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Managing Infectious Diseases in Child Care and Schools
A m e r i c a n A c a d e m y o f P e d i a t r i c s
A m e rica n A cad e m y o f P e diatrics
Managing Infectious Diseases

in Child Care and Schools
A Quick Reference Guide, 3rd Edition Managing Infectious
Diseases in Child Care
Edited by Susan S. Aronson, MD, FAAP, and Timothy R. Shope, MD, MPH, FAAP
Completely revised and updated, the new 3rd edition of this

award-winning quick reference guide provides the information New in 3rd Edition
you need to know—fast—about the prevention and management Completely reviewed and updated through-
and Schools
of infectious diseases in child care and school settings. out to reflect the latest guidance and recom-
Presented in an easy-to-use format, this must-have mendations, including alignment with new
guide provides editions of
Content from the premier American Academy of Pediatrics —— Caring for Our Children: National Health
sources of information on infectious d iseases and child and Safety Performance Standards: Guide-
care settings, Red Book® and Caring for Our Children lines for Early Care and Education Programs,
Quick Reference Sheets on more than 50 common infectious 3rd Edition A Quick Reference Guide, 3rd Edition
diseases and symptoms that occur in children in group settings —— Red Book®: 2012 Report of the Committee on
Easy-to-read explanations on how infectious diseases spread Infectious Diseases, 29th Edition
Strategies for limiting the spread of infection New infectious disease Quick Reference
When exclusion is and is not indicated Sheets
Guidance about which situations require immediate help —— Bedbugs
Immunization information
—— Cryptosporidiosis
A Quick Reference Guide, 3rd Edition

Ready-to-use sample letters and forms for parents or referrals
And much more!
New diapering “how-to” poster
New forms and resources added to
About the Editors Chapter 11
Susan S. Aronson, MD, FAAP, works at the New Web links to professional development
Pennsylvania Chapter of the American Academy materials
of Pediatrics as a pediatric advisor for the Early
Childhood Education Linkage System–Healthy
Child Care Pennsylvania. In 2011, she retired from her appointment as clinical professor of pediatrics at
the University of Pennsylvania in Philadelphia. A nationally recognized expert on health and safety issues
in early education and child care settings, Dr Aronson is an advisor to the Executive Committee of the
American Academy of Pediatrics Section on Early Education and Child Care. She is the author/editor of
Healthy Young Children, 5th Edition (2012). She is known to many educators from 2 decades of reading her column (“Ask
Dr. Sue Your Health and Safety Questions”) in www.ChildCareExchange.com Exchange magazine.
Timothy R. Shope, MD, MPH, FAAP, is an associate professor of pediatrics at the Children’s Hospital of
Pittsburgh of University of Pittsburgh Medical Center. Dr Shope is a member of the American Academy
of Pediatrics Section on Early Education and Child Care and regularly speaks and writes about exclusion
and return-to-care criteria for mildly ill children in child care and schools. He retired after 21 years of
service in the Navy in 2011.
Editors
Available in print and eBook formats! Print as many Quick Reference Sheets as you need with the eBook version. Susan S. Aronson, md, faap Timothy R. Shope, md, mph, faap
For other pediatric resources, visit the American Academy of Pediatrics Online
Bookstore at www.aap.org/bookstore.
AAP
A m e r i c a n A c a d e m y o f P e d i a t r i c s
Managing Infectious
Diseases in Child Care
and Schools
A Quick Reference Guide, 3rd Edition
Editors
Susan S. Aronson, md, faap
Timothy R. Shope, md, mph, faap
American Academy of Pediatrics

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ISBN: 978-1-58110-765-4
eISBN: 978-1-58110-809-5
MA0662
The recommendations in this publication do not indicate an exclusive course of treatment or serve as a standard of medical care.
Variations, taking into account individual circumstances, may be appropriate.
Copyright © 2013 American Academy of Pediatrics. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or
transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior permission from the publisher.
No permission is necessary to make single copies of Quick Reference Sheets for noncommercial, educational purposes.
Printed in the United States of America.
9-317/0613 1 2 3 4 5 6 7 8 9 10

Reviewers/Contributors • • • III
Reviewers/Contributors
Editors
Susan S. Aronson, MD, FAAP
Timothy R. Shope, MD, MPH, FAAP
Technical Reviewers
Abbey Alkon, RN, PhD
Nancy Alleman, RN, CPNP
Sandra Cianciolo, RN, BSN, MPH
Margaret C. Fisher, MD, FAAP
Danette S. Glassy, MD, FAAP
Barbara U. Hamilton, MA
Andrew Hashikawa, MD, FAAP
Harry L. Keyserling, MD, FAAP
Sandy McDonnell, MSN, RN, CRNP, PNP-BC
Linda Satkowiak, ND, RN, CNS, NCSN
Kam Sripada, EdM
Howard L. Taras, MD, FAAP
American Academy of Pediatrics Disaster Preparedness Advisory Council
Additional Reviewers
Rebecca L. Slayton, DDS, PhD
AAP Board of Directors Reviewer

Sara H. Goza, MD, FAAP

Errol R. Alden, MD, FAAP
Executive Director/CEO
Roger F. Suchyta, MD, FAAP
Associate Executive Director
Maureen DeRosa, MPA
Director, Department of Marketing and Publications
Mark Grimes
Director, Division of Product Development
Jeff Mahony
Manager, Digital Strategy and Product Development
Fan Tait, MD, FAAP
Associate Executive Director/Director, Department of Child Health and Wellness
Jeanne M. VanOrsdal, MEd
Manager, Early Education and Child Care Initiatives

Table of Contents • • • V
Table of Contents
Foreword .................................................................................................................................................................IX
About This Book ..................................................................................................................................................... X
What Is New in This Edition? ................................................................................................................................ XI
Chapter 1 Introduction: Keeping Healthy............................................................................................................. 1

Strengthening Resistance to Infections....................................................................................................................................3
Structuring and Managing the Environment.........................................................................................................................3
Reducing the Numbers of Harmful Germs.............................................................................................................................4
Exclusion When Necessary of Children and Adults Who Are Ill.......................................................................................4
The Role of the Child Care Health Consultant and School Health Personnel.............................................................5
Planning and Policies....................................................................................................................................................................6
What Families Can Do to Reduce Illness From Infection in Child Care and Schools................................................7
What Staff Members Can Do to Reduce Illness From Infection in Child Care and Schools................................. 11
What Health Professionals Can Do to Reduce Illness From Infection in Child Care and Schools...................... 15
Chapter 2 How Infection Spreads ...................................................................................................................... 17

Infection Spread by Contact With People or Objects ....................................................................................................... 19
Infection Spread by the Fecal-Oral Route ........................................................................................................................... 19
Infection Spread by the Respiratory Route ......................................................................................................................... 19
Infection Spread Through Blood, Urine, and Saliva ........................................................................................................ 19
Chapter 3 Infection Control Measures................................................................................................................21

Administration and Consultation ......................................................................................................................................... 23
Sanitation, Disinfection, and Maintenance ........................................................................................................................ 25
Hand Hygiene ............................................................................................................................................................................. 31
Changing Diapers, Soiled Disposable Training Pants, and Soiled Underwear.......................................................... 35
Chapter 4 Health of Teachers/Caregivers and Other Staff Members................................................................39

Introduction ................................................................................................................................................................................ 41
Regular Health Checkups: Health Appraisals .................................................................................................................... 41
Health Limitations of Staff Members.................................................................................................................................... 43
Learn About and Practice Minimizing Risk of Illness and Injury ................................................................................. 45
Evaluating Performance Using Health Policies and Procedures ................................................................................... 47
Chapter 5 Recognizing the Ill Child: Inclusion/Exclusion Criteria.................................................................... 49

Daily Health Check .................................................................................................................................................................... 51
When to Call Emergency Medical Services (and Also Notify Parents/Legal Guardians)......................................... 51
Situations That Require Urgent Medical Attention ......................................................................................................... 52
Conditions That Do Not Require Exclusion to Control Spread of Disease to Others ........................................... 52
Conditions Requiring Temporary Exclusion ...................................................................................................................... 55
Procedures for a Child Who Requires Exclusion ............................................................................................................... 56
Reportable/Notifiable Conditions ......................................................................................................................................... 56
Preparing for Managing Illness .............................................................................................................................................. 56
Chapter 6 Signs and Symptoms Chart................................................................................................................ 57

VI • • • table of contents
Chapter 7 Quick Reference Sheets ....................................................................................................................67

Bedbugs.......................................................................................................................................................................................... 69
Bites (Human and Animal)....................................................................................................................................................... 71
Boil/Abscess/Cellulitis............................................................................................................................................................... 73
Campylobacter................................................................................................................................................................................ 75
Chickenpox (Varicella-Zoster Infections)............................................................................................................................. 77
Cryptosporidiosis........................................................................................................................................................................ 79
Cytomegalovirus (CMV) Infection.......................................................................................................................................... 81
Dental Caries (Early Childhood Caries or Cavities)........................................................................................................... 83
Diarrhea......................................................................................................................................................................................... 85
Diarrhea Caused by Specific Types of E coli (Escherichia coli)............................................................................................ 87
Ear Infection................................................................................................................................................................................. 89
Fever................................................................................................................................................................................................ 91
Fifth Disease (Human Parvovirus B19)................................................................................................................................. 93
Giardiasis....................................................................................................................................................................................... 95
Haemophilus influenzae Type b (Hib)........................................................................................................................................ 97
Hand-Foot-and-Mouth Disease.............................................................................................................................................. 99
Hepatitis A Infection................................................................................................................................................................101
Hepatitis B Infection................................................................................................................................................................103
Herpes Simplex Virus...............................................................................................................................................................105
HIV/AIDS....................................................................................................................................................................................107
Impetigo.......................................................................................................................................................................................109
Influenza......................................................................................................................................................................................111
Lice (Pediculosis Capitis).........................................................................................................................................................113
Lyme Disease (and Other Tick-borne Diseases)................................................................................................................115
Measles.........................................................................................................................................................................................117
Meningitis...................................................................................................................................................................................119
Molluscum Contagiosum.......................................................................................................................................................121
Mononucleosis...........................................................................................................................................................................123
Mosquito-borne Diseases........................................................................................................................................................125
Mouth Sores...............................................................................................................................................................................127
MRSA (Methicillin-resistant Staphylococcus aureus)...........................................................................................................129
Mumps.........................................................................................................................................................................................131
Pinkeye (Conjunctivitis)..........................................................................................................................................................133
Pinworms.....................................................................................................................................................................................135
Pneumonia..................................................................................................................................................................................137
Respiratory Syncytial Virus (RSV).........................................................................................................................................139
Ringworm....................................................................................................................................................................................141
Roseola (Human Herpesvirus 6)...........................................................................................................................................143
Rotavirus......................................................................................................................................................................................145
Rubella (German Measles)......................................................................................................................................................147
Salmonella.....................................................................................................................................................................................149
Scabies..........................................................................................................................................................................................151
Shigella...........................................................................................................................................................................................153
Shingles (Herpes Zoster).........................................................................................................................................................155
Strep Throat (Streptococcal Pharyngitis) and Scarlet Fever..........................................................................................157
Sty..................................................................................................................................................................................................159
Thrush (Candidiasis)................................................................................................................................................................161
Tuberculosis (TB)......................................................................................................................................................................163
Upper Respiratory Infection (Common Cold)..................................................................................................................165
Urinary Tract Infection............................................................................................................................................................167

Table of Contents • • • VII
Vomiting......................................................................................................................................................................................169
Warts (Human Papillomavirus).............................................................................................................................................171
Whooping Cough (Pertussis).................................................................................................................................................173
Yeast Diaper Rash (Candidiasis)...........................................................................................................................................175
Chapter 8 Role of the Health Consultant in Child Care and Schools................................................................177

Why Does an Early Care and Education Program, a Before- and After-School Child Care Program,
or a School Need a Health Consultant? ....................................................................................................................179
What Are the Qualifications of a Health Consultant? ...................................................................................................179
What Does a Health Consultant Do? .................................................................................................................................180
Where Can a Child Care Program or School Find a Health Consultant? .................................................................181
Chapter 9 Immunization Schedule and Information.........................................................................................183

Preventing Diseases With Routine Childhood Immunizations ..................................................................................185
Unimmunized/Under-immunized Children ....................................................................................................................185
Teacher/Caregiver Immunizations ......................................................................................................................................185
Chapter 10 Infectious Disease Outbreaks, Epidemics, and Bioterrorism/

