Revise parent visits or minimize visits and require them to occur only in the school office antibiotics bladder infection purchase 500mg ciprofloxacin with visa. Restrict the number of people in the school building that are not students or staff to a minimal number and ensure that someone is assigned to enforce the rules zosyn antimicrobial coverage generic ciprofloxacin 500 mg. Only allow employees that are required for student instruction and student services to be in the building during school hours antibiotic resistance new york times ciprofloxacin 500mg without prescription. Dealing with Illness (See also Appendix A antibiotics for ear infection generic ciprofloxacin 250 mg, Sample Health Protocol for Schools): · · Any person exhibiting signs of illness will be sent to the nurse immediately for evaluation antibiotics bladder infection discount ciprofloxacin 500 mg with visa. Few people will be allowed in the room antibiotic resistance activity ciprofloxacin 1000 mg line, and the room will be disinfected frequently antibiotic resistant klebsiella pneumoniae buy discount ciprofloxacin 500 mg. Students/staff will be walked out of the building from the room to persons driving them home treatment for uti bactrim ciprofloxacin 1000mg without prescription. If possible and if adequate equipment is available, take regular temperature checks of students and staff. Encourage parents and staff to bring their own thermometers and take the temperatures of their children or their own temperature before entering the building. Alternate schedule - minimize numbers of students in gymnasium, require social distancing (Goal: 6 feet). Teachers use controlled entrance and exits -meet students at classroom utilizing outside entry door as much as possible to pick up and take to gym, fields, multipurpose rooms, etc. Schedule outdoor activities as much as possible with weather conditions being considered Use separate partitions in open spaces; utilize markings on gymnasium floor/wall/field (student section/work stations). Manage social distancing when moving students to gymnasium/field Students should be provided own equipment for class/prohibit equipment sharing. Blended Learning/Flipped classroom for concepts and skills relating to each standard (utilizing technology platforms). Self-Management - Individualized programs multiple activity stations allowing for personal choice with personal recording (record keeping, personalized logs, goal-setting, etc. Games and sport activities that require close guarding and potential contact with another player should not be included. Workstation equipment set-up should consider strategies for social distancing throughout activity. All efforts should be made at every level to assist students in creating personal activities and exercise plans that include logging and reporting of learning processes, achievement of standards and all available assessment benchmarks. Larger playground equipment that cannot be disinfected between uses should not be used until social distancing requirement can be eased. Classroom energizers/mindful minutes can be done in the classroom where students stay at or near their assigned desks/workstations. Provide regular classroom breaks for outdoor or hallway walking and movement activities. The Board expects the superintendent to keep the Board informed of changes made pursuant to this resolution. The Board reserves its authority over decisions relating to the school year calendar. This resolution will continue until the state of emergency in Missouri ends, as declared by the Governor, or the Board revokes the resolution in whole or in part. Identify core planning team (key school personnel, representatives from local first responders, emergency management agencies, medical and mental health departments and/or providers, community leaders and other key stakeholders. Threat and Hazard Specific Annex-specifies actions to address specific threat or hazard. Explains intent and gives an overall picture of how the school will protect students, staff and visitors. Provides an overview of broad roles and responsibilities of school staff, families, guardians and community partners as well as organizational functions during all emergencies. Addresses the role of information in implementation of activities occurring before, during and after an emergency. Describes critical training and exercises the school will use in support of the plan. Covers general support requirements and availability of services and support for all types of emergencies. Covers general policies and identifies/references related policies and procedures that exist outside the plan. Describes overall approach to planning and the assignment of plan development and maintenance responsibilities. May include "reverse evacuation" procedures to move from outside buildings to inside. Courses of action to secure buildings and grounds during immediate threat in or around school. Primary objective is to quickly ensure all school staff, students and visitors are secured in rooms away from immediate danger. May include "lockout," similar to lockdown but activities are still allowed indoors with external doors secured. Courses of action when students/staff are required to remain indoors for potential extended period of time. Courses of action for accounting for the whereabouts and well-being of students, staff and visitors. Communication and coordination (internal and external) during emergencies and disasters. Communication of emergency protocols before emergency and communication after emergency. Courses of action to ensure essential functions continue during an emergency and immediate aftermath. Courses of action the school will implement to address emergency medical, public health and mental health counseling issues. Courses of action to implement on a routine, ongoing basis to secure the school from criminal threats originating from both inside and outside the school. Threat and Hazard Specific Annexes Natural Hazards · Earthquakes · Tornados · Lightning · Severe wind · Hurricanes · Floods · Wildfires · Extreme temperatures · Landslides or mudslides · Tsunamis · Volcanic eruptions · Winter precipitation Technological Hazards · Explosions/accidental release of toxins (external) · Accidental release of hazardous materials (internal) · Hazardous materials release from highways/railroads · Radiological releases from nuclear power stations · Dam failure · Power failure · Water failure Biological Hazards · Infectious diseases (pandemic, epidemic, etc. Processes described will be coordinated with appropriate representatives for public health, emergency medical services, mental health, law enforcement, fire department and emergency management. Establish policies and procedures for appropriate response to public health, medical and mental health concerns. Effective response to address public health, emergency medical and mental health issues. Provide post-emergency support for issues related to public health, medical or mental health concerns. Before public health, medical or mental health concern · Identify and evaluate issues related to public health, emergency medical aid and mental health concerns. During public health, medical or mental health concern · Report concerns of potential public health, medical or mental health concerns. Evaluate potential for long-term closure and resources necessary to accommodate those with identified needs. After public health, medical or mental health concern · Provide support resources for victims and responding staff. Scope the annex outlines responsibilities for staff in the threat or event of a pandemic outbreak of disease that impacts the school community. Emergency Action Plan A pandemic is a global disease outbreak for which there is little to no immunity. A virus or disease can spread quickly when students, staff or visitors are exposed outside the school so precautionary measures are necessary to reduce potential impact to the school community and educational operations. Public health authorities have identified characteristics and challenges unique to a pandemic, including but not limited to: · A global spread is considered inevitable when the pandemic virus emerges. Death rates could be unpredictable due to the significant number of people who become infected, the virulence of the virus, and the characteristics and vulnerability of affected populations (elderly, those with chronic disease, and children). Pandemics may cause economic and social disruption such as schools and businesses closing, travel bans, and canceling of community events. Care of sick family members and fear of exposure can result in significant absenteeism in the workforce. Before Pandemic Event: · Develop policies and procedures for preventative measures for all staff. Implement "social distancing" rules for gatherings, classrooms and movement through buildings. Make accommodations for those who are considered high risk or have functional or emotional needs. Evaluate situation and determine if school closing is necessary to reduce spread of illness. Communicate with parents/guardians of exposed students and initiate process of release. Activate alternative education procedures for those in containment or released to parents/guardians. After Pandemic Event: · Monitor local, state and federal emergency management notices and alerts to determine feasibility of return to facilities and operations. The following questions are provided to assist districts in evaluating the 2019-20 school closure year to prepare for any future closures. Could staff have processed screening more effectively and with further discretion? Even though school is opening, there are still some people who are sick from the virus. We will continue to provide you with the most vital and up-to-date information as soon as possible. Because the virus can still be spread person-to-person, please keep children who are sick at home. Here are some tips for helping those sick with the virus: Keep the sick person as comfortable as possible. Keep the people who are sick with the virus away from the people who are not sick. In the near future, we will provide you more information about how school days and schoolwork missed during the school closure will be made up. This document has been modified from documents created by the