Manual For School Health Programs

Management of Infectious Diseases

School nurses “are front-line health care providers, serving as a bridge between the health care and education systems and other sectors as well as links to broader community health issues through the student populations they serve. The COVID-19 pandemic has also heightened the need for team-based care, infection control and prevention, person-centered care, and other population-based skills that reflect the strengths of community and public health nurses.”

(National Academy of Medicine, 2021, p. 2)

Vaccinations

(See Vaccinations at Chapter 6: Laws, Rules, and Regulations)

Staying Home When Sick

Students and staff should remain home when gastrointestinal or respiratory illnesses are present. Districts should have a procedure in place for reporting illnesses and communicable diseases to the school nurse. Districts should provide policies and procedures to parents and staff on how to report an illness and when they must stay home. Each district should check with their physician and local public health departments on guidelines for both students and staff. Districts should also consult their human resources department for policies on staff illness.

Proper Ventilation Ventilation is another component of maintaining a healthy environment. Bringing in as much outdoor air as the ventilation system allows and opening windows, when possible, helps to decrease the particles of airborne infectious diseases circulating in a room. To improve air quality, districts should also do routine maintenance and cleaning of their ventilation systems to ensure the system works properly and well-maintained (CDC, 2019). The Environmental Protection Agency has an air quality toolkit for schools.

Hand and Respiratory Hygiene

Handwashing is the number one intervention to prevent illness in schools. The school nurse should instruct students on how and when to wash their hands properly. School nurses can also remind students to cough into a tissue or sleeve. Posters in restrooms and the health office can help emphasize the importance of handwashing (CDC, 2023a).

Staff should know where to obtain gloves and other personal protective equipment (PPE) and be reminded not to touch blood or infectious material. (See Standard Precautions) The school health program should practice and encourage masking when appropriate or advised, such as during an outbreak or when individuals have respiratory symptoms. Examples of body fluids that transmit infection that results in illness include the following:

Table 10. Diseases Spread Through Contact with Body Fluids

It is important to remember that any person could have disease-causing organisms in their body fluids, even if they have no signs or symptoms of illness. Consequently, school staff should follow the recommendations below in all situations, not just those involving an individual known to have an infectious disease.

In the school setting, staff should take reasonable steps to prevent individuals from having direct skin or mucous membrane contact with any moist body fluid from another person. Specifically, avoid direct contact with all the following:

1. Blood (find more detail about preventing exposure to blood or blood-contaminated body fluids in standard precautions).
2. All other body fluids, secretions, and excretions, regardless of whether they contain visible blood.
3. Non-intact skin (any area where the skin surface is not intact, such as moist skin sores, ulcers or open cuts).
4. Mucous membranes.

If someone’s hands or other skin surfaces are contaminated with body fluids from another person, they should wash with soap and water as soon as possible.

In general, staff should wear standard medical vinyl or latex gloves whenever they anticipate direct contact with any body fluid from another person. Staff should make gloves available and easily accessible in any setting where contact with body fluids could take place. Staff should always wash hands immediately after removing gloves. Staff should also have access to pocket masks or other devices for mouth-to-mouth resuscitation.

Mucous membranes cover the eyes and the inside of the nose and mouth, along with certain other parts of the body. In a school setting, avoiding mucous membrane contact with body fluids means, for practical purposes, that one does not get these fluids in one’s eyes, nose, or mouth. Someone can generally accomplish this by not rubbing their eyes with their hands, and not putting their hands or anything touched by unwashed hands (such as food) in one’s mouth. Good handwashing is vital to preventing mucous membrane exposure to disease-causing organisms.

Cleaning/Disinfecting

Each district should review policies and procedures for cleaning and disinfecting the health office, student rooms, equipment, floors, and other student areas. Districts should ensure staff follow cleaning and disinfecting standards. Access updated Centers for Disease Control and Prevention guidelines here.

Districts may need to institute an enhanced cleaning/disinfection routine during an outbreak of illness or communicable disease. The school nurse, administration, and maintenance personnel must all be involved in determining the products and frequency of the service.

