text: COMMUNICABLE DISEASES IN SCHOOLS A Reference Guide Student Medical Services and District Nursing Services Student Health and Human Services Division Los Angeles Unified School District 3rd Edition 2005 Table of Contents PART I: INTRODUCTION TO COMMUNICABLE DISEASES IN SCHOOLS……………………...1 Overview……………………………………………………………………………………………………… .2 General Inclusion and Exclusion Criteria……………………………………………………..3 Definition of Terms……………………………………………………………………………………….5 PART II: POLICIES ON THE CONTROL OF COMMUNICABLE DISEASE IN SCHOOLS……..7 PART III: COMMONLY ENCOUNTERED COMMUNICABLE DISEASES…………………………..12 Chickenpox (Varicella-Zoster Infections)…………………………………………………….13 Chlamydia…………………………………………………………………………………………………….14 Common Cold (Upper Respiratory Infections)…………………………………………….15 Conjunctivitis ("Pink Eye")………………………………………………………………………….16 Cytomegalovirus (CMV)………………………………………………………………………………..17 Diphtheria…………………………………………………………………………………………………….18 Fifth Disease (Human Parvovirus B19)…………………………………………………………19 Foodborne Illness (Food Poisoning)……………………………………….…………………….20 Giardiasis……………………………………………………………………………………………………..21 Gonorrhea…………………………………………………………………………………………………….22 Hand, Foot, and Mouth Disease (Commonly Enterovirus)…………………………..23 Head Lice (Pediculosis)………………………………………………………………………………..24 Hepatitis A, B, and C…………………………………………………………………………….……..25 Herpes (Oral and Genital)…………………………………………………………………………….27 HIV/AIDS……………………………………………………………………………………………………….28 Impetigo (& MRSA)……………………………………………………………………………………….30 Influenza (Flu)……………………………………………………………………………………………..31 Lyme Disease……………………………………………………………………………………………….32 Measles (Rubeola)………………………………………………………………………………………..33 Meningitis………………………………………………………………………………………….…………34 Molluscum Contagiosum………………………………………………………………………………35 Mononucleosis……………………………………………………………………………………………..36 Mumps………………………………………………………………………………………………………….37 Pinworms……………………………………………………………………………………………………..38 Pertussis (Whooping Cough)…………………………………………………………………………39 Ringworm (Tinea)…………………………………………………………………………………………40 Rubella (German Measles)……………………………………………………………………………41 Scabies………………………………………………………………………………………………………….42 Scarlet Fever…………………………………………………………………………………………………43 Strep Throat………………………………………………………………………………………………….44 Tetanus……………………………………………………………………………………………..………..45 Tuberculosis………………………………………………………………………………………..….…..46 Warts (Genital and Non-Genital)…………………………………………………………..…….47 West Nile Virus (& Mosquito-borne Diseases)……………………………………………….48 PART IV: BIOTERRORISM AND COMMUNICABLE DISEASES AT SCHOOLS……………………49 PART V: APPENDICES……………………………………………………………………………………………….53 Appendix A: County of Los Angeles Reportable Diseases and Condition………….54 Appendix B: Guide to Immunizations Required for School Entry……………………..56 Appendix C: LAUSD Policies and Bulletins…………………………………………………………59 Bulletin 1645: Infection Control Procedures for the Prevention And Spread of Communicable Diseases……………………………….60 Bulletin 1937: Reporting Communicable Diseases……………………………………..67 Bulletin 1660: Immunization Guidelines for School Admission………………….77 Bulletin 1959: Tuberculosis Examination Requirements for New Entering Students ……………………………………………………….83 Bulletin Z-70: Students with HIV/AIDS Infection………………………………………..87 Bulletin Z-69: Employees with HIV/AIDS Infection…………………………………….92 Bulletin Z-72: Bioterrorism Preparedness Response: Health Perspective………………………………………………………………96 Reference Guide 1304: West Nile Virus Precautions………………………………….103 Part I Introduction to Communicable Disease in Schools -1- Overview From a very young age through adolescence, students spend a great deal of time in the school setting. Schools place a high priority on attendance which is necessary for optimal student learning and achievement. Yet, the nature of schools (close, confined contact among students and staff) make the transmission of infectious disease possible. Determining the likelihood that an infection will spread from one person to another requires an understanding of the ease and mechanism by which a particular organism is transmitted, as well as some knowledge of the host immunity (i.e., Has the student been vaccinated against the disease? Does the student have a compromised immune system?). We must also recognize that many schools do not have a full-time health professional on-site, and some students have limited access to medical services. This makes it important to have some reference for administrators and staff (including school nurses and physicians) to make informed decisions when intervening in communicable disease cases. This Reference Guide has been compiled using existing District publications along with the most current available information from the American Academy of Pediatrics and the Center for Disease Control and Prevention. In addition, current State, County and Los Angeles Unified School District policies are reflected in this Reference Guide. The changing nature and evolving understanding of communicable diseases, particularly with the transmission of new disease entities between countries, makes it important to stay abreast of local disease patterns and infection control policy. District personnel are advised to contact Student Medical Services or District Nursing Services (Communicable Disease Team) if there are any questions regarding the management of communicable disease in schools. The Reference Guide is designed to be a quick reference for LAUSD personnel. The following sections describe general recommendations for inclusion/exclusion and readmission to school due to illness. There is also a section defining the terms used in this Reference Guide. Part II references the various policies that relate to the control of communicable diseases in school. Part III catalogues common infectious diseases in alphabetical order, offering general information as well as specific exclusion, readmission and contact guidelines for school settings. Part IV gives a brief summary of bioterrorism and includes a table describing early clinical signs of certain infectious agents that could be used in a bioterrorist attack. The appendices found in Part V give more specific information about communicable disease control, including District bulletins and reference sheets and forms from other agencies. All of this is in an effort to keep students, staff, and families healthy and able to participate fully in the educational process. -2- General Inclusion and Exclusion Criteria Determining when to include and exclude students from school is a difficult decision, particularly as there are different factors that influence the decision. On the one hand, schools are inclusive institutions that accommodate children with a variety of medical issues. Student attendance is linked to academic achievement, therefore avoiding unnecessary exclusion is important for student success. On the other hand, children and adolescents who attend school with a communicable disease put others at risk. Fortunately, most of the commonly encountered infections in school-age children (e.g., respiratory viruses) are relatively harmless. In some cases, children exposed to certain infection through contact with other children develop immunity that protects the children as they grow older. This Reference Guide is designed to help staff make an informed decision about when to exclude students from the school setting. While guidance of this type is helpful, there are multiple different presentations of infectious diseases in children. School personnel are not expected (nor qualified, in some cases) to make a diagnosis of a communicable disease in a student. Staff are encouraged to use what is presented in this Guide and their best judgment to help ensure a safe and healthy school environment. Table 1 lists general conditions that need medical attention and are referred to as "general exclusion criteria" in the Reference Guide. In addition, California law requires exclusion if a student's immunization status does not comply with Health and Safety Code (Division 105) and Administrative Code (Title 17) regulations. The laws address immunization against communicable diseases such as polio, diphtheria, pertussis, tetanus, measles, mumps, rubella, Hepatitis B, and varicella. The laws allow exemptions due to personal beliefs and certain medical conditions. There are other situations where students can be admitted "conditionally" (see Appendix B). Remember, most illnesses do not require exclusion. Conditions and diseases not listed in Table 1 generally do not require automatic exclusion. Table 1: General Exclusion Criteria for Schools1 Call emergency medical services Has difficulty breathing or is unable to speak for a student who: Has blue, purple or gray skin or lips Is increasingly less responsive, or unconscious Is vomiting blood Has signs of meningitis (stiff neck, fever2 and headache) Is severely dehydrated (lethargic, sunken eyes, no urine) Has a serious injury or is experiencing severe pain Is acting very strangely, less alert or very withdrawn 1 Adapted from: American Academy of Pediatrics, Managing Infectious Diseases in Child Care and Schools. Aronson S and Shope T (Eds.) 2005 2 See definition of fever -3- Get immediate medical attention Has a fever and looks more than mildly ill 2 (within one hour) for a student who: Has a quickly spreading purple or red rash Has a large volume of blood in the stools Has an injury that may require medical treatment, such as a deep cut that may require stitches Has an animal or human bite that breaks the skin Has any medical condition that is outlined in the child's care plan as requiring medical attention Temporarily exclude a student An illness that prevents the student from participating if there is: comfortably in school activities An illness that results in a need for care that is greater than the staff can provide without compromising the health and safety of other students An illness that poses a risk of spread of disease to others Fever1 and behavior change or other signs and symptoms (e.g., sore throat, rash, vomiting, diarrhea) Diarrhea3 or blood in the stool not explained by dietary change, medications or hard stool. Vomiting more than 2 times in the previous 24 hours, unless the vomiting is determined to be from a non-communicable condition and the child is not in danger of dehydration Abdominal pain that continues for more than 2 hours or intermittent pain associated with fever or other signs and symptoms Mouth sores with excessive drooling (in young children) Rash with fever or behavioral changes Pink or red conjunctiva (whites of the eyes) with white or yellow eye mucous drainage—until treatment has been started Impetigo—until 24 hours after treatment has been started Strep throat (or other streptococcal infection)—until 24 hours after treatment has been started Head lice—until after the first treatment (note: exclusion is not necessary before the end of the school day) Scabies—until after treatment has been given Chickenpox (varicella)—until all lesions have dried and crusted Whooping Cough (pertussis)—until 5 days after appropriate treatment (antibiotic) Any child determined by the local health department to be contributing to the transmission of illness during an outbreak 3 See definition of diarrhea -4- Readmission to school after exclusion for a communicable disease generally falls to the school principal or principal's designee. There may be instances where certain readmission criteria should be met and these are delineated in the listings of each communicable disease (Part III). In more serious cases of infection, the attending physician or the local health department should clear the student before readmission. Definitions of Terms Bacteria: Organisms that may be responsible for localized or generalized diseases and can survive in and out of the body. They can be treated effectively with antibiotics. Body fluids: Urine, stool, saliva, blood, nasal discharge, eye discharge and tissue discharge (i.e., seepage from wound). Not all body fluids transmit all types of micro- organisms. Communicable disease: A disease caused by a micro-organism (e.g., bacteria, virus, fungus, parasite) that can be transmitted from person to person by an infected body fluid or respiratory spray. This may occur with or without an intermediary agent (e.g., mosquito) or object (e.g., table surface). Dermatitis: An inflammation of the skin caused by irritation or infection. Diarrhea: More frequent loose or watery stools compared to the student's normal pattern (not associated with change in diet or use of medications). Exclusion may be needed if diarrhea can not be contained in toilet or there are other signs, such as blood or color change (black). Fever: An elevation of the body temperature. While there are several definitions of fever, for the purpose of evaluating a student in school, fever is defined as temperature: >101°F (38.3°C) oral >102°F (39°C) rectally >100°F (37.8°C) axillary (armpit) or measurement by equivalent method Fever is an indication of the body's response to something, but is neither a disease nor a serious problem by itself. Fungi: Plantlike organisms such as yeasts, molds, mildews and mushrooms that get their nutrition from other living organisms or dead organic matter. Health care professional: Practices medicine by an established licensing body with or without supervision. The most common types of health care professionals include physician, nurses, nurse practitioners, and physician assistants. Immunizations: Vaccines that are given to children and adults to help them develop protection (antibodies) against specific infections. Vaccines may contain an inactivated or killed agent or a weakened live organism. -5- Incubation period: Time between exposure to an infectious microorganism and beginning of symptoms. Mantoux intradermal skin test: Involves the injection of a standard amount to tuberculin protein under the skin. The reaction to the protein on the skin can be measured and the result is used to assess the likelihood of infection with tuberculosis. Parasite: An organism that lives on or in another living organism (e.g., tick, louse) Universal precautions: Apply to blood and other body fluids containing blood, semen and vaginal secretions-- but not generally stool, nasal secretions, sputum, sweat, tears, urine, saliva, or vomitus, unless they contain visible blood or are likely to contain blood. Universal precautions include avoiding injuries caused by sharp instruments or devices and the use of protective barriers such as gloves, gowns, masks and protective eyewear, which can reduce the risk of exposure of a worker to materials that may contain blood-borne pathogens while the worker is providing first aid or care. Virus: A microscopic organism that may cause disease. Viruses can grow or reproduce only in living cells. -6- Part II Policies on the Control of Communicable Disease in Schools -7- Policies Concerning Communicable Disease in Schools The health and safety of the students is guided by several policies, some are LAUSD- specific and others are part of California health, administrative and educational codes. Listed below are some of the pertinent policies for communicable disease identification, reporting, treatment and prevention. While these are provided for reference, it should be noted that policies can not cover every possible individual scenario. It is each staff member's responsibility to use good judgment when dealing with communicable diseases. Student Medical Services and District Nursing Student Medical Services (Communicable Disease Team) are available 213-763-8342 for consultation, and should be used as a resource when there is any question regarding District Nursing communicable disease diagnosis, exclusion, (Communicable Disease Team) reporting, readmission and notification 213-763-8372 criteria. Exclusion of students with communicable disease "A pupil while infected with any contagious or infectious disease may not remain in any public school." (California Code of Regulations, Title 5, Education, 202.) "The governing body of any school district may exclude children of filthy or viscous habits, or children suffering from contagious or infectious diseases." (California Education Code, 