitis. In an outbreak of invasive Hib disease in child care, rifampin prophylaxis may be indicated for all non-pregnant contacts, especially when unimmunized or incompletely immunized children attend the child care facility (3).

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

7.2.0.1 Immunization Documentation
7.2.0.2 Unimmunized/Underimmunized Children
7.2.0.3 Immunization of Staff
7.3.2.2 Informing Parents/Guardians of Haemophilus Influenzae Type B (HIB) Exposure

REFERENCES

1. Centers for Disease Control and Prevention, Advisory Committee on Immunization Practices. 2016. Immunization schedules. https://www.cdc.gov/vaccines/schedules/hcp/index.html. 
   
2. 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.
   
3. American Academy of Pediatrics. Haemophilus Influenzae Type B (HIB) 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: 367
   

NOTES

Content in the STANDARD was modified on 8/9/2017.

7.3.2.2: Informing Parents/Guardians of Haemophilus Influenzae Type B (HIB) Exposure

When a child with invasive Haemophilus influenzae type b (Hib) infection is in care, the facility should inform parents/guardians of other children who are unimmunized or incompletely immunized that they may have been exposed to the Hib bacteria and may have risk of developing serious Hib disease. Consultation with health department authorities or the primary health care provider of the unimmunized or incompletely immunized child is recommended.
Staff and children in child care who are not immunized or not age-appropriately immunized (under the age of four years) against invasive Hib disease do not need to be excluded from the child care setting unless there is another reason for exclusion (1). Staff should get the Hib vaccine if recommended by their primary health care provider. Please reference Standard 3.6.1.1: Inclusion/Exclusion/Dismissal of Children for a comprehensive list of exclusion criteria. 

RATIONALE

There is a risk of secondary cases of invasive Hib disease occurring among child care contacts of a child with invasive Hib disease. Risk of secondary cases of invasive Hib disease occurring among child care attendees is greatest among, and may be limited to, children younger than four years of age who are not immunized, not age-appropriately immunized, or have certain immune deficiencies (2). 

COMMENTS

Sample letters of notification to parents/guardians that their child may have been exposed to an infectious disease are contained in the current edition of Managing Infectious Diseases in Child Care and Schools (AAP).

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

7.2.0.1 Immunization Documentation
7.2.0.2 Unimmunized/Underimmunized Children
7.2.0.3 Immunization of Staff
7.3.2.1 Immunization for Haemophilus Influenzae Type B (HIB)

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. American Academy of Pediatrics. Haemophilus Influenzae Type B (HIB) 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: 367
   

NOTES

Content in the STANDARD was modified on 8/9/2017.

7.3.2.3: Reporting Requirements for Haemophilus Influenzae Type B Infections

Haemophilus influenzae type b (Hib) is a bacteria that can cause infections in children. If a child has been diagnosed with a Hib infection, early care and education programs should:^1–2

• Report the Hib infection to the state, local, tribal, or territorial health department
• Work with the child care health consultant, if available, who can offer advice on notifying the health department and staff/families
• Communicate with staff and parents/guardians to inform them about the exposure. Programs should work with the health department or primary care providers
• for treatment and ways to control the spread of infection
• Check children exposed to Hib for fever or signs of illness, and refer them to medical care if symptoms develop

RATIONALE

Hib spreads from person to person by inhaling respiratory droplets or by direct contact with respiratory secretions (e.g., mucus).³ Programs must report Hib infections to public health departments. Infected children can spread the infection, and exposed children who develop fever or illness should see a health care provider. Children who have been exposed may need treatment with antibiotics or immunizations. All children in early care and education programs should receive all recommended age-appropriate Hib vaccines.¹

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

7.2.0.1 Immunization Documentation
7.3.2.1 Immunization for Haemophilus Influenzae Type B (HIB)
7.3.2.2 Informing Parents/Guardians of Haemophilus Influenzae Type B (HIB) Exposure
Appendix G: Recommended Childhood Immunization Schedule

REFERENCES

1. American Academy of Pediatrics. Section 3: Summaries of infectious diseases. In: Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH, eds. Red Book: 2021 Report of the Committee on Infectious Diseases. Elk Grove Village, IL: American Academy of Pediatrics; 2021:345-349.

2. American Academy of Pediatrics. Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide. Aronson SS, Shope TR, eds. 5th ed. Itasca, IL: American Academy of Pediatrics; 2020

3. Centers for Disease Control and Prevention. National Notifiable Diseases Surveillance System (NNDSS): Haemophilus Influenzae, invasive disease. CDC.gov Web site. Last reviewed April 16, 2021. Accessed April 25, 2022. https://ndc.services.cdc.gov/case-definitions/haemophilus-influenzae-invasive-disease-2015/

NOTES

Content in the standard was modified on 7/05/2022.

7.3.3.1: Influenza Immunizations for Children and Staff

To reduce the spread of influenza, early care and education programs should require annual immunization for influenza for children and staff.

Programs should:

• Ask families to provide written documentation of the current year’s influenza vaccine for children age 6 months and older. Children who turn 6 months during influenza season should be vaccinated and provide documentation to their early care and education program. Families who choose not to vaccinate their child(ren) against influenza should provide appropriate documentation for personal, religious, and/or medical reasons.
• Require all staff to receive an annual influenza vaccine before the start of or during the current influenza season.
• Encourage family members of children and staff to receive the annual influenza vaccine if they are eligible.

RATIONALE

The American Academy of Pediatrics (AAP) and the Advisory Committee on Immunization Practices (ACIP) recommend annual influenza vaccination for all people, age 6 months and older, preferably before the influenza season.1–3 Immunization remains effective throughout the influenza season, even when the seasonal vaccine is received early in the season. Infants who reach 6 months of age during influenza season should receive the vaccine if it is still recommended at that time.^1–4 Vaccination of program staff, children, and other close contacts is particularly important to protect vulnerable adults/children who are at greater risk of complications from influenza. That includes children/adults with certain medical conditions and unvaccinated people. Children under 2 years old are more likely to have serious complications from influenza. Since children under 6 months are too young to receive the vaccine, staff, family members, and eligible children should be vaccinated to protect these younger infants.^1,2 Immunization efforts should continue throughout the entire influenza season, since the season varies year to year.⁵ Influenza season typically starts in the fall or winter and can last through the spring.⁶

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

7.2.0.3 Immunization of Staff
7.3.3.3 Influenza Prevention Education

REFERENCES

1. Committee on Infectious Diseases. Recommendations for prevention and control of influenza in children, 2020-2021. Pediatrics. 2020;146(4):e2020024588. doi:10.1542/peds.2020-024588 

2. Centers for Disease Control and Prevention. Summary: ‘Prevention and control of seasonal influenza with vaccines: Recommendations of the advisory committee on immunization practices (ACIP)—United States, 2020-21.’ CDC.gov Web site. Last reviewed August 26, 2021. Accessed November 3, 2021. https://www.cdc.gov/flu/professionals/acip/summary/summary-recommendations.htm

3. Centers for Disease Control and Prevention. Who needs a flu vaccine. CDC.gov Web site. Last reviewed October 27, 2021. Accessed November 3, 2021. https://www.cdc.gov/flu/prevent/vaccinations.htm

4. Centers for Disease Control and Prevention. Flu & young children. CDC.gov Web site. Last reviewed October 25, 2021. Accessed November 3, 2021. https://www.cdc.gov/flu/highrisk/children.htm

5. Centers for Disease Control and Prevention. Misconceptions about seasonal flu and flu vaccines. CDC.gov Web site. Last reviewed October 25, 2021. Accessed November 3, 2021. https://www.cdc.gov/flu/prevent/misconceptions.htm

6. Centers for Disease Control and Prevention. Flu season. CDC.gov Web site. Last reviewed September 28, 2021. Accessed November 3, 2021. https://www.cdc.gov/flu/about/season/flu-season.htm

NOTES

Content in the STANDARD was modified on 02/25/2022.

7.3.3.2: Influenza Control

When influenza is circulating in the community, facilities should encourage parents/guardians to keep children with symptoms of acute respiratory tract illness with fever at home until their fever has subsided for at least twenty-four hours without use of fever reducing medication.

Caregivers/teachers with symptoms of acute respiratory tract illness with fever also should remain at home until their fever subsides for at least twenty-four hours.

RATIONALE

The Centers for Disease Control and Prevention (CDC) recommends that caregivers/teachers encourage parents/guardians of sick children to keep the children home and away from their regular child care setting until the children have been without fever for twenty-four hours, to prevent spreading illness to others (1).

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

7.3.3.1 Influenza Immunizations for Children and Staff
7.3.3.3 Influenza Prevention Education

REFERENCES

7.3.3.2: Influenza Control

When influenza cases are reported in the community, early care and education programs should take measures to avoid an outbreak or further spread in the program.

Programs should:

• Temporarily exclude children/staff with symptoms of acute respiratory tract illness (e.g., cough, sore throat, sneezing, runny nose) along with fever.¹
  • Children and staff should stay home until fever-free for at least 24 hours without the use of fever-reducing medication.²
• Separate children who become ill from the other children until the ill child can be taken home.
• Record when children or staff is ill, including details about their symptoms (especially when influenza is verified through testing).

RATIONALE

Children/staff who have influenza symptoms can easily spread the disease to others. The Centers for Disease Control and Prevention (CDC) recommends that ill children and staff stay away from the early care and education program until they are fever-free without having taken fever-reducing medicine for 24 hours.^2–4 To decrease influenza transmission, contact with other children should be limited if a child becomes ill while attending the program. Programs should maintain records in accordance with local public health guidelines and communicate with families about influenza outbreaks in early care and education programs.

COMMENTS

Programs should maintain records in accordance with local public health guidelines and communicate with families about influenza outbreaks in early care and education programs.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

7.3.3.1 Influenza Immunizations for Children and Staff
7.3.3.3 Influenza Prevention Education

REFERENCES

1. American Academy of Pediatrics. Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide. Aronson SS, Shope TR, eds. 5th ed. Itasca, IL: American Academy of Pediatrics; 2020

2. Centers for Disease Control and Prevention. Treatment: What you need to know. CDC.gov Web site. Last reviewed August 31, 2021. Accessed November 3, 2021. https://www.cdc.gov/flu/treatment/treatment.htm

3. Centers for Disease Control and Prevention. Information for schools & childcare providers. CDC.gov Web site. Last reviewed October 15, 2021. Accessed November 3 2021. https://www.cdc.gov/flu/school/index.htm?web=1&wdLOR=cD384314D-FBBA-8543-9B5D-485815343038

4. Centers for Disease Control and Prevention. Healthy habits to protect against flu. CDC.gov Web site. Last reviewed August 26, 2021. Accessed November 3, 2021. https://www.cdc.gov/flu/prevent/actions-prevent-flu.htm

NOTES

Content in the STANDARD was modified on 02/25/2022.

7.3.3.3: Influenza Prevention Education

To prepare for influenza season, early care and education programs should provide ongoing infectious disease education for staff and make necessary equipment and supplies available for all staff and children.

• Staff education should include:
  • The importance of early influenza vaccination for eligible children and staff¹
  • Practicing infection prevention measures, including:
  • Respiratory hygiene and cough etiquette (sneezing into the elbow or covering the mouth and nose with a tissue when coughing or sneezing; disposing of a used tissue in the nearest trash can, preferably touchless)²
  • Hand hygiene (Wash hands often with soap and water for at least 20 seconds. If soap and water are not available, use an alcohol-based hand rub. Supervise children when using alcohol-based hand rub, and keep the container out of reach of young children)^3,4
  • Not touching one’s eyes, nose, or mouth¹
  • Cleaning and disinfecting surfaces and objects (including frequently touched surfaces) that could be infected with the influenza virus¹
• How to reduce exposure to sick people. If exposed to influenza, monitor for symptoms and stay home if symptoms develop.¹
• Children and staff should stay home until fever-free for at least 24 hours without the use of fever-reducing medication.¹
• Programs should provide:
  • Tissues and touchless trash cans for disposal
  • Adequate supplies for hand-washing (i.e., soap, disposable towels), where sinks are available
  • Alcohol-based hand sanitizer (kept out of reach of young children)⁴

RATIONALE

Ongoing staff education is necessary to reduce the spread of influenza. Practicing respiratory and hand hygiene, cough etiquette, and having appropriate supplies available supports influenza prevention. Immunization is the best way to prevent influenza in adults and children 6 months and older.¹

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

7.2.0.3 Immunization of Staff
7.3.3.1 Influenza Immunizations for Children and Staff
7.3.3.2 Influenza Control
Appendix G: Recommended Childhood Immunization Schedule
Appendix H: Recommended Adult Immunization Schedule
Appendix J: Selection and Use of a Cleaning, Sanitizing or Disinfecting Product
Appendix K: Routine Schedule for Cleaning, Sanitizing, and Disinfecting

REFERENCES

1. Centers for Disease Control and Prevention. Preventive steps. CDC.gov Web site. Last reviewed October 25, 2021. Accessed November 3, 2021. https://www.cdc.gov/flu/prevent/prevention.htm
   

2. Centers for Disease Control and Prevention. Coughing and sneezing. CDC.gov Web site. Last reviewed April 22, 2020. Accessed November 3, 2021. https://www.cdc.gov/healthywater/hygiene/etiquette/coughing_sneezing.html

3. Centers for Disease Control and Prevention. When and how to wash your hands. CDC.gov Web site. Last reviewed June 26, 2019. Accessed November 3, 2021. https://www.cdc.gov/healthyschools/bam/child-development/how-to-wash-hands.htm

4. American Academy of Pediatrics. Keep hand sanitizers out of children’s reach. AAPPublications.org Web site. Published May 20, 2020. Accessed November 3, 2021. https://www.aappublications.org/news/2020/05/20/parentplus052020
   

NOTES

Content in the STANDARD was modified on 02/25/2022.

