IPC needs assessment

Needs assessments were critical steps in guideline development to determine the topics and recommendations included in this document. The assessments (2011, 2023) sought to identify the populations served, the most frequent IPC situations encountered by RMH and RMFR programs’ staff, and the methods and resources used to manage IPC situations. The survey findings are summarized in detail elsewhere. ^{Reference Guzman-Cottrill, Bryant and Zerr3}

Focus group and site visits

The RMHC® Conference in Chicago (2011 International, 2023 Regional with Chapters from the Americas) held two focus groups. In January 2012, two authors toured three RMH programs in Houston, TX with an RMH programs organizational leader and program managers. These activities provided greater insight regarding the IPC challenges, the variety of physical structures of RMH programs, and the types of questions staff members have about management of patients and families with an infectious condition or a history of exposure to others with infections.

Scope

The scope of this update is specifically for family-centered residential facilities that provide accommodation and other services to families with children who are ill and injured. However, these facilities may vary in the populations served, whether healthcare services are provided (RMH and RMFR programs do not provide healthcare services), human and fiscal resources, and governance structure. In such situations, adapt the recommendations to meet these specific conditions. While this guidance was developed for facilities providing pediatric family-centered care, it could be adapted for facilities serving adult patients and their family members and caregivers.

If a family-centered residential facility is located within a medical facility, then the facility’s IPC-related policies and procedures will supersede the recommendations contained in this practice update. In most situations, a hospital policy or procedure will contain more detailed and structured instructions than this document provides.

This document provides recommendations to prevent the spread of infections in RMH and RMFR programs. The authors did not include recommendations to prevent infections caused by pathogens (germs) that are rare, especially for children, or for which evidence is emerging, for example, Candida auris. RMH and RMFR programs should direct questions about germs that are not discussed in this document to infection prevention and control experts in the affiliated medical facility.

Food preparation

To reduce the chance of people getting food poisoning, the US CDC and Food and Drug Administration (FDA) recommend 4 simple rules: clean, separate, cook, and chill (see Supplementary Material, Figure 1). ^27,28

Clean

Rinse fresh fruits and vegetables under running water. Wash your hands before, during, and after meal preparation, especially when handling uncooked meat, poultry, seafood, eggs or flour. After the meal is prepared, wash all used utensils and cutting boards with hot, soapy water either by hand or in a dishwasher. Clean with disinfectant all countertops and other soiled surfaces. Choose a disinfectant marketed for use on kitchen or bathroom surfaces per the disinfectant brand’s instructions. Wash your hands before eating.

Separate

Keep uncooked meat, poultry, seafood, and eggs contained apart from ready-to-eat foods when stored in the refrigerator and while being handled during meal preparation on cutting boards, plates, etc. Use appropriate containers to keep juices from raw foods from contacting ready-to-eat foods.

Cook

Cook foods to specific internal temperatures to kill any contaminating germs (see Supplementary Material, Table 1). Cook microwaved food to an internal temperature of 74^oC/165^oF. Use food thermometers inserted midway into the food to ensure food has reached appropriate internal temperatures.

Chill

Most bacteria multiply more rapidly at room temperature. To help prevent foodborne illness, refrigerate uncooked perishable food like meat, poultry, seafood, eggs, dairy, fruit, and vegetables, as well as cooked leftovers within 2 hours of being at room temperature. Keep refrigerators at 4^oC/40^oF or below. Keep freezers –18^oC/0^oF or below. Discard all foods before they are likely to spoil (see Supplementary Material, Table 2).

Of note, in this section, our primary focus is on preventing foodborne illnesses from contaminated food products. However, we also emphasize the importance of preventing the transmission of other infectious diseases while handling food for others. Individuals exhibiting respiratory symptoms such as coughing or sneezing, as well as gastrointestinal symptoms like vomiting or diarrhea, may inadvertently contaminate food during preparation and potentially pass on infectious illnesses to others. Therefore, it is strongly recommended that individuals involved in food preparation do not have symptoms of illness, as outlined in Appendices B1 and B2.

Background

Bed bugs (Cimex lectularis) are reddish brown, wingless, insects measuring 1-7 mm in length. During the day, bed bugs hide in the seams of mattresses, bedding, box springs, headboards, under carpets, and behind loose wallpaper and at night they feed on the blood of sleeping humans. Clues of a possible bed bug infestation include a sweet, musty odor in the space and rust-colored blood spots on mattresses or furniture. Complaints of finding itchy skin bumps upon waking should raise suspicion of a bed bug infestation.

Over the past 30 years, reports have increased of bed bug infestations in homes, hotel rooms, apartments, dormitories, and hospitals. ^{Reference McMenaman and Gausche-Hill39} Bed bugs can be carried on suitcases, furniture, clothing, and other personal items. Clothing and luggage can spread bed bugs from one infested room to another because they can be carried on suitcases, furniture, clothing, and other personal items. Bed bugs may also travel short distances (i.e., room to room or apartment to apartment) by migrating along pipes or ventilation ducts.

Bed bug bites often result in itchy red bumps that look similar to or slightly larger than mosquito bites. They usually appear on parts of the body exposed during sleeping. Not all people bitten by bed bugs develop a skin reaction, which is an allergic response.

Bed bugs have not been proven to transmit infectious diseases but occasionally skin that has been scratched will become secondarily infected with bacteria that normally live on the skin. ⁴⁰ Individuals with bed bug bites are not contagious.

Practical guidance exists for prevention and management of bed bugs in group living facilities. Guidelines by Gangloff-Kaufmann et al include photos of bed bugs at different life stages and detailed instructions for carrying out inspections. ^{Reference Gangloff-Kaufmann and Pichler41}

Successful eradication of bed bugs is best accomplished by professionals who perform a thorough inspection and, if indicated, apply an insecticide. More than one treatment with insecticide may be required.

Recommendations

1. 1. If a family-centered residential facility suspects a bed bug infestation, instruct families to inspect bedding, mattresses, luggage, clothing, and other belongings for the presence of bed bugs.

2. 2. If bed bugs are present, the facility should:

   1. a. Notify its affiliated healthcare facility to have it assess relevant inpatient rooms for infestation.

   2. b. Wash and dry clothing and bedding at hot temperatures.

   3. c. Seal items that are not amenable to washing and drying in a plastic bag and remove them from the facility.

   4. d. Consider pursuing professional inspection and evaluation for treatment with insecticide.

   5. e. Perform serial room inspections after taking these measures.

3. 3. If inspection finds one room is infested, the facility should inspect other rooms based on the guidance of a pest-elimination specialist. In some locales, it is typical to inspect rooms above, below, and on either side of a room with a bed bug infestation.

4. 4. Adjunctive control measures include:

   1. a. Vacuuming (when bed bugs have been identified, use a HEPA-equipped vacuum that is dedicated only to pest control)

   2. b. Reducing clutter where bed bugs could hide

   3. c. Eliminating peeling paint and plaster and caulking cracks and crevices in wall and furniture that could harbor bedbugs

   4. d. Encasing mattresses and box springs in protective covers.

