Disease Handbook for Childcare Providers PDF

Disease Handbook for Childcare Providers New Hampshire Department of Health and Human Services Division of Public Health Services Bureau of Infectious Disease Control 29 Hazen Drive Concord, NH 03301-6527...

Disease Handbook for Childcare Providers New Hampshire Department of Health and Human Services Division of Public Health Services Bureau of Infectious Disease Control 29 Hazen Drive Concord, NH 03301-6527 Tel: 603-271-4496 Fax: 603-271-0545 https://www.dhhs.nh.gov/dphs/cdcs/handbook.htm Revised: January 2018  TABLE OF CONTENTS Introduction (1 page) Acknowledgments (1 page) What Everyone Needs to Know Immunization Requirements (1 page) Diseases That Are Preventable With Vaccines (2 pages) When A Child Should Be Excluded Or Dismissed (2 pages) When Staff Should Be Excluded (1 page) What Diseases Must Be Reported To Health Officials (1 page) A Primer on Preventing Disease Child Abuse (1 page) Diapering Recommendations (3 pages) Pets In Daycare Facilities (1 page) Food Handling For Childcare Settings (3 pages) Rashes (1 page) Disease Fact Sheets AIDS (See HIV) Norovirus (2 pages) Campylobacteriosis (2 pages) Oral Herpes (1 page) Chicken Pox /Varicella /Shingles (2 pages) Pediculosis /Head Lice (3 pages) Cold Sores (See Oral Herpes) Pertussis /Whooping Cough (2 pages) Common Cold – Influenza (2 pages) Pink Eye (See Conjunctivitis) Conjunctivitis (2 pages) Pinworms (1 page) Diarrhea (1 page) Polio (See Poliomyelitis) Diphtheria (1 page) Poliomyelitis (1 page) E. Coli 0157:H7 (1 page) Rabies (2 pages) Eastern Equine Encephalitis (EEE) (2 pages) Ringworm (1 page) Fifth Disease (2 pages) Roseola (1 page) German Measles (See Rubella) Rotavirus (1 page) Giardiasis (1 page) RSV (1 page) Haemophilus Influenza Type B (2 pages) Rubella /German Measles (1 page) Hand, Foot & Mouth (2 pages) Salmonellosis (2 pages) Head Lice (See Pediculosis) Scabies (2 pages) Hepatitis A (2 pages) Scarlet Fever (See Strep Throat) Hepatitis B (1 page) Shigellosis (1 page) Herpes (See Oral Herpes) Shingles (See Chicken Pox) Hib (See Haemophilus Influenza Type B) Strep Throat /Scarlet Fever (2 pages) HIV /AIDS (1 page) Swimmer’s Itch (1 page) Impetigo (1 page) Tetanus (1 page) Influenza (See Common Cold) Tuberculosis (1 page) Lyme Disease (2 pages) Whooping Cough (See Pertussis) Measles (2 pages) West Nile Virus (WNV) (2 pages) Meningococcal Illness (Meningitis) (2 pages) MRSA (2 pages) Reference List (1 page) Mumps (1 page) Glossary (2 pages) Division of Public Health Services Disease Handbook for Childcare Providers Bureau of Infectious Disease Control REVISED –January 2018  Introduction The New Hampshire Division of Public Health Services, Bureau of Infectious Disease Control, prepared this manual for childcare providers and parents/guardians of children attending childcare. The disease fact sheets, which comprise most of this document, are intended to familiarize people with specific infectious disease problems commonly encountered in childcare. The fact sheets can be easily photocopied for distribution to parents and guardians. In the event that any of the illnesses mentioned in this manual occur among children attending childcare, parents or guardians should be promptly notified by the childcare provider and urged to contact their family physician to obtain specific medical care advice. Childcare directors should immediately notify the Bureau of Infectious Disease Control concerning any unusual disease occurrence in their facilities so that appropriate disease-control measures may begin promptly. To contact the Bureau of Infectious Disease Control call (603) 271- 4496. Division of Public Health Services Disease Handbook for Childcare Providers Bureau of Infectious Disease Control REVISED –January 2018  Acknowledgements: We extend our appreciation to the many individual and community partners who gave generously of their time and effort in the development of the original version of this manual, as well as those who participated in this update, including: o The Berlin Health Department, o Cheshire Medical Center, o Concord Hospital Child Care Center, o East Side Learning Center, o Manchester Health Department, o Nashua Health Department, and o The current and former dedicated staff from the Division of Public Health Services. Also, special thanks to the many childcare providers who gave us valuable input on the content, organization and design of this manual. New Hampshire Department of Health and Human Services Division of Public Health Services Bureau of Infectious Disease Control The Department of Health and Human Services’ Mission is to join communities and families in providing opportunities for citizens to achieve health and independence. Division of Public Health Services Disease Handbook for Childcare Providers Bureau of Infectious Disease Control REVISED –January 2018  NH Division of Public Health Services Immunizations Required for Childcare Attendance Vaccine Recommended Schedule Comment DTaP (Diphtheria, Tetanus, a 2 months, 4 months, 6 months, 15-18 Age appropriately required for childcare cellular pertussis) months, 4-6 years. attendance per routine childhood vaccination schedule. If the child has a contraindication to the pertussis vaccine they would receive a vaccine called DT which does not contain the pertussis antigen. IPV (Polio) 2 months, 4 months, 6-18 months, 4-6 Age appropriately required for years Childcare attendance per routine childhood vaccination schedule. Hib (Haemophilus 2 months, 4 months, 6 months, 12-15 Age appropriately required for childcare influenzae Type b) months attendance. If the child starts the series late or is behind, fewer doses may be required. If the child is unvaccinated, one dose at 15 months or older is adequate. The Hib vaccine is not required after 59 months of age. MMR 12-15 months, second dose 4-6 years Age appropriately required for childcare (measles, mumps, rubella) of age. attendance per routine childhood vaccination schedule. 2nd dose must be at least 1 month after dose one. Varicella 12-15 months, second dose 4-6 years Age appropriately required for childcare (chickenpox) of age. attendance per routine childhood vaccination schedule. 2nd dose must be at least 3 months after dose one (for children ages 12 months to 12 years). A laboratory test to confirm immunity is acceptable. Hep B Birth, 1-2 months, 6-18 months. Age appropriately required for childcare (hepatitis-B) attendance. Immunizations Recommended for Childcare Attendance Vaccine Recommended Schedule Comment Hep A 12 months and at 18 months Age appropriate recommended for childcare (Hepatitis A vaccine) attendance per routine childhood vaccination schedule. Influenza vaccine 6-months and older, one dose annually. Recommended annually. If it’s the first time receiving vaccine, two doses are required.. PCV-13 (pneumococcal) 2 months, 4 months, 6 months, 12-15 Age appropriately recommended for childcare months. attendance, per routine childhood vaccination schedule. If the child starts the series late or is behind, fewer doses may be required. Recommended for certain high risk children over 59 months. Rotavirus Rotarix (RV1) 2 months, 4 months. Age appropriate recommended for childcare OR attendance per routine childhood vaccination Rotateq (RV5) 2 months, 4 months, 6 schedule. months. Recommended Immunization Schedule for children aged 18 years or younger approved by the Advisory Committee on Immunization Practice (ACIP), the American Academy of Pediatrics (AAP), and the American Academy of Family Practice (AAFP). If you have any questions about a child’s compliancy, please call the child’s primary care provider or the New Hampshire Immunization Program (603-271-4482) Additional Immunization Resources for Child Care Providers: https://www.dhhs.nh.gov/dphs/immunization/ccproviders.htm Division of Public Health Services Disease Handbook for Childcare Providers Bureau of Infectious Disease Control REVISED –January 2018  DISEASES THAT ARE PREVENTABLE WITH VACCINES This group of diseases includes measles, mumps, rubella, varicella (chickenpox), polio, pertussis, How can the spread of these diseases be diphtheria, tetanus, Haemophilus influenza type b, prevented? and 7 types of streptococcus pneumoniae, hepatitis 1. All children in daycare must be immunized B and hepatitis A. Prior to immunization appropriately for their age, in accordance programs, these diseases were a major cause of with the NH State Law: RSA 141:C-20. widespread illness, often with permanent medical Specific information about immunization complications and even death. Most of these schedules can be found on the diseases were a problem especially in children, Immunization Requirements Section in this although adults were also affected. handbook and on the appropriate fact sheets. Who gets these diseases? 