7.3.4.1: Mumps

Mumps is a contagious viral disease characterized by swelling of one or more salivary glands, usually the parotid glands. Any child or caregiver/teacher with suspected mumps should be excluded until the diagnosis of mumps or another infectious disease requiring exclusion is ruled out. Children or caregivers/teachers with proven mumps infection should be excluded for five days following the onset of parotid gland swelling (1).

Due to the risk of transmission and to control outbreaks of mumps, consider excluding children without documentation of vaccination with one or more doses of MMR vaccine or laboratory evidence of immunity including those children who have been exempted from this immunization. Excluded children can be readmitted immediately after immunization. Children who continue to be exempted from mumps immunization because of medical, religious, or other reasons should be excluded until at least twenty-six days after the onset of parotitis in the last person with mumps in the affected child care facility. Adults born during or after 1957 should have received one dose of MMR vaccine unless they have a medical contraindication or can provide laboratory evidence of immunity.

During an outbreak, a second dose of MMR (measles, mumps, and rubella) should be offered to the following groups:

1. Inadequately immunized people for whom two doses are recommended (preschool-aged children, school and college students, health care professionals, international travelers);
2. Adults born during or after 1957 without evidence of immunity who previously have received one dose of mumps vaccine. Adults born before 1957 generally are considered immune to mumps.

Mumps is designated as a notifiable disease at the national level, and local and/or state public health officials should be notified immediately about suspected cases of mumps involving children or caregivers/teachers in the child care setting. Facilities should cooperate with health department officials in notifying parents/guardians of children who attend the facility about exposures to children or staff with mumps.

RATIONALE

Mumps is a vaccine-preventable disease which is uncommon in children who receive at least two doses of live-attenuated MMR vaccine. The virus typically causes a systemic infection with swelling of the salivary glands, usually one or more of the parotid glands. In up to one-third of infections, the person is asymptomatic or has only a mild upper respiratory tract illness. Mumps can cause an infection of the central nervous system (e.g., encephalitis, meningitis), kidneys, and other organs. Involvement of the ovaries (in females) and testes (males) can occur, especially in those beyond puberty.

Mumps is spread typically by respiratory tract droplets or contact with respiratory tract secretions. The incubation period ranges from twelve to twenty-five days after exposure, typically sixteen to eighteen days. Infected people are contagious from one to two days before parotid swelling until five days after parotid swelling.

Mumps is an infectious disease and, therefore, routine exclusion of infected children is warranted. The American Academy of Pediatrics (AAP) and the Centers for Disease Control and Prevention (CDC) have revised the period of communicability to five days after the onset of parotid swelling (1).

Several mumps outbreaks have occurred since 2006 (2,3). Experience with outbreak control for other vaccine-preventable diseases indicates that the control strategy stated in the standard is effective.

COMMENTS

For more information on mumps, consult the current edition of the Red Book from the AAP.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

REFERENCES

1. Centers for Disease Control and Prevention. 2008. Updated recommendations for isolation of persons with mumps. MMWR 57:1103-5. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5740a3.htm.
2. Centers for Disease control and Prevention. 2010. Update: Mumps outbreak-New York and New Jersey, June 2009-January 2010. MMWR 59:125-29. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5905a1.htm.
3. Centers for Disease Control and Prevention. 2006. Updated recommendations of the ACIP for the control and elimination of mumps. MMWR 55:629-30. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5522a4.htm.

7.3.5.1: Recommended Control Measures for Invasive Meningococcal Infection in Child Care

Identification of an individual with invasive meningococcal infection in the child care setting should result in the following:

1. Immediate notification of the local or state health department;
2. Notification of parents/guardians about child care contacts to the person with invasive meningococcal infection;
3. Assistance with provision of antibiotic prophylaxis and vaccine receipt, as advised by the local or state health department, to child care contacts;
4. Frequent updates and communication with parents/guardians, health care professionals, and local health authorities.

RATIONALE

Due to the increased transmissibility of meningococcal infections following close personal contact with oral and respiratory tract secretions of a person with infection, institution of antibiotic prophylaxis within twenty-four hours of diagnosis of the index case is advised. Younger age and close contact with an infected person increases the attack rate of meningococcal disease among child care attendees to several hundred fold greater than the general population. As outbreaks may occur in child care settings, chemoprophylaxis with oral rifampin is the prophylaxis of choice for exposed child contacts. In some cases, intramuscular ceftriaxone may be used as an alternative if a contraindication to oral rifampin exists in the contact (1,2). In contacts over eighteen years of age, oral rifampin, ciprofloxacin, or intramuscular ceftriaxone, are effective (2,3). Rifampin is not recommended for pregnant women.

In addition to chemoprophylaxis with an oral antimicrobial agent, immunoprophylaxis with a meningococcal vaccination of age-eligible contacts in an outbreak setting, if the infection is due to a serogroup contained in the vaccine, may be recommended by the local or state health department (1,2).

COMMENTS

For facilities that care for older school-age children, meningococcal vaccine is recommended at eleven or twelve years of age with a second dose administered at sixteen years of age.

For additional information regarding meningococcal disease, consult the current edition of the Red Book from the American Academy of Pediatrics (AAP).

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

REFERENCES

1. American Academy of Pediatrics. Meningococcus 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: 107-108

2. Centers for Disease Control and Prevention. 2007. Revised recommendations of the Advisory Committee on Immunization Practices to vaccinate all persons aged 11-18 years with meningococcal conjugate vaccine. MMWR 56:749-95. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5631a3.htm.

3. American Academy of Pediatrics, Committee on Infectious Diseases. 2009. Prevention and control of meningococcal disease: Recommendations for use of meningococcal vaccines in pediatric patients. Pediatrics 123:1421-22.

7.3.5.2: Informing Public Health Authorities of Meningococcal Infections

Meningococcal disease is designated as notifiable at the national level, and local and/or state public health department authorities should be notified immediately about the occurrence of invasive meningococcal disease in a child care facility. Timely reporting results in early recognition of outbreaks and prevention of additional infections. Facilities should cooperate with their local or state health department officials in notifying parents/guardians of children who attend the facility about exposures to children with invasive meningococcal infections. Early intervention minimizes anxiety and concern that may result from identification of an attendee with an invasive meningococcal infection. This may include providing local health officials with the names and telephone numbers of parents/guardians of children in involved classrooms or facilities.

RATIONALE

Neisseria meningitidis is a cause of serious infections, including meningitis, in young children and adolescents. Infection is spread from person to person by direct contact with respiratory tract droplets that contain N. meningitidis organisms (1,2).

COMMENTS

Sample letters of notification to parents/guardians that their child may have been exposed to an infectious disease are contained in the publication of the American Academy of Pediatrics (AAP), Managing Infectious Diseases in Child Care and Schools, 2nd Ed. For additional information regarding meningococcal disease, consult the current edition of the Red Book from the AAP.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

REFERENCES

1. Centers for Disease Control and Prevention. 2007. Revised recommendations of the Advisory Committee on Immunization Practices to vaccinate all persons aged 11-18 years with meningococcal conjugate vaccine. MMWR 56:749-95. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5631a3.htm.
2. American Academy of Pediatrics, Committee on Infectious Diseases. 2009. Prevention and control of meningococcal disease: Recommendations for use of meningococcal vaccines in pediatric patients. Pediatrics 123:1421-22.

7.3.6.1: Attendance of Children with Erythema Infectiosum (EI) (Parvovirus B19)

Children who develop Erythema Infectiosum (EI), also known as fifth disease, following infection with parvovirus B19, should 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 fever, headache, and muscle aches, followed by an intensely red rash on the cheeks 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 respiratory tract secretions at the time of occurrence of the rash (1,2).

COMMENTS

Parvovirus B19 infections may be more serious in people with certain immune deficiencies and in people with hemolytic anemia such as sickle cell anemia. Parvovirus B19 infection in pregnancy may cause fetal loss or intrauterine growth retardation.

For additional information regarding parvovirus B19,consult the current edition of the Red Book from the American Academy of Pediatrics (AAP).

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

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. American Academy of Pediatrics. Parvovirus B19 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: 602-606
   
   

7.3.7.1: Informing Public Health Authorities of Pertussis Cases

Local and/or state public health authorities should be notified immediately about suspected or confirmed cases of pertussis (whooping cough) involving children or caregivers/teachers in the child care setting. Facilities should cooperate with their local or state health department officials in notifying parents/guardians of children who attend the facility about exposures to children or adults with pertussis. This may include providing health department officials with the names and telephone numbers of parents/guardians of children in the classrooms or facilities involved.

Guidelines for use of antibiotics and immunization for prevention of pertussis in people who have been in contact with children or adults who have pertussis should be implemented in cooperation with public health department officials. Children and staff who have been exposed to pertussis, especially those who are incompletely immunized, should be observed for respiratory tract symptoms for twenty-one days after the last contact with the infected person.

RATIONALE

Notification of health department officials when suspected or confirmed pertussis occurs in a child or staff member in a child care center will help ensure the following (1-3):

1. All children have received age-appropriate immunization;
2. Appropriate antibiotic prophylaxis is provided to children and adults exposed to the child first infected with pertussis;
3. Children and adults are observed for respiratory tract symptoms.

COMMENTS

Sample letters of notification to parents/guardians that their child may have been exposed to an infectious disease are contained in the current publication of the American Academy of Pediatrics (AAP), Managing Infectious Diseases in Child Care and Schools (1). For additional information regarding pertussis, consult the current edition of the Red Book (2), also from the AAP.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

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. 

7.3.7.2: Prophylactic Treatment for Pertussis (Whooping Cough)

Staff and children who have been exposed to someone with pertussis (whooping cough), regardless of immunization status, should be treated with preventive (prophylactic) antibiotics. Also, exposed staff and children should complete all age-appropriate vaccines. Staff and children who have been exposed should work with their health care provider or the local health department to decide on the appropriate treatment and when they may return to the early care and education program.^1–3 

RATIONALE

Pertussis can cause severe symptoms in infants that can put them at risk for severe disease.² Preventive treatment is recommended for high-risk people within 21 days of exposure to someone who is infected. High-risk people are at a higher risk for developing severe illness, or exposing others who may develop more severe illness. Preventive treatment for children and staff can reduce spread in early care and education programs.¹

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

7.2.0.1 Immunization Documentation
7.2.0.3 Immunization of Staff
7.3.7.1 Informing Public Health Authorities of Pertussis Cases
7.3.7.3 Exclusion for Pertussis (Whooping Cough)

REFERENCES

1. Centers for Disease Control and Prevention. Pertussis (whooping cough), postexposure antimicrobial prophylaxis, information for health professionals. CDC.gov Web site. Last reviewed November 18, 2019. Accessed March 1, 2022. https://www.cdc.gov/pertussis/pep.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fpertussis%2Foutbreaks%2Fpep.html

2. American Academy of Pediatrics. Section 3: Summaries of infectious disease, pertussis. In: Kimberlin DW, Barnett, ED, Lynfield R, Sawyer MH, eds. Red Book: 2021 Report of the Committee on Infectious Diseases. Elk Grove Village, IL: American Academy of Pediatrics; 2021:578-589

3. American Academy of Pediatrics. Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide. Aronson SS, Shope TR, eds. 5th ed. Itasca, IL: American Academy of Pediatrics; 2020

NOTES

Content in the standard was modified on 7/05/2022.

7.3.7.3: Exclusion for Pertussis (Whooping Cough)

Children and staff with pertussis (whooping cough) symptoms or diagnosis should be excluded from early care and education programs and be examined by a health care provider. 

Children and staff with suspected or diagnosed pertussis may return to their early care and education program when:^1–3

• They have completed 5 days of antibiotic treatment for pertussis.
• 21 days have passed from the start of a cough that is not treated with antibiotics.  
• Children are able to fully participate in the program.
• The child may be cared for without compromising the health and safety of the other children in the group.
  

Children and staff who are exposed to someone with pertussis, even if they do not have symptoms, should be evaluated by a health care provider to decide if vaccines, preventive antibiotic treatment, or temporary exclusion from a program are needed.^2–3 Once a pertussis diagnosis is confirmed in a program, local public health officials should be told. 

RATIONALE

Pertussis is a highly contagious respiratory infection that can cause serious symptoms in infants and young children, especially in those who have not completed the recommended pertussis vaccines. Temporary exclusion from early care and education programs and appropriate treatment of staff and children are essential to reduce the spread of the illness. Staff and children who are exposed, even if immunized, can spread pertussis and need examination/treatment by a health care provider.^2-3

COMMENTS

For more information on pertussis, please visit: https://www.cdc.gov/pertussis/index.html

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

7.2.0.3 Immunization of Staff
7.3.7.1 Informing Public Health Authorities of Pertussis Cases
7.3.7.2 Prophylactic Treatment for Pertussis (Whooping Cough)

REFERENCES

1. American Academy of Pediatrics. Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide. Aronson SS, Shope TR, eds. 5th ed. Itasca, IL: American Academy of Pediatrics; 2020

2. Centers for Disease Control and Prevention. Pertussis (whooping cough), post exposure antimicrobial prophylaxis, information for health professionals. CDC.gov Web site. Last reviewed November 18, 2019. Accessed December 7, 2021. https://www.cdc.gov/pertussis/pep.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fpertussis%2Foutbreaks%2Fpep.html

3. American Academy of Pediatrics. Chapter 3: Summaries of infectious disease, pertussis. In: Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH, eds. Red Book: 2021 Report of the Committee on Infectious Diseases. Elk Grove Village, IL: American Academy of Pediatrics; 2021:578-589

    

NOTES

Content in the standard was modified on 7/05/2022.

