Are your state's caregivers/teachers told their occupational risk for CMV, #1 birth defects virus?

I am a former licensed in-home child care provider who was unaware of my occupational risk for cytomegalovirus (CMV), the #1 birth defects virus, until it was too late to help my daughter, Elizabeth, born with microcephaly and severely disabled by congenital CMV (see attached image). She died at 16 during a seizure in Nyack, New York.

If I had known about my increased risk for CMV (the virus is often excreted by otherwise healthy toddlers), I would have only cared for children over the age of two in my home.  Recent surveys show that most child care providers do not know about CMV and many acknowledge using diaper wipes to clean (Thackeray and Magnusson, 2016). As you might be aware, diaper wipes do not effectively remove CMV from hands (Stowell et al., 2014). I will never know if I got CMV from my own toddler or the several toddlers I cared for professionally (and voluntarily in church nursery), but naturally I'm upset I wasn't warned about CMV and how to reduce my chances of contacting it. 

Do you know if your state requires CMV education for women of childbearing age, especially those who have or care for toddlers?

If you want to help prevent the leading viral cause of birth defects, consider contacting your local and state child care licensing agencies and OSHA offices. The following is the recent email I have been sending to my state's agencies:

Dear [New York Child Care/Teaching Licensing Agencies and OSHA--start your state child care licensing search by clicking here]:

I recently moved back to New York (Baldwinsville) and am looking into the training that is provided to NY licensed child care providers. I don't believe cytomegalovirus (CMV) information is included in the training materials. Those who create the child care training in NY, the Early Childhood Education and Training Program  (https://www.ecetp.pdp.albany.edu/index.aspx) may not know about the CMV law passed in 2018 (https://www.nysenate.gov/legislation/bills/2017/s2816/amendment/original) and the NY health commissioner's letter stating:  "While exposure to CMV may be difficult to avoid, particularly for those who have young children already, it is imperative that we give women of reproductive age the information they need to make informed decisions for themselves and their families... 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"   (HOWARD A. ZUCKER, M.D., J.D ,Commissioner of Health for New York State, August 2018 letter: https://www.health.ny.gov/commissioner/letters/docs/2018-08.pdf).   

I'm sure New York's caregivers/teachers are already being trained in infection prevention, but, I agree with Dr. Zucker's letter stating it is "imperative" they learn about CMV in order to take seriously the careful measures needed to protect their pregnancies and to "make informed decisions for themselves and their families." I'm happy to see the NY Health Department website states that "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..." Thankfully this information is provided in English and Spanish at: https://www.health.ny.gov/diseases/communicable/cytomegalovirus/fact_sheet.htm  but the following link on that page is broken: Further information on cytomegalovirus from Wadsworth Center for Laboratories and Research.

I have reached out to the NY Early Childhood Education and Training Program  about CMV to let them know there are several free CMV educational resources available such as the new online workshop, "Occupational Exposure to Cytomegalovirus (CMV): Preventing Exposure in Child Care and Educational Settings, Including OSHA Advisories",  by Nellie Brown, MS, CIH, Certified Industrial Hygienist, and Director, Workplace Health and Safety Program, Worker Institute, Cornell University – ILR School. Nellie Brown's email is njb7@cornell.edu in case you want to contact her about doing a live Q and A over Zoom. (See below my signature for links to free resources such as her publication, video and the CDC's CMV flyers, and the National CMV Foundation posters, etc.) 

I'm sure you are aware of the CMV "Hazard Recognition"  by the Occupational Safety and Health Administration (OSHA) that states: "Childcare workers are at increased risk for exposure to cytomegalovirus (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  (https://www.osha.gov/SLTC/cmv/hazards.html). 

As you are probably aware, in Caring for Our Children: National Health and Safety Performance Standards; Guidelines for Early Care and Education Programs, the American Academy of Pediatrics 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” (Standard 7.7.1.1 Staff Education and Policies on Cytomegalovirus (CMV), modified 3/31/17, http://nrckids.org/CFOC/Database/7.7.1.1).  

Please let me know if you can think of ways I can help get educate caregivers/teachers about their CMV risk.

