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Saturday, February 11, 2023

Including children with known congenital CMV in New York

Page 116 - Model Child Care Health Policies, published by the American Academy of Pediatrics, recommends staff members acknowledge and accept “Occupational Risk” of working in child care “including infections that can damage a fetus during pregnancy” 


NEW LAW IN NEW YORK

Did you know about the new law aimed at educating child care providers and pregnant women about cytomegalovirus (CMV), the leading viral cause of birth defects?


I am a CMV advocate (but not a doctor). However, I and can help direct you to more information. If you don't know what congenital CMV is, or about the new law named "Elizabeth's Law," in memory of my daughter,  I suggest reading: 


Once child care providers learn about CMV, their increased risk and need to carefully follow infection control policies, or learn there is a known case of congenital CMV in their group, they may be wondering if they should work with that child. 

According to the National CMV Foundation: "Precautions for Caregivers: Contact with infected bodily fluids, including saliva or urine of young children, is a major cause of CMV infection among pregnant women –  especially mothers, daycare workers, preschool teachers, therapists, and nurses. Studies in childcare settings suggest that as many as 75% of toddler-aged children have cmv in their urine or saliva, and viable CMV can persist on hands for at least 15 minutes. Per the AAPs 2015 Red Book recommendations for CMV, which states that healthcare workers, even when pregnant, do not need to exclude children with CMV, as up to 80% of asymptomatic children are shedding CMV at any time. Universal precautions are enough to minimize exposure." Learn more at: https://www.nationalcmv.org/resources/for-childcare-providers and/or see their flier, "Should I Exclude a Child Born With CMV?"

Caregivers/teachers should be referred to their primary care doctor or health department  for counseling about their risk of CMV infection per the guidelines in Caring for Our Children: 7.7.1.1: Staff Education and Policies on Cytomegalovirus (CMV), which states: 

Cytomegalovirus (CMV) is a viral infection that is common in children. Up to 70% of children ages 1 to 3 years in group care settings excrete the virus (1).
Staff of childbearing age who care for infants and children should be provided the following information:

  1. The increased probability of exposure to cytomegalovirus (CMV) in the child care setting;
  2. The potential for fetal damage when CMV is acquired during pregnancy;
  3. The importance of hand hygiene measures (especially handwashing and avoiding contact with urine, saliva, and nasal secretions) to lower the risk of CMV;
  4. The availability of counseling and testing for serum antibody to CMV to determine the caregiver/teacher’s immune status.

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.
Since saliva can transmit CMV, staff should be advised not to share cups or eating utensils, kiss children on the lips, or allow children to put their fingers or hands in another person’s mouth. 

RATIONALE
CMV is the leading cause of congenital infection in the United State and approximately 1% of live born infants are infected prenatally (1). While most infected fetuses likely escape resulting illness or disability, 10% to 20% may have hearing loss, developmental delay, cerebral palsy, or vision disturbances (1). Although maternal immunity does not entirely prevent congenital CMV infection, evidence indicates that acquisition of CMV during pregnancy (primary maternal infection) carries the greatest risk for resulting illness or disability of the fetus (2).

Children enrolled in child care facilities are more likely to acquire CMV than are children cared for at home (2). Epidemiologic data, as well as laboratory testing of viral strains, has provided evidence for child-to-child transmission of CMV in the child care setting (1). Rates of CMV excretion vary among facilities and between class groups within a facility. Children between one and three years of age have the highest rates of excretion; published studies report excretion rates between 30% and 40% (2). Many children excrete CMV asymptomatically and intermittently for years.

With regard to child-to-staff transmission, studies have shown increased rates of infection with CMV in caregivers/teachers ranging from 8% to 20% (2). The increased risk for exposure to CMV and high rates of acquisition of CMV in caregivers/teachers could lead to increased rates of congenital CMV infection. Meticulous hand hygiene can reduce the rates of infection by preventing CMV transmission. 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 (1). 

