Sunday, November 11, 2018

Child Care Unions/Directors: Occupational Risk of CMV (#1 birth defects virus)


Lisa Saunders, a licensed child care provider, never heard of her occupational risk for CMV,  until after her daughter Elizabeth was born with a small, damaged brain from congenital CMV. Elizabeth is seen here as a newborn in 1989 with her mother and big sister. Elizabeth died at 16 during a seizure in 2006. 


Lisa Saunders
PO Box 389
Mystic, CT, 06355
                          
RE: CMV (#1 birth defects virus) is Occupational Risk for Caregivers/Teachers

Dear Child Care Directors/Teacher Unions/Licensing Programs:

I’m Lisa Saunders, a former licensed child care provider who was unaware of my occupational hazard for contracting cytomegalovirus (CMV) until it was too late. My daughter Elizabeth was born at Christmas time in 1989 with a severally damaged brain because I caught CMV when pregnant. Surrounded by Christmas decorations in the hospital, I tried to recover from the shock when I was given a pamphlet to read that stated women who work in child care are at greater risk for CMV. This letter contains CMV information and links to free resources to educate workers.
Please ensure child care centers have adopted the “Staff Education and Policies on Cytomegalovirus” set forth by the American Academy of Pediatrics (AAP) in Caring for Our Children. Workers have the right to “receive information and training about hazards” (Occupational Safety and Health Act of 1970). Not educating staff about CMV can be costly for everyone. The estimated cost of congenital CMV to the US health care system is $1.86 billion annually, with a cost per child of more than $300,000” (Modlin et al., 2004).
Every year, congenial CMV causes disability in an estimated 4,000 babies in the U.S.* According to the Centers for Disease Control and Prevention (CDC), About one out of every 200 babies is born with congenital CMV infection. However, only about one in five babies with congenital CMV infection will be sick from the virus or have long-term health problems...A pregnant woman can pass CMV to her unborn baby…This can happen when a pregnant woman is infected with CMV for the first time, or is infected with CMV again during pregnancy.” Congenital CMV can cause hearing and vision loss, developmental delays, microcephaly and seizures.  
"Up to 70% of children ages 1 to 3 years in group care settings excrete [CMV]...With regard to child-to-staff transmission, studies have shown increased rates of infection with CMV in caregivers/teachers ranging from 8% to 20%” (Caring for Our Children, AAP et al., revised 2017).
Mothers of young children in group care are also at increased risk for contracting CMV (Pass et al., 1986). Surveys show that most women have never heard of CMV (Doutre et al, 2016), including child care providers (Thackeray and Magnusson, 2016).   Many caregivers surveyed acknowledge using diaper wipes to clean, but diaper wipes do not effectively remove CMV from hands (Stowell et al., 2014). Although soap and water is best, hand sanitizer will reduce levels of CMV when a sink is not readily available.  Staff are usually trained in disinfecting procedures but this only helps reduce CMV transmission if they are motivated to follow them. CMV prevention can be built into infectious diseases training. CMV is also a blood-borne pathogen.

From CDC--You May Be Able to Reduce Your Risk: “The saliva and urine of children with CMV have high amounts of the virus. You can avoid getting a child’s saliva in your mouth by, for example, not sharing food, utensils, or cups with a child. Also, you should wash your hands after changing diapers. These cannot eliminate your risk of getting CMV, but may lessen the chances of getting it” ("Congenital CMV Facts for Pregnant Women and Parents" flyer at: cdc.gov/cmv).

Staff Education and Policies on Cytomegalovirus (CMV): According to Caring for Our Children (AAP, et al.): "Female employees of childbearing age should be referred to their primary health care provider or to the health department authority for counseling about their risk of CMV infection. This counseling may include testing for serum antibodies to CMV to determine the employee’s immunity against CMV infection…it is also important for the child care center director to inform infant caregivers/teachers of the increased risk of exposure to CMV during pregnancy” (content in STANDARD modified 3/31/17, Visit: nrckids.org/CFOC/Database/7.7.1.1)

Examples of CMV Protocols in Other Countries: In Queensland, Australia, suggested control measures include: "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" (Queensland Government). In Germany, to protect day care workers from primary CMV infection, their “CMV serostatus must be checked at the beginning of their pregnancy.” If the worker “is seronegative, she is excluded from professional activities with children under the age of three years” (Stranzinger et al., 2016).

