Prevention and Control of Communicable Diseases

Cleaning, Sanitizing, and Disinfection

This section provides general information about cleaning, sanitizing, and disinfecting; guidelines for specific items commonly used in the child care and school setting; and a checklist for choosing a disinfectant other than bleach.

Definitions

Cleaning - Mechanical process (scrubbing) using soap or detergent and water to remove dirt, debris, and many germs. It also removes imperceptible contaminants that interfere with sanitizing and disinfection.

Sanitizing - Chemical process of reducing the number of disease-causing germs on cleaned surfaces to a safe level. This term is usually used in reference to food contact surfaces, mouthed toys, or objects.

Disinfecting - Chemical process that uses specific products to destroy harmful germs (except bacterial spores) on environmental surfaces.

General Information

• Lessen the harmful effects of germs (bacteria and viruses) by keeping their numbers low.
• Effectively control germs by frequent, thorough handwashing, cleaning and sanitizing surfaces and objects that come into contact with children, and proper handling and disposal of contaminated items.
• Follow proper cleaning and sanitizing practices, whether dirt is seen or not. Germs can live on wet and dry surfaces and on those items that do not look soiled or dirty.
• Increase the frequency of cleaning and sanitizing to control certain communicable diseases.
• Treat all body fluids as infectious because disease-causing germs can be present even in the absence of illness.
• Know that children who do not show symptoms of illness may be as infectious as those who do have symptoms.

Glove Use

• Wear disposable gloves (consider using non-latex gloves as a first choice) when:
  • Handling blood (e.g., nosebleeds, cuts) or items, surfaces, or clothing soiled by blood or body fluids.
  • Covering open cuts, sores, or cracked skin.
  • Cleaning bathrooms, diapering areas, or any areas contaminated with stool, vomit, or urine.
• Remove gloves properly and discard after each use.
• ALWAYS WASH HANDS IMMEDIATELY when gloves are removed. Also, wash hands when there has been contact with any body fluids. Follow handwashing and gloving procedures.

When Using Cleaning, Sanitizing, or Disinfecting Products, Always:

• Consider the safety of children.
• Choose a product appropriate for the task.
• Follow the label instructions for mixing, using, and storing solutions.
• Read the warning labels.
• Store these products safely out of reach of children.
• Clean soiled surfaces and items before using sanitizers or disinfectants.

Cleaning

• Use warm/hot water with any household soap or detergent.
• Scrub vigorously to remove dirt and soil. Use a brush if the item is not smooth or has hard-to-reach corners, such as toys and bottles.
• Change the water when it looks or feels dirty, after cleaning the bathrooms and diaper changing area, and after cleaning the kitchen.
• Always clean the least dirty items and surfaces first (for example, countertops before floors, sinks before toilets).
• Always clean high surfaces first, then low surfaces.
• Disposable towels are preferred for cleaning. If using reusable cloths/rags, a different clean cloth/rag should be used for each cleaning activity.  Launder reusable cloths/rags between cleaning uses. DO NOT use sponges since they are hard to clean.
• Clean completely on a regular schedule and spot clean as needed.

Sanitizing or Disinfecting Products

• Bleach (Sodium hypochlorite)

  Bleach solutions of differing concentrations can be used for sanitizing and disinfecting. You can prepare your own bleach solutions by mixing specified amounts of household bleach and water, or you can purchase commercially prepared bleach-containing products. Make sure the bleach solution is appropriate for the type of item to be sanitized or disinfected.

  Bleach is safe when used as directed, effective against germs when used at the proper concentration, inexpensive if you make your own solutions, and readily available. However, bleach is corrosive to metals and can strip floor wax. It is also ineffective in the presence of body fluids and soil (you must always clean first), unstable when mixed with water (it needs to be made fresh daily), and dangerous if mixed with other products.

  • Bleach solution 1 - disinfectant
    
    This solution contains approximately 800 parts per million (ppm) of sodium hypochlorite. Only surfaces with blood or heavy fecal contamination need to be disinfected.

  • Bleach solution 2 - sanitizer
    
    This solution contains 50 to 200 parts per million (ppm) of sodium hypochlorite. For equipment that is washed/rinsed/sanitized in sinks (immersion), a solution of 50 to 100 ppm should be used. For surfaces that are cleaned in place, such as high chairs and other eating surfaces, a solution of 100 to 200 ppm should be used.
    
