Section 1 - Guidelines: Staff and Children

Prevention and Control of Communicable Diseases

Section 1 - Guidelines: Staff and Children

General Exclusion Guidelines for Ill Children/Staff

Certain symptoms in children may suggest the presence of a communicable disease. Excluding an ill child may decrease the spread of the disease to others in the child care and school settings.

Recommended exclusion varies by the disease or infectious agent. Children with the symptoms listed below should be excluded from the child care or school setting until symptoms improve, or a healthcare provider has determined that the child can return, or children can participate in routine activities without more staff supervision than can be provided.

NOTE: It is recommended that child care/preschool providers and schools have policies that are clearly written for excluding sick children and staff. These policies should be placed in the student handbook or on the child care or school website. Parents/guardians and staff should be given or directed to these resources at the beginning of each school year or when the child is enrolled or the staff member is hired. This will help prevent problems later when the child or staff member is ill.

Exclude Children with Any of the Following:

Illness

Unable to participate in routine activities or needs more care than can be provided by the child care/school staff.

Fever

A child's normal body temperature varies with age, general health, activity level, the time of day and how much clothing the child is wearing. Everyone's temperature tends to be lower early in the morning and higher between late afternoon and early evening. Body temperature will also be slightly higher with strenuous exercise. Most medical professionals define fever as a body core temperature elevation above 100.4°F (38°C), and a fever that remains below 102°F (39°C) is considered a low-grade fever. If a child is younger than three months of age and has a fever, it’s important to always inform the caregiver immediately so they can call their healthcare provider right away.

When determining whether the exclusion of a child with fever is needed, a number of issues should be evaluated: recorded temperature; whether the fever is accompanied by behavior changes, headache, stiff neck, difficulty breathing, rash, sore throat, and/or other signs or symptoms of illness; or if the child is unable to participate in routine activities. Any child who has an elevated body temperature that is not excluded should be closely monitored for possible change(s) in their condition. The temperature should be measured before giving medications to reduce the fever.

Measurement method	Normal temperature range for Children
Rectal	36.6°C to 38°C (97.9°F to 100.4°F)
Ear	35.8°C to 38°C (96.4°F to 100.4°F)
Oral	35.5°C to 37.5°C (95.9°F to 99.5°F)
Axillary (armpit)	34.7°C to 37.3°C (94.5°F to 99.1°F)

“Pediatric fever as defined by different measurement methods”, source: Pediatric Society of Canada, 2009 update*. When measuring ear temperatures, follow the manufacturer’s instructions to ensure accurate results.

Signs/Symptoms of Possible Severe Illness

Until a healthcare provider has done an evaluation to rule out severe illness, when the child is unusually tired, has uncontrolled coughing, unexplained irritability, persistent crying, difficulty breathing, wheezing, or other unusual signs.

Diarrhea

Until the child has been free of diarrhea for at least 24 hours or until a medical exam indicates that it is not due to a communicable disease. Diarrhea is defined as an increased number of stools compared with a child's normal pattern, along with decreased stool form and/or stools that are watery, bloody, or contain mucus.

Vomiting

Vomiting two or more times in the previous 24 hours, unless determined to be caused by a non-communicable condition, and the child is not in danger of dehydration.

Mouth Sores with Drooling

Until a medical exam indicates the child may return or until sores have healed.

Rash with Fever or Behavior Change

Until a medical exam indicates these symptoms are not those of a communicable disease that requires exclusion.

Eye Drainage

When purulent (pus) drainage and/or fever or eye pain is present, or a medical exam indicates that a child may return.

Unusual Color of Skin, Eyes, Stool, or Urine

Until a medical exam indicates the child does not have hepatitis A. Symptoms of hepatitis A include yellow eyes or skin (jaundice), gray or white stools, or dark (tea or cola-colored) urine.

For specific guidelines for child care settings, see Specific Disease Exclusion for Child Care.
For specific guidelines for school settings, see Specific Disease Exclusion for Schools.

Specific guidelines can be found at: http://child caredese.mo.gov/childhood/child-care

For more information, call the Missouri Department of Health and Senior Services (MDHSS) Bureau of Communicable Disease Control and Prevention at 573-751- 6113 or 800-392-0272 (24/7), or call your local health department.

Specific Disease Exclusion for Child Care

See individual fact sheets for exclusion and other information on the diseases listed below.

Specific Diseases

Acute Bronchitis (Chest Cold)/Bronchiolitis

Until fever is gone and the child is well enough to participate in routine activities.

Campylobacteriosis

Until the child has been free of diarrhea for at least 24 hours. Children who have Campylobacter in their stools but who do not have symptoms do not need to be excluded.

No one with Campylobacter should use swimming beaches, pools, spas, water parks, or hot tubs until 2 weeks after diarrhea has stopped.

Exclude symptomatic staff with Campylobacter from working in food service or providing child care. Other restrictions may apply; call your local health department for guidance.

Chickenpox

Until all the blisters have dried into scabs, usually by day 6 after the rash began.

Chickenpox can occur even if someone has had the varicella vaccine. These are referred to as “breakthrough infections” and are usually less severe and have an atypical presentation. The rash may be atypical in appearance with fewer vesicles and predominance of maculopapular lesions. Persons with breakthrough varicella should be isolated until no new lesions have appeared for at least 24 hours.

Although extremely rare, the vaccine virus has been transmitted to susceptible contacts by vaccine recipients who develop a rash following vaccination. Therefore, exclude vaccine recipients who develop a rash after receiving varicella vaccine.

Conjunctivitis (Pinkeye)

Children in daycare with oozing eyes should not attend because close contact is unavoidable. Also, if the child has a fever or behavior changes, the child is unable to participate, or if staff members determine they cannot care for the child without compromising their ability to care for other children in the group. Allergic and chemical conjunctivitis are not contagious.

COVID-19

Until symptoms improve and the child has been fever-free for 24 hours without the use of a fever-reducing medicine.

After this time, the child may return, but it is encouraged to consider additional steps to prevent the spread of respiratory viruses for the next 5 days.

Children who never have symptoms but test positive for COVID-19 may be contagious. Additional precautions are encouraged for 5 days after the positive test.

Croup

Until fever is gone and the child is well enough to participate in routine activities.

Cryptosporidiosis

Until the child has been free of diarrhea for at least 24 hours.

No one with Cryptosporidium should use swimming beaches, pools, water parks, spas, or hot tubs for 2 weeks after diarrhea has stopped for 24 hours.

Exclude symptomatic staff with Cryptosporidium from working in food service or providing child care until 24 hours after diarrhea has stopped. Other restrictions may apply; call your local health department for guidance.

Cytomegalovirus (CMV) Infection

None. Educational programs on CMV, its potential risks, and appropriate hygienic measures to minimize occupationally acquired infection should be provided for female workers in child care centers.

Diarrhea (Infectious)

Until the child has been free of diarrhea for at least 24 hours. The length of time may vary depending on the organism. For some infections, the person must also be treated with antibiotics or have negative stool tests before returning to child care. (See fact sheet for specific organism when known.)

No one with diarrhea should use swimming beaches, pools, water parks, spas, or hot tubs for at least 2 weeks after diarrhea has stopped. (See specific disease information for additional times.)

Staff with diarrhea may be restricted from working in food service or providing child care. Other restrictions may apply; call your local health department for guidance.

Enteroviral Infection

Until the child has been free of diarrhea and/or vomiting for at least 24 hours.

None, for mild, cold-like symptoms, as long as the child is well enough to participate in routine activities.

Fifth Disease (Parvovirus)

None, if other rash-causing illnesses are ruled out by a healthcare provider. Persons with fifth disease are no longer infectious once the rash begins.

Giardiasis

When a child is infected with Giardia and has symptoms, the child should be excluded until free of diarrhea for at least 24 hours. Treatment of asymptomatic carriers is not effective for outbreak control, and it is not recommended that carriers be excluded from child care.

No one with Giardia should use swimming beaches, pools, spas, water parks, or hot tubs for 2 weeks after diarrhea has stopped.

Exclude symptomatic staff with Giardia from working in food service. Other restrictions may apply; call your local health department for guidance.

