6.1 RESPIRATORY TRACT INFECTIONS
Please note that if a staff member has no contact with the children, or with anything with which the children come in contact, the staff requirements in these standards do not apply to that staff member.
HAEMOPHILUS INFLUENZAE TYPE B (Hib)
immunization for
haemophilus influenzae type b
All children in child care shall have received age-appropriate immunizations with an
H. influenzae type b (Hib) conjugate vaccine (
1).
Children in child care, who are not immunized or not age-appropriately immunized, shall be excluded from care immediately if the child care facility has been notified of a documented case of an invasive Hib infection. These children shall be allowed to return when the risk of infection is no longer present, as determined by the health department.
RATIONALE: Appropriate immunization of children with an
H. influenzae type b conjugate vaccine prevents the occurrence of disease and decreases the rate of carriage of this organism, thereby decreasing the risk of transmission to others (
2,
3).
COMMENTS: Transmission of
H. influenzae type b may occur among unimmunized young children in group child care, especially children younger than 24 months of age.
For additional regarding Hib disease, consult the
Red Book from the American Academy of Pediatrics (AAP). Contact information for the AAP is located in Appendix BB.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
informing parents of hib exposure
If a child with invasive
H. influenzae type b (Hib) infection has been in care, the facility shall inform parents of other children who attend the facility, after consultation with the health department, that their children may have been exposed to the Hib bacteria and may have greater risk of developing serious Hib disease if their child is unimmunized or incompletely immunized. The facility shall recommend that parents contact their child's health care provider.
RATIONALE: The risk of secondary cases of Hib disease occurring among child care contacts does not seem to be uniform. Studies of child care contacts of children with Hib disease have varied in identification of an increased risk of Hib disease in this setting
In general, the risk of secondary Hib disease is probably lower for child care contacts than it is for household contacts. The risk of secondary cases of Hib disease occurring among child care attendees is greatest among, and may be limited to, children younger than 2 years of age who are not immunized (
6). In settings with more than one classroom, increased risk has been shown only for children in the classroom of the infected child (
6,
7).
COMMENTS: Sample letters of notification to parents that their child may have been exposed to an infectious disease are contained in the (National Academy for the Education of Young Children (NAEYC) publication,
Healthy Young Children. Contact information is located in Appendix BB.
For additional information regarding Hib disease, consult the
Red Book from the American Academy of Pediatrics (AAP). Contact information for the AAP is located in Appendix BB.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
informing public health authorities of hib cases
Local and/or state public health authorities shall be notified immediately about cases of
H. influenzae type b (Hib) infections involving children or child care providers in the child care setting. Facilities shall cooperate with their health department in notifying parents of children who attend the facility about exposure to children with Hib disease. This may include providing local health officials with the names and telephone numbers of parents of children in classrooms or facilities involved.
The health department may recommend rifampin,
an antibiotic taken to prevent infection, for chil-dren in care and staff members, to prevent secondary spread of Hib disease in the facility. Antibiotic prophylaxis is not recommended for pregnant women because the effect of rifampin on the fetus has not been established.
RATIONALE: Because the risk of secondary cases of Hib disease seems to be variable among child care contacts of children with Hib disease, opinions differ as to the most appropriate guidelines for the use of rifampin to prevent infection in the child care setting. Rifampin treatment of children exposed to a child with Hib disease can reduce the prevalence of Hib respiratory tract colonization in treated children and reduce the subsequent risk of invasive Hib infection, particularly in children under 2 years of age (
6). Prophylaxis should be initiated as soon as possible, when 2 or more cases of invasive disease have occurred within 60 days and when unimmunized or incompletely immunized children attend the child care
In addition, children who are not immunized or are not age-appropriately immunized should receive a dose of vaccine and should be scheduled for completion of the
Recommended Childhood Immunization Schedule from the American Academy of Pediatrics (AAP) (
1,
8). See Appendix G.