The National Association of School Nurses reminds school nurses of the difference between cleaning and disinfecting:

• “Cleaning—using soap (or detergent) and water to physically remove germs, dirt, and impurities from surfaces or objects. This process does not necessarily kill germs, but by removing them, it lowers their numbers and the risk of spreading infection.
• Disinfecting—using chemicals to kill germs on surfaces or objects. (National Association of School Nurses, n.d.)

(See Standard Precautions.)

Management and Containment of Cases or Outbreaks

The school nurse and local public health should work together to prevent or mitigate illness or outbreaks of infectious diseases. The school should follow disease outbreak control measures and reporting required by state laws, the Missouri Department of Health and Senior Services’ rules governing the control of communicable diseases dangerous to public health, and any city or county laws and rules.

Standard Precautions

Bloodborne Pathogens

Using standard precautions (formerly universal precautions) acknowledges that any person’s body fluids, including blood, may be infectious, and includes the need to use personal protective equipment (PPE) such as gloves, masks, or clothing to prevent exposure to body substances. These precautions include:

• Wearing disposable gloves for contact or anticipated contact with any person’s blood or body fluids.
• Wearing protective gown/apron if soiling of clothes is likely.
• Wearing goggles and/or mask as appropriate when splashing of blood/bloody fluids is likely.
• Always washing hands after removing gloves or when hands have come in contact with blood or any body-fluid/excretion.

In addition:

1. If any body fluids come into contact with the mucous membrane surfaces of the nose or mouth, immediately flush the area with water. If the mucous membrane surfaces of the eye are contaminated, irrigate with clean water or saline or sterile solutions designed for this purpose.
2. Take precautions to avoid injuries with sharp instruments contaminated with blood. Do not recap needles. After use, place disposable syringes, needles, and other sharp items in puncture-resistant, leak-proof containers for disposal; place the puncture-resistant containers as close as practical to the use area. School districts should have a clear procedure for sharps usage and disposal.
3. Persons providing health care who have exudative skin lesions or weeping dermatitis should refrain from all direct care, and from handling care equipment, until the condition resolves.

The Missouri Code of State Regulations, 19 CSR 20-20.092, requires public employers in the state of Missouri having employees with occupational exposure to blood or other potentially infectious materials to follow the Occupational Safety and Health Administration standards as codified in 29 CFR 1910.1030.

The rule establishes the current standard of practice for preventing transmission of infectious blood-borne agents in occupational settings and contains public health and risk management policies. School administrators and other school personnel involved in making health policy decisions should become familiar with this rule and consider, in consultation with appropriate legal counsel, adopting the policies that it describes, including the development of an exposure control plan. Exposure control plans should include a statement on providing hepatitis B vaccine to appropriate school staff.

The Occupational Safety and Health Administration (OSHA) guidelines, which is the standard adopted by the Missouri Department of Health and Senior Services also require:

• Persons with assigned occupational duties that may expose them to blood receive the hepatitis B vaccine. Vaccination of all school staff is neither feasible nor necessary. The district should provide staff with potential exposure three doses of hepatitis B vaccine free of charge. Such individuals include:
  • The person(s) assigned primary responsibility for providing first aid.
  • Special education/early childhood development personnel who may have contact with children infected with hepatitis B. These children may have special behavioral and/or medical problems which increase the likelihood of hepatitis B transmission.
  • The person(s) assigned primary responsibility for cleaning up body fluid spills.

If a staff member refuses the offered vaccine, the district should require them to sign a statement indicating they refused the offered vaccine. School nurses (RNs and LPNs) licensed under Chapter 335, RSMo, are required, according to Section 191.694 RSMo, to adhere to standard precautions, including the appropriate use of handwashing, protective barriers, and care in the use and disposal of needles and other sharp instruments.

Procedures for Cleaning Spills of Blood or Other Body Fluids

Please refer to the Prevention and Control of Communicable Disease [NEEDS LINK], Missouri Department of Health and Senior Services, 2011, p. 35-40 for further guidance, including guidance for the use of bleach and other types of disinfecting products.

