Employer-Sponsored Childcare Employer-sponsored childcare and onsite childcare have become prevalent and are often selected as an option for families who are unable to utilize relative or other forms of nonrelative childcare. An advantage of employer-sponsored or onsite childcare is that the child or the children are located in close physical proximity to the parent. For young infants, this proximity may facilitate breastfeeding, and for older children, transportation to and from work/childcare activities as well as proximity to after school activities offer opportunities for increased parent-child interactions. Financial benefits including direct payroll deduction and increased productivity by parents who may be able to devote time saved to their jobs. Additionally, an employed parent may be less likely to be absent if he or she is in close proximity to a mildly ill child in an employer-based childcare arrangement. Accessibility and observation of a child in employer-based care may be an incentive to keep the child in the employer-based care arrangement and continue with employee obligations.

Ill Childcare Ill childcare is defined as the provision of care for a child who is mildly ill and who does not meet criteria for exclusion from childcare. However, some childcare facilities may not be able to accommodate a mildly ill child, translating into parental absences, ranging from 5 to 29 days annually and a corresponding cost to employees ranging from $2 to $12 billion annually (http://nascd. com/index.htm). Following a 1998 needs assessment for ill childcare, a collaboration of childcare providers formed the National Association for Sick Child Daycare (NASCD), a nonprofit educational organization that serves as a resource for ill childcare programs. Arrangement for the provision of ill childcare may vary with the needs and the structure of the center. Considerations affecting the choice of an appropriate alternative include the need to ensure the child’s health and well-being, increased costs of alternative arrangements, the desire to reduce parental absenteeism from work, disruption of the child’s routine, and the potential for spread of infection to children or adults in the alternative setting (5).

Models include temporary or permanent arrangements for the care of ill children and dedicated locations within a facility or a separate facility in which ill care is provided. Temporary arrangements may best be suited for a local or community outbreak of a communicable disease, while a permanent ill childcare location may serve the needs of a higher volume facility or a community where ill childcare cannot be provided effectively within an existing childcare center.

Although ill childcare raises concerns about children’s emotional and medical needs and the risk of transmission among children in such settings (6), few studies have addressed these issues. A comparison of 118 children who attended a center providing short-term care for children with mild illnesses with an age-matched cohort of ill children who received care from a home care provider in their own homes indicated no increased risk of subsequent illness in the former group (7). The provision of ill childcare may require additional training of staff including availability of facilities to maintain segregation of children with a variety of illnesses. Providers of care for ill children should be well versed in strategies to prevent transmission of potentially infectious microorganisms, both among attendees and staff, and should be able to maintain vigilance for changes in conditions of children who are mildly ill. Hospitals that provide employer-based childcare may be uniquely situated to provide ill childcare and may provide a sense of reassurance to parents due to their proximity to the availability of medical care services, if needed. While these facilities are not intended to replace evaluation by a healthcare provider, childcare providers with training and experience related to provision of care for mildly ill children may result in appropriate care for mildly ill children.

Backup Childcare Care of children who receive care from an individual provider may be interrupted when the provider becomes ill or is unable to provide care for another reason. In these situations, availability of backup childcare is beneficial. One of the challenges to providers of intermittent care is that the need for these services is variable and the care provided is frequently transient, lasting only for the duration of the incapability of a regular provider. Although backup childcare arrangements facilitate continuation of care for children and sustainability of employment for parents, settings that provide urgent childcare should be evaluated prior to their need to ensure that they meet local licensing requirements.

Sibling Childcare When children are hospitalized for acute and chronic conditions, a need has developed to provide care for their siblings while their parents spend time with the hospitalized child. In certain inpatient units, such as intensive care or transplant units, age and developmental limitations may not be conducive to sibling visits. Additionally, care for well siblings of hospitalized children may be a challenge for families who reside at significant distances from the hospital. Therefore, the provision of childcare for well siblings of hospitalized children provides a service to families of pediatric inpatients and optimizes compliance with visitation policies. Hospitals or medical centers that provide employer-based care could extend care of employee children to that of temporary care for siblings of hospitalized children.

