Lisa Saunders, former child care provider and mother of Elizabeth, born with a severely damaged brain from congenital CMV. Lisa did not know she had an occupational risk for CMV.
Poster: Educating Child Care Providers/Early Childhood Teachers About Their Occupational Risk for Cytomegalovirus (CMV)
Brenda Balch, MD, American Academy of Pediatrics (AAP) Early
Hearing Detection and Intervention Connecticut Chapter Champion
INTRODUCTION
8 - 20% of child care providers contract CMV every
year (
Red
Book, AAP, 2015) as compared to 1-4% of women (who have never had CMV)
in the general population (
CDC, 2018).
On average, 30-40% of preschoolers in day care excrete CMV in their saliva
and/or urine (
Red Book, AAP,
p. 144). "Up to 70% of children ages 1 to 3 years in group care
settings excrete the virus (“Staff Education and Policies on Cytomegalovirus” (
http://nrckids.org/CFOC/Database/7.7.1.1,
Caring for Our
Children: National Health and Safety Performance Standards; Guidelines for
Early Care and Education Programs, AAP et al., modified 2017)
Parents of children in day-care centers are at
increased risk for contracting CMV (
Pass et al, 1986). “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).
“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)."Children
enrolled in child care facilities are more likely to acquire CMV than are
children cared for at home” (
Caring for Our Children, AAP
et al., modified 2017).
American Academy of Pediatrics, et al., states:
“Female employees of childbearing age should be referred to their primary
health care provider or to the health department authority for counseling about
their risk of CMV infection. This counseling may include testing for serum
antibodies to CMV to determine the employee’s immunity against CMV
infection...it is also important for the child care center director to inform infant
caregivers/teachers of the increased risk of exposure to CMV during
pregnancy” (
Caring for Our Children, AAP
et al., modified 2017).
“I was a pregnant licensed child care provider, church
nursery volunteer 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 don’t effectively remove CMV”--Lisa
Saunders, mother of Elizabeth born with congenital CMV (seen above). Elizabeth
had a small, damaged brain, hearing and vision loss, cerebral palsy,
developmental delays and epilepsy. Elizabeth died during a seizure at the age
of 16 in 2006.
PURPOSE
Explain why most child care providers have not heard
about CMV.
Suggest methods for improving education
to ultimately prevent CMV.
LOW CMV AWARENESS AMONG CHILD CARE PROVIDERS
2016: 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).
2018: 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)
IF CMV WAS A PROBLEM, WOULDN’T MY DOCTOR TELL ME?
6 Possible Reasons
Women Are Unware of CMV
1) CMV prevention education is not "part of standard prenatal care”
2) Doctors don’t want to frighten, worry or
“burden” patients.
New York Times: "The American College of
Obstetricians and Gynecologists [ACOG] used to encourage counseling for
pregnant women on how to avoid CMV. But [ in 2015], the college
reversed course...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.” (
Saint
Louis, 2016).
3) Low media coverage. In the HealthNewsReview.org
article, "Why does CMV get so much less news coverage than Zika
— despite causing far more birth defects?" the author
states, “Researchers we spoke with identified the same factors –
fear and the epidemic/endemic nature of the diseases – as driving the media
disparity” (
Shipman,
2018).
4) Although U.S. workers have the right to
“receive information and training about hazards” (
Occupational Safety and
Health Act of 1970), there are no federal laws governing CMV education
policies for child care workers. The
Department
of Labor states, "Education and training requirements vary by setting,
state, and employer."
5)"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” (
Cannon
and Davis, 2005).
6) Medical training downplays the dangers. Pediatrician Megan Pesch, M.D., of the University of Michigan’s C.S. Mott Children’s Hospital, whose third daughter was born with congenital CMV and a progressive hearing loss, said, "I went back and looked at my notes at what I’d learned in residency and medical school, and what we learned was so rudimentary and basic...I waver between feeling guilty and feeling furious. I have spent — how many years of my life in developmental pediatrics? — how could I not have known?”(
Washington Post, "
How a common, often harmless virus called cytomegalovirus can damage a fetus,"
May 15, 2021.)
GERMANY AND AUSTRALIA
Germany: “to protect DCWs [daycare workers]
from primary infection, their CMV serostatus must be checked at the
beginning of their pregnancy. When the DCW is seronegative, she is excluded
from professional activities with children under the age of three years…“
(
Stranzinger et
al., 2016).
“In Australia, state governments have differing
recommendations for pregnant ECEC [early childhood education and care
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).
\
CMV LAWSUIT BY CHILD
CARE WORKER
In 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).
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...”