7.3.8.1: Attendance of Children with Respiratory Syncytial Virus Infection (RSV)

Respiratory syncytial virus (RSV) is a common cause of respiratory tract infection in infants and young children, but all ages can be infected. RSV infects most children at least once by the age of 2, and reinfection is common.¹

RSV causes mild symptoms in most people, usually for 5-7 days. But, RSV can lead to serious breathing problems in some children. RSV causes cold symptoms in the upper respiratory tract, which includes the nose, mouth, and throat. More serious respiratory symptoms may follow in the lungs. Young children who are sicker may also have trouble feeding (i.e., breastfeeding/chestfeeding, bottle feeding), have fewer wet diapers, be less active, or be more difficult to soothe.^1,2

RSV Symptoms in Young Children
Upper Respiratory Tract Infection	Lower Respiratory Tract Infection
Cold symptoms may include:  Runny nose  Poor feeding Decrease in appetite  Coughing  Sneezing  Fever  Fussiness	Symptoms may include cold symptoms plus:  Fast breathing  Flaring nostrils  Grunting noise with breathing  Head bobbing with breathing  Belly moving with breathing  Ribs pulling in while breathing  Wheezing

Outbreaks of RSV are common in early childhood programs. Children with diagnosed RSV infection may return to programs when:²

• The child can take part in all program activities.
• The child does not need more care than the staff can offer without putting the health and safety of other children at risk.
• Other exclusion criteria no longer apply.

For more information on inclusion and exclusion criteria for ill children, see Standard 3.6.1.1 Inclusion/Exclusion/Dismissal of Ill Children.

Early childhood programs can limit the spread of RSV by:²

• Using good hand hygiene practices
• Not allowing children to share food, bottles, toothbrushes, or mouthed toys
• Teaching children and staff to cover their coughs and sneezes
• Throwing away facial tissues after one use
• Cleaning and sanitizing surfaces regularly, and more often during outbreaks

 

RATIONALE

RSV is a well-known cause of respiratory tract illness in children and is more common in the winter and early spring.² RSV often causes cold-like symptoms in older children, and adults. In most younger children, RSV causes upper respiratory symptoms but can also cause lower respiratory tract infections including bronchiolitis and/or pneumonia in infants and young children under 2. Premature infants, infants or children with chronic heart and lung problems (i.e., asthma) and immunocompromised children may be at a higher risk for more severe illness. When a child has an RSV infection, programs should tell the parents or guardians of children who have a higher risk.

RSV spreads by droplets in the air from coughing and sneezing, contact with nose and mouth secretions, or contact with the virus on surfaces or objects such as tables.^1,2 The RSV virus can spread infection through nasal secretions and saliva for 3-4 weeks or longer.¹

It is important to prevent and reduce RSV infection in high-risk infants by educating parents, guardians, and staff about the importance of decreasing exposure to and transmission of RSV. Prevention may include limiting (when possible) exposure to contagious settings, using good hand hygiene, and avoiding contact with people with respiratory tract infections.

COMMENTS

For more information on RSV, see:

• CDC: https://www.cdc.gov/rsv/index.html

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

Appendix J: Selection and Use of a Cleaning, Sanitizing or Disinfecting Product
Appendix K: Routine Schedule for Cleaning, Sanitizing, and Disinfecting

REFERENCES

1. American Academy of Pediatrics. Section 3: Summaries of infectious disease, Respiratory Syncytial Virus. In: Kimberlin DW, Barnett, ED, Lynfield R, Sawyer MH, eds. Red Book: 2021 Report of the Committee on Infectious Diseases. Itasca, IL: American Academy of Pediatrics; 2021:628-638

2. American Academy of Pediatrics. Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide. Aronson SS, Shope TR, eds. 5th ed. Itasca, IL: American Academy of Pediatrics; 2020

NOTES

Content was modified on 3/30/2023.

7.3.9.1: Immunization with Streptococcus Pneumoniae Conjugate Vaccine (PCV13)

Pneumococcal conjugate (PCV13) vaccine is recommended for all children from two through fifty-nine months of age, including children in child care facilities. The vaccine is recommended to be administered at two, four, six, and twelve through fifteen months of age (1-3,5). Healthy children between twenty-four and fifty-nine months of age who are not immunized completely for their age should be administered one dose of PCV13 (3,5).

Children two years of age or older at high risk of invasive disease caused by Streptococcus pneumoniae (including sickle cell disease, asplenia, HIV, chronic illness, cochlear implant or immunocompromised) who have received their recommended doses of PCV should receive S. pneumoniae polysaccharide vaccine two or more months after receipt of the last dose of PCV (1-3,5).

RATIONALE

Appropriate immunization of children with S. pneumoniae conjugate vaccine prevents the occurrence of invasive disease and decreases transmission to others.

Pneumococcal disease among children including children in out-of-home child care due to strains in the PCV7 vaccine has decreased since introduction of PCV7 vaccine that was used until the licensure of PCV13 by the U.S. Food and Drug Administration (FDA) and recommended for use by the Advisory Committee on Immunization Practices (ACIP) and the American Academy of Pediatrics (AAP) (3-5). PCV13 provides protection from invasive disease from six additional pneumococcal serotypes. The risk of contacting invasive pneumococcal disease is highest in children less than sixty months of age. The risk for invasive disease is greatest in infants, young children, elderly people and children of some American Indian populations (2,3).

COMMENTS

The pneumococcal conjugate vaccine containing thirteen pneumococcal serotypes (PCV13) will expand coverage against six additional serotypes of S. pneumonia not contained in PCV7 (5).

For additional information regarding S. pneumoniae disease, consult the current edition of the Red Book from the AAP.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

REFERENCES

1. American Academy of Pediatrics, Committee on Infectious Diseases. 2000. Technical report: Prevention of pneumococcal infections, including the use of pneumococcal conjugate and polysaccharide vaccines and antibiotic prophylaxis. Pediatrics 106:367-76.
2. Centers for Disease Control and Prevention. 2000. Preventing pneumococcal disease among infants and young children: Recommendations of the Advisory Committee on Immunization Practices. MMWR 49 (RR09). http://www.cdc.gov/mmwr/pdf/rr/rr4909.pdf.
3. Centers for Disease Control and Prevention. 2008. Updated recommendation from the Advisory Committee on Immunization Practices for use of 7-valent pneumococcal conjugate vaccine (PCV7) in children aged 24-59 months who are not completed vaccinated. MMWR 57:343-44. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5713a4.htm.
4.  Centers for Disease Control and Prevention. 2010. Licensure of a 13-valent pneumococcal conjugate vaccine (PCV13) and recommendations for use among children – Advisory Committee on Immunization Practices, 2010. MMWR 59:258-61. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5909a2.htm.
5. American Academy of Pediatrics, Committee on Infectious Diseases. 2010. Policy statement: Recommendations for the prevention of Streptococcus pneumoniae infections in infants and children: Use of 13-valent pneumococcal conjugate vaccine (PCV13) and pneumococcal polysaccharide vaccine (PPSV23). Pediatrics 126:186-90.

7.3.9.2: Informing Public Health Authorities of Invasive Streptococcus Pneumoniae

Drug resistant invasive Streptococcus pneumoniae in all ages and all invasive (including non-drug resistant) S. pneumoniae in children younger than five years of age are designated as notifiable diseases at the national level. Local and/or state public health authorities should be notified about cases of invasive S. pneumoniae infections involving: children less than five years of age, caregivers/teachers in the child care setting, or drug resistant invasive S. pneumoniae disease in a person of any age.

Facilities should cooperate with their local or state health department officials in notifying parents/guardians of children who attend the facility about exposure to children with invasive S. pneumoniae disease. This may include providing local health officials with names and telephone numbers of parents/guardians 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 (1). Prophylaxis of contacts after the occurrence of a single case of invasive S. pneumoniae disease is not recommended.

Infants and young children who are not immunized or who are not age-appropriately immunized should receive a dose of PCV13 and should be scheduled for completion of the “Recommended Childhood Immunization Schedules” from the American Academy of Pediatrics (AAP), Centers for Disease Control and Prevention (CDC), and American Academy of Family Physicians (AAFP) to provide protection from invasive pneumococcal disease (2-6). (See Appendix G.)

COMMENTS

For additional information regarding S. pneumoniae disease, consult the current edition of the Red Book from the AAP.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

REFERENCES

1. Rauch, A. M., M. O’Ryan, R. Van, et al. 1990. Invasive disease due to multiply resistant Streptococcus pneumoniae in Houston, Texas day-care centers. Am J Dis Child 144:933-27.
2. American Academy of Pediatrics, Committee on Infectious Diseases. 2010. Policy statement: Recommendations for the prevention of Streptococcus pneumoniae infections in infants and children: Use of 13-valent pneumococcal conjugate vaccine (PCV13) and pneumococcal polysaccharide vaccine (PPSV23). Pediatrics 126:186-90.
3. Centers for Disease Control and Prevention. 2000. Preventing pneumococcal disease among infants and young children. MMWR 49 (RR09). http://www.cdc.gov/mmwr/pdf/rr/rr4909.pdf.
4. Centers for Disease Control and Prevention. 2008. Updated recommendation from the Advisory Committee on Immunization Practices for use of 7-valent pneumococcal conjugate vaccine (PCV7) in children aged 24-59 months who are not completed vaccinated. MMWR 57:343-44. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5713a4.htm.
5. Centers for Disease Control and Prevention. 2010. Licensure of a 13-valent pneumococcal conjugate vaccine (PCV13) and recommendations for use among children, 2010. MMWR 59:258-61. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5909a2.htm.
6. American Academy of Pediatrics, Committee on Infectious Diseases. 2000. Prevention of pneumococcal infections, including the use of pneumococcal conjugate and polysaccharide vaccines and antibiotic prophylaxis. Pediatrics 106:367-76.

7.3.10.1: Measures for Detection, Control, and Reporting of Tuberculosis

Tuberculosis is designated as a notifiable disease at the national level and local and/or state public health authorities should be notified immediately about suspected or confirmed cases of tuberculosis infection or disease involving children or caregivers/teachers in the child care setting. Facilities should collaborate with local or state health department officials to notify parents/guardians about potential exposures to people with tuberculosis disease. This may include providing the health department officials with identifying information from children in the child care facilities as well as adolescents and adults who may have had contact with child care attendees.

Transmission of tuberculosis infection should be controlled by requiring all adolescents and adults who are present while children are in care to have their tuberculosis status assessed with a tuberculin skin test (TST) or interferon-gamma release assay (IGRA) blood test before caregiving activities are initiated. In people with a reactive TST or positive IGRA, chest radiography without evidence of active pulmonary disease and/or documentation of completion of therapy for latent tuberculosis infection (LTBI) or completion of therapy for active disease should be required. These people should be cleared for employment by their primary care provider or a health department official. Review of the health status of any adolescent or adult with a child care contact with a reactive TST, a positive IGRA or tuberculosis disease in the past should be part of routine annual health appraisal (1,2).

Tuberculosis screening by TST or IGRA of staff members with previously negative skin tests should not be repeated on a regular basis unless a caregiver/teacher is at risk of acquiring a new infection or required by the local or state health department recommendations. Anyone who develops an illness consistent with tuberculosis should be evaluated promptly by a primary care provider. The need for additional testing beyond placement of a TST or IGRA in immunosupressed people and adults over sixty years of age will be at the recommendation of an individual’s primary care provider or the local or state health department. Staff members with previously reactive TSTs or positive IGRA should be under the care of a primary care provider 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 loss, unexplained fever, and other potential risk factors.

RATIONALE

Young children acquire tuberculosis infection usually from adults and rarely from adolescents (1,2). 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 via contact with objects such as clothes, dishes, floors, and furniture.

COMMENTS

The two stages of tuberculosis are:

1. Latent tuberculosis infection (LTBI), reflected by a reactive TST or IGRA and the absence of symptoms;
2. Active tuberculosis (tuberculosis disease), reflected by a reactive TST or IGRA and the presence of symptoms, including but not limited to cough, fever, and weight loss.

Virtually all tuberculosis is transmitted from adults and adolescents with tuberculosis disease. Infants and young children with active tuberculosis are not likely to transmit the infection to other children or adults because they generally are unable to forcefully cough out organisms into the air.

A TST should be placed and interpreted by an experienced health care professional. IGRA is only recommended for immunocompetent children four years of age and older, adolescents, and adults.

For additional information regarding tuberculosis, consult the current edition of the Red Book from the American Academy of Pediatrics (AAP).

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

7.3.10.2 Attendance of Children with Latent Tuberculosis Infection or Active Tuberculosis Disease

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. American Academy of Pediatrics. Tuberculosis 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: 829-853

7.3.10.2: Attendance of Children with Latent Tuberculosis Infection or Active Tuberculosis Disease

Children with active tuberculosis disease may attend group child care once effective therapy has been instituted, adherence to therapy has been documented, and clinical symptoms are absent. Local health officials or a primary care provider may recommend return to out-of-home child care once a child is considered non-infectious to others.

