Transmission dynamics of enteric bacteria in day-care centers

The Importance of a Healthy Microbiome in Pregnancy and Infancy and Microbiota Treatment to Reverse Dysbiosis for Improved Health

BACKGROUND

The microbiome of newborn infants during the first 1000 days, influenced early on by their mothers' microbiome health, mode of delivery and breast feeding, orchestrates the education and programming of the infant's immune system and determines in large part the general health of the infant for years.

METHODS

PubMed was reviewed for maternal infant microbiome health and microbiota therapy in this setting with prebiotics, probiotics, vaginal seeding and fecal microbiota transplantation (FMT).

RESULTS

A healthy nonobese mother, vaginal delivery and strict breast feeding contribute to microbiome health in a newborn and young infant. With reduced microbiome diversity (dysbiosis) during pregnancy, cesarean delivery, prematurity, and formula feeding contribute to dysbiosis in the newborn. Microbiota therapy is an important approach to repair dysbiosis in pregnant women and their infants. Currently available probiotics can have favorable metabolic effects on mothers and infants, but these effects are variable. In research settings, reversal of infant dysbiosis can be achieved via vaginal seeding or FMT. Next generation probiotics in development should replace current probiotics and FMT.

CONCLUSIONS

The most critical phase of human microbiome development is in the first 2-3 years of life. Preventing and treating dysbiosis during pregnancy and early life can have a profound effect on an infant's later health.

Microbial contamination of hands with or without the use of bidet toilets (electric toilet seats with water spray) after defecation

Bidet toilets (electric toilet seats with water spray) are increasing in popularity worldwide. However, the extent of reduction of microbial contamination of the hands with the use of bidet toilets after defecation is unclear. Microbe contamination of the hands with and without the use of bidet toilets after defecation was examined in 32 nursing students. Double gloves were worn on the dominant hand and four layers of toilet paper were used to wipe the buttocks after defecation, and microbe contamination of the second glove (outer glove) of the double gloves was examined. The volunteers were free to select the flow volume, wash time of the bidet, and the type of bidet. Without the use of a bidet toilet, the average value ± standard deviation of the number of microbes attached to the gloves was 39,499.3 ± 77,768.3 colony forming units (cfu)/glove; however, it was 4,146.9 ± 11,427.7 cfu/glove when the bidet toilet was used. The number of microbes adhering to gloves was significantly reduced when a bidet toilet was used (p < 0.00001, Wilcoxon signed-rank test).

The Use of Electric Toilet Seats with Water Spray Is Efficacious in Maintaining Hand Hygiene in Experimental Model

A simulation experiment was conducted to examine hand contamination from wiping the buttocks after the use and non-use of an electric toilet seat with water spray. A model of the buttocks was smeared with artificial diarrheal feces containing Serratia marcescens, and wiped by the participants wearing disposable gloves with 4 sheets of toilet paper after the use and non-use of the water spray of an electric toilet seat. Subsequently, the presence of S. marcescens on the surface of the gloves was quantified. After using the water spray, the mean count±standard deviation of S. marcescens was 0.067±0.249 colony-forming units (cfu)/glove, and it was 4,275±6,069 cfu/glove when water spray was not used. The cfu of S. marcescens was significantly lower when the water spray was used (p<0.00001) prior to wiping the artificial diarrheal feces. This result supports the effectiveness of water spray to prevent defecation-related hand contamination.

A Cross Sectional Study of the Association between Sanitation Type and Fecal Contamination of the Household Environment in Rural Bangladesh

We conducted a cross sectional study to assess 1) the association between access to basic sanitation and fecal contamination of sentinel toy balls and 2) if other sanitation factors such as shared use and cleanliness are associated with fecal contamination of sentinel toy balls. We assessed sanitation facilities in 454 households with a child aged 6-24 months in rural Bangladesh. We defined "basic" sanitation as access to improved sanitation facilities (pit latrine with a slab or better) not shared with other households. In each household, an identical toy ball was given to the target child. After 24 hours, the balls were rinsed to enumerate fecal coliforms as an indicator of household fecal contamination. Households with basic sanitation had lower fecal coliform contamination than households with no access to basic sanitation (adjusted difference in means: -0.31 log₁₀ colony forming units [CFU]/toy ball; 95% confidence interval [CI]: -0.61, -0.01). Shared sanitation facilities of otherwise improved type were more likely to have visible feces on the latrine slab compared with private facilities. Among households with access to improved sanitation, households with no visible feces on the latrine slab had less toy ball contamination than households with visible feces on the latrine slab (adjusted difference in means: -0.38 log₁₀ CFU/toy ball; 95% CI: -0.77, 0.02). Access to basic sanitation may prevent fecal contamination of the household environment. An Improved sanitation facility used by an individual household may be better in preventing household fecal contamination compared with improved facilities shared with other households.

Diagnostic Dilemma in the Treatment of a Fatal Case of Bloody Diarrhea

Although diarrhea is the most commonly reported pediatric illness in the United States, mortality is usually a rare and unexpected event. We report the case of a healthy 13-month-old male that succumbed to a diarrheal illness of unclear etiology. Presenting signs included frequent nonbloody stools that progressed to frankly bloody stools over 72 hours. Associated symptoms included fever, tenesmus, relief with stool passage, and significant fatigue. On examination, the patient appeared tired and lay with legs curled toward his chest. The abdominal exam was remarkable for hypoactive bowel sounds, diffuse tenderness to palpation without guarding or rebound pain, and intermittent prolapse of rectal tissue. Abdominal plain films demonstrated a paucity of bowel gas, especially in the rectum; and ultrasound revealed thickening of bowel loops in the left lower quadrant. Abdominal computed tomography scan showed decreased enhancement of the mucosa of the rectosigmoid colon. The patient deteriorated rapidly with cardiorespiratory arrest occurring 48 hours after admission. Despite a protracted effort at cardiopulmonary resuscitation, perfusing heart rate or rhythm could not be reestablished. Autopsy revealed infarction and necrosis of the rectosigmoid colon with invasive gram-negative bacilli. Here we present his perplexing case, diagnostic evaluations, and suggest a unifying diagnosis.

Transient and sustained effects of child-care attendance on hospital admission for gastroenteritis

BACKGROUND

There is evidence that children experience a transient increase in mild episodes of gastroenteritis when they start attending out-of-home child care. We assessed the transient and sustained effects of cumulative day-care attendance, age at first enrolment and type of child care facility attended on hospitalization rates for gastroenteritis.

