Thursday, January 24, 2019

CMV in the Child Care/Early Childhood Education Setting: Protect Your Pregnancy




Are you pregnant or plan to be and have a toddler in daycare or work in child care/early childhood education? If you don't know about your increased exposure to cytomegalovirus (CMV), the leading viral cause of birth defects, you should.

 The Centers for Disease Control and Prevention (CDC) states, "A woman who is infected with CMV can pass the virus to her developing baby during pregnancy." 

"The 'inconvenient truth' about CMV is that it is often found in the child care setting," says Lisa Saunders, leader of the Child Care Providers Education Committee with the National CMV Foundation.

"Almost all the babies that I see who have congenital CMV, there is an older toddler at home who is in daycare," said Dr. Jason Brophy, a pediatric infectious disease specialist, in the Ottawa Citizen (Payne, 2018). “Children cared for at daycare or in preschool education exhibit a two to three times greater risk of acquiring infections… 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 and Goldbaum, 2007).

The CDC states, “Most people infected with CMV show no signs or symptoms. That’s because a healthy person’s immune system usually keeps the virus from causing illness. However, CMV infection can cause serious health problems for people with weakened immune systems and for unborn babies (congenital CMV).” Congenital CMV can cause hearing and vision loss, developmental delays, microcephaly and seizures. 

According to the CDC, “About one out of every 200 infants is born with congenital cytomegalovirus (CMV) infection. However, only about one in five babies born with congenital CMV infection will have long-term health problems. A pregnant woman can pass CMV to her fetus following primary infection, reinfection with a different CMV strain, or reactivation of a previous infection during pregnancy." 

Congenital CMV is estimated to disable 4,000 babies every year in the U.S. (4 million annual births/200 with 1/5 sick or long-term health problems = 4,000 disabled by cCMV).  

CMV is a common infection spread in child care centers. Toddlers can spread CMV to each other, their child care providers and families. According to the American Academy of Pediatrics (AAP), on average, 30-40% of preschoolers in day care excrete CMV in their saliva and/or urine (Red Book: 2015 Report of the Committee on Infectious Diseases, AAP, p. 144)*. The book, Caring for Our Children: National Health and Safety Performance Standards; Guidelines for Early Care and Education Programs,  co-authored by the AAP, states in the section, "Staff Education and Policies on Cytomegalovirus (CMV)," that  "Up to 70% of children ages 1 to 3 years in group care settings excrete the virus” (AAP et al., modified 2017)**

Lisa Saunders, a former in-home licensed child care provider, was unaware of her increased risk for CMV. “My daughter Elizabeth was born with a severally damaged brain because I caught CMV when pregnant. I tried to recover from the shock when the hospital staff gave me a pamphlet stating that women who work in child care are at greater risk for CMV. Had I known this before I was pregnant with Elizabeth, I would have been extra diligent about taking prevention measures.  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 diaper wipes offer little protection against CMV." Elizabeth died at the age of 16 during a seizure in 2006. 

Awareness has improved little since Elizabeth's birth in 1989. Recent surveys show that most women have still never heard of CMV (Doutre et al, 2016). Child care providers, too, are largely unaware of CMV, despite their occupational hazard for the virus. and many acknowledge using diaper wipes to clean (Thackeray and Magnusson, 2016). Diaper wipes do not effectively remove CMV from hands (Stowell et al., 2014). 

REDUCE YOUR CHANCES OF CONTRACTING CMV
  • The CDC provides a fact sheet of prevention tips. “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). 
  • Although soap and water is best, hand sanitizer will reduce levels of CMV when a sink is not readily available.   
  • CMV is also a blood-borne pathogen. "Although risk of contact with blood containing one of these viruses is low in the child care setting, appropriate infection-control practices will prevent transmission of bloodborne pathogens if exposure occurs. All child care providers should receive regular training on how to prevent transmission of bloodborne infections and how to respond should an exposure occur (www. osha.gov/SLTC/bloodbornepathogens/index.html)" (Red Book, AAP, 2015, p. 145).
  • The National CMV Foundation provides more CMV prevention tips. 

PREGNANT WOMEN WHO ARE AT INCREASED RISK FOR CMV

In the general population, approximately 1 - 4% is the estimated “annual rate of a pregnant woman who is CMV antibody negative catching CMV for the first time in pregnancy” ("CMV in Pregnancy: What Should I Know?," Demmler-Harrison,MD,  2014). 

