Transcript Infectious Disease in Out of Home Child Care, Part II

Infectious Disease in Out of
Home Child Care
Part II: Illnesses Transmitted by the Fecal-Oral Route
Jonathan B. Kotch, MD, MPH, FAAP, Director
National Training Institute for Child Care Health Consultants
The University of North Carolina at Chapel Hill
Objectives for Part II
At the end of this training learners will be
able to:


Describe the causes and consequences of
infectious diseases in child care transmitted
by the fecal-oral route, and
Identify modes of transmission and
prevention of infectious diseases in child care
transmitted by the fecal-oral route.
Fecal-oral Transmission
 Gastroenteritis
 Infections that may occur without
gastroenteritis




Hepatitis A
Polio
Paratyphoid and typhoid fever (Salmonella)
Hemolytic-uremic syndrome (E. coli
O157:H7)
Enteric Pathogens
(Churchill & Pickering, 1997)
 Parasites
 Giardia
 Cryptosporidium
 Viruses
Astrovirus
Calicivirus
Enteric Adenovirus
Enteroviruses
(polio)
 Hepatitis A
 Rotavirus




 Bacteria







Shigella
Salmonella
Campylobacter
E. coli 0157:H7
Other E. coli
Yersinia
Clostridium difficile
Norovirus



Associated with outbreaks on cruise ships,
hospitals, hotels, restaurants, schools, camps,
and college campuses
Second most common cause of viral
gastroenteritis in child care settings in North
Carolina
More susceptible to bleach than to quaternary
ammonium and phenolic disinfectants
Where Are the Germs?

Laborde et al., 1994




Hands; staff and child
Hard toys
Classroom sinks and faucets
Laborde et al., 1993


Hands (RR=2.0)
Moist sites (1.1<RR<1.6)
Pathogen Transmission
(Jiang et al., 1998)

Transmission within the center



Diapers, chairs, floors, toys, doorknobs
contaminated by researchers
Within 1-2 hours hands, toy balls, window,
walker, cabinets, doors contaminated
Transmission to homes

Next day, car seats, toys, high chairs, cribs,
diaper changing areas, rims of tubs
contaminated
Exclusion






1
Criteria
Inexplicable bloody stools
Abdominal pain for more than 2 hours
Intermittent pain associated with fever or other
signs and symptoms
Vomiting
Diarrhea
Hepatitis A
1Courtesy of
Steve Shuman
Sanitation and Hygiene




Diapering technique
Hand hygiene (soap and water is best;
waterless alcohol product second)
Sanitary food preparation and service
Physical environment



Separation of food services and diapering
Sanitary disposal of waste
#, location and design of sinks and toilets
Caregiver Training

Handwashing



Black et al., 1981
Bartlett et al., 1988
Handwashing and sanitation
(Kotch et al., 1994)


Respiratory -- Not
Severe diarrhea


Newer centers, RR=3.1
Younger children, RR=1.97
Handwashing Study
Conclusions
(Kotch et al., 1994)



Handwashing effective for severe diarrhea,
not for URI
Effect modified by age of child and length of
center operation
Written guidelines associated with newer
centers
Importance of the Physical
Environment

Physical barriers
limited compliance


Access to sink in
room
Distance to sink from
changing table

Need for sanitary
toileting facilities
More Recent Randomized,
Controlled Studies of Handwashing

Uhari and Mottonen, 1999.




Significantly fewer child and staff illnesses
Fewer antibiotic prescriptions
Fewer parental absences from work
Roberts, et al., 2000.

50% reduction in child diarrheal illness in
children over 24 months of age
Immunizations




Less common for gastroenteritis but still important
The first generation rotavirus immunization had to be
pulled from the market but a new and improved
version is now available and recommended by the
Advisory Committee on Immunization Practices
(ACIP)
Hepatitis A immunization is now recommended for all
children at 12 mo. of age
Poliovirus, which causes “juvenile paralysis”, is also
in the fecal-oral category.
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 II