Guidelines for Prevention and Management of Infectious Diseases in Schools

Transcription

1 Guidelines for Prevention and Management of Infectious Diseases in Schools Information for Schools in Waterloo Region Produced by: Region of Waterloo Public Health Infectious Disease Program Revised: October 2014

2 Table of Contents Introduction Reporting 1.1 Important Phone Numbers Legal Reporting Requirements Confidentiality Public Health Role Enforcement of Immunization of School Pupils Act Most Common Reportable Diseases in Schools Reporting High Absentee Rates Chickenpox Reporting Exclusion Guidelines 2.1 Chickenpox Exclusion Children who are Immune-Suppressed Exclusion Guidelines for Infectious Disease in Schools (Charts) Serious Illnesses due to Infectious Diseases 3.1 Serious Illness in School Settings Infection Prevention Measures 4.1 Routine Practices Prevention of Blood-borne Infections Pregnancy and Common Childhood Infections 5.1 Introduction Fact Sheet - Fifth Disease and Pregnancy Fact Sheet - Chickenpox and Pregnancy Appendices List of Reportable Diseases 34 Monthly Chickenpox Report Form 35 Wash your hands/clean your Hands (alcohol based rub) Poster 36 Cover Your Cough Poster 38 2

3 Introduction Almost one in five persons living in Waterloo Region either attend or work in a school or day care setting. The daily mix of students and staff provides numerous opportunities for germs to be passed between everyone in these settings, and especially from child to child. Children are natural explorers of their environments, play closely together and readily share their possessions, food and germs. Preventing and controlling the spread of infections that can be associated with these types of settings starts with information. This manual has been designed to provide information to staff about common infections and to assist in preventing of further transmission of the illness in the school setting. These guidelines will provide information on: Which diseases are reportable to Public Health Role of schools and Region of Waterloo Public Health (PH) personnel in reporting and follow-up of diseases General disease prevention information Exclusion recommendations for students with infectious diseases Information sheets that can be copied and shared as needed We hope you will continue to find these guidelines to be a helpful resource and tool to use in your school and we look forward to receiving your feedback For more information and/or to give feedback: Region of Waterloo Public Health, Infectious Diseases Reporting Line: ext Helpful websites: This entire document and further information including infectious diseases, vaccines and hand hygiene can be found on our Region of Waterloo Public Health website at: Further reliable, current information and printable fact sheets on common childhood infections can be found at the Canadian Pediatric Society website: Caring for Kids Illnesses and Infections 3

4 1.0 Reporting 1.1 Important Public Health Phone Numbers (TTY ) Infectious Diseases Reporting Line: , ext For reporting diseases designated in the guidelines or to obtain general information. Respiratory Intake Line: , ext For reporting of respiratory outbreaks, high absentee rates due to respiratory illness or to obtain general information. Health Protection & Investigation Division Public Health Inspector on-call line: , ext For reporting diseases designated in the guidelines, enteric outbreaks or to obtain information on cleaning/sanitation guidelines, water quality and safe food handling. Emergency After-hours or Weekend Reporting After 4:30 p.m. weekdays; all day weekends and holidays for urgent issues requiring notification of public health. Region of Waterloo Public Health (for referral to all Region of Waterloo Public Health programs and services) All reportable diseases are to be reported by telephone to the Region of Waterloo Public Health, using the telephone numbers listed in these guidelines. Telephone reporting allows a consistent and timely response to any questions or disease outbreaks in schools and assists in preventing further spread of the disease within both the school and the surrounding community. 4

5 1.2 Legal Requirements for Reporting Student Illness School personnel are legally required to report infectious diseases on the reportable disease list (see Appendices) that may have been diagnosed in students at the school. The Health Protection and Promotion Act, R.S.O. 1990, c. H.7, Section 28 states: The principal of a school who is of the opinion that a pupil in the school has or may have a communicable disease shall, as soon as possible after forming the opinion, report thereon to the medical officer of health of the health department in which the school is located. The Health Protection and Promotion Act allows for the following information to be reported to Public Health in respect to a pupil with an infectious disease: 1. Name and address in full 2. Date of birth in full 3. Sex 4. Name and address in full of the school that the pupil attends It is not necessary for school personnel to confirm a diagnosis of a reportable infectious disease with the physician of a student prior to reporting the disease to the Health Department. The Region of Waterloo Public Health staff will confirm and follow up all information with the physician and case or family. Staff Illness The Ontario Health Protection and Promotion Act does not require that principals report illness of staff members to Public Health. There may be circumstances when it would be important for Public Health Staff to be aware of an illness in a staff member (such as pertussis/ whooping cough) so that classroom notification may occur. In these cases, the permission of the staff member to share this information should be obtained prior to reporting the information to Public Health. Alternatively, the staff member can be given the option to report the information themselves so that the appropriate follow-up or investigation can occur. However, reportable diseases in all persons of all ages are also reported to public health by laboratories and physicians. In circumstances where a staff person has a reportable disease, Public Health will be aware and take appropriate action if indicated in order to protect other staff and students. 5

