with children under the age of 3 years have jobs outside the home.' Thus ... outside the home;1 20% have some sort of group day care.1-3 ... In the day-care centre the daily interaction of diapered ... Stability of the infecting agent (Table I): Many viruses survive in ... spread of infection: close contact of four or more toddlers ...
I Editorial
Infectious diseases in day-care centres: minimizing te risk E. Lee Ford-Jones, MD, FRCPC Mee-Hai Marie Kim, MD Barbara A. Yaffe, MD, MHSc, FRCPC Anthony E.A. Ford-Jones, MD, FRCPC William H. Abelson, MD, FRCPC Robert M. Issenman, MD, FRCPC Ronald Gold, MD, FRCPC
In Canada today only one in five households includes the traditional working father and stay-home mother;' indeed, 52% of women with children under the age of 3 years have jobs outside the home.' Thus, approximately 2 million Canadian children require some form of child care outside the home;1 20% have some sort of group day care.1-3 It has recently been recognized that the incidence of infectious disease - particularly respiratory tract infections, enteric infections, and infections due to Haemophilus influenzae, Neisseria meningitidis, hepatitis A virus and cytomegalovirus (CMV) - in day-care centres is high. Although two exhaustive descriptions of the specific management of these diseases have been published,45 preventing infection in these group settings can be accomplished only with a knowledge of the mechanisms and risks of transmission and the pattems of illness. Mechanisms and risks of transmission In the day-care centre the daily interaction of diapered children from 5 or 10 families amplifies the transmission of infectious disease3 as a result of the following factors. Duration of exposure: Children attending daycare centres are exposed to large amounts of From the Division of Infectious Diseases, Hospital for Sick Children, Toronto, the departments of Pediatrics, University of Toronto, McMaster University, Hamilton, Ont., and Joseph Brant Memorial Hospital, Burlington, Ont., and the Department of Public Health, Toronto
Reprint requests to: Dr. E. Lee Ford-Jones, Division of Infectious Diseases, Hospital for Sick Children, 555 University Ave., Toronto, Ont. M5G 1X8
infectious material being shed by children who are carrying and incubating infectious agents but are not yet exhibiting symptoms (this period lasts 48 hours or more in the case of respiratory syncytial virus [RSV] and parainfluenza viruses),6 by those who have symptoms and by those who are recovering from infections (convalescent carriers). Stability of the infecting agent (Table I): Many viruses survive in large numbers in the environment - for hours in the case of respiratory viruses, such as RSV and influenza viruses, and for days in the case of enteric viruses, such as rotavirus and hepatitis A virus.7-11 Infecting dose: The inoculum required to produce infection is often small. In adults, 10 to 100 of the appropriate organisms may cause giardiasis or shigellosis,12 and even a single rhinovirus may result in infection.13 Host defence: Both the incidence and the severity of respiratory and enteric viral infections and many bacterial infections are greatest in infants. Respiratory and enteric pathogens, CMV, H. influenzae, N. meningitidis and many other infectious agents have their highest attack rates in children under the age of 2 years. Repeat infections: Because symptomatic infections occur on re-exposure to RSV and other respiratory and enteric viruses throughout life, children in day-care centres will likely have more infections than those reared entirely in the home. An adult may have a symptomatic RSV infection as soon as 7 weeks after a first infection, even though there is only one strain of the virus.14 Similarly, Norwalk agent may infect an adult 1 week after an earlier infection.15 Route of transmission: Communicable disease may be transmitted in the day-care centre by two routes: direct child-to-child or child-to-adult (staff or parent) contact; and indirect transmission, CMAJ, VOL. 137, JULY 15, 1987
105
through airborne spread or contamination of inanimate objects (fomites). The frequent introduction of new children into the day-care centre will amplify transmission; each new child not only introduces new pathogens but also is susceptible to the others' pathogens. There are several reasons for the particularly efficient transmission of infection in the day-care
centre and a total of 15 working days because of all illness.18 Many important costs to society of the extra acute infections have not yet been fully considered. These include extra visits to health care facilities, especially at night and on weekends; lost time from work because of the child's illness or the parents' secondary disease; extra use of public transit; purchases of prescription or patent drugs; alternative arrangements for child care; and family "stress" because of a child who seems "always" to have a fever, cold, diarrhea etc. Infections of their children in the day-care centre environment need not be one more issue about which working parents feel guilty; there are precautions that can be taken to minimize the risk.
centre. * Children have repeated close physical contact in playing with other children and adults.16 * Children, particularly younger infants, have been observed to put their hands in their mouths every 1 to 3 minutes.10 * Children are ignorant of basic hygiene and may be incontinent of feces.16 * Children require frequent hands-on contact by staff who are also caring for infected children.16 Transport of children in crowded vehicles to the day-care centre may also be important in the spread of infection: close contact of four or more
The solutions It is very encouraging that specialists in pediatric infectious disease are now recognizing what child psychologists have known and recommended for years:19 day-care centres require rigorously enforced staffing ratios of 1:3 to 1:4 for infants and toddlers, even during periods of vacation and staff illness; a primary caregiver should be -assigned to each child in the day-care centre; and day-care centre personnel should be trained to minimize the risk of transmission of infection among the children (for example, by ensuring that diapered children not gather regularly in groups larger than three or four). It is also clear that the problem of providing high-quality care, with appropriate wages for staff, at a cost parents can afford will not be resolved without a large infusion of interest translated into dollars. While awaiting evidence that various measures actually prevent infections, physicians and public health officials should take reasonable precautions to reduce the risk of transmission of infectious disease. The Centers for Disease Control (CDC) of the US Public Health Service recently published a kit, Stop Disease, for use in preventing infectious disease. The kit includes a handbook of general information about infectious diseases, specific handbooks for the day-care centre director, the centre staff and the parents of the children, and
toddlers - shouting, laughing, sneezing, coughing and wrestling - in the daily trips to and from the day-care centre must surely enhance transmis-
sion.17 Patterns of illness Four patterns of occurrence of illness emerge, depending on the populations in which symptoms develop:16 primarily children (e.g., H. influenzae type b infection); adults (staff and family) and children (e.g., viral diarrhea or respiratory disease); primarily adults (staff and family) (e.g., hepatitis A); and fetuses of staff or mothers (e.g., CMV infection).
