Management of Communicable Diseases in Schools

1. DISINFECTANTS, OSHA BLOODBORNE PATHOGEN STANDARD ANDOTHER TOPICS ON MANAGEMENT OF COMMUNICABLE DISEASES IN SCHOOLSScott Maag Vice President of Research and OperationsBuckeye International, Inc.

2. TOPICS • Disinfectants • OSHA Bloodborne Pathogen Standard • Influenza Viruses (Including Avian Influenza) • Norovirus • Non-Polio Enterovirus • Zika Virus • Staphylococcus Aureus/MRSA • Head Lice • Scabies • Giardia

3. DISINFECTANTS

4. Disinfectants • Disinfectant Versus Sanitizer • How Disinfectants Work

5. Disinfectant Vs. Sanitizer • Disinfectant – “a substance, or mixture of substances, that destroys or irreversibly inactivates bacteria, fungi and viruses, but not necessarily bacterial spores, in the inanimate environment.”1 • Sanitizer – “a substance, or mixture of substances, that reduces the bacterial population in the inanimate environment by significant numbers, (e.g., 3 log 10 reduction) or more, but does not destroy or eliminate all bacteria.”1 - food contact surface sanitizers are used in food service • Disinfectants and sanitizers are also called antimicrobial pesticides, and they are regulated by the U.S. EPA

6. Disinfectant Vs. Sanitizer D=Disinfectant (Quat-based, Diluted 1:256) S=Non-food Contact Surface Sanitizer (Citric Acid-based, Diluted 1:4)

7. How Disinfectants Work • Can work in a variety of ways involving effects on microorganism components including cell membrane, cell proteins, enzymes, and DNA • Quat disinfectants, for example, are known for disrupting the cell membranes of bacteria – quats are able to attach to bacteria to begin with because the quats’ charge is positive and the bacterial cell surface is negative

8. OSHA BLOODBORNE PATHOGEN STANDARD

9. OSHA’s Bloodborne Pathogen Standard • History • Pathogens • Infectious Materials • Modes of Transmission • Prevention • Cleaning Procedures

10. History December 6, 1991 Federal Register 29 CFR 1910.1030 Established in March 1992 “…reasonably be anticipated to come into contact with blood or other OPIM as a result of doing their job duties.”2 (OPIM = Other Potentially Infectious Materials) Limit occupational exposure to blood and other potentially infectious materials since any exposure could result in transmission of bloodborne pathogens which could lead to disease or death.

11. Pathogens Hepatitis B (HBV) “Inflammation of the liver” - can cause cirrhosis and cancer of liver HBV vaccine available - routine for children and healthcare workers No cure for chronic HBV – medications reduce chance of developing severe liver diseases 50-100 times more infectious than HIV3, easily spread by sex or injection drug use Very durable can survive in dried blood for at least seven days Tens of thousands per year are infected (19,200 in 2014)3

13. Pathogens Hepatitis C (HCV) “Non-A, Non-B Hepatitis.” No vaccine to prevent HCV. Cure may be achievable with medications taken daily for months. Leading cause of cirrhosis & the leading cause of liver transplantation in the US Of 100 persons infected with HCV about4: 75-85 persons develop long-term infection (chronic) 15-25 persons develop acute HCV and recover Virus can survive on environmental surfaces for up to 3 weeks 2.7-3.9 million Americans estimated to have chronic infection4

14. Pathogens Human Immunodeficiency Virus (HIV) Attacks CD4 cells (T cells) in the immune system Causes AIDS – Acquired Immunodeficiency Syndrome People who are infected carry the virus for many years before AIDS symptoms develop Testing is the only way to know if you are infected 1.2 million people in US are living with the virus – 13% are unaware they are infected (2013 information)5 No cure, treatment is improving Very fragile virus

16. Pathogens Directive Number: CPL 02-02-069 Effective Date: November 27, 2001 Subject: Enforcement Procedures for the Occupational Exposure to Bloodborne Pathogens (Purpose: This instruction establishes policies and provides clarification to ensure uniform inspection procedures are followed when conducting inspections to enforce the Occupational Exposure to Bloodborne Pathogens Standard) "Bloodborne Pathogens": While HBV and HIV are specifically identified in the standard, the term includes any pathogenic microorganism that is present in human blood or OPIM and can infect and cause disease in persons who are exposed to blood containing the pathogen. Pathogenic microorganisms can also cause diseases such as hepatitis C, malaria, syphilis, babesiosis, brucellosis, leptospirosis, arboviral infections, relapsing fever, Creutzfeldt-Jakob disease, adult T-cell leukemia/lymphoma (caused by HTLV-I), HTLV-I associated myelopathy, diseases associated with HTLV-II, and viral hemorrhagic fever.