6 1.3 Confidentiality When dealing with health information, everyone has a right to privacy. Personal information can only be gathered and used in a restricted way and the identity of pupils or staff will not be released to the community or to other individuals at the school. The Medical Officer of Health (MOH) is the Health Information Custodian for Region of Waterloo Public Health. The MOH and all persons who act as agents of the MOH (all public health staff) have the responsibility to ensure that personal health information is collected, used, stored and shared with full regard for the protection of privacy and the confidentiality of personal health information. 1.4 Public Health Role The Infectious Disease Program and the Health Protection & Investigation Program share responsibility under the Health Protection and Promotion Act for receiving reports of infectious diseases from physicians, laboratories or schools and providing the appropriate follow-up or outbreak control measures to prevent the further spread of the disease in the school or community. Depending on the disease, these measures may include one or more of the following: Review of immunization status of students in a classroom or throughout the school An information letter to parents, students and staff Legal exclusion by order of the Medical Officer of Health of certain students from the school who are not appropriately or fully immunized or whose medical conditions may put them at a high risk if they develop a reportable disease (e.g., students undergoing chemotherapy) A recommendation for certain students and staff to receive specific preventive antibiotics or immunization An antibiotic clinic or immunization clinic on-site at the school for students or staff if needed The definition of an outbreak varies with each infectious disease, for example; one case of measles in a school constitutes an outbreak. 6

7 1.5 Enforcement of Immunization of School Pupils Act (ISPA) The Immunization of School Pupils Act requires that students attending schools in Ontario be immunized against tetanus, diphtheria, polio, measles, mumps, rubella, and as of July 2014, pertussis, meningococcal disease and chickenpox. The chickenpox vaccine will only be required for children born on or after January 1, 2010 and who have not already had the infection. Under the Act, Region of Waterloo Public Health (ROWPH) is required to maintain immunization records of all students in public and Catholic schools. Between March and June of each year, ROWPH enforces the ISPA, reviews immunization records of all students and can suspend, for up to 20 days, students who have incomplete or no immunization history. Parents may decide because of medical, religious or philosophical reasons not to immunize their child. The ISPA allows for exemptions based on medical or philosophical grounds. A notarized Statement of Conscience or Religious Belief Affidavit must be signed and on file at Public Health. It is parents' responsibility to provide proof of immunization or exemption to Public Health. For more information, please call the Immunization Information Line at , ext Most Common Reportable Diseases in Schools The Health Protection and Promotion Act list a number of reportable diseases or diagnoses. School personnel will most commonly encounter only a few of these reportable diseases in students or staff in the school setting. The majority of illnesses are of a non-reportable nature. Physicians, hospitals and laboratories are also required to report all reportable infectious diseases. The more serious infectious diseases, such as meningitis and group A strep, are most often reported directly from the hospital. Listed below are the diseases most commonly reported from schools: Chickenpox Diarrhea Pertussis Respiratory Illness Public Health requires the total number of cases by age group in a school to be reported monthly If several students in a class are affected Whooping Cough High absentee rates often due to influenza 7

8 1.7 Reporting high absentee rates Influenza is a common infection in schools during the influenza season each year and may cause a sudden increase in absentee rates. Schools are not required to report cases of influenza in individual students or staff members, but are requested to report when absentee rates rise significantly (especially during the traditional influenza season between vember to April). Automated Reporting: Since the spring of 2009, reporting of absentee rates has been done centrally at both the Waterloo Catholic District School Board and Waterloo Region District School Board for those schools reporting their daily absentee information through Trillium. This data is reported the next day to Public Health. Public Health staff will contact any schools reporting elevated absentee rates to determine if the absences are due to illness or other factors. Telephone Reporting: Public and private schools may continue to report increased absentee rates by telephone to the Region of Waterloo Public Health at , ext or to our Respiratory Outbreak Desk at , ext. 5506, especially if a school is not reporting absentee data to the Board office on a daily basis. Private schools may also call directly to report increased absentee rates. Increased absentee rates in school children are often a first indication that influenza (or occasionally norovirus) has appeared in the community. Reporting this type of absenteeism from schools helps Public Health in surveillance for this disease and in alerting health care facilities in the area to increase their preparation. Schools may also report any clusters of illness (e.g. several students in a classroom who are away with diarrhea, nausea or vomiting) and Public Health will investigate as appropriate to ensure there is no food or water-related issues. 8

9 1.8 Chickenpox Reporting Reporting Aggregate Number of Cases: The Ministry of Health requests that the total number (aggregate number) of chickenpox cases by age group be reported to each month when cases of this disease occur in a school. This information is valuable in establishing rates of infection in different age groups and will be especially important with the increased use of the chickenpox vaccine. **** (See Attached Appendices Chickenpox Monthly Reporting Form) AGE NUMBER OF CASES Monthly aggregate reports may be made by FAX or by phone to Public Health see Appendices Reporting an Individual Case: An individual case of chickenpox is legally reportable in the following circumstances: A pupil was hospitalized due to chickenpox A pupil develops serious complications due to chickenpox (encephalitis, pneumonia etc) A pupil passed away due to complications of chickenpox An individual case report may be made by calling the Infectious Diseases Program at , ext

