Infection Prevention and Control in Residential Facilities for Pediatric Patients and Their Families

Judith A. Guzman-Cottrill, DO; Karen A. Ravin, MD; Kristina A. Bryant, MD; Danielle M. Zerr, MD; Larry Kociolek, MD; Jane D. Siegel, MD

Disclosures

Infect Control Hosp Epidemiol. 2013;34(10):1003-1041. 

In This Article

Specific Diseases and Pathogens

Bed Bugs

Background. Bed bug infestations involving homes, hotel rooms, apartments, dormitories, and hospitals have been reported with increasing regularity in the United States over the last 30 years.[27] Bed bugs (Cimex lectularis) are reddish-brown wingless insects 1–7 mm in length. During the day, bed bugs hide themselves in the seams of mattresses and bedding, in crevices of box springs and wooden headboards, under carpets, or behind loose wallpaper, emerging at night to feed on the blood of sleeping humans. Clues that suggest an infestation include rust-colored blood spots on mattresses or furniture or a sweet, musty odor.

Infestations are spread when the insects are carried from place to place on suitcases, furniture, clothing, and other personal items. Moving personal items such as clothing and luggage from an infested room to another room in the facility may spread the infestation. Bed bugs may also travel short distances (ie, room to room or apartment to apartment) on their own, migrating along pipes or ventilation ducts.

Bed bug bites most often result in itchy red papules at the site of the bites that may appear similar to bites caused by mosquitoes and other bugs. However, they are usually larger and on parts of the body exposed during sleeping. Not all people bitten by bed bugs develop a skin reaction because the skin reaction is often an allergic response. Bed bugs have not been proven to transmit infectious disease, but occasionally skin that has been scratched will become secondarily infected with bacteria that normally live on the skin.[28] Individuals with bed bug bites are not contagious. Complaints of waking with itchy skin lesions that were not present before going to sleep should prompt suspicion of a bed bug infestation. If a bed bug infestation is suspected, follow the recommendations below.

Recommendations:

  1. Instruct families to inspect bedding, mattresses, luggage, clothing, and other personal items for the presence of bed bugs.

  2. Wash and dry clothing and bedding at hot temperatures to eliminate bed bugs.

  3. Seal items that are not amenable to washing and drying in a plastic bag and remove them from the facility.

  4. Successful eradication of bed bugs from the environment is best accomplished by professionals who perform a thorough inspection and, if indicated, application of an insecticide. Eradication of bed bugs may require more than 1 treatment, and thus serial room inspections are necessary. If 1 room is found to be infested, inspect all rooms.

  5. Adjunctive control measures include (1) vacuuming, (2) reducing clutter where bed bugs could hide, (3) eliminating peeling paint and plaster and caulking cracks and crevices in wall and furniture that could harbor bedbugs, and (4) encasing mattresses and box springs in protective covers.

  6. The program manager should notify the affiliated healthcare facility about the discovery of bedbugs so that the relevant inpatient rooms can be assessed for infestation.

Clostridium difficile Diarrhea

Background .Clostridium difficile (commonly referred to as "C. diff" or "C. difficile") is a bacterium that may be found in the intestines of healthy infants but in only a small percent of otherwise healthy adults.[29–31]C. difficile is one of the most frequent infections acquired by individuals within the healthcare setting.[29] When infection does occur, C. difficile most often leads to colitis (ie, inflammation of the large intestine), manifested as fever, abdominal pain and/or cramping, and diarrhea with or without blood.[31]C. difficile colitis occurs most often in hospitalized patients receiving antibiotics, other medications such as chemotherapy, or surgery, although it can also occur in individuals without risk factors.[31,32]

C. difficile has the ability to form hardy spores that are able to survive for extended periods of time on environmental surfaces and on the hands of individuals who come into contact with these spores.[9] Uninfected individuals can acquire C. difficile from ingestion of spores found in the environment. In healthcare facilities, effective methods to reduce transmission include avoiding unnecessary antibiotic use, placement of patients with C. difficile–associated diarrhea on isolation precautions, use of gloves followed by hand washing with soap and water, and thorough cleaning of rooms of infected patients.[9,29–32]

Recommendations:

  1. Restrict individuals with symptoms of C. difficile–associated diarrhea, such as fever and bloody diarrhea, from entering the family-centered residential facility.

  2. Allow individuals with C. difficile-associated diarrhea to enter into the facility once treatment with appropriate antimicrobials has been initiated, their diarrhea has resolved, and they have been without fever and diarrhea for 24 hours. Individuals whose symptoms have resolved do not need a negative C. difficile test of their stool to be permitted entry into the facility.

  3. Restrict individuals with recent C. difficile–associated diarrhea (defined as C. difficile diarrhea in the past 1 month) from food preparation and food handling in the common kitchen area.

  4. Allow healthy individuals exposed to an individual with C. difficile infection to enter the facility.

  5. Refer any guest who develops an illness concerning for C. difficile infection for medical evaluation. If C. difficile infection is the likely cause, the guest must vacate the facility.

  6. Educate individuals exposed to a patient with C. difficile–associated diarrhea about the importance of consistent use of disposable gloves when caring for a child with C. difficile–associated diarrhea and hand hygiene after glove removal. It is recommended to thoroughly wash hands with soap and water for at least 40–60 seconds from initiation to drying rather than use alcohol-based hand rub.

  7. When a guest with a recent C. difficile infection (defined as C. difficile diarrhea in the past 1 month) vacates the facility, clean the surfaces of that person's room and bathroom with household bleach diluted with water (1 part bleach and 9 parts water).

Conjunctivitis (Pink Eye)

Background. Conjunctivitis is an inflammation of the mucous membrane lining the inside surface of the eyelids and covering the globe (eyeball) of the eye. The eye appears red and may have a clear or purulent (cloudy, pus-containing) discharge. Acute conjunctivitis has both noninfectious and infectious causes. Infectious etiologies may include either bacterial or viral pathogens. Bacterial pathogens commonly include respiratory bacteria, such as Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis, as well as Staph aureus. The most common viral pathogens include adenovirus and enterovirus; however, other viruses, such as influenza, herpes simplex virus, measles, and rubella, may also cause conjunctivitis.

