Communicable Disease Toolkit

Some germs and parasites may be found in the environment, on surfaces, in the air, or in the water. Others can be found on the skin or inside people. Some germs are harmful, and others help to keep harmful germs in check. When a parasite or germ such as a virus, bacteria, or fungus invades a person or multiplies in an abnormal way, the infection results in disease.

After exposure to a germ, there is a period of time between the germ invading the body and the beginning of symptoms. This is called the “incubation period.” When someone is sick with an infection, they can spread that illness to others for a different period of time, called the “contagious period.” Individuals can be contagious before, during, and after they have symptoms. Each illness has a different incubation and contagious period. For some illnesses, particularly new ones, the periods may not be known.

When diseases can spread from person to person either directly or through another object or agent, they are called communicable diseases. Communicable diseases spread:

• on people’s hands
• through the air after someone coughs, sneezes, or talks
• through contact with an open sore or body fluid, such as feces, vomit, urine, saliva, or blood
• through contact with an object or surface that has been contaminated
• through contaminated food or water
• from the bite or sting of an insect or animal

Different measures to prevent the spread of communicable diseases may be required depending on the way that disease is spread. Early care and education programs are strongly encouraged to implement multiple, or layered, prevention strategies to reduce the spread of all communicable diseases, including:

• Handwashing
  • Handwashing is the most effective way to prevent the spread of disease. Post and follow instructions on handwashing posters for adults and children at every handwashing sink.
• Exclusion
  • Exclusion of adults and children with communicable disease when a person meets the criteria for exclusion as listed on the Communicable Disease and Exclusion from Child Care chart and whenever instructed by a health care professional.
• Daily Health Checks
  • Conduct a Daily Health Check at the beginning of each day and whenever someone shows possible signs of illness.
• Hygiene
  • Be vigilant about proper cleaning, sanitation, disinfection and food handling practices following North Carolina Child Care Rules and Laws.
• Immunization
  • Promote immunization against vaccine preventable diseases.
• Policy
  • Develop and implement communicable disease policies, including:
    • Immunization policy
    • Health promotion and disease prevention policy
    • Reportable Diseases policy
    • Staff health policy
    • Exclusion policy
• Communication
  • Communicate to families and staff that they should:
    • stay home when sick
    • inform the early care and education program when diagnosed with a communicable disease
    • are aware of any potential exposures to a communicable disease
• Training and technical assistance
  • Request training and technical assistance from your local Child Care Health Consultant

This toolkit provides guidance for communicable disease prevention and control in early care and education (ECE) settings. ECE programs must follow all applicable rules and laws referenced at the beginning of each section of this document, including:

• Communicable Disease Laws and Rules
• Immunization Laws and Rules

Child Care Laws and Rules, including:

• Chapter 110 General Statutes Child Care Facilities
• 10A NCAC 09 Child Care Rules
• 15A NCAC 18A Sanitation of Child Care Centers

Best practice standards are also referenced:

• Caring for Our Children
• Managing Infectious Diseases in Child Care and Schools by the American Academy of Pediatrics (available for purchase)
• Centers for Disease Control and Prevention
  • Children under age 4
  • Children aged 4-11

Following each applicable law, rule, or best practice, an explanation of how to follow these rules will be detailed.

Early care and education programs should develop written policies for the management and care of children and early educators who become ill with a contagious disease. Programs must balance the needs of the individual who is ill and their family, while also protecting the health and well-being of others. The policy should be developed in consultation with a Child Care Health Consultant and should include the procedures for:

• Following the program’s Emergency Medical Care plan
• Responding to seasonal and pandemic infectious disease
• Assuring Medical Action Plans for children with special health care needs are current
• Determining exclusion and return to child care for children and adults based on the Communicable Disease and Exclusion from Child Care chart and/or guidance from the local health department
• Obtaining and sharing resources from reputable sources like the American Academy of Pediatrics (AAP) or the Centers for Disease Control and Prevention (CDC) that contain information:
  • about common childhood illnesses (signs and symptoms, how the illness is spread, length of time the person is contagious, and time between exposure and the beginning of symptoms)
  • what early educators and the family should do to control the spread of the illness
  • exclusion and inclusion criteria
• Separating children or adults when they become ill at child care
• Maintaining current contact information for emergency contact(s) for children and early educators
• Documenting illnesses in the program including name of person(s) affected, date and time of illness, description of symptoms, the response of the staff person to these symptoms, and who was notified (such as a family/guardian, health care professional, or health department) and the response
• Notifying staff and families of children who are exposed to communicable diseases
• Notifying the local health department about reportable diseases (include who is responsible for reporting in the program)

Determining if exclusion is required based on symptoms
Certain situations and symptoms require exclusion from child care according to NC Child Care Rules.

