How do day care facilities impact infection control?

Over 20 million children attend some form of Day Care at an out-of-home group care facility. These Child Day Care facilities include various types of out-of-home child care that is attended on a routine basis such as nursery schools, preschool programs, or partial-or full-day programs based either in a nonresidential Child Care center or in another person’s home. Child Day 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. In the United States, Child Care facilities include Child Care Centers, small family Child Care homes (1-6 children), large family Child Care homes (7-12 children), and facilities for ill children or for children with special needs. Child Day Care centers are licensed and regulated by state governments and individually care for a larger number of children (i.e., larger enrollment) than are cared for in a family home setting. Family Child Care homes may or may not be licensed or registered depending on individual state requirements. In the US, more children are cared for in Child Day Care homes than in Day Care centers.

Grouping of children in Day Care programs is generally done by age. Although this may vary with the size and resources of the individual Day Care facility, the most common groups consist of:

  • Infants (birth to 12 months of age)

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  • Toddlers (13 through 35 months of age)

  • Preschoolers (36 through 59 months of age)

  • School-aged children (5 though 12 years of age)

Age grouping reflects the developmental status of the children in each group. Infants and toddlers who require diapering or assistance in using the toilet have significant hands-on contact with care providers. They have oral contact with the environment, have poor control over their secretions and excretions, and have immunity to fewer common pathogens. Toddlers likewise are at an age where they are in the process of completing their primary immunization series, so while their immunity to common infections and vaccine-preventable illnesses is better, it may still be incomplete. Toddlers also have frequent direct contact with each other and with secretions of other toddlers during routine play. Consequently, attention to infection control measures is especially important in Child Day Care programs that provide infant and toddler care.

Children in group Day Care have an increased rate of communicable infectious diseases and are prescribed antibiotics more often and for longer durations than children not in Day Care. Much of this increase in infections is seen during the first 2 years of age; by age 3 the rates of infection in children in Day Care are similar to non-Day Care attendees. Adult caregivers also have an increased risk of acquiring and transmitting infectious diseases, particularly in the first year of contact with children in the Day Care setting and working with infants and toddlers.

Transmission of infection in child Day Care is influenced by features of the child care program (attendees, staff, facility) and features of the specific infectious agent. Many aspects of group child care impact infection control and transmission of infectious agents:

The ages of the children and their immunization status. The younger infants included may not have yet completed their primary immunizations, creating a population of children susceptible to certain vaccine-preventable illnesses. This is further enhanced if attendees are behind in recommended immunizations.

Caregivers’ practice of personal hygiene and immunization status

Ratio of children to caregivers. This contact is enhanced when there is crowding, limited space in the center and with increased ratio of children to caregivers.

Environmental sanitation Lack of control of secretions may also lead to contamination of environmental surfaces and contributeto fomite transmission for those microbes that can survive for significant times on surfaces.

Food-handling procedures

Physical space and quality of the facilities (crowding)

Frequency of use of antimicrobial agents in the children

Adherence to standard precautions for infection control

Features of thespecific infectious agentthat affect transmission in group settings include:

  • Route ofspread, infective dose, and survival in the environment

  • Frequency of an asymptomaticinfection or carrier state

  • Immunity to therespective pathogen

What policies need to be adhered to for infection prevention and control in day care facilities?

There are four major areas in which Day Care center policies and practices may have an impact on preventing and controlling the spread of infection in the facility:

Exclusion of ill Children and Caregivers (see Appendix 1 and Appendix 2 for recommended general and organism-specific exclusion criteria)

1) Day Care facilities must have written policies to which they adhere for management of illnesses in both children and childcare providers.

2) There must be written policies for exclusion of ill children and providers as well as for when they may return to the facility.

Immunization

1) All children and childcare providers must be adequately immunized according to individual state requirements.

2) Day Care facilities must ensure and maintain documentation of immunization status for both providers and children.

Physical Structure and Maintenance of Day Care Facilities

1) Aspects of the physical design of the Day Care center must allow for adequate space and facilities appropriate to maintain essential hygienic practices (sinks near toileting and diapering areas, child-sized toilets, food preparation areas separate from child care areas, etc.).

2) Policies regarding frequent and appropriate sanitization of the facility (especially of food-handling, diapering, and toilet areas) should be maintained.

3) Attention to criteria by which children are cohorted

a) Separation of children by age in order to reduce transmission of infectious diseases; children in diapers should generally be separated from toilet-trained children.

b) An appropriate ratio of children to caregivers should be maintained.

Hygienic Practices

1) Day Care facilities must maintain and enforce a written policy for appropriate hygienic practices including:

a) Hand hygiene techniques and frequency (hand washing and use of hand-sanitizing products).

b) Appropriate diapering techniques.

c) Appropriate food-handling techniques.

d) Appropriate cleaning of toys, sleep equipment, linens, and all surfaces which may harbor infectious fomites.

e) Universal precautions for spillage of body fluids (blood, urine, feces, etc.).