48211) "Students showing signs and symptoms of communicable or infectious diseases shall be excluded from attending school. The Student Health Services Division, in cooperation with the County of Los Angeles, Department of Health Services, shall prescribe such measures as shall be necessary for the control of communicable diseases, including the exclusion and readmission of students. (For provisions relating to employees, see Board Rule 1942.) Students whose continued presence would constitute a clear and present danger to the life, safety, or health of other students or school personnel shall be exempted or excluded." (LAUSD Board Rule 2312) "It shall be the duty of the principal or other person in charge of any public, private or Sunday School to exclude therefrom any child or other person affected with a disease presumably communicable, until the expiration of the prescribed period of isolation for the particular communicable disease. If the attending physician, school physician, or health officer finds upon examination that the person is not suffering from a communicable disease, he may submit a certificate to this effect to the school authority who shall readmit the person." (California Code of Regulations, Title 17, Public Health, 2526) -8- "A parent or guardian having control or charge of any child enrolled in the public schools may file annually with the principal of the school in which he is enrolled a statement in writing, signed by the parent or guardian, stating that he will not consent to a physical examination of his child. Thereupon the child shall be exempt from physical examination, but whenever there is a good reason to believe that the child is suffering from a recognized contagious or infectious disease, he shall be sent home and shall not be permitted to return until the school authorities are satisfied that any contagious or infectious disease does not exist." (California Education Code, 49541) Exclusion of school employees with communicable disease "… [regarding communicable disease]… applicants and employees with any acute or chronic (e.g., tuberculosis AIDS/HIV infection) communicable diseases which may endanger health or safety of self and/or others, shall be evaluated on an individual basis in relation to the successful performance of the core duties of the class for which applying or in which serving…" (LAUSD Board Rule 1942) Reporting communicable diseases A list of reportable diseases for the County of Los Angeles is included in the Appendix A of this Reference Guide. All reporting of communicable disease within LAUSD is coordinated by the District Nursing Communicable Disease Unit and Student Medical Services. Please use the phone numbers listed above to receive information and assistance in the event of a communicable disease case on a school campus. "It shall be the duty of every health care provider, knowing of or in attendance on a case or suspected case of any of the diseases or conditions listed in [Appendix A], to report to the local health officer for the jurisdiction where the patient resides... Where no health care provider is in attendance, any individual having knowledge of a person who is suspected to be suffering from one of the diseases or conditions listed in [Appendix A] may make such a report." (California Code of Regulations, Title 17, section 2500) Please note: "Health care provider" includes physicians, surgeons, nurse practitioners, physician assistants, registered nurses, school nurses, infection control practitioners, dentists and others as specified in subsections (h) in Title 17 section 2500 "It shall be the duty of anyone in charge of a public or private school, kindergarten, boarding school, or day nursery to report at once to the local health officer the presence or suspected presence of any of the communicable diseases." (California Code of Regulations, Title 17, section 2508) -9- Notification of communicable disease "The Director, Student Medical Services, and the Director, District Nursing Services, must be consulted before any notification (written or oral) to parent/guardian or school employees regarding possible exposure to any communicable disease." (LAUSD Bulletin No. 1937, Reporting Communicable Diseases, September 2005) Immunizations Immunization is an important method of preventing certain communicable diseases, especially in group settings such as schools and child care. The California School Immunization Law requires children to have a series of immunizations before they enter school (public and private elementary and secondary schools). See LAUSD Bulletin No. 1660.2 "Immunization Guidelines for School Admission" and the California Immunization Handbook (7th Ed. July 2003- most recent edition available on the Los Angeles DHS website: (http://www.dhs.ca.gov/ps/dcdc/izgroup/pdf/HandbookText.pdf). A guide to the immunizations required for school entry is included in this Reference Guide, Appendix B. "… the governing board of any school district shall cooperate with the local health officer in measures necessary for the prevention and control of communicable diseases in school age children. For that purpose the board may use any funds, property, and personnel of the district, and may permit any person licensed as a physician and surgeon, or any person licensed as a registered nurse acting under the direction of a supervising physician and surgeon … to administer an immunizing agent to any pupil whose parents have consented in writing to the administration of such immunizing agent." (California Education Code 49403) "A 'Health Record' card and health history must be maintained for each student. Mandated health information such as immunization status, child health and disability prevention screening, visual activity, color vision testing, audiometric test results, scoliosis screening results, and tuberculosis test results must be recorded. Reports of school physicians and school nurses are also recorded." (LAUSD Board Rule 2309) "Physicians of the County of Los Angeles, Department of Health Services, or school physicians or any school nurse under supervision of a school physician, may immunize students on school premises. The school nurse will notify the school of the date set for giving immunizations and will assist with the program. A parent or guardian consent slip, provided by the County of Los Angeles, Department of Health Services, shall be completely filled out and be on file at he school before an immunization may be given." (LAUSD Board Rule 2313) - 10 - Tuberculosis "Students who have never attended a California school must present written evidence of a Mantoux (PPD) skin test… (1) All Kindergarten students. Tests must be given within 1 year prior to school entry. (2) All other students in grades 1-12 who have never attended any school in California" (County of Los Angeles DHS, TB Test Requirements. See Appendix C- LAUSD Bulletin No. 1659) "A parent or guardian consent slip, provided by the District, shall be completely filled out and be on file at the school before a Mantoux Tuberculin Skin Test may be given. If the test is positive, it shall be followed by an X-ray of the chest. The skin test must be administered and read within 48 to 72 hours by a member of the staff of District Tuberculosis Prevention Services. (For tuberculin skin testing of employees, see Board Rule 1950.)" (LAUSD Board Rule 2313) Exposure control plan and general sanitation "Universal precautions shall be observed to prevent contact with blood or other potentially infectious materials…" and "Each employee shall ensure that the worksite is maintained in a clean and sanitary condition." (LAUSD, Bloodborne Pathogens—Exposure Control Plan, July 2005) "Clean all contaminated areas and materials first with soap/detergent and water. An LAUSD approved commercial product may be used for cleaning surfaces which are not contaminated with blood…" (See approved chemical product list for use in the District at http://www.lausd-oehs.org/productreview_chemical.asp) "For washable surfaces always use freshly made 1:10 bleach solution (1 part bleach to 9 parts cold water) when cleaning up blood." (LAUSD Bulletin No. 1645, Infection Control Guidelines for Preventing the Spread of Communicable Diseases, July 2005) - 11 - Part III Commonly Encountered Communicable Diseases - 12 - Chickenpox (Varicella-Zoster Infections) 1. What is chickenpox? Chickenpox is an infectious disease caused by the varicella-zoster virus that results in a rash, most often occurring in persons less than 15 years old. 2. What are the signs and symptoms of chickenpox? The most obvious sign of chickenpox infection is the development of a blister-like rash. This rash begins with small, red spots that develop into blisters (vesicles) after a few hours. It first appears on the trunk and face, but can spread over the entire body. These blisters will become pus-filled after 3- 4 days, and then develop into scabs. Fever, itching, cough, runny nose, and/or headache commonly accompany this rash. 3. Incubation period: Usually 14 – 16 days. 4. Contagious period: From 1 – 2 days before the rash appears until after the last crop of vesicles. A person no longer spreads the virus when all blisters have scabs and no new blisters are forming. 5. How does infection with chickenpox occur? Chickenpox is a highly infectious virus; it spreads from person to person by direct contact with an infected person or by breathing in air containing germs that are released when the infected person coughs or sneezes. 6. How can infection with chickenpox be prevented? Chickenpox can be prevented with a vaccination that is required by law for school admission. There are other methods to prevent chickenpox in immunocompromised children after exposure (such as varicella-zoster immune globulin, VZIG). VZIG must be given very early after exposure to be effective. 7. Is there a treatment for chickenpox? Antiviral medication and treatment should be considered for individuals at increased risk for moderate to severe disease (e.g., >12 years old, chronic skin or lung infections, immunocompromised, etc.). Antivirals are most effective when administered early in the course of the disease. Children that have chickenpox should not be given aspirin, as it can lead to serious liver disease (Reye's syndrome). 8. What are the circumstances in which chickenpox could be significant? One in ten children has a complication that is serious enough to visit a health care provider. Complications include: infected skin lesions, other infections (such as pneumonia), dehydration from vomiting or diarrhea, and exacerbation of asthma. Adults, infants, adolescents, and people with weak immune systems are more likely to have a serious illness with complications. 9. Can you get chickenpox more than once? Yes, but it is very rare. Cases are generally mild with less fever and fewer blisters than the first time. 10. Exclusion: Yes – routine exclusion of infected children from school is warranted until they are not longer contagious. 11. Readmission: When all blisters have scabs and there are no new blisters appearing (usually 6 days after the start of the rash in healthy individuals). 12. Contacts and reporting: Consider sending letters to parents and employees to protect immunocompromised or pregnant individuals exposed to chickenpox. Call Nursing Services Communicable Disease Unit before any notification to parents or staff. - 13 - Chlamydia 1. What is chlamydia? Chlamydia is a common sexually transmitted disease that is caused by the bacterium Chlamydia trachomatis. (C. trachomatis may also cause neonatal conjunctivitis, blindness and pneumonia in young infants). Most people with chlamydia have no symptoms and may not seek health care for their infection. When chlamydia is diagnosed, it can be easily treated and cured. Untreated chlamydia can cause serious health problems and infertility. 2. What are the signs and symptoms of chlamydia? While 75% of infected women and 50% of infected men will show no symptoms, those men and women that do show symptoms experience pain and difficulty when urinating and abnormal discharge from the penis or vagina. Men may also have swelling in the testicles. Some women experience abdominal pain, lower back pain, nausea, fever, pain during intercourse, and bleeding between menstrual periods. 3. Incubation period: Varies with the type of infection, the average is 5 – 7 days. 4. Contagious period: Communicable until the organism is eradicated by appropriate antibiotic. 5. How does infection with chlamydia occur? Chlamydia is passed from an infected person to a healthy person through anal, oral, or vaginal sexual contact. In addition, it can be passed from a mother to her baby during birth. 6. How can infection with chlamydia be prevented? Frequent examination of sexually active individuals and safe sex practices, including the use of latex condoms during sexual contact are effective prevention measures. 7. Is there a treatment for chlamydia? Chlamydia can be treated and cured with antibiotics. 8. What are the circumstances in which chlamydia could be significant? If left untreated, chlamydia bacteria can spread into a woman's uterus or fallopian tubes, and can lead to the development of pelvic-inflammatory disease, which can cause chronic pelvic pain and infertility. If chlamydia is passed to a baby during birth, an eye infection or pneumonia can result. In men, untreated chlamydia typically causes a urinary infection and, potentially, infertility. 9. Exclusion: None unless they meet other exclusion criteria (see "General Exclusion Criteria") 10. Readmission: No restrictions. 11. Contacts and reporting: All sexual contacts of patients with Chlamydia infection should be evaluated and treated. Chlamydia is a reportable disease to the County. Call Nursing Services Communicable Disease Unit if there is a need to report a case of chlamydia. - 14 - Common Cold (Upper Respiratory Infection) 1. What is the common cold? The common cold is a highly contagious viral infection of the upper respiratory tract that increases in prevalence during the fall and winter. 2. What are the signs and symptoms of the common cold? Symptoms of the common cold often include runny nose, sneezing, sore throat, cough, and headache. Fever is usually slight but can climb to 102 degrees Fahrenheit in infants and young children. While nasal discharge usually is watery and clear at the onset, it can become colored and thick after a few days. This has no correlation with bacterial infections, although occasionally the common cold can lead to ear or sinus infections that require treatment with antibiotics. High fever, significantly swollen glands, severe facial pain in the sinuses, and a cough that produces mucus may indicate a complication or more serious illness requiring a doctor's attention. 3. Incubation period: From 2 – 14 days 4. Contagious period: Usually few days before signs and symptoms appear and while clear runny nasal secretions are present. Viral shedding is most abundant in the first few days of infection and usually ceases within 7 – 10 days. 5. How does infection with the common cold occur? The common cold is passed person-to-person through direct or close contact with mouth and nose secretions, including inhalation of tiny droplets containing the virus. Transmission can also happen indirectly when a healthy person touches an object or surface that has been soiled by nasal or oral discharges from the infected person and then touches his or her eyes or nose. 6. How can infection with the common cold be prevented? General hygiene measures, such as frequent hand washing, covering the mouth and nose with tissues when coughing or sneezing, and proper disposal of tissues are the best methods of prevention. If possible, one should avoid close, prolonged exposure to persons who have colds. 7. Is there a treatment for common cold? Only the symptoms can be treated, there is no cure or vaccine for the common cold at this time. Children that have a viral infection should not be given aspirin, for they run the risk of developing a rare but serious illness called Reye's syndrome. 