Reducing Contagious Illness in Child Care PDF

H December 2006 Reducing Contagious Illness in the Child Care Setting EALTHHINTS Texas Cooperative Extension The Texas A&M University System Editors: Janet M. Pollard, MPH & Caro...

H December 2006 Reducing Contagious Illness in the Child Care Setting EALTHHINTS Texas Cooperative Extension The Texas A&M University System Editors: Janet M. Pollard, MPH & Carol A. Rice, Ph.D., RN Vol. 10 No. 10 develops only after exposure to a multitude of germs. Young children in large groups are breed- ing grounds for the organisms that cause illness. Little hands rub drippy noses and then transfer Taking action for yourself & your kids infectious agents to other children or to shared toys.”1 Children cough and sneeze, releasing Y oung children get sick. It’s that simple. “A infectious agents into the air and onto other child’s immunity improves with time. children and shared items that may be mouthed School-age children gradually become less or touched and transferred to the mucous mem- prone to common illnesses and recover more branes (eyes, nose, mouth, genitals) of another quickly from the diseases they do catch.”1 “In- child. Not only can these infectious agents spread fants and young children who spend time in from child to child but from child to provider, group child care settings generally have a higher among providers, and from provider to child number of illnesses than children kept at home. (e.g., when changing a diaper of one child and Frequently, those caring for young children then diapering or wiping the nose of another experience increased illnesses as well.”2 child without taking appropriate precautions). Childhood illness may not affect a family until a All child care providers should learn and use child starts child care or school. After that, it may health precautions to prevent or reduce illness. seem to the family that the child is sick all the Since some illnesses are contagious even before time. “This pattern is normal as [the] child builds symptoms appear, care providers need to be a robust immune system. Resistance to infection aware of how diseases are communicated among children and between children and providers. INSIDE “By always observing caution, providers can do H E A L T H H I N T S... much to prevent the spread of disease.”2 Common types of communicable diseases..... 2 This issue of HealthHints will address these health Modes of transmission........................................ 3 precautions, giving practical, step-by-step guide- Handwashing........................................................ 4 lines for preventing and reducing the spread of A note about types of soap................................. 5 illness in your child care facility. Cleaning, sanitizing, & disinfecting.................. 6 Recipes for cleaning & sanitizing...................... 7 Best practices for reducing the spread of infection................................................................. 8 Gloving procedure: How & why?..................... 10 A note about shoes............................................... 13 “Potentially” infectious........................................ 14 Child care provider.............................................. 16 Resources............................................................... 16 References.............................................................. 17 1  5 Sore throat – Most sore throats are caused Common Types of by viruses, but about 15 percent of children’s sore throats are caused by strepto- Communicable Diseases cocci – the bacteria that causes strep throat. Fevers above 101 degrees F are common in What to watch for strep throat, and swallowing can be so painful that the child may have difficulty T he terms communicable disease and eating.1 infectious illness are used interchangeably and sometimes misunderstood. These Other common illnesses in children are: terms simply mean that the illness is contagious Chicken pox – Itchy, fluid-filled blisters or “catchable.” “A communicable disease is any caused by a virus.5 bacterial, viral, or parasitic infection in the body that can be spread from one individual to an- Ringworm – Skin infection caused by a other.”2 Communicable or infectious diseases can fungus (not by a worm).6 vary from the common cold and flu to more Head lice – Tiny insects that infest the hair uncommon diseases like meningitis and hepati- of the scalp and sometimes eyebrows and tis.2 eyelashes, resulting in intense itching and sometimes red bumps that become crusty Currently, the top five infectious illnesses that and ooze.7 keep children home from child care or school Impetigo – Skin disorder caused by bacterial are: infection and characterized by crusty skin 1 Colds – More than 200 different viruses are lesions. Typically, the infection begins as a known to cause the symptoms of the com- cluster of tiny blisters, followed by oozing mon cold. Some seldom produce serious and the formation of a thick, honey or illnesses. Others produce mild infections in brown-colored crust that is firmly stuck to adults but can precipitate severe lower the skin.2, 8 respiratory infections in young children. Children have about 6–10 colds per year, Infectious diseases of a more serious nature may while adults average about 2–4 colds per include: year.3 Meningitis – Viral or bacterial infection that 2 Gastroenteritis – Commonly called “stom- causes inflammation of the membranes cov- ach flu,” though not akin to the flu for ering the brain and spinal cord. Symptoms which we can be vaccinated, gastroenteritis is may include fever and chills, nausea and characterized by vomiting and diarrhea, vomiting, stiff neck, sensitivity to light, and which can lead to dehydration, particularly mental status changes.9 in young children. Gastroenteritis can be Hepatitis – Inflammation of the liver, which caused by viral, bacterial, or parasitic infec- can be caused by an infection from parasites, tions; however, viral gastroenteritis is highly bacteria, or viruses (such as hepatitis A, B, or contagious and is responsible for the major- C). Symptoms may include dark urine and ity of outbreaks in developed countries.4 pale or clay-colored stools, loss of appetite, 3 Ear Infection (otitis media) – Respiratory fatigue, abdominal pain or distention, gen- illnesses, such as colds and allergies, cause eral itching, jaundice, nausea and vomiting, congestion, which may squeeze shut a child’s low-grade fever, weight loss, and breast eustachian tube – the tiny drainage pipe for development in males.10 the middle ear. Fluid trapped in the middle HIV/AIDS – Viral infection caused by ear can become a breeding ground for human immunodeficiency virus (HIV) that viruses or bacteria (i.e., viral or bacterial ear gradually destroys the immune system, re- infection, respectively).1 sulting in infections that are hard for the 4 Pink eye (conjunctivitis) – Pink eye can be a body to fight. Any symptoms of illness may viral or bacterial infection that results in occur since infections can occur throughout inflammation of the clear membrane that the body. Most individuals infected with HIV covers the white part of the eye and lines the progress to AIDS (acquired immunodefi- inner