COMMENTS TO THE CONSULTATION DRAFT OF STAYING HEALTHY IN EARLY CHILDHOOD EDUCATION AND CARE
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Issue
The person with the
infection spreads the
germ into the
environment
Germs can spread in a
number of ways:
coughing and
sneezing, touching
infectious body fluids
or secretions, touching
contaminated
surfaces, animals,
food.
A sneeze can spread
droplets as far as two
metres away. The
droplets may be
breathed in directly by
another person, or
another person may
touch a surface
contaminated with the
droplets, then touch
their mouth, eyes or
nose.
Comment
This description of the chain of infection works well for diseases that are spread by contact with a contaminated
environment (e.g. gastrointestinal infections) but does not work so well for diseases that are spread directly from one
person to another without passing through the environment (eg scabies, head lice, respiratory droplets deposited
directly onto another person’s mucous membranes).
This section should be re-written to reflect established modes of transmission, i.e. contact, droplet, airborne, vector
borne and food borne modes of transmission.
This section should distinguish between infectious diseases that are spread by droplet transmission (e.g. influenza)
and those spread by airborne transmission (e.g. measles and chickenpox).
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Germs can spread ….
if a person touches
infectious body fluid,
then puts their hands
in their mouth, or if
they prepare and eat
food without first
washing their hands.
Main ways to prevent
infection
Germs can be present
on the skin, hair,
feathers and scales of
animals and in their
faeces and urine
Antibacterial soaps
Cloth towels cannot
be used without prior
laundering due to the
risk of
recontaminating or
cross-contaminating
hands
Factors that may
contribute to
dermatitis include….:
Pertussis
Include, ‘through non-intact skin’.
This section should include information on design features at the childcare facility that promote infection prevention
and control, e.g. appropriate number and placement of hand washing basins (including in outdoor play areas and at
nappy changing stations), use of impervious surfaces and materials that readily cleaned, well ventilated spaces, etc.
This should include ‘mouth and saliva’.
It may be useful to state that these soaps can cause skin irritation in some people.
This statement should clarify that cloth towels are not to be shared between people.
Add, ‘using some types of disposable gloves, particularly by susceptible people’.
This should include that pertussis is a serious risk to infants and can cause life threatening illness in this age group
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Measles
This should include that encephalitis and subacute sclerosing panencephalitis are serious complications of measles
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Mumps
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Measles/varicella
spreads by droplets
Wearing gloves does
not replace the need to
wash your hands, and
you should ensure you
wash your hands
before putting gloves
on and after taking
them off.
Latex gloves are
preferable2
This should include that orchitis can occur in post-pubertal males (because of the increasing number of males
working in childcare)
‘Droplets’ should read ‘airborne droplets’ to distinguish between droplet transmission and airborne transmission
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This should refer to hand hygiene rather than hand washing.
Latex gloves provide a high level of protection in healthcare settings, however there are concerns about the use of
latex gloves and associated latex allergy in childcare settings, as latex allergy has been reported in children other than
those with recognised risk factors such as spina bifida ( Ref: Shield S et al 1992, ‘Prevalence of latex sensitivity in
children evaluated for inhalant allergy’, Allergy Proc, 13(3):129-131).
Children attending childcare settings may be at significant risk of exposure to latex and acquiring latex allergy
because:
 childcare services are more likely to use cheaper, powdered supermarket brands of latex gloves rather than
the more expensive low protein, powder free medical grade examination gloves used in healthcare
 children may be regularly exposed to latex, including via their mucous membranes (e.g. when staff wear
powered latex gloves to prepare and handle food and to change a child’s nappy, from inhaling latex powder
when staff remove powdered gloves near children, and from touching surfaces that are contaminated with
latex powder such as nappy change mats).
Some authorities are suggesting that latex gloves should not be used in childcare because of latex allergy risks to
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children (and staff) (Ref: University of NSW 2003 section 16.4
http://www.sphcm.med.unsw.edu.au/SPHCMWeb.nsf/resources/CCModelPolicies.pdf/$file/CCModelPolicies.pdf)
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Vinyl gloves are not
recommended
Vinyl gloves provide a lower level of protection than latex gloves for healthcare workers in healthcare settings,
however childcare care workers are at lower risk of contact with blood and body substances (including frequency,
duration and volume of contact), and therefore appropriate vinyl gloves may be adequate in this setting and prevent
the risk of latex allergy among staff and children from the use of non-medical examination grade powdered latex
gloves.