2. It is recommended that all adults working Some people believe that these diseases are no in a childcare setting, including volunteers, longer a problem in the United States or that should have proof of immunization or children can’t get them anymore. This is not immunity to the following vaccine- true! These diseases are still circulating. Cases preventable diseases: diphtheria, tetanus, of these diseases do occur, particularly in pertussis, measles, mumps, rubella, unimmunized or inadequately immunized children hepatitis B, varicella, and polio. Although and adults. Measles staged a strong comeback in evidence of such immunization or the U.S. in the late eighties and early nineties in immunity is not required for childcare unimmunized preschool children and also in high workers, they are strongly recommended. school and college age students. From 1989-1991 3. If a documented case of measles, mumps, there were 123 measles associated deaths reported. rubella, polio, diphtheria, tetanus, varicella Forty-nine percent of these deaths were in children or pertussis occurs in your childcare less than 5 years of age. Ninety percent of the facility, you must notify the New fatal cases had no history of vaccination. Hampshire Division of Public Health Services, Bureau of Infectious Disease Children in childcare settings and their adult Control.. Their staff will assist you in caretakers are especially at risk. This is because starting any necessary identification and the children may be too young to be fully vaccination of susceptible children and immunized and because the close contact that adults. They will also instruct you on occurs in childcare facility allows easy spread of procedures for closely watching for any many diseases. additional cases and for notifying the parents. In this document, each vaccine preventable disease is presented briefly. Although it is Acceptable evidence of immunization or unlikely that you will ever see a case of most of immunity in adults can be provided in several these diseases, it is very important that you be ways, which vary by the age of the adult and the aware of them and of your vital role in preventing specific disease, as listed below: their spread. For further information, please contact your healthcare provider. Division of Public Health Services Disease Handbook for Childcare Providers Bureau of Infectious Disease Control REVISED –January 2018  DISEASES THAT ARE PREVENTABLE WITH VACCINES (cont). Adult Vaccination Recommendations Varicella (Chickenpox) Tetanus/diphtheria (Td) or tetanus, diphtheria, Written documentation of age appropriate acellular pertussis (Tdap) – All adults need a Td vaccination, booster every 10 years following the completion Anyone born in the United States before of the primary 3 dose series. A one-time dose of 1996, Tdap is now the vaccine of choice for any adult Laboratory evidence of immunity or regardless ofage who is due for a Td booster. laboratory confirmation of disease for Anyone who has close contact with infants less anyone born after 1998. than 12 months of age should have the Tdap at least one month prior to contact. It is suggested an Hepatitis B interval of 2 years or more since the last dose of Documentation of 3 doses of hepatitis B vaccine Td, as the minimum interval prior to the given at appropriate intervals (or) laboratory administration of Tdap. evidence of immunity is recommended. Measles Influenza Born before 1957 (or) documentation of One dose of influenza vaccine is highly vaccination with at least two doses of live measles recommended annually for all childcare workers. vaccine, with the first dose given on or after the first birthday and the second live dose at least 28 days from the first (or) laboratory evidence of immunity. Mumps Documentation of vaccination with live mumps vaccine on or after the first birthday (or) laboratory evidence of immunity (or) documentation of physician-diagnosed mumps is recommended. Rubella Documentation of vaccination with rubella vaccine on or after the first birthday (or) laboratory evidence of immunity is recommended. A history of rubella, without laboratory confirmation is NOT acceptable. For women not immune, vaccination during pregnancy is not advised. Vaccine should be administered after delivery. Division of Public Health Services Disease Handbook for Childcare Providers Bureau of Infectious Disease Control REVISED –January 2018  WHEN CHILDREN SHOULD BE EXCLUDED OR DISMISSED FROM A CHILDCARE SETTING 3.6.1 Management of Illness 4. Vomiting illness (two or more episodes of A facility shall not deny admission to or send vomiting in the previous 24 hours) until home a child because of illness unless one or vomiting resolves or until a healthcare more of the following conditions exist. The provider determines the illness to be non- parent, legal guardian or other authorized by the communicable, and the child is not in parent shall be notified immediately when a child danger of dehydration. has a sign or symptom requiring exclusion from 5. Rash with fever or behavior change, until the facility, as described below: a) The illness a healthcare provider determines that these prevents a child from participating comfortably in symptoms do not indicate a communicable facility activities; b) The illness results in a disease. greater care need than the childcare staff can provide without compromising the health and Rationale: safety of the other children; or c) The child has Exclusion of children with many mild infectious any of the following conditions: diseases is likely to have only a minor impact on 1. Temperature: Oral temperature 101 F or the incidence of infection among other children in greater; rectal temperature 102 F or the group. Thus, when formulating exclusion greater; axillary (i.e., armpit) temperature policies, it is reasonable to focus on the needs and 100 F or greater, accompanied by behavior behavior of the ill child and ability of staff in the changes or other signs or symptoms of out-of-home childcare setting to meet those needs illness until medical evaluation indicates without compromising the care of other children inclusion in the facility. Oral temperature in the group. shall not be taken on children younger than 4 years (or younger than 3 years if a Chicken pox, measles, rubella, mumps and digital thermometer is used). Only pertussis are highly communicable illnesses for persons with specific health training shall which routine exclusion of infected children is take rectal temperature. warranted. It is also appropriate to exclude 2. Symptoms and signs of possible severe children with treatable illnesses until treatment is illness (such as unusual lethargy, received and until treatment has reduced the risk uncontrolled coughing, irritability, of transmission. persistent crying, difficult breathing, wheezing, or other unusual signs), until The presence of diarrhea, particularly in diapered medical evaluation allows inclusion. children, and the presence of vomiting increase 3. Uncontrolled diarrhea, that is, increased the likelihood of exposure of other children to the number of stools, increased stool water, infectious agents that cause these illnesses. It and/or decreased form that is not may not be reasonable to routinely culture contained by the diaper, until diarrhea children who present with fever and sore throat or stops. diarrhea. However, in some outbreak settings, Division of Public Health Services Disease Handbook for Childcare Providers Bureau of Infectious Disease Control REVISED –January 2018  WHEN CHILDREN SHOULD BE EXCLUDED OR DISMISSED FROM A CHILDCARE SETTING (cont.) identifying infected children and excluding or treatment of them may be necessary. Fever is defined as an elevation of body temperature above normal. The presence of fever alone has little relevance to the spread of disease and may or may not preclude a child’s participation in childcare. The height of the fever does not necessarily indicate the severity of the child’s illness. A child’s over-exertion in a hot, dry climate may produce a fever. Life-threatening diseases, such as meningitis, cause a small proportion of childhood illness with fever. Generally, young infants show less fever with serious illness than older children. Infants and children older than 4 months should be excluded whenever behavior changes and/or signs or symptoms of illness accompany fever. Infants 4 months old or younger should be excluded when rectal temperature is 101 F or above, or axillary (i.e., armpit) temperature is 100 F or above, even if there has not been a change in their behavior. It is unreasonable and inappropriate for childcare staff to attempt to determine which illnesses with fevers may be serious. The child’s parents or legal guardians, with the help of their child’s healthcare provider, are responsible for these decisions; therefore, parents should be informed promptly when their child is found to have a fever while attending childcare. Excerpted from Caring For Our Children, National Health and Safety Performance Standards: Guidelines for Out-of-Home Child Care Programs, The American Public Health Association (Washington DC) and the American Academy of Pediatrics (Elks Grove Village, IL), 2011. Division of Public Health Services Disease Handbook for Childcare Providers Bureau of Infectious Disease Control REVISED –January 2018  WHEN STAFF SHOULD BE EXCLUDED OR DISMISSED FROM A CHILDCARE SETTING (cont.) WHEN STAFF SHOULD BE EXCLUDED OR DISMISSED FROM A CHILDCARE SETTING A facility should not deny admission to or send home a staff member or substitute with illness m) Scabies, until after treatment has been unless one or more of the following conditions completed; exists. The staff member should be excluded as n) Purulent conjunctivitis, defined as pink or follows: red conjunctiva with white or yellow eye a) Chickenpox, as directed by Bureau of discharge, often with matted eyelids after Infectious Disease Control; sleep, and including eye pain or redness of b) Shingles, only if the lesions cannot be the eyelids or skin surrounding the eye, covered by clothing or