CONCLUSION
“Approximately 1-4% of all pregnant women will experience a
primary CMV infection during their pregnancy. If you work in a child care
setting, the risk increases to approximately 10%. If you have a toddler at
home who is actively infected with CMV and shedding CMV in their saliva or
urine, the risk is even higher, approaching 50% in some
studies” (“CMV In Pregnancy: What Should I Know?”,
Demmler-Harrison,
2014).
In the U.S., “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).
Child care licensing agencies should instruct child care
centers and preschools to educate staff about CMV. The book,
Model
Child Care Health Policies, has 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)” (American Academy of Pediatrics, Pennsylvania
Chapter, Aronson, SS, ed., 2014, p. 116).
HOW YOU CAN HELP
Contact country/state/county child care licensing programs,
public health departments, labor departments and labor unions geared to
early childhood educators/child care providers. Ask department
commissioners how they protect the unborn children of workers. Offer CMV
prevention information:
1. "Staff Education and Policies on Cytomegalovirus (CMV)," 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. You can download that page as a pdf by clicking on the upper right side of the webpage: "Save as PDF"
2. Centers for Disease Control and Prevention (CDC) CMV info available in English and Spanish:
5. Model Child Care Health Policies, a book by the American Academy of Pediatrics, has 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)” (American Academy of Pediatrics, Pennsylvania Chapter, Aronson, SS, ed., 2014, p. 116).
10 Reasons Why Caregivers/Teachers Must be Educated About CMV
1) According to OSHA, CMV is a "Recognized Hazard". OSHA states that all workers have the right to “receive information and training on job hazards, including all hazardous substances in your workplace.” OSHA and CMV: "Childcare jobs may involve contact with children infected with CMV or their saliva, nasal secretions, or excrement. CMV is spread through exposure to infected body fluids. Since a person with CMV may show no symptoms, childcare workers should utilize proper handwashing and sanitization procedures. Childcare workers should also use personal protective equipment (PPE), such as gloves, to help prevent exposure to body fluids” (www.osha.gov/SLTC/cmv/hazards.html).
2) HOWARD A. ZUCKER, M.D., J.D ,Commissioner of Health for New York, stated: "According to the Centers for Disease Control and Prevention (CDC), female workers of reproductive age in child care centers should be educated on CMV and its potential risks, and should have access to appropriate hygiene measures to minimize occupationally-acquired infection " (August 2018).
3) American Academy of Pediatrics stated: “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” (Staff Education and Policies on Cytomegalovirus (CMV), "Caring for Our Children: National Health and Safety Performance Standards; Guidelines for Early Care and Education Programs", American Academy of Pediatrics et al.).
4) Approximately 1 in 200 children are born in the U.S. with congenital CMV. The impact on the fetus may include deafness, blindness, cerebral palsy, developmental disabilities, seizures and even death (www.cdc.gov/cmv).
5) Congenital cytomegalovirus is a more common cause of disabilities than Zika, Down syndrome and fetal alcohol syndrome. CMV is the leading viral cause of birth defects ("Cytomegalovirus Infection in Pregnancy: Should All Women Be Screened?", Carlson et al., 2010).
6) CMV is a viral infection that is common in children. Up to 70% of children ages 1-3 years in group care settings excrete CMV. The New York Health Department website states, "In daycare centers, where hand washing practices may not be as good, there may be a greater risk of infection...Pregnant women working in child care facilities should minimize direct exposure to saliva and avoid kissing babies or young children on the mouth. Hugging is fine and is not a risk factor...." Information is provided in English and Spanish at: https://www.health.ny.gov/diseases/communicable/cytomegalovirus/fact_sheet.htm
7) Recent surveys show that most child care providers do not know about CMV and many acknowledge using diaper wipes to clean hands instead of following proper protocols (Thackeray and Magnusson, 2016). Diaper wipes do not effectively remove CMV from hands (Stowell et al., 2014).
8) Child care providers serving children receiving assistance through the Child Care and Development Fund program must receive training on topics covered by the Child Care and Development Block Grant Act of 2014. “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)” (Caring for Our Children Basics).
9) Child care providers accredited by National Association for the Education of Young Children should already be familiar with the document, “NAEYC Early Childhood Program Standards and Accreditation Criteria & Guidance for Assessment,” which acknowledges the need to "reduce occupational hazards such as infectious diseases (e.g., exposure of pregnant staff to CMV…)”
10) Potential Cost of 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, 2017)
###
NOTE: Illustration by Marianne Greiner. Reference citations available
on primary author’s CMV blog at:
https://congenitalcmv.blogspot.com/. Contact author Lisa Saunders at: PO Box 389, Mystic, CT
06355, lisa.saunders@nationalcmv.org or LisaSaunders42@gmail.com