17. Other Potentially Infectious Materials (Aside from blood) semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva, any body fluid visibly contaminated with blood and all body fluids in situations where it is difficult or impossible to differentiate between body fluids…

18. Transmission of Pathogens Normally, unbroken skin forms an impervious barrier against bloodborne pathogens Open sores, cuts, abrasions, acne, sunburn, blisters Mucous Membranes: eyes, nose and mouth (i.e. a splash of contaminated fluid to your eye, nose, mouth or open sore could result in transmission)

19. Prevention Treat all potentially infectious material as if it were contaminated Personal Protective Equipment (PPE) 3 Step Cleaning – contain, clean, decontaminate Handwashing soft, antibacterial soap (if possible) avoid harsh, abrasive soaps

20. Hard Surface Clean - Up • Use gloves, gowns and eye protection • To clean up the spill: • Apply an absorbent to soak up the infectious material. • Contaminated broken glassware shall NOT be picked up by hand. Use a brush and dust pan, tongs or forceps. • Pick up the moist absorbent. • Place the absorbent into a regulated waste container (if it would be capable of releasing infectious material if compressed or during handling). Any brush, dust pan, tongs or forceps must be discarded or decontaminated before reuse. • Clean the spill area with a general purpose cleaner or disinfectant cleaner to remove gross filth. • Decontaminate area with disinfectant with HIV, HBV& HCV claim, with TB claim or with bleach. • Place the towel which was used for cleaning into the regulated waste container.

21. Appropriate Disinfectant Products • OSHA letter June 30, 1989 Clarifies use of HIV claimed disinfectant • OSHA letter February 28, 1997 Clarifies use of HIV & HBV claimed disinfectants EPA's Registered Sterilizers, Tuberculocides, and Antimicrobial Products Against HIV-1, and Hepatitis B and Hepatitis C Viruses. (Updated March 14, 2016) http://www.epa.gov/pesticide-registration/selected-epa-registered-disinfectants Directive Number: CPL 02-02-069 Subject: Enforcement Procedures for the Occupational Exposure to Bloodborne Pathogens Any of the above products are considered effective when used according to the manufacturer's instructions, provided the surfaces have not become contaminated with agents or volumes of or concentrations of agents for which higher level disinfection is recommended.NOTE: Fresh solutions of diluted household bleach made up daily (every 24 hours) are also considered appropriate for disinfection of environmental surfaces and for decontamination of sites following initial cleanup (i.e., wiping up) of spills of blood or other potentially infectious materials. Contact time for bleach is generally considered to be the time it takes the product to air dry.

22. Bleach • Strong odor • Corrosive to eyes and skin • Short shelf life, needs test paper to test concentration • Can damage clothes and other fabrics

23. Phenolics • Skin depigmentation • Possible disposal problems down sanitary sewers • High cost • Not to be used around neonatal area

24. “Texas public school districts are required to implement bloodborne pathogen exposure control plans.”6

25. Influenza Viruses Including AvianInfluenza

26. Influenza Viruses • Types of virus • Preventing • Avian Influenza

27. The Influenza Virus Virus which infects the respiratory tract (nose, throat and lungs) Three types that infect people Influenza A Influenza B Influenza C

29. Influenza A Tend to cause epidemics of disease almost every winter Divided into subtypes based on two surface proteins • H (hemagglutinin) 18 types • N (neuraminidase) 11 types • Found in many different animals – ducks, chickens, pigs, whales, horses, etc. • Birds are thought to be the source of Influenza A viruses in other animals

30. Influenza B Tend to cause epidemics almost every winter No subtypes Circulates widely only among humans Influenza B and A (H1N1 & H3N2) are included in each year’s Influenza vaccine

31. Influenza C Causes mild respiratory illness and not thought to cause epidemics Flu shot does not protect against type C Influenza

32. Preventing Influenza Get vaccinated each fall Avoid close contact with individuals Stay home when you are sick Cover your mouth and nose Wash your hands Avoid touching eyes, mouth & nose Clean and disinfect frequently touched surfaces (influenza virus on a surface may be able to infect for up to 48 hours)

33. Avian Influenza A Known as bird flu Variety of strains with a variety of symptoms – most cause no or mild symptoms Low Pathogenic – may go undetected, cause mild symptoms Highly pathogenic – highly contagious and rapidly fatal (90-100% mortality within 48 hours)