surface of the eyelids.1 ciency syndrome – the most serious stage of HIV disease, which causes severe damage to 2 the immune system) if not treated. People infected with HIV, however, may have no Modes of Transmission symptoms for up to 10 years, but they can still transmit the infection to others. The immune system gradually weakens until How infection spreads they are diagnosed with AIDS.2, 11, 12 U nderstanding how germs are transmitted can help us in identifying the best ways to prevent or reduce the spread of illness. There are four primary ways common illnesses that children acquire are spread: Children in group child care are going to get ill...it’s inevitable ~ 1 airborne/respiratory, 2 fecal/oral, Young children have a lower resis- 3 blood/body fluids, and tance to infection and communicable 4 direct contact.13, 14 disease. Chances of exposure are increased Airborne/respiratory because of the large numbers of indi- Airborne/respiratory transmission of infection viduals with whom they come into occurs when germs (viruses, bacteria, parasites) contact. pass from the lungs, throat, or nose of one Children in child care settings play person to another person through the air.14 together, sharing toy and joys.13 Respiratory infections, such as colds and flu, are responsible for most illnesses. Most colds present with fever, runny nose, coughing, and sneezing. Illness is spread by coughs or sneezes into the air or by secretions from the nose or mouth. Other illnesses that are spread by air- borne droplets include chicken pox, hand-foot- mouth disease, measles, mumps, whooping cough, and rubella.13 Fecal/oral Fecal/oral transmission occurs when feces or objects contaminated with feces are touched and then the mouth is touched.14 These types of infection are usually intestinal infections that cause diarrhea. In these cases, viruses, bacteria, or parasites spread infection from person to person directly from the bowel movement to the mouth, usually by way of the hands; by diaper- ing; or indirectly by food or other objects that get into the mouth.13 Some examples of illnesses spread through fecal/oral transmission include viral enteritis, E coli 0157:H7, Giardia, Cryptosporidiosis, Shingella, Salmonella, or Hepatitis A. 3 Blood/body fluids Blood/body fluid transmission occurs only when Handwashing there is direct contact with blood or body fluids of an infected person and an uninfected person. HIV, Hepatitis B, and Hepatitis C are some Number 1 way to prevent the spread of illness examples of diseases transmitted through direct contact with the blood/body fluids of an infected “ G erms multiply rapidly in warm, moist person.13, 14 places. When objects or hands touch places where there are a lot of germs, Direct contact they pick up the germs, which then enter the Direct contact transmission occurs when an body through the nose, eyes, mouth, and/or uninfected person touches the skin or body fluid broken skin.”2 For this reason, the hands are a (e.g., nasal secretions, oral secretions) of an primary avenue for the transport of germs into infected person or touches a contaminated the body. In fact, handwashing is the number surface – in other words, they come into “direct one way to prevent the spread of communi- contact” with the virus, bacteria, or parasite. cable disease. This message cannot be empha- Skin infections and infestations such as impe- sized enough to the provider, parent, and child. tigo, lice, scabies, ringworm, and herpes simplex Simply running hands under water for a couple are generally transmitted through direct contact. of seconds and drying them on a towel, how- Contact with nasal and oral secretions can ever, is not enough. Share and emphasize the spread illnesses such as chicken pox, influenza, following guidelines for appropriate measles, meningococcal meningitis, mumps, handwashing from the National Resource whooping cough, rubella, and pink eye.13, 14 Center for Health and Safety in Child Care.15 For more information on illnesses and their When Hands Should Be Washed modes of transmission, see the chart entitled Hands should always be washed upon arrival for “How Some Childhood Infectious Diseases Are the day or when moving from one child care Spread” at: group to another. Also, wash hands at the fol- http://www.dfps.state.tx.us/handbooks/ lowing times: ms_homes_standards/apx_v_d.htm, as well as the descriptions of communicable Before and after ~ diseases at eating, handling food, or feeding a child; http://www.dfps.state.tx.us/handbooks/ giving medication; and ms_homes_standards/apx_v_e.htm). playing in water that is used by more than Regardless of how disease is transmitted or how one person. minor or severe the illness, the precautions necessary to prevent their spread are the same.2 After ~ Let’s take a look at precautionary measures your diapering; child care program can take to minimize the using the toilet or helping a child use the spread of communicable disease and promote a toilet; healthy environment for the children in your handling bodily fluid (mucus, blood, vomit), care. from sneezing, wiping and blowing noses; from mouths, or from sores; handling uncooked food, especially raw meat and poultry; handling pets and other animals; playing in sandboxes; and cleaning or handling the garbage.15 4 Steps for Handwashing Helping Children with Handwashing Children and staff members should wash their Caregivers should provide assistance with hands using the following method: handwashing at a sink for a child who can be safely cradled in one arm and for children who 1 Check to be sure a clean, disposable paper can stand but not wash their hands indepen- (or single-use cloth) towel is available. dently. A child who can stand should either use a child-size sink or stand on a safety step at a 2 Turn on warm water, no less than 60 height at which the child’s hands can hang freely degrees F and no more than 120 degrees F, to under the running water. After assisting the a comfortable temperature. child with handwashing, the staff member should wash his or her own hands. 3 Moisten hands with water, and apply liquid soap to hands. If a child is unable to stand and is too heavy to hold safely to wash hands at the sink, caregivers 4 Rub hands together vigorously until a soapy should use the following method: lather appears, and continue for at least 10- Wipe the child’s hands with a damp paper 15 seconds. Rub areas between fingers, towel moistened with a drop of liquid soap. around nailbeds, under fingernails, jewelry, Then discard the towel. along the back of hands and up wrists.16 For Wipe the child’s hands with a clean, wet young children, who cannot understand the paper towel until the hands are free of soap. amount of time recommended, have them Then discard the towel. sing the alphabet (abc) song; twinkle, Dry the child’s hands with a clean paper twinkle little star; or twice through the towel.15 happy birthday song.17 A Note about Types of Soap 5 Rinse hands under running water, no less than 60 degrees F and no more than 120 Hands should be washed with liquid soap and degrees F, until they are free of soap and dirt. water when possible, but an alcohol-based Leave the water running while drying hands. hand sanitizer can be helpful as a supplement or substitute when soap and water are not 6 Dry hands with a clean, disposable paper or available. Look for a hand sanitizer with at least single-use cloth towel. 