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

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

Communicable (Infectious) Diseases In Schools

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 ousDiseaseControlGuide pdf

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

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).

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.

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

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

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)

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%

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

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)

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

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.

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.

MRSA Resources Tacoma-Pierce County Health Department Washington State Department of Health Centers for Disease Control and Prevention

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

Norovirus  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!

Animals In Schools

Zoonotic Diseases 21  Salmonella  Reptiles  Chicks  Owl Pellets  Psittacosis (parrot fever)  Rabies  West Nile Virus  Hanta Virus  Lice  Classroom Pets  DOH Zoonotic Disease ZOO.HTM ZOO.HTM 

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,  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.

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:

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

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

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

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

Playground visitors

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

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

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.

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 !!

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

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.

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

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.

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

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

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 hours  Tissue necrosis  Seek medical care

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

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) or for more information Mosquito Control

Eliminate Standing Water

Online Dead Bird Reporting System  Report any dead crows, jays, or raptors to the WA DOH’s online dead bird reporting website

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

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.

Safe And Effective Cleaning

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

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

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 cleaners/EWGschoolcleaningsupplies.pdf

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.

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.

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)

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

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

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

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

Infection Control

 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.

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.

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

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.

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.

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.

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 : “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).

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

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)

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

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 seconds

Resources  The Quick & Easy Guide to Green Cleaning in Schools  Cleaning For Healthy Schools Toolkit  Cleaning Supplies Can Contaminate Classroom Air  Guide to Green Cleaning: Healthier Cleaning & Maintenance, Practices and Products for Schools  Informed Green Solutions nal_Cleaning.html  Characteristics of Selected Disinfectants csSelectedDisinfectants.pdf

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 (360) , fax (360) Join my list serve for timely information! Resources available on my web site.