• A child must be isolated from others and picked up as soon as possible if he/she:
• Is unable to participate comfortably in activities, as determined by early educators
• Needs more care than early educators can provide without compromising the health and safety of other children
• Has a fever (taken at armpit or orally). Fever is defined as:
  • a child older than two months has a temperature of 101 degrees Fahrenheit or higher
  • an infant younger than two months has a temperature of 100.4 degrees Fahrenheit or higher
• Has two or more episodes of vomiting within a 12-hour period
• Has more than two stools above the child’s normal pattern and diarrhea is not contained by a diaper or when toilet trained children are having accidents.

Exception: Child care centers who are specifically licensed to care for mildly ill children may be able to provide care to children with some of the symptoms on the above list.

See Caring for Our Children Appendix A Signs and Symptoms Chart for a list of:

• Sign or symptoms of illness
• Common causes of those symptoms
• What might be seen
• Actions to take if a child exhibits the symptoms listed

When a child or early educator becomes sick at home

Families and early educators should be familiar with the early care and education program’s communicable disease policy. Children and early educators should stay home when ill. Communicate with families and early educators how they should report absence due to illness to the early care and education program.

Early educators who provide direct care to children or are in contact with food or other items used by children, may be reassigned duties that would prevent the spread of the illness. For example, administrative work or maintenance.

When a child becomes sick while in care

When a child becomes sick while at child care and is no longer able to participate in routine group activities:

• Determine if the child requires first aid or CPR and administer as needed
• Follow the Emergency Medical Care plan to obtain appropriate medical attention for the child
• If the child does not require immediate medical attention, call the child’s parent, legal guardian, or emergency contact to pick them up. Do not send children home on group transportation.
• Separate the child who is sick from other children in a supervised, quiet area that is:
  • in a separate room or
  • in the classroom using a partition or screen to separate the area from space used by other children.

The designated sick area must allow for appropriate supervision, be located so that health and sanitation measures can be carried out without interrupting activities of other children and early educators, and contain:

• a bed, mat or cot
• a suitable container in case the child vomits.

Anything disposable that is used in the sick area must be disposed of in plastic lined, covered trash receptacle. If used, the container for vomitus must be cleaned and disinfected after each use. Any reusable items from the designated sick area, including thermometers and toys must be cleaned and sanitized after each use. Linens must be changed after each use.

Responding to vomiting and diarrheal events

Child care centers are required by NC Sanitation Rules to have written procedures in place for employees to follow in case there are episodes of vomiting or diarrhea that occur in the center. These procedures must address steps staff will take to minimize:

• the spread of contamination and
• the exposure of staff, children, food, and surfaces to vomitus or fecal matter.

The written procedures must include the following information:

• which child care center employees will be part of a designated clean-up response team
• a supply list for vomit and diarrhea cleanup kit items to include:
  • disposable personal protective equipment (gloves, apron, mask, shoe covers, and hair
    restraint)
  • two disposable plastic bags
  • paper towels
  • a scoop or scraper
  • a mop and bucket and
  • an approved disinfectant.
• the location of the supplies in the vomit and diarrhea cleanup kits
• a procedure for preventing access to the contaminated area
• the steps used to properly clean and disinfect the contaminated area
• the steps for properly storing contaminated articles of clothing and cloth diapers that came into contact with the vomit or diarrhea.

The steps to clean and disinfect the contaminated area are:

• for hard surfaces, remove the vomit or diarrhea, wash the contaminated surface, and use an approved disinfectant
• for carpet or upholstery, remove the vomit or diarrhea without use of vacuum, wash all
  surfaces, and steam clean or use an approved disinfectant.