10 2.0 Exclusion Guidelines 2.1 Chickenpox Exclusion 1999 Recommendations remain in effect CHILDREN WITH MILD CHICKENPOX MAY RETURN TO SCHOOL OR DAY CARE AS SOON AS THEY FEEL WELL ENOUGH TO PARTICIPATE IN NORMAL ACTIVITIES, REGARDLESS OF THE STAGE OF THE RASH They do not need to stay home for the previously recommended five days after onset of rash, or until the rash has dried. Children with more severe cases or those who are not completely well (who continue to run a fever or have infected lesions) must stay home. This is a province wide change in policy adopted by the Ontario Ministry of Health, and follows the recommendations from the Canadian Pediatric Society. Research shows that by the time the rash appears, it is too late to stop the spread of the disease. Chickenpox is most infectious one to two days before the rash and when children feel most ill. If there are any concerns or questions, please feel free to contact or refer parents to the Region of Waterloo Public Health Infectious Diseases Line at , ext Children who are Immune-Suppressed Parents of students who have immune-suppressing medical conditions or who are receiving treatments that may alter their ability to fight an infection are advised by the cancer and transplant centers to speak with their child s teacher regarding exposure to infectious diseases. School staff are responsible for informing parents or children who are immunesuppressed when there is chickenpox activity in the school, especially if it is in the same classroom. If there has been significant exposure, these children will receive a preventative injection called VZIG, usually at the hospital. Children who are immunesuppressed include those with leukemia or other cancers, or who have had organ transplants such as a liver or a kidney transplant. 10

11 Managing Infections Exclusion Guidelines for Child Care Providers and Schools Region of Waterloo Public Health October 2014 DISEASE CHICKENPOX CONJUNCTIVITIS (PINK EYE bacterial or viral) HOW TO RECOGNIZE Fever, fatigue, and loss of appetite followed by the appearance of small spots which start off pink in color then change to blisters before crusts form. Runny, red eyes plus crusted discharge. HOW IT SPREADS Contact with infected person or contact with items of linen and clothing which have been contaminated from the blisters. Direct or indirect contact (articles contaminated could be tissue, towel, door handle, clothing). WHEN IT IS CONTAGIOUS Usually 1-2 (could be up to 5) days before rash appears until all blisters become dry. Most infectious before rash and when child is ill. Bacterial: Infectious until 24 hours of appropriate antibiotic treatment received. Viral: Infectious as long as there is eye discharge. REPORT TO PUBLIC HEALTH Call: , ext WHAT TO DO WITH THE CHILD * May return as soon as well enough to participate normally in all activities If bacterial, child can return after 24 hours of appropriate antibiotic treatment. If viral, no need to exclude unless there is an outbreak. INTERVENTION FOR CONTACTS Parents of children who are immunesuppressed (e.g., cancer treatment, leukemia, organ transplant, etc.) should be informed of exposure in the classroom. CALL PUBLIC HEALTH , EXT 5275 FOR MORE INFORMATION IF ANY CONTACT IS: Pregnant See fact sheet *This recommendation from the Canadian Paediatric Society and the Ontario Ministry of Health came into effect in Exclusion of children for 5 days from onset of rash does not slow down the spread of chickenpox. Children are most infectious 1-2 days before the rash and when feeling ill. NOTE: School staff are still responsible for informing parents of immune-suppressed children when there is chickenpox activity in the school.

12 DISEASE DIARRHEA FIFTH DISEASE HOW TO RECOGNIZE Frequent loose, watery or bloody stools. Low fever; distinctive rash begins with slapped cheek appearance, changes to lace-like body rash on arms then legs (may become worse when exposed to sunlight or heat). Rash may last for weeks or sometimes months. HOW IT SPREADS Contact with contaminated food, water, soiled articles or fecally contaminated hands. Primarily by secretions from nose and throat. Outbreaks lasting 2-6 months may occur every 3-5 years in a community WHEN IT IS CONTAGIOUS For duration of illness. In some instances a carrier state may persist for several months. Primarily before onset of rash, until after appearance of rash. REPORT TO PUBLIC HEALTH - ONLY if number of cases are more than usual. Call , ext WHAT TO DO WITH THE CHILD Send child home if two or more episodes and stay home until diarrhea has stopped for 24 hour period. For certain other types of diarrhea, the exclusion period is longer. Please contact , ext for more information. need to stay home. Once the rash appears a child is no longer infectious. INTERVENTION FOR CONTACTS Only for pregnant contacts. CALL PUBLIC HEALTH , EXT 5275 FOR MORE INFORMATION IF ANY CONTACT IS: Pregnant See fact sheet or refer to Board Policies 12

13 DISEASE FOOD POISONING GIARDIASIS HAND, FOOT & MOUTH DISEASE HOW TO RECOGNIZE May include one or several symptoms such as nausea, vomiting, diarrhea or others. Onset may be gradual or sudden. Symptoms can include chronic diarrhea (pale greasy stools), fatigue, weight loss, stomach pain. May have organism present but not have symptoms. Small ulcers in mouth, (mildly painful), mild fever, small water spots on the palms, soles, and between fingers and toes, or buttocks. Mainly in children 6 months to 4 years. HOW IT SPREADS Consumption of food or water containing any organism which causes food poisoning or person to person spread. See Diarrhea Section of this chart. Contact with contaminated water, food, soiled articles or fecally contaminated hands. Person to person spread most common. Direct contact with nose and throat discharges and feces of infected persons. isolation is required, as spread is difficult to prevent. WHEN IT IS CONTAGIOUS Varies but especially when symptoms present. Entire period of infection During the acute stage of illness (incubation period is 3 to 5 days). Several weeks if in the stools. REPORT TO PUBLIC HEALTH Call , ext to arrange for collection of specimens of stool, and suspect food. Call , ext WHAT TO DO WITH THE CHILD Stay home until symptoms are gone. Physician may prescribe medication on a case by case basis. Stay home until free of symptoms for 24 hours. Do not go swimming until free of symptoms for 14 days (e.g., in a pool) Return when fever returns to normal range. INTERVENTION FOR CONTACTS Physician may prescribe medication on a case by case basis. CALL PUBLIC HEALTH , EXT 5275 FOR MORE INFORMATION IF ANY CONTACT IS: 13

