Child Care and Communicable Diseases

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Chapter 167 Child Care and Communicable Diseases

Linda A. Waggoner-Fountain

More than 23.7 million children <5 yr of age attend a child care facility. These facilities can include some type of out-of-home care on a routine basis such as nursery school, preschool, or a full-day program based either in a child care center or in another person’s home. Regardless of the age at entry, children entering day care are more prone to infections. Exposure to larger groups of children increases a child’s probability of getting sick. Child-care facilities can be classified on the basis of size of enrollment, ages of attendees, health status of the children enrolled, and type of setting. As defined in the USA, child-care facilities consist of child-care centers, small and large family child-care homes, and facilities for ill children or for children with special needs. Centers are licensed and regulated by state governments and care for a larger number of children than are cared for in family homes. In contrast, family child-care homes are designated as small (1-6 children) or large (7-12 children), may be full day or part day, and may be designed for either daily or sporadic attendance. Family child-care homes generally are not licensed or registered, depending on state requirements.

Although the majority of children who attend child-care facilities are cared for in child-care home settings, most studies of infectious diseases among children in out-of-home child care have been conducted among infants (birth to 12 mo of age) and toddlers (13-36 mo of age) who are enrolled in a child-care center. Almost any organism has the potential to be spread and to cause disease in a child-care setting. Epidemiologic studies have established that children in child-care facilities are 2-18 times more likely to acquire a variety of infectious diseases than are children not enrolled in child care (Table 167-1). Children in child-care facilities are more likely both to receive more courses of antimicrobial agents for longer periods and to acquire antibiotic-resistant organisms. Transmission of infectious agents in group care depends on the age and immune status of the children, season, hygiene practices, crowding, environmental characteristics of the facilities, and characteristics of the pathogen, including its infectivity, survivability in the environment, and virulence. Rates of infection, duration of illness, and risk for hospitalization tend to decrease among children in child-care facilities after the 1st 6 mo of attendance and decline to levels observed among home-bound children after 3 yr of age. In general, children starting out-of-home care at 2 yr of age handle respiratory tract infections and their complications better than children starting at 6 mo of age. Adult caregivers are also at increased risk for acquiring and transmitting infectious diseases, particularly in the 1st year of contact with children in these settings.

Table 167-1 INFECTIOUS DISEASES IN THE CHILD-CARE SETTING

DISEASE INCREASED INCIDENCE WITH CHILD CARE
RESPIRATORY TRACT INFECTIONS
Otitis media Yes
Sinusitis Probably
Pharyngitis Probably
Pneumonia Yes
GASTROINTESTINAL TRACT INFECTIONS
Diarrhea (rotavirus, calicivirus, astrovirus, enteric adenovirus, Giardia lamblia, Cryptosporidium, Shigella, Escherichia coli O157:H7, and Clostridium difficile) Yes
Hepatitis A Yes
SKIN DISEASES
Impetigo Probably
Scabies Probably
Pediculosis Probably
Tinea (ringworm) Probably
INVASIVE BACTERIA INFECTIONS
Haemophilus influenzae type b No*
Neisseria meningitidis Probably
Streptococcus pneumoniae Yes
ASEPTIC MENINGITIS
Enteroviruses Probably
HERPESVIRUS INFECTIONS
Cytomegalovirus Yes
Varicella-zoster virus Yes
Herpes simplex virus Probably
BLOOD-BORNE INFECTIONS
Hepatitis B Few case reports
HIV No cases reported
Hepatitis C No cases reported
VACCINE-PREVENTABLE DISEASES
Measles, mumps, rubella, diphtheria, pertussis, tetanus Not established
Polio No
H. influenzae type b No*
Varicella Yes
Rotavirus Yes

* Not in the postvaccine era; yes in the prevaccine era.

Epidemiology

Infectious illnesses among children in child care and their contacts occur in several different patterns. With many viral infections, children often are infectious 2-3 days before they exhibit symptoms of illness. Respiratory tract infections and diarrhea are the most common diseases associated with child care. These infections occur in children, child-care staff, and household contacts and can spread to the community. Respiratory tract pathogens and enteric pathogens can infect both children and adults in these settings but may have varying degrees of impact, depending on the person’s underlying health, previous exposures, and age. Infections caused by hepatitis A virus might not be clinically apparent in young children who attend child care but can cause major clinical disease among older children and adult contacts, including child-care staff and household contacts. Other diseases, such as otitis media, varicella, and invasive Haemophilus influenzae type b disease usually affect children rather than adults. Some common infections, such as cytomegalovirus (CMV) and parvovirus B19 infection, can have serious consequences for the fetuses of pregnant women or for immunocompromised persons. Hepatitis B virus (HBV) transmission has been reported rarely in a child-care setting. Transmission of hepatitis C virus (HCV), hepatitis D virus (HDV), and HIV has never been reported in a child-care setting. Both infections and infestations of the skin may be acquired through contact with contaminated linens or through close personal contact.

Respiratory Tract Infections

Respiratory tract infections account for the majority of child care-related illnesses. Children <2 yr of age who attend child-care centers have more upper and lower respiratory tract infections than do age-matched children not in child care. The organisms responsible for these illnesses are similar to those that circulate in the community and include respiratory syncytial virus, parainfluenza viruses, influenza viruses, adenoviruses, rhinoviruses, coronaviruses, parvovirus B19, and Streptococcus pneumoniae. The risk for developing otitis media is 2-3 times greater among children who attend child-care centers than among children cared for at home. Most prescriptions for antibiotics for children <3 yr of age in child care are to treat otitis media. These children also are at increased risk for recurrent otitis media, which further increases use of antimicrobial agents in this population. Pharyngeal carriage of group A streptococcus occurs earlier among children in child care, although outbreaks of clinical infections with this organism are uncommon. Airborne droplets from the respiratory tract can spread via direct contact with another person’s mucous membranes or by touching surfaces contaminated with secretions. This intimate contact is a routine part of the play and care of young children, regardless of setting. The most common surfaces from which airborne droplets can be spread are the hands; consequently, the most efficient form of infection control in the child-care setting is good hand washing.

Gastrointestinal Tract Infections

Acute infectious diarrhea is 2 to 3 times more common among children in child care than among children cared for in their homes. Outbreaks of diarrhea, which occur frequently in child-care centers, usually are caused by enteric viruses such as rotaviruses, enteric adenoviruses, astroviruses, and caliciviruses or by enteric parasites such as Giardia lamblia or Cryptosporidium. The most common enteropathogens, such as rotavirus and G. lamblia, are characterized by low infective doses and high rates of asymptomatic excretion among children in child care. Bacterial enteropathogens such as Shigella and Escherichia coli O157:H7, and, less commonly, Campylobacter, Clostridium difficile, and Bacillus cereus, also have caused outbreaks of diarrhea in child-care settings. Salmonella

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