34. Avian Influenza A Spreads through saliva, nasal secretions and feces Avian Influenza viruses don’t usually infect humans

35. Avian Influenza A Strains of Concern Highly Pathogenic Asian Avian Influenza A (H5N1) Virus in Africa, Asia, Europe, and the Middle East and new Avian Influenza A (H7N9) Virus in China – these have caused most human illness worldwide Spread to humans from contact with infected birds and droppings (there has been human-to-human spread, but it has been rare) Avian Influenza A Symptoms in Humans Flu like – fever, cough, sore throat, muscle aches Eye infections, pneumonia, acute respiratory distress, stomach illness, neurologic changes

36. Avian Influenza A Fear is: virus will change and infect humans easily Spread easily between people Influenza pandemic could begin BUT at this time Asian Avian Influenza A Virus (H5N1) and new Avian Influenza A Virus (H7N9) have not been detected in birds and humans in the U.S.

37. A Few Notes on Pandemic Preparedness Last pandemic was 2009 H1N1 pandemic Most people will not be immune to a pandemic influenza virus, and a vaccine may not be immediately available A preparedness plan may consider communication with public health department, emergency communication with parents/students/staff, sick leave policies, methods for continuing education and services in case of school closures, etc.7,8 Daily influenza prevention measures such as hand washing, cleaning/disinfecting surfaces, etc. should also be relevant for prevention of pandemic flu Having adequate supplies such as soap and tissues would be important during a pandemic

38. NOROVIRUS (PREVIOUSLY CALLED NORWALK-LIKE VIRUS)

39. Norovirus Symptoms of Norovirus Spread of Norovirus Norovirus Prevention Measures Source: CDC/Jessica A. Allen and Alissa Eckert (Illustrator), ID# 21348, https://cdc.gov/phil/home.asp, accessed December 2016.

40. Symptoms of Norovirus Illness is sometimes called “stomach flu,” though norovirus is not related to influenza virus Norovirus causes inflammation of intestines and/or stomach Most common symptoms: diarrhea, vomiting, nausea, stomach pain Less common symptoms: fever, headache, body aches Symptoms usually start 12-48 hours after exposure; people generally feel better in 1-3 days Norovirus illness can lead to dehydration if lost fluids are not replaced

41. Spread of Norovirus Norovirus-containing stool or vomit gets into the mouth of an uninfected person, for example • Contaminated food or drinks are consumed • A contaminated surface is touched and then fingers are put into mouth • Direct contact is had with an infected person Contagious period: before symptoms until 2 weeks after recovery (most contagious while sick plus a few days after) Spread is quick in enclosed facilities Most US outbreaks November-April9

42. Norovirus Prevention Measures Wash hands with soap and water • After changing diapers • After using the toilet • Before preparing food • Before eating Hand sanitizers may be used in addition to soap and water, but they are not substitutes Handle foods correctly (e.g., wash raw produce) Clean and disinfect hard, nonporous surfaces If infected, stay home and do not prepare food when you are most contagious

43. Non-Polio Enterovirus

44. Non-Polio Enterovirus What Non-Polio Enteroviruses Are How to Prevent the Spread

45. What Non-Polio Enteroviruses Are Viruses in the Enterovirus genus other than polio virus Can cause mild or no symptoms, especially in adults Can cause illness such as viral conjunctivitis; viral meningitis; and hand, foot, and mouth disease Spread from exposure of eye, nose, or mouth to an infected person’s mouth or nose secretions, stool, or blister fluid Enterovirus D68 caused an outbreak in 2014

46. How to Prevent the Spread of Non-Polio Enteroviruses Wash hands often with soap and water Avoid touching eyes, nose, and mouth with unwashed hands Avoid close contact with someone who is sick Clean and disinfect frequently touched surfaces Encourage covering coughs and sneezes Stay home when sick

47. ZIKA VIRUS

48. Zika Virus Transmitted primarily through the bite of Aedes species mosquitoes Most infected people have no symptoms or mild symptoms Zika virus infection during pregnancy may lead to microcephaly and other birth defects Schools may take measures to prevent mosquito bites, for example: • Removing outside standing water sources where mosquitoes can lay eggs (such as uncovered trash cans) • Ensuring that opened windows have functioning screens to keep mosquitoes out of classrooms

49. STAPHYLOCOCCUS AUREUS / METHICILLIN RESISTANT (MRSA)

50. Staphylococcus Aureus/MRSA • What is Staph • Where is Staph Found • What is MRSA • How Common is Staph • How is Staph Spread • How to Prevent Staph Infections