Conjunctivitis is a relatively infrequent cause of healthcare-associated infection;[33] however, in neonates conjunctivitis is more common and can be associated with serious invasive disease involving multiple organs.[34,35] Many large, community-based outbreaks of conjunctivitis have been documented.[36,37] School-aged children and those living in crowded urban areas have been identified as groups at high risk for infection in such events.[38,39] Elementary schools,[40] college campuses,[41] and military facilities[42,43] have also been the site of reported outbreaks.

The viruses and bacteria that most commonly cause conjunctivitis are transmitted by hand-to-eye contact from hands that are contaminated with the infectious eye drainage, from contaminated objects (shared towels and washcloths, eye drop solution, or contact lens solution), and potentially by direct inoculation into the eye via large respiratory droplets from an ill individual who is coughing. Infected individuals should be presumed contagious until symptoms have resolved. Transmission may be reduced by careful hand hygiene. The AAP recommends that "except when viral or bacterial conjunctivitis is accompanied by systemic signs of illness, infected children should be allowed to remain in school once any indicated therapy is implemented, unless their behavior is such that close contact with other students cannot be avoided."[44]

Recommendations:

  1. Restrict individuals with severe conjunctivitis (ie, copious eye discharge, eye irritation causing frequent eye rubbing or itching, or conjunctivitis accompanied by fever or respiratory symptoms) from entering the facility.

  2. Allow individuals with mild conjunctivitis (pink eye with no active discharge, minimum eye irritation, and no fever) to enter the facility, but require such guests to confine themselves to their personal room until symptoms have resolved.

  3. Allow healthy individuals exposed to a person with conjunctivitis to enter the facility. No special precautions are required.

  4. Educate all family members about the importance of frequent hand hygiene, avoidance of sharing personal items (eg, towels and washcloths, eye drops, and contact lens solutions), and prompt removal and careful handling of contaminated items (eg, tissues, towels, and linens).

Diarrheal Illness With/Without Vomiting: Bacterial or Viral

Background. Diarrhea may be caused by many infectious and noninfectious etiologies. Acute infectious diarrhea is often accompanied by fever, vomiting, and loose stools (that take the shape of a container), sometimes containing blood or mucus. Some specific viral and bacterial causes of diarrhea are associated with potentially severe illness and are easily transmitted. These organisms are transmitted by direct contact with infected feces or objects that have been contaminated with feces (eg, diapers, clothing, linens, and toys).

Two viruses of note for ease of transmissibility are rotavirus and norovirus. Rotavirus diarrhea is a disease primarily of infants. The incidence of rotavirus in infants has decreased since the reintroduction of the rotavirus vaccine in 2006, but it is important to be aware that shifts in the specific serotypes could cause an increase in the incidence of disease. Norovirus is known as the "cruise ship virus" and is noteworthy for ease of transmission among healthy individuals of all ages.

Recommendations:

  1. Restrict individuals with acute diarrhea from the family-centered residential facility until they have met the following 2 criteria: fever-free and diarrhea-free (without the use of antidiarrheal medications) for at least 24 hours.

  2. Restrict individuals with the following types of bacterial diarrhea (or bacterial colitis, a more severe form of diarrhea) until they receive written medical clearance for entry: Shiga toxin–producing Escherichia coli (including E. coli O157:H7), Shigella, and Salmonella serotype Typhi (the cause of typhoid fever). Individuals who are healthy but are known to be shedding these specific bacteria should also be excluded until they receive written medical clearance for entry.[23]

  3. Restrict individuals from entry with proven norovirus or rotavirus infection, because both viruses are easily spread from person to person and have a high risk of causing outbreaks. Younger children, especially those who are diapered, may shed high concentrations of these viruses in their stools and pose a higher risk of transmission to others compared with older children and adults.[45,46] Environmental cleaning and disinfection is especially important when these viruses cause diarrhea.

  4. Some types of bacterial diarrhea require antibiotic treatment and some types do not. Thus, antibiotic treatment is not necessarily a requirement for entry to the facility.

  5. Restrict individuals with diarrheal illness occurring within the previous 2 weeks from food preparation and food handling in the common kitchen area.

  6. Allow healthy individuals exposed to a person with diarrhea to enter the facility.

  7. Educate all family members about the importance of frequent hand hygiene and appropriate, prompt removal and careful handling of contaminated items (eg, diapers, clothing, and linens). Washing hands with soap and water for 40–60 seconds from beginning to drying rather than use of alcohol-based hand rub is preferred when hands are visibly soiled.

  8. Refer any individual who develops acute diarrhea for medical evaluation. Until they are evaluated, require that the symptomatic individual and their asymptomatic family members restrict themselves to their private room.

  9. In severe or outbreak situations, additional restrictions may be enforced by the local health department or affiliated medical facility.

Diphtheria

Background. Diphtheria is an infection caused by the bacterium. Corynebacterium diphtheriae. This vaccine-preventable disease is rare in developed countries but remains an important cause of life-threatening disease in Africa, Latin America, Asia, the Middle East, and parts of Europe, where vaccination coverage is suboptimal.[47] Severe diphtheria is associated with upper airway obstruction, myocarditis (severe inflammation of heart muscle), and nerve damage.[47]

Recommendations:

  1. Restrict individuals with confirmed or suspected diphtheria from the family-centered residential facility. Allow entry into the facility when they are proven to be no longer contagious. Require written medical clearance from a healthcare provider or local public health department, stating that they are no longer contagious (this includes written documentation of completing the recommended course of antibiotics (usually at least 10 days of antibiotics, depending on the specific disease) and 2 negative cultures proving eradication of bacteria.[47]

  2. Regardless of their immunization status, restrict healthy individuals exposed to a person with confirmed or suspected diphtheria from the facility until they obtain written medical clearance from a healthcare provider or public health department, stating that they are not a risk for transmitting the infection.

  3. Refer individuals who develop symptoms of diphtheria for medical evaluation. Instruct the individual and family members to vacate the facility immediately. Contact the local public health department for further instruction. If the individual is diagnosed with diphtheria, notify the public health department and the program manager immediately. The program manager should identify, notify, and instruct exposed guests to contact their healthcare provider and public health department. Postexposure testing and prophylactic treatment may be recommended, regardless of immunization status.

