Infectious diseases in schools and child care facilities

Challenging the Conventional Interpretation of HCMV Seronegativity

The majority of adults in the world (around 83%) carry antibodies reactive with HCMV and are thought to retain inactive or latent infections lifelong. The virus is transmitted via saliva, so infection events are likely to be common. Indeed, it is hard to imagine a life without exposure to HCMV. From 45 seronegative individuals (13 renal transplant recipients, 32 healthy adults), we present seven cases who had detectable HCMV DNA in their blood and/or saliva, or a CMV-encoded homologue of IL-10 (vIL-10) in their plasma. One case displayed NK cells characteristic of CMV infection before her HCMV DNA became undetectable. In other cases, the infection may persist with seroconversion blocked by vIL-10. Future research should seek mechanisms that can prevent an individual from seroconverting despite a persistent HCMV infection, as HCMV vaccines may not work well in such people.

Variation in surface decontamination practices among Michigan child care centers compared to state and national guidelines

BACKGROUND

Environmental decontamination is one of the most effective methods to prevent transmission of infectious pathogens in child care centers (CCCs). Alongside state recommendations, national organizations-including the American Academy of Pediatrics (AAP)-offer best-practice policies. In Michigan, these sets of guidelines differ, and the extent to which CCC practices agree with either set of protocols is unknown.

METHODS

A survey of environmental decontamination practices was administered at a professional meeting of CCC directors (N = 24) in a single Michigan county. CCC practices (eg, products, locations, frequencies) were compared to state and AAP guidelines. Bivariate analyses investigated CCC characteristics as predictors of decontamination policy agreement.

RESULTS

CCC agreement with established policy was slightly higher for national AAP guidelines (66%) than Michigan standards (59%). The use of an outside child care health consultant was strongly associated with a significantly higher level of agreement with state decontamination policy (P = .01).

CONCLUSION

We noted substantial disagreement between county CCC practices and state/national guidelines, regardless of CCC size or director experience. Results highlight opportunities to improve CCC director familiarity with current state and nationally advised protocols, to consolidate state licensing and AAP guidelines, and to promote the use of child care health consultants.

Kingella kingae: carriage, transmission, and disease

Kingella kingae is a common etiology of pediatric bacteremia and the leading agent of osteomyelitis and septic arthritis in children aged 6 to 36 months. This Gram-negative bacterium is carried asymptomatically in the oropharynx and disseminates by close interpersonal contact. The colonized epithelium is the source of bloodstream invasion and dissemination to distant sites, and certain clones show significant association with bacteremia, osteoarthritis, or endocarditis. Kingella kingae produces an RTX (repeat-in-toxin) toxin with broad-spectrum cytotoxicity that probably facilitates mucosal colonization and persistence of the organism in the bloodstream and deep body tissues. With the exception of patients with endocardial involvement, children with K. kingae diseases often show only mild symptoms and signs, necessitating clinical acumen. The isolation of K. kingae on routine solid media is suboptimal, and detection of the bacterium is significantly improved by inoculating exudates into blood culture bottles and the use of PCR-based assays. The organism is generally susceptible to antibiotics that are administered to young patients with joint and bone infections. β-Lactamase production is clonal, and the local prevalence of β-lactamase-producing strains is variable. If adequately and promptly treated, invasive K. kingae infections with no endocardial involvement usually run a benign clinical course.

[Infectious diseases and use of health care resources in children less than 2 years-old who attend kindergarten]

INTRODUCTION AND OBJECTIVES

Parents often ask paediatricians for advice about the best way to care for their children. There are discrepancies in the literature on this subject. The objective of this study is to evaluate the influence of attending kindergartens on the risk of acute infections and the use of health care resources in children less than 24 months.

POPULATION AND METHODS

A prospective longitudinal study was conducted on two cohorts of children 0-24 months (born between 1 January and 30 September 2010), who were grouped according to whether they attended kindergarten or not, and were usually seen in 33 pediatric clinics of the Principality of Asturias Public Health Service.

RESULTS AND CONCLUSIONS

A total of 975 children were studied, of whom 43.7% attended a kindergarten at 24 months. Attending kindergarten increases the risk of pneumonia by 131%, recurrent wheezing by 69%, bronchitis by 57%, and otitis media by 64%. Early exposure to kindergarten increases the risk of pneumonia from 2.31 to 2.81, and the mean emergency room visits from 1 to 2.3. The mean antibiotic cycle is 1.7 in children who do not go to kindergarten, 3.4 if started within the first 6 months, and 2 if they start at 18 months. Day-care attendance is a risk factor of infectious diseases that increases if attending kindergartens from an early age.

