Child Care and Communicable Diseases

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Chapter 167 Child Care and Communicable Diseases

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 rarely is associated with outbreaks of diarrhea in child-care settings, because person-to-person spread of this organism is uncommon. Outbreaks of hepatitis A in children enrolled in child-care facilities have resulted in community-wide outbreaks. Hepatitis A usually is mild or asymptomatic in young children and often is identified only after symptomatic illness becomes apparent among either older children or adult contacts of children in child care. Enteropathogens and hepatitis A virus are transmitted in child-care facilities by the fecal-oral route and only rarely by contaminated food or water. Children in diapers constitute a high risk for the spread of gastrointestinal infections through the fecal-oral route. Enteric illness and hepatitis A are more common in centers that care for children who are not toilet trained and where proper hygienic practices are not followed.

Skin Diseases

The most commonly recognized skin infections or infestations in children in child care are impetigo caused by Staphylococcus aureus or group A streptococcus, pediculosis, scabies, tinea capitis, and tinea corporis. Many of these diseases are spread by contact with infected linens, clothing, hairbrushes, and hats and through direct personal contact; they more often affect children >2 yr of age. The magnitude of these infections and infestations in children in child care is not known. Parvovirus B19, which causes fifth disease (erythema infectiosum), is spread through the respiratory route, and outbreaks have occurred in child-care centers. The rash of fifth disease is a systemic manifestation of parvovirus B19 infection; the child is no longer contagious once the rash is present (Chapter 243). The greatest health hazard is for pregnant women and immunocompromised hosts owing to their respective risks for fetal loss and aplastic crisis.

Invasive Organisms

Prior to universal immunization, primary H. influenzae type b invasive disease was more common among children in child care, although evidence for increased risk for secondary cases from H. influenzae type b in a child-care setting remains less convincing. There is an indication that the risk for primary disease caused by Neisseria meningitidis is higher among children in child care than among children cared for at home. Child-care attendance is associated with nasopharyngeal carriage of penicillin-resistant Streptococcus pneumoniae and invasive pneumococcal disease, especially among children with a history of recurrent otitis media and use of antibiotics. Secondary spread of S. pneumoniae and N. meningitidis has been reported, indicating the potential for outbreaks to occur in this setting. Routine use of pneumococcal conjugate vaccine has decreased the incidence of invasive disease and reduced carriage of serotypes of S. pneumoniae contained in the vaccine both in the child and in younger siblings. With the recent licensure of a conjugate meningococcal vaccine for routine use in healthy adolescents, the use of conjugate meningococcal vaccine in children <2 yr of age is anticipated in the future. Outbreaks of aseptic meningitis from echovirus 30 have been reported among children in child-care centers as well as among their parents and their teachers.

Herpesviruses

Studies of CMV infection in child-care centers have shown that as many as 70% of diapered children continuously shed CMV in urine and saliva after they become infected. CMV-infected children often transmit the virus to other children with whom they have contact, as well as to their care providers and their mothers at a rate of 8-20% per year. Transmission occurs as a result of contact with either saliva or urine. The overwhelming majority of primary infection with and reactivation of CMV in otherwise healthy children results in asymptomatic shedding of CMV virus; nonetheless, this shedding can pose a health risk for previously uninfected pregnant child-care providers or immunocompromised persons (Chapter 247). Varicella often is transmitted in child-care centers, but routine use of varicella vaccine has reduced this risk. Vaccinated children who become infected with varicella often have mild, atypical symptoms and signs of disease that can result in delayed recognition and spread of infection to susceptible contacts. The role of child-care facilities in the spread of herpes simplex virus, especially during episodes of gingivostomatitis, requires further clarification.

Blood-Borne Pathogens

Because it is impossible to identify every child who might have a blood-borne infection such as HBV, HCV, HDV, or HIV, it is critical that standard universal precautions be observed routinely to reduce the risk for transmitting these viruses. Transmission of hepatitis B among children in child care has been documented in a few rare instances, but the risk for transmission, which already was low, has declined with implementation of universal immunization of infants with HBV vaccine. Transmission of HCV and HDV in child-care settings has not been reported.

Issues about HIV in child care include the potential risk for HIV transmission within the child-care setting and concerns of opportunistic infections of HIV-infected children. No cases of HIV transmission in out-of-home child care have been reported. Children with HIV infection enrolled in child-care facilities should be monitored for exposure to infectious diseases, and their health and immune status should be evaluated frequently.