Background

The virus SARS-CoV-2 causes coronavirus disease 2019 (COVID-19). The COVID-19 virus spreads through droplets and small viral particles that are breathed in or that land on people’s eyes, noses, or mouths. People who have COVID-19 can spread infection even if they do not have symptoms of illness. The risk of getting COVID-19 is higher when people are exposed to an infected person for over fifteen minutes, at a close distance, when the infected person has symptoms, and in indoor spaces with poor ventilation. The chance of getting COVID is lower when the infected or exposed person is wearing a well-fitting face mask. ⁴²

COVID-19 can cause a range of symptoms, but most commonly causes respiratory symptoms similar to a cold or flu, such as fever, congestion, cough, and fatigue. ⁴³ Other symptoms include headache, muscle aches, loss of taste or smell, nausea, vomiting, and diarrhea. Some people who have had COVID-19 can have long-term effects called “long COVID” or post-COVID conditions (PCC).

Most people with COVID-19 have mild symptoms, although COVID-19 can also cause severe symptoms or death. People who are older, have weakened immune systems, or have certain underlying health conditions are more likely to become very ill from COVID-19. Children served by RMH and RMFR programs may fall into higher risk groups.

Vaccination for COVID-19 has been very important in reducing the risk of severe illness, hospitalization, and death. People who are up-to-date with their COVID-19 vaccines, meaning that they have received all the doses for which they are eligible, have a lower risk of severe illness, hospitalization, and death than those who are unvaccinated or have not completed all doses. It is likely that people will continue to be recommended to get doses of updated vaccines. ⁴⁴

Recommendations

1. 1. Restrict individuals with suspected or confirmed COVID-19 from entering the family-centered residential facility until 5 days from when they were diagnosed with COVID-19 or had their first symptoms (whichever is earlier) and until they have been fever-free for 24 hours without the use of fever-reducing medicine.

2. 2. Instruct a guest to stay in their private room until their symptoms (runny nose, cough, etc.) are resolved.

3. 3. If symptoms resolve within 10 days after their illness began, they should wear a mask that is well-fitting and high quality (e.g., procedural or surgical mask) when indoors and around others (such as in community spaces in the facility) through day 10. It is important to note that recommendations for how long a person should wear a mask may change.

4. 4. Guests who have had close exposure to someone with COVID-19 (e.g., being less than 6 feet away from a person who has COVID-19 for at least 15 minutes) should wear a high-quality mask when around others and test immediately if they develop symptoms. Even if they do not develop symptoms, they should test at least 5 days after their last exposure and continue masking until 10 days after the exposure.

5. 5. Refer any guest who develops an illness suspected to be COVID-19 for medical evaluation. If diagnosed with COVID-19, the guest must leave the facility until they meet the criteria in 1 above.

6. 6. COVID-19 vaccines reduce the risk of severe disease in guests, staff, and volunteers. (Please see “Staff Member and Volunteer Illness and Vaccination” and “Health Screening of Guests and Visitors of RMHC® Programs” above for more details.)

7. 7. Although the risk of getting COVID-19 because of contact with potentially contaminated surfaces is low, facilities should use EPA-registered disinfectants according to their manufacturer’s instructions for use.

8. 8. Facilities should have an ongoing partnership with their affiliated healthcare facility’s infection prevention and control experts and their public health department for current COVID-19 prevention recommendations on the use of masking and other measures, and how these recommendations apply. Recommendations for facilities may differ from those for the general community because of the expected presence of children with underlying health conditions.

Background

Clostridioides difficile (commonly referred to as “C. diff” or “C. difficile”) is a bacterium that may be found in the intestines of healthy infants and in a smaller percent of otherwise healthy children and adults. ^{Reference Kociolek, Gerding and Carrico45,Reference Kimberlin, Barnett, Lynfield and Sawyer46} C. difficile infection (CDI) is one of the most frequent infections that occurs in healthcare ^{Reference Kociolek, Gerding and Carrico45} and commonly leads to inflammation of the large intestine (colitis), along with fever, abdominal pain and/or cramping, and diarrhea with or without blood. ^{Reference Kimberlin, Barnett, Lynfield and Sawyer46,Reference McDonald, Gerding and Johnson47} CDI occurs most often in hospitalized patients who get antibiotics, chemotherapy, or surgery. It also can occur in people who do not have risk factors. ^{Reference Kimberlin, Barnett, Lynfield and Sawyer46,Reference McDonald, Gerding and Johnson47}

C. difficile has the ability to survive for extended periods of time on surfaces and on the hands of the people who come into contact with the spores. ^{Reference Kociolek, Gerding and Carrico45} Uninfected individuals can acquire C. difficile by unknowingly swallowing these spores after coming in contact with them. In healthcare facilities, preventing transmission of C. difficile involves avoiding unnecessary antibiotic use, placing patients with CDI on contact precautions (patient cared for in a private room and healthcare personal wear gowns and gloves), washing one’s hands with soap and water after removing gloves used during care, and thoroughly cleaning the rooms of infected patients. ^{Reference Kociolek, Gerding and Carrico45} In residential settings, prevention strategies are focused on hand washing and disinfecting surfaces. There is no vaccine available for C. difficile.

Recommendations

1. 1. Guests and visitors who have or develop symptoms of CDI, such as fever or bloody diarrhea:

   1. a. Should seek medical evaluation. If the medical evaluation shows that a guest may have CDI, the guest must leave the family-centered residential facility.

   2. b. Should not enter or re-enter the facility until they have started treatment with appropriate antibiotics, their diarrhea has resolved, and they have been fever-free for 24 hours without the use of fever-reducing medicine.

   3. c. Once symptoms have resolved, they do not need a negative C. difficile test to enter or reenter the facility. Best practices discourage repeat testing of C. difficile to prove the person is no longer infected.

2. 2. Guests with recent CDI (defined as having had a diagnosis of CDI within one month) should be restricted from food preparation and food handling in the common kitchen area

3. 3. Once they check out from the facility, the surfaces of their room and bathroom should be cleaned with household bleach diluted with water (1 part bleach, 9 parts water).

4. 4. Guests and visitors who have been exposed to someone with CDI but who do not have symptoms of illness:

   1. o Should be allowed to enter the facility

   2. o If caring for someone with CDI, they should be educated about the importance of consistent use of disposable gloves and washing the full surface of both hands with soap and water for at least 15 seconds after glove removal.

Background

Conjunctivitis is an inflammation of the inside surface lining of the eyelids and covering of the eyeball. The eye may appear red and may have a clear or cloudy discharge. Conjunctivitis has both noninfectious and infectious causes that can be bacterial or viral. Conjunctivitis does not necessarily require treatment with topical or oral antibiotics.

Many large, community-based outbreaks of conjunctivitis, including outbreaks among school children, on college campuses, and in military facilities have been documented. ^{Reference Ariga, Shimada and Ohgami48–Reference Ong, Dashraath and Lee55} In neonates, conjunctivitis can be associated with serious invasive disease that involves multiple organs. ^{Reference Brito, Oliveira, Matos, Abdallah and Gontijo Filho56,Reference Haas, Larson, Ross, See and Saiman57} Careful hand hygiene can reduce transmission.

Individuals who have conjunctivitis should be considered contagious until their symptoms have resolved. The viruses and bacteria that most commonly cause conjunctivitis are transmitted to eyes from hands that are contaminated with the infectious eye drainage, from contaminated objects (shared towels and washcloths, eye drop solution, or contact lens solution), or potentially by direct inoculation into the eye via large respiratory droplets from an ill individual who is coughing.