Georgia Department of Education. The school(s) may be closed for several days or weeks to reduce contact among children and stop the spread of the virus. We know this is a hard time for our community and our hearts go out to those who are ill. You may wish to check our school district webpage for updated information and tune to local news stations for more details about our plans to continue education and possibly reopen the school(s). Here are some tips for helping those who are sick with the virus: Keep the sick person as comfortable as possible. For fever, sore throat and muscle aches, use ibuprofen (Motrin) or acetaminophen (Tylenol). We will contact you as soon as we have information about classes or school reopening, and we will also inform the local news media. We encourage all parents to encourage their children to read whatever textbooks are available at home, to read other material at home, to practice computations and writing, and access instructional programs on the internet, network, public, and/or access channels. As of this writing, there have been no confirmed cases of this virus in County. At this time, local public health officials tell us that students can continue to safely attend classes and schools will remain open. The spread of the virus will be monitored closely in the coming days and we will follow recommendations of public health officials in response to any changes in the status of the virus which could affect our schools and community. In the event there are confirmed cases in County, we will work with public health officials to carefully evaluate necessary actions. If school closings become necessary, we will inform our community immediately using our website, our education channel, and the media. We will inform you of our plans to continue education in some form [school may want to attach instructions for education continuity] Please continue to implement the following measures to protect against the virus: Staying home from work or school and limiting contact with others when you are sick Covering your nose and mouth with a tissue when you cough or sneeze and properly discard used tissues. If no tissue is available, cough or sneeze into your upper sleeve, not your hands. Frequently washing your hands with soap and water or an alcohol-based hand sanitizer Avoiding touching your eyes, nose and mouth. Literature numbers to be used for ordering literature are listed under each item below. Wash Your Hands (flyer/poster) English, Spanish, Bosnian, English laminated, 8Ѕ"x11" this flyer/poster provides brief instructions on proper handwashing. It is appropriate for use with all audiences to encourage good handwashing habits at all times. Display the poster in all restrooms English laminated #297 Spanish #238 Bosnian #1267 and food-preparation areas, use as a handout in awareness displays/activities or attach to newsletters/bulletins. It can be placed on refrigerators, on stall doors in public restrooms, on metal cabinets in food preparation areas and in offices on metal file cabinets. It can be displayed in all restrooms and food-preparation areas, used as a handout in awareness displays/ activities, or attached to newsletters/ bulletins. This flyer/poster provides brief instructions on the proper etiquette for covering your cough and handwashing. It is intended for all worksites and particularly clinical and residential care settings. It could be posted in employee break areas, made available as a handout for community awareness displays/activities, and handed out during employee orientations. The #1034 8Ѕ"x11" Spanish and Bosnian versions are only #1030 11"x14" available in electronic format. Public Health Message E-cards E-cards are electronic postcards that send public health messages in the click of a button. All you need is an e-mail address (or a group contact list) to send a personalized health message directly to cell phones or personal computers. Preparation and Cleaning · Inspect all buses and transport vehicles for cleanliness and safety. Inventory, collect, and purchase enough cleaning equipment and hygiene supplies with the understanding that buses will be disinfected more frequently and thoroughly than previous years. Ensure Material Safety Data is available for all chemical products used in the process. Modifications to Transportation · When feasible, assign drivers to a single bus and a specific route and take other measures to minimize the number of drivers who use a vehicle. When necessary, exchange drivers as opposed to loading students onto a different vehicle. Work with the community to provide appropriate crossing guards and work with parents in neighborhoods surrounding the school building to provide supervision for students walking to school. Prior to the first day of school, encourage parents to add chalk marks or tape at the bus stop in six-foot intervals to teach students the appropriate distancing techniques. However, do not open windows if they pose a safety risk to passengers or employees, or other vulnerable individuals such as students with asthma. Prohibit eating or drinking (unless medically required) or chewing gum on the bus. Consider installing hand sanitizer stations inside buses or provide drivers and passengers with access to alcohol-based hand sanitizers containing at least 60% alcohol on the bus. Prepare a list of drivers for respective routes and other school related functions. Cross-train drivers on routes to ensure that more than one employee is prepared to drive a route if there are unexpected absences. Training Ensure drivers and maintenance/cleaning staff are properly trained in the use of the tools and products as related to cleaning of buses and other transportation vehicles. Appropriate protocols for coughs and sneezes for employees and students so that employees can model appropriate behavior and correct students. The appropriate methods for cleaning buses, including opening doors and windows for effective circulation and to avoid extensive exposure to cleaning fumes. The location of and how to use eye wash stations in the case of chemical contact with eyes. Techniques for minimizing exposure such as: o Using gloves when handling and disposing of trash o Avoiding touching surfaces often touched by passengers o Universal precautions when handling bodily fluids. Transportation Management or Routing Departments · · · · · · Follow social distancing guidelines of six feet of separation. Consider placing barriers between workstations if they cannot be separated by six feet. Provide cleaning supplies to clean surfaces before, during, and after the workday. Telepractice is an approved way to deliver services to students in the state of Missouri. School districts may consider contracting with telepractice vendors to help support: *Make-up time for missed services *Medically fragile students unable to return *Grade-level screenings *Assistance with caseload management *Evaluations *Regular therapy services · · · · · Students can receive telepractice in a school setting or in their own home. Generally, the school and caregiver need a reliable internet connection, computer or tablet with video camera options and speakers. Students of all ages have experience with screen-based technology and are comfortable interacting in this manner. Telepractice services delivered in the home setting, will provide caregivers assisting with facilitation of the therapy session, benefits from coaching, cueing and use of therapy strategies resulting in improved student progress. If entering into a contract for telepractice, districts should be discerning about the teletherapy vendor with whom they enter a contract. Not all vendors are equal and considerations beyond the lowest hourly or subscription cost are important.
Scabies virus 3030 1000 mg ciprofloxacin, only if the child has not been treated after notifying the family at the end of the prior program day 10th antimicrobial workshop purchase 250 mg ciprofloxacin with visa. Chickenpox (varicella) infection 1 game proven ciprofloxacin 250mg, until all lesions have dried or crusted (usually six days after onset of rash and no new lesions have appeared for at least 24 hours); k antibiotic resistance sweeping developing world generic ciprofloxacin 750mg without a prescription. Any child determined by the local health department to be contributing to the transmission of illness during an outbreak bacterial reproduction order ciprofloxacin 750 mg line. Toys antibiotic hives cheap 750mg ciprofloxacin overnight delivery, equipment antibiotics for uti child ciprofloxacin 750 mg fast delivery, and surfaces used by the ill child should be cleaned and disinfected after the child leaves; b virus game purchase 500 mg ciprofloxacin. Discuss the signs and symptoms of illness with the parent/guardian who is assuming care. If necessary, provide the family with a written communication that may be given to the primary care provider. The communication should include onset time of symptoms, observations about the child, vital signs and times. The nature and severity of symptoms and or requirements of the local or state health department will determine the necessity of medical consultation. Telephone advice, electronic transmissions of instructions are acceptable without an office visit; c. If the child has been seen by their primary health provider, follow the advice of the provider for return to child care; 144 Caring for Our Children: National Health and Safety Performance Standards d. If the child seems well to the family and no longer meets criteria for exclusion, there is no need to ask for further information from the health professional when the child returns to care. Children who had been excluded from care do not necessarily need to have an in-person visit with a health care provider;. Contact the local health department if there is a question of a reportable (harmful) infectious disease in a child or staff member in the facility. If there are conflicting opinions from different primary care providers about the management of a child with a reportable infectious disease, the health department has the legal authority to make a final determination; f. In collaboration with the local health department, notify the parents/guardians of contacts to the child or staff member with presumed or confirmed