Young children have an increased susceptibility and high age-specific attack rates for numerous diseases. Infections in childcare settings are transmitted primarily by personto-person spread of pathogens through body substances, including feces, saliva, nasal secretions, and urine; through direct contact; or by hands of children and care providers. Children, especially toddlers, in childcare have frequent person-to-person contact and often have poor personal hygiene with regard to contact with and disposal
of potentially infectious body substances (43,46,53,54). Frequent hands-on contact by staff, often in hectic circumstances, provides additional opportunity for personto-person spread via the care providers’ hands both to other children and to other care providers (49,52,55,56). The lack of fecal continence in children who are not toilet trained and the tendency for children to explore their environment with their hands and mouths lead to frequent sharing of oral secretions and fecal-oral spread of infection (46,52,54,57, 58 and 59).

Children also share secretions and excretions via fomites; contaminated toys and environmental surfaces are important in the epidemiology of childcare-associated infections. These areas, especially surfaces in classrooms of non-toilet-trained children, are often contaminated with enteric microorganisms (52,59, 60, 61, 62 and 63). Many microorganisms associated with childcare related infections can survive on environmental surfaces for considerable periods of time. Some, including CMV, rotavirus, and Giardia, have been isolated from environmental surfaces in childcare facilities (58,64, 65 and 66). The concentration of microorganisms recovered from surfaces and air samples in childcare center classrooms is inversely related to the age of the children in the room (67). Environmental levels of fecal coliforms in childcare classrooms often increase during outbreaks of diarrheal illness (49). Group A Streptococcus was isolated from plastic toy food during an investigation of two cases of invasive GAS infections in a childcare facility (68). Although mouthing behavior is uncommon among children 3 and 4 years of age, such as the children involved in this outbreak, food replica toys encourage mouthing behavior and are examples of the types of fomites that contribute to transmission.

Airborne transmission also contributes to spread of pathogens. Respiratory tract infections, transmitted through respiratory aerosols and droplets, are the most common infections associated with childcare attendance (12,19,22,23,48,69). Studies in crowded homes and childcare settings have shown that risk of respiratory tract infections, including otitis media, increases as the number of children per room increases (8,70,71). Results from a series of longitudinal studies suggest that a positive association exists between frequency of respiratory tract illness and childcare among preschool children. These results also suggest that this association is related to the number of children in the group, may be moderated by length of time in childcare, and is reversed to a protective effect in school-aged children, with the differences disappearing by 13 years of age (12,72).

Common source and food-borne transmission rarely are reported causes of outbreaks in childcare settings (73, 74, 75, 76 and 77). However, unhygienic food-handling practices have been shown to be a risk factor for illness spread by fecal-oral transmission in childcare facilities (14,55), and clinicians may not have recognized fully the significance of food-borne transmission in this setting.

Childcare Providers Childcare providers, like healthcare providers, are at risk of occupational exposure to infectious microorganisms (78,79). The majority of childcare providers are women; many of whom are of childbearing age (80, 81 and 82). Childcare providers have an increased endemic risk for a number of infections including CMV, parvovirus B19, and Giardia and an increased epidemic risk for infections with other agents such as Shigella, hepatitis A, and Cryptosporidium. Infections caused by pathogens, such as varicella, parvovirus B19, and CMV, which are common in childcare settings, pose a significant risk of adverse consequences for pregnancy outcomes. However, few studies have focused on infections among childcare providers, and the actual risk of maternal or fetal infection or of specific adverse pregnancy outcomes as a result of these likely exposures has not been well defined.

Childcare providers experience annual rates of CMV seroconversion ranging between 8% and 20%, compared with hospital employees who experience annual rates of seroconversion of 2% (58,80,83,84,85,86). During community outbreaks of erythema infectiosum, childcare providers were found to be among the most affected occupational groups, with seroconversion rates ranging from 9% to 31% (87, 88, 89 and 90). In a prevalence study of hepatitis A antibodies among childcare providers employed in 37 randomly selected childcare centers in Israel during 1997, 90% (402 of 446) of the childcare providers had antibodies to hepatitis A. The authors concluded that childcare providers are at high risk of occupational exposure to hepatitis A, and postulated that seronegative employees may have a twofold chance of acquiring hepatitis A (91). Since the recommendation for universal immunization of children over 12 months of age in 1995, the risk for infection with hepatitis A after occupational exposure in a childcare setting may be reduced. However, the risk of exposure to unimmunized children and international adoptees may warrant hepatitis A immunization of childcare providers (92).