Children, adolescents, and adults with latent tuberculosis infection (LTBI) (reactive tuberculin skin test [TST] or a positive interferon-gamma release assay [IGRA] without evidence of active tuberculosis disease) may attend group child care. Appropriate therapy in consultation with a primary care provider is recommended to prevent progression to active tuberculosis disease (1).

RATIONALE

Efforts to prevent transmission of tuberculosis in child care should focus on permitting children with active tuberculosis disease to attend group child care only after the child is considered non-infectious to others. Children with latent tuberculosis are not infectious to others and may attend group child care but should receive appropriate therapy.

COMMENTS

For additional information regarding tuberculosis, consult the current edition of the Red Book from the American Academy of Pediatrics (AAP).

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

7.3.10.1 Measures for Detection, Control, and Reporting of Tuberculosis

REFERENCES

1. American Academy of Pediatrics. Latent Tuberculosis Infection 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: 829-853, 108-109, 182, 831 , 832-835, 835t, 836t

7.3.11.1: 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 (rhinorrhea), or ear infection (otitis media) should 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:
 
1.    The illness has a specified cause that requires exclusion, as determined by other specific performance
       standards in Child and Staff Inclusion/Exclusion/Dismissal, Standards 3.6.1.1-3.6.1.4;
2.    The illness limits the child’s comfortable participation in child care activities;
3.    The illness results in a need for more care than the staff can provide without compromising the health and
       safety of other children (1).
 
Treatment with antibiotics should not be required or otherwise encouraged as a condition for attendance of children with mild respiratory tract infections unless directed by the primary health care provider and/or local health officials.

RATIONALE

The incidence of acute diseases of the respiratory tract, including the common cold, croup, bronchitis, pneumonia, and ear infections (otitis media), is common in infants and young children, whether they are cared for at home or attend out-of-home facilities. However, children in child care experience more frequent respiratory tract infections when compared to children cared for at home (2). Infants and young children may have more upper respiratory infections when they first enter out-of-home group child care (1,2).
 
Routine hand hygiene and cough etiquette may reduce the incidence of most acute upper respiratory tract infections among children in child care. Frequently, infected children shed viruses before they are symptomatic, and some infected children never become overtly ill. Therefore, exclusion criteria based on symptoms will not reduce transmission of upper respiratory tract infections among child care attendees.
 
Parents/guardians may pressure their primary care provider to prescribe antibiotics because they believe that antibiotics will shorten the duration of exclusion from child care. Primary health care providers and caregivers/teachers should reinforce an understanding of the ineffectiveness of antibiotics on duration of viral upper respiratory tract infection and should attempt to ensure children remain in child care unless they meet exclusion criteria. Please reference Standard 3.6.1.1: Inclusion/Exclusion/Dismissal of Children for a comprehensive list of exclusion criteria. 

COMMENTS

Uncontrolled coughing, difficult or rapid breathing, and wheezing (if associated with difficult breathing) may represent severe illness requiring medical evaluation before readmission to the facility.
 
For additional information regarding unspecified respiratory tract infections, consult a child care health consultant, primary health care provider, and/or the local health department. For additional information, consult the current edition of the Red Book from the American Academy of Pediatrics (AAP) and Managing Infectious Diseases in Child Care and Schools (AAP).

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

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. 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. Dowell, S. M. Marcy, S. F., B. Schwartz, W. R. Phillips, et al. 1998. Principles of judicious use of antimicrobial agents for pediatric upper respiratory tract infections. Pediatrics 101:163-65.
   

4. 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: 140-141

NOTES

Content in the STANDARD was modified on 8/9/2017.

7.4.0.1: Control of Enteric (Diarrheal) and Hepatitis A Virus (HAV) Infections

Facilities should employ the following procedures, in addition to those stated in Child and Staff Inclusion/Exclusion/Dismissal, Standards 3.6.1.1-3.6.1.4, to prevent and control infections of the gastrointestinal tract (including diarrhea) or hepatitis A (1,2):
Exclusion:

a. Toilet trained children who develop diarrhea should be removed from the facility by their parent/guardian. Diarrhea is defined as stools that are more frequent or less formed than usual for that child and not associated with changes in diet.

c. Decisions about caring for the child while awaiting parent/guardian pick-up should be made on a case-by-case basis providing care that is comfortable for the child considering factors such as the child's age, the surroundings, potential risk to others and the type and severity of symptoms the child is exhibiting. The child should be supervised by someone who knows the child well and who will continue to observe the child for new or worsening symptoms. If symptoms allow the child to remain in their usual care setting while awaiting pick-up, the child should be separated from other children by at least 3 feet until the child leaves to help minimize exposure of staff and children not previously in close contact with the child. All who have been in contact with the ill child must wash their hands. Toys, equipment, and surfaces used by the ill child should be cleaned and disinfected after the child leaves.
d. Caregivers/teachers with diarrhea as defined in Standard 3.6.1.2 should be excluded. Separation and exclusion of children or caregivers/teachers should not be deferred pending health assessment or laboratory testing to identify an enteric pathogen.
e. Exclusion for diarrhea should continue until  diapered children have their stool contained by the diaper (even if the stools remain loose), when toilet-trained children are not having “accidents”, and when stool frequency is no more than 2 stools above normal for that child during the time in the program day.
f.  Exclusion for hepatitis A virus (HAV) should continue for one week after onset of illness and after all contacts have received vaccine or immune globulin as recommended.
g. Alternate care for children with diarrhea or hepatitis A should be provided in facilities for children who are ill that can provide separate care for children with infections of the gastrointestinal tract (including diarrhea) or hepatitis A.

Informing parents/guardians and public health:

a. The local health department should be informed immediately of the occurrence of HAV infection or an increased frequency of diarrheal illness in children or staff in a child care facility.
b. If there has been an exposure to a person with hepatitis A or diarrhea in the child care facility, caregivers/teachers should inform parents/guardians, in cooperation with the health department, that their children may have been exposed to children with HAV infection or to another person with a diarrheal illness.
c. If a child or staff member is confirmed to have hepatitis A disease (HAV), all other children and staff in the group should be checked to be sure everyone who was exposed has received the hepatitis A vaccine or immune globulin within 2 weeks of exposure.  

Return to Care:

a. Children can be readmitted when they are able to fully participate in program activities without the caregivers/teachers having to compromise their ability to care for the health and safety of other children in the group.
b. Children and caregivers/teachers 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, Shiga toxin-producing Escherichia. coli (STEC),or Salmonella enterica serotype Typhi. For Shigella and STEC, resolution of symptoms and two negative stool cultures are required for readmission, unless state requirements differ. For Salmonella serotype Typhi, resolution of symptoms and three negative stool cultures are required for return to child care. For Salmonella species other than serotype Typhi, documentation of negative stool cultures are not required from asymptomatic people for readmission to child care.

RATIONALE

Intestinal organisms, including HAV, cause disease in children, caregivers/teachers, and close family members (1,2). 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 intestinalis, Shigella, and Cryptosporidium have been the main organisms implicated in outbreaks
Caregivers/teachers should always 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. Contamination of hands, communal toys, and other classroom objects is common and plays a role in transmission of enteric pathogens in child care facilities.
Studies frequently find that fecal contamination of the environment is common in centers and is highest in infant and toddler areas, where diarrhea or hepatitis A are known to occur most often. Studies indicate that the risk of diarrhea is significantly higher for children in centers than for age-matched children cared for at home or in small family child care homes. The spread of infection from children who are not toilet trained to other children in child care facilities, or to their household contacts is common, particularly when Shigella, rotavirus, Giardia intestinalis, Cryptosporidium, or HAV are the causal agents (1,2).
With recommendations for administration of rotavirus vaccine between two and six months of age and 2 doses of hepatitis A vaccine given at least 6 months apart between 12 and 23 months, rates of disease due to rotavirus and hepatitis A have decreased.
To decrease diarrheal disease in child care due to all pathogens, staff and parents/guardians must be educated about modes of transmission as well as practical methods of prevention and control. Staff training in hand hygiene, combined with close monitoring of compliance, is associated with a significant decrease in infant and toddler diarrhea (1,2). Staff training on a single occasion, without close monitoring, does not result in a decrease in diarrhea rates; this finding emphasizes the importance of monitoring as well as education. Therefore, appropriate hygienic practices, hygiene monitoring, and education are important in limiting diarrheal infections and hepatitis. Asymptomatic children can still easily transmit infection to susceptible adults who often develop signs and symptoms of disease and may become seriously ill.

COMMENTS

Sample letters of notification to parents/guardians that their child may have been exposed to an infectious disease are contained in the current publication of the American Academy of Pediatrics (AAP), Managing Infectious Diseases in Child Care and Schools. For additional information regarding enteric (diarrheal) and HAV infections, consult the current edition of the Red Book, also from the AAP.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

Appendix A: Signs and Symptoms Chart
Appendix G: Recommended Childhood Immunization Schedule

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. 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

   
   
3. American Academy of Pediatrics. Hepatitis A Virus (HAV) 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: 392-400

NOTES

Content in the STANDARD was modified on 4/5/2017.

7.4.0.2: Staff Education and Policies on Enteric (Diarrheal) and Hepatitis A Virus (HAV) Infections

Diarrheal (enteric) infections are illnesses where someone develops more watery or more frequent stools than what is normal for them. Diarrhea is caused by intestinal infections and is more common in early care and education programs because these infections spread easily through diapering, poor hand hygiene, and toileting.¹ These infections can cause outbreaks in early care and education programs. To prevent and control the spread of diarrheal infections and hepatitis A, programs should follow procedures and have staff education that includes

• Routine education for staff, food handlers, and maintenance workers on proper hand hygiene, proper food preparation and storage, proper diapering, and cleaning, sanitizing, and/or disinfecting surfaces and materials.^2–3 
• Regular staff education on how to decrease spread of diarrheal illness through information on
  • How germs that cause diarrheal illnesses and hepatitis A are spread
  • Symptoms of diarrheal illness and hepatitis A
  • How to prevent spread of diarrheal illness and hepatitis A
• Proper use and cleaning of water play materials³
• Information on appropriate choice of and handling of animals in programs⁴
• Guidelines for routine administration of hepatitis A and rotavirus vaccines should be enforced to prevent infection and spread in programs.³

At least annually, early care and education programs should review all procedures for preventing diarrheal infections. All staff, food handlers, and maintenance workers should review procedures on preventing diarrheal infections. Staff should review age-specific criteria for inclusion and exclusion of children who have a diarrheal illness or hepatitis A, and infection control procedures.

RATIONALE

Viruses, bacteria, and parasites in stool can cause disease in children and staff in early care and education programs. Infections are spread in these settings from contact with stool during diapering and toileting. Although many intestinal infections can cause diarrhea, rotavirus, other intestinal viruses, Giardia intestinalis, Cryptosporidium, shigella, and E. coli are the most common causes of outbreaks in children in early care and education programs.³ Proper diapering and toileting, and infection control measures can reduce infections.⁴ Following program procedures and regular staff education can reduce spread of diarrheal illnesses.

Routine childhood vaccination for rotavirus and hepatitis A have decreased outbreaks from these viruses.¹ Children and staff in early care and education programs should receive all recommended age-appropriate vaccines. Staff should watch children for signs of disease to detect it early and to carry out steps to control it. Programs should consult the local health department to find out if the increased frequency of diarrheal illness needs public health intervention.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

7.4.0.1 Control of Enteric (Diarrheal) and Hepatitis A Virus (HAV) Infections
Appendix G: Recommended Childhood Immunization Schedule
Appendix H: Recommended Adult Immunization Schedule
Appendix K: Routine Schedule for Cleaning, Sanitizing, and Disinfecting

REFERENCES

1. American Academy of Pediatrics. Section 2: Recommendation for care of children in special circumstances; children in group childcare and schools. In: Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH, eds. Red Book: 2021 Report of the Committee on Infectious Diseases. Elk Grove Village, IL: American Academy of Pediatrics; 2021:117-118. 

2. American Academy of Pediatrics. Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide. Aronson SS, Shope TR, eds. 6th ed. 2022.

3. Collins JP, Shane AL. Infections associated with group childcare. Principles and Practice of Pediatric Infectious Diseases. 5^th ed. 2018;25–32.e3. doi.org/10.1016/B978-0-323-40181-4.00003-7

4. Shane AL, Mody RK, Crump JA, et al. Infectious Diseases Society of America clinical practice guidelines for the diagnosis and management of infectious diarrhea. Clinical Infectious Diseases. 2017;65(12):e45-e80. doi.org/10.1093/cid/cix669

NOTES

Content in the STANDARD was modified on 4/5/2017 and 09/13/2022.

7.4.0.3: Reporting Requirements for Diarrheal Infections

Diarrheal infections are more common in early care and education programs because infection is spread through diapering, poor hand hygiene, and toileting.¹ Certain infections can cause outbreaks in programs. If a program has a diarrhea outbreak (more than two children or staff) or a child or staff member has been diagnosed with hepatitis A or diarrheal infection¾including Shiga toxin-producing E. coli (STEC), shigella, salmonella, campylobacter, Giardia intestinalis, or Cryptosporidium¾programs should^1–2

• Tell the program’s child health consultant who can give guidance.
• Report the infection to the state, local, tribal, or territorial health department.
• Work with the health department to tell parents/guardians and staff about exposure and any treatment that is needed to control spread in early care and education programs.
• Watch exposed children for signs of illness, and refer them to medical care if symptoms develop.

