1. Communicable and Zoonotic Disease Control Safe & Effective Cleaning May 2010 Pacific NW Association of Independent Schools

2. DOH School Environmental Health and Safety Program  Provide technical support & training, develop resources  Local Health Jurisdictions (LHJs)  Schools: K – 12 th grade  IAQ  Best Practices Manual  Asthma Plan implementation - reducing triggers in schools  Investigations  “Green Cleaning”  Rehab the Lab / Hazardous Chemicals  Integrated Pest Management (IPM)  Healthy High Performing Schools  Work with organizations and agencies concerned with SEH&S  Website and List Serve  DOH Fall 2010 SHE&S Workshops - Free  Nov. 2 – Dec. 2, 8:30-3:30  Dave Waddell – 12:30-3:30 2

3. Communicable (Infectious) Diseases In Schools

4. Infectious Diseases in the US  Every year, schools close due to infectious disease outbreaks  Infectious diseases are illnesses that are transmitted from one person to another via various routes  OSPI/DOH Infectious Disease Guide for School Staff, April 2004 http://www.k12.wa.us/healthservices/pubdocs/Infecti ousDiseaseControlGuide3-11-04.pdf

5. Common Routes of Transmission  Person-to-Person  Contaminated surfaces  Foodborne  Waterborne

6. Infectious Diseases and Children  Children and youth are particularly efficient vectors for disease transmission.  Children have less developed immune systems than adults.  Children may not be fully immunized against vaccine-preventable diseases (or require boosters).  Schools tend to be densely packed environments.  School environments may not be routinely cleaned and disinfected in a manner that reduces possibilities for disease transmission (i.e. playgrounds).

7. Consequences of Infectious Diseases for Schools  Students and staff may be affected by illnesses.  If handled poorly, community trust in schools is shaken.  Depending on the disease, may cause high rates of illness, potentially some deaths in the school community.  Absences may cause schools to close for days or weeks – Continuity of Operations plans may need to be enacted.

8. Some Common Infectious Diseases That Affect Schools  Viral Infections  Gastroenteritis – Noroviruses  Influenza  Varicella (Chicken Pox)  Meningitis  Bacterial Infections  E. Coli  MRSA  Strep throat  Meningitis  Fungal Infections  Ringworm

9. MRSA Case  In Fall 2007, the death of a high school football player in Virginia focused the nation on MRSA in Schools  Within a month or two, several more MRSA outbreaks were reported across the nation, closing several schools and triggering cleaning efforts

10. MRSA  Type of “staph” infection  Often causes skin infections  Resistant to (not killed by) penicillin  Treatable with appropriate antibiotic  Lives on surfaces for days – at least 70! (Methicillin-Resistant Staphylococcus aureus)

11. MRSA in High School Athletic Facilities  Journal of EH, Jan/Feb 2010  10 high school athletic training facilities  90% - 2 or more positive surfaces for MRSA  ~50% of surfaces tested positive  Water coolers – 80%  Treatment/taping tables – 70%  Sink faucet handles – 60%  Shower handles – 50%  Ice Machine – 30%  9 high school wrestling facilities  Wrestling mats – 89%  Locker room benches – 78%  Treatment table – 56%  Doorknob – 44%

12. What does MRSA look like?  Spider bite  Turf burn  Impetigo  Boil  Abscess Source: LA County Health DepartmentSource: Mark Grubb, MD Source: CDC

13. How is MRSA spread?  Skin to Skin Contact  Touching MRSA infected skin  Touching drainage from MRSA skin infection  Surface to Skin Contact  Sharing personal items (skin ointments, razors, bar soap, towels)  Touching unclean sports equipment (weights & benches) and practice surfaces (wrestling mats)

14. What increases the risk of MRSA infection?  Close skin contact w/ someone who has MRSA  Skin disease or injury  Lack of good hygiene  Sharing personal items  Sharing sports equipment  Overcrowded living conditions  Lack access to healthcare  Incorrect use or overuse of antibiotics

15. Controlling MRSA  Washing hands frequently!!  Do not touch other people’s skin lesions.  Report potential skin infections to the coach / nurse.  Use a towel between skin and gym equipment.  Do not share clothes, towels, water bottles, or personal hygiene items. No body cosmetic shaving.  Soap shower right after all practices and competitions.  Wash uniforms with soap/hot water, dry in a hot dryer after each use.  Use alcohol-based hand sanitizer when soap and water are not available.