Potential morbidity The morbidity associated with infectious diseases arising out of the day-care centre environment has not yet been fully defined in terms of either the potential physical or cognitive effect of the diseases or the cost to society. A parent may lose an estimated 4.7 working days per year because of diarrhea in a child attending a day-care
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posters about the importance of handwashing, methods of handwashing and diaper-changing, and signs of infection in children. The handbooks and posters were developed by the CDC with the assistance of day-care centre staff to ensure that the recommended practices were feasible. The kit (GPO #017-023-00172-8) is available for $4 (US) plus postage and handling from the Superintendent of Documents, US Government Printing Office, Washington, DC 02042, USA.
References 1. Sharing the Responsibility: Report of the Special Committee on Child Care, cat no SW41-1/1986E, Dept of Supply and Services, Ottawa, 1987 2. Brunel PA: Changing social trends: day care. Pediatr Infect Dis 1985; 4: 574-575 3. Marwick C, Simmons K: Changing childhood disease pattern linked with day-care boom. JAMA 1984; 251: 12451251 4. The Child Day Care Infectious Disease Study Group, Centers for Disease Control: Public health considerations of infectious diseases in child day care centers. J Pediatr 1984; 105: 683-701 5. Peter G, Giebink GS, Hall CB et al: Report of the Committee on Infectious Diseases, 20th ed, Am Acad Pediatr, Evanston, Ill, 1986 6. Frank AL, Taber LH, Wells CR et al: Patterns of shedding of myxoviruses and paramyxoviruses in children. J Infect Dis 1981; 144: 433-441 7. Hall CB, Douglas RG Jr, Geiman JM: Possible transmission
CASA DE CAMPWO-* CONTEST RULES 1. All entries must be typewritten (in either English or French) signed and dated. 2. Entrants must be paid-up 1987 members of the Canadian Medical Association. 3. Entries must be received on or before September 30, 1987. 4. Entries and the information they contain become the property ofCMAJand will not be returned. 5. One prize only will be awarded. 6. Entries will be judged by a committee of editorial staff of CMAJ. 7. Employees (and their immediate families living in the same household) of the Canadian Medical Association, Sunquest Tours, Casa de Campo, their advertising and promotional agencies and related companies ofthe above are not eligible to enter. 8. Tiavel arrangements will be made through Sunquest Tours and the trip is subject to Sunquest's terms and conditions as follows: a) Tlips depart from Toronto and will not be available over Christmas, New Year's or March break. b) Once trips are booked no changes can be made to the date of travel or the listed passengers. c) Tickets not used on the flight for which they have been issued cannot be reissued for another date oftravel. d) Tickets will be issued within seven days of departure. e) Passengers must be 21 years of age or over. 0 All bookings are subject to 100% cancellation penalties. g) Cancellation insurance is not available.
by fomites of respiratory syncytial virus. J Infect Dis 1980; 141: 98-102 8. Bean B, Moore BM, Steiner B et al: Survival of influenza viruses on environmental surfaces. J Infect Dis 1982; 146: 47-51 9. Keswick BH, Pickering LK, DuPont HL et al: Survival and detection of rotaviruses on environmental surfaces in day care centers. App) Environ Microbiol 1983; 46: 813-816 10. Hutto C, Little EA, Ricks R et al: Isolation of cytomegalovirus from toys and hands in a day care center. I Infect Dis 1986; 154: 527-530 11. Hadler SC, McFarland L: Hepatitis in day care centers: epidemiology and prevention. Rev Infect Dis 1986; 8: 548557 12. Pickering LK, Woodward WE: Diarrhea in day care centers. Pediatr Infect Dis 1982; 1: 47-52 13. Douglas RG Jr: Pathogenesis of rhinovirus common colds in human volunteers. Ann Otol Rhino) Laryngol 1970; 79: 563-571 14. Glezen WP, Taber LH, Frank AL et al: Risk of primary infection and reinfection with respiratory syncytial virus. Am J Dis Child 1986; 140: 543-546 15. Dolin R, Blacklow NR, DuPont H et al: Transmission of acute infectious non-bacterial gastroenteritis in volunteers by oral administration of stool filtrates. J Infect Dis 1971; 123: 307-311 16. Goodman RA, Osterholm MT, Granoff DM et al: Infectious diseases and child day care. Pediatrics 1984; 74: 134-139 17. Klein JO: Infectious diseases and day care. Rev Infect Dis 1986; 8: 521-526 18. Pickering LK, Bartlett AV, Woodward WE: Acute infectious diarrhea among children in day care: epidemiology and control. Rev Infect Dis 1986; 8: 539-547 19. Young KT, Zigler E: Infant and toddler day care: regulations and policy implications. Am J Orthopsychiatry 1986; 56: 43-55
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