COMMENTS: For additional information regarding Hib disease, consult the
Red Book from the American Academy of Pediatrics (AAP). Contact information for the AAP is located in Appendix BB.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
immunization with
s. pneumoniae conjugate vaccine
All children less than 23 months of age in child care shall have received age-appropriate immunizations with
S. pneumoniae conjugate vaccine. Children age 24 to 59 months of age at high risk of invasive disease caused by
S. pneumoniae (including sickle cell disease, asplenia, HIV, chronic illness or immunocompromised) shall be recommended to receive
S. pneumoniae conjugate vaccine. All other children 24-59 months of age shall be encouraged to be protected against invasive
S. pneumoniae disease through immunization, especially children who attend out-of-home child care and children of American Indian, Alaska Native, and African-American descent (
9,
10,
11).
RATIONALE: Pneumococcal disease among children in out-of-home child care has been reported more frequently over the last decade in the U.S. and other developed countries. In the U.S., the risk for contracting an invasive pneumococcal infection in out-of-home child care (as defined as child care greater than 4 hours/week outside the home) increases by 2 to 3 times in children less than 60 months of age. Appropriate immunization of children with
S. pneumoniae conjugate vaccine prevents the occurrence of disease and decreases transmission to others.
The risk for invasive disease is greatest in children who attend out-of-home child care and children of American Indian, Alaska Native, and African-American descent (
10,
11).
COMMENTS: For additional information regarding
S. pneumoniae disease, consult the
Red Book from the American Academy of Pediatrics (AAP). See also Appendix G. Contact information for the AAP is located in Appendix BB.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
informing public health authorities of invasive
S. pneumoniae
Local and/or state public health authorities shall be notified immediately about cases of invasive
S. pneumoniae infections involving children or child care providers in the child care setting. Facilities shall cooperate with their health department in notifying parents of children who attend the facility about exposure to children with invasive
S. pneumoniae disease. This may include providing local health officials with the names and telephone numbers of parents of children in classrooms or facilities involved.
RATIONALE: Secondary spread of
S. pneumoniae in child care has been reported, but the degree of risk of secondary spread in child care facilities is unknown (
12). Prophylaxis of contacts after the occurrence of a single case of invasive
S. pneumoniae disease is not recommended.
In addition, children who are not immunized or are not age-appropriately immunized should receive a dose of vaccine and should be scheduled for completion of the
Recommended Childhood Immunization Schedule from the American Academy of Pediatrics (AAP) (
9). See Appendix G.
COMMENTS: For additional information regarding
S. pneumoniae disease, consult the
Red Book from the American Academy of Pediatrics (AAP). Contact information for the AAP is located in Appendix BB.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
NEISSERIA MENINGITIDIS (MENINGOCOCCUS)
informing public health authorities of meningococcal infections
Local and/or state public health authorities shall be notified immediately about cases of meningococcal infections involving children or child care providers in the child care setting. Facilities shall cooperate with their local health department officials in notifying parents of children who attend the facility about exposures to children with meningococcal infections. This may include providing local health officials with the names and telephone numbers of parents of children in involved classrooms or
RATIONALE:
Neisseria meningitidis is an important cause of bacterial meningitis in childhood. The infection is spread from person to person by direct contact with respiratory tract secretions (including large droplets) that contain
N. meningiditis organisms.
COMMENTS: Sample letters of notification to parents that their child may have been exposed to an infectious disease are contained in the National Academy for the Education of Young Children (NAEYC) publication,
Healthy Young Children. Contact information is located in Appendix BB.
For additional information regarding meningococcal disease, consult the
Red Book from the American Academy of Pediatrics (AAP). Contact information for the AAP is located in Appendix BB.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
health department recommendations on antibiotics
When the health department recommends administering an antibiotic to prevent secondary infection of meningococcal disease within the facility, an antibiotic to prevent an infection shall be administered to staff members and children, with parental permission (
13,
14,
15).
RATIONALE: Children and staff exposed, by close contact for an extended period to the child first infected with meningococcal disease, are at risk for contracting invasive meningococcal disease (
13). The attack rate of meningococcal disease for this population is more than 300 times higher than rates in the general population (
14).