14 DISEASE HEADLICE (Pediculosis) HEPATITIS A HEPATITIS B IMPETIGO HOW TO RECOGNIZE Presence of lice or nits (eggs) in hair; head scratching. Fever, jaundice (yellowing of skin and eyes), loss of appetite, nausea, tiredness. Children may not show symptoms. Fever, jaundice (yellowing of skin and eyes), loss of appetite, nausea, tiredness. Infected lesions are pustules on the skin that burst and form thick yellow crusts, often around mouth, nose, diaper area, arms and lower part of legs. HOW IT SPREADS Spreads easily through head to head contact. May be spread indirectly through sharing head clothing, brushes, and clips, etc. Consumption of contaminated water or food; contact with fecally contaminated hands; sexual transmission Blood to blood contact with carrier or case; sexual transmission. Contact with infected person or articles. Often spread on hands. WHEN IT IS CONTAGIOUS As long as lice or eggs remain alive on the person. For 14 days from the date of onset of symptoms. If jaundice develops, until 7 days after the onset of jaundice. From weeks before onset to months or years after recovery. May be infectious for life (if person is a carrier). While there is pus in the sores or hours after treatment begins. REPORT TO PUBLIC HEALTH Call , ext Call WHAT TO DO WITH THE CHILD Refer to child care/school policy regarding management of pediculosis in students and classrooms. After consultation with Public Health. exclusion normally required. Call for more information. Stay home until 24 hours after antibiotic treatment begins. INTERVENTION FOR CONTACTS Public Health does not have a role in management or enforcement issues. However, you can access the information line by dialing , ext Close contacts may be a candidate for immunization. Call for more information. CALL PUBLIC HEALTH , EXT 5275 FOR MORE INFORMATION IF ANY CONTACT IS: 14

15 DISEASE INFLUENZA MEASLES MENINGOCOCCAL MENINGITIS or MENINGOCOCCEMIA MENINGITIS (other bacterial such as pneumococcal) HOW TO RECOGNIZE Sudden onset of fever; chills; headache; muscle aches; cough. Fever; cough; eyes red and sensitive to light; red blotchy rash lasting for at least 3 days, appearing on the face first and then spreading to other parts of the body. Fever; vomiting; lethargy; headache; stiff neck and back; pinpoint purple rash on skin as illness progresses. Fever; vomiting; lethargy; headache; stiff neck and back. HOW IT SPREADS Contact with secretions from nose, throat or mouth. Contact with infected person (coughing and sneezing) or articles soiled with discharge from nose and throat. Extremely infectious. By direct contact with secretions from nose, throat or mouth. Most cases occur as single cases. Varies. WHEN IT IS CONTAGIOUS 3-5 days from onset of symptoms in adults; up to 7 days in children. 3-5 days before onset of rash until 4 days after. Up to 7 days prior to the start of symptoms until 24 hours after starting proper antibiotics. t contagious to others. REPORT TO PUBLIC HEALTH Immediately call , ext Immediately call , ext , ext WHAT TO DO WITH THE CHILD Stay home until symptoms resolve. Stay home for at least 4 days after rash onset. INTERVENTION FOR CONTACTS CALL PUBLIC HEALTH , EXT 5275 FOR MORE INFORMATION IF ANY CONTACT IS: t generally. Immunesuppressed see next column for atrisk contacts. Exclusion of incompletely or non-immunized students or atrisk students from school until up to 2 incubation periods after last case. for those with direct contact with saliva of the case. Pregnant On chemotherapy Immunesuppressed due to other reasons t immunized Immunized before 1 st birthday Public Health will assess exposed persons to determine if preventive antibiotic and immunization is needed 15

16 DISEASE MENINGITIS (Viral) MONONUCLEOSIS (Mono) MUMPS HOW TO RECOGNIZE Fever; vomiting; lethargy; headache; stiff neck and back. Fever, sore throat; tender, enlarged glands in neck. Generally mild disease in children. Fever, swelling and tenderness of one or both sides of face. HOW IT SPREADS By secretions from nose, throat or mouth or from fecally contaminated hands. May be a rare complication of chickenpox, mumps, measles or other viral infections. Direct or indirect contact with saliva. i.e., kissing, sharing utensils or toys. Contact with infected person or articles soiled with discharge from mouth, nose or throat. WHEN IT IS CONTAGIOUS t contagious to others. Most infectious when ill, but can be prolonged for a year or more. From 7 days before swelling and possibly up to 9 days after (minimal after 5 days). REPORT TO PUBLIC HEALTH , ext , ext WHAT TO DO WITH THE CHILD Stay home until child is well enough to return. Return as long as child is well enough. Stay home until 5 days after onset of swelling. INTERVENTION FOR CONTACTS There is no contact follow-up or intervention for this type of meningitis. see next column for at-risk contacts. Exclusion of incompletely or non-immunized students or atrisk students from school until up to 2 incubation periods after last case. CALL PUBLIC HEALTH , EXT 5275 FOR MORE INFORMATION IF ANY CONTACT IS: t immunized 16