Hepatitis A

Background. Hepatitis A is an illness associated with fever, fatigue, jaundice (yellow skin), poor appetite, and nausea. Severe liver disease is rare and usually occurs in people with underlying chronic conditions.[48]

Individuals with acute hepatitis A infection are most infectious during the 1–2 weeks before they develop jaundice or other symptoms.[48] The virus is excreted in the stool at high levels during those 1–2 weeks, then the amount of virus decreases substantially by 1 week after the onset of jaundice. A hepatitis A vaccine is available to people older than 1 year of age and is highly effective in preventing this infection.

Recommendations:

  1. Restrict individuals with hepatitis A infection until they receive written medical clearance for entry into the family-centered residential facility, stating that it has been at least 1 week since illness onset and the patient is no longer contagious.

  2. Allow healthy individuals exposed to a person with hepatitis A to enter the facility only if the healthy individual is vaccinated against hepatitis A (2 doses of vaccine). Outbreaks of hepatitis A can occur in unvaccinated households, and the incubation period can be prolonged (15–50 days).[48]

  3. Educate all family members about the importance of frequent hand hygiene and appropriate, prompt removal and careful handling of contaminated items (eg, diapers, clothing, and linens). Washing hands with soap and water for 40–60 seconds from beginning to drying, rather than use of alcohol-based hand rub, is preferred if visibly soiled with feces.

  4. Refer individuals who develop symptoms of hepatitis A for medical evaluation. Instruct the individual and family members to vacate the facility immediately. If the individual is diagnosed with hepatitis A, notify the local public health department and program manager immediately. The program manager should identify, notify, and instruct exposed guests to contact their healthcare provider or public health department. Exposed individuals may require postexposure vaccination or immunoglobulin.[48]

  5. In severe or outbreak situations, additional restrictions may be enforced by the local health department or affiliated medical facility.

Hepatitis B, Hepatitis C, and Human Immunodeficiency Virus (HIV)

Background. Hepatitis B virus (HBV) can cause both acute and chronic liver disease. Some patients may appear healthy, but others may be ill with nausea, vomiting, jaundice (yellowing of the skin), or in some cases severe liver disease.[49] Chronic infections may lead to cirrhosis (scarring of the liver), liver failure, and cancer.[50] HBV is spread by exposure to infected blood or body fluids. Transmission from an infected individual can occur by transfusion of blood that has not been screened for HBV, injection drug use, needlestick injuries, and sexual contact with an infected person. HBV can also be spread from mother to infant during pregnancy or at the time of birth.[49,50] Transmission of HBV infection in child care settings has been described but occurs rarely. Such transmission is most likely to occur through direct contact with blood from an infected person after an injury or from bites or scratches that break the skin.[23] There is a 3-dose vaccine regimen that protects against hepatitis B virus, the first dose of which is recommended in the United States for all infants at the time of birth or before being discharged from the nursery. See Appendix B ("Vaccines") for more information.

Hepatitis C virus (HCV) is another virus that causes both acute and chronic liver disease. Chronic infections may lead to liver failure and cancer.[51] Persons who are infected with HCV may feel well and not know they are infected.[52] HCV is spread by exposure to infected blood or body fluids. The most common risk factors are injection drug use, a history of multiple sex partners, and a history of receipt of a blood transfusion prior to 1992. HCV can also be spread from mother to infant and rarely by household contact.[51,52] The transmission risks of HCV infection in child care settings are unknown but are likely to be extremely low.[23] There is currently no vaccine available to protect against HCV infection.

HIV causes an infection that attacks the immune system. It causes a variety of clinical manifestations and, in its advanced stage, acquired immunodeficiency syndrome (AIDS), which is associated with an increased risk of many life-threatening infections.[53] Transmission of HIV occurs only by contact with blood or certain body fluids (eg, semen, vaginal secretions, and human milk). Transmission does not occur by casual contact and has not been documented in settings such as school or child care.[53] There is currently no vaccine to protect against HIV infection, but there are effective medications that greatly reduce the risk of transmission from person to person.

Recommendations:

  1. Allow individuals infected with HBV, HCV, or HIV to enter the family-centered residential facility without restriction, except for the following special situations:

    1. Restrict entrance of an individual with HBV, HCV, or HIV infection and open skin lesions that cannot be covered or other conditions that might allow contact with their body fluids.

    2. If an infected person or their family member has behaviors (eg, biting) that might put others at risk of contact with their blood or body fluids, specific restrictions may be required and should be determined on an individual basis.[23,54]

  2. Allow healthy individuals who have been exposed to a person infected with HBV, HCV, or HIV to stay at the facility without restriction.

  3. Educate families about the importance of appropriate, prompt disposal of items contaminated with blood and/or body fluids (eg, bandages, sanitary pads or tampons, and items that have been used for injection of medication).[43,53]

  4. Educate family members about the importance of good hand hygiene, appropriate glove use, and appropriate handling of blood and body fluids.[54] Advise that they should not share personal items such as toothbrushes or razors with others. Contaminated items should be handled following standard precautions.

Herpes Simplex Virus (HSV) Infections

Background. Herpes simplex viruses (HSV) cause a spectrum of clinical infections, including cold sores or "fever blisters" (herpes labialis); painful skin rashes characterized by clusters of small, fluid-filled blisters; and genital rashes or ulcers.[55] The occurrence of HSV lesions localized to the fingers or toes is called herpetic whitlow. A severe HSV skin rash can develop in individuals with eczema (eczema herpeticum). Primary HSV gingivostomatitis is a common infection in young children associated with many painful mouth ulcers in and around the mouth, drooling, high fever, and swollen lymph nodes in the neck.[55] HSV can cause severe, life-threatening disease in young infants, affecting the brain, liver, and lungs.[55] Skin rash may or may not be present in newborns infected with HSV. HSV can also cause encephalitis or meningitis in older children and adults. HSV is an uncommon cause of conjunctivitis. People with cold sores are advised to avoid kissing newborns or immune-compromised individuals.

Like the varicella-zoster (chickenpox or shingles) virus, HSV remains latent in the body after the first infection. For this reason, recurrences of HSV-related skin rashes or cold sores are common. Recurrent episodes of oral HSV may not be obvious; the virus may be present in saliva even in the absence of visible lesions.[55] The virus is spread though contact with infected lesions or contaminated secretions.

Recommendations:

  1. Allow healthy individuals with isolated labial (lip) cold sores to enter the family-centered residential facility, as long as the individual is capable of frequent hand hygiene according to the recommended procedure and can follow instructions not to kiss others. If the individual is young or incapable of hand hygiene, then either restrict the individual from entrance until the cold sore is completely crusted and dry or confine to the individual's room.

