DAY CARE INFECTIONS

13 million children under 5 years of age use child care services. National Center for Health Statistics, 2010

90 percent of families with preschool children use child care services. National Commission on Children, 2010

TYPES OF DAY CARE SETTINGS Small family child-care home  6 children licensing not required Large family child-care home 7-12 children variable licensing requirements Centers  13 children Licensed Facilities for ill children Facilities for children with special needs APHA/AAP Out-of-Home Child Care Guidelines, 1992.

HIGH RISK PERSONNEL Susceptible to childhood infections (measles, mumps, chickenpox, etc.) Immunocompromised asplenia cancer transplantation HIV Pregnant women Grossman Ed 8, Infection Control in the Child Care Center, Demos Medical Publisher, 2012

HIGH RISK CHILDREN Risk Factors: Infancy Immunocompromised Chronic lung disease Cardiac disease Physical handicaps Chronic skin disease Grossman, Ed 8, Infection Control in the Child Care Center, Demos Medical Publisher, 2012.

HIGH RISK CHILDREN FOR SPREADING INFECTION Children living in impoverished conditions multiple care givers transient “family” or shelter poor sanitary conditions untreated infections in the home Children from developing nations Children with immune deficiencies Children with chronic infections

DAY CARE FACTORS THAT INCREASE TRANSMISSION OF PATHOGENS Large numbers of children in close contact Infants and toddlers have no independent personal hygiene are incontinent put everything in their mouths Children are susceptible to most infectious agents Infected children may be contagious before symptomatic Parvovirus B19 Varicella Infected children may be asymptomatic Giardia Hepatitis A

RESPIRATORY TRANSMISSION Bacteria Bordetella pertussis Haemophilus influenzae type B Mycobacterium tuberculosis Neisseria meningitidis Streptococcus pneumoniae Viruses Adenovirus Influenza Measles Parainfluenza Parvovirus B19 Respiratory syncytial virus Rhinovirus Rubella Varicella

FECAL-ORAL TRANSMISSION

TRANSMISSION BY SKIN OR MUCOUS MEMBRANE CONTACT

TRANSMISSION BY INOCULATION OR SPLATTERING OF BLOOD Cytomegalovirus Hepatitis B Hepatitis C Human immunodeficiency virus

ILLNESSES AND ABSENTEESIM IN DAY CARE CHILDREN (2 YEAR SURVEILLANCE PERIOD)

ANTIBIOTIC USE IN DAY CARE CHILDREN (2 MONTH SURVEILLANCE PERIOD)

ENVIRONMENTAL COLIFORM CONTAMINATION (2946 SAMPLES) Number Contaminated (%) Inanimate objects307 (15) Toy balls 73 (46) Hands131 (17) Van et al, JAMA, 1991.

HEPATITIS A

Child care attendees or employees account for 14% of all cases of Hepatitis A in the United States.

ETIOLOGIC AGENT Small non-enveloped RNA virus

EPIDEMIOLOGY Source infected human High risk child care centers large numbers of children longer hours diapered children Mode of spread fecal-oral

CLINICAL MANIFESTATIONS Most children are asymptomatic 80% of adults are symptomatic Rash Fatigue Jaundice Anorexia Dark urine Light stools Vomiting

INCUBATION PERIOD 15 to 50 days INFECTIOUS PERIOD Among symptomatic persons, infectivity has waned by the time the individual seeks medical care.

Hepatitis A serology Supportive DIAGNOSIS THERAPY

PREVENTION Standard precautions Vaccine Immune serum globulin

CHILD CARE EXCLUSION Infected children can return 10 days after onset of symptoms During an outbreak, return to day care will be governed by the public health department

RECOMMENDATIONS FOR OTHER CHILDREN Hepatitis A vaccine Immune serum globulin, if exposed Children should be taught how to minimize risks of transmission by handwashing

RECOMMENDATIONS FOR PERSONNEL Hepatitis A vaccine Significant risks of infection in the day care setting

PARENTAL ADVICE Pre-attendance Hepatitis A vaccine

VARICELLA

BEFORE 1995 INTRODUCTION OF THE VARICELLA VACCINE IN THE UNITED STATES 4 million cases per year 11,000 hospitalizations per year 100 varicella associated deaths Meyer PA et al, J Infect Dis, 2000