    The Missouri Food Code states that the range of the sanitizing solution must be from 50 to 200 ppm. It must not exceed 200 ppm. Chlorine test kits are available for purchase to check the concentration of your solution. Licensed facilities are required to use a test kit to measure the strength of the sanitizing solution.

• Quaternary ammonia products (quats)
  
  There are many types of quaternary ammonia products with differing chemical formulations, but the common chemical name of the active ingredient is dimethyl benzyl ammonium chloride. It is It is important to read the label and follow the instructions carefully to ensure that you are using a product appropriate for the type of item to be sanitized or disinfected.
  
  Use the information within Section 2 to determine if the product meets the criteria for both a sanitizer and/or disinfectant. For example, if using for disinfection after a blood spill or splatter, it must meet OSHA requirements for the bloodborne pathogen exposure plan, that is, be EPA-registered as tuberculocidal, or list that HIV and hepatitis B viruses are killed by the product.
  
  Use the test kit daily to monitor the correct concentration of the product used in the food areas (200 to 400 ppm). In child care areas, concentrations should not exceed 200 ppm.  A separate test kit is needed to measure the concentration of the quat solution. Obtain test kits from your chemical supplier.
  
  Use separate bottles and label each clearly with its intended use, the name of the product, date mixed, food/mouthed contact use, or general disinfection. Always STORE OUT OF CHILDREN’S REACH – undiluted quats can be fatal if ingested.

Remember when using QUATS:

Read the label and follow the manufacturer's directions exactly for:

• how to mix product

• how to apply the solution

• how long to leave on the surface

• whether to rinse after exposure time

• safety concerns when used around children

The solution for use on food contact surfaces may differ from that used for general disinfection. Read the label and follow the directions exactly. For more information about a specific product call the distributor or the company.

• Other sanitizing or disinfecting products
  
  Check with your local health department to determine if the product can be used in your facility. Always read the label and follow the directions carefully.

Disinfecting Procedures

Blood and body fluid spills or soiling

1. Wear a disposable medical glove for any blood and body fluid cleanup.
2. Use disposable towels to ALWAYS clean objects and surfaces contaminated with blood and body fluids (stool, urine, vomit) and discard them in a plastic-lined, covered waste container.
3. Scrub the area with soap or detergent and water to remove blood or body fluids and discard paper towels. Rinse the area with clean water.
4. Disinfect immediately using bleach solution 1 or another appropriate disinfecting product on any items and surfaces contaminated with blood and body fluids (stool, urine, vomit).
5. Allow surface to air dry.
6. Discard disposable gloves. If using utility gloves, follow the cleaning/disinfecting procedure.
7. Wash your hands immediately.

Sanitizing Procedures

General

1. Clean first with soap or detergent and water.
2. Rinse.
3. Spray the area thoroughly with bleach solution 2 or another appropriate sanitizing product.
4. Wipe the area to evenly distribute the sanitizer using single-service, disposable paper towels.
5. Discard paper towels in a plastic-lined container.
6. Allow to air dry.
7. Wash hands.

Water play tables

1. Before any new group of children begins an activity at a water play table or water basin, the table or basin must be washed, rinsed, and sanitized.
2. Chlorine is maintained at 10 to 50 ppm (parts per million).
3. Any child participating in an activity at a water play table or basin washes his or her hands before the activity.
4. The water table or basin is emptied as soon as the water play activity is over.

Washable items like linens, towels, bedding

1. Use hot water in a washing machine. This is acceptable for soaking, cleaning, sanitizing, and disinfecting washable articles.
2. Read the label on the laundry detergent.
3. Read the label and follow directions exactly if using bleach.
4. Dry items in a dryer on high heat.

Items in contact with food or are mouthed (toys, eating utensils, dishes, formula bottles)

Three separate sinks (or basins) method

1. Sink/Basin #1: wash items in hot water using detergent (bottle brushes as needed).
2. Sink/Basin #2: rinse in clear water.
3. Sink/Basin #3: soak items in bleach solution 2 for at least one minute.
4. Remove items, DO NOT rinse, and place on rack to air dry.

Dishwashers

To be acceptable, a dual process for cleaning with the detergent and agitation, and sanitizing with heat or chemicals must be provided.