Environmental Health Emergencies................................................................................................. 187
Why Children Are Especially Vulnerable............................................................................................................................189
Planning.......................................................................................................................................................................................189
Types of Infectious Disease Emergencies............................................................................................................................189
Symptom Records ....................................................................................................................................................................190
Parent Notification...................................................................................................................................................................190
Tracking Procedure...................................................................................................................................................................191
Corrective Action.......................................................................................................................................................................191
Chapter 11 Sample Letters, Forms, and Relevant Resources............................................................................193

Routine Schedule for Cleaning, Sanitizing, and Disinfecting......................................................................................197
Selecting an Appropriate Sanitizer or Disinfectant.........................................................................................................199
Recommended Immunization Schedule for Persons Aged 0 Through 18 Years—2013.........................................206
Catch-up Immunization Schedule for Persons Aged 4 mo Through 18 Years Who Start Late or
Who Are More Than 1 Month Behind—United States, 2013...............................................................................210
Recommended Adult Immunization Schedule—United States, 2013.........................................................................213
Sample Health Information Consent Form.......................................................................................................................215
Cleaning Up Body Fluids........................................................................................................................................................216
Diapering.....................................................................................................................................................................................217
Situations that Require Medical Attention Right Away.................................................................................................220
Enrollment/Attendance/Symptom Record .......................................................................................................................221
Parent/Legal Guardian Alert Letter .....................................................................................................................................222
Symptoms or Suspected Illness—Sample A .......................................................................................................................223
Symptoms or Suspected Illness—Sample B .......................................................................................................................224
Medication Administration Packet......................................................................................................................................225
Return to Group Care Form .................................................................................................................................................230
Gloving.........................................................................................................................................................................................231
Child Care Staff Health Assessment....................................................................................................................................232
Sample Food Service Cleaning Schedule............................................................................................................................233
Glossary ..............................................................................................................................................................235
Index ...................................................................................................................................................................243

Foreword • • • IX
Foreword
In the United States, more than two-thirds of children younger than 6 years, and almost all children older than
6 years, spend significant time in child care and school settings outside of the home. Exposure to groups of
children increases the risk of infectious diseases. This fact has important personal, public health, economic, and
social consequences. The intent of this book is to provide an easy-to-use reference for those who are responsible
for the prevention and management of infectious diseases in child care and school settings—teachers/caregivers,
pediatric practitioners, public health professionals, and parents. This is the third edition of this book. New
topics were added at the request of enthusiastic users. Review of scientific evidence since the previous editions
led to a few changes as well.
In this book, educators in group care settings and schools are interchangeably called teachers/caregivers and
educators. Teachers/caregivers will find that this book offers easy-to-read explanations for how infectious diseases
spread, how to prepare for inevitable illness, and how to incorporate measures that limit any excess burden of ill-
ness associated with group activities. The Signs and Symptoms Chart (Chapter 6) will help nonmedical professionals
become aware of what might cause various signs and symptoms. The set of fact sheets (Chapter 7, “Quick Reference
Sheets”) describes specific types of infectious diseases in common terms, with guidance about how they spread and
what needs to be done by teachers/caregivers, children, and families when someone in the group has a disease. By
using this book as a handy reference, teachers/caregivers can feel more confident in making decisions about inclu-
sion and exclusion of ill children and in seeking advice from medical and public health professionals when necessary
to reduce the burden of infectious diseases on other children and staff members.
Pediatricians and other health professionals will find this book helpful as a reference that facilitates communication
with teachers/caregivers. Pediatric health professionals are the primary source of information for teachers/caregivers
about the management of infectious diseases for individual children and the implications of these infections for
groups of children and the adults who care for them. Pediatric health professionals can use the content of the book
to identify exclusion and inclusion recommendations, supplement their communications with educators about
infectious diseases of patients, and augment their instructions for the care of the child for parents and teachers/
caregivers involved in the child’s care. They also can use the content of the book to identify the need for linking
teachers/caregivers with public health authorities when necessary.
Parents will benefit from the content of this book because it will provide a common means for communication
among family members, pediatric health professionals, and teachers/caregivers that is based on the best available
evidence and expert opinion about best practices. Additionally, parents and teachers/caregivers will benefit from
the Quick Reference Sheets. These may be copied. For example, a health professional can give a copy to parents to
share with teachers/caregivers, or teachers/caregivers can send copies home to parents. Use these sheets to describe
a condition or infection affecting their child or the group of children to which their child is exposed.
This book also addresses the controversial subject of exclusion and return-to-care criteria. Controversy exists
because often, teachers/caregivers, pediatric practitioners, public health professionals, and parents disagree about
which conditions require exclusion. For example, children with runny noses may be excluded unnecessarily, but
others with diarrhea that is associated with loss of bowel control that causes a child to have an accident may be
allowed to stay, when their loss of bowel control may pose a greater infection risk. Adding to the confusion, each
state health department and licensing agency has unique rules or exclusion criteria for determining which symp-
toms, diseases, and conditions require exclusion from child care or school.
The recommendations in this book are based on the best available medical information as determined by the
American Academy of Pediatrics. Some of the exclusion criteria in this book are more detailed than existing guide-
lines and can be followed without conflict with existing rules or regulations. Others will conflict because they
are evidence-based and the evidence does not support practices that have become embedded in existing rules or
regulations developed without the benefit of current evidence. It is our hope that policy makers incorporate the
exclusion and return-to-care recommendations in this book as they move toward revising their state requirements
and regulations.
— Susan S. Aronson, MD, FAAP
Timothy R. Shope, MD, MPH, FAAP

X • • • about this book
About This Book

Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide is a tool to encourage common understand-
ing among teachers/caregivers, families, and health professionals about infectious diseases in group care settings for
children. This easy reference guide identifies
The role of teachers/caregivers, families, public health, and health professionals in preventing and controlling the
spread of communicable infections
Symptoms of infections commonly found in group settings for children
How infections are spread (routes of transmission)
When to seek medical attention
Inclusion and exclusion criteria
Strategies and sample forms for communications involving directors/teachers/caregivers, parents/guardians, and
health professionals
Some resources for professional development for directors/teachers/caregivers related to infectious diseases
Others who are involved with group care settings for children, such as state licensing professionals and policy makers,
will find this guide helpful when writing, updating, and implementing regulations, state policies, requirements for
quality improvement rating systems, and educating others about these issues.
The first 5 chapters of this book offer information to implement the specific guidelines found in the table in
Chapter 6 and in the Quick Reference Sheets in Chapter 7. Chapters 8, 9, and 10 discuss health consultation, immu-
nization schedules, and infectious disease situations that require immediate action. Chapter 11 provides many forms
and links to Web sites with materials that the reader may find helpful in implementing the recommended practices.
The Glossary at the end of the book lists terms that may not be familiar or that have a special meaning in the fields
of education and health.
The information in this quick reference guide is based on the latest recommendations that address health and safety
in group care settings from the following organizations:
American Public Health Association
Centers for Disease Control and Prevention
Maternal and Child Health Bureau, Health Resources and Services Administration, US Department of Health and
Human Services
For a general guide on caring for young children, refer to
American Academy of Pediatrics. Caring for Your Baby and Young Child: Birth to Age 5. Shelov SP, Altmann TR, eds. 5th
ed. New York, NY: Bantam Books; 2009
The references for the content of the quick reference guide are as follows:
American Academy of Pediatrics, American Public Health Association, National Resource Center for Health and
Safety in Child Care and Early Education. Caring for Our Children: National Health and Safety Performance Standards:
Guidelines for Early Care and Education Programs. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics; 2011.
http://nrckids.org/CFOC3. Accessed March 21, 2013
American Academy of Pediatrics. Red Book: 2012 Report of the Committee on Infectious Diseases. Pickering LK, ed. 29th ed.
Elk Grove Village, IL: American Academy of Pediatrics; 2012. http://www.aapredbook.org. Accessed April 15, 2013

What Is New in This Edition? • • • XI
What Is New in This Edition?

Completely reviewed and updated text throughout to reflect the latest guidance and recommendations, including

alignment with new editions of
—Caring
— for Our Children: National Health and Safety Performance Standards: Guidelines for Early Care and Education
Programs, 3rd Edition
—Red
— Book: 2012 Report of the Committee on Infectious Diseases, 29th Edition
New infectious disease Quick Reference Sheets

—Bedbugs
—
—Cryptosporidiosis
—
New forms and resources added to Chapter 11

New Web links to professional development materials


c h a p t e r 1
Introduction:
Keeping Healthy
•••1•••

introduction: keeping healthy • • • 3
Introduction: Keeping Healthy
Keeping children and the adults who care for them healthy Healthful nutrition such as breastfeeding infants until

is a goal of staff members, families, public health officials, they are at least 12 months of age, which decreases their
and health professionals. However, there are many factors risk of catching respiratory and gastrointestinal infec-
that can make staying healthy a challenge. When children tious diseases, and offering recommended types and
first enter group settings, they are more vulnerable to portions of food to all children and adults
infectious diseases because it may be their first exposure Getting enough sleep and exercise
to germs that cause common infections. They may be too Choosing safe activities
young to have received enough doses of recommended Following healthful practices such as hand hygiene,
vaccines to have developed disease-resisting immunity. cough and sneeze etiquette, and oral hygiene
Infants and toddlers try to touch everything and put their Providing necessary care to individuals with special
hands in their mouths often. Children in group care play health needs
and eat close together, so they easily pass germs to each Health education
other. Although preschool-aged children and adults may
know about hygiene, they do not consistently do what Structuring and Managing the Environment
they should. The groups for whom infectious disease in Provide enough space to prevent crowding. In child

group settings is of greatest concern include infants and care settings, this should be no less than 42 to 50 square
young children, children with special health conditions, feet of floor area per child excluding the space occupied
and pregnant women. by furnishings or used only by adults. Having enough
Because children and adults spread germs even when they space reduces the concentration of germs in the air and
do not have any symptoms, sending home (excluding) those on surfaces.
who are mildly ill is not an effective way to control the Avoid intermixing of groups of children. Minimize shar-

spread of most common germs. People may spread infec- ing of space and surfaces among groups.
tion when they are developing an illness, when they have Provide enough easily accessible flushing toilets and

recovered from their own illness, or when they have germs sinks so that each group of children can have easy access
in their bodies but show no signs of illness. The majority of and use only their own.
the illnesses are respiratory infections, such as colds and ear Avoid using the floor to change diapers, disposable train-

infections, with fewer involving the gastrointestinal system, ing pants, or soiled underwear. Using the floor for these
such as vomiting and diarrhea. changes contaminates the floor and could allow those
crawling or walking in this area to spread germs around.
The approaches to keeping children and their teachers/ Choose surfaces that can be easily cleaned and sanitized.

caregivers healthy involve 3 types of measures: The best are nonporous, smooth surfaces. Soft materi-
1) Strengthening resistance to infections; 2) structur- als should be easy to put into a washing machine and
ing and managing the environment to reduce the likeli- should be washed often.
hood of contact between people and germs that might Separate food preparation areas from any area used for

cause infectious diseases; and 3) reducing the number of another purpose, away from any surface involved with
disease-causing germs in the environment. The following toileting or diaper or soiled underwear changing.
paragraphs briefly explain each of these measures, some Make sure that heating, ventilation, and air-condi-

of which will be discussed in more detail in later chapters: tioning systems meet current health standards. Have
these systems checked by an American Society of
Strengthening Resistance to Infections Heating, Refrigerating and Air Conditioning Engineers
Measures that foster health and well-being make people (ASHRAE)–certified heating, ventilation, and air-
better able to resist infectious diseases. These include conditioning (HVAC) contractor to ensure that fresh
Immunization that keeps everyone, including teachers/ air circulates and the equipment prevents buildup of
caregivers and parents/legal guardians, up to date and germs in the air that people will breathe.
on time with recommended vaccine schedules

4 • • • Managing Infectious Diseases in Child Care and Schools
Practice Integrated Pest Management, an approach

