welcome to the snohomish health district, partners in ... infections...the “5 c’s” (living...

(Giersing, 2016)

Class Instructions

Welcome to Snohomish Health District Child Care Health Outreach Program’s distance learning course entitled:

“Staph Infections Including MRSA”

Course Description: In this class, child care providers will gain information about infections caused by Staphylococcus aureus and MRSA (methicillin-resistant staphylococcus aureus) bacteria. The class will discuss the difference and similarities between the two strains of bacteria, including how they are spread and how infections in child care environments can be reduced and prevented. Instructions will be given on what to do if a child in your child care is diagnosed with the infection and what your health policy should say according to the WAC. A disease fact sheet is also attached to this learning module. This class can be downloaded and printed out or viewed on your computer screen. When viewed on your computer, you will be able to click on the links that are provided throughout the text. To receive 2 STARS credit for this course you must:

Read the text carefully and completely.

Answer all test questions. Do not leave any unanswered.

Complete the assignment thoughtfully and thoroughly. Do test and assignment individually. No copying or group work. (Note: it is acceptable to

discuss the material as a group, but test/assignment must be done by yourself. (If assignments appear to have been copied, no credit will be given to either party.)

Return the course evaluation form or include your comments at the end of the test.

Understand the course learning objectives. (On next page)

Test, assignment and evaluation should be emailed or postmarked on or before March 31, 2018 in order to receive credit. Please understand that late assignments cannot be accepted. Save a copy of your test for your records. A certificate of completion will be sent to you via email upon successful completion of this course. Please clearly print your name and an email address on your test. Please remember to include your STARS ID number on your test in order to receive STARS credit. If you need a STARS ID number, visit http://merit.del.wa.gov for assistance. As always, these materials are yours to keep as a resource and you are free to share them.

Please note: This distance learning class is meant to provide basic educational information and is not to be used for diagnosis or treatment. If you have health concerns, please contact your health care provider. There is much more information about Staph infections and MRSA than can be covered in this two-hour distance learning course. We encourage you to read more on the web sites found throughout the text and in the reference section at the end of this course.

http://merit.del.wa.gov/

Please allow 4 weeks to receive test results and certificate. Your MERIT credits should be entered by April 21, 2018. Trainer Contact Information: This course was updated by public health nurse and educator: Bonnie J. Decker, RN, BSN

My office hours are M-F 8am to 4pm Phone: 425.339.5250 Email: [email protected]

Core Competencies This course fulfills the following Core Competencies for Early Care and Education Professionals from Washington State Department of Early Learning: Content Area V: Health, Safety and Nutrition Responding to Health Needs of Children Level 1

a. Practices appropriate hand-washing techniques. g. Demonstrates knowledge of basic childhood illnesses.

Level 2 a. Promotes good health and provides an environment that contributes to the prevention of illness. e. Follows procedure to avoid transmission of communicable diseases.

Level 3

a. Designs and assesses sanitary environments inside and outside. b. Models and provides direction on sanitation.

Scoring of test and assignment is as follows:

Section Points Possible

Pause and Reflect #1 – Are We at Risk? 6

Pause and Reflect #2 –Review Your Health Policy 6

True/False 20

Multiple Choice 18

Course Learning Objectives

After reading the course text, participants will be able list on their test the 5 “C”s

that increase the risk that bacteria will spread, and will be able to state at least 5

precautions they will take in their child care environment to reduce the risk of

MRSA and staph bacterial spread.

After reading about the risks for transmission of staph infections, participants will evaluate their own child care environment for risks and write at least one change that can be made to reduce the risk(s). After reading the course section on Child Care Policy, participants will be evaluate their own policies, identify areas of improvement and write at least one improvement they would make to their policy.

“Please feel free to contact me at any time with your questions about the class content, test, any concerns, or comments. Hope you enjoy the class!”

~Bonnie

mailto:[email protected]

Fill in the Blank 18

Short Answer 9

Assignment – Scenarios 23

Understanding of Instructions -

Total Points 100

*A passing score is 80 points. All questions must be answered.

Snohomish Health District Child Care Health Outreach Program ~Staph Infections Including MRSA~ 2018 Page 1 Commercial use of these materials is prohibited: permission for non-commercial use is appreciated.