Women at higher risk for CMV include:

Parents with children in group care
“Almost all the babies that I see who have congenital CMV, there is an older toddler at home who is in daycare,” said Dr. Jason Brophy, a pediatric infectious disease specialist, in the Ottawa Citizen (Payne, 2018). “Parents of children attending day-care centers” are at increased risk for contracting CMV (Pass et al, 1986).

The American Academy of Pediatrics states, “Spread of CMV from an asymptomatic infected child in child care to his or her pregnant mother or to a pregnant child care provider, with subsequent transmission to the fetus, is the most important consequence of child care related CMV infection...Children enrolled in child care programs are more likely to acquire CMV than are children primarily cared for at home.” (Red Book: 2015 Report of the Committee on Infectious Diseases, AAP, p. 144). 

Childcare workers
According to the CDC, “People who have frequent contact with young children may be at greater risk of CMV infection because young children are a common source of CMV. By the age of five months, one in three children has been infected with CMV, but usually does not have symptoms. CMV can be present in a child’s body fluids for months after they become infected. Regular hand washing, especially after contact with body fluids of young children, is commonly recommended to avoid spread of infections, including CMV.”

“Studies of CMV seroconversion among female child care providers have found annualized seroconversion rates of 8% to 20%. Women who are or who may become pregnant and who are CMV naïve are at risk of being infected during pregnancy and transmitting CMV to their fetus. In view of the risk of CMV infection in child care staff and the potential consequences of gestational CMV infection, female child care staff members should be counseled about these risks. This counseling includes discussion between the woman and her health care provider.” (Red Book: 2015 Report of the Committee on Infectious Diseases, AAP, p. 144, 145). 

HEALTH CARE WORKERS ARE NOT AT INCREASED RISK

“Healthcare workers, regardless of the type of patient contact, do not have an increased risk of developing CMV infection when compared with the general population,” states the American Academy of Otolaryngology-Head and Neck Surgery. “The annual seroconversion rate for primary infection among healthcare providers was 2.3% compared with 2.1% among pregnant women in the community… Adults are at a much higher risk of acquiring CMV from children living in the same household than from an occupational exposure” (“Care of Children Infected with Cytomegalovirus,” American Academy of Otolaryngology-Head and Neck Surgery).

WHY DO MOTHERS OF YOUNG CHILDREN CONTRACT CMV AT HIGHER RATES THAN HEALTH CARE WORKERS?

Unlike health care workers, pregnant women are not routinely educated on how to reduce their chances of contracting CMV. According to the New York Times, "The American College of Obstetricians and Gynecologists [ACOG] used to encourage counseling for pregnant women on how to avoid CMV. But last year, the college reversed course, saying, ‘Patient instruction remains unproven as a method to reduce the risk of congenital CMV infection.’ Some experts argue that because there is no vaccine or proven treatment, there is no point in worrying expecting women about the virus...Guidelines from ACOG suggest that pregnant women will find CMV prevention 'impractical and burdensome,' especially if they are told not to kiss their toddlers on the mouth — a possible route of transmission.” (“CMV Is a Greater Threat to InfantsThan Zika, but Far Less Often Discussed,” Saint Louis, 2016).

WHY IS CMV MORE OF A PROBLEM FOR CHILD CARE PROVIDERS 
THAN HEALTH CARE WORKERS?

  • Although licensed child care providers usually have a protocol for sanitizing hands and surfaces, they don't know about CMV. This lack of knowledge makes diligently following the time-consuming sanitizing protocols less likely. “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).  
  • Many caregivers acknowledge using diaper wipes to clean (Thackeray and Magnusson, 2016).  “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)” (Stowell et al., 2014). 
  • Unlike Germany, there is no law regulating methods of CMV control in the child care setting. According to the Department of Labor, "Education and training requirements vary by setting, state, and employer." In most states, with the exception of Utah and recently, Idaho, child care centers are not required by law to ensure workers know their occupational risk for CMV despite the fact that workers have the right to “receive information and training about hazards” (Occupational Safety and Health Act of 1970).  Find your state's child care licensing programs. 
  • Child 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,” says Jessica Rachels of the Idaho CMV Advocacy Project, former child care provider and mother of Natalie born with congenital CMV in 2006. 
  • Child care directors/policy makers may not know about CMV because they haven't heard about it from their own primary healthcare providers. "When child care directors learn about CMV, some worry they will frighten away qualified staff to work with the toddlers. They also may not know where to get a standardized memo to give their workers," says Lisa Saunders, a former licensed in-home child care providers.  
  • There are 562,420 child care workers in the U.S. (Dept. of Labor, 2017): “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).


