Pediatric Annals

Management of Communicable Diseases in Day Care Centers

Cynthia E Trumpp, MD; Raymond Karasic, MD

Abstract

The past decade has witnessed a steady trend toward the care of young children outside the home. It is estimated that over five million children in the United States currently attend some type of day care facility. One unwelcome consequence of this phenomenon has been the occurrence of outbreaks of communicable diseases within, or originating from, day care centers. Since effective measures are often available to prevent the spread of disease from sick children to their contacts, it is imperative that pediatricians and family practitioners recognize potential day care outbreaks and intervene appropriately.

In this article, we will discuss the transmission of a variety of communicable diseases in the day care setting, emphasizing the prevention of spread to contacts and the management of epidemics in progress. We will define "day care center" (DCC) as a facility outside the home, which provides a portion of the daily care for children less than fi ve years of age. Included in the definition are group day care centers, family day care homes, and nursery schools.

FACTORS PROMOTING SPREAD OF INFECTION IN DAY CARE CENTERS

What are the unique features of the DCC which foster the spread of communicable diseases? Most day care settings have in common the close physical proximity of many children, which facilitates the transmission of infectious agents. Moreover, the daily return of DCC enrollees to their families permits the reciprocal spread of illness to and from the community.

The care of infants and toddlers in group settings poses a special problem for several reasons:

1) This age group is uniquely susceptible to a myriad of infectious agents (eg Haemophilus influenzae type b) which are spread by close personal contact.

2) Certain infections which cause significant disability in older children and adults (eg hepatitis A) are mild or subclinical in infants and toddlers, thus allowing silent spread.

3) The youngest DCC enrollees are usually unimmunized against, and therefore susceptible to, infection with measles, mumps, and rubella.

4) Children in diapers are likely to be both victims and vectors of disease transmitted via the fecal-oral route (eg shigellosis).

Many DCCs suffer from understaffing, non-standardized training of staff, and lack of comprehensive, written guidelines. In addition, physical facilities are often unsatisfactory, with overcrowding of children, poor ventilation, and inadequate numbers of sinks, toilets, and areas for changing and disposing of diapers. All of these factors can contribute to the spread of infection in DCCs.

RESPIRATORY TRACT INFECTION

Upper respiratory tract infections are, by far, the most commonly diagnosed illnesses in DCCs. Furthermore, respiratory infections and non-specific febrile illnesses appear to be more common among young children in DCCs than in children of similar ages receiving home care.p 1

Much of our understanding of the natural history, epidemiology, and etiology of respiratory tract infections in DCCs is the result of studies performed by Dr. Frank Loda and associates from the University of North Carolina School of Medicine.p 2 Over a 40-month period, these investigators prospectively studied children attending the Frank Porter Graham Child Development Center, and documented multiple discrete outbreaks of respiratory illness. In general, the viral pathogens were similar to those isolated from sick children in the community, and included parainfluenza viruses, adenoviruses, enteroviruses, respiratory syncytial virus, rhinoviruses, and influenza viruses. Several predictable disease patterns were identified. Parainfluenza viruses and respiratory syncytial virus were frequently associated with lower respiratory tract infections, such as laryngotracheitis (croup), tracheobronchitis, bronchiolitis, and pneumonia. Adenoviruses and enteroviruses tended to cause febrile illnesses associated with upper respiratory tract symptoms. It is noteworthy that viruses, not considered to be part of the normal flora of the respiratory tract, were recovered…

The past decade has witnessed a steady trend toward the care of young children outside the home. It is estimated that over five million children in the United States currently attend some type of day care facility. One unwelcome consequence of this phenomenon has been the occurrence of outbreaks of communicable diseases within, or originating from, day care centers. Since effective measures are often available to prevent the spread of disease from sick children to their contacts, it is imperative that pediatricians and family practitioners recognize potential day care outbreaks and intervene appropriately.

In this article, we will discuss the transmission of a variety of communicable diseases in the day care setting, emphasizing the prevention of spread to contacts and the management of epidemics in progress. We will define "day care center" (DCC) as a facility outside the home, which provides a portion of the daily care for children less than fi ve years of age. Included in the definition are group day care centers, family day care homes, and nursery schools.

