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. 


RE: CMV (#1 birth defects virus) is Occupational Risk for Caregivers/Teachers

Dear Child Care/Teacher Unions:
In your effort to protect caregivers/teachers and their unborn children, please ensure workers know their occupational risk for cytomegalovirus (CMV), the leading viral cause of birth defects. “CMV Is a Greater Threat to Infants Than Zika, but Far Less Often Discussed” (New York Times, 2016). 
Each year, one in 200 babies is born with congenital (present at birth) CMV infection in the U.S. According to the Centers for Disease Control and Prevention (CDC), "one in five babies with congenital CMV infection will be sick from the virus or have long-term health problems." Congenital CMV can cause hearing loss, developmental and motor delay, vision loss, microcephaly (small head) and seizures. Congenital CMV is estimated to disable 4,000 babies annually.
As you know, workers have the right to “receive information and training about hazards” (Occupational Safety and Health Act of 1970). Yet, recent surveys show that most women have never heard of CMV—including child care providers (Thackeray, Magnusson, 2016). Many child care providers 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.  Licensed caregivers/teachers are trained in effective disinfecting procedures, but these protocols can only help reduce CMV transmission if workers are motivated to follow them.  CMV is also a blood-borne pathogen.

Staff Education and Policies on Cytomegalovirus (CMV): According to Caring for Our Children (American Academy of Pediatrics (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…Up to 70% of children ages 1 to 3 years in group care settings excrete the virus...With regard to child-to-staff transmission, studies have shown increased rates of infection with CMV in caregivers/teachers ranging from 8% to 20%...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). Print Staff Education and Policies on CMV by clicking "Save as PDF" at: nrckids.org/CFOC/Database/7.7.1.1

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).

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...”

U.S. Child Care Health Policies: The book, Model Child Care Health Policies (AAP, 2014), 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 book states that programs should describe their commitment “to best practice, as indicated in CFOC3 [Caring For Our Children 3rd Editionwhich includes CMV education]...A policy might specify intended compliance with accreditation standards, such as those of the National Association for the Education of Young Children (NAEYC) (www.naeyc.org) [which mentions CMV as an “occupational hazard”] for center-based care or the National Association for Family Child Care (www.nafcc.org)..." (page xviii).
The Child Care and Development Block Grant Act of 2014 has created regulatory changes. The Administration for Children and Families published Caring for our Children Basics (based on Caring for Our Children) in 2015 to “align basic health and safety efforts across all early childhood settings." In the section, “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.


Lisa Saunders was a licensed child care provider unaware of her increased risk for CMV until after her daughter Elizabeth was born severally disabled by congenital CMV in 1989. Lisa is the author of "The Danger of Spreading CMV: How We Can Protect Our Children" (ChildCare Aware of America, June 2017). Referenced citations on her blog at: congenitalcmv.blogspot.com.


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

Wednesday, October 10, 2018

New color version of "Once Upon a Placemat: A Table Setting Tale" to stop CMV, #1 birth defects virus

Now families, schools and child care centers have two options when teaching their children how to set the table and share a meal, not the germs--such as cytomegalovirus (CMV), the #1 birth defects virus. "Once Upon a Placemat: A Table Setting Tale" can be purchased as a coloring book (1st edition) or in color (2nd edition). Photograph by Jessica Rachels of the
Idaho CMV Advocacy Project

IMMEDIATE RELEASE

New color version of "Once Upon a Placemat: A Table Setting Tale" 
to stop CMV, #1 birth defects virus

bOOKS INCLUDE lesson plan for children

Staff can work it into STEAM (science, technology, engineering, art and math)*


Read aloud the fairytale, "Once Upon a Placemat: A Table-Setting Tale" by Lisa Saunders and Jackie Tortora, with the children in your care then share a meal together. Help the children wash their hands and set their place setting by referring to the tableware characters. 

Teacher/parents can say things such as, "Remember, Mr. Knife is afraid the dish will run away with the spoon, so put his teeth toward Mr. Plate" and "Miss Cup hates it when people share her without giving her a bath first because of those naughty germs." 