Potential Cost of Not Warning Child Care Providers about CMV: In New South Wales, “a childcare worker and her severely disabled son were awarded $4.65 million. A Court of Appeal ruled that the child's disabilities resulted from the woman being infected with cytomegalovirus (CMV) at work (Hughes v SDN Children's services 2002)” (Queensland Government, Australia). Meridian Lawyers state: “The allegations of negligence were that Sydney Day Nursery breached its duty of care to Linda ...by failing to warn her of the risks of CMV in circumstances where the centre knew or ought to have known of the risks of CMV to pregnant women...” The Lawyers suggest child care centers get written confirmation from employees showing understanding of CMV and infectious diseases (see meridianlawyers.com.au\insights\infectious-diseases-child-care-what-about-staff-members).

U.S. Child Care Health Policies: The book, Model Child Care Health Policies**, includes a sample document to be signed by staff (paid or volunteer) to show “Acceptance of Occupational Risk by Staff Members,” which includes “exposure to infectious diseases (including infections that can damage a fetus during pregnancy)” (p. 116). 
The Child Care and Development Block Grant Act of 2014 created regulatory changes. The Administration for Children and Families published Caring for our Children Basics (based on Caring for Our Children, AAP, et al.) in 2015 to “align basic health and safety efforts across all early childhood settings." In “Prevention of Exposure to Blood and Body Fluids” it states: “Caregivers and teachers are required to be educated regarding Standard Precautions [developed by CDC] before beginning to work in the program and annually thereafter. For center-based care, training should comply with requirements of the Occupational Safety and Health Administration (OSHA).”

RESOURCES FOR EDUCATING CHILD CARE PROVIDERS/TEACHERS ABOUT CMV
·        CDC flyers: "Congenital CMV Facts for Pregnant Women and Parents" In English and En Español at: cdc.gov/cmv
·        Utah Department of Health, required by law to educate child care providers about CMV, has brochures in English and Spanish, “CMV What Childcare Providers Need to Know (English)” | “Lo qué los proveedores de cuidado infantil necesitan saber sobre CMV (Spanish)” at: health.utah.gov/cshcn/programs/cmv.html
·        National CMV Foundation: Wall posters: www.nationalcmv.org/resources/educational-downloads

Women have the right to know how to protect their pregnancies. Thank you in advance for your help!

Lisa Saunders
Leader, Child Care Providers Education Committee
National CMV Foundation, Inc.

About Lisa Saunders: Lisa was instrumental in helping Connecticut become the second state in the U.S. to pass a law requiring newborns be tested for CMV if they fail their hearing screen. She is still trying to raise awareness through public speaking, TV interviews, books, and through articles such, "The Danger of Spreading CMV: How We Can Protect Our Children" (ChildCare Aware of America, June 2017).  Reference citations can be found on her blog at: congenitalcmv.blogspot.com.

*In the U.S., congenital CMV (cCMV) causes disability in an estimated 4,000 babies annually:
(4 million annual births/200 born with cCMV/5 sick or long-term health problems = 4,000 disabled by cCMV).

**Pennsylvania Chapter of the American Academy of Pediatrics. Model Child Care Health Policies, 5th Edition, Aronson, SS, ed. (2014). Elk Grove Village, IL. Copyright © 2014 Pennsylvania Chapter of the American Academy of Pediatrics. All rights reserved. Permission is granted to reproduce or adapt content for use within a child care setting. These policies are for reference purposes only and shall not be used as a substitute for medical or legal consultation, nor be used to authorize actions beyond a person’s licensing, training or ability. 
Lisa Saunders holding a photograph of her daughter Elizabeth (1989-2006), born disabled by congenital CMV. Lisa is at the 2015 ceremonial signing of a law aimed at battling CMV with Connecticut Governor Malloy.