Because outbreaks may occur in child care settings, chemoprophylaxis with rifampin or ceftriaxone is indicated for exposed child care contacts. Children in child care who are exposed to a child or an adult with meningococcal infection should receive rifampin
or ceftriaxone
as soon as possible to prevent an infection, preferably within 24 hours of diagnosis of the primary case (
14,
15). In contacts over 18 years of age, ciprofloxacin is effective. Rifampin and ciprofloxacin are not recommended for pregnant women.
COMMENTS: For additional information regarding meningococcal disease, consult the
Red Book from the American Academy of Pediatrics (AAP). Contact information for the AAP is located in Appendix BB.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
protective measures for meningococcal infection
When an antibiotic to prevent an infection with
Neisseria meningitidis (meningococcal infection) is indicated for child care contacts, all children and staff members, for whom prophylaxis has been recommended, shall be excluded from attending the facility until these measures have begun. Any exposed individual who develops a febrile illness (one accompanied by a fever) shall receive prompt medical evaluation.
New entry children shall not be enrolled in a child care facility in which a case of invasive
N. meningitidis has been documented until 2 months has elapsed since the diagnosis was made.
RATIONALE: Children and staff exposed, by close contact for an extended period to the child first infected with meningococcal disease, are at risk for contracting invasive meningococcal disease (
13). The attack rate of meningococcal disease for this population is more than 300 times higher than rates in the general population (
14).
Because outbreaks may occur in child care settings, chemoprophylaxis with rifampin or ceftriaxone is indicated for exposed child care contacts. Children in child care who are exposed to a child or an adult with meningococcal infection should receive rifampin
or ceftriaxone
as soon as possible to prevent an infection, preferably within 24 hours of diagnosis of the primary case (
14,
15). In contacts over 18 years of age, ciprofloxacin is effective. Rifampin and ciprofloxacin are not recommended for pregnant women.
COMMENTS: For additional information regarding meningococcal disease, consult the
Red Book from the American Academy of Pediatrics (AAP). Contact information for the AAP is located in Appendix BB.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
informing public health authorities of pertussis cases
Local and/or state public health authorities shall be notified immediately about cases of pertussis involving children or child care providers in the child care setting. Facilities shall cooperate with their local health department officials in notifying parents of children who attend the facility about exposures to children with pertussis. This may include providing the health department officials with the names and telephone numbers of parents of children in the classrooms or facilities involved.
Guidelines for use of antibiotics and immunization for prevention of pertussis in individuals who have been in contact with children who have pertussis shall be implemented in cooperation with officials of the health department. Children and staff who have been exposed to pertussis, especially those who are incompletely immunized, shall be observed for respiratory tract symptoms for 20 days after the last contact with the infected person.
RATIONALE: Notification of health department officials when pertussis occurs in a child or staff member in a child care center will help ensure the following (
16,
17):
a) All children have received age-appropriate immunization;
b) Erythromycin prophylaxis (or other recommended antibiotic therapy, if erythromycin is not tolerated) is provided to those exposed to the child first infected with pertussis;
c) Children and adults are observed for respiratory tract symptoms.
COMMENTS: Sample letters of notification to parents that their child may have been exposed to an infectious disease are contained in the National Academy for the Education of Young Children (NAEYC) publication,
Healthy Young Children. Contact information for the NAEYC is located in Appendix BB.
For additional information regarding pertussis, consult the
Red Book from the American Academy of Pediatrics (AAP). Contact information for the AAP is located in Appendix BB.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
prophylactic treatment for pertussis
When there is a known or suspected occurrence of pertussis in a child care facility, all staff members and children in care shall initiate the appropriate prophylactic treatment (usually administration of erythromycin or another appropriate antibiotic) and any additional treatment deemed medically necessary by a health care provider before they are allowed to return to the facility.
Adults and children who have been in contact with a person infected with pertussis shall be monitored closely for respiratory tract symptoms for 20 days after the last contact with the infected person.