Sincerely,

Lisa Saunders

CMV Education Advocate

Baldwinsville, NY (formerly of Mystic, CT)

LisaSaunders42@gmail.com

Lisa's CMV-Related Resume
Facebook: https://www.facebook.com/congenitalcmvnews/

Blog: https://congenitalcmv.blogspot.com/

PSA: "Had I known (about CMV)

Learn more about Lisa's CMV work in Cornell Alumni Magazine's: In Memory of Elizabeth: Her daughter's death from a preventable disability spurs Lisa Avazian Saunders '82 into action (2015). Lisa was instrumental in helping Connecticut become the second state to pass a CMV testing law: "Mystic Mom 'Overwhelmed' by Governor Signing Law on ‘Stealth Virus’ That Can Catch Pregnant Women Unaware"(Erik Ofgang, May 27, 2015 Updated Mar 6, 2017).

Lisa is the author of:    

1. Help Childcare Providers Fight CMV: Protect Newborns from #1 Birth Defects Virus
2. Once Upon a Placemat--A Table Setting Tale: Coloring Book and CMV Prevention Tool
3.  Anything But A Dog!: The Perfect Pet For A Girl With Congenital Cmv  

CMV RESOURCES

FLYERS

Centers for Disease Control and Prevention (CDC):

“CMV Fact Sheet for Pregnant Women and Parents

English: https://www.cdc.gov/cmv/downloads/cmv-parents-fact-sheet-508.pdf

Spanish: https://www.cdc.gov/cmv/downloads/cmv-parents-fact-sheet-sp-508.pdf

Utah has a great website with many downloadable resources for child care providers. See: CMV What Childcare Providers Need to Know (English) | Lo qué los proveedores de cuidado infantil necesitan saber sobre CMV (Spanish)

National CMV Foundation: Flyers on several CMV related topics at: https://www.nationalcmv.org/resources/educational-downloads. 

One I recommend for classroom walls: “Are You Pregnant?”: https://www.nationalcmv.org/NCMVF/media/ncmvf/download-content/CMV_Awareness-Flyer_11x17.pdf?ext=.pdf

PRESENTATIONS

For Caregivers/Teachers/Educators: "CMV Training Module Video": https://aural.rehab.uconn.edu/cmv-training-module/ (This work was supported by the AUCD and the LEND Pediatric Audiology Program made possible through a Cooperative Agreement with the Health Resources and Services Material Child Health Bureau (MCHB) grant awarded to the University of Connecticut A.J. Pappanikou Center for Excellence in Developmental Disabilities (Grant #3T73MC30115-01-01) in consultation with Child

For Employers: 

There is now a free, online CMV presentation by Cornell University's Nellie Brown, MS, CIH, Certified Industrial Hygienist, and Director, Workplace Health and Safety Program, Worker Institute, Cornell University – ILR School.  No fees or registration are required. Nellie Brown's email is njb7@cornell.edu in case you want to contact her about doing a live Q and A over Zoom. Nellie Brown’s presentation is available as the following:

1. Publication: Brown, N. J. (2019, November). Occupational exposure to cytomegalovirus (CMV): Preventing exposure in child care and educational settings, including OSHA advisories. Ithaca, NY: Cornell University, ILR School. Available from: https://digitalcommons.ilr.cornell.edu/conference/45/

2. Vimeo: https://vimeo.com/450219803
3. Download video workshop: https://vimeo.com/user43999427/download/450219803/e5b7be27db
   

 MORE INFORMATION   

NEVER HEARD OF CMV?

"There is more than one ‘C virus’ out there. It's called cytomegalovirus or CMV,” says Gail J. Demmler-Harrison, MD, Professor, Baylor College of Medicine. A pediatric infectious diseases expert with over 30 years experience and expertise in diagnosis and management of children with congenital CMV at Texas Children’s Hospital,  Dr. Demmler-Harrison states: "Congenital CMV continues to be the most common congenital viral infection in this country, affecting thousands of babies each year, year after year, and it is a common cause of hearing loss, vision loss, and disabilities in our children."  In her article,“CMV In Pregnancy: What Should I Know?”, she writes, “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” (Texas Children’s Hospital, 2014). (Watch/read her interview in the New York Times article, CMV Is a Greater Threat to Infants Than Zika, but Far Less Often.)

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).”  

A suggested protocol for child centers includes:

Acceptance of Occupational Risk by Staff Members:  "Each staff member (paid or volunteer) is required to review with a supervisor the following acknowledgment of occupational risk and sign the statement to acknowledge and agree to accept the risk: “I understand there are health risks related to working in child care. These include, but are not limited to, exposure to infectious diseases (including infections that can damage a fetus during a pregnancy)..."