THE COST OF NOT WARNING WOMEN ABOUT CMV

Not educating all women of childbearing age about CMV can be costly for everyone--and not just in heartache. 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).

POTENTIAL COST TO CHILD CARE CENTERS FOR NOT WARNING WORKERS 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 of Australia 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 their suggested protocol for educating child care providers about CMV at: https://www.meridianlawyers.com.au/insights/infectious-diseases-child-care-what-about-staff-members/

According the Sector, a publisher specializing in early childhood education and care (ECEC), “In Australia, state governments have differing recommendations for pregnant ECEC educators working with young children. Some states, such as Queensland, suggest relocating educators who are pregnant to care for children aged over two to reduce contact with urine and saliva” (Clark, 2019).

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).
  
U.S. CHILD CARE HEALTH POLICIES

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 its “Prevention of Exposure to Blood and Body Fluids” section, 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).”

WHAT SHOULD U.S. CHILD CARE DIRECTORS/POLICY MAKERS DO?

  • Recommendations from the American Academy of Pediatrics et al., in Caring for Our Children state: "Female employees [caregivers/teachers] 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… With current knowledge on the risk of CMV infection in child care staff members and the potential consequences of gestational CMV infection, 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” (see: nrckids.org/CFOC/Database/7.7.1.1).
  • Ensure child care centers have adopted the “Staff Education and Policies on Cytomegalovirus” set forth by the American Academy of Pediatrics (AAP) et al., in Caring for Our Children.
  • Remember, workers have the right to “receive information and training about hazards” (Occupational Safety and Health Act of 1970). CMV prevention can be built into the infectious diseases training they already receive.

RESOURCES FOR EDUCATING CHILD CARE PROVIDERS/TEACHERS ABOUT CMV


Q. and A.

Question: "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?"

Answer: The American Academy of Pediatrics states, ”CMV excretion is so prevalent that attempts at isolation or segregation of children who excrete CMV are impractical and inappropriate. Similarly, testing of children to detect CMV excretion is inappropriate, because excretion often is intermittent and results of testing can be misleading. Therefore, use of Standard Precautions and hand hygiene are the optimal methods of prevention of transmission of infection” (Red Book, American Academy of Pediatrics (AAP), 2015, p. 145).

Gail J Demmler-Harrison, MD, says, “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.” 
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/cmvregistry or contact: cmv@bcm.edu.

Question: How long can the CMV virus stay alive on objects and surfaces? 
Answer: According to the Congenital CMV Disease Research Clinic & Registry, “CMV is a fragile virus and it does not live on objects and surfaces for very long. One study reported that CMV could be isolated from a smooth plastic toy 30 minutes after the child had mouthed the toy and set it down. Toys and other objects mouthed by young children may be easily disinfected by washing them with a solution of one part chlorine bleach to nine parts water, rinsing thoroughly with water, and drying. Non-immersible or stuffed toys should be allowed to air dry for several hours between use” (Fall 1996).

POSSIBLE CMV PROTOCOLS FOR CHILD CARE CENTERS
  • CMV prevention education added to the licensing training. Childcare providers are typically trained in first aid, CPR, and other topics. CMV prevention should be included in training about preventing infectious diseases.  
  • Give each childcare employee/volunteer a CMV brochure (see Utah's brochure for childcare providers).
  • CMV prevention added to a childcare center’s handbook. See Staff Education and Policies on Cytomegalovirus (Caring for Our Children, American Academy of Pediatrics, et al.). 
  • CMV information added to a New Staff Orientation Form. The form should be signed to show the childcare provider read and understood they should consult their healthcare provider about their risk for CMV.
  • CMV Prevention discussed at a childcare center’s parent orientation.
  • Signs about CMV prevention hanging in day care centers so staff and parents can see them.
  • 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 book states that programs should describe their commitment “to best practice, as indicated in CFOC3 [Caring For Our Children 3rd Edition, which 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)..." (Pennsylvania Chapter of the American Academy of Pediatrics. Model Child Care Health Policies, 5th Edition, Aronson, SS, ed. (2014). 
  • Consider the protocol posted in Queensland, Australia, which recommends the relocation of workers who are pregnant, or “expect to become pregnant, to care for children aged over two to reduce contact with urine and saliva.” See their list of safety measures in “Cytomegalovirus (CMV) in early childhood education and care services,” on the Workplace Health and Safety webpage. 
  • Lawyers in Australia list ways a child care center can ensure their workers know about CMV. 
  • Training Module: See “Infectious Disease in Child Care Settings Training Module version 3, revised 4/23/13” (citation: The National Training Institute for Child Care Health Consultants. Infectious disease in child care settings version 4. Chapel Hill (NC): The National Training Institute for Child  Care Health Consultants, Department of Maternal and Child Health, The University of  North Carolina at Chapel Hill; 2013.)   