Recommendations

1. 1. Restrict individuals with severe conjunctivitis (i.e., copious eye discharge, eye irritation causing frequent eye rubbing or itching, or conjunctivitis accompanied by fever or respiratory symptoms) from entering the family-centered residential facility.

2. 2. Allow individuals with mild conjunctivitis (“pink eye” with no active discharge, minimum eye irritation, and no fever) to enter the facility, but require such guests to stay in their personal room until their symptoms have resolved.

3. 3. Allow individuals who were exposed to a person with conjunctivitis but who do not have symptoms of illness to enter the facility. No special precautions are required.

4. 4. Educate guests and visitors about the importance of frequent hand hygiene, avoidance of sharing personal items (e.g., towels and washcloths, eye drops, and contact lens solutions), and prompt removal and careful handling of contaminated items (e.g., tissues, towels, and linens).

Background

Cytomegalovirus (CMV) is a common viral infection. Symptoms vary by age and some people with the infection may not show any symptoms. People who have symptoms of CMV may have a mild illness with fever, body aches, a sore throat, and/or swollen glands in the neck. CMV can cause a mononucleosis (“mono”), similar to the illness caused by the Epstein Barr virus (EBV).

Most healthy people do not get seriously ill from CMV. In people who are immune compromised, infection can affect multiple organs. When a pregnant person is infected with CMV, the infection can be passed to the unborn baby across the placenta. One in five babies infected with CMV before birth (congenital CMV) may have long-term health problems including developmental and hearing abnormalities. ⁵⁸

Most person-to-person transmission of CMV is a result of exposure to infected secretions such as saliva or urine. Children who attend childcare centers can be infected with CMV and will shed the virus in their urine or saliva. On average, 30%-40% of childcare attendees who are 1-3 years of age are excreting CMV. In some studies, as many as 70% of children excrete the virus. ^{Reference Kimberlin, Banerjee, Barnett, Lynfield and Sawyer59} Because CMV is so prevalent in the population and children shed the virus without symptoms, those with known CMV do not need to be excluded from entering the family-centered residential facility. Measures to prevent CMV transmission include frequent handwashing or use of alcohol-based hand sanitizer, avoiding contact with body fluids, and cleaning hands whenever exposed to body fluids. There is no vaccine available for CMV.

Recommendations

1. 1. Allow individuals with current or past CMV infection to enter the family-centered residential facility

2. 2. Instruct guests and visitors on good hand hygiene, especially after handling diapers and touching body fluids like saliva and nasal secretions

3. 3. Remind guests and visitors to avoid sharing unwashed cups and utensils

4. 4. Inform pregnant people about the risk of CMV infection and educate them about ways to prevent infection.

Background

Diarrhea may be due to infectious and noninfectious causes. Fever, vomiting, and loose stools (stools that take the shape of a container) that sometimes contain blood or mucus often accompany infectious diarrhea. Some viral and bacterial causes of diarrhea are associated with potentially severe illness, are highly contagious, and are transmitted by direct contact with infected feces or objects that have been contaminated with feces (e.g., diapers, clothing, changing tables, and toys).

Rotavirus and norovirus are two viruses that spread easily from person-to-person. Rotavirus diarrhea primarily affects infants. The incidence of rotavirus in infants has decreased since the reintroduction of the rotavirus vaccine in 2006, but children who are unvaccinated are at risk of this type of diarrhea.

Norovirus easily spreads among healthy individuals of all ages. Some people with norovirus have vomiting without diarrhea. There is no vaccine available for norovirus.

Follow these recommendations if any person develops new diarrhea or vomiting, including when the cause is unknown.

Recommendations

1. 1. Restrict individuals with acute diarrhea with or without vomiting from entering the family-centered residential facility until they have been fever-free and diarrhea-free (without the use of fever-reducing or anti-diarrheal medications) for at least 24 hours. Do not require proof of having received antibiotic treatment to enter the facility. Some types of bacterial diarrhea require antibiotic treatment and some types do not.

2. 2. Restrict individuals with the following types of bacterial diarrhea and individuals who do not have symptoms of illness but are known to be shedding these bacteria until they receive written medical clearance for entry:

   1. a. Shiga toxin-producing Escherichia coli (also called E. coli O157:H7)

   2. b. Shigella

   3. c. Salmonella serotype Typhi (the cause of typhoid fever).

3. 3. Restrict individuals with known norovirus or rotavirus infection from entering the facility (see recommendation 1). Both viruses spread easily from person-to-person and have a high risk of causing outbreaks. Younger children, especially those who are diapered, may shed high concentrations of these viruses in their stools. ^{Reference Kimberlin, Barnett, Lynfield and Sawyer60,61} Environmental cleaning and disinfection is especially important when these viruses cause diarrhea. Use of a bleach-containing product or a diluted bleach solution should be used for cleaning when norovirus is suspected or diagnosed or when an outbreak of diarrheal illness occurs.

4. 4. Restrict individuals who had diarrheal illness within the previous 2 weeks from food preparation and food handling in common areas.

5. 5. Allow individuals who were exposed to a person who has diarrhea but who do not have symptoms of illness to enter the facility.

6. 6. Educate guests and visitors about:

   1. a. The importance of frequent hand hygiene

   2. b. When hands are visibly soiled or they have potentially been in contact with surfaces with diarrheal-causing germs, they should wash them with soap and water for at least 15 seconds over using alcohol-based hand sanitizer. ⁶²

   3. c. Appropriate, prompt removal and careful handling of contaminated items (e.g., diapers, clothing, and linens).

7. 7. Refer any guest who develops diarrhea for medical evaluation. Until they are evaluated, require that they and their family members restrict themselves to their private room.

8. 8. In severe or outbreak situations, notify the local health department and affiliated healthcare facility for guidance and potential recommendations for additional restrictions.

Background

Diphtheria is an infection caused by the bacteria Corynebacterium diphtheriae. This vaccine-preventable disease is rare in North America and most of Europe but continues to cause life-threatening disease in Africa, Latin America, Asia, the Middle East, and parts of Europe where vaccination coverage is suboptimal. Respiratory diphtheria can cause fever, a severe sore throat and swollen glands in the neck. Diphtheria can also cause a skin infection with a painful, open sore. Severe diphtheria is associated with blockage of the upper airway, myocarditis (severe inflammation of heart muscle), and nerve damage. ^{Reference Kimberlin, Barnett, Lynfield and Sawyer63}

Recommendations

1. 1. Restrict individuals with confirmed or suspected diphtheria from the family-centered residential facility. Allow entry to the facility when they can provide written medical clearance from a licensed clinician or local public health department stating that they are no longer contagious (this includes written documentation of completion of the recommended course of antibiotics (usually at least 10 days of antibiotics, depending on specific disease) and 2 negative cultures proving eradication of bacteria. ^{Reference Kimberlin, Barnett, Lynfield and Sawyer63}

2. 2. Regardless of their immunization status, restrict individuals exposed to a person with confirmed or suspected diphtheria who do not have symptoms of illness from the facility until they obtain written medical clearance from a licensed clinician or public health department, stating that they are not a risk for transmitting the infection.