Table of Contents

What is “Staph” (pronounced: staff) ......................................................................................... 2

What is “MRSA” (pronounced mur-suh)..................................................................................... 3

Skin Infections ........................................................................................................................ 4

Boil ..................................................................................................................................... 4

Cellulitis .............................................................................................................................. 4

Impetigo .............................................................................................................................. 4

Invasive Disease .................................................................................................................... 4

Signs of Invasive Infection .................................................................................................. 5

Examples of Invasive Infections ......................................................................................... 5

Treatment .................................................................................................................................. 5

Antibiotics ............................................................................................................................... 5

Decolonization ....................................................................................................................... 6

How Staph and MRSA Spread .................................................................................................. 6

Damaged Skin ....................................................................................................................... 6

The “5 C’s” (Living with MRSA, 2006) .................................................................................... 7

High Risk Settings .................................................................................................................. 7

Prevention ................................................................................................................................. 8

Infection Control Practices ..................................................................................................... 8

Practice Proper Handwashing ............................................................................................ 9

Clean and Disinfect ............................................................................................................ 9

Use Universal Precautions ............................................................................................... 10

Cover Broken Skin............................................................................................................ 11

Exclusion Guidelines ............................................................................................................ 12

Washington Administrative Code (WAC) for Excluding Children and Staff ...................... 12

Notify .................................................................................................................................... 14

Parent Letters ................................................................................................................... 14

Confidentiality ................................................................................................................... 14

......................................................................................................................................... 15

Washington Administrative Code (WAC) for Notifiying Parents and Staff ....................... 15

Reporting .......................................................................................................................... 15

Works Cited ............................................................................................................................. 16

Resources ............................................................................................................................... 17


Staph Infections Including MRSA

***Pre-Test Take a few minutes BEFORE you read the course materials and answer the 5 true or false questions on the test. You do not have to go back and change your answers after reading the text. These questions will not be graded.

Recently, there has been a lot of talk about “MRSA” and “staph” infections because they are becoming more common in the community. In the United States, Staphylococcus aureus infection accounts for approximately 300,000 hospitalizations per year. (Giersing, 2016) As we all know, what goes around in the community at large will soon find its way into the child care environment. Therefore, it is important for child care providers to be aware of these infections and understand how to prevent them from spreading in their home or center.

What is “Staph” (pronounced: staff)

“Staph” is the term commonly used for the bacteria named staphylococcus. There are more than 30 types of staphylococci bacteria that cause infections, but the most common type of staph infection is caused by Staphylococcus aureus (pronounced: staff-ill-oh-KOK-us AW-ree-us), or S. aureus. Staph bacteria can be found on the skin of healthy people on any part of the body. Areas where it is more commonly found include the inside of the nose, the armpits, groin, genital area and hands.

Of these areas, the nose is the most common place where staph bacteria can be found. One of our body’s defense systems against infection is our skin. Healthy skin and mucus membranes (such as those inside the nose and mouth) keep germs from getting into our bodies and causing us harm. A healthy immune system is also important in fighting off germs. (CDC, 2017). Colonized vs. Infected When someone has the bacteria on their skin but it does not cause an infection, it is called “colonization.” They can be “colonized” with the bacteria but they are not sick. People who are colonized are also called “carriers.” As many as 1 in every 3 adults are colonized with staph bacteria and do not show signs of illness. (CDC, 2017)

Gram stain of S. aureus as seen under a microscope Photo credit: CDC/ Jeff Hageman, M.H.S


A person can pick up the bacteria by being in close contact with someone who is infected or a carrier. People more likely to be colonized are healthcare workers, hospitalized patients, dialysis patients, insulin-dependent diabetics, injection drug users, and people with eczema. (Shinefield HR,

2009).

People who are carriers can shed the bacteria. That means that they can potentially spread the bacteria to others. However, in order to cause illness in themselves or others, the staph bacteria have to get through the skin barrier by a cut, scrape, surgical wound, etc.

When staph bacteria get into damaged skin, they can cause an infection and the person is said to be “infected.” Staph Food Poisoning When these bacteria get into food that is held at improper temperatures, they can multiply and produce a toxin (a poison). If ingested, the toxin can cause a person to have nausea, stomach ache, vomiting, and sometimes a fever. This is called ‘staph food poisoning’. This is not an infection but a reaction to the poison in the food that was eaten.

What is “MRSA” (pronounced mur-suh)

MRSA is a kind of staph bacteria. It is a type of staph bacteria that is resistant to some of the antibiotics that are normally used, including methicillin, penicillin, and amoxicillin. (UpToDate,

2017) MRSA is the term used for the name Methicillin-Resistant Staphylococcus aureus.

MRSA was first found in Britain in 1961 and was mainly found in hospitals and nursing homes. (NIAID, 2016) It is thought that this strain of bacteria developed because of improper use of antibiotics; the bacteria became a resistant strain. Over time, MRSA spread into the general community. Now anyone can be at risk of infection from MRSA.