FACTORS PROMOTING SPREAD OF INFECTION IN DAY CARE CENTERS

What are the unique features of the DCC which foster the spread of communicable diseases? Most day care settings have in common the close physical proximity of many children, which facilitates the transmission of infectious agents. Moreover, the daily return of DCC enrollees to their families permits the reciprocal spread of illness to and from the community.

The care of infants and toddlers in group settings poses a special problem for several reasons:

1) This age group is uniquely susceptible to a myriad of infectious agents (eg Haemophilus influenzae type b) which are spread by close personal contact.

2) Certain infections which cause significant disability in older children and adults (eg hepatitis A) are mild or subclinical in infants and toddlers, thus allowing silent spread.

3) The youngest DCC enrollees are usually unimmunized against, and therefore susceptible to, infection with measles, mumps, and rubella.

4) Children in diapers are likely to be both victims and vectors of disease transmitted via the fecal-oral route (eg shigellosis).

Many DCCs suffer from understaffing, non-standardized training of staff, and lack of comprehensive, written guidelines. In addition, physical facilities are often unsatisfactory, with overcrowding of children, poor ventilation, and inadequate numbers of sinks, toilets, and areas for changing and disposing of diapers. All of these factors can contribute to the spread of infection in DCCs.

RESPIRATORY TRACT INFECTION

Upper respiratory tract infections are, by far, the most commonly diagnosed illnesses in DCCs. Furthermore, respiratory infections and non-specific febrile illnesses appear to be more common among young children in DCCs than in children of similar ages receiving home care.p 1

Much of our understanding of the natural history, epidemiology, and etiology of respiratory tract infections in DCCs is the result of studies performed by Dr. Frank Loda and associates from the University of North Carolina School of Medicine.p 2 Over a 40-month period, these investigators prospectively studied children attending the Frank Porter Graham Child Development Center, and documented multiple discrete outbreaks of respiratory illness. In general, the viral pathogens were similar to those isolated from sick children in the community, and included parainfluenza viruses, adenoviruses, enteroviruses, respiratory syncytial virus, rhinoviruses, and influenza viruses. Several predictable disease patterns were identified. Parainfluenza viruses and respiratory syncytial virus were frequently associated with lower respiratory tract infections, such as laryngotracheitis (croup), tracheobronchitis, bronchiolitis, and pneumonia. Adenoviruses and enteroviruses tended to cause febrile illnesses associated with upper respiratory tract symptoms. It is noteworthy that viruses, not considered to be part of the normal flora of the respiratory tract, were recovered from routine nasal wash cultures in about 10% of asymptomatic children. This observation reminds us that viral shedding may precede signs and symptoms of respiratory illness, or may occur in the absence of clinical disease, a fact which undoubtedly contributes to the difficulty in preventing transmission.

In the University of North Carolina study, bacterial pathogens were isolated less frequently than viruses from the upper respiratory tract. The Group A streptococcus was cultured from a small proportion of children under three years of age and, as expected, was associated with pharyngitis in older children. Although in this study Mycoplasma pneumoniae was isolated infrequently, a previous report from Sweden demonstrated that M. pneumoniae can spread rapidly among a group of susceptible children.p 3 In that experience, younger children tended to have febrile upper respiratory illnesses, while pneumonia occurred only in children over five years old.

Guidelines for exclusion of children from DCCs vary widely. Information from a Swedish study suggests that centers which adhere to a strict policy of exclusion (ie exclusion of all illnesses except afebrile upper respiratory infections) may enjoy a slight reduction in the incidence of minor illness, compared to DCCs which adopt less stringent policies.p 1 However, there is no conclusive evidence that a strict policy of this kind lessens the incidence of serious infection. In formulating a policy of exclusion for respiratory tract illness, one must consider the capabilities of the individual day care facility, since DCCs differ enormously in their ability to care for sick children. Ideally, such a policy should result from collaboration between the DCC staff and a knowledgeable medical consultant. We suggest the following guidelines for exclusion of children with respiratory tract infection:

1) Children with afebrile upper respiratory infection should not be excluded.

2) Children receiving antimicrobial therapy, who are afebrile and otherwise well, need not be excluded.