This section should include that polyethylene gloves are not recommended for contact with blood and body fluids,
i.e. plastic food handling gloves.
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Powder-free gloves
are preferable,
because powdered
gloves may contribute
to latex allergies
When changing a
nappy, it is important
to wash your hands
before you put on
gloves, so that when
you have finished
changing the child,
you can remove the
dirty gloves and dress
the child with your
clean hands, without
needing to wash your
This statement should stress that powdered latex gloves must not be used because of the increased risk of latex
allergy for both staff and children.
This section should be amended to state that workers are to perform hand hygiene using alcohol based hand rub after
removing gloves and before dressing the child, because hands may be accidentally contaminated during glove
removal or due to a breach of the glove’s integrity (PPE failure).
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hands in between.
This also means that
bottles are cleaned
less often and there is
a higher risk of germs
growing in the stale
detergent.
Panadol
High-risk groups
include elderly people,
people who are
diabetic, and people
who are alcoholic
This statement should include the following points:
 Germs can be dispersed into the environment by the spray mechanism
 The trigger mechanism on the spray bottle cannot be cleaned and dried properly thereby encouraging
bacterial growth
 The use of chemicals in spray bottles can cause health and safety issues such as respiratory irritation and
sensitisation.
Brand names of medications (i.e. Panadol) should not be used.
This statement should also include pregnant women, given the predominance of women of reproductive age working
in childcare.
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Measles—highly
infectious virus spread
by droplets
‘Droplets’ should read ‘airborne droplets’ to distinguish between airborne transmission and droplet transmission.
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If cloth towels are
used they must be
laundered before they
are reused due to the
risk of contaminating
clean hands.
How to wash hands
with soap and water
This statement should clarify that cloth towels are not to be shared between people.
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How to clean hands
with hand rub
This section should include a statement about how rings can prevent proper hand hygiene and harbour bacteria, and
should be removed or kept to a minimum. (Ref: Trick et al (2003), ‘Impact of Ring Wearing on Hand Contamination
and Comparison of Hand Hygiene Agents in a Hospital’, Clin Infect Dis, 36 (11): 1383-1390.
This should specify the minimum percentage of ethanol of the ABHR (some brands available on the market have <
70v/v ethanol).
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When there is a
chance you may come
in contact with body
fluids, including
faeces, vomit or
blood’; ‘when
cleaning faeces, blood
or vomit, including
when it is on clothes’;
and ‘If there is a
chance that you may
come in contact with
faeces, vomit or
blood, you should
wear disposable
gloves.’
When preparing
bleach solutions for
cleaning
These statements should include urine, because childcare workers are at high risk of exposure to cytomegalovirus,
and this is of particular concern given the predominance of women of reproductive age working in childcare (Ref:
Billette de Villemeur et al 2011, ‘Occupational risk for cytomegalovirus but not parvovirus B19 in childcare
personnel on France’, Journal of Infection, 63:457-467).
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Disposable gloves
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An area should be
specifically set aside
for changing nappies.
Table 8 Nappy
changing procedure
If faeces spill onto the
change surface, clean
This section should stress that disposable gloves are not to be re-used, for example by washing gloved hands in
between nappy changes, or by laundering gloves for re-use.
Add, ‘This area should have ready access to a hand washing basin’.
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Bleach is not a cleaning agent. This statement should read, ‘When preparing bleach or other chemical solutions for
cleaning and disinfection’.
This section should recommend that hand hygiene using alcohol based hand rub should be included between
removing gloves and dressing the child.
Include urine because of the risk of exposure to cytomegalovirus.
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the surface with
detergent and warm
water and leave it to
dry.
Wear gloves when
handling and
preparing bleach.
Dispose of dirty
tissues immediately.
Staff clothing or overclothing should be
washed daily in hot
water.
Include, ‘use safety eyewear if there is a risk of splashes of bleach to the face, for example if decanting bleach from
concentrated solutions in primary containers’.
Include, ‘into an appropriate receptacle such as a lined rubbish bin’.