Haemophilus influenzae type B (Hib) Disease

Until the child has been treated and is well enough to participate in routine activities.

Hand, Foot, and Mouth Disease

Until fever is gone and the child is well enough to participate in routine activities (sores or rash may still be present). Children with uncontrollable drooling may need exclusion.

Head Lice

Until treatment has started and no live lice are seen. Nits are NOT considered live lice. Children do not need to be sent home immediately if lice are detected; however, they should not return until effective treatment is given.

Hepatitis A

Consult with your local or state health department. Each situation must be looked at individually to decide if the person with hepatitis A can spread the virus to others.

Hepatitis B

None, unless the child has unusually aggressive behavior (e.g., biting) that cannot be controlled, oozing sores that cannot be covered, or bleeding problems. The child’s health professional and the child care program director or school principal should assess on a case-by-case basis to determine whether exclusion from some activities is necessary. Children with hepatitis B infection should not be excluded from school, child care, or other group care settings solely based on their hepatitis B infection.

Hepatitis C

None, unless the child has unusually aggressive behavior (e.g., biting) that cannot be controlled, oozing sores that cannot be covered, or bleeding problems. The child’s health professional and the child care program director or school principal should assess on a case-by-case basis to determine whether exclusion from some activities is necessary. Children with hepatitis C infection should not be excluded from school, child care, or other group care settings solely based on their hepatitis C infection.

Herpes, Oral

Primary infection: Until those children who do not have control of their oral secretions no longer have active sores inside the mouth.
Recurrent infections (fever blisters and cold sores): None.

HIV/AIDS

None, unless the child has unusually aggressive behavior (e.g., biting) that cannot be controlled, oozing sores that cannot be covered, or bleeding problems. The child’s health professional and the child care program director or school principal should assess on a case-by-case basis to determine whether exclusion from some activities is necessary. Children with HIV infection should not be excluded from school, child care or other group care settings solely based on their HIV infection.

Impetigo

If impetigo is confirmed by a healthcare provider, until 24 hours after treatment and sores are dry or improving. Oozing or crusted lesions on exposed skin should be covered with a watertight dressing.

Influenza

Until fever is gone without the aid of fever-reducing medication and the child is well enough to participate in routine activities.

Decisions about extending the exclusion period could be made at the community level, in conjunction with local and state health officials. More stringent guidelines and longer periods of exclusion – for example, until complete resolution of all symptoms – may be considered for people returning to a setting where high numbers of high-risk people may be exposed, such as a camp for children with asthma or a child care facility for children younger than 5 years old.

Measles

Until 4 days after the rash appears. A child with measles should not attend any activities during this time period.

Consult with your local or state health department regarding the exclusion of exposed unvaccinated children and staff.

Meningococcal Disease

Consult with your local or state health department. Each situation must be looked at individually to determine appropriate control measures to implement. Most children may return after the child has been on appropriate antibiotics for at least 24 hours and is well enough to participate in routine activities.

Methicillin-Resistant Staphylococcus aureus (MRSA)

If draining sores are present and cannot be completely covered and contained with a clean, dry bandage or if a person cannot maintain good personal hygiene.

Children who are only colonized do not need to be excluded.

Activities: Children with draining sores should not participate in any activities where skin-to-skin contact is likely to occur until their sores are healed. This means no contact sports.

Molluscum Contagiosum

None. Encourage parents/guardians to cover bumps with clothing when there is a possibility that others will come in contact with the skin. If not covered by clothing, cover with a bandage.

Activities: Exclude any child with bumps that cannot be covered with a water-tight bandage from participating in swimming or other contact sports.

Mononucleosis

None. As long as the child is well enough to participate in routine activities.

Mosquito-Borne

None.

Mumps

Until 5 days after swelling begins.

Consult with your local or state health department regarding the exclusion of exposed unvaccinated children and staff.

Norovirus

Children and staff who are experiencing vomiting and/or diarrhea should stay home from child care until they have been free of diarrhea and vomiting for at least 48 hours.

No one with vomiting and/or diarrhea consistent with norovirus should use pools, swimming beaches, water parks, spas, or hot tubs for at least 2 weeks after diarrhea and/or vomiting symptoms have stopped.

Staff involved in food preparation should be restricted from preparing food for 72 hours after symptoms stop.

Parapertussis

None, if the child is well enough to participate in routine activities. Cases should avoid contact with infants aged <6 months until they have completed 5 days of appropriate antibiotic treatment or 21 days have passed since cough onset.

Pertussis (Whooping Cough)

Children and symptomatic staff with pertussis should be excluded until 5 days after appropriate antibiotic treatment begins. During this time, the person with pertussis should NOT participate in any child care or community activities. If not treated with 5 days of antibiotics, exclusion should be for 21 days after cough onset.

If there is a high index of suspicion that the person has pertussis (regardless of whether the individual received prophylaxis), exclude until the individual has been evaluated by a medical provider and deemed no longer infectious by the local health department, 5 days of antibiotics are completed or until the laboratory test comes back negative.

Pinworms

None.

Pneumococcal Infection

None, if the child is well enough to participate in routine activities.

Pneumonia

Until fever is gone and the child is well enough to participate in routine activities.

Respiratory Infection (Viral)

Until fever is gone and the child is well enough to participate in routine activities.

Respiratory Syncytial Virus (RSV) Infection

Until fever is gone and the child is well enough to participate in routine activities.

Ringworm

Children should be excluded until treatment has been started, or if on the scalp, until 24 hours after treatment has been started.

Any child with ringworm should not participate in gym, swimming, and other close contact activities that are likely to expose others until 72 hours after treatment has begun or the lesions can be completely covered.

Roseola

Until fever is gone and other rash illnesses, especially measles, have been ruled out.

Rotaviral Infection

Until 7 days after the rash appears.

Exclude unvaccinated children and staff in which a case of rubella occurs for at least 3 weeks after the onset of rash in the last reported person who developed rubella.

Salmonellosis

Until the child has been free of diarrhea for at least 24 hours. Children who have Salmonella in their stools but who do not have symptoms do not need to be excluded.

Exclude symptomatic staff with Salmonella from working in food service or providing child care. Other restrictions may apply; call your local health department for guidance.

*If a case of Salmonella typhi is identified in a child care center or school, please consult with your local or state health department. Each situation must be looked at individually to determine appropriate control measures to implement.

Scabies

Until 24 hours after treatment begins.

Shigellosis

Children and child care staff with diarrhea should be excluded from child care until 48 hours after diarrhea has stopped, or until 24 hours after diarrhea has stopped and the child has been on at least 24 hours of appropriate antibiotics, or after one negative stool culture for Shigella. The child care should be closed to new admissions during outbreaks, and no transfer of exposed children to other centers should be allowed. Stool specimens should not be obtained earlier than 48 hours after discontinuation of antibiotics. Antimicrobial therapy is effective in shortening the duration of diarrhea and eradicating organisms from feces.

No one with Shigella should use swimming beaches, pools, water parks, spas, or hot tubs until 1 week after diarrhea has stopped.

Food service employees infected with Shigella bacteria should be excluded from working in food service. An employee may return to work once they are free of the Shigella infection based on test results showing 2 consecutive negative stool cultures that are taken at least 24 hours after diarrhea ceases, not earlier than 48 hours after discontinuation of antibiotics, and at least 24 hours apart; or the food employee may be reinstated once they have been asymptomatic for more than 7 calendar days.

In the absence of laboratory verification, the excluded food handler may return to work after symptoms of vomiting and/or diarrhea have resolved, and more than 7 calendar days have passed since the food handler became asymptomatic.

Shingles (Zoster)

None, if blisters can be completely covered by clothing or a bandage. If blisters cannot be covered, exclude until the blisters have crusted. Persons with severe, disseminated shingles should be excluded regardless of whether the sores can be covered.

Staph Skin Infection

If draining sores are present and cannot be completely covered and contained with a clean, dry bandage or if the person cannot maintain good personal hygiene.

Children who are only colonized do not need to be excluded.

Activities: Children with draining sores should not participate in activities where skin-to-skin contact is likely to occur until their sores are healed. This means no contact sports.