WHY DOES CONGENITAL CMV REMAIN LITTLE-KNOWN IN THE U.S.?

Six Possible Reasons

When told about CMV for the first time, some women dismiss CMV warnings from non-medical professionals and say, "If CMV was really a risk to my pregnancy, if I wasn't supposed to kiss my toddler around the mouth or consider not caring professionally for toddlers, my doctor would have told me."

The following are six reasons why most women have never heard of CMV: 

1) CMV prevention education is not part of a doctor’s “standard of care.” 

2) Low profile of congenital CMV: "hygienic practices do not appear to be widely discussed by healthcare providers and prospective mothers are often unaware of both CMV disease and the potential benefits of hygienic practices. The virtual absence of a prevention message has been due, in part, to the low profile of congenital CMV. Infection is usually asymptomatic in both mother and infant, and when symptoms do occur, they are non-specific, so most CMV infections go undiagnosed.” (“Washing our hands of the congenital cytomegalovirus disease epidemic,” Cannon and Finn Davis., 2005.)

3) Some doctors have cited the following reasons for not educating women about CMV: 
  • Don’t want to frighten their patients:  "The list of things we're supposed to talk about during women's first visit could easily take two hours and scare them to death,” said OB-GYN Laura Riley, M.D., director of infectious disease at Massachusetts General Hospital in FitPregnancy magazine (June/July, 2008). 
  • According to the New York Times in 2016, "The American College of Obstetricians and Gynecologists [ACOG] used to encourage counseling for pregnant women on how to avoid CMV. But last year, the college reversed course, saying, ‘Patient instruction remains unproven as a method to reduce the risk of congenital CMV infection.’ Some experts argue that because there is no vaccine or proven treatment, there is no point in worrying expecting women about the virus...Guidelines from ACOG suggest that pregnant women will find CMV prevention 'impractical and burdensome,' especially if they are told not to kiss their toddlers on the mouth — a possible route of transmission.” (“CMV Is a Greater Threat to Infants Than Zika, but Far Less Often Discussed,” Saint Louis, 2016). 

4) Still no national public awareness campaign: “Despite being the leading cause of mental retardation and disability in children, there are currently no national public awareness campaigns to educate expecting mothers about congenital CMV,” states Clinical Advisor article, “Educate pregnant women to prevent congenital CMV” (2014) .

5) Low media coverage about congenital CMV: In the article, "Why does CMV get so much less news coverage than Zika — despite causing far more birth defects?", Matt Shipman, the research communications lead at North Carolina State University, writes,  “Researchers we spoke with identified the same factors – fear and the epidemic/endemic nature of the diseases – as driving the media disparity.” The lack of consistent Media coverage on CMV is a problem in regard to prevention, diagnosis and treatment (HealthNewsReview.org, 2018).

6) Child Care providers, though they have an occupational risk for CMV, are not being told about CMV, despite recommendation from the American Academy of Pediatrics et al., in Staff Education and Policies on Cytomegalovirus. This could be because there is no central U.S. daycare center licensing procedures to enforce daycare licensing education and methods of CMV control. According to the Department of Labor, "Education and training requirements vary by setting, state, and employer." In most states, with the exception of Utah and recently, Idaho, child care centers are not required by law to ensure workers know their occupational risk for CMV even though workers have the right to “receive information and training about hazards” (Occupational Safety and Health Act of 1970).  

What Can Be Done to Raise CMV Awareness Until Prevention Becomes a Doctor's "Standard of Care"?


“61 % of children under the age of 5 are cared for in a child care facility...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). 
Thank you in advance for trying to protect our unborn children!

Lisa Saunders
Leader, Child Care Providers Education Committee
National CMV Foundation, Inc.
lisa.saunders@nationalcmv.org or childcare@nationalcmv.org 
PO Box 389, Mystic, CT 06355

Additional Notes on Risk of CMV Transmission:

According to the CDC, "Risk of transmission for primary infection is 30 to 40% in the first and second trimesters, and 40 to 70% in the third trimester. The risk of transmission following non-primary infection is much lower (3%). The risk of complications to the fetus is greatest if a primary infection occurs during the first trimester.” 


