DAY CARE
INFECTIONS
13 million children under
5 years of age use child
care services.
National Center for Health Statistics, 2010
90 percent of families
with preschool children
use child care services.
National Commission on Children, 2010
TYPES OF DAY CARE SETTINGS
 Small family child-care home
• 6 children
• licensing not required
 Large family child-care home
• 7-12 children
• variable licensing requirements
 Centers
• 13 children
• Licensed
 Facilities for ill children
 Facilities for children with special needs
APHA/AAP Out-of-Home Child Care Guidelines, 1992.
HIGH RISK PERSONNEL
 Susceptible to childhood infections
(measles, mumps, chickenpox, etc.)
 Immunocompromised
• asplenia
• cancer
• transplantation
• HIV
 Pregnant women
Grossman Ed 8, Infection Control in the Child Care Center,
Demos Medical Publisher, 2012
HIGH RISK CHILDREN
Risk Factors:
 Infancy
 Immunocompromised
 Chronic lung disease
 Cardiac disease
 Physical handicaps
 Chronic skin disease
Grossman, Ed 8, Infection Control in the Child Care Center,
Demos Medical Publisher, 2012.
HIGH RISK CHILDREN FOR
SPREADING INFECTION
 Children living in impoverished
conditions
• multiple care givers
• transient “family” or shelter
• poor sanitary conditions
• untreated infections in the home
 Children from developing nations
 Children with immune deficiencies
 Children with chronic infections
DAY CARE FACTORS THAT INCREASE
TRANSMISSION OF PATHOGENS
 Large numbers of children in close contact
 Infants and toddlers have
• no independent personal hygiene
• are incontinent
• put everything in their mouths
 Children are susceptible to most infectious agents
 Infected children may be contagious before symptomatic
• Parvovirus B19
• Varicella
 Infected children may be asymptomatic
• Giardia
• Hepatitis A
RESPIRATORY TRANSMISSION
Bacteria
Bordetella pertussis
Haemophilus influenzae type B
Mycobacterium tuberculosis
Neisseria meningitidis
Streptococcus pneumoniae
Viruses
Adenovirus
Influenza
Measles
Parainfluenza
Parvovirus B19
Respiratory syncytial virus
Rhinovirus
Rubella
Varicella
FECAL-ORAL TRANSMISSION
Bacteria
Campylobacter
Clostridium difficile
E. coli 0157:H7
Salmonella
Shigella
Viruses
Parasites
Astrovirus
Cryptosporidium
Calicivirus
Enterobius vermicularis
Enteric adenovirus Giardia lamblia
Enteroviruses
Hepatitis A
Rotavirus
TRANSMISSION BY SKIN OR
MUCOUS MEMBRANE CONTACT
Bacteria
Viruses
Parasites and Fungi
Group A streptococci Herpes simplex
Pediculosis
Staphylococcus aureus Varicella zoster
Scabies
Molluscum contagiosum Tinea capitis
Tinea corporis
TRANSMISSION BY
INOCULATION OR
SPLATTERING OF BLOOD
 Cytomegalovirus
 Hepatitis B
 Hepatitis C
 Human immunodeficiency virus
ILLNESSES AND ABSENTEESIM
IN DAY CARE CHILDREN
(2 YEAR SURVEILLANCE PERIOD)
Illness Episodes
Days Absent
Age (years) CC Homes CC Centers CC Homes CC Centers
1
1-2
17
16
5
16
15
10
7
11
3-4
9
6
5
9
5
7
4
4
5
Cordell RL, Pediatrics 100:850, 1997.
ANTIBIOTIC USE IN DAY CARE
CHILDREN
(2 MONTH SURVEILLANCE PERIOD)
CC Centers CC Homes Home
% who received
antibiotics
36%
7%
8%
Mean duration
of antibiotics
21
5
5
Pickering, Infect Dis Child 11:61, 1998.
ENVIRONMENTAL COLIFORM
CONTAMINATION
(2946 SAMPLES)
Number Contaminated (%)
Inanimate objects
307 (15)
Toy balls
73 (46)
Hands
131 (17)
Van et al, JAMA, 1991.
HEPATITIS A
HEPATITIS A
Child care attendees or employees account
for 14% of all cases of Hepatitis A in the
United States.
ETIOLOGIC AGENT
Small non-enveloped RNA virus
EPIDEMIOLOGY
 Source
• infected human
 High risk child care centers
• large numbers of children
• longer hours
• diapered children
 Mode of spread
• fecal-oral
CLINICAL MANIFESTATIONS
 Most children are asymptomatic
 80% of adults are symptomatic
 Rash
 Fatigue
 Jaundice
 Anorexia
 Dark urine
 Light stools
 Vomiting
INCUBATION PERIOD
15 to 50 days
INFECTIOUS PERIOD
Among symptomatic persons, infectivity
has waned by the time the individual seeks
medical care.
DIAGNOSIS
Hepatitis A serology
THERAPY
Supportive
PREVENTION
 Standard precautions
 Vaccine
 Immune serum globulin
CHILD CARE EXCLUSION
 Infected children can return 10 days after
onset of symptoms
 During an outbreak, return to day care
will be governed by the public health
department
RECOMMENDATIONS FOR
OTHER CHILDREN
 Hepatitis A vaccine
 Immune serum globulin, if exposed
 Children should be taught how to
minimize risks of transmission by
handwashing
RECOMMENDATIONS FOR
PERSONNEL
 Hepatitis A vaccine
 Significant risks of infection in the day
care setting
PARENTAL ADVICE
Pre-attendance Hepatitis A vaccine
VARICELLA
BEFORE 1995
INTRODUCTION OF
THE VARICELLA VACCINE
IN THE UNITED STATES