Although MRSA has been nicknamed the “superbug” because of its resistance to several

antibiotics, it is not any more ‘powerful’ than other staph bacteria. MRSA looks and acts the same way as the more common staph bacteria; it causes the same illnesses. The only difference is that it can be more difficult to treat because it is resistant strain and has to be treated with different antibiotics. It is also not as common in the community as staph. While many people can be colonized with staph bacteria, only less than 2% of the population is colonized with MRSA. (CDC, 2017)

Colonized: A person is said to be ‘colonized’ when they have the bacteria on their skin but do not show symptoms of illness. A colonized person is a “carrier.”

MRSA is a kind of staph bacteria that is resistant to several, but not all, antibiotics.

Infected: A person is infected when the bacteria has entered the skin or body and is causing an illness.

Photo courtesy of LA Health Department

MRSA looks and acts like other staph bacteria but it has to be treated with different antibiotics.


Symptoms of Staph and MRSA

Staphylococcus aureus and MRSA bacteria caused infections can cause the same signs and symptoms of infection. (Pickering, 2009) The infections can range from a simple bump to a difficult to treat blood infection, etc. The type of infection will get its name depending on where it is on the body, how deep the infection goes and how treatable it is with antibiotics.

Skin Infections

Boil When staph and MRSA affect the skin, the infection will usually start with a small cut or opening in the skin where the bacteria gets in. The area of the skin may become:

red

swollen

painful

warm to the touch and,

a fever may develop A bump or pimple will appear that may look like a “bug or spider’s bite.” The bump then becomes a pus-filled boil (also called an abscess). It may open and drain pus.

Cellulitis Cellulitis is an infection that occurs when the bacteria has infected the deeper layers of the skin. It is a larger swollen area that is also red, warm and painful to touch. Sometimes it can start with an open sore (a boil that progressed). Other times there is no obvious break in the skin.

Cellulitis on the hand

Impetigo Impetigo is a skin infection that is usually caused by either streptococcus (strep) or staphylococcus (staph) bacteria. Recently MRSA is also becoming a common cause of impetigo. (American Academy of Pediatrics, 2015)

Symptoms of an impetigo skin infection are:

a rash of small red spots that become blisters

an itching blister that is found anywhere on the skin, usually around the nose, lips, hands, or arms. The blister will have a thick, honey-colored discharge that dries, crusts, and sticks to the skin.

Invasive Disease Sometimes a staph infection, including MRSA, will develop from a skin infection into an invasive disease. This happens when the bacteria gets deeper into the skin and goes into the blood stream. When this happens, the infection can become a serious disease affecting the bones, blood, or the lungs. (CDC, 2017) Most severe cases occur among persons in hospitals and health care facilities who have weakened immune systems.

Impetigo Photo Courtesy of LA Health Department

Boil- CDC/Bruno Colgnard, MD


Signs of Invasive Infection

When the bacteria invade the blood stream and make a person ill, the common signs are:

a high temperature of 38C (100.4F) or above chills generally feeling unwell dizziness confusion pain, swelling, and tenderness in the affected body part

Examples of Invasive Infections

There are many ways that the bacteria can affect the body once it has entered the body. The bacteria can cause the following illnesses: (Melendez, 2016)

blood poisoning (sepsis) – which could lead to septic shock,

where your blood pressure drops to a dangerously low level

urinary tract infection (UTI) – infection of the tubes through

which urine passes

endocarditis – infection of the heart valves

pneumonia – a lung infection

septic arthritis – a joint infection

osteomyelitis – a bone infection

Treatment Antibiotics As with any skin infection, getting treatment early minimizes the chances of an infection becoming worse. It is important to have any wound or skin area that appears to be infected evaluated by a health care provider. Staph and MRSA infections require treatment by a medical professional. Skin and soft tissue infections are often cleaned, drained, and treated with appropriate antibiotics.

Sometimes a culture is taken of the infected site to find out what type of bacteria is causing the infection. Knowing the type of bacteria is important to be able to prescribe the correct

antibiotics. MRSA, for example, has to be treated with very specific antibiotics as it has become resistant to several of the more commonly prescribed antibiotics. After a staph or MRSA infection has healed, it is possible to get another infection; (Rose, 2009) In other words, a person cannot become immune to a staph or MRSA infection because they have had one in the past.