Most staff will wash their work clothes at home, and unless they are provided with a uniform then this clothing will
be their personal clothing. Recommending a hot wash means that staff will experience additional expense and time
associated with washing these clothes as this will require a separate was to other clothes washed in cold water. A hot
wash uses significantly more energy and may damage some fabrics over time. The dilution effect of a machine wash
combined with detergent should be sufficient to remove any infectious agents. Unless there is good evidence to
support a hot wash, this recommendation should be removed.
Include a statement recommending that hand hygiene should be performed using alcohol based hand rub between
removing gloves and dressing the child.
Remove your gloves.
Dress the child and
wash the child’s hands
and your hands
Start a ‘Toys to wash’ Include, ‘or if a toy has been placed in a child’s mouth’.
box and place toys in
it during the day if
you see a child sneeze
on a toy, or if the toy
has been used by a
child who is unwell.
Adults and children
Replace with, ‘Adults and children must perform hand hygiene by washing their hands with soap and water or
must wash their hands applying hand rub after playing in the sandpit’.
with soap and water or
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a hand rub after
playing in the sandpit.
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Animals
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Workplace health and
safety Acts in
Australian states and
territories place a duty
of care on employers to
ensure workplace
health and safety
Every education and
care service needs to
ensure it has effective
infection control
policies and procedures
in place, including
strategies to prevent
exposure to infectious
diseases and minimise
risks from chemicals,
and processes to ensure
that infection control
measures are carried
out.
Employers of educators
and other staff have an
obligation to minimise
the risk to all staff from
exposure to diseases
that are preventable by
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Include a sentence about ensuring the hygienic cleaning of fish tanks (to prevent exposure to fish zoonoses such as
M. marinum).
This should reflect the wording of the new harmonised WHS legislation that is being enacted by the states/territories.
For example state, ‘Work health and safety Acts in Australian states and territories place a duty of care on persons
conducting a business or undertaking to ensure the health and safety of workers and others so far as is reasonably
practicable’.
Replace with, ‘Every education and care service needs to ensure that infection risks are prevented or minimised so far as
is reasonably practicable, including strategies to prevent or minimise exposure to infectious diseases and chemicals used
to manage infection risks, and processes to ensure that infection control measures are implemented and maintained’.
Include, ‘Infections acquired by staff that are reliably attributable to their work must be notified to the workplace health
and safety regulator in their state or territory’.
Replace with, ‘Persons conducting a business or undertaking in education and childcare services have a duty of care to
ensure, so far as reasonably practicable, the work health and safety of educators and other staff at risk of exposure to
diseases that are preventable by vaccination’.
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vaccination.
being restricted to
working with children
over 12 months old
not being able to work
at all during outbreaks
of bacterial diseases
Employers should:
Recommended
vaccinations for
educators and other
staff
pertussis—this is
especially important for
educators and other
staff caring for the
youngest children who
are not fully vaccinated
Some vaccinations are
not recommended
during pregnancy, or if
a person has a disease
or is undergoing
treatment that affects
Include, ‘if they have not received an adult pertussis booster (dTpa)’.
Remove ‘bacterial’ because staff may also be removed or have work restrictions placed on them if they are nonimmune and there are outbreaks of viral diseases such as measles, varicella and hepatitis A.
Include, ‘manage the work health and safety risks of workers who refuse vaccination, who cannot be vaccinated due
to medical contraindications or who do not respond to vaccination (e.g. following rubella vaccination). These
workers remain at risk and their risk should be managed in other ways including by pre-exposure strategies such as
safe work practices and appropriate work placement (e.g. don’t place workers who have not had an adult pertussis
booster(dTpa) to care for infants), and post-exposure strategies such as work adjustments/restrictions/placements (eg
restricting a non-immune worker during a measles outbreak) and post-exposure prophylaxis/chemoprophylaxis(e.g.
post-exposure hepatitis A immunoglobulin/vaccine).
If the guidance is to be used by facilities providing care for older children (e.g. school-based services), then it should
clarify that hepatitis A vaccination is only required for childcare workers and not those caring for older children
unless other risk factors exist (e.g. working in a remote Indigenous community).
This sentence needs to clarify that staff require an adult pertussis booster (dTpa) in addition to their childhood
vaccination/infection because immunity from childhood immunisation/infection wanes over time.
This statement should clarify that influenza vaccination is recommended for pregnant women in who are going to be
in their second and third trimester of pregnancy during the influenza season.