4 million cases per year
11,000 hospitalizations per year
100 varicella associated deaths
Meyer PA et al, J Infect Dis, 2000
AFTER INTRODUCTION OF
VARICELLA VACCINE
IN THE UNITED STATES
1995-2000
New Cases:
 California
 Texas
 Pennsylvania
71% 
84% 
79% 
ETIOLOGIC AGENT
DNA virus
EPIDEMIOLOGY
 Source
 infected human:
-respiratory tract
-infected lesions
 Mode of spread
 airborne
 direct contact
CLINICAL MANIFESTATIONS



Pruritic vesicular rash
Fever
Systemic symptoms
INCUBATION PERIOD
10 to 21 days
INFECTIOUS PERIOD
Until lesions are crusted
DIAGNOSIS
 Clinical
 Viral culture
 Serology
THERAPY
Acyclovir for high risk individuals
PREVENTION
 Vaccine
 Airborne and Contact precautions
 VZIG in high risk exposed children
 Post-exposure vaccination of
susceptible children and adults
CHILD CARE EXCLUSION
Infected children can return when lesions
are crusted (approximately 5 to 7 days)
RECOMMENDATIONS FOR
OTHER CHILDREN
 VZIG for high risk exposed children
 Varicella vaccine
RECOMMENDATIONS FOR
PERSONNEL
 Varicella vaccine for susceptible adults
THEORETIC CONCERNS
Increased Varicella in Older Children and
Adults who have:
 Never received the vaccine
 Have waning immunity
 Have less booster exposures to VZV
 later varicella disease
  herpes zoster
INFLUENZA
ETIOLOGIC AGENT
Enveloped RNA virus
EPIDEMIOLOGY

Source
• infected human
 Mode of spread
• large droplet aerosol
• small droplet aerosol
• direct and indirect contact with
infected secretions
INFLUENZAE ATTRIBUTABLE
MORBIDITY IN NORMAL
CHILDREN LESS THAN 1YEAR
OF AGE
Increased Hospitalization
 Increased Outpatient Visits
 Increased Antibiotic Use