  2. Restrict individuals with active HSV skin or eye lesions from entering the facility until written medical clearance from a healthcare provider is obtained. In general, the individual must be able to completely cover the rash with clothing, bandage, or other appropriate dressing. If the rash is unable to be completely covered, restrict entrance to the individual until the rash is completely crusted and dry. If entry is permitted, confine the individual to his or her private room until lesions are completely crusted and dry.

  3. Restrict those with primary herpetic gingivostomatitis from the facility if active lesions and drooling are present. Once the individual has recovered from the illness, written medical clearance from a healthcare provider is required, stating that the patient does not pose an infectious risk to others.

  4. Allow healthy individuals who have been exposed to a person infected with HSV to stay at the facility without restriction.

  5. Educate family members about the importance of frequent hand hygiene, avoidance of sharing personal items, and prompt removal and careful handling of potentially contaminated items (eg, tissues, towels, and linens). Advise family to avoid direct, close contact with lesions to prevent person-to-person transmission.

Lice

Background.Head lice infestation is common, particularly among school-aged children of all socioeconomic groups.[56,57] Head lice are small, wingless insects (about the size of a sesame seed) that prey on the blood of humans.[57] Head lice lay eggs (nits) in an individual's scalp, where they remain firmly attached to the hair shaft until they hatch by a sticky substance produced by the louse. The nits are incubated by body heat. Once hatched, the louse injects saliva into an individual's scalp during feeds. Over time, louse saliva can cause the scalp to become irritated and lead to scalp itching, which is the most common symptom encountered during head lice infestation. However, because scalp itching may not develop for several weeks after becoming infested, many individuals are initially asymptomatic. Occasionally, skin breakdown from scratching the affected site may result in a bacterial infection of the scalp.

Head lice do not fly or hop; rather, they move by crawling.[56] Therefore, transmission is most likely to occur from direct contact with the head of an infested individual, such as from sleeping in the same bed.[56,57] Head lice can also be transmitted from sharing of personal items that have contact with the head, such as combs, brushes, pillows, and hats. However, because lice do not survive when away from the scalp for more than a day, transmission is less likely to occur by this method. Of note, head lice do not transmit other infectious agents.[57]

Recommendations

  1. Restrict individuals with untreated head lice from entering the family-centered residential facility.

  2. Refer individuals with suspected head lice for evaluation by a healthcare provider before facility entry. If the diagnosis is confirmed, the individual should undergo treatment as recommended by their healthcare provider. Once treatment has been completed, allow the individual to enter the facility. Instruct the family to keep the individual's personal items, such as combs, brushes, hats, and pillows, inside their private room.

  3. Encourage asymptomatic bedmates of infested individuals to receive prophylactic treatment for head lice.

  4. Allow healthy, asymptomatic family members of someone with head lice to enter the facility as long as they have been evaluated and active lice infestation has been excluded.

  5. Refer any guest who develops symptoms of head lice for evaluation. Until they are evaluated, restrict the symptomatic individual and their asymptomatic family members to their private room.

  6. Launder bed linens with hot water (ie, greater than 130°F), thoroughly clean the room surfaces, and vacuum the floor and furniture. Place any items that cannot be laundered (eg, stuffed animals and pillows) in a plastic bag for 2 weeks prior to reuse.

Measles

Background. Measles is a highly contagious viral infection that is transmitted by inhalation of respiratory droplets when infected individuals cough or sneeze. It commonly presents with symptoms of fever, cough, nasal congestion, conjunctivitis (pink eye), and a red rash that begins on the face then spreads to the entire body. The measles virus (rubeola) can also cause ear infections, pneumonia, croup, hepatitis, encephalitis, and diarrhea. Measles infection is rare in developed countries because of routine childhood immunization. However, measles remains a leading cause of childhood disease and death globally. Outbreaks have occurred during the past several years due to importation of disease by travelers and infections in individuals who are incompletely immunized.[58]

Individuals are contagious from 1 to 2 days before the onset of symptoms until 4 days after the rash appears.[9,23,58]

Recommendations:

  1. Restrict individuals with confirmed or suspected measles from the family-centered residential facility. Allow entry into the facility when they are no longer contagious, usually 4 days after the appearance of the rash.[9] Require written medical clearance from a healthcare provider or local public health department, stating that they are no longer contagious.[23,58]

  2. Restrict healthy individuals exposed to a person with confirmed or suspected measles from the facility until they obtain written medical clearance from a healthcare provider or public health department, stating that they are not a risk for transmitting the infection.

  3. Refer individuals who develop symptoms of measles for prompt medical evaluation. Instruct the individual and family members to vacate the facility immediately. Contact the local public health department for further instruction. If the individual is diagnosed with measles, notify the public health department and the program manager immediately. The program manager may be asked to identify, notify, and instruct exposed guests to contact their healthcare provider and public health department. Postexposure prophylactic treatment must be administered to high-risk exposed individuals within 6 days of exposure.

Meningitis, Bacterial or Viral

Background. Bacterial meningitis is a serious bacterial infection of the membranes that cover the brain and spinal cord characterized by fever, severe headache, vomiting, and neck stiffness. Bacterial meningitis can lead to hearing loss, brain damage, and learning disabilities.

Most types of bacterial meningitis are not easily spread from person to person. However, there are 2 specific types of bacterial meningitis, Haemophilus influenza type b (Hib) and Neisseria meningitidis (meningococcal) meningitis, that can be contagious to close contacts. Both bacteria can also cause other types of serious infections, such as bloodstream infections. Hib infections are rare because there is a vaccine that protects against this infection. Meningococcal vaccines are available but do not prevent infection caused by all strains of this group of bacteria. The bacteria can be spread from person to person by inhaling or having direct contact with infected respiratory tract secretions.[59,60] This can occur through coughing, kissing, and sneezing. People who have close contact with a person who is sick with Hib or meningococcal meningitis are at increased risk of contracting the disease.[59,60] Exposed contacts are sometimes given prophylactic antibiotics to prevent them from becoming sick with the same bacteria;[59,60] a physician or the local public health department will determine if an exposed person qualifies for postexposure prophylaxis and which antibiotic to prescribe. Streptococcus pneumoniae, another bacterium that causes bacterial meningitis, is not spread from person to person.