METHODS

Cox proportional hazard models were used to estimate the risk of being hospitalized for gastroenteritis in two large cohorts of preschool (<6 years old) and elementary school-going (6-10 years old) children in Denmark. Day-by-day child-level registry data were used. Together, the two cohorts comprised 443,872 children, 21,038 hospitalizations and 1742,284 child-years (1994-2011).

RESULTS

From first day-care attendance until 12 months of cumulated attendance, preschool children attending day-care centres, but not those attending day-care homes, had an increased risk of hospitalization for gastroenteritis compared with children never attending registered day-care. Such increased risk was highest shortly after starting day-care attendance and then gradually declined. After 12 months of attendance, attending either day-care centres or day-care homes was associated with a lower risk for hospitalization. Such decreased risk was confined to children starting day-care attendance before the age of one year and extended throughout, but not beyond, their preschool years.

CONCLUSIONS

Attending day-care centres is associated with a higher risk for gastroenteritis hospitalization until completing 1 year of attendance. However, if children start attending day-care before the age of 1 year, they experience a lower risk of being hospitalized during their preschool years. This apparent protective effect does not last into the elementary school years.

Diversity of bacterial communities of fitness center surfaces in a U.S. metropolitan area

Public fitness centers and exercise facilities have been implicated as possible sources for transmitting community-acquired bacterial infections. However, the overall diversity of the bacterial community residing on the surfaces in these indoor environments is still unknown. In this study, we investigated the overall bacterial ecology of selected fitness centers in a metropolitan area (Memphis, TN, USA) utilizing culture-independent pyrosequencing of the 16S rRNA genes. Samples were collected from the skin-contact surfaces (e.g., exercise instruments, floor mats, handrails, etc.) within fitness centers. Taxonomical composition revealed the abundance of Firmicutes phyla, followed by Proteobacter and Actinobacteria, with a total of 17 bacterial families and 25 bacterial genera. Most of these bacterial genera are of human and environmental origin (including, air, dust, soil, and water). Additionally, we found the presence of some pathogenic or potential pathogenic bacterial genera including Salmonella, Staphylococcus, Klebsiella, and Micrococcus. Staphylococcus was found to be the most prevalent genus. Presence of viable forms of these pathogens elevates risk of exposure of any susceptible individuals. Several factors (including personal hygiene, surface cleaning and disinfection schedules of the facilities) may be the reasons for the rich bacterial diversity found in this study. The current finding underscores the need to increase public awareness on the importance of personal hygiene and sanitation for public gym users.

Effect of cleaning and disinfection of toys on infectious diseases and micro-organisms in daycare nurseries

Background

The rising number of children in daycare nurseries increases opportunities for the transmission of infectious diseases. Pathogens may be transmitted directly from child to child via sneezing, coughing and touching, or indirectly via the environment. Toys are among the fomites with the highest pathogen load, but their role in disease transmission is unknown.

Aim

To determine if washing and disinfection of toys can reduce sickness absence and microbial pathogen load in the nursery environment.

Methods

Twelve nurseries (caring for 587 children) were randomized to intervention and control groups. The intervention consisted of washing and disinfection of toys and linen every two weeks for three months by a commercial cleaning company. The extent and causes of sickness absence among the children were recorded in both groups before and after introduction of the intervention. Ten sampling points in each nursery were examined for bacteria and respiratory viruses.

Results

The presence of respiratory virus DNA/RNA was widespread, but very few pathogenic bacteria were found in the environment. The intervention reduced the presence of adenovirus [odds ratio (OR) 2.4, 95% confidence interval (CI) 1.1–5.0], rhinovirus (OR 5.3, 95% CI 2.3–12.4) and respiratory syncytial virus (OR 4.1, 95% CI 1.5–11.2) compared with the control group, but the intervention had no effect on sickness absence or disease patterns in the nurseries.

Conclusion

Although cleaning and disinfection of toys every two weeks can decrease the microbial load in nurseries, it does not appear to reduce sickness absence among nursery children.

Application of quantitative microbial risk assessment for selection of microbial reduction targets for hard surface disinfectants

BACKGROUND

This quantitative microbial risk assessment (QMRA) included problem formulation for fomites and hazard identification for 7 microorganisms, including pathogenic Escherichia coli and E coli 0157:H7, Listeria monocytogenes, norovirus, Pseudomonas spp, Salmonella spp, and Staphylococcus aureus. The goal was to address a risk-based process for choosing the log10 reduction recommendations, in contrast to the current US Environmental Protection Agency requirements.

METHOD

For each microbe evaluated, the QMRA model included specific dose-response models, occurrence determination of aerobic bacteria and specific organisms on fomites, exposure assessment, risk characterization, and risk reduction. Risk estimates were determined for a simple scenario using a single touch of a contaminated surface and self-inoculation. A comparative analysis of log10 reductions, as suggested by the US Environmental Protection Agency, and the risks based on this QMRA approach was also undertaken.

RESULTS

The literature review and meta-analysis showed that aerobic bacteria were the most commonly studied on fomites, averaging 100 colony-forming units (CFU)/cm(2). Pseudomonas aeruginosa was found at a level of 3.3 × 10(-1) CFU/cm(2); methicillin-resistant S aureus (MRSA), at 6.4 × 10(-1) CFU/cm(2). Risk estimates per contact event ranged from a high of 10(-3) for norovirus to a low of 10(-9) for S aureus.

CONCLUSION

This QMRA analysis suggests that a reduction in bacterial numbers on a fomite by 99% (2 logs) most often will reduce the risk of infection from a single contact to less than 1 in 1 million.

Microbiological analysis of environmental samples collected from child care facilities in North and South Carolina

BACKGROUND

Children cared for outside the home are at an increased risk of enteric disease. Microbiological analyses were performed on environmental samples collected from child care facilities in North and South Carolina.

METHODS

There were 326 samples collected from 40 facilities corresponding to common surfaces (77% of samples) and the hands of care providers (23% of samples). Samples were analyzed for total aerobic plate counts (APCs), total coliforms, biotype I Escherichia coli, and pathogens Shigella spp, Salmonella enterica, E coli O157, Campylobacter jejuni, and human norovirus.

RESULTS

Median APCs and coliform counts for hands were 4.6 and 1.0 log10 colony-forming units (CFU) per hand, respectively. Median APCs for surfaces were 2.0 and 2.6 log10 CFU for flat and irregular surfaces, respectively. Coliforms were detected in 16% of samples, with counts ranging from 1.0 log10 to > 4.3 log10 CFU, with higher counts most often observed for hand rinse samples. Biotype I E coli counts were below assay detection limits (< 1 log10 CFU) for all but 1 sample. No samples were positive for any of the 4 bacterial pathogens, whereas 4 samples showed evidence of human norovirus RNA.