60 percent alcohol in it.18 Follow the manufacturer’s directions. Generally, directions 7 If taps do not shut off automatically, turn for hand sanitizers require placing enough hand taps off with a disposable paper or single-use sanitizer in the palm of your hand to thor- cloth towel. oughly cover your entire hand and rubbing hands together until dry.16 8 Throw the disposable paper towel into a lined trash container; or place single-use Provide and encourage the use of alcohol-based cloth towels in the laundry hamper; or hang hand sanitizers to wash hands immediately if a individually labeled cloth towels to dry. Use child comes into contact with any body fluid at hand lotion to prevent chapping of hands, if locations where handwashing facilities may not desired.15 be available.16 Note: Plain, liquid soap and water are best. Liquid soap is more sanitary than bar soap where multiple people will be using the soap. Antibacterial soaps are NOT needed. Antibac- terial soaps may contain triclosan, a chemical that kills both bad and good bacteria. While bad bacteria can make you sick or cause infection, good bacteria can help you. The triclosan in antibacterial soaps may change the balance of bacteria on your skin and may even make bacteria harder to kill.17 5 Cleaning, Sanitizing & Disinfecting Keeping a healthy environment I n addition to handwashing, cleaning and sanitizing/disinfecting surfaces that could pose a risk to children or staff is one of the most important steps to reducing the spread of communicable diseases in the child care set- ting.19 Before we go any further, let’s take a moment to distinguish the terms cleaning, sanitizing, and disinfecting. Cleaning – Removing dirt and soil with soap Clothes rinsed in sanitizing solution – used and water. for food-preparation areas, large toys, books, and activity centers. Sanitizing – Removing dirt and soil AND certain bacteria so that the number of germs is Dipping the object in a container filled with reduced to such a level that the spread of disease sanitizing solution – used for smaller toys.19, 20 is unlikely. It is important to note that the duration of Disinfecting – Removing dirt and soil AND contact and concentration of the sanitizing bacteria AND virtually all germs.20 solution vary with the type of application. More chemical is required when a cloth or object is Sanitizing and disinfecting are often used to dipped into sanitizing solution because each describe the same type of “cleaning” – to remove time the cloth or object is dipped, some germs germs to a level that the spread of disease from are released into the solution, potentially con- one person to another is unlikely.20 For this taminating the solution if it is not at a high reason, we will use the word sanitizing through- enough concentration. When applying sanitizing out the remainder of this issue of HealthHints to solution, always read the label and follow in- describe such “cleaning.” structions for dilution and minimum contact time.19 Routine cleaning with detergent and water is the most useful method for removing germs from In general, it is best not to rinse off sanitizer or surfaces in the child-care setting. Some items wipe the object dry right away. A sanitizer must and surfaces, however, require the additional be in contact with the germs long enough to kill step of sanitizing after cleaning to reduce the them ~ number of germs on a surface to a level that is for spray bleach solution, usually allow a unlikely to transmit disease.19 Sanitizing applies minimum of 2 minutes to air dry; to many routine housekeeping procedures for cleaned and rinsed dishes submerged in a including bedding, bathrooms, kitchen properly prepared bleach solution, usually countertops, floors, and walls.20 allow 1 minute of contact time.19 (See more details in the next section – Recipes for Clean- Sanitizer solutions can be applied in several ways ing & Sanitizing.) to surfaces that have been cleaned with deter- gent and rinsed: Since chlorine evaporates into the air leaving no residue, surfaces sanitized with bleach may be Spray bottle – used for diaper-changing sur- left to air dry. Some industrial sanitizers, how- faces, toilets, potty chairs, door knobs, cabinet ever, require rinsing in fresh water before the handles, phone receivers, countertops, and object can be used again.19 tables. 6 Recipes for Cleaning & Sanitizing For regular cleaning, detergent and water is most useful. For sanitizing, household bleach with water is recommended. It is effective, economical, convenient, easy to mix, non-toxic, safe if handled properly, and readily available. Be sure to purchase “household” bleach and not bleach used for industrial application, which can be hazardous. Household bleach comes in two strengths: 5.25% hypochlorite (regular strength) or 6% (ultra strength). (Note: Use bleach with caution on metal or metallic surfaces. If bleach is found to be corrosive, use a different sanitizer on these materials.)19 Recipe for spray application on surfaces that have been cleaned and rinsed: (minimum contact time = 2 minutes) 1/4 cup household bleach + 1 gallon of cool water or 1 tablespoon household bleach + 1 quart of cool water. This recipe is appropriate for bathrooms, diapering areas, countertops, tables, toys, door knobs, cabinet handles, phone receivers, sinks, floors, and surfaces contaminated with body fluid. Note: Always clean the surface first. If there is a spill, wipe up as much as possible with a paper towel; then clean and sanitize. Where surfaces contaminated with body fluids are involved, wear gloves (see Gloving Procedure in this issue of HealthHints). Recipe for submerging of eating utensils that have been cleaned and rinsed: (minimum contact time = 1 minute) 1 tablespoon bleach + 1 gallon of cool water. Important notes about bleach: Bleach solution and water loses its strength and is weakened by heat and sunlight. Therefore, it should be mixed with cool, fresh water every day for maximum effectiveness. Any leftover bleach solution should be discarded at the end of the day. Spray bottles and containers should be clearly labeled and stored out of reach of children.19 Industrial Products In addition to bleach-sanitizing solution, industrial products are also available. Choose products that meet the Environmental Protection Agency’s (EPA’s) standards for “hospital grade” germicides (solutions that kill germs). Be cautious of industrial products labeled as “disinfec- tants,” having “germicidal action,” or that simply say “kills germs” – they may not have the same effectiveness as bleach and water or EPA-approved hospital grade germicides. Always read the label for instructions.19 For a sample cleaning/sanitizing schedule, see http://www.healthykids.us/chapters/ cleaning_pf.htm. 7  dispensed so the container will not be Best Practices for Reducing touched during diaper changing; the Spread of Infection a plastic bag for any soiled clothes; disposable gloves (put gloves on before Diapering, food preparations, equipment... handling soiled