Viral meningitis is an illness characterized by fever, headache, vomiting, and neck stiffness. Unlike bacterial meningitis, most types of viral meningitis are usually not as severe and are not as easily spread from person to person. Enteroviruses are common causes of viral meningitis and are spread through direct contact with stool (diarrhea) and respiratory fluids (coughing and saliva) or by touching items contaminated with stool or respiratory secretions.[61] Some types of viral meningitis are transmitted by mosquitoes (eg, West Nile virus) and are not spread person to person.

Recommendations:

  1. Allow individuals who have been discharged from the hospital after treatment for bacterial meningitis entry into the family-centered residential facility providing they meet all other criteria. Once a child with bacterial meningitis has received 24 hours of antibiotic therapy and is discharged from the hospital, he or she is no longer contagious.

  2. Allow healthy individuals who have been exposed to a person with bacterial or viral meningitis to enter the facility without restriction.

  3. Refer healthy exposed individuals to the child's healthcare provider or public health department to determine if he or she qualifies for postexposure antibiotics to prevent the disease. Allow individuals who are prescribed postexposure antibiotics entry into the facility. The antibiotics may be indicated for the exposed person's own health safety. Thus, the exposed person does not pose a risk to others.

  4. Immediately refer any guest who develops an illness concerning for meningitis for medical evaluation. Notify the program manager if it is determined that the person has either Hib or meningococcal disease (see "Background" above). In such cases, the program manager should identify, notify, and instruct exposed guests to contact their healthcare provider immediately to determine if they qualify for postexposure antibiotic prophylaxis.

  5. Restrict entrance to the facility to individuals who have been discharged from the hospital after treatment for viral meningitis until they are fever-free for 24 hours and diarrhea (if present) has completely resolved.

Multidrug-resistant Bacteria (MDRO): People Known to be Colonized

Background. Bacteria that have become resistant to the common antibiotics used to treat infections are referred to as multidrug-resistant organisms (MDROs). Some people may have an MDRO living on their skin or in their bodies but are not ill. This is called bacterial colonization. People can be colonized with an MDRO transiently, intermittently, or persistently over several months.[62,63] People with chronic medical conditions (eg, cancer, kidney failure, and transplant recipients) are at highest risk of acquiring an MDRO.

Methicillin-resistant Staphylococcus aureus (MRSA), one of the most well-known MDROs, is a type of bacteria that is resistant to many antibiotics. MRSA infections frequently involve the skin, causing boils or abscesses. Healthy individuals may have MRSA bacteria living inside their nostrils or on their skin. MRSA can also cause very serious disease, including pneumonia, infection of bones and joints, and abscesses deep within the body. MRSA may be spread person to person when there is close contact with the infected fluid or pus that is draining.

Vancomycin-resistant enterococcus (VRE) is a different type of bacteria that lives in the intestines of some people and can sometimes cause infection; VRE infections are rare in children and usually occur in people with chronic illness, such as cancer.[64,65]

There are other bacteria, called gram-negative bacteria, that have developed resistance to many antibiotics. These highly resistant bacteria can be found in the intestines of some people and may cause infections. These bacteria are usually identified when a patient is hospitalized, but when studied, many healthy people in the community have been found to be colonized with these resistant bacteria.

There may be special circumstances when a referring hospital has experienced high transmission rates of a specific MDRO; therefore, additional restrictions may be recommended by the facility's IPC department.

Recommendations:

  1. Allow individuals known to be "colonized" with an MDRO entry to the family-centered residential facility as long as the person is currently healthy, is able to follow recommended hygienic practices, and is able to contain their body fluids (eg, stool).

  2. If a family-centered residential facility or its referring medical facility has experienced high transmission rates of a specific MDRO, additional restrictions may be considered. Consultation with local IPC specialists is recommended.

  3. If the individual has a specific disease caused by an MDRO (eg, skin infection or respiratory infection), please refer to the specific disease section for more guidance.

  4. Allow healthy individuals exposed to a person known to be colonized with an MDRO entry to the facility without restriction.

  5. Educate all family members about the importance of frequent hand hygiene and appropriate removal and careful handling of contaminated items (eg, diapers, clothing, and linens).

Mumps

Background. Mumps is a viral infection that presents with swelling of 1 or more salivary glands of the head and neck, usually the parotid glands, which are located on the face, immediately in front of the earlobes. Rarely, it can cause complications affecting other organ systems of the body.[66]

Mumps is transmitted by respiratory droplets generated during coughing or sneezing. Individuals are most contagious from 1 to 2 days before parotid gland swelling until 5 days after the onset of symptoms.[9,67] Mumps can be prevented by vaccination.

Recommendations:

  1. Restrict individuals with mumps from the family-centered residential facility until it has been at least 5 days from the onset of parotid gland swelling and they obtain written medical clearance from a healthcare provider.[9]

  2. Restrict healthy individuals exposed to a person with mumps from entry into the facility until they obtain written medical clearance from a healthcare provider, stating that they are not a risk for transmitting the infection.[23] Exposed individuals can become ill with mumps anywhere from 12 to 25 days after exposure.[67]

  3. Refer individuals who develop symptoms of mumps for medical evaluation. Instruct the individual and family members to vacate the facility immediately. If the individual is diagnosed with mumps, notify the local public health department and program manager immediately. The program manager should identify, notify, and instruct exposed guests to contact their healthcare provider or public health department.

Pertussis

Background. Pertussis is a prolonged cough illness caused by. Bordetella pertussis. The typical incubation period is 7–10 days, although rarely it may be as long as 21 days. Initial signs are nonspecific and include runny nose, sneezing, and possibly low-grade fever. Although cough in this initial, or catarrhal, phase is variably present and mild, there is a high burden of organisms in the nose and throat, increasing the likelihood of transmission to others. During the paroxysmal phase of pertussis, some patients manifest the classic signs of pertussis, including severe, episodic cough; inspiratory whoop; and forceful coughing followed by vomiting. Young infants may present with feeding difficulties or apnea (breath holding) during coughing spells. Infection may be life threatening or fatal in infants who are too young to be protected by immunization and have very small airways.