8. Exclusion: Generally none for children with the common cold, unless they meet other exclusion criteria (see "General Exclusion Criteria") 9. Readmission: Upon recovery, by school principal or principal's designee. - 15 - Conjunctivitis ("Pink Eye") 1. What is conjunctivitis? Conjunctivitis is a condition in which the conjunctiva, the clear membrane that covers the eye, becomes inflamed. Conjunctivitis is caused by bacteria, viruses, chemicals, allergies, etc. Infectious conjunctivitis is commonly known as "pink-eye". 2. What are the signs and symptoms of conjunctivitis? Signs and symptoms vary according to the kind of conjunctivitis: Bacterial Conjunctivitis is characterized by redness, itching and pain in the eyes, with discharge containing mucus and or pus. It may affect one or both eyes. Viral Conjunctivitis is characterized by redness, watery eyes, sensitivity to light and may affect only one eye. Allergic Conjunctivitis is characterized by itching, redness and excessive tearing usually of both eyes. Chemical Conjunctivitis is characterized by red, watery eyes especially after swimming in chlorinated water. 3. Incubation period: Depends on the type of conjunctivitis. 4. Contagious period: Allergic and chemical conjunctivitis are not contagious. Bacterial conjunctivitis contagious period ends when the course of medication is started. Viral conjunctivitis contagious period continues while the signs or symptoms are present. 5. How does infection with conjunctivitis occur? Conjunctivitis caused by bacteria or viruses can be passed from an infected person to a healthy person through direct contact, or through indirect contact with articles, such as those used for eye makeup, that are freshly soiled with infectious discharge. Conjunctivitis caused by an allergy is not contagious. 6. How can infection with conjunctivitis be prevented? Strict personal hygiene, careful hand washing, use of separate towels, prompt treatment of bacterial infected eyes, and avoiding contagious individuals can help prevent the spread of conjunctivitis. 7. Is there a treatment for conjunctivitis? Bacterial conjunctivitis can be treated with antibiotics that are usually given in the form of eye drops. 8. What are the circumstances in which conjunctivitis could be significant? If left untreated, conjunctivitis can create serious complications, such as infection in the cornea, lids, and tear ducts. One type of conjunctivitis, caused by the bacterium Chlamydia trachomatis, can lead to blindness. 9. Exclusion: Yes, for bacterial conjunctivitis; and no, for other forms except on recommendation of health department or the child's health professional for epidemic viral conjunctivitis. 10. Readmission: After exclusion for bacterial conjunctivitis, the child may return after treatment has begun with antibiotic eye drops or ointment. - 16 - Cytomegalovirus Infection (CMV) 1. What is CMV? Cytomegalovirus (CMV) is a common virus that infects 50%-85% of adults in the United States by 40 years of age. CMV is the most common infection among those transmitted from a pregnant mother to her baby. 2. What are the signs and symptoms of CMV? For most healthy persons who acquire CMV after birth, there are few symptoms and no long-term health consequences. Some adolescents and adults may have a mononucleosis-like infection with a prolonged fever and a mild hepatitis. 3. Incubation period: Unknown 4. Contagious period: Unknown. Virus continues to be excreted and urine and saliva for many months and sometimes for several years. 5. How does infection with CMV occur? Transmission of CMV occurs through various modes: close contact with a person excreting the virus in saliva, breast milk, urine, blood, and tears; sexual contact; blood transfusions; organ transplants; and from a mother to her baby before, during and after birth. CMV has been shown to spread in households and day care centers. 6. How can infection with CMV be prevented? To decrease the transmission of CMV, good personal hygiene is recommended. This includes care when handling children and items like soiled diapers, avoidance of contact with oral secretions, and simple hand washing with soap and water, which is effective in removing the virus from the hands. This is especially important for women of childbearing age working with young children. 7. Is there a treatment for CMV? Treatment consists of an antiviral medication that is used for certain patients, depending on age, disease, and mode of transmission. Treatment decisions are reserved for experienced health care professionals. 8. Should children infected with CMV stay home from school to prevent spreading the disease? CMV infection without symptoms is common in infants and children. There is no need to either screen or exclude CMV-excreting children from schools or institutions because the virus is frequently found in many healthy children and adults. Absence from school should only occur if symptoms are severe enough to prevent attendance. 9. What are the circumstances in which CMV could be significant? Infection can be significant in infants born to women whose first infection with CMV occurs during pregnancy. In addition, people with weak immune systems, such as organ transplant recipients and persons infected with HIV, may experience pneumonia, eye infections, gastrointestinal disease, or even death due to CMV. Hence, these groups should take extra hygienic precautions to prevent infection. 10. Exclusion: Generally none for children with CMV, unless they meet other exclusion criteria (see "General Exclusion Criteria") 11. Readmission: Upon recovery, by school principal or principal's designee. - 17 - Diphtheria 1. What is diphtheria? Diphtheria is an acute disease caused by a toxin produced by the bacterium Corynebacterium diphtheriae. Diphtheria was once a major cause of death in children, but due to the development of an effective vaccine in the 1920s, cases of diphtheria in the United States are very rare today. However, diphtheria still occurs in other parts of the world, and most recently caused an epidemic in the former Soviet Union. 2. What are the signs and symptoms of diphtheria? Diphtheria begins with symptoms such as sore throat, loss of appetite, and low-grade fever. It most commonly affects the throat and tonsils or skin. Diphtheria of the throat and tonsils causes a bluish-white membrane to form at the back of the mouth (on the soft palate) within 2-3 days. This membrane sticks to the tissues and attempts to remove it cause bleeding. Its color can change to grayish green or black if bleeding occurs. The membrane may cause an airway obstruction and prevent the ability to breathe, which can lead to serious complications. Diphtheria of the skin causes a scaling rash or ulcers with clearly marked edges. Diagnosis of diphtheria is determined by taking a culture from these lesions or membranes. 3. Incubation period: From 2 – 5 days. 4. Contagious period: Varies. The average is 2 - 6 weeks if untreated; less than 4 days if appropriately treated. 5. How does infection with diphtheria occur? Infected persons may shed the bacteria to others through their respiratory secretions by coughing or sneezing and from their infected wounds. Ill persons can remain contagious for 2-6 weeks without antibiotic treatment. Individuals who are chronic carriers of diphtheria, i.e. those who carry the bacteria but do not manifest signs or symptoms of diphtheria, may remain contagious for up to 6 months. 6. How can infection with diphtheria be prevented? The diphtheria vaccine can prevent this disease. It is usually combined with the tetanus vaccine (Td) or with both tetanus and pertussis vaccines (DTaP). Persons of all ages should be vaccinated against diphtheria, and it is required for school admission. 7. Is there a treatment for diphtheria? Antitoxin and antibiotics are used in cases of throat and tonsil infection. Antibiotics are used for skin infections. 8. What are the circumstances in which diphtheria could be significant? Most complications of diphtheria are due to the effects of the toxin. The toxin can spread through the blood to other parts of the body and can cause ear infections, pneumonia, heart failure, paralysis, respiratory failure, and death. 9. Exclusion: Immediate isolation and exclusion in the case of the disease. 10. Readmission: Student and contacts are readmitted only by written permission of the County of the Los Angeles, Department of Health. 11. Contacts and reporting: Identification, surveillance and treatment of close contacts in congruence with County of the Los Angeles, Department of Public Health policy. Diphtheria is an immediately reportable disease, call Nursing Services Communicable Disease Unit. - 18 - Fifth Disease (Human Parvovirus B19) 1. What is fifth disease? Fifth disease is a mild rash illness caused by human parovirus B19 that occurs most commonly in children. 2. What are the signs and symptoms of fifth disease? A child infected with fifth disease has a characteristic "slapped-cheek" rash on the face, followed by a lacy red rash on the trunk and limbs. Occasionally, the rash may itch. The illness usually starts 7 to 10 days before the appearance of the rash with a low-grade fever, muscle aches and headache, but some children may be asymptomatic. The rash usually resolves in 7-10 days, but can reappear after exposure to sunlight or heat. 3. Incubation period: From 4 – 14 days but can be as long as 21 days. 4. Contagious period: Healthy individuals are contagious until the rash appears. 5. How does infection with fifth disease occur? During the early part of the illness, before the rash appears, the virus can be passed from an infected person to a healthy person through direct contact with saliva, sputum, or nasal mucus. The virus may also spread through blood products and from a mother to her unborn baby. 6. How can infection with fifth disease be prevented? There is no vaccine or medicine that prevents fifth disease at this time. Frequent hand washing is recommended as a practical and effective method to decrease the chance of becoming infected. 7. Is there a treatment for fifth disease? Treatment of symptoms such as fever, pain, or itching is usually all that is needed, unless a more serious condition develops. 8. Does keeping an infected child home from school help prevent the spread of fifth disease? Excluding persons with fifth disease from work, child care centers, or schools is not likely to prevent the spread of the virus, since people are contagious before they develop the rash and are no longer contagious once the rash appears. 9. What are the circumstances in which fifth disease could be significant? Fifth disease is usually a mild illness that resolves on its own among children and adults who are otherwise healthy. However, fifth disease may cause a serious illness in persons with sickle-cell disease or similar types of chronic anemia. Persons with weak immune systems, due to leukemia, cancer, organ transplants, HIV, etc. are also risk for serious illness due to fifth disease infection and should seek medical care if exposed. Pregnant women who may be exposed to fifth disease should consult their health professional about their immune status and risk of infection. 10. Exclusion: Generally none unless the child has sickle cell disease or compromised immune system or they meet other exclusion criteria (see "General Exclusion Criteria") 11. Readmission: Upon recovery, by school principal or principal's designee. 12. Contacts and reporting: Non reportable, but consider sending letters to parents and employees to protect immunocompromised or pregnant individuals exposed to fifth disease. Call Nursing Services Communicable Disease Unit before any such notification to parents or staff. - 19 - Foodborne Illness (Food Poisoning) 1. What is foodborne illness? Foodborne illness, or food poisoning, is caused by consuming contaminated food or beverages. Many different microbes can contaminate foods. More than 250 different foodborne illnesses have been described. Most of these diseases are infectious, caused by a variety of bacteria, viruses, and parasites. Harmful toxins and chemicals can also contaminate food, such as those found in poisonous mushrooms. 2. What are the symptoms of a foodborne illness? Symptoms vary based on the cause of food poisoning; hence there is no one "syndrome" caused by foodborne illness. In all types of foodborne disease, the microbe or toxin enters the body through the gastrointestinal tract, and often causes nausea, vomiting, abdominal cramps, and diarrhea. 3. Incubation period: May begin within hours to days of food ingestion, depending on the organism. 4. Contagious period: Varies according to the organism. 5. What are the most common microbes that cause foodborne illness? Bacteria causing foodborne illness include Salmonella, E. Coli, Shigella, Clostridium botulinum, and others. Viruses include hepatitis A and Calicivirus or Norwalk-like virus, while parasites like Giardia lamblia (see chapter on Giardiasis) and Cryptosporidia can also cause foodborne diseases. There is so much overlap that it is rarely possible to say which microbe is likely to be causing a given illness unless laboratory tests are done to identify the microbe, or the illness is part of a recognized outbreak. 6. How can foodborne illness be prevented? Thoroughly cook all foodstuff (i.e., meat, poultry, eggs). Avoid cross-contamination by washing hands, utensils and cutting boards after contact with raw meat or poultry. Refrigerate prepared foods and leftovers. Protect food against contamination by washing hands and rinsing vegetables. 7. Is there treatment for foodborne illnesses? There are many different types of foodborne illnesses and they may require different treatments depending on the symptoms they cause. Fluids and electrolyte replacement are important. Medical attention may be necessary if symptoms are severe. Antibiotics are not always needed. 8. What are the circumstances in which foodborne illness could be significant? While some foodborne illnesses are self-limited in nature, others are, or can become, serious illnesses. Certain strains of E. Coli can result in bleeding disorders and kidney failure. Botulism can result in paralysis and death, particularly in infants. Immunocompromised individuals may be at greater risk for severe disease in some cases. All persons suffering from foodborne illness may become dehydrated, and possibly septic. 9. Exclusion: Yes, if person is symptomatic or meets other exclusion criteria (see "General Exclusion Criteria"). In cases of salmonella infections, symptomatic employees (including food handlers) should be referred to employee health for assessment, treatment and readmission 10. Readmission: By school nurse or physician, the County of Los Angeles, Department of Health Services or other licensed physician. 11. Contacts and reporting: Many foodborne illness pathogens, as well as commercial food products suspected of causing illness are reportable to the County. Call Nursing Services Communicable Disease Unit if there is a need to report a foodborne illness or outbreak. - 20 - Giardiasis 1. What is Giardiasis? Giardiasis is an intestinal infection caused by a parasite (Giardia lamblia). The organism is common in the stools of young children in child care programs and schools, and outbreaks in these settings can occur. 2. What are the signs and symptoms of Giardiasis? Acute watery diarrhea Excessive gas Abdominal pain and cramps Decreased appetite Weight loss Individual can be infected and infectious without signs and symptoms. The asymptomatic carrier state is more common in children than adults. 3. Incubation period: One to 4 weeks after exposure. 4. Contagious period: Highly variable, but infected individuals can be contagious for months. 5. How does infection with Giardia occur? Ingestion of contaminated water or food, contamination of water supply by human or animal feces, and hand- to- mouth transfer of cysts from feces of infected individuals. Individuals may contract the organism while drinking from streams or lakes while camping. Outbreaks can occur with contamination of the public water supply. Asymptomatic carriers probably are more important to the spread of disease than persons with active disease. 