Two types are available, commercial and household:

• National Sanitation Foundation (NSF) approved commercial dishwashers are required in commercial child care or school food service. The NSF standards require that the water temperature reach 180 o F, or that there is 50 to 100 ppm chlorine in the final rinse of the dishwasher. Common temperature at the utensil surface should reach 160 o F.
• Household dishwashers must have a heat sanitizing setting. If at the end of the cycle, when the machine is opened, the dishes are too hot to touch, then the items are sanitized. It is strongly recommended that household dishwashers carry the NSF mark of approval.

Green Cleaning Products

There has been an increased interest in using “green” cleaning products in child care settings, schools, and homes. This interest is twofold: first, it is due to reports about increased allergies, sensitivities, and illness in children associated with chemical toxins in the environment and second, these products tend to cause less damage to the environment.

Children are more vulnerable to chemical toxins because of their immature immune systems, rapidly developing bodies, and their natural behaviors. They play on the floor, are very tactile having much body contact with the tables, desks, or play equipment, and have oral behaviors of mouthing toys and surfaces and putting their hands in their mouths.

Green cleaning products can be used in child care and school settings. Green sanitizers or disinfectants must be approved by your local public health agency or your child care consultant.

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.

How to Mix Bleach Solutions

• Prepare bleach solution 1 daily or as needed.
• Test bleach solution 2 daily using a test kit to ensure solution is maintained at 100 ppm chlorine.
• Date bleach when opened; do not keep longer than 30 days.
• Date bleach when purchased; do not keep longer than 3 months.
• Always follow the manufacturer’s instructions exactly.
• Store bleach safely out of reach of children.
• NEVER MIX bleach with any other household product.

NOTE: Mix the bleach solution in an airtight, cloudy plastic container and label container with the date made and bleach solution contents.

Diapering

General Information

Child care providers and school health staff can help prevent the spread of infectious organisms by changing diapers in a separate designated area and by using effective cleaning and disinfecting practices. Germs found in the stool can be spread when the hands of caregivers or children contaminate objects, surfaces, or food. Infections that can be spread by contact with stool include: bacteria (e.g., Salmonella, Shigella, Campylobacter), parasites (e.g., Cryptosporidium, Giardia, pinworms), and viruses (e.g., rotavirus, norovirus, hepatitis A virus).

Note: The importance of using good body mechanics cannot be over emphasized when changing diapers of larger or older children, as well as infants and toddlers. Use appropriate bending and lifting techniques to prevent injury.

Basic principles

• Change diapers in a designated diapering area.
• Follow safety procedures and do not leave children unattended.
• Use surfaces that can be easily cleaned and sanitized.
• Use a separate area for diapering that is away from the medication, food storage, food preparation, and eating areas.
• Dispose of soiled diapers in a covered waste container.
• Wash hands of both staff and children after diapering.
• DO NOT allow objects such as toys, blankets, pacifiers, or food in the diapering areas.
• Consult with your child care health consultant or school nurse for any special diapering issues.

Equipment

Changing Surface

• The changing surface should be separate from other activities.
• The surface should be smooth, moisture-resistant, and of an easily cleanable material.
• For extra protection use a non-absorbent, disposable paper under the child.
• The changing surface should be next to a handwashing sink.

Handwashing Sink and Supplies

• Adequate handwashing facilities should be available to school staff when diapering children in school settings.
• The handwashing sink should be equipped with both hot and cold running water mixed through one faucet (hot water temperature not greater than 1200 F).
• The water controls should ideally be foot-operated or knee-operated to avoid contamination of hands and/or water controls.
• If faucets are not foot-operated or knee-operated, turn off faucet handles with a disposable paper towel.
• The changing sink should not be the same as the food preparation sink.
• Liquid soap, paper towels, and fingernail brush should be within reach.
• Single-service, disposable towels should be used instead of cloth towels.

Handwashing Procedures

The hands of the provider and child must be washed after each diaper change. Refer to handwashing information in Section 3. Check with your child care health consultant or school nurse to determine which handwashing procedures are appropriate for different age groups of children.

Diapers

• High-absorbency disposable diapers are preferred because cloth diapers do not contain stool and urine as well and require more handling (the more handling, the greater chances for spread of germs).
• All diapers must have an absorbent inner lining completely contained within an outer covering made of waterproof material that prevents the escape of stool and urine.
• Soiled clothing should be placed in a plastic bag and sent home each day.
• If cloth diapers are used, talk with your child care health consultant about concerns and procedures.