a dressing until the until examined by a physician and lesions have crusted; approved for readmission; c) Rash with fever or joint pain, until o) Haemophilus influenza type b (Hib), until diagnosed not to be measles or rubella; directed by the Bureau of Infectious d) Measles, as directed by the Bureau of Disease Control; Infectious Disease Control; p) Meningococcal infection, until directed by e) Rubella, as directed by the Bureau of the Bureau of Infectious Disease Control; Infectious Disease Control; q) Respiratory illness, if the illness limits the f) Diarrhea illness, nausea and /or vomiting staff member’s ability to provide an three or more episodes of diarrhea during acceptable level of childcare and the previous 24 hours or blood in stools, compromises the health and safety of the until 48 hours after the resolution of children. symptoms unless vomiting is identified as r) There may be other communicable a non-communicable condition such as diseases that pose a threat to the public’s pregnancy or digestive disorder or deemed health that are not specifically listed here non-infectious by a healthcare for which it may be appropriate to restrict professional; certain activities of cases, suspect cases, g) Hepatitis A virus, as directed by the and close contacts until they are no longer Bureau of Infectious Disease Control; infectious in consultation with the health h) Pertussis, as directed by the Bureau of department. Infectious Disease Control; i) Skin infections (such as impetigo), until Childcare providers who have herpes cold sores 24 hours after treatment has been initiated; should not be excluded from the childcare facility, j) Tuberculosis, as directed by the Bureau of but should: Infectious Disease Control and the 1) Cover and not touch their lesions; Tuberculosis program; 2) Carefully observe handwashing policies; k) Strep throat or other streptococcal 3) Refrain from kissing or nuzzling infants or infection, until 24 hours after initial children, especially children with antibiotic treatment and end of fever; dermatitis. l) Head lice, from the end of the day of Excerpted from Care For Our Children, National Health and discovery until the first treatment; Safety Performance Standards: Guidelines for Out-Of-Home Childcare Programs, American Public Health Association, 2011. Division of Public Health Services Disease Handbook for Childcare Providers Bureau of Infectious Disease Control REVISED –January 2018 Placeholder for “What Diseases Must Be Reported to Health Officials: Should go to: https://www.dhhs.nh.gov/dphs/cdcs/documents/reportablediseases.pdf  Child Abuse The NH Division for Children, Youth and Families (DCYF) is dedicated to assisting families in the protection, development, permanency and well being of their children and the communities in which they live. Child protection and family support services are provided by Child Protective Service Workers (CPSWs) in 12 District Offices throughout New Hampshire. Under certain circumstances, DCYF also provides voluntary services to families that request them. These are available to families that have not had a finding of abuse or neglect. DCYF strives to protect children from abuse and neglect and to help families nurture their children into physically and emotionally healthy adults. The prevention and identification of child abuse and neglect is a community responsibility that depends on the cooperation of all community members. In situations where abuse, neglect or sexual abuse is suspected or if discussion with the family does not relieve concerns, then the Division for Children, Youth and Families should be contacted at 603-271-6562 or 1-800-894-5533 (In state only) 24 hours per day. If you suspect that a child is being abused or neglected, NH state law requires that you report your concerns to the DCYF Central Intake Unit immediately. Proof of abuse or neglect is not required before reporting. Early reporting often prevents greater harm to children and other family members. The same law that requires reporting (RSA 169-C) also states that any person who makes a report in good faith is immune from any civil or criminal liability. It is better to make your concerns known than to remain silent and possibly allow a child to be seriously harmed. Division of Public Health Services Disease Handbook for Childcare Providers Bureau of Infectious Disease Control REVISED –January 2018  DIAPERING RECOMMENDATIONS Changing diapers in a sanitary way is essential to Disposable gloves prevent infectious organisms present in the stool Although gloves are not necessary for diaper from spreading. If the organisms, which cause changing, they may reduce contamination of the infectious diarrhea, hepatitis-A, giardiasis and other caregiver’s hands and reduce the presence of illnesses, are accidentally ingested, the disease may infectious disease agents under the fingernails and be transmitted. You can help prevent illness by from the hand surfaces. Even if gloves are used, remembering the following guidelines as you diaper caregivers must wash their hands after each child’s children. diaper changing to prevent the spread of disease- causing agents. Caregivers must remove the gloves Equipment Concerns For Diapering: using the proper technique otherwise the contaminated gloves will spread infectious disease Changing area and surface agents. Children should be discouraged from remaining in or entering the diaper changing area. Keep the Potty chairs changing surface away from children, preferably at Use of potty chairs should be discouraged. If potty least 36 inches from the floor. Cover it with a chairs are used, they should be emptied into a toilet, smooth, moisture-resistant, easily cleanable cleaned in a utility sink, sanitized after each use, material. For extra protection, use disposable and stored in the bathroom. After the potty is single-service covers for each child. A changing sanitized, the utility sink should also be sanitized. table should be nonporous, kept in good repair, and Potty chairs should not be washed in a sink used for cleaned and sanitized after each use to remove washing hands. If potty chairs are used, they should visible soil, followed by wetting with an approved be constructed of plastic or similar nonporous sanitizing solution. Diaper changing should not be synthetic products. Wooden potty chairs should not conducted on surfaces used for other purposes, be used, even if the surface is coated with a finish. especially not on any counter that is used during The finished surface of wooden potty chairs is not food preparation or mealtimes. durable and, therefore, may become difficult to wash and sanitize effectively. Hand washing sink and towels The best hand washing sink is one equipped with Diapers both hot and cold running water mixed through one Use of disposable diapers is recommended to best faucet (with a minimum water temperature at least reduce the risk of infections. Cloth diapers require 60-degrees and not greater than 120-degrees). more handling than disposable diapers (the more Ideally, water controls should be foot, knee or wrist handling the greater chance of infection). When operated to avoid contamination of or by hands. cloth diapers are used, no rising or dumping of The sink should be in the same room as the contents of the diaper shall be performed at the changing surface. Keep soap and towels nearby. childcare facility. Clean diapers should be stored Use single-service towels (e.g., paper towels) away from dirty diapers. A child’s diaper should be instead of cloth towels. checked for wetness and feces as least hourly, and whenever the child indicates discomfort or exhibits behavior that suggests a soiled or wet diaper. Diapers should be changed when they are found to be wet or soiled. Division of Public Health Services Disease Handbook for Childcare Providers Bureau of Infectious Disease Control REVISED –January 2018  DIAPERING RECOMMENDATIONS (cont.) Diapering Procedures: b) If safety pins are used, close each pin The following diaper changing procedure should be immediately once it is removed and keep posted in the changing area and should be followed pins out of the child’s reach. Never hold for all diaper changes. pins in your mouth; c) Lift the child’s legs as needed to use Step 1: Get organized. Before you bring the disposable wipes to clean the skin on the child to the diaper changing area, wash your child’s genitalia and buttocks. Remove the hands and bring what you need to the diaper- stool and urine from front to back and use a changing table: fresh wipe each time. Put the soiled wipes a) Non-absorbent paper liner large enough to into the soiled diaper or directly into a cover the changing surface from the child’s plastic-lined, hands-free covered can. shoulders to beyond the child’s feet; b) Fresh diaper, clean clothes (if you need Step 4: Remove the soiled diaper without them); contaminating any surface not already in contact c) Wipes for cleaning the child’s genitalia and with stool or urine. buttocks removed from the container or a) Fold the soiled surface of the diaper inward; dispensed so the container will not be b) Put soiled disposable diapers in a covered, touched during diaper changing; plastic-lined, hands-free covered can. If d) A plastic bag for any soiled diapers; reusable cloth diapers are used, put the e) Disposable gloves, if you plan to use them soiled cloth diaper and its contents (without (put gloves on before handling