3) While high or persistent fever generally warrants medical evaluation, fever alone is not an absolute contraindication to attendance at the DCC.

4) Children with known or suspected measles, mumps, rubella, or varicella should be excluded until non-infective.

5) In general, any child too ill to participate in normal activities should be excluded, unless the center is specifically equipped to care for sick children.

INFECTION DUE TO HAEMOPHILUS INFLUENZAE TYPE B

Until recently, the communicability of H. influenza type b disease among young children was not recognized. However, we now know that household contacts of children with invasive H. influenzae type b infections are at increased risk of developing serious illness due to this organism.p 4 Most recognized new (secondary) cases of illness resulting from exposure to an initial (index) case of H. influenzae infection manifest as meningitis, and occur within one week of diagnosis of the index case. The risk of developing secondary disease is greatest for children less than 24 months of age, with serious infection occurring in over three percent of contacts. This risk diminishes with increasing age, so that beyond four years of age, household contacts have approximately the same likelihood of developing H. influenzae type b disease as other children of similar age.

At present, we do not have comparable data on the risk of secondary disease due to influenzae type b in the day care setting. However, there have been several recent reports of multiple cases of invasive H. influenzae infections occurring in DCCs.^sup 5,6^ Although we cannot calculate the exact incidence of secondary illness from these selected experiences, it is clear that significant spread of disease can occur in DCCs. Therefore, until we have more precise data, we consider it reasonable to assume that DCC contacts have the same risk of developing secondary illness as household contacts of comparable age.

Among the many antimicrobial agents tested, rifampin has proven to be the most successful drug for eradicating colonization of the upper airway with H. influenzae type b.^sup 7,8^ Furthermore, recent evidence from a nationwide collaborative study directed by the Centers for Disease Control indicates that rifampin is also effective in preventing secondary disease in household and day care contacts.p 9

The dose of rifampin recommended for contacts of invasive disease due to H. influenzae type b is 20 mg/kg (maximum: 600 mg) orally, given as a single daily dose for a total of four days. Side effects of rifampin include nausea, vomiting, and orange discoloration of urine and body secretions. The drug is contraindicated during pregnancy and in the presence of liver disease.

The Committee on Infectious Diseases of the American Academy of Pediatrics has recently published specific recommendations regarding chemoprophylaxis with rifampin for contacts of invasive H. influenzae type b disease.p 10 We concur with these recommendations, and have summarized them in Table 1. The rationale for administering rifampin prophylaxis to contacts over four years of age (in settings where there are children less than four years old) is that older individuals exposed to an index case may become colonized with H. influenzae type b, and transmit the organism to susceptible younger children. In addition, chemoprophylaxis with rifampin is advised for the index case prior to discharge from the hospital, because systemic antimicrobial therapy may fail to eradicate nasopharyngeal carriage of the organism.

The optimal management of children exposed to H. influenzae disease in the day care setting requires the cooperation of public and private health care resources in the community. We offer the following general guidelines:

1) Cases of bacterial meningitis should be reported to the appropriate public health department.

2) The director of the DCC (and medical consultant, if available) should be notified that children in the facility have been exposed to a serious and potentially communicable disease.

3) If chemoprophylaxis with rifampin is judged to be indicated, an expethent plan for distribution should be instituted.

4) Parents should be advised to observe their children for the development of serious infection. Any child experiencing signs and symptoms compatible with H. influenzae infection requires immediate medical attention, whether or not chemoprophylaxis was given.

INFECTION DUE TO NEISSERIA MENINGITIDIS

The communicability of disease due to N. meningitidis among all age groups is well-established, and outbreaks have occurred in DCCs.p 11 The Committee on Infectious Diseases of the American Academy of Pediatrics recommends that prophylaxis be given to household, DCC and nursery school contacts of patients with meningococcal disease.p 10 Rifampin is the drug of choice, unless the organism is known to be sensitive to sulfonamides. Dosages of rifampin and sulfadiazine for meningococcal prophylaxis are given in Table 2.

When illness due to N. meningitidis occurs in a DCC, one should follow the general approach outlined in the section on H. influenzae type b disease.