Outbreaks of Kingella kingae infections in daycare facilities

During the past decade, transmission of the bacterium Kingella kingae has caused clusters of serious infections, including osteomyelitis, septic arthritis, bacteremia, endocarditis, and meningitis, among children in daycare centers in the United States, France, and Israel. These events have been characterized by high attack rates of disease and prevalence of the invasive strain among asymptomatic classmates of the respective index patients, suggesting that the causative organisms benefitted from enhanced colonization fitness, high transmissibility, and high virulence. After prophylactic antibacterial drugs were administered to close contacts of infected children, no further cases of disease were detected in the facilities, although test results showed that some children still carried the bacterium. Increased awareness of this public health problem and use of improved culture methods and sensitive nucleic acid amplification assays for detecting infected children and respiratory carriers are needed to identify and adequately investigate outbreaks of K. kingae disease.

30 years of study of Kingella kingae: post tenebras, lux

Kingella kingae is a Gram-negative bacterium that is today recognized as the major cause of joint and bone infections in young children. This microorganism is a member of the normal flora of the oropharynx, and the carriage rate among children under 4 years of age is approximately 10%. K. kingae is transmitted from child to child through close personal contact. Key virulence factors of K. kingae include expression of type IV pili, Knh-mediated adhesive activity and production of a potent RTX toxin. The clinical presentation of K. kingae invasive infection is often subtle and may be associated to mild-to-moderate biologic inflammatory responses, highlighting the importance a high index of suspicion. Molecular diagnosis of K. kingae infections by nucleic acid amplification techniques enables identification of this fastidious microorganism. Invasive infections typically respond favorably to medical treatment, with the exception of cases of endocarditis, which may require urgent valve replacement.

Prevalence of pharyngeal carriage of Kingella kingae in young children and risk factors for colonization

The carriage rate of Kingella kingae among Jewish and Bedouin children living in southern Israel paralleled the age-related incidence of invasive infections. Age 6-29 months was a significant risk factor for K. kingae colonization in both ethnic groups; day-care attendance was a risk factor in Jewish children, whereas living in a shanty town was negatively associated with carriage in Bedouins.

Cytomegalovirus as an occupational risk in daycare educators

BACKGROUND

Cytomegalovirus (CMV) infection continues to be an important occupational risk in the daycare setting. A comprehensive update of scientific evidence is timely to inform and promote appropriate preventive measures.

METHODS

A review of the literature was conducted to examine the evidence for an occupational risk of CMV infection in daycare educators. Sources included Medline, government documents and additional references from published bibliographies. The key words used for searches were 'child day care centres' or 'nurseries' and 'cytomegalovirus' or 'cytomegalovirus infection'.

RESULTS

EIGHT CMV SEROPREVALENCE STUDIES ON DAYCARE EDUCATORS IN INDUSTRIALIZED COUNTRIES WERE FOUND: four in the United States, three in Canada and one in Italy. Risk factors for seropositivity were older age, nonwhite race, foreign birth, birth in a low- or middle-income country, diaper changing, having children at home, and a child to educator ratio greater than 6:1 in children 18 to 35 months of age. Risk factors for seroconversion were younger age and working with young children. These studies suggest that daycare centres may be a high-risk setting for CMV infection.

DISCUSSION

Recommendations to prevent CMV infection in this setting include handwashing, selective serological screening, avoiding work with younger children if pregnant and, in some cases, preventive leave from work. Evaluation and expert opinion of the effectiveness of various preventive options for CMV acquisition are needed to ensure that recommendations are evidence-based.

Outbreak of Kingella kingae skeletal system infections in children in daycare

OBJECTIVE

The objective of this study is to describe the investigation of an outbreak of one culture-proven and two presumptive cases of Kingella kingae osteomyelitis detected within a 15-day period in a daycare center in Israel.

METHODS

Surveillance pharyngeal cultures were obtained from all attendees at the index daycare center and from two neighboring facilities. Combined amoxicillin-rifampin prophylaxis was administered to all children aged 6 to 30 months living in the community. K. kingae isolates were typed by pulsed field gel electrophoresis, random amplified polymorphic DNA analysis and sequencing of the rRNA genes.

RESULTS

Surveillance cultures showed that four of 11 attendees at the index facility as well as five of 12 and one of 15 attendees at neighboring daycare centers carried K. kingae. Typing of isolates showed that the isolate from a child with osteomyelitis was identical to all other isolates from the same daycare center and different from organisms derived from the other facilities. Administration of prophylactic antibiotics resulted in partial eradication of the organism.

CONCLUSIONS

Dissemination of K. kingae in a susceptible pediatric population may result in an outbreak of invasive disease. Our experience suggests the need for increased alertness for clusters of K. kingae infections among children in daycare.

Pediatrician attitudes to exclusion of ill children from child-care centers in Israel: pressure on ambulatory practices

BACKGROUND

The exclusion of ill children from child-care centers may be associated with high social, economic and medical costs.

OBJECTIVE

To assess the opinions of pediatricians working in an outpatient setting in Israel on the exclusion/return of children in child-care centers.