soiled emptying or rinsing) in a plastic bag or into clothing or diapers); a plastic-lined, hands-free covered can to f) A thick application of any diaper cream give to the parents or laundry service; (when appropriate) removed from the c) If gloves are used, remove them using the container to a piece of disposable material proper technique and put them into a plastic- such as facial or toilet tissues. lined, hands-free covered can; d) Whether or not gloves are used, use a Step 2: Carry the child to the changing table, disposable wipe to clean the surface of the keeping soiled clothing away from you and any caregiver’s hands and another to clean the surface you cannot easily clean and sanitize after child’s hands, and put the wipes into the the change. plastic-lined, hands-free covered can; a) Always keep a hand on the child; e) Check for spills under the child. If there are b) If the child’s feet cannot be kept out of the any, use the paper that extends under the diaper or from contact with soiled skin child’s feet to fold over the disposable paper during the changing process, remove the so a fresh, unsoiled paper surface is now child’s shoes and socks so the child does not under the child’s buttocks. contaminate these surfaces with stool or urine during the diaper changing; Step 5: Put on a clean diaper and dress the c) Put soiled clothes in a plastic bag and child. securely tie the plastic bag to send the soiled a) Slide a fresh diaper under the child; clothes home. b) Use a facial or toilet tissue to apply any necessary diaper creams, discarding the Step 3: Clean the child’s diaper area. tissue in a covered, plastic-lined, hands-free a) Place the child on the diaper change surface covered can; and unfasten the diaper but leave the soiled c) Note and plan to report any skin problems diaper under the child; such as redness, skin cracks, or bleeding; Division of Public Health Services REVISED – January 2018 Bureau of Infectious Disease Control  DIAPERING RECOMMENDATIONS (cont.) d) Fasten the diaper. If pins are used, place your hand between the child and diaper SOURCE: Caring For Our Children, National when inserting the pin. Health and Safety Performance Standards: Guidelines for Out-Of-Home Childcare Programs. Step 6: Wash the child’s hands and return the http://cfoc.nrckids.org/ child to a supervised area. a) Use soap and water, no less than 60 degrees F and no more than 120 degrees F, at a sink to wash the child’s hands, if you can. b) If the child is too heavy to hold for hand washing or cannot stand at the sink, use commercial disposable diaper wipes or follow this procedure: I. Wipe the child’s hands with a damp paper towel moistened with a drop of liquid soap; II. Wipe the child’s hands with a paper towel wet with clear water; III. Dry the child’s hands with a paper towel. Step 7: Clean and sanitize the diaper-changing surface. a) Dispose of the disposable paper liner used on the diaper changing surface in a plastic- lined, hands-free covered can; b) Clean any visible soil from the changing surface with detergent and water; rinse with water. c) Wet the entire changing surface with the sanitizing solution (e.g., spray a sanitizing bleach solution of ¼ cup of household liquid chlorine bleach in one gallon of tap water, mixed fresh daily); d) Put away the spray bottle of sanitizer. If the recommended bleach dilution is sprayed as a sanitizer on the surface, leave it in contact with the surface for at least two (2) minutes. The surface can be left to air dry or can be wiped dry after two (2) minutes of contact with the bleach solution. Step 8: Wash your hands using proper technique. Division of Public Health Services REVISED – January 2018 Bureau of Infectious Disease Control  PETS IN CHILDCARE FACILITIES Infants and children less than 5 years old are more 6. Wash hands with soap and warm water likely than most people to get diseases from after contact with animals or their animals. Reptiles (e.g., lizards, snakes, turtles), environment. amphibians (e.g., frogs, toads, newts, salamanders), and young birds (e.g., baby chicks, Because wild animals can carry diseases that are ducklings) should not be permitted in rooms dangerous to people, children should not have occupied by children. Children and infants should direct contact with wildlife. Teach children never not have contact with these animals or items that to handle unfamiliar animals, wild or domestic, have been in contact with these animals or their even if the animal appears to be friendly. environments. For concerns about pets in a childcare facility When bringing appropriate pets into a childcare please contact the Division of Public Health facility, the following guidelines should be Services, Bureau of Infectious Disease and followed: Control at (603) 271-4496. 1. Children should always be properly supervised when animals are available. For more information please view the Centers for 2. Areas should be designated for animal Disease Control and Prevention’s website: contact. Such areas should be properly http://www.cdc.gov/healthypets/ cleaned regularly and after animal contact. Food or drink should not be consumed in these areas. 3. No animals should be allowed to run freely. 4. All animals should be in good physical condition and vaccinated against transmittable diseases. Dogs, cats, and ferrets require proof of current rabies vaccination. Animals should be kept clean and free of intestinal parasites, fleas, ticks, mites, and lice. 5. All fecal material must be cleaned from the cage of any mammal or bird on an as needed basis, (at a minimum of one time per week), and appropriate sanitizer used. Reptiles, fish and insects must be cared for in a manner to minimize odor and maintain health. Persons cleaning cages must wear gloves, masks, and glasses or goggles. Cleaning should be preformed by individuals >5 years old, under the supervision of an adult. Ideally, cleaning should be performed when other children are not in the room. Division of Public Health Services Disease Handbook for Childcare Providers Bureau of Infectious Disease Control REVISED –January 2018  FOOD HANDLING FOR CHILDCARE. FOOD HANDLING FOR CHILDCARE SETTINGS In order to prevent foodborne illness caused by wise, do not allow children to eat foods that bacteria, viruses and parasites, it is very important have been dropped on the floor. that food be handled properly. Persons who have 10. Discard all food left on plates at the end of signs or symptoms of illness, including vomiting, mealtime. diarrhea or infectious skin lesions which can not be 11. Do not reuse lunch bags or bags from other covered, or who are infected with foodborne items because of possible contamination. pathogens (e.g., Salmonella, Shigella, E. coli 12. Food should be stored away from areas O157:H7) should not handle food. Whenever where diapering is done. possible, staff who diaper children and have frequent exposure to feces should not prepare food How to Properly Defrost Foods for others. Careful handwashing needs to be 1. Plan ahead to allow time for defrosting food practiced at all times, especially for caregivers who properly. prepare food. 2. Defrost food in the refrigerator. If defrosting outside the refrigerator, place Preparing, Eating and Storing Food food in a sealed plastic bag and immerse in 1. Wash hands well before and after touching cold water, changing the water frequently. food. 3. Do not refreeze foods unless the package 2. Wash utensils, platters, counter tops and label states that it is safe to refreeze. cutting boards with hot soapy water before 4. Follow instructions for microwave defrost as and after contact with raw meat or poultry given in operating manuals of microwave. products. 3. Staff who diaper children and have frequent What to Do If the Freezer Fails or The exposure to feces should not prepare food Power Goes Out for others. 1. Keep the refrigerator-freezer door closed. 4. Canned soup and poultry products should be 2. If your refrigerator-freezer will be shut off eaten immediately after opening. for more than two hours, make immediate 5. Fruits and vegetables should be rinsed well. arrangements for alternate storage of food 6. Wash meal service area before and after elsewhere. Transport food in insulated serving food with hot soapy water followed coolers or in thick layers of paper. with a disinfectant solution. (Note: You can 3. When the power comes back on, throw away make your own disinfectant by mixing one any food with an unusual color or odor. Do tablespoon of bleach with one quart water not taste this food. prepared fresh daily.) 4. If refrigerated foods are above 40 F for more 7. Wash children’s hands before eating. than two hours, most perishable foods will 8. Use separate utensils for each child. If be need to be discarded. interrupted while feeding an infant, wash 5. Frozen foods can be refrozen if they are at hands again before continuing and before or below 40 F or still contain ice crystals. feeding another child. 9. Oversee mealtime and encourage children not to share food, plates, or utensils. Like- Division of Public Health Services Disease Handbook for Childcare Providers Bureau of Infectious Disease Control REVISED –January 2018  FOOD HANDLING FOR CHILDCARE SETTINGS (cont.) Infant Formula Freezing Food Prepared infant formula or bottled milk should be 1. Wrap meat in freezer paper, plastic wrap or refrigerated and clearly labeled with the child’s first foil if not already wrapped properly. and last names. Any formula or bottled breast milk 2. Date packages using the oldest first. not consumed by an infant may be used later in the 3. Check the freezer temperature regularly. It day if dated and stored in the refrigerator. should be at or below 0 F. Otherwise, is should be discarded or returned to the parent at the end of the day. Leftover Food 1. Do not reuse leftovers that have already Shopping Guidelines been served. 