Infectious Disease Control Administrative Guidelines And Procedures

Fire Safety Issues:

• Purell and other effective hand sanitizers contain 70% ethanol to kill bacteria and viruses. This makes it quite flammable. Fire Regulations require that:
• Dispensers not be installed next to or above electrical outlets, switches, or near other sources of ignition (including electrical devices or oxygen outlets)
• A corridor width of 6 feet or greater is required for dispensers to be mounted in corridors.
• Dispensers must not be installed over carpeted surfaces unless they are located in a sprinklered smoke compartment

Standard Precautions

Standard precautions are used for all contact with blood and other body fluids, secretions, and excretions; non-intact skin; and mucous membranes. These precautions must be used at all times, regardless of a person’s infection status or diagnosis.

Appropriate equipment (including personal protective equipment) must be readily available to staff members who are responsible for the clean-up of bodily spills.  

Standard precautions include:

• Follow hand hygiene guidelines (see above).
• Wear gloves (clean, nonsterile) when touching blood, body fluids, non-intact skin, or contaminated items. Always practice hand hygiene whenever gloves are removed. Gloves are not a substitute for hand hygiene.
• Gowns, masks, and eye protection should be worn during procedures and activities that are likely to generate splashes or a spray of blood or body fluids.
• Disinfect surfaces and equipment contaminated with blood or body fluids using a 1:10 solution of bleach for 30 seconds, or any EPA-approved disinfectant used according to manufacturers’ recommendations. Bleach solutions should be mixed on a routine basis and stored in an opaque bottle.
• Dispose of all sharps in a puncture-proof container, this includes cutting tools that may have caused injury during use. (Scissors, exacto etc.)
• Dispose of infectious waste (anything contaminated with blood or body fluids) in a leak-proof sealable bag.

Custodial Staff Procedure

 If necessary, block off area. Assemble the necessary equipment: Approved disinfectant, gloves, paper towels, disposal bag, if necessary, a mop, mop bucket, wringer. Optional equipment: gown, booties, cap, goggles, and wet floor sign.

• Put on gloves
• Spray floor with an approved disinfectant and let soak for 3-5 minutes.
• Wipe up with paper towel and place all contaminated paper towels in plastic disposal bag.
• Repeat process as many times as necessary to make sure that all material has been removed from the floor and other surfaces.
• When all blood or body fluids have been removed, spray area again with an approved disinfectant and allow to dry for 10 minutes.
• Seal bag and dispose outside of classroom.
• If a mop is used, mop head should be removed immediately after use and disposed of.

Respiratory Hygiene/Cough Etiquette

Posters and signs to remind students and staff about cough etiquette and hand hygiene will be displayed in bathrooms, cafeteria, classrooms etc. In addition, parents/guardians will receive similar information through school communication forums such as newsletters, and will be reminded to keep sick children home from school.

Education of students and staff on appropriate cough etiquette includes:

• Cough or sneeze into elbow crease if no tissue is available
• Cover the mouth and nose with a tissue when coughing or sneezing and immediately disposing of tissue into wastebasket and;
• Practice hand hygiene often.
• Classrooms will be supplied with tissues

Vaccine-preventable Diseases

Immunizations and Requirements

Vaccine-preventable diseases include, at the time this document was created, chickenpox (varicella), diphtheria, Haemophilus influenzae type b (Hib), hepatitis A, hepatitis B, invasive pneumococcal disease, pertussis, polio, measles, mumps, rubella, and tetanus.

Missouri statutes (167.181) specifies minimum immunization requirements for enrollment in school. These requirements apply to all students attending a City of St. Louis pre-school program and kindergarten through grade twelve.

Every year, DHSS updates and distributes the most current childhood immunization recommendations and school requirements to all schools that have kindergartens and 7th grades. It is the responsibility of the school nurse and the Family Resource Center to obtain the most current version of the childhood immunization schedule and requirements for school entry.

Exclusion

In accordance with the law and regulations, provides for exclusion of students from school if immunizations are not up to date, but exemptions are permitted at school entry for medical and religious reasons. The only exception for exclusion of unimmunized or partially immunized children without medical or religious exemptions is for homeless children: The federal McKinney Vento Homeless Assistance Act of 2001 stipulates that homeless children cannot be denied entry to school for not possessing immunization records.

DOH is authorized to implement and enforce the requirements for isolation and quarantine pursuant to 105 C.M.R. 300.200.

Notification

The school nurse and school physician in collaboration with DOH determine whether some or all parents/guardians and staff should be notified immediately.