DIARRHEAL ILLNESS

A variety of pathogens have been implicated in DCC-related outbreaks of diarrhea, including Shigella,^sup 12,13^ Giardia,^sup 14,15^ Campylobacter,p 16 Salmonella,p 17 and rota virus.^sup 18,19^

Epidemics of diarrheal illness are usually caused by identifiable enteropathogens. This was demonstrated in a prospective study performed in Houston by Dr. Larry Pickering and colleagues, who identified 15 outbreaks of diarrhea occurring in nine DCCs over a 19-month period.p 19 In each outbreak (defined as two or more cases of diarrhea within a 48-hour period), these investigators were able to isolate one or more pathogens from stool. In contrast, enteropathogens were rarely recovered in sporadic cases of diarrhea.

The organisms involved in diarrheal epidemics generally have the potential for person-to-person spread by the fecal-oral route. Both Shigella and Giardia can produce clinical illness with ingestion of as few as ten organisms, a fact which favors person-to-person transmission of these agents. This mode of transmission also occurs with rotaviral infection, and may play a role in outbreaks of Campylobacterp 20 and Salmonellap 17 enteritis. To date, epidemics of diarrhea in DCCs have rarely resulted from food-borne or water-borne spread.

Table

TABLE 1CHEMOPROPHYLAXIS FOR CONTACTS OF INVASIVE DISEASE DUE TO H. INFLUENZAE TYPE B

TABLE 1

CHEMOPROPHYLAXIS FOR CONTACTS OF INVASIVE DISEASE DUE TO H. INFLUENZAE TYPE B

Table

TABLE 2CHEMOPROPHYLAXIS FOR CONTACTS OF MENINGOCOCCAL DISEASE

TABLE 2

CHEMOPROPHYLAXIS FOR CONTACTS OF MENINGOCOCCAL DISEASE

Two features of giardiasis in DCCs deserve mention. First, this agent tends to cause prolonged outbreaks, sometimes lasting months.p 15 Secondly, more than 50% of children excreting cysts may be asymptomatic, allowing disease to go unrecognized.

In general, attack rates (proportion of contacts who become infected) for diarrheal illness are highest in children less than two years of age. Toddlers in diapers, with their combination of dubious hygiene and unimpaired mobility, pose a particular hazard, not only to peers in the DCC, but to family members as well. Several studies have documented the spread of diarrheal illness by young children from the DCC into families.p 12

However, the responsibility for outbreaks of diarrhea does not rest solely with toddlers. A number of epidemics have been associated with inadequate physical facilities and major lapses in personal and environmental hygiene. This is especially disconcerting, given our knowledge that hand washing alone is effective in reducing the spread of diarrhea.p 21

The prevention of diarrheal outbreaks in DCCs requires an informed approach, guided by common sense. Our recommendations are listed in Table 3.

When a sporadic case of proven or suspected infectious diarrhea occurs in a child attending day care, that child should be excluded from the DCC, at least until symptoms abate.

When a DCC experiences two or more episodes of diarrhea within a 48-hour period, this constitutes an outbreak, and requires that additional steps be taken to prevent further spread:

1) Cultures of stool should be obtained from all symptomatic individuals. When giardiasis is strongly suspected, examination of stool (or, rarely, duodenal contents) for parasites should be considered. In outbreaks of giardiasis, it may be necessary to examine stools of asymptomatic children, as well.

2) In general, when a treatable enteropathogen (eg Shigella, Campylobacter, Giardia) is isolated from an individual, he or she should receive specific antimicrobial therapy (Table 4).

3) Children with diarrhea should be excluded from day care until asymptomatic and culture-negative.

4) During an outbreak, no new children should be enrolled at the DCC.

5) In situations where infection rates are high and facilities allow, cohorting of infected children may be more practical than exclusion.

HEPATITIS A

Studies of recent outbreaks of hepatitis A in communities have made it clear that a significant proportion (up to 30%) of cases originate in DCCs.p 22

Epidemiologic studies of DCC-related outbreaks of hepatitis A from Arizona and Louisiana have provided us with several important observations.^sup 22,23^ A major finding is that, unlike adults, preschool children infected with hepatitis A virus usually are asymptomatic, or have nonspecific illness. As a consequence, epidemics of hepatitis A in DCCs often are unrecognized until overt hepatitis develops in adult contacts of infected children. In an outbreak, over 70% of clinical cases occur in household contacts, mainly parents. Moreover, the risk of clinical illness is greatest for adults having regular contact with one- or two-year-old children in diapers.

