"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.
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.
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
Adler refers to five prevention education
studies in his article, “Prevention of Maternal–Fetal Transmission of
Cytomegalovirus” (2015). They are:
- 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
- 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
- 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
- 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
- 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
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
Adler refers to five prevention education studies in his article, “Prevention of Maternal–Fetal Transmission of Cytomegalovirus” (2015). They are:
Links to read the PREVENTION STUDIES listed in Adler's 2015 summary paper,
"Prevention of Maternal–Fetal Transmission of Cytomegalovirus"
- 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
- 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
- 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
- View in Article
- | Crossref
- | PubMed
- | Scopus (18)
|
- Google Scholar
- 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;
- View in Article
- | Abstract
- | Full Text
- | Full Text PDF
- | Scopus (42)
|
- Google Scholar
- 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
- View in Article
- | Abstract
- | Full Text
- | Full Text PDF
- | PubMed
- | Scopus (122)
|
- Google Scholar
For more information, contact:
Lisa Saunders, PO Box
389, Mystic, CT 06355, LisaSaunders42@gmail.com,
CongenitalCMV.blogspot.com
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