17 DISEASE PERTUSSIS (Whooping Cough) PINWORMS HOW TO RECOGNIZE Initial mild cold symptoms followed by irritating dry hacking cough. Coughing becomes paroxysmal (spasms, often with highpitched whoop ) within 1-2 weeks; coughing paroxysms may be followed by vomiting or gagging. Cough is often worse at night and may last 1-2 months or longer. Anal itching; disturbed sleep, irritability; and sometimes secondary infection of the scratched skin. Worms may be seen at anus. HOW IT SPREADS Contact with infected person (coughing and sneezing) or articles soiled with discharge from nose, mouth or throat. Direct transfer of eggs by hand from rectum to mouth or indirectly through clothing, bedding, food, or other articles contaminated with eggs. Eggs can survive up to 3 weeks in environment. WHEN IT IS CONTAGIOUS From beginning of mild cold symptoms to 3 weeks after onset of coughing spasms if not treated with antibiotics or 5 days after beginning treatment with antibiotics. Can be up to 2 weeks after treatment begins. REPORT TO PUBLIC HEALTH , ext WHAT TO DO WITH THE CHILD Stay home for 3 weeks from the onset of cough or until cough stops or 5 days after starting antibiotics (whichever occurs first). exclusion required. INTERVENTION FOR CONTACTS Assessment and treatment of household contacts may be recommended in some circumstances. CALL PUBLIC HEALTH EXT 5275 FOR MORE INFORMATION IF ANY CONTACT IS: Pregnant Infants under 1 year 17

18 DISEASE RINGWORM a) scalp RINGWORM b) body ROSEOLA HOW TO RECOGNIZE Skin infection; scaly; mildly itchy rings. Hair breaks off leaving bald spot. Flat, spreading ring-shaped area, moist or crusted. Reddish around edges with white scales in centre. Fever; rash (usually 2 days or less) begins as fever subsides. Most commonly occurs in children under 2 years of age. HOW IT SPREADS Direct or indirect contact with skin and scalp lesion. Person to person or animal to human. Direct contact with lesions or contaminated clothing, floors, shower stalls, benches. Person to person or animal to human. Viral infection which may be spread by direct contact with droplets from persons carrying the virus (not very contagious). WHEN IT IS CONTAGIOUS As long as lesions are present and viable spores persist on contaminated materials. REPORT TO PUBLIC HEALTH WHAT TO DO WITH THE CHILD Can attend once treatment has started. Same as above. Can attend once treatment has started. Keep child from gym and swimming pools until treatment is completed. Avoid direct contact sports (e.g., wrestling) until treatment is completed. During fever phase and possibly by persons who shed virus without any symptoms. Return if child is well enough. INTERVENTION FOR CONTACTS CALL PUBLIC HEALTH , EXT 5275 FOR MORE INFORMATION IF ANY CONTACT IS: 18

19 DISEASE RUBELLA (German Measles) SCABIES SCARLET FEVER HOW TO RECOGNIZE Mild fever; cold symptoms; swollen neck glands; rash. Lesions round finger webs, wrists, elbows, skin folds, armpits, lower portion of buttocks, beltline. Itching more intense at night. Fever; headache; sore throat; vomiting/fine red rash that feels like sandpaper; flushing of cheeks; white area around mouth. (Strep throat with a sunburnlike rash on the body) HOW IT SPREADS Contact with infected person or articles soiled by body secretions (nose, throat, mouth). Usually direct skin-to-skin contact. Through clothing only if the infected person wore it immediately beforehand. It is a form of streptococcal disease usually through direct contact with infected person or large respiratory droplets. May occur as individual cases or cause outbreaks. WHEN IT IS CONTAGIOUS From 1 week before until up to 1 week after onset of rash. Until all mites are destroyed, usually after 1 2 treatments. For 24 hours after starting antibiotics. REPORT TO PUBLIC HEALTH , ext WHAT TO DO WITH THE CHILD Stay home until 7 days after onset of rash. Stay home until the day after treatment. Stay home until 24 hours after starting antibiotics treatment. INTERVENTION FOR CONTACTS see next column for at-risk contacts. Exclusion of incompletely or non-immunized students or atrisk students from school until up to 2 incubation periods after last case. Consult family physician: possible preventative treatment of those with extensive direct skin-to-skin exposure. CALL PUBLIC HEALTH , EXT FOR MORE INFORMATION IF ANY CONTACT IS: Pregnant t immunized 19

20 DISEASE STREP THROAT HOW TO RECOGNIZE Fever; sore throat; redness and white spots on throat. Most common in children ages 6 to 12. HOW IT SPREADS Usually through direct contact with respiratory droplets (coughs, sneezes) with infected person. WHEN IT IS CONTAGIOUS Until 24 hours after starting antibiotic. REPORT TO PUBLIC HEALTH WHAT TO DO WITH THE CHILD Stay home until 24 hours after starting antibiotics treatment. INTERVENTION FOR CONTACTS CALL PUBLIC HEALTH , EXT 5275 FOR MORE INFORMATION IF ANY CONTACT IS: STREPTOCOCCAL INFECTIONS INVASIVE A very rare form of streptococcal infection causing Necrotizing Fasciitis (a deep muscle & skin infection) or Sepsis (overwhelming infection of the blood). Usually occurs as an isolated case spread is extremely rare but slightly increased for family members exposed to saliva or drainage from case. Until 24 hours after starting antibiotic , ext Intensive medical treatment required. for those with direct contact with saliva of case or household contacts. 20

