Monday, October 31, 2016

Former Childcare Provider Lists 13 Things You Should Know/Do About CMV--Much More Widespread Than Zika


(Photo caption): Lisa Saunders was a licensed day care provider in 1989 when she gave birth to daughter Elizabeth born with microcephaly, a serious birth defect that resulted from Saunders contracting cytomegalovirus (CMV) while pregnant.

IMMEDIATE RELEASE
Lisa Saunders, Parent Representative
Congenital Cytomegalovirus Foundation
LisaSaunders42@gmail.com


Former Licensed Day Care Provider and Mother of Child Born with Microcephaly Warns Childcare Workers of Increased Risk of CMV--Much More Widespread Than Zika

According to the CDC, “About one out of every 150 babies are born with congenital CMV infection.”

Mystic, Conn.—Licensed day care provider Lisa Saunders was not informed that caring for young children put her pregnancy at risk. In fact, most day care workers are largely unaware of cytomegalovirus (CMV), the leading viral cause of birth defects—much more widespread than Zika. According to the Centers for Disease Control and Prevention (CDC), “About one out of every 150 babies are born with congenital [present at birth] CMV infection.” (http://www.cdc.gov/cmv/congenital-infection.htm)

In 2015, Saunders, parent representative of the Congenital Cytomegalovirus Foundation, was instrumental in the passage of the Connecticut CMV bill mentioned in the New York Times article, "CMV Is a Greater Threat to Infants Than Zika, but Far Less Often Discussed" (Oct. 25, 2016). Saunders said, “The prevention education part of the CVM bill didn’t pass because of funds so I must keep warning the public until doctors make it a standard practice of care to educate their patients about it" (Saunders's book, Anything But a Dog! The perfect pet for a girl with CMV (cytomegalovirus), is seen behind Dr. Gail Demmler-Harrison in the live interview embedded in the New York Times article). 

In 1987, Saunders became a licensed in-home day care provider in Maryland. She said, “Nowhere in the licensing literature was there a mention of CMV and the extra precautions I should take. In 1989, my second daughter, Elizabeth, was born with microcephaly, a small, severely damaged brain, caused by congenital CMV. It was then that I received information from the hospital stating day care providers were at increased risk for contracting the disease because toddlers are often shedding it through their bodily fluids.” Elizabeth died 16 years later during a seizure in 2006.

Shortly after moving to Connecticut in 2010, Saunders received a call from a local grandmother who said her grandson was just born disabled by congenital CMV. Saunders said, “The baby's mother had been a college student interning at a Connecticut day care center while pregnant. She, too, had not been educated about CMV and how to protect her pregnancy. When I visited the mother and baby in the hospital, the attending nurse asked me why more wasn’t being done to raise awareness of this leading viral cause of birth defects.” 

What are the 13 things childcare workers need to know or do about CMV?

Lisa Saunders created the following list:

1. The article, "Group day care and cytomegaloviral infections of mothers and children," states that between 44 to 100% of two-year-olds at a single given time were shedding CMV.  

2.  “Pregnant childcare employees should be informed about CMV, assess their risk by serologic testing or avoid if possible caring for children less than 2 years age for the duration of pregnancy," states Stuart P. Adler M.D. of the CMV Research Foundation Inc. in his article, "Prevention of Maternal–Fetal Transmission of Cytomegalovirus." 


In 2012 (and 2015), the American Academy of Pediatrics (AAP) stated their CMV policy for childcare workers: "In view of the risk of CMV infection in child care staff and the potential consequences of gestational CMV infection, child care staff members should be counseled about risks. This counseling may include testing for serum antibody to CMV to determine the child care provider’s protection against primary CMV infection, but routine serologic testing is not recommended." (Page 145, AAP Red Book): https://redbook.solutions.aap.org/Documen…/RB12_interior.pdf

3. CMV is the leading viral cause of birth defects. It causes mental retardation, liver disease, cerebral palsy, and deafness, causing more disabilities than Down syndrome, as a result of infection in pregnant women. 

4. According to the Centers for Disease Control and Prevention (CDC), "People who care for or work closely with young children may be at greater risk of CMV infection than other people because CMV infection is common among young children..." (http://www.cdc.gov/cmv/clinical/features.html).