3. 3. Refer individuals who develop symptoms of diphtheria for medical evaluation. Instruct the individual and family members to leave the facility immediately. Contact the local public health department for further instruction. If the individual is diagnosed with diphtheria, notify the public health department and the program manager. The program manager should identify, notify, and instruct exposed guests to contact their primary care physician or licensed clinician and the public health department, which may recommend post-exposure testing and preventative treatment regardless of immunization status.

Background

Hepatitis A is a virus that usually spreads through contact with infected persons and by eating or drinking contaminated food or water. In recent years, hepatitis A outbreaks have occurred among people who have eaten contaminated foods, had close contact with others who are infected, and among people who use drugs, are experiencing homelessness, and by men who have sex with men. The illness is characterized by fever, fatigue, jaundice (yellow skin), poor appetite, and nausea. It also rarely causes severe liver disease, usually in people with underlying chronic conditions. ^{Reference Kimberlin, Barnett, Lynfield and Sawyer64}

Individuals with acute hepatitis A infection are most infectious 1-2 weeks before they develop jaundice or other symptoms. ^{Reference Kimberlin, Barnett, Lynfield and Sawyer64} High levels of the virus are excreted in the stool during those weeks, then the amount of virus decreases substantially one week after jaundice appears.

The hepatitis A vaccine is recommended for children and adolescents, for those at risk for severe disease from hepatitis A, and for those in settings that provide services to adults with risk factors for hepatitis A, including group homes.

Recommendations

1. 1. Restrict individuals with hepatitis A infection from entering the family-centered residential facility until they receive written medical clearance that states at least one week has passed since the illness began and that the individual is no longer contagious.

2. 2. Allow individuals who have been exposed to a person with hepatitis A to enter the facility, only if they are vaccinated against hepatitis A with 2 doses of vaccine. Outbreaks of hepatitis A can occur in unvaccinated households, and the incubation period can be prolonged (15-50 days). ^{Reference Kimberlin, Barnett, Lynfield and Sawyer64}

3. 3. Educate all family members about the importance of frequent hand hygiene and appropriate, prompt removal and careful handling of contaminated items (e.g., diapers, clothing, and linens). When hands are visibly soiled or potentially have come in contact with stool, instruct them to wash their hands with soap and water, rather than alcohol-based hand sanitizer.

4. 4. Refer individuals who develop symptoms of hepatitis A for medical evaluation. Instruct the individual and family members to leave the facility immediately. If the medical evaluation diagnoses the person with hepatitis A, notify the local public health department and program manager. The program manager should identify, notify, and instruct exposed guests to contact their physician or public health department. Exposed individuals may require post-exposure vaccination or immunoglobulin. ⁶⁵

5. 5. In severe or outbreak situations, the local health department or affiliated medical facility may enforce additional restrictions.

Background

Recommendations

1. 1. Allow individuals who are infected with HBV, HCV, or HIV to enter the family-centered residential facility without restrictions, except for in the following situations:

   1. a. Restrict entrance of an individual who has an HBV, HCV, or HIV infection and open sores on their skin that cannot be covered, or other conditions that might allow contact with their body fluids.

   2. b. Consider specific restrictions, determined on an individual basis, if an infected person or their family member has behaviors (e.g., biting) that might put others at risk of contact with their blood or body fluids. ^{Reference Shope and Hashikawa24,Reference Rathore and Jackson70,Reference Kimberlin, Barnett, Lynfield and Sawyer71}

2. 2. Allow individuals who have been exposed to a person infected with HBV, HCV, or HIV to stay at the facility without restriction.

3. 3. Educate families about the importance of appropriate, prompt disposal of items contaminated with blood and or body fluids (e.g., bandages, sanitary pads or tampons, and items that were used for injection of medication). ^{Reference Shope and Hashikawa24,Reference Kimberlin, Barnett, Lynfield and Sawyer69} Educate family members about the importance of good hand hygiene, appropriate glove use, and appropriate handling of blood and body fluids. ^{Reference Rathore and Jackson70,Reference Kimberlin, Barnett, Lynfield and Sawyer71} Advise that they should not share personal items such as toothbrushes or razors.

Background

Herpes simplex viruses (HSV) cause a spectrum of clinical infections, including:

1. 1. Cold sores or “fever blisters” (rashes made up of painful clusters of small, fluid-filled blisters)

2. 2. Genital rashes or ulcers

3. 3. Sores on the fingers or toes, called “herpetic whitlow”

4. 4. A severe skin rash in individuals with eczema (called eczema herpeticum)

5. 5. Primary HSV gingivostomatitis, which is common in young children and associated with many ulcers in and around the mouth, drooling, high fever, and swollen lymph nodes in the neck

6. 6. Severe, life-threatening illness in young infants that can affect the brain, liver, and lungs. Newborns who are infected with HSV may or may not have a skin rash.

7. 7. Encephalitis or meningitis in older children and adults.

Like varicella, the chickenpox, and shingles virus, HSV stays in the body after a person’s first infection. Reactivation of HSV-related skin rashes and cold sores is common. Cases of oral HSV may not be obvious and the virus may be present in saliva even in the absence of visible sores. ^{Reference Kimberlin, Barnett, Lynfield and Sawyer72} The virus spreads though contact with infected sores or contaminated secretions. People with cold sores should avoid kissing or having their mouths come in contact with newborns or immune compromised individuals. There is no vaccine available for HSV.

Recommendations

1. 1. Allow individuals who have isolated labial (lip) cold sores to enter the family-centered residential facility if they are capable of frequent hand hygiene and can follow instructions not to kiss others. If the person is young or incapable of hand hygiene, then restrict them from entrance until the cold sore is completely crusted and dry or restrict them to their private room.

2. 2. Restrict individuals with active HSV affecting their skin or eyes from entering the facility until they have obtained written medical clearance from a licensed clinician. In general, the individual must be able to completely cover the rash with clothing, bandage(s), or other appropriate dressing. If the rash is unable to be completely covered, restrict entrance until the rash is completely crusted and dry. If permitting entry, restrict the individual to their private room until the rash is completely crusted and dry.

3. 3. Restrict those with primary herpes gingivostomatitis (see 5. above) from entering the facility if active sores and drooling are present. Once they have recovered from the illness, require written medical clearance from a licensed clinician that states that the patient is no longer contagious.

4. 4. Allow individuals who have been exposed to a person who is infected with HSV who do not have symptoms of illness to stay at the facility without restriction.

5. 5. Educate family members about the importance of frequent hand hygiene, avoidance of sharing personal items, and prompt removal and careful handling of potentially contaminated items (e.g., tissues, towels, and linens). Advise family to avoid direct, close contact with rashes to prevent person-to-person transmission.

Background

Head lice infestation is common, particularly among school-aged children of all socioeconomic groups. ^{Reference Frankowski and Bocchini73,Reference Kimberlin, Barnett, Lynfield and Sawyer74} Head lice are small wingless insects (about the size of a sesame seed) that prey on the blood of humans. ^{Reference Frankowski and Bocchini73} They move by crawling. Head lice lay eggs (nits) in an individual’s scalp where they are incubated by body heat and remain attached firmly to the hair shaft until they hatch. Once hatched, the louse injects saliva into an individual’s scalp when it feeds, which causes the scalp to become irritated and itchy. An itchy scalp is the most common symptom of head lice infestation, but because scalp itching may not develop for several weeks after becoming infested, many individuals initially do not have symptoms. Occasionally, skin breakdown from scratching the affected site may result in a bacterial infection of the scalp.