RATIONALE

Viruses, bacteria, and parasites in stool can cause disease in children and staff in early care and education settings. Infections spread in these settings from contact with stool during diapering and toileting and from poor hand hygiene. Although many intestinal infections can cause diarrhea, rotavirus, other intestinal viruses, Giardia intestinalis, Cryptosporidium, shigella, and E. coli are the most common causes of outbreaks in children in early care and education settings.³ Routine childhood vaccination for rotavirus and hepatitis A have decreased outbreaks from these viruses.¹ All children and staff in early care and education programs should receive all recommended age-appropriate vaccines. Staff should watch children for signs of disease to detect it early and to carry out steps to control it. Programs should consult the local health department to find out if the increased frequency of diarrheal illness needs public health intervention.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

7.4.0.1 Control of Enteric (Diarrheal) and Hepatitis A Virus (HAV) Infections
7.4.0.2 Staff Education and Policies on Enteric (Diarrheal) and Hepatitis A Virus (HAV) Infections
7.4.0.4 Maintenance of Records on Incidents of Diarrhea
Appendix G: Recommended Childhood Immunization Schedule

REFERENCES

1. American Academy of Pediatrics. Section 2: Recommendation for care of children in special circumstances; children in group childcare and schools. In: Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH, eds. Red Book: 2021 Report of the Committee on Infectious Diseases. Elk Grove Village, IL: American Academy of Pediatrics; 2021:117-118. 

2. American Academy of Pediatrics. Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide. Aronson SS, Shope TR, eds. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2022.

3. Collins JP, Shane AL. Infections associated with group childcare. Principles and Practice of Pediatric Infectious Diseases. 5^th ed. 2018;25–32.e3. doi.org/10.1016/B978-0-323-40181-4.00003-7

NOTES

STANDARD was last modified on 09/13/2022.

7.4.0.4: Maintenance of Records on Incidents of Diarrhea

The facility should maintain a record of children and caregivers/teachers who have diarrhea while at home or at the facility. This record should include:

1. The child or caregiver’s/teacher’s name;
2. Dates the child or caregiver/teacher is ill;
3. Reason for diarrhea, if known;
4. Whether the child or caregiver/teacher was in attendance at the child care facility during the diarrhea episode;
5. Any leakage of feces from the diaper while the child was in attendance at the child care facility.

Infection with certain enteric diseases or pathogens (cryptosporidiosis, giardiasis, hepatitis A virus [HAV], salmonellosis, Shiga toxin-producing E. coli [STEC], shigellosis) is designated as notifiable at the national level. The facility should 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) with diarrhea within the facility within a two-week period or occurrence of an enteric agent which is notifiable at the national level.

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/guardian 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. Cases of these infections in household contacts may require questioning about illness in the child attending child care, testing the child for infection, and possible use of hepatitis A vaccine or immune globulin in contacts. Information concerning infectious 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/guardians with children in the facility.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

7.5.1.1: Conjunctivitis (Pinkeye)

Conjunctivitis (pinkeye), defined as redness and swelling of the covering of the white part of the eye (1), may result from a number of causes. Bacteria, viruses, allergies, chemical reactions, and immunological conditions may manifest as redness and discharge from one or both eyes. Management of pinkeye should involve frequent hand hygiene to prevent the spread (1). Children and staff with conjunctivitis (pinkeye) should not be excluded from child care unless:

1. They are unable to participate in activities;
2. Care for other children would be compromised because of the care required by the child with conjunctivitis;
3. The person with conjunctivitis meets any of the following exclusion criteria outlined in Standard 3.6.1.1; or                  
4. A health care professional or health department recommends exclusion of the person with conjunctivitis.

Children and staff in close contact with a person with conjunctivitis should be observed for symptoms and referred for evaluation, if necessary. If two or more children in a group care setting develop conjunctivitis in the same period, seek advice from the program’s child care health consultant or public health authority about how to prevent further spread (1). Children who have severe prolonged symptoms should be evaluated by their primary care provider (1)

RATIONALE

Hand contact with eye, nose, and oral secretions is the most common way that organisms causing conjunctivitis are spread from person to person. Careful hand hygiene and sanitizing of surfaces and objects exposed to infectious secretions are the best ways to prevent spread.
Conjunctivitis may be caused by both infectious and non-infectious conditions. The length of time that a person is considered contagious due to a bacterial or viral conjunctivitis depends on the organism. Antibiotic eye drops and oral medications may decrease the time that a person is considered to be contagious from a bacterial conjunctivitis. For viral conjunctivitis, the contagious period continues while the signs and symptoms are present (1). 

COMMENTS

Occasionally, conjunctivitis might occur in several children at the same time or within a few days of each other. Some children with conjunctivitis may have other symptoms including fever, nasal congestion, respiratory, and gastrointestinal tract symptoms.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

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.

NOTES

Content in the STANDARD was modified on 3/31/17.

7.5.2.1: Enterovirus Infections

Enterovirus is a form of severe respiratory illness (1). Enteroviruses may cause one or more symptoms including cough, strep throat (pharyngitis), mouth sores or ulcers, chest pain, rashes, headaches, diarrhea, muscle aches, and pink eye (conjunctivitis). These symptoms usually are accompanied by fever. A common enterovirus infection in young children is “hand-foot-and-mouth disease” in which fever and blister-like eruptions in the mouth and/or a rash (usually on the palms and soles) may occur.
Children and staff with enterovirus infections should not be excluded from child care unless:

1. They are unable to participate in activities;
2. Care for others would be compromised because of the care that the child with enterovirus requires;
3. The person infected with enterovirus has fever or a change in behavior;
4. A health care professional or health department recommends exclusion of the individual(s) with enterovirus infections.

Children and staff in close contact with an infected person should be observed for symptoms of enterovirus infections and referred for evaluation, if indicated.
Supportive care, proper cough and sneeze etiquette, frequent hand hygiene, disposal of facial tissues that contain nasal secretions after each use, and sanitizing surfaces and objects potentially exposed to infectious secretions, are recommended methods for preventing further spread of the infection (2,3).  For people with severe or prolonged symptoms, an evaluation by a primary health care provider may be necessary.

RATIONALE

Enterovirus infections are common in children and may be spread by fecal-oral contact and contact with body fluids and secretions (1-3). Enteroviruses may survive for prolonged periods on environmental surfaces. There is no specific treatment for enterovirus infections (4). Shedding of enteroviruses in respiratory and gastrointestinal tract secretions may occur after symptoms have resolved. Shedding from the gastrointestinal tract of previously infected individuals may be prolonged. Therefore, meticulous hand hygiene following toilet use and diaper changing activities should be practiced (4). 

COMMENTS

Occasionally, enterovirus infections might occur in several children at the same time or within a few of days of each other. Consultation with a child care health consultant and the local health department may be sought when several children have signs and symptoms of an enterovirus infection.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

Appendix K: Routine Schedule for Cleaning, Sanitizing, and Disinfecting

REFERENCES

1. U.S. Department of Health and Human Services, Administration for Children and Families, Head Start. Early childhood health and wellness - Enterovirus. 2016. https://eclkc.ohs.acf.hhs.gov/physical-health/article/enterovirus.  
   
2. 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.

3. American Academy of Pediatrics. Enterovirus D68 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: 331-334, 658, 692

4. U.S. Centers for Disease Control and Prevention. 2016. Non-polio enterovirus: Prevention & treatment. https://www.cdc.gov/non-polio-enterovirus/about/prevention-treatment.html.      

NOTES

Content in the STANDARD was modified on 8/9/2017.

7.5.3.1: Human Papillomaviruses (HPV) (Warts)

Children and staff with warts should not be excluded from child care.

Human papillomaviruses (HPV) cause a number of skin and mucous membrane infections; the most common infection is the skin wart. These dome shaped, sometimes conical lesions generally appear on fingers, hands, feet, and face. HPV that causes these lesions are spread via person to person contact. However they are not very contagious. Warts do not require covering with an occlusive dressing. Hand hygiene should be regularly practiced to reduce opportunities for transmission of HPV (1,2).

RATIONALE

The length of time that an individual with a skin wart is considered contagious varies. However the presence of a wart likely represents an opportunity for transmission. The time from contact to the appearance of a wart may vary from months to years. In addition to hand hygiene after contact with warts, sharing of clothing and towels should be avoided. People with warts should be discouraged from touching and scratching warts.

COMMENTS

The HPV that causes skin warts differs from the HPV that causes genital warts and cervical cancer. Treatments of skin warts including liquid nitrogen and topical antiviral agents may result in earlier clearance of warts; however, warts may reappear, requiring additional treatments. Over time, most warts disappear without treatment. The appearance of skin warts is a common occurrence; immunocompromised people may have more lesions that may be present for an extended duration. The HPV vaccine does not prevent or treat skin warts.

For more information, consult the current edition of the Red Book from the American Academy of Pediatrics (AAP).

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

REFERENCES

1. American Academy of Pediatrics. Human Papillomaviruses (HPV) 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: 582-590
2. 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.

7.5.4.1: Impetigo

Impetigo is a common skin infection caused by bacteria. Lesions can be small, red, fluid-filled blisters or red with yellow crusting. When children or staff have lesions that look like impetigo, early care and education programs should:^1–2

• Wash the affected skin areas and cover lesions with a dressing 
• Practice good hand hygiene 
• Clean and sanitize toys, surfaces, or equipment the infected staff or child has touched
• Wash contaminated clothing or sheets
• Tell the family/guardian, and encourage the child or staff to see their health care provider
  

Children or staff with impetigo may stay in the program until the end of the day as long as lesions can be covered. No exclusion is needed if they start medical treatment before they return to the program and lesions are covered while at the program. Children and staff in close contact with an infected person should watch for symptoms of impetigo and be evaluated by a health care provider if they develop symptoms. The local health department should be told if several children develop impetigo.^1–2

RATIONALE

Impetigo is a skin infection caused by bacteria that commonly live on the skin. It is common among young children whose hand hygiene may not be adequate and is caused when the bacteria enter the skin through a sore or opening. The bacteria may spread from contact with another person with impetigo lesions, from sores on one’s own skin on a different part of the body, or from contact with surfaces that have bacteria. Programs should document when children or staff have been infected with impetigo, and parents/guardians of the child should be told to get medical care. When there is an impetigo infection within the program, careful hand hygiene and sanitizing surfaces and objects that have been touched by the infected person are the best ways to prevent spread.¹

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

Appendix A: Signs and Symptoms Chart

REFERENCES

1. American Academy of Pediatrics. Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide. Aronson SS, Shope TR, eds. 5th ed. Itasca, IL: American Academy of Pediatrics; 2020
2. American Academy of Pediatrics. Section 2: Recommendation for care of children in special circumstances; children in group childcare and schools. In: Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH, eds. Red Book: 2021 Report of the Committee on Infectious Diseases. Elk Grove Village, IL: American Academy of Pediatrics; 2021:128. 

NOTES

Content in the standard was modified on 7/05/2022.

7.5.5.1: Lymphadenitis

When children or staff with lymphadenitis are identified:

1. They should undergo evaluation by a primary care provider to attempt to assess an infectious etiology, if one has not been defined previously;
2. The child should be excluded from child care, if care for others would be compromised by the care required by the child with lymphadenitis;
3. If the child with lymphadenitis has fever or a change in behavior, the child should be excluded until evaluated;
4. Exclusion should occur if a health care professional or health department official recommends this action.

Children and staff in close contact with an affected child should be observed for symptoms of infection and referred for evaluation, if indicated. The local health department should be notified if a caregiver/teacher has a concern that several children have symptoms of lymphadenitis.

Lymphadenitis, an inflammation and generally an enlargement of one or more lymph nodes (glands), may result from both non-infectious and infectious causes. Lymphadenopathy is an enlargement of a lymph node without inflammation. The most common infectious sources of lymphadenitis are bacteria and viruses, with fungi and parasites accounting for fewer infections. Lymphadenitis in children usually is acute, with rapid onset and symptoms involving the lymph nodes of the head and neck. Lymph nodes in other sites, including the groin and on one or both sides of the body may be affected. The affected lymph node(s) may be swollen with areas of redness overlying the swelling and may be painful to touch. In some cases a “chain” of lymph nodes may be palpated. The inflammation of one or more lymph nodes may represent an infectious etiology. Evaluation by a primary care provider may be indicated to define the underlying etiology and to assess potential for transmission and need for treatment.

RATIONALE

Lymphadenitis is a common presentation of a number of infectious and non-infectious etiologies. Most types of infectious lymphadenitis may be described as acute and bilateral, acute and unilateral, and subacute or chronic (1). It is helpful to categorize lymphadenitis because certain infectious organisms are more likely to be associated with one of the three categories. It also is important to identify the infectious organism responsible for the lymphadenitis because this information has implications for management and treatment, including child care inclusion and exclusion policies. Careful hand hygiene and disinfection of surfaces and objects potentially exposed to infectious material are the best ways to prevent spread. The presence of children with lymphadenitis should be noted by caregivers/teachers, and parents/guardians of children should be notified to seek care, if indicated.

COMMENTS

Occasionally, lymphadenitis might occur in several children or staff members at the same time or within a few of days of each other.

For more information, consult the current edition of the Red Book from the American Academy of Pediatrics (AAP).