reportable infectious infection. When a child or staff member who is in contact with others has a reportable disease; b. If a reportable illness occurs among the staff, children, or families involved with the program; c. Clusters of mild respiratory illness, ear infections, and certain dermatological conditions are common and generally do not need to be reported. Caregivers/teachers should work with their child care health consultants to develop policies and procedures for alerting staff and families about their responsibility to report illnesses to the program and for the program to report diseases to the local health authorities. Excluding children with mild illnesses is unlikely to reduce the spread of most infectious agents (germs) caused by bacteria, viruses, parasites and fungi. As a child gets older s/he develops immunity to common infectious agents and will become ill less often. Since exclusion is unlikely to reduce the spread of disease, the most important reason for exclusion is the ability of the child to participate in activities and the staff to care for the child. Children attending child care frequently carry contagious organisms that do not limit their activity nor pose a threat to their contacts. Written notes should not be required for return to child care for common respiratory illnesses that are not specifically listed in the excludable condition list above. For specific conditions, Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide, 4th Edition has educational handouts that can be copied and distributed to parents/guardians, health professionals, and caregivers/teachers. For more detailed rationale regarding inclusion/ exclusion, return to care, when a health visit is necessary, and health department reporting for children with specific symptoms, please see Appendix A: Signs and Symptoms Chart. State licensing law or code defines the conditions or symptoms for which exclusion is necessary. States are increasingly using the criteria defined in Caring for Our Children and the Managing Infectious Diseases in Child Care and Schools publications. Usually, the criteria in these two sources are more detailed than the state regulations so can be incorporated into the local written policies without conflicting with state law. If a child has been in a very hot environment and heatstroke is suspected, a higher temperature is more serious; d. Oral temperatures are difficult to take for children younger than four years of age; 145 Chapter 3: Health Promotion and Protection f. Rectal temperatures should be taken only by persons with specific health training in performing this procedure and permission given by parents/guardians, however this method is not generally practiced due to concerns about proper procedure and risk of accusations of sexual abuse; g. Axillary (armpit) temperatures are accurate only when the thermometer remains within the closed armpit for the time period recommended by the device; h. A facility should not deny admission to or send home a staff member or substitute with illness unless one or more of the following conditions exists: a. However, it is not practical to test all ill staff members to determine whether they have common cold viruses or influenza infection. Chickenpox, until all lesions have dried and crusted, which usually occurs by six days; c. Shingles, only if the lesions cannot be covered by clothing or a dressing until the lesions have crusted; d. Measles, until four days after onset of the rash (if the staff member or substitute has the capacity to develop an immune response following exposure); f. Stool samples need to be collected at least 48 hours after antibiotic treatment is complete. Other types of Salmonella do not require negative test results from stool cultures. Vomiting illness, two or more episodes of vomiting during the previous twenty-four hours, until vomiting resolves or is determined to result from noninfectious conditions; h. Hepatitis A virus, until one week after symptom onset or as directed by the health department; i. Pertussis, until after five days of appropriate antibiotic therapy or until 21 days after the onset of cough if the person is not treated with antibiotics; j. Tuberculosis, until noninfectious and cleared by a health department official or a primary care provider; l. Strep throat or other streptococcal infection, until twenty-four hours after initial antibiotic treatment and end of fever; m. Head lice, from the end of the day of discovery until after the first treatment; n. Haemophilus influenzae type b (Hib), prophylaxis, until cleared by the primary health care provider; p. This includes a respiratory illness in which the staff member is unable to consistently manage respiratory secretions using proper cough and sneeze etiquette. A fully immunized child with a contagious, infectious or communicable condition will likely not have an illness that is harmful to the child or others. Hand and personal hygiene is paramount in preventing transmission of these organisms. Axillary (under the arm) temperatures are less accurate, but are a good option for infants and young children when the caregiver/teacher has not been trained to take a rectal temperature. Therefore, tympanic thermometers should not be used in children under four months of age, where fever detection is most important. Mercury thermometers can break and result in mercury toxicity that can lead to neurologic injury. Although not a hazard, temporal thermometers are not as accurate as digital thermometers (2). If rectal temperatures are taken, steps must be taken to ensure that all caregivers/teachers are trained properly in this procedure and the opportunity for abuse is negligible (for example, ensure that more than one adult present during procedure). Rectal temperatures should be taken only by persons with specific health training in performing this procedure and permission given by parents/guardians. Many state or local agencies operate facilities that collect used mercury thermometers. For more information on household hazardous waste collections in your area, call your State environmental protection agency or your local health department. In a systematic review, infrared ear thermometry for fever diagnosis in children finds poor sensitivity. Mercury containing thermometers and any waste created from the cleanup of a broken thermometer should be disposed of at a household hazardous waste collection facility. Rectal temperatures should be taken only by persons with specific health training in performing this procedure. Oral (under the tongue) temperatures can be used for children 147 Chapter 3: Health Promotion and Protection 3. The child or staff member should be readmitted when the health department official or primary care provider who made the initial determination decides that the risk of transmission is no longer present. Control of outbreaks of infectious diseases in child care may include age-appropriate immunization, antibiotic prophylaxis, observing well children for signs and symptoms of disease and for decreasing opportunities for transmission of that may sustain an outbreak. Removal of children known or suspected of contributing to an outbreak may help to limit transmission of the disease by preventing the development of new cases of the disease (1). When children are not permitted to receive care in their usual child care setting and cannot receive care from a parent/guardian or relative, they should be permitted to receive care in one of the following arrangements, if the arrangement meets the applicable standards: a. Care in a separate small family child care home or center that serves only children with illness or temporary disabilities; c. Young children enrolled in group care experience a higher incidence of mild illness (such as upper respiratory infections or otitis media) and other temporary disabilities (such as exacerbation of asthma) than those who have less interaction with other children. Sometimes, these illnesses preclude their participation in the usual child care activities. To accommodate situations where parents/guardians cannot provide care for their own children who are ill, several types of alternative care arrangements have been established. The majority of viruses are spread by children who are asymptomatic, therefore, exposure of children to others with active symptoms or who have recently recovered, does not significantly raise the risk of transmission over the baseline (2). These diseases are transmitted by direct person-to-person contact or by sharing personal articles such as combs, brushes, towels, clothing, and bedding. Prohibiting the sharing of personal articles and providing space so that personal items may be stored separately helps prevent these diseases from spreading. A hand sanitizing dispenser is an alternative to traditional handwashing (3,4); f. Handwashing sinks should be stationed in each room that is designated for the care of ill children to promote hand hygiene and to give the caregivers/teachers an opportunity for continuous supervision of the other children in care when washing their hands. The sink must deliver a consistent flow of water for twenty seconds so that the user does not need to touch the faucet handles. Diaper changing areas should be adjacent to sinks to foster cleanliness and to enable caregivers/teachers to provide continuous supervision of other children in care. Indoor space that the facility uses for children who are ill, including classrooms, hallways, bathrooms, and kitchens, should be separate from indoor space used with well children. The facility may use a single kitchen for ill and well children if the kitchen is staffed by a cook who has no child care responsibilities other than food preparation and who does not handle soiled dishes and utensils until after food preparation and food service are completed for any meal; b. If the program for children who are ill is in the same facility as the well-child program, well children should not use or share furniture, fixtures, equipment, or supplies designated for use with children who are ill unless they have been cleaned and sanitized before use by well children; c. Children whose symptoms indicate infections of the gastrointestinal tract (often with diarrhea) should receive their care in a space separate