1. Allow adequate transport time to and from 2. Refrigerate unused leftovers immediately. grocery shopping to prevent spoilage of Store in small shallow covered containers. fresh or defrosting of frozen products. Date packages and discard if not used within 2. Do not buy or use food from containers that 72 hours. Meat can be refrigerated safely are leaking, bulging or severely dented. for two days. 3. Do not buy jars that are cracked or have 3. Reheat leftovers all the way through. Bring bulging lids or cans that are bulging or gravies to a rolling boil. leaking. 4. Purchase meat and dairy products last. Proper Hand Washing Technique Refrigerate these products as soon as you Children and babies should have their hands get to the childcare center. washed: 1) upon arrival to the daycare facility, 2) before eating/preparing food, 3) after Refrigerating Food toileting/diapering changes, and 4) after touching 1. Keep the refrigerator clean and establish a body secretions 5) after playing outside, especially regular cleaning schedule. after playing sandboxes. 2. Defrost the freezer when necessary. Ice buildup prevents refrigerators from cooling Adults (including staff, volunteers, students and properly. parent helpers) should wash their hands: 1) when 3. Avoid overcrowding in the refrigerator. The they arrive at the daycare facility, before starting more crowded it is, the less cooling effect. work, 2) before eating/preparing food, or feeding 4. Check the gaskets regularly; they should be children, 4) after toileting/diapering a child or using flexible to keep the cold air from leaking the bathroom themselves, and 4) after handling out. body secretions. 5. Keep a thermometer and check the temperature inside on a regular basis. The How to Properly Wash Your Hands temperature should be at or below 40 F. 1. Use soap, preferably liquid, and warm 6. Refrigerate perishable bag lunches. If running water. refrigeration is not available, put a container 2. Wash your hands for at least 10 seconds filled with frozen water, a plastic bag with while rubbing your hands vigorously as you ice cubes or a cold or frozen beverage into wash them. the bag for storage. 3. Wash ALL surfaces including: back of hands, wrists, between fingers and under nails. Division of Public Health Services Disease Handbook for Childcare Providers Bureau of Infectious Disease Control REVISED –January 2018  FOOD HANDLING FOR CHILDCARE SETTINGS (cont.) 4. Rinse your hands well. Leave water running. 5. Dry your hands with a single-use towel (e.g., a paper towel) 6. Turn off the water using a PAPER TOWEL instead of your bare hands. 7. Throw the paper towel away. Division of Public Health Services Disease Handbook for Childcare Providers Bureau of Infectious Disease Control REVISED –January 2018  RASHES Rashes may occur for many reasons and it is impossible to cover in this manual all the causes for a rash. In most cases, rashes that last for more than a day that are accompanied by fever and/or other symptoms of illness, or rashes that develop all over the body should be referred to a physician for diagnosis before a child returns to the childcare facility. Sensitive rashes that are caused from plant sensitivity such as poison ivy, poison oak and poison sumac often have unusually shaped blister-like sores. The fluid in these blisters is not contagious to others. People react to direct contact from the plant or from indirect contact from clothing, or other objects contaminated from plant contact. (A family pet can also indirectly pass this to people when its fur is contaminated). It is best to consult a physician for treatment. Hives is a rash that may happen when a person is hypersensitive to such things as certain foods, drugs, and bee stings. It may also be due to emotional factors. The rash is usually itchy, raised, reddish welts on the skin. Hives that are accompanied by difficulty breathing, unusual anxiety and hives occurring all over the body needs to be seen by a physician immediately. Another common rash experienced by children during the summer months is known as Swimmer’s Itch. It is a form of dermatitis (i.e., inflammation of the skin) that is caused by larvae of certain worms when they attempt to penetrate the skin. This results in a mild allergic reaction. The worms that cause Swimmer’s itch are commonly found in water after being excreted from birds, waterfowl and mammals. Generally, no treatment is required for the rash since it goes away in a few days and does not cause lasting effects. Swimmer’s Itch is not spread from person-to-person. Division of Public Health Services Disease Handbook for Childcare Providers Bureau of Infectious Disease Control REVISED –January 2018  CAMPYLOBACTER (cont.) CAMPYLOBACTER Campylobacteriosis is an intestinal illness caused by How can the spread of this disease be the bacterium Campylobacter of which there are prevented? many types. 1. Wash hands thoroughly after using the toilet and diapering children. Who gets this disease? 2. Wash hands thoroughly before preparing Anyone can. The illness occurs in all age groups. food. 3. Keep children who have diarrhea at home. How is it spread? 4. Wash children’s toys frequently, especially Campylobacter is spread by the fecal-oral route. if they have diarrhea. Water, milk or food (especially poorly cooked 5. Make sure children wash their hands after poultry products) contaminated with handling pets or have contact with animal Campylobacter, or contact with infected animals feces. may also be a source of infection to people. 6. Symptomatic staff with positive stool cultures for Campylobacter should be What are the symptoms? excluded from work. Diarrhea (which may be severe and bloody), 7. Always treat raw poultry, beef and pork as if stomach cramps, abdominal pain, vomiting and they are contaminated and handle fever are the usual symptoms. accordingly. 8. Wrap fresh meats in plastic bags at the How soon do symptoms appear? market to prevent blood from dripping onto The symptoms generally appear between one and other foods. seven days, but can take longer. 9. Refrigerate foods promptly; minimize holding at room temperature. 10. Avoid ingesting unpasteurized milk. Can a person have this disease without 11. Use separate cutting boards for raw poultry knowing it? and beef to prevent cross contamination with Yes. Although symptoms usually go away after one other foods. to 10 days on their own, there may still be germs in 12. Cutting boards and counters used for the stools for several weeks if treatment is not preparation should be washed immediately given. after use to prevent cross contamination with other foods. What is the treatment? 13. Be certain all foods (especially beef and Although antibiotic therapy may not shorten the poultry products) are thoroughly cooked. illness, it does shorten the amount of time the germ is passed in the stools. Therefore, in the childcare setting, treatment is recommended for adults and children with Campylobacter in their stools. This will reduce the chance of spread to others. Division of Public Health Services Disease Handbook for Childcare Providers Bureau of Infectious Disease Control REVISED –January 2018  CAMPYLOBACTER (cont.) Who should be excluded? Any person with diarrhea shall be excluded from foodhandling, from childcare agencies and from direct care of hospitalized or institutionalized patients until 48 hours after resolution of symptoms. Children can return to childcare once they are no longer having diarrhea. Reportable? Yes. Campylobacteriosis is reportable by New Hampshire law to the Division of Public Health Services, Bureau of Infectious Disease Control at (603) 271-4496. Division of Public Health Services Disease Handbook for Childcare Providers Bureau of Infectious Disease Control REVISED –January 2018  CHICKENPOX (VARICELLA) AND SHINGLE (cont.) CHICKENPOX (VARICELLA) AND SHINGLES Chickenpox is a very contagious disease caused by the varicella-zoster virus. It usually begins with a How is it spread? mild fever and an itchy rash. The rash starts with Chickenpox is contagious from 1-2 days before the crops of small red bumps on the stomach or back rash appears to until the blisters have become and spreads to the face and limbs. The red bumps crusted over. It is spread by close contact (i.e., rapidly become blistered, oozy and then crust over. sharing breathing space or direct touching contact) People may have only a few bumps or may be with infected secretions from the nose, throat or totally covered. rash. Once a person has had chickenpox, the varicella- How soon do symptoms appear? zoster virus stays without symptoms in the body’s The symptoms generally appear from 14-16 days nerve cells. In some people (for unknown reasons), after exposure but in some cases can occur as early the virus can become active again at some later time as 10 days or as late as 21 days after contact. as “shingles” or zoster. This problem includes a Chickenpox and shingles are usually diagnosed by red, painful, itchy, blistery rash, usually in the