6. How can infection with Giardia be prevented? Practice careful and frequent hand-washing, especially after the use of the toilet or changing soiled clothing Identify and treat family members, staff and children who have symptoms. Exclude people with diarrhea until they are symptom-free. Note: Treatment and exclusions of asymptomatic carriers is not effective for outbreak control. 7. Is there a treatment for Giardiasis? Treatment generally consists of an anti-parasitic drug and correction of any electrolyte imbalances or dehydration. Treatment for asymptomatic carriers is generally not recommended. 8. Exclusion: Yes, if diarrhea is present or the child is unable to participate and staff determines that they cannot care for the child without compromising their ability to care for the health and safety of the other children in the group Note: For caregivers/teachers and children without symptoms (i.e. recently recovered or exposed) testing stool cultures, treatment and exclusions are not necessary. 9. Readmission: Once exclusion criteria (diarrhea) has resolved. 10. Contacts and reporting: Giardiasis is a reportable disease to the County. Call Nursing Services Communicable Disease Unit if there is a need to report a case of Giardiasis. - 21 - Gonorrhea 1. What is gonorrhea? Gonorrhea is a common sexually transmitted disease caused by the bacterium Neisseria gonorrhoeae. 2. What are the signs and symptoms of gonorrhea? In males, signs and symptoms include a burning sensation when urinating and a yellowish white discharge from the penis. Painful or swollen testicles may also occur. In females, gonorrhea may be asymptomatic or painful or burning sensation when urinating, and a yellowish or occasionally bloody vaginal discharge. Women with no or mild gonorrhea symptoms are still at risk for developing serious complications from the infection (PID, ectopic pregnancy, or infertility). Symptoms of rectal infection in both men and women include painful bowel movements, discharge, anal itching, soreness, and bleeding. Infections in the throat cause few symptoms. 3. Incubation period: 1 – 30 days, usually 3 – 5 days following exposure. 4. Contagious period: Weeks or months if untreated, even if asymptomatic. Communicable period ends with appropriate antibiotic therapy. 5. How does infection with gonorrhea occur? Gonorrhea is spread through sexual contact: vaginal, oral, or anal. It can also be spread from mother to child during birth. An infected person can spread gonorrhea even if they are not showing symptoms. 6. How can infection with gonorrhea be prevented? Abstinence and safe sex practices such as the use of latex condoms are the most effective prevention measures. 7. Is there a treatment for gonorrhea? Antibiotics can successfully cure gonorrhea in adolescents and adults. 8. What are the circumstances in which gonorrhea could be significant? Untreated gonorrhea can cause permanent problems in both men and women. In women, gonorrhea is a common cause of pelvic inflammatory disease, which can cause severe abdominal pain and infertility. In men, gonorrhea can cause a painful condition of the testicles that can also result in infertility. Gonorrhea can in some instances cause a life-threatening infection. In addition, persons with gonorrhea are more likely to contract and transmit HIV. Lastly, the infant of a pregnant woman with gonorrhea can contract the disease and develop a life-threatening infection, which may lead to blindness. 9. Exclusion: None unless they meet other exclusion criteria (see "General Exclusion Criteria") 10. Readmission: No restrictions. 11. Contacts and reporting: All sexual contacts of patients with gonorrhea infection should be evaluated and treated. Gonorrhea is a reportable disease to the County. Call Nursing Services Communicable Disease Unit if there is a need to report a case of gonorrhea. - 22 - Hand, Foot, and Mouth Disease (Commonly Enterovirus) 1. What is hand, foot, and mouth disease? Hand, foot, and mouth disease (HFMD) is a common illness caused by a virus (most commonly Enterovirus 71 and Coxsackievirus A16) in infants and children. It is rarely serious. Although it mainly occurs in children under 10 years old, adults may also be at risk. HFMD is not to be confused with foot- and-mouth disease of cattle, sheep, and swine, which is unrelated. 2. What are the signs and symptoms of HFMD? HFMD begins with a mild fever, poor appetite, a sore throat, and general signs of a "cold." A few days after the fever begins, sores develop in the mouth. The sores appear as red spots that turn into blisters on the tongue, gums, and inside of the cheeks. A skin rash may also occur which develops over 1-2 days and is characterized by flat or red raised spots that may blister. The rash does not itch and usually occurs on the palms of the hands and soles of the feet. A person with HFMD may have only the rash on the body or the mouth ulcers. Nearly all patients recover without medical treatment in 7-10 days. 3. Incubation period: 3 – 6 days. 4. Contagious period: Virus may be shed for several weeks after the infection starts; respiratory shedding of the virus is usually limited to < 1 week. 5. How does infection with HFMD occur? HFMD is moderately contagious, and infection is spread from person to person by direct contact with nose and throat discharge or the stool of an infected person. HFMD is not transmitted to or from pets or other animals. A person is most contagious during the first week of the illness. 6. How can infection with HFMD be prevented? A vaccine for the HFMD virus does not exist at this time; hygiene is the best prevention measure. This includes frequent hand washing, especially after diaper changes, and disinfection of contaminated surfaces with household cleaners. Children are often excluded from childcare programs, schools, or other group settings during the first few days of their illness, but these measures will not reduce disease transmission because some children shed the virus without symptoms, and other children may shed virus for weeks after recovery. 7. Is there a treatment for HFMD? HFMD cannot be cured by medication, but treatment is available for symptoms such as fever or pain in the mouth from ulcers. 8. What are the circumstances in which HFMD could be significant? Rarely, HFMD may be associated with serious infections such as: viral meningitis/encephalitis with fever, headache, stiff-neck; or a polio-like paralysis. The individual may need to be hospitalized. 9. Exclusion: None for children with the HFMD, unless they meet other exclusion criteria (see "General Exclusion Criteria") 10. Readmission: Upon recovery, by school principal or principal's designee. 11. Contacts and reporting: Non reportable, but consider sending letters to parents when there is an outbreak of HFMD. Call Nursing Services Communicable Disease Unit before any such notification to parents or staff. - 23 - Head Lice (Pediculosis) 1. What are head lice? Head lice are parasitic insects called Pediculus humanus capitis that must feed on blood to live. Having head lice is very common; as many as 6-12 million people worldwide get head lice each year. 2. What are the signs and symptoms of head lice? Signs that head lice are present include: a tickling feeling of something moving in the hair; itching caused by an allergic reaction to the bites; irritability; and, sores on the head from scratching that may become infected. Head lice lay eggs, called nits, that are hard to see and are often confused for dandruff or hair-spray droplets. Once hatched and full grown, a live louse is about the size of a sesame seed, and they are tan to grayish white. 3. Incubation period: 6 – 10 days from laying to hatching of eggs 4. Contagious period: Until treated with a chemical that kills lice and viable eggs have been killed or removed 5. Who is at risk for getting head lice? Anyone who comes in close contact with someone who already has head lice, or with contaminated clothing and other belongings, is at risk for getting head lice. Preschool and elementary-age children are most often infested. 6. How does infestation with head lice occur? Infestation with head lice occurs by direct contact with an already infested person, which is common during play at school and at home. Infestation can also occur by the wearing of infested clothing such as hats, scarves, etc.; by using infested combs or brushes; or, by lying on a bed or a couch that has been in contact with an infested person. Presence of nits alone does not indicate active infestation. 7. How can infestation with head lice be prevented? It is probably impossible to totally prevent head lice infestations. Avoiding contact with an infested person or objects as mentioned above is the best prevention measure. Inspection of children demonstrating symptoms, especially in areas where head lice are prevalent, is also helpful. 8. Is there a treatment for head lice? Over the counter treatments and prescription drugs are available for treating head lice. Treatment often entails combing out the eggs and casings (nits) attached to the hair shaft with a specialized or fine-toothed comb. It is important to treat the infested person and any infested family members; wash or dry clean all clothing and bed linens; store stuffed animals and comforters in a plastic bag for 2 weeks; clean combs and brushes; and vacuum the floor and furniture. 9. What are the circumstances in which head lice could be significant? Head lice rarely pose a serious problem. Sores that occur due to scratching can become infected, in which case a physician should be consulted. 10. Exclusion: Yes, when a student has the signs and symptoms of infestation (the most specific being the presence of a live louse). The condition does not warrant immediate exclusion. Inform parents of suspected infestation and avoid any activity that involves the child in head-to-head contact with other children or sharing of any head gear until the end of the school day. 11. Readmission: After the child has received the proper treatment they may return to school. While the removal of nits is desirable to avoid diagnostic confusion, the presence of nits alone (after treatment) is not sufficient criteria to exclude children from school. - 24 - Hepatitis A, B, and C 1. What are hepatitis A, B, and C? Hepatitis A, B, and C are liver diseases caused by the hepatitis A, B, and C virus, respectively. 2. What are the signs and symptoms of hepatitis A, B and C? All three viruses can cause asymptomatic infection, and adults are more likely to have symptoms than children. Symptoms common to the three viruses are as follows: fatigue, loss of appetite, nausea, vomiting, abdominal discomfort, jaundice (yellowing of the skin and eyes), and dark urine. In addition, hepatitis A is usually more abrupt in onset; hepatitis B may cause joint pains and rash. 3. Incubation period: Hepatitis A: 15 – 50 days; average 25 – 30 days Hepatitis B: 45 – 160 days; average 90 days Hepatitis C: 14 – 180 days; average 45 days 4. Contagious period: Hepatitis A: 2 weeks before onset of signs and symptoms, infectivity is minimal one week after onset of jaundice Hepatitis B: As long as the virus is present in the blood of the infected person Hepatitis C: Unknown 5. How does infection with hepatitis A, B, and C occur? Hepatitis A is found in an infected person's feces, thus it is usually spread from person to person by putting something in the mouth that has been contaminated with the feces of a person with hepatitis A. Hepatitis B is found in bodily fluids and blood, and it is spread from person to person through unprotected sex, needle sharing, or blood transfusion. It can also be spread from mother to infant. Hepatitis C is found in bodily fluids and blood, and is usually spread through needle sharing, needlesticks or sharps exposure, and blood transfusions. It can also be passed from a pregnant mother to her baby during birth. Rarely spread through sexual contact. 6. How can infection with hepatitis A, B, or C be prevented? Hepatitis A: A vaccine is available for persons 2 years of age and older. Major methods of prevention include general sanitation and personal hygiene. There is an immune globulin for exposed individuals who meet specific criteria. Hepatitis B: A vaccine is available for all ages. Other methods of prevention include sanitation, universal precautions and the use of latex condoms. Hepatitis C: There is no vaccine to prevent hepatitis C available at this time. Avoidance of needle sharing by injection drug users or people receiving tattoos or body piercing is a helpful preventative measure, as is using latex condoms during sexual contact. Note: Students with Hepatitis B, Hepatitis C or HIV are generally not required to be identified to school personnel. Universal precautions should be taken when handling any blood or body fluids in school settings to acknowledge the risk of exposure to all types of unrecognized disease. Continued - 25 - 7. Is there a treatment for hepatitis A, B, or C? Treatment is generally supportive. No cure exists at this time for hepatitis A or B, but medication for chronic hepatitis B infection is available. For hepatitis C, a combination of drug therapy is available to treat chronic infection. 8. What are the circumstances in which hepatitis A, B, or C could be significant? Hepatitis A: There is no long-term infection risk associated with hepatitis A, and one cannot get the disease again after having it once, although upon initial infection prolonged or relapsing symptoms may occur for 6-9 months. Hepatitis B has more serious implications for chronic infection in infants, children, and adults. Persons who have hepatitis B are at risk for developing chronic hepatitis with its complications at advancing age, including liver cancer. Hepatitis C: Persons who have hepatitis C are at risk for developing chronic hepatitis with its complications at advancing age, including liver cancer. 9. Exclusion: Hepatitis A: Yes, o children should be excluded for 1 week after onset of illness; refer to health professional o staff with the illness, especially food handlers, should also be excluded for 1 week after onset of illness Hepatitis B: Yes, if the child with known Hepatitis B exhibits any of the following: o weeping sores that cannot be covered o biting or scratching behavior o a bleeding problem o generalized dermatitis that may produce wounds or weepy tissue fluid that can not be covered Hepatitis C: (Same as Hepatitis B) 10. Readmission: Hepatitis A: One week after the onset of illness and upon recovery from symptoms Hepatitis B: When skin lesions are dry or covered; when the child is clear to return by a health professional Hepatitis C: When skin lesions are dry or covered; when the child is clear to return by a health professional 11. Contacts and reporting: Reportable to the County (only acute cases are investigated); outbreaks of Hepatitis A may require immune globulin shots given by the health department. Call Nursing Services Communicable Disease Unit if there is a need to report a case of viral hepatitis. - 26 - Herpes (Oral and Genital) 1. What is herpes? Herpes is an infection caused by two different but closely related viruses– herpes simplex virus type 1 and herpes simplex virus type 2. Both can cause sores in the mouth (oral herpes), genitals (genital herpes), or skin that comes in contact with these areas. Genital herpes is considered to be a sexually transmitted disease. More serious complication of herpes infection can occur in the newborn and when there is involvement of the eyes. 2. What are the signs and symptoms of herpes? Symptoms of oral herpes include "cold sores" or "fever blisters" that appear on the lips or inside of the mouth. They are common in young children, and harmless in children and adults. Symptoms of genital herpes include blistery sores that appear on the genitalia and buttocks that can be accompanied by pain in the infected area and flu-like symptoms. Sores can also be found on the skin, as in the case of wrestlers (herpes gladiatorum) or those with eczema (eczema herpeticum). After the primary infection, the virus persists for life and can result in occasional "flare-ups" or recurrence. 