CONCLUSION

The relative absence of pathogens and biotype I E coli in environmental samples suggests the child care facilities sampled in this study managed fecal contamination well.

Hygienic conditions in child-care facilities in North Carolina and South Carolina: an integrated microbial and observational study

BACKGROUND

In the United States almost one-quarter (23%) of children younger than age 5 years participate in some form of out-of-home child care; these children are 2.3-3.5 times more likely to contract acute gastrointestinal illness.

METHODS

Observational investigations were done to understand the hygienic conditions and practices of 40 child-care facilities in North Carolina and South Carolina. These data were compared with microbiological indicator data (aerobic plate counts and coliform counts) collected from selected surfaces in each facility. Results from the two data sets were analyzed using nonparametric statistical methods to reveal potential risk factors for enteric disease transmission.

RESULTS

Statistically significant differences (P ≤ .05) in surface microbial counts were observed when comparing family child-care homes versus centers and between facilities participating in the Child and Adult Care Food Program and those that do not participate. Facilities without written surface cleaning or food preparation policies had statistically significantly higher microbial counts on surfaces.

CONCLUSIONS

Our unique study, which combined observational and microbiological data, provided revealing information about the relationship between hygiene indicators and sanitary practices in child-care facilities in the southeastern United States.

[Shigella sonnei outbreak in a school in Northern Spain]

In October 2012, an outbreak of acute gastroenteritis caused by Shigella sonnei was detected in a nursery and primary school in the north of Spain affecting 112 people: 63.7% were pupils and teachers and 35.7% their co-habitants. The source was a sick child who had travelled to an endemic country, and the key trigger factor was inadequate hygiene in one of the toilets of the school. The enforcement of strict hygiene measures was essential for controlling the outbreak.

Toys and toilets: cross-sectional study using children's toys to evaluate environmental faecal contamination in rural Bangladeshi households with different sanitation facilities and practices

OBJECTIVE

To evaluate household faecal contamination using children's toys among 100 rural Bangladeshi households categorised as 'cleaner' (toilet that reliably separates faeces from the environment and no human faeces in/around living space) or 'less clean' (no toilet or toilet that does not reliably separate faeces from the environment and human faeces in/around living space).

METHODS

We distributed toy balls to each household and rinsed each study toy and a toy already owned by the household in 200 ml of Ringer's solution. We enumerated faecal coliforms and faecal streptococci from each rinse using membrane filtration methods.

RESULTS

Study toys from 39 cleaner households had lower mean faecal coliform contamination than toys from 61 less clean households (2.4 log10 colony-forming units (CFU)/200 ml vs. 3.2 log10 CFU/200 ml, P = 0.03). However, wealth measures explained a portion of this relationship. Repeat measures were moderately variable [coefficient of variation (CV) = 6.5 between two toys in the household at the same time, CV = 37.6 between toys in the household at two different times 3-4 days apart]. Too few households owned a non-porous toy to compare groups without risk of bias.

CONCLUSION

In rural Bangladesh, improved sanitation facilities and practices were associated with less environmental contamination. Whether this association is independent of household wealth and whether the difference in contamination improves child health merit further study. The variation found was typical for measures of environmental contamination, and requires large sample sizes to ascertain differences between groups with statistical significance.

A novel and potentially valuable exposure measure: Escherichia coli in oral cavity and its association with child daycare center attendance

This study investigated the occurrence of Escherichia coli, an indicator of fecal contamination, in saliva samples from 141 children up to 36 months old, 53 not attending and 88 attending a child daycare center after exposure to a public daycare center and home environments. Two samples from each child were collected on the same day at 07:00 and 15:00 h and plated on MacConkey agar for identification. Samples E. coli negative in the morning and positive in the afternoon were statistically associated with the condition of the child attending daycare center (Odds ratio = 2.72; 95% confidence interval = 1.15/6.46). Exposure to the daycare center environment favored the potential risk of transmission of enteropathogens, as demonstrated by the presence of E. coli in saliva. The method proved to be easy to sample, non-invasive and feasible in young children. The findings suggest a novel and potentially valuable exposure measure.

How we didn't clean up until we washed our hands: shigellosis in an elementary and middle school in North Texas

BACKGROUND

Shigella outbreaks often continue for months and are linked frequently to poor hygiene and hand washing. Such outbreaks are found often in day care facilities, but rarely are reported in schools. We present the investigation of an outbreak in autumn 2007 at a building that housed an elementary school and a middle school in separate wings in a small Texas city north of Dallas-Fort Worth.

METHODS

We canvassed local hospitals, school attendance records, and physician offices for cases. Ill individuals were interviewed using a standard questionnaire for symptoms, disease onset, and the presence of the illness in an ill person's household.

RESULTS

A music teacher was the index case for this outbreak of gastrointestinal illness caused by S. sonnei. Ten percent of the students in the school building were ill, and 15 households had secondary cases. Installing liquid soap in dispensers in student restrooms was the initial control measure, followed by sustained instruction in hand washing, scheduled hand washing times, and monitored cleaning and disinfection procedures for surfaces and inanimate objects. Enhanced surveillance detected no new cases in the school district.

CONCLUSIONS

Appropriate soap supplies and repeated instruction in hand washing and its monitoring were needed to control the outbreak.

Infection control in paediatric office settings

Transmission of infection in the paediatric office is of increasing concern. The present document discusses routes of transmission of infection and the principles of current infection control measures. Prevention includes appropriate office design and administrative policies, triage, routine practices for the care of all patients (eg, hand hygiene; use of gloves, masks, eye protection and gowns for specific procedures; adequate cleaning, disinfection and sterilization of surfaces and equipment including toys, and aseptic technique for invasive procedures), and additional precautions for specific infections. Personnel should be adequately immunized, and those infected should follow work-restriction policies.