21 DISEASE TUBERCULOSIS (TB) HOW TO RECOGNIZE Pulmonary (lungs) Cough for more than 3 weeks, fatigue, fever, weight loss, night sweats. Extra-pulmonary (outside of lungs) Weight loss, feeling unwell, swollen gland(s), or other symptoms depending on location of infection. TB can occur in almost any part of the body. HOW IT SPREADS On droplets in the air expelled when a person with active pulmonary TB coughs or sneezes. WHEN IT IS CONTAGIOUS Only Pulmonary TB is contagious. Can spread from when cough symptoms begin until approximately 2 weeks after treatment is begun or as advised by physician. Contagiousness of these cases varies greatly requires close and prolonged exposure (household contact). Extrapulmonary or latent tuberculosis is not contagious to others. REPORT TO PUBLIC HEALTH WHAT TO DO WITH THE CHILD Region of Waterloo Public Health staff and physician will advise regarding length of exclusion. INTERVENTION FOR CONTACTS Region of Waterloo Public Health staff will advise as to whether follow-up is necessary for contacts in classroom. CALL PUBLIC HEALTH , EXT 5275 FOR MORE INFORMATION IF ANY CONTACT IS: Fact Sheets: Current fact sheets on common childhood infections are available from the Canadian Pediatric Society at: Caring for Kids Illnesses and Infections 21

22 3.0 Serious Illnesses or Death Due to Infectious Diseases 3.1 Serious Illnesses in School Settings A sudden severe illness or death within the school community due to an infectious disease is very rare. When such cases do happen though, there is always a natural concern around whether or not other classmates or staff may also become ill or are at a risk of carrying or acquiring the infection. Public Health maintains close communication with school and board administrative staff in these situations to provide information and assist in the development of any communication if needed. The introduction of childhood vaccines to prevent meningococcal disease and pneumococcal infections has thankfully reduced the risk of these very serious illnesses in students in recent years. Since the early 1990 s, a more serious form of streptococcal ( strep ) infection called invasive group A strep (sometimes referred to as flesh eating disease ) has reemerged as a rare cause of severe and sometimes life-threatening illnesses. These serious streptococcal infections are extremely rare in children but they may sometimes occur as a complication after another illness such as recent chickenpox or respiratory infection. The risk for further transmission in school settings is very low in these cases. Such infections tend to occur as isolated cases and are not transmitted by the type of casual contact that normally occurs in a school setting. In the event that a student or staff member is diagnosed with one of these serious infections, the Region of Waterloo Public Health will provide more specific information, letters or fact sheets as required and in coordination with school communication personnel or traumatic events teams. Please also refer to your board communication protocols. 22

23 4.0 Infection Prevention Measures Good hygiene provides protection against acquiring many infections. This includes encouraging everyone, including students and staff members, to cover one s mouth when coughing or sneezing, disposing of any used tissues in the garbage and washing hands after using a tissue or coming into contact with secretions from the mouth or nose. People must also avoid sharing anything that comes into contact with their mouth (drinks, straws, cigarettes, lipstick, lip balm, mouth guards, etc.). 4.1 Routine Practices an overview Routine practices are a combination of actions or practices that should be used when providing first aid or care for anyone. Routine practices are based on the idea that every person is treated as if they have an infection that could be passed to others. If people treat others as if they have an infection, and protect ourselves, then the chances of being exposed to an illness are smaller. Routine practices include: Hand washing Barrier precautions (gloves or masks) Cleaning Personal hygiene The sections following contain very practical steps that anyone can take in a school setting, to reduce the risk of acquiring or passing germs Personal Hygiene products While most personal hygiene actions will occur at home, the following supplies and products can support hygiene practices while in the school setting: Soap Toilet paper Alcohol-based hand rub Paper towels Tissues Garbage bags or disposal units 23

24 4.1.2 Hand Washing Regular and thorough washing of hands with soap and water is one of the most effective ways of keeping ourselves healthy and stopping the spread of infection to others. Properly washing hands will physically remove germs that have been picked up through daily activity before they can be transferred to our mouths, nose or eyes (which are common entry points for germs into our bodies). When hands are not visibly soiled and hand washing facilities are not immediately available, alcohol-based hand rub can be used to kill germs on the hands. When to wash hands Hands should be washed for at least 15 seconds (the time it takes to sing Happy Birthday twice) in the following situations: Whenever hands are visibly dirty Before and after providing care or first aid to a person where contact with blood or body fluids may occur Before and after meals or snacks Before and after preparing food Before putting on disposable or reusable gloves for first aid or cleaning and after removing gloves After using the toilet After blowing your nose After handling pets or animals How to wash hands Use warm water to wet your wrists and hands Add enough soap to get a good lather when you rub your hands together Scrub your palms and the areas between fingers and the thumb. Scrub for at least 15 seconds. Rinse your hands in warm water until the soap lather is gone. Rinse from the wrist down to the fingertips. Dry your hands using a paper towel (or your own clean towel) Use a paper towel or clean towel to turn off the water taps so that you do not recontaminate you clean hands What kind of hand soap is best? Regular soap is best bet for daily routine washing. The most important action of soap is to physically remove the dirt and germs from hands through the scrubbing action. Antibacterial soaps are not recommended for routine hand washing. Their use should be restricted to specific healthcare settings and patients. 24

