A Review of State Licensing Regulations to Determine Alignment with Best Practices to Prevent Human Norovirus Infections in Child-Care Centers

Abstract

Objectives

Close, frequent contact between children and care providers in child-care centers presents many opportunities to spread human noroviruses. We compared state licensing regulations for child-care centers with national guidelines written to prevent human noroviruses.

Methods

We reviewed child-care licensing regulations for all 50 U.S. states and the District of Columbia in effect in June 2015 to determine if these regulations fully, partially, or did not address 14 prevention practices in four topic areas: (1) hand hygiene, (2) exclusion of ill people, (3) environmental sanitation, and (4) diapering.

Results

Approximately two-thirds (8.9) of the 14 practices across all state regulations were partially or fully addressed, with few (2.6) fully addressed. Practices related to exclusion of ill people and diapering were fully addressed most often, while practices related to hand hygiene and environmental sanitation were fully addressed least often.

Conclusion

Regulations based on guidelines for best practices are one way to prevent the spread of human noroviruses in child-care facilities, if the regulations are enforced. Our findings show that, in mid-2015, many state child-care regulations did not fully address these guidelines, suggesting the need to review these regulations to be sure they are based on best practices

In 2011, 61% of all U.S. children ≤5 years of age spent time in child care.¹ The close, frequent contact between children and their care providers presents opportunities to spread enteric pathogens that cause acute gastroenteritis. Although many enteric pathogens can cause acute gastroenteritis, most cases in the United States are attributed to viruses (e.g., human noroviruses, rotaviruses, and hepatitis A virus) rather than bacteria or parasites.² In general, these enteric viruses are highly contagious because of their low infectious dose, large number of particles shed in feces and vomitus, and resistance to environmental conditions.^3,4 As such, prevention strategies (e.g., hand hygiene, environmental sanitation, and exclusion of sick people) are similar. Overall, rates of illness attributed to rotaviruses and hepatitis A virus in the United States have declined since 2006 because of the wide availability and use of vaccines.^5,6 However, no vaccine is currently available for human noroviruses, so proper implementation of prevention strategies is important, especially in child-care settings, which, along with schools, accounted for 214 of 3,494 (6%) of reported outbreaks from 2009 to 2012.⁷

All 50 U.S. states and the District of Columbia (hereinafter “states”) have licensing regulations for child-care centers that establish minimum requirements to protect the health and safety of children, including the prevention of acute gastroenteritis.⁸ Multiple recommending bodies, such as the Centers for Disease Control and Prevention (CDC)⁹ and the American Academy of Pediatrics,¹⁰ have prepared guidelines on best practices to prevent acute gastroenteritis, but many states may not be using the guidelines to inform regulations. We compared state licensing regulations for child-care centers with national guidelines written to prevent the spread of human noroviruses, a leading cause of acute gastroenteritis, in child-care environments.^11–13

METHODS

The most recent licensing regulations for child-care centers were downloaded in portable document format (PDF) from the government websites of all states in June 2015.^14–71 We focused on regulations for child-care centers (i.e., nonresidential facilities providing child-care services) and did not review regulations for family or group daycare homes (i.e., facilities located in a licensee's residence).⁸

We identified 14 prevention practices in four topic areas: (1) hand hygiene, (2) exclusion of ill people, (3) environmental sanitation, and (4) diapering. The first three topic areas were based on CDC's human noroviruses outbreak prevention guidelines.⁹ CDC practices do not address diapering, but we included this topic area because of the high concentration of human noroviruses in feces^72,73 and the frequency of diapering in child-care centers. To assess diapering regulations, we used standards from Caring for Our Children: National Health and Safety Performance Standards: Practices for Early Care and Education Programs (hereinafter, CFOC), which was developed jointly by the American Academy of Pediatrics, American Public Health Association, and National Resource Center for Health and Safety in Child Care and Early Education. These standards represent the best evidence, expertise, and experience on health and safety practices for child-care centers.¹⁰

We then created a system to score the 14 practices based on methods used by Cradock et al.⁷⁴ (Table 1). If the state regulation fully addressed an individual practice, the practice was assigned two points. Fully addressed practices were defined as those aligned with CDC or CFOC standards. If the regulation partially addressed a practice, the practice was assigned one point. If a practice was not addressed by the regulation, the practice was assigned zero points. Two of the 14 practices (isolation of ill children and separation of diaper-changing and food areas) were scored only as fully addressed (two points) or not addressed (zero points), because it was not possible to partially address these practices. One reviewer knowledgeable about human noroviruses prevention guidelines reviewed and then assigned a score to the 14 practices in the state regulations using this system. Any uncertainties were reconciled with another expert.