from other children with other illnesses. Limiting child-to-child interaction, separating staff responsibilities, and not mixing supplies, toys, and equipment reduces the likelihood of disease being transmitted between children d. Children with chickenpox, pertussis, measles, mumps, rubella, or diphtheria, require a room with separate ventilation including fresh outdoor air (1);. Each room/home that is designated for the care of children who are ill should have a handwashing sink that can provide a steady stream of clean, running water that is at a comfortable temperature at least for twenty seconds (2). At least forty hours of training in prevention and control of infectious diseases and care of children who are ill, including subjects listed in Standard 3. At least two prior years of satisfactory performance as a director of a regular facility; c. At least twelve credit hours of college-level training in child development or early childhood education. In addition, facilities should document, for each caregiver/teacher, twenty hours of pre-service orientation training on care of children who are ill beyond the orientation training specified in Standards 1. Recognition and documentation of signs and symptoms of illness including body temperature; 2. Communication with parents/guardians of children who are ill; Knowledge of immunization requirements; 5. Provide care in a place with which the child is familiar and comfortable away from other children in care; c. Offer a program with trained personnel planned in consultation with qualified health care personnel and with ongoing medical direction. Unfamiliar places and caregivers/teachers add to the stress of illness when a child is sick. Based on these evaluations, the training on care of children who are ill should be updated with a minimum of six hours of annual training for individuals who continue to provide care to children who are ill. Work experience in child care facilities will help the caregiver/teacher develop these skills. States that have developed rules regulating facilities have recognized the need for training in illness prevention and control and management of medical emergencies. Staff members caring for children who are ill in special facilities or in a get well room in a regular center should meet the staff qualifications that are applied to child care facilities generally. Caregivers/teachers have to be prepared for handling illness and must understand their scope of work. Special training is required of caregivers/teachers who work in special facilities for children who are ill because the director and the caregivers/teachers are dealing with infectious diseases and need to know how to prevent the spread of infection. Each caregiver/teacher should have training to decrease the risk of transmitting disease (1). The child care health consultant should have the knowledge, skills and preparation as stated in Standard 1. The facility should involve the child care health consultant in development and/or implementation, review, and signoff of the written policies and procedures for managing specific illnesses. The facility staff and the child care health consultant should review and update the written policies annually. The facility should assign the child care health consultant the responsibility for reviewing written policies and procedures for the following: a. Plans for surveillance of illnesses that are admissible and problems that arise in the care of children with illness;. Plans for staff training and communication with parents/guardians and primary care providers; f. The expert consensus is based on theories of child development including attachment theory 151 Chapter 3: Health Promotion and Protection family must be given primary consideration in the care of children who are ill. Facilities should use the expertise of primary care providers to design and provide a child care environment with sufficient staff and facilities to meet the needs of children who are ill (2,3). The best interests of the child and family must be given primary consideration in the care of children who are ill. Consultation by primary care providers, especially those whose specialty is pediatrics, is critical in planning facilities for the care of children who are ill (1). State or local health department (especially public health nursing, infectious disease, and epidemiology departments). This standard ensures that child care facilities are continually reviewed by an appropriate state authority and that facilities maintain appropriate standards in caring for children who are ill. Current status of the illness, including potential for contagion, diet, activity level, and duration of illness; c. Health care, diet, allergies (particularly to foods or medication), and medication and treatment plan, including appropriate release forms to obtain emergency health care and administer medication; d. Communication between parents/guardians, the child care program and the primary care provider (medical home) requires the free exchange of protected medical information (2). Facilities who serve children who are ill should include children with conditions listed in Standard 3. This could include lethargy or lack of responsiveness, irritability, persistent crying, difficulty breathing, or having a quickly spreading rash; b. Fever (temperature for an infant or child older than 2 months that is above 101° F [38. Diarrhea (Defined by stool that is occurring with more frequency or is less formed in consistency than usual in the child and not associated with changes in diet. For toilet-trained children, exclusion is required when diarrhea is causing "accidents". Exclude children whose stool frequency exceeds 2 stools above normal frequency) and one or more of the following: 1. Signs of dehydration, such as dry mouth, no tears, lethargy, sunken fontanelle (soft spot on the head); 2. Blood or mucus in the stool until it is evaluated for organisms that can cause dysentery; 3. Vomiting 2 or more times in the previous 24 hours, unless vomiting is determined to be caused by a noncommunicable or noninfectious condition and the child is not in danger of dehydration;. Contagious stages of pertussis, measles, mumps, chickenpox, rubella, or diphtheria, unless the child is appropriately isolated from children with other illnesses and cared for only with children having the same illness; f. Untreated infestation of scabies or head lice; exclusion not necessary before the end of the program day; g. Abdominal pain that is intermittent or persistent and is accompanied by fever, diarrhea, vomiting, or other signs and symptoms; j. Upper or lower respiratory infection in which signs or symptoms require a higher level of care than can be appropriately provided; and m. Severely immunocompromised children and other conditions as may be determined by the primary health care provider and/or child care health consultant (1,2). Diarrheal illnesses that require an intensity of care that cannot be provided appropriately by a caregiver/teacher could result in temporary exclusion (1,2).
Five studies65 antibiotics raise blood sugar buy 250 mg ciprofloxacin with visa,71 antibiotics for sinus and lung infection 1000 mg ciprofloxacin free shipping,72 virus hunters of the cdc generic 500mg ciprofloxacin free shipping,74 antibiotic klebsiella ciprofloxacin 250 mg on-line,78 disclosed and met the needed sample size to determine significant findings antibiotics for acne cause weight gain generic ciprofloxacin 500mg otc, whereas the remaining studies did not report this value or did not obtain the needed study participants antimicrobial use guidelines ciprofloxacin 750mg visa. One study66 was funded by a grant from the Asthma and Allergy Research Group virus 868 buy cheap ciprofloxacin 500 mg, whereas the remaining studies received funding from pharmaceutical companies or the members of the study teams were or had been a consultant or speaker for a pharmaceutical company or employees of a pharmaceutical company antibiotic resistance report 2015 purchase ciprofloxacin 1000 mg without prescription. Continuous variables, such as nasal symptom scores, were analyzed in forest plots, and, where possible, the results of several trials were grouped. The workgroup and ultimately the Joint Task Force reviewed these draft assessments, applied their assessments of clinical importance for each patient-important outcome, and determined an overall quality of evidence across outcomes. For studies in which there had been incomplete reporting of information that might affect bias assessment, an attempt was made to contact authors to provide additional information. The level of methodologic quality for the identified literature is summarized after each clinical question. Inconsistency: studies are reviewed in terms of populations, interventions, and outcomes for similarity, or consistency, among the compared studies. Indirectness: analysis occurs around comparisons, populations, and outcomes among intervention studies. Indirectness in comparisons occurs when one drug is compared with placebo and another drug is compared with placebo, but the researchers do not compare the first drug and the second drug in a head-to-head comparison. Indirectness in populations means that the population in which the drug was studied doe not reflect the population in which the study drug would be used. Imprecision: when too few study participants were enrolled or too few events occurred in the study, imprecision is detected. There are 4 levels of evidence: High: the team is very confident that the true effect lies close to the estimate of the effect. The true effect is likely to be substantially different from the estimate of effect. Articles are not individually graded for these components but are reviewed overall by the guideline writing group and assigned an overall quality rating. This difference in approach to the quality assessment is reflected in the discussion within the Clinical Statement Profile for each of the 3 questions. The separate quality assessment tables for each of the 3 questions are included within this document. Both groups were provided the opportunity to comment, propose changes, and approve or disapprove each statement. Actual or potential conflicts of interest were disclosed semiannually, and transparency