Transcript Slide 1

Managing Diarrheal Disease
in the Child-Care
Environment: The Science
and Practice
Angela Fraser, Ph.D.
Clemson University
Introduction
• Between 21-37 million episodes of diarrheal disease
occur each year in children under 5 years old.
• Children in child care 2.3-3.5X more likely to get
diarrhea than those cared for in their own home.
• Between 1996 and 2006, 75 reported enteric outbreaks
in child-care settings:
• 55.7% cases attributed to viruses,
• 39.6% bacteria, and
• 6.6% parasites.
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Fact Sheet Subject Areas
• Food Handling
• Hand Hygiene
• Diapering
• General Sanitation
• Clean-up of Vomit and Feces
• Exclusion
• Outbreak Control
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FOOD HANDLING
Foodborne Disease
• 48 million Americans contract a foodborne disease
each year.
• Most cases are not life-threatening.
• 3,000 people die.
• 125,000 are hospitalized due to complications.
• Serious complications more common in high-risk
populations
• young children (<5 years),
• older adults (>65 years), and
• the chronically ill.
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Step 1: Buying
• Buy food from an approved source that has passed
a state or federal inspection, such as a grocery store
or a food retailer.
• Whole uncut fruits and vegetables can come from
any source.
• Grocery stores/convenience stores
• Foodservice suppliers
• Farmers Markets
• Home gardens
• Roadside vendors
• Community supported agriculture (CSAs)
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Step 2: Storage
• Store unopened, non-perishable food:
• in a cool dry area;
• on clean shelving that is at least 12 inches off the floor or in
clean kitchen cupboards;
• in a tightly covered container if removed from its original
packaging.
• Never store food under any plumbing lines (especially
kitchen sinks).
• Never store food on the floor.
• Label and date the container, not the lid, with the name
of the food.
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Refrigeration and Freezing
• Refrigeration
• Keep at 39°F or colder.
• Store highly perishable foods in the coldest part of the
refrigerator — usually toward the back of the
refrigerator.
• Put raw animal foods in a container and store on the
lowest shelf so juices do not contaminate other foods.
• Freezing
• Freezer temperatures slow bacterial growth, but do not
necessarily kill bacteria.
• Keep freezer temperatures below 0°F.
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Storing Foods Brought from Home
• Always label and date food brought from home.
• Check food to determine if it needs to be kept cold,
refrigerate immediately.
• Make sure food is in sealed containers, such as
screw-top drink bottles, plastic containers, plastic
bags, or unopened packages.
• If a lunch container is leaking (such as a container of
soup from a lunch bag), remove it, and clean the
refrigerator and any lunch bags or containers that
were soiled.
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Step 3: Preparation
• Washing fruits and vegetables:
• Wash whole fruits and vegetables you will not peel with
warm water before eating or preparing for cooking.
• Never use detergent or bleach solutions to wash fresh
produce.
• Immerse leafy green vegetables in a clean colander with
warm running tap water to remove any dirt or debris. Dry in a
salad spinner or blot with paper towels.
• Scrub fresh produce that has firm skin, such as melons, with a
clean produce brush.
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Cooking
• Proper cooking makes most foods safe because the
process kills harmful microorganisms, such as
bacteria, some viruses, and parasites. Cooking does
not always destroy toxins.
• Foods must be cooked without interruption until the
minimum required internal temperature is reached:
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Whole cuts of beef or pork – 145°F or hotter
Fish – 145°F or hotter
Ground beef – 155°F or hotter
Poultry/eggs – 165°F or hotter
Leftovers – 165°F or hotter
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Special Consideration — Eggs
• The FDA Food Code (Chapter 7) requires that raw or
partially cooked animal foods not be served to highly
susceptible populations, such as children.
• Eggs are one raw animal food of great concern and can
be contaminated with Salmonella.
• Pasteurized eggs or egg products must be substituted
for the use of raw eggs unless the raw eggs are
combined as an ingredient in baked goods, such as
cakes, muffins, or bread.
• Never allow children to lick the spoon or taste eggbased batter or dough.