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their immune system.
For example, an
educator who usually
works in the babies
room becomes pregnant,
and she is not immune
to CMV.
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Chickenpox
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The disease is more
severe in adults and in
people of any age who
have impaired
immunity.
Responsibilities of
educators and other
staff
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This statement incorrectly implies that women become immune to CMV from previous infection, and that only
seronegative women should be relocated to a lower risk area. Pre-conceptual CMV immunity reduces the risk of
congenital infection but the protection is incomplete. Intrauterine transmission and symptomatic congenital infection
from re-infection can occur in women who are seropositive prior to pregnancy. Because congenital infection can
result from maternal re-infection, avoiding exposure to CMV through behavioural changes and work adjustments
should be beneficial for seropositive as well as seronegative women. (Ref: Ross et al. (2010), ‘Cytomegalovirus reinfections in healthy seroimmune women’, JID, 201(1 Feb): 386-389; Boppana et al (2001), ‘Intrauterine
transmission of cytomegalovirus to infants of women with pre-conceptual immunity’, N Eng J Med, 344(18):13661371; Wang et al (2011), ‘Attribution of congenital cytomegalovirus infection to primary versus non-primary
maternal infection’, CID, 52(15 Jan):e11-e15).
Include in this section, ‘Anyone who works with children and who has not previously been infected with chickenpox
should be immunised, or be certain that they are immune to chickenpox by having a blood test’.
Include in this section ‘and can cause serious complications such as pneumonia and encephalitis’.
Include in this section, ‘Ensure non-immune staff are vaccinated. Protect non-immune staff if cases of chickenpox
occur at the facility, for example by arranging vaccination or immunoglobulin if advised by a medical practitioner, or
removing non-immune staff from child contact during the outbreak if advised by the public health unit’.
Controlling the spread
of infection
Chickenpox
Include in this section, ‘Discuss with the public health staff who in the education and care service might need preventive
treatment and who should be excluded from care’.
The fact sheet should also discuss the management of staff with shingles (and children with childhood shingles).
Vaccination after
exposure can usually
prevent a person
getting symptoms of
Include ‘Non-immune exposed staff should be referred promptly to their doctor for advice about vaccination. Parents
who are non-immune or whose children are non-immune should be advised to seek medical advice’.
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chickenpox if the
vaccine is given within
3 days of exposure, and
may prevent symptoms
when given up to five
days after exposure.
Avoid contact between
the person who is ill,
and children or frail
and elderly people,
until the person is
feeling well.
Cytomegalovirus
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Description
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This risk is highest
during the first half of
the pregnancy and in
women who have not
been infected before.
During initial infection
or reactivation
Responsibilities of
educators and other
staff
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Include, ‘and pregnant women’.
If the guidance is to be used by facilities providing care for older children (e.g. school-based services), then it should
clarify that CMV is primarily an occupational risk for those caring for pre-school aged children but that exposure
may occur in some at-risk settings involving older children such as special needs.
This section should include a statement that CMV re-infection with a different strain of CMV can occur in a previously
infected person (note: a prevailing misconception exists that primary CMV infection provides complete protection against
re-infection).
Add, ‘However re-infection with intrauterine transmission and congenital infection can occur in a woman who has had
previous CMV infection’. (Ref: Ross et al. (2010), ‘Cytomegalovirus re-infections in healthy seroimmune women’,
JID, 201(1 Feb): 386-389; Boppana et al (2001), ‘Intrauterine transmission of cytomegalovirus to infants of women
with pre-conceptual immunity’, N Eng J Med, 344(18):1366-1371; Wang et al (2011), ‘Attribution of congenital
cytomegalovirus infection to primary versus non-primary maternal infection’, CID, 52(15 Jan):e11-e15).
Replace with, ‘During initial infection, re-infection or reactivation’.
Include, ‘Ensure that staff wear disposable gloves for activities involving contact with urine, such as changing nappies’.
Include, ‘Where practicable, relocate pregnant women to work with older children to reduce the level of contact with urine
and saliva’. (Ref: Pass et al (1990), ‘Increased risk of cytomegalovirus infection among day care centre workers’, Paed
Infect Dis J, 9:465-470; Adler, S (1989), ‘Cytomegalovirus and child day care’, New Eng J Med, 321(19):1290-1296).