In 2015, Connecticut passed a law aimed at battling CMV (by testing newborns who fail their hearing screen for CMV) and now provides information for child care providers on the Connecticut Department of Public Health (CT DPH) webpage at: http://portal.ct.gov/DPH/Family-Health/EHDI/CMV(The Connecticut Office of Early Childhood’s Division of Licensing for Child Care Providers/Operators now includes “Congenital Cytomegalovirus” under Disease and Prevention” on its website.) Connecticut child care centers may wish to download this CT DPH/National CMV Foundation flyer:  “Are You Pregnant” National CMV Awareness

Note from Lisa Saunders: 
"I’m Lisa Saunders, leader of Childcare Providers Education Committee with the National CMV Foundation. In 1989, I was a pregnant, licensed child care provider who didn’t know about CMV until it was too late. Like other licensed child care providers, I was trained in proper hand sanitizing protocols, but to save time, I used diaper wipes to clean my hands after handling toddler saliva not realizing diaper wipes don't kill CMV.  My daughter Elizabeth was born with a small, damaged brain from congenital CMV. It wasn’t until after her birth that I received information stating child care providers are at increased risk for contacting CMV. This occupational hazard was not discussed in my child care licensing training. Had I known about CMV (hear song, "Had I Known") I would have been more careful to follow the hand sanitizing protocols in my home child care center, the church nursery I volunteered in, and with my own toddler as mothers of toddlers are also at increased risk for CMV). I realize that CMV in child care is a very “inconvenient truth,” yet I would have given anything to spare my daughter Elizabeth 16 years of suffering until she died during a seizure in 2006."

REFERENCES


Adler, S. P. (1989, November 9). Cytomegalovirus and child day care. Evidence for an increased infection rate among day-care workers. New England Journal of Medicine. Retrieved from: https://www.nejm.org/doi/full/10.1056/NEJM198911093211903?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub%3Dpubmed

American Academy of Pediatrics, American Public Health Association, National Resource Center for Health and Safety in Child Care and Early Education. (Revised 2017).National Health and Safety Performance Standards: Guidelines for Early Care and Education Programs. Retrieved from Caring for Our Children:http://nrckids.org/CFOC/Database/7.7.1.1

American Academy of Pediatrics. "CHILDREN IN OUT-OF-HOME CHILD CARE". Pickering LK, Baker CJ,Kimberlin DW, Long SS, eds. (2012). Red Book: Report of the Committee on Infectious Diseases (29th ed.). Elk Grove Village, IL: American Academy of Pediatrics. Retrieved fromhttps://redbook.solutions.aap.org/DocumentLibrary/RB12_interior.pdf

Billette de Villemeur; Agathe; Gratacap-Cavallier, Bénédicte; Caseya, Romain; Baccard-Longère, Monique; Goirand, Laurence; Seigneurin, Jean-Marie; Morand, Patrice. (2011). Occupational risk for cytomegalovirus, but not for parvovirus B19 in child-care personnel in France.ScienceDirect, 457-467. Retrieved fromhttps://www.sciencedirect.com/science/article/pii/S0163445311004592

Centers for Disease Control and Prevention (CDC). (Page last reviewed: June 6, 2018). Cytomegalovirus (CMV) and Congenital CMV Infection. Retrieved from Centers for Disease Control and Prevention (CDC):https://www.cdc.gov/cmv/clinical/features.html

Department of Labor, Occupational Employment Statistics: Childcare Workers. (2017, May). Retrieved from Bureau of Labor Statistics:https://www.bls.gov/oes/current/oes399011.htm

Department of Labor, Occupational Outlook Handbook, Childcare Workers,. (2018 , June 11). Retrieved from Bureau of Labor Statistics, U.S.: https://www.bls.gov/ooh/personal-care-and-service/childcare-workers.htm

DeWald, Olivia; Turovac, Casey; Balch, Brenda; Cienkowski, Kathleen. (2018). National Child Care Provider's Awareness of Congenital Cytomegalovirus. Poster session presented at Early Hearing Detection and Intervention (EHDI) Conference in Denver, CO.