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Potentially Hazardous Food
• Potentially hazardous foods are moist, low acid, and
have some protein.
• To prevent bacteria from growing, keep potentially
hazardous foods above 135°F or below 41°F.
Potentially Hazardous Foods:
•macaroni and cheese
•cooked vegetables, such as
corn and broccoli
•oven fried chicken
•hot dogs
•cole slaw
•melon slices
Non-Potentially Hazardous
Foods:
• waffles
• rolls
• Jell-O®
• apple and orange slices
• bread
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Step 4: Serving
• Provide a clean and sanitized utensil for each
serving bowl and dish.
• Do not:
• lay utensils on the table as they could contaminate the
food when the utensil is used to get seconds.
• let children serve themselves from large boxes of
cookies, cereal or crackers.
• let children share the same utensil or dish when eating.
• allow children to eat food that has fallen on the floor.
• The same goes for utensils. Use a new one or clean
and sanitize the “fallen” one.
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Step 5: After Mealtime and
Snack
• Throw out uneaten food that
has been served (don’t put it
back in the jar or bag).
• Never put milk or other
beverages that have been
poured into glasses or cups
back in their original
containers.
• You can save unpeeled fruits
and unopened nonperishable
packaged food. Wash fruit
before storing.
Cooling
• If food is improperly cooled and in the temperature
danger zone for >4h, bacteria might grow.
• Put potentially hazardous food in containers at depths no
greater than 2-3 inches.
• Loosely cover containers with a lid, plastic wrap, or foil.
• Label and date food containers.
• Refrigerate immediately.
• It is best to use foods within 3-4 days after cooking. If
you cannot use the food in this time frame, freeze it.
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Reheating
• Reheat large servings of
leftovers to above 165°F.
• Never reheat food in a crock
pot or a slow cooker. Takes
too long to heat food to safe
temperatures.
• When reheating in a
microwave, stir periodically
and rotate food for even heat
distribution.
Food Safety for Field Trips
• Safe foods for outings:
• peanut butter and jelly sandwiches
• cookies
• crackers
• fresh unpeeled fruit
• commercially dried fruit
• unopened cans of fruit or pudding
• Foods that must be cold:
• meat sandwiches
• milk or foods that contain milk
• peeled or cut fruits and
vegetables
• opened cans of fruit
• Use clean sealable lunch boxes for storing and transporting
lunches and snacks.
• Use sealable containers or zip-lock bags to hold foods that are to
be placed in lunch boxes.
• Store all packed lunches and snacks in a refrigerator until placing
them in a cooler before departure.
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Packing the Cooler
• Place ice packs or bags of ice
in the bottom of the cooler.
• Loosely arrange pre-chilled
lunches loosely on top of ice.
• Fill the remaining space in the
cooler with ice packs or ice
bags. A full cooler will
maintain a cold temperature
longer than a partially filled
cooler.
• Once the cooler is closed, do
not open it again until ready
to eat.
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Baby Food
• After opening, label the can or jar
• with name, date and time opened.
• Place portion of baby food for one
• feeding in a clean bowl.
• Never feed directly out of the jar.
• Bacteria in saliva could contaminate
• the food and make it unsafe for
• later use.
• Refrigerate unserved portions in the original jar.
• Throw away unused portions within 36 hours after opening —
preferably within 24 hours.
• Observe the “use by” dates on unopened jars of baby food.
Breast Milk and Infant Formula
• Breast Milk
• Ask parents to label each container with the name of the child
and the date the milk was pumped.
• Refrigerate and use breast milk within one day.
• Infant Formula
• If using ready-to-feed formula, shake the can well before
opening and pour the amount of formula needed for one feeding
into a sterilized bottle.
• If using powdered formula, prepare the formula according to
the manufacturer’s directions.
• Never add new formula to a half-filled bottle of formula.
• Refrigerate and use prepared formula within one day.
• Throw out leftover formula in the bottle after feeding.
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Bottle Sterilization
• Wash with detergent and warm water, rinse, and air dry.
• Sterilization
• Fill a large pot with water.