COMMENTS

For additional information regarding CMV, consult the CMV chapter in the current edition of the Red Book from the American Academy of Pediatrics (AAP).

TYPE OF FACILITY
Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home
RELATED STANDARDS
3.6.1.1 Inclusion/Exclusion/Dismissal of Ill Children
REFERENCES
  1. Aronson, S. S., T. R. Shope, eds. 2017. Managing infectious diseases in child care and schools: A quick reference guide, 4th Edition.Elk Grove Village, IL: American Academy of Pediatrics.
  2. American Academy of Pediatrics. Cytomegalovirus (CMV) Infection In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2018 Report of the Committee on Infectious Diseases. 31st Edition. Itasca, IL:  American Academy of Pediatrics; 2018: 310-317
NOTES

Content in the STANDARD was modified on 3/31/17.

(Visit: https://nrckids.org/CFOC/Database/7.7.1.1)



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).


NOTE:

Although I know personally of one lawsuit settled out of court in the US (so there is no record of it), I do know of these published cases involving what can happen if women are not educated about their CMV risks: 

1) Connecticut: Lawsuit featured in the article, "Couple wins $37.6 million in Superior Court ruling against UConn Health for fertility procedure that left one child dead and her twin requiring lifetime medical attention", which included the comment, The Center for Advanced Reproductive Services did not inform Monroe-Lynch and 'knowledgeably obtain her consent' about the risks associated with a CMV infection, according to the lawsuit” (Hartford Courant, 2021). The lawyers' website states, “The devastating consequences of contracting congenital CMV infection early in pregnancy are well-known in the medical community. There are simple safeguards in place to protect prospective parents and their children from this horrible disease” (Walsh Woodard LLC, 2021)


2) Australia: 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)” (WorkSafe). Lawyers commented, “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…”(Meridian Lawyers).


Friday, February 10, 2023

Effectiveness of CMV Prevention Education

 


See bibliography for more

Adler, S.P., et al., Prevention of child-to-mother transmission of cytomegalovirus by changing behaviors: a randomized controlled trial. Pediatr Infect Dis J, 1996. 15(3): p. 240-6.(https://pubmed.ncbi.nlm.nih.gov/8852913/)

Adler, S. P., Finney, J. W., Manganello, A. M., & Best, A. M. (2004). Prevention of child-to-mother transmission of cytomegalovirus among pregnant women.J Pediatr, 145(4), 485-491.(https://pubmed.ncbi.nlm.nih.gov/15480372/)

Bate, S.L. and M.J. Cannon, A social marketing approach to building a behavioral intervention for congenital cytomegalovirus. Health Promot Pract, 2011. 12(3): p. 349-60.(https://journals.sagepub.com/doi/10.1177/1524839909336329)

Cannon, M.J., et al., Awareness of and behaviors related to child-to-mother transmission of cytomegalovirus. Prev Med, 2012. 54(5): p. 351-7. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4494733/)

Cannon, M.J. and K.F. Davis, Washing our hands of the congenital cytomegalovirus disease epidemic. BMC Public Health, 2005. 5: p. 70. (https://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-5-70)

Finney, J.W., K.M. Miller, and S.P. Adler, Changing protective and risky behaviors to prevent child-to-parent transmission of cytomegalovirus. J Appl Behav Anal, 1993. 26(4): p. 471-2. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1297873/)

Harvey, J., & Dennis, C. L. (2008). Hygiene interventions for prevention of cytomegalovirus infection among childbearing women: systematic review. J Adv Nurs, 63(5), 440-450.(https://pubmed.ncbi.nlm.nih.gov/18727745/)

Hughes, B. L., K. M. Gans, C. Raker, E. R. Hipolito, and D. J. Rouse. "A Brief Prenatal Intervention of Behavioral Change to Reduce the Risk of Maternal Cytomegalovirus: A Randomized Controlled Trial." Obstet Gynecol 130, no. 4 (Oct 2017) (https://pubmed.ncbi.nlm.nih.gov/28885428/)