Some infections are spread through contact of contaminated blood with either a mucous membrane or an open wound. Although it is theoretically possible, infection is unlikely to spread via toddler biting in a group setting. Most of these bites do not break the skin, and if a bite does break the skin, the mouth of the biter does not stay on the victim long enough for blood to transfer from the victim to the biter. If there are concerns about transmission of hepatitis B, hepatitis C, or HIV infection, it is recommended to check the status of the biter rather than the bite victim as part of the initial evaluation process.

Antibiotic Use and Bacterial Resistance

Antibiotic resistance has become an alarming problem in child-care facilities, because the incidence of infection by organisms resistant to frequently used antimicrobial agents has increased dramatically. The estimated annual rate of antibiotic use among children in child care is 2-4 times higher than among age-matched children cared for at home and the mean duration of antibiotic treatment is 4 times longer among children in child care. This frequency of antibiotic use combined with the propensity for person-to-person transmission of pathogens in a crowded environment has resulted in an increased prevalence of antibiotic-resistant bacteria in the respiratory and intestinal tracts, including S. pneumoniae, H. influenzae, Moraxella catarrhalis, E. coli O157:H7, and Shigella species.

Prevention

Written policies designed to prevent or to control the spread of infectious agents in a child-care center should be available and should be reviewed regularly. It is suggested that all programs use a health consultant to help with development and implementation of infection-control policies. Standards for environmental and personal hygiene should include maintenance of current immunization records for both children and staff, appropriate policies for exclusion of ill children and caretakers, targeting of potentially contaminated areas for frequent cleaning, adherence to appropriate procedures for changing diapers, appropriate handling of food, management of pets, and surveillance for and reporting of communicable diseases. Staff whose primary function is preparing food should not change diapers. Strategies for improving adherence to these standards should be implemented. Appropriate and thorough hand hygiene is the most important factor for reducing infectious diseases in the child-care setting. Children at risk for introducing an infectious disease should not attend child care until they are no longer contagious (Tables 167-2 and 167-3).

Table 167-2 DISEASE- OR CONDITION-SPECIFIC RECOMMENDATIONS FOR EXCLUSION OF CHILDREN IN OUT-OF-HOME CHILD CARE

CONDITION	MANAGEMENT OF CASE	MANAGEMENT OF CONTACTS
Hepatitis A virus (HAV) infection	Serologic testing to confirm HAV infection in suspected cases Exclusion until 1 week after onset of jaundice	If ≥1 case is confirmed in child or staff attendees or ≥2 cases in households of staff or attendees, HAV vaccine or IG should be administered within 14 days of exposure to unimmunized staff and attendees In centers without diapered children, HAV vaccine or IG should be given to unimmunized classroom contacts of index case Asymptomatic IG recipients may return after receipt of IG
Impetigo	Exclusion until 24 hr after treatment has been initiated Lesions on exposed skin covered with watertight dressing	No intervention needed unless additional lesions develop
Measles	Exclusion until 4 days after beginning of rash and when the child is able to participate	Immunize exposed children without evidence of immunity within 72 hr of exposure Children who do not receive vaccine within 72 hr or who remain unimmunized after exposure should be excluded until at least 2 wk after onset of rash in the last case of measles
Mumps	Exclusion until 5 days after onset of parotid gland swelling	In outbreak setting, people without documentation of immunity should be immunized or excluded Immediate readmission may occur following immunization Unimmunized people should be excluded for ≥26 days following onset of parotitis in last case
Pediculosis capitis (head lice)	Treatment at end of program day and readmission on completion of first treatment	Household and close contacts should be examined and treated if infested No exclusion is necessary
Pertussis	Exclusion until 5 days of appropriate antimicrobial therapy course have been completed	Immunization and chemoprophylaxis should be administered as recommended for household contacts Symptomatic children and staff should be excluded until completion of 5 days of antimicrobial therapy course Untreated adults should be excluded until 21 days after onset of cough
Rubella	Exclusion until 6 days after onset of rash for postnatal infection	Pregnant contacts should be evaluated
Salmonella serotype Typhi infection	Exclusion until diarrhea resolves 3 negative stool culture results required before readmission	Stool cultures should be performed for attendees and staff; infected people should be excluded on the basis of age
Non–serotype Typhi Salmonella infection	Exclusion until diarrhea resolves. Negative stool culture results not required for non–serotype Typhi Salmonella species.	Symptomatic contacts should be excluded until symptoms resolve Stool cultures are not required for asymptomatic contacts Antimicrobial therapy is not recommended for asymptomatic infection or uncomplicated diarrhea or for contacts
Scabies	Exclusion until after treatment given	Close contacts with prolonged skin-to-skin contact should have prophylactic therapy Bedding and clothing in contact with skin of infected people should be laundered
Shiga toxin–producing Escherichia coli (STEC), including E. coli O157:H7, or Shigella infection	Exclusion until diarrhea resolves and results of 2 stool cultures are negative for these organisms, depending on state regulations	Meticulous hand hygiene; stool cultures should be performed for contacts Center(s) with cases should be closed to new admissions during E. coli O157:H7 outbreak
Staphylococcus aureus skin infections	Exclusion only if skin lesions are draining and cannot be covered with a watertight dressing	Meticulous hand hygiene Cultures of contacts are not recommended
Streptococcal pharyngitis	Exclusion until 24 hours after treatment has been initiated and the child is able to participate in activities	Symptomatic contacts of documented cases of group A streptococcal infection should be tested and treated if test results are positive
Tuberculosis	For active disease, exclusion until determined to be noninfectious by physician or health department authority May return to activities after therapy is instituted, symptoms have diminished, and adherence to therapy is documented No exclusion for latent tuberculosis infection	Local health department personnel should be informed for contact investigation
Varicella	Exclusion until all lesions have dried and crusted, usually 6 days after onset of rash in immunocompetent people; may be longer in immunocompromised people	Varicella vaccine should be administered by 3-5 days after exposure, and varicella-zoster IG should be administered up to 96 hr after exposure when indicated