A model of exposure to rotavirus from nondietary ingestion iterated by simulated intermittent contacts

Existing microbial risk assessment models rarely incorporate detailed descriptions of human interaction with fomites. We develop a stochastic-mechanistic model of exposure to rotavirus from nondietary ingestion iterated by simulated intermittent fomes-mouth, hand-mouth, and hand-fomes contacts typical of a child under six years of age. This exposure is subsequently translated to risk using a simple static dose-response relationship. Through laboratory experiments, we quantified the mean rate of inactivation for MS2 phage on glass (0.0052/hr) and mean transfer between fingertips and glass (36%). Simulations using these parameters demonstrated that a child's ingested dose from a rotavirus-contaminated ball ranges from 2 to 1,000 virus over a period of one hour, with a median value of 42 virus. These results were heavily influenced by selected values of model parameters, most notably the concentration of rotavirus on fomes, frequency of fomes-mouth contacts, frequency of hand-mouth contacts, and virus transferred from fomes to mouth. The model demonstrated that mouthing of fomes is the primary exposure route, with hand mouthing contributions accounting for less than one-fifth of the child's dose over the first 10 minutes of interaction.

Are we aware how contaminated our mobile phones with nosocomial pathogens?

Background

The objective of this study was to determine the contamination rate of the healthcare workers' (HCWs') mobile phones and hands in operating room and ICU. Microorganisms from HCWs' hands could be transferred to the surfaces of the mobile phones during their use.

Methods

200 HCWs were screened; samples from the hands of 200 participants and 200 mobile phones were cultured.

Results

In total, 94.5% of phones demonstrated evidence of bacterial contamination with different types of bacteria. The gram negative strains were isolated from mobile phones of 31.3% and the ceftazidime resistant strains from the hands were 39.5%. S. aureus strains isolated from mobile phones of 52% and those strains isolated from hands of 37.7% were methicillin resistant. Distributions of the isolated microorganisms from mobile phones were similar to hands isolates. Some mobile phones were contaminated with nosocomial important pathogens.

Conclusion

These results showed that HCWs' hands and their mobile phones were contaminated with various types of microorganisms. Mobile phones used by HCWs in daily practice may be a source of nosocomial infections in hospitals.

Screening for faecal contamination in primary schools in Crete, Greece

BACKGROUND

Hygienic conditions in primary schools are a major concern for both governmental organizations and families. Particularly, the occurrence of faecal indicators on children's hands and various school surfaces has been associated with increased risk of diarrhoeal diseases. The presence of faecal streptococci on environmental surfaces and children's hands and the possible correlation with socio-economic factors were examined.

METHODS

Overall, 1956 samples from hands and 1470 samples from surfaces were collected from 20 primary schools in Heraklion, Crete, Greece.

RESULTS

Faecal streptococci were found at 52.9% of children's hands and at 16.7% of other surfaces. Children, who had parents with the highest education level (>12 years), had the lowest percentage (48.8%) of faecal contamination on their hands. Furthermore, boys exhibited higher levels of hands contamination compared with girls. Among the environmental surfaces examined, the school canteen reception was the most contaminated area.

CONCLUSION

High faecal contamination was detected in primary schools in the examined region. Children's hands were highly infected (52.9%), while boys exhibited higher levels of contamination. The educational level of parents correlated well with the contamination of children's hands.

Child care-associated outbreak of Escherichia coli O157:H7 and hemolytic uremic syndrome

We present an outbreak of E. coli O157:H7 diarrhea in an urban child care center. Eleven of 45 attendees with diarrhea had positive tests (stool culture or shiga-like toxin assay) for E. coli O157:H7. Two of these 11 (18%) progressed to hemolytic uremic syndrome. Diarrheal illness in child care centers should be considered a public health risk. Staff education, hand washing, and cohorting or exclusion of attendees with diarrhea must be performed to help control infectious outbreaks.

Field trial of a low cost method to evaluate hand cleanliness

OBJECTIVE

To evaluate a simple low cost method for measuring hand contamination as an objective assessment of handwashing practices.

METHOD

As part of a larger randomized controlled trial of handwashing promotion with soap conducted in squatter settlements of Karachi, Pakistan, a randomly selected subset of 52 mothers in households receiving soap and handwashing promotion and 28 mothers in control households directly pressed three fingers of their right hand onto MacConkey agar plates on weekly unannounced visits from April to September 2002, and monthly from October 2002 to March 2003. The MacConkey plates were incubated at 44 degrees C for 24 h, and evaluated for growth of thermotolerant coliform bacteria.

RESULTS

The proportion of samples that had detectable thermotolerant coliforms (50%) was similar in households that received soap and control households (52%, P = 0.40). In the week after evaluation of the mothers' hands, the proportion of households that reported diarrhoea was similar regardless of whether or not the mother had thermotolerant coliforms detected by direct finger imprint (18.6%vs. 19.1%, Relative Risk 0.99, 95% CI 0.96, 1.03).

CONCLUSIONS

A three finger direct imprint test using MacConkey agar for thermotolerant coliforms was not a useful method to assess regular handwashing practices with soap in Karachi. Developing better measures of handwashing behaviour remains an important research priority.

Microbial evaluation of foodservice surfaces in Texas child-care centers

Children under the age of 5 years experience a disproportionately high rate of bacterial enteric infections. Research has shown a relationship between inadequate child-care center sanitation and illnesses in children. This cross-sectional study assessed the sanitation levels of foodservice surfaces in a sample of 36 Texas child-care centers via recovery and identification of selected enteric gram-negative bacteria. The centers in this study had the capacity to care for 50 to 332 children and represented diverse socioeconomic and racial profiles. Forty-one percent (68 of 167) of total swab samples collected tested positive for bacteria. Twenty-seven different types of bacteria were identified from positive swab samples. Most of the bacteria found are considered opportunistic pathogens, which can pose serious health risks to those with compromised immune systems, such as young children. Two types of bacteria recovered, Salmonella paratyphi A and Klebsiella pneumonia, are considered nonopportunistic and can infect healthy individuals. The most common areas of bacterial contamination were the sink drain area of the dishwashing sink, the hand-washing sink faucet handles, the handle of the garbage can lid, and cutting boards. It is vital for child-care staff to wash their hands often and disinfect all surfaces, because even surfaces that appear clean can harbor microorganisms.