line the typical appearance of the rashes. along one side of the body. There is no fever. The virus is shed in the blister fluid of the rash and can What is the treatment? cause chickenpox in a person who has not had it, if The chickenpox symptoms may be treated with that person has direct contact with the infected anti-itching medicine and lotions, fever control, shingles blisters. fluids and rest. Because of a possible association with Reye’s Syndrome (i.e., vomiting, liver Who gets this disease? problems and coma), salicylate-containing products Anyone who is exposed to chickenpox and has not (i.e., aspirin) should not be used for fever control. had it before has a very good chance of developing Acetaminophen may be used for fever control. chickenpox. It is most common in school-aged Scratching should be avoided because it can cause children. If you have had chickenpox once, second infection and scarring. A medication to decrease attacks are very rare. Shingles is most common in the severity of symptoms is available for high-risk adults, as a person must have already had children. This must be given within 24 hours of the chickenpox to develop shingles. onset of rash. Please consult the Division of Public Health Services, Bureau of Infectious Disease When a pregnant woman or a person with a weak Control or the child’s physician for more immune system who has not had chickenpox is information. exposed he/she should contact a physician. Chickenpox does not cause serious illness in healthy children. Adults may, occasionally, be seriously ill with chickenpox. Division of Public Health Services Disease Handbook for Childcare Providers Bureau of Infectious Disease Control REVISED –January 2018  CHICKENPOX (VARICELLA) AND SHINGLE (cont.) How can the spread of this disease be Reportable? prevented? Yes, chickenpox is reportable by New Hampshire The ACIP recommends that children attending law to the Division of Public Health Services, daycare facilities and schools be vaccinated for Bureau of Infectious Disease Control at (603) 271- chickenpox. New Hampshire currently requires 4496 varicella vaccination for school or daycare attendance. The two dose series should be completed at 12-15 months and again at 4-6 years. The ACIP also recommends that daycare workers, who have no history of chickenpox disease, be tested for immunity. If testing shows susceptibility, 2 doses of varicella vaccine should be administered separated by one month. Each childcare facility should have a system so that it is notified if a child or staff member develops chickenpox or shingles. This is so the facility may take appropriate measures if there is a pregnant or immunocompromised member in the facility. (Recently the Advisory Committee on Immunization Practice has recommended the use of varicella vaccine for susceptible persons who have been exposed to varicella). The childcare facility should watch closely for early signs of chickenpox in other children for three weeks following the most recent case. If a child or staff member develops a suspicious rash, he/she should be sent to his/her healthcare provider so that the rash can be diagnosed. However, chickenpox is highly contagious and in spite of your best efforts, you will probably have several more cases if children have not already had the disease. Who should be excluded? Children should be excluded from daycare after the rash eruption first appears and until the vesicles become dry and crusted over. In certain situations exposed unvaccinated children without symptoms do need to stay at home. Generally exposed children, who have been vaccinated, do not need to stay at home. Adults with shingles should be excluded if vesicles/blisters cannot be covered. Division of Public Health Services Disease Handbook for Childcare Providers Bureau of Infectious Disease Control REVISED –January 2018  COMMON COLD & INFLUENZA (cont.) COMMON COLD & INFLUENZA Common colds are mild infections of the nose and What is the treatment? throat, which are very common in young children While there is medication available, most health (and in adults who are around them), and are caused care providers suggest rest and plenty of fluids. To by many different viruses. Usually the viral illness see if there is bacterial infection in addition to the causes some combination of stuffy nose, runny viral infection, a healthcare provider should nose, sore throat, cough, runny eyes, ear fluid and evaluate a child who has a high fever, persistent fever. cough, or earache. Because of a possible association with Reye’s Syndrome (i.e., vomiting, Influenza (the flu) is also caused by a virus (e.g., liver problems and coma), salicylate-containing influenza-A, influenza-B) and causes symptoms of products (i.e., aspirin) are not recommended for fever, headache, sore throat, cough, muscle ache control of fever. and fatigue. Most people with influenza feel too ill to attend childcare. How can the spread of these diseases be prevented? Occasionally, the common cold or influenza can be Influenza vaccine is the primary method of complicated by a bacterial infection such as an ear preventing influenza and its severe complications. infection, sinus infections, or pneumonia. These The vaccine should be given annually beginning at complications can be treated with appropriate 6 months of age. Two doses should be given the antibiotics after evaluation by their health care first year the child receives the influenza vaccine. provider. Annual influenza vaccination is recommended for Who gets these diseases? all children aged 6 months through age 18 with Anyone can. Young children may be sick with priority given to the following persons for influenza these illnesses several times per year. As the vaccine if influenza vaccine supplies are limited: number of persons in contact with a child increases, Children 6 months to 18 years so does the likelihood of exposure to the common Pregnant women viruses that cause the cold and flu. Persons aged 50 years old and older Persons of any age with certain chronic How are they spread? medical conditions The viruses can be transmitted from one person to Persons who live with or care for persons at another in respiratory secretions (i.e., saliva, nasal high risk discharge, and phlegm). Infected droplets may be scattered through sneezing or coughing or they may land on surfaces touched by other persons, who then Additional ways to prevent the spread of touch their eyes, nose or mouth. these diseases: Get adequate rest, good nutrition, plenty of How soon do symptoms appear? fluids The symptoms of a common cold appear as soon as Avoid people who are sick 12-72 hours after exposure. The symptoms of Observe children for symptoms of coughing, influenza appear in 1-4 days after exposure, and sneezing, headache, fatigue, fever. Notify typically last 2-3 days. parent to pick child up Remind children if they sneeze or cough into their hand or tissue, they must properly dispose of the tissue and wash their hands Division of Public Health Services Disease Handbook for Childcare Providers Bureau of Infectious Disease Control REVISED –January 2018  COMMON COLD & INFLUENZA (cont.) Runny noses and eyes should be promptly wiped, then wash their hands Disposable tissues should be used. Keep tissues available Toys that children put in their mouths and frequently used surfaces (e.g., tables) should be washed and disinfected at least once each day The childcare facility should have fresh air and be aired out completely once a day, even in the winter months Who should be excluded? Children should be excluded if they have a fever or are unable to participate in general activities. Exclusion is of little benefit since viruses are likely to spread. Reportable? No. Influenza is not reportable, but please notify the Division of Public Health Services, Bureau of Infectious Disease Control at (603) 271-4496 of influenza outbreaks. The common cold is not reportable. Division of Public Health Services Disease Handbook for Childcare Providers Bureau of Infectious Disease Control REVISED –January 2018  CONJUNCTIVITIS (Pink Eye) cont. CONJUNCTIVITIS (Pink Eye) Conjunctivitis is an infection of the eyes commonly The incubation period varies depending upon the known as “pink eye”. Conjunctivitis can be cause whether it is viral or bacterial; symptoms may purulent or nonpurulent. It is most often caused by develop in 5 –12 days depending on the cause. a virus (like those which cause the common cold), (Bacterial 24-72 hours, viral 12 hours to 12 days). but can also be caused by bacteria, allergies or chemicals. The conjunctiva – the clear layer over How is it diagnosed and treated? the whites of the eyes – becomes pink and there Signs and symptoms of purulent conjunctivitis are may be tearing and discharge from the eyes. Eyes white or colored discharge from the eye, eye may be itchy or even painful. In the morning, the redness, eyelid swelling, eye pain, and sometime discharge may make the eyelids stick together. fever. It is often difficult to tell if the cause is Conjunctivitis is a mild illness. Viral conjunctivitis bacterial or viral. Occasionally the doctor will will go away by itself in one to three weeks. examine the discharge under the microscope or culture it. Often an antibiotic eye medicine will be Who gets this disease? given because treatment of bacterial conjunctivitis Anyone can get it. Conjunctivitis is caused by a shortens the length of symptoms and decreases virus