Fungi. A few fungi can infect the skin (eg, ringworm) or

that uses the least toxic methods to avoid or control mucous membranes (eg, thrush). Less commonly, fungi
pests. Common pests include insects, mice, rats, and can infect other body tissues.
other vermin. Insect bites may carry disease into the
Hand hygiene removes germs from the skin. Germs on hands
body or make an itchy opening that can get infected.
are often transferred by touching the hands to the mouth,
Rodents and other vermin bring disease-causing germs
nose, eyes, other body openings, or surfaces that other
into the facility, contaminating food and surfaces that
people touch. Germs can live on surfaces for some time.
people touch.
Frequent practice of hand hygiene is a key tool to control
——To reduce the risk of exposure to pests, block, remove,
infectious diseases. For more about hand hygiene, see
or discourage the pests from entering places humans
Chapter 3, page 31.
use. Use screens on doors and windows. Fill the holes
that pests use to gain entry into the building. Surface hygiene removes germs from surfaces that are likely
——Eliminate standing water, fruit trees, and open trash to be contaminated during routine use and by contact
that attract biting and stinging insects close to where with body fluids. Surfaces that need routine cleaning fol-
children play. lowed by sanitizing or disinfecting include doorknobs and
——In some circumstances, use of insect repellent may cabinet handles, diaper-changing and toilet area surfaces,
be necessary. hand-washing sinks and faucets, food preparation surfaces
and utensils, computer keyboards, telephones, mouthed
Reducing the Numbers of Harmful Germs toys, frequently handled shared art and writing tools, and
floors and mats where children play, eat, and rest. Section
Germ is the common term for a large variety of microbial
3.3 and Appendix K of Caring for Our Children, 3rd Edition
agents that can grow in or on people. Infection occurs when
(see Chapter 11, 197), offer details for the procedures and
a germ usually causes a disease, although it is possible to
routine maintenance schedules that should be followed
have an infection without any outward symptoms of dis-
for surface hygiene. (See the reference for and Web link to
ease. Germs include bacteria (eg, streptococcus), viruses
the online version of Caring for Our Children in “About This
(eg, influenza), fungi (eg, ringworm), and parasites (eg, lice).
Book” on page X.)
Many germs are present in the environment. Some are car-
ried harmlessly by people who do not seem ill. Others are Special attention is needed when exposure to body fluids
in the soil and air around us. Still others are only present occurs. Common exposures occur when someone blows or
when someone has an infectious disease that the specific wipes a nose, coughs or sneezes, or has a cut or scrape. In
germ causes. While some germs are usually harmful, others these instances, follow the procedures outlined in Section
help to keep the harmful germs in check. That is why pub- 3.2.3: Exposure to Body Fluids of Caring for Our Children,
lic health authorities urge avoiding unnecessary use of anti- which addresses these situations and also describes a pro-
biotic soaps and medications. Emerging science suggests cedure known as Standard Precautions when cleanup of a
that increasing certain helpful bacteria in the diet in foods body fluid is necessary. For more details about this proce-
called probiotics may reduce the risk of some infections. dure, see Chapter 3.
More research is needed to determine which, if any, foods
called probiotics are safe and effective. Increased vigilance Exclusion When Necessary of Children and Adults
in reducing exposure to germs is required to protect people Who Are Ill
who have weakened immune systems. Staff members in early care and education programs and
The germs that can cause infectious diseases in people school-age programs must decide whether children are
include too ill to participate in care or require more care than can
Viruses. These commonly cause colds, flu, and diarrhea reasonably be provided without compromising care of the
as well as total body infections such as chickenpox and others in the group. These are the most likely reasons why
measles. children and teachers/caregivers who are ill may need to be
Bacteria. Some cause skin, intestinal, and serious deep tis- excluded. In addition, some specific symptoms or diagno-
sue infections. Others are not harmful and keep harmful ses require exclusion to reduce the spread of illness. (See
bacteria in check. Chapter 5, 51.)
Parasites. Some cause diarrhea; others, itching around the
anus. Lice and scabies are insect parasites that can cause
discomfort and are troublesome to many people.

Decisions about exclusion should be based on written crite- Common, minor illnesses sometimes have consequences.
ria. Written exclusion policies promote consistency and aid They can cause some short-term discomfort for the child
in diffusing disagreements between parents/legal guardians and lost work if a family member must stay home to care
and program/school staff members about the handling for the ill child. Staff members and families/legal guardians
of children who are ill. Programs must follow their state who are involved with children who participate in group
licensing laws or codes outlining exclusion. Chapter 7 of settings may have more than the average number of ill-
this book contains Quick Reference Sheets that incorpo- nesses too. These illnesses may interfere with their ability
rate Caring for Our Children exclusion criteria and provide to be productive at work. Children are less likely to benefit
teachers/caregivers and center directors with reproducible from the educational program if they are absent for illness
handouts about each condition. In center-based child care, or present and ill. Educators are less likely to be able to
the director, rather than the teacher/caregiver, should be implement a quality program if they are ill. Family mem-
in charge of maintaining exclusion policies and communi- bers who are infected by their children who are in group
cating with parents/legal guardians, health professionals, care may not be productive at work or home. They may
and public health personnel. blame staff members for not doing enough to prevent their
children from becoming ill.
Common respiratory infections most often cause coughs
and colds that are relatively harmless and resolve with- Some practical measures help reduce the frequency and
out treatment. On average, infants in child care have 8 to severity of common infections. For example, the risk of
10 common respiratory infections annually. As children infection is decreased by keeping the same individuals
grow older, they have fewer common respiratory infections, together in a group, avoiding intermixing children from
but even adults have an average of 4 common respiratory one group with those of another group. Excluding children
infections per year. Until they reach 3 years of age, children with certain conditions, environmental infection control
participating in group care have more respiratory infections procedures, and immunizations will all be discussed in
than those cared for only at home. This difference is great- more detail in chapters 3 and 5.
est when comparing the number of respiratory infections
Disease-causing germs can spread by
among children in group care with that of children who
Contact with hands that have touched the nose and eyes

have no other children living in their home. The increased
or have been used to “cover your mouth.”
number of infections is most troublesome for infants.
Covering your mouth with your hands. This spreads

Infants have small body structures and immature functions
germs unless hand hygiene is practiced immediately
that make them vulnerable to complications from common
afterward—before any surface is touched. It is better to
respiratory infections. For example, infants are more likely
use an elbow or shoulder to cover your mouth and nose
than older children to have ear infections or feeding diffi-
to keep the germs where they are less likely to be spread
culties when they have a common cold.
to others.
Germs that infect the digestive system can cause diarrhea Coughing or sneezing. These are body responses to irrita-

and vomiting. These gastrointestinal illnesses occur less tion of the respiratory tract and send infectious droplets
often than common respiratory infections, but nearly all from a person who has an infectious disease into the air.
children get at least one each year. As with respiratory Then susceptible children and adults breathe these germs
infections, gastrointestinal infections become less frequent into their bodies.
and less severe as a child grows older. Touching infectious body fluids or secretions (eg, mucus,

saliva, blood, urine, stool) of someone who has germs
Children who have been enrolled in group care longer have
that cause disease.
fewer infections. When older children first enter a group
Touching an object previously contaminated by someone

care setting, they are likely to have more frequent infections
with germs from infectious body fluids or secretions.
than their age-mates who have been enrolled in group care
for 1 or 2 years. Each time a child is exposed to a new germ,
The Role of the Child Care Health Consultant and
the child’s immune system responds and learns to recog-
School Health Personnel
nize and defend against this type of germ in the future.
Sometimes this response prevents symptoms. Other times, Quality improvement in child care or school should
if the immune system is not able to control the infection, include having a health professional work collaboratively
the child becomes ill. In general, mild illnesses help chil- with educators to identify and implement measures to
dren’s immune systems to develop in a healthy way. reduce illness. Often, a health professional who performs
this function in the child care setting is called a Child

Care Health Consultant (CCHC). An analogous role is and consultants, including determining who will commu-
performed by school health personnel in the school. When nicate with parents/legal guardians, children’s health pro-
families, administrators, teachers/caregivers, and health fessionals, and others who may be involved. As a starting
professionals work together, they can promote healthful point for developing site-specific policies, readers may want
behaviors that prevent infections and illness. Child care to use the current edition of Model Child Care Health Policies.
programs and schools should have an ongoing relation- The Early Childhood Education Linkage System-Healthy
ship with a health professional who, in the role of a CCHC, Child Care Pennsylvania, a program of the Pennsylvania
provides consultation, technical assistance, advice, and Chapter of the American Academy of Pediatrics, is the
professional development to reduce the incidence and compiler and editor of these best-practice policies. More
spread of infections as well as advice about what to do information about Model Child Care Health Policies can
about outbreaks. be found at www.aap.org/bookstore and www.ecels-
healthychildcarepa.org. In addition, the following quick
Many types of health professionals from a variety of
reference handouts may help to inform those involved in
health settings can function as CCHCs. Nurses and doc-
managing infectious disease issues:
tors usually provide health professional advice and services
“What Families Can Do to Reduce Illness From Infection
in K-12 schools. Chapter 8 discusses this role in more
in Child Care and Schools” on page 7
detail, including where to find health professionals who
“What Staff Members Can Do to Reduce Illness From
can provide child care health consultation services. While
Infection in Child Care and Schools” on page 11
CCHCs and school health professionals provide consulta-
“What Health Professionals Can Do to Reduce Illness
tive services and input into the health operations of the
From Infection in Child Care and Schools” on page 15
program or school, health care services for the individual
child should be coordinated by the child’s usual source When their child is moderately or severely ill, parents/legal
of pediatric services. The usual source of pediatric health guardians should remind their child’s health professional
care services is called the medical home (see “Use Preventive about the settings where the child is enrolled and ask for
Pediatric Care—A Medical Home Can Help” on page 8). specific information to share about the diagnosis and care,
as well as whether the child’s illness might pose a risk to
The director of a child care program or the principal of a
others in the child’s group. Health professionals are legally
school should perform or assign a staff member to perform
required to obtain the parent’s/legal guardian’s written
as a health advocate for integration of health policies into
consent before sharing any information about a child with
day-to-day operations. The person who has responsibility
child care or school personnel. Parents/legal guardians
for internal implementation of health and safety in child
should authorize their child’s health professional to share
care is called a child care health advocate. The health advocate
information directly with appropriate members of the
interacts with a health professional who visits, consults,
child’s education program about potentially communicable
and provides technical assistance and professional develop-
diseases or other conditions. Staff members need firsthand
ment for staff members on an ongoing basis.
information from the child’s health professionals to pro-
vide appropriate care for the child and others in the child’s
Planning and Policies
group. Even if parents/legal guardians understand what a
The management of the health component of an educa- health professional tells them, they may not accurately con-
tional program in child care or school requires focused vey that information to others who care for the child.
planning. All facilities need written health policies that
clarify the roles and responsibilities of each staff member

What Families Can Do to Reduce Illness From Infection in

Child Care and Schools
Germs are everywhere—on every surface that people play materials, and floors where children crawl and peo-
touch and in the air we breathe. Parents/legal guardians ple walk with their shoes. Some germs can survive in an
can work with teachers/caregivers and health profession- inactive state on dry surfaces for quite a long time and
als to protect children against infectious illness in the become active when they come in contact with a moist
following 3 ways: surface again.
1. Keep the number of germs that enter the body down
Avoid unnecessary use of antibiotics. These can reduce
to a level that the body can manage.
the numbers of healthful germs that keep the disease-
Follow hand and surface hygiene practices in the
causing germs in check. Cleaning and sanitizing surfaces
standards from sections 3.2.2, “Hand Hygiene,”
as appropriate helps to reduce the number of germs to
and 3.3, “Cleaning, Sanitizing, and Disinfecting,”
a level the body can handle. (See pages 25–29 for clean-
in Caring for Our Children, 3rd Edition.
ing and sanitizing guidelines.) Germs can get inside the
Prepare and pack food brought from home fol-
body by touching contaminated surfaces with hands and
lowing food safety practices for cleaning, cooking,
then touching the eyes, nose, or mouth. Do not eat or
chilling, and separating foods to prevent food
drink without first practicing hand hygiene. Germs can
poisoning. For details, see the Partnership for
be passed by sharing glasses, forks, and spoons that have
Food Safety Education at www.fightbac.org or
not been properly cleaned. Some germs travel through
www.befoodsafe.org.
the air. Ventilating with fresh, healthful air is a good way
Catch your sneezes and coughs with a disposable
to reduce the concentration of germs in the air.
tissue or use your elbow to keep from spread-
ing germs onto surfaces and into the air. Throw Hand hygiene is one of the most important measures
away the tissue after one use and then practice to prevent the spread of germs. Provide accessible
hand hygiene. sinks with warm water, soap, and disposable or cloth
2. Keep children healthy with good nutrition, recom- towels used by only one person and laundered when
mended exercise, and up-to-date receipt of vaccines soiled. Wash your hands and your children’s hands. If
and other preventive pediatric health care services. you choose to use hand sanitizers, use only those that
Pediatric health professionals monitor health, teach contain at least 60% alcohol and only when hands look
parents/legal guardians how to keep their children clean. They must be used according to the manufac-
well, give vaccines, and help parents/legal guardians turer’s instructions for the amount and contact time
manage illnesses. Receiving vaccines is a safe way on the skin and only for children older than 24 months
for children’s bodies to learn how to handle disease- and adults. Remember that these products are toxic if
causing germs and prevent illness. ingested and flammable. The times when you should
3. Manage the environment to reduce the likelihood practice hand hygiene for you and your children are
that children will be challenged by an overwhelming When you come inside from outside at child care/
number of disease-causing germs or be weakened school and at home
by exposure to harmful substances. For example, Before and after
do not allow smoking at any time in areas children ——Food handling and eating
occupy. Provide healthful ventilation, temperature, ——Giving medication
and humidity of indoor air. Make it easy to practice ——Handling water used by more than one person
hand hygiene. (eg, using a water table, swimming or wading)
After
More About How to Keep the Number of Disease- ——Diapering
Causing Germs Down to a Manageable Level ——Using the toilet (Use a towel to handle the sink fau-
Germs like warm, moist places. They live in body fluids, cet tap if it does not automatically turn on and off
in foods, and on surfaces. Germs live on surfaces that are and again if needed to open the door in a commu-
touched, such as toilets, door handles, tables, toys, moist nal restroom.)
➤continued