"The story of 'Once Upon a Placemat' is a fun, hands on way to learn about setting a table, germs, and CMV. I have given them to my local head start programs," says Jessica Rachels of the Idaho CMV Advocacy Project (learn more about Jessica's CMV advocacy work that includes "Once Upon a Placemat" coloring books at: 

Staff can work it into STEAM (science, technology, engineering, art and math). STEAM is a popular way to package and present the interconnectedness of Science, Technology, Engineering, Art and Math in the regular curriculum. When you talk about germs, the coloring book, “Once Upon a Placemat” (Art and Literacy), introduces germs (science, biology) in a format that integrates the arts.  Drawing and writing activities can be planned to further integrate those domains.  Teachers can further bring in technology and engineering by designing activities that help the children to "invent" equipment or machines to help better wash hands, keep food fresh and germ free, etc.  Math can enter into the plan by graphing how long children wash their hands, how often they wash their hands, how many uses the classrooms get out of a single pump bottle of hand soap, etc. With a little more thought (and a few trips to Pinterest!), lots of germ-based activities can be created and integrated.

If possible, give each child a "Share a Meal, Not the Germs" picnic kit with these suggested items:  

  • Bag (paper or reusable insulated bag).
  • Plate, cup, napkin, fork, spoon, knife.
  • Crayons or washable markers.
  • Placemat with tableware characters, which can be laminated (see below for links*).
  • Picnic food (homemade or prepackaged that would use all utensils, such as peanut butter, crackers, applesauce and cake).
  • Hand sanitizer or sanitizing wipes. 
  • Sink hand-washing sign and tri-fold flyer on CMV prevention to take home (found on blog post: https://congenitalcmv.blogspot.com/2018/05/free-cmv-prevention-tool-kit-for.html)
  • If funds are available, give a child their own bound copy of the coloring book version of “Once Upon a Placemat: A Table Setting Tale,” or the 2nd edition with images already colored, to share with their families so their parents can reinforce the table-setting lesson and learn how to prevent CMV, the leading viral cause of birth defects virus, as well as other diseases.
*FREE Teaching Program Tool kit found at:
·       Educational Coloring Book: Contact LisaSaunders42@gmail.com for a free pdf version of Once Upon a Placemat: A Table Setting Tale (or the educational fairy tale can be purchased as a bound coloring book on Amazon, Createspace or AuthorLisaSaunders.com).
·       Placemats:
Side one: Placemat with tableware characters with space for your coloring artist's name (perfect for laminating and using as a table-setting reminder).
Side two: Germ prevention tips and hand-washing instructions.
·       Video: Short introduction of  the tableware characters by Lisa Saunders, the parent representative of the Congenital Cytomegalovirus Foundation. 


REVIEWS OF ONCE UPON A PLACEMAT

"A clever way to get across an important message about prevention of infectious diseases common to us all. Most people know how colds and flu are spread, but they don't know about how other germs are spread by sharing food, drinks and utensils.”
Dr. Gail Demmler Harrison, Congenital CMV Disease Research Clinic & Registry

“Short story--big impact. Once Upon a Placemat finally accomplished what we could not--getting our kids to remember how to correctly set the table! Now, I hear my 12-year-old saying to herself, “Mr. Knife stands between Mrs. Spoon and Mr. Plate. Mr. Knife keeps his eyes and teeth toward Mr. Plate because he doesn’t trust him since there was that time the ‘dish ran away with the spoon.’ What a brilliant extension to an old nursery rhyme. Once Upon a Placemat will also help your kids better understand the importance of washing their hands before meals and not sharing dishes before washing them first. Finally, a story that sticks!”
Dr. Rebecca Cihocki, Audiologist, Scottsdale, Arizona.

"The lesson of how to set a table is valuable as this is part of encouraging a family to sit down and eat together—a main intervention in preventing obesity."  
Alison Dvorak, MS, RDN, CDN, Franklin, Connecticut.

