NORFOLK, Va. - Advances in the diagnosis, treatment and prevention of infectious diseases have improved the health of children in the child care setting, but infants and toddlers continue to have the highest age-specific attack rates for many pathogens, said Larry K. Pickering, MD, director of the Center for Pediatric Research, Norfolk, Va.
Pickering, who is also editor of the Red Book, reviewed the primary and secondary methods for prevention of infectious diseases in child care and schools, including those for diarrhea associated with Escherichia coli and rotavirus, Neisseria meningitidis, hepatitis A virus (HAV) and Streptococcus pneumoniae.
Although the source of most HAV cases is usually unknown (45%), 24% are associated with direct contact, and 14% are linked directly to child care center attendance or employment. For this reason, precautions should be taken in child care, Pickering said.
General prevention measures like hand washing should be observed. However, if a case of HAV is reported, immune globulin (IG) should be administered to exposed children and employees; if given within two weeks after exposure, IG is 80% to 90% effective in preventing symptomatic infection.
Routine vaccination against HAV is not recommended for child care center staff or all children, but should be considered in settings with ongoing or recurrent outbreaks and in communities where cases in the child care centers contribute substantially to the total number of HAV cases.
The vaccine is not indicated for children younger than 2 years, an age group where transmission frequently occurs during asymptomatic infection from a diapered child.
A child with HAV infection should be temporarily excluded from attending day care until one week from onset of illness/jaundice or until IG has been given appropriately, Pickering said.
Major causes of diarrhea in child care centers include bacteria, viruses and protozoa. Outbreaks occur because asymptomatic excretion is common, dose contact is frequent, immunologic immaturity, and poor personal hygiene. The outbreaks are most commonly caused by rotavirus and other enteric viruses, and Giardia lamblia. Pickering said diarrhea caused by E. coli O157:H7 and Shigella are the most worrisome to the physician, and the most frustrating cases of diarrhea are from unknown sources.
Children newly enrolled in a center have an increased susceptibility to diarrheal disease because of their lack of immunity to these common child care infections. This is just one of several characteristics associated with disease in a child care center, he said.
If a child has diarrhea, Pickering recommends temporarily excluding the child from the child care and reviewing the procedures for group separation, hand washing and cleaning procedures. The child should return to day care when the diarrhea has ceased.
Diarrhea infections that require exclusion from out-of-home child care settings include E. coli O157:H7 and Shigella. The child should be excluded until diarrhea resolves and two cultures are negative. Children with stools not contained by diapers should be excluded until diarrhea resolves. The same rule applies to children with blood or mucus in the stools.
A child with a gastrointestinal tract infection who has vomited two or more times in the previous 24 hours should be kept from attending child care until vomiting has resolved or is judged to be noncommunicable by a physician, Pickering said.
Viruses and bacteria are the primary causes of community respiratory tract infections such as otitis media (OM), pharyngitis, sinusitis, bronchitis and pneumonia. Children have the highest incidence rates of these illnesses - especially children attending child care centers compared with children not enrolled in child care. However, it is not always necessary to send home a child with a respiratory tract infection, he said.
These diseases are also more common among children in homes where people smoke.
Respiratory tract infections which require exclusion are pertussis, tuberculosis, streptococcal pharyngitis and mumps. A child with pertussis may return to the center after five days of appropriate treatment. A child with tuberculosis should be kept from day care until determined noninfectious by a physician or health department official.
Streptococcal pharyngitis requires a child be excluded until 24 hours after treatment and until the child has been without fever for 24 hours. A child with mumps should be excluded until nine days after onset of parotid swelling.
Children attending child care centers full time are at an increased risk for acquiring OM, the most common illness for which children are prescribed antibiotics. The mean number of courses of antibiotic therapy in children younger than 3 years who attend care centers is 3.3 per year. This antibiotic use may be associated with an increase in antibiotic-resistant respiratory and gastrointestinal tract organisms, Pickering said.
Children with recurrent OM and other chronic respiratory tract diseases could benefit from influenza vaccine. Studies have shown that children 6-30 months of age who attend child care centers had decreased OM occurrence after receiving influenza vaccine.
Three organisms should be considered with invasive bacterial disease: Haemophilus influenzae, S. pneumoniae and N. meningitidis.
"H. influenzae type 6 disease in child care centers is a concern, but conjugate vaccines have significantly reduced this disease in children," Pickering said.
Vaccines for H. influenzae are available for use in children younger than 2 years, but vaccines for S. pneumoniae and N. meningitidis are available only for children 2 years and older. This often presents a problem, because children too young to receive the vaccines can be at an increased risk for disease when attending child care centers.
The risk of disease from N. meningitidis in child care may be increased. The risk of invasive disease due to S. pneumoniae is increased in children in child care. Disease associated with penicillin-resistant S. pneumoniae has become a problem in this environment as a result of antibiotic overuse.
S. pneumoniae primary invasive disease occurs in child care centers, and penicillin-resistant outbreaks of meningitis and bacteremia have been reported. Pickering estimates that 10% to 40% of children in child care centers carry penicillin-resistant strains of S. pneumoniae. Multidrug-resistant outbreaks of Shigella also occur, he said.
Children in child care centers are most often grouped by age, which aids in the spread of disease. Child care characteristics associated with disease include the presence of children in diapers, inadequate number of staff members, failure to isolate children with diarrhea, environmental contamination and new children entering the center.
Organisms in child care centers can be spread through direct and indirect contact, common sources like food or water, and environmental mediums like fomites and contaminated surfaces.
Infants are particularly noted for spreading disease through direct contact because of their hand-to-mouth behavior. Children 1-12 months put their hands to their mouth an average of 64 times per hour. The frequency decreases by half to 34 times an hour at 13-24 months of age; by 31-48 months of age, children touch their hands to their mouth an estimated eight times an hour.
For your information:
- Pickering LK. Prevention: the cornerstone of you practice, infectious disease progress and setbacks. Presented a the American Academy of Pediatrics 1998 Spring Session. April 4-7. Atlanta.
- American Academy of Pediatrics. In: Peter G, ed. 1997 Red Book: Report of the Committee on Infectious Diseases. 24 ed. Elk Grove Village, IL: American Academy of Pediatrics; 1997:239-242.
- CDC, American Academy of Pediatrics. Principles of judicious use of antimicrobial agents for pediatric upper respiratory tract infections. Pediatrics 1998;101:163s-184s.
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