Teachers and Staff

DOH recommends that all adults working in schools (including volunteers and student teachers) have immunity to measles, mumps, rubella, diphtheria, tetanus, and chickenpox. An annual influenza vaccination is also recommended for those who are in contact with children.

DOH in collaboration with the school nurses maintain confidential immunization records for school staff, because staff members without documentation of immunity may be excluded if a vaccine preventable disease manifests in the school.

Reporting Requirements

The School Nurse will report to DOH if a documented case of any of the diseases listed below occurs in the school (19 CSR 20-20.020). 

Diseases that must be reported:

• chickenpox (varicella);
• diphtheria;
• Haemophilus influenzae type b (Hib);
• hepatitis A; See “Diseases Spread Through the Intestinal Tract”
• hepatitis B; See “Diseases Spread Through the Intestinal Tract”
• pertussis;
• polio;
• measles;
• mumps;
• rubella;
• other, as directed by public health authorities

Standard Measures

The following measures will be taken in the event of the occurrence of any of the vaccine preventable diseases listed above. Exceptions and specific additional measures will be noted in sections discussing each disease. The school nurse will notify the DOH and under the direction of Public Health will:

• Exclude infected individuals during their infectious period.
• Collaborate with DOH Public Health Nurses to identify who has been exposed, determining the “zones of exposure” for the disease (see below).
• Identify all susceptibles among exposed students and staff.
• Identify high-risk, exposed susceptibles and refer them to their health care providers.
• Exclude all exposed susceptibles who cannot be vaccinated (or take antibiotics if indicated) for medical or religious reasons during the appropriate time period.
• Notify students, staff, parents/guardians, and others.
  • Conduct surveillance for two incubation periods.

School Attendance Guidelines

Varicella/Vaccine Modified Varicella Syndrome: If students or staff have had chickenpox disease with vesicles present, they may return to school when all blisters are crusted over and dry. If no vesicles were present, they may return to school when the lesions are faded (i.e., the skin lesions are in the process of resolving; lesions do not need to be completely resolved) or no new lesions appear within a 24-hour period, whichever is later.

Shingles: Same as varicella.

Diphtheria: No identified cases or carriers of C. diphtheriae may return to school until two cultures from the nose, throat, or skin sores are negative for the bacteria.

Haemophilus Influenzae Type B Illness (Hib Disease): Children and staff who are not ill with Hib disease may return as soon as the appropriate antibiotic treatment has begun. Children or staff who are ill should be excluded while they are ill and until 24 hours after initiating antimicrobial treatment.

Measles: A student or staff member with measles should not return until at least 4 days after the appearance of the rash (counting the day of rash onset as day zero).

If there is one case of measles, susceptible individuals must be excluded from days 5 through 21, after exposure to the case during the infectious period. If exposure was continuous, or there were multiple exposures, these individuals must be excluded through the 21st day after rash onset in the last case. After exposure, those defined as susceptible are individuals without proof of immunity, as defined by:

• Born in the U.S. before January 1, 1957 (with the exception of individuals in the health care setting, where year of birth doesn’t apply).
• Two doses of measles-containing vaccine given at least 4 weeks apart, beginning at > 12 months of age, and the second dose given prior to or within 72 hours of exposure. (In some situations, individuals receiving their first dose within 72 hours of exposure will be considered immune.)
• Serologic proof of immunity.

When case(s) of disease occur, susceptible individuals, including those with medical or religious exemptions who are not vaccinated, must also be excluded for the appropriate time period as outlined in Rules of Department of Health and Senior Services (19 CSR 20-20.030).

Mumps: A student or staff member will be excluded until 9 days after the onset of swelling (counting the initial day of gland swelling as day zero).

Pertussis (Whooping Cough): A student or staff member with confirmed pertussis will be excluded until 3 weeks after the onset of cough or after they have completed 5 days of appropriate antibiotic therapy.

Polio: Individuals with polio should be excluded for 6 weeks after onset or until the virus can no longer be recovered from sample.

Rubella: A student or staff member with rubella may return 7 days after the onset of the rash (counting the day of rash onset as day zero). Unimmunized persons must also be excluded until 21 days after the date of rash onset in the last case.

Diseases Spread Through the Intestinal Tract

Because students and staff who have intestinal tract diseases do not always feel sick or have diarrhea, the best method for preventing spread of these diseases is an ongoing prevention program. DOH believes the best prevention program is to promote hand washing after using the bathroom and before preparing or eating food. In addition, DOH recommends all schools ensure that bathrooms have an adequate supply of soap (preferably liquid), running water, paper towels, and toilet paper.