6. Daycare.com provides helpful CMV prevention tips and advice for daycare workers at: https://www.daycare.com/fastfacts/illness/cytomegalovirus.html

Also read: National Health and Safety Performance Standards: Guidelines for Early Care and Education Programs. (n.d.). Standard 7.7.1.1: Staff Education and Policies on Cytomegalovirus (CMV). Retrieved from Caring for Our Children: http://cfoc.nrckids.org/StandardView/7.7.1.1
Here is an excellent article geared to childcare providers: http://www.southingtonearlychildhood.org/cmv-risks/



The following is a funny video staring, "Rhonda Rhinovirus," a germ who loves to tell stories about how they like to travel. It includes information on CMV (in the herpesvirus family, like chicken pox). It was produced by the worldwide LDS church as a result of Utah's request to educate on on CMV prevention. It's very entertaining! Watch: https://www.lds.org/callings/church-safety-and-health/training-and-video-resources/communicable-diseases?lang=eng

7. The National CMV Foundation provides CMV prevention tips for "Care Giver Health" at: https://www.nationalcmv.org/cmv-prevention/caregiver-health.aspx

8. Will it make a difference if women are educated on CMV prevention?
"because of concerns about effectiveness (i.e., Will women consistently follow hygienic practices as the result of interventions?), the medical and public health communities appear reluctant to embrace primary CMV prevention via improved hygienic practices, and educational interventions are rare. ...There is strong evidence, however, that educational interventions can prevent other infectious diseases with similar transmission modes, suggesting that effective interventions can also be found for CMV. Until a CMV vaccine becomes available, effective educational interventions are needed to inform women about congenital CMV prevention"(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1182379/).Three studies prove CMV prevention education works--two studies in the U.S, "Prevention of child-to-mother transmission of cytomegalovirus among pregnant women" (https://www.ncbi.nlm.nih.gov/pubmed/15480372) and "Prevention of Primary Cytomegalovirus Infection in Pregnancy" (http://www.ebiomedicine.com/.../S2352-3964(15.../abstract) plus one in France (http://www.journalofclinicalvirology.com/.../S13.../abstract). Dr. Stuart Adler summarizes: "For seronegative pregnant women who are at high risk because of exposure to a young child in the home or in large group childcare, hygienic precautions are simple, inexpensive, and highly effective.":http://www.ebiomedicine.com/.../S2352-3964(15.../fulltext
Gail J Demmler-Harrison, MD, Director, Congenital CMV Disease Research, Clinic and Registry, states: “Studies have shown that women who know they are CMV seronegative, know they are pregnant, and know about their toddler's CMV shedding are the most likely to prevent CMV transmission and reduce their risk from over 50 percent during pregnancy to a risk of less than 5 percent during pregnancy.  It is not likely that isolated instances of exposure to saliva or drool will result in transmission. Most studies suggest prolonged repeated exposures over time are important for CMV transmission.”
9. Present educational material for day care providers. Utah, the first state to require congenital CMV prevention education (law passed in 2013), provides this brochure for childcare providers: http://health.utah.gov/cshcn/pdf/CMV/CMV%20What%20Childcare%20Providers%20Need%20to%20know.pdf 


According to the National Congenital CMV Disease Registry: “Changing the duties of a teacher or care giver from children known to have CMV infection to other children may not reduce their risk of acquiring CMV. It is a common virus in all children. In fact, studies reveal that between 30 and 80% of children between the ages of 1-3 years of age who attend some form of group care are excreting CMV. In this setting transmission of CMV is usually transmitted from child-to-child by direct contact with bodily fluids such as saliva or urine. It also may be transmitted to care givers. Therefore it is wise for care givers in this type of setting to be aware of CMV and consider knowing their CMV antibody status. If results are negative, they are susceptible to catching CMV for the first time and it is a potential risk to the fetus if they are pregnant. On the other hand, if results of a CMV antibody titer (IgG) is positive, they have already acquired CMV at some time in their life and their risk is greatly reduced. Additionally, it is important for all care givers to practice good hygienic measures. This is achieved by hand washing with soap and water, especially after diaper changes and any contact with a child's bodily fluids. Kissing and sharing food or drink also should be avoided.” 