Child Care and Schools, continued
——Handling any body fluid (eg, blood, mucus, vomit, Vaccinate
sores) or coming into contact with tissues, ban- Children should receive all nationally recommended
dages, or other items contaminated with body fluids vaccines. They should get their routine checkups on
——Having contact with animals or cleaning the cages time and use a source of health care that is licensed and
or litter boxes of pets and other animals (including certified by a recognized professional board to provide
tropical fish) pediatric care. In the United States, most recommended
——Playing in sandboxes or at playgrounds vaccines are required for attendance in child care pro-
——Handling trash or garbage grams and schools. The risk of exposure to vaccine-
preventable diseases is increased when children gather
Use Preventive Pediatric Care—A Medical Home in groups. Unless medical, religious, or philosophical
Can Help exemptions exist, the child’s immunization record
Families should seek pediatric care that is accessible, should demonstrate that the child received the vaccines
continuous, comprehensive, coordinated, compassion- shown in the current recommended childhood and ado-
ate, culturally effective, and family centered. Such a lescent immunization schedules available at www.cdc.
source of health care is known as a medical home (see gov/vaccines/schedules and www.aap.org/immunization.
www.medicalhomeinfo.org). A medical home is pro- These schedules are published on an annual basis, typi-
vided for children using a team-based approach, led cally in January or February (see the 2013 schedules for
by pediatricians or family practice physicians, and will children and adults on pages 206–214). Children who
likely include physician assistants, nurse practitioners, have not received all of the recommended age-appro-
medical assistants, and others. A pediatric medical home priate immunizations before enrollment should receive
works with families to promote their child’s well-being, the vaccines they are missing as soon as possible. When
starting with prenatal counseling of families about their children and adults who care for them do not have the
baby and continuing until the child reaches adulthood. nationally recommended vaccines, they not only put
When available health care does not meet the criteria of themselves at risk but also increase the risk of others.
a medical home, families should seek care from a source Under-vaccinated individuals can spread infections to
that most closely meets the medical home concept in others who are too young to have received enough vac-
their community. cine doses to be protected or have a medical condition
that precludes their receipt of some vaccines.
Choose Breast Milk as the Best Food for Infants
Research that shows that breast milk (human milk), Manage Illness
with its unique mixture of ingredients (fatty acids, Families should communicate with staff members in

lactose, amino acids, vitamins, minerals, enzymes, and their child’s group care setting about signs of illness in
other components), helps protect infants from illness. their child.
Feeding infants breast milk helps offset the increased Ask staff members to advise the families of children

risk of infection from group care exposure for infants about what to watch for if an outbreak of a par-
in child care. Health professionals can help mothers ticular illness occurs among the children in their
establish successful and enjoyable feeding. They can child’s group.
teach mothers how to express, store, and transport Families should plan to pick up children promptly

milk to child care for times when mother and baby and care for them in a comfortable place away from
cannot be together for feedings. Early educators need others when their children are too ill to remain in the
to practice appropriate storage and handling of breast group care setting. Understand that program staff
milk to preserve its benefits, avoid wasting it, and ensure members make decisions about excluding children
that children receive only their own mother’s milk. from child care or school based on a variety of factors.
Children with certain types of infections must be
➤continued


Child Care and Schools, continued
excluded from care, while children with other infec- diagnosis and care, as well as whether the child’s ill-
tions might be able to attend. Criteria include whether ness might pose a risk to others in the child’s group.
the child feels well enough to participate in regular Health professionals are legally required to obtain the
activities and if teachers/caregivers can care for the parent’s/legal guardian’s written consent before shar-
child given the current staffing situation without coming any information about a child with child care or
promising care of the other children in the program. school personnel. The parent/legal guardian should
These decisions might vary depending on the assess- authorize the child’s health professional to share
ment by staff members of circumstances at the time. information directly with appropriate members of the
At routine health visits (checkups), parents/legal
child’s education program about potentially commu-
guardians should inform their child’s health profes- nicable diseases or other conditions. Staff members
sional about the group care settings and schools need firsthand information from the child’s health
where their child is enrolled. professionals to provide appropriate care for the child
When their child is moderately or severely ill, parents/
and others in the child’s group. Even if parents/legal
legal guardians should remind their child’s health pro- guardians understand what a health professional tells
fessional about the settings where the child is enrolled them, they may not accurately convey that informa-
and ask for specific information to share about the tion to others who care for the child.

What Staff Members Can Do to Reduce Illness From Infection

in Child Care and Schools
Germs are everywhere—on every surface that people When you come inside from outside at child care/

touch and in the air we breathe. Adults who work in school and at home, after breaks, and when moving
child care programs and schools can collaborate with from one group to another
families and health professionals to protect children Before and after

(and themselves) against infectious illness in the follow- ——Preparing food or beverages
ing ways: ——Eating, handling food, or feeding a child
1. Keep the number of disease-causing germs that enter ——Giving medication or applying a medical ointment
the body down to a level that the body can manage. or cream in which a break in the skin (eg, sores, cuts,
2. Make sure you and the families you serve use preven- scrapes) may be encountered
tive care from health professionals. ——Playing in water (including swimming) that is used
3. Follow healthful practices such as good nutrition, by more than one person
exercise, and sleep to keep the body fit and able to ——Diaper changing, unless hand hygiene was recently
resist disease. performed for another purpose and no new con-
4. Get recommended immunizations that help you and tamination has occurred
the children avoid vaccine-preventable illnesses. After

——Using the toilet or helping a child use a toilet;
How to Keep the Number of Germs Down to a changing a diaper, disposable training pants, or
Manageable Level soiled underwear; or touching inside the garment to
Germs like warm, moist places. They live in body fluids, see if diapers or underwear need to be changed
in foods, and on surfaces. Germs live on surfaces that ——Handling body fluids (eg, mucus, blood, vomit) from
are touched, such as toilets, door handles, tables, and sneezing, wiping and blowing noses, mouths, or sores
floors where children crawl and people walk with their ——Handling animals or cleaning up animal waste,
shoes. Some germs can survive in an inactive state on cages, containers, or aquariums
dry surfaces for quite a long time. Some survive hours, ——Playing in sand, on wooden play sets, and outdoors
others days and weeks. They become active when they ——Cleaning or handling garbage
come in contact with a moist surface again. Germs can
get inside the body by touching contaminated surfaces Practice Preventive Care—A Medical Home Can
with hands and then touching the eyes, nose, or mouth, Help Staff Members and Children
or by simply eating without practicing hand hygiene. Seek care that is accessible, continuous, comprehensive,
Germs can be passed by sharing glasses, forks, spoons, coordinated, compassionate, culturally effective, and
and mouthed toys that have not been properly cleaned. family centered. Such a source of health care is known
Some germs travel through the air. Diluting the air as a medical home (see www.medicalhomeinfo.org). A
with fresh, healthful air is a good way to keep the con- medical home is provided for children using a team-
centration of germs as low as possible. based approach, led by pediatricians or family practice
physicians, and will likely include physician assistants,
Hand hygiene is one of the most important measures nurse practitioners, medical assistants, and others. For
to prevent the spread of germs. Provide accessible sinks adults, the team will be led by family practice physicians
with warm water, soap, disposable towels, hand lotion, or internists and include nurse practitioners and other
and easy-to-understand posted instructions to facilitate nonphysician clinicians in a private setting or health
good hand-washing practices for all adults and children department clinic. A medical home works with families
in each group area where activities take place. If hands to promote their child’s well-being and with adults to
look clean, children older than 24 months and adults promote their wellness throughout life. When a medical
may use an alcohol-based hand sanitizer as an alterna- home that meets the definition is not available, seek care
tive to hand washing. Children require close supervision from a source that most closely meets the medical home
when using a hand sanitizer. Practice hand hygiene at concept in the community.
the following times:
➤continued


in Child Care and Schools, continued
Communicate Appropriately a health professional may be warranted if 1) there is a
It is difficult for staff members and families to deal with concern about the effect of a diagnosis on the health of
illnesses and documentation for program records while others in the group; 2) there is a concern that parents/
attending to other responsibilities. The same is true for legal guardians did not adequately communicate the
health professionals. The usually fast-paced work of severity of symptoms to the health professional; or 3) a
health professionals may lead to overlooked messages care plan is needed for a child who might require special
and misunderstandings. When seeking information accommodation. Consult the Quick Reference Sheets in
from a child’s health professional, be sure the family Chapter 7 first to be sure a note is truly needed.
has completed the forms used by the health profes- Notifying parents/legal guardians about their child’s
sional to meet legal requirements to release any infor- exposure to a potential infection, outbreak, or epidemic
mation. The federal law known as the Health Insurance without causing alarm or prompting inappropriate
Portability and Accountability Act of 1996 (HIPAA) action is challenging. Before children are enrolled in
allows doctors to guide school and child care personnel child care or school, educators should explain to fami-
with information without written consent. However, lies what to expect for communication about these
many physicians may refuse to transfer health informa- issues. At enrollment, parents/legal guardians need
tion about a child without such consent from parents/ more than a written brochure. Review the key issues
legal guardians. Most health professionals require that verbally, including common situations, program proce-
parents/legal guardians complete their office’s version dures, and policies. Families need to know how they will
of a HIPAA consent form. Even though HIPAA does receive information or updates (Should they refer to a
not apply to educators, it is best for all those who are program policies booklet or a bulletin board? Will they
not family members to obtain consent from parents/ be contacted personally or receive a written notice? Will
legal guardians to share information about their child, routine notifications differ from times when there is a
noting that the purpose is to collaborate for the benefit potential outbreak?).
of the child’s care. See page 215 for a sample consent
form that educators can use. Then, provide a clear, brief Receive Recommended Vaccines
statement of your concern or question in whatever form Families and appropriate staff members of the child
of communication you use. Ask the person who answers care facility or school can work together to be sure
the phone in the health care office about the best way to that children, staff members, and regular volunteers
communicate with the health professional. receive all recommended vaccines and checkups from
Of course, staff members should first share concerns licensed health professionals who are qualified to pro-
about the child’s health and development with the vide such care. Most states require nationally recom-
family. In addition, you can provide a written note that mended vaccines for attendance in child care programs
families can take to their child’s health professional to and schools. For adults, vaccines are recommended but
describe your specific observations and ask for a return rarely required. In many programs only hepatitis B vac-
note. Alternately, you can fax the note to the health cine must be offered by the employer to comply with
professional’s office and call to confirm that the fax the regulations of the Occupational Safety and Health
was received. You can send your question by e-mail Administration for those who are likely to come into
or give it by phone to the physician’s office manager. contact with blood in the course of their work. Health
Indicate when would be the best time if the health pro- insurance and employer benefits may or may not pay
fessional wants to call and discuss your concerns. for vaccines, but the cost of the illnesses they prevent
is many times greater than the cost of the vaccines.
Routine notes for return after illnesses are not necessary
The risk of exposure to vaccine-preventable diseases is
if the child seems well. Generally, health professionals
increased when people gather in groups for any reason,
determine whether a child is well by asking parents/
especially when children are part of those gatherings.
legal guardians how the child seems to them, so a note
adds very little information in most cases. A note from ➤continued