Prevention Guidelines for Infectious Diarrhea

• Strictly enforce all handwashing, bathroom, diapering, and cleanliness procedures.
• Carefully monitor field trips to farms, cider mills, and petting zoos. Students should not be allowed to drink raw or unpasteurized milk or apple cider, and they should wash their hands after contact with any animals. If hand washing facilities will not be available, provide students with waterless, alcohol-based hand sanitizers.
• Be careful about choosing pets for the classroom. Reptiles such as snakes, iguanas, and turtles can shed salmonella and are poor choices as classroom pets.
• Enforce environmental cleaning and sanitation.
• Instruct students and staff not to share food, drink, or eating/drinking utensils.
• Sharing of water bottles by sports teams should be particularly discouraged.

School Attendance and Return Guidelines for Infectious Diarrhea

• When students or staff have uncontrolled, severe, or bloody diarrhea and fever or vomiting, or if diarrhea cannot be contained by diapers (in those students using them), they will be excluded until fever and diarrhea are gone
• When students or staff have mild diarrhea, take special precautions or exclude.
• When students or staff who do not prepare food or feed students are found to have infectious diarrheal organisms in their stool (positive stool tests) but have no diarrhea or illness symptoms, take special precautions but do not exclude them. However, during outbreaks, a negative stool test may be required to permit attendance.
• When staff who prepare food or feed children have positive stool tests, exclude them from these duties until the isolation and quarantine (19 CSR 20-20.030) back-to-work requirements are met regarding that particular organism.

Salmonella, Shigella, E. coli O157:H7, Campylobacter: See school attendance and return guidelines for infectious diarrhea above.

Pinworm: Because pinworms are not considered an emergency, students or staff identified with pinworms do not need to be sent home from school. Infected individuals will be referred to a health care provider for diagnosis and treatment and may return after treatment has begun. When pinworm infection occurs in a school, the school nurse and school physician will determine, based on their judgment, whether some or all parents/guardians and staff should be notified.

Hepatitis A: Children and adults with acute hepatitis A will be excluded from school for 1 week after the onset of the illness or until their fever has resolved, whichever is later.

Giardia: See school attendance and return guidelines above.

Norovirus: See school attendance and return guidelines for infectious diarrhea in the introduction to this section.

Hand, Foot, and Mouth Disease (Coxsackievirus): There is no need to exclude anyone who is well enough to attend school.

Prevention guidelines: Follow strict handwashing and personal hygiene procedures. Always wash hands after using the bathroom, after diapering or assisting a student in the bathroom, and before eating or handling food. Careful attention to environmental cleaning and sanitation is also very important in reducing spread. For additional prevention guidelines, see the “Infection Prevention and Control in the School Setting” section in this Administrative Guidelines.

Diseases Spread Through the Respiratory Tract

Respiratory tract diseases are spread primarily through microscopic infectious droplets (droplet transmission) generated in or settling on the mucous membranes of the nose, mouth, throat, or eye. These droplets are generated by a person primarily during coughing, sneezing, talking, or nose blowing. Group A streptococcus and Neisseria meningitidis are examples of bacteria that are droplet-borne. Respiratory transmission of infectious particles is less frequent and occurs when very small (≤ 5μm) particles remain suspended in the air for long periods of time, or when dust particles contain the infectious agent. Measles and tuberculosis are examples of diseases spread through respiratory transmission.

Respiratory tract diseases may be mild (viral colds and strep throat) or life-threatening (bacterial meningitis). Some of these diseases are more common in children; others, like the viral cold, affect all ages fairly equally.

Prevention Guidelines:

• Hand washing and cleanliness are essential to stop the spread of all respiratory tract diseases. Hands should be washed with soap and warm running water or an alcohol-based hand sanitizer.
• Encourage staff and students to wash their hands after wiping or blowing noses; after contact with any nose, throat, or eye secretions; and before preparing or eating food.
• Keep a supply of disposable towels, alcohol-based hand gel, and tissues in each classroom, and encourage their use.
• Dispose of towels or tissues contaminated with nose, throat, or eye fluids in a step-can with a plastic liner. Keep them away from food and classroom materials.
• Teach children and staff to cough or sneeze toward the floor or to one side, away from people. If they sneeze or cough into a hand or tissue, they must properly dispose of the tissue and wash their hands.
  • Discourage the sharing of food and/or beverages, including water bottles.