Infectious disease in pediatric out-of-home child care

Provision of some form of child care outside of the home is certainly not a new phenomenon. In the past, most out-of-home care was provided by a relative, a friend, or someone who had a specific relationship with the family of the child. The frequency of utilization of child care centers for out-of-home care and the different formats of out-of-home care services has increased within recent decades and will vary by geographic location. Also, there is an increased utilization of temporary child care such as "mother's day out" or baby-sitting services provided at churches, grocery stores, and other places. Child care centers represent special risks for transmission of infectious agents because young children exhibit high susceptibility to many community-acquired viruses and bacteria; they lack developmental understanding required for good hygiene; and they frequently receive antibiotics (appropriately and inappropriately). Infections acquired in child care centers can significantly impact the health of the children who acquire the infection and also result in significant economic impacts on the child's family, particularly if 1 or more of the parents has to lose time from work. In the United States, it is estimated that families who have children in child care lose 13 days of work per year for all types of infections. Interventions that have proven valuable for reducing infections within child care centers include the following: (1) formal written policies for infection control within the child care center, (2) formal education of child care center staff concerning infection control practices (needs to be repeated; preferably on a recurring basis), (3) good hand hygiene by both staff and children, (4) appropriate cleaning of contaminated surfaces, (5) separation of food preparation and diaper changing, (6) exclusion of certain ill children, (7) cohorting ill children when exclusion is not possible, (8) ensuring adequate age-appropriate immunization of child care attendees and staff, and (9) optimal ratios of children to staff.

Toys in a pediatric hospital: are they a bacterial source?

BACKGROUND

In children's hospitals, children are commonly provided with toys. Measures to guarantee the safety of these toys are usually not taken. This study was conducted to determine whether toys were contaminated with potentially pathogenic bacteria when they arrived in the hospital, and whether they were contaminated in the hospital.

METHODS

The study was conducted during a 3-month period. Children who were hospitalized for at least 3 days were chosen as study subjects. Once these children were identified, cultures from their toys were obtained within the first 48 hours of admission. After this first culture, toys were cleaned with 4% chlorhexidine and water and were immediately re-cultured. Following cultures were collected on days 5 to 7, 10 to 15, and every week thereafter until the owner-patient was discharged. Specimens were collected in a standardized manner with moistened swabs and placed in transport media. They were later inoculated onto trypticase soy agar with 5% sheep blood and brain heart infusion agar, incubated at 37 degrees C for 48 hours and examined for colony growth at 24 to 48 hours.

RESULTS

Seventy children's toys were included in this study. Patients' median age was 26 months (range: 1 day to 9 years). Respiratory infections (43%) and diarrhea (26%) were the most common causes of hospitalization. Fifty-three (76%) toys were made of plastic, 8 (11%) metallic, and 9 (13%) other materials. Twenty-nine (41%) were brought from home, 38 (55%) were purchased from roving vendors, and 3 (4%) were purchased from toy stores. All first cultures were positive for at least 1 pathogenic microorganism: 55 (78%) coagulase-negative Staphylococcus (CNS); 26 (37%) Bacillus spp; 13 (18%) Staphylococcus aureus; 8 (11%) alpha-hemolytic Streptococcus; 5 (9%), Pseudomonas spp; 2 (3%) Stenotrophomonas maltophilia, and 6 (11%) other gram-negative organisms. After toys were cleaned, subsequent cultures showed significant decreases in bacterial growth rates (P <.05). Because some patients were discharged, additional cultures were obtained for only 31 toys.

CONCLUSIONS

Toys entering a hospital can be contaminated with potentially dangerous bacteria and may provide unnecessary risks for nosocomial infection. Effective measures must be implemented to prevent the spread of infections via toys.

Is drinking water a risk factor for endemic cryptosporidiosis? A case-control study in the immunocompetent general population of the San Francisco Bay Area

BACKGROUND

Cryptosporidiosis, caused by Cryptosporidium, is an enteric illness that has received much attention as an infection of immunocompromised persons as well as in community outbreaks (frequently waterborne). There are, however, no studies of the risk factors for sporadic community-acquired cryptosporidiosis in the immunocompetent US population. We undertook a case-control study in the San Francisco Bay Area as part of a national study sponsored by the Centers for Disease Control and Prevention to ascertain the major routes of transmission for endemic cryptosporidiosis, with an emphasis on evaluating risk from drinking water.

METHODS

Cases were recruited from a population-based, active surveillance system and age-matched controls were recruited using sequential random-digit dialing. Cases (n = 26) and controls (n = 62) were interviewed by telephone using a standardized questionnaire that included information about the following exposures: drinking water, recreational water, food items, travel, animal contact, and person-to-person fecal contact, and (for adults) sexual practices.

RESULTS

In multivariate conditional logistic regression analyses no significant association with drinking water was detected. The major risk factor for cryptosporidiosis in the San Francisco Bay Area was travel to another country (matched odds ratio [95% confidence interval]: 24.1 [2.6, 220]).

CONCLUSION

The results of this study do not support the hypothesis that drinking water is an independent risk factor for cryptosporidiosis among the immunocompetent population. These findings should be used to design larger studies of endemic cryptosporidiosis to elucidate the precise mechanisms of transmission, whether waterborne or other.

Comparative surface-to-hand and fingertip-to-mouth transfer efficiency of gram-positive bacteria, gram-negative bacteria, and phage

AIMS

To determine the transfer efficiency of micro-organisms from fomites to hands and the subsequent transfer from the fingertip to the lip.

METHODS AND RESULTS

Volunteers hands were sampled after the normal usage of fomites seeded with a pooled culture of a Gram-positive bacterium (Micrococcus luteus), a Gram-negative bacterium (Serratia rubidea) and phage PRD-1 (Period A). Activities included wringing out a dishcloth/sponge, turning on/off a kitchen faucet, cutting up a carrot, making hamburger patties, holding a phone receiver, and removing laundry from the washing machine. Transfer efficiencies were 38.47% to 65.80% and 27.59% to 40.03% for the phone receiver and faucet, respectively. Transfer efficiencies from porous fomites were <0.01%. In most cases, M.luteus was transferred most efficiently, followed by phage PRD-1 and S. rubidea. When the volunteers' fingertips were inoculated with the pooled organisms and held to the lip area (Period B), transfer rates of 40.99%, 33.97%, and 33.90% occurred with M. luteus, S. rubidea, and PRD-1, respectively.

CONCLUSIONS

The highest bacteral transfer rates from fomites to the hands were seen with the hard, non-porous surfaces. Even with low transfer rates, the numbers of bacteria transferred to the hands were still high (up to 10(6) cells). Transfer of bacteria from the fingertip to the lip is similar to that observed from hard surfaces to hands.

SIGNIFICANCE AND IMPACT OF THE STUDY

Infectious doses of pathogens may be transferred to the mouth after handling an everyday contaminated household object.

Bacterial water quality in the personal water bottles of elementary students

BACKGROUND

Samples of drinking water were collected directly from the personal water bottles of students at an elementary school in Calgary, Alberta.