16. Cleaning for MRSA  Athletic areas are critical, including PE.  Maintaining equipment in good repair.  Developing & following routine schedules for cleaning & disinfecting sports equipment.  Clean and disinfect all hard surfaces that may contact skin at least daily with an EPA-approved disinfectant, including benches, weights, workout machines, floor and wall mats, etc. Before and after use is preferred.  Clean locker rooms and shower areas daily.  Keep soap dispensers full – fragrance free, NOT antibiotic soap.  Have separate cleaning mops (preferably micro-fiber) and buckets for athletic areas.

17. MRSA Resources Tacoma-Pierce County Health Department www.tpchd.org/mrsa Washington State Department of Health http://www.doh.wa.gov/Topics/Antibiotics/MRSA.htm Centers for Disease Control and Prevention www.cdc.gov/ncidod/dhqp/ar_mrsa_ca.htm

18. Noroviruses  Noroviruses are a group of single-stranded RNA, nonenveloped viruses that cause acute gastroenteritis in humans.  CDC estimates that 50% of all foodborne outbreaks of gastroenteritis can be attributed to noroviruses  Noroviruses are transmitted through the fecal-oral route, by consumption of fecally contaminated food or water, direct person-to-person spread, or environmental and fomite contamination.  Quaternary compounds are NOT effective against Noroviruses

19. Norovirus  24-48 hour incubation period  Sudden onset vomiting, diarrhea, cramping  Low-grade fever  Symptoms last 1-2 days  Viruses in stool and vomit  Can shed virus for days to 2 weeks after symptom free  Highly contagious (10 viruses can cause illness)  Lives for days on surfaces, where it can be “picked up” by others – at least 7!

20. Animals In Schools

21. Zoonotic Diseases 21  Salmonella  Reptiles  Chicks  Owl Pellets  Psittacosis (parrot fever)  Rabies  West Nile Virus  Hanta Virus  Lice  Classroom Pets  DOH Zoonotic Disease http://www.doh.wa.gov/ehp/ts/ ZOO.HTM http://www.doh.wa.gov/ehp/ts/ ZOO.HTM  http://www.nasphv.org/documentsCompendiaAnimals.html

22. Guidelines for Animals in Schools Health and Safety Guide K-12 Schools in Washington, Second Edition  Section O: Animals in Schools  Appendix F: Animals in the Classroom NASPHV Compendium of Measures to Prevent Disease Associated with Animals in Public Settings, 2009 -  Appendix D: Guidelines for Animals in School and Childcare Settings Animals are effective and valuable teaching aids, but safeguards are required to reduce the risk for infection and injury. www.nasphv.org/Documents/AnimalsInPublicSettings.pdf

23. Reduce the potential for injuries Reduce disease transmission Increase the probability that incidents / problems identified with animal contact settings will be 1) reported 2) documented 3) handled appropriately Public contact with animals should occur in settings where measures are in place to:

24. Injuries Injuries associated with animals in public settings:  Bites  Kicks  Falls  Scratches  Stings  Crushing of the hands or feet  Being pinned between the animal and a fixed object. *Extreme example: a Kansas teenager was killed while posing for her senior year photo with a tiger being restrained by its handler at an animal sanctuary

25.  Enteric diseases  Allergies  Injuries  Rabies exposures  Infections Health Risks Associated with Animal Contact

26. What’s happening in class?  Classroom pets  Animal visits  Dissection  owl pellets  road kill  Habitat projects  reptiles  amphibians  fish

27. Classroom “dissections” Road Kill Owl pellets Where’s the gloves? Biohazard protections?

28. Playground visitors

29. Chicks and Ducklings  Chicks and ducklings are inappropriate in schools due to high risk of salmonellosis and campylobacteriosis

30. Reptiles and Amphibians  All reptiles and amphibians can carry salmonella  Students under 12 should be prohibited from handling reptiles and amphibians  No turtles under 4 inches in length are allowed in schools  Discourage children from “kissing” or having them in close contact with their faces  Instruct any child handling them to wash their hands immediately afterwards

31. Parrots, Parakeets, Cockatiels, and Macaws Psittacosis (Parrot Fever)  Infection that can cause pneumonia and other serious health problems  Inhalation of dust from dried droppings and secretions, and dust from feathers  Pet birds should never  Brought to school showing signs of illness  Be allowed to fly free in a classroom  Be handled by children  Their waste must be contained in their clean cages  Birds permanently housed on school property in cages should be treated prophylactically for psittacosis for 45 days prior to entering the premises.