Childcare providers compared with nonproviders have a significantly higher risk of at least one infectious disease and lose more work days due to infectious diseases (79,93,94). Childcare providers should receive all immunizations routinely recommended for adults, as shown on the adult immunization schedule, which is updated annually (www.cdc.gov/vaccines).

During outbreaks of diarrhea in childcare centers, 40% of care providers developed diarrhea (95). During a multicommunity outbreak of shigellosis, the overall median attack rate among employed staff of childcare centers was 6%, with a range of 0% to 17% (96). In outbreaks of group A streptococcal (GAS) infection and echovirus 30 infection (97,98) in childcare centers, both microorganisms have been shown to infect and cause disease in adult providers and parents. A cross-sectional study of 477 childcare staff revealed a seroprevalence for parvovirus B19 IgG antibodies of 70%. Seropositivity was associated with age, and among staff <40 years of age, with length of group childcare contact (89). A concern is that an infected pregnant woman could transmit the virus transplacentally, leading to fetal hydrops, intrauterine growth retardation, isolated pleural and pericardial effusion, and death, but congenital malformations have not been linked to prenatal parvovirus B19 infection. Estimates of the risk of fetal loss when a pregnant woman of unknown antibody status is exposed are 2.5% for fetal death after household exposure and 1.5% after occupational exposure in a school (87).

Family Members Family members of both providers and children may be infected by pathogens transmitted in childcare settings. Parents of children who attend a childcare facility and persons who provide care to these children have increased risk of acquiring infections such as CMV (58,80,82,83,84,86,99), parvovirus B19 (87, 88, 89 and 90), hepatitis A virus (HAV) (91,93), and diarrhea (95,96,100). Mothers of children in childcare are at increased risk of acquiring childcare-associated infections (83,87,101, 102 and 103). Preschool children often introduce infections into their families (9,54,87,101,102,104). Secondary attack rates among household contacts are often high (53,74,79,103,105), especially for highly communicable diseases such as shigellosis. In the case of hepatitis A, clinical illness among older household contacts may be the first indication of transmission within a childcare facility (101). Older siblings, secondarily infected at home, may spread infections to other children through school and play contact.

The Community Childcare-associated infections generally reflect agents circulating in the community. Transmission within childcare facilities amplifies the prevalence of pathogens in the community, including Giardia, Cryptosporidium, Shigella, hepatitis A, and CMV. Interrupting disease transmission in childcare settings may lead to a reduction in the disease burden within the community and to a reduction in expenditures associated with infectious diseases outbreaks.

The economic burden of illness associated with group childcare was estimated at $1.5 billion annually adjusted to 2005 U.S. dollars (106). Precise mechanisms for estimating illness burden and for evaluating effectiveness of infection control interventions are rare due to challenges associated with performing such assessments (107). Economic evaluations of outbreaks occurring in the school setting and modeling of vaccine prevention efficacies have been described frequently in the literature, but few economic analyses of outbreaks of infections associated with group childcare have been published. In order to perform an economic analysis, information required for the analysis must often be collected concomitantly with an outbreak investigation. Due to numerous variables, computerized models must often be created to perform these evaluations. Attributing an outbreak to group childcare is challenging, because although these settings may promote transmission of infection, childcare attendees and staff interact with household contacts external to the childcare arrangement, thus facilitating secondary spread. An economic analysis of a childcare-associated outbreak of Shigella sonnei in southwestern Ohio in 2001 incurred an overall cost of $821,725 to contain the outbreak of over 1,600 infections, which was the equivalent of $514 per culture confirmed case (96). A prospective evaluation of 208 families with at least one childcare enrollee, conducted from November 2000 to May 2001 in the Boston area, documented 2,072 viral illnesses over 105,352 person days. Among the 834 subjects,
1,683 URIs and 389 gastrointestinal tract illnesses (GI) were reported during the study period with a total mean cost of $49 per URI and $56 per GI episode. Decreased parental productivity during missed days of work to care for a child who was not in childcare accounted for a significant proportion of the nonmedical costs (106).