METHODS

Total and fecal coliforms and heterotrophic bacteria were enumerated using membrane filtration and agar plate count methods respectively.

RESULTS

The Canadian Drinking Water Quality Guidelines (CWQG) criterion was exceeded for total coliform in 13.3% of 75 samples. Fecal coliform and total heterotrophic criteria were exceeded in 8.9% (of 68 samples) and 64.4% (of 76 samples) respectively.

FINDINGS

The use of personal water bottles for students in elementary classrooms is not recommended.

Antimicrobial activity of home disinfectants and natural products against potential human pathogens

OBJECTIVE

To assess the efficacy of both natural products (vinegar, baking soda) and common commercial disinfectants (Vesphene IIse, TBQ, Clorox, Lysol Disinfectant Spray, Lysol Antibacterial Kitchen Cleaner, Mr. Clean Ultra, ethanol) designed for home or institutional use against potential human pathogens, including selected antibiotic-resistant bacteria.

DESIGN

A quantitative suspension test was used to assess the efficacy of selected disinfectants following exposure times of 30 seconds and 5 minutes. Activity was assessed against Staphylococcus aureus, Salmonella choleraesuis, Escherichia coli O157:H7, and Pseudomonas aeruginosa. Selected disinfectants were also tested against poliovirus, vancomycin-susceptible and -resistant Enterococcus species, and methicillin-susceptible and -resistant S. aureus.

RESULTS

The following compounds demonstrated excellent antimicrobial activity (>5.6-8.2 log10 reduction) at both exposure times: TBQ, Vesphene, Clorox, ethanol, and Lysol Antibacterial Kitchen Cleaner. Mr. Clean eliminated 4 to >6 logs10 and Lysol Disinfectant approximately 4 logs10 of pathogenic microorganisms at both exposure times. Vinegar eliminated <3 logs10 of S. aureus and E. coli, and baking soda <3 logs10 of all test pathogens. All tested chemical disinfectants completely inactivated both antibiotic-resistant and -susceptible bacteria at both exposure times. Only two disinfectants, Clorox and Lysol, demonstrated excellent activity (>3 log10 reduction) against poliovirus.

CONCLUSIONS

A variety of commercial household disinfectants were highly effective against potential bacterial pathogens. The natural products were less effective than commercial household disinfectants. Only Clorox and Lysol disinfectant were effective against poliovirus.

Absence due to illness among toddlers in day-care centres in relation to child group structure

The present work demonstrates a close association between illness-associated absence among children below 4 y of age in day-care, and the age-related composition of the child groups. The study, which spanned a 4 y period and is based on illness-related absence from day-care in a Stockholm suburb, shows that morbidity decreases significantly among young children as age-integration in the groups is intensified. Absence due to illness was most common in toddler groups of infants up to 3 y of age. Among sibling groups of children in the age range 0-6 y, illness-related absence was lower among toddlers compared to toddlers in age-separated groups, and significantly lower in extended sibling groups in the age range 0-12 y. Morbidity among children older than 3 y was not affected in the same way by group structure.

The study of hygiene behaviour in Botswana: a combination of qualitative and quantitative methods

This paper describes a study from northern Botswana which explored the relationship between hygiene behaviour and diarrhoeal diseases in young children. Both qualitative and quantitative data collection methods were used. The qualitative methods included observations, key informant interviews, in-depth interviews and focus groups. The quantitative methods included spot check observations, anthropometric measurements, the monitoring of diarrhoea morbidity and the administration of a socioeconomic questionnaire. A profile of hygiene behaviours was developed for this community and traditional beliefs related to diarrhoea were identified. The methods described provided considerable information in a short period of time. They were also relatively inexpensive and easy to implement, thus providing a model for further studies dealing with hygiene behaviour in developing countries. The information gathered enabled the identification of areas needing further research, the development of health education programmes and provided the basis for larger epidemiological studies.

Faecal contamination on children's hands and environmental surfaces in primary schools in Leeds

Gastro-intestinal diseases continue to be a major health problem in primary schools in the UK. This study, which took place in 20 primary schools in the Leeds area, investigated the presence of faecal indicator bacteria on children's hands and environmental surfaces. Faecal streptococci were used as an indicator of faecal contamination. A handwashing knowledge score was developed for each child. Those children with good hygiene knowledge had less faecal contamination on their hands (relative risk: 1.4, 95% CI = 1.09-1.81, P = 0.005). Those schools with higher hand counts were more likely to have had a reported outbreak of gastroenteritis in the past. Values of the Townsend Deprivation Index, an indicator of deprivation, were compared with the hand results and those schools in high deprivation areas had higher hand counts. Of the swabs taken from surfaces in the toilet areas and classrooms, the carpets in the classrooms were the most frequently contaminated surfaces.

Occurrence of Giardia lamblia in children of municipal day-care centers from Botucatu, São Paulo State, Brazil

Considering that the number of day-care centers for pre-school-age children has expanded rapidly in developing countries, and that these institutions presenting conditions that facilitate the transmission of many enteric agents, a parasitological survey was carried out in three municipal day-cares from Botucatu: two in the urban area (one in downtown area and the other one in the city periphery area) and the third in the rural area. Three separate stool specimens were collected from 147 children ranging from 0 to 72 months old and 20 staff members. Each stool specimen was processed by Lutz and zinc sulfate flotation methods. The frequency of giardiasis observed among children of downtown, periphery and rural day-cares was 69.6%, 52.7% and 69.6%, respectively. Only one employee was positive for G. lamblia. The examination of three stool specimens increased the positivity for G. lamblia: from the ninety three final positive examinations, 24 (25.5%) and 8 (8.5%) were positives only after examination of the second and third samples, respectively. Others intestinal organisms like Ascaris lumbricoides (20.4%), Trichuris trichiura (19.0%). Hymenolepis nana (8.8%), Entamoeba coli (22.4%) and Blastocystis hominis (32.0%) were frequently found in the children. There was no significant association among localization of the day-cares, sex of the children and the levels of G. lamblia infection. According to the age, G. lamblia was found mainly in children between 12 to 47 months old.

