1. Infectious Disease in Out of Home Child Care Jonathan B. Kotch, MD, MPH, FAAP, Director National Training Institute for Child Care Health Consultants The University of North Carolina at Chapel Hill Part II: Illnesses Transmitted by the Fecal-Oral Route

2. Objectives for Part II At the end of this training learners will be able to: Describe the causes and consequences of infectious diseases in child care transmitted by the fecal-oral route, and Identify modes of transmission and prevention of infectious diseases in child care transmitted by the fecal-oral route.

3. Fecal-oral Transmission  Gastroenteritis  Infections that may occur without gastroenteritis  Hepatitis A  Polio  Paratyphoid and typhoid fever (Salmonella)  Hemolytic-uremic syndrome (E. coli O157:H7)

4. Enteric Pathogens (Churchill & Pickering, 1997)  Parasites  Giardia  Cryptosporidium  Viruses  Astrovirus  Calicivirus  Enteric Adenovirus  Enteroviruses (polio)  Hepatitis A  Rotavirus  Bacteria  Shigella  Salmonella  Campylobacter  E. coli 0157:H7  Other E. coli  Yersinia  Clostridium difficile

5. Norovirus Associated with outbreaks on cruise ships, hospitals, hotels, restaurants, schools, camps, and college campuses Second most common cause of viral gastroenteritis in child care settings in North Carolina More susceptible to bleach than to quaternary ammonium and phenolic disinfectants

6. Where Are the Germs? Laborde et al., 1994 Hands; staff and child Hard toys Classroom sinks and faucets Laborde et al., 1993 Hands (RR=2.0) Moist sites (1.1<RR<1.6)

7. Pathogen Transmission (Jiang et al., 1998) Transmission within the center Diapers, chairs, floors, toys, doorknobs contaminated by researchers Within 1-2 hours hands, toy balls, window, walker, cabinets, doors contaminated Transmission to homes Next day, car seats, toys, high chairs, cribs, diaper changing areas, rims of tubs contaminated

8. Exclusion Criteria 1 Inexplicable bloody stools Abdominal pain for more than 2 hours Intermittent pain associated with fever or other signs and symptoms Vomiting Diarrhea Hepatitis A 1 Courtesy of Steve Shuman

9. Sanitation and Hygiene Diapering technique Hand hygiene (soap and water is best; waterless alcohol product second) Sanitary food preparation and service Physical environment Separation of food services and diapering Sanitary disposal of waste #, location and design of sinks and toilets

10. Caregiver Training Handwashing Black et al., 1981 Bartlett et al., 1988 Handwashing and sanitation (Kotch et al., 1994) Respiratory -- Not Severe diarrhea Newer centers, RR=3.1 Younger children, RR=1.97

11. Handwashing Study Conclusions (Kotch et al., 1994) Handwashing effective for severe diarrhea, not for URI Effect modified by age of child and length of center operation Written guidelines associated with newer centers

12. Importance of the Physical Environment Physical barriers limited compliance Access to sink in room Distance to sink from changing table Need for sanitary toileting facilities

13. More Recent Randomized, Controlled Studies of Handwashing Uhari and Mottonen, 1999. Significantly fewer child and staff illnesses Fewer antibiotic prescriptions Fewer parental absences from work Roberts, et al., 2000. 50% reduction in child diarrheal illness in children over 24 months of age

14. Immunizations Less common for gastroenteritis but still important The first generation rotavirus immunization had to be pulled from the market but a new and improved version is now available and recommended by the Advisory Committee on Immunization Practices (ACIP) Hepatitis A immunization is now recommended for all children at 12 mo. of age Poliovirus, which causes “ juvenile paralysis ”, is also in the fecal-oral category.

16. Acknowledgement Supported by Grant #U93-MC00003 from the Maternal and Child Health Bureau of the Health Resources and Services Administration, U.S. Department of Health and Human Services. END OF PART II