clothing or diapers – see Gloving Procedure in this issue of N ow that we’ve focused on the import- HealthHints); and ance of handwashing, cleaning, and a thick application of any diaper cream sanitizing, let’s look at some significant (when appropriate) removed from the areas where these and other procedures are container to a piece of disposable material important and necessary to the health and safety such as facial or toilet tissue. of the children in our care: diapering, Step 2: Carry the child to the changing table, handling food, keeping soiled clothing away from you and any handling equipment and personal items, and surfaces you cannot easily clean and sanitize ventilation and fresh air. after the change. Always keep a hand on the child. Diapering If the child’s feet cannot be kept out of the When diapering, it is especially important to diaper or from contact with soiled skin dur- keep hands and surfaces clean to reduce the risk ing the changing process, remove the child’s of fecal/oral transmission of germs. The diaper- shoes and socks so the child does not con- ing surface should be kept clean with the use of taminate these surfaces with stool or urine a plastic-covered pad. Make sure the pad is free during diaper changing. of cracks or tears. If the diapering surface cannot Put soiled clothes in a plastic bag, and se- be easily cleaned after each use, then use a curely tie the plastic bag to send the soiled disposable material, such as a paper sheet, shelf clothes home. paper, or wax paper on the changing table. Discard the disposable material after each Step 3: Clean the child’s diaper area. diapering. Place the child on the diaper-change surface and unfasten the diaper, but leave the soiled It is also important to sanitize the diapering diaper under the child. surface after each use and at the end of each day. If safety pins are used, close each pin imme- Be sure to wash hands with soap and warm diately once it is removed, and keep pins out water immediately after diapering each child. of the child’s reach. Never hold pins in your Be careful to clean between fingers and under- mouth. neath jewelry and fingernails.21 Wearing dispos- Lift the child’s legs as needed to use dispos- able gloves is also recommended. able wipes to clean the skin on the child’s genitalia and buttocks. Remove stool and The following is a detailed guide from the urine from front to back, and use a fresh National Resource Center for Health and Safety wipe each time. Put the soiled wipes into the in Child Care to help keep you and the children soiled diaper or directly into a plastic-lined, in your care safe and healthy when changing hands-free covered can. diapers:22 Step 4: Remove the soiled diaper without con- Step 1: Get organized. Before you bring the taminating any surface not already in contact child to the diaper-changing area, wash your with stool or urine. hands, and gather and bring what you need to Fold the soiled surface of the diaper inward. the diaper-changing table: Put soiled disposable diapers in a covered, non-absorbent paper liner large enough to plastic-lined, hands-free covered can. If reus- cover the changing surface from the child’s able cloth diapers are used, put the soiled shoulders to beyond the child’s feet; cloth diaper and its contents (without empty- fresh diaper, clean clothes (if you need them); ing or rinsing) in a plastic bag or into a wipes for cleaning the child’s genitalia and plastic-lined, hands-free covered can to give buttocks, removed from the container or to parents or the laundry service. 8  Remove gloves using the proper technique Step 8: Wash your hands, and record the diaper (see Gloving Procedure), and put them into a change in the child’s daily log. plastic-lined, hands-free covered can. In the daily log, record what was in the Use a disposable wipe to clean the surfaces of diaper and any problems (such as a loose the caregiver’s hands and another to clean stool, an unusual odor, blood in the stool, or the child’s hands. Put the wipes into the any skin irritation). Report as necessary.22 plastic-lined, hands-free covered can. Check for spills under the child. If there are As a reminder, you can post these steps from the any, use the paper that extends under the “Diapering” poster found at child’s feet to fold over the disposable paper http://www.globalhealthychildcare.org/Download/ so a fresh, unsoiled paper surface is now DiaperingPoster.jpg above your diaper-changing under the child’s buttocks. area: Note: Gloves must be worn when blood or 1 Keep supplies ready. bodily fluids containing blood are present 2 Protect the surface with clean, non-porous (see Gloving Procedure). disposable paper. 3 Keep one hand on the child at all times. Step 5: Put on a clean diaper and dress the child. 4 Place the soiled diaper in a container lined Slide a fresh diaper under the child. with a plastic bag. Use facial or toilet tissue to apply any neces- 5 Wipe front to back. Use each cloth or towel sary diaper creams, discarding the tissue in a only once. covered, plastic-lined, hands-free covered 6 Diaper and dress the child. can. 7 Wash your hands and the child’s. Assist the child back to the group. Note and plan to report any skin problems 8 Place soiled clothes in a plastic bag. such as redness, skin cracks, or bleeding. 9 Remove disposable paper. Clean and sanitize. Fasten the diaper. If pins are used, place your 10 Wash your hands. hand between the child and the diaper when 11 Dry hands. inserting the pin. 12 Dispose of the towel in a container lined with a plastic bag.23 Step 6: Wash the child’s hands, and return the child to a supervised area. 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. Step 7: Clean and sanitize the diaper-changing surface. Dispose of the disposable paper liner used on the diaper-changing surface in a plastic-lined, hands-free covered can. Clean any visible soil from the changing surface with detergent and water; rinse with water. Wet the entire changing surface with the sanitizing solution. 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 2 minutes. The surface can be left to air dry or can be wiped dry after 2 minutes of contact with the bleach solution. 