Doutre, S. M. Barrett, T. S. Greenlee, J. & White, K. R. . (2016). Losing Ground: Awareness of Congenital Cytomegalovirus in the United States. Journal of Early Hearing Detection and Intervention, 1(2), 9-48. Retrieved fromhttp://digitalcommons.usu.edu/cgi/viewcontent.cgi?article=1035&context=jehdi

Joseph, Serene A; Béliveau, Claire; Muecke,Cristin J; Rahme, Elham; Soto,Julio C; Flowerdew, Gordon; Johnston, Lynn; Langille, Donald; Gyorkos, Theresa W. (2006, Sept).Cytomegalovirus as an occupational risk in daycare educators. Retrieved from PMC:http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2528629/

March of Dimes. (Last reviewed: Nov. 2013). Cytomegalovirus and Pregnancy. Retrieved from March of Dimes:https://www.marchofdimes.org/complications/cytomegalovirus-and-pregnancy.aspx

Modlin, John F; Arvin, Ann; Fast, Patricia; Myers, Martin; Plotkin, Stanley; Rabinovich, Regina . (2004, July 15 ). Vaccine Development to Prevent Cytomegalovirus Disease: Report from the National Vaccine Advisory Committee. Oxford Academic. Retrieved fromhttps://academic.oup.com/cid/article-lookup/doi/10.1086/421999

Infectious diseases & child care: what about staff members? (n.d.). Retrieved from Meridian Lawyers, Australia: https://www.meridianlawyers.com.au/insights/infectious-diseases-child-care-what-about-staff-members/

NAEYC. (2014, April 1). National Association for the Education of Young Children: Early Childhood Program Standards and Accreditation Criteria & Guidance for Assessment.Retrieved from National Association for the Education of Young Children: https://s3.amazonaws.com/fwk-interactives/0Early+Childhood+Studies/Assessments+/EP004/CECS+EP004_Assessment_Criteria+and+Standards.pdf

Nesti,Maria M. M. and Goldbaum, Moisés . (2007, July/Aug). Infectious diseases and daycare and preschool education.Jornal de Pediatria, 83(40). Retrieved fromhttp://www.scielo.br/pdf/jped/v83n4/en_v83n4a04.pdf

Occupational Safety and Health Administration. (Revised 2016).Workers' Rights Booklet. Retrieved from Department of Labor: Occupational Safety and Health Administration:https://www.osha.gov/Publications/osha3021.pdf

Pass RF, Hutto C. (1986, Jul-Aug 8). Group day care and cytomegaloviral infections of mothers and children.Retrieved from National Center for Biotechnology Information:http://www.ncbi.nlm.nih.gov/pubmed/3018892

Pennsylvania Chapter of the American Academy of Pediatrics. Model Child Care Health Policies, 5th Edition, Aronson,SS, ed. (2014). Elk Grove Village, IL.

Queensland Government (Australia). (Last Updated 04 April 2017).Cytomegalovirus (CMV) in early childhood education and care services. Retrieved January 1, 2017, from Workplace Health and Safety:https://www.worksafe.qld.gov.au/injury-prevention-safety/workplace-hazards/hazardous-exposures/biological-hazards/cytomegalovirus-cmv-in-early-childhood-education-and-care-services

Saint Louis, Catherine . (2016, Oct. 24). CMV Is a Greater Threat to Infants Than Zika, but Far Less Often Discussed. New York Times. Retrieved from https://www.nytimes.com/2016/10/25/health/cmv-cytomegalovirus-pregnancy.html

Schleiss, M.D., Mark R. (2008). Congenital Cytomegalovirus Infection: Update on Management Strategies. Current treatment options in neurology vol. 10,3, 186-92. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3539797/

Stowell, Jennifer D; Forlin-Passoni, Daniela; Radford, Kay; Bate, Sheri L; Dollard, Sheila C; Bialek, Stephanie R.; Cannon, Michael J; Schmid, D. Scott . (2014, January). Cytomegalovirus Survival and Transferability and the Effectiveness of Common Hand-Washing Agents against Cytomegalovirus on Live Human Hands. American Society for Microbiology, 80(2 455-461). Retrieved fromhttp://aem.asm.org/content/80/2/455.full

Stranzinger J, Kozak A, Schilgen B, et al. (2016). Are female daycare workers at greater risk of cytomegalovirus infection? A secondary data analysis of CMV seroprevalence between 2010 and 2013 in Hamburg, Germany. Retrieved from GMS Hygiene and Infection Control:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4844919/

Thackeray, Rosemary; Magnusson, Brianna M. (2016, April). Child Care Provider Awareness and Prevention of Cytomegalovirus and Other Infectious Diseases. Child & Youth Care Forum, 45(2), 301–314. Retrieved fromhttp://link.springer.com/article/10.1007%2Fs10566-015-9325-y