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Pregnant women or
women considering
pregnancy who work
with young children
should pay particular
attention to good hand
hygiene after contact
with body secretions,
especially after
changing nappies or
assisting in toilet care.
Description
Responsibilities of
educators and other
staff
Include, ‘Inform staff who are pregnant or considering pregnancy about CMV risks and how to protect against infection’.
Include, ‘and wear disposable gloves for tasks involving contact with urine’.
Include, ‘and should consider working with older children where practicable to reduce to reduce the level of contact with
urine and saliva’.
Include, ‘There is some evidence that acquiring hand, foot and mouth disease during pregnancy may result in
congenital infection in rare cases’. (Ref: Monif GRG & Baker DA eds (2004), Infectious diseases in obstetrics and
gynecology, 5th edn, Parthenon Publishing, Boca Raton.
Include, ‘‘Ensure non-immune staff are vaccinated. Protect non-immune staff if cases of hepatitis A occur at the
facility, for example by referring for vaccination as per medical advice, or removing staff from contact with children
in affected areas of the centre or from contact with children requiring nappy changes or assistance with toileting’.
Include, ‘Ensure staff wear disposable gloves for nappy changes and contact with faeces’.
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Hepatitis B spreads
when infectious body
fluids …
Responsibilities of
educators and other
staff
Replace with ‘Hepatitis B spreads when infectious blood and body fluids …’.
Include, ‘If inappropriately discarded sharps (needles and syringes) are an identified hazard at the facility, ensure
procedures for the safe handling and disposal of sharps and provide training to staff’.
Include, ‘Ensure hepatitis B vaccination for educators and other staff who care for children with intellectual disabilities.
Although the risk is low, seek advice about hepatitis B immunisation if the children are not immunised’.
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131
&
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145
&
Controlling the spread
of infection
Responsibilities of
educators and other
staff
Controlling the spread
of infection
Responsibilities of
educators and other
staff & Controlling the
spread of infection
Children with measles
should be excluded for
at least 4 days after the
appearance of the rash.
Ensure that all staff
have received two
doses of MMR if they
were born after 1966.
Include, ‘Ensure a protocol for managing accidental blood and body fluid exposures and needlestick injuries’.
Include, ‘Ensure good hand hygiene and wear disposable gloves when handling blood and body fluids’.
Include, ‘Ensure a protocol for managing accidental blood and body fluid exposures and needlestick injuries’.
Include, ‘Ensure good hand hygiene and wear disposable gloves when handling blood and body fluids’.
Include, ‘Wear disposable gloves when handling blood and body fluids’
As per comments for hepatitis B and C, include information about ensuring good hand hygiene and wearing disposable
gloves when handling blood and body fluids’
This should state ‘Staff and children with measles…’.
Replace with ‘Ensure that all staff have received two doses of MMR if they were born during or since 1966.’ (Ref: The
Australian Immunisation Handbook, 9th edn (2008)
http://www.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook-measles)
Include, ‘Manage the risk to staff who are not immune, for example by restricting them from the facility during an
outbreak if advised by the public health unit’.
Include, ‘Ensure that all staff have received two doses of MMR if they were born during or since 1966.’ (Ref: The
Responsibilities of
Australian Immunisation Handbook, 9th edn (2008)
educators and other
staff & Controlling the http://www.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook-measles)’.
spread of infection
Responsibilities of
educators and other
Include, ‘Ensure that all staff have received two doses of MMR if they were born during or since 1966.’ (Ref: The
Australian Immunisation Handbook, 9th edn (2008)
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staff & Controlling the
spread of infection
Responsibilities of
educators and other
staff & Controlling the
spread of infection
Staff vaccination table
http://www.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook-measles)’.
Include, ‘Ensure that staff have received an adult pertussis booster vaccine (dTpa). Manage the risk where staff have not
received a booster, for example by not placing these persons to care for infants.
Measles: This should clarify that the person requires 2 doses of MMR if born during or since 1966.
Pertussis: This should clarify that the person requires an adult pertussis booster (dTpa), because childhood infection or
immunisation alone will not provide adequate protection because of waning immunity.
Patricia Coward
[Personal information removed by NHMRC]
[Personal information removed by NHMRC]
[Personal information removed by NHMRC]
10.01.12
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