"Lisa Saunders is always such an entertaining author. Her audience not only gets to enjoy a clever fairytale, but gets to learn important life lessons on how to protect babies from congenital CMV and other infections."
Marti Perhach, Group B Strep International

Once Upon a Placemat (1st edition black and white for coloring): 

Thursday, September 13, 2018

Ask your Local Access TV station to Air Interview with CMV Doctor, Mom, and Singer/Songwriter!

Debra Lynn Alt, Lisa Saunders and Dr. Gail Demmler-Harrison discuss preventing congenital cytomegalovirus (CMV), the leading viral cause of birth defects, on SEC-TV  on September 5, 2018.  Photograph by Neil Harrison. 


Want your community to watch a TV interview about congenital cytomegalovirus (CMV) found at: https://www.youtube.com/watch?v=oJRTYQbEj7c&t=318s?

Everyone in the U.S. has a Local Access TV station. Their purpose is to air shows that serve the community. Find the local access station for your town/state by googling it or click on this link because it may be found on this list:

Contact your station by calling them first so they can tell you what they need (like proof you live in their viewing area). They may be able to get all the information they need through an email that goes something like the following:

Dear Local Access Station:

I live and/or work in the region serviced by your community access TV station and would like you to air a 30-minute talk show about congenital cytomegalovirus (CMV), the leading viral cause of birth defects. It can be prevented if women are educated about CMV. You can learn more about congenital CMV at the Centers for Disease Control Prevention at: https://www.cdc.gov/cmv/overview.html


The talk show guests include: 


  1. Gail Demmler-Harrison, MD, Director of Congenital CMV Disease Research, Clinic and Registry; Professor, Pediatrics, Section Infectious Diseases, Baylor College of Medicine; Attending Physician, Infectious Diseases Service, Texas Children's Hospital, (832) 824-4387, Email: cmv@bcm.edu. Visit: https://www.bcm.edu/departments/pediatrics/sections-divisions-centers/cmvregistry
  2. Lisa Saunders, host of the show and mother of a child born disabled by congenial CMV: Email: LisaSaunders42@gmail.com, Visit: www.authorLisaSaunders.com
  3. Debra Lynn Alt, singer/songwriter, performs her song about CMV, "Had I Known (about CMV)"; debrasong@gmail.com;  www.debrasong.com

To retrieve the 30-minute TV interview about CMV, please click into this Dropbox link

There, you will find three files.
  1. The one with "YouTube" can be uploaded to any web site that takes videos, YouTube, FB, etc.
  2. The one with "MPEG2 LF" can be played "as is" by many Community Access TV stations.
  3. The one with "ProRes LF" is the very large data original file and can be converted to any other playback type.

My address (or work address) is: (your address)

The show was filmed at Southeastern Connecticut Television (SEC-TV) Studios.
SEC-TV: Community Television for Groton, Ledyard, Mystic, Stonington, North Stonington, and Voluntown, Connecticut. Address: SEC-TV, 80 Plaza Court, Groton, CT 06340
Studio Phone: 860-449-1477Email: info@sec-tv.org, Visit: http://www.sec-tv.org/


Sincerely,
[your name and contact information]



Friday, August 24, 2018

Poster: "Increasing Child Care Provider Awareness of Congenital Cytomegalovirus"


"Increasing Child Care Provider Awareness of Congenital Cytomegalovirus (CMV)"

by

Lisa Saunders, Leader of Childcare Providers Education and Outreach, National CMV Foundation; Brenda Balch, MD, American Academy of Pediatrics (AAP) Early Hearing Detection and Intervention Connecticut Chapter Champion



Presented at: CMV Public Health and Policy Conference, September 23-25, 2018 (poster session: Mon., Sept 24, 2018), DoubleTree Hotel, Burlington, Vermont: https://cmv.usu.edu/schedule.cfm

Click for poster as a PDF document or PowerPoint slide.
Click for PDF of What You Can Do to Help and References or see below:


  INTRODUCTION

ØThere are 562,420 child care workers in the U.S.(Dept. of Labor, 2017).
ØEvery year, 8 - 20% of child care providers contract CMV (AAP, 2012) as compared to 1-4% of women in the general population (CDC, 2018).
Ø“7 in 10 children (70 percent) between 1 and 3 years of age who go to day care may have CMV. They can pass it on to their families, caretakers and other children” (March of Dimes).
ØSixty one percent “of children under the age of 5 are cared for in a child care facility” (Thackeray and Magnusson, 2016).
ØMothers of toddlers in group care are also at increased risk for CMV        (Pass and Hutto, 1986).ØMany child care providers use diaper wipes to clean, but diaper wipes do not kill CMV (Thackeray and Magnusson, 2016).
ØMost child care providers have never heard of CMV despite recommendations from the American Academy of Pediatrics (AAP): “Staff of childbearing age who care for infants and children should be provided the following information...The availability of counseling and testing for serum antibody to CMV to determine the caregiver/teacher’s immune status...child care staff members should receive counseling in regard to the risks of acquiring CMV from their primary health care provider. However, 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” (AAP et al., 2017).ØLicensed child care providers are typically trained in first aid, CPR, etc., to ensure the health of children in their care. CMV prevention can be included in training on infectious diseases. 

“I was a licensed child care provider and the mother of a toddler yet I didn’t know about CMV. I always washed my hands after changing diapers, but often too busy chasing toddlers to get to the sink after wiping noses and picking up toys, I used diaper wipes to clean my hands not realizing they didn’t kill CMV.”
Lisa Saunders, mother of Elizabeth born with congenital CMV in 1989.


PURPOSE

ØHighlight to child care providers and child care policy makers that CMV is an occupational risk" (Joseph et al, 2006) or “occupational hazard” (NAEYC, 2014).
ØExplain why most child care providers have not heard about CMV.

ØSuggest methods for improving CMV education and ultimately preventing CMV.

CMV AWARENESS LEVELS

Ø2016: Only 9 % of women surveyed in the general population have heard of CMV (Doutre et al., 2016).
Ø2016: Only 18.5% of licensed “in-home” daycare providers surveyed have heard of CMV and “Providers do not know how to appropriately sanitize surfaces to reduce spread of disease” (Thackeray and Magnusson, 2016).
Ø2018: A nationwide child care survey confirmed: "Consistent with previous research, child care providers do not have knowledge regarding CMV or cCMV" (DeWald et al., 2018).

WHY HAVEN’T CHILD CARE PROVIDERS HEARD OF CMV?

ØCMV prevention education is not part of a doctor’s “standard of care”.
ØThere is no nationwide child care licensing program to enforce education and methods of CMV control: "Education and training requirements vary by setting, state, and employer" (Dept. of Labor, 2018).

WORKER PROTECTION IS THE LAW OF THE LAND

Under the Occupational Safety and Health Act of 1970 (OSH Act), workers have the right to “receive information and training about hazards” (OSHA, 2016). CMV is also a bloodborne pathogen. 

WHY CMV IS A PROBLEM FOR CHILD CARE PROVIDERS

ØLicensed child care providers already have a protocol for sanitizing hands and surfaces but must understand the need to diligently follow this protocol. “Increasing risk perception is important because providers may not be concerned about taking measures to reduce the probability of infection if they feel that they are at low risk” (Thackeray and Magnusson, 2016).
Ø“Small children have habits that facilitate the dissemination of diseases, such as putting their hands and objects in their mouths, very close interpersonal contact…(Nesti et al, 2007).
ØMany caregivers use diaper wipes to clean. “Viable CMV was recovered from 4/20 hands 10 min after diaper wipe cleansing. CMV remains viable on hands for sufficient times to allow transmission.” When soap and water are not available, hand sanitizer may be used: “After cleansing, no viable virus was recovered using water (0/22), plain soap (0/20), antibacterial soap (0/20), or sanitizer (0/22)”
     (Stowella et al., 2014).
ØChild care providers don’t always have access to a sink:
“As a child care worker, I remember being pregnant and eating snacks and lunch on the playground without washing my hands first.”  Jessica Rachels of the Idaho CMV Advocacy Project, former child care provider and mother of Natalie born with congenital CMV in 2006. 