 ABOUT LISA SAUNDERS:
Lisa Saunders, a former in-home licensed child care provider, was trained in CPR and infection control but was not told about her occupational risk for CMV until after her daughter Elizabeth was born severally disabled by congenital CMV in 1989. At the time of Elizabeth's birth, Saunders was operating a daycare center for toddlers in her home, volunteering in her church nursery on Sunday, and was the mother of a toddler--all things that put her pregnancy at greater risk for CMV. Elizabeth had an abnormally small, damaged brain (microcephaly), was profoundly mentally and visually impaired, and had cerebral palsy. After Elizabeth's birth, Saunders was then given educational materials stating that people who care for or work closely with young children may be at greater risk of CMV infection. "This information came too late for my family," says Saunders. Elizabeth died at 16 during a seizure in 2006. Although Saunders was instrumental in helping Connecticut pass a CMV testing law in 2015, wrote a book about Elizabeth’s life, Anything But a Dog: the perfect pet for a girl with congenital CMV (Unlimited Publishing, 2008), and articles such, "The Danger of Spreading CMV: How We Can Protect Our Children" (ChildCare Aware of America, June 2017) and “HelpChildcare Providers Fight CMV” (National CMV Foundation, March 5, 2018), CMV prevention steps remain little known.  

 * From Red Book: 2015 Report of the Committee on Infectious Diseases, AAP, p. 144, 145:
CYTOMEGALOVIRUS INFECTION. Spread of CMV from an asymptomatic infected child in child care to his or her pregnant mother or to a pregnant child care provider, with subsequent transmission to the fetus, is the most important consequence of child carerelated CMV infection (see Cytomegalovirus Infection, p 317). Children enrolled in child care programs are more likely to acquire CMV than are children primarily cared for at home. Excretion rates from urine or saliva in children 1 to 3 years of age who attend child care centers usually range from 30-40% but can be as high as 70%, and intermittent excretion commonly continues for years. Studies of CMV seroconversion among female child care providers have found annualized seroconversion rates of 8% to 20%. Women who are or who may become pregnant and who are CMV naïve are at risk of being infected during pregnancy and transmitting CMV to their fetus.

 In view of the risk of CMV infection in child care staff and the potential consequences of gestational CMV infection, female child care staff members should be counseled about these risks. This counseling includes discussion between the woman and her health care provider. In utero fetal infection can occur in women with no preexisting CMV immunity (maternal primary infection) or in women with preexisting antibody to CMV (maternal nonprimary infection) by either acquisition of a different viral strain during pregnancy or from reactivation of an existing maternal infection. CMV excretion is so prevalent that attempts at isolation or segregation of children who excrete CMV are impractical and inappropriate. Similarly, testing of children to detect CMV excretion is inappropriate, because excretion often is intermittent and results of testing can be misleading. Therefore, use of Standard Precautions and hand hygiene are the optimal methods of prevention of transmission of infection. 

 BLOODBORNE VIRUS INFECTIONS 
HBV, HIV, and hepatitis C virus (HCV) are bloodborne pathogens. Although risk of contact with blood containing one of these viruses is low in the child care setting, appropriate infection-control practices will prevent transmission of bloodborne pathogens if exposure occurs. All child care providers should receive regular training on how to prevent transmission of bloodborne infections and how to respond should an exposure occur (www. osha.gov/SLTC/bloodbornepathogens/index.html).

**American Academy of Pediatrics, American Public Health Association, National Resource Center for Health and Safety in Child Care and Early Education. Caring for Our Children: National Health and Safety Performance Standards; Guidelines for Early Care and Education Programs, 4th ed. Itasca, IL: American Academy of Pediatrics; 2019, http://nrckids.org/CFOC, retrieved Jan. 2019.

 ***See below for the form, "Acceptance of Occupational Risk by Staff Members" with the following suggested citation from p. ii:   Pennsylvania Chapter of the American Academy of Pediatrics. Model Child Care Health Policies. Aronson, SS, ed. 5th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2014. www.ecels-healthychildcarepa.org. 
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." 

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

"Acceptance of Occupational Risk by Staff Members" form. Model Child Care Health Policies, 5th Edition, Aronson, SS, ed., Pennsylvania Chapter of the American Academy of Pediatrics (2014)., p. 116.
Copyright page ii from: Model Child Care Health Policies, 5th Edition, Aronson, SS, ed., Pennsylvania Chapter of the American Academy of Pediatrics (2014).

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