Health Protection Agency information indicates that approximately half of children’s GP consultations are for infectious diseases. Children are more susceptible to infectious diseases for a number of reasons including immature immunity, lack of prior exposure to infections and incomplete vaccinations. But social aspects also play a part in children’s vulnerability. A higher degree of close contact, sharing communal facilities and, importantly, lower levels of good hygiene practice mean that schools can be the ideal setting for infections.
Most of these infections will be self limiting although unpleasant for the child or staff member. Others however can cause wider impact, even forcing schools to close for operational reasons if the majority of staff are infected, such as in the case of diarrhoea and vomiting outbreaks or influenza. Good hygiene practices in schools can reduce the spread of these illnesses and allow school children the best possible opportunity for their education. How infections spread To understand the role hygiene can play in preventing illness in schools, it is important to know how infectious disease can spread.
Infectious diseases can be spread in a number of ways in schools. Aerosol spread (small droplets) is when the organisms which cause the disease are spread from the infected person via droplets in the air (caused by coughing, sneezing or during close conversation) and then inhaled by another person. Diseases spread in this way include colds, influenza (flu), measles and mumps.
Direct contact spread is when skin contact, such as holding hands, transmits some contagious skin diseases and infestations such as ringworm and scabies. Head to head contact will also facilitate the transmission of head lice.
Lastly infection can be spread the faecal/oral route. For some diseases, including viral gastroenteritis and Hepatitis A, the infecting organism is excreted in the faeces. If the infected person does not wash their hands properly after using the toilet, then they can spread the infection to others. Food can also become contaminated if it is handled by an infected person who hasn’t washed their hands properly, and objects such as toys and flush handles. People can pick up the infecting organism by eating the contaminated food or touching contaminated surfaces and then putting their fingers in their mouth.
Off sick Of the infectious illnesses that do end up affecting schools, gastrointestinal and respiratory infections are among the major contributors to absenteeism. These infections cause a significant burden on students through lost days in education and to parents and carers who have to take time off work to care for a sick child. Certain infections, such as measles, chickenpox and parvovirus, can cause complications for pregnant women and immunocompromised people. In such circumstances, schools should know who to contact for advice, i.e. the school nurse, the HPA’s local health protection unit or ask the individual to seek advice from their health practitioner.
Hand washing is the single most important hygiene measure in reducing the risk of transmitting infections amongst children and staff. Hands are used for all sorts of activities during the course of a school day and can become easily contaminated from daily activities such as using the toilet or outdoor play. Germs on a person’s hand can easily be passed onto others by direct touch or by contamination of objects. Once on the hands it is easy for germs to get into the mouth.
Some infectious diseases, such as chickenpox and measles, can be passed on to others before the infected person has any symptoms of being unwell. Some people carry certain infections, including hand, foot and mouth disease, and ringworm, without becoming unwell at all and can pass these on to susceptible people. For these reasons it is important that high standards of basic hygiene and cleanliness are maintained at all times and not just in the event of an outbreak.
A clean environment Infection control is not just about clean hands; a clean environment is also essential to prevent or minimise transmission of infectious diseases. There should be a regular daily cleaning regime in place which is undertaken by suitably trained staff. Colour coding of mops, mop buckets and cloths is recommended and all staff should be made aware of which colour is dedicated to which area, i.e. red for toilet areas, blue for classrooms and other general areas, green for kitchen area, etc. In the event of an outbreak the cleaning regime should be increased to at least twice daily with special attention to areas which are most likely to have been contaminated by hands such as toilet flush handles, taps, light switches, handrails, door handles, and so on.
Some infectious spores survive very well in the environment and can stay on an inanimate object for several days. For this reason it is essential to have a robust cleaning regime which should commence as soon as an outbreak is suspected. A suitable disinfectant should be used and it is important to know that hypochlorite (bleach) solutions do not eliminate all viruses/bacteria, therefore should be used after the area has been disinfected.
Carpets and rugs should be cleaned using a steam cleaner as any other method will not be effective in removing the bacteria or virus particles.
With any gastrointestinal illness, staff and children should not return to school until they have had no further symptoms for 48 hours and until they feel well enough to return. Other infections have their own exclusion periods dependent on how long the infection is infectious to others and parents should be advised to keep their children at home until the period of infectivity has passed.
An ‘outbreak’ can usually be defined as when there are two or more cases of a similar illness in the same class or when there is an unusually high number of children with a similar illness. Unfortunately outbreaks of infection within schools are inevitable due to the large numbers of people in close contact with each other. However by having simple hygiene and infection control programmes, schools can effectively reduce disruptions due to infectious disease and maximise the time available for a child’s education.
Asha Abrahams is Health Protection Nurse Specialist, North East and North Central London Health Protection Unit, Health Protection Agency