PREVENTION EDUCATION PREVENTS CMV

In five studies published between 1993 and 2015, the efficacy of hygienic precautions in CMV seronegative pregnant women was shown to be greater than 75% (Adler, 2015).

WOMEN SHOULD LEARN ABOUT CMV BEFORE PREGNANCY

Ø“Women who are exposed to CMV prior to conception or within the first trimester of pregnancy and seroconvert have increased risk of their infant being infected with CMV” (Thackeray and Magnusson, 2016).
ØForty-nine percent of pregnancies are unplanned—“Unintended pregnancy is associated with an increased risk of problems for the mom and baby. If a pregnancy is not planned before conception, a woman may not be in optimal health for childbearing” (CDC).

WHAT OTHER COUNTRIES ARE DOING ABOUT CMV IN CHILD CARE

ØIn Germany, “to protect [day care workers] from primary infection, their CMV serostatus must be checked at the beginning of their pregnancy. When the [day care worker] is seronegative, she is excluded from professional activities with children under the age of three years in order to prevent feto- or embryopathy in her offspring“
     (Stranzinger  et al., 2016).
ØIn Queensland, Australia, they relocate workers who are pregnant, or expect to become pregnant, to care only for children over two years old in order to reduce contact with urine and saliva
     (Queensland Government, Australia, 2017).
ØIn New South Wales, Australia, in a landmark decision, 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, 2017). 

CONCLUSION
ØBecause it is not a doctor’s “standard of care” to educate women about CMV, child care licensing programs can reach a large number of high risk women.
Ø"Women at highest risk are those caring daily for children less than 24 months of age. These women, should they become pregnant, should either request to care for children over age 2 years for the duration of pregnancy or be tested for IgG antibodies to CMV. If they lack antibodies to CMV (immunity) they should care for children over age 2 years for the duration of pregnancy. If this is not possible they should carefully follow hygienic precautions and be retested for CMV monthly for the first 5 months of pregnancy,“ states Stuart P. Adler M.D, Director, CMV Research Foundation.
Ø“Intervening with child care providers and parents through child care facilities are key opportunities to reduce prevalence of CMV infection and other diseases” (Thackeray and Magnusson, 2016).
ØCongenital CMV has been estimated to cost the US health care system $1.86 billion annually, with a cost per child of more than $300,000 (Modlin et al., 2004). Since prevention education has been shown to reduce the spread of CMV by more than 75%, improving a child care provider’s awareness of CMV could mean a substantial savings to the US health care system.



WHAT YOU CAN DO TO HELP

        Contact your state’s Departments of Health, Labor, OSHA, and Child Care Licensing (found at: childcareaware.org/providers), and ask for CMV education to be featured on their websites. Ask that CMV education be included in the training child care providers receive on infectious diseases.
        CMV flyer links are available at the CDC, National CMV Foundation, some state websites, and CongenitalCMV.blogspot.com. The “Staff Education and Policies on Cytomegalovirus” in Caring for Our Children can be found at: nrckids.org/CFOC/Database/7.7.1.1
        Child care directors may worry about frightening their workers. Remind them they probably already have proper sanitizing procedures in place through compliance with protocols set forth by the National Association for the Education of Young Children (NAEYC), which states, “Procedures are in place that address steps to reduce occupational hazards such as infectious diseases (e.g., exposure of pregnant staff to CMV…)" (NAEYC, 2014, p.90).
        Contact state chapters of organizations that promote the health of their members such as child care and teacher unions, NAEYC, Early Head Start programs, and child care centers. Offer CMV flyers or links to them.
        In 2015, Connecticut passed a law requiring CMV testing when an infant fails the hearing screen. Prevention education did not pass, but 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. We are still working on making CMV training mandatory for child care providers.

