Caring for Our Children (CFOC)

Chapter 7: Infectious Diseases

7.6 Bloodborne Infections

7.6.1 Hepatitis B Virus (HBV)

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
RELATED STANDARDS
3.1.5.2 Toothbrushes and Toothpaste
3.2.3.4 Prevention of Exposure to Blood and Body Fluids
3.3.0.2 Cleaning and Sanitizing Toys
3.3.0.3 Cleaning and Sanitizing Objects Intended for the Mouth
3.6.1.1 Inclusion/Exclusion/Dismissal of Ill Children
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
RELATED STANDARDS
3.6.1.1 Inclusion/Exclusion/Dismissal of Ill Children
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
RELATED STANDARDS
3.2.3.4 Prevention of Exposure to Blood and Body Fluids
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
RELATED STANDARDS
3.2.3.4 Prevention of Exposure to Blood and Body Fluids
3.6.4.3 Notification of the Facility About Infectious Disease or Other Problems by Parents/Guardians
3.6.4.4 List of Excludable and Reportable Conditions for Parents/Guardians
REFERENCES
  1. 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
RELATED STANDARDS
3.2.3.4 Prevention of Exposure to Blood and Body Fluids
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 Hepatitis C Virus (HCV)

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
RELATED STANDARDS
3.2.3.4 Prevention of Exposure to Blood and Body Fluids
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 Human Immunodeficiency Virus (HIV)

7.6.3.1: Attendance of Children with HIV

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

 


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
RELATED STANDARDS
3.2.3.4 Prevention of Exposure to Blood and Body Fluids
3.6.1.1 Inclusion/Exclusion/Dismissal of Ill Children
REFERENCES
  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. 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
3.2.3.4 Prevention of Exposure to Blood and Body Fluids
7.6.3.1 Attendance of Children with HIV
9.4.1.3 Written Policy on Confidentiality of Records
9.4.1.4 Access to Facility Records
9.4.1.5 Availability of Records to Licensing Agency
9.4.1.6 Availability of Documents to Parents/Guardians
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
RELATED STANDARDS
3.2.3.4 Prevention of Exposure to Blood and Body Fluids
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
RELATED STANDARDS
3.2.3.4 Prevention of Exposure to Blood and Body Fluids
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.