  • installing hand washing facilities close to nappy changing areas
  • washing hands frequently, especially after contact with urine and saliva and after removing disposable gloves
  • using disposable hand wipes or alcohol-based hand rub for situations where hand washing facilities are not readily available
  • covering cuts with water-resistant dressings
  • using disposable gloves for activities that involve contact with urine and saliva
  • providing information to workers about CMV risks and work practices to reduce the risk of infection
  • purchasing equipment and toys that are easily cleaned
  • instructing workers not to kiss children on the mouth and face
  • implementing cleaning programs for surfaces and items that are soiled with urine and saliva, including nappy change mats, potties, feeding utensils and toys
  • implementing procedures for hygienic nappy changing and the storage and disposal of soiled nappies
  • taking steps to prevent urine from spraying into the face of workers if infants pass urine during nappy changing (especially infant boys)
  • implementing laundry procedures for linen that is soiled with urine and saliva, e.g. make sure that soiled personal clothing and linen are placed in a sealed bag and sent home with the child for washing
  • implementing procedures for cleaning up accidental spills of urine that could occur during toilet training
  • relocating workers who are pregnant, or who expect to become pregnant, to care for children aged over two to reduce contact with urine and saliva." 





9. The article, ”Cytomegalovirus as an occupational risk in daycare educators,” states: "studies in industrialized countries have confirmed that children attending daycare have higher excretion rates of CMV than children not attending day-care and that horizontal transmission is common between children in daycare and their adult contacts"  (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2528629/).


10. "There are pregnant teachers and other care givers at our school who work closely with children known to have CMV infection. For their safety, should these employees be relieved from their duties in caring for these children?"

A: According to the Congenital CMV Disease Research Clinic & Registry (Fall 1996): “Changing the duties of a teacher or care giver from children known to have CMV infection to other children may not reduce their risk of acquiring CMV. It is a common virus in all children. In fact, studies reveal that between 30 and 80% of children between the ages of 1-3 years of age who attend some form of group care are excreting CMV. In this setting transmission of CMV is usually transmitted from child-to-child by direct contact with bodily fluids such as saliva or urine. It also may be transmitted to care givers. Therefore it is wise for care givers in this type of setting to be aware of CMV and consider knowing their CMV antibody status. If results are negative, they are susceptible to catching CMV for the first time and it is a potential risk to the fetus if they are pregnant. On the other hand, if results of a CMV antibody titer (IgG) is positive, they have already acquired CMV at some time in their life and their risk is greatly reduced. Additionally, it is important for all care givers to practice good hygienic measures. This is achieved by hand washing with soap and water, especially after diaper changes and any contact with a child's bodily fluids. Kissing and sharing food or drink also should be avoided.” (https://www.bcm.edu/web/pediatrics/documents/cmv2-2-96.pdf)

11. Check to see if your state's health department webpage includes congenital CMV prevention. For example, Connecticut's Health Department has the following information: http://www.ct.gov/dph/cwp/view.asp?a=3138&q=527824To contact your state’s daycare licensing division, the place to begin is here:
Healthy Childcare America, a division of American Academy of Pediatrics, with state contacts found at:  http://www.healthychildcare.org/Contacts.html
12. Check to see if your state’s day care licensing literature explains increased risk of contracting CMV for childcare workers, the blood test needed to determine if antibodies are present, and provide CMV prevention brochures and posters for the day care center. 

13. Teach children and their families table-setting and CMV prevention with free, downloadable “color-me-in" placemats that includes a germ prevention tip from Miss Cup who insists no one share her. The placemats provide space for including your own information when reproducing them. Find the placemat at: https://drive.google.com/file/d/0B9Klfxar2CmjbWlfQlpGS3VDMlBXVklDN0JnM0lxa3lXRVpR/view            

A short video by Lisa Saunders, https://youtu.be/_0jDOKPFg4M, explains the placemat characters from her booklet, "Once Upon a Placemat: A Table Setting Tale." 

***
According to Brenda K. Balch, MD, "Cytomegalovirus (CMV) is the most common congenital viral infection in the US and the leading infectious cause of developmental disabilities and hearing loss in children. The time has come for the AAP,  ACOG [American College of Obstetricians and Gynecologists], and the CDC to partner and actively and effectively get the message out about CMV diagnosis, treatment and prevention in mothers and infants." Dr. Balch is Connecticut's American Academy of Pediatrics (AAP) Early Hearing Detection and Intervention Chapter Champion.