Unless medical, religious, or philosophical exemptions legal guardians may need to be informed that there
exist, immunization records should demonstrate that is such a child in the group because that child poses
adults and children received the vaccines shown in cur- a risk of exposure of others to illness as well as to
rent immunization schedules for children and adults themselves. While schools cannot exclude children
at www.cdc.gov/vaccines/schedules and www.aap.org/ whose families refuse to give their children vaccines
immunization. Routine and catch-up schedules are for personal reasons, early education and child care
published on an annual basis, typically in January or programs may want to obtain legal counsel to decide
February (see the 2013 schedules for children and adults what to do in these cases. As a minimum, the program
on pages 206–214). Children and adults who have not should make parents/legal guardians of these children
received recommended age-appropriate vaccines before aware that in the event of an exposure to a vaccine-
enrollment should be immunized as soon as possible. preventable disease, a child who has not been immu-
Annual flu vaccine and a single dose of tetanus, diph- nized will need to be excluded from the facility.
theria, acellular pertussis (Tdap) vaccine for teachers/ Program or school staff members should work with

caregivers is especially important. families and appropriate professionals to develop
plans to care for children whose needs for care differ
Use the Health Record Review as a Tool from those of typically developing children. This is
Each child’s health record should be reviewed by des- especially important for children who need accom-
ignated staff members at the early care and education modations to fully participate in all activities or who
program or school with parents/legal guardians at time have increased risk of an infectious disease—those who
of enrollment, clarifying questions about the child’s are incompletely immunized or unimmunized; those
health with parents/legal guardians and the child’s with a condition that makes them vulnerable to infec-
health professional. Use this as an opportunity to tion; those who do not have a medical home and use
emphasize the 3-way partnership among parents/legal emergency departments, resulting in fragmented or
guardians, the program, and health professionals. sporadic medical care; or those who travel outside the
Check nutrition and feeding plans. For infants, United States.
support mothers who are breastfeeding their babies.
Research shows that breast milk, with its unique Manage Illness
mixture of fatty acids, lactose, amino acids, vitamins, Communicate with staff members in the facility and

minerals, enzymes, and other components, helps families with discretion and regard for privacy about
protect infants from illness. Establish routines for the risk of illness in the group—in general and when a
receiving, storing, and feeding expressed breast milk. specific increased risk through exposure has occurred.
Arrange the feeding schedule and an environment The Quick Reference Sheets in Chapter 7 may be help-
to support the mother who wants to breastfeed the ful handouts to share with staff members and families
infant at drop-off, pickup, and drop-in times dur- when an outbreak occurs.
ing the day. Ask about nutrition at home and foods Help families develop a plan for how they will care for

that will come from home to the program to plan their children when their children are ill.
for healthful nutrition that enables the child to be Notify families when children in the group have been

healthy and able to resist infection. exposed to an infectious disease. Depending on the
Enforce the policy that children must have up-to- circumstances and disease, the extent of this notifi
date immunizations for participation in the program. cation may range from just the child’s immediate
Exceptions (eg, medical, religious, or philosophical group to the entire facility. The health department
exemptions) should be properly documented as should be notified for a few contagious diseases
required by state law. If parents/legal guardians that might pose a risk for others in a group care set-
choose not to have their child fully immunized, they ting (see Chapter 7, “Quick Reference Sheets,” for
should be informed in writing about the increased these specific conditions). Such notification might
risk of vaccine-preventable diseases. Other parents/ ➤continued


be coordinated with the child’s health professional. Establish an Ongoing Relationship With a Health
Educators must recognize their duty to report an Professional as a Child Care Health Consultant or
outbreak or a serious infectious illness that has been School Health Personnel
diagnosed in a child who is enrolled in the group care
setting to public health authorities. Often, the physi- Some programs have a school nurse who can observe
cian’s or laboratory’s report of the diagnosis of the and advise on health and safety. Others must make
disease to public health authorities does not include arrangements with a community health professional
consideration of the exposure of others who are not for these services as a paid consultant or volunteer. It is
members of the child’s immediate family. essential that every program has a health professional
Make a plan to care for children who become ill
who provides ongoing observations and input on health
and are waiting for their families to pick them up. and safety matters. The program’s health consultant
Children who are ill may require care in a comfortable should have expertise in child health and development
place away from others if they are too ill to remain in and be able to work with staff members in a collabora-
the group care setting. The plan should ensure that all tive fashion. The role includes recognizing unacceptable
children are directly supervised and receive competent risks and working on ways of reducing those risks that
and nurturing care from someone familiar to them. are acceptable to educators and families. In addition,
The location of the child who is ill should not increase the health professional can identify and collaborate
the exposure of others who have not already been in on incorporating health-promoting behaviors into the
contact with the child. educational curriculum. The role of the health consul-
Establish mechanisms for communication with
tant for early care and education programs is defined
children’s health professionals when there are ques- in Caring for Our Children, 3rd Edition, Standard 1.6.0.1
tions about diagnosis and care or when children are and for school health personnel in School Health: Policy
moderately or severely ill or possibly have an illness & Practice, 6th Edition, American Academy of Pediatrics
that poses a risk to others in the group care setting. (AAP). Specific training in how to be a Child Care Health
Educators need to have clear directions about care Consultant (CCHC) or provide school health services is
that must be provided during the time children are available.
in the program. Health professionals can make better For those who serve in the role of CCHC, the
diagnoses and treatment decisions about a specific Pennsylvania Chapter of the AAP has a DVD set,
concern when they know about behaviors that the Health and Safety Consultation in Child Care, that provides
educators have observed. As previously indicated, basic instruction about this role; it is available for
confidentiality laws require parent/legal guardian order at www.ecels-healthychildcarepa.org. Each state
consent for exchange of information from health also has a Web link for CCHCs at www.healthychildcare.
professionals to educators. However, once consent is org/contacts.html. Every state has trainers who are
provided to the health professional and preferably to graduates of the National Training Institute for Child
the child care/school also, essential exchange of infor- Care Health Consultants at the University of North
mation should occur. Carolina, Chapel Hill.

What Health Professionals Can Do to Reduce Illness

From Infection in Child Care and Schools
Children are enrolled in group settings from infancy. Teachers/caregivers should not be expected to rely on
These settings include informal neighborhood arrange- relayed communications from families. Even though
ments, more organized group care in home-based family members may understand the instructions,
settings, center-based early education programs, and they do not necessarily share that information effec-
schools for older children. Aggregation in groups tively with others who care for their child.
increases the risk of the spread of infectious diseases, Help develop a plan for care of children with special

but it also offers opportunities for health promotion needs related to chronic or acute infections and for
and prevention. National statistics show that children at-risk children. Provide these care plans to all teach-
who are enrolled in group care and schools are better ers/caregivers involved in the child’s care in writing.
immunized than those who do not participate in such Where the child’s care plan includes special proce-
arrangements. dures, arrange for all the child’s teachers/caregivers to
learn from a health professional how to perform these
Health professionals can help families and educators
procedures. As with communicating management
manage infectious diseases in child care and schools in
instructions, parents/legal guardians who may know
many ways.
how to perform health care procedures may not have
Determine and make sure you understand current care

the teaching skills to instruct others who care for their
arrangements for each child in your practice. Parents/
child to perform the procedures correctly.
legal guardians may move children from relative care
Provide educational sessions on health topics for fami-

to nonrelative, home-based family child care arrange-
lies and teachers/caregivers.
ments to center-based programs and back again in the
Educate families and teachers/caregivers about appro-

same day or on different days each week, or change
priate inclusion and exclusion practices.
arrangements for a variety of reasons. Before- and
Help determine the severity of children’s illnesses

after-school programs are used by many families and
and what levels of illness each child care program
may be recreational, educational, or minimally super-
and school can manage with available personnel
vised. The names of the programs do not necessarily
and other resources.
describe the type of care. Drop-in child care is now
Sensitively respond to questions asked by families and

offered in many health clubs, bowling alleys, shopping
teachers/caregivers about the implications of infec-
malls, and other locations.
tious diseases for children’s participation in a group
Support mothers who are breastfeeding their babies,

care setting. Avoid suggesting that the child’s partici-
and endorse breastfeeding as an important preventive
pation in a group care setting is necessarily the source
health care strategy. Research shows that breast milk,
of a particular infectious illness. Community and
with its unique mixture of fatty acids, lactose, amino
family exposure, as well as exposure in a group care
acids, vitamins, minerals, enzymes, and other compo-
setting, are all potential sources of any individual ill-
nents, helps protect infants from illness.
ness. Be cautious about making negative comments to
Keep good immunization records and implement

families about the care provided by teachers/caregivers
reminder/recall systems to ensure each child is age-
who are responsible not only for a particular child but
appropriately immunized and up-to-date with all pre-
for the entire group of children.
ventive care services. Encourage all children, families,
Provide thoughtful advice for the family of a child

and staff members who have any contact with child
with recurrent infections. Assess whether the child
care programs and schools to be appropriately immu-
is having more frequent or severe infectious diseases
nized and up-to-date with all recommended preventive
than is typical for the age of the child. If so, consider
care services.
asking for parent/legal guardian consent to discuss
Provide management instructions for children who are

preventive measures with teachers/caregivers, such as
ill, not only to families but also to teachers/caregivers
more frequent and careful hand hygiene for children
who are responsible for observing for illness and giv-
ing treatment to children at any time during the day. ➤continued

What Health Professionals Can Do to Reduce Illness

From Infection in Child Care and Schools, continued
and staff members, better hygiene in diapering and involves periodic site visits to make observations, pro-
toileting areas, and better ventilation of rooms. vide needed advice and professional development for
Inquire about whether the facility has access to a
staff members, as well as access for questions from
health consultant who might be available to assess staff members at other times. National school health
the program’s operation to see whether any additional standards recommend comparable health professional
measures would be helpful to reduce the risk of infec- input and planning for all school programs (Caring for
tion. National guidelines for out-of-home child care Our Children, 3rd Edition).
recommend that all group care settings have health Use antibiotics in accordance with recommended

professional input at some level of frequency that practices.