32. School Guidelines  Educate students of all ages in proper hand washing techniques after handling animals.  Have a school policy and procedures on animals. PROPER HAND WASHING !!

33. Contact with rabid mammals can expose persons to rabies virus through:  bites  contamination of mucous membranes (splashes, rubbing eyes, etc.)  scratches, wounds contaminated with infected saliva or nervous tissue. * Note: Although no human rabies deaths caused by animal contact in public exhibits have been recorded, multiple rabies exposures have occurred, requiring extensive public health investigation and medical follow-up ($$$$ and worry and pain – Montana elementary school and the dead bat.) Rabies

34. Rabies School Guidelines  Stray animals should never be brought onto school campuses because the health and vaccination status of these animals is seldom known.  Verified rabies vaccination is required for all dogs, cats, and ferrets which are brought onto school property for instructional purposes.  Puppies and kittens under 3 months and not vaccinated against rabies should not be handled by children or at school.

35. Bugs at School ?  Head lice  Stinging insects  Ticks  Poisonous spiders

36. Head Lice  Parasitic insect adapted to living mainly on the scalp and neck hairs.  Not a health hazard or responsible for the spread of any disease.  Not a sign of uncleanliness.  Transmitted by direct contact with live louse through head-to-head contact (mostly) or through contact with personal articles such as hats or combs.  “No Nit” policies – not recommended.

37. Stinging Insects Wasps and Hornets  Beneficial insects – eat insects that damage shade trees and crops and house flies  Nests can be in trees, on buildings or underground, depending on species  Attracted to sugary fluids & drinks (sodas) at picnics or in garbage cans

38. Ticks  Hard Ticks: Lyme Disease, Rocky Mountain Spotted Fever  Open forest, sagebrush, grasslands, woodland edges  Soft Ticks: Tick-borne relapsing fever – most common tick-borne disease in WA.  Avoid getting bitten  Wear long pants and a long-sleeved shirt. Tuck your pant legs into socks or boots and shirt into pants  Use tick repellent when necessary, and carefully follow instructions on the label  Buddy Checks

39. Spiders Black Widow  Common in eastern WA, some on the western side.  Undisturbed piles of wood, outbuildings, rock piles, hay bales, crawl spaces.  Shy, bite reluctantly – usually when provoked. Hobo Spider  Mature spiders common from mid-summer through fall  Uncommon above basements or ground level  Build funnel-shaped webs in dark, moist areas, wood piles, crawl spaces, perimeters of homes  Bite  Painless  Blister in 15-35 hours  Tissue necrosis  Seek medical care

40. West Nile Virus West Nile Virus in Washington 2009 WNV-Positive Humans: 32 – 1 death WNV-Positive Horses: 67 WNV-Positive Birds: 22 WNV-Positive Mosquito Pools: 341

41. Eliminate mosquito larval habitats  For lined or contained water bodies  Remove or circulate the water  Larvae eating fish  Mosquito “dunks” or “bits” – larvicide Bacillus thuringiensis israelensis (Bti) – follow directions  For water bodies that can reach other water bodies  Retention pond with outlet, ditches, pond with stream  Licensed pesticide applicator needed to apply larvicides  May need an NPDES permit  Contact DOH Zoonotic Disease Program at (360) 236-3385 or zd@doh.wa.gov for more information Mosquito Control

42. Eliminate Standing Water

43. Online Dead Bird Reporting System  Report any dead crows, jays, or raptors to the WA DOH’s online dead bird reporting website http://www.doh.wa.gov/ehp/ts/Zoo/WNV/reportdeadbird.html

44. Hanta Virus  Sin Nombre virus, Hantavirus Pulmonary Syndrome  Deer mice in North America  WA ST: ~14% of 1,100 tested deer mice  ~6 inches nose to tail, grayish to light brown on top  Large ears, white belly, furry tail  Virus in urine, saliva, droppings  Exposure through inhaling contaminated dust, droppings, dried urine  Pets, snakes, predators not infected, can’t spread  No evidence for person-to-person spread  Average 1-5 cases/year in WA ST  Suspect all rodent contaminated areas

45. Cleaning up Rodent Infested Areas  Wear rubber, latex, vinyl, or nitrile gloves.  Do not stir up dust by vacuuming, sweeping, etc.  Thoroughly wet contaminated areas with 10% bleach.  Soak for 10 minutes, remove soaked materials.  Mop/sponge area with bleach solution.  Steam clean/shampoo upholstered materials/carpet.  Soak dead rodents with bleach solution, double bag with all cleaning materials, dispose.  Clean/Disinfect gloves before removal.  Wash hands thoroughly after removing gloves.