Model Child Care Health Policies (American Academy of Pediatrics, Pennsylvania Chapter, Aronson, SS, ed., 2014, p. 116).   See: http://ecels-healthychildcarepa.org/publications/manuals-pamphlets-policies/item/download/332_de718b5d0a40682caf26b57e9307bc91.html

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). Meridian Lawyers of Australia stated: "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…" (Suggested policy of Meridian Lawyers of Australia found at: www.meridianlawyers.com.au/insights/infectious-diseases-child-care-what-about-staff-members/)

Want to help your state's teachers/caregivers?

TO DO:

Contact your state’s childcare care licensing department, department of health, department of labor, and local universities with occupational medicine and public health programs. CMV is a bloodborne pathogen. Contact your state's health and child care licensing commissioner. Ask them to follow the recommendations made by the American Academy of Pediatrics and OSHA or work at getting your state to pass a law requiring CMV education. 

If the policy makers need incentive to spend money on prevention education, consider this: 

Annual cost of caring for children disabled cCMV by state: 

In 2018, 3,791,712 babies were born in U.S. with 1/200 born with cCMV x 1/5 disabled by cCMV= 3,792 babies disabled by cCMV in 2018.  In New York in 2018, the annual cost of caring for children disabled by cCMV can be calculated at 226,238 births x .1% cCMV disabled = 226  babies X $300,000/year = $67,800,00 or over 67 million dollars to care for cCMV disabled children in New York in 2018.

BARRIERS TO GETTING LEGISLATION PASSED

·        CMV is unknown: Since legislators have never heard of CMV, they think if it was a problem, OB/GYNs would say so. 

·        Cost: What is the cost to providing CMV education (CT estimated it to be $40,000 per year). 

·        Some doctors and Early Education Teachers/Child Care Leaders may not support bill: Some medical professionals oppose public policy and legislation mandating medical practice. The daycare industry may worry about frightening  away their workers.

·        Extra work: Some state departments and programs don’t want the extra work of providing CMV prevention education and training—especially if there is no funding for it. 

·        Finding legislators to introduce the bill: It is hard to introduce a bill on a problem very few have heard of. Legislators worry about getting enough support such as people testifying at the hearing, writing letters, calling legislators and visiting their offices. Many legislators don’t understand why just telling their their state to educate women doesn’t produce a real, lasting change in awareness. 

SOLUTIONS

Streamline educating legislators: Create a one-page CMV fact sheet  (click here for example) telling them what they quickly need to know to convince others. Provide a pocket folder that includes back-up documents such as the bills passed in other states (find them at www.nationalcmv.org/cmv-research/advocacy), the new CMV flyers from CDC:

 (Spanish/English), flyers/posters from the National CMV Foundation (so they see educational materials already exist), relevant newspaper articles and scientific studies.

Attract Media Attention: Give yourselves a name such as [your state name] CMV Advocacy Project. Create a Facebook page with your group name on it and complete the “About” section. Sent media releases to TV/radio/newspapers quoting doctors and parents. Send resulting links of coverage to all the legislators—you never know who will really care.

Get your state’s (or county’s) health department behind you: You may get resistance because it means work for them if it passes, but remind them that staff such as child care providers are at increased risk for CMV. Under the Occupational Safety and Health Act of 1970 (OSH Act), workers have the right to “receive information and training about hazards.”

Stress the Benefits: You may be apposing medical professional groups so you must articulate the benefits to legislators. According to Brenda K. Balch, MD, Connecticut's American Academy of Pediatrics (AAP) Early Hearing Detection and Intervention (EHDI) Chapter Champion, our CMV “testing protocol allows for a more timely diagnosis of the etiology of the infants hearing loss and is less expensive than imaging and genetic testing.” A CMV testing law will also “increase healthcare workers’ and parents’ awareness of CMV research and possible intervention strategies for congenital CMV.”

Find an advisor to help guide you:  You may have connections to an organization eager and Corporate Affairs willing to help you.

If you live in CT:

The Connecticut Department of Public Health (CT DPH) website has flyers and information: http://portal.ct.gov/DPH/Family-Health/EHDI/CMV. The National CMV Foundation allowed the CT DPH to embed their logo in their “Are You Pregnant” National CMV Awareness Flyer.

You may wish to distribute the above flyer with this letter from Dr. Brenda Balch on the back:

https://drive.google.com/file/d/1xjQKI8SE1awlHPdD-k27ZwG62W7dnlv3/view?usp=sharing

Letters to medical community:

CT Department of Public Health (DPH) About CMV For Obstetric Health Care Providers and About CMV Testing for Obstetric Health Care Providers.

CT Department of Public Health (DPH) and American Academy of Pediatrics (AAP) About CMV for Pediatric Care Providers.