Another random document with
no related content on Scribd:
approach as the royal party turns the angle opposite Oldtown. The
king is always seated in a six-oared gig belonging to the ship to
which he is proceeding, whilst the canoes contain his eldest son,
young Eyo, and his three brothers, with an innumerable host of slave
attendants. He has a gigantic parti-coloured parasol held over his
head on these occasions, as he has whenever walking about his
town, or seated in one of his court-yards, overlooking his trade
books. The musical band accompanying the king consists of an
Egbo drum, placed transversely in the canoe, which is not beaten on
the ends as our drums are, but on the top of its longitudinal surface
with a pair of sticks; an instrument formed of iron, as of the saucers
of two shovels welded face to face, and struck with a piece of the
same metal; a cow’s-horn, blown rather discordantly; and clattering-
boxes made of bamboo matting, with a string to them held in the
hands like Spanish castanets, and shaken vigorously to produce a
noise by the agitation of the pebbles or pieces of broken crockery-
ware they contain. Yet, with this primitive attempt at music, the
banners flying from the canoes, the simultaneous hoisting of flags on
all the ships in the river, and the return of a salute from the vessel to
which he is proceeding, when the king’s party becomes visible, gives
the whole scene a very animated appearance.”
By-the-by, mention has several times been made of the curious
institution existing in this part of the world known as the order of
“Egbo.” It is a sort of negro brotherhood of kings, chiefs, and free
men, and the title is derived from “Ekpe,” the Efik name for tiger.
There are eleven grades, the three superior of which are not
purchaseable by slaves. In former times the Egbo title was confined
entirely to freemen, the second or third generation of a slave born
within the pale of an Egboman’s dwelling being liberated by this fact,
and allowed to purchase it after their parents were dead. It cannot be
compared to any institution familiar to European minds but to that of
Freemasonry. Previous to initiation, the Egbo candidate is obliged to
go through a number of ceremonial observances; as, for instance, on
a “Brass Egbo”—one of the superior grades—applicant’s admission
into that order, his body is daubed over with yellow dye to simulate
brass, and there is a sacrifice of animals on the occasion. The
secrets and meetings of Egbo men are strictly private. If a man,
woman, or child have a complaint of grievance against a master or
neighbour, he or she has only to give notification of it by slapping an
Egbo gentleman on the front of his body, or by going into the market
square and tolling the large Egbo bell. The gentleman apprised by
the first-mentioned form of notice, is bound to have at once an Egbo
meeting to redress the grievance complained of, and if this be found
to be trivial the punishment is inflicted on the complainant. When an
Egbo man wants to make a proclamation relative to a theft
committed, or the recovery of a debt, he sends out into the town
what is supposed to be Idem, or spiritual representation of Egbo, a
man with a black vizard on his black face, and the whole of his body
covered cap-a-pie with a fantastical dress of bamboo matting. This
personage is sometimes preceded by a few drummers, and he
always has a bell fastened to his side, which rings as he goes along.
In his left hand he carries a bunch of green leaves (for he is believed
to have been exorcised from the woods, and of course must keep up
his sylvan character); in his right is an enormous cow-hide whip with
which he flogs every slave, man or woman, whom he meets, as taste
or inclination may suggest. A brutal peculiarity of the Egboship is
this, that the want of a single variety of the title will expose him who
is so unfortunate as to lack it, to the lashings of the Idem of that
particular grade which he has not purchased. If an individual who is
in possession of all the inferior grades, and of three of the superior
ones, happens to be out on the day when the Idem of that particular
Egbo that he was in want of is walking, he is marked out from the
common multitude and treated with extra severity. Should the Idem
not meet any slave in the streets to whip on his rounds, he is at
liberty to go into their houses and whip them to his heart’s content.
The sound of Egbo bells, and the name of Egbo day, are enough to
terrify all the slave population of Duketown, and when they hear it
they hide in every available place. Latterly females have been
permitted to buy Egbo privileges, but are not allowed to be present at
the councils of the Egbo gentlemen, nor to enter at any time within
the wall of the Egbo Palaver-house. When a yellow flag floats from
the king’s house it is understood to be Brass Egbo day, and none but
a few of the privileged are allowed to walk abroad. A strip of cloth of
the same colour nailed to any man’s door implies that his house is
under the powerful protection of Brass Egbo, the indication being
significant of the master’s absence from home. If an Idem meets a
European in his progress, where there are two roads or pathways
available, the Idem walks off on the one different from that which the
white man is approaching; if there be but one road, the latter is
expected to turn his back and let the supposed spirit pass unnoticed
and undisturbed. “Aqua Osong,” the last day of the Kalabar week, is
grand Egbo day, on which there is a carnival and Egbo procession,
with the usual amount of brutality. All legal and judicial proceedings
in the country are ushered in and carried out under Egbo
demonstrations, for the purpose evidently of keeping the law in
terrorem over the slave population. And no stronger evidence of this
can be adduced than that a man tried and condemned by Egbo law
has to forfeit all his slaves and other property in his possession, no
matter to whom this latter may belong. These are all divided as prey
amongst the highest Egbo authorities. Persons sentenced to death
by Egbo trial are allowed what is considered a privilege of leaving
this world in a state of intoxication. There is a class of people called
Bloodmen, who live in the interior at the plantations, and whose
presence in Duketown does not give much comfort to the Egbo
authorities. Sometime after the death of King Eyamba in 1846, a
number of slaves belonging to the duke’s family ran away from their
owners, and entered into a blood covenant for mutual protection. In a
short time others joined them, and they now amount to several
thousands. The present King of Duketown, Duke Ephraim, is the
lineal descendant of the master of the original refugees, and
consequently has considerable influence over them. Some time back
they tried to be allowed the establishment of a separate Egboship for
themselves, but were refused. They come into town whenever any
ceremonial is to be performed having reference to a deed of blood;
but what their relation is to the Egbo order still remains a profound
secret. The gentlemen at Old Kalabar have all private fetishes at
their houses—the skulls of human beings, the bones of leopards,
hippopotami, crocodiles, and manattis, arranged according to the
owner’s taste and fancy. Peculiar species of food are not eaten by
many families, from the fact that some members of them die after
eating of such condiments, and their ju-ju consequently places an
interdict on their use.
At Lunda, another settlement in Western Africa, the individual at
the head of the State is called the “Mambo.” This gorgeous
personage, together with his chief ministers, is thus described by the
traveller Valdez, to whom audience was given:
“The Mambo sat on a number of tiger-skins, so arranged that all
the tails radiated, thus forming the figure of a large star, and in the
centre was spread an enormous lion-skin, which covered a portion of
all the others. A stool, covered with green cloth and placed on the
lion-skin, formed the throne of the Mambo. This dignitary was
dressed in a most magnificent style, far surpassing in grandeur of
display all the other potentates of the interior of Africa. His head was
adorned with a mitre, about two spans high, in shape resembling a
pyramid, and formed of feathers of a bright scarlet colour. His
forehead was encircled by a diadem ornamented with a great variety
of valuable jewels of great brilliancy; a sort of frill or fan of green
cloth, supported by two small ivory arrows, was standing up from the
back of his head; the neck and shoulders being covered with a kind
of spencer or capuchin without sleeves. The upper part of this cape
was ornamented with the bottom of cowrie shells, under which was a
row of imitation jewels. The lower part had a most brilliant and
dazzling effect, in consequence of a great number of small mirrors,
or square and round pieces of looking-glass, being tastefully
arranged alternately with the precious stones all round it. His
shoulders, breast, and back, were thus covered with a garment at
which no one in that resplendent sunshine could for one moment
look fixedly.
“The arms above the elbows were ornamented with a band of
cloth of about four inches broad, the borders and edges of which had
attached to them strips of skin, with hair of about four or five inches
long hanging down like a fringe. None but the Muata Cazembe, or
prime minister, and his nearest relatives are allowed to wear this
badge of royalty. From his elbows to the wrist the arms were
ornamented with sky-blue stones, while the yellow cloth, something
similar to the Highlandman’s kilt, extended from the waist to the
knees. This garment had two borders of about four inches wide, the
upper one blue, and the lower red.
“He also had a kind of girdle or swathe of several yards long,
which was worn in a rather peculiar manner; one end of it being
fastened to the other cloth by a small ivory arrow a little below the
waist, and the whole then wound round the body in small regular
folds. A leather belt which is girt round the body preserves this
garment in its place. Both are considered as the insignia of imperial
authority.
“The insipo or girdle of hide is cut from the entire length of an ox’s
skin, and is about five or six inches in breadth. When the insipo is
girded on, the tassel of the tail is left trailing under a sort of fan,
formed by the folds or plaits as before mentioned. The Muata
Cazembe had hung from his insipo under his right hand a string of
pearls, to the end of which a small bell was attached, which,
knocking against his legs as he moved, rang at intervals. He had
also pearls strung round his legs from his knees downwards, similar
to those he wore on his arms. While the whole of his body was thus
richly ornamented, his face, hands, and feet were left entirely
uncovered.
“The Muata Cazembe had seven umbrellas, forming a canopy to
shelter him from the sun. These varied in colour, and were fastened
to the ground with long bamboos, covered with stuff of different hues
manufactured by the natives. Twelve negroes simply clad, and each
of them holding in his hand a nhumbo’s tail, were stationed round the
umbrellas.
“The nhumbo is an antelope about the size of a three-year old ox,
and of a chestnut colour, having a black cross along the back, and a
great deal of hair about the shoulder-blades—about the same
quantity as a horse has upon his mane and tail. It has cloven feet,
head and horns like a buffalo, and the flesh is excellent food. The
nhumbo tails held by the negroes were in the form of a broom, and
the part which served as a handle was adorned with beads of
various colours. All the tails were put in motion at the same time
whenever the Muata Cazembe thought proper to make a sign with a
small one of the same kind, which he used himself.
“At a short distance from him were negroes gravely employed in
looking for and sweeping away whatever was unpleasant or
offensive to the sight. After them came two other negroes, with
baskets on their shoulders, to pick up anything which might be
overlooked; but the place was so clear that not one of them could
find anything to do, although, according to custom, the appearance
of being busy was kept up. Two curved lines issued from the
extremities of the Muata’s chair, and met at the distance of twenty
paces in front, opposite the Mambo. The line on the left was marked
by the point of a stick which was trailed along the ground; that on his
right by chalk. In front of these curved lines, forming an avenue of
about three spans in width, were two files of figures resembling idols,
beginning from the sides of the curved lines. The size of these
figures, which were only half-lengths, was about twenty inches; they
were nailed to sticks thrust in the ground, were very rudely made,
had Kaffir features, and were ornamented with the horns of beasts.
In the centre of the avenue was a cage in the form of a barrel,
containing another smaller figure.
“Two negroes sat on the ground near the two outermost figures
fronting the king, each having an earthen vessel full of live ashes
before him, and were employed in throwing on the fire a quantity of
leaves, which produced a dense aromatic smoke. The backs of the
images being placed towards the Muata Cazembe, from under the
last—the one nearest the earthen vessels—a rope was extended to
the Mambo’s feet; for what purpose I could not by any means
ascertain.
“The two wives of the Mambo were the only ones present in the
Chipango, the gate of which was open. One of these ladies was
sitting on a stool, covered with a green cloth; her arms, neck, and
bosom ornamented with stones of different colours, and her head
adorned with scarlet feathers, like the head-dress of the Mambo, but
shorter and smaller.
“The second wife sat on a lion’s skin at the left-hand side of the
gate, with no other dress than a cloth, which was entirely without
ornaments. Behind the two wives stood more than four hundred
women of different ages, all dressed in nhandas, a kind of
interwoven cloth made of the bark of trees.”
In another part of this strange country the ruler is known by the
euphonious title of “Jaga;” and whenever a vacancy occurs in the
government by the death of the Jaga, the Tendalla or prime-minister
convokes the heads of the electoral college, which comprises the
Macotas or counsellors, the Cazas or noblemen, and the Catondo or
commander-in-chief, who together with himself (the Tendella),
compose the cabinet council. When this body is assembled they
proceed to investigate the claims of the various individuals
connected with the families who are considered as legitimate
aspirants to the regal dignity.
Having first decided as to the family, their next inquiry has
reference to the individual best qualified to bear the royal dignity; but
it is seldom that matters proceed so far, for it is generally understood
beforehand by the members of the electoral college who is the
legitimate and popular claimant.
These important questions once settled, they next proceed to
build a suitable house for a new Jaga, and to lay out the garden,
etc., and also to erect houses for themselves around it. After these
preliminary proceedings, they next direct their steps to the residence
of the man of their choice, and unceremoniously entering, bring him
out as if he were a malefactor and present him to the multitude, who,
amidst the clang of marimbas and beating of drums, raise a
simultaneous shout on his appearance. He is then conveyed on the
shoulders of his sons, or of the people, to the Quilombo or fortified
residence provided for him, where he remains for several days, none
being allowed to visit him, with the exception of two relations and the
Tendella. At the end of two months he removes to a house
previously prepared on the borders of the River Undua, where he
remains for twenty or thirty days. Here he may be said to form his
new ministry—deposing some officers and appointing others. On this
occasion he also selects his principal wife. When all these
arrangements are finished, the Jaga returns to the locality where he
intends to reside, and fixes the exact spot as follows:—Having
formed his Quilombo, he takes his bow and discharges an arrow,
and wherever it falls there he must erect his permanent residence,
called Semba. Around it are built the houses of his wives, who in
general amount to fifty in number. Next to these are located the
senzales of the Macotas and their wives of the followers of the
former Jaga, and lastly of those who were with the elected Jaga at
the Senzald, where formerly he acted as Maquita.
The last of these ceremonies is that called the Sambamento, after
which the Jaga is considered qualified to exercise all the functions of
his office.
The particular period at which this most cruel and barbarous
custom originated is not known. Some of the Jagas have been
known to dispense with it altogether.
When it is decided to celebrate the Sambamento, some of the
Sovas or Maquitas are dispatched to find the Nicango or victim. The
person selected is uniformly a black, who must have no relationship
or connection with the Jaga or any of the Maquitas or Macotas.
When the Nicango arrives, he is received at the Quilombo and
treated in the same manner as the Jaga; he is provided with
everything he requires, and all his orders are obeyed with the same
promptitude.
The day on which the Sambamento is to be celebrated being
appointed, the Maquitas are informed of the fact, and as large a
number of the people as can be accommodated at the Quilombo
being invited, they all assemble in front of the residence of the Jaga.
The Maquitas and the Macotas form themselves into a circle, the
rest of the people assembling around. The Jaga then takes his seat
in the centre of the circle, on an iron stool, in a circular concave form
with a hole through the centre of the top. The Bansacuco is seated
beside the Jaga, together with all the concubines. The Cassange-
Cagongue then strikes the gong, which is of iron in the form of an
arch, with two small bells attached, and with a bar across it. The
Cassange-Cagongue continues to ring the bells during the
ceremony.
The Nicango is then introduced and placed in front of the Jaga,
but with his back towards him. The Jaga being provided with a
cutlass of a semi-circular form, commences operations by cutting
open the back of the Nicango until he reaches the heart, which he
extracts, and having taken a bit of it he spits it out and gives it to be
burned.
The Macotas in the meantime hold the corpse of the Nicango in
such a manner that the blood from the wound in the back is
discharged against the breast and belly of the Jaga, and falling
through the hole in the iron stool is collected by the Maquitas in their
hands; they then rub their breast and beard with it, at the same time
making a great clamour vociferating “Great is the Jaga and the rites
of the State.”
The corpse of the Nicango is next carried to some distance,
where it is first skinned and then divided into small pieces and
cooked with the flesh of an ox, a dog, a hen, and some other
animals. The meal being prepared it is first served to the Jaga, next
to the Maquitas and Macotas, and then to all the people assembled,
and woe to the unhappy wight who has the temerity to refuse
partaking of the repast from any repugnance to the ingredient, as in
such case the law made and provided is that he and his family forfeit
their liberty and are therefore at once sold into captivity.
Singing and dancing conclude the Sambamento.
CHAPTER XVIII.
Dr. Livingstone’s reception by Shinte—A South-African Chieftess—