Invasive staph and MRSA infections, as those mentioned above, can be serious and require special medical care. People with an invasive infection are usually treated in a

hospital as the infection can be life threatening and even fatal (cause death).

http://www.nhs.uk/conditions/dizziness/Pages/Introduction.aspx

http://www.nhs.uk/conditions/Blood-poisoning/Pages/Introduction.aspx

http://www.nhs.uk/conditions/septic-shock/Pages/Introduction.aspx?url=Pages/What-is-it.aspx

http://www.nhs.uk/Conditions/Urinary-tract-infection-adults/Pages/Introduction.aspx

http://www.nhs.uk/conditions/Endocarditis/Pages/Introduction.aspx

http://www.nhs.uk/conditions/Pneumonia/Pages/Introduction.aspx

http://www.nhs.uk/conditions/septic-arthritis/Pages/Introduction.aspx

http://www.nhs.uk/conditions/Osteomyelitis/Pages/Introduction.aspx


Decolonization A person who is colonized can ‘auto-infect’ themselves. (Clarke, 2014) For example, the broken skin of a fingertip can get infected if a person picks his or her nose while it is colonized with staph bacteria. Hospitalized patients who are colonized are at a much higher risk of auto-infecting themselves. This is why hospitalized patients are often tested to see if they are colonized before or at the time of being admitted. If they are, treatment is given to rid the body of the bacteria and prevent infection. This process is called ‘decolonization’. Decolonization of a patient also helps keep the hospital staff and environment from becoming

contaminated with the bacteria.

How Staph and MRSA Spread

Anyone can get a staph or MRSA infection. (Living with MRSA, 2006)

Basically, staph bacteria, including MRSA, are spread by:

having direct skin-to-skin contact with another person’s infection

sharing personal items, such as towels or razors, that have touched infected skin

touching surfaces or items, such as used bandages, that are contaminated with the bacteria.

The staph bacteria are everywhere and can survive for a long time on surfaces. It is important to note that merely touching a surface or a person that is contaminated with the bacteria does not mean one will definitely get an infection. It is possible, however, to pick up the bacteria and carry it to another place or pass it on to another individual. It is also possible to become colonized with the bacteria, but not develop an infection.

Damaged Skin A healthy intact skin can keep the bacteria from entering the skin and causing an infection.

Sometimes, staph infections including MRSA can occur in undamaged (intact) skin such as at the site of a hair follicle. However, infection is much more likely when damaged skin comes into direct contact with drainage from an infected wound. (CDC, 2017) This is one of the main reasons that any sores that a staff person or child may have must be covered. Covering

wounds also helps prevent them from becoming infected with other bacteria as well. Examples of damaged skin that is more likely to get infected include:

Cuts, scrapes, or other injury to skin

Surgical sites

Cold sores

Eczema (a medical condition in

which skin is dry and inflamed)

Human, animal, and insect bites

Staph or MRSA bacteria are most likely to cause an infection when you have a cut or scrape that is not

covered. (CDC, 2017)


The “5 C’s” (Living with MRSA, 2006)

An easy way to remember the main factors that increase the risk that the bacteria will spread are referred to as the “5 C’s.”

The “5 C’s” are as follows:

Crowding

Skin-to-skin Contact

Compromised skin (cuts, scrapes, surgery)

Contaminated items and surfaces

Lack of Cleanliness

High Risk Settings People most at risk for infection are those that are in situations or settings that have one or more of the “5 C’s”. These settings include athletic facilities, dormitories, hospitals, correctional facilities (prisons), military barracks, schools and child care facilities. (CDC, 2017)

Athletes in contact sports, such as wrestling for, involve a high degree of skin to skin contact and sharing of gym equipment. It is a good idea for children who participate in sports to wash their hands immediately after the sporting event and to shower as soon as possible afterwards. Hospitalized individuals can come in contact with the bacteria through the colonized hands of nurses or through contaminated hospital equipment. Patients can also “auto- infect” themselves if, for example, they are colonized with staph and their own bacteria get into their surgical wound. Hospitalized persons may have immune systems that are weakened and not able to fight off the bacteria. Children in child care settings can be considered at higher risk for acquiring staph infections, including MRSA. They share toys, play equipment, and crowded spaces. They are more apt to have cuts or scrapes, and not likely to practice good handwashing and general hygiene. There is often skin-to-skin contact during play and social interactions. Infants and toddlers may have diaper areas with compromised skin.

Wikipedia: surgical site CCHOP: scraped knee


People in contact with animals can become infected because animals can transmit staph bacteria to humans and vice versa. Some animals can also be colonized with the bacteria and not show signs of infection. People should wash their hands after touching pets or picking up their feces to prevent from getting contaminated with bacteria.

(Living with MRSA, 2006)

Prevention

Infection Control Practices

Staph infections, including MRSA, can be prevented by reducing the 5 C’s (mentioned on page 7) and by:

Frequent handwashing

Keeping cuts or scrapes covered with clean, dry bandages

Keeping skin clean

Excluding children with illness symptoms until evaluated or treated by a medical professional

Educating staff and parents about staph and MRSA

Cleaning and sanitizing mouthed toys after each child’s use

Keeping personal items such as tissues, bedding, razors, or towels from being shared

Teaching children not to touch rashes, wounds, or dirty bandages

Taking antibiotics properly and according to instructions. Make sure that antibiotics are always finished completely, even if the symptoms have gone away. Never share antibiotics with others.