Future investigations of outbreaks of illness associated with group childcare could utilize computerized models and paradigms to assess the economic impact of outbreaks. In an era of limited funding, an understanding of expenses and allocation of resources will be important information to justify utility of interventions.

Emergence of antimicrobial-resistant strains of bacteria resulting from inappropriate use of antimicrobial agents is a serious public health issue. While antimicrobial use among all preschool aged children is notable, children enrolled in out of home childcare generally receive more antimicrobial treatments than children in home care (21,34,41,108). During an 8-week period of observation of 270 children, antimicrobial agents were used by 36% of children in childcare centers compared to 7% and 8% of children in childcare homes or in home care, respectively (p < .001). The mean duration of antimicrobial therapy prescribed for children in childcare centers (20 days) differed significantly (p < .001) from children in childcare homes (4 days) and children in home care (5 days). The estimated annual rates of antimicrobial treatment ranged from 2.4 to 3.6 times higher for children in childcare when compared with children in home care (41).

As a result of this increase in antimicrobial use, an association of childcare center attendance with colonization or infection with resistant bacteria has been documented. Outbreaks of illness due to resistant Streptococcus pneumoniae (29,30,40,109, 110, 111, 112, 113, 114 and 115,116,117, 118, 119 and 120) and S. sonnei (96,121,122), as well as colonization due to resistant Haemophilus influenza (123), Escherichia coli (42,94,124), and methicillin-resistant Staphylococcus aureus (32,37) have been described. In a written survey of 135 licensed childcare directors in Pennsylvania in 2007 to assess opinions of antimicrobial use for childhood illnesses, approximately one-half (52%) of respondents agreed that children are prescribed antimicrobial agents unnecessarily and 89% believed that parents pressure physicians to prescribe unnecessary antimicrobial agents. However, policies requiring receipt of antibiotics prior to returning to the childcare center were notable. Most directors reported that children with conjunctivitis with white or yellow discharge, conjunctivitis with watery discharge, or diarrhea were excluded from the childcare center until antibiotics were prescribed. Although receipt of antibiotics prior to the child’s return to a childcare center was not always required in other scenarios, including clear rhinorrhea and afebrile cough, directors frequently reported that antibiotics were sometimes required. In centers with larger enrollments, directors were more likely to exclude children with ear pain until the child receives antibiotics (125). Educational campaigns including the AAP’s Healthy Childcare America (HCCA) Campaign, (http://www.healthychildcare.org/index.html) and the Centers for Disease Control and Prevention’s (CDC’s) Get Smart Campaign, (http://www.cdc.gov/getsmart/) provide targeted information to parents, childcare, and healthcare providers to assist with choices for judicious use of antimicrobial agents. Efforts should disseminate information that most illnesses acquired in the childcare setting are attributable to viruses, for which supportive care is optimal and for which antimicrobial therapy is economically and scientifically disadvantageous. Additionally, immunization against common viral and bacterial pathogens is an effective means of reducing the prevalence and severity of infections with these microorganisms (126). The current recommended immunization schedule for children can be found at www.cdc.gov/vaccines. This schedule is updated annually in January.

Upper and Lower Respiratory Tract Infections Infections of the upper respiratory tract are the most common illnesses involving children in both home and childcare settings (127). Studies have documented the association between childcare attendance and increased risk of URIs especially in children <3 years of age (127). Using different methods, the risk of contracting a respiratory tract infection was found to be 2 to 3 times higher among children cared for at home (8,127,128, 129 and 130).

Respiratory tract symptoms were involved in 45% to 85% of illness episodes reported among children attending childcare facilities in various geographic locations (19,22,23).

Respiratory tract infections that have been studied in the childcare setting include pharyngitis, sinusitis, otitis media, the common cold, bronchiolitis, and pneumonia (20,131, 132 and 133). Microorganisms responsible for illness in the childcare settings are similar to microorganisms that circulate in the community. Depending on the season, these microorganisms include parainfluenza, influenza, respiratory syncytial virus, adenovirus, rhinovirus, coronavirus, metapneumovirus, parvovirus B19, and S. pneumoniae. Infections due to Haemophilus influenzae b and pertussis have experienced dramatic declines in the United States although cases and outbreaks continue to occur (134). In a group childcare setting, adolescents or adults may serve as the index case for pertussis outbreaks or tuberculosis infections (135, 136, 137, 138, 139 and 140), particularly when children or adults are not appropriately immunized against pertussis (134,135).