3. Incubation period: 2 days to 2 weeks 4. Contagious period: The primary infection is generally communicable for 1 to 2 weeks after signs or symptoms appear. In recurrent infections the largest amount of virus is shed for 3 to 4 days after signs or symptoms appear. There may be a low level of viral shedding when infected individuals have no signs or symptoms 5. How does infection with herpes occur? Herpes is spread by touching, kissing, and sexual contact. It can be passed from one person to another, or from one part of the body to another, even when sores are not present. 6. How can infection with herpes be prevented? Sores in the mouth or genital area should not be touched, and if they are, prompt hand washing should follow. People with sores in the mouth should avoid kissing and sharing food or drink with other people, especially infants, children, and pregnant women. Covering open herpes skin lesions is advisable. Wrestlers may need to have mats washed/disinfected between matches if there is suspicion or known herpes gladiatorum. 7. Is there a treatment for herpes? Antiviral medications, such as acyclovir, can be prescribed to help speed up the healing of sores and weaken the virus. Individuals with more than six episodes a year may be advised to take daily antiviral medications to prevent episodes. 8. What are the circumstances in which herpes could be significant? Herpes infections are much more serious in newborns. It is possible for a mother to pass herpes to her baby during birth, but the risk is much higher with primary infection of the mother. 9. Exclusion: No, unless the child has mouth ulcers and blisters and does not have control of drooling, or the child meets other exclusion criteria (see "General Exclusion Criteria"). Note: Athletes with exposed herpes lesions participating in close contact sport (e.g., wrestling) may need to be excluded from practice or competition until lesions heal or clearance from a physician declaring the condition noninfectious. 10. Readmission: Upon recovery and exclusion criteria resolved (no drooling or exposed open sores). - 27 - HIV/AIDS 1. What are HIV and AIDS? Human immunodeficiency virus (HIV) is an infection that destroys the body's immune system and can cause a broad spectrum of disease. Acquired immunodeficiency syndrome (AIDS) represents the most severe end of the clinical spectrum of HIV infection. 2. What are the signs and symptoms of HIV and AIDS? HIV: While many HIV-infected people may not have any symptoms, they may experience rapid weight loss, dry cough, recurring fever or profuse night sweats, profound and unexplained fatigue, and swollen lymph glands. HIV infected persons can also have diarrhea that can last for more than a week, white spots on the tongue, and pneumonia. However, no one should assume that they are infected if they have any of these symptoms. The only way to determine whether one is infected is to be tested for HIV. AIDS: HIV destroys certain blood cells (T-cells) that are crucial to immune system function, and this damage can lead to the development of AIDS. Signs of AIDS include certain opportunistic infections that are generally rare, such as Pneumocystis carinii pneumonia and Kaposi's sarcoma. Diagnosis of AIDS requires a T-cell count below a certain level, which may or may not be accompanied by the presence of an opportunistic infection. 3. Incubation period: Clinical symptoms after HIV infection have appeared in less than 1 year to longer than 10 years. Average is 2 – 4 years. The incubation period is shorter in children. 4. Contagious period: Lifelong in infected persons who may or may not be symptomatic 5. How does infection with HIV occur? HIV is passed from one person to another by having sexual intercourse (anal, vaginal, or oral) with an HIV-infected person, by sharing needles with an injection drug user who is infected with HIV, or by having blood or bodily fluid contact with a person infected with HIV. In addition, the virus can be passed from an HIV-infected mother to her baby before or during birth and through breast-feeding. HIV is not transmitted by casual contact such as handshaking, hugging, sneezing, or sharing toilet seats and is not acquired from saliva, tears, or urine. 6. How can infection with HIV be prevented? Education on the methods of transmission of HIV is an important component of prevention. Prevention of HIV transmission by sexual contact can be accomplished by abstinence and safe sex practices such as the use of latex condoms. Universal precautions and standard procedures should be followed in the handing of potentially infectious material (see LAUSD Bulletin No 1645, "Infection Control Procedures for the Prevention and Spread of Communicable Diseases," July 2005 and LAUSD "Bloodborne Pathogens—Exposure Control Plan," July 2005) 7. Is there a treatment for HIV or AIDS? There is no cure or vaccine for HIV or AIDS at this time. However, early intervention and treatment with antiretroviral drugs can slow the disease progression and prolong and improve the quality of life. Continued - 28 - 8. What are the policies surrounding HIV/AIDS and school attendance? A child or adult infected with HIV should not be isolated or excluded from any activity that their health status permits them to participate in. Their diagnosis of HIV/AIDS must remain confidential by law. Students and/or families are not required to disclose HIV infection status to anyone in the education system. No information regarding a person's HIV status will de divulged to any individual or organization without a Court Order or informed written, signed, and dated consent of the person with HIV infection (or the parent or guardian of a legal minor). For more information, see LAUSD Bulletins No.Z-70 and Z-69, "Students with HIV/AIDS Infection" and "Employees with HIV/AIDS Infection," August 2001. 9. Exclusion: No, unless the child meets other exclusion criteria (see "General Exclusion Criteria") or has bleeding problems or weeping skin lesions that cannot be covered. In such cases, school attendance will be decided on an individual basis with consideration given to any risk for the infected person and any possible risk to others. Age, maturity level, physical condition, neurological development, behavior, psychological needs and requirement for special environment or physical care will be considered. 10. Readmission: Children who are known to be infected with HIV and have been excluded because of risk of exposure to infections posed by group settings may return to school upon clearance from the child's health professional who is knowledgeable about HIV infection. Skin lesions must be dry and covered and bleeding must be controlled. Complex cases of admission/readmission will be evaluated on an individual basis involving a collaborative decision making process, which should include the school principal, family and medical personnel. 11. Contacts and reporting: AIDS (cases meeting the criteria) is a reportable condition, but school personnel will generally not be involved with disease surveillance. Remember confidentiality of HIV/AIDS status is a legal requirement and any questions regarding students with HIV/AIDS should be directed to Student Medical Services or Nursing Services Communicable Disease Unit. - 29 - Impetigo (and MRSA) 1. What is impetigo? What is MRSA? Impetigo is a skin infection caused by bacteria (Group A streptococci or Staphylococcus aureus). Impetigo typically affects school-aged children, most often during the hot and humid summer months. It has a preference for skin that has already been injured by other skin problems, such as eczema or poison ivy. A potentially more serious strain of the bacterium S. aureus has emerged in recent years that is resistant to certain antibiotics (Methicillin-resistant S. aureus, or MRSA). Community-associated MRSA will be discussed with impetigo, but they are clinically distinct entities. 2. What are the signs and symptoms of impetigo? MRSA? Impetigo can affect skin anywhere on the body, but it most often affects the face. It causes itchy skin with tiny blisters especially around the mouth and nose. Blisters will eventually burst to reveal areas of red skin that may weep fluid. Gradually, a tan or yellowish-brown crust will cover the infected area. Community–associated MRSA usually presents as pimples, boils or abscesses. They may be painful and may be misdiagnosed as "spider bites." School personnel will generally only know that a student is infected with MRSA if given the diagnosis by a health care provider as it may be difficult to distinguish from other common skin infections. 3. Incubation period: Skin sores develop in 7 – 10 days after bacteria attach to the skin. 4. Contagious period: Until the skin sores are treated with antibiotic for at least 24 hours or the crusting lesions are no longer present. 5. How does infection with impetigo occur? Impetigo (and MRSA) can be passed from person to person. When someone in a household has impetigo, the infection can be passed to other family members on clothing, towels, and bed linens that have touched the infected person's skin. Impetigo can also be spread from one area of the skin to another by scratching. On the face, the infection usually spreads along the edges of an affected area, but it may also spread to more distant parts of the body on contaminated fingers. 6. How can infection with impetigo be prevented? Good general hygiene practices, such as a daily bathing with soap and water can help prevent impetigo. Areas of skin that have been injured should be kept clean and covered. Covering sores with gauze, loosely to allow airflow, can help prevent spreading the bacteria in group settings. If a family member is infected, all family members should use different towels. 7. Is there a treatment for impetigo? MRSA? Impetigo is usually treated with antibiotics, which may be given by the mouth. In very mild cases, a topical antibiotic may be used. Community-associated MRSA is best treated with good wound care (incision and drainage by health care provider), coverage with a clean, dry bandage, and in some cases antibiotics (to which the organism is susceptible). 8. Exclusion: Yes, as soon as impetigo is suspected. If the family is unable to pick up the child promptly, wash affected area with soap and water and cover it with a clean, dry bandage. Exclusion for MRSA is only recommended if the student is unable to cover skin lesion and control body fluids. 9. Readmission: After 24 hours of appropriate (antibiotic) treatment for impetigo or when lesions are healed, by school principal or principal's designee. - 30 - Influenza (Flu) 1. What is the flu? The flu is a contagious disease caused by the influenza virus that attacks the nose, throat, and lungs. Most people recover in 1-2 weeks, but some develop serious complications. 2. What are the signs and symptoms of the flu? Fever, chills, headache, tiredness, dry cough, sore throat, nasal congestion, and body aches are all common flu symptoms. Children can have nausea, vomiting and diarrhea. 3. Incubation period: Usually from 1 – 4 days. 4. Contagious period: From the day before signs or symptoms appear until 7 days after the onset of flu. Children can be contagious longer. 5. How does infection with the flu occur? The flu is spread when an infected person coughs, sneezes, or speaks and another person inhales this virus. The flu can also be spread when a person touches a surface that has the flu virus on it, such as a door handle, and then touches his or her nose or mouth. 6. How can infection with the flu be prevented? A flu shot can be obtained each fall, before flu season, for prevention. The elderly, people with chronic medical conditions or who are immunocompromised, and very young children (6 – 23 months) are recommended to get the flu shot as they are more likely to develop complications. Persons who care or work with these high-risk groups may also be eligible for the flu shot. Please check with a school/CD nurse or the Department of Public Health regarding current indications for the immunization. Good personal hygiene such as hand washing can also help prevent infection. 7. Is there a treatment for the flu? The flu cannot be cured by medication, although some antiviral drugs taken within the first two days of illness can reduce the duration of the disease. Rest, drinking plenty of liquids, avoiding alcohol and tobacco use, and taking nonprescription medication to relieve symptoms can help. A child or teenager with flu-like symptoms, particularly fever, should not be given aspirin without first consulting a physician, as a rare but serious illness called Reye's syndrome can result. 8. What are the circumstances in which the flu could be significant? While most people recover from the flu in 1-2 weeks, some people develop life-threatening complications. People ages 65 years and older, people of any age with chronic conditions, and very young children are more likely to get complications from the flu such as sinus and ear infections, bronchitis, and pneumonia. The flu can also make chronic health problems worse; for example, people with asthma may experience asthma attacks while they have the flu, and people with chronic congestive heart failure may experience a worsening of their condition. Unusual strains of flu (avian flu) may pose greater risk to populations. The management, exclusion and readmission of students and/or staff with avian flu may be different than the guidelines below. 9. Exclusion: None, unless the child meets other exclusion criteria such as fever with behavior changes, or if the child appears to be severely ill and also when the child is unable to participate comfortably in activities as determined by the school staff (see "General Exclusion Criteria"). 10. Readmission: Upon recovery, by school principal or principal's designee. - 31 - Lyme Disease 1. What is Lyme disease? Lyme disease is an infection caused by the bite of ticks infected with Lyme disease spirochetes (a type of bacteria). There are other tick-borne diseases, but the discussion will focus on Lyme disease since it serves as a general model for tick-borne disease prevention, exclusion, and readmission in school settings. 2. What are the signs and symptoms of Lyme disease? Most patients will have a red, slowly expanding "bull's eye" rash accompanied by general tiredness, fever, headache, stiff neck, muscle aches, and joint pain. If untreated, more serious complications can result. 3. Incubation period: 3 – 31 days from tick bite to appearance of rash. 4. Contagious period: Lyme disease is not contagious except through blood transfusion. 5. How does infection with Lyme disease occur? Infection occurs after a bite by a tick infected with Lyme disease bacteria (the tick usually has to be attached for greater than 36 hours). Lyme disease cannot be spread from person to person (i.e. one cannot become infected from touching or kissing a person who has Lyme disease, from a health care worker who has treated someone with the disease, or by sexual contact). 6. How can infection with Lyme disease be prevented? Avoiding a tick bite is the most effective measure of prevention. This can be aided by wearing appropriate clothing when in tick-infested areas (e.g., tall grassy, bushes, wooded areas), daily tick checks, and quick removal of attached ticks. The use of insect repellants should be used on children only as directed by the manufacturer and according to Center for Disease Control (CDC) instructions. 7. Can a person be reinfected with Lyme disease? Yes. Having had Lyme disease once does not protect against reinfection. 8. Is there a treatment for Lyme disease? Antibiotic treatment for 3-4 weeks is generally effective in early disease. Later disease may require intravenous antibiotics. In later disease, treatment failures may occur and retreatment may be necessary. 9. What are the circumstances in which Lyme disease could be significant? If Lyme disease is untreated, weeks to months after infection some patients may develop arthritis including intermittent episodes of swelling and pain in the large joints and neurologic abnormalities such as meningitis and facial palsy may occur. Rarely, heart problems, including an enlarged heart, can result. 