Always wearing gloves if caring for a wound. As a general rule, all wound care should be done at home, not at the child care.

Discouraging children from picking scabs or scratching wounds. Squeezing or poking wounds can push the infection deeper into the skin

Keeping nails short and clean

Using paper towels instead of cloth towels for drying hands. If cloth towels are used, they must be washed after each single use

Using universal precautions when caring for non-intact skin or potential infections

Disinfecting surfaces that touch skin, like diaper changing pads, toys, mats, gym equipment, and toilet seats. When surfaces aren’t clean, germs can survive for longer periods of time.


Practice Proper Handwashing Handwashing is critical in preventing the spread of disease. Child care providers and children must all wash hands properly and often to prevent staph and other bacteria from being passed from one person to another. Proper handwashing includes the following steps:

1. Turn on warm water.

2. Scrub soap onto wrists, tops and palms of hands, and under fingernails for approximately 20 seconds.

3. Rinse hands well with running water.

4. Dry hands with a clean, disposable towel.

5. Turn off faucet with a paper towel to prevent recontamination of hands.

Teaching children to properly wash hands is also very important. Very young children should be assisted with handwashing. Older children should be supervised to ensure they are being thorough. Everyone’s hands should be washed upon arrival at the child care. This step helps keep germs from individuals’ homes from entering the child care environment. Hands also need to be washed throughout the day, especially after using the restroom, diapering or assisting children with toileting, after wiping

noses, before eating or preparing food, after applying topical ointments, when coming in from outside, after handling garbage, and many other times during the day when hands may be contaminated.

Using soap and water is the best way to ensure that hands are clean. Although not a replacement for proper handwashing, instant hand sanitizers can be used when soap and water are not available. Hands should be properly washed at a sink as soon as possible. Times when instant hand sanitizers may be appropriate include after wiping a child’s nose while out on the playground, while on a field trip or in a vehicle. Make sure the hand sanitizer is alcohol-based with at least 60% alcohol.

Clean and Disinfect While following proper sanitation is important at all times, it is especially important to make sure that procedures are closely adhered to when a known case of a communicable condition is at the child care.

A child care provider should routinely:

Practice proper hand washing

Clean and sanitize regularly

Use universal precautions and gloves when necessary

Ensure all sores, cuts, scrapes are kept clean and covered

To prevent the spread of staph bacteria and other germs, it is important to regularly clean surfaces and objects that are touched often by children and staff.

“Hand hygiene is the most effective means of reducing germs and infections in group care settings.” Managing Infectious Diseases in Child Care and Schools, 2nd ed.

http://www.cdc.gov/niosh/topics/bbp/universal.html


Areas in a child care that are touched often are called “high touch surfaces”.

Examples of “high touch surfaces” include:

counter tops and faucets

bathroom faucets, toilet handles, diaper areas

door knobs, handles and light switches

remote controls, keyboards, game consoles and phones

play tables, toys and chairs

any surface that children or staff touch everyday

Cleaning Contaminated Surfaces If there is a known case of staph or MRSA infection in the child care, a disinfecting strength product should be used to disinfect all “high touch surfaces” in the child’s classroom. The product should be on the list of products registered as a disinfectant by the Environmental Protection Agency (EPA). It should be labeled “effective against MRSA” and used according to the manufacturer’s instructions. Bleach, when used at a disinfectant strength, is an effective product. Bleach If using bleach to disinfect for staph including MRSA, follow the steps the 3 step process:

1. Clean with dish soap or detergent 2. Rinse with water 3. Disinfect () and leave item wet 4. Wait at least 2 minutes 5. Air dry or wipe off with a clean paper towel 6. Rinse again all objects and surfaces that come in contact with food or a child’s mouth (e.g. toys, tables). Rinsing is important because this disinfecting solution is stronger than the general purpose sanitizing solution normally used on these items.

Routine laundry procedures can be used to prevent the spread of staph including MRSA. Linen, towels or clothing can be washed with water and regular laundry detergent. Clothes should be dried in a hot dryer. If items have been contaminated with the bacteria, they can be laundered separately, but this is not absolutely necessary. (CDC, 2017)

Use Universal Precautions Universal precautions, including proper glove use, help reduce the spread of infectious organisms. Gloving should be practiced when performing activities that include contact with potentially infectious body fluids, such as diapering and wound care. Equally important to reducing the spread of germs is the process of removing the gloves. Removing soiled gloves carefully will assure that the hands and other surfaces are not inadvertently contaminated.

