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U. S. Food and Drug Administration
FDA Consumer
Health Talk With Dr. Frank Young
In Day-Care Centers, Cleanliness Is a Must
by Frank E. Young, M.D., PhD
Commissioner of Food and Drugs
Day-care centers have become a way of life in America. More than half of all
mothers of children too young to care for themselves hold jobs outside the home.
For them--indeed for millions of American families--day-care centers provide a
service that is a necessity. If both parents work, a solo parent caring for a
child must work, or other family support systems are inadequate, child day care
answers a critical need. Unfortunately, though, it often provides something
else--a focal point for certain kinds of infectious diseases that can all to
easily spread not only to others in the day-care center, but far and wide into
the community.
The problem involves illnesses, particularly enteric (small intestine)
infections, that usually show themselves as diarrhea and other disturbances in
the gastrointestinal tract.
Enteric illnesses are commonly associated with "food poisoning. "But in the
nation's day-care centers, tainted food is often not the culprit. Rather, the
illnesses most often result from fecal contamination because staff and children
fail to follow the dictates of ordinary common sense about things like hand
washing and cleanliness.
The major contributors to the spread of enteric diseases--person-to-person
contact, water and food--are interrelated and part of a persistent cycle.
Attacking one part of the problem will have little effect. What's needed is a
concerted effort directed at all sources of transmission of enteric pathogens.
Studies show that children under 3 who are cared for in day-care centers are
more subject to diarrheal attacks than other youngsters. Likewise, day-care
center workers and families of these young day-care children seem to suffer more
bouts of diarrhea. L.K. Pickering, M.D., a professor of pediatrics at the
University of Texas, noted in an editorial in the American Journal of Public
Health that diarrhea was 30 percent more common in day-care children than in
children cared for at home.
Another study found that day-care children under 3 had diarrhea twice as
often as children remaining at home. A study reported in the September 1988
journal Pediatrics found an average of 3.8 diarrhea outbreaks per child per year
in day-care centers in Houston, Texas. Similar findings have been reported from
cities throughout the United States.
A recent family survey by Pickering and his colleagues showed that the
average head of household or spouse lost 13 workdays because of illness in his
or her day-care-center child; just under five of those lost days were due to
diarrhea disease.
The spread of enteric illnesses to family members is documented in several
surveys, one of which found that 10 of 56 family members of ill children were
afflicted but only 1 of 45 family members of well children developed the
illness. The episodes can be quite severe. One study reported a median duration
of 12 days, while another noted that episodes lasted as long as six weeks.
Hospitalizations were not all that infrequent.
The cause of these infections is usually some well-known pathogen such as the
hepatitis A virus, rotavirus, Giardia, E. coli, Cryptosporidium, Shigella, or
Campytobacter.
The human gut, including that of small children, normally contains many of
the pathogenic bacteria and viruses that can cause diarrhea, but the body's
natural defenses usually keep them well under control. More important, these
potentially dangerous organisms don't ordinarily get spread around. But fecal
contamination can be a prime source of disease in centers that care for children
under 3--those still in diapers and still being toilet trained. Hands, toys,
diaper-changing areas, and just about everything else can be contaminated with
fecal matter. Children and adults who touch these contaminated objects and then
put their fingers to their mouths are prime candidates for disease.
A microbiologist in FDA's Center for Food Safety and Applied Nutrition,
writing in the January/February 1989 issue of the Journal of Environmental
Health, cautioned that diarrhea may not be the only consequence of fecal
contamination in day-care centers. Noting that children generally have symptoms
far longer than adults, he commented that diarrhea persisting a week or more can
lead to nutrient losses and can also compromise the immune system. Further, in
an important reminder that all of us should heed, he pointed out that both a
form of arthritis and certain neuromuscular disorders have been associated with
bacteria that cause diarrhea. And he reported the disquieting fact that some of
the strains of pathogens causing outbreaks of diarrhea disease are extremely
resistant to commonly used disinfectants.
Minimize the danger of infection caused by fecal contamination. Preventive
measures include:
- Hand washing. As simple as it may seem, hand washing is, as Professor
Pickering says, "the single most preventive measure in the day-care center."
Indeed, one study showed that outbreaks could be cut in half simply by
requiring staff and children to wash their hands after diaper changes and
bowel movements.
- Providing separate diaper-changing areas, preferably with disposable cover
sheets and smooth, nonabsorbent, easily cleaned surfaces.
- Cleaning and disinfecting the diapering area after each use.
- Keeping younger children--especially those in diapers--separate from older
children during the day.
- Keeping children with diarrhea at home.
- Segregating children whose diarrhea has stopped but who may still be
carriers.
- Providing staff education on preventive measures and regular follow-ups to
be sure the measures are being taken.
The U.S. Centers for Disease Control describes proper hand washing as
follows:
- Use soap and running water.
- Rub your hands vigorously as you wash them.