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

REFERENCES

1. Thorrell, E. A., P. J. Chesney. 2008. Cervical lymphadenitis and neck infections. In Principles and practice of infectious diseases, eds. S. S. Long, L. K. Pickering, C. G. Prober. 3rd ed. Philadelphia: Churchill Livingstone.

7.5.6.1: Immunization for Measles

All children in a child care facility should have received age-appropriate immunizations with measles, mumps, and rubella (MMR) vaccine or with measles, mumps, rubella, and varicella (MMRV) vaccine (1). If a case of measles occurs in a child care setting, interrupting subsequent spread depends on prompt immunization of people at risk of exposure or people already exposed who cannot provide documentation of measles immunity, including date of immunization. Children and adults in child care who are not immunized or not age-appropriately immunized against measles should be excluded from care immediately if the child care facility has been notified of a documented case of measles occurring in a child or adult in the center. These children should not be allowed to return to the facility until at least two weeks after the onset of rash in the last case of measles, as determined by health department officials.

Adults born before 1957 can be considered immune to measles. Adults born during or after 1957 should receive one or more doses of MMR vaccine unless they have a medical contraindication, documentation of one or more dose of vaccine, history of measles based on primary care provider diagnosis, or laboratory evidence of immunity.

RATIONALE

Measles is one of the most highly infectious of all infections transmitted by direct contact with infectious droplets or by airborne spread (2). Outbreaks of measles have been reported in unimmunized populations. Transmission to unimmunized people in the U.S. from importation of measles by international travelers occurs on a regular basis (2). Appropriate immunization of children and adults with MMR vaccine prevents the occurrence of measles disease (2). Any case of measles identified in a child or adult in a child care setting should be reported to local or state health department officials immediately (2).

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

REFERENCES

1. American Academy of Pediatrics. Immunizations in special clinical circumstances.  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: p. 105-106

2. 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.

7.5.7.1: Molluscum Contagiosum

Molluscum contagiosum is a skin disease, similar to warts, that causes one or more flesh-colored, translucent lesions with small indentations. Some lesions also have an eczema-like appearance to their outer edge. The virus that causes molluscum contagiosum is spread by person-to-person contact. It also may be transmitted by sharing towels and clothing containing residual virus acquired by contact with the lesions of an infected person. The virus may be spread to other sites by scratching and manipulating lesions. Clusters of molluscum-associated lesions commonly occur on the trunk, extremities, and face. People with eczema or who are immunocompromised may have more extensive lesions that are present for prolonged periods of time (1).

The virus causing these lesions is spread via person-to-person or person-to-object-to person; however, it is not very contagious. Despite its name, it is more likely that a person will spread the virus to a site on his or her body than to another individual. Lesions do not require covering with a dressing. Hand hygiene should be regularly practiced to reduce opportunities for transmission of the virus causing molluscum contagiosum.

Children and staff with molluscum contagiosum should not be excluded from child care (2).

RATIONALE

The length of time that a person with a molluscum contagiosum lesion is considered contagious varies; however, the presence of a lesion likely represents an opportunity for transmission. The time from contact to the appearance of a lesion or lesions may vary from weeks to months. In addition to hand hygiene after contact with lesions, sharing of clothing and towels should be avoided. People with molluscum contagiosum should be discouraged from touching and scratching their lesions (2).

COMMENTS

Molluscum contagiosum lesions may be pruritic (itchy), resulting in release of virus from and introduction of bacteria into the area. The application of a bag filled with ice may reduce the urge to scratch. Treatment of lesions is a cosmetic issue and does not usually affect resolution. Over time, lesions disappear without treatment.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

7.5.3.1 Human Papillomaviruses (HPV) (Warts)

REFERENCES

1. American Academy of Pediatrics. Molluscum contagiosum 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: 565-566

2. 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.

7.5.8.1: Attendance of Children with Head Lice

Children should not be excluded immediately or sent home early from early care and education due to the presence of head lice (1). If head lice are present, children should avoid any head-to-head contact with other children and should avoid the sharing of any headgear while finishing out the day (2).

Parents/guardians of affected children should be notified and informed that their child must be treated before returning to the child care facility. Parents/guardians should be encouraged to follow Integrated Pest Management (IPM) best practices, which entails using the least hazardous means to control pests, including head lice. Pesticides (such as pediculicide, an agent used to destroy lice) are applied according to the manufacturer’s instructions and in a manner that minimizes skin contact, and inhalation (3). In addition to treating the affected child with a pediculicide, machine wash and dry clothing, bed linens and other items that the infested child wore or used during the two days before the treatment with the pediculocide. Use the hot water (130 degrees F) laundry cycle and the high heat drying cycle. Clothing and items that are not washable can be dry cleaned or seal these items in a plastic bag for two weeks. Soak combs and brushes in hot water (at least 130 degrees F) for 5-10 minutes. Vacuum the floor and furniture, particularly where the infested child sat or lay, recognizing that the risk of getting infested by a louse that fell onto a rug, carpet or furniture is very low (3).

Children and staff who have been in close contact with an affected child should be examined and treated if infested, defined as the presence of adult lice or nits (eggs) on a hair shaft within three to four millimeters from the scalp. Do not use fumigant sprays; they can be toxic if inhaled or absorbed through the skin (3). 

RATIONALE

Head lice infestation in children attending child care is common and is NOT a sign of poor hygiene. Transmission occurs by direct contact with hair of infested people and less commonly by direct contact with personal items of infested people. Head lice survive less than one to two days if they fall off a person and cannot feed; nits cannot hatch and usually die within a week if they are not kept at the same temperature as that found close to the human scalp. Head lice are not responsible for the spread of any disease, only the discomfort of infestations. The institution of “no-nit” policies before permitting return of an infested child to child care or school are not effective in controlling transmission (1,3).

Child care programs should not institute a “no-nit” policy.

COMMENTS

Treatments for head lice generally are safe and effective when used as directed. Some treatments may cause an itching or a burning sensation of the scalp. Most products used to treat head lice are pesticides that can be absorbed through the skin. Therefore, all medicines used for treatment of lice should be used with care and only as directed. Although not medically necessary, removal of nits that are attached within one centimeter of the base of the hair shaft may be manually performed (1). Removing the nits may help in situations where outbreaks are occurring in the group to determine whether a child who has been treated became reinfested after treatment or merely has residual non-viable nits. Utilize your child care health consultant to help with this issue. In addition, the following resources may be useful to help with education and information about treatment from the CDC, AAP and the California Child Care Program: http://www.cdc.gov/parasites/lice/head/treatment.html, http://www.healthychildren.org/English/health-issues/conditions/from-insects-animals/Pages/Signs-of-Lice.aspx, and http://cchp.ucsf.edu/sites/cchp.ucsf.edu/files/HeadLice_FCCH_IPM.pdf.
 

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

REFERENCES

1. U.S. Centers for Disease Control and Prevention. 2015. Head lice information for schools. http://www.cdc.gov/parasites/lice/head/schools.html.
   
2. 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.
   
3. U.S. Centers for Disease Control and Prevention. 2015. Parasites - lice - head lice. Treatment. http://www.cdc.gov/parasites/lice/head/treatment.html. 
   
4. American Academy of Pediatrics, Council on School Health, Council on Infectious Diseases. 2015: Head lice. Pediatrics 135(5):http://pediatrics.aappublications.org/content/135/5/e1355.
   

NOTES

Content in the STANDARD was modified on 8/25/2016.

7.5.9.1: Attendance of Children with Ringworm

Children with ringworm of the scalp (tinea capitis) or body (tinea corporis) should receive appropriate treatment. Children receiving treatment should not be excluded from child care.

Children and staff in close contact with an affected child should receive periodic inspections for early lesions and should receive therapy, if lesions are noted. Contact with lesions should be avoided. Dry coverings over treated lesions should be encouraged.

RATIONALE

Ringworm infections result 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 requires oral medicine for four to six weeks (1). Treatment of ringworm of the body requires topical medicine for a minimum of four weeks (2). Oral therapy is available if lesions are extensive or unresponsive to topical therapy. Direct contact with sources of ringworm should be avoided to prevent transmission (1,2).

COMMENTS

Personal items should not be shared. The lesion resulting from the fungal infection is usually circular (hence the term “ringworm”) but other non-fungal and non-infectious rashes may have a similar appearance. People receiving oral treatment for ringworm of the scalp may attend child care or school. Haircuts, shaving of the scalp, and wearing of head coverings are not indicated for treatment of tinea capitis. Using long sleeves or long pants to cover extremity lesions is sufficient to reduce the shedding of spores and transfer of topical medications from the sores to surfaces in the child care facility.

For additional information regarding ringworm, consult the current edition of the Red Book from the American Academy of Pediatrics (AAP).

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

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. American Academy of Pediatrics. Ringworm 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: 124t, 128

7.5.10.1: Staphylococcus Aureus Skin Infections Including MRSA

The following should be implemented when children or staff with lesions suspicious for Staphylococcus aureus infections are identified:

1. Lesions should be covered with a dressing;
2. Report the lesions to the parent/guardian with a recommendation for evaluation by a primary care provider; and
3. Exclusion is not warranted unless the individual meets any of the following criteria:
   1. Care for other children would be compromised by care required for the person with the S. aureus infection;
   2. The individual with the S. aureus infection has fever or a change in behavior;
   3. The lesion(s) cannot be adequately covered by a bandage or the bandage needs frequent changing; and
   4. A health care professional or health department official recommends exclusion of the person with S. aureus infection (1).

Meticulous hand hygiene following contact with lesions should be practiced (1). Careful hand hygiene and sanitization of surfaces and objects potentially exposed to infectious material are the best ways to prevent spread. Children and staff in close contact with an infected person should be observed for symptoms of S. aureus infection and referred for evaluation, if indicated.

A child may return to group child care when staff members are able to care for the child without compromising their ability to care for others, the child is able to participate in activities, appropriate therapy is being given, and the lesions can be covered (1).

S. aureus skin infections initially may appear as red raised areas that may become pus-filled abscesses or “boils,” surrounded by areas of redness and tenderness. Fever and other symptoms including decreased activity, bone and joint pain, and difficulty breathing may occur when the infection occurs in other body systems. If any of these signs or
symptoms occur, the child should be evaluated by his/her primary care provider.

RATIONALE

S. aureus (also known as “Staph”) is a bacterium that commonly causes superficial skin infections (cellulitis and abscesses). It also may cause muscle, bone, lung, and blood (invasive) infections. One type of S. aureus, called methicillin-resistant S. aureus or “MRSA,” is resistant to one or more classes of antibiotics. S. aureus and MRSA have been the source of attention due to increasing rates of infections from these bacteria associated with health care associated (HCA) infections and in healthy children and adults in the community. Transmissibility and infectivity is comparable to infections with S. aureus without methicillin resistance. Therefore signs and symptoms, incubation and contagion periods, control of spread, and exclusion guidelines are identical for all S. aureus infections, including infections with methicillin resistance or MRSA (1,2).

Most people with skin infections due to S. aureus do not develop invasive infections; they may experience recurrent skin infections. Infants and children who are diapered and pre-adolescents and adolescents who participate in team sports may have an increased risk for developing S. aureus skin infections. This is likely due to frequent breaks of skin and the sharing of towels. The incubation period for S. aureus skin infections is unknown. Some people may carry MRSA without having symptoms of active infection. These people are considered to be “colonized” with S. aureus; however, they are not considered to be infectious when they do not have active infection.

S. aureus skin infections may occur at sites of skin trauma. Pus and other material draining from skin lesions should be considered to be infectious. Treatment of S. aureus skin infections may be accomplished with an oral or an intravenous antibiotic or a combination of both. In some cases, incision and drainage of the lesion(s) alone may be required. In other instances, incision and drainage of smaller lesions with the use of a topical antibiotic may result in a cure. Skin lesions are considered to be infectious until they have healed; therefore, they should be kept covered and dry. Frequent hand hygiene to prevent spread of S. aureus should be practiced at home and in child care (1). Evaluation by a primary care provider in people with severe or prolonged symptoms may be indicated.

COMMENTS

S. aureus skin infections are common, especially among infants wearing diapers and adolescent members of sports teams. Infections may be more common among children where other family members have or have had skin lesions and during the warmer months when skin exposure to trauma may be increased. Shedding of bacteria from skin lesions may occur until the lesion has healed. Occasionally S. aureus infections may occur in several children at the same time or within a few of days of each other. Consultation with a health care professional and the local health department may be sought when several people have these symptoms.

For additional information for parents/guardians and caregivers/teachers, refer to information posted by the Centers for Disease Control and Prevention (CDC) at https://www.cdc.gov/mrsa/index.html.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

Appendix A: Signs and Symptoms Chart

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. Staphylococcus Aureus 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: 350, 477, 735, 746

7.5.11.1: Attendance of Children with Scabies

A child who is suspected of having scabies should see a health care provider. If scabies is confirmed, the child should begin treatment before returning to the program. A child with a confirmed case of scabies may be excluded until treatment has begun (1).

RATIONALE

Scabies is caused by a mite and manifests as an intensely itchy, red rash triggered by the burrowing of female mites into the skin. These burrows appear as gray or white thread-like crooked lines. Transmission usually occurs through prolonged close person-to-person contact (1,2). Epidemics and localized outbreaks may require stringent and consistent measures to treat contacts of the person infected. Individuals who have had prolonged skin-to-skin contact with people infested by scabies may benefit from prophylactic treatment. Bedding used and clothing worn next to the skin for three days prior to treatment should be washed in hot water and dried in a hot dryer cycle. Items that cannot be laundered should be stored in sealed plastic bags for at least 4 days because scabies mites cannot survive away from humans for more than 4 days (1).