The importance of the infected toddler in the transmission of hepatitis A cannot be overemphasized. In a recent study performed in Arizona, Dr. Stephen Hadler and associates from the Centers for Disease Control examined risk factors for the spread of hepatitis A in DCCs, and found that the presence of children less than two years old was the main determinant of whether hepatitis would spread in a DCC.p 24 These authors studied outbreaks (defined as hepatitis A involving three or more families over a three-month period) occurring in 85 DCCs, and found that 63% of centers enrolling infants (less than one year of age) experienced outbreaks, while outbreaks occurred in only 4.6% of DCCs accepting exclusively children age two years or older. These investigators also determined that the introduction of hepatitis into a DCC is related to the number of children attending the center, and the number of hours that the center is open per day. In summary, outbreaks of hepatitis A are most likely to affect large DCCs which provide care for children less than two years of age.

Table

TABLE 3GUIDELINES FOR PREVENTING OUTBREAKS OF INFECTIOUS DIARRHEA AND HEPATITIS A IN DAY CARE CENTERS

TABLE 3

GUIDELINES FOR PREVENTING OUTBREAKS OF INFECTIOUS DIARRHEA AND HEPATITIS A IN DAY CARE CENTERS

Table

TABLE 4DRUGS AND DOSAGES FOR SELECTED ENTEROPATHOGENS

TABLE 4

DRUGS AND DOSAGES FOR SELECTED ENTEROPATHOGENS

Because hepatitis A is transmitted person-to-person by the fecal-oral route, the prevention of outbreaks involves an approach similar to that given for infectious diarrhea (Table 3). Handwashing, especially after changing diapers, remains the most important hygienic measure.

Immune globulin (IG), formerly called immune serum globulin (or "gamma globulin"), is effective in preventing hepatitis A, when administered to contacts soon after exposure. Therefore, when cases of hepatitis are identified in DCCs, one should consider the use of IG in all exposed individuals. The dose of IG for contacts of hepatitis A is 0.02 ml/kg, given once, intramuscularly. Table 5 lists guidelines for administering IG in the day care setting. When a case of hepatitis arises in a facility enrolling only children over two years of age, the recommendations of Table 5 may be modified. In this situation, where the risk of spread is low, use of IG may be restricted to children who are cared for in the same room as the index case, plus adult staff.p 25

Table

TABLE 5USE OF IMMUNE GLOBULIN FOR DAY CARE CONTACTS OF HEPATITIS A

TABLE 5

USE OF IMMUNE GLOBULIN FOR DAY CARE CONTACTS OF HEPATITIS A

In general, it is not necessary to exclude children from day care during outbreaks of hepatitis A. In fact, exclusion of infected children and closure of a DCC are likely to aggravate an outbreak by encouraging enrollment of infected children at other facilities.

SUMMARY

In this article, we have focused on specific communicable diseases in day care centers, and have provided guidelines for prevention and control of outbreaks, and management of contacts.

Given the growing number of working mothers in the United States and the related increase in child care outside the home, it is inevitable that physicians caring for children will encounter illnesses acquired in the day care setting. Only by understanding the unique epidemiologie characteristics of day care centers will practitioners be able to recognize potential outbreaks and help prevent the further spread of communicable diseases.

REFERENCES

1. Strangert K: Respiratory illness in preschool children with different forms of day care. Pediatrics 1976; 57:191.

2. Loda FA, Glezen WP, Clyde WA Jr: Respiratory disease in group day care. Pediatrics 1972; 49:428.

3. Sterner G, DeHevesy G. Tunevall G, et al: Acute respiratory illness with Mycoplasma pneumoniæ. An outbreak in a home for children. Acta Paediatr Scand 1966; 55:280.

4. Ward Jl, Fraser DW. Baraff LJ, el al: Haemophilus influenzae meningitis. A national study of secondary spread in household contacts. N Engl J Med 1979;301:122.

5. Ginsburg CM, McCracken GH Jr, Rae S, et al: Haemophilus influenzae type b disease. Incidence at a day-care center. J A M A 1977: 238:604.