Person-to-person transmission of Chlamydophila pneumoniae among children in the childcare setting has been reported without occurrence of disease (141). Kingella kingae colonizes the oropharynx and respiratory tracts of young children and has been associated with invasive disease (142, 143, 144, 145 and 146). Invasive K. kingae osteomyelitis/septic arthritis has been reported in two children in a childcare center with nine other children in the same class found to be colonized. Matching pulse-field gel electrophoresis (PFGE) patterns supported child-to-child transmission (142). GAS infection among children and adult staff in the childcare setting has been reported (68,147) but is not common (68,147). Following a fatal case of invasive disease, 25% of 258 children and 8% of 25 providers had GAS isolated from throat cultures (147). In Israel, a study
conducted in childcare centers showed the prevalence of GAS to be 3% in infants and 8% in toddlers. Carriage was not associated with respiratory tract symptoms (148).

Respiratory tract infections contribute to the burden of otitis media, antibiotic use, and absenteeism experienced by children in out-of-home childcare. Approximately 29% of respiratory tract infections among young children are complicated by otitis media (20). Children with respiratory tract infections in Seattle childcare facilities were absent for an average of 0.9 days per illness episode; these infections accounted for 3,558 days of absence, representing almost half of the total 7,635 days of illness-related absences among these children (22). Among children in San Diego childcare facilities, illness episodes involving rhinitis accounted for 2,335 days of absence (1.6 days per child year), an average of 0.3 days absent per illness episode (23).

Children who have been enrolled in group childcare for some time may have no greater risk of respiratory tract infections than their same-aged peers who stay at home (9,12,44,149). Results from the National Institute of Child Health and Human Development Study of Early Childcare support this finding and suggest that, although childcare was associated with increased illness in children younger than 2 years of age, the difference was negligible by 3 years of age (12). Children who first entered out-of-home childcare after 3 years of age experience more illness than their classmates who were in childcare before 3 years of age (150). However, the excess respiratory tract illness among children in childcare centers may protect those children against respiratory infections during the early school years (72).

Although results of the few studies assessing the impact of childcare attendance on lower respiratory tract infections are not definitive, they suggest an increased risk among children in childcare (151, 152, 153, 154 and 155). After other risk factors were controlled, children hospitalized with lower respiratory tract infections at one of four Atlanta area hospitals were more likely than control patients to have been in out-of-home childcare (152). Center care posed a greater risk for hospitalization than care in a childcare home. However, other studies have found no association between lower respiratory tract illnesses and childcare (108,155).

Most authorities agree that children with mild to moderate symptoms of viral upper respiratory infection, such as rhinitis, cough, pharyngitis, or otitis media, may continue in their usual childcare arrangement unless they meet other criteria for exclusion (3,43,156). Care should be taken to clean objects, including toys, and surfaces contaminated with oral or nasal secretions. Tissues, towels, or other material used to wipe children’s noses and mouths should be handled as contaminated items (3,43,48,158). Hand hygiene protocols must be followed carefully (3,43,48,156,159).

Immunization of healthy people 6 months of age and older, including adults, with influenza vaccine is encouraged to reduce the impact of influenza on the health of both the children and their contacts (156,160). Influenza and other respiratory tract infections predispose children to otitis media. Immunization against influenza may provide some protection against otitis among vaccines and may even reduce respiratory illness among household contacts (161, 162, 163 and 164).

Invasive Bacterial Infections The risk of developing invasive bacterial infections, especially meningitis and bacteremia caused by H. influenzae type b (Hib) before routine use of Hib vaccine in the United States, was higher among children attending childcare centers than in children cared for at home (109,165). The incorporation of conjugated Hib vaccine into the routine immunization schedule to prevent invasive Hib disease has dramatically decreased the frequency of invasive Hib infections. Since use of conjugated Hib vaccine in infants beginning at 2 months of age in October 1990 (166,167), the average annual rate of invasive Hib infections has declined from over 20,000 cases per year to <100 cases of known serotype b H. influenzae per year from 2003 through 2008 (168). The prevention of invasive Hib infections in childcare settings today requires ensuring appropriate immunization of all enrolled children, complete reporting to allow the characterization of suspect vaccine failures, standardized serotyping procedures, and serotype tracking for all invasive H. influenzae infections (169).