Immunity wanes 5–10 years after immunization, leaving adolescents and adults susceptible to this infection.[67] Although adolescents or adults may develop classic pertussis, they may have only mild cough that resembles a "smoker's cough," bronchitis, or asthma.[68]

Bordetella pertussis is spread by respiratory droplets; outbreaks of pertussis have been reported in hospitals,[69] schools,[70] child care centers,[71] and other residential facilities.[72] Transmission occurs when large droplets containing infectious microorganisms are expelled during coughing or sneezing and subsequently contact the mouth, nasal mucosa, or eyes of a susceptible host. Transmission may also occur when the mucous membranes are touched with unwashed contaminated hands after contact with infectious secretions or an object contaminated with secretions. Patients without classic or severe symptoms may transmit pertussis.[73] If not treated with appropriate antibiotics, infected people typically remain infectious during the first 3 weeks of cough.

Recommendations:

  1. Restrict individuals with pertussis from the family-centered residential facility until treatment has been completed and written medical clearance is obtained from a healthcare provider. Persons with pertussis are contagious until they have completed 5 days of appropriate antibiotic therapy, most often a specific antibiotic such as azithromycin.[74] Cough may persist for many weeks after effective treatment and is not a reason for continued exclusion from the facility.

  2. During the initial routine screening process upon facility entry, screen family members and other close contacts of infected children for respiratory symptoms, because infants and young children commonly acquire pertussis from a family member who has not yet sought medical care for cough illness.[75]

  3. Restrict healthy individuals exposed to pertussis from the facility until active infection has been excluded and prophylactic antibiotics have been started. Written medical clearance from a healthcare provider is required. Specific antibiotics (eg, azithromycin or erythromycin) can prevent the development of pertussis in susceptible individuals who are exposed to pertussis.

  4. Restrict healthy individuals exposed to pertussis who refuse or are unable to take prophylactic antibiotics for 21 days after the last pertussis exposure. Written medical clearance from a healthcare provider is required.

  5. When a case of pertussis is identified in a guest, staff member, or volunteer, identification of exposed persons is essential so that prophylactic antibiotics can be prescribed by their medical care provider or local health department.[74] In this situation, notify the program manager immediately. Exposed guests should be identified, notified, and instructed to contact their healthcare providers. The local public health department may also assist with this task.

  6. Vaccines are available to prevent pertussis in children and adults. A single dose of tetanus toxoid-reduced diphtheria toxoid- and acellular pertussis (Tdap) vaccine is recommended for all adults who have close contact with infants younger than 12 months of age.[76]

Rashes of Unknown Cause

Background. Skin rashes can have many different causes, including bacteria, viruses, fungi, parasites, allergies, medications, insect bites, and medical conditions. A rash can sometimes be the sign of a contagious infection. However, a rash that develops without fever or other signs or symptoms of acute illness is usually not indicative of a contagious infection.[23]

Recommendations:

  1. Refer individuals with a rash and fever for medical evaluation. Manage entry, or reentry, into the family-centered residential facility for each case on an individual basis, based on recommendations of the healthcare provider.

Respiratory Diseases

Background. Respiratory diseases may present as upper tract disease, such as "the common cold," sinusitis, or croup, or they may manifest as lower tract disease, such as pneumonia or bronchiolitis. Lower tract respiratory disease can be associated with substantial morbidity and mortality, the risk of which depends on the age of the patient, underlying disease, and the organism causing the infection.

Upper respiratory tract infections are most commonly caused by respiratory viruses, including adenovirus, rhinovirus, RSV, human metapneumovirus, influenza viruses, parainfluenza viruses, and coronaviruses. Lower respiratory tract infections can be caused by either viruses or bacteria. In infants and severely immune-compromised individuals, these viruses can cause severe lower tract disease. RSV bronchiolitis is the most common cause of hospitalization for respiratory disease in infants.[77] In severely immune-compromised individuals, RSV pneumonia carries high morbidity and mortality[78] and can be associated with large outbreaks.[79] In both children and adults, bacterial pathogens such as Streptococcus pneumoniae and atypical bacteria such as Mycoplasma pneumoniae and Legionella cause pneumonia.

Most respiratory viruses are spread by respiratory droplets through coughing and sneezing. For certain respiratory viruses, such as RSV, direct contact with infected respiratory secretions or objects contaminated with respiratory secretions is another way the virus can be spread. Bacterial causes of respiratory disease are spread by respiratory droplets before patients have received 24 hours of effective antibiotics.

It is important to be aware of epidemics of respiratory tract viruses, most frequently influenza virus in various worldwide locations. For example, epidemics caused by the SARS virus (severe acute respiratory syndrome CoV) of 2003 began in Asia but spread to other continents. Similarly, pandemic influenza A (H1N1) 2009 virus had a worldwide distribution with foci of infection changing over time. Various different bird influenza viruses have circulated in China but have not spread far. The local health department sends alerts to the healthcare community when there is risk of a dangerous virus being introduced into a specific community.

Influenza is the only respiratory tract virus for which a vaccine is available and recommended annually for all individuals 6 months of age and older. High-risk prematurely born infants may receive a monthly dose of RSV antibody (palivizumab, or Synagis) during the RSV season to prevent severe disease and hospitalization if they meet the criteria defined by the AAP.

Recommendations:

  1. Restrict individuals with viral respiratory illness from entering the family-centered residential facility until they have been fever-free for 24 hours without antifever medication. Require the guest to restrict themselves to their private room until all symptoms (eg, runny nose, cough, and congestion) are resolved.

  2. Restrict individuals diagnosed with bacterial pneumonia from facility entry until they have received 24 hours of effective antibiotics and have been fever-free for 24 hours, with the exception of Legionella. Allow entry for patients with Legionella pneumonia, because it is not transmitted from person to person. See "Pertussis" for specific information about management of persons diagnosed with pertussis.

  3. Allow healthy individuals exposed to a person with a respiratory illness to enter the facility. See "Pertussis" for specific information about management of persons exposed to pertussis.

  4. Educate all family members about the importance of cough etiquette, frequent hand hygiene, and appropriate removal and careful handling of contaminated items (eg, tissues, clothing, linens, and toys).

  5. From the time when the influenza season is approaching and influenza vaccine becomes available in a community, take the opportunity to remind families of the importance of getting influenza vaccine. A new vaccination is required each year. It would be especially helpful for families to be directed to places where they can obtain vaccine.