RATIONALE: Even if outbreaks of pertussis in child care facilities have not been reported, children and staff who attend out-of-home child care occasionally contract pertussis. The spread of infection to contacts who are incompletely immunized can be reduced by treating the primary case and susceptible contacts with prophylactic antibiotics, usually
COMMENTS: For additional information regarding pertussis, consult the
Red Book from the American Academy of Pediatrics (AAP). Contact information for the AAP is located in Appendix BB.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
Children and staff members with characteristic symptoms (primarily cough) of pertussis shall be excluded from child care pending evaluation by a health care provider. The child or staff member may not return to the facility until:
a) Five days after initiation of a 10-14 day course of erythromycin or other recommended antibiotic therapy;
b) Three to four weeks after the onset of the cough;
c) The medical condition allows.
RATIONALE: Even if outbreaks of pertussis in child care facilities have not been reported, children and staff who attend out-of-home child care occasionally contract pertussis. The spread of infection to contacts who are incompletely immunized can be reduced by treating the primary case and susceptible contacts with prophylactic antibiotics, usually
COMMENTS: For additional information regarding pertussis, consult the
Red Book from the American Academy of Pediatrics (AAP). Contact information for the AAP is located in Appendix BB.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
GROUP A STREPTOCOCCAL (GAS) INFECTION
exclusion for group A streptococcal infections
Children with group A streptococcal (GAS) respiratory tract, skin, or ear infections shall be excluded from child care until 24 hours after antibiotic treatment has been initiated and until the child has no fever for 24 hours.
RATIONALE: Streptococcal respiratory tract infections and scarlet fever resulting from GAS have been reported in children in child care, but are not a major problem (
18,
19). Group A streptococcal respiratory tract infections may resolve without treatment; however, GAS respiratory tract infections can be complicated by pneumonia, arthritis, rheumatic fever, and glomerulonephritis (
20).
Early identification and treatment of GAS infection in children and adults are important in reducing transmission and subsequent occurrence of disease. Consultation with the health department is advised when high rates of streptococcal infection occur in child care facilities. Parents of children exposed to a child with documented GAS infection should be notified of the exposure.
COMMENTS: For additional information regarding group A streptococcal respiratory tract infection, consult the
Red Book from the American Academy of Pediatrics (AAP). Contact information for the AAP is located in Appendix BB.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
informing caregivers of group A STREPTOCOCCAL infection
Parents who become aware that their child is infected with group A streptocci (GAS), has strep throat, or has scarlet fever, shall inform caregivers within 24 hours.
When exposure to GAS infection occurs, care-
givers, in cooperation with health department officials, shall inform the parents of other children who attend the facility, that their children may have been exposed.
RATIONALE:
Periodically, the incidence of rheumatic fever seems to increase (
20). Identification and treatment of streptococcal infections of the respiratory tract are central to preventing rheumatic fever. Therefore, awareness of the occurrence of streptococcal infection in child care is important. Adult child care staff members are not immune to streptococcal infections and may be carriers of organisms that cause disease in children. When outbreaks of streptococcal disease occur, interventions are available to limit transmission of streptococcal infection. Consultation with the health department is advised when high rates of streptococcal infection occur in child care facilities.
This information could be useful to the exposed child's health care provider if the exposed child deve-lops illness.
COMMENTS: Sample letters of notification to parents that their child may have been exposed to an infectious disease are contained in the (National Academy for the Education of Young Children (NAEYC) publication,
Healthy Young Children. Contact information is located in Appendix BB.
For additional information regarding group A streptococcal infections, consult the
Red Book from the American Academy of Pediatrics (AAP). Contact information for the AAP is located in Appendix BB.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
MEASURES FOR DETECTION AND CONTROL OF tuberculosis
Local and/or state public health authorities shall be notified immediately about suspected cases of tuberculosis disease involving children or child care providers in the child care setting. Facilities shall cooperate with their local health department officials in notifying parents of children who attend the facility about exposures to children or staff with tuberculosis disease. This may include providing the health department officials with the names and telephone numbers of parents of children in the classrooms or facilities involved.