Bleach Disinfecting Recipe

1 tablespoon of unscented bleach (8.25%) in one quart of cool water

https://www.epa.gov/pesticide-registration/list-h-epas-registered-products-effective-against-methicillin-resistant



Proper Glove Removal Steps

1. Grasp outside edge near

wrist. Peel away from hand turning the glove inside-out. Do not let the outside of the glove touch the inside of your hand.

2. Hold the removed glove in

the opposite gloved hand.

3. Slide ungloved fingers under

the wrist of the remaining glove. Be careful not to touch the outside of the glove.

4. Discard gloves in a hands-

free covered container. Wash hands.

Cover Broken Skin It is always recommended to keep cuts, abrasions, and other skin injuries covered with a bandage. Bandages help maintain the area clean and free from contact with germs. It can help prevent an infection from occurring. Known infections, including staph and MRSA infections, should be kept covered until completely healed. Infected sores may drain pus containing bacteria. Covering the sore keeps the drainage from making contact with surfaces and spreading the infectious germs to other children.

Bandages should be well taped on all 4 sides to keep drainage from seeping through. Sometimes more than one layer of sterile dressing may be necessary to contain the drainage. Covering the sore also helps keep other germs from infecting the area causing a secondary infection Bandages also help contain the prescribed antibiotic ointment.

Is There a Vaccine to Prevent Staph Infections?

For the past 15 years, scientists have been trying to develop a vaccine to prevent Staphylococcus aureus infections. Finally, recent studies have shown some positive results and it is hopeful that we may have an effective vaccine in the near future. But, for now, there is no vaccine available to the public to protect against this nasty bug. (Giersing, 2016)


Child Care Health Policies

Child care providers need to have written health policies which describe when children are to be excluded from care and how illnesses or injuries will be handled. Refer to your child care regulations (WACs) for more details on writing your health policies or call the Child Care Health Outreach Program (CCHOP) for a sample policy. When a child or staff appears to have an area on the skin that looks infected (see page 4 list of symptoms), the child care provider should:

Call the child’s parent/guardian to come pick them up

Exclude the child until he/she is evaluated by a medical professional

Notify other parents if a contagious disease is diagnosed, and

Disinfect classroom environment, especially the “high touch surfaces”

Exclusion Guidelines

Exclusion means to deny a child to care, or send them home if they are already in care, when a disease poses a potential harm to other children or staff members. When a child has a rash that is accompanied by a fever or a suspected skin infection, the child care provider should not try to diagnose what the illness might be. Instead, the child care provider should call the

parents and explain why the child must be picked up (e.g. “she has a sore on her finger that might be infected”). The child should be kept out of child care until he or she is seen by a health care professional and, if necessary, treated. The parent should be asked to call or bring a note stating the diagnosis that they received from the health care provider. A written note is best.

If the child is prescribed antibiotics, they can return 24 hours after the first dose. The first dose of any medication should always be given at home.

Washington Administrative Code (WAC) for Excluding Children and Staff

Child Care Center WAC

170-295-3030 (2) You must exclude children and staff with the following symptoms from care: (d) for suspected

contagious skin infection such as impetigo and scabies: the child may return twenty-four hours after starting antibiotic treatment.

Family Home WAC

170-296A-3210 (3) The licensee’s health plan must include provisions for excluding or separating a child, staff

person or household member with contagious disease as described in WAC 246-110-010 or any of the following: (iv) Rash ….

School-Age Center WAC 170-297-3210 (2) The licensee’s health policy must include provisions for excluding or separating a child or

program staff person with a contagious disease…

http://app.leg.wa.gov/wac/default.aspx?cite=246-110-010


A child who has been diagnosed as having a MRSA or staph skin infection and is being treated accordingly by a medical professional does not have to be excluded from attending child care. However, they can be excluded for certain other reasons.

Exclude the child or staff if the

drainage from the wound cannot remain covered and contained

with a clean, dry dressing taped on all 4 sides;

child or staff does not feel well enough to participate in regular

activities comfortably;

care for the other children is compromised by caring for the

child with the infection

child or staff has a fever or a change in behavior.

child has not been on prescribed antibiotics for at least 24 hours. (Caring for Our Children, 2011)

Many people can be colonized and not know that they are. If a health care provider says that a person is a ‘carrier’ of Staph or MRSA they should not be excluded from child care unless they have an infection. Managing Infectious Diseases in Child Care and

Schools, 4th ed.

Pause and Reflect #1 –Are We at Risk?

Review the class section on How Staph and MRSA Spread and Prevention. Evaluate or assess your child care facility for things that pose a risk for the

spread of staph and MRSA bacteria.