Table 1.

Coding criteria to determine alignment of child-care center regulations with 14 practices that prevent human norovirus infections, 50 U.S. states and the District of Columbia, June 2015

^aBest practice comes from: Hall AJ, Vinje J, Lopman B, Park GW, Yen C, Gregoricus N, et al. Updated norovirus outbreak management and disease prevention guidelines [published erratum appears in MMWR Morb Mortal Wkly Rep 2011;60(20):670]. MMWR Recomm Rep 2011;60(RR3):1-15.

^bNot possible to partially address this practice

^cBest practice comes from: American Academy of Pediatrics, American Public Health Association, National Resource Center for Health and Safety in Child Care and Early Education. Caring for our children: national health and safety performance standards: guidelines for early care and education programs. 3rd ed. Elk Grove Village (IL): American Academy of Pediatrics; 2011.

CDC = Centers for Disease Control and Prevention

CFOC = Caring for Our Children

NA = not applicable

ppm = parts per million

EPA = U.S. Environmental Protection Agency

Before coding began, each PDF of state regulations was searched by key words. For hand hygiene, key words were “hand,” “wash,” “saniti,” and “rub.” For the exclusion of ill people topic area, key words were “sick,” “ill,” “disease,” and “exclu.” For environmental sanitation, key words were “clean,” “disinfect,” “saniti,” “bodily,” “fluid,” “ppm,” “vomit,” and “bleach.” For diapering, the key word was “diaper.” Each key word was entered independently into the “find” bar of the PDF version of each state licensing regulation, and results were highlighted with a color designated for that topic area (e.g., yellow for hand hygiene or pink for exclusion of ill people). The search results were reviewed to ensure search terms encompassed all relevant data.

Next, two scores were calculated by aggregating individual state-level scores.⁷⁴ The first score we calculated was a comprehensiveness score, defined as the mean number of practices across all state-level regulations that partially or fully addressed the CDC or CFOC practices (i.e., number of practices that scored one or two points). We then calculated a strength score, defined as the mean number of practices associated with each topic area across all state-level regulations that were fully addressed (i.e., number of practices that scored two points). We then calculated descriptive statistics (mean, standard deviation, and range) for practices within each topic area as well as for all 14 practices to determine how state child-care regulations as a whole addressed prevention practices.

RESULTS

The overall comprehensiveness score was 8.9, indicating that 64% of the 14 practices recommended by CDC and CFOC were partially or fully addressed across all state regulations (Table 2). However, the overall strength score (2.6) showed that most practices listed in regulations were not fully addressed. When reviewing the comprehensiveness and strength scores by four topic areas, our findings showed the hand-hygiene comprehensiveness score was high (2.3 of 3.0) but the strength score was low (0.4 of 3.0). Similarly, the comprehensiveness score for exclusion of ill people was also high (2.4 of 3.0) but the strength score was low (0.9 of 3.0). The lowest comprehensiveness (1.7 of 4.0) and strength (0.2 of 4.0) scores were in the area of environmental sanitation. The comprehensiveness (2.5 of 4.0) and strength (1.1 of 4.0) scores for the four diapering practices were higher than those for environmental sanitation but were still low.

Table 2.

Comprehensiveness^a and strength^b scores for alignment of child-care center regulations to prevention and control guidelines for human noroviruses, 50 U.S. states and the District of Columbia, June 2015

^aThe comprehensiveness score was calculated as the average number of practices coded as either partially (one point) or fully (two points) addressed based on CDC guidelines (Hall AJ, Vinjé J, Lopman B, Park GW, Yen C, Gregoricus N, et al. Updated norovirus outbreak management and disease prevention guidelines [published erratum appears in MMWR Morb Mortal Wkly Rep 2011;60(02):670]. MMWR Morb Mortal Wkly Rep 2011;60(RR3):1-15.) or CFOC guidelines (American Academy of Pediatrics, American Public Health Association, National Resource Center for Health and Safety in Child Care and Early Education. Caring for our children: national health and safety performance standards: guidelines for early care and education programs. 3rd ed. Elk Grove Village (IL): American Academy of Pediatrics; 2011.)

