A Review of Enteric Outbreaks in Child Care Centers: Effective Infection Control Recommendations

Article excerpt


Mothers working outside of the home and subsidies for child care have resulted in an increasing demand for child care services. Approximately 25% of children are in daycare situations in North America and other developed regions (Bushnik, 2006; Japan External Trade Organization, 2005; Year Book Australia, 2002). Enteric (gastrointestinal) illness in daycare centers (DCCs) is not an uncommon event and is facilitated by placing numerous children from diverse backgrounds together in a confined space. The unhygienic nature of children's habits, such as mouthing equipment and toys, touching each other during play, and failing to wash hands after toileting, also aids the transmission of infectious disease agents between children. Diapered children increase the risk of infectious agents spreading to others via caregivers' hands, clothing, change tables, and leakage. Declining immunity from maternal antibodies (i.e., from breastfeeding) after six to 12 months of age also increases the risk of illness, especially for those one to two years of age (Guerrant, Huges, Lima, & Crane, 1990). Whether a child is a symptomatic or asymptomatic carrier of an infectious agent, they pose a risk to other family members through transmission in the home.


The purpose of our study was to review documented outbreaks of enteric illness in DCCs published in the last 10 years to identify the most common types of infectious agents reported, mode of transmission, morbidity and mortality, age of cases, the number of staff and contacts affected, and the practices found effective by investigators.

Knowing which practices are effective and understanding the epidemiology of enteric diseases in DCCs may lead to a reduction in occurrence, resulting in decreased economic and social burden for families, decreased medical costs, and a healthier environment for both children and staff.


Study Criteria

Inclusion Criteria

We performed a systematic review of the literature to identify outbreak reports of gastrointestinal illness in daycare settings published or occurring between January 1996 and November 2006. The review was not limited to any geographical area. The reports fell into one of three categories: published in peer-reviewed scientific journals, published on the Internet by government organizations, or internal reports from public health agencies.

Exclusion Criteria

The types of studies we excluded were the following:

* outbreaks of respiratory and childhood communicable diseases;

* outbreak information concerning children older than six years of age;

* community-acquired illness or outbreaks associated with hospital and outpatient settings;

* reports not written in English;

* outbreaks reported by the press but not confirmed by a public health agency; and

* long-term retrospective studies, burden of disease studies, and reviews.

Search Strategy

Computer-aided searches of MEDLINE, Agricola, and Scopus from the earliest entry to November 2006, as well as all databases within Current Contents [R], The Institute for Scientific Information, from 1999 to 2006 were completed to identify outbreak reports. The following journals were hand searched for relevant papers because abstracts are not submitted to the above databases:

* Canada Communicable Disease Report, 1996-2006;

* Public Health Epidemiology Report Ontario, 1996-2004;

* Canadian Journal of Infectious Diseases, 1996-2006;

* Minnesota State Foodborne Outbreak Summaries, 1999-2004;

* New South Wales Public Health Bulletin, 1996-2005;

* Public Health Reports, 2001-2006;

* Environmental Health Reviews, 1996-2006;

* Ontario Branch, Canadian Institute of Public Health Inspectors News, 1996-2006; and

* Communicable Disease Corner (Capital Health Region, Edmonton, Alberta), 2001-2006. …