How does research guide current infection control practices in day care facilities?

  • Hand washing and the use of hand sanitizers are effective in reducing the transmission of infectious diseases in child day care.

  • Lack of immunization in children attendees (recommended vaccines missed, lapsed or refused) elevates the risk of measles and pertussis in Day Care facilities (suggesting increased risk for other vaccine-preventable infections as well).

  • The risk of diarrheal illness is substantially higher in older children (toilet-trained) grouped with younger children (not toilet-trained) as compared to those older children not grouped with incontinent children.

  • Day Care facilities with significant crowding have increased risk of infection transmission when compared to those not overcrowded.

  • Infection control programs (educational training, monitoring, interventions, etc.) can reduce the transmission of infectious diseases in child Day Care including respiratory and diarrheal illnesses.

What are the consequences of ignoring infection control concepts in day care facilities?

Lack of adherence to recommended infection control policies and procedures in the child Day Care setting can lead to increased transmission of infections among susceptible children as well as caregivers. Because of the relatively close contact among young children that exists in most child Day Care facilities, infections in Day Care have the potential to be amplified and spread among many attendees causing an outbreak. Such outbreaks may have public health implications, particularly if they involve vaccine-preventable infections. Since children in Day Care are also more likely to be treated with antibiotics, they are more likely to become colonized with antibiotic-resistant bacteria. Lack of adherence to infection control policies can further promote spread of these organisms among other attendees creating a larger cohort of children colonized with antibiotic-resistant bacteria.

In addition, an increase in infectious diseases among children in Day Care can have significant impacts on their families and the community at large. Infectious illnesses acquired in Day Care settings, either by the children or their adult caregivers, can be spread to family members. If appropriate measures to reduce the transmission of infection in child Day Care facilities are ignored, the likely consequences of the resulting increase in childhood illnesses includes:

1) An increase in missed work by one or both parents resulting in loss of income

2) A loss in revenue to the child Day Care facility due to absenteeism

3) An increase in illness of family members and household contacts (potential secondary loss in revenue)

4) Increase in antimicrobial use and in organisms with multiple antimicrobial resistances

Summary of current controversies.

As noted above, child Day Care in the United States is a large service industry that involves millions of children and providers. While there are many areas of potential controversy, there are two areas that parents are often concerned about:

1. Illness exclusion criteria – Policies related to exclusion of sick children tend to be the most controversial aspects of child Day Care.

2. Immunization/ vaccine deferral or refusal – there are some parents who distrust vaccines and prefer to either defer or delay many of the routinely recommended immunizations.

Overview of important clinical trials, meta-analyses, case control studies, case series, and individual case reports related to infection control and day care.

See Table I for a detailed summary of the research about infection control in day care facilities.

Table I.
STUDY FINDINGS
Boyce JM, 2002 Extensive review of data regarding hand washing and hand antisepsis in healthcare settings; concluded that the use of hand-sanitizing gels is an effective means of achieving adequate hand hygiene
Black, 1981 Demonstrated that good hand hygiene (hand washing) is effective at reducing diarrheal illness in child Day Care centers
Roberts L, 2000Roberts L, 2000 Randomized, controlled trials which found that adherence to infection control measures practices (hygiene interventions, monitoring, education) decreases both respiratory and diarrheal infections in children in child Day Care centers
Uhari M, 1999 Randomized, controlled trial which found that adherence to infection control measures decreases infection as well as antibiotic use (24% fewer prescriptions) in Day Care attendees.
Ponka A, 2003 Study demonstrating that infection control practices (enhanced hygiene practices) reduced absences in Day Care by 26%
Vessey JA, 2007 Hand sanitizing gel is acceptable alternative to hand washing
Feikin DR, 2000 Increased risk of measles and pertussis in children in Day Care not immunized against these infections (personal exemptors)
Barros AJD, 1999 Better hygienic practices decrease diarrheal illness in Day Care
Reves RR, 1990 Increased antibiotic use in Day Care attendees results in increased antimicrobial resistance among colonizing organisms in these children
Niffenegger JP, 1997 Study demonstrating the effectiveness of hand washing in child care.
Richardson M, 2001 Literature review of evidence-based data forming the basis for exclusion and re-entry requirements for Day Care programs.
Petersen NJ, 1986 Study of fecal coliform bacteria on hands, surfaces and air in child Day Care centers; demonstrated increased contamination inversely related to age of children associated with the source sample; results have implications for physical design of day care centers.

Controversies in detail.

