Child care center directors' opinions, overuse of antibiotics, and social policy.

From the Department of Maternal and Child Health, Gillings School of Global Public Health (J.B.K.), and the Department of Medicine (D.J.W.), University of North Carolina at Chapel Hill Received January 11, 2010; accepted January 13, 2010; electronically published February 22, 2010. Infect Control Hosp Epidemiol 2010; 31:412-413 2010 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2010/3104-0015$15.00. DOI: 10.1086/651306 The Concise Communication by M’ikanatha et al in this issue of Infection Control and Hospital Epidemiology, “Child Care Center Exclusion Policies and Directors’ Opinions on the Use of Antibiotics,” is a useful window into child care policies and child care directors’ opinions about the use of antibiotics in child care. Given our knowledge that infectious disease is more common among children in child care than among children reared at home, it not surprising that directors, not to mention parents, are concerned. For parents, a child’s illness often means medical expenses, a day (or more) of lost wages, or the extra expense of hiring an in-home caregiver or placing their child in a facility specializing in the care of children with acute, self-limited illness or injury. For directors, although they generally do not refund tuition for a child’s sick days, a reputation for unusually high illness rates or even strict infection control policies could mean the loss of potential customers. These are powerful incentives for both directors and parents to try to reduce the impact of infectious disease on the individual child and on the child care center. Americans are hooked on medication, and antibiotics are a case in point. There are communicable diseases that occur among children in child care for which requiring antibiotic treatment is appropriate. For example, children with impetigo or streptococcal pharyngitis should be excluded until 24 hours after initiation of antibiotic treatment. It is understandable that parents and providers would extrapolate from this example to other infectious diseases. Yet most infections acquired in child care are due to viruses, making antibiotic treatment worse than futile, adding both to medical care costs and the real risk of selection of antibiotic-resistant organisms. The American Academy of Pediatrics (AAP) explicitly states that the following conditions do not necessitate exclusion: nonpustular rash without fever and behavioral change, conjunctivitis without fever and behavioral change, and carriage of methicillin-resistant Staphylococcus aureus. Furthermore, they do not include viral upper respiratory infections in their list of exclusions. The best way to deal with infectious disease in child care is to prevent it with immunization. A good example of a recently introduced vaccine that has resulted in measurable reduction in illness rates among children in out-of-home child care is varicella, for which exposure to child care had been a risk. There is hope that immunization against rotavirus will reduce the risk of child care–acquired diarrhea due to rotavirus, the leading cause of infectious diarrhea in child care. In addition, general practices that have been validated to reduce infection transmission should be used, such as appropriate hand hygiene, proper environmental cleaning/disinfection of diaper-changing surfaces and toys, and safe food preparation. Nevertheless, increased risk of infectious disease among children in out-of-home child care will continue to be a problem for the foreseeable future. The recommendation made by M’ikanatha et al for more education of parents, child care providers, and healthcare providers is very reasonable, and mechanisms exist for offering such education. For example, the joint publication of the AAP, the American Public Health Association, and the National Resource Center for Health and Safety in Child Care (2002) includes recommendations for exclusion from and readmission to child care for children with infectious disease. The National Training Institute for Child Care Health Consultants (CCHCs) at the University of North Carolina at Chapel Hill (http://nti.unc.edu) has trained more than 400 child health professionals, predominantly nurses, who in turn have trained more than 4,000 CCHCs in 50 states to provide health and safety training, continuing education, consultation, and technical assistance to both centerbased and home-based group child care providers. Similarly, the AAP’s Healthy Child Care America Campaign (http:// www.healthychildcare.org/index.html) provides education and support to pediatricians and other healthcare providers