10. Exclusion: None, unless they meet other exclusion criteria (see "General Exclusion Criteria") 11. Readmission: Upon recovery, by school principal or principal's designee. 12. Contacts and reporting: Lyme disease is reportable to the County. Call Nursing Services Communicable Disease Unit if there is a need to report a case of Lyme disease. - 32 - Measles (Rubeola) 1. What is measles? Measles is an acute, highly contagious viral disease. The disease can be severe with complications such as pneumonia and inflammation of the brain leading to death in about two of every thousand cases. 2. What are the signs and symptoms of measles? The infected person first experiences a fever lasting about 2-4 days that can peak as high as 103-105 degrees Fahrenheit. This is followed by the onset of a cough, runny nose, conjunctivitis (pink eye) and Koplik spots (small red spots in the mouth). The rash (dusky, red blotchy) usually begins at the hairline, and then involves the face and upper neck. Over the next 3 days, the rash gradually proceeds downward on the body, reaching the hands and feet. Diagnostic testing for measles should be undertaken by a qualified health professional and the state public health laboratory. 3. Incubation period: 8 – 12 days from exposure to onset of signs and symptoms. 4. Contagious period: From 1 – 2 days before the first signs or symptoms appear until 4 days after the appearance of the rash. 5. How does infection with measles occur? The disease is highly contagious, and can be transmitted prior to and after the appearance of the rash. The virus resides in the mucus in the nose and throat of the infected person. When the infected person sneezes, coughs, or speaks another person can inhale this virus from the air and become ill. Touching an infected surface can also spread the virus, which remains active and contagious on infected surfaces for up to 2 hours. Measles spreads so easily that anyone who is not immunized may get it. 6. How can infection with measles be prevented? The measles vaccine can prevent this disease. The vaccine is usually given as part of a combination vaccine, called MMR that protects against measles, mumps, and rubella. There is an immune globulin that can be given after exposure to measles, usually for immunocompromised and unimmunized patients. 7. Is there a treatment for measles? There is no cure or treatment for measles; only its symptoms can be treated. 8. What are the circumstances in which measles could be significant? Complications of measles are more common among children under 5 years of age and adults over 20 years old, and can include ear infection, pneumonia, encephalitis (brain inflammation), and death. Measles in pregnant women can result in miscarriage, premature birth, or a low-birth-weight baby. 9. Exclusion: Yes, measles is highly communicable illness for which routine exclusion of infected children is warranted. Unimmunized children (exempted from measles immunization for medical, religious, or other reasons) if not immunized within 72 hours of exposure, should be excluded from school until at least 2 weeks after the onset of rash in the last case of measles. 10. Readmission: Four days after beginning of rash and with clearance from County of the Los Angeles, Department of Health or other treating physician. 11. Contacts and reporting: Measles is reportable to the County. Call Nursing Services Communicable Disease Unit if there is a need to report a case of measles. - 33 - Meningitis 1. What is meningitis? Meningitis is an infectious disease causing swelling and inflammation of the membranes and the fluid surrounding the brain and spinal cord. Meningitis can be caused by a bacterium or a virus. Knowing whether meningitis is caused by a virus or bacterium is important because the severity of illness and the treatment differ. Viral meningitis is generally less severe and resolves without specific treatment, while bacterial meningitis caused by meningococcal bacteria is a serious disease and can be fatal. Unlike viral meningitis, bacterial meningitis must be treated with antibiotics. 2. What are the signs and symptoms of meningitis? Often, the symptoms of viral meningitis and bacterial meningitis are the same. High fever, headache, and stiff neck are common symptoms of meningitis in anyone over the age of 2 years. These symptoms can develop over several hours, or they may take 1-2 days. Other symptoms may include nausea, vomiting, discomfort looking into bright lights, confusion, and sleepiness. As the disease progresses, patients may have seizures. Children infected with the meningococcal bacteria can have a quickly progressing course that includes a dusky-purple rash and shock or coma. 3. Incubation period: Viral Meningitis: 3 – 6 days Bacterial Meningitis: Less than 4 days 4. Contagious period: Viral Meningitis: Varies with causative organism Bacterial Meningitis: Until after 24 hours of antibiotics 5. How does infection with meningitis occur? Most viruses and bacteria that cause meningitis spread through person to person contact and respiratory secretions. Some viruses are spread through fecal-oral routes. 6. How can infection with meningitis be prevented? There are safe and effective vaccines against some of the bacteria that cause meningitis. One effective method of prevention both viral and bacterial infections is to wash hands thoroughly and often. In institutional settings such as schools and child care centers, washing objects and surfaces with a District-approved disinfectant (e.g., dilute bleach solution) can be a very effective way to inactivate a virus. In some cases of bacterial meningitis, antibiotic prophylaxis may be indicated for close contacts to the infected individual. 7. Is there a treatment for meningitis? Bacterial meningitis can be treated with a number of effective antibiotics, but no specific treatment exists for viral meningitis at this time. Individuals with meningitis may be managed in the hospital based on their general condition and the severity of their disease. 8. Exclusion: Yes, as soon as it is suspected. 9. Readmission: When the child is cleared to return by a health professional. 10. Contacts and reporting: Meningitis is a reportable condition. Call Nursing Services Communicable Disease Unit before any reporting and to discuss if there is a need for notification to parents or staff. - 34 - Molluscum Contagiosum 1. What is molluscum contagiosum? Molluscum is a benign skin disease caused by a virus, somewhat similar to warts. Humans are the only known source of the virus. While infectivity is generally low, there are occasional outbreaks that have been reported, including in child care centers. 2. What are the signs and symptoms of molluscum contagiosum? Molluscum only affects the skin and not other parts of the body. It is characterized by small, flesh- colored bumps on the skin, often with a tiny, hard, indented, seed-like center. Lesions commonly occur on the trunk, face, arms and legs, but rarely are generalized over the entire body. The exceptions are with eczema or immunocompromised people, who tend to have more intense and widespread eruptions. 3. Incubation period: Usually between 2 and 7 weeks, but may be as long as 6 months. 4. Contagious period: Unknown 5. How does infection with molluscum contagiosum occur? The virus is spread person-to-person through close contact or through inanimate objects such as towels. Infectivity is generally considered low. 6. How can infection with molluscum contagiosum be prevented? Although molluscum contagiosum bumps represent a viral infection, they are very mildly contagious and most often are spread to other areas of the affected child's body, rather than to other children. Children should avoid scratching the bumps, as they can become infected with bacteria or further spread the virus to another site. As with other communicable disease, hand washing is important and not sharing personal objects (towels) with infected individuals. Molluscum contagiosum bumps do not need to be covered like shingles or other oozing sores. 7. Is there a treatment for molluscum contagiosum? Treatment is a personal choice and not an infection control issue for a group care setting. The bumps usually go away on their own in a few months as the person develops antibodies to the virus. Alternatively, treatments may be used; however, there is little agreement on effective treatments. 8. Exclusion: No 9. Readmission: No restrictions - 35 - Mononucleosis 1. What is mononucleosis? Mononucleosis is an infectious disease caused by the Epstein-Barr Virus (EBV) commonly known among the general public as "mono." Most people become infected with EBV some time during their lives, but do not necessarily develop mononucleosis. 2. What are the signs and symptoms of mononucleosis? Symptoms of infectious mononucleosis include fever, sore throat, swollen lymph glands, and fatigue. Sometimes, a swollen spleen or liver involvement may develop. Heart problems or involvement of the central nervous system occur only rarely. 3. Incubation period: Estimated to be 30 – 50 days 4. Contagious period: Unknown, but probably before symptoms appear and many months after infection symptoms. 5. How does infection with mononucleosis occur? Most individuals exposed to people with infectious mononucleosis have previously been infected with the virus and are not at risk for infectious mononucleosis. Transmission of the virus requires intimate contact with the saliva of an infected person; transmission through the air or blood does not normally occur, although infection has been reported through blood transfusion. 6. How can infection with mononucleosis be prevented? Avoiding direct contact with the saliva of an infected person may help prevent transmission. However the fact that many healthy people can carry and spread the virus intermittently for life, and that they are usually the primary reservoir for person-to-person transmission, makes the transmission of the virus almost impossible to prevent. As a general measure, people with signs and symptoms of mononucleosis should not donate blood or prepare food for others. 7. Is there a treatment for mononucleosis? Only the symptoms of mononucleosis may be treated. No vaccine or antiviral drugs are available at this time. 8. What are the circumstances in which mononucleosis could be significant? Rupture of an organ is a risk in patients with an enlarged spleen or liver who plays contact sports. In rare instances bleeding disorders or testicular or cardiac inflammation can lead to more severe complications of EBV infection. EBV has also been associated with distinct types of cancer. 9. Exclusion: No, unless they meet other exclusion criteria (see "General Exclusion Criteria"). However, contact sports should be avoided until patient has fully recovered and the spleen is no longer enlarged/palpable. 10. Readmission: Upon recovery, by school principal or principal's designee. - 36 - Mumps 1. What is mumps? Mumps is an acute illness caused by the mumps virus. After a vaccine was introduced in 1967, the incidence of mumps decreased rapidly. In 1986 and 1987 there was a relative resurgence of mumps in young adults, indicating a need for two doses of the vaccine to confer immunity. Since 1989, there has been a steady decline in reported mumps cases as a result of implementation of the second dose recommendation for the mumps vaccine. 2. What are the signs and symptoms of mumps? Mumps begins with a low-grade fever, headache, loss of appetite, muscle aches, and a generalized sick feeling. Mumps most commonly affects the parotids glands in front and below the ear or under the jaw. Within 2 days, the infection in the salivary glands begins to be marked with an earache and/or jaw pain. Symptoms tend to decrease after one week and usually resolve in 10 days. Some infections show no symptoms, while others may show only non-specific or respiratory symptoms. In teenage boys, painful swelling of the testicles may appear; girls may have swelling of the ovaries which may cause abdominal pain. 3. Incubation period: 16 – 18 days 4. Contagious period: From 1 – 2 days before to 5 days after the swelling of glands 5. How does infection with mumps occur? Transmission of mumps virus occurs when a healthy person comes in contact with an infected person's saliva, or when an infected person spews airborne droplets containing the virus by coughing, sneezing, or talking, and a healthy person breathes them in. 6. How can infection with mumps be prevented? The mumps vaccine can prevent this disease. The vaccine is usually given as part of a combination vaccine, called MMR that protects against measles, mumps, and rubella. 7. What are the circumstances in which mumps could be significant? Mumps can cause complications in the central nervous system, including meningitis. Testicular, ovarian, and heart inflammation, as well as pancreatic infection, can also occur. Deafness caused by mumps was significant in children in the pre-vaccine era. 8. Exclusion: Yes, mumps is highly communicable illness for which routine exclusion of infected children is warranted. For outbreaks, exclude exposed children who have not been immunized until they become immunized; or if they are not immunized because of an accepted exemption, continue to exclude them until the health department determines it is safe for them to return. 9. Readmission: Nine days after onset of symptoms (swelling of glands) and with clearance from County of the Los Angeles, Department of Health or other treating physician. 10. Contacts and reporting: Mumps is reportable to the County. Call Nursing Services Communicable Disease Unit if there is a need to report a case of mumps. - 37 - Pinworms 1. What are pinworms? Pinworm refers to an infection caused by small, white, threadlike worms ( 0.25" – 0.5" long ) that live in the large intestine. It has been estimated that 5%-15% of the U.S. population is infected, and higher rates are seen in pre-school and school aged children. 2. What are the signs and symptoms of pinworms? Children with pinworm infections have itching and irritation around the anal or vaginal area. Worms may be seen, especially after the child has been sleeping for a few hours, around the anus 3. Incubation period: 1 to 2 months or longer from the time of ingesting the pinworm egg until an adult worm migrates to the anal area. 4. Contagious period: As long as the female worms are discharging eggs to the skin around the anus. 5. How does infection with pinworms occur? The transmission of pinworm eggs occurs by the fecal-oral route. This may occur directly or indirectly by coming in contact with contaminated toys, bedding, clothing, toilet sheets, or baths. Pinworm eggs remain infective for 2 to 3 weeks in indoor environments and infestation with pinworms commonly cluster within families. 6. How can infection with pinworms be prevented? Good hand hygiene is the most effective method of prevention. Parents may bathe the child in the morning to remove a large proportion of eggs that are laid at night and frequently change underwear, bedclothes, and bed sheets to decrease egg contamination. Wash toys frequently and clean and sanitize surfaces used for eating, toileting, food preparation, and diapering. 7. Is there a treatment for pinworms? Treatment with oral medication once or repeated in 2 weeks may be necessary for the whole family and the group of children who share common environment. 8. Exclusion: No 9. Readmission: No restrictions - 38 - Pertussis (Whooping Cough) 1. What is pertussis or whooping cough? Whooping cough is an acute infection caused by the bacterium Bordetella pertussis. It is one of the most common childhood diseases involving the throat and lungs, especially encountered in unimmunized populations. Whooping cough is a serious illness in children and may result in complications and death. Adolescents and adults who become infected with whooping cough, although contagious, usually have a milder illness. 