COMMENTS

Cleaning with potentially toxic agents is unnecessary and is not effective in reducing transmission of scabies mites. Optimal control is achieved by treatment of infested people and their close contacts.

For additional information, see the Centers for Disease Control and Prevention (CDC) Website at http://www.cdc.gov/parasites/scabies/.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

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. Scabies 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: 1098t

NOTES

Content in the STANDARD was modified on 8/9/2017.

7.5.12.1: Thrush (Candidiasis)

Children with thrush do not need to be excluded from group settings (1). Careful hand hygiene and sanitization of surfaces and objects potentially exposed to oral secretions including pacifiers and toothbrushes is the best way to prevent spread (1). Toothbrushes and pacifiers should be labeled individually so that children do not share toothbrushes or pacifiers, as specified in Standard 3.1.5.2. The presence of children with thrush should be noted by caregivers/teachers, and parents/guardians of the children should be notified to seek care, if indicated.

Treatment of thrush may consist of a topical or an oral medication. Most people are able to control thrush without treatment. Evaluation by a primary care provider of people with severe or prolonged symptoms may be indicated.

RATIONALE

Thrush is a common infection, especially among infants (1). Thrush is caused by yeast, a type of fungus called Candida. This fungus thrives in warm, moist areas (skin, skin under a diaper, and on mucous membranes). Thrush appears as white patches on the mucous membranes, commonly on the inner cheeks, gums, and tongue, and may cause diaper rash. The yeast that causes thrush lives on skin and mucous membranes of healthy people and is present on surfaces throughout the environment. An imbalance in the normal bacteria and fungi on the skin may cause the yeast to begin growing on the mucous membranes, appearing as white plaques that are adherent. Intermittent thrush may be normal in infants and young children. People with exposure to moisture, those receiving antibiotics, or those with an illness may develop thrush (2).

COMMENTS

Occasionally, thrush might occur in several individuals at the same time or within a couple of days of each other. Consultation with a health care professional and the local health department may be sought when several individuals have these symptoms.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

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. American Academy of Pediatrics. Thrush (Candidiasis) 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: 264

7.6.1.1: Disease Recognition and Control of Hepatitis B Virus (HBV) Infection

Facilities should have written policies for inclusion and exclusion of children known to be infected with hepatitis B virus (HBV) and for immunization of all children with hepatitis B vaccine per the “Recommended Immunization Schedules” for children and adolescents. All infants should complete a three dose series of hepatitis B vaccine beginning at birth as recommended by the American Academy of Pediatrics (AAP) and Centers for Disease Control and Prevention (CDC) (1). When a child who is an HBV carrier is admitted to a facility, the facility director and primary caregivers/teachers should be informed.

Children who carry HBV chronically and who have no behavioral or medical risk factors, such as aggressive behavior (such as biting or frequent scratching), generalized dermatitis (weeping skin lesions), or bleeding problems, may be admitted to the facility without restrictions.

Testing of children for HBV should not be a prerequisite for admission to facilities.

With regard to infection control measures and handling of blood or blood-containing body fluids, every person should be assumed to be an HBV carrier with regard to blood exposure. All blood should be considered as potentially containing HBV. Child care personnel should adopt Standard Precautions, as outlined in Prevention of Exposure to Blood and Body Fluids, Standard 3.2.3.4.

Toys and objects that young children (infants and toddlers) mouth should be cleaned and sanitized, as stated in Standards 3.3.0.2-3.3.0.3.

Toothbrushes and pacifiers should be individually labeled so that the children do not share toothbrushes or pacifiers, as specified in Standard 3.1.5.2.

RATIONALE

Prior to routine hepatitis B immunization of infants, transmission in child care facilities was reported (2,3). Currently the risk of transmitting the disease in child care is theoretically small because of the low risk of transmission, implementation of infection control measures, and high immunization rates. 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 (1). However, children who are HBV carriers (particularly children born in countries highly endemic for HBV) could be enrolled in child care. Thus, transmission of HBV in the child care setting is of concern to public health authorities.

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 rare. 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 a susceptible person. 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 much lower than that of blood.

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 (1), but each situation should be evaluated individually. In the rare circumstance that an unimmunized child bites a known HBV carrier, the hepatitis B vaccine series should be initiated (4).

COMMENTS

Parents/guardians 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 current edition of the Red Book from the AAP.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

REFERENCES

1. Centers for Disease Control and Prevention. 2005. A comprehensive immunization strategy to eliminate transmission of hepatitis B virus infection in the United States. MMWR 54 (RR16). http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5416a1.htm.
2. Deseda, D. D., C. N. Shapiro, K. Carroll. 1994. Hepatitis B virus transmission between a child and staff member at a day-care center. Pediatr Infect Dis J 13:828-30.
3. Shapiro, C. N., L. F. McCaig, K. F. Genesheimer, et al. 1989. Hepatitis B virus transmission between children in day care. Pediatr Infect Dis J 8:870-75.
4. Shane, A. L., L. K. Pickering. 2008. Infections associated with group child care. In Principles and practice of pediatric infectious diseases, eds. S. S. Long, L. K. Pickering, C. G. Prober. 3rd ed. Philadelphia: Churchill Livingstone.

7.6.1.2: Observation and Follow-Up of a Child Who is a Hepatitis B Virus (HBV) Carrier

The primary caregiver/teacher should 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. If this type of behavior occurs, the child’s primary care provider or the health department should evaluate the need for immediate disease prevention measures with hepatitis B immune globulin and should 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/teachers are informed that a known HBV-carrier child is in care. However, parents/guardians 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 (1).

COMMENTS

For additional information regarding HBV infections, consult the current edition of the Red Book from the American Academy of Pediatrics (AAP).

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

REFERENCES

1. Centers for Disease Control and Prevention. 2005. A comprehensive immunization strategy to eliminate transmission of hepatitis B virus infection in the United States. MMWR 54 (RR16). http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5416a1.htm.

7.6.1.3: Staff Education on Prevention of Bloodborne Diseases

All caregivers/teachers should receive training at employment and annually thereafter as required by the Occupational Safety and Health Administration (OSHA) on how to prevent transmission of bloodborne diseases, including hepatitis B virus (HBV), hepatitis C virus (HCV), and HIV (1).

RATIONALE

Efforts to reduce risk of transmitting diseases in child care through hygiene and environmental standards in general should focus primarily on blood precautions, limiting saliva contamination (no sharing of utensils, pacifiers, tooth brushes), and ensuring that children are appropriately immunized against HBV. People, including caregivers/teachers, who may be expected to come into contact with blood as a part of their employment, are required to be trained how to protect themselves from bloodborne diseases by their employers and be offered hepatitis B vaccine at no charge to them, within ten working days of initial assignment (1,2).

COMMENTS

If the employee initially declines hepatitis B vaccination but at a later date, while still covered under the acceptable timeline (ten working days), decides to accept the vaccination, the employer should make hepatitis B vaccination available at that time. The employer should require that employees who decline to accept the offer of hepatitis B vaccination sign the Occupational Safety and Health Administration’s (OSHA) “Hepatitis B Vaccine Declination” statement (1). The “Hepatitis B Vaccine Declination” statement can be found at http://www.ecels-healthychildcarepa
.org/content/Keeping Safe 07-27-10.pdf.

For additional information regarding HBV and HCV infections, consult the associated chapters in the current edition of the Red Book from the American Academy of Pediatrics (AAP).

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

REFERENCES

1. Occupational Safety and Health Administration. 2008. Bloodborne pathogens. Title 29, pt. 1910.1030. http://www.osha
   .gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=10051.
2. Centers for Disease Control and Prevention. 2005. A comprehensive immunization strategy to eliminate transmission of hepatitis B virus infection in the United States. MMWR 54 (RR16). http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5416a1.htm.

7.6.1.4: Informing Public Health Authorities of Hepatitis B Virus (HBV) Cases

Staff members known to have acute or chronic hepatitis B virus (HBV) infection should not be restricted from work but should receive training on how to prevent transmission of bloodborne diseases. HBV infection is designated as a notifiable disease at the national level. Cases of acute HBV in any child or employee of a facility should be reported to the health department for determination of the need for further investigation or preventive measures (1).

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 to be rare. 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 current edition of the Red Book from the American Academy of Pediatrics (AAP).

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

REFERENCES

1. Centers for Disease Control and Prevention. 2008. Recommendations for identification and public health management of persons with chronic hepatitis B virus infection. MMWR 57 (RR08). http://www.cdc.gov/mmwr/preview/mmwrhtml/
   rr5708a1.htm.

7.6.1.5: Handling Injuries to a Hepatitis B Virus (HBV) Carrier

Injuries that lead to bleeding by a hepatitis B virus (HBV) carrier child or adult should 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 of children and adults against HBV (1).

COMMENTS

For additional information regarding HBV infections, consult the current edition of the Red Book from the American Academy of Pediatrics (AAP).

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

REFERENCES

1. Centers for Disease Control and Prevention. 2008. Recommendations for identification and public health management of persons with chronic hepatitis B virus infection. MMWR 57 (RR08). http://www.cdc.gov/mmwr/preview/mmwrhtml/
   rr5708a1.htm.

7.6.2.1: Infection Control Measures with Hepatitis C Virus (HCV)

Standard Precautions, as outlined in Standard 3.2.3.4, should be followed to prevent infection with hepatitis C virus (HCV) infection. Children with HCV infection should not be excluded from out-of-home child care. Hepatitis C is designated as a notifiable disease at the national level and local and/or state public health authorities should be notified about cases of hepatitis C infections involving children or adults in the child care setting.

RATIONALE

The seroprevalence (frequency) of HCV infection in young children is less than 1% and most acute infections are asymptomatic. Transmission risks of HCV in a child care setting are unknown. The general risk of HCV infection from exposure to blood-containing body fluids entering through the skin is estimated to be ten times greater than that of HIV but lower than that of hepatitis B virus (HBV) (1). Transmission of HCV via contamination of mucous membranes (eyes, nose, mouth) or broken skin probably has an intermediate risk between that for blood infected with HIV and HBV (2).

COMMENTS

For additional information regarding HCV infections, consult the current edition of the Red Book from the American Academy of Pediatrics (AAP).

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

REFERENCES

1. Centers for Disease Control and Prevention. 2009. Guidelines for prevention and treatment of opportunistic infections in HIV-infected adults and adolescents. MMWR 58 (RR04). http://www.cdc.gov/mmwr/pdf/rr/rr5804.pdf.
2. Centers for Disease Control and Prevention. 2015. Hepatitis C. http://www.cdc.gov/hepatitis/hcv/index.htm

7.6.3.1: Attendance of Children with HIV

Children infected with HIV should be admitted to child care as long as their health status allows participation in program activities. Children who enter child care should not be required to be tested for HIV or to disclose their HIV status (1,2). HIV is not spread by the type of contact that regularly occurs in child care (1). Standard Precautions should be adopted for handling all blood and blood-containing body from all children (1,2).
If exposure to a highly contagious disease (such as measles or chicken pox) occurs at the facility, parents/guardians of all children, including children with HIV, should be notified as they can pose a serious health risk to children with compromised immune systems (1).

RATIONALE

Overall, the risk factor for transmission of HIV is low because HIV is not spread by the type of contact that typically occurs in child care. HIV is not spread through non-bloody saliva, tears, stool, or urine (1). 

COMMENTS

If the program is aware of a child attending with positive HIV status and there is a strong risk of transmission of blood-borne pathogens occurring, it is recommended the child’s health care provider, parents/guardian, and the program director meet to assess whether the child can participate in group care activities. Examples of high-risk transmissions are: generalized dermatitis, bleeding problems, or biting (1). A public health authority with expertise in HIV prevention/transmission or the child’s health provider should be consulted as specific issues regarding participation arise.
For additional information regarding HIV, consult the current edition of the Red Book from the American Academy of Pediatrics (AAP).

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

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. American Academy of Pediatrics. Human Immunodeficiency Virus (HIV) 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: 401, 459-476, 506

NOTES

Content in the STANDARD was modified on 3/31/17.

7.6.3.2: Protecting HIV-Infected Children and Adults in Child Care

Parents/guardians of all children, including children infected with HIV, should be notified immediately if the child has been exposed to chickenpox, tuberculosis, fifth disease (parvovirus B19), diarrheal disease, measles, or other infectious diseases through contact with other children in the facility. In particular, immune-compromised children who are exposed to measles or chickenpox should be referred immediately to their primary care provider to receive the appropriate preventive measure (immune globulin or immunization) following exposure and decision about readmission to the child care facility (1). Information regarding a child whose immune system does not function properly to prevent infection, whatever the cause, should be available to caregivers/teachers 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 should be brought to the prompt attention of the parent/guardian of the child whose immune system does not function properly. The parent/guardian may elect to seek medical advice regarding the child’s continued participation in the facility. Injuries that lead to bleeding by a child with HIV should be handled promptly using Standard Precautions in the manner recommended for any such injury to any child.

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, cytomegalovirus (CMV), tuberculosis, Cryptosporidium, Salmonella, and measles virus (1,2). 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.

Caregivers/teachers should know about a child’s special health care needs so they can offer protection for that child. 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.