25 Liquid soap that can be dispensed with a pump is most hygienic. Bar soap should not be shared between persons. What about alcohol-based hand rubs or gels? Alcohol-based hand rubs (ABHR) or gels are very effective in killing most germs and can be very useful when soap and water are not available. ABHR will, within 15 seconds, kill up to percent of the common germs that may cause illness. The recommended alcohol concentration for hand rubs is at least 62%. These hand rubs are now available in a variety of sizes including small individual containers or larger pump-action containers that can be shared. To use alcohol-based hand rubs: Hands should be dry and have no visible dirt Squirt a quarter-sized portion of hand ABHR into the palm of one hand Rub ABHR over the surface of both hands and between fingers Continue rubbing until hands are dry (about 15 seconds) Barrier Protection Using a barrier such as a tissue or glove physically prevents germs from being spread to you or others and the risk of infection is avoided. Tissues: Tissues should be handy and available for persons to cover their nose and mouth when coughing or sneezing. Once a tissue is used, it should be thrown in the garbage and hands should be washed immediately (or an alcohol-based hand rub applied if hands are not visibly soiled). Gloves: Gloves should be used whenever there may be contact with another person s body fluids (e.g., saliva, blood, mucous, stool). Single use disposable gloves provide a barrier between the skin of your hands and the potentially contaminated body fluids. It also protects the other person from germs that might be on your hands. It is important to wash hands before and after using gloves, even when gloves are disposed of immediately. The process of taking off contaminated gloves can sometimes result in transferring germs to your own hands, so washing hands after use should be as important as using the gloves. Heavy duty rubber gloves that are re-usable or shared are often provided for environmental cleaning tasks. These gloves should be cleaned thoroughly after the 25

26 activity for which they were used and hands should also be washed before and after donning these gloves. Protective Clothing: In some situations, an apron, gown or even a separate set of clothes may be used in situations where direct contact with body fluids is likely to occur. These items should be removed carefully and taken home to be laundered or gently placed in a laundry bin (if provided) for cleaning. rmal laundry cycles and detergent are effective in removing and disabling any germs. 4.2 Prevention of Blood-borne infections Blood-borne infections are very rare in children and the risk for transmission in school settings remains extremely low. However, it is important to assume that all blood is potentially infectious and use the following practices when there is a possibility of contact with blood or blood-tinged body fluids. School personnel come into contact with blood or other potentially infectious body fluids in the course of providing first aid or caring for a student with a bleeding nose etc. The key steps in handling blood or other body fluids that contain visible blood or any objects that have been contaminated with blood include: 1. Wash your hands: Hand washing remains the best defense against any infection, including bloodborne infections. If at all possible, wash hands before and after exposure to blood or any other body fluids and before and after removing gloves. Washing with plain soap and water or alcohol-based hand rub is effective. 2. Wear Gloves: Wear disposable gloves whenever applying first aid or cleaning up blood or body fluid spills from surfaces. Clean, non-sterile vinyl or latex gloves protect any open areas on hands that could be exposed to blood. It is important to wash hands well after removal of gloves. 3. Clean Contaminated Surfaces: Wearing gloves, immediately wipe up spills of blood with paper towels and dispose of them into a plastic lined garbage receptacle. Wash the area with hot water and a household cleaner and then rinse. Apply a specially made solution of household bleach (mix 1 part bleach to 9 parts water) to the area and leave the solution on the surface for 10 minutes and then wipe the area dry. For carpet or upholstered surfaces a low level disinfectant (check the label) may be used 26

27 instead. The carpet should be cleaned with an industrial carpet cleaner as soon as possible following spot disinfection. 4. Dispose of Contaminated Articles: Contaminated tissues, paper towels, etc.: Dispose of any blood-soiled articles into a plastic bag and then tie it at the top. Dispose of bag in the garbage. Laundry: Wearing gloves, rinse blood-stained laundry in cold water but do not remove body fluids by spraying with water. Launder using a regular laundry detergent with household bleach (according to product instructions and where suitable for fabrics) and a normal machine wash and dry. If unable to launder on site, place the contaminated laundry in a plastic bag and then tie it shut for transport home. A second outer bag is recommended only if the bag is leaking. If contaminated clothing is brought to community dry cleaners the item should be appropriately labeled and the cleaning personnel should be informed. Sharps: Any object that could break, cut or puncture the skin can be considered a sharp. Examples are needles, blades, knives or broken glass. Used needles, lancets or an object that has caused a puncture of a person s skin must be considered contaminated and handled with caution. Wear gloves when handling sharps Dispose of sharps in a puncture resistant container and secure with the lid (glass containers should not be used) Dispose of any sharps according to workplace procedures Diabetic syringes and lancets must be disposed of in approved biohazard containers which are available at designated pharmacies For further guidelines, please refer to the applicable Health and Safety Policies for your school board. Posters Hand hygiene posters (laminated) are available from Public Health by calling the main number at and asking for the Resource Centre. They may also be printed from these guidelines or the ROWPH website. In addition, Cover your Cough posters are available for printing from these guidelines or the ROWPH website. Copies are not available through the Resource Centre. See Appendices to view these posters. 27