Because head lice do not fly or hop, ^{Reference Haas, Larson, Ross, See and Saiman57} transmission mostly occurs from direct contact with the head of an infested individual, such as from sleeping in the same bed. ^{Reference Frankowski and Bocchini73,Reference Kimberlin, Barnett, Lynfield and Sawyer74} Head lice can spread from by sharing a bed and/or personal items that have contact with the head (e.g., combs, brushes, pillows, and hats). Lice do not survive when away from the scalp for more than day. Of note, head lice do not transmit other infectious agents. ^{Reference Frankowski and Bocchini73}

Recommendations

1. 1. Restrict individuals with suspected untreated head lice, and their household contacts, from entering the family-centered residential facility until they have received a medical evaluation.

   1. a. If medical evaluation rules out head lice, allow the individual to enter the facility.

   2. b. If medical evaluation confirms head lice, the individual should undergo treatment as recommended by a licensed clinician. Once treatment is complete, the individual may enter the facility.

   3. c. Encourage bedmates of individuals with confirmed head lice to also be treated for having head lice, even if they do not have symptoms.

   4. d. Instruct guests and family members to keep the affected individual’s personal items (e.g., combs, brushes, hats, and pillows) inside their private room.

2. 2. Refer any guest who develops symptoms of head lice for medical evaluation. Restrict the symptomatic individual and their family members to their private room until they have been medically evaluated and confirmed to not have head lice. If they are confirmed to have head lice, follow the recommendations above.

3. 3. Launder bed linens with water that is hotter than 130° F

4. 4. Thoroughly clean the surfaces in the affected person’s room and vacuum the floor and furniture

5. 5. Place any items that cannot be laundered (e.g., stuffed animals and pillows) in a plastic bag for 2 weeks prior to reuse.

Background

Measles is a highly contagious viral infection. Measles is spread when an infected person coughs, sneezes or talks, sending droplets containing the virus into the air or onto a surface. Infection can occur if someone breathes the air containing the infectious droplets (the virus stays in the air for up to two hours) or touches a contaminated surfaces and then touches their own eyes, noses or mouths. Measles commonly presents with symptoms of fever, cough, nasal congestion, conjunctivitis (pink eye), and a red rash that begins on the face then spreads to the entire body. ⁷⁵ The measles virus (rubeola) can also cause ear infections, pneumonia, croup, hepatitis, encephalitis, and diarrhea.

Individuals are contagious from 4 days before the onset of rash through 4 days after the rash appears. ^{Reference Siegel, Rhinehart, Jackson and Chiarello8,Reference Shope and Hashikawa24,Reference Kimberlin, Barnett, Lynfield and Sawyer76}

Measles remains a leading cause of childhood disease and death globally. Outbreaks have occurred during the past several years due to importation of disease by travelers and infections in individuals who are immunized incompletely. ^{Reference Kimberlin, Barnett, Lynfield and Sawyer76} The measles vaccine is safe and effective and is routinely recommended for all healthy children aged 12 months and older.

Recommendations

1. 1. Restrict individuals from the family-centered residential facility who are suspected or confirmed to have measles. Allow entry into the facility when they are no longer contagious, usually 4 days after the appearance of the rash. ^{Reference Siegel, Rhinehart, Jackson and Chiarello8} Prior to entry, require written medical clearance from a licensed clinician or local public health department that states that they are no longer contagious. ^{Reference Shope and Hashikawa24,Reference Kimberlin, Barnett, Lynfield and Sawyer76}

2. 2. Restrict all individuals who have been exposed to a person with suspected or confirmed measles until they obtain written medical clearance from a licensed clinician or public health department that states that they are not a risk for transmitting the infection.

3. 3. Refer individuals who develop symptoms of measles, and their family members, to leave the facility immediately and receive prompt medical evaluation. Notify the medical facility in advance that individuals are being referred for measles evaluation so that appropriate isolation precautions can be initiated and exposures to others are prevented.

4. 4. Contact the referring medical facility and local public health department for further instruction and assistance with testing to confirm the measles diagnosis.

5. 5. If medical evaluation confirms the individual has measles, notify the person’s primary care physician or licensed clinician and the program manager immediately, who will:

   1. a. Identify and notify exposed guests and instruct them to immediately consult a licensed clinician or the public health department for possible post-exposure prophylaxis.

   2. b. Non-immune individuals who have a normal immune system and are not pregnant should receive measles vaccine up to 72 hours after exposure.

   3. c. High-risk individuals who have a compromised immune system may receive immune globulin up to 6 days after exposure to measles.

Background

Recommendations

1. 1. Allow individuals who were discharged from the hospital after treatment for bacterial meningitis to enter the family-centered residential facility. An individual with bacterial meningitis who has received 24 hours of antibiotic therapy and been discharged is no longer contagious.

2. 2. Allow individuals who were exposed to a person with bacterial or viral meningitis who do not have symptoms of illness to enter the facility without restrictions and refer them to their primary care physician or licensed clinician or to the public health department to determine if they qualify for post-exposure antibiotics to prevent the disease.

3. 3. Allow individuals who are prescribed post-exposure antibiotics to enter the facility. The antibiotics may be indicated for the exposed person’s own health and safety, not because they pose a risk to others.

4. 4. If a guest develops symptoms of meningitis, immediately refer them for medical evaluation. Notify the program manager if the medical evaluation finds that the person has Hib or meningococcal meningitis. In such cases, the program manager should identify, notify, and instruct exposed guests to contact their primary care physician, licensed clinician or public health authorities immediately to find out if they should receive post-exposure antibiotics.

5. 5. Restrict entrance to the facility to individuals who have been discharged from the hospital after treatment for viral meningitis until they are fever-free for 24 hours and diarrhea (if present) has resolved completely.

Background

Mpox (formerly known as monkeypox) is a viral illness endemic to West and Central Africa that in 2022 became a global outbreak with over 30,000 cases and more than 40 deaths in the United States. Cases of mpox in children were rare but a more recent outbreak in the Democratic Republic of the Congo has included children. ⁷⁹

Symptoms of mpox include fever, swollen lymph nodes, and flu-like symptoms like headache and malaise. A rash appears 1-4 days after the onset of fever. The rash begins as flat red or discolored areas that become small, raised bumps then vesicles and finally sores filled with pus. The rash often starts on the face or the mouth, and then moves to the arms and legs, including the palms and soles. Over time, the sores may develop a central dimple and ultimately form a crust. Mpox can look like other common childhood illness such as chickenpox or hand foot and mouth disease.

Mpox typically spreads by direct contact with the rash. Less commonly, it can spread by prolonged periods of face-to-face interaction because of exposure to saliva and upper respiratory secretions. ⁸⁰ People with mpox are infectious from the time symptoms start until the rash is fully healed. Mpox has been spread by contaminated linens, but in the recent outbreak, the risk of spread via contaminated surfaces was low. ⁸¹

Recommendations

1. 1. Restrict individuals with confirmed or suspected mpox infection (painful, undiagnosed rash) from entry into the family-centered residential facility.