Write the answer to the following questions on your test:

What specific risk(s) for the spread of bacteria do you notice in your facility?

What changes can you think of that will reduce the risk that the bacteria may spread to other children?


Notify There are several things that child care providers need to know about the notification process in a child care.

Parent Letters

If a child or staff is diagnosed by a health care provider with a contagious infection caused by a staph or MRSA bacteria, the child care provider must notify the parents/guardians of the children who have been in contact with the infected person. Child care staff should also receive a letter so that they can be

informed and monitor for additional cases in the other children or themselves. If the child care facility works with a health consultant (e.g. infant nurse consultant), that person should also be made aware of the situation so that they can assist with disease prevention and control.

The child care center WAC requires that this notification take place in writing. Notification can be done by posting a letter (e.g. on the door to the room) or hand delivering a letter to the parent or guardian.

The child care provider should not post or send out a letter before they have a health care provider’s diagnosis of a disease.

The Snohomish Health District’s Child Care Health Outreach Program’s website has a Staph and MRSA letter/fact sheet that child care providers may use. Many other disease fact sheets for common childhood diseases can also be found on this website. Follow the link below to access a complete list of disease fact sheets especially created for child care programs and schools. http://www.snohd.org/Diseases-Risks/Disease-Fact-Sheets Child care providers are encouraged to use these letters when appropriate and to call the Child Care Health Outreach Program if they have any questions.

Confidentiality

Confidentiality regarding the child’s name and illness should be maintained. If working with the health department, the child’s name and contact information may be shared if requested and needed for prevention and control of disease.

If a health care provider or parent tells you that a child is a ‘carrier’ or is ‘colonized’ with a staph or MRSA bacteria, the other parents or staff do not need to be

informed unless there is an actual infection.

http://www.snohd.org/Portals/0/Snohd/Diseases/files/MRSAFacts_CD.pdf

http://www.snohd.org/Portals/0/Snohd/Diseases/files/MRSAFacts_CD.pdf

http://www.snohd.org/Diseases-Risks/Disease-Fact-Sheets

http://www.snohd.org/Diseases-Risks/Disease-Fact-Sheets


Washington Administrative Code (WAC) for Notifiying Parents and Staff

Reporting A staph or MRSA infection is not a reportable condition* and a child care provider does not need to report it to the local health department or to their Department of Early Learning (DEL) licensors.

However, if an outbreak occurs in which 2 or more children or staff have been confirmed with infections, it is strongly recommended to contact both the local health department and DEL licensor for assistance in preventing the spread of the bacteria. In Snohomish County, child care providers should contact the Child Care Health Outreach Program to report an outbreak or with related questions or concerns at 425.339-5250 or

[email protected].

*A list of Notifiable Conditions for Washington State can be found by clicking of the following link: http://www.doh.wa.gov/ForPublicHealthandHealthcareProviders/NotifiableConditions/ListofNotifiableConditions

Child Care Center WAC

170-295-3010 (2) Your health policies and procedures must have information on how you plan to: (g) Notify parents that

children have been exposed to infectious diseases and parasites; 170-295-3030 (6) You must notify parents in writing when their children have been exposed to infectious diseases or parasites. The notification may consist of either a letter to parents or posting a notification for parents in a visible location.

Family Home WAC 170-296A-3210- (1) When the licensee becomes aware that he or she, a household member, staff person or child in care

has been diagnosed with any of the contagious diseases described in WAC 246-110-010, the licensee must, within 24hrs notify: (c) Parents or guardians of each of the children in care.

School-Age Center WAC 170-297-3210 (1a) …Notify parents or guardians of each of the children in care within 24hrs…

Pause and Reflect #2 –Review Your Health Policy

Review your child care’s current health policy on excluding ill children. Write the answer to the following 3 questions on your test:

What does your policy say about exclusion of children with rashes or infections?

What does your policy say about notifying parents of infectious diseases?

Does the policy need improvement? How would you change it if you could?

mailto:[email protected]

http://www.doh.wa.gov/ForPublicHealthandHealthcareProviders/NotifiableConditions/ListofNotifiableConditions

http://www.doh.wa.gov/ForPublicHealthandHealthcareProviders/NotifiableConditions/ListofNotifiableConditions


In Conclusion

Young children in group settings are considered at higher risk than the general public of being infected by staph, including

MRSA. (Rose, 2009) Because keeping children healthy is a prime responsibility of child care providers, understanding the basic facts about these bacteria will help in the never ending task of maintaining healthy environments for children. This course discussed those basic facts including the symptoms of infection, risks for transmission, treatment, and prevention. Also reviewed were the child care policies and sanitation procedures that should be followed. Works Cited (2016). Retrieved from NIAID: https://www.niaid.nih.gov/research/mrsa-antimicrobial-

resistance-history (2017). Retrieved from UpToDate: https://www.uptodate.com/contents/methicillin-resistant-

staphylococcus-aureus-mrsa-beyond-the-basics#H5515598 (2017). Retrieved June 9, 2016, from CDC: http://www.cdc.gov/mrsa/definition/index.html America Academy of Pediatrics, American Public Health Association, National Resource

Center for Health and Safety in Child Are and Early Education. (2011). Caring for Our Children. Elk Grove Village, IL: American Academy of Pediatrics;.