STEC (Shiga toxin- producing Escherichia coli) Infection

Until diarrhea has ceased for 48 hours, and two follow-up tests at the state public health laboratory obtained at least 24 hours apart have tested negative. Specimens should not be obtained earlier than 48 hours after discontinuation of antibiotics. Further requirements may be necessary during outbreaks.

The child care location should be closed to new admissions during the outbreak, and no transfer of exposed children to other centers should be allowed.

No one with STEC should use swimming beaches, pools, water parks, spas, or hot tubs until 2 weeks after diarrhea has stopped.

Food service employees with STEC infection should be excluded from working in food service. An employee may return to work once they are free of the STEC infection based on test results showing 2 consecutive negative stool specimens that are taken at least 24 hours after diarrhea ceases, not earlier than 48 hours after discontinuation of antibiotics, and at least 24 hours apart; or the food employee may be reinstated once they have been asymptomatic for more than 7 calendar days.

Streptococcal Infection (Strep Throat/Scarlet Fever)

Until 24 hours after antibiotic treatment begins and until the child is without fever.

Children without symptoms, regardless of a positive throat culture, do not need to be excluded from child care. Persons who have strep bacteria in their throats and do not have any symptoms (carriers) appear to be at little risk of spreading infection to those who live, attend child care, or work around them.

Tick-Borne

None.

Tuberculosis (TB)

A person with a newly positive tuberculin skin test (TST) or interferon gamma release assay (IGRA) should see a healthcare provider as soon as possible after the positive test is detected for further evaluation and possible treatment. Consult with your local or state health department immediately. Each situation must be evaluated individually to determine whether the person is contagious and poses a risk to others. Latent tuberculosis infection and tuberculosis disease are reportable conditions in Missouri.

Viral Meningitis

Until fever is gone or diarrhea has stopped and the child is well enough to participate in routine activities.

Warts

None.

Yeast Infection (Candidiasis)

None.

Other Communicable Diseases

Consult your local or state health department or the child's healthcare provider regarding exclusion guidelines for other infections not described in this manual. Special exclusion guidelines may be recommended in the event of an outbreak of an infectious disease in a child care setting. Consult your local or state health department when there is more than one case of a communicable disease.

For more information, call Missouri Department of Health and Senior Services (MDHSS) Bureau of Communicable Disease Control and Prevention at 573-751- 6113 or 800-392-0272 (24/7), or call your local health department.

Specific Disease Exclusion for Schools

Specific Diseases

See individual fact sheets for more information on the diseases listed below.

Acute Bronchitis (Chest Cold)/Bronchiolitis

Until fever is gone and the child is well enough to participate in routine activities.

Campylobacteriosis

Until the child has been free of diarrhea for at least 24 hours. Further exclusion may be necessary during outbreaks.

No one with Campylobacter should use swimming beaches, pools, water parks, spas, or hot tubs until 2 weeks after diarrhea has stopped.

Exclude symptomatic staff with Campylobacter from working in food service. Other restrictions may apply; call your local health department for guidance.

Chickenpox

Until all the blisters have dried into scabs; usually by day 6 after the rash began.

It takes 10 to 14 days after receiving vaccine to develop immunity. Vaccine failures occasionally occur. The incubation period is 10 to 21 days. Therefore, exclude children who:

appear to have chickenpox regardless of whether or not they have received varicella vaccine, or
develop blisters within 10 to 21 days after vaccination.

Chickenpox can occur even if someone has had the varicella vaccine. These are referred to as “breakthrough infections” and are usually less severe and have an atypical presentation. The bumps rather than blisters may be present; therefore, scabs may not present. These cases should be excluded until all bumps/blisters/scabs (sores) have faded and no new sores have occurred within a 24-hour period, whichever is later. Sores do not need to be completely resolved.

Conjunctivitis (Pinkeye)

None, unless the child has fever or behavior changes, or the child is unable to participate, and staff members determine they cannot care for the child without compromising their ability to care for other children in the group.

COVID-19

Until symptoms improve and the child has been fever-free for 24 hours without the use of a fever-reducing medicine. After this time, the child may return, but it is encouraged to consider additional steps to prevent the spread of respiratory viruses for the next 5 days.

If a child has never had symptoms but tested positive for COVID-19, they may be contagious. It is encouraged to take added precautions for the 5 days after the positive test.

Cryptosporidiosis

Until the child has been free of diarrhea for at least 24 hours. Further exclusion may be necessary during outbreaks.

No one with Cryptosporidium should use swimming beaches, pools, water parks, spas, or hot tubs for 2 weeks after diarrhea has stopped.

Exclude symptomatic staff with Cryptosporidium from working in food service or providing child care until they have been free of diarrhea for at least 24 hours. Other restrictions may apply; call your local health department for guidance.

Cytomegalovirus (CMV) Infection

None.

Diarrhea (Infectious)

Children with diarrhea that could be infectious should be excluded until the child has been free of diarrhea for at least 24 hours. Other exclusions or preventive measures may be necessary, depending on the organism.

Restrict students from sharing communal food items in the classroom. In the classroom, children should not serve themselves food items that are not individually wrapped. The teacher should hand out these items after washing his/her hands.

No one with infectious diarrhea (of unknown cause) should use swimming beaches, pools, water parks, spas, or hot tubs for at least 2 weeks after diarrhea has stopped.

Exclude symptomatic staff with diarrhea from working in food service. Dependent on the organism, other restrictions may apply; call your local health department for guidance.

Enteroviral Infection

Until the child has been free of diarrhea for at least 24 hours.

Fifth Disease (Parvovirus)

None, if other rash-causing illnesses are ruled out by a healthcare provider. Persons with fifth disease are no longer infectious once the rash begins.

Giardiasis

Until the child has been free of diarrhea for at least 24 hours. Further exclusion may be necessary during outbreaks.

No one with Giardia should use swimming beaches, pools, spas, water parks, or hot tubs for 2 weeks after diarrhea has stopped.

Exclude symptomatic staff with Giardia from working in food service. Other restrictions may apply; call your local health department for guidance.

Hand, Foot, and Mouth Disease

Until fever is gone and the child is well enough to participate in routine activities (sores or rash may still be present).

Head Lice

Until treatment has started and no live lice are seen. Nits are NOT considered live lice. Children do not need to be sent home immediately if lice are detected; however they should not return until effective treatment is given.

Hepatitis A

Consult with your local or state health department. Each situation must be looked at individually to decide if the person with hepatitis A can spread the virus to others.

Hepatitis B

Hepatitis C

None, unless the child has unusually aggressive behavior (e.g., biting) that cannot be controlled, oozing sores that cannot be covered, or bleeding problems. The child’s health professional and the child care program director or school principal should assess on a case-by-case basis to determine whether exclusion from some activities is necessary. Children with hepatitis C infection should not be excluded from school, child care, or other group care settings solely based on their hepatitis C infection.

Herpes Gladiatorum

Contact Sports: Exclude from practice and competition until all sores are dry and scabbed. Treatment with oral medication may shorten exclusion time. Follow the athlete’s healthcare provider’s recommendations and specific sports league rules for when the athlete can return to practice and competition.

Herpes, Oral

None.

HIV/AIDS

None, unless the child has unusually aggressive behavior (e.g., biting) that cannot be controlled, oozing sores that cannot be covered, or bleeding problems. The child’s health professional and the child care program director or school principal should assess on a case-by-case basis to determine whether exclusion from some activities is necessary. Children with HIV infection should not be excluded from school, child care or other group care settings solely based on their HIV infection.

Impetigo

If impetigo is confirmed by a healthcare provider, exclude until 24 hours after treatment. Lesions on exposed skin should be covered with watertight dressing.

Influenza

Until fever is gone and the child is well enough to participate in routine activities.

Measles

Until 4 days after the rash appears. A child with measles should not attend any activities during this time period.

Consult with your local or state health department regarding the exclusion of exposed unvaccinated children and staff.

Meningococcal Disease

Consult with your local or state health department. Each situation must be evaluated individually to determine the appropriate control measures to implement. Most children can return after they have been on appropriate antibiotics for at least 24 hours and are well enough to participate in routine activities.

Methicillin-Resistant Staphylococcus aureus (MRSA)

If draining sores are present and cannot be completely covered and contained with a clean, dry bandage or if a person cannot maintain good personal hygiene.