Viral contamination of environmental surfaces on a general paediatric ward and playroom in a major referral centre in Riyadh

In order to determine the incidence of viral contamination of environmental surfaces in a hospital in Saudi Arabia. A 6-month prospective study was carried out on a general paediatric ward in which both enteric and respiratory viruses were screened. Weekly samples were taken between August 1993-February 1994. A total of 155 samples were taken in which 11 (7%) tested positive for rotavirus. No other viruses were detected. Internal and external temperatures were monitored and an increase in rotavirus incidence was noted with decrease in temperature. Rotavirus was detected on surfaces involving human activity (toilet handles, televisions, toys and vital signs chart). One patient had rotavirus on his hands but no staff were found to carry rotavirus. Further contamination of environmental surfaces (9%) was detected during an increased incidence of rotavirus infection. A proper programme of disinfection and handwashing is essential in order to eliminate this mode of transmission.

Diaper type and fecal contamination in child day care

In this study, modern all-in-one, front closure, reusable cloth diapers were compared with single-use, disposable paper diapers for their effect on fecal contamination in the child day care environment. Four licensed child day care centers were surveyed from which 1722 bacterial samples were cultured. The frequency of isolation of fecal organisms ranged from a low of 12% of the total bacterial isolates at a center using cloth diapers to a high of 46% and 45%, respectively, obtained at a center using first paper and then cloth diapers. Diaper type, cloth versus paper, when the method of application and the handling are made comparable, showed no significant difference in the frequency or the intensity of fecal contamination in child day care centers, as measured in the play/sleep area, the diaper change area, or on the hands of the care givers and children. Future studies to control microbial contamination in child day care centers should focus on effective ways of reducing contamination of sink faucets, hands of the caregivers, and hands of the children.

Fecal contamination in child day care centers: cloth vs paper diapers

OBJECTIVES

Cloth diapers with front closure and all-in-one design were compared with paper diapers containing absorbent gel material for their influence on fecal contamination of the environment in licensed child day care centers.

METHODS

One infant room and two toddler rooms in each of four day care centers were monitored for the presence of fecal bacteria. Microbial samples were taken from the play/sleep area, the diaper-changing area, and the hands of the caregivers and the children. Sampling was done twice weekly for two 4-week periods. Each center used either cloth or paper diapers during the first period, changing to the other diaper type during the second period.

RESULTS

A total of 1722 samples were cultured, 881 during the first 4 weeks and 841 during the second 4 weeks. The frequency of isolation of fecal organisms ranged from a low of 12% of the total bacteria isolates at a center using cloth diapers, to highs of 46% and 45%, respectively, at a center using first paper and then cloth diapers. Sink faucets and the hands of the caregivers and the children were often contaminated.

CONCLUSIONS

Analysis of the results of comparisons between cloth and paper diapers showed no significant difference in the frequency (F = .380, P < .535) or the intensity of fecal contamination in child day care centers.

Control of infections in child care

The control of infections in child-care centres involves vaccination of children and staff, attention to hygiene (particularly to handwashing), exclusion of children (and employees) while infectious and/or grouping of infectious children, separation of toilet-trained children from those in nappies, and judicious use of antimicrobial agents and vaccination during outbreaks. By reporting cases of infectious diseases in patients with child-care contact to public health authorities, doctors can assist in controlling such diseases in child care.

Infectious diarrhoea in children: controlling transmission in the child care setting

An increase in the number of preschool children cared for within groups in child care centres has been associated with increasing numbers of women in the workforce. Children at this age are at high risk for gastrointestinal diseases caused by a large number of enteric pathogens, and the risk is increased by the greater potential for person-to-person transmission within group care. This report considers the pathogens that may cause diarrhoeal illness in children, with particular reference to those that have been reported in formal day care settings. The major risk factors for transmission of these agents and a high rate of diarrhoeal illness in the child care setting include attendance of non-toilet-trained children, staff combining nappy changing and food preparation duties, large enrollment, low staff-to-child ratio, and poor hygiene and child handling practices. Investigations undertaken during an outbreak of diarrhoea have frequently used limited diagnostic testing, often suitable for identifying only bacterial and protozoal agents. Such limited investigations have tended to incriminate agents that have prolonged carriage and are easily identifiable in standard microbiology laboratories. Finding a pathogen in these circumstances needs to be interpreted with caution. Prevention and control measures include training and education in good personal hygiene, emphasis on the need for frequent handwashing, separation of change areas from food handling and eating areas, routine cleaning and disinfection of environmental surfaces and personal items, and exclusion of any child or child care worker with diarrhoea.

Survival of hepatitis A virus on human hands and its transfer on contact with animate and inanimate surfaces

The survival of hepatitis A virus (HAV; strain HM175) on the hands of five volunteers was determined by depositing 10 microliters of fecally suspended virus on each fingerpad and eluting the inoculum after 0, 20, 60, 120, 180, and 240 min. The amount of virus recovered from each fingerpad at 0 min was approximately 6.0 x 10(4) PFU. At the end of 4 h, 16 to 30% of the initially recoverable virus remained detectable on the fingerpads. HAV inocula (10 microliters; approximately 1.0 x 10(4) PFU) placed on fingerpads or 1-cm-diameter metal disks were used to determine virus transfer to clean surfaces upon a 10-s contact at a pressure of nearly 0.2 kg/cm2. When the inoculum was dried for 20 min, virus transfer from fingerpad to fingerpad, fingerpad to disk, and disk to fingerpad ranged from 2,667 to 3,484 PFU, while 0 to 50 PFU could be transferred after 4 h of drying. Elevation of the contact pressure alone from 0.2 to 1.0 kg/cm2 resulted in an approximately threefold increase in the amount of virus transferred. Incorporation of friction (10 half turns of the finger during 10 s of contact) with the low and high levels of pressure gave two- and threefold increases in the PFU of virus transferred, respectively. Pressure and friction were found to significantly affect HAV transfer (F = 33.98; P less than 0.05), irrespective of the mode of transfer used. No statistically significant interaction was observed between mode of transfer and pressure or friction. The findings of this quantitative study suggest that human hands may play an important role in the direct as well as the indirect spread of HAV.

Patterns of fecal coliform contamination in day-care centers

During a six-month period, on four separate occasions, six licensed day-care centers had cultures taken from environmental surfaces as well as the hands of children and teachers. Fecal coliforms were recovered from 64 (9.5%) of the 675 surfaces sampled. Recovery rate was not influenced by a center's socioeconomic status, time of year, or presence of children who were not toilet trained. Recovery rates did differ significantly in different areas, with the kitchen showing a relatively high recovery rate (19%), and toys and toilets showing remarkably low rates (2% and 4%). Centers with formal hand-washing procedures had lower recovery rates than those without such practices. We also demonstrated a high recovery rate from hands of staff (16%); 6% of children had positive cultures. Contamination of hands and classroom objects is a potential source for the transmission of enteric diseases for children in day-care centers. A program directed at reducing contamination would be important in preventing the spread of diarrheal illness.