9 Gloving Procedure: How & Why? Why use gloves? “Gloves provide a protective barrier against germs that cause infections. Use gloves made of dispos- able latex. If you’re allergic to latex, use vinyl gloves. Wearing gloves does not replace the need to wash your hands. Latex and vinyl gloves are a good barrier, but they may not be completely non-porous. Wearing gloves reduces contamination, but does not eliminate it. If the gloves become contaminated while you are wearing them, be sure to remove them before touching clean surfaces. Disposable gloves should be worn: when contact with blood or blood-containing fluids is likely, particularly if the caregiver’s hands have open cuts or sores – for instance, when providing first aid or changing a diaper with bloody diarrhea; and when cleaning surfaces contaminated with blood or body fluids, such as large amounts of vomit or feces. For added protection, wear gloves when changing the diaper of a child with diarrhea or a diagnosed gastrointestinal disease. Wearing gloves for routine diaper changing is optional. If your skin does come into contact with blood or other body fluids, immediately and thoroughly wash the contaminated skin.”24 How to use gloves? Using the appropriate gloving procedure can keep you and the children you care for safer from infection. Use the following steps, in order, when using disposable gloves: Wash your hands and dry them. Put on a clean pair of gloves. Provide the appropriate care – disposing of any contaminated materials in a leak-proof, plastic bag that can be tied or sealed. Remove each glove carefully. Grab the first glove at the palm and strip the glove off. Touch dirty surfaces only to dirty surfaces. Ball up the dirty glove in the palm of the other gloved hand. With the clean hand, strip the glove off from underneath the wrist, turning the glove inside out. Touch dirty surfaces only to dirty surfaces. Discard the gloves immediately in a plastic bag-lined step can. Wash your hands.19 For a visual depiction of the gloving procedure, see http://nrc.uchsc.edu/CFOC/ PDFVersion/Appendix%20D.pdf. 10 Handling Food Clean kitchenware, countertops, and other Of particular concern when handling food is things that have come in contact with spoiled taking precautions against foodborne illness (i.e., food or raw meat, chicken, or eggs. Sanitize food poisoning) and any other illness that can by spraying them with the household bleach occur through fecal/oral transmission. E. coli is solution, allowing it to stand for at least 2 one type of bacteria, typically contaminating minutes, and then dry with a paper towel or ground meat, that can cause severe illness and allow to air dry.27 be particularly threatening to children younger than 5 years. E. coli can potentially cause kidney Always wash your hands, utensils, failure and even death in these children.25 countertops, cutting boards, clothes, towels, aprons, and sinks in hot soapy water after Thus, the rule of thumb for food handling to handling raw meat.25 reduce the risk and spread of any communicable disease is “cool it, clean it, cook it.”25 Wash high-chair trays, bottles, and nipples in a dishwasher, if available. If the trays do not Cool It fit in the dishwasher, wash with detergent, Raw meat and poultry (especially ground meats) rinse, spray with the bleach solution, and air are more perishable than most foods. Bacteria dry. 27 can multiply in ground meat and poultry in a temperature range between 39-140 degrees F (4- All eating and drinking utensils, tableware, 60 degrees C). Keep these products and other and kitchenware should be cleaned and products refrigerated. Keep meats on ice if you sanitized after each use, or disposable items are more than an hour from the store to the can be used.28, 29 Be sure to label any drinking child care facility. Defrost meats by placing them cups brought in for a child with his/her in a container that will hold juices and let them name and keep out of reach of other chil- thaw in the refrigerator – NEVER at room dren. temperature. Cook or freeze meat within 1–2 days.25 The easiest way to clean and sanitize dishes is to use a dishwasher, which incorporates chemi- Clean It cals or heat sanitizing.28 Food-preparation areas should be kept separate from eating, laundry, toileting, and diapering If handwashing, you’ll need three different areas.26 Cleaning of food-preparation areas and basins (compartments): utensils requires a bit more diligence in the child 1 one for washing, care setting than at home. Use the following 2 one for rinsing, and guidelines outlined by Global Healthy Child 3 one for sanitizing. Care to help with cleaning food-handled items (as well as mouthed toys): Use the following procedure for handwashing utensils (or toys): Don’t use cloths or towels used to wipe 1 Scrape off any leftover food. countertops or other food-contact surfaces 2 Use the first compartment to wash the for anything else. These cloths must be dishes (or toys) thoroughly in hot water sanitized after they are used.27 containing a detergent solution. 3 Rinse in the second compartment. Don’t use a sponge – use a cloth that can be 4 Use the third compartment to sanitize laundered. The structure of natural and the dishes (or toys) by one of these methods: artificial sponges provides an environment in – The safest and easiest method is to which germs thrive.28 immerse the dishes (or toys) for at least 2 minutes in a lukewarm – not less than Wash food-contact surfaces with detergent 75 degrees F (24 degrees C) – bleach and water, rinse, sanitize with bleach solu- solution. Then air dry the sanitized items. tion, and air dry.27 – Immerse the dishes (and toys) for at least 30 seconds in water heated to 170 degrees F (77 degrees C). The water 11  temperature should be maintained at that Cook It temperature throughout the sanitizing Be sure to cook foods to appropriate tempera- process. A hot-water booster is usually tures before serving. High heat kills harmful required to heat water to a high enough bacteria. When cooking raw ground meat, cook temperature. To avoid burning the skin until you see no pink in the meat and the coolest while immersing dishes and utensils in part of the meat reaches 165.2 degrees F (74 this hot-water bath, use special racks degrees C).25 A meat thermometer (available at designed for this purpose. Then air dry most grocery stores) can be used to test meat’s the items. Because it requires very hot internal temperature. water, this method is less safe than the bleach-sanitizing method.28 Handling Equipment & Personal Items Toys and equipment should be cleaned and Pick up and touch clean spoons, knives, and sanitized frequently, particularly in programs forks by their handles, not by any part that that care for infants and toddlers, who tend to will be in contact with food. When children put everything in their mouths.2 You can follow help set the table, be sure they have washed the schedule set forth in the Sample Cleaning/ their hands thoroughly, and remind them Sanitizing Schedule at http://www.healthykids.us/ not to touch the parts of the tableware that chapters/cleaning_pf.htm. will have contact with food and go into the mouth. Handle clean cups, glasses, and Toys bowls so that fingers and thumbs don’t Toys that cannot be washed and sanitized should touch the insides or the rims of these items.30 not be used in your program. If a toy is placed in a child’s mouth or has come into contact with Be mindful of good hygiene when around body secretions or excretions, set it aside to be food: cleaned and sanitized. Make sure you have – Wear clean clothes, and maintain a high enough toys to replace the contaminated toy standard of personal cleanliness. with another throughout the day until there is – Wash your hands using correct hand- time for cleaning/sanitizing. Small toys with washing procedures before preparing hard surfaces can be put in a dishpan labeled and serving food and as necessary to “soiled toys” until cleaning can occur. Machine- keep your hands free of dirt, germs, and washable cloth toys should be for use by one body fluids. child only until these toys can be laundered. – Also keep your hands clean while han- You will need to monitor children closely to dling food-contact surfaces, dishes, and