of discussion was maintained. Reaching Workgroup Consensus on Statements and Conclusions the workgroup used a modified Delphi process for the determination of the strength of the recommendation and the statement profile for each question. The Delphi method is a structured, interactive, decision-making process used by a panel of experts to arrive at a consensus when there are differing views and perspectives. The workgroup members discussed all the answers and then were encouraged to modify their answers on the next round(s) of email voting and teleconferences until a consensus was reached. Studies used for appraisal and synthesis Eight studies61-69 dealing with this clinical question were identified, but 3 of these62-64 were excluded because the data provided in the articles could not be used for analysis. Modgill et al63 reported the change in daytime and nighttime symptom scores in box and whiskers graphs (See Appendix B and Table 1 below for characteristics of included studies and Appendix D for risk of bias tables for the individual questions. Characteristics of Included Studies and Determination of Risk of Bias the detailed characteristics of each study, including setting, participants entering and completing the study, participant demographics, inclusion and exclusion criteria, power analysis, and intervention, as well as primary and secondary end point outcomes, M. A summary of study characteristics used for the quality assessment is given in Table 1. A separate risk of bias table for question 1 is available for review in Appendix D. Risk of bias: moderate On the basis of information provided in the published studies, the workgroup made an initial assessment of the factors that may contribute to the risk of bias (random sequence generation, allocation concealment, blinding adequacy, completeness of data reporting, adequacy of sample size, funding source and other potential biases, eg, failure to submit studies with negative results for publication). After obtaining additional information from the authors, the workgroup updated their assessment of the risk of bias. The detailed author responses for question 1 are included in the footnotes to the risk of bias table in Appendix D. Given this additional information, the workgroup recommended that the risk of bias should be considered moderate. Quality assessment of secondary outcomes the secondary outcomes differed between the references, and many outcomes were supported by only one reference. Development of Forest Plots Comparing Change in Symptom Score and Adverse Effects Because the outcome measures used were different in the 5 pooled studies, none of the study findings could be pooled in a forest plot to establish a more confident estimate of effect. Expert opinion comment on evidence quality: There were 3 large studies (Anolik65 [332 patients], Benincasa and Lloyd67 [454 patients], and Ratner et al69 [287 patients]) that accounted for more than 90% of the patients studied. One study used mometasone furoate nasal spray, 200 mg/d, as the intranasal corticosteroid and loratadine, 10 mg/d, as the oral antihistamine. In the first study,65 the participants self-reported the mean total nasal symptom score. In the second study,66 the Rhinoconjunctivitis Quality-of-Life Questionnaire, peak nasal inspiratory flow, mean total nasal symptom score, and nitric oxide levels were reported. In the third study,67 nasal, eye, and headache symptom scores were assessed on a categorical rating scale of 0 to 9. In the fourth study,68 nasal symptom scores were self-reported by the participant based on a 4-point Likert scale, whereas mean blood eosinophil and nasal lavage eosinophils and subepithelial cells were measured in the laboratory environment (nasal lavage eosinophils and subepithelial cells were reported in box and whiskers graphs and therefore not included in this analysis). In the fifth study,69 nasal symptom scores in which a visual analogue score based on a range of 0 to 100 was used and measurement performed by a clinician. Four studies65,67-69 have a placebo arm to compare the intervention of choice to , whereas the third study66 is a cross-over study design, and therefore the participants act as their own controls. However, 1 study65 met the identified sample size, 3 studies66-68 did not report the sample size needed to detect significance, and 1 study69 reported the sample size needed but did not enroll the needed number of participants. Two studies66,69 identified imprecision issues attributable to a small sample size,66 which leads to a large confidence interval, and 1 study69 reported the inability to enroll the needed number of participants. Likewise, the studies by Ratner et al69 and Barnes et al66 did not discuss blinding of outcome assessment. When contacted, the authors of these 3 studies were unable to provide further details because the study documents were not available. Value judgments: the treatment outcomes assessed in this analysis would be valued as important by most patients. Role of patient preferences: Some patients may want to begin with dual therapy with the hope or expectation that two drugs should be better than one, even if data do not support this. One study compared beclomethasone (200 mg intranasally twice daily for a total of 400 mg intranasally daily) vs montelukast (10 mg oral once daily). The study that included participants with persistent asthma compared fluticasone propionate aqueous nasal spray (200 mg intranasally once daily) vs montelukast (10 mg daily) with both arms using fluticasone propionate and salmeterol. The researchers used the following: the Composite Symptom Score70 (Fig 17); mean Daytime Nasal Symptom Score70 (Fig 18); and the Daytime and Nighttime Symptom Scores based on a 5-point Likert scale73 (Fig 19) or a 4-point Likert scale. The study72 with patients with persistent asthma as the study population also measured morning peak expiratory flow (Fig 22), evening peak expiratory flow (Fig 23), percentage of symptom-free days (Fig 24), and percentage of albuterol-free days (Fig 25). The studies provide head-to-head comparisons of intranasal corticosteroids (beclomethasone70 or fluticasone propionate aqueous nasal spray71-74 vs montelukast). Three studies71,72,74 met the sample size determination to identify significant findings, 1 study70 did not meet the sample size determination, and 1 study73 did not disclose the sample size needed. One study73 could have had imprecision issues because of a small sample size; however, the confidence interval is not large. The authors do not disclose how many participants were needed to detect significance in 2 of the 5 included studies. Furthermore, the included studies might not have been adequately powered to ascertain the lack of effect of the combination. In the study by Benincasa and Lloyd,67 there was a nonsignificant trend to a reduction in eye symptom scores with combination therapy. Further properly designed and powered studies to support these conclusions are needed. Studies used for appraisal and synthesis Five studies met the criteria for analysis. Characteristics of Included Studies and Determination of Risk of Bias the detailed characteristics of each study, including setting, participants entering and completing the study, participant demographics, inclusion and exclusion criteria, power analysis, intervention, and primary and secondary end point outcomes, are reviewed in the tables in Appendix B. A summary of study characteristics used for the quality assessment is given in Table 4. A separate risk of bias table for question 2 is available for review in Appendix D. It is possible that for one study72 there could have been bias based on the fact that individuals with asthma were included and, potentially, improvement in lower airway symptoms could have led to a perception of upper airway improvement. The workgroup updated the risk of bias for the references reviewed to answer this question after obtaining additional information from the authors. The detailed responses are included in the footnotes to the risk of bias for question 2 studies in Appendix D. Given this additional information, the workgroup recommended that the risk of bias should be considered low. Question 2: Change in mean daytime total nasal symptom score with subgroup analysis. Development of Forest Plots Comparing Change in Symptom Score and Adverse Effects Because the 5 included studies did not use the same outcome as defined in Table 3, it was not possible to construct forest plots that would include all studies on one plot. Therefore, individual forest plots were constructed for (1) change in mean composite score,70 (2) change in mean daytime nasal symptoms score,70 (3) change in mean daytime nasal symptoms score,73 (4) change in mean morning peak expiratory flow,72 (5) change in mean evening peak expiratory flow,72 (6) percentage change in mean symptom-free days,72 and (7) percentage change in mean albuterol-free days. The forest plots comparing the change in mean daytime nasal symptom scores with subgroup analysis and the change in mean nighttime total nasal symptom score with subgroup analysis are presented in Figure 1 and Figure 2. Quality improvement opportunity: Reduced use of a less effective agent and increased use of a more effective agent. Question 2: Change in mean nighttime total nasal symptom score with subgroup analysis. Risks, harms, and costs: There was no significant difference in the rate of adverse effects among treatment options. After long-term use in susceptible populations, cataracts, increased intraocular pressure, and glaucoma have been reported, especially when combined with inhaled or oral corticosteroids. For montelukast, headache is the most common adverse effect and is reported more frequently than placebo in controlled trials. There are postmarketing reports with montelukast of rare neuropsychiatric events (eg, aggression, depression, suicidal thinking, behavioral changes, dream abnormalities), which appear consistent with a druginduced effect. Risk of bias overall for the articles: (1) random sequence generation: low risk of bias; (2) allocation concealment: low risk of bias; (3) blinding of participants and personnel: low risk of bias; (4) incomplete outcome data: low risk of bias; (5) selection reporting: low risk; and (6) other