^bThe strength score was calculated as the average number of practices coded as fully (two points) addressed based on CDC or CFOC guidelines.

SD = standard deviation

CDC = Centers for Disease Control and Prevention

CFOC = Caring for Our Children

Two of the 14 practices were fully addressed by more than half of states: isolation of ill children (45 states) and separation of diaper-changing and food areas (35 states). More than half of the states did not address five practices: bodily fluid cleanup (42 states), areas to disinfect (39 states), hand sanitizer use (35 states), disinfecting diaper-changing table (26 states), and wearing gloves when changing diapers (29 states). No state fully addressed exclusion of ill children and staff members, but most states partially addressed exclusion of ill children (45 states) and exclusion of ill staff members (32 states). Within the topic area of environmental sanitation, areas to disinfect and bodily fluid cleanup were each fully addressed by one state. Areas to disinfect were partially addressed by 11 states, and bodily fluid cleanup was addressed by eight states. Additionally, no state fully addressed disinfecting of surfaces, but 35 states partially addressed this practice (Tables 3 and 4).

Table 3.

Frequency with which practices associated with prevention of human norovirus infection were addressed in child-care center regulations, 50 U.S. states and the District of Columbia, June 2015

^aThe scoring system gives two points for practices that are fully addressed in the state regulations, one point for practices that are partially addressed in the state regulations, and zero points for practices that are not addressed in the state regulations.

^bNot all percentages total to 100 because of rounding.

^cIt was not possible to partially address this practice.

NA = not applicable

Table 4.

Results of alignment scoring^a of child-care center regulations with 14 practices that prevent human norovirus infection, 50 U.S. states and the District of Columbia, June 2015

^aThe scoring system gives two points for practices that are fully addressed in the state regulations, one point for practices that are partially addressed in the state regulations, and zero points for practices that are not addressed in the state regulations.

^bYear refers to the year that the state's child-care regulations were last updated as of June 2015.

DISCUSSION

Nearly all state regulations required children and staff members to wash their hands, but most did not fully address how children and staff members should wash their hands. For example, many state regulations either did not cite the length of time to spend in handwashing or cited varying durations. The length of time spent in handwashing is important because several studies showed that the longer the wash time, the more microorganisms are removed from hands.^75–77 However, there is a lack of consensus by recommending bodies (e.g., CDC, the U.S. Food and Drug Administration, and the World Health Organization) on how long to wash hands. This lack of consensus may explain why most state regulations did not specify the length of handwashing time in their regulations. Nonetheless, the most recent CDC guidelines for preventing human norovirus infections recommend a wash time of at least 20 seconds.⁹

Few state regulations addressed hand sanitizer use as an adjunct to or substitute for handwashing. Evidence of hand sanitizer efficacy against human noroviruses varies.^78–80 At present, alcohol-based hand rubs are the only type of hand sanitizer recommended by health organizations such as CDC and the World Health Organization (WHO).^9,81 These hand rubs are effective against vegetative bacterial cells but less so against human noroviruses.^{78–80,82,83} Alcohol alone cannot eliminate human noroviruses from hands, but certain formulations of alcohol-based hand rubs have been shown to reduce the number of viral particles.^78–80,84 Until conclusive evidence about the efficacy of hand sanitizers (alcohol-based or non-alcohol-based) against human noroviruses is available, hand sanitizers will presumably not be fully addressed in state regulations.