After cleaning and disinfecting the area,

• Discard all disposable items that came into contact with the vomit or diarrhea, including cleaning items and personal protective equipment (PPE) in a secured trash area, then wash hands.
• Put on fresh disposable gloves, then clean and disinfect non-disposable cleaning items such as scoops, scrapers, mop heads, mop handles, and buckets, then wash hands again.

Contaminated articles of clothing and cloth diapers that came into contact with the vomit or diarrhea must not be rinsed. Send cloth diapers to a diaper service, if used. If contaminated items are to be sent home:

• place them in a sealed plastic bag or other sealed container,
• store out of reach of children, and
• send home with the child on the same day to be laundered.

Returning to child care

Determining length of exclusion for mild symptoms that resolve on their own

Some symptoms are mild and improve on their own without evaluation or treatment by a health care professional. In this case, no illness is identified or diagnosed, but the child may be able to return when they feel better.

Early educators should communicate regularly with the child’s family to help determine when the child’s symptoms are improving, and they are well enough to return. Before returning, children must be able to participate comfortably in activities without needing more care than early educators can provide.

Certain symptoms that do not improve on their own may require a child or adult to be seen by a health care professional.
Health care professionals, such as a physician, nurse practitioner or physician assistant licensed in North Carolina, can identify signs and symptoms of illness as a specific diagnosis. Some illnesses may require testing to confirm the diagnosis. The diagnosis of a specific communicable disease will help determine if the person poses a health risk to others. Health care professionals can also give guidance on any special care a child needs upon returning to child care.
The early educator who communicates with the parent, legal guardian, or emergency contact person who is picking up the child can provide a Sample Confirmation that a Child can Safely Return to Child Care form which includes symptoms the child has experienced, and either the date the child care return or a space for a doctor’s note for returning.
NC Child Care Rules require exclusion for the following communicable diseases and conditions:

• lice, until completion of first treatment
• scabies
• chicken pox or a rash suggestive of chicken pox
• tuberculosis, until a health professional provides a written statement that the child is not infectious
• strep throat, until 12 hours after antibiotic treatment has started and no fever is present
• pertussis, until five days after treatment has started
• hepatitis A virus infection, until one week after onset of illness or jaundice
• impetigo, until 24 hours after treatment has started.

See the Communicable Diseases and Exclusion from Child Care chart for guidance and information about these and other communicable diseases including:

• the name of the disease
• important details about the disease
• symptoms
• prevention measures
• length of required exclusion

Detailed information about preventing the spread of communicable disease can be found in the latest edition of Managing Infectious Diseases in Child Care and Schools from the American Academy of Pediatrics. A Child Care Health Consultant in your community can provide additional guidance.
While contagious, adults with a communicable disease or condition must be excluded from work or reassigned duties that will prevent the spread of the disease to others. Consult a Child Care Health Consultant for guidance.

Requirement for child care operators to report certain diseases
Certain serious communicable diseases must be reported because they are considered dangerous to the public health. The North Carolina Communicable Disease rule requires operators of licensed child care centers or family child care homes to notify cases or suspected cases of these reportable diseases to the local health director of the county or district in which the school or facility is located or their designated representative. The reporting process may differ from county to county. Contact the Child Care Health Consultant in your community or the local health department (LHD) for more information.

When reporting a communicable disease to the local health department (LHD), have as much of the following information available as possible:

• full name, birthdate, county of residence, and contact information of person with communicable disease
• name and contact information of parent or legal guardian (for a child)
• name of communicable disease, and when symptoms started, or diagnosis was made
• staff schedules and attendance records to determine other people who may have been exposed.

Receiving reports from the local health department

LHDs receive communicable disease reports from health care professionals and laboratories. The LHD determines if an investigation is needed to identify who was exposed to the disease. The LHD then provides guidance and instructions about reducing the spread of the disease. Early care and education programs are required to comply with LHD guidance.

Exclusion of children during vaccine preventable disease outbreaks

Most Vaccine Preventable Diseases (VPD) are reportable. Children who are un-immunized or under-immunized may require exclusion during a vaccine preventable disease outbreak. This may include children who:

• are not yet eligible for a vaccine due to their age or
• have medical or religious exemptions to vaccination.

