Why add cytomegalovirus (CMV) to the OSHA Bloodborne Pathogens Standard

(Illustration from the Woodcutter's Tale by Marianne Greiner. Coloring by Suzanne Doukas Niermeyer)

Caregivers/teachers regularly bandage bloody cuts. Cytomegalovirus (CMV), the leading viral cause of birth defects, is transmitted through bodily fluids such as saliva, urine and blood.

I, along with others before me, have asked OSHA if they can add CMV to its bloodborne pathogens standard, because then, "employers having employees with exposure to blood or other potentially infectious materials (OPIM) must train employees annually regardless of the employees' prior training or education" (Standard Interpretations, 2007). 

Despite OSHA recognizing CMV as a hazard to childcare workers on its webpage at: https://www.osha.gov/cytomegalovirus/hazards, I know from personal experience that most child care providers are unaware of their occupational risk for congenital CMV (www.cdc.gov/cmv/index.html).

Although I was a licensed, in-home child care provider at the time of my pregnancy with Elizabeth, born with congenital CMV in 1989, I was not educated about the virus. When I learned about CMV after receiving Elizabeth’s diagnosis, my head spun. I thought I lived in a country that told its workers about their occupational hazards. Elizabeth’s brain was small and damaged. She had deafness, blindness, mental challenges, cerebral palsy and epilepsy. She died during a seizure in 2006.

Shockingly, years later, child care providers are still unaware of CMV. In 2012, I received an email from a distressed grandmother about her grandson just born with congenital CMV. The baby's mother was a high school student interning in a daycare center. The young mother, just like me decades earlier, was unaware she was putting her pregnancy at increased risk by working with young children. When I visited the family in the hospital, the attending nurse asked me, "Knowing what you do about CMV, why haven’t you launched an awareness campaign?" I explained to her that I've been trying for years--with little, long-term result. 

Between 8 - 20% of child care providers contract CMV every year (American Academy of Pediatrics 2017) as compared to 1-4% of women (who have never had CMV) in the general population (CDC). Recent studies show that child care providers are largely unaware of CMV 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).  

Most caregivers/teachers are still unaware of CMV because:

1) Although OSHA lists CMV as a "Recognized Hazard", 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." 

2) CMV education is not "part of standard prenatal care” (Washington Post, 2021);

3) Doctors don’t want to frighten, worry or “burden” patients (New York Times, 2016);

4) CMV is a “silent virus” that goes largely undiagnosed--"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 Davis, 2005).

5) Medical training downplays the dangers. Michigan pediatrician Megan Pesch, MD, was shocked when her third daughter was born with congenital CMV. She stated that  "many health-care providers tend to minimize or ignore the risks." She 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...”(Washington Post, 2021).

It pains me that caregivers/teachers are slipping through the cracks--that their unborn children are not benefitting from the Occupational Safety and Health Act of 1970. Most workers in the childcare industry are not receiving their right to “receive information and training about hazards”. Their babies are paying the price for this neglect.

Please take a moment to "meet" these two mothers living near me who had no other children at the time of their pregnancy, but because of their professions, were unknowingly at increased risk for CMV. I met them at the June 2021 Cytomegalovirus Awareness Month event in central New York where we placed over 220 silver rocks (the color of CMV awareness) on the Trail of Hope (Buchiere, 2021) to honor the estimated number of babies born disabled by congenital CMV in New York each year.  You can watch Autumn (born with congenital CMV in 2015), the beautiful daughter of Kristin Schuster of Canandaigua, "help" us with the rocks in the music video,  "Had I Known (about CMV)". Autumn's mother, Kristin, stated that her "risk for contracting CMV came through her former job as a pre-kindergarten teacher when she was pregnant with her daughter Autumn" (Vallelunga, 2022). Jessica Keukelaar of Macedon watched us place the rocks with her first child Kyleigh, born with congenital CMV in 2018. 