2. 2. Refer any individual who develops a rash suspected to be mpox for prompt medical evaluation. Restrict those individuals to a private room until evaluation is complete.

3. 3. Contact local public health department if an individual in the facility is diagnosed with mpox.

4. 4. Individuals exposed to mpox but who do not have symptoms of illness do not need to restricted from entry unless directed by the local public health department. ⁸²

5. 5. Clean and disinfect all surfaces touched by someone who has been found to have an mpox infection. Disinfect per CDC recommendations using an EPA-registered hospital-grade disinfectant approved for emerging pathogens list Q, which can be found at www.epa.gov. ⁸³

Background

Bacteria that have become resistant to the common antibiotics are referred to as multidrug-resistant organisms (MDROs). Some people may have an MDRO living on their skin or in their bodies but they are not ill. This is called being “colonized” with an MDRO. People can be colonized with an MDRO intermittently or consistently. ^{Reference Fritz, Krauss and Epplin84,Reference Lacey, Flaxman, Scales and Wilson85}

People with chronic medical conditions (e.g., cancer, kidney failure, and transplant recipients) are at highest risk of becoming colonized or infected with an MDRO. There may be special circumstances when a referring hospital has experienced high transmission rates of a specific MDRO; therefore, additional restrictions may be recommended by the affiliated medical facility’s IPC department. Vaccines are not available for the prevention of the MDROs described here.

Recommendations

1. 1. Allow individuals known to be “colonized” with an MDRO entry to the family-centered residential facility, as long as the person currently does not have symptoms of illness, is able to follow recommended hygienic practices, and is able to contain their body fluids (e.g., stool).

2. 2. If a facility or its referring medical facility has experienced high transmission rates of a specific MDRO, additional restrictions may be considered. Consultation with local IPC specialists is recommended.

3. 3. If the individual has a specific disease caused by an MDRO (e.g., skin infection or respiratory infection), please refer to the specific disease section for more guidance.

4. 4. Allow individuals exposed to a person known to be colonized with an MDRO but who do not have symptoms of illness to enter the facility without restriction.

5. 5. Educate all family members about the importance of frequent hand hygiene and appropriate removal and careful handling of contaminated items (e.g. diapers, clothing, and linens).

Background

Mumps is a viral infection characterized by the swelling of one or more salivary glands of the head and neck, usually the glands located on the face immediately in front of the earlobes. Rarely, it can cause complications affecting other organ systems of the body. ^{Reference Kimberlin, Barnett, Lynfield and Sawyer88}

Mumps spreads through contact with respiratory droplets and saliva. Individuals are most contagious several days before the appearance of swollen glands until 5 days after the onset of symptoms. ^{Reference Siegel, Rhinehart, Jackson and Chiarello8,Reference Kimberlin, Barnett, Lynfield and Sawyer88} Mumps can be prevented by vaccination.

Recommendations

1. 1. Restrict individuals with mumps from the family-centered residential facility until at least 5 days from the appearance of swollen glands. Individuals must obtain written medical clearance from a licensed clinician before entering the facility. ^{Reference Siegel, Rhinehart, Jackson and Chiarello8}

2. 2. Restrict individuals who have been exposed to a person with mumps, even if they do not have symptoms of illness, from entry the facility until they obtain written medical clearance from a licensed clinician that states that they are not a risk for transmitting the infection. ^{Reference Shope and Hashikawa24} Exposed individuals can become ill with mumps 12-25 days after exposure. ^{Reference Kimberlin, Barnett, Lynfield and Sawyer88}

3. 3. If someone in the facility develops symptoms of mumps, instruct the person and family members to leave the facility immediately and refer them for medical evaluation. If they are diagnosed with mumps, notify the local public health department and program manager immediately. The program manager should identify, notify, and instruct exposed guests to contact their primary care physician or licensed clinician, or the public health department.

Background

Pertussis is an illness caused by Bordetella pertussis characterized by a prolonged cough. ^{Reference Kimberlin, Barnett, Lynfield and Sawyer89} The typical incubation period for pertussis is 7-10 days, although rarely it can be as long as 21 days. Pertussis may start with a runny nose, sneezing, and a low-grade fever. Although during this initial phase a person’s cough may be mild, the high volume of the germ in their nose and throat increases the likelihood of transmission. During the next phase, people may begin to show classic signs of pertussis, including severe, episodic coughing with a “whooping” sound during their inhalation and forceful coughing followed by vomiting. Young infants who have pertussis may have difficulty feeding or may experience apnea (breath holding) during coughing spells. Pertussis infection can be life threatening or fatal in infants who have very small airways and are too young to be protected by immunization.

Immunity wanes 5-10 years after immunization, leaving adolescents and adults susceptible to getting pertussis. ^{Reference Skoff and Martin90} Although adolescents or adults may develop pertussis, they may have mild cough without the “whooping” sound on inhalation. The cough may sound like a “smoker’s cough,” bronchitis, or asthma. ^{Reference Cherry91}

Outbreaks of pertussis have been reported in hospitals, ^{Reference Bryant, Humbaugh and Brothers92} schools, ^{Reference Liko and Cieslak93} childcare centers, ^{Reference Hochwald, Bamberger, Rubin, Gershtein and Srugo94} and other residential facilities. ^{Reference Fisher, Long, McGowan, Kaselis and Smith95} Pertussis spreads through large respiratory droplets that a person expels during coughing or sneezing. These droplets then contact another person’s mouth or eyes, or they are breathed in. Transmission also can occur after touching infectious droplets on a surface or object. Patients without classic or severe symptoms may transmit pertussis. ^{Reference Yeh and Batt96} Typically, infected people typically are infectious for 3 weeks if they do not get treated with appropriate antibiotics.

Vaccines are available to prevent pertussis in children and adults. A single dose of tetanus toxoid-reduced diphtheria toxoid and acellular pertussis (Tdap) vaccine is recommended for all adults who have close contact with infants younger than 12 months of age. ^{Reference Havers, Moro, Hunter, Hariri and Bernstein97}

Recommendations

1. 1. Restrict individuals with pertussis from the family-centered residential facility until they have completed treatment and obtained written medical clearance from a licensed clinician. A person who has pertussis is contagious until they have completed 5 days of appropriate antibiotic therapy. ^{Reference Kimberlin, Barnett, Lynfield and Sawyer89} Facilities do not need to restrict individuals who have received effective treatment but are still coughing. Cough may persist for many weeks after the illness.

2. 2. During the initial routine screening process upon facility entry, screen family members and other close contacts of children who have respiratory symptoms. Infants and young children commonly acquire pertussis from a family member who has not yet sought medical care for their illness. ^{Reference Bisgard, Pascual and Ehresmann98}

3. 3. Restrict individuals who have been exposed to pertussis from the facility, even if they do not have symptoms of illness, until active infection has been ruled out and preventative antibiotics have been started. ^{Reference Kimberlin, Barnett, Lynfield and Sawyer89} Preventative antibiotics are indicated even if exposed people are up to date on immunization. Written medical clearance from a licensed clinician is required for a person who has been exposed to pertussis to be allowed to enter the facility.

4. 4. Individuals exposed to pertussis who refuse or are unable to take their prescribed antibiotics should be restricted from the facility for 21 days after last pertussis exposure, even if they do not have symptoms of illness. Require written medical clearance from a licensed clinician before allowing entry.