46. Safe And Effective Cleaning

47. Why consider “green cleaning”?  Better for student health  Better for custodial health  Better for the environment  “Green” products “reduce the health and environmental impacts compared to similar products and services used for the same purpose.” Executive Order 13423

48. Hazardous for Human Health  Asthma & respiratory ailments  Quats  Bleach  Fragrances  Eye, nose, throat, and skin irritation  Fatigue  Reproductive disorders  Burns  Major organ damage  Cancer  Dizziness/Headaches

49. Cleaning Supplies Study  13 large CA school districts  “Airborne brew of chemicals”  21 cleaners tested – released  6 chemicals known to cause asthma  11 contaminants known, probable, or possible cancer-causing in humans  hundreds of compounds with little or no hazard information  Green cleaners released a lower overall number of measurable air contaminants, particularly lower levels of VOCs  Environmental Working Group, School Cleaning Supplies, November 2009 http://www.ewg.org/files/2009/10/school- cleaners/EWGschoolcleaningsupplies.pdf

50. Elements of a Cleaning Program  Understand the unique requirements of your buildings.  Continuously examine the entire cleaning process and identifying areas needing improvement.  Program should be designed to have a positive impact on cleanliness and the health and performance of occupants.

51. Review and update cleaning and sanitizing policies  Clean and disinfect regularly touched surfaces regularly.  Use EPA registered cleaner/disinfectants for influenza.  Review safe chemical management policies.  Ensure that products are being used as directed on the label by trained professionals.

52. Selecting Products  Preferred products  Disinfectants - EPA approved for the intended purpose  Third Party Certified  Green Seal  Neutral pH  No phosphates, dye, fragrance, butyl cellusolve, nonylphenol ethoxylate  Meets or exceeds the California VOC requirements  Low hazard rating  Use only when and where needed  Concentrated (reduce packaging)

53. Copyright 2008, Healthy Schools Network Inc. 53 Less-toxic Ingredients Use these: Instead of these:  Alcohol ethoxylates Nonylphenol ethoxylates or and/or polyglucosides alkylphenol ethoxylates  Hydrogen peroxide Harsh acids/alkali builders  Corn based esters Petroleum distillates  Vegetable derived Petroleum derived surfactants surfactants  Fruit derived solvents Petroleum solvents or harsh and acids acids

54. Products of Most Concern  Aerosol Sprays  Acid Toilet Cleaner  Degreasers/Solvents  Disinfectants  Metal Polish  Graffiti/Paint Removers  Floor Strippers

55. Special Concerns  Cake toilet deodorizers – paradicholorobenzene  Teratogen, Carcinogen, 100% volatile  D-Limonene: Citrus & Terpene Solvents  Sensitizer, Neurotoxin, Irritant  Nano Technology (nano-silver)  “Air Fresheners”  Anti-microbial soaps  Triclosan / Triclocarban  Possible endocrine disrupters  Bacterial resistance  Killing good bacteria  What about the viruses?  Ubiquitous in the environment

56. Good Cleaning Practices  Prevention  Walk-off mats  High efficient vacuum filters  No chemicals brought in by staff/parents  Automatic dilution  Avoid aerosols  Spray into cloths  Read the MSDS  No upholstered furniture  Clutter control  Control food in classrooms – including snack storage  Nitrile or vinyl gloves, not latex  Microfiber cloths

57. Infection Control

58.  Persons with flu symptoms should stay home from the first sign of symptoms until fever free for 24 hours without fever reducing medication.  Cover nose and mouth when coughing or sneezing.  Wash hands with soap and water. Use alcohol-based hand sanitizers if you can’t wash.  Try to maintain spatial separation of at least 3 feet from others, if possible.

59. Flu viruses on surfaces  Flu types A & B survive up to 48 hours on hard, nonporous surfaces – stainless steel, plastic.  Survive less than 12 hours on porous surfaces – cloth, paper, tissues.  Up to 72 hours on wet surfaces.  Flu virus survives for about 5 minutes on the hands after transfer from an environmental surface.