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. Annual training on use of Standard Precautions and periodic staff monitoring may increase compliance and staff knowledge of this policy.

All caregivers/teachers should be taught the basic principles of individuals’ rights to confidentiality.

For additional information regarding HIV, consult the current edition of the Red Book from the American Academy of Pediatrics (AAP).

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

7.6.3.1 Attendance of Children with HIV

REFERENCES

1. Centers for Disease Control and Prevention. 2009. Guidelines for prevention and treatment of opportunistic infections in HIV-infected adults and adolescents. MMWR 58 (RR04). http://www.cdc.gov/mmwr/pdf/rr/rr5804.pdf.
2. Centers for Disease Control and Prevention. 2009. Guidelines for the prevention and treatment of opportunistic infections among HIV-exposed and HIV-infected children. MMWR 58 (RR11). http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5811a1.htm.

7.6.3.3: Staff Education About Preventing Transmission of HIV Infection

Caregivers/teachers should be knowledgeable about routes of transmission and about prevention of transmission of bloodborne pathogens, including HIV, and should 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 (1). 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 people 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 does not occur. Cases suggest that contact with blood from an HIV-infected person 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 rare. If a bite results in blood exposure to either person involved, the U.S. Public Health Service recommends post-exposure follow-up, including consideration of post-exposure prophylaxis (2). Due to risks of disease transmission, as a part of Standard Precautions, no food should be given to a child (or adult) that initially was in the mouth (or pre-chewed) by someone else.

COMMENTS

For additional information regarding HIV, consult the current edition of the Red Book from the American Academy of Pediatrics (AAP).

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

REFERENCES

1. Tokars, J. L., R. Marcus, D. H. Culver, et al. 1993. Surveillance of HIV infection and Zidovudine use among healthcare workers after occupational exposure to HIV-infected blood. Ann Intern Med 118:913-19.
2. Havens, P. L., L. M. Mofenson. 2009. Evaluation and management of the infant exposed to HIV-1 in the U.S. Pediatrics 123:175-87.

7.6.3.4: Ability of Caregivers/Teachers with HIV Infection to Care for Children

HIV-infected adults who do not have open and uncoverable skin lesions, other conditions that would result in contact with their body fluids, or a transmissible infectious disease may care for children in child care programs. However, immunosuppressed adults with HIV infection may be at increased risk of acquiring infectious agents from children and should consult their primary care provider about the safety of continuing to work in child care. All caregivers/teachers, especially caregivers/teachers known to be HIV-infected, should be notified immediately if they may have been exposed to varicella, fifth disease (parvovirus B19), tuberculosis, diarrheal disease, measles, or other infectious diseases through contact with children or other adults in the facility, in order to obtain appropriate therapy (1).

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: a) have open skin sores that cannot be covered, b) other conditions that would allow contact with their body fluids, or c) a transmissible infectious disease, 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 primary care providers regarding the advisability of their continuing to work in a facility.

COMMENTS

For additional information regarding HIV, consult the current edition of the Red Book from the American Academy of Pediatrics (AAP).

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

REFERENCES

1. Centers for Disease Control and Prevention. 2009. Guidelines for prevention and treatment of opportunistic infections in HIV-infected adults and adolescents. MMWR 58 (RR04). http://www.cdc.gov/mmwr/pdf/rr/rr5804.pdf.

7.7.1.1: Staff Education and Policies on Cytomegalovirus (CMV)

Cytomegalovirus (CMV) is a viral infection that is common in children. Up to 70% of children ages 1 to 3 years in group care settings excrete the virus (1).
Staff of childbearing age who care for infants and children should be provided the following information:

1. The increased probability of exposure to cytomegalovirus (CMV) in the child care setting;
2. The potential for fetal damage when CMV is acquired during pregnancy;
3. The importance of hand hygiene measures (especially handwashing and avoiding contact with urine, saliva, and nasal secretions) to lower the risk of CMV;
4. The availability of counseling and testing for serum antibody to CMV to determine the caregiver/teacher’s immune status.

Female employees of childbearing age should be referred to their primary health care provider or to the health department authority for counseling about their risk of CMV infection. This counseling may include testing for serum antibodies to CMV to determine the employee’s immunity against CMV infection.
Since saliva can transmit CMV, staff should be advised not to share cups or eating utensils, kiss children on the lips, or allow children to put their fingers or hands in another person’s mouth. 

RATIONALE

CMV is the leading cause of congenital infection in the United State and approximately 1% of live born infants are infected prenatally (1). While most infected fetuses likely escape resulting illness or disability, 10% to 20% may have hearing loss, developmental delay, cerebral palsy, or vision disturbances (1). Although maternal immunity does not entirely prevent congenital CMV infection, evidence indicates that acquisition of CMV during pregnancy (primary maternal infection) carries the greatest risk for resulting illness or disability of the fetus (2).

Children enrolled in child care facilities are more likely to acquire CMV than are children cared for at home (2). 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 (1). Rates of CMV excretion vary among facilities and between class groups within a facility. Children between one and three years of age have the highest rates of excretion; published studies report excretion rates between 30% and 40% (2). Many children excrete CMV asymptomatically and intermittently for years.

With regard to child-to-staff transmission, studies have shown increased rates of infection with CMV in caregivers/teachers ranging from 8% to 20% (2). The increased risk for exposure to CMV and high rates of acquisition of CMV in caregivers/teachers could lead to increased rates of congenital CMV infection. Meticulous hand hygiene can reduce the rates of infection by preventing CMV transmission. 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 of acquiring CMV from their primary health care provider. However, it is also important for the child care center director to inform infant caregivers/teachers of the increased risk of exposure to CMV during pregnancy (1). 

COMMENTS

For additional information regarding CMV, consult the CMV chapter in the current edition of the Red Book from the American Academy of Pediatrics (AAP).

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

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. American Academy of Pediatrics. Cytomegalovirus (CMV) Infection 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: 310-317

NOTES

Content in the STANDARD was modified on 3/31/17.

7.7.2.1: 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, should be excluded from child care. In selected situations, children with mild disease who are in control of their oral secretions may not need to be excluded. The facility’s child care health consultant or health department officials should be consulted.

Caregivers/teachers with herpetic gingivostomatitis, cold sores, or herpes labialis should do the following:

1. Refrain from kissing and nuzzling children;
2. Refrain from sharing food and drinks with children and other caregivers;
3. Avoid touching the lesions;
4. Wash their hands frequently;
5. Cover any skin lesion with a bandage, clothing, or an appropriate dressing if practical.

Caregivers/teachers should be instructed in the importance of and technique for hand hygiene and other measures aimed at limiting transfer of infected material, such as saliva, tissue fluid, or fluid from a skin sore.

Caregivers/teachers who work in a child care program with young infants should avoid caring for infants including neonates when the caregiver has an active “fever blister” on their lips.

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. Multiple, painful sores in the mouth and throat may prevent oral intake and necessitate hospitalization for hydration (1). 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 (1). Transmission of herpes simplex in child care is uncommon (2). However, neonates are at the highest risk for disseminated disease.

For additional information regarding herpes simplex, consult the herpes simplex chapter in the current edition of the Red Book from the American Academy of Pediatrics (AAP).

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

REFERENCES

1. Prober, C. G. 2008. Herpes simplex virus. In Principles and practice of pediatric infectious diseases, eds. S. S. Long, L. K. Pickering, C. G. Prober. 3rd ed. Philadelphia: Churchill Livingstone.
2. Schmitt, D. L., D. W. Johnson, F. W. Henderson. 1991. Herpes simplex type I infections in group care. Pediatr Infect Dis J 10:729-34.

7.7.3.1: Roseola

Children with roseola (exanthema subitum) or clinical evidence of infection with human herpes virus 6 or 7 need not be excluded from child care as long as they are able to participate in normal activities comfortably and staff finds they can care for the child without jeopardizing the health or safety of other children.

RATIONALE

Roseola is a viral disease caused by human herpes virus 6 or 7 (HHV6, HHV7) that causes fever for three to seven days and then, as the fever disappears, a red, raised rash appears often on the trunk with spread to the face and extremities. A seizure may occur as a CNS (central nervous system) manifestation in patients with primary infection. Almost all children have been infected with HHV6 by two years of age. The virus is transmitted to children from healthy adults via saliva. The incubation period is reported to be nine to ten days, so a child may expose others at home and in child care before becoming ill. No antiviral therapy is recommended in otherwise healthy children. The virus, like other herpes viruses, can become latent in the body (virus DNA persists in some cells, including salivary glands) (1).

COMMENTS

Once the rash appears, the child is usually felling better.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

REFERENCES

1. Hall, C. B. 2008. Human herpes viruses 6 and 7 (roseola, exanthem subitum). In Principles and practices of pediatric infectious diseases, eds. S. S. Long, L. K. Pickering, C. G. Prober. 3rd ed. Philadelphia: Churchill Livingstone.

7.7.4.1: Staff and Parent/Guardian Notification About Varicella-Zoster (Chickenpox) Virus

The child care facility should notify all staff members and parents/guardians 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 with impaired immunity for any reason including HIV infection, steroid use, cancer chemotherapy, or organ transplantation (1,2).

RATIONALE

Prior to introduction of varicella vaccine, about 5% to 10% of adults were susceptible to varicella-zoster virus. Within twenty-four hours after exposure is recognized, susceptible child care staff members who are pregnant and are exposed to children with chickenpox should be referred to health care professionals who are knowledgeable in the area of varicella infection during pregnancy. The Centers for Disease Control and Prevention (CDC) and the American Academy of Pediatrics (AAP) recommend use of varicella vaccine in non-pregnant susceptible people twelve months of age and older within three days but up to five days after exposure to varicella. When indicated, VariZIG, an immune globulin preparation, or intravenous immune globulin (IGIV) also can be administered following exposure (2).

COMMENTS

Outbreaks of varicella in child care have decreased since institution of the two dose varicella recommendations (3).

Sample letters of notification to parents/guardians that their child may have been exposed to an infectious disease are contained in the current edition of Managing Infectious Diseases in Child Care and Schools, a publication of the American Academy of Pediatrics (AAP). For additional information regarding varicella, consult the current edition of the Red Book, also from the AAP.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

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. Centers for Disease Control and Prevention. 2016. Chickenpox (Varicella ) prevention & treatment. https://www.cdc.gov/chickenpox/about/prevention-treatment.html. 
   
3. Lopez, A. S., M. Marin. 2016. Strategies for the control and investigation of a varicella outbreaks 2008. Atlanta: Centers for Disease Control and Prevention, National Center for Immunization and Respiratory Diseases. https://www.cdc.gov/chickenpox/outbreaks/manual.html.  
   

7.7.4.2: Exclusion of Children with Varicella-Zoster (Chickenpox) Virus

The varicella-zoster virus causes shingles and chickenpox. Chickenpox is very contagious and can spread in early care and education programs.¹ Programs with children and staff who have chickenpox should temporarily exclude them, using the following exclusion and inclusion criteria: 

• Exclude all staff and children with chickenpox until all lesions have crusted over and no new lesions appear in the last 24 hours.^2–3
• Staff and children who are vaccinated for chickenpox and develop chickenpox lesions without crusts should be excluded until no new lesions appear in the last 24 hours.²
• Children may return when their lesions are crusted over for 24 hours or more, when they can fully participate, and when staff can care for the child without compromising the care of other children.³

The varicella-zoster virus causes shingles in people who have had chickenpox or the chickenpox vaccine. Shingles is spread through direct contact. Programs with children and staff who have shingles should use the following exclusion and exclusion criteria:^3–4

• Exclude staff and children if they can’t cover the lesions.
• Staff and children may attend if they can cover their lesions or when all lesions have crusted over.
• Staff and children may return when the lesions that cannot be covered are crusted over, when children can fully participate, and when staff can care for the child without compromising the care of other children.³
  

RATIONALE

Varicella-zoster is highly contagious and can easily spread in early care and education programs. The virus spreads from person to person by direct contact, by inhaling the virus that gets into the air from open lesions, and through infected respiratory secretions in the air. A person with chickenpox is contagious beginning one to two days before a rash develops until all the lesions have crusted over. These people are contagious until no new lesions have appeared for 24 hours. Some people are at a higher risk for severe illness if they get chickenpox: people who are immunocompromised, newborns, and pregnant people.¹ Staff and children who have chickenpox should be excluded from early care and education programs to help control spread and to limit contact with high-risk people. 

Varicella-zoster is a vaccine-preventable disease. Staff and children should get all recommended vaccines to help prevent infections in early care and education programs.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

REFERENCES

1. Centers for Disease Control and Prevention. Chickenpox (Varicella). CDC.gov Web site. Last reviewed April 28, 2021. Accessed April 21, 2022. https://www.cdc.gov/chickenpox/hcp/index.html

2. American Academy of Pediatrics. Section 2: Recommendation for care of children in special circumstances; children in group childcare and schools. In: Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH, eds. Red Book: 2021 Report of the Committee on Infectious Diseases. Elk Grove Village, IL: American Academy of Pediatrics; 2021:116-126. 

3. American Academy of Pediatrics. Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide. Aronson SS, Shope TR, eds. 5th ed. Itasca, IL: American Academy of Pediatrics; 2020

4. Centers for Disease Control and Prevention. Shingles (Herpes Zoster. CDC.gov Web site. Last reviewed April 28, 2021. Accessed April 21, 2022. https://www.cdc.gov/shingles/hcp/clinical-overview.html

NOTES

Content in the standard was modified on 7/05/2022.