bias: unclear risk of bias. In asthma there are subpopulations of patients who are high producers of cysteinyl leukotrienes and may respond better to montelukast than to inhaled corticosteroids. In the interim, studies have been published that compare the effectiveness of combination azelastine and fluticasone administered in a single device to monotherapy with one of these agents. One additional study compares using concomitant administration of the 2 agents in individual devices to monotherapy with each agent. Thus, there was the possibility of some inconsistency compared with the other studies; P2, Small sample size. The main objective was to investigate the effect of rhinitis therapy on asthma outcomes in patients with both seasonal allergic rhinitis and persistent asthma. Table 8 Question 2: Quality Assessment for Daytime Nasal Symptom Scores Quality assessment No. Although not a primary end point, one study demonstrated reduction of ocular symptoms and improvement in quality of life (Figs 30, 31, 34 and 35 in Appendix B). Studies used for appraisal and synthesis Five relevant studies address this question. Given the fact that only one study used separate sprays, we are unable to make a statement on the comparative efficacy of combined vs 2 separate sprays of fluticasone propionate and normal saline and azelastine. For all the primary end point evaluations for each of these studies, treatment with fluticasone propionate and normal saline and azelastine was more effective than fluticasone propionate and normal saline alone. Characteristics of Included Studies and Determination of Risk of Bias the detailed characteristics of each study, including setting, participants entering and completing the study, participant demographics, inclusion and exclusion criteria, power analysis, intervention, and s primary and secondary end point outcomes, may be reviewed in the tables in Appendix B. A summary of study characteristics used for the quality assessment is given in Table 10. A separate risk of bias table for question 3 is available for review in Appendix D. The workgroup updated the risk of bias (random sequence generation, allocation concealment, blinding adequacy, completeness of data, reporting, adequacy of sample size, funding source and other potential biases, eg, failure to submit studies with negative findings for publication) that may contribute to risk of bias. The detailed responses are included in the footnotes to the risk of bias for question 3 studies in Appendix D. Development of Forest Plots Comparing Change in Symptom Score and Adverse Effects Because the 5 included studies did not all use the same outcome as outlined in Table 10, it was not possible to construct forest plots that would include all studies on one plot. Forest plots that compare more than one study are included in this document, whereas all forest plots (Figs 28e36) may be reviewed in Appendix B. Although many clinicians likely start with monotherapy and then add a second agent, none of the studies looked at this therapeutic option. Given the qualifying prestudy period and the few weeks of seasonal pollen exposure, it is highly unlikely that a study starting with monotherapy, failing monotherapy, and then moving to combination therapy would be able to be adequately designed and completed. Therefore, this will likely remain a patient-by patient decision that the clinician will need to make. There is confidence that the true effect lies close to the estimate of the effect. The option of using a single intranasal spray device that contains both types of agents provides more convenient administration but with increased cost and, possibly, no greater benefit than the use of 2 separate nasal spray devices each of which contain one type of agent. Using a single intranasal device that contains 2 medications increases the cost of therapy for most patients. Concurrent therapy with both agents in separate devices is also a greater cost than that of monotherapy with either agent. Benefit-harm assessment: the benefit of using the combination for patients with conditions not adequately controlled with a single agent outweighs the harm. Although not the focus of this systematic review, the 2 individual medications are available as single agents in generic form, and their combined cost is significantly lower than the single dualmedication device. Therefore, the physician and patient may discuss the risks and benefits of using 2 single-drug devices rather than the one dual-medication device. Intentional vagueness: Inadequate response or control allows for some interpretation by clinicians and patients. For initial therapy, some patients may be reluctant to use 2 drug entities with aggregate greater cost when one agent may be sufficient, whereas others may want to begin with 2 agents because of greater likelihood of symptom control. The relative costs and convenience of using a combination single device vs concurrent therapy with agents in separate devices may also influence patient preference. Because of the increased volume of medication when using 2 separate nasal spray devices concurrently, there should, ideally, be several minutes between the use of the 2 devices to ensure adequate absorption. This will contribute to further inconvenience for the patient and possibly reduce adherence. In the United States, the branded single device combination therapy often requires preapproval for coverage from many pharmacy benefit plans. Clinicians should use their expertise in assisting patients to evaluate the best treatment choice through shared decision making in consideration of evidence of benefits, harms, and cost of combination therapy, allowing patients to express their values and preferences and participate in the medical decisionmaking process. Differences of opinion: One workgroup member thought that it would be cost ineffective to recommend combination therapy for initial treatment as an alternative to either of the component monotherapies. Combination therapy significantly improved the overall ocular symptoms compared with fluticasone or placebo but not azelastine. Discussion Although it is likely that most clinicians will think that the answers to the 3 questions asked align closely with their clinical experience for most patients, in select patients the above clinical recommendations may not always apply. Individual patients and their response to treatment may be different and influence the applicability of recommendations. Even strong recommendations do not necessarily represent a legally defined standard of care. Although all the therapeutic options are approved for children younger than 12 years, the studies in this systematic review did not include children; therefore, we cannot make definitive conclusions regarding clinical response in this age group. The clinician may choose, at times, to extrapolate the conclusions reached for the adult population to children. However, method and ease of delivery, concern with long-term adverse effects of some medications, and intolerance of select adverse effects may alter the therapeutic choice in children. The answers to the 3 questions also may not necessarily apply to other populations, such as pregnant and nursing women and senior patients. Physiologic changes during pregnancy can influence rhinitis, and selection of agents must consider safety to the fetus and to the mother (see Summary Statements 98-104 in the 2008 Rhinitis Updated Practice Parameter4). In senior patients, rhinitis may also be influenced by agerelated physiologic changes, such as cholinergic hyperactivity, anatomical changes, and medications taken for other medical conditions, and patients may be more vulnerable to certain adverse effects (see Summary Statement 106 in the 2008 Rhinitis Updated Practice Parameter4). Four of the studies75,76,78 used the same study arms of fluticasone propionate aqueous nasal spray, 200 mg/d, vs fluticasone propionate aqueous nasal spray, 200 mg/d, plus azelastine, 548 mg, whereas the fifth study77 used the same study arms and the dosage of fluticasone propionate aqueous nasal spray remained the same but the dosage of azelastine increased to 1,100 mg/d. The outcomes measures reported in the 5 studies were total nasal symptom score as mean difference,75,76,78 total nasal symptom score as least squares mean,77 total ocular symptom score,75 Rhinoconjunctivitis Quality of Life Questionnaire,77 and total adverse events. The outcome of interest is the patient symptomebased measure of nasal symptom scoring. One study reported the outcomes as least squares mean; therefore, the outcomes from this study needed to be reported separately from the other studies. One study77 could have had imprecision issues attributable to a small sample size because the confidence interval is larger than that of the other studies in this group. Sample sizes were an issue in all 5 analyzed studies in that the authors did not indicate the number of participants randomized to each study arm in 2 studies,78 the authors did not disclose how many participants were needed to detect significance in 2 studies,75,77 and the number of evaluable participants needed to detect significance was not met in 1 study. In the study by Ratner et al,69 151 individuals were randomized, 150 completed postbaseline diary data, and 147 patients completed the study. Although the authors did not indicate within the article the needed sample size before participant enrollment, there was a low dropout rate and statistical significance was reached.