5. 5. If a guest is suspected to have pertussis, notify the program manager immediately and refer them to get a medical evaluation by their primary care physician or a licensed clinician. The program manager should notify the local health department to help identify and notify exposed guests. ^{Reference Bryant, Humbaugh and Brothers92}

Background

People can become ill with upper tract or lower tract respiratory infections. Upper tract respiratory infections include “the common cold,” sinusitis, and croup. Lower tract respiratory infections include pneumonia and bronchiolitis. Lower tract respiratory infections are associated with substantial morbidity and mortality. The risk of a person having a severe lower respiratory infection depends on a person’s age, underlying conditions, and the organism that is causing the infection.

The viruses adenovirus, rhinovirus, respiratory syncytial virus (RSV), human metapneumovirus, influenza viruses, parainfluenza viruses, and the coronaviruses most commonly cause upper respiratory tract infections.

Viruses or bacteria can cause lower respiratory tract infections. In infants and severely immune compromised individuals, these viruses can cause severe lower tract respiratory disease. In severely immune compromised individuals and people with underlying conditions (prematurity, chronic lung disease, heart disease, etc.), RSV pneumonia carries high morbidity and mortality. ^{Reference Chatterjee, Mavunda and Krilov99} In infants, RSV bronchiolitis is the most common cause of hospitalization for respiratory disease. ^{Reference Suh, Movva and Jiang100} RSV can be associated with large outbreaks. ^{Reference Vakrilova, Nikolova, Slavov, Radulova and Slancheva101}

In children and adults, bacteria such as Streptococcus pneumoniae and atypical bacteria, such as Mycoplasma pneumoniae and Legionella, cause pneumonia.

Most respiratory viruses spread through respiratory droplets expelled during coughing and sneezing. For certain respiratory viruses, such as RSV, a person also can get sick from direct contact with infected respiratory secretions or objects that have been contaminated with infectious droplets.

Respiratory infections caused by bacteria spread by droplets expelled by the person who is sick before they have received 24 hours of effective antibiotics.

It is important to be aware of respiratory viruses that may become epidemics or pandemics. Local health departments often send health alerts when there is a community at risk for spread of a dangerous virus. In 2009, the influenza virus H1N1 became a worldwide pandemic. In late 2019, the coronavirus SARS-CoV-2, which causes COVID-19, quickly spread across the globe becoming a multiyear pandemic (see Supplementary Material, Appendix C, COVID-19 for additional information).

Vaccines are available that prevent disease due to influenza, RSV, and SARS-CoV-2. Individuals who are 6 months of age and older should receive an influenza vaccine annually. An RSV vaccine, approved by the FDA in 2023, is recommended for pregnant people to protect their newborns. ¹⁰² New RSV vaccines have been approved for individuals 60 years and older. ¹⁰³ Infants who were born prematurely and those who are high risk for infection may receive a monthly dose of RSV antibody (palivizumab) during the RSV season. Another RSV antibody treatment (nirsevimab) can protect young or high-risk infants from severe RSV disease with only one injection. ¹⁰⁴

Recommendations

1. 1. Restrict individuals with viral respiratory illnesses from entering the family-centered residential facility until they have been fever-free for 24 hours without taking fever-reducing medicine.

2. 2. After they no longer have a fever, allow entry to the facility but require that guests restrict themselves to their private rooms until all their symptoms (e.g., runny nose, cough, and congestion) resolve. See COVID-19 for specific information about management of individuals diagnosed with COVID-19.

3. 3. Restrict individuals diagnosed with bacterial pneumonia from entering the facility until they have received 24 hours of effective antibiotics, and they have been fever-free for 24 hours without taking fever reducing medicine. If their infection is from Legionella, allow entry because Legionella pneumonia does not spread from person-to-person. See Pertussis and/or COVID-19 for specific information about management of individuals diagnosed with these germs.

4. 4. Allow individuals who have been exposed to a person with a respiratory illness and who do not have symptoms of illness to enter the facility. See Pertussis and/or COVID-19 for specific information about management of individuals exposed to these germs.

5. 5. Educate all family members about the importance of cough etiquette, frequent hand hygiene, and appropriate removal and careful handling of contaminated items (e.g. tissues, clothing, linens, and toys).

6. 6. As the influenza season approaches and once the influenza vaccine becomes available, remind families of the importance of getting vaccinated every year. If It would be especially helpful for families to be directed to places where they can obtain vaccine. See COVID-19 for specific information about the COVID-19 vaccine.

Background

Ringworm or “tinea” is a type of skin infection caused by several different species of fungus. A ringworm infection can occur on the scalp (tinea capitis), the body (tinea corporis), the hands (tinea manuum), the feet (tinea pedis or “athlete’s foot”), the nails (tinea unguium), the groin or inner thighs (tinea cruris of “jock itch”), and the beard area (tinea barbae). Typical symptoms include red, itchy skin, a ring-shaped rash, and hair loss.

Ringworm spreads by contact with personal items from someone who ^{Reference Shope and Hashikawa24} has a ringworm infection, such as towels, clothing, or hair care items, or surfaces that are contaminated with the fungus. It also can spread by contact with an infected dog or cat.

Treatment for ringworm depends on where the infection is on the body. Over-the-counter topical medication can treat infections on the skin, but a prescription medication taken by mouth is used to treat infections on the scalp. There are rare reports of infections that are resistant to antifungal medicines. ^{Reference Caplan, Chaturvedi and Zhu105}

Recommendations

1. 1. Allow entry of individuals who have ringworm infection once they have begun treatment for the infection. A rash should not be not used as a reason for excluding someone who has begun treatment, as a ringworm rash may persist for several weeks. ^{Reference Shope and Hashikawa24}

2. 2. Refer guests who develop a rash while staying at the facility for medical evaluation by their primary care physician or licensed clinician.

Background

Scabies is an itchy skin infestation caused by the mite Sarcoptes scabiei var. hominis. Outbreaks of scabies, especially crusted scabies, have occurred in hospitals, ^{Reference Sponselli, De Maria and Caputi106} nursing homes, ^{Reference Mounsey, Murray, King and Oprescu107} and other residential facilities, sometimes lasting for several months.

Common symptoms of scabies include an itchy, bumpy rash between the fingers and toes, around the wrists and the elbows, under the breasts, and in the genital area. ^{Reference Thomas, Coates, Engelman, Chosidow and Chang108} A rash also may occur on the head, neck, palms, and soles in children.

Crusted or Norwegian scabies is a severe form of scabies that primarily affects the elderly and those who are immune compromised. Individuals with crusted scabies are very infectious because of the large number of mites present.

Scabies usually spreads by prolonged skin-to-skin contact with a person who is infected. Occasionally, contact with contaminated items such as clothing or linen can result in transmission.

Recommendations

1. 1. Restrict individuals who have untreated scabies from entering the family-centered residential facility.

2. 2. Allow entry to the facility once an individual’s treatment has been completed. Treatment usually can be done overnight. Itching may persist for several weeks after scabies treatment and should not be used as a reason for exclusion.

3. 3. Refer all family members who were exposed to the person infested with scabies, even if they do not have symptoms, for medical evaluation by their primary care physician or licensed clinician. Typically, individuals who had prolonged skin-to-skin contact with a person infested with non-crusted scabies receive treatment. ¹⁰⁹ A facility does not need to exclude people who have been exposed to someone with scabies unless they have a rash.