METHODS

A questionnaire on practices of exclusion/return of children in child-care centers, in general and according to specific signs and symptoms, was administered to a random computer-selected cross-sectional sample of 192 primary care community pediatricians in Israel.

RESULTS

One hundred and seventy-three pediatricians completed the questionnaires, for a response rate of 90%; 147 were board-certified and 26 were not. About half the pediatricians felt pressured by parents requesting antibiotic therapy to accelerate the return of their sick child to the child-care center. The majority also believed their practice was overloaded by often unnecessary demands for medical notes by the child-care centers before children could return. More than half based their decision to exclude children on "common sense" and the remainder, on accepted guidelines. Except for scabies and lice, there were no significant correlations between the physicians' stipulation for a note on return of the child and the specific illness guidelines.

CONCLUSIONS

This study shows that a high proportion of pediatricians based their exclusion practices on "common sense" and personal understanding instead of established guidelines, and that the guidelines did not affect their opinion on the duration of illness that warrant a note. Furthermore, half were subjected to parental pressure to employ inappropriate practices. These findings, combined with our earlier survey of child-care centers staff, indicate that better education of parents and day-care staff about ill child-care-center-exclusion policy in Israel would increase their common understanding with pediatricians.

Knowledge and Beliefs About Guidelines for Exclusion of Ill Children From Child Care

BACKGROUND

The American Academy of Pediatrics published national child care illness exclusion guidelines in 1992 and 2002. To our knowledge, no published studies have examined child care providers', parents', and pediatricians' knowledge or beliefs about these guidelines.

OBJECTIVE

To compare parents', pediatricians', and center-based child care providers' (CCPs) knowledge and beliefs about exclusion guidelines.

DESIGN

Cross-sectional survey conducted in 2000 of 80 CCPs, 142 parents, and 36 pediatricians in Baltimore City. Main outcome measures included familiarity with and knowledge of exclusion guidelines and beliefs about exclusion effectiveness among these groups.

RESULTS

Response rates were 58% for parents, 59% for pediatricians, 85% for CCPs. Sixteen percent of child care providers (CCPs), 39% of parents, and 53% of pediatricians had not seen any written exclusion guidelines. Compared with national guidelines for 12 common symptoms, responses from CCPs and parents indicated overexclusion, while pediatricians indicated underexclusion. The groups scored similarly in number of correct answers on knowledge items (CCPs 63%, parents 64%, pediatricians 61%, P = .44). More CCPs and parents than pediatricians believed that exclusion effectively controlled infection spread and that sick children should be excluded because they spread disease, would be more comfortable, and recover faster at home (P < .001).

CONCLUSIONS

This survey found CCPs, parents, and pediatricians all failed to recognize how national guidelines recommended managing 4 out of 10 common conditions on average. CCPs were more likely than pediatricians to believe that exclusion was warranted to control infection or for the child's personal needs.

Exclusion of ill children from child-care centers in Israel

The aim of the study was to examine criteria for ill children in child-care centers. A questionnaire on practices of exclusion/return of children according to specific signs and symptoms was mailed to the directors of care centers in central Israel. Thirty-six of the 60 questionnaires (60%) were returned by mail and the reminded were completed in personal visits to the CCCs achieving a response rate of 100%. About half (51.7%) used "common sense" and "personal feelings" to exclude children and to allow their return, and 29 (48.3%) used the guidelines of the Ministries of Education and Health or other authorities. The percentage of centers excluding children by signs/symptoms was as follows: high fever (>38 degrees C), 100%; low-grade fever, 76.7%; asthma exacerbation, 80.0%; heavy cough, 75.0%; eye discharge or conjunctivitis, 83.3%; diarrhea and vomiting more than twice per day, 100%; rash, 72.3%; otalgia, 46.7%; and infected skin lesion, 66.7%. Only four centers excluded children with head lice. Most centers required a physician's note on return of a child after high fever (76.7%), eye discharge or conjunctivitis (48.3%), and from 75 to 80%, respectively, for frequent vomiting and bloody or mucinous diarrhea. The results show that exclusion practices among child-care centers (CCCs) vary widely, suggesting the need for the establishment of a uniform exclusion and return policy in Israel, with distribution of clear, up-to-date guidelines on the prevention and control of communicable diseases to all day-care centers. In a simple way, this study identified attitudes concerning the exclusion/return of sick children in CCCs and was useful for the discussion of the related policy with CCCs responsible and national health and educational authorities.

Influence of school closure on the incidence of viral respiratory diseases among children and on health care utilization

We evaluated the effect of school closure on the occurrence of respiratory infection among children ages 6-12 years and its impact on health care services. During this period, there were significant decreases in the diagnoses of respiratory infections (42%), visits to physician (28%) and emergency departments (28%) and medication purchases (35%). The present study provides quantitative data to support school closure during an influenza pandemic.