Scabies

Background. Scabies is an itchy skin infestation caused by the mite. Sarcoptes scabiei var. hominis. Common symptoms include itching and a bumpy rash between the fingers and toes, around the wrists and the elbows, under the breasts, and in the genital area.[80] Rash may also occur on the head, neck, palms, and soles in children. Crusted or Norwegian scabies is a severe form of scabies that affects primarily the elderly and those who are immune compromised. Outbreaks of scabies, especially crusted scabies, have occurred in hospitals,[81] nursing homes,[82] and other residential facilities, sometimes lasting for several months.

Scabies is usually transmitted by prolonged skin-to-skin contact with an infected person.[80] Occasionally, contact with contaminated items such as clothing or linen can result in transmission. Individuals with crusted scabies are very infectious because of the large number of mites present.

Recommendations:

  1. Restrict individuals with untreated scabies from entry to the family-centered residential facility.

  2. Allow individuals to enter the facility once treatment has been completed (usually overnight). Itching may persist for several weeks after scabies treatment and is not a reason for exclusion.

  3. Refer all healthy family members/household members of an infected person to a healthcare provider for treatment, but these individuals need not be excluded from the facility unless a rash is present.

  4. Wash and dry all clothes and linen used by an affected person in hot water and high heat cycle to kill mites and prevent reinfestation. Place any items that cannot be laundered (eg, stuffed animals and pillows) in a plastic bag and dispose of them.

  5. Rooms occupied by guests subsequently diagnosed with scabies do not require application of pesticides.[83] However, the furniture and carpeting in a room occupied by a person with crusted scabies should be thoroughly cleaned and vacuumed to remove skin crusts and scales that may contain mites.

  6. Because crusted scabies is very contagious, a single case in a guest should prompt surveillance for additional cases in guests or staff members. Multiple cases of crusted scabies in guests and/or staff members should prompt notification of the local public health department to assist with control measures.

Skin and Soft Tissue Infections

Background. Infections of the skin and soft tissues are caused most frequently by. Staph aureus (also referred to as "staph") or Streptococcus pyogenes (also referred to as "strep" or "group A strep"). Staph infections may be caused by staph strains that are very susceptible to antibiotics or MRSA (methicillin-resistant Staphylococcus aureus) strains that are resistant to many frequently used antibiotics. The likelihood of a particular organism depends on the type of skin infection (eg, impetigo, cellulitis, or abscess), the cause of infection (eg, unknown, trauma, or animal bite), and the individual's underlying risk factors (eg, previous history of skin infections and immune function).[84] Many skin infections are easily treated with oral antibiotics alone. Some types of skin infections, especially those caused by Staph aureus, may require a minor surgical procedure to drain pus from an abscess (also called a boil), if present. If the infection is particularly severe, it may necessitate hospital admission for intravenous (IV) antibiotics.[84] In recent years, there has been an increase in frequency of skin infections due to MRSA, and therefore the spread of MRSA is of particular concern for healthcare facilities.[85]

The risk of transmission of bacteria to others depends on the type of skin infection and the specific bacteria causing the infection. Staph aureus (including MRSA) is easily transmitted from person to person by direct contact with infected fluids, such as pus draining from a boil or the respiratory secretions of an individual with staphylococcal pneumonia.[86] Individuals can sometimes be colonized, meaning that the bacteria live in their nose, in their throat, or on their skin but they do not have symptoms of infection.[86,87] Transmission can be minimized by avoiding direct contact with infected fluids, close attention to hand hygiene, and containment of draining fluid with frequent dressing changes.[85]

Recommendations:

  1. If the individual's skin infection is caused by group A streptococcus (GAS), please refer to the following section, "Streptococcal Infections (Including Strep Throat)," for guidance.

  2. Restrict individuals with skin and soft tissue infections and active drainage from the infection site. After an individual has a surgical drainage of an infected abscess (boil), allow entry into the facility as long as the skin lesions can be kept completely covered at all times with a clean and dry dressing.

  3. Allow healthy individuals exposed to someone with a skin infection entry to the facility without restriction.

  4. Refer individuals who develop a skin infection while staying at the facility for medical evaluation. Until evaluated, restrict the individual to his or her private room.

  5. Educate all family members about the importance of frequent hand hygiene and appropriate, prompt removal and careful handling of contaminated items (eg, used bandages, clothing, and linens).

Streptococcal Infections (Including Strep Throat)

Background. Strep throat is caused by group A streptococcal (GAS) bacteria. It most commonly presents as an infection of the throat and tonsils called pharyngitis or tonsillitis. Symptoms include fever, sore throat, and enlarged lymph nodes in the neck. Scarlet fever is a characteristic red, sandpaper-like rash that can occur along with strep throat.[88]

Strep throat can be spread by contact with respiratory secretions or by sharing contaminated objects, such as utensils, cups, and straws.[88] Individuals are considered contagious until they have been treated with appropriate antibiotics for 24 hours.[23]

Recommendations:

  1. Restrict individuals with an active GAS infection from entry to the family-centered residential facility.

  2. Allow individuals to enter the facility once they have completed at least 24 hours of antibiotic treatment and are fever-free for 24 hours (without the use of fever-lowering medications).[9,23]

  3. Allow healthy individuals who have been exposed to someone with a documented case of GAS infection or strep throat to enter the facility.

  4. Refer exposed individuals who develop symptoms for medical evaluation; they should undergo testing and be treated if that test is positive and the previous steps apply to their entry to the facility.[23]

Tuberculosis

Background.Tuberculosis (TB) is a disease caused by infection of the lungs and other organ systems with. Mycobacterium tuberculosis bacteria. After infection with M. tuberculosis, the bacteria may remain in the body and not cause disease, called latent TB infection (LTBI). Persons with LTBI have no symptoms and are not infectious.[89] Sometimes rather than remaining latent, the bacteria will cause active disease. Active disease can occur at any time in a person with untreated LTBI, but it most commonly occurs 1–6 months after infection and is characterized by fever, chills, night sweats, weight loss, and cough.[90] TB is transmitted by small airborne respiratory droplets that may remain suspended in the air and travel long distances. It is usually transmitted only through air and not by contact with surfaces or objects.[89]

LTBI is not contagious. Persons with active TB disease are potentially contagious until they are treated with antituberculosis medications. Follow-up testing is often performed to prove that they are no longer contagious. Persons most at risk of acquiring TB are those who have shared the same air space in a household or other enclosed environment with a person with active TB infection for a prolonged period of time.[89]

Recommendations:

  1. Restrict individuals with active tuberculosis from the family-centered residential facility until they have been judged to be noninfectious and they have written medical clearance from the treating healthcare provider or local public health department. Verbal medical clearance by direct telephone consultation with a public health official is also acceptable.