Although most state regulations fully addressed isolation of ill children from healthy children (45 states), none fully addressed exclusion of sick children and staff members. No regulation stated how long the child or staff member should be excluded from the facility. Excluding ill people is critical because noroviruses are known to be easily transmitted from person to person (e.g., 69% of reported human norovirus outbreaks from 2009 to 2012 were transmitted from person to person⁷). Per current CDC guidelines, individuals who have a human norovirus infection can return to work 48–72 hours after symptoms are resolved, because they are then generally past the most infectious period of the illness.⁹ Some state regulations had other requirements, such as allowing children (15 states) and workers (12 states) to return to child care only after approval from a health-care provider. Six states allowed children and four states allowed staff members to return after a “recommended” period of exclusion but did not specify what recommendation was being referenced. All of the requirements given by state regulations on when children and staff can return after being ill could be problematic because sick people continue to shed virus particles at low levels for weeks after symptoms are resolved.^73,85,86

Practices related to environmental sanitation were also not fully addressed by most state regulations. One common reason for this is that the terms “sanitizing” and “disinfecting” were used incorrectly or interchangeably. For example, a number of state regulations required potty chairs to be sanitized after use. However, because potty chairs come in contact with bodily fluids, they should be disinfected rather than sanitized.⁹ To eliminate human noroviruses from environmental surfaces contaminated with bodily fluids (e.g., vomit and fecal matter) or during an outbreak, a surface must be disinfected and not sanitized.⁹ In addition to not defining the proper pathogen removal treatment, most state regulations (42 states) did require surfaces to be cleaned before disinfection or sanitization. This step is critical because organic matter (e.g., filth, vomit, or fecal matter) can affect the efficacy of disinfectants.^87,88 Lastly, no state regulations listed the proper disinfection concentration for noroviruses. Many disinfectants are not effective against human noroviruses at regulated concentrations and/or contact times.^89–92 For example, chlorine bleach can only eliminate human noroviruses at disinfecting concentrations of 1,000–5,000 parts per million (ppm), not at sanitizing concentrations of 50–200 ppm.^87–89,93 The 11 state regulations that listed a concentration for using chlorine bleach to disinfect recommended concentrations of <1,000 ppm, which would be effective against vegetative bacteria, fungi, and some viruses, but not necessarily human noroviruses.

Diapering can also contribute to the spread of human noroviruses, but state regulations only partially addressed guidelines that could prevent the spread of human noroviruses by contaminated hands and environmental surfaces. One way to minimize contamination of hands with feces during diaper changing is to wear single-use gloves, which was fully addressed by only six state regulations. Wearing gloves while changing diapers can prevent hand contamination, especially under fingernails and around nail beds, which are difficult to clean.⁹⁴ However, gloves could provide workers with a false sense of security, so handwashing rather than glove use is widely recommended by public health experts.

Dirty diapers must be discarded in a sanitary manner to prevent surface contamination. The American Academy of Pediatrics et al.¹⁰ recommends using washable, plastic-lined, covered, hands-free containers to store dirty diapers. However, only four states fully addressed all four conditions for storing soiled diapers. Diaper-changing surfaces must be properly cleaned before disinfection because human noroviruses may be more resistant to disinfection when in feces.^87,88 During and after diapering, human noroviruses can be transferred to surfaces and hands in the surrounding area. As such, diapering areas must be separate from food preparation and serving areas,^87,95 and staff members who change diapers should never handle food. No states fully addressed all four diapering practices that could reduce the transmission of human noroviruses.

Limitations

This study was subject to several limitations. First, our findings were based on regulations that were in effect as of June 2015 and do not reflect changes made after this date. Second, noninclusion of a practice in a state's regulations does not mean that particular practice is not known or not enforced. County- or city-level regulations for child-care centers may exist, or the standard for a practice could be in a sub-regulatory guidance or policy. Third, how regulations are communicated and enforced varied by state, district, and inspector. As such, full or partial compliance with national guidelines on best practices is difficult to discern from written regulations alone. Additionally, child-care centers might pursue national accreditation from one of three national early childhood accreditation agencies: National Association for the Education of Young Children, National Accreditation Commission for Early Care and Education Programs, or National Early Childhood Program Accreditation, which might require more rigorous infectious disease control standards than are presented in state regulations.

CONCLUSIONS

Enforcing regulations based on guidelines for best practices, such as those prepared by CDC⁹ and CFOC,¹⁰ is one way to reduce the burden of illness from human noroviruses in child-care facilities. However, our findings indicate that many state child-care regulations have not fully addressed CDC or CFOC guidelines for prevention of human norovirus infections in child-care centers. Therefore, state child-care regulations should be reviewed and revised to be sure they are based on best practices known to prevent human norovirus infections.