Tuberculosis transmission shall be controlled by requiring regular and substitute staff members and volunteers to have their tuberculosis status assessed with a one-step or two-step Mantoux intradermal skin test prior to beginning employment unless they produce documentation of the following:
a) A positive Mantoux intradermal skin test result in the past, or
b) Tuberculosis disease that has been treated appropriately in the past.
The one-step Mantoux intradermal tuberculin test shall suffice except that for individuals over 60 years of age or those who have a medical condition that reduces their immune response, the use of the two-step method is required. Individuals with a positive Mantoux intradermal skin test or tuberculosis disease in the past shall be evaluated with chest radiographs and shall be cleared for work by their physician or a health department official. Review of the health status of any staff member with a positive Mantoux intradermal skin test or tuberculosis disease in the past shall be part of the routine annual staff health
In large and small family child care homes, this requirement applies to all adolescents and adults who are present while the children are in care.
Tuberculosis screening by
Mantoux intradermal skin testing, using the one-step procedure, of staff members with previously negative skin tests shall not be repeated on a regular basis unless required by the local or state health department. Anyone who develops an illness consistent with tuberculosis shall be evaluated promptly by a physician. Staff members with previously positive skin tests shall be under the care of a physician who, annually, will document the risk of contagion related to the person's tuberculosis status by performing a symptom review including asking about chronic cough, unintentional weight, unexplained fever and other potential risk factors.
RATIONALE: Young children acquire tuberculosis infection from infected adults or occasionally, infected adolescents (
21). Tuberculosis organisms are spread by inhalation of a small particle aerosol produced by coughing or sneezing by an adult or adolescent with contagious (active) pulmonary tuberculosis. Transmission usually occurs in an indoor environment. Tuberculosis is not spread through objects such as clothes, dishes, floors, and furniture.
The one-step Mantoux method of intradermal PPD skin testing involves injecting the material known as PPD into the skin so that a bleb is raised as the material is injected. For most healthy individuals, the one-step test is sufficient to detect latent TB or active TB disease. TB testing depends on cell-mediated immunity and the anemnestic or memory response where the body recalls a previous encounter with the antigen and reacts to it. In older individuals and those who have one of a group of specific conditions that reduce immune response, the first Mantoux test can produce a false negative response to a first test. In these individuals, the two-step method is recommended, involving repeating the Mantoux test procedure with an interval of at least one week to get an accurate result. Anamestic memory for most antigens occurs within one week after stimulation with the substance -thus a second test may be positive when a first is negative and indicate that an individual has latent TB or TB disease. The need for a two-step test for individuals under 60 years of age should be determined by the clinician performing the test or by the local department of health.
COMMENTS: The two stages of tuberculosis are:
a) Latent tuberculosis infection, when the tuberculosis germ is in the body and causes a positive Mantoux intradermal skin test but does not cause sickness;
b) Active tuberculosis (tuberculosis disease), when the tuberculosis germ is in the body and causes sickness.
Virtually all tuberculosis is transmitted from adults and adolescents with tuberculosis disease. Infants and young children with tuberculosis are not likely to transmit the infection to other children or adults because they generally do not produce sputum and are unable to forcefully cough out large numbers of organisms into the air.
Only Mantoux intradermal skin test, containing 5 tuberculin units of purified protein derivative administered intradermally, should be used for skin testing. Multiple puncture tests should no longer be used because several problems severely limit their use. Problems include a lack of antigen standardization, false-positive and false negative results, and variable sensitivity and specificity.
For additional information regarding tuberculosis, consult the
Red Book from the American Academy of Pediatrics (AAP). Contact information for the AAP is located in Appendix BB.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
attendance of children with tuberculosis infection
Children with tuberculosis infection or disease can attend child care if they are receiving appropriate therapy.