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Typical community, county, and state emergency procedures (including information on state disaster and pandemic influenza plans, emergency operation centers, and incident command structure); k. Community resources for post-event support such as mental health consultants, safety consultants; l. Which individuals or agency representatives have the authority to close child care programs and schools and when and why this might occur; m. Communicating with Parents/Guardians: Facilities should share detailed information about facility disaster planning and preparedness with parents/guardians when they enroll their children in the program, including: a. Portions of the Emergency/Disaster Plan relevant to parents/guardians or the public; b. Procedures and instructions for what parents/guardians can expect if something happens at the facility; c. Description of how parents/guardians will receive information and updates during or after a potential emergency or disaster situation; d. Situations that might require parents/guardians to have a contingency plan regarding how their children will be cared for in the unlikely event of a facility closure. Facilities should conduct an annual drill, test, or "practice use" of the communication options/mechanisms that are selected. Providing clear, accurate, and helpful information to parents/guardians as soon as possible is crucial. Sharing written policies with parents/guardians when they enroll their child, informing them of routine practices, and letting them know how they will receive information and updates, will help them understand what to expect. Notifying parents/guardians about emergencies or disaster situations without causing alarm or prompting inappropriate action is challenging. Sometimes, it will be necessary to provide information to parents/guardians before all details are known. In a serious situation, the federal government, the governor, or the state or county health official may announce or declare a state of emergency, a public health emergency, or a disaster. If a facility is unsure of what to do, the first point of contact in any situation should be the local health authority. The local health authority, in partnership with emergency personnel and other officials will know how to engage the appropriate public health and other professionals for the situation. Each state is required to maintain a state disaster preparedness plan and a separate plan for responding to a pandemic influenza. These plans may be developed by separate agencies, and the point person or the key contact for a child care facility can be the State Emergency Coordinator, a representative in the State Department of Health, an individual associated with the agency that licenses child care facilities for that state, or another official. The State Child Care Administrator is a key contact for any facility that receives federal support. To develop an Emergency/Disaster Plan that is effective and in compliance with state requirements, the facility must identify who their key contact would be (and what the requirements for their program might be in an emergency or disaster situation) in advance of an unexpected situation. Identifying and connecting with the appropriate key contact before a disaster strikes is crucial for many reasons, but particularly because the identified official may not know how to contact or connect with individual child care facilities. In addition, representatives within the local school system (especially school administrators and school nurses) may have effective and more direct connections to the state disaster preparedness and response system. If facilities do not communicate with the schools in their area on a regular basis, staff should consider establishing a direct link to and partnership with school representatives already involved in disaster planning and response efforts. Certain emergency/disaster situations may result in exceptions being made regarding state or local regulations (either in existing facilities or in temporary facilities). In these situations, facilities should make every effort to meet or exceed the temporary requirements. Early childhood professionals, child care health and safety experts, child care health consultants, health care professionals, and researchers with expertise in child development or child care may be asked to support the development of or help to implement emergency, temporary, or respite child care. These individuals may also be asked to assist with caring for children in shelters or other 397 Chapter 9: Administration temporary housing situations. A "shelter-in-place" refers to "the process of staying where you are and taking shelter, rather than trying to evacuate" (2). Early education and child care facilities and pediatricians are rarely considered or included in disaster planning or preparedness efforts, and unfortunately the needs of children are often overlooked. Children have important physical, physiological, developmental, and psychological differences from adults that can and must be anticipated in the disaster planning process. Staff, pediatricians, health care professionals, and child advocates can and should prepare to assume a primary mission of advocating for children before, during, and after a disaster (1). These professionals should be open to fulfilling this obligation in whatever manner presents, in whatever capacity is required at the moment. For additional resources on disaster planning for child care and early education programs, see the following Websites. Forming a committee of staff members, parents/ guardians, and the child care health consultant to produce/review a plan for dealing with the flu each year including specific plans if there is a flu pandemic; 2. Reviewing the seasonal flu plan during and after flu season so that key staff could discuss how the program would plan for a more serious outbreak or pandemic; 3. Assigning one person to identify reliable sources of information regarding the seasonal flu strain or pandemic flu outbreak considering local, state and national resources, monitor public health department announcements and other guidance, and forward key information to staff and parents/guardians as needed (the child care health consultant can be especially helpful with this); 4. Including the infection control policy and procedure (see below) and a communication plan (see below) in the seasonal flu plan; 5. Including a communication plan (see below), the infection control policy and procedure (see below), and the child learning and program operations plan (see below) in the pandemic flu plan. A list of key contacts such as representatives at the local/state health departments and agencies that regulate child care and their plans to combat or address seasonal or pandemic influenza (programs can extend an invitation for consultation from these departments when formulating the plan). Development of a plan of action for addressing key business continuity and programmatic issues relevant to pandemic flu; 9. Communication to parents/guardians encouraging them to have a back-up plan for care for their children if the program must be closed; 10. Knowledge of services in the community that can help staff, children, and their families deal with stress and other problems caused by a flu pandemic; 12. Communicate with other child care programs in the area to share information and possibly share expertise and resources. How to help control the spread of flu by handwashing/ cleansing and covering the mouth when coughing or sneezing (see. How to recognize a person that may have the flu, and what to do if they think they have the flu (see. Developing a plan for keeping children who become ill at the child care facility away from other children until the family arrives, such as a fixed place for holding children who are ill in an area of their usual caregiving room or in a separate room where interactions with unexposed children and staff will be limited; 2. Establishing and enforcing guidelines for excluding children with infectious diseases from attending the child care facility (1); 3. Teaching staff, children, and their parents/guardians how to limit the spread of infection (see. Educating families about the influenza vaccine, including that experts recommend yearly influenza vaccine (and an influenza-specific vaccine, for example H1N1, if necessary) for everyone, however, if there is a vaccine shortage, priority should be given to children and adolescents six months through eighteen years of age, caregivers/teachers of all children younger than five years of age, and health care professionals (see. Staff caring for all children should receive annual vaccination against influenza (and an influenzaspecific vaccine such as what was used during the 2009 H1N1 pandemic, if necessary) each year, preferably before the start of the influenza season (as early as August or September) and as long as influenza is circulating in the community, immunization should continue through March or April; 7. Maintaining accurate records when children or staff are ill with details regarding their symptoms and/or the kind of illness (especially when influenza was verified through testing); 8. Determining guidelines to support staff members to remain home if they think they might be ill and a mechanism to provide paid sick leave so they can stay home until completely well without losing wages. Plan ways to continue basic functions (meeting payroll, maintaining communication with staff, children, and families) if modifications to program planning are necessary or the program is closed. The facility should also include procedures for staff and parent/guardian training on this plan. Some of the above plan components may be beyond the scope of ability in a small family child care home. In this case, the caregiver/teacher should work closely with a child care health consultant to determine what specific procedures can be implemented and/or adapted to best meet the needs of the caregiver/teacher and the families s/he serves. A pandemic flu is a flu virus that spreads rapidly across the globe because most of the population lacks immunity (1,2). The goals of planning for an influenza pandemic are to save lives and to reduce adverse personal, social, and economic consequences of a pandemic. In the twentieth century, three flu pandemics were responsible for more than fifty million deaths worldwide, including more than 20 million deaths in the United States (2). The 2009 influenza A (H1N1) pandemic was the first in the 21st century that resulted in between 151,700 and 575,400 deaths worldwide (2). As it is not possible to predict with certainty when the next flu pandemic will occur or how severe it will be, seasonal flu management and preparation is essential to minimize the potentially devastating effects (1-4). Vaccination is the best method for preventing flu and its potentially severe complications in children (1,2,5,6). Child care health consultants are very helpful with finding and coordinating the local resources for