Infectious Disease in Out of Home Child Care Jonathan B. Kotch, MD, MPH, FAAP, Director National Training Institute for Child Care Health Consultants The University of North Carolina at Chapel Hill Part I: Statement of the Problem and Respiratory Transmission

Objectives for Part I At the end of this training learners will be able to: Describe the causes and consequences of the most frequent infectious diseases in child care, and Identify modes of transmission and prevention of infectious diseases transmitted by the respiratory route.

Percent of Children 1-6, By Type of Care, 2001 (America ’ s Children 2003)

Infectious Disease in Child Care Increased frequency of illness Greater severity of illness More frequent antibiotic use Increased risk for acquiring resistant organisms May carry home illnesses and infect family members

Cost (in Millions) of Child Care- associated Illness 1 ( Haskins, 1989) Absence from work ($1,300) Treatment of otitis ($420) Treatment of HiB infections ($17.3) Long term care ($40) Treatment of respiratory infections ($78) 1 courtesy of Ralph Cordell, CDC

Consequences Human suffering, adults and children Costs Short term Medical Lost wages Additional child care costs Long term Death Chronic sequelae CMV and Parvovirus B19 ROM

Risk Factors Children < 2 years of age Size of facility (number of children) Age-mixing Staff who both diaper and feed or prepare food Staff experience, education and training Staff:child ratio Ill child in the room

Physical Characteristics of the Facility Sinks and toilets Ventilation Food preparation areas Over-crowding Toys that are often mouthed

Ways to Transmit Infectious Agents Respiratory Fecal-oral Direct contact: Skin- to-skin Blood, urine, saliva Arthropod borne (via insects) Zoonoses (from animals)

Respiratory Transmission Recurrent otitis media (ROM) Meningitis URI (colds, sinusitis) Pharyngitis (sore throat) Lower respiratory infection (pneumonia) Uncommon

Respiratory Pathogens (Churchill & Pickering, 1997) Bacteria Hib N. meningitidis S. pneumoniae S. pyogenes Bordetella pertussis M. tuberculosis Viruses Adenovirus Coronavirus Enteroviruses Influenza/Parainfluenza M/M/R Parvovirus B19 RSV Varicella

Exclusion Criteria – General Principles 2 Illness prevents the child from participating Illness results in a greater need for care than staff can provide Child is suspected by health authorities to contribute to transmission of illness. Fever with behavior changes, or signs and symptoms of illness. 2 Courtesy of Steve Shuman

Signs and Symptoms 3 Lethargy Uncontrolled coughing Inexplicable irritability or persistent crying Difficult breathing Wheezing Other unusual signs for the child 3 Courtesy of Steve Shuman

Prevention Strategies Immunizations Hib Varicella-zoster MMR, DTaP Pneumococcus Rotavirus Health benefits of immunizations Influenza vaccination of day care children is effective in reducing influenza-related morbidity among household contacts. (Hurwitz et al., 2000)

Acknowledgement Supported by Grant #U93-MC00003 from the Maternal and Child Health Bureau of the Health Resources and Services Administration, U.S. Department of Health and Human Services. END OF PART I