or bacterium and is highly contagious. infectiousness. There is not treatment for viral Preschoolers and school-age children have it most conjunctivitis; it will go away by itself but may last often and can spread it to people taking care of them a week or more. or to each other. Signs and symptoms of nonpurulent conjunctivitis How is it spread? are clear watery discharge from the eye, without eye Both viral and bacterial conjunctivitis spread by redness or pain or fever. contact with discharge from the eye. Children often pass it along by rubbing their eyes and getting How can the spread of this disease be discharge on their hands and then: prevented? a) Touches another child’s eye. 1. Follow hand washing and center cleanliness b) Touches another child’s hands. The second guidelines. child then touches his/her eyes. 2. Teach children to avoid rubbing their eyes c) Touches an object. Another child touches the 3. Keep children’s eyes wiped free of object and then puts his/her hands into his/her discharge. eyes. 4. Always use disposable tissues/towels for wiping and washing. Never use the same Staff washing, drying or wiping a child’s face and tissue/towel for more than one child. then using the same washcloth/towel/paper 5. Always wash your hands after wiping a towel/tissue on another child’s face can also pass it child’s eyes. along. Staff could also get eye discharge on their 6. Teach children to wash their hands after hands when wiping a child’s eyes and then pass it wiping their eyes. along as outlined above. 7. Dispose of tissues/towels in lined, covered container kept away from food and childcare materials. Division of Public Health Services Disease Handbook for Childcare Providers Bureau of Infectious Disease Control REVISED –January 2018  CONJUNCTIVITIS (Pink Eye) cont. 8. Be sure articles that may touch children’s eyes (e.g., pillowcases, sheets, towels binoculars, prisms, toy cameras) are washed well with soap and hot water at least once daily. Who should be excluded? It is recommended that children and staff with purulent conjunctivitis be excluded from childcare until examined by a healthcare provider and approved for re-admission, with or without treatment. Children with nonpurulent conjunctivitis do not need to be excluded from childcare. Reportable? No. Conjunctivitis is not reportable by New Hampshire state law to the Division of Public Health Services, Bureau of Infectious Disease Control. However, Public Health Professionals are available for consultation at (603) 271-4496. Division of Public Health Services Disease Handbook for Childcare Providers Bureau of Infectious Disease Control REVISED –January 2018  DIARRHEA (Infectious Diarrhea) Diarrhea is defined as: 1) an increase in the How is it spread? number of stools over what is normal for that The germs that can cause infectious diarrhea are person, and 2) stools which are not formed (i.e., spread by fecal-oral route. loose and watery and take the shape of the container they are in). (NOTE: Breast-fed babies How is it diagnosed and treated? may have stools that are normally not formed). The germs can be diagnosed by stool cultures or by looking at stool under a microscope for eggs or There are two (2) general types of diarrhea: parasites. (The healthcare provider will ask for a infectious and non-infectious. stool sample and send it to a laboratory for analysis). The physician will decide on Infectious Diarrhea is caused by a virus, appropriate treatment. parasite, or bacterium. It can spread quickly from person-to-person, especially in daycare centers. How can the spread of diarrhea be Some of the causes of infectious diarrhea, such as Campylobacteriosis, shiga-toxin producing E. prevented? coli, giardiasis, salmonellosis and shigellosis, are Hand washing is the most important way to stop discussed in their own fact sheets found in this the spread. Specific methods for preventing the document. There are other agents that can also spread of infectious diarrhea are discussed in each cause infectious diarrhea in children. These fact sheet. include parasites (e.g., cryptosporidiosis, amoeba) other bacterial (e.g., yersinia) and other viruses Who should be excluded? (e.g., Rotavirus). Although these other disease- Any person with diarrhea shall be excluded from causing organisms are not discussed in detail, the food handling, from childcare agencies and from general principles outlined in this section are direct care of hospitalized or institutionalized applicable to prevent the spread of any of these patients until 48 hours after resolution of germs. symptoms.. Children who have 2 or more stools above their normal amount should be excluded as Non-infectious Diarrhea can be caused by toxins it impedes the caregiver’s ability to care for the (e.g., certain types of food poisoning), chronic children and maintain sanitary conditions. For diseases (e.g., cystic fibrosis) or antibiotics (e.g., diarrhea caused by a specific agent, see the related ampicillin). Non-infectious diarrhea DOES NOT fact sheet to learn if exclusion is necessary. spread from person-to-person. Reportable? Who gets it? Non-specific diarrhea is not reportable. Clusters Anyone can catch infectious diarrhea. It can of diarrhea illness in a facility should be reported spread especially quickly among babies and to the Division of Public Health Services, Bureau young children who are not toilet-trained or who of Infectious Disease and Control at (603) 271- may not wash their hands well after going to the 4496. bathroom. It can also easily spread to the adults taking care of them and helping them with diapering and toileting. Division of Public Health Services Disease Handbook for Childcare Providers Bureau of Infectious Disease Control REVISED –January 2018  DIPHTHERIA Diphtheria is a potentially serious bacterial months, 6 months, and 15-18 months, and 4-6 infection of the nose and throat. years of age. Patients and carriers of diphtheria should receive Who gets this disease? appropriate treatment and not return to childcare Diphtheria occurs primarily among unimmunized until two (2) cultures from both the nose and or inadequately immunized people. throat (and from skin sores in cutaneous diptheria), are negative for the bacteria. These How is it spread? cultures should be taken at least 24 hours apart The bacteria are spread by direct contact with and no sooner than 24 hours after finishing discharge from the nose, throat, skin, eyes, or antibiotic treatment. Where culture is impractical, from sores of infected persons. Articles or food isolation may be ended after 14 days of contaminated with discharge can also spread appropriate treatment. infection. Who should be excluded? What are the symptoms? Children and staff should be excluded until Diphtheria causes a sore throat and swollen bacteriological examination proves them not to be tonsils, with a grayish covering and swollen carriers. glands in the neck. It can lead to severe throat swelling that can block breathing. The bacteria Reportable? also produce a toxin (a type of poisonous Yes, Diphtheria is reportable by New Hampshire substance) that can cause severe and permanent law to the Division of Public Health Services, damage to the nervous system and heart. Bureau of Infectious Disease Control at (603) 271-4496. What is the Treatment? Diphtheria is treated primarily with an antitoxin, along with antibiotics. Antibiotics are also given to the carriers of the diphtheria (e.g., people who test positive for diphtheria but who are not sick). Individuals who have been in contact with an infected person and are not adequately vaccinated should receive a booster. How can the spread of this disease be prevented? The combination vaccine Diphtheria, Tetanus and acellular Pertussis (DTap), is required for both childcare and school attendance. The Advisory Committee on Immunization Practices (ACIP) recommends immunizing children against diphtheria, along with pertussis and tetanus, beginning as early as six weeks of age. The five dose series should be completed at 2 months, 4 Division of Public Health Services Disease Handbook for Childcare Providers Bureau of Infectious Disease Control REVISED –January 2018  E. COLI 0157:H7 E. coli 0157:H7 is an intestinal illness caused by a How soon do symptoms appear? bacterium that can cause severe bloody diarrhea, Symptoms appear 12-72 hours after exposure with anemia, and –in some cases- kidney failure. the average being 48 hours. Who gets this disease? Can a person have this disease without Anyone is susceptible to this particular category of knowing it? E. coli 0157:H7, but it most seriously affects young Yes. The organism is identified through stool children and the elderly. culture testing. Usually symptoms disappear in a few days but the bacteria can remain in the How is it spread? intestinal tract for several weeks. This bacterium lives in a small number of healthy cattle. When the infected animal is slaughtered, the What is the treatment? meat can become contaminated. The bacteria may Seek medical help for identification of the also contaminate raw milk by being present on the organism. Usually the person is treated for diarrhea cow’s udder. dehydration with fluid replacement. E. coli 0157:H7 is spread by eating contaminated food – most often undercooked beef, especially How can the spread of this disease be undercooked ground beef. Contaminated meat prevented? looks and smells normal. Drinking unpasteurized 1. Wash hands thoroughly after diapering and milk and swimming in or drinking sewage- using the bathroom. contaminated water can also cause infection. 