1. Illness Exclusion Criteria

Policies related to the exclusion of sick children tend to be the most controversial and contentious aspects of child Day Care. Exclusion of children from Day Care is often inconvenient for parents and costly for some as the excluded child will likely need to have a doctor’s visit before returning to Day Care; likewise, alternative care may not be available necessitating that the parent miss work to care for the child. Parents may disagree with physicians and Day Care providers about which illnesses require exclusion and for how long, whether exclusion is effective at interrupting transmission, etc. While not every infectious illness has been studied, there are studies to support exclusion for many communicable illnesses as an effective infection control measure. Recommendations for readmission to Day Care are based on data for the specific infectious pathogen involved and are generally evidence-based. The emergence of drug-resistant organisms in the community setting (e.g., methicillin-resistant Staphylococcus aureus) provides new challenges for Day Care programs as new studies are done to better define the risks of a particular pathogen in the community setting and written policies must be regularly updated to incorporate new recommendations.

2. Immunization/Vaccine Deferral or Refusal

There are some parents who distrust vaccines and prefer to either defer or delay many of the routinely recommended childhood immunizations. They may feel that the incidence of many of the vaccine-preventable illnesses is now so low that their child is more at risk for a vaccine-related adverse event than acquiring a vaccine-preventable illness. They may also have an exaggerated idea of the risks of the recommended vaccines or about immunization in general.

This is a larger topic in Pediatric care in general than can be addressed here, but when studied, most of these concerns have proven to be unsubstantiated. Specifically regarding the Day Care setting, there is at least one study that demonstrated an increased risk of 2 vaccine-preventable illnesses (measles and pertussis) in children in Day Care who were not immunized against these infections. Many states allow personal preference as a reason for exemption separate from medical and religious exemptions, so there will continue to be parents who obtain exemptions for their children from some or all vaccines. Since all states require children to be immunized according to the recommended schedule for age for entrance into a Day Care center, the issue of vaccine refusal will continue to be a difficult one for Day Care providers. Written policies for management of unimmunized children in the case of an outbreak in the Day Care center or community are essential. Review of these policies with the parent may provide an opportunity for education about the rationale and benefit of immunization.

What national and international guidelines exist related to infection control in day care facilities?

The American Academy of Pediatrics (AAP), the American Public Health Association and the National Resource Center for Health and Safety in Child Care and Early Education jointly publish comprehensive health and safety performance standards that provide key instructions in best practices for infection control and can be used by health care professional to guide decisions about management of infectious diseases in child Day Care facilities:

Caring for Our Children: National health and safety performance standards: guidelines for early care and education programs. ed 3, 2011.

This publication is available online at the National Resource Center (NRC) website; which also contains links to specific standards for licensing of child care centers and family child care homes for each individual state. The AAP also has a website with links to similar resources.

What other consensus group statements exist and what do key leaders advise?

The American Academy of Pediatrics addresses issues of infection control in child Day Care in two of its regular publications, both of which are periodically updated:

  • The Red Book: 2012 Report of the Committee on Infectious Diseases contains brief summaries of infectious diseases affecting children as well as recommendations for care of children in special circumstances including out-of-home child Day Care.

  • Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide (2009) provides information and guidance for infections in children attending Day Care and in school settings.

References

American Academy of Pediatrics. Children in out-of-home child care. In Pickering LK, Baker CJ, Kimberlin DW, et al. eds.Red Book: 2012 Report of the Committee on Infectious Diseases, 29th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2012, p.133-52.

American Academy of Pediatrics, American Public Health Association, National Resource Center for Health and Safety in Child Care and Early Education. Caring for Our Children: National health and safety performance standards: guidelines for early care and ecudation programs. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics; Washington , D.C.: American Public Health Association; 2011.

American Academy of Pediatrics. Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide. Aaronson SS, Shope TR, eds. 2nd ed. Elk Grove Village, IL: American Academy of Pediatrics, 2009.

Waggoner-Fountain LA. Child Care and Communicable Diseases. In Kliegman RM, Stanton BF, St. Geme JW, et al. eds. Nelson Textbook of Pediatrics, 19th ed. Philadelphia: Elsevier Saunders; 2011.

Shane AL, Pickering LK. Infections Associated with Group Childcare. In Long SS, Pickering LK, Prober CG eds. Principles and Practice of Pediatric Infectious Diseases. 3rd ed. Philadelphia: Churchhill Livingstone; 2008.

Yamauchi T. Guidelines for attendees and personnel. In Grossman LB ed. Infection Control in the Childcare Center and Preschool. 8th ed. New York: Desmos Medical; 2012.

Boyce JM, Pittet D. Healthcare Infection Control Practices Advisory Committee. Society for Healthcare Epidemiology of America. Association for Professionals in Infection Control. Infectiuos Diseases Society of America. Guideline for Hand Hygiene in Health-Care Settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Infect Control Hosp Epidemiol. 2002; 23 (12 Suppl): S3-40.