1. Use absorbent floor-sweeping material to cover larger body fluid spills prior to cleaning.
2. Wear sturdy, non-permeable gloves and other protective clothing as necessary.
3. Use disposable absorbent towels or tissues, along with soap and water, to clean the area of the spill as thoroughly as possible.
4. If the gloves worn to clean up the spill are reusable rubber gloves, wash them with soap and running water prior to removal. Place disposable gloves in an impermeable plastic bag. Regardless of the type of gloves used, take care during glove removal to avoid contamination of the hands. However, whether any known contamination occurs, thoroughly wash the hands with soap and water after removing the gloves.
5. If the person doing the clean-up has any open skin lesions, take precautions to avoid directly exposing the lesions to the body fluids.
6. If direct skin exposure to body fluid accidentally occurs, thoroughly wash the exposed area with soap and water for at least 15 seconds.
7. Always keep one or more clean-up kits on hand for blood/body fluid spills in one or more central locations so that they are readily accessible. The clean-up kit should consist of the following items:
   • Absorbent floor-sweeping material
   • Liquid soap
   • Disinfectant
   • Small buckets
   • Rubber or plastic gloves
   • Disposable towels or tissues
   • Impermeable plastic bags

Caution: If using diluted bleach solution, do not use the solution for any other purpose than the clean-up described above. Mixing this solution with certain other chemicals can produce a toxic gas. Also, dilute any EPA—approved disinfectant used according to manufacturer’s instructions. It is not appropriate or necessary to add more disinfectant than the directions indicate. Doing so will make the disinfectant more toxic and could result in skin or lung damage to individuals using it.

COVID-19 and Other Pandemic/Endemic Infections

The COVID-19 outbreak of 2019-2022 was one of the worst pandemics the United States and other countries have seen in many decades. Public health, researchers, and health care systems developed and implemented strategies that eventually slowed the pandemic and allowed life to have a sense of normalcy. Although COVID-19 infections continue to this day, most people now have some protection, or immunity, against COVID-19 due to vaccination, previous infection, or both. This immunity, combined with the availability of tests and treatments, has greatly reduced the risk of severe illness, hospitalization, and death from COVID-19 for many people. Students also returned to the classroom with many environmental interventions to prevent and mitigate spread, such as distancing, screening, testing, and enhanced cleaning and disinfecting.

School nurses should also continue to work with their local public health agency to identify the need for enhanced prevention. The CDC is the best resource for finding current information on emerging illnesses and recommended procedures to be ready.

Resources

Table 11. Resources for Infection Control

References

• CDC. (2023a, August). Hand hygiene in schools and early care and education settings. Accessed at https://www.cdc.gov/clean-hands/prevention/about-hand-hygiene-in-schools-and-early-care-and-education-settings.html?CDC_AAref_Val=https://www.cdc.gov/handwashing/handwashing-school.html
• Centers for Disease Control and Prevention. (2024). Vaccines and immunizations. Accessed at https://www.cdc.gov/vaccines/index.html
• Missouri Department of Health and Senior Services. (2023). Communicable diseases. Accessed at https://www.sos.mo.gov/cmsimages/adrules/csr/current/19csr/19c20-20.pdf
• National Academy of Medicine. (2021, May). The future of nursing 2020–2030: Charting a path to achieve health equity. Accessed at https://nap.nationalacademies.org/resource/25982/Highlights_Future%20of… _final.pdf
• National Association of School Nurses. (n.d.) Covid-19 resources. Accessed at https://www.nasn.org/covid19ref/home
• National Association of School Nurses. (n.d.). Covid-19 reference. Accessed at https://schoolnursenet.nasn.org/covid19ref/glossary/cleaning-and-disinfection-in-the-nurses-office-space
• U.S. Department of Labor Occupational Safety and Health Administration. (2019, May). Blood-Borne pathogens. Accessed at https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARD… 51
• U.S. Environmental Protection Agency. (2023, May). Indoor air quality tools for schools: Preventive maintenance guidance documents. Accessed at https://www.epa.gov/iaqschools/indoor-air-quality-tools-schools-preventive-maintenance-guidance-documents