4. 4. Wash and dry all clothes and linens used by the affected person in hot water and dry with a high heat cycle to kill mites and prevent reinfestation. Temperatures more than 50°C or 122°F for 10 minutes will kill mites and eggs. Place any items that cannot be laundered (e.g., stuffed animals and pillows) in a plastic bag for at least 72 hours or up to one week.

5. 5. Rooms occupied by guests who were subsequently diagnosed with scabies do not require the application of pesticides. Thoroughly clean and vacuum furniture and carpeting in a room occupied by a person with scabies to remove skin crusts and scales that may contain mites.

6. 6. Crusted scabies is very contagious. A single case in the facility should prompt notification of the program manager and the local public health department to assist with investigation for additional cases, referrals for medical treatment, and control measures for cleaning clothing, bedding, and furniture.

Background

Infections of the skin and soft tissues are caused most frequently by Staphylococcus aureus (also referred to as “Staph”) or Streptococcus pyogenes (also referred to as “Strep” or Group A strep; refer to the Streptococcal infections section), and other less common bacteria. Staph infections may be caused by staph strains that are very susceptible to antibiotics or by MRSA (see MRSA section above). Sometimes the specific bacteria can indicate the type of skin infection (e.g., impetigo, cellulitis, and abscess), the events leading to the infection (e.g., unknown, trauma, and animal bite), and the individual’s underlying risk factors (e.g., previous history of skin infections and immune compromise). ^{Reference Stevens, Bisno and Chambers110}

Many skin infections are easily treated with oral antibiotics. Some skin infections, especially those caused by Staph, may require a minor surgical procedure to drain pus from an abscess (also called a boil), if present. If the infection is severe, it may require hospital admission for intravenous (IV) antibiotics. ^{Reference Stevens, Bisno and Chambers110}

The ways these bacteria spread depends on the type of skin infection and the specific bacteria. Staph, including MRSA, transmit easily through direct contact with infected fluids, such as pus and through respiratory secretions from a person with pneumonia (see MRSA section). ^{Reference Stevens, Bisno and Chambers110} People can minimize the risk of transmission by avoiding direct contact with infected fluids, careful hand hygiene and using dressings to cover skin infections with draining fluid and changing dressings frequently. ^{Reference Popovich, Aureden and Ham111}

Individuals also can be colonized with these bacteria, meaning the bacteria live in their nose, throat, or on their skin, but they do not have symptoms of illness. ^{Reference Popovich, Aureden and Ham111}

Recommendations

1. 1. If group A streptococcus (Strep) is the cause of the individual’s skin infection, refer to Streptococcal infections section.

2. 2. Restrict individuals from entering the family-centered residential facility with skin and soft tissue infections if they have active drainage from the infection site. After an individual has surgical drainage of an infected abscess (boil), the facility may allow entry if the affected skin can be kept completely covered at all times with a clean and dry dressing.

3. 3. Allow individuals who have been exposed to someone with a skin infection who do not have symptoms of illness to enter the facility.

4. 4. Refer individuals who develop a skin infection while staying at the facility for medical evaluation. Until evaluated, restrict the individual to their private room.

5. 5. Educate guests and family members about the importance of frequent hand hygiene and careful handling of contaminated items (e.g., used bandages, clothing, and linens) with appropriate, prompt cleaning or disposal.

Background

The most common infection caused by group A streptococcus (GAS) is pharyngitis, commonly called strep throat. Symptoms include fever, sore throat, and enlarged lymph nodes in the neck. Scarlet fever can occur along with strep throat, and it is characterized by a red, sandpaper-like rash. ^{Reference Kimberlin, Barnett, Lynfield and Sawyer112} GAS can cause other infections including skin and soft tissue infections, pneumonia, musculoskeletal infections, bloodstream infection, and sepsis. Sepsis is the body’s overactive and toxic response to infection. Sepsis can be life threatening.

GAS can spread through contact with the respiratory secretions of a person who is infected. ^{Reference Kimberlin, Barnett, Lynfield and Sawyer112} A person is considered contagious until they have been treated with appropriate antibiotics for 24 hours. ^{Reference Shope and Hashikawa24} The is no vaccine available to prevent GAS infections.

Recommendations

1. 1. Restrict individuals who have active, untreated GAS infections from entry to the family-centered residential facility.

2. 2. Allow entry once they have completed at least 24 hours of antibiotic treatment and have been fever-free for 24 hours without the use of fever-reducing medication. ^{Reference Siegel, Rhinehart, Jackson and Chiarello8,Reference Shope and Hashikawa24}

3. 3. Allow individuals who were exposed to someone with a documented case of GAS infection to enter the facility if they do not have symptoms of illness.

4. 4. Refer for medical evaluation individuals who were exposed to GAS and develop symptoms for testing and treatment if the test is positive. Apply the previous steps to their reentry to the facility. ^{Reference Shope and Hashikawa24}

Background

Tuberculosis (TB) is a disease caused by infection of the lungs and other organ systems with Mycobacterium tuberculosis bacteria. TB is transmitted by small airborne respiratory droplets that may remain suspended in the air and travel long distances. It usually spreads only through air and not by contact with surfaces or objects. ^{Reference Jensen, Lambert, Iademarco and Ridzon113}

Individuals with active TB should be considered contagious until they are treated with antituberculosis medications. They will receive follow-up testing to prove that they are no longer contagious. Those who are most at risk of getting TB have shared the same air space for a prolonged period in an enclosed environment with a person who has an active TB infection. ^{Reference Jensen, Lambert, Iademarco and Ridzon113}

A person can have latent TB (LTBI) after infection with M. tuberculosis. This occurs when the bacteria remain in the body but do not cause disease. A person with LTBI and no symptoms is not contagious. ^{Reference Jensen, Lambert, Iademarco and Ridzon113} Sometimes the bacteria cause active disease in a person with untreated LTBI. This can occur at any time after their infection, but most commonly it happens 1-6 months following the infection. It is characterized by fever, chills, night sweats, weight loss, and cough. ^{Reference Kimberlin, Barnett, Lynfield and Sawyer114} There is no vaccine available in the United States to prevent TB infection.

Recommendations

1. 1. Restrict individuals with active tuberculosis from entry to the family-centered residential facility until they have written medical clearance from the treating licensed clinician or local public health department that they are considered non-infectious. Verbal medical clearance by direct telephone consultation with a public health official is also acceptable.

2. 2. Allow individuals with LTBI infection to enter the facility.

3. 3. Restrict all family members who were exposed to a person with active TB from entering the facility until they have written medical clearance from the treating licensed clinician or the local public health department that they are considered non-infectious. Verbal medical clearance by direct telephone consultation with a health department official is also acceptable.

4. 4. Ask any guest with a new diagnosis of active TB and their family members to leave the facility immediately. Require written medical clearance for readmission to the facility per the instructions above. Based upon consultation with the local public health department, the program manager may need to identify and notify all exposed guests and instruct them to seek medical attention. ^{Reference Shope and Hashikawa24}

Background

The varicella-zoster virus is the cause of chickenpox and shingles. It is highly contagious.

Recommendations