Like Kristin and myself, Jessica worked with young children during her pregnancy and was unaware of her occupational risk for CMV. In support of a New York law to educate child care providers about CMV, she wrote a letter to Assemblymember Rosenthal’s office stating, “I was a caregiver in a daycare center when I became pregnant with my daughter born with congenital cytomegalovirus (CMV)... I had never heard of CMV or the precautions to take. This bill [Elizabeth’s Law] is important to me because it came as a complete shock when my daughter was born full term, in 2018, with numerous urgent health issues due to CMV. She was transferred to a different hospital to be in the NICU where she spent the first two weeks of her life; she was very ill. My daughter has developmental delays, spastic cerebral palsy which affects her entire body, eating and digestive difficulties, progressive hearing loss, microcephaly, and more. Some of the extra equipment Kyleigh requires on a daily basis are, a wheelchair due to immobility, gastrostomy tube for proper nutrition, cochlear implant for hearing, and special orthotics for her hands, wrists, ankles, and feet. She had surgery for her cochlear implant at 17 months, a double hip reconstruction at two years, and surgery to have her g-tube placed at three years. She also takes numerous medications several times per day, and receives 11 Botox injections quarterly to help with her spasticity. Congenital CMV has affected every aspect of Kyleigh’s life, as well as our whole family. I wish that someone took the time to educate me about CMV since I was at an increased risk of infection ”( Jessica's Memo in Support of “Elizabeth’s Law” 2022). 

In 2022, we three moms, former caregivers/teachers, helped New York pass the CMV education bill, "Elizabeth's Law", named in memory of my daughter. Although it is now required for child care providers to receive printed information about CMV (NYAssembly.gov, 2022),  they are still not required to receive actual training on this recognized "hazard”.  I think it's important to recognize the significance of this statement made in 2022: "Childcare workers, but not healthcare workers, have an increased risk of prevalent and incident CMV infection, a risk that is further increased with the presence of at least one child living at home. These findings suggest that enforcing simple, conventional hygienic measures in childcare settings could help reduce transmission of CMV, and that special precautionary measures for preventing CMV infection may not be required for pregnant healthcare workers."(Prevalence, incidence, and risk factors associated with cytomegalovirus infection in healthcare and childcare worker: a systematic review and meta-analysis, Balegamire et al.,2022)

If training incurs additional costs, it is also important to consider the medical care costs of NOT preventing congenital CMV: "Congenital CMV-related sequelae affect over 5000 children annually, and costs are greater than $1 billion annually in direct medical care in the United States" (Kabani, 2020). Of course there are other costs to congenital CMV, such as lost wages, the cost of providing specialized education, etc. Another estimate: "at least 3000 [newborns] are estimated to develop permanent neurologic disabilities each year due to cCMV infection...With an estimated annual cost of up to $4 billion in the United States, cCMV infection is an enormous public health concern..." ("Cost-effectiveness of Universal and Targeted Newborn Screening for Congenital Cytomegalovirus Infection" (Gantt, S, 2016). 

OSHA's CMV Hazard Recognition page, https://www.osha.gov/cytomegalovirus/hazards, states, "To help prevent CMV infections, employers and workers should treat all body fluids as if they are potentially infectious with CMV and follow the precautions described in the Control and Prevention page. Depending on workers’ job tasks and exposures, this may include following universal precautions as required in OSHA's Bloodborne Pathogens (BBP) standard (29 CFR 1910.1030), as well as standard precautions, which expand universal precautions beyond what the BBP standard requires." 

According to the OSHA webpage, Cytomegalovirus - Standards | Occupational Safety and Health Administration (osha.gov):

This section highlights OSHA standards and directives (instructions for compliance officers) and other related information that may apply to possible worker exposure to cytomegalovirus (CMV).

OSHA Standards

There is no specific OSHA standard covering CMV. However, there are some OSHA standards that may apply to preventing occupational exposure to sources of CMV.

• OSHA's Personal Protective Equipment (PPE) standards (29 CFR 1910 Subpart I), which include requirements for when employees must use gloves and eye and face protection, may apply to protecting workers from CMV.
• OSHA's Bloodborne Pathogens (BBP) standard (29 CFR 1910.1030) applies to occupational exposure to human blood and other potentially infectious materials. The BBP standard applies to occupational exposure to some human body fluids, including blood and saliva in dental procedures, which can transmit CMV. The BBP standard also describes measures could serve as a framework to control non-bloodborne exposures, including to body fluids such as urine, feces, and saliva (except in dental procedures) to which the standard does not apply.

Thank you for your attention to this serious matter.

Sincerely, 

Lisa Saunders

LisaSaunders42@gmail.com

216 Peakwood Ln, Apt 15

Baldwinsville, NY 13027

New York Stop CMV

About Lisa's CMV work