HAV, hepatitis A vaccine; IG, immunoglobulin.

From Pickering LK, Baker CJ, Kimberlin DW, et al, editors: Red book: 2009 report of the Committee on Infectious Diseases, ed 28, Elk Grove Village, IL, 2009, American Academy of Pediatrics, p 129.

Table 167-3 GENERAL RECOMMENDATIONS FOR EXCLUSION OF CHILDREN IN OUT-OF-HOME CHILD CARE

SYMPTOM(S)	MANAGEMENT
Illness preventing participation in activities, as determined by child care staff	Exclusion until illness resolves and able to participate in activities
Illness that requires care greater than staff can provide without compromising health and safety of others	Exclusion or placement in care environment where appropriate care can be provided without compromising care of others
Severe illness suggested by fever with behavior changes, lethargy, irritability, persistent crying, difficulty breathing, progressive rash	Medical evaluation and exclusion until symptoms have resolved
Rash with fever or behavioral change	Medical evaluation and exclusion until illness is determined not to be communicable
Persistent abdominal pain (≥2 hr) or intermittent abdominal pain associated with fever, dehydration, or other systemic signs and symptoms	Medical evaluation and exclusion until symptoms have resolved
Vomiting ≥2 times in preceding 24 hr	Exclusion until symptoms have resolved, unless vomiting is determined to be caused by a noncommunicable condition and child is able to remain hydrated and participate in activities
Diarrhea or stools containing blood or mucus	Medical evaluation and exclusion until symptoms have resolved
Oral lesions	Exclusion until child or staff member is considered to be noninfectious (lesions crusted and dry)

From Pickering LK, Baker CJ, Kimberlin DW, et al, editors: Red book: 2009 report of the Committee on Infectious Diseases, ed 28, Elk Grove Village, IL, 2009, American Academy of Pediatrics, p 128.

In the USA, there are 15 diseases and organisms for which all children should be immunized unless there are contraindications: diphtheria, pertussis, tetanus, measles, mumps, rubella, polio, hepatitis A and B, varicella, H. influenzae type b, S. pneumoniae, rotavirus, N. meningitidis, and influenza. Rates of immunization among children in licensed child-care facilities are high, in part because of laws in almost all states that require age-appropriate immunizations of children who attend licensed child-care programs. Routine vaccination has had a significant beneficial effect on the health of children in child-care settings. Vaccines against influenza, H. influenzae type b, HBV, rotavirus, varicella, S. pneumoniae, and hepatitis A are of particular benefit to children in child-care centers. Influenza vaccination of younger infants reduces influenza infection and secondary sequelae in both children and the adults who care for them in both their home and in child-care settings. Child-care providers should receive all immunizations that are recommended routinely for adults and have a pre-employment health evaluation, including a tuberculin skin test. Local public health authorities should be notified of cases of reportable communicable disease that occur in children or providers in child-care settings.