• Place cleaned feeding and preparation equipment into water.
• Make sure equipment is completely
covered with water and no air
bubbles are trapped.
• Cover pot with a lid; bring to rolling boil.
• Boil for five minutes.
• Keep pot covered until bottles are needed.
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HAND HYGIENE
Providers Should Wash Hands:
• Before and after:
• preparing food or
beverages
• eating or handling food
• feeding a child
• giving medication
• applying a medical
ointment or cream to
skin that may be broken
• diapering
• After:
• Using toilet or helping a child
use a toilet
• handling bodily fluids from
sneezing, wiping and blowing
noses, mouths, or sores
• handling animals or cleaning
up animal waste
• cleaning or handling the
garbage
• using chemicals
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How to Wash Hands
• Water should be a warm, comfortable temperature 60°F-120°F.
• Moisten hands and apply soap.
• With hands out of the water stream, rub hands together
vigorously until a soapy lather appears and continue for 10 to
15 seconds.
• Rinse hands under warm, running water until free of soap and
dirt.
• Thoroughly dry hands with one of the following:
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single-use paper towels
continuous towel system that supplies the user with a clean towel
heated-air hand drying device
hand drying device that employs an air-knife system that delivers high
velocity, pressurized air at ambient temperatures
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Alcohol-based Hand Rubs
• Only use when no visible debris on
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hands.
Apply required volume of product
to the palm of one hand.
Rub hands together--required
volume must keep the hand
surfaces “wet” for at least 15
seconds or as indicated by the
manufacturer.
Rub all surfaces of the hands and
fingers.
Allow hands to air-dry; do not use
paper towels to dry hands.
Children must be constantly
supervised when using hand
sanitizers to avoid over-dispensing,
consumption, or eye contact.
DIAPERING
Preparation
• Keep necessary items near the diaper changing table.
• Carry the child to the changing table, keeping soiled clothing
away from you and any surface you cannot easily clean and
disinfect afterwards.
• Place the child on the diaper-changing surface.
• Always keep a hand on the child.
• Remove the child’s shoes and socks so the child does not contaminate
these surfaces with stool or urine during the diaper change.
• Put soiled clothes in a plastic bag and securely tie the plastic bag to send
home.
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Removing the Dirty Diaper
1. Unfasten diaper, but leave it under child.
2. Lift the child’s legs as needed.
3. Remove stool and urine by wiping from front to back,
using a fresh wipe each time.
4. Put the soiled wipes into soiled diaper or directly into
a plastic-lined, hands-free covered trashcan.
5. Remove soiled diaper without contaminating any
surface not already in contact with stool or urine.
6. Fold soiled surface of diaper inward; put soiled
diapers in covered, plastic-lined, hands-free, trashcan.
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Putting on a New Diaper
1. Check for spills under child. If any, use paper that
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extends under child’s feet to fold over dirty paper so
a fresh, unsoiled paper surface is under child’s
behind.
Slide a fresh diaper under the child.
Use a facial or toilet tissue to apply any necessary
diaper creams, discarding tissue in a covered,
plastic-lined, hands-free trashcan.
Fasten diaper and replace clothing, socks, and shoes.
Wash the child’s hands first then wash your hands.
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SANITATION
Cleaning
• Cleaning = removal of dirt, food, and grease from a
surface.
• Two steps to effective cleaning:
1. Washing with a detergent – detergents help reduce the
surface tension of water so can lift soil from a surface.
2. Rinsing with warm water – rinsing removes the
suspended soil and detergent from a surface.
• A cleaned surface may look visibly unsoiled, but may
still be contaminated with pathogenic microorganisms.
• Cleaning must be followed by sanitizing or disinfecting.
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Sanitizers
• Sanitizers reduce the number of bacteria on a surface
to levels considered safe as determined by public
health codes and regulations.
• Sanitizers used on food-contact surfaces and soft
surfaces, such as textiles, fabrics, and carpeting.
• Food-contact sanitizers must reduce the bacterial count
by 5 logs or 99.999%.