6. Ward JI. Gorman G, Phillips C, et al: Hemophilia influenzae type b disease in a day-care center. Report of an outbreak. J Pediatr 1978; 92:713.

7. Granoff DMn Gilsdorf J, Gessert C, et al: Haemophilus influenzae type b disease in a day care center. Eradication of carrier state by rifampin. Pediatrics 1979; 63:397.

8. Horner DB, McCracken G H Jr, Ginsburg CM, et al: A comparison of three antibiotic regimens for eradication of Haemophilus influenzae type b from the pharynx of infants and children. Pediatrics 1980; 66:136.

9. Band J D, et al: Prevention of Haemophilus influenzae type b(Hib) disease by rifampin. Presented at the 21st Interscience Conference on Antimicrobial Agents and Chemotherapy, Chicago, November 1981.

10. Repon of the Committee on Infectious Diseases (Redbook), ed 19. Evanston, Illinois, American Academy of Pediatrics, 1982.

11. Jacobson JA, Filice GA, Holloway JT: Meningococcal disease in day-care centers. Pediatrics 1977; 59:299.

12. Weissman JB, Schmerler A, Weiler P, et al: The role of preschool children and day-care centers in the spread of shigellosis in urban communities. J Pediatr 1974; 84:797.

13. Weissman JB, Schmerler A, Gangarosa EJ, et al: Shigellosis in day-care centers. Lancet 1975; 1:88.

14. Black RE, Dykes AC, Sinclair SP, et al: Giardiasis in day-care centers: Evidence of person-to-person transmission. Pediatrics 1977; 60:486.

15. Keystone JS, Krajden S. Warren MR: Person-to-person transmission of Giardia lamblia in day-care nurseries. Can Med Assoc J 1978; 119:241.

16. Cadranel S, Rodesch P, Butzler JP, et al: Enteritis due to "related Vibrio" in children. Am J Dis Child 1973; 126:152.

17. Lieb S, Gunn RA, Taylor DN: Salmonellosis in a day-care center. J Pediatr 1982: 100:1004.

18. Rodriguez WJ, Kim HW, Brandi CD, et al: Common exposure outbreak of gastroenteritis due to type 2 rota virus with nigh secondary attack rate within families. J Infect Dis 1979; 140:353.

19. Pickering LK, Evans DG, DuPont HL, et al: Diarrhea caused by Shigella, rotavirus, and Giardia in day-care centers: Prospective study. J Pediatr 1981; 99:51.

20. Blaser MJ, Waldma n RJ, Barren T. et al: Outbreaks of Campylobacter enteritis in two extended families: Evidence for person-to-person transmission. J Pediatr 1981; 98:254.

21. Black RE. Dykes AC, Anderson KE, et al: Handwashing to prevent diarrhea in day-care centers. Am J Epidemial 1981; 113:445.

22. Hadler SC, Webster HM, Erben JJ. et al: Hepatitis A in day-care centers. A community-wide assessment. N Engl J Med 1980; 302:1222.

23. Storch G, McFarland LM, Kelso K. et al: Viral hepatitis associated with day-care centers. JAMA 1979; 242:1514.

24. Hadler SC, Erben JJ, Francis DP, et al: Risk factors for hepatitis A in day-care centers. J Infect Dis 1982; 145:255.

25. Hepatitis Surveillance Report No. 47. Atlanta, Centers for Disease Control December 1981.

TABLE 1

CHEMOPROPHYLAXIS FOR CONTACTS OF INVASIVE DISEASE DUE TO H. INFLUENZAE TYPE B

TABLE 2

CHEMOPROPHYLAXIS FOR CONTACTS OF MENINGOCOCCAL DISEASE

TABLE 3

GUIDELINES FOR PREVENTING OUTBREAKS OF INFECTIOUS DIARRHEA AND HEPATITIS A IN DAY CARE CENTERS

TABLE 4

DRUGS AND DOSAGES FOR SELECTED ENTEROPATHOGENS

TABLE 5

USE OF IMMUNE GLOBULIN FOR DAY CARE CONTACTS OF HEPATITIS A

10.3928/0090-4481-19830301-05

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