Black RE, Dykes AC, Anderson Ke, Wells JG, et al. Handwashing to prevent diarrhea in day-care centers. Am J Epidemiol. 1981; 113(4): 445-51.

Roberts L, Smith W, Jorm L, Patel M, et al. Effect of infection control measures on the frequency of upper respiratory infection in child care: a randomized, controlled trial. Pediatrics .2000; 105: 738-42.

Roberts L, Jorm L, Patel M, Smith W, et al. Effect of infection control measures on the frequency of diarrheal episodes in child care: a randomized, controlled trial. Pediatrics. 2000; 105: 743-46.

Uhari M, Möttönen M. An open randomized controlled trial of infection prevention in child day-care centers. Pediatr Infect Dis J. 1999; 18(8): 672-77.

Pönkä A, Poussa T, Laosmaa M. The effect of enhanced hygiene practices on absences due to infectious diseases among children in day care centers in Helsinki. Infection. 2004; 32 (1): 2-7.

Vessey JA, Sherwood JJ, Warner D, Clark D. Comparing hand washing to hand sanitizers in reducing elementary school students’ absenteeism. Pediatric Nursing. 2007; 33: 368-72.

Feikin DR, Lezotte DC, Hamman, RF, Salmon DA, et al. Individual and community risks of measles and pertussis associated with personal exemptions to immunization. JAMA. 2000; 284 (24): 3145-50.

Barros AJD, Ross DA, Fonseca WVC, Williams LA, et al. Preventing acute respiratory infections and diarrhoea in child care centres. Acta Paediatrica. 1999; 88: 1113-18.

Reves RR, Jones JA. Antibiotic use and resistance patterns in day care centers. Semin Pediatr Infect Dis. 1990; 1: 212-21.

Niffenegger JP. Proper handwashing promotes wellness in child care. J Pediatr Health Care. 1997; 11: 26-31.

Richardson M, Elliman D, Maguire H, Simpson J, et al. Evidence base of incubation periods, periods of infectiousness and exclusion policies for the control of communicable diseases in schools and preschools. Pediatr Infect Dis J. 2001; 20: 380-91. Erratum in: Pediatr Infect Dis J 2001; 20: 653.

Petersen NJ, Bressler GK. Design and modification of the day care environment. Rev Infect Dis. 1986; 8: 618-21.

Carabin H, Gyorkos TW, Soto JC, Penrod J, et al. Estimation of direct and indirect costs because of common infections in toddlers attending day care centers. Pediatrics. 1999; 103: 556-62.

Ackerman SJ, Duff SB, Dennehy PH, Mafilios MS, et al. Economic impact of an infection control education program in a specialized preschool setting. Pediatrics. 2001; 108: E102.

Appendix I (Table II) and Appendix II (Table III) are below.

Table II.
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 greater care 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 hrs) or intermittent abdominal pain associated with fever, dehydration, or other systemic sings and symptoms Medical evaluation and exclusion until symptoms have resolved
Vomiting ≥2 times in preceding 24 hrs Exclusion until symptoms have resolved, unless vomiting is determined to be causes 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 American Academy of Pediatrics. Children in out-of-home child care. In: Pickering LK, Baker CJ, Kimberlin DW, Long SS, eds. Red Book: 2012 Report of the Committee on Infectious Diseases. 29th ed; 2012: page 137.

Table III.
Condition Management of Case Management of Contacts
Hepatitis A Virus (HAV) infection Serologic testing to confirm Hepatitis A virus infection in suspected cases. Exclusion until 1 week after onset of jaundice. If ≥1 case confirmed in child or staff attendees or ≥2 cases in households of staff or attendees, HAV vaccine or Immune Globulin (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 to center after receipt of IG.*
Impetigo Exclusion until 24 hrs after treatment has been initiated. Lesions on exposed skin should be covered with watertight dressing. No intervention 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 hrs of exposure. Children who do not receive vaccine within 72 hrs or who remain unimmunized after exposure should be excluded until at least 2 weeks after onset of rash in the last case of measles. (IG use)*
    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 the 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 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. Three negative stool culture results required for 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 E.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 ases 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 hrs 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 positive.
    Tuberculosis (TB) 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 TB infection (LTBI). Local health department personnel should be notified for contact investigation.*
    Varicella (chickenpox) 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 Immune Globulin (or IGIV) should be administered up to 96 hours after exposure when indictated.*

#From American Academy of Pediatrics. Children in out-of-home child care. In: Pickering LK, Baker CJ, Kimberlin DW, Long SS, eds. Red Book: 2012 Report of the Committee on Infectious Diseases. 29th ed; 2012: page 138-40.

*For more information, see specific recommendations pertinent to this infection in the SUMMARIES OF INFECTIOUS DISEASES section in the referenced text above.

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