2. What are the signs and symptoms of whooping cough? The initial stage is characterized by a runny nose, sneezing, low-grade fever, and a mild cough. The second stage begins with bursts of numerous, rapid coughs followed by a characteristic, long, high- pitched inspiratory whoop. During such an attack, a patient may turn blue, especially children and young infants. Vomiting and exhaustion commonly follow the episode, but the individual usually appears normal between attacks. The second stage lasts for 1-6 weeks, but may persist for up to 10 weeks. In the last stage, the cough begins to subside and disappears over a period of 2-3 weeks. 3. Incubation period: 6 – 21 days; usually 7 – 10 days 4. Contagious period: From the beginning of symptoms until 2 weeks after the cough begins depending on age immunization status. An infant who has no pertussis immunization may remain infectious for 6 weeks or more after the cough starts. 5. How does infection with whooping cough occur? Transmission of the whooping cough bacteria from one person to another usually occurs through direct contact with or inhalation of airborne droplets of respiratory secretions. Less commonly, transmission can occur through contact with freshly contaminated objects touched by an infected person. 6. How can infection with whooping cough be prevented? The pertussis vaccine can prevent whooping cough. The immunization for pertussis is usually given with one for diphtheria and tetanus (DTaP). Other measures include hand washing and prophylactic antibiotics for exposed close contacts. 7. Is there a treatment for whooping cough? Antibiotics can be used to treat whooping cough. 8. What are circumstances in which whooping cough could be significant? Young infants are at highest risk for developing complications from whooping cough. The most common complication is bacterial pneumonia. Neurologic complications such as seizures, etc. may also occur as a result of a reduced oxygen supply to the brain due to coughing. 9. Exclusion: Yes, pertussis is highly communicable illness for which routine exclusion of infected children is warranted. Exclude close contacts who are coughing until they receive appropriate evaluation and treatment. 10. Readmission: After 5 days of appropriate antibiotic treatment (which is given for a total of 14 days) and with clearance from County of the Los Angeles, Department of Health or other treating physician. People who do not receive appropriate antibiotic therapy should be excluded from school for 21 days after the onset of symptoms. 11. Contacts and reporting: Whooping cough (pertussis) is a reportable disease. Call Nursing Services Communicable Disease Unit before any reporting and to discuss if there is a need for notification to parents or staff. - 39 - Ringworm (Tinea) 1. What is ringworm? Ringworm is a contagious fungal infection of the skin (tinea corporis), scalp (tinea capitis), feet (tinea pedis), and the nails (tinea unguium). Despite its name, it has nothing to do with worms. The name comes from the characteristic red ring that can appear on an infected person's skin. 2. What are the signs and symptoms of ringworm? Ringworm of the body shows up as a flat, round patch anywhere on the skin except for the scalp and feet. The groin is a common area of infection. As the rash gradually expands, its center clears to produce a ring and there may be scales on the edges. More than one patch might appear, and the patches can overlap. The area is sometimes itchy. Ringworm of the scalp begins with a small pimple that becomes larger, leaving scaly patches of temporary baldness. Infected hairs become brittle. Yellowish crusty areas sometimes develop. Ringworm of the foot is also called "athlete's foot." It appears as a scaling or cracking of the skin, especially between the toes. Ringworm of the nails causes the infected nails to become thicker, discolored, and brittle, or to become chalky and disintegrate. 3. Incubation period: Approximately 10 – 14 days 4. Contagious period: Unknown, but likely infectious as long as lesions are present with viable fungus. 5. How does infection with ringworm occur? People can get ringworm by direct skin-to-skin contact with an infected person or pet. People can also get ringworm indirectly by contact with objects or surfaces that an infected person or pet has touched, such as hats, combs, brushes, bed linens, stuffed animals, gym mats, and shower stalls. In rare cases, ringworm can be spread by contact with soil. 6. How can infection with ringworm be prevented? The fungus is very common and it is contagious even before symptoms appear. Steps to prevent infection include the following: educating the public about the risk of ringworm from infected persons and pets; keeping common-use areas clean, especially in schools, day-care centers, gyms, and locker rooms; using District-approved disinfecting solutions on sleeping mats and gym mats; and, avoiding the sharing of clothing, towels, hair brushes, or other personal items. Infected persons can prevent infection from spreading by: completing treatment as instructed even after symptoms disappear; avoiding sharing personal items with others; and, minimizing contact with others by covering lesions. 7. Is there a treatment for ringworm? Ringworm can be treated with an anti-fungal medicine. The medicine can be in tablet or liquid form taken by mouth, or as a cream applied directly to the infected area. Anti-fungal creams can be purchased in a pharmacy, without a prescription, for ringworm of the skin and foot. More extensive infections and ringworm of the scalp and nails usually require a prescription medication. 8. What are the circumstances in which ringworm could be significant? Lack of or inadequate treatment can result in an infection that will not clear up. 9. Exclusion: Yes, at the end of the school day for treatment. 10. Readmission: Once treatment is started, reasonable effort should be made to cover exposed skin lesions. Readmission may be granted by school staff or private physician. - 40 - Rubella (German Measles) 1. What is rubella? Rubella, also called German measles, is an infectious disease caused by a virus. Although mild in children, rubella can be associated with significant disease in adults. If a pregnant woman gets rubella during the first 3 months of pregnancy, her baby is at risk of dying or of having serious birth defects. 2. What are the signs and symptoms of rubella? Symptoms of rubella may include a rash, slight fever, aching joints, headaches, discomfort, runny nose, and redness of eyes. A red or pink rash first appears on the face and spreads from head to toe. The lymph nodes just behind the ears and at the back of the neck may swell, causing soreness and pain. Many people with rubella have few or no symptoms, and only about half of the people who have the disease get a rash. 3. Incubation period: Usually 16 – 18 days 4. Contagious period: May be spread 7 days before to 14 days after the appearance of the rash 5. How does infection with rubella occur? Rubella is spread from person to person when an infected person coughs or sneezes and an uninfected person comes in direct contact with these respiratory and throat secretions. In addition, a mother can pass rubella to her fetus. 6. How can infection with rubella be prevented? There is a safe and effective vaccine to protect against rubella. The vaccine is usually given as part of a combination vaccine, called the MMR vaccine that protects against measles, mumps, and rubella. 7. Is there a treatment for rubella? Only the symptoms of rubella can be treated. 8. What are the circumstances in which rubella could be significant? If rubella is contracted in the early months of pregnancy it is associated with a high rate of serious birth defects such as deafness, cataracts, heart defects, and liver or spleen damage. 9. Exclusion: Yes, rubella is highly communicable illness for which routine exclusion of infected children is warranted. For outbreaks, exclude exposed children who have not been immunized until they become immunized; or if they are not immunized because of an accepted exemption, continue to exclude them until the health department determines it is safe for them to return. 10. Readmission: Six days after onset of rash and with clearance from County of the Los Angeles, Department of Health or other treating physician. 11. Contacts and reporting: Rubella is reportable disease. Call Nursing Services Communicable Disease Unit if there is a need to report a case of rubella. - 41 - Scabies 1. What is scabies? Scabies is an infestation of the skin with a microscopic mite. Scabies spreads rapidly under crowded conditions where there is frequent skin-to-skin contact between people, such as in childcare facilities. 2. What are the signs and symptoms of scabies? Symptoms of scabies include pimple-like irritations, burrows, or rash of the skin, especially in the webbing between the fingers; the skin folds on the wrist, elbow, or knee; the penis; the breast; or the shoulder blades. Intense itching is common, especially at night. Sores can result due to scratching and can sometimes become infected by bacteria. 3. Incubation period: 4 – 6 weeks for those who have never been infected. 1 – 4 days for those who have been previously infested. 4. Contagious period: Until insect infestation is treated. 5. How does infestation with scabies occur? Scabies is spread to a healthy person by direct, prolonged, skin-to-skin contact with a person already infested with scabies. Infestation may also occur by sharing clothing, towels, and bedding. Infestation is easily spread to sexual partners and household members. 6. How can infestation with scabies be prevented? Health education regarding cleanliness of person, garments, and bedclothes, and the need to be selective of intimate contacts can help prevent the spread of scabies. Having scabies once does not prevent one from becoming infected again since the body does not build up an immune response to scabies. 7. Is there a treatment for scabies? Several topical treatments, such as creams and lotions, are available to treat scabies. Even when treatment has eliminated the mites, itching may continue for 2-3 weeks and does not mean that one is still infested. No new burrows or rashes should appear 24-48 hours after effective treatment. Close contacts with the patient should be treated at the same time. Infested bedding and clothing should be laundered (in hot water) and items that can not be laundered should be stored in a sealed plastic bag for at least 4 days. 8. What are the circumstances in which scabies could be significant? People with weakened immune systems, infants and the elderly are at risk for a more severe form of scabies called Norwegian or crusted scabies. 9. Exclusion: Yes, until after treatment is completed. 10. Readmission: After treatment has been completed (usually complete overnight). 11. Contacts and reporting: Family members and close contacts to the infected individual should be treated at the same time, even if they have no signs or symptoms are present. Scabies is only reportable to the County in atypical cases. Call Nursing Services Communicable Disease Unit if there is a need to report an atypical case. - 42 - Scarlet Fever 1. What is scarlet fever? Scarlet fever is a rash that sometimes occurs in people with strep throat. Both scarlet fever and strep throat are caused by the same bacteria called group A streptococcus. The rash of scarlet fever is usually seen in children under the age of 18. 2. What are the signs and symptoms of scarlet fever? A rash first appears as tiny red bumps on the chest and abdomen. This rash may then spread all over the body. It looks like a sunburn and feels like a rough piece of sandpaper. It is usually redder in the armpits and groin areas. The rash lasts about 2-5 days. After the rash is gone, the skin on the tips of the fingers and toes often begins to peel. The face is flushed with a pale area around the lips. The throat is very red and sore, and can have white or yellow patches. Fever, chills, swollen lymph nodes and "strawberry tongue" can be seen. Other, less common, symptoms include nausea, vomiting, headache, and body aches. 3. Incubation period: 2 – 5 days 4. Contagious period: Approximately 10 days if untreated. Uncomplicated cases are communicable during incubation and clinical illness. Adequate treatment with antibiotic will decrease the probability of transmission from patients or carriers within 24 hours. 5. How does infection with scarlet fever occur? The illness can be spread to an uninfected person through contact with throat, mouth and nasal fluids of an infected person. Also, drinking from the same glass or sharing utensils with an infected person can spread the illness. 6. How can infection with scarlet fever be prevented? There is no vaccine against the bacteria that causes scarlet fever available at this time. Thorough handwashing and avoidance of contact with an infected person's throat, mouth, or nasal secretions are helpful prevention measures. 7. Is there a treatment for scarlet fever? Scarlet fever can be treated with antibiotics. It is very important to finish the prescribed medication, even when symptoms subside in order to prevent the development of complications or antibiotic- resistance bacteria. 8. What are the circumstances in which scarlet fever can be significant? If scarlet fever is not treated, or if prescribed antibiotics are not completed, rheumatic fever can occur in a small percentage of people. Rheumatic fever is a disease characterized by pain and swelling of tissues in various parts of the body and kidney problems. 9. Exclusion: Yes, until treatment has been initiated for 24 hours 10. Readmission: After a minimum of 24 hours of antibiotic treatment. - 43 - Strep Throat 1. What is strep throat? Strep throat is an infectious disease characterized by a sore throat. It is called "strep" after the bacterium that causes the infection (group A streptococcus). 2. What are the signs and symptoms of strep throat? Signs and symptoms of strep throat include: a sore throat that is red from inflammation, white patches on the tonsils or back of throat, swollen lymph nodes in the neck, fever, and headache. Children may also experience stomach pain, nausea, or vomiting. Strep throat is usually not accompanied by a stuffy nose or cough. 3. Incubation period: 2 – 5 days 4. Contagious period: Same as Scarlet Fever 5. How does infection with strep throat occur? The bacteria that cause strep throat are spread through direct contact with mucus from the nose or throat of persons who are infected or through contact with infected wounds or sores on the skin. Ill persons, such as those who have strep throat or skin infections, are most likely to spread the infection. Persons who carry the bacteria but have no symptoms are much less contagious. Treating an infected person with an antibiotic for 24 hours or longer greatly decreases their ability to spread the bacteria. 6. How can infection with step throat be prevented? Good hygienic measures, such as frequent hand washing and avoiding contact with mucus from an infected person are the best prevention methods. 7. Is there a treatment for strep throat? Strep throat can be treated with antibiotics. A throat swab is usually needed to test for the infection and make the diagnosis. It is very important to finish the prescribed medication, even when symptoms subside in order to prevent the development of complications or antibiotic-resistant bacteria. 8. What are the circumstances in which strep throat could be significant? If strep throat is not treated, or if the prescribed course of antibiotics is not completed, rheumatic fever can occur in a small percentage of people. Rheumatic fever is a disease characterized by pain and swelling of tissues in various parts of the body and kidney problems. Other complication of strep throat can include ear infections, sinusitis and abscess in the tonsils. 9. Exclusion: Yes, until treatment has been initiated for 24 hours 10. Readmission: After a minimum of 24 hours of antibiotic treatment. The untreated cases are excluded until clinical recovery, not less than 7 days. - 44 - Tetanus 1. What is tetanus? Tetanus is an acute, often fatal, disease caused by a toxin produced by Clostridium tetani. The spores that produce the tetanus toxin usually enter the body through a wound. Although the incidence of tetanus has declined since the introduction of a vaccine, the late 1990s saw an increase in tetanus cases among young injection drug users in California. 