American Academy of Pediatrics. (2015). Retrieved from Red Book: https://redbook.solutions.aap.org/book.aspx?bookid=1484

CDC. (2011, January 17). Healthcare-associated Infections (HAIS). Retrieved June 9, 2016, from Staphylococcus aureus in Healthcare Settings: http://www.cdc.gov/HAI/organisms/staph.html

CDC. (2017). MRSA Tracking. Retrieved from https://www.cdc.gov/mrsa/tracking/index.html Giersing, B. K. (2016, June 3). Status of vaccine research and development of vaccines for

Staphylococcus aureus . Vaccine, pp. Pages 2962-2966. Klevens RM, M. M. (2007). Invasive methicillin-resistant Staphylococcus aureus infections in

the United States. JAMA, 1763-1771. Lowy, F. (2003). Antimicrobial resistance: the example of Staphylococcus aureus. J clin

Invest., 1265-1273. Melendez, e. a. (2016). 272 Characteristics of USA500/Iberian Methicillin-Resistant

Staphylococcus aureus (MRSA) Invasive Disease. Open Forum of Infectious Diseases. Pickering, L. K. (2009). Red Book. Elk Grove Village: American Academy of Pediatrics. PubMed Health. (2011). Retrieved April 10, 2012, from

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001863/ Rose, B. (2009). MRSA Infections in Child Care Programs. Berkeley: California Childcare

Health Program. https://cchp.ucsf.edu/sites/cchp.ucsf.edu/files/mrsaen022309.pdf Shinefield HR, R. N. (2009). Staphylococcal infections: a historical perspective. Infect Dis Clin

North Am., 1-15. Washington State Department of Health; Tacoma Pierce County Health Department; Group

Health Coooperative. (2006). Living with MRSA.


Resources Local Resources

Snohomish Health District This website includes child care information for disease prevention, brochures, logs, posters, fact sheets, and parent letters. www.snohd.org

National Resources

Centers for Disease Control and Prevention (CDC) Information on MRSA Call 1-800-232-4636 (1-800-CDC-INFO) http://www.cdc.gov/mrsa/community/index.html

Environmental Protection Agency (EPA) https://www.epa.gov/pesticide-registration/list-h-epas-registered-products-effective-against-methicillin-resistant

Posters and Fact Sheets

A child’s first line of defense against MRSA: A WELL-INFORMED PARENT MRSA FAQs (Frequently Asked Questions)

Children’s Activity Lesson

“Rotten Apples” lesson (see next page)

http://www.snohd.org/

http://www.cdc.gov/mrsa/community/index.html



http://www.cdc.gov/mrsa/pdf/MRSA_Broch_Parent.pdf

http://www.cdc.gov/mrsa/pdf/SHEA-mrsa_tagged.pdf


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Rotten Apples

Objective: To learn that our skin protects our bodies from germs

Materials: 2 uncut apples

Cutting board, knife, and an adult to do the cutting

Instructions:

1) Talk to the children about how our skin protects us from germs. If our hands touch something with germs, the germs can be washed off of our hands and won’t make us sick. Our skin doesn’t let germs into our bodies.

2) Show the children the two apples. Talk about how the peel of the apple is like our skin.

3) The adult then takes the knife and cuts a few

chunks off of the peel of one of the two apples. The other apple is left intact.

4) Have the children pass the apples around and

touch them with their unwashed hands. Point out that germs from our hands are getting on the “skin” of the whole apple but are not able to get inside the “body” of the apple. The apple that has cuts, however, is getting germs inside because the “skin” is not there to protect it. (Teacher note: The cuts on the apple also let oxygen come in contact with the inside of the apple, which speeds decomposition.)

5) Place the apples in an out of the way location, such as on a shelf out of reach. 6) Have the children go and wash their hands. 7) Let the apples sit on the shelf for several days. Later, bring the apples down and talk

to the children about how the uncut apple looks just like it did when it started, but the cut apple looks “sick.”

8) Talk about how it is important to take care of any cuts and scrapes that happen –

washing with soap and water and covering with a bandage.

~Last page~

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