- Wash all surfaces (including backs of hands, wrists, between fingers, and
under fingernails).
- Rinse well and leave the water running.
- Dry hands with a single-use towel.
- Turn off water using a paper towel covering freshly washed hands.
Day-care staff members should wash their hands when they start work, before
preparing or serving food, after diapering a child or wiping his nose or
cleaning up messes, and after a trip to the bathroom. For children, the routine
is much the same, CDC advises. Center staff should be sure that children's hands
are washed when they arrive, before they eat or drink, and after they use the
toilet or have their diapers changed
It's also important that the diaper-changing area is located well away from
food-serving areas and that a separate sink is used for preparing food and
washing dishes.
CDC recommends that only washable, preferably hard-surfaced toys be used
around children still in diapers. Toys should be washed daily. Stuffed toys, if
they're used by children in diapers, should be washed at least once a week.
Obviously, the need for cleanliness is not limited to hands and playthings.
All facilities and supplies at day-care centers should be washed with soap and
water and then disinfected on a regular, frequent schedule. For disinfectants,
CDC recommends either a commercial product that kills bacteria, viruses, and
parasites such as Giardia or a bleach solution. To make the bleach solution, mix
one-fourth cup of bleach with a gallon of water (or one tablespoon per quart).
The solution should be made daily but can be stored in a spray bottle.
Disinfectants must be kept out of the reach of children.
Any parent knows how disagreeable even a short bout of diarrhea can be in a
young child. But public health workers know that diseases spread from day-care
centers can have further, more ominous consequences. A day-care center child who
contracts hepatitis A, for example, will probably develop only mild symptoms or
none at all. Spread to adult family members, however, the infection carries the
risk of more serious illness, as well as the possibility of further transmission
to the community, particularly if the adult handles or prepares food. According
to the National Restaurant Association, there are 8 million food service workers
in 550,000 establishments in this country. It is easy to see how enteric disease
in a day-care center child can have far-reaching effects into a wider world. In
two studies, 13 percent to 40 percent of reported cases of hepatitis A in the
community had some form of association with outbreaks in day-care centers.
FDA has model sanitation and food protection codes to which commercial food
establishments must adhere. These same codes should apply to day-care centers
that handle food, even though centers are not regulated by FDA. At FDA's urging,
the National Environmental Health Association devoted its 1987 annual mid-year
conference to day-care problems, particularly those associated with food
protection and sanitation. The agency also recently signed a memorandum of
understanding with the Department of Health and Human Service's Head Start
Bureau. It provides for increased cooperation between Head Start and FDA's
Center for Food Safety and Applied Nutrition to ensure that day-care centers
follow standard sanitation and food protection requirements. And FDA continues
to work closely with local and state regulators of day-care centers who are
responsible for inspecting these facilities to help ensure that standard public
health guidelines are being met.
My advice to parents of day-care center toddlers is: Make sure the day-care
center is on guard against contamination that can make your child, you, and lots
of other people needlessly sick. The risk is not just a bout of diarrhea. The
risk is serious health problems down the road that can--and should--be prevented
FDA Consumer, 8/89
Updated Information on FDA Food Codes
December 1995
Since the publication of the FDA Consumer article in 1989, FDA has updated
model codes related to the preparation of food in food establishments. This
update is currently embodied in the 1995 FDA Food Code and is intended to apply
to child care centers. There are several noteworthy provisions in that Code
which can help prevent the spread of food borne diseases:
- Child care center operators must maintain oversight of their employees who
prepare food to ensure that those who are ill or exhibit certain symptoms
associated with food borne illness do not prepare food or engage in other
activities that could contaminate the food.
- Employees who prepare food are required to report certain symptoms,
illnesses, and high-risk conditions related to food borne illness with which
they may have been associated.
- The Code specifies an acceptable method for food employee hand washing
during the preparation of food and special hand washing products (washing twice
and using a nailbrush) that are necessary in certain situations, e.g., after
using the toilet.
- Touching ready-to-eat food with bare hands is prohibited. Proper utensils
or single-service gloves may be used to satisfy this requirement.
- In order to destroy disease-causing organisms, potentially hazardous foods
(this means those that can support the growth of disease-causing organisms and
includes many foods like cut melons, boiled potatoes, fried rice, and others
that you might not think could be dangerous must be:
- Cooked to certain temperatures for 15 seconds, depending on the type of
food.
- Held cold at 41 degrees F or less or hot at 140 degrees F.
- Reheated rapidly to at least 165 degrees F.
Consult the FDA Food Code for specific temperature requirements and for
special provisions related to microwave cooking and reheating.
Young children attending child care centers are particularly susceptible to
food borne illness and special precautions apply.
For example: individual packages of food, like crackers, must not be reserved
if they are not eaten, even if they remain unopened; and pasteurized eggs should
be used instead of shell eggs.
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