Jeon, J., et al. Knowledge and awareness of congenital cytomegalovirus among women. Infect Dis Obstet Gynecol, 2006. 2006: p. 80383. (https://pubmed.ncbi.nlm.nih.gov/17485810/)

Levis, D. M., Hillard, C. L., Price, S. M., Reed-Gross, E., Bonilla, E., Amin, M., . . . Cannon, M. J. (2017). Using theory-based messages to motivate U.S. pregnant women to prevent cytomegalovirus infection: results from formative research. BMC Womens Health, 17(1), 131. (https://bmcwomenshealth.biomedcentral.com/articles/10.1186/s12905-017-0482-z)

MMWR (2008) Knowledge and practices of obstetricians and gynecologists regarding cytomegalovirus infection during pregnancy--United States, 2007.MMWR Morb Mortal Wkly Rep, 2008. 57(3): p. 65-8.(https://pubmed.ncbi.nlm.nih.gov/18219267/)

Price, S. M., Bonilla, E., Zador, P., Levis, D. M., Kilgo, C. L., & Cannon, M. J. (2014). Educating women about congenital cytomegalovirus: assessment of health education materials through a web-based survey. BMC Womens Health, 14, 144. (https://bmcwomenshealth.biomedcentral.com/articles/10.1186/s12905-014-0144-3) From abstract: "To increase awareness of CMV, the Centers for Disease Control and Prevention (CDC) developed draft health education materials. The purpose of this study was to pilot test two health education materials to gauge their appeal and to determine if they increase knowledge about CMV and motivate audiences to seek additional information on CMV and adopt CMV prevention behaviors." From results: "CMV knowledge score increased significantly after presentation of either the video or factsheet (from 3.7 out of 10 to 9.1 out of 10, p <0.001)...From conclusion: "Overall, we found that the health education materials improved women’s knowledge of CMV and encouraged them to adopt prevention behaviors. Given the low awareness levels among women currently, these findings suggest that appropriate education materials have the potential to greatly increase knowledge of CMV."

Revello, M. G., Tibaldi, C., Masuelli, G., Frisina, V., Sacchi, A., Furione, M., . . . for the, C. S. G. (2015). Prevention of Primary Cytomegalovirus Infection in Pregnancy(). EBioMedicine, 2(9), 1205-1210.doi:10.1016/j.ebiom.2015.08.003 (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4588434/)

Ross, D.S., et al., Women's knowledge of congenital cytomegalovirus: results from the 2005 HealthStyles survey. J Womens Health (Larchmt), 2008. 17(5): p. 849-58. (https://www.liebertpub.com/doi/abs/10.1089/jwh.2007.0523)

Thackeray, R., B.M. Magnusson, and E.M. Christensen, Effectiveness of message framing on women's intention to perform cytomegalovirus prevention behaviors: a cross-sectional study. BMC Womens Health, 2017. 17(1): p. 134. (https://bmcwomenshealth.biomedcentral.com/articles/10.1186/s12905-017-0492-x)

Thackeray, R. and B.M. Magnusson, Women's attitudes toward practicing cytomegalovirus prevention behaviors. Prev Med Rep, 2016. 4: p. 517-524. (https://pubmed.ncbi.nlm.nih.gov/27747148/)

Vauloup-Fellous, C., Picone, O., Cordier, A. G., Parent-du-Chatelet, I., Senat, M. V., Frydman, R., & Grangeot-Keros, L. (2009). 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, 46 Suppl 4, S49-53. doi:10.1016/j.jcv.2009.09.003 (https://pubmed.ncbi.nlm.nih.gov/19811947/#:~:text=Conclusions%3A%20These%20results%20suggest%20that,following%20counseling%20than%20before%20counseling.)

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