What does the term ‘germs’ usually refer to?? 2- What

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Chapter 11. Managing Infectious Diseases

Science and experience tell us that infectious disease, especially gastrointestinal disease, which means vomiting and diarrhea, and respiratory disease, including coughs, colds, sore throats, and runny noses, are increased among children who are cared for in out-of-home group settings. In addition, such children may be at increased risk for certain other infections that may be transmitted by insects or by body fluids. It's also true that children who are cared for in group out-of-home settings are more likely to experience infectious illnesses that are more severe and more prolonged (although 90% of those infections are mild and self-limited, requiring no special treatment).

But there's good news, too. Infectious illnesses such as pneumonia and influenza, which together were the leading causes of death among U.S. children in the early 20th century, have declined 99.7 percent. Common childhood illnesses such as diphtheria, whooping cough, measles, mumps, and rubella are rare except in communities where immunization rates are low, and polio is unheard of in our country today.

Although younger children are more susceptible to infectious illness because their immune systems are immature, as they grow older, the incidents of infectious disease decreases as their immune systems mature. Furthermore, children who experience more infectious disease at an early age in group out-of-home care have a decreasing incidence of infectious disease as they grow older. In fact, they have less infectious illnesses in kindergarten than children who were taken care of exclusively at home. Illness also decreases with years of attendance in out-of-home early care and education settings.

Figure 11.1. As children get older, they get sick less often. Image by College of the Canyons ZTC Team is based on image from Managing Infectious Disease in Head Start Webinar by Head Start Early Childhood Learning & Knowledge Center, which is in the public domain

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There are negative consequences of childhood illness, including: ● It’s unpleasant to be sick (for children or the adults that may also become infected). ● Illnesses that are minor in children can be much more serious for adults and pregnant

women. ● Some illnesses have severe effects (and can even be life-threatening). ● There are short-term medical costs. ● There may also be additional child care costs or lost wages for parents/caregivers of

children that must be excluded from group care. ● Overuse of antibiotics in an effort to get children well contributes to antibiotic resistance

among common bacteria.

To prevent illness we need to understand the different ways illness is spread, how immunizations protect children, and what universal precautions early care and education program staff can take to prevent the spread of illness.

Learning Objectives

At the end of this chapter, you should be able to: ● Describe each of the ways illness is transmitted. ● Identify symptoms of infectious disease that is common during early childhood. ● Explain how immunization prevents illness. ● Identify standard precautions to prevent illness. ● Outline criteria for exclusion from care for ill children and staff. ● Recall licensing requirements for handling medication in early care and education

programs. ● Explain the communication about illness that should happen between families and early

care and education programs.

How Illnesses are Transmitted

Bacteria, viruses, fungi, and parasites that cause illness can be transmitted in five ways, including through:

1. the respiratory route 2. the fecal-oral route 3. the direct contact route 4. the bodily fluid route (including blood, urine, vomit, and saliva) 5. the vector-borne route

Respiratory Transmission

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Most respiratory germs stay in the nose, sinuses, mouth and throat, or possibly the middle ear. Upper respiratory illnesses (colds) are the most common and the most likely to be transmitted in early care and education settings.

The more common respiratory illnesses include: ● Sinusitis ● Sore throat ● Common cold ● Recurrent middle ear infection ● Strep throat ● RSV ● Pneumonia ● Bronchitis

Pneumonia and bronchitis are rarely the result of an infection picked up in an early education setting. We also have immunizations for many respiratory diseases that are rarely transmitted in early care and education settings today, including:

● Mumps ● Measles ● Bacterial meningitis ● Chicken pox ● Diphtheria ● Pertussis ● Pneumonia ● Seasonal flu

If we could actually see what comes out of a child’s mouth along with a cough or a sneeze, we might appreciate the respiratory route of infectious disease transmission more.

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Figure 11.2. What it might look like if we could see what a child coughs or sneezes. Image from Managing Infectious Disease in Head Start Webinar by Head Start Early Childhood Learning & Knowledge Center is in the public domain.