2. What are the signs and symptoms of tetanus? The most common form of tetanus is generalized tetanus. Symptoms of generalized tetanus usually descend throughout the body; first there is a stiff jaw, then neck, and then problems swallowing followed by rigidity of abdominal muscles. Other symptoms include fever, sweating, elevated blood pressure, and rapid heart rate. Spasms may occur frequently and last for several minutes, and continue for 3-4 weeks. Complete recovery may take months. Another form of generalized tetanus is neonatal tetanus which occurs in newborn infants, often through an infection of an unhealed umbilical stump. Neonatal tetanus is common in some developing countries but is very rare in the United States. 3. Incubation period: Usually 3 – 21 days 4. Contagious period: Not directly transmitted from person to person 5. How does infection with tetanus occur? Tetanus is not contagious from person to person. Transmission is usually by contaminated wounds. In addition, tetanus may follow surgery, burns, animal bites, etc. 6. How can infection with tetanus be prevented? The tetanus vaccine can prevent this disease. Primary immunization is commonly given to infants and toddlers as a combined vaccine of diphtheria, tetanus and pertussis (DTaP). However, tetanus immunity decreases 10 years after receiving the vaccine. Thus, additional booster doses of tetanus vaccines are required every 10 years to maintain immunity. If a person experiences a major or unclean wound, it may be necessary for them to receive a vaccine or immune globulin to protect them from tetanus, even if they were vaccinated as an infant. A physician should be consulted in the event of injury to determine what steps are necessary to prevent tetanus. 7. What are the circumstances in which tetanus could be significant? Tetanus can cause spasms of respiratory muscles, which result in difficulty breathing. Pneumonia is a common complication of tetanus. Elevated blood pressure and heart rate can also occur. In recent years, tetanus has been fatal in approximately 11% of reported cases, with death occurring more frequently in persons over 60 years of age and in unvaccinated individuals. 8. Exclusion: Yes, for the duration of illness 9. Readmission: Upon recovery, with clearance by the County of Los Angeles, Department of Public Health or other licensed physician. 10. Contacts and reporting: Tetanus is reportable disease. Call Nursing Services Communicable Disease Unit if there is a need to report a case of tetanus. - 45 - Tuberculosis 1. What is tuberculosis? Tuberculosis (TB) is a disease caused by the bacterium Mycobacterium tuberculosis that classically affects the lungs. TB infection ("inactive" or "latent") is when a person has a positive TB skin test, but no signs or symptoms of disease and a negative chest x-ray. Infected individuals are not contagious, but they may develop active TB disease at some time in the future. TB disease refers to those that have a positive TB skin test, an abnormal chest x-ray, and may spread TB to others. 2. What are the signs and symptoms of TB? TB infection is without signs or symptoms. TB disease may cause a bad cough that lasts longer than 2 weeks, chest pain, coughing up blood or phlegm, weakness or fatigue, weight loss, poor appetite, chills, fever, and night sweats. 3. Incubation period: TB can be carried in the body for many years without active disease. 4. Contagious period: Persons with latent TB infection are not contagious. While adolescents and adults with active TB disease are usually contagious, infants and young children are generally not. This is due to their unique disease process and the decreased ability to expel bacterium when they cough. 5. How does infection with TB occur? The bacteria that cause TB are spewed into the air when a person with active TB disease coughs or sneezes. People nearby may breathe in these bacteria and become infected. 6. How can infection with TB be prevented? There is a vaccine for TB called BCG that is administered to infants and small children in countries where TB is common. The BCG vaccine does not always protect people from TB and is not recommended for routine use in the United States. Prevention of the progression from latent TB infection to active TB disease is usually accomplished through a course of an anti-tuberculosis drug. General public health measures are also instituted to prevent the spread of TB. 7. Is there a treatment for TB? Various anti-tuberculosis drugs are available for the treatment of TB disease. The entire course of drug treatment must be completed in order to prevent bacteria from becoming drug-resistant. 8. What are the circumstances in which infection with TB could be significant? TB can be fatal if left untreated. However, it can be prevented and controlled once contracted. It is important that the condition is diagnosed early in individuals with risk factors (i.e., HIV infection). 9. Exclusion: Yes, for persons with active TB disease who have not started appropriate therapy. No, for persons with latent TB infection, whether or not they are receiving treatment. 10. Readmission: Upon starting and adherence to effective therapy for TB disease, the student is approved to return by local health professionals and considered non-infectious to others. Students seeking readmission after exclusion for TB disease should be referred to the LAUSD Nursing Services Communicable Disease Unit for readmission. 11. Contacts and reporting: Tuberculosis is reportable to the County. Contact investigation of TB disease will be performed according to County of the Los Angeles, Department of Public Health policy. - 46 - Warts (Genital and Non-Genital) 1. What are warts? Warts are non-cancerous skin growths caused by a viral infection in the top layer of the skin. Viruses that cause warts are called human papillomavirus (HPV). Common warts usually appear on the hands and feet, while genital warts appear in the gential area and are considered to be a sexually transmitted disease. 2. What are the signs and symptoms of warts? Warts are usually skin-colored and feel rough to the touch, but they can be dark, flat, and smooth. There are a variety of types: Common warts usually appear on the fingers and hands, and are most frequently found where skin has been broken. These are often called "seed" warts because the blood vessels to the wart produce black dots that look like seeds. Most often seen in young children. Plantar warts are found on the soles of the feet. Most do not stick up and they can be painful. Plantar warts are most commonly seen in school age children and teenagers. Flat warts are smaller and smoother than other warts, they tend to grow in large numbers (20-100 at a time), and they are common on the face. Most often seen in young children. Genital warts are clusters of wart-like lesions in the genital area (vulva, vagina, anus, cervix, penis, scrotum, groin, or thigh). They usually occur as soft, moist, pink or red swellings. They can be raised or flat, single or multiple, small or large. They can take weeks to months to appear after contact with an infected person. 3. Incubation period: Unknown, but estimated at 3 months to several years 4. Contagious period: As long as visible lesions are present. (Warts are only mildly contagious). 5. How does infection with warts occur? Warts are spread person-to-person through direct or, sometimes, indirect contact. Many HPV infections show no signs or symptoms, so people can pass the virus unknowingly to another person. This is frequently the case in the spread of genital warts, when people unaware of their infection pass HPV to a sex partner. Rarely, pregnant women can pass HPV to their babies during vaginal delivery. 6. How can infection with warts be prevented? Avoidance of direct contact with another person's warts is the best mode of prevention. Wash hands after touching a wart and do not share towels. Genital warts can be prevented by abstinence and safe sex practices. Use of condoms can reduce but not eliminate the risk of infection. Sexually active women should have regular Pap smears to screen for cervical cancer. 7. Is there a treatment for warts? Many warts disappear on their own over months or years. The lesions can be removed by a dermatologist, with daily application of duct tape, or by over-the-counter treatments with salicylic acid. (Note: salicylic acid is not to be used on genital warts). 8. What are the circumstances in which infection with warts could be significant? Genital warts can cause cancer in the cervix, anus, and penis. Regular health check-ups, including Pap smears in women, are important to screen for pre-cancerous conditions and cervical cancers. 9. Exclusion: None, unless they meet other exclusion criteria (see "General Exclusion Criteria") 10. Readmission: No restrictions - 47 - West Nile Virus (and Mosquito-borne Disease) 1. What is West Nile virus? The West Nile virus is one of several viral diseases spread by infected mosquitoes. Other examples of such viruses include eastern and western equine encephalomyelitis, and St. Louis and La Crosse encephalitis. West Nile Virus will be discussed in more detail as it has received the most media attention in recent years. West Nile virus is established as a seasonal epidemic in North America with flares in months with more mosquitoes (summer-fall). 2. What are the signs and symptoms of West Nile virus? The majority of people (80%) who are infected with West Nile virus will show no signs of illness. Up to 20% of people who become infected will develop West Nile fever and will experience mild symptoms, including fever, headache, and body aches, with an occasional skin rash on the trunk of the body and swollen lymph glands. The most serious symptoms occur in the small percentage with West Nile encephalitis and meningitis: headache, high fever, neck stiffness, disorientation, coma, tremors, convulsions, muscle weakness, and paralysis. 3. Incubation period: 5 - 15 days (West Nile); 2 - 15 days (others) after infected mosquito bite. 4. Contagious period: Not contagious to other persons through regular contact 5. How does infection with West Nile virus occur? West Nile virus occurs through the bite of an infected mosquito. Mosquitoes become infected after biting an infected bird (usually a crow or jay). West Nile virus may be transmitted rarely through transplanted organs or blood transfusion, and from a mother to her fetus. There is no evidence that West Nile virus can be spread from person to person under normal causal contact. 6. What can be done to reduce the risk of being infected with West Nile Virus? Protective measures to prevent West Nile virus exposure include: Avoid activity outside when mosquitoes are most active, especially at dawn and dusk. When outdoors, wear long pants, long sleeve shirts, and other protective clothing. Fit doors and windows have tight fitting screens; repair or replace torn screens. Eliminate all sources of standing water that can support mosquito breeding. Contact your local mosquito and vector control agency if there is a significant mosquito problem (for school sites, please contact the Integrated Pest Management Unit at 213-745-1427). 7. Is there a treatment for West Nile virus? There is no specific treatment for West Nile virus infection. In more severe cases, intensive supportive therapy is indicated, often involving hospitalization. 8. What are the circumstances in which West Nile Virus could be significant? Persons over 50 years of age have the highest risk of severe disease, i.e. developing encephalitis. 9. Exclusion: No, unless they meet other exclusion criteria (see "General Exclusion Criteria"). 10. Readmission: Upon recovery, by school principal or principal's designee. 11. Contacts and reporting: Dead birds may be a sign of West Nile virus disease, and they should not be handled with bare hands. Contact the California Department of Health Services West Nile Virus Hotline for information on disposal and reporting. See Reference Guide 1304 "West Nile Virus Precautions" (September 16, 2004). - 48 - Part IV Bioterrorism and Communicable Diseases in Schools - 49 - Bioterrorism Since the September 11th attacks, there has been a heightened concern and awareness of the use of biological agents in terrorist activities. Some of the agents have already been described in this reference guide (e.g., food-borne illness, influenza), but there are other, more rare agents that are classified as high priority by the Center for Disease Control and Prevention (CDC) in the table below. Category A Category B (easily disseminated; high rates of mortality; (moderately easy to disseminate; moderate may cause panic) rates of morbidity and low mortality) Anthrax Q fever Smallpox Brucellosis Plague Eastern/western equine encephalitis Tularemia Ricin toxin Botulism Clostridia toxin Viral Hemorrhagic Fevers (e.g., Ebola) Food and water-borne illness (e.g., Salmonella, Shigella, E. coli O157:H7) Children may be particularly vulnerable to a bioterrorist attack compared to adults. This is due to their higher respiratory rate, increased skin absorption, high surface (skin) to volume (weight) ratio, and the general crowded conditions of schools and child care centers. The symptoms of illness caused by bioterrorism agents are similar to symptoms of other common infectious diseases (e.g., fever, headache, vomiting, diarrhea). Furthermore, the symptoms may not be evident immediately upon exposure to the infectious agent. It may be very difficult to distinguish between intentional infection and a naturally occurring outbreak. Schools are where many children spend a good portion of their day, supervised by teachers, administrators, and health professionals. This makes the school setting a good place to monitor unusual signs and symptoms, or recognize patterns of illness that may be occurring in a greater than average number of students (or staff). Schools have become increasingly prepared for disasters and there are policies to guide schools in crisis intervention (See LAUSD Bulletin 962 "Organizing for Crisis Intervention" May 3, 2004). In acting as part of the many first-line responders, school staff and District health professionals should have a basic understanding of bioterrorism and the agents that may cause immediate and significant harm. LAUSD Bulletin Z-72 "Bioterrorism Preparedness Response: Health Perspective" (September 3, 2002) describes the roles and responsibilities of district personnel in the unlikely event of a bioterrorism attack directed at schools and school children. The following table describes some of the early signs and symptoms that may help distinguish the CDC's Category A and B biologic agents. More complete descriptions of each agent can be found using the links to CDC fact sheets available the CDC website (www.bt.cdc.gov ). - 50 - Prominent Early Clinical Manifestations After Exposure to Bioterrorist Agents Early Clinical Manifestations Agents/Disease Links to more information Respiratory Flu-like illness with or Tularemia www.bt.cdc.gov/agent/tularemia/pdf/tularemiafacts.pdf without atypical pneumonia Brucellosis www.cdc.gov/ncidod/dbmd/diseaseinfo/brucellosis_g.htm (seen on chest radiograph) Q fever www.cdc.gov/ncidod/dvrd/qfever/index.htm Encephalomyelitis Flu-like illness with cough Anthrax (inhalational) www.bt.cdc.gov/agent/anthrax/pdf/needtoknow.pdf and difficulty breathing Plague (pneumonic) www.bt.cdc.gov/agent/plague/plaguefaq.pdf Tularemia (inhalational) Ricin www.bt.cdc.gov/agent/ricin/pdf/ricinfacts.pdf Staph. enterovirus B (aerosol) Hantavirus www.cdc.gov/ncidod/diseases/hanta/hps/noframes/FAQ.htm Sore throat (with pus) and Tularemia (oropharyngeal) swollen lymph nodes (neck) Dermatologic Small red spots in the mouth, Smallpox www.bt.cdc.gov/agent/smallpox/overview/overview.pdf progressing to vesicular rash (fluid filled bubbles); fever, headache and malaise Small sore that develops into Anthrax (cutaneous) blister, then a black ulcer (all are painless) Ulcers to the skin and mouth; Tularemia (ulceroglandular) painful, swollen glands and flu-like illness Small purple spots Viral hemorrhagic fever www.