She gives her guests “a bit of her mind”—Breaches of Court
etiquette—Abyssinian cure for melancholy—Mr. Bruce and the
Lady Sittina—Greasing the King of Seenaar—Majesty in
Madagascar—A Malagasey palace—The Feast of the Queen’s
Bath—A Court ball in Madagascar.
urning from Western to Southern Africa, let us see how
royalty comports itself. As in the former case there is a
wide choice of potentates, but we will take but two—
Shinte, King of Makalolo, and Manenko, Chieftess of
Balonda.
“We (Dr. Livingstone and party) were honoured with a grand
reception by Shinte about eleven o’clock. The native Portuguese and
Mambari went fully armed with guns, in order to give Shinte a salute,
their drummer and trumpeter making all the noise their very old
instruments would produce. The kotla, or place of audience, was
about a hundred yards square, and two graceful specimens of a
species of banian stood near the end. Under one of these sat Shinte
on a sort of throne covered with a leopard’s skin. He had on a
checked jacket and a kilt of scarlet baize edged with green; many
strings of large heads hung from his neck, and his limbs were
covered with iron and copper armlets and bracelets; on his head he
wore a helmet made of beads woven neatly together, and crowned
with a great bunch of goose-feathers. Close to him sat three lads
with large sheaves of arrows over their shoulders.
“When we entered the kotla, the whole of Manenko’s party saluted
Shinte by clapping their hands, and Sambanza did obeisance by
rubbing his chest and arms with ashes. One of the trees being
unoccupied I retreated to it for the sake of the shade, and my whole
party did the same. We were now about forty yards from the chief
and could see the whole ceremony. The different sections of the tribe
came forward in the same way that we did, the head man of each
making obeisance with ashes which he carried with him for the
purpose; then came the soldiers, all armed to the teeth, running and
shouting towards us, with their swords drawn and their faces
screwed up so as to appear as savage as possible for the purpose, I
thought, of trying whether they could not make us take to our heels.
As we did not, they turned round towards Shinte and saluted him,
then retired. When all had come and were seated, then began the
curious capering usually seen in pictures. A man starts up, and
imitates the most approved attitudes observed in actual fight, as of
throwing one javelin, receiving another on the shield, springing on
one side to avoid a third, running backwards or forwards, leaping,
etc. This over, Sambanza and the spokesman of Nyamoana stalked
backwards and forwards in front of Shinte, and gave forth in a loud
voice all they had been able to learn either from myself or people of
my past history and connection with the Makololo; the return of the
captives, the wish to open the country to trade, etc. Perhaps he is
fibbing, perhaps not—they rather thought he was; but as the Balonda
had good hearts, and Shinte had never done harm to any one, he
had better receive the white man well and send him on his way.
Sambanza was gaily attired, and, besides a profusion of beads, had
a cloth so long that a boy carried it after him as a train.
“Behind Shinte sat about a hundred women clothed in their best,
which happened to be a profusion of red baize. The chief wife of
Shinte, one of the Matebele or Zulus, sat in front with a curious red
cap on her head. During the intervals between the speeches these
ladies burst forth into a sort of plaintive ditty; but it was impossible for
any of us to catch whether it was in praise of the speaker, of Shinte,
or of themselves. This was the first time I had ever seen females
present in a public assembly. Generally the women are not permitted
to enter the kotla, and even when invited to come to a religious
service they would not enter until ordered to do so by the chief; but
here they expressed approbation by clapping their hands and
laughing to different speakers, and Shinte frequently turned round
and spoke to them.
“A party of musicians, consisting of three drummers and four
performers on the piano, went round the kotla several times, regaling
us with their music. The drums are neatly carved from the trunk of a
tree, and have a small hole in the side covered with a bit of spider’s
web; the ends are covered with the skin of an antelope pegged on,
and when they wish to tighten it they hold it to the fire to make it
contract—the instruments are beaten with the hands.
“The piano, named marimba, consists of two bars of wood placed
side by side here quite straight, but farther north bent round so as to
resemble half the tire of a carriage wheel; across these are placed
about fifteen wooden keys, each of which is two or three inches
broad, and fifteen or eighteen inches long—their thickness is
regulated according to the deepness of the note required; each of
the keys has a calabash beneath it from the upper part of each a
portion is cut off to enable them to embrace the bars, and form
hollow sounding-boards to the keys, which also are of different sizes
according to the note required, and little drumsticks elicit the music.
Rapidity of execution seems much admired among them, and the
music is pleasant to the ear.
“When nine speakers had concluded their orations Shinte stood
up, and so did all the people. He had maintained true African dignity
of manner all the while; but my people remarked that he scarcely
took his eyes off me for a moment. About a thousand people were
present according to my calculation, and three hundred soldiers. The
sun had now become hot, and the scene ended by the Mambari
discharging their guns.
“As the river seemed to come from the direction in which we
wished to go, I was desirous of proceeding farther up with the
canoes, but Nyamoana interposed numerous objections, and the
arrival of Manenko herself settled the point in the negative. She was
a tall strapping woman, about twenty years of age, and distinguished
by a profusion of ornaments and medicines, which latter are
supposed to act as charms. Her body was smeared all over with a
mixture of fat and red ochre as a protection against the weather, a
necessary precaution, for, like most of the Balonda ladies, she was
in a state of frightful nudity, not so much from want of clothing as
from her peculiar ideas of elegance in dress. When she arrived with
her husband Sambanza, she listened for some time to the
statements I was making to the people of Nyamoana, after which her
husband commenced an oration, during the delivery of which he
picked up a little sand, at intervals of two or three seconds, and
rubbed it on the upper part of his arms and chest. This is a common
mode of salutation in Londa; and when they wish to be excessively
polite they bring a quantity of ashes or pipe-clay in a piece of skin
and rub it on the chest and upper front part of each arm; others drum
their ribs with their elbows, while others touch the ground with one
cheek after the other and clap their hands. When Sambanza had
finished his oration he rose up and showed his ankles ornamented
with a bundle of copper rings. Had they been very heavy they would
have impeded his walk; and some chiefs wore so many as to be
forced to keep one foot apart from the other, the weight being a
serious inconvenience in walking. Gentlemen like Sambanza who
wish to ape their betters adopt their gait, strutting along with only a
few ounces of ornament on their legs just as if they had double the
number of pounds. When I smiled at Sambanza’s walk the people
remarked, ‘That is the way in which they show off high blood in these
parts.’
“When erecting our sheds at the village, Manenko, the chieftess,
fell upon our friends and gave us a specimen of her powers of
scolding. Masiko had once sent to Samoana for a cloth, which is a
common way of keeping up intercourse. After receiving it he returned
it, because it had the appearance of having had witchcraft medicine
on it. This was a grave offence; and Manenko had now a good
excuse for retaliation, as Masiko’s ambassadors had slept in one of
the huts of her village without asking leave. She set upon them
furiously, advancing and receding in true oratorical style, belabouring
her own servants for allowing the offence, and raking up the faults
and failings of the objects of her ire ever since they were born; in
conclusion, expressing her despair of ever seeing them become
better until they were all killed by alligators. Masiko’s people received
this torrent of abuse in silence, and as neither we nor they had
anything to eat, we parted next morning. In reference to the sale of
slaves they promised to explain to Masiko the relationship which
exists between even the most abject of his people and our common
Father, and that no more kidnapping ought to be allowed. We
promised to return through his town when we came back from the
sea-coast.
“Manenko gave us some manioc roots in the morning, and had
determined to carry our baggage to her uncle Shinte. We had heard
a sample of what she could do with her tongue, and as neither my
men nor myself had much inclination to encounter this black virago
we proceeded to make ready the packages; but she said the men
whom she had ordered for the service would not arrive until to-
morrow. I felt annoyed at this further delay and ordered the packages
to be put into the canoes at once: but Manenko was not to be
circumvented in this way; she came forward with her people, seized
the baggage, and declared that she would carry it in spite of me. My
men succumbed and left me powerless. I was moving off in high
dudgeon to the canoes when she kindly placed her hand on my
shoulder and, with a motherly look, said, “Now, my little man, just do
as the rest have done.” My feeling of annoyance of course vanished,
and I went out to try for some meat.
Ignorance of court etiquette in savage no less than in civilized
countries is a fruitful source of danger, or at least unpleasantness, to
the traveller ambitious to move in what the newspapers vaguely
describe as “select circles.” Mr. Stern, in his recent travels among
the Falashas of Abyssinia, was on one occasion advised of this fact
in a rather astonishing manner. Breakfast was served in the royal
tent, and it was during the progress of the meal that our traveller
nearly lost the esteem and regard he had hitherto enjoyed.
“According to the Abyssinian notion every man who claims to be of
patrician descent, should emulate the noises made by a certain
unclean animal whilst eating his meals. My ignorance of this elegant
acquirement (for I had unfortunately not yet attained it) drew upon
me the frowns as well as the whispered censures of the guests.
Unconscious of the cause of this unexpected notoriety, I asked
whether there was anything peculiar in my appearance or
deportment that provoked criticism. ‘Certainly,’ was the rejoinder,
‘your conduct is so ungentlemanly that all the guests think you must
be a very low fellow and quite unaccustomed to move in genteel
society.’ ‘And to what am I indebted for this good opinion?’ returned
I. ‘To the mode in which you eat; for if you were a gentleman you
would show by the smacking of your lips the exalted station to which
you belong; but since you masticate your food in this inaudible
manner every one believes that you are a beggar and accustomed to
eat in that unostentatious manner which pretended poverty prompts
individuals to adopt.’ I assured them that any breach of etiquette
must be attributed to the difference of the customs in my own
country and not to the low motive they assigned, an apology which
amply satisfied the most accomplished courtier in the royal tent.”
It is the constant practice in Abyssinia to beset the king’s doors
and windows within his hearing, and there, from early morning to
night, to cry for justice as loud as possible in a distressed and
complaining tone, and in all the different languages they are master
of, in order to their being admitted to have their supposed grievances
heard. In a country so ill governed as Abyssinia is, and so
perpetually involved in war, it may be easily supposed there is no
want of people who have real injuries and violence to complain of:
but if it were not so, this is so much the constant usage, that when it
happens (as in the midst of the rainy season) that few people can
approach the capital or stand without in such bad weather, a set of
vagrants are provided, maintained, and paid, whose sole business it
is to cry and lament, as if they had been really very much injured and
oppressed; and this, they tell you, is for the king’s honour, that he
may not be lonely, by the palace being too quiet. This, of all their
absurd customs, was the most grievous and troublesome to Mr.
Bruce. Sometimes, while Mr. Bruce was busy in his room in the rainy
season, there would be four or five hundred people, who all at once
would begin, some roaring and crying, as if they were in pain, others
demanding justice, as if they were that moment suffering, or if in the
instant to be put to death; and some groaning and sobbing as if just
expiring; and this horrid symphony was so artfully performed, that no
ear could distinguish but that it proceeded from real distress. Mr.
Bruce was often so surprised as to send the soldiers at the door to
bring in one of them, thinking him come from the country, to examine
who had injured him: many a time he was a servant of his own, or
some other equally known; or, if he was a stranger, upon asking him
what misfortune had befallen him he would answer very composedly,
nothing was the matter with him; that he had been sleeping all day
with the horses; that hearing from the soldiers at the door that Mr.
Bruce was retired to his apartment he and his companions had come
to cry and make a noise under his window, to do him honour before
the people, for fear he should be melancholy by being too quiet
when alone, and therefore hoped that he would order them drink that
they might continue with a little more spirit.
In the course of his Abyssinian journeyings, the traveller just
mentioned had occasion to pass through a place called Arendi,
which was governed by a female named Sittina, or the Lady. Our
traveller waited on this high and mighty personage. Upon entering
the house, a black slave laid hold of him by the hand, and placed
him in a passage, at the end of which were two opposite doors. Mr.
Bruce did not well know the reason of this; but staid only a few
minutes, when he heard one of the doors at the end of the passage
open, and Sittina appeared magnificently dressed, with a kind of
round cap of solid gold upon the crown of her head, all beaten very
thin, and hung round with sequins; with a variety of gold chains,
solitaires, and necklaces of the same metal, about her neck. Her hair
was plaited in ten or twelve small divisions like tails, which hung
down below her waist; and over her was thrown a common cotton
white garment. She had a purple silk stole, or scarf, hung very
gracefully upon her back, brought again round her waist, without
covering her shoulders or arms. Upon her wrists she had two
bracelets like handcuffs, about half an inch thick, and two gold
manacles of the same at her feet, full an inch in diameter, the most
disagreeable and awkward part of her dress. Mr. Bruce expected she
would have hurried through with some affectation of surprise. On the
contrary, she stopped in the middle of the passage, saying, in a very
grave manner, “Kifhalec,—how are you?” Mr. Bruce thought this was
an opportunity of kissing her hand, which he did, without her shewing
any sort of reluctance. “Allow me as a physician, Madam,” said Mr.
Bruce, “to say one word.” She bowed with her head, and said, “Go in
at that door, and I will hear you.” The slave appeared, and carried
him through a door at the bottom of a passage into a room, while her
mistress vanished in at another door at the top, and there was the
screen he had seen the day before, and the lady behind it. She was
a woman scarcely forty, taller than the middle size, had a very round
plump face, her mouth rather large, very red lips, the finest teeth and
eyes he had seen; but at the top of her nose, and between her
eyebrows, she had a small speck made of antimony, four-cornered,
and of the size of the smallest patches formerly worn by ladies of
fashion; another rather longer upon the top of her nose, and one in
the middle of her chin.
“Tell me what you would say to me as a physician.” “It was,
madam, but in consequence of your discourse yesterday. That heavy
gold cap with which you press your hair will certainly be the cause of
a great part of it falling off.” “I believe so; but I should catch cold, I
am so accustomed to it, if I was to leave it off. Are you a man of
name and family in your own country?” “Of both, madam.” “Are the
women handsome there?” “The handsomest in the world, madam;
but they are so good, and so excellent in all other respects, that
nobody thinks at all of their beauty, nor do they value themselves
upon it.” “And do they allow you to kiss their hands?” “I understand
you, madam, though you have mistaken me. There is no familiarity in
kissing hands; it is a mark of homage and distant respect paid in my
country to our sovereigns, and to none earthly besides.” “O yes! but
the kings.” “Yes, and the queens too, always on the knee, madam.
On her part, it is a mark of gracious condescension, in favour of
rank, merit, and honourable behaviour; it is a reward for dangerous
and difficult services, above all other compensation.” “But do you
know that no man ever kissed my hand but you?” “It is impossible I
should know that, nor is it material. Of this I am confident, it was
meant respectfully, cannot hurt you, and should not offend you.” “It
certainly has done neither,” replied Her Majesty—and so ended her
first lesson on the etiquette of civilized life.
On another occasion, while in the neighbourhood of Seenaar, our
traveller waited on the king; and about eight o’clock came a servant
from the palace, telling Mr. Bruce that then was the time to “bring his
present.” He sorted the separate articles with all the speed he could,
and went directly to the palace. The king was sitting in a large
apartment, as far as he could guess, at some distance from the
former. He was naked, but had several clothes lying upon his knee,
and about him, and a servant was rubbing him over with very
stinking butter or grease, with which his hair was dropping as if wet
with water. Large as the room was, it could be smelled through the
whole of it. The king asked Mr. Bruce if he ever greased himself as
he did? Mr. Bruce said, very seldom, but fancied it would be very
expensive. He then told him that it was elephant’s grease, which
made people strong, and preserved the skin very smooth. Our
traveller said he thought it very proper, but could not bear the smell
of it, though his skin should turn as rough as an elephant’s for the
want of it. The king replied, that if Mr. Bruce had used it, his hair
would not have turned so red as it was, and that it would all become
white presently, when that redness came off. “You may see,”
continued he, “the Arabs driven in here by the Daveina, and all their
cattle taken from them, because they have no longer any grease for
their hair. The sun first turns it red, and then perfectly white; and you
will know them in the street by their hair being the colour of yours. As
for the smell, you will see that cured presently.”
After having rubbed him abundantly with grease, the servants
brought him a pretty large horn, and in it something scented, about
the consistence of honey. It was plain that civet was a great part of
the composition. The king went out at the door, Mr. Bruce supposes
into another room, and there two men deluged him with pitchers of
cold water. He then returned, and a slave anointed him with this
sweet ointment; after which he sat down as completely dressed,
being just going to his woman’s apartment where he was to sup. Mr.
Bruce told him, he wondered why he did not use rose-water as in
Abyssinia, Arabia, and Cairo. He said he had it often from Cairo,
when the merchants arrived; but as it was now long since they came,
his people could not make more, for the rose would not grow in his
country, though the women made something like it of lemon-flower.
Making a skip from Abyssinia to Madagascar we there find the
“Royal state” a ludicrous blending of gingerbread splendour and
magnificent muddle. By-the-by, things may have reformed here by
this time, as the queen of whom this description treats is lately dead:
let us hope that this is the case. Our business, however, is to recite
the evidence of our witnesses—the witness in this case being the
courageous and truthful Ida Pfieffer.
“Towards four o’clock our bearers carried us to the palace. Over
the door is fixed a great gilt eagle with extended wings. According to
the rule here laid down by etiquette we stepped over the threshold
first with the right foot, and observed the same ceremony on coming
to a second gate leading to a great court-yard in front of the palace.
Here we saw the queen sitting on a balcony on the first storey, and
were directed to stand in a row in the court-yard opposite to her.
Under the balcony stood some soldiers, who went through sundry
evolutions, concluding with a very comic point of drill which consisted
in suddenly poking up the right foot as though suddenly stung by a
tarantula.
“The queen was wrapped, according to the custom of the country,
in a wide silk simbu and wore on her head a big golden crown.
Though she sat in the shade a very large crimson umbrella was held
up over head; this being, it appears, a point of regal state.
“The queen is of rather dark complexion, and sturdily built, and
although already seventy-five years of age she is, to the misfortune
of her poor country, still hale and of active mind. At one time she is
said to have been a great drunkard, but she has given up that fatal
propensity some years ago.
“To the right of the queen stood her son Prince Rakoto, and on the
left her adopted son Prince Ramboasalama; behind her sat and
stood sundry nephews and nieces and other relatives, male and
female, and several grandees of the empire.
“The minister who had conducted us to the palace made a short
speech to the queen; after which we had to bow three times and to
repeat the words ‘Esaratsara tombokoe,’ equivalent to ‘We salute
you cordially,’ to which she replied ‘Esaratsara,’ which means ‘well-
good.’ Then we turned to the left to salute the tomb of Prince
Radama lying a few paces on one side, with three similar bows;
whereupon we returned to our former place in front of the balcony
and made three more. Mr. Lambert (who accompanied Madam
Pfieffer) on this occasion, held up a gold piece of fifty franks value
and put it in the hands of the minister who accompanied us. This gift,
which every stranger has to offer the first time he is presented at
court, is called ‘Monosina.’ It is not customary that it should consist
of a fifty-franc piece; the queen contents herself with a Spanish
dollar, or a five-frank piece. After the delivery of the gold piece, the
queen asked Mr. Lambert if he wished to put any question to her, or
if he stood in need of anything; to which he answered, ‘No.’ She also
was condescending enough to turn to me and ask if I was well and if
I had escaped the fever. After I had answered this question, we
stayed a few minutes longer looking at each other, and then the
bowings and greetings began anew. We had to take leave of
Radama’s monument, and on returning were reminded not on any
account to put the left foot first over the threshold.”
The royal palace of Madagascar is described by Mrs. Pfieffer as a
very large wooden building, consisting of a ground floor and two
storeys surmounted by a peculiarly high roof. The storeys are
surrounded by broad galleries. Around the building are pillars, also of
wood, eighty feet high, supporting the roof which rises to a height of
forty feet above them, resting in the centre on a pillar no less than a
hundred and twenty feet high. All these columns, the one in the
centre not excepted, consist of a single trunk; and when it is
considered that the woods which contain trees of sufficient size to
furnish these columns are fifty or sixty English miles from the capital,
that the roads are nowhere paved and in some places are quite
impassable, and that all the pillars are dragged hither without the
help of a single beast of burden or any kind of machine, and are
afterwards prepared and set up by means of the simplest tools, the
building of this place may with truth be called a gigantic undertaking,
and the place itself be ranked among the wonders of the world. In
bringing home the chief pillar alone five thousand persons were
employed and twelve days were occupied in its erection.
“All these labours were performed by the people as compulsory
service for which they received neither wages nor food. I was told
that during the progress of the work fifteen thousand persons fell
victims to the hard toil and the want of proper nourishment. But the
queen is little disturbed by such a circumstance—half the population
might perish if only her high behests were fulfilled.
“In front of the principal building a handsome and spacious court-
yard has been left. Around this space stands several pretty houses,
all of wood. The chief building is in fact uninhabited and contains