The germs that are in this contaminated cloud of exhalation can wind up on surfaces and hands and be transmitted to others. Staff and children who are able to are encouraged to cough into their sleeves. Covering your mouth with your hand only transfers these germs to your hand. This will be addressed more in depth later in the chapter.

Fecal-Oral Transmission

When organisms that live in our intestines get into our mouths they can cause illness. Usually, this happens via someone’s hands, usually our own. Fecal-oral routes diseases include:

● Hepatitis A ● diarrhea ● hand, foot, and mouth disease ● pinworms ● rotavirus ● norovirus ● giardia ● shigella ● cryptosporidiosis

That is why it is so important that everyone wash hands after using the bathroom, changing diapers, when preparing food, and before eating.

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Direct Contact Transmission

Direct contact with another person’s skin (or hair) puts infants and children at risk of illnesses such as:

● cold sores ● conjunctivitis ● pink eye ● impetigo ● lice ● scabies ● ringworm (a fungus, not a worm).

Bodily Fluid Transmission

Bodily fluids, including saliva, urine, vomit, and blood, can cause illness, such as: ● Dental caries (by saliva) ● Cytomegalovirus or CMV (by urine) ● Hepatitis B (preventable by vaccine) ● Hepatitis C (rare in children) ● HIV (no cases of transmission in an early education setting)

Vector-Borne Transmission

A vector is a living thing that can transmit disease. We know, for example, that ticks can transmit Lyme disease and Rocky Mountain spotted fever. Fleas are known to transmit Bubonic plague and typhus. Mosquitoes can infect people with St. Louis encephalitis (SLE), dengue fever, Zika virus, and West Nile disease. Rats and mice can transmit leptospirosis, trichinosis, hantavirus, and bacterial food poisoning. Raccoons can spread raccoon roundworm.

While these illnesses are relatively uncommon, the risk reminds us of the importance of ● utilizing integrated pest management techniques to keep insects and rodents out of

buildings (covered later in this chapter) ● using insect repellant specifically recommended for children during outdoor activities ● removing standing water in which mosquitoes can lay their eggs

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● checking for and removing ticks in centers when children come back in after playing in or near heavily wooded areas.1

Universal Precautions to Prevent the Spread of Illness There are some standard practices that prevent, or reduce the risk of, the spread of illness in early care and education programs. These are modeled after practices in health care, where everyone is treated as being potentially infected with something that is contagious. Many illnesses are actually contagious before the infected person is symptomatic, so waiting until you see signs of illness is an ineffective way of preventing its spread. Child care providers can practice these four things to help control the spread of illness:

1. Hand washing 2. Use of disposable nonporous gloves when working with bodily fluids 3. Disinfecting potentially contaminated surfaces 4. Proper disposal of potentially contaminated waste2

Handwashing Regular handwashing is an important step to minimizing the spread of germs. Hands pick up germs from all of the things they touch and then spread them from one place to another. Germs that are on hands can also enter the body when a person eats or when they touch their eyes, nose, mouth, or any area on the body where the skin is broken (because of a cut, rash, etc.). All that is needed for handwashing is soap and clean, running water. Handwashing with soap and water removes visible dirt and hidden germs. Studies have demonstrated that handwashing reduced the number of diarrheal illnesses by 31 percent and respiratory illnesses by 21 percent. Hands should be washed:

● before eating, feeding, or preparing food. This prevents germs from getting into the mouth from hands.

● after touching saliva (after feeding or eating), mucus (wiping a nose, using a tissue), bodily fluids (toileting, diapering), food, or animals

● when visibly dirty, after touching garbage, or after cleaning

The Center for Disease Control recommends the following handwashing steps: 1. “Wet your hands with clean, running water (warm or cold) and apply soap.” 2. “Rub your hands together to make a lather and scrub your hands well; be sure to scrub

the backs of your hands, between your fingers, and under your nails.”

2 California Child Care Health Program. (2011). Health and Safety in the Child Care Setting: Prevention of Infectious Disease. University of California San Francisco.

1 Managing Infectious Disease in Head Start Webinar (Transcript) by Head Start Early Childhood Learning & Knowledge Center is in the public domain.