About Lisa Saunders:

Lisa Saunders is the parent representative of the Congenital Cytomegalovirus Foundation, which raises awareness about maternal testing for first infection during pregnancy, newborn testing, and the need to develop a vaccine. Saunders and her work to get Connecticut to pass a CMV bill was featured in Cornell’s Alumni Magazine (Sept/Oct 2015) and was widely covered in the media (News 8 at CT Capitol RE: CMV). She is the author of the memoir, Anything But a Dog! The perfect pet for a girl with CMV (cytomegalovirus), which is also being released in Japan in December 2016. A short story about her daughter Elizabeth's life with congenital CMV is told through images and music on this three-minute video. To educate entire families in a fun and memorable way, Saunders recently published the short booklet,  “Once Upon a Placemat: A Table Setting Tale,” which includes CMV prevention tips such as refraining from sharing dishes plus a free teaching tool kit with downloadable placemats for coloring and a video. Visit Lisa at www.authorlisasaunders.com

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For more information from doctors/medical professionals, scientists, contact: 

Brenda K. Balch, MD, Connecticut's American Academy of Pediatrics Early Hearing Detection and Intervention Chapter Champion, who was instrumental in the passage of the Connecticut CMV bill. She has a strong interest in congenital CMV because it is a major cause of hearing loss (she sent Testimony to CT’s HB 5525). Contact: bkbalch@sbcglobal.net.
Gail J Demmler-Harrison, MD, Professor, Pediatrics, Section Infectious Diseases, Baylor College of Medicine, Attending Physician, Infectious Diseases Service, Texas Children's Hospital, CMV Registry, CMV Research and CMV Clinic. The CMV Registry supports CMV research, disseminates information and provides parent support. Visit: https://www.bcm.edu/departments/pediatrics/sections-divisions-centers/cmvregistryContact: 832-824-4330,gjdemmle@texaschildrens.org.
Dr. Stuart Adler and Registry Personnel
514 Diane Lane, Richmond, VA 23227

Stuart Adler, M.D., Professor Emeritus of Pediatrics and Professor of Microbiology and Immunology, Virginia Commonwealth University. (sent Letter of Testimony to CT’s HB 5147).
Phone: (804) 264-8296, Email: spadler123@gmail.com 


Lenore Pereira, Ph.D., Congenital CMV Foundation founder and Professor, Cell and Tissue Biology Department, University of California San Francisco, at lenore.pereira@ucsf.edu, or visit www.congenitalcmv.org. The Congenital CMV Foundation raises awareness about maternal testing for first infection during pregnancy, newborn testing and the need to develop a vaccine. 

Eugene D. Shapiro, M.D., Professor of Pediatrics, Epidemiology and Investigative Medicine, Yale University, eugene.shapiro@yale.edu (sent Letter of Testimony to CT’s HB 5147).

PARENTS

Lisa Saunders, Congenital CMV Foundation parent representative (mother of Elizabeth severely disabled by congenital CMV, 1989-2006), PO Box 389, Mystic, CT 06355, LisaSaunders42@gmail.com (sent Letter of Testimony to CT’s HB 5147).

Casey Famigletti of New Canaan, Connecticut, mother of child born disabled by congenital CMV (sent Letter of Testimony to CT’s HB 5147).

UTAH

Stephanie Browning McVicar, Au.D., CCC-A, DOCTOR OF AUDIOLOGY (she worked tirelessly to pass the Utah bill), Specialty Services Program Manager, State EHDI Director, State of Utah Department of Health, Children with Special Healthcare Needs, Children's Hearing and Speech Services, (801) 584-8218, smcvicar@utah.gov (click on Utah's Children's Hearing and Speech Services to download English/Spanish pamphlets for daycare providers, doctors and parents).


NOTE FROM LISA SAUNDERS: 
Although the U.S. Senate passed legislation in 2014 recommending that “more effort be taken to counsel women of childbearing age of the effect this virus can have on their children” because "The incidence of children born with congenital cytomegalovirus can be greatly reduced with public education and awareness," and designated the month of June as "National Congenital CMV Awareness Month," in 2015, the American College of Obstetricians and Gynecologists (ACOG) has reversed it's decision to instruct their pregnant patients on what it takes to prevent CMV transmission (you can read about that in the NY Times article).  ACOG's new position on CMV instruction, recently revised in 2015, is that patients will think such guidelines difficult to implement because  "they often are considered impractical or burdensome." (see page 1514 of the ACOG Practice Bulletin (June 2015), [151 Cytomegalovirus, Parvovirus B19, Varicella Zoster, and Toxoplasmosis in Pregnancy (June 2015]) 

When I contacted the CDC in July 2016 to ask why they took down CMV prevention tips such as pregnant mothers refraining from kissing their toddlers around the mouth or sharing utensils with them, I received a response in August 2016 stating, "The prevention recommendations currently on the CDC website are consistent with 2015 guidelines from the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics." 

Perhaps these following daycare organizations will post CMV prevention information:





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