Immunization records must be kept current throughout the year. Up to date records allow the local health department (LHD) to work quickly during an outbreak to protect those who are not fully immunized.

The local health director (or their representative) will:

• confirm the individual has the vaccine preventable disease
• determine which children must be excluded from care
• determine the date individual children may return to child care
• provide guidance on how to prevent the spread of the disease and keep your early care and education program and community safe.

Outbreaks of communicable disease

An outbreak is when there is a sudden or unexpected rise in the number of individuals with similar illness symptoms. Outbreaks can occur within an early care and education program or in the community. Any rise in a disease or condition, even those which are not required to be reported, may be considered an outbreak. Contact a Child Care Health Consultant or the LHD for appropriate control measures.

Early care and education programs should notify families and staff about potential or confirmed exposures to a communicable disease. This should be done without identifying the person with the communicable disease. Programs must notify of exposure if the health department requires notification.

Notification should include:

• the name of the communicable disease, both the common name and the medical term
• which symptoms to watch for
• how long after exposure to watch for symptoms
• how the disease is spread

A sample notification letter of exposure to communicable disease can be found here.

Notification of an exposure to a communicable disease is necessary to:

• Help families identify any signs and symptoms of disease early before the disease worsens.
• Reduce the risk of spreading the disease to family members or friends and avoid an outbreak. Some illnesses, while mild for children and healthy young adults, are more harmful to people who are pregnant, older, or have preexisting illnesses or weakened immune systems.
• Prevent a loss of trust between the staff, families, and the child care program. If staff or families become ill themselves or find out about disease spread from others, they will want to know why information was not shared when it was known.

Proper hand hygiene is one of the best ways to prevent the spread of illness. Following safe diapering and toileting procedures correctly is vital to preventing the spread of illnesses carried in human feces. Contacting and working with a local Child Care Health Consultant is one way to learn more about how illness is spread and steps that can be taken to prevent the spread of communicable disease. Visit the NC Child Care Health and Safety Resource Center’s poster library to print handwashing or diapering posters or request printed copies at no cost.

Guidance to reduce the spread of illness in early care and education settings:

Masks

Early care and education programs may consider using masks to help control the spread of disease during outbreaks of respiratory illnesses, such as RSV, influenza, or COVID. Individuals over age two can use masks unless:

• the person has a medical or behavioral condition that prevents using a mask safely
• the person is actively eating, drinking, or sleeping
• the mask prevents necessary communication.

To facilitate learning and social/emotional development, staff may choose to wear clear paneled masks that allow others to see their mouth.

Share CDC guidance and information with early educators and families on the proper use, wearing, and removal of masks. If the child care program requires temporary masking to reduce the spread of illness, the program should have a supply of masks available for all children and early educators that are present.

Standard Precautions

Standard Precautions are a way of preventing the spread of communicable disease by treating everyone’s blood and body fluid as potentially infectious. Standard precautions involve:

• using equipment, including gloves and other personal protective equipment (PPE), that protect others from blood and body fluids
• doing tasks, including cleaning up spills of body fluids or blood, using safe methods (see Caring for Our Children, Appendix L)

Early educators should use Standard Precautions when there is potential contact with blood or other bodily fluids, except human milk. Although human milk may be thought of as a body fluid by some people, it is not necessary to wear gloves when feeding or handling human milk. The risk of exposure to communicable diseases during feeding or from milk that the child regurgitates is not significant.

Early care and education programs with employees are required to comply with the Occupational Health and Safety Administrations Bloodborne Pathogen Standard, enforced by the North Carolina Department of Labor, including an exposure control plan and annual training.
Respiratory Etiquette
Respiratory etiquette reduces the spread of respiratory illnesses by covering coughs and sneezes. Adults and children should be reminded to avoid sneezing or coughing into bare hands. Individuals should cough or sneeze into a tissue which is immediately discarded. If a tissue is not available, individuals should sneeze into their elbows.