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3. “Continue rubbing your hands for at least 20 seconds. Need a timer? Hum the “Happy Birthday” song from beginning to end twice.”

4. “Rinse your hands well under running water.” 5. “Dry your hands using a clean towel or air dry them.”

Figure 11.3. Illustrations of the 5 steps of handwashing. Stop Germs! Wash Your Hands by the Centers for Disease Control and Prevention is in the public domain

Infants and young children will need help with handwashing. Caring for Our Children recommends that caregivers:

● Safely cradle an infant in one arm to wash their hands at a sink. ● Provide assistance with handwashing for young children that cannot yet wash their

hands independently. ● Offer a stepping stool to young children so they may safely reach the sink.3

Wearing Disposable Gloves Teachers and caregivers should wear gloves when they anticipate coming into contact with any of the following (on a child’s body or a contaminated surface)

● Blood or bodily substances (i.e., fluids or solids) ● Mucous membranes (e.g., nasal, oral, genital area) ● Non-intact skin (e.g., rashes or cuts and scrapes)4

Once the gloves are soiled, it’s important to remove them carefully. 1. Using a gloved hand, grasp the palm area of the other gloved hand and peel off the first

glove. 2. Hold the removed glove in the gloved hand. 3. Slide fingers of the ungloved hand under the remaining glove at the wrist and peel off the

second glove over the first glove. 4. Discard the gloves in a waste container.5

5 Sequence for Putting On Personal Protective Equipment (PPE) by the Centers for Disease Control and Prevention is in the public domain.

4 The Basics of Standard Precautions by Karen Jones, Linda R. Greene, and Lona Mody is in the public domain.

3 Health Tips for Home Visitors to Prevent the Spread of Illness by Head Start National Center on Health is in the public domain.

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Figure 11.4. Safe glove removal. Image by the Centers for Disease Control and Prevention is in the public domain

After you remove your gloves you should wash your hands. “Do not reuse the gloves: this can spread germs from one child to another…Gloves provide added protection from communicable disease only if used correctly. If you use gloves incorrectly, you actually risk spreading more germs than if you don’t use gloves at all. Pay attention to your gloving technique so that you do not develop a false sense of security (and carelessness) when wearing gloves.”6

Cleaning and Disinfecting Washing Surfaces Germs spread onto surfaces from hands and objects (tissues or mouthed toys) or from a sneeze or cough. It is important to clean all surfaces well, including toys and any surface that a young child puts in his mouth, because germs cannot be seen and it is easy to overlook surfaces that do not look soiled or dirty.

Toileting and diapering involve germs from bodily fluids and fecal material. These germs spread easily in a bathroom onto hands, flushers, and faucets. Routinely washing bathroom surfaces removes most germs and prevents them from spreading. The kitchen is another area of the home where it is important to clean surfaces well.

The terms “cleaning,” “sanitizing,” and “disinfecting” deserve close attention.

Cleaning removes visible soil, dirt, and germs. Soap and water will clean most surfaces.

Sanitizing reduces, but does not totally get rid of, germs to a level that is unlikely to cause disease. Sanitizers may be appropriate to use on surfaces where you eat (such as a table or high chair tray) and with toys that children place in their mouths. It is important to follow the instructions on the label, which may also include rinsing surfaces after using the sanitizing product.

6 California Child Care Health Program. (2011). Health and Safety in the Child Care Setting: Prevention of Infectious Disease. University of California San Francisco.

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Disinfecting destroys or inactivates infectious germs on surfaces. Disinfectants may be used on diaper-changing tables, toilets, and countertops.7

Early care and education programs can create a bleach and water solution of one tablespoon household bleach to one quart water for surfaces that need to be sanitized or disinfected. To use effectively, the surface must be wetted with the solution and allowed to air dry. A fresh bleach solution should be made each day to maintain effectiveness, and stored in a clearly labeled spray bottle out of children’s reach. Research shows that other chemicals (e.g. ammonia, vinegar, baking soda, Borax) are not effective against some bacteria.8 “Items that can be washed in a dishwasher or hot cycle of a washing machine do not have to be disinfected because these machines use water that is hot enough for a long enough period of time to kill most germs.”9