Children who are only colonized do not need to be excluded.

Activities: Children with draining sores should not participate in any activities where skin-to-skin contact is likely to occur until their sores are healed. This means no contact sports.

Molluscum Contagiosum

None. Encourage parents/guardians to cover bumps with clothing when there is a possibility that others will come in contact with the skin. If not covered by clothing, cover with a bandage.

Activities: Exclude any child with bumps that cannot be covered with a water-tight bandage from participating in swimming or other contact sports.

Mononucleosis

None, as long as the child is well enough to participate in routine activities.

Sports: Contact sports should be avoided until the student has recovered fully and the spleen is no longer palpable.

Mosquito-Borne

None.

Mumps

Until 5 days after swelling begins.

Exclude unvaccinated children and staff if two or more cases of mumps occur. Exclusion will last through at least 26 days after the onset of parotid gland swelling in the last person with mumps. Once vaccinated, students can be readmitted immediately.

Norovirus

Children and staff who are experiencing vomiting and/or diarrhea should be excluded until they have been free of diarrhea and vomiting for at least 24 hours.

Staff involved in food preparation should be restricted from preparing food for 48 hours after symptoms stop. The staff may perform other duties not associated with food preparation 24 hours after symptoms have stopped.

No one with vomiting and/or diarrhea that is consistent with norovirus should use pools, swimming beaches, water parks, spas, or hot tubs for at least 2 weeks after diarrhea and/or vomiting symptoms have stopped.

Parapertussis

None, if the child is well enough to participate in routine activities.

Pertussis (Whooping Cough)

Exclude children and symptomatic staff until 5 days after appropriate antibiotic treatment begins. During this time, the person with pertussis should NOT participate in any school or community activities. If not treated with 5 days of antibiotics, exclusion should be for 21 days after cough onset.

If there is a high index of suspicion that the person has pertussis, exclude until the individual has been evaluated by a medical provider and deemed no longer infectious by the local health department, 5 days of antibiotics are completed or until the laboratory test comes back negative.

Pinworms

None.

Pneumococcal Infection

None, if the child is well enough to participate in routine activities.

Pneumonia

Until fever is gone and the child is well enough to participate in routine activities.

Respiratory Infection (Viral)

Until fever is gone and the child is well enough to participate in routine activities.

None, for respiratory infections without fever, as long as the child is well enough to participate in routine activities.

Ringworm

Until treatment has been started, or if on the scalp, until 24 hours after treatment has been started.

Any child with ringworm should not participate in gym, swimming, and other close-contact activities that are likely to expose others until 72 hours after treatment has begun or the lesion can be completely covered.

Sports: Athletes with ringworm of the body in sports with person-to-person contact cannot participate in matches for 72 hours after starting treatment unless the area can be covered. Follow the athlete’s healthcare provider’s recommendations and the specific sports league rules for return to practice and competition.

Follow the athlete’s healthcare provider’s recommendations and the specific sports league rules for when the athlete can return to practice and competition.

Rotaviral Infection

Until the child has been free of diarrhea for at least 24 hours. Further exclusion may be necessary during outbreaks.

Rubella (German Measles)

Until 7 days after the rash appears.

Exclude unvaccinated children and staff for at least 3 weeks after the onset of rash in the last reported person who developed rubella.

Salmonellosis

Until the child has been free of diarrhea for at least 24 hours. Further exclusion may be necessary during outbreaks.

Exclude symptomatic staff with Salmonella from working in food service. Other restrictions may apply; call your local health department for guidance.

*If a case of Salmonella typhi is identified in a child care center or school, please consult with your local or state health department. Each situation must be evaluated individually to determine the appropriate control measures to implement.

Scabies

Until 24 hours after treatment begins.

Shigellosis

Until the child has been free of diarrhea for at least 24 hours. Further exclusion may be necessary during outbreaks.

No one with Shigella should use swimming beaches, pools, recreational water parks, spas, or hot tubs until 2 weeks after diarrhea has stopped.

Food service employees infected with Shigella bacteria should be excluded from working in food service. An employee may return to work once they are free of the Shigella infection based on test results showing 2 consecutive negative stool cultures that are taken at least 24 hours after diarrhea ceases, not earlier than 48 hours after discontinuation of antibiotics, and at least 24 hours apart; or the food employee may be reinstated once they have been asymptomatic for more than 7 calendar days.

Other restrictions may apply; call your local health department for guidance.

Shingles (Zoster)

None, if blisters can be completely covered by clothing or a bandage. If blisters cannot be covered, exclude until the blisters have crusted.

Persons with severe, disseminated shingles should be excluded regardless of whether the sores can be covered.

Staph Skin Infection

If draining sores are present and cannot be completely covered and contained with a clean, dry bandage or if the person cannot maintain good personal hygiene.

Children who are only colonized do not need to be excluded.

Activities: Children with draining sores should not participate in activities where skin-to-skin contact is likely to occur until their sores are healed. This means no contact sports.

STEC (Shiga toxin- producing Escherichia coli) Infection

Until the child has been free of diarrhea for at least 24 hours. Further exclusion may be necessary during outbreaks.

No one with STEC should use swimming beaches, pools, water parks, spas, or hot tubs until 2 weeks after diarrhea has stopped.

Streptococcal Infection (Strep Throat/Scarlet Fever)

Until 24 hours after antibiotic treatment begins and until the child is without fever.

Children without symptoms, regardless of a positive throat culture, do not need to be excluded from school. Persons who have strep bacteria in their throats and do not have any symptoms (carriers) appear to be at little risk of spreading infection to those who live, attend school, or work around them.

Tick-Borne

None.

Tuberculosis

Viral Meningitis

None, if the child is well enough to participate in routine activities.

Warts

None.

Yeast Infection (Candidiasis)

None.

Other Communicable Diseases

Consult your local or state health department or the child's healthcare provider regarding exclusion guidelines for other infections not described in this manual. Special exclusion guidelines may be recommended in the event of an outbreak of an infectious disease in a school setting.
Consult your local or state health department when there is more than one case of a reportable disease or if there is increased absenteeism.

Communicable Disease Concerns for Pregnant Women

Working in a child care or school setting may involve frequent exposure to children infected with communicable diseases. Certain communicable diseases can have serious consequences for pregnant women and their fetuses. It is helpful if women know their medical history (which of the diseases listed below they have had and what vaccines they have received) when they are hired to work in a child care or school setting. The child care or school employers should inform employees of the possible risks to pregnant women and encourage workers who may become pregnant to discuss their occupational risks with a healthcare provider. These women should also be trained on measures to prevent infection with diseases that could harm their fetuses.

The following communicable diseases have implications for pregnant women:

Cytomegalovirus (CMV)
Fifth disease (Parvovirus B19)
Hand, Foot, and Mouth (Enteroviral Infections)
Hepatitis B
Human Immunodeficiency Virus (HIV)
Rubella (German Measles)
Varicella-Zoster (Chickenpox and Shingles)

Pregnant women who are exposed to these diseases should notify their healthcare providers.

All persons who work in child care or school settings should know if they have had chickenpox or rubella disease or these vaccines. If they are unsure, they should have blood tests to see if they are immune. If they are not immune (never had disease or vaccine), they should strongly consider being vaccinated for chickenpox and rubella before considering or attempting to become pregnant.

Fact sheets for each of the above diseases are included in this section.

Cytomegalovirus (CMV) and Pregnancy

What is CMV?

Cytomegalovirus (CMV) is a virus that infects 50% to 85% of adults in the United States by age 40. Once a person has been infected with CMV, the virus remains in the body for life, typically in an inactive (latent) form. Disease may occur again in persons with weakened immune systems.

What illness does it cause?

Most healthy people who acquire CMV have no symptoms. Occasionally, people develop mononucleosis-like symptoms such as fever, sore throat, fatigue, and swollen glands.

Is this illness serious?

For most healthy adults, CMV is not a problem. About 1% to 4% of uninfected women develop first-time CMV infection during their pregnancy. Healthy pregnant women are not at special risk for disease from CMV infection. When infected with CMV, most women have no symptoms, and very few have a disease resembling mononucleosis. However, about one-third of women who become infected with CMV for the first time during pregnancy pass the virus to their unborn babies.