RATIONALE: Children can return to regular activities as soon as effective therapy has been instituted, adherence to therapy has been documented, and clinical symptoms have disappeared. If approved by local health officials, children may attend out-of-home child care once they are considered non-infectious to
COMMENTS: For additional information regarding tuberculosis, consult the
Red Book from the American Academy of Pediatrics (AAP). Contact information for the AAP is located in Appendix BB.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
attendance of children with erythema infectiosum (EI)
Children who develop erythema infectiosum (EI), also known as fifth disease, following infection with parvovirus B19, shall be allowed to attend child care because they are no longer contagious when signs and symptoms appear.
RATIONALE: EI is caused by parvovirus B19. EI begins with a fever, headache, and muscle aches, and is followed by a rash, which is intensely red with a "slapped cheek" appearance. A lace-like rash appears on the rest of the body. Isolation or exclusion of an immunocompetent person with parvovirus B19 infection in the child care setting is not necessary because little to no virus is present in the respiratory tract secretions at the time of occurrence of the rash (
22).
COMMENTS: For additional information regarding parvovirus B19, consult the
Red Book from the American Academy of Pediatrics (AAP). Contact information for the AAP is located in Appendix BB.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
UNSPECIFIED RESPIRATORY TRACT INFECTION
attendance of children with unspecified respiratory tract infection
Children without fever who have mild symptoms associated with the common cold, sore throat, croup, bronchitis, rhinitis (runny nose), or otitis media (ear infection) shall not be denied admission to child care, sent home from child care, or separated from other children in the facility unless their illness is characterized by one or more of the following conditions:
a) The illness has a specified cause that requires exclusion, as determined by other specific performance standards in Child Inclusion/Exclusion/Dismissal,
STANDARD 3.065 through
STANDARD 3.068;
b) The illness limits the child's comfortable participation in child care activities;
c) The illness results in a need for more care than the staff can provide without compromising the health and safety of other children.
Treatment with antibiotics shall not be required or otherwise encouraged as a condition for attendance of children with mild respiratory tract infections unless directed by local health authorities.
RATIONALE: The incidence of acute diseases of the respiratory tract, including the common cold, croup, bronchitis, pneumonia, and otitis media, is high in infants and young children, whether they are cared for at home or attend out-of-home facilities (
23). Studies suggest that children who attend child care facilities have a significantly higher risk of upper and lower respiratory tract infections compared to children who are cared for at home and that infants and young children in child care have a higher incidence of these infections when they first begin to attend child care (
24,
25,
26).
Children, 3 years of age and younger, experience an average of 5 to 10 respiratory tract infections each year, most of which are not severe and are caused by viruses that infect the respiratory tract (
27). There is no evidence that the incidence of most acute diseases of the respiratory tract can be reduced among children in child care by any specific intervention other than routine sanitation and personal hygiene.
Exclusion of ill children from the facility has not been found of value in preventing common respiratory infections.
When compliance with environmental infection control practices is high in child care settings, a reduction in episodes of colds is possible (
28). Most children with viral respiratory tract infections remain infectious for at least 5 to 8 days. Frequently, infected children are shedding viruses before they are obviously ill, and some infected children never become overtly ill. Therefore, excluding children with respiratory tract disease from child care is not likely to limit transmission of respiratory tract infections in the child care setting.
The inappropriate use of antibiotics is a serious public health problem leading to development of antibiotic resistance (
29,
30). Inappropriate antibiotic use in child care for mild respiratory tract infections is common even though these infections are often caused by viruses. Parents may attempt to pressure physicians into prescribing antibiotics for infections because they falsely believe that antibiotics will shorten the time when their children are excluded from child care.
COMMENTS: Uncontrolled coughing, difficult or rapid breathing, and wheezing (if associated with difficult breathing or if the child has no history of asthma) may represent severe illness or even a life-threatening condition. Exclusion in these cases is for the child's safety. The child should receive medical care before being allowed to return to the facility.
For additional information regarding unspecified respiratory tract infections, consult the
Red Book from the American Academy of Pediatrics (AAP). Contact infor