REFERENCES

Adler, S. P. (2015, September). Prevention of Maternal–Fetal Transmission of Cytomegalovirus. Volume 2, Issue 9, Pages 1027–1028. BioMedicine. Retrieved November 9, 2016, from http://www.ebiomedicine.com/article/S2352-3964(15)30098-0/fulltext
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 from https://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 from https://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 from http://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 from https://academic.oup.com/cid/article-lookup/doi/10.1086/421999
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 from http://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
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
Stowella, 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 from http://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 from http://link.springer.com/article/10.1007%2Fs10566-015-9325-y

Adler refers to five prevention education studies in his article, “Prevention of Maternal–Fetal Transmission of Cytomegalovirus” (2015). They are:
  1. Adler, S.P., Finney, J.W., Manganello, A.M., and Best, A.M. Best prevention of child-to-mother transmission of cytomegalovirus by changing behaviors: a randomized controlled trial. Pediatr. Infect. Dis. J. 1996; 15: 240–246
  2. Adler, S.P., Finney, J.W., Manganello, A.M., and Best, A.M. Prevention of child-to-mother transmission of cytomegalovirus among pregnant women. J. Pediatr. 2004; 145: 485–491
  3. Finney, J.W., Miller, K., and Adler, S.P. Changing protective and risky behaviors to prevent child-to-parent transmission of cytomegalovirus. J. Appl. Behav. Anal. 1993; 26: 471–472 
  4. Revello, M.G., Tibaldi, C., Masuelli, G., Frisina, V., Sacchi, A., Furione, M., Arossa, A., Spinillo, A., Klersy, K., Ceccarelli, M., Gerna, G., Todros, T., and the CCPE Study Group. Prevention of primary cytomegalovirus infection in pregnancy.EBioMedicine. 2015; 2: 1205–1210 
  5. Vauloup-Fellous, C., Picone, O., Cordier, A.G. et al. Does hygiene counseling have an impact on the rate of CMV primary infection during pregnancy? Results of a 3-year prospective study in a French hospital. J. Clin. Virol. 2009;46: S49–S53 

Links to read the PREVENTION STUDIES listed in Adler's 2015 summary paper, 

"Prevention of Maternal–Fetal Transmission of Cytomegalovirus"
  1. Adler, S.P., Finney, J.W., Manganello, A.M., and Best, A.M. Best prevention of child-to-mother transmission of cytomegalovirus by changing behaviors: a randomized controlled trial. Pediatr. Infect. Dis. J. 199615240–246
  2. Adler, S.P., Finney, J.W., Manganello, A.M., and Best, A.M. Prevention of child-to-mother transmission of cytomegalovirus among pregnant women. J. Pediatr. 2004145485–491
  3. Finney, J.W., Miller, K., and Adler, S.P. Changing protective and risky behaviors to prevent child-to-parent transmission of cytomegalovirus. J. Appl. Behav. Anal. 199326471–472 
  4. View in Article 
  5. Crossref
  6.  
  7. PubMed
  8.  
  9. Scopus (18)
  10.  | 
  11. Google Scholar
  12. Revello, M.G., Tibaldi, C., Masuelli, G., Frisina, V., Sacchi, A., Furione, M., Arossa, A., Spinillo, A., Klersy, K., Ceccarelli, M., Gerna, G., Todros, T., and the CCPE Study Group. Prevention of primary cytomegalovirus infection in pregnancy.EBioMedicine201521205–1210 
  13. View in Article 
  14. Abstract
  15.  
  16. Full Text
  17.  
  18. Full Text PDF
  19.  
  20. Scopus (42)
  21.  | 
  22. Google Scholar
  23. Vauloup-Fellous, C., Picone, O., Cordier, A.G. et al. Does hygiene counseling have an impact on the rate of CMV primary infection during pregnancy? Results of a 3-year prospective study in a French hospital. J. Clin. Virol. 2009;46S49–S53 
  24. View in Article 
  25. Abstract
  26.  
  27. Full Text
  28.  
  29. Full Text PDF
  30.  
  31. PubMed
  32.  
  33. Scopus (122)
  34.  | 
  35. Google Scholar





For more information, contact: 

Lisa Saunders, PO Box 389, Mystic, CT 06355, LisaSaunders42@gmail.com, CongenitalCMV.blogspot.com