prevent shared mouthing of toys.19 utensils. – Do not prepare or serve food while ill Bedding with a communicable disease or with Cribs and crib mattresses as well as any resting/ uncovered hands or skin lesions. If you napping mats should have non-porous, easy-to- have skin lesions on your hands, you wipe surfaces that are used only by one child should wear gloves while involved with and/or cleaned and sanitized between each food. child’s use. Bedding (sheets, pillows, blankets, – Keep your hair covered with a hairnet or and sleeping bags) should be washable, and each cap while preparing food.31 child’s bedding should be kept separate from – Be sure children always wash their hands others. Lice infestations, scabies, ringworm, and before and after eating. other diseases can spread in bedding material that various children use. Providing bedding for For a sample food each child and storing each set in individually service cleaning labeled bins, cubbies, or bags in a manner that schedule, see separates the personal articles of one individual http:// from those of another will prevent the spread of nrc.uchsc.edu/ disease.19 Space children 24 or more inches apart CFOC/ during nap or rest time, and alternate them head PDFVersion/ to foot to prevent any spread of illness.13 Appendix%20S.pdf. 12 Personal Items Warm Weather Personal items, such as hats, coats, combs, Germs multiply rapidly in warm, moist places.2 brushes, toothbrushes, pacifiers, and clothes Humidity increases in warm weather and can should never be shared. Hats, combs, and also lead to the growth of mold and dust mites brushes are of particular concern because if in fabrics, which in turn can cause allergies to there is a lice infestation, it could be easily spread flare up. Children with allergic irritation of their from one child’s head to another. Each of these respiratory tract are more likely to pick up items should be labeled and stored separately.2 infectious diseases. To prevent this, it may be necessary to dehumidify and cool the air.32 A Note about Shoes Cold Weather When infants play, they touch the surfaces on Even in cold weather, some form of ventilation is which they play with their hands, then put necessary. During naptime, put a sleeper gar- their hands in their mouths. Shoes may be ment over infants’ clothing and a warm blanket conduits of infectious material when people over older children to keep them comfortable walk on surfaces that are contaminated with and let in a little fresh air.32 Bundle children up, disease-causing organisms, then walk into the and let them play outside when weather per- infant play area. mits. Before walking on surfaces that infants use In cold weather, indoor air can also become very specifically for play, adults and children should dry. When this happens, the dry air draws water remove or cover the shoes they have worn from mucous membranes in the nose and draws outside of the infant play area. Socks, shoe moisture from the skin. This loss of fluid from covers, or other shoes/slippers specified only the membranes can interfere with the protective for the infant play area may be worn.19 functions of the mucous barrier and makes people more susceptible to illness.32 Ventilation & Fresh Air To prevent the drying of mucous membranes, “Exchanging indoor air with outdoor air is key don’t overheat rooms. You’ll know humidity is to reducing the density of contagious germs. too low when you get static shocks from walking Wherever people gather in groups, they exhale across the floor. In general, try to keep indoor their germs into their surroundings.”32 This is temperatures between 64–75 degrees F (18–24 especially true for airborne/respiratory transmit- degrees C) in cold weather to reduce the drying ted germs. effect.32 For this reason, allowing children to play out- doors as often as possible is important.29 It is also important to keep rooms children use appropri- ately heated, cooled, and ventilated to keep temperatures comfortable and prevent germs from growing or collecting. Try to ~ open windows and air out rooms at least once a day (opening windows maximizes ventilation), keep indoor humidity between 30–50 per- cent, and keep indoor temperature between 64–82 degrees F (18–28 degrees C).32 13  “Mild cases of hepatitis A don’t require treat- “Potentially” Infectious ment, and most people who are infected recover completely with no permanent liver damage. Unlike hepatitis B and C, hepatitis A doesn’t Necessity of always taking precautions develop into chronic hepatitis or cirrhosis – both potentially fatal conditions.”35 “Practicing good hygiene – including washing S ince symptoms often do not appear until some time after a child is infected with an your hands often – is one of the best ways to illness, it is important to always use pre- protect against hepatitis A. Effective vaccines are cautions. We have covered many of the neces- available for people who are most at risk.”35 sary precautions, but let’s take a few moments to focus on areas that sometimes evoke fear – Hepatitis B (HBV) illnesses that are more severe, like HIV and “For you to become infected with HBV, infected hepatitis. blood, semen, vaginal secretions, or saliva must enter your body. You can’t become infected HIV through casual contact – hugging, dancing, or Please know that “to become infected with HIV, shaking hands – with someone who has hepatitis infected blood, semen, or vaginal secretions B. You also can’t be infected in any of the follow- must enter your body.”33 This does not happen ing ways: through regular contact – hugging, kissing, coming into contact with the sweat or tears shaking hands, or dancing with a child.33 of someone with HBV; sharing a swimming pool, telephone, or toilet HIV is most commonly transmitted by ~ seat with someone who has the virus; or sexual contact; donating blood.”36 infected blood and blood transfusion (the American blood supply has been tested for Hepatitis B, like HIV, is most commonly trans- HIV since 1985,33 and improved blood- mitted through ~ screening became available in 1992,34 which sexual transmission; has substantially reduced infection by blood needle sharing or accidental needle sticks; and transfusion); transmission from mother to child.36 needle sharing or accidental needle sticks; and transmission from mother to child.33 Hepatitis B, however, is nearly 100 times as infectious as HIV.36 Hepatitis There are three types of hepatitis viruses that are For some people, the infection of the liver be- of concern: Hepatitis A, B, and C. comes chronic, leading to liver failure, liver cancer, or cirrhosis – a condition that causes Hepatitis A (HAV) permanent scarring of the liver. Hepatitis A virus “is usually transmitted via the fecal-oral route. That means that someone with Like HIV, you’re especially at risk if you are an the virus handles food you eat without washing intravenous (IV) drug user who shares needles his or her hands after using the toilet. You can or other paraphernalia or have unprotected also contract the virus by drinking contami- sexual contact with an infected partner. You’re nated water, eating raw shellfish from water also at higher risk for hepatitis B infection if you polluted with sewage, or being