Caring for Our Children (CFOC)

Chapter 7: Infectious Diseases

7.4 Enteric (Diarrheal) Infections and Hepatitis A Virus (HAV)

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

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

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

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.

b. Diapered children should be excluded if stool is not contained in the diaper, stool frequency exceeds two or more stools above normal for that child during the program day, blood or mucus in the stool, abnormal color of stool, no urine output in eight hours, jaundice (when skin and white parts of the eye are yellow, a symptom of hepatitis A), fever with behavior change, or looks or acts ill.

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 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.


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 intestinalisShigella, 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.

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.
Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home
RELATED STANDARDS Toilet Learning/Training Type of Diapers Worn Handling Cloth Diapers Checking For the Need to Change Diapers Diaper Changing Procedure Procedure for Changing Children’s Soiled Underwear, Disposable Training Pants and Clothing Situations that Require Hand Hygiene Handwashing Procedure Assisting Children with Hand Hygiene Training and Monitoring for Hand Hygiene Hand Sanitizers Routine Cleaning, Sanitizing, and Disinfecting Cleaning and Sanitizing Toys Cleaning and Sanitizing Objects Intended for the Mouth Cleaning Individual Bedding Cleaning Crib and Other Sleep Surfaces Animals that Might Have Contact with Children and Adults Prohibited Animals Care for Animals Inclusion/Exclusion/Dismissal of Ill Children Staff Exclusion for Illness Guidelines for Taking Children’s Temperatures Infectious Disease Outbreak Control Space Requirements for Care of Children Who Are Ill Qualifications of Directors of Facilities That Care for Children Who Are Ill Program Requirements for Facilities That Care for Children Who Are Ill Caregiver/Teacher Qualifications for Facilities That Care for Children Who Are Ill Child-Staff Ratios for Facilities That Care for Children Who Are Ill Child Care Health Consultants for Facilities That Care for Children Who Are Ill Licensing of Facilities That Care for Children Who Are Ill Information Required for Children Who Are Ill Inclusion and Exclusion of Children from Facilities That Serve Children Who Are Ill Compliance with U.S. Food and Drug Administration Food Sanitation Standards, State and Local Rules Staff Restricted from Food Preparation and Handling Precautions for a Safe Food Supply Leftovers Preparation for and Storage of Food in the Refrigerator Storage of Foods Not Requiring Refrigeration Storage of Dry Bulk Foods Supply of Food and Water for Disasters Cleaning Food Areas and Equipment Food and Nutrition Service Policies and Plans Infant Feeding Policy Contents of Child’s Records Pre-Admission Enrollment Information for Each Child Contents of Admission Agreement Between Child Care Program and Parent/Guardian Contents of Child’s Primary Care Provider’s Assessment Health History Contents of Medication Record Contents of Facility Health Log for Each Child Release of Child’s Records
Appendix A: Signs and Symptoms Chart
Appendix G: Recommended Childhood Immunization Schedule
  1. Aronson, S. S., T. R. Shope, eds. 2017. Managing infectious diseases in child care and schools: A quick reference guide, 4th 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

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