AFTER INTRODUCTION OF VARICELLA VACCINE IN THE UNITED STATES New Cases: California 71%  Texas 84%  Pennsylvania 79% 

ETIOLOGIC AGENT DNA virus

EPIDEMIOLOGY Source infected human: -respiratory tract -infected lesions Mode of spread airborne direct contact

CLINICAL MANIFESTATIONS Pruritic vesicular rash Fever Systemic symptoms

INCUBATION PERIOD 10 to 21 days INFECTIOUS PERIOD Until lesions are crusted

DIAGNOSIS Clinical Viral culture Serology THERAPY Acyclovir for high risk individuals

PREVENTION Vaccine Airborne and Contact precautions VZIG in high risk exposed children Post-exposure vaccination of susceptible children and adults

CHILD CARE EXCLUSION Infected children can return when lesions are crusted (approximately 5 to 7 days)

RECOMMENDATIONS FOR OTHER CHILDREN VZIG for high risk exposed children Varicella vaccine RECOMMENDATIONS FOR PERSONNEL Varicella vaccine for susceptible adults

THEORETIC CONCERNS Increased Varicella in Older Children and Adults who have: Never received the vaccine Have waning immunity Have less booster exposures to VZV  later varicella disease   herpes zoster

INFLUENZA

ETIOLOGIC AGENT Enveloped RNA virus

EPIDEMIOLOGY Source infected human Mode of spread large droplet aerosol small droplet aerosol direct and indirect contact with infected secretions

INFLUENZAE ATTRIBUTABLE MORBIDITY IN NORMAL CHILDREN LESS THAN 1YEAR OF AGE Increased Hospitalization Increased Outpatient Visits Increased Antibiotic Use Neuzil KM et al, NEJM, 2000 Izurieta HS et al, NEJM, 2000

High risk children Chronic lung disease Congenital heart disease Immunocompromised Sickle cell disease Diabetes Chronic renal failure Metabolic disease Under 2 years of age

CLINICAL MANIFESTATIONS Fever Headache Myalgias/Arthralgias Chills Pharyngitis Rhinorrhea Cough/Croup/Bronchitis

INCUBATION PERIOD 1 to 3 days INFECTIOUS PERIOD Influenza A - 6 days prior to 7 days after symptoms Influenza B -6 days prior to 14 days after symptoms

DIAGNOSIS Viral Culture Rapid tests (immunofluorescent or enzyme immunoassay) THERAPY Influenza A-Amantadine -Rimantadine -Zamamivir (inhaled) -Oseltamivir Influenza B -Zamamivir (inhaled) -Oseltamivir

PREVENTION Annual influenza vaccine high risk children - recommended* healthy children 6 to 23 months - encouraged* Prophylactic antiviral therapy for high risk children *Recommendations of the ACIP, MMWR, 2002

CHILD CARE EXCLUSION Until child is able to participate in child care center activities

RECOMMENDATIONS FOR OTHER CHILDREN Avoid aspirin during influenza season Annual influenza vaccine RECOMMENDATIONS FOR PERSONNEL Annual influenza vaccine

MOLLUSCUM CONTAGIOSUM

ETIOLOGIC AGENT DNA virus

EPIDEMIOLOGY Source infected human Mode of spread direct skin to skin contact contaminated formites

CLINICAL MANIFESTATIONS Small painless skin lesions notable for a central dimple Lesions are usually on face, trunk and limbs Lesions spontaneously disappear within 6-12 months

INCUBATION PERIOD 2-24 weeks INFECTIOUS PERIOD As long as child has visible lesions

DIAGNOSIS Clinical Biopsy Usually unnecessary Cryotherapy Curettage Laser Cimetidine Topical therapies Acyclovir for high risk individuals THERAPY

PREVENTION No vaccine available Handwashing Cover lesions with clothing

CHILD CARE EXCLUSION None recommended

PREVENTIVE STRATEGIES

ENTRANCE REQUIREMENTS FOR CHILDREN Medical history Immunizations Diphtheria-Pertussis-Tetanus Hemophilus influenza B Hepatitis A Hepatitis B Influenza Mumps Polio Rubella Rubeola Varicella Pneumococcus

ENTRANCE REQUIREMENTS FOR STAFF Medical history Immunizations Diphtheria-Tetanus Hepatitis A Hepatitis B Influenza Mumps Polio Rubella Rubeola Varicella (Pertussis)

EXCLUSION FROM CHILD CARE