Colds and Influenza: The school nurse, through clinical assessment, will determine when a student or staff member should go home. Fever guidelines are 100.4o F or higher under the arm, 101.5o F by mouth. Sick students and staff should stay home from school until they have been without fever and have not used fever reducing medication for 24 hours, to help prevent spreading illness to others.

Group A Streptococcal Infections: (strep throat, scarlet fever, etc.) People with streptococcal pharyngitis should not return to school until at least 24 hours after beginning appropriate antibiotic treatment and resolution of their fever. Mildly ill students and staff can continue to attend school while awaiting the results of a strep culture. Antibiotics should be taken for the full course of prescribed treatment, primarily to prevent rheumatic fever or other complications.

Fifth Disease (Erythema Infectiosum): Students or staff with fifth disease should continue to attend school. By the time they are diagnosed with the rash, they are usually no longer contagious.

Invasive Meningococcal Disease: Individuals with invasive meningococcal disease are generally too ill to attend school. They may return to school when they are well (after hospital treatment).

Various strains of the bacterium Neisseria meningitidis can cause invasive meningococcal disease that is serious and sometimes fatal. The most common illness is meningitis, an inflammation of the coverings of the brain and spinal cord. People with invasive meningococcal disease are usually very ill and are hospitalized.

Notification guidelines: The school nurse and school physician, collaborating with DOH and school officials, will develop a system for immediate notification of appropriate parties, including parents/guardians and staff.

Severe Acute Respiratory Syndrome: If a student or staff member has SARS, is suspected of having SARS, or has been exposed to a person with SARS, the DOH and DHSS in collaboration with school officials will recommend and enforce appropriate public health actions. These may include isolation, quarantine and information dissemination and will be determined by circumstances and available information.

Meningitis: Since fecal shedding of virus can continue for several weeks after onset of infection and can also occur without signs of clinical illness, there is no reason to keep people out of school if they feel well enough to attend. For school attendance guidelines for Hib or pneumococcal or meningococcal meningitis, refer to the appropriate section.

Notification guidelines: The school nurse and school physician will decide, based on their judgment, whether some or all parents/guardians or staff should be notified.

Infectious Mononucleosis: Since both sick and healthy people can carry and spread this virus intermittently for life, there is no need to exclude students or adults with this disease, as long as they are feeling well.

Tuberculosis: students or staff diagnosed with suspected or confirmed TB disease should not attend school or work in schools until they have begun taking prescribed TB antibiotics and their health care provider states in writing that they are not contagious. Students or staff who have a positive TB skin test and no symptoms of active TB should not be restricted from school.

What School Administrators, Staff, and Parents/Guardians Should Know About TB:

• Infants and young children under age 10 with TB lung disease are usually not contagious.
• The DOH recommends a TB risk assessment, performed by the child’s health care provider prior to the child’s entry into school. Students or staff who have a positive TB skin test and no symptoms of TB should not be restricted from school.
• In, Missouri, TB screening for school employees and volunteers is required.

Diseases Spread Through Direct Contact

Diseases spread through direct contact include impetigo, ringworm, conjunctivitis, scabies, pediculosis, and herpes simplex infection and are caused by superficial bacterial or viral infections or parasitic infestations. They are common and are generally not serious. They are spread by direct contact with infectious secretions, infected skin areas, or contaminated objects. Because students are constantly touching their surroundings and the people around them, these infections are easily spread among students and staff.

Prevention Guidelines

• Follow hand hygiene guidelines in the “Infection Prevention and Control in the School Setting” section in this chapter.
• Encourage staff and students to wash their hands after contact with any possibly infectious secretions.
• Keep a supply of disposable towels, alcohol-based hand gel, and tissues in each classroom, and encourage their use.
• Dispose of towels or tissues contaminated with secretions in a step-can with a plastic liner. Keep them away from food and classroom materials.
• Discourage the sharing of food and/or beverages, including water bottles.
• Wash frequently used surfaces such as tables and counters daily.
• Do not permit students to share personal items such as combs, brushes, hats, or clothing.
• Provide adequate individual storage areas for students’ clothing items such as coats, hats, scarves, and mittens.
• Wash and cover sores, cuts, and scrapes promptly, and keep infected eyes wiped dry.
• Report rashes, sores, runny eyes, and severe itching to a student’s parents/guardians so they may contact their health care provider for diagnosis and appropriate treatment.

Impetigo: Impetigo is not considered an emergency, so students or staff identified with a suspected impetigo rash during the day do not need to be sent home from school. Sores should be kept lightly covered. Affected students and staff may return to school after 24 hours of local therapy.