Each year in the United States, about 1 in 750 children are born with or develop disabilities as a result of congenital (meaning from birth) CMV infection. Most babies with congenital CMV never have health problems. However, some may eventually develop hearing and vision loss; problems with bleeding, growth, liver, spleen, or lungs; and mental disability. Sometimes health problems do not occur until months or years after birth. Of those with symptoms at birth, 80% to 90% will have problems within the first few years of life. Of those infants with no symptoms at birth, 5% to 10% will later develop varying degrees of hearing and mental or coordination problems.

CMV infection can be serious in people with weakened immune systems, such as persons infected with Human Immunodeficiency Virus (HIV), organ/bone marrow transplant recipients, chemotherapy/radiation patients, and people on steroids. Such persons are at risk for infection of the lungs (pneumonia), part of the eye (retinitis), the liver (hepatitis), the brain and covering of the spinal cord (meningoencephalitis), and the intestines (colitis). Death can occur.

I’ve recently been exposed to someone with CMV. How will this exposure affect my pregnancy?

As previously stated, since 50% to 85% of women have already been infected and are immune, being exposed will have no effect on their pregnancy. When a woman who has never had CMV becomes infected during pregnancy, there is a potential risk that the infant may have CMV-related problems. The risk increases if infection occurs in the first half of pregnancy.

I have had a blood test for CMV. What do the results of the blood test show?

Blood tests for CMV may show that you:

Have already had the disease and do not need to be concerned. It is uncommon for the virus to become active again in someone who has had a previous infection and for the virus to cause infection in the unborn child.
Have not had the disease. You may want to consider reducing your contact with children, especially those under 2 1/2 years of age.
Are currently experiencing an infection. You should discuss this with your healthcare provider.

If I develop CMV, what do I need to do about my pregnancy?

If you were exposed to CMV, you should consult your healthcare provider for information about diagnosis, possible lab tests, and follow-up.

Is there any way I can keep from being infected with CMV?

There is no preventive vaccine. Most people with CMV have no symptoms, but they can spread the virus in their urine, saliva, blood, tears, semen, and breast milk. So, throughout the pregnancy, practice good personal hygiene to reduce the risk of exposure to CMV.

Wash your hands with soap and water after contact with diapers or saliva.
DO NOT kiss children on the mouth or cheek. Instead, kiss them on the head or give them a hug.
DO NOT share food, drinks, utensils (spoons or forks), or cups.
Clean and sanitize items contaminated with saliva. Clean and disinfect items contaminated with urine.
Female child care or school workers who expect to become pregnant should consider being tested for antibodies to CMV. If antibody testing shows that the woman has not had CMV, contact with children less than age 2 1/2 (where the majority of virus circulates) should be reduced.

Information on the Web:

http://www.cdc.gov/cmv/index.html

Fifth Disease (Parvovirus B19) and Pregnancy

What is parvovirus B19?

Parvovirus B19 is a virus that commonly infects humans. About 50% of all adults have been infected sometime during childhood or adolescence. Parvovirus B19 infects only humans. There are animal parvoviruses, but they do not infect humans. Therefore, a person cannot catch parvovirus B19 from a dog or a cat.

What illnesses does parvovirus B19 infection cause?

The most common illness caused by parvovirus B19 infection is “fifth disease,” a mild rash illness that occurs most often in children. The ill child usually has an intense redness of the cheeks (a “slapped- cheek” appearance) and a lacy red rash on the trunk and limbs. Occasionally, the rash may itch. The child is usually not very ill. The rash resolves in 7 to 10 days. However, if the person is exposed to sunlight or heat, the rash may come back. Recovery from parvovirus infection produces lasting immunity and protection against future infection.

An adult who has not previously been infected with parvovirus B19 can be infected and have no symptoms or can become ill with a rash and joint pain, and/or joint swelling. The joint symptoms usually go away in a week or two, but may last several months.

Are these illnesses serious?

Fifth disease is usually a mild illness. It goes away without medical treatment among children and adults who are otherwise healthy. Joint pain and swelling in adults usually go away without long-term disability. During outbreaks of fifth disease, about 20% of adults and children are infected without getting any symptoms at all. However, the disease can be severe in children with sickle cell anemia, other blood disorders, or weakened immune systems and in pregnant women.

I’ve recently been exposed to someone with fifth disease. How will this exposure affect my pregnancy?

Usually, there are no serious complications for a pregnant woman or her baby following exposure to a person with fifth disease. About 50% of women are already immune to parvovirus B19, and these women and their babies are protected from infection and illness. Even if a woman is susceptible and gets infected with parvovirus B19, she usually experiences only a mild illness. Likewise, her unborn baby usually does not have any problems because of the parvovirus B19 infection.

Sometimes, however, parvovirus B19 infection will cause the unborn baby to have severe anemia, and the woman may have a miscarriage. This occurs in less than 5% of all pregnant women who are infected with parvovirus B19 and occurs more commonly during the first half of pregnancy. There is no evidence that parvovirus B19 infection causes birth defects or developmental delay.

What should I do about this exposure?

If you have been in contact with someone who has fifth disease or you have an illness that might be caused by parvovirus B19, you may wish to discuss your situation with your healthcare provider.

Your healthcare provider can do a blood test to see if you have become infected with parvovirus B19.

I have had a blood test for parvovirus B19. What do the results show?

A blood test for parvovirus B19 may show that you:

Are immune to parvovirus B19 and have no sign of recent infection. You have protection against parvovirus B19.
Are not immune and have not yet been infected. You may wish to avoid further exposure during your pregnancy.
Have had a recent infection. You should discuss this with your healthcare provider.

If I’m infected, what do I need to do about my pregnancy?

There is no universally recommended approach to monitor a pregnant woman who has a documented parvovirus B19 infection. Some healthcare providers treat a parvovirus B19 infection in a pregnant woman as a low-risk condition and continue to provide routine prenatal care. Other healthcare providers may increase the frequency of doctor visits and perform blood tests and ultrasound examinations to monitor the health of the unborn baby. The benefit of these tests in this situation, however, is not clear. If the unborn baby appears to be ill, there are special diagnostic and treatment options available. Your obstetrician will discuss these options with you and their potential benefits and risks.

Is there a way I can keep from being infected with parvovirus B19 during my pregnancy?

There is no vaccine or medicine that can prevent parvovirus B19 infection. Frequent handwashing is recommended as a practical and probably effective method to reduce the spread of parvovirus.

Excluding persons with fifth disease from work, child care centers, schools, or other settings is not likely to prevent the spread of parvovirus B19 since ill persons are only contagious before they develop the characteristic rash.

The Centers for Disease Control and Prevention (CDC) does not recommend that pregnant women routinely be excluded from a workplace where a fifth disease outbreak is occurring, because of the problems noted above. Rather, CDC considers this to be a personal decision for the woman after discussion with her family, healthcare provider, and employer.

Information on the Web:

https://www.cdc.gov/parvovirus-b19/about/parvovirus-b19-in-pregnancy.html?CDC_AAref_Val=https://www.cdc.gov/parvovirusb19/pregnancy.html

Hand, Foot, and Mouth Disease and Pregnancy

(Enteroviral Infections)

What causes hand, foot, and mouth disease (HFMD)?

HFMD is caused by viruses that belong to the enterovirus genus (group). This group of viruses includes polioviruses, coxsackieviruses, echoviruses, and enteroviruses. The most common cause of HFMD is coxsackievirus A16, but sometimes HFMD is also caused by enterovirus 71 or other enteroviruses.

What illness does it cause?

Most enteroviral infections are asymptomatic or manifest as minor malaise. HFMD is a common illness of infants and young children. It occurs most frequently in the summer and early fall. The disease usually begins with a fever, poor appetite, malaise (feeling vaguely unwell), and often with a sore throat. One or 2 days after fever onset, painful sores usually develop in the mouth. They begin as small red spots that blister and then often become ulcers. The sores are usually located on the tongue, gums, and inside of the cheeks. These sores may last 7 to 10 days. A non-itchy skin rash develops over 1–2 days. The rash has flat or raised red spots, sometimes with blisters. The rash is usually located on the palms of the hands and soles of the feet; it may also appear on the buttocks and/or genitalia. A person with HFMD may have only the rash or only the mouth sores. The disease is usually self-limited, but in rare cases has been fatal in infants.

