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 – 12th grade
 IAQ
 Best Practices Manual
 Asthma Plan implementation - reducing triggers in schools
 Investigations
 “Green Cleaning”
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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 2004
http://www.k12.wa.us/healthservices/pubdocs/Infecti
ousDiseaseControlGuide3-11-04.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
(Methicillin-Resistant Staphylococcus aureus)
 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!
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
Source: LA County Health Department
Source: Mark Grubb, MD
 Boil
 Abscess
Source: CDC
Source: CDC
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
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
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
 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!
Animals
In
Schools
Zoonotic
Diseases
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.nasphv.org/documentsCompendiaAnimals.html
21
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
Public contact with animals should occur
in settings where measures are in place
to:
• 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
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
Health Risks Associated with Animal Contact
Enteric diseases
Allergies
Injuries
Rabies exposures
Infections
What’s happening in class?
 Classroom pets
 Animal visits
 Dissection
 owl pellets
 road kill
 Habitat projects
 reptiles
 amphibians
 fish
Classroom “dissections”
Owl pellets
Where’s the gloves?
Biohazard protections?
Road Kill
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
PROPER HAND
WASHING!!
 Educate students of all ages in proper
hand washing techniques after
handling animals.
 Have a school policy and
procedures on animals.
Rabies
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
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 ?


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
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 15-35 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
Mosquito Control
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
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
http://www.doh.wa.gov/ehp/ts/Zoo/WNV/reportdeadbird.html
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 2009
http://www.ewg.org/files/2009/10/schoolcleaners/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)
Less-toxic Ingredients
Use these:
 Alcohol ethoxylates
and/or polyglucosides
 Hydrogen peroxide
 Corn based esters
 Vegetable derived
surfactants
 Fruit derived solvents
and acids
Instead of these:
Nonylphenol ethoxylates or
alkylphenol ethoxylates
Harsh acids/alkali builders
Petroleum distillates
Petroleum derived surfactants
Petroleum solvents or harsh
acids
Copyright 2008, Healthy Schools Network
Inc.
53
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
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 (85o-110oF) 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 120oF.
 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 10-15 seconds
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
Join my list serve for timely information!
www.doh.wa.gov/ehp/ts/school
Resources available on my web site.
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
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