• Non-food contact sanitizers reduce bacteria by at least
3 logs or 99.9%.
• Sanitizers are not effective against viruses and fungi.
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Disinfectants
• Disinfectants are used to destroy or irreversibly
inactivate the microorganisms listed on their label,
which may include bacteria, fungi, and viruses, but
not necessarily spores.
• Disinfectants are used on all hard surfaces that are
not considered food-contact surfaces.
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Food-Contact Surfaces
• Before and after preparing
food, always clean and
sanitize:
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countertops
sinks
highchair trays
tables used for eating
placemats
bibs
• Disinfectants generally not
used for food-contact surfaces
because they can leave
harmful residues.
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When To Disinfect
• Housekeeping surfaces:
• clean and disinfect surfaces with a low or intermediate-level
disinfectant on a weekly basis.
• High-touch surfaces:
• clean and disinfect surfaces every day, even if not visibly
dirty. If they become visibly dirty, clean immediately.
• Bathroom surfaces:
• clean and disinfect at least twice a day to reduce spread of
pathogens. If surface becomes visibly soiled, clean and
disinfect more often.
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Sanitizing/Disinfecting a Surface
1.
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Clean surface with warm
soapy water.
Rinse with clean water.
Thoroughly saturate the
surface with a sanitizing or
disinfecting solution.
Allow sanitizer/disinfectant
to stand for appropriate
contact time.
Air dry. Do not rinse off
the sanitizing/disinfecting
solution.
CLEAN-UP OF
VOMIT AND FECES
Designated Clean-up Staff
• Identify one or two employees to be in charge of
cleaning up vomit and feces.
• Food workers should NEVER clean-up vomit or feces.
• Train designated workers in proper:
• use of personal protective equipment in bodily fluid clean-up
kit—gloves and apron;
• cleaning and disinfecting of surfaces contaminated by bodily
fluids;
• disposal methods for vomit and fecal matter, which are
classified as infectious waste by OSHA.
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Bodily Fluid Clean-up Kit
• Protective gear
• 2 pairs of disposable gloves*
• 1 face mask
• 1 disposable gown with sleeves*
• 1 disposable hair cover
• 1 pair of shoe covers
• Cleaning supplies
• 1 sealable, plastic bag or biohazard bag with twist tie
• 1 scoop/scraper
• disposable towels
• absorbent powder/solidifier (such as kitty litter)
• bottle of disinfectant
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Isolating Sick Individuals
• Clear all individuals from the area after a vomiting or diarrheal
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episode, including the sick individual.
Move all children who have similar symptoms to a separate area.
Restrict staff members’ activities to one area or room to reduce
the spread of microorganisms from sick individuals to healthy
individuals.
Remove all toys and other materials used by sick children from
healthy children until items have been thoroughly cleaned and
disinfected.
Each child should have a clean outfit to change into in the event
that the original clothing becomes contaminated.
Machine wash any clothing that may have been contaminated in
hot water with detergent; dry the items in a dryer on high heat.
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Cleaning Procedures
• Put on proper personal protective equipment.
• Block off affected space to prevent re-entry.
• Cover spill with absorbent powder/disposable towels to soak up
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fluid.
Scoop up the solidified powder or soaked towels, and place them
in a sealable plastic bag.
Cover area with disinfectant soaked paper towels or rags for 5-10
minutes or let air dry.
Wipe up residual disinfectant with paper towels.
Remove all personal protective equipment.
Dispose of bag in accordance with local regulations.
Wash hands thoroughly.
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EXCLUSION
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Procedures for Sick Children
• Contact family to pick up the child as
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soon as possible.
Document details in child’s file--date,
time, symptoms, actions taken, and
caregiver’s name with signature.
Tell family member about symptoms
and what is required for child to
return.
Ask family to share information with
their health care provider.
Contact the local health department if
questions about a notifiable
communicable disease.
When to Exclude a Child
• Symptoms
• Persistent abdominal pain (continuing for more than two hours) or
intermittent abdominal pain accompanied by fever, dehydration or
other systemic symptoms.