in close contact were born in or travel to parts of the world with a person who’s infected – even if that where hepatitis B is widespread. person has no signs or symptoms. In fact, the disease is most contagious before signs and Most people infected as adults recover fully from symptoms ever appear.”35 hepatitis B, even if their signs and symptoms are severe. Infants and children are much more “Although not usually as serious as other types likely to develop a chronic infection. Although of viral hepatitis, hepatitis A causes inflamma- no cure exists for hepatitis B, a vaccine can tion that affects your liver’s ability to function.”35 prevent the disease.36 14 Hepatitis C (HCV) Potentially Infectious: Taking Precautions “In general, you contract hepatitis C by coming Because symptoms of all illnesses are not always in contact with blood contaminated with the immediately visible, we have to treat all blood, virus. Most people with hepatitis C became body fluids, and secretions as “potentially” infected through blood transfusions received infectious. Spills of urine, stool, vomit, blood, before 1992, the year improved blood-screening saliva, human milk, nasal discharge, eye dis- tests became available. charge, and injury or tissue discharge (e.g., from a cut or sore) should always be treated as “poten- You can also contract the virus by injecting tially” infectious. Let’s take a look at how to drugs with contaminated needles and, less safely handle body fluids: commonly, from contaminated needles used in tattooing and body piercing. Needle exchange Treat all body fluids as if they are contagious. programs, which increase the availability of Wash your hands after any contact with sterile needles, are helping to reduce the risk of body fluids. hepatitis C, HIV, and other blood-borne diseases. Wear gloves while cleaning (see Gloving Procedure). While household rubber gloves A small percentage of babies born to mothers are adequate for most spills, disposable with hepatitis C acquire the infection during gloves should always be used when blood childbirth. Mother-to-infant transmission rates may be present. are higher among women infected with both For small spills of urine or stool, wipe off and hepatitis C and HIV.”34 clean away visible soil with a little detergent solution; rinse with clean water; follow with All strains of the hepatitis virus cause the liver to sanitizer solution applied to the surface and become inflamed, which interferes with its left for the appropriate contact time (usually ability to function. Hepatitis C is generally 2 minutes). considered to be among the most serious of For larger spills, take care to avoid splashing these viruses. Vaccines exist for hepatitis A and any contaminated material onto the mucous B, but no vaccine for hepatitis C has been devel- membrane of your eyes, nose, or mouth, or oped.34 into any open sores you may have. Note: Sores or cuts should always be covered and In rare cases, hepatitis C may be transmitted appropriately cared for to avoid antibiotic- sexually. And in many people infected with resistant staph infections, which have be- hepatitis C, no risk factor can be identified. come more prevalent in schools and day care settings. (For more information on MRSA and appropriate care, see the issue of HealthHints related to this topic at http:// fcs.tamu.edu/health/ Health_Education_Rural_Outreach/ Health_Hints/2006/october06/staph.pdf.) Wipe up as much of the visible material as possible with disposable paper towels, and carefully place the soiled paper towels and other soiled disposable material (e.g., tissue, bandages, diapers, etc.) in a leak-proof, plastic bag that can be securely tied or sealed. Immediately use a detergent or a disinfec- tant-detergent to clean the spill area; then rinse the area with clean water. For blood and body fluid spills on carpet, blot to remove body fluids from the fabric as quickly as possible; then spot clean the area with detergent-disinfectant (rather than bleach solution); sanitize by continuing to apply and extract the detergent-disinfectant 15  until there is no visible soil. Follow the manufacturer’s instructions for the use of the Child Care Providers sanitizer to be sure the carpet is sanitized by the treatment. Dry the surface. Shampoo or steam-clean the contaminated surface as Taking care of yourself soon as possible. “ D Indisposable mops and other equipment uring the first six to twelve months of used to clean up body fluids should be employment, most care providers get cleaned and sanitized, rinsed with fresh sick more than usual because they are sanitizing solution, wrung as dry as possible, exposed to a wide variety of germs. Caring for and air-dried. others can also cause stress, which lowers resis- Remove and bag clothing (yours and those tance to illness.”2 worn by children) soiled by body fluids. Put on fresh clothes only after washing the soiled Care providers who are ill should take care of skin and hands of everyone involved. themselves, not the children. Allow your own Reuseable household rubber gloves used for body the opportunity to get well. If you are ill, general cleaning should be treated as a stay home and recuperate. You cannot provide contaminated surface, which means sanitiz- the best quality of care if you are sick, and you ing solution should be applied to them. may spread the illness to others if you come to Remove, dry, and store these gloves away work. Get well and stay well by choosing healthy from food and food surfaces. Discard dispos- behaviors: able gloves in a sealed, plastic bag. Wash your hands. Always wash your hands, even if you Maintain current immunizations, especially have been wearing tetanus. gloves.19, 37 Take scheduled breaks and vacations. Observe good nutrition. Exercise regularly. Don’t smoke. Rest sufficiently each day. Engage in hobbies/activities that do not involve caring for someone else.2 Resources for Your Child Care Center Need resources for your child care center? Check out some of these... Infectious Diseases in Child Care Facilities – Fact sheet with statistics on illnesses in child care (great for presentations) at http://www.nfid.org/_old1/content/factsheets/childcare.html Gloving – Description and pictures of how to put on and remove disposable gloves at http://nrc.uchsc.edu/CFOC/PDFVersion/Appendix%20D.pdf Healthy Handwashing – Poster at http://www.globalhealthychildcare.org/Download/ HealthyHandwashingPoster.jpg Clean & Sanitize – Poster at http://www.globalhealthychildcare.org/Download/CleanandSanitizePoster.jpg Diapering – Poster at http://www.globalhealthychildcare.org/Download/DiaperingPoster.jpg Blood & Body Fluid Safety – Poster at http://www.globalhealthychildcare.org/Download/ BloodandBodyFluidsPoster.jpg Sample Cleaning/Sanitizing Schedule at http://www.healthykids.us/chapters/cleaning_pf.htm Sample Food Service Cleaning Schedule at http://nrc.uchsc.edu/CFOC/PDFVersion/Appendix%20S.pdf 16 References 1. Mayo Clinic (2006). Children’s illness: Top 5 causes of missed school. Retrieved December 15, 2006. From http://mayoclinic.com/health/childrens-conditions/CC00059. 