It is difficult to always anticipate when a cough or sneeze is about to happen and there may be a chance that hands become contaminated during or after a cough or sneeze. Follow all respiratory etiquette with proper handwashing to limit the spread of germs from potentially contaminated hands. Clean other surfaces that may have become contaminated with respiratory droplets from a sneeze or cough.

Multi-lingual videos, posters, and handouts are available to help early educators and children reinforce this practice. Free downloadable posters and flyers can be found at on the CDC website and guidance on Coughing and Sneezing.
Glove and Personal Protective Equipment (PPE) Use
Use of disposable gloves is required if contact with blood or body fluids containing blood is likely. Gloves are required for diapering procedures when the early educator has cuts, sores, or chapped skin on their hands.

Early care and education programs may choose to use barriers such as disposable gloves to prevent contact with body fluids during diapering. Other PPE, such as eye protection, disposable gowns, or shoe coverings may be used if splashing or contamination of clothes is likely, for example when cleaning up blood spills, or episodes of vomiting or diarrhea. Gloves are not necessary for handling human milk or assisting children with respiratory etiquette.

Cohorting

Cohorting means keeping people together in a small group and having each group stay together throughout the day. Separating children into cohorts reduces the chance of illnesses spreading from one group to another. This practice can also limit the spread of communicable illnesses between individuals when used in combination with other preventative measures.

Additional measures to prevent the spread of illness:

• To prevent the spread of illnesses through respiratory droplets while children sleep, be sure children are separated as much as possible while sleeping. Cribs, cots, mats and play pens in child care centers are required to be placed at least eighteen inches apart or separated by partitions that prevent physical contact. It is recommended that partitions are made of nonabsorbent, easily cleanable material. National best practice standards recommend spacing children thirty-six inches from each other for nap time. Placing children so that they are head-to-toe can also be helpful.
• Prioritize outdoor activities. Maintain cohorts if feasible in outdoor play spaces.
• Both family style food service and water play are prohibited during the outbreak and investigation of a communicable disease or condition at child care centers.

Ventilation

Improving ventilation is another strategy that can reduce the number of harmful particles in the air. Bringing fresh outdoor air into a building can prevent virus particles from concentrating inside.

Check that ventilation systems are operating properly and increase circulation of outdoor air as much as possible by opening screened windows and doors, using fans, or other appropriate methods. Do not open windows and doors if they pose a safety or health risk. During transportation, open or crack windows in buses and other forms of transportation, if doing so does not pose a safety risk.

Check for hazards such as mold, Legionella (bacteria that causes Legionnaires’ disease), and lead and copper contamination from plumbing that has corroded after reduced operation or temporary building shutdown.

For more specific information about maintenance, use of ventilation equipment or plumbing, actions to improve ventilation and reduce hazards, consult with your local Environmental Health Specialist, or refer to CDC guidance:

• Ventilation in Schools and Child Care Programs
• Interactive School Ventilation Tool
• Ventilation FAQs

Transporting children to child care:

In addition to general safety requirements regarding transportation, consider this health guidance when transporting children.

All staff providing transportation should be free of any symptoms of illness.

Staff should conduct a daily health check on all children when they get on a vehicle for group transportation. If children have symptoms of illness, they should not be transported with other children.

Transporting children from child care:

If a child becomes sick during the day, they should not use group transportation to return home.

If a driver or other transportation staff become sick during the day, they should not drive students until they are healthy.

Child care facilities should have a plan for getting sick students home safely.

While transporting children:

Keep windows cracked while the vehicle is in motion to increase air circulation, if appropriate, safe, and weather permitting.

Clean vehicles regularly. Children should not be present when a vehicle is being cleaned. Cleaning should focus on frequently touched surfaces.

Ensure safe use and storage of cleaning and disinfection products including storing products securely away from children and adequate ventilation when staff use such products.

This document was initially developed by the NC Child Care Health and Safety Resource Center and published on May 2023 following review by representatives of the following:

• Division of Child and Family Well-being
• Division of Child Development and Early Education
• NC Children’s Environmental Health Branch
• NC Communicable Disease Branch

Last updated in August 2023 to incorporate vomiting and diarrheal event plan and cleaning requirements to meet 15A NCAC 18A .2800 Sanitation of Child Care Center rules effective July 1, 2023.