  2. Allow persons with latent TB infection (LTBI) to enter the facility without restriction.

  3. Restrict entrance to the facility to healthy family members exposed to a person with active TB until they have written medical clearance from the treating healthcare provider or the local public health department. Verbal medical clearance by direct telephone consultation with a health department official is also acceptable.

  4. Ask any guest who is newly diagnosed with active TB and his or her family to vacate the facility immediately. Require written medical clearance for readmission to the facility. On the basis of consultation with the public health department, the program manager may be asked to identify and notify all exposed guests and instruct them to seek medical attention.[23]

Varicella-zoster Virus (Chickenpox and Shingles)

Background. The varicella-zoster virus is highly contagious and is the cause of both chickenpox and shingles. Chickenpox is characterized by fever and an itchy body rash of fluid-filled blisters on a red base ("dew drops on a rose petal"). The rash is typically scattered over the body, including the scalp, and it eventually forms scabs. The severity of disease increases with age and is most severe in those with weakened immune systems.[91] Chickenpox may be complicated by pneumonia, brain inflammation (encephalitis), or bacterial infections.[91] After chickenpox, the varicella-zoster virus remains dormant in the body. Routine vaccination against varicella reduces the risk of acquiring chickenpox.

Shingles (also called herpes zoster) is an illness that occurs when the latent varicella-zoster virus becomes active again. Shingles is characterized by clusters of very painful blister-like skin lesions that can develop anytime in a person's lifetime but that most commonly occur after the age of 60 years or during periods of immune compromise. Pain may persist long after the lesions of shingles have healed.

A person with chickenpox is highly contagious starting from 2 days before the first onset of rash until all blisters are completely dried and crusted.[91] During chickenpox, the virus is transmitted via respiratory secretions and direct contact with the skin lesions. In a household setting, chickenpox has a secondary transmission rate to susceptible individuals of up to 96%;[92] in the hospital setting, the secondary transmission rate ranges from 4.5% to 29%.[93] At least 1 hospital outbreak involving a family-centered residential facility has been reported.[3]

A person with shingles is contagious until all blisters are completely dried and crusted. During an episode of shingles the virus is transmitted via direct contact with the skin or contaminated items. In immune-compromised patients, the virus may be present in respiratory tract secretion if disseminated zoster develops, and the rash may be present on both sides of the body. Person-to-person transmission has been described in hospital[94] and adult long-term care facility[95] settings. However, if an individual has a healthy immune system and localized lesions that can be covered, it is unlikely that transmission will occur.

Recommendations for Chickenpox:

  1. Restrict individuals with active chickenpox from entrance to the family-centered residential facility.

  2. Once the rash is completely crusted and the patient is without fever, allow an individual with chickenpox to enter the facility without restriction; written medical clearance from a healthcare provider is required prior to facility entry, stating that the rash is completely crusted and the person is no longer contagious.

  3. Significant exposures to chickenpox are defined in Table 1.[91] Restrict persons who have been recently exposed to chickenpox until the criteria in Table 2 are met. Prior to entry, require written medical clearance from a healthcare provider that documents why the exposed individual is not contagious. To be considered noncontagious, 1 of the following 4 criteria must be met (see Table 2):[96] (1) the person has a past history of having had chickenpox or shingles (diagnosed by a healthcare professional); (2) the person has documentation of 2 doses of varicella-containing vaccine, separated by at least 3 months; (3) the person has documented varicella antibodies (also known as a positive varicella IgG blood test); or (4) it has been at least 21 days since the person's last significant exposure to the person with chickenpox (if the exposed person received postexposure prophylaxis [IVIG or VariZIG], it must be 28 days since the last exposure).

Request that individuals with suspected chickenpox vacate the facility immediately and seek medical evaluation. Require written medical clearance to return.

Individuals with chickenpox are considered contagious during the 2 days before the first appearance of rash.[91] If an individual diagnosed with active chickenpox entered the facility anytime during the 2 days before rash onset (or while the person has a rash), notify the program manager immediately. The program manager must identify and notify exposed guests and instruct them to immediately consult a healthcare provider to determine if postexposure prophylaxis is recommended.

Recommendations for Shingles:

  1. Allow individuals with an active case of shingles to enter the family-centered residential facility only if there is written confirmation that the following criteria are met: (1) the rash is localized on one side of the body and can be completely covered by a dressing and/or clothing, (2) the person has a normal immune system, (3) the person is not taking medications that can weaken his or her immune system, and (4) the person is capable of frequent hand hygiene and understands the importance of caring for the lesions and dressings in such a way as to contain the lesions. If all criteria cannot be met, then the individual should be restricted from the facility.

  2. If the individual with shingles meets criteria to allow entry, restrict the individual to his or her private room at all times until the rash is completely crusted.

  3. Educate all family members about the importance of frequent hand hygiene and appropriate disposal of potentially contaminated items (eg, dressings, clothing, and linens).

  4. People nonimmune to varicella can get chickenpox if directly exposed to shingles. Interview individuals recently exposed to a person with shingles about the level of exposure to the skin lesions. If the person's exposure was significant (see Table 1), then require written medical clearance prior to entry to the facility. The documentation should include the reason why the exposed individual is not contagious to others. To be considered noncontagious, 1 of the following 4 criteria must be met (see Table 2): (1) the person has a past history of having chickenpox or shingles (diagnosed by a healthcare provider), (2) the person has documentation of 2 doses of varicella-containing vaccine separated by at least 3 months, (3) the person has documented varicella antibodies (also known as a positive varicella IgG blood test), and (4) it has been at least 21 days since the person's last contact with the rash (if the exposed person received postexposure prophylaxis [IVIG or VariZIG], it must be 28 days since the last exposure).

  5. Request individuals suspected of having shingles to vacate immediately and refer them for medical evaluation. If the person is diagnosed with shingles (and chickenpox is ruled out), then refer to the above guidance for managing individuals with an active case of shingles.

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