Neuzil KM et al, NEJM, 2000
Izurieta HS et al, NEJM, 2000
 High risk children
 Chronic lung disease
 Congenital heart disease
 Immunocompromised
 Sickle cell disease
 Diabetes
 Chronic renal failure
 Metabolic disease
 Under 2 years of age
CLINICAL MANIFESTATIONS
 Fever
 Headache
 Myalgias/Arthralgias
 Chills
 Pharyngitis
 Rhinorrhea
 Cough/Croup/Bronchitis
INCUBATION PERIOD
1 to 3 days
INFECTIOUS PERIOD
Influenza A -
6 days prior to 7 days
after symptoms
Influenza B -
6 days prior to 14 days
after symptoms
DIAGNOSIS
Viral Culture
Rapid tests (immunofluorescent or
enzyme immunoassay)
THERAPY
Influenza A
Influenza B
-Amantadine
-Rimantadine
-Zamamivir (inhaled)
-Oseltamivir
-Zamamivir (inhaled)
-Oseltamivir
PREVENTION
 Annual influenza vaccine
• high risk children - recommended*
• healthy children 6 to 23 months encouraged*
Prophylactic antiviral therapy for high
risk children
*Recommendations of the ACIP, MMWR, 2002
CHILD CARE EXCLUSION
Until child is able to participate in child
care center activities
RECOMMENDATIONS FOR
OTHER CHILDREN
 Avoid aspirin during influenza season
 Annual influenza vaccine
RECOMMENDATIONS FOR
PERSONNEL
 Annual influenza vaccine
MOLLUSCUM
CONTAGIOSUM
ETIOLOGIC AGENT
DNA virus
EPIDEMIOLOGY

Source
• infected human
 Mode of spread
• direct skin to skin contact
• contaminated formites
CLINICAL MANIFESTATIONS
 Small painless skin lesions notable for a
central dimple
 Lesions are usually on face, trunk and
limbs
 Lesions spontaneously disappear within
6-12 months
INCUBATION PERIOD
2-24 weeks
INFECTIOUS PERIOD
As long as child has visible lesions
DIAGNOSIS
 Clinical
 Biopsy
THERAPY
 Usually unnecessary
 Cryotherapy
 Curettage
 Laser
 Cimetidine
 Topical therapies
 Acyclovir for high risk individuals
PREVENTION
 No vaccine available
Handwashing
Cover lesions with clothing
CHILD CARE EXCLUSION
None recommended
PREVENTIVE
STRATEGIES
ENTRANCE REQUIREMENTS
FOR CHILDREN
 Medical history
 Immunizations
• Diphtheria-Pertussis-Tetanus
• Hemophilus influenza B
• Hepatitis A
• Hepatitis B
• Influenza
• Mumps
• Polio
• Rubella
• Rubeola
• Varicella
• Pneumococcus
ENTRANCE REQUIREMENTS
FOR STAFF
 Medical history
 Immunizations
• Diphtheria-Tetanus
• Hepatitis A
• Hepatitis B
• Influenza
• Mumps
• Polio
• Rubella
• Rubeola
• Varicella
• (Pertussis)
EXCLUSION FROM CHILD CARE
INFECTION
Chickenpox
Conjunctivitis
Bacterial
Viral
Diarrhea
EXCLUSION UNTIL:
Lesions are dry and crusted
24 hours after the initiation of therapy
Exudate disappears
Diarrhea can be contained
Infection has been treated (eg. Shigella)
Hepatitis (A,B,C)
Asymptomatic
Herpetic Gingivostomatitis
Lesions are dry and crusted
Impetigo
48 hours after effective therapy
Measles (Rubeola)
5 days from the appearance of the rash
Pediculosis/Scabies
Infestation has been treated
Pertussis
5-7 days after initiation of antibiotics
Rotavirus
Asymptomatic
Salmonella
Diarrhea can be contained
Streptococcal Infection
Upper Respiratory Illness
24 hours after initiation of antibiotics
Lack of fever