Cloth Diaper Considerations

• The outer covering and inner lining must both be changed with each diaper change.
• Outer coverings must not be reused until they are laundered.
• Each child should have an individually labeled, covered, and plastic-lined diaper pail.
• Soiled diapers or clothing should NOT be rinsed in sinks or toilets.
• The diaper or clothing soiled with stool must be put in separate plastic bags before placing into the diaper pail.
• Soiled cloth diapers and/or clothing should be sent home each day in clean plastic bags.
• An adequate supply of diapers and diaper coverings must be available for each day.

Diapering procedures, see Diapering within Section 2.

Changing pull-ups/toilet learning procedures, see Changing Pull-ups/Toilet Learning Procedure within Section 2. 

Disposable Gloves

• Non-latex gloves without powder should be considered because of possible allergy to latex in staff and children.
• Gloves should be worn when changing the diaper of a child with diarrhea or a known infection that is spread through the stool.
• Pregnant women or women considering pregnancy should wear gloves when changing any diaper.
• Staff should wear gloves if they have open cuts, sores, or cracked skin, or if the children have open areas on their skin.
• Gloves should be discarded and hands washed after each diaper change.
• Gloves must be single-use only. Food service gloves are not appropriate.

Disposable Wipes

• A sufficient number of pre-moistened wipes should be dispensed before starting the diapering procedure to prevent contamination of the wipes and/or the container.
• Each child should have an individually labeled container of wipes that is not shared with others. Put the child's full first and last name on the container.

Skin Care Items

• Child care providers and schools must have policies regarding use of these products. Parents/guardians or healthcare providers must provide written, signed directions for their use.
• If skin care items are used, keep them within the provider’s reach and out of the reach of children.
• Each child must have an individually labeled container of skin care products that is not shared with others. Label the container with the child's full first and last name.
• Skin care products must be used according to package directions.

Plastic Bags

• Disposable plastic bags must be used to line waste containers and to send soiled clothing or cloth diapers home.
• Plastic bags must be stored out of children’s reach.

Waste Containers and Diaper Pails

• A tightly covered container, preferably with a foot-operated lid, is recommended.
• The container must be kept away from children.
• The container must be lined with a disposable plastic trash bag.
• The waste container should be emptied before full and at least daily.
• The container should be cleaned with detergent and water, rinsed, and disinfected daily.

Potty Chair or Commodes (Not Recommended)

• Flush toilets are recommended rather than commodes or potty chairs. However, if potty chairs or commodes are used, frames should be smooth and easy to clean.
• Empty the potty chair or commode into the toilet, clean with soap and water, rinse, and disinfect after each use. Empty dirty cleaning water into the toilet and not the hand sink.
• If a potty chair or commode has wheels, lock wheels into position while using.
• Utilize proper body mechanics when moving and positioning a child on a potty chair or commode.

Cleaning and Sanitizing Supplies Needed

• Disposable gloves and towels.
• Cleaning solution.
• Sanitizing solution

Sanitizing Procedures

1. Clean first with soap or detergent and water.
2. Rinse.
3. Spray the area thoroughly with an appropriate sanitizing product.
4. Wipe the area to distribute the sanitizer evenly using single-service, disposable paper towels.
5. Discard paper towels in a plastic-lined container.
6. Allow surface to air dry.
7. Wash your hands.

If you have questions about cleaning and sanitizing procedures, ask your child care health consultant or school nurse for specific instructions.

Changing Pull-ups/Toilet Learning Procedure

*Note: This procedure is recommended for wet pull-ups only. For soiled pull-ups follow diapering procedure.

Preparation

Wash Hands

Thoroughly with soap and warm running water for 15-20 seconds using posted procedure.

Assemble Supplies (Within Reach)

1. Clean disposable pull-up*.
2. Disposable wipes or paper towels.
3. Gloves, when used.

Put Gloves On

See gloving recommendations per program policies.

Stand Child By The Toilet

1. Provide privacy.
2. Assist child to remove clothing, if necessary. Put soiled clothing in a plastic bag.

Teach Child to Remove Pull-up

Tear sides of pull-up to remove. Place pull-up directly into plastic bag, tie and place in a plastic lined waste container.

Teach Child to Wipe Bottom

1. Teach child to wipe from front to back (once per wipe). Use the child’s own disposable wipes.
2. Place wipes in waste container.

Remove Gloves

Place gloves in waste container.

Toileting

Encourage Independent Toileting

1. Allow child to sit on toilet.
2. Praise for toileting attempt/success.
3. Allow child to wipe bottom.
4. Encourage child to flush toilet.

Clean Phase