Cleaning and disinfecting are essential. Studies have shown that some germs, including influenza virus, can survive on surfaces for two to eight hours; rotavirus can survive up to 10 days.10

Surface/Item Clean Disinfect Frequency

Countertops and Tabletops X X Daily and when soiled

Food prep and service areas X X Before and after use; between prep of raw and cooked food

Floors X X Daily and when soiled

Door and cabinet handles X X Daily and when soiled

Carpets and large rugs X Vacuum daily; clean monthly for infants, every 3 months for other ages and when soiled

Small rugs X Shake or vacuum daily; launder weekly

Utensils, surfaces, and toys that go in the mouth or have been in contact with bodily fluids

X X After each child’s use

Toys not contaminated with bodily fluids X Weekly

Dress up clothes not worn on the head X Weekly

10 California Preschool Curriculum Framework (Volume 2) by the California Department of Education is used with permission.

9 California Child Care Health Program. (2011). Health and Safety in the Child Care Setting: Prevention of Infectious Disease. University of California San Francisco.

8 California Preschool Curriculum Framework (Volume 2) by the California Department of Education is used with permission.

7 Health Tips for Home Visitors to Prevent the Spread of Illness by Head Start National Center on Health is in the public domain.

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Hats X After each child’s use

Sheets and pillowcases X Weekly and when visibly soiled

Blankets and sleeping bags X Monthly and when visibly soiled

Cubbies X Weekly

Cribs X Weekly

Handwashing sinks including faucet, soap dispenser, and surrounding area X X Daily or when soiled

Toilet seats, handles, door knobs or handles in toileting area, floors X X Daily and immediately is soiled

Toilet bowls X X Daily

Changing tables X X After each child’s use

Potty chairs (discouraged in child care because of contamination risks) X X After each child’s use

Any surface contaminated with bodily fluids (saliva, mucus, vomit, urine, stool, or blood) X X Immediately

Water containers X X Daily

Table 11.1. Schedule for Cleaning and Disinfecting. Source: Table 8.2. Paris, J. Chapter 8. Prevention of Illness. Safety, Health, and Nutrition in Early Childhood Education. College of the Canyons. V1.0; 2020. CC BY 4.0

Disposal of Waste Proper disposal and storage of garbage waste prevent the spread of disease, odors, and problems with pests. Disposable items (diapers, gloves, paper towels, and facial tissues) should be thrown away immediately in an appropriate container. Make sure the container is water and rodent-proof, operated with a foot pedal, is lined with a plastic bag, within reach of diaper changing area, handwashing sink, and food preparation areas, out-of-reach of and unable to be knocked over by infants and toddlers. The containers should be emptied, cleaned, and sanitized daily.11

Diaper Changing

11 California Child Care Health Program. (2011). Health and Safety in the Child Care Setting: Prevention of Infectious Disease. University of California San Francisco.

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Diaper changing areas should be smooth and nonporous (such as a plastic-covered pad), have a raised edge to prevent children from falling, be near a sink, be out of reach from children, and away from food preparation areas.12

The following diaper changing procedure should be posted in the changing area and followed to protect the health and safety of children and staff:

1. Before bringing the child to the diaper changing area, perform hand hygiene (including putting on gloves, if using) and bring supplies to the diaper changing area, and place a disposable liner on the changing area.

2. Carry/bring the child to the changing table/surface, keeping soiled clothing away from you and any surfaces you cannot easily clean and sanitize after the change. Always keep a hand on the child.

3. Remove the soiled diaper and clothing without contaminating any surface not already in contact with stool or urine. Put soiled diaper in covered waste container. Put any soiled clothing in a plastic bag that is securely closed to give to family.

4. SClean the child’s diaper area with disposable wipes and place soiled wipes into a covered waste container.

5. Remove the disposable liner and gloves and place in waste container 6. Use facial tissue to apply any creams or ointments. Slide clean diaper under the child

and fasten it and dress the child. 7. Wash the child’s hands and return the child to a supervised area. 8. Clean and disinfect the diaper-changing surface and any equipment or supplies that