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Managing infectious diseases in child

care and schools a quick reference

Managing Infectious Diseases in Child Care and Schools

Quick Reference Guide to Pediatric Care 2nd Edition

Infectious Diseases and Antimicrobial Stewardship in

Clinical Infectious Diseases Study Guide A Problem

Practical clinical microbiology and infectious

Assisted Reproductive Technologies and Infectious

Infectious Diseases: A Case Study Approach Jonathan Cho

Preventing Occupational Exposures to Infectious Disease

Managing Infectious Diseases

Completely revised and updated, the new 3rd edition of this

A Quick Reference Guide, 3rd Edition

American Academy of Pediatrics

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Library of Congress Control Number: 2013931766

Printed in the United States of America.

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AAP Board of Directors Reviewer

American Academy of Pediatrics

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About This Book ..................................................................................................................................................... X

What Is New in This Edition? ................................................................................................................................ XI

Chapter 1 Introduction: Keeping Healthy............................................................................................................. 1

Chapter 2 How Infection Spreads ...................................................................................................................... 17

Chapter 3 Infection Control Measures................................................................................................................21

Chapter 4 Health of Teachers/Caregivers and Other Staff Members................................................................39

Chapter 5 Recognizing the Ill Child: Inclusion/Exclusion Criteria.................................................................... 49

Chapter 6 Signs and Symptoms Chart................................................................................................................ 57

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Chapter 7 Quick Reference Sheets ....................................................................................................................67

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Chapter 8 Role of the Health Consultant in Child Care and Schools................................................................177

Chapter 9 Immunization Schedule and Information.........................................................................................183

Chapter 10 Infectious Disease Outbreaks, Epidemics, and Bioterrorism/

Chapter 11 Sample Letters, Forms, and Relevant Resources............................................................................193

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About This Book

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What Is New in This Edition?

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Introduction: Keeping Healthy

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Practice Integrated Pest Management, an approach

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What Families Can Do to Reduce Illness From Infection in

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What Families Can Do to Reduce Illness From Infection in

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What Families Can Do to Reduce Illness From Infection in

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What Staff Members Can Do to Reduce Illness From Infection

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What Staff Members Can Do to Reduce Illness From Infection

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What Staff Members Can Do to Reduce Illness From Infection

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What Staff Members Can Do to Reduce Illness From Infection

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