28 5.0 Pregnancy and Common Childhood Infections 5.1 Pregnancy and Infectious Diseases Infectious diseases or exposures during pregnancy may require additional consideration or medical advice and follow-up. Women working in settings where infections are common should speak with their physician, nurse practitioner or midwife regarding whether or not there may possible risks for them if they are exposed to or develop certain infections. Testing ahead of time may be helpful in determining if the woman may already be immune to some of the diseases that may be of concern during pregnancy. Additional information can be obtained from the Region of Waterloo Public Health Reproductive Health Program at Several fact sheets have been included with these guidelines for reference. 5.2 Fifth Disease and Pregnancy (Parvovirus B19, Erythema Infectiosum) Please see attached fact sheet and refer to your Board policies 5.3 Chickenpox and Pregnancy Please see attached fact sheet and refer to your Board policies 28

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31 Chickenpox and Pregnancy What is chickenpox? Chickenpox is a very common infectious disease caused by the varicella-zoster virus. It is usually a mild childhood infection. Ninety-five per cent of young adults have had chickenpox and are therefore immune for life. What are the symptoms? Chickenpox may begin with a fever, followed in a day or two by a rash that can be very itchy. The rash starts with red spots that soon turn into fluid-filled blisters that look like dew drops on a rose petal. After a few days crusts form over the blisters. What is the incubation period? A person can develop symptoms 2 3 weeks (usually days) after being exposed to an infectious person. How is it spread? Chickenpox is easily spread person to person from respiratory drops in the air, or direct contact with the fluid in a chickenpox blister. When is it infectious? Chickenpox is infectious for as long as five days, but usually only 1 2 days before the onset of rash and continuing until all blisters are crusted or five days from the appearance of the first blister (whichever comes first). What is shingles? Shingles is a painful, burning rash usually on one side of the body or face caused by the reappearance of the chickenpox virus. After a person recovers from chickenpox the varicellazoster virus becomes inactive in the nerve roots in the body and usually remains there for life. Sometimes it is reactivated by conditions such as older age, stress and immune suppression. It is not triggered by an exposure to someone with chickenpox. It is infectious by direct contact with the rash, but only to someone who has not had chickenpox (the person exposed would develop chickenpox, not shingles). Should an infected person be excluded from school or day care?, unless the child does not feel well enough to participate in normal activities. The Ontario Ministry of Health and Canadian Pediatric Society adopted this policy in Research shows that by the time the rash appears, it is too late to stop the spread of the disease. Chickenpox is most infectious 1 2 days before the rash and when children feel most ill. Is chickenpox dangerous? The vast majority of children who get chickenpox do well. Sometimes chickenpox has been associated with complications such as bacterial skin infections, pneumonia and encephalitis (swelling of the brain). Rarely, chickenpox in healthy children has been associated with severe strep A skin infections known as necrotizing fasciitis (referred to in the media as flesh eating disease) and strokes (virus attacks vessels in the brain). Chickenpox can be more severe in adults, pregnant women, newborns and persons who are immune suppressed (e.g. leukemia). next page

32 What are the concerns in pregnancy? There can be concerns both for the fetus and the pregnant mother. Risks to Fetus: In the first 20 weeks, there is a small increased risk (1 3%) of congenital anomalies such as shortened limbs, eye and brain damage and skin lesions. After 20 weeks there is minimal increased risk unless the woman develops chickenpox within five days before or 48 hours after delivery. If this occurs, the infant is at high risk of severe infection. Risks to pregnant woman: Pregnant women can develop a more severe infection. Antiviral medication is usually given. They are also at an increased risk (5 10%) of developing severe pneumonia. What should I do if I am pregnant and have not had chickenpox? Your health care provider can do a blood test to see if you have had chickenpox. Seventy to eighty per cent of adults who think they have not had chickenpox are actually immune when tested indicating they did have chickenpox in the past. If you lived in a developing country you are less likely to be immune because chickenpox is less common in these countries. If the blood test shows you have not had chickenpox, avoid exposure to chickenpox. You can reduce your risk of exposure by getting the chickenpox vaccine for eligible household members who have not had chickenpox. What should I do if I am pregnant and have been exposed to chickenpox? If you have had chickenpox you are not at risk. The infection cannot be transferred to the fetus unless you actually get chickenpox during your pregnancy. It is important to determine if you have been exposed to someone during the infectious period (see above). If you have not had chickenpox or are uncertain, see your physician for a blood test and follow up: 1. If the blood test confirms you are immune you are at no risk 2. If the blood test indicates you are not immune your doctor may recommend a vaccine called VZIG (varicella-zoster immune globulin) it is a blood product that contains antibodies to protect you from getting chickenpox from that exposure. It must be given within 96 hours after the exposure. Your doctor may also advise that you get the vaccine called Varivax after your pregnancy to protect yourself in the future. 3. If you get infected with chickenpox you should see your doctor as soon as possible because antiviral medication and close follow up is recommended. If you get chickenpox within five days before or 48 hours after delivery your baby is at high risk of severe infection, so they will be given the VZIG vaccine shortly after birth to protect them. References 1. Committee on Infectious Diseases, American Academy of Pediatrics (2009). Red Book (28th ed). 2. References: Tan MP, Koren G., The Motherisk Program. Chickenpox in Pregnancy: Revisited. Reproductive Toxicology. 2005, June CDC Pink Book. Epidemiology and Prevention of Vaccine-Preventable Disease, 12th ed May Region of Waterloo Public Health Infectious Diseases Program n n TTY n Fax