2. Avoid eating undercooked beef, especially hamburger. An infected person having diarrhea can pass the 3. Avoid drinking from unknown water sources,, bacteria from one person to another if hand-washing raw milk, and unpasteurized apple juice. habits are not adequate. This is more likely to 4. Teach children good hand washing techniques happen among toddlers who are not toilet trained. Who should be excluded? Young children usually continue to shed the Children who are infected with this bacterium will bacteria in their stool a week or two following their be excluded from childcare while they are illness. symptomatic. Infected adults should be excluded from childcare centers, food handling, and direct What are the symptoms? care healthcare, until their stool cultures are free of They vary from mild diarrhea to a bloody diarrhea E. coli 0157:H7 on two (2) consecutive specimens with severe abdominal cramps and little or no fever. collected not less than 24-hours apart. If antibiotics Vomiting may occur late in the illness. A small have been given, the initial cultures should be percent may develop hemolytic uremic syndrome obtained at least 48-hours after the last dose. (HUS), a condition that destroys the red blood cells and causes kidney failure. This is more likely to Reportable? occur in children under five years of age and the Yes. E. coli 0157:H7 is reportable by New elderly, and may lead to death. Hampshire law to the Division of Public Health Services, Bureau of Infectious Disease Control at (603) 271-4496. Division of Public Health Services Disease Handbook for Childcare Providers Bureau of Infectious Disease Control REVISED –January 2018  EASTERN EQUINE ENCEPHALITIS (cont.) EASTERN EQUINE ENCEPHALITIS What is eastern equine encephalitis? Who is at risk for eastern equine Eastern equine encephalitis (EEE) is an uncommon encephalitis? but serious disease caused by EEE virus. EEE is an Anyone can get EEE, but some people are at arbovirus (short for arthropod-borne, meaning increased risk, such as people living in or visiting spread by insects). The virus can be transmitted to areas where the disease is common and people who horses, other animals, and in rare cases, people. work outside or participate in outdoor recreational activities in areas where the disease is common. How do people get eastern equine Children and those over age 50 are more susceptible encephalitis? to the disease. The risk of getting EEE is highest The EEE virus grows in birds that live in freshwater from late July through September. swamps. The virus has a complex life cycle involving birds and a specific type of mosquito, What is the treatment for eastern equine called Culiseta melanura. This particular mosquito encephalitis? does not bite people. Sometimes though, the virus There is no specific treatment for eastern equine can escape from its marsh habitat by means of other encephalitis. Antibiotics are not effective against mosquitoes that feed on both birds and mammals. viruses, and no effective anti-viral drugs have yet These mosquitoes can transmit the virus to animals been discovered. Care of the patient centers around and people. treatment of symptoms and complications. What are the symptoms of EEE? How common is eastern equine Infection can cause a range of illnesses. Most encephalitis? people have no symptoms; others get only a mild EEE is a rare disease. An average of 6 cases are flu-like illness with fever, headache, and sore throat. reported in the United States in most years. There For people with infection of the central nervous is concern, however, that EEE is re-emerging. In system, a sudden high fever (103 to 106 ), severe NH, EEE has been found in horses, mosquitoes and headache, and stiff neck can be followed quickly by several species of birds. In 2014, 3 cases of EEE seizures and coma. About one third of these were reported in humans in NH. patients die from the disease. Of those that survive, many suffer permanent brain damage and require How can eastern equine encephalitis be lifetime institutional care. prevented? A vaccine is available for horses, but not for How soon after exposure do symptoms humans. Prevention of the disease centers around appear? controlling mosquitoes and on individual action to Symptoms of EEE usually appear 4 to 10 days after avoid mosquito bites. To avoid being bitten by the the bite of an infected mosquito. mosquitoes that transmits EEE: If possible, stay inside between dusk and dawn, How is eastern equine encephalitis when mosquitoes are most active diagnosed? When outside between dusk and dawn, wear Diagnosis is based on tests of blood or spinal fluid. long pants and long-sleeved shirts Division of Public Health Services Disease Handbook for Childcare Providers Bureau of Infectious Disease Control REVISED –January 2018  EASTERN EQUINE ENCEPHALITIS (cont.) Use an insect repellent with DEET or Picaridin according to the manufacturer’s directions when outside. Oil of lemon eucalyptus and IR3535 have been found to provide protection similar to repellents with low concentrations of DEET Clothing can be treated with permethrin according to the manufacturer’s directions When possible wearing long sleeves and pants while outside Put screens on windows and make sure they do not have holes Eliminate standing water and other mosquito breeding locations from your property. Do not alter natural water bodies. The management of ponds and wetlands is regulated by the Department of Environmental Services and any alterations require a permit before work may begin For more information about eastern equine encephalitis, call the New Hampshire Department of Health & Human Services, Bureau of Infectious Disease Control at (603) 271-4496 or visit our website at www.dhhs.nh.gov or the Centers for Disease Control and Prevention at www.cdc.gov. Division of Public Health Services Disease Handbook for Childcare Providers Bureau of Infectious Disease Control REVISED –January 2018  FIFTH DISEASE (cont.) FIFTH DISEASE Fifth disease is an illness caused by a virus called How soon do symptoms appear? human parvovirus B19. Although people may be It takes from 4-21 days after exposure to develop asymptomatic with the illness, most children with it the characteristic rash illness of Fifth disease. develop a facial rash (i.e., “slapped check” People with the rash are past the period of appearance) and a lace-like rash on the trunk and infectiousness to others. The highest risk of extremities. The rash may reappear for several transmitting the Fifth disease virus to others is felt weeks following exposure to non-specific stimuli to occur before the rash develops. such as sunlight, change in temperature or emotional stress. How is it diagnosed and treated? A healthcare provider based on the characteristic Except for the rash, the patient is typically rash and any other accompanying symptoms may otherwise well: but some give a history of mild diagnose Fifth disease. There is no specific general symptoms one to four days before rash treatment for Fifth disease. onset. Fever, sore throat or pain and swelling in the joints may also occur. How can the spread of this disease be Who gets this disease? prevented? 1. Because transmission of the Fifth disease Although most commonly recognized in children, virus usually occurs before the rash develops anyone is susceptible. Studies indicate previous – when a child may seem well or has a non- infection with Fifth disease correlates with a lower specific illness – excluding children with the risk of a second infection. Outbreaks in schools Fifth disease rash is of no proven value. often begin in late winter or early spring and may However, it is very important for a continue until the school year is over. healthcare provider to rule out other rash- causing illnesses (e.g., measles, chickenpox) In the U.S. about 50% of the adult population are that may require exclusion from childcare. already immune to the disease. Some studies 2. Transmission of infection can be lessened by indicate the pregnant women who are exposed to routine hygienic practices for control of Fifth disease and subsequently develop infection respiratory infections, which include hand may have an increased risk for fetal death. washing and disposal of facial tissues However, this risk is felt to be extremely low. containing respiratory secretions. There is no evidence that the infection during 3. People with particular concerns about pregnancy causes fetal malformations (i.e., birth contracting Fifth disease (e.g., pregnant defects). Pregnant childcare workers should contact women) should consult their healthcare their obstetricians. providers. How is it spread? The virus that causes Fifth disease has been found in the respiratory secretions of patients and is, therefore, most likely spread by direct person-to- person contact through the respiratory route. Division of Public Health Services Disease Handbook for Childcare Providers Bureau of Infectious Disease Control REVISED –January 2018  FIFTH DISEASE (cont.) Who should be excluded? Children with Fifth disease MAY attend daycare or school, as they are not contagious after onset of rash. Routine exclusion of pregnant women from the workplace where Fifth disease is occurring is not recommended. Reportable? No, Fifth disease is not reportable by New Hampshire l