2. ARCH National Resource Center for Respite and Crisis Care Services (1996). Preventing the spread of disease: Tips for providers. Retrieved November 10, 2006. From http://www.archrespite.org/ archfs42.htm. 3. National Institute of Allergy and Infectious Diseases (2006). Common cold. Retrieved November 27, 2006. From http://www3.niaid.nih.gov/healthscience/healthtopics/colds/cause.htm. 4. Cleveland Clinic Health Information Center (2006). Gastroenteritis. Retrieved November 27, 2006. From http://www.clevelandclinic.org/health/health-info/docs/3900/3901.asp. 5. U.S. National Library of Medicine and National Institutes of Health (2006). Chicken pox. Retrieved November 22, 2006. From http://www.nlm.nih.gov/medlineplus/ency/article/001592.htm. 6. U.S. National Library of Medicine and National Institutes of Health (2006). Ringworm. Retrieved November 22, 2006. From http://www.nlm.nih.gov/medlineplus/ency/article/001439.htm. 7. U.S. National Library of Medicine and National Institutes of Health (2006). Head lice. Retrieved November 22, 2006. From http://www.nlm.nih.gov/medlineplus/ency/article/000840.htm. 8. U.S. National Library of Medicine and National Institutes of Health (2006). Impetigo. Retrieved November 22, 2006. From http://www.nlm.nih.gov/medlineplus/ency/article/000860.htm. 9. U.S. National Library of Medicine and National Institutes of Health (2006). Meningitis. Retrieved November 22, 2006. From http://www.nlm.nih.gov/medlineplus/ency/article/000680.htm. 10. U.S. National Library of Medicine and National Institutes of Health (2006). Hepatitis. Retrieved November 22, 2006. From http://www.nlm.nih.gov/medlineplus/ency/article/001154.htm. 11. U.S. National Library of Medicine and National Institutes of Health (2006). HIV infection. Re- trieved November 22, 2006. From http://www.nlm.nih.gov/medlineplus/ency/article/000602.htm. 12. U.S. National Library of Medicine and National Institutes of Health (2006). AIDS. Retrieved November 22, 2006. From http://www.nlm.nih.gov/medlineplus/ency/article/000594.htm. 13. BC Health Planning (2003). Preventing illness in the child care setting. Retrieved November 27, 2006. From http://www.healthservices.gov.bc.ca/ccf/child/publicat/comm/com018.pdf. 14. Texas Department of Family and Protective Services (2006). Minimum standard rules for licensed child-care centers: When communicable disease is diagnosed or suspected. Retrieved November 10, 2006. From http://www.dfps.state.tx.us/handbooks/ms_homes_standards/apx_v_b.htm. 15. National Resource Center for Health and Safety in Child Care (2006). Handwashing. Retrieved November 20, 2006. From http://www.healthykids.us/chapters/handwashing_pf.htm. 16. Texas Department of State Health Services (2006). Information on staphylococcal infections for day care administrators and care givers. Retrieved October 5, 2006. From http://www.dshs.state.tx.us/ idcu/health/antibiotic_resistance/mrsa/mrsa_daycareadmin.pdf. 17 References... 17. Tacoma-Pierce County Health Department (2006). What should I use to wash my hands? Re- trieved October 6, 2005. From http://www.tpchd.org/files/library/12b59c64cf77a8a0.pdf. 18. GroupHealth Cooperative, Tacoma-Pierce County Health Department, & Washington State Department of Health (2006). Living with MRSA. Retrieved October 6, 2006. From http:// www.tpchd.org/files/library/3550750db4a81b14.pdf. 19. American Academy of Pediatrics, American Public Health Association, and National Resource Center for Health and Safety in Child Care (2002). Caring for Our Children: National Health and Safety Performance Standards: Guidelines for Out-of-Home Child Care Programs, 2nd edition. Elk Grove Village, IL: American Academy of Pediatrics and Washington, DC: American Public Health Association. Retrieved November 27, 2006. From http://nrc.uchsc.edu/CFOC/index.html. 20. National Resource Center for Health and Safety in Child Care (2006). Cleaning and sanitizing. Retrieved November 20, 2006. From http://www.healthykids.us/chapters/cleaning_pf.htm. 21. Texas Department of State Health Services (2005). Communicable diseases notes for schools and child care centers. Retrieved November 20, 2006. From http://www.dshs.state.tx.us/idcu/health/ schools_childcare/resources/. 22. National Resource Center for Health and Safety in Child Care (2006). Diapering. Retrieved No- vember 20, 2006. From http://www.healthykids.us/chapters/diapering_pf.htm. 23. Global Healthy Child Care (2005). Diapering. Retrieved November 20, 2006. From http://www.globalhealthychildcare.org/Download/DiaperingPoster.jpg. 24. Global Healthy Child Care (2005). Gloves. Retrieved December 4, 2006. From http://www.globalhealthychildcare.org/default.aspx?page=poi&language=content&content_id=6. 25. Global Healthy Child Care (2005). Ground meat and food poisoning. Retrieved December 4, 2006. From http://www.globalhealthychildcare.org/ default.aspx?page=poi&content_id=8&language=content. 26. National Resource Center for Health and Safety in Child Care (2006). Food Preparation. Retrieved November 20, 2006. From http://www.healthykids.us/chapters/food_pf.htm. 27. Global Healthy Child Care (2005). Care of equipment and utensils. Retrieved December 4, 2006. From http://www.globalhealthychildcare.org/default.aspx?page=fp&content_id=66&language=content. 28. Global Healthy Child Care (2005). Washing dishes and mouthed toys. Retrieved December 4, 2006. From http://www.globalhealthychildcare.org/ default.aspx?page=fp&content_id=73&language=content. 29. Global Healthy Child Care (2005). Stopping the spread of respiratory diseases. Retrieved Decem- ber 4, 2006. From http://www.globalhealthychildcare.org/ default.aspx?page=poi&language=content&content_id=14. 30. Global Healthy Child Care (2005). Handling clean dishes and utensils. Retrieved December 4, 2006. From http://www.globalhealthychildcare.org/ default.aspx?page=poi&language=content&content_id=68. 18 References... 31. Global Healthy Child Care (2005). Food preparation hygiene. Retrieved December 4, 2006. From http://www.globalhealthychildcare.org/default.aspx?page=fp&content_id=194&language=content. 32. Global Healthy Child Care (2005). Fresh air, temperature, and humidity. Retrieved December 4, 2006. From http://www.globalhealthychildcare.org/ default.aspx?page=poi&language=content&content_id=16. 33. Mayo Clinic (2006). HIV/AIDS. Retrieved December 15, 2006. From http://mayoclinic.com/health/ hiv-aids/DS00005. 34. Mayo Clinic (2006). Hepatitis C. Retrieved December 15, 2006. From http://mayoclinic.com/health/ hepatitis-c/DS00097. 35. Mayo Clinic (2006). Hepatitis A. Retrieved December 15, 2006. From http://mayoclinic.com/health/ hepatitis-a/DS00397. 36. Mayo Clinic (2006). Hepatitis B. Retrieved December 15, 2006. From http://mayoclinic.com/health/ hepatitis-b/DS00398. 37. Global Healthy Child Care (2005). Blood and body fluids safety. Retrieved December 4, 2006. From http://www.globalhealthychildcare.org/default.aspx?page=poi&content_id=2&language=content. Attn: Janet M. Pollard 2251 TAMU College Station, Texas 77843-2251 Extension programs serve people of all ages regardless of socioeconomic level, race, color, sex, religion, disability, or national origin. The Texas A&M University System, U.S. Department of Agriculture, and the County Commissioners Courts of Texas Cooperating A member of The Texas A&M University System and its statewide Agriculture Program 19