this planning. In addition most state and/or local health departments have resources for pandemic flu planning. Managing infectious diseases in child care and schools: A quick reference guide, pp. Fire, monthly; Tornadoes, on a monthly basis in tornado season; Floods, before the flood season; Earthquakes, every six months; Hurricanes, annually; Threatening person outside or inside the facility; Rabid animal; Toxic chemical spill; Nuclear event. A fire evacuation procedure should be approved and certified in writing by a fire inspector for centers, and by a local fire department representative for large and small family child care homes, during an annual on-site visit when an evacuation drill is observed and the facility is inspected for fire safety hazards. Depending on the type of disaster, the emergency drill may be within the existing facility such as in the case of earthquakes or tornadoes where the drill might be moving to a certain location within the building (basements, away from windows, etc. They should aim to evacuate all persons in the specific number of minutes recommended by the local fire department for the fire evacuation, or recommended by emergency response personnel. Cribs designed to be used as evacuation cribs, can be used to evacuate infants, if rolling is possible on the evacuation route(s). The routine practice of such drills fosters a calm, competent response to a natural or human generated disaster when it occurs (1). The extensive turnover of both staff and children, in addition to the changing developmental abilities of the children to participant in evacuation procedures in child care, necessitates frequent practice of the exercises. It also provides a means to contact visitors if needed (such as a disease outbreak) or to ensure all individuals in the building are evacuated in case of an emergency. In centers caring for more than thirty children enrolled, the center director should assign one caregiver per classroom, the responsibility of bringing the class roster on evacuation drills and accounting for every child and classroom staff at the onset of the evacuation, at the evacuation site and upon return to a safe place. Small and large family home child caregivers/teachers should count or use a daily roster to be sure that all children and staff are safely evacuated and returned to a safe space for ongoing care during an evacuation drill. Assigning responsibility to use a roster(s) in a center, or count the children and adults in a large or small family child care home, ensures that all children and adults are accounted for. Practice accounting for children and adults during evacuation drills makes it easier to do in an emergency situation. The legal guardian(s) of the child should be established and documented at this time. The telephone authorization should be confirmed by a return call to the parents/guardians. If a previously unauthorized individual drops off the child, he or she will not be authorized to pick up the child without first being added to the authorization record. Policies should address how the facility will handle the situation if a parent/ guardian arrives who is intoxicated or otherwise incapable of bringing the child home safely, or if a non-custodial parent attempts to claim the child without the consent of the custodial parent. Should an unauthorized individual arrive without the facility receiving prior communication with the parent/ guardian, the parent/guardian should be contacted immediately, preferably privately. If the information provided by the parent/guardian does not match the information and identification of the unauthorized individual, the child will not be permitted to leave the child care facility. If the individual does not leave and his or her behavior is concerning to the child care staff or if the child is abducted by force, then the police should be contacted immediately with a detailed description of the individual and any other obtainable information such as a license plate number. Caregivers/ teachers should consider having a child car seat policy stating all authorized persons that pick-up a child have an age-appropriate car seat to transport a child from the child care program. Many child care facilities have extra car seats on hand to lend in case a parent/guardian forgets one (1). Caregivers/teachers should consult local police or the local child protection agency about their recommendations for how staff can obtain support from law enforcement authorities to avoid incurring increased liability by releasing a child into an unsafe situation or by improperly refusing to release a child. The plan should be developed in consultation with the child care health consultant and child protective services. If these efforts fail, the facility should immediately implement the written policy on actions to be followed when no authorized person arrives to pick up a child. If an authorized person does not come to pick up a child, and one cannot be reached, the caregiver/teacher must know what authority to call and to whom they can legally and safely release the child. A daily attendance record should be maintained, listing the times of arrival and departure of the child, as well as the person dropping off and picking up; b. Parents/guardians are expected to communicate (confirmation required) with the caregiver/teacher/program on a daily basis by a specified time if their child will not be in attendance; c. A printed roster should be available in the event of an evacuation drill or evacuation to account for the children in care. This standard ensures that the facility knows which children are receiving care at any given time including evacuation. It aids in the surveillance of child: staff ratios, knowledge of potentially infectious diseases. Accurate record keeping also aids in tracking the amount (and date) of service for reimbursement and allows for documentation in the event of child abuse allegations or legal action involving the facility. Furthermore, each year, twenty to forty children die from hyperthermia after being left/locked in a car or van. Some of these unfortunate deaths include children whose parents/guardians meant to drop their child off at a child care program or preschool; thus, timely communication with these parents/guardians could prevent death from hyperthermia (1,2). Some notification system should be used to alert the caregiver/teacher whenever the responsibility for the care of the child is being transferred to or from the caregiver/teacher to another person. Heat related deaths to young children in parked cars: An analysis of 171 fatalities in the United States, 1995-2002. Maximum travel time for children (no more than forty-five minutes in one trip); m. Procedures to ensure that no child is left in the vehicle at the end of the trip or left unsupervised outside or inside the vehicle during loading and unloading the vehicle; n. It is necessary for the safety of children to require that the caregiver/teacher comply with requirements governing the transportation of children in care, in the absence of the parent/guardian. Not all vehicles are designed to safely transport children, especially young children. Others have died or been injured when left outside the vehicle when thought to have been loaded into the vehicle. Vehicle selection to safely transport children, based on vehicle design and condition; c. Maximum travel time for children (no more than forty-five minutes in one trip); i. Procedures to ensure that no child is left in the vehicle at the end of the trip or left unsupervised outside or inside the vehicle during loading and unloading the vehicle; j. It is necessary for the safety of children to require that the caregiver comply with minimum requirements governing the transportation of children in care, in the absence of the parent/guardian. The process of loading and unloading children from a vehicle can distract caregivers/teachers from adequate supervision of children either inside or outside the vehicle. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Child care facilities should have a policy on the use and maintenance of play areas that address the following: a. Staff training (to be addressed as employees receive training for other safety measures);. Inventory, once at the time of purchase, and updated when changes to equipment are made in the playground; 2. Audits of the active (gross motor) play areas (indoors and outdoors) by an individual with specialized training in playground inspection, once a year; 3. Daily safety check of the grounds for safety hazards such as broken bottles and toys, discarded cigarettes, stinging insect nests, and packed surfacing under frequently used equipment like swings and slides; 5. Documentation of the recommended inspections should be maintained in a master file. Indoor play spaces must also be properly laid out with care given to the location of equipment and the energy-absorbing surface under the equipment. A written policy with procedures is essential for education of staff and may be useful in situations where liability is an issue. The technical issues associated with the selection, maintenance, and use of playground equipment and surfacing are complex and specialized training is required to conduct annual inspections. Active play areas are associated with the most frequent and the most severe injuries in child care (1). Parents/guardians expect that their child Reference 404 Caring for Our Children: National Health and Safety Performance Standards will be adequately supervised and will not be exposed to hazardous play environments, yet will have the opportunity for free, creative play. For information about playground safety see the Public Playground Safety Handbook, available at. Also, in the event of recalls, the information provided by the manufacturer allows the owner to identify the applicability of the recall to the equipment on hand. Products used in areas occupied by children must have these instructions for identification, maintenance, repair, and reference in case of recall. Corrective actions taken to eliminate hazards and reduce the risk of injury should be included in the reports. Annual review of such records provides a mechanism for periodic monitoring and improvement of equipment and surface type and quality (1).