Household contacts of people with Neisseria meningitidis infections are at increased risk of disease, but the magnitude of risk for childcare contacts is uncertain. Reports from outbreaks suggest that childcare contacts of cases are at increased risk (170, 171 and 172). However, from 1998 to 2008, the incidence of invasive meningococcal disease has reached a historic low in the United States (173). From 1993 to 2001 in the Netherlands, clustering of N. meningitidis cases beyond chance occurred at a rate of 3% (CI: 2-4%) and concluded that this rate was likely the result of direct transmission (174). Childcare center attendance was reported as the likely exposure for 8/40 (20%) of clusters, accounting for 13/82 (16%) cases of invasive disease with multiple serotypes. Childcare attendees who develop clinical disease while enrolled in group care often result in the need for administration of chemoprophylaxis to family and childcare centers.

In the event of a case of invasive N. meningitidis disease in a facility, rifampin prophylaxis generally should be given to childcare contacts (both children and adults) (3,43,156,165). It is often not necessary to administer rifampin to all center attendees as they may not have had at-risk contact with the case. Public health authorities and healthcare providers should be involved in evaluating the significance of exposure on an individual basis. Routine immunization of healthy preschool aged children with a meningitis vaccine is not recommended unless the child is 2 years of age or older and has an underlying, predisposing condition, anatomical or functional asplenia, persistent complement deficiencies or human immunodeficiency virus (HIV), or plans to travel to a country with highly endemic or epidemic disease (156,175). Immunization may be useful in controlling outbreaks caused by serogroups to which the vaccine confers immunity.

Childcare attendance was shown to be a risk factor for primary invasive pneumococcal disease (111,112,120), for nasopharyngeal carriage of S. pneumoniae, and for carriage of antibiotic-resistant strains for children in childcare centers (29,30,110,112,114,115,120,176, 177 and 178). Secondary spread of S. pneumoniae in the childcare setting has been reported, but the exact risks are not known (40,111,112).
Incorporation of a conjugated pneumococcal vaccine into the routine childhood immunization schedule in the United States in 2000 has resulted in a dramatic reduction in the frequency of invasive pneumococcal disease (179). With expansion of coverage of pneumococcal serotypes by six with the recommendation for routine use of PCV13, further disease reduction may occur (177,178).

The emergence of antibiotic-resistant strains of pneumococci is a matter of both clinical and public health concern. Israeli investigators reported that the risk of resistant pneumococcal infections in children who attended childcare centers and who had received at least one course of antimicrobial treatment in the previous 3 months was 12.9 times that of children who had neither of these risk factors (180). In studies among children attending four Houston childcare centers, S. pneumoniae was recovered from 40% of 140 children younger than 3 years (181). Intermediate penicillin resistance was found in 11% of isolates; none was highly resistant. During a 7-year prospective study, upper respiratory tract cultures were collected monthly from 72 children (39). Each child had an average of 2.1 episodes of S. pneumoniae colonization; 68% had resistant pneumococci isolated at least once. In another study, multiply resistant strains were isolated from nasopharyngeal cultures from 9 of 47 children in a center attended by two toddlers hospitalized with invasive pneumococcal infections (40). After isolation of resistant S. pneumoniae from the middle ear fluid of a child with otitis media, researchers found that 52 of 250 exposed children were carriers of a resistant pneumococcus (118). Carriage was associated with receipt of antimicrobial agents, especially at prophylactic doses. This association has been demonstrated previously (110,182). Studies in an Omaha childcare center suggest that decreasing antibiotic use may control the spread of resistant pneumococci (110). Resistant pneumococci may persist among children in centers. Although treatment with rifampin or rifampin and clindamycin can reduce the prevalence of carriage temporarily (112), it may not eliminate carriage or reduce spread (40,181) and is not recommended.