60. EPA Design for the Environments (DfE) pilot project for disinfectants DfE logo on an EPA-authorized antimicrobial pesticide label:  Least-hazardous classes  Unlikely carcinogenic or endocrine disruptor properties  Unlikely to cause developmental, reproductive, mutagenic, or neurotoxicity issues  Mixtures, including inert ingredients, have been reviewed and are accepted by EPA  Does not require the use of Agency-mandated personal protective equipment  No unresolved or unreasonable adverse effects reported  No unresolved efficacy

61. Cleaning and Disinfecting When surfaces are not visibly dirty  Clean the surface with a commercial product that is both a detergent (cleans) and a disinfectant (kills germs). These products can be used when surfaces are not visibly dirty. When surfaces are visibly dirty  Wash the surface with a general household cleaner (soap or detergent), rinse with water and follow with a disinfectant. This method should be used for visibly dirty surfaces.

62. Cleaning and Disinfecting  Keep hard surfaces like countertops, tabletops, desktops and bathroom surfaces clean and disinfected daily.  Use disposable sanitizer cloths to wipe electronic items that are touched often.

63. Cleaning and Disinfecting  Keep surfaces touched by more than one person clean and disinfected daily.  Door handles  Faucets  Keyboards  Railings  Phones  Clean and disinfect surfaces where someone has been ill – coughing and sneezing.

64. Restrooms  Clean and disinfect bathroom surfaces at least daily.  Keep soap and paper towel dispensers full.  IPC (2006) 416.5: “Tempered (85 o -110 o F) water shall be delivered from public hand-washing facilities through an approved water temperature limiting device that conforms to ASSE 1070.”  WAC 246-366-060: “Adequate, conveniently located toilet and handwashing facilities shall be provided for students and employees.  Hot water at a maximum of 120 o F.  Hand-operated, self-closing faucets must deliver at least 10 seconds of water at a time, (15 seconds in food service).

65. Bleach  Disinfectant, NOT a cleaner.  Always clean with soap/detergent first.  Make a fresh solution daily.  Disinfecting:  General: 1 T / quart water  Food contact surfaces: ~1t / quart of water  3-5 minutes wet contact time  Noro virus/vomit: 10% bleach solution (after cleaning!)  10 minute wet contact time  Never mix with ammonia or acid products  Use gloves, ventilation, eye protection

66. Microfiber Mop Systems  Reduce chemical use (~50 – 75%)  Cut water use (~ 90%) ~100,000 gallons/year  Reduce injuries (chemical exposure, back strain, accidents)  Effective (reduce dirt, avoid cross-contamination)

67. Fragrance Free Soap  Mild Chemically  Biodegradable  Green Seal Certified  Fragrances have no hygienic function  Dispensers in all UW campus bathrooms  Avoid antibacterial soaps

68. Hand Sanitizers  Not a substitute for hand washing  Not effective on dirty hands  At least 60% alcohol (70%+ more effective)  Fragrance free  We do NOT recommend Benzalkonium chloride or triclosan based hand sanitizers.  Supervision required:  Flammable – fire department requirements  Alcohol poisoning  Do we need it on every desk? High VOC levels  Read the label – are kids/teachers bringing in the appropriate kind?  No children < 1 year old  Hands should stay wet for 10-15 seconds

69. Resources  The Quick & Easy Guide to Green Cleaning in Schools http://www.healthyschoolscampaign.org/programs/gcs/thankssu.php  Cleaning For Healthy Schools Toolkit http://www.cleaningforhealthyschools.org/  Cleaning Supplies Can Contaminate Classroom Air http://www.ewg.org/schoolcleaningsupplies/overview  Guide to Green Cleaning: Healthier Cleaning & Maintenance, Practices and Products for Schools www.healthyschools.org  Informed Green Solutions http://www.informedgreensolutions.org/publications/Asthmagens_in_Institutio nal_Cleaning.html  Characteristics of Selected Disinfectants http://www.cfsph.iastate.edu/BRM/resources/Disinfectants/Characteristi csSelectedDisinfectants.pdf

70. Nancy P. Bernard, MPH Program Manager, IAQ / School EH&S Office of Environmental Health, Safety, & Toxicology Washington State Department of Health PO Box 47825, Olympia, WA 98504-7825 (360) 236-3072, fax (360) 236-2261 Nancy.Bernard@doh.wa.gov 70 Join my list serve for timely information! www.doh.wa.gov/ehp/ts/school Resources available on my web site.