• Fever accompanied by behavior changes or other signs and
symptoms that are suggestive of a severe illness
• For infants under 4 months: a rectal temperature of 101°F or greater
• For infants and children older than 4 months:
• Auxiliary (under the arm) temperature greater than 100°F
• Oral temperature greater than 101°F
• Rectal temperature greater than 102°F
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Vomiting two or more times during a 24-hour period
Diarrhea (three or more loose stools in a 24-hour period)
Jaundice
Sore throat with a fever.
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When to Exclude a Child
• Diagnosed Illnesses
• Norovirus
• Rotavirus
• Hepatitis A virus
• Shigella spp.
• Enterohemorrhagic or
shiga toxin-producing E.
coli
• Salmonella Typhi and other
Salmonella spp.
• Campylobacter spp.
• Giardia lamblia
When a Child Can Return
• Diarrhea
• After diarrhea has stopped or after a doctor clears the child
to return
• Children having diarrhea with blood or mucus must have a
medical note to return to the child-care center
• Vomiting
• After vomiting stops unless the child is known not to be
contagious
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When a Child Can Return
• Children can return with the resolution of the symptoms and a
medical note:
Rotavirus – after diarrhea stops
E. coli – after diarrhea stops
Salmonella spp. – after diarrhea stops
Campylobacter– after diarrhea stops
Norovirus – after diarrhea and vomiting stops
Hepatitis A virus – one week after onset of illness or jaundice if symptoms are mild
Shigella – after diarrhea stops and after five days of antibiotics or a negative lab test
E. coli O157:H7 – after diarrhea stops and two lab tests taken 24 hours apart are
negative
• Salmonella Typhi
• Children under 5 years of age: exclude until diarrhea stops and three stool cultures
are negative for Salmonella Typhi
• Children 5 years of age and older: exclude until 24 hours without diarrhea
• Giardia – after diarrhea stops or the child has taken antibiotics for at least 24 hours
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When to Exclude Staff
• Symptoms
• vomiting
• diarrhea
• jaundice
• sore throat with a fever
• Diagnosed with:
• Norovirus
• Hepatitis A virus
• Shigella spp.
• Enterohemorrhagic or
shiga toxin-producing E.
coli
• Salmonella Typhi
When Staff Can Return
• Norovirus – after 48 hours without any symptoms or with written
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medical note that free of the infection
Shigella spp. – after 7 days without any symptoms or with written
medical note that free of infection based on test results showing two
consecutive negative stool samples no earlier than 48 hours after
stopping antibiotic use and at least 24 hours apart
Enterohemorrhagic or shiga toxin-producing E. coli – after 7 days
without any symptoms or with written medical note that the employee
is free of infection based on test results that show two consecutive
negative stool samples no earlier than 48 hours after stopping antibiotic
use and at least 24 hours apart
Hepatitis A virus – if they have been jaundice for more than 7 days,
have had symptoms other than jaundice for more than 14 days, or with
written medical note that the employee is free of infection
Salmonella Typhi – with written medical note that they are free from
infection
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OUTBREAK CONTROL
Contacting Local Health Department
• An outbreak is occurrence of two or more cases of a disease,
injury, or other health condition in a given area or among a
specific group of people during a specific period.
• When illnesses are suspected provide the following information to
the health department:
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number of children ill
number of childcare providers ill
symptoms
onset of illness
duration of illness
any events that might have been linked to the illnesses (meals, field trips,
animal contact) and the dates that they occurred
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Informing Parents and Staff
• A plan for communicating outbreak information between child-
care center staff members and parents/guardians must be
established.
• Common Methods for Communicating
• A letter or other written communication
• Telephone calls or in-person meetings
• Using online technology, including e-mails, text messages, and
announcements on a website
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Cleaning during an Outbreak
• Increased cleaning and sanitation protocols
immediately after a suspected outbreak has been
identified.
• Focus on areas with greatest likely environmental
contamination:
• increase cleaning of bathrooms to 1X/hour during high
frequency use
• increase cleaning of high-touch surfaces to 1X/2 hours
during high frequency use.
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