Occurrence of infectious symptoms in children in day care homes

Transmission of enteric pathogens is facilitated in child day care centers, including family day care homes, by frequent and intimate exposure among susceptible hosts, with diaper changing as the highest-risk procedure for such transmission. The objective of this study was to evaluate the effectiveness of an intervention program in decreasing the incidence of infectious disease symptoms in children attending family day care homes during a 12-month period. Each of 24 family day care homes was randomly assigned to an intervention or control group. The intervention included four components: (1) a handwashing educational program and (2) use of vinyl gloves, (3) use of disposable diaper changing pads, and (4) use of an alcohol-based hand rinse by the day care provider. Symptoms of enteric disease (diarrhea and vomiting) were significantly reduced in intervention family day care homes (p less than or equal to 0.05), whereas respiratory symptoms were not significantly different between intervention and control family day care homes (p = 0.35). Diarrhea was reported in 1 of every 100 child care days, representing one diarrhea episode per month in a typical family day care home.

Alcohol-impregnated wipes as an alternative in hand hygiene

The antimicrobial effectiveness of four hand-wash products for health care personnel included three liquid soaps that contained 4% chlorhexidine gluconate, 1% triclosan, or no antiseptic ingredient, respectively, and a 30% w/w ethyl alcohol-impregnated hand wipe. These products were evaluated for reduction in bacterial counts on hands after extended use of 15 handwashes per day for 5 consecutive days. The order of greatest to least log reduction among products at the end of the 5-day test period was chlorhexidine gluconate (2.01), triclosan (1.52), alcohol wipe (0.04), and control soap (0.03). Skin condition before and after handwash was assessed for each treatment group. Subjects reported less skin irritation with alcohol wipes than with the two antiseptic products. Repeated washing with alcohol wipes results in reductions in bacterial colony counts comparable with nonmedicated soap, sufficient to prevent transmission of pathogens by the hands in most situations that arise in nonacute health care settings. This evidence, in addition to increased user acceptability reported by the subjects who used alcohol wipes, suggests that alcohol wipes are an acceptable alternative to soap-and-water handwashing in nonacute health care settings.

Recurrent outbreaks of giardiasis in a child day care center, Wisconsin

In the 19-month period September 1983-March 1985, three outbreaks of giardiasis occurred in one large child day care center. Control measures instituted during each outbreak included case finding; pharmacologic treatment and follow-up testing of stool specimens for cases of giardia infection in day care children and staff, and their household contacts; facilitating and stressing personal and environmental hygiene, including altering diapering practices and teaching appropriate hand washing techniques. In the first, second, and third outbreaks, overall attack rates (stool analysis positive for Giardia lamblia) were determined for those persons with greater than or equal to 2 stool specimens submitted; attack rates in children were 47, 17, and 37 per cent, respectively; for tested staff, the rates were 35, 13, and 9 per cent; and for tested household contacts were 18, 9, and 5 per cent. Attack rates were highest for ambulatory diapered children, children attending the day care center greater than or equal to 40 hours per week, and children who were infected with G. lamblia in the most recent previous outbreak. Despite extensive efforts to identify cases, a cure rate of greater than 90 per cent in treated cases, and improvements in personal and environmental hygiene practices, G. lamblia infections recurred in outbreak proportions.

Effects of diaper types on diaper dermatitis associated with diarrhea and antibiotic use in children in day-care centers

Infants and toddlers in day-care centers have a relatively high frequency of diarrhea and/or oral antibiotic use, and may be at increased risk of developing diaper dermatitis when diapered. A six-month, prospective, double-blind study was conducted in day-care centers in Houston, Texas, to determine the frequency of diarrhea, antibiotic use, and diaper dermatitis in infants and toddlers wearing conventional (cellulose-only core) disposable diapers or disposable diapers with a core of absorbent gelling material (AGM) and cellulose. A questionnaire was administered weekly to the day-care staff to gather health information, and weekly visual examinations were made of children for diaper dermatitis. The frequency of diarrhea was 1.9 episodes per child-year and that of antibiotic use was 3.3 courses per child-year. Infants diapered in disposable diapers with AGM had a significantly (P 0.032) lower mean grade of diaper dermatitis during diarrhea episodes and a lower (P 0.054) mean grade during antibiotic use, compared to those diapered in conventional disposable diapers. There was no significant difference between groups with regard to isolation of Staphylococcus aureus or Candida albicans from superficial skin cultures of the diapered area. The results indicate that diarrhea and antibiotic use occur frequently in children in day-care centers, and that the severity of diaper dermatitis is less in children wearing AGM disposable diapers than those wearing conventional disposable diapers in that setting.

Asymptomatic excretion of rotavirus before and after rotavirus diarrhea in children in day care centers

A 12-month prospective study of diarrhea in children in day care centers (DCCs) provided an opportunity to evaluate the duration of excretion of rotavirus from children before and after episodes of diarrhea caused by rotavirus. Ninety-nine episodes of rotavirus diarrhea occurred in 94 children. Asymptomatic rotavirus excretion occurred in 50% of children tested on the day before diarrhea occurred, 31% two days before diarrhea, and 9% in days 3 through 5 before diarrhea. Two children had positive specimens 11 and 13 days, respectively, before illness. During the week after cessation of diarrhea, 32% had positive specimens; 12% had positive stool specimens during the second week after diarrhea episodes. Electrophoretic testing of rotavirus RNA from stool specimens showed different electrophoretic migration patterns of the genomic RNA among the pairs tested, but the genomic RNA was the same within each pair of symptomatic and asymptomatic specimens. Excretion of rotavirus before and after diarrhea is common in children in DCCs; the role that asymptomatic excretion plays in the spread of this disease within DCCs is unknown.

Infectious diseases in day-care centers: transmission and approaches to prevention

Child day care is used increasingly by both single-parent and two-parent families. With the growth in numbers of children receiving day care outside the home comes a greater awareness of the potential for disease transmission. Epidemiologic patterns of spread of such diseases as Hemophilus influenzae type b, hepatitis A, diarrheal diseases, and cytomegalovirus are changing with respect to attendance at a day-care center. Not only is this a problem for the staff and children who attend a center, but it also may be a public health concern as these diseases could spread to households and the community at large. This review will identify those transmissible infectious agents frequently found in children who attend day-care centers with an emphasis on approaches to prevention and methods for decreasing secondary spread.