Is HFMD illness serious?

HFMD illness is usually not serious. HFMD caused by coxsackievirus A16 infection is a mild disease, and nearly all patients recover without medical treatment in 7 to 10 days. Complications are uncommon. Rarely, the patient with coxsackievirus A16 infection may also develop “aseptic” or viral meningitis, in which the person has fever, headache, stiff neck, or back pain, and may need to be hospitalized for a few days. Another cause of HFMD, enterovirus 71 (EV71), may also cause viral meningitis and, rarely, more serious diseases, such as encephalitis or poliomyelitis-like paralysis.

EV71 encephalitis may be fatal. In 1998, a major outbreak in Taiwan caused nearly 130,000 cases and resulted in 78 deaths, nearly all of them in children under 5 years old. Newborns without maternal antibody who acquire this infection are at risk for serious disease with a high mortality rate.

I’ve recently been exposed to someone with enteroviruses. How will this exposure affect my pregnancy?

Enteroviruses, including those causing HFMD, are very common. Therefore, pregnant women are frequently exposed to them, especially during the summer and fall months. Most enteroviral infections during pregnancy cause mild or no illness in the mother. Although the available information is limited, currently, there is no clear evidence that maternal enteroviral infection causes adverse outcomes of pregnancy, such as abortion, stillbirth, or congenital defects. However, mothers infected shortly before delivery may pass the virus to the newborn. Babies born to mothers who have symptoms of enteroviral illness around the time of delivery are more likely to be infected. Most newborns infected with an enterovirus have mild illness, but, in rare cases, they may develop an overwhelming infection of many organs, including the liver and heart, and die from the infection. The risk of this severe illness in newborns is higher during the first two weeks of life.

If I develop HFMD, what do I need to do about my pregnancy?

If you were exposed to HFMD, consult your healthcare provider for information about diagnosis, possible lab tests, and follow-up.

Is there any way I can keep from being infected with HFMD?

There is no preventive vaccine. Most people with HFMD have no or few symptoms, but they can spread the virus in secretions from the nose or mouth and in stool. Specific prevention for HFMD or other non-polio enterovirus infections is not available, but the risk of infection can be lowered by good hygienic practices.

So throughout the pregnancy, practice good personal hygiene to reduce the risk of exposure to enteroviruses:

Wash your hands with soap and water after contact with diapers and secretions from the nose or mouth.
DO NOT kiss children on the mouth.
DO NOT share food, drinks, or utensils (spoons or forks), or cups.
Clean and sanitize items contaminated with secretions from the nose or mouth. Clean and disinfect items contaminated with stool.

Information on the Web:

https://www.cdc.gov/hand-foot-mouth/index.html

Hepatitis B Virus and Pregnancy

What is hepatitis B, and what illness does this cause?

Hepatitis B is a viral illness. The hepatitis B virus infects the liver and can cause serious disease. Persons who are newly infected with the hepatitis B virus (acute infection) may develop symptoms such as loss of appetite, tiredness, stomach pain, nausea, vomiting, dark (tea or cola-colored) urine, light- colored stools, and sometimes rash or joint pain. Jaundice (yellowing of eyes or skin) may also be present. Some people have no symptoms at all and may not know they have been infected. If the virus is present for more than six months, the person is considered to have a chronic (lifelong) infection. As long as persons are infected with the hepatitis B virus, they can spread the virus to other people.

Is hepatitis B serious?

Most people who have an acute infection recover without problems. Approximately 90% of infected infants will develop chronic infection. The risk goes down as a child gets older. Approximately 25% to 50% of children infected between the ages of 1 and 5 years will develop chronic hepatitis. The risk drops to 6% to 10% when a person is infected over 5 years of age. Most people who are chronically infected have no symptoms and feel healthy. However, some people do develop non-specific symptoms at times when the virus is reproducing and causing liver problems. People with lifelong hepatitis B infection can develop cirrhosis of the liver, liver cancer, and/or liver failure, which can lead to death.

If I've been exposed to someone infected with the hepatitis B virus, what should I do?

An exposure is defined as contact with blood or other body fluids of an infected person. Contact includes touching the blood or body fluids when you have open cuts or wounds (that are less than 24 hours old or wounds that have reopened), splashing blood or bloody body fluids into the eyes or mouth, being stuck with a needle or other sharp object that has blood on it, or having sex or sharing needles with someone with hepatitis B virus. A baby can get hepatitis B from its infected mother during childbirth. It is not spread through food or water or by casual contact (e.g., shaking hands or kissing the face of a person who is infected with hepatitis B).

Everyone who has exposure to a person infected with the hepatitis B virus should have blood tests done as soon as possible to determine whether treatment is needed.

At the time of exposure, persons who have never had the disease or vaccine (susceptible to the virus) should receive a dose of hepatitis B immune globulin (HBIG) and the first dose of hepatitis B vaccine. Doses two and three of the vaccine series should be completed on schedule. In some cases, people who have already been vaccinated may be tested and/or revaccinated.

How will this exposure affect my pregnancy?

If a mother develops hepatitis B during her pregnancy, there is a chance that the baby may also become infected. If the mother develops acute hepatitis in the third trimester of pregnancy or the immediate postpartum period, the risk of infection for the newborn baby may be 60% to 70%. It is very important that the baby receive treatment right after birth to get as much protection as possible.

If you have the hepatitis B virus in your blood, you can pass hepatitis B to your baby during the birthing process. About 90% of infected infants will develop chronic infection. They may have the virus for the rest of their lives and be a source to spread the disease. There may be long-term effects from acquiring hepatitis B at such an early age.

Can anything be done to protect my baby?

All pregnant women should be tested for the hepatitis B virus early in their pregnancy. The testing should be done during each pregnancy. If the blood test is positive for the hepatitis B virus, the baby should receive the first dose of hepatitis B vaccine along with a shot of HBIG within the first 12 hours of life. The vaccine series should be completed on time. Check with your healthcare provider for the schedule for doses 2 and 3 of the vaccine. Once the baby has turned 1 year of age, the baby should have a blood test to make sure infection did not occur and that the vaccine is protecting the baby.

I have had a blood test for hepatitis B. What do the results of the blood test show?

The blood test for hepatitis B may show that you:

Are immune (had hepatitis B disease or vaccine in the past) and have no sign of recent infection. You are protected and do not need to worry about hepatitis B.
Are not immune and have not yet been infected. You should receive the hepatitis B vaccine series if you are at risk of blood exposures at your job or through risk behaviors in your personal life. Talk to your healthcare provider about this.
Have had a recent infection. Discuss the situation with your healthcare provider.
Have chronic infection. Talk to your healthcare provider about regular medical evaluation and monitoring.

Is there a way I can keep from being infected with hepatitis B during my pregnancy?

Yes, get vaccinated. It is safe to get the hepatitis B vaccine while you are pregnant. In the meantime:

Wear gloves when handling blood and body fluids.
Clean and disinfect contaminated objects or surfaces and wear gloves.
Wash hands after removing gloves.
DO NOT share personal care items, such as toothbrushes, razors, or nail clippers.
If your sexual partner is infected with the hepatitis B virus, use latex condoms during intercourse.
DO NOT share needles to inject drugs or to perform tattoos or body piercings.

Information on the Web:

Hepatitis B - FAQs, Statistics, Data, & Guidelines | CDC

For more information, call the Missouri Department of Health and Senior Services (MDHSS) Bureau of Genetics and Healthy Childhood at 573-751-6266 or call your local health department.

Human Immunodeficiency Virus (HIV) and Pregnancy

What is HIV?

Human immunodeficiency virus (HIV) is a retrovirus that attacks the body’s immune system allowing other infections to occur. Advanced HIV infection is called Acquired Immunodeficiency Syndrome (AIDS).

HIV can be spread when the body fluids (blood, semen, vaginal fluids, and breast milk) of an infected person enter your body. In adults, the virus is most often spread through sexual contact or by sharing needles. Although it is rare, there are some children who become infected with the virus from their infected mothers during pregnancy, at the time of birth, or through breastfeeding. With the current screening guidelines, spread through blood transfusion is rare.

I’ve recently been exposed to HIV. What should I do?

An exposure is defined as direct contact with the blood or body fluids of an infected person. Contact includes touching the blood or body fluids when you have open cuts or wounds (that are less than 24 hours old or wounds that have reopened), splashes of blood or body fluids into the eyes or mouth, being stuck with a needle or other sharp object that has blood on it, or having sex or sharing needles with someone with HIV. A baby can get HIV from its infected mother during childbirth and from drinking breast milk from an infected mother. In Missouri most women are screened for HIV during pregnancy; therefore, risk of HIV transmission from mother to infant is unlikely. However, without proper treatment, transmission can occur during childbirth. Breast feeding is not recommended.

Everyone who has an exposure to HIV should have a blood test to determine whether or not they have been infected with the virus. The test should be repeated 3 months and 6 months after exposure to completely rule out infection.

How will this exposure affect my pregnancy?

All pregnant women should be tested for HIV early in their pregnancy. If a woman is infected with HIV during her pregnancy, there is a chance that she could give the infection to her baby. About 25% of babies of infected mothers who do not receive antiretroviral treatment may become infected, whereas, about less than 2% become infected when the mother receives antiretroviral treatment. The infant can become infected anytime during pregnancy, but infection usually happens just before or during delivery. Women who are infected with HIV should not breastfeed their babies; the retrovirus is present in the breast milk.

HIV infection can be diagnosed early in infants using special viral diagnostic tests, polymerase chain reaction (PCR). An infant may be tested as early as 48 hours and may be tested periodically for up to 2 years. After the age of 18 months a child may be tested using an antibody test. By that time the baby will no longer have mother’s antibodies in the blood.

How can I tell if I'm infected with HIV?

The only way to determine whether you are infected is to be tested for HIV infection. You cannot rely on symptoms to know whether or not you are infected with HIV. Most people who are infected with HIV may have vague symptoms such as low grade fever, body aches, swollen lymph nodes and glands, however, some do not have any symptoms for many years.

What are the HIV/AIDS symptoms?

The symptoms listed below are not specific for HIV and may have other causes. Most persons with HIV have no symptoms at all for several years. The only way to determine whether you are infected is to be tested for HIV infection. HIV testing should be an integral part of routine medical care. Talk to your health care provider about being tested.

Early symptoms (weeks to months after exposure)

Flu-like illness
Swollen lymph nodes
Rash

Late symptoms (years after exposure)

Persistent fevers
Night sweats
Prolonged diarrhea
Unexplained weight loss
Purple bumps on skin or inside the mouth and nose
Chronic fatigue
Swollen lymph nodes
Recurrent respiratory infections

I have had a blood test for HIV. What do the results of the blood test show?

There are several steps to test for HIV. They are all done on the same sample. First, an enzyme immunoassay (EIA) can be performed. For this test to be accurate, it should be conducted a minimum of three weeks to three months after a known exposure. It takes that long to develop sufficient antibodies for testing. If negative, the person has no HIV antibodies. If the EIA is positive, a Western blot test is done to confirm the result. The person is considered HIV-infected if the Western blot is positive. Early in the infection, it is possible to have a positive EIA and a negative Western blot test, so further testing or retesting in a month’s time is recommended. In some circumstances, an HIV viral load (number of viral particles) may be requested for diagnostic and treatment purposes.

Is there a way I can keep from being infected with HIV during my pregnancy?

Use new latex condoms every time you have sex. Limit the number of partners.
Wear plastic or latex gloves when handling blood and body fluids.
Clean and disinfect contaminated objects or surfaces and wear gloves.
Wash hands after removing gloves.
DO NOT share personal care items, such as toothbrushes, razors, or nail clippers.
DO NOT share needles to inject drugs or to perform tattoos or body piercings.
Ask your sex partners if they have been tested and what the results were.

Information on the Web:

http://cdc.gov/hiv/default.htm

For more information, call the Missouri Department of Health and Senior Services (MDHSS) Bureau of HIV, STD, and Hepatitis at 573-751-6439 or call your local health department.

Rubella (German Measles) and Pregnancy

What is rubella?

Rubella (German Measles) is a viral infection. Symptoms include generalized skin rash, swollen glands in the area behind the ears and the neck (lymphadenopathy), and slight fever. It is estimated that up to 50% of persons infected with rubella may not have any symptoms.

What illness does rubella infection cause? Is this illness serious?

Rubella is usually a mild illness. However, there may be severe illness in adults who are not immune (have not had the disease in the past or have not had the vaccine). Swelling, stiffness, and/or pain of the joints may occur in up to 70% of adult women infected with rubella. Rare complications include a bleeding problem called thrombocytopenia and infection of the brain (encephalitis). If rubella occurs during pregnancy, especially during the first 12 weeks, a condition known as congenital rubella syndrome (CRS) may occur in the developing baby and can result in miscarriage, fetal death/stillbirth, and severe birth defects. A baby with CRS may have eye abnormalities (i.e., cataracts, glaucoma), heart defects, hearing impairment/deafness, and developmental delays.

How can a pregnant woman protect herself and her developing baby from being exposed to rubella?

It is recommended that all women make sure they are immune to rubella (have a blood test to show evidence of antibodies to rubella) before they get pregnant, and be tested for rubella early in their pregnancy.

What should I do about a rubella exposure during pregnancy?

The risk of congenital infection and CRS is highest during the first 12 weeks of gestation (first trimester) and decreases thereafter; defects are rare when infection occurs after the 20th week of pregnancy. When a pregnant woman is exposed to rubella, a blood test for rubella antibody should be done as soon as possible. If you have been exposed to someone with rubella or have developed a rash illness that might be rubella, you should consult your healthcare provider.

I have had a blood test for rubella. What do the results of the blood test show?

The blood test for rubella may show that you:

Are immune (had rubella disease or vaccine in the past) and have no sign of recent infection. You are protected from rubella.
Are not immune and have not yet been infected. You may wish to avoid anyone with rubella during your pregnancy.
Have or had a recent infection. You should discuss what the risks are based on your stage of pregnancy with your healthcare provider.

What do I do if I am not immune to rubella?

All adults working with children should know their vaccine history or immune status. If you are not immune, you should be vaccinated with MMR (measles, mumps, and rubella) vaccine. When you are given the vaccine, you should avoid becoming pregnant for at least one month after immunization.

Rubella vaccine should not be given to pregnant women.
If you are pregnant and not immune, you should receive MMR vaccine after your baby is delivered.

Information on the Web:

http://www.cdc.gov/rubella

Varicella/Herpes Zoster Virus (Chickenpox and Shingles)

What is varicella-zoster?

Varicella/herpes zoster is a herpes virus that causes two distinct diseases, varicella and shingles. Varicella, or chickenpox, is the primary infection, and it is a common childhood illness that is highly contagious. After a person has had chickenpox, the virus remains inactive in the body for many years. Herpes zoster, or shingles, occurs when the virus becomes active again. About 1 in 3 people in the United States will develop shingles in their lifetime.

What illnesses does varicella-zoster cause?

Chickenpox first occurs as a blister-like skin rash and fever. It takes from 10-21 days after exposure for someone to develop chickenpox. The rash commonly occurs in batches with different stages present all at the same time (i.e., bumps, blisters, and sores); it is typically quite itchy. The blisters usually scab over in 6 days. A person with chickenpox is contagious from 1-2 days before the rash appears until all blisters have formed scabs. Infectiousness may be prolonged in persons with altered immunity.

Shingles occurs when the inactive virus in a person who has recovered from chickenpox becomes active again. Early signs of illness include pain, itching, or tingling of the skin before the rash appears. The rash presents as painful blister-like sores, usually on one side of the body, often on the face or torso. Shingles does not spread as shingles from one person to another. People who have never had chickenpox or did not get the chickenpox vaccine can get infected with chickenpox from someone who has shingles by having direct contact with the fluid from the shingles rash blisters, or breathing in virus particles that come from the blisters.

Are chickenpox and shingles serious illnesses?

Infants, adolescents, adults, persons with weakened immune systems, and pregnant women are at higher risk for severe chickenpox infection and complications. However, healthy children may also develop serious/fatal complications, and initial chickenpox infections in adults can be extremely serious and may result in death. Severe complications include secondary bacterial infections, pneumonia (bacterial and viral), brain inflammation (encephalitis), congenital varicella syndrome, and severe neonatal varicella.

The most common complication from shingles is long-term nerve pain in the area where the rash occurred, called postherpetic neuralgia (occurs in an estimated 10% to 18% of those infected, but rarely occurs in people younger than 40 years old). People with weakened immune systems are more likely to have complications from shingles, and they are more likely to have a severe, long-lasting rash. Shingles can lead to serious complications involving the eye, including vision loss, and the rash can also become infected with bacteria. Very rarely, shingles can lead to pneumonia, hearing problems, encephalitis, and death.

Can you get chickenpox if you've been vaccinated?

Yes, it is possible to get chickenpox despite being vaccinated, but the first dose of vaccine is about 85% effective at preventing mild chickenpox and 97% effective at preventing severe chickenpox. Two doses of vaccine are recommended and are much more effective than one in preventing infection. Vaccinated persons who get chickenpox generally have a milder illness with less fever and fewer than 50 spots or bumps, which may have an atypical appearance.

What should I do about an exposure to varicella?

If you have been in contact with someone with chickenpox or shingles, or you have a rash-associated illness that might be chickenpox or shingles, discuss your situation with your healthcare provider. Laboratory tests may be done to see if you have become infected with the virus or have had the disease in the past. For exposed persons that do not have evidence of immunity to varicella (i.e., those who haven’t had varicella in the past or been vaccinated according to current recommendations), the vaccine is effective in preventing illness or reducing severity if used within three days, and possibly up to five days, of exposure. For exposed persons who do not have evidence of immunity to varicella and are ineligible for vaccination, like pregnant women, passive immunization with a medication called varicella-zoster immune globulin is recommended. If you are pregnant and not immune and have been exposed to chickenpox or shingles, call your healthcare provider immediately (see next section below).

I'm pregnant and have recently been exposed to someone with chickenpox. How will this exposure affect me or my pregnancy?

Pregnant women who get varicella are at risk for serious complications, primarily pneumonia, which can be fatal. Susceptible pregnant women (those without evidence of immunity) are at risk for associated complications when they contract varicella.

Susceptible pregnant women who have been exposed to the virus may be given varicella-zoster immune globulin to reduce their risk of disease complications, but in order for this medication to be most helpful, it needs to be given as soon as possible after exposure.
If you are pregnant and you get chickenpox during the:
- First half (about 20 weeks) of your pregnancy, there is a very slight risk (0.4% to 2.0%) of the baby being born with congenital varicella syndrome, a rare group of serious birth defects, including scarring on the skin, abnormalities in limbs, brain, eyes, and low birth weight.
- Second half of your pregnancy, the baby may have an infection without having any symptoms and then get shingles (herpes zoster) early in life without having extrauterine chickenpox (varicella).
Newborns whose mothers develop varicella rash from five days before to two days after delivery are at risk for a potentially life-threatening infection called neonatal varicella. The infant should receive preventive treatment with varicella-zoster immune globulin. Historically, the mortality rate for neonatal varicella was reported to be about 30%, but varicella-zoster immune globulin and intensive support care have reduced the mortality to about 7%.

I’m pregnant and have had a blood test for chickenpox. What do the results of this test show?

The blood test can show that you:

Are immune (have already had varicella disease or varicella vaccine) and have no sign of recent infection.
Are not immune and have not yet been infected. You should avoid anyone with chickenpox during your pregnancy.
Have or recently had an infection. You should discuss what the risks are for your stage of pregnancy with your healthcare provider.

Is there a way I can keep from being infected with chickenpox and shingles?

Yes, make sure all your vaccines are up to date, especially if you are planning a pregnancy. Vaccination is the best way to protect yourself and others. The Centers for Disease Control and Prevention (CDC) recommends two doses of the varicella (chickenpox) vaccine, separated by one month, for children, adolescents, and adults who have never had chickenpox and were never vaccinated. You should avoid becoming pregnant for at least one month after the last vaccination. The varicella vaccine should not be given to pregnant women. If you are pregnant, have your healthcare provider give you the varicella vaccine during the postpartum visit (6 to 8 weeks after delivery).

Shingles Vaccination, what you should know:

Your risk for getting shingles increases as you get older or if you have a weakened immune system. In order to prevent shingles and the complications from the disease, the CDC recommends the shingles vaccine (Shingrix), separated by 2 to 6 months, for adults 50 years of age and older. Shingrix is also recommended for adults 19 years and older who have weakened immune systems because of disease or therapy.

Anyone 50 years of age or older should get the shingles vaccine, regardless of whether they recall having had chickenpox or not. Studies show that more than 99% of Americans born on or before 1980 have had chickenpox, even if they don’t remember getting the disease. Additionally, those who have previously received a different shingles vaccine called Zostavax® still need two doses of Shingrix.

Most people who have shingles only have it one time; however, you can have it more than once. If you have had shingles in the past, Shingrix can help prevent future occurrences of the disease. There is no specific length of time that you must wait after having shingles before receiving the vaccine, but generally, you should make sure the shingles rash has gone away before getting vaccinated.

The decision on when to get vaccinated should be made with your healthcare provider. Shingles vaccination is the only way to protect against shingles and postherpetic neuralgia (Shingrix is more than 90% effective at preventing both). The decision on when to get vaccinated should be made with your healthcare provider.

Additional information can be found at:

https://www.cdc.gov/shingles

For more information, call the Missouri Department of Health and Senior Services (DHSS) Bureau of Communicable Disease Control and Prevention at 573-751-6113 or 800-392-0272 (24/7), or call your local health department.

Human Biting Incidents

Biting can be a common occurrence in the child care and school setting. The risk of getting hepatitis B virus (HBV) or Human Immunodeficiency Virus (HIV) from a bite is extremely low for either the child who did the biting or the child or staff member who was bitten. It is very difficult to spread these viruses through biting. In addition, most infants are now being vaccinated against the hepatitis B virus, and the number of preschool children (3 to 5 years) with chronic hepatitis B infection is expected to be low. However, biting may cause an infection at the bite site.

Written policies and procedures should be in place before biting incidents occur in order to ensure proper communication with parents/guardians and staff.

Child care and school staff, what to do if a biting incident occurs in the child care or school setting:

Determine if the bite broke the skin (produced an open wound or puncture wound) and/or caused bleeding.
Wear gloves when providing immediate first aid to the bite wound. The wound should be carefully cleaned with soap and water.
Inform the parents/guardians of both children of the biting incident as soon as possible when two children are involved.
If the bite broke the skin, it is recommended that the family or staff consult with a healthcare provider as soon as possible for any further instructions.
DO NOT share the names or any information about the children involved in the biting incident.
Release of any information may be a breach of confidentiality or data privacy.
Document the incident in writing as established by your facility’s policy.

Parent/guardian or staff member, reasons to call your healthcare provider:

To determine if blood tests and/or treatment are needed. It is unlikely that the bite will be the source of infection for hepatitis B or HIV, but each situation must be looked at on a case-by-case basis.
If the bitten person is not up-to-date for tetanus/diphtheria/pertussis and hepatitis B vaccinations, the person should receive these vaccines as soon as possible.
If the bitten person has any of the following signs of infection:
- Increased swelling, redness, warmth, or tenderness at the site.
- Pus at the site.
- Fever of 100°F or higher.

If any of these symptoms occur or if the bitten person begins to act sick or the wound does not heal, call your healthcare provider immediately.

Prevention and Control

Parents/guardians and child care and school staff should develop a behavior modification plan to prevent further incidents.
A child who is infected with HIV or the hepatitis B virus and continues to bite should be assessed by a team of medical experts to determine an appropriate response plan to prevent the risk of spread of these viruses.

Call your child care health consultant or your local or state health department for additional assistance with these incidents. For questions about possible exposures, call the Missouri Department of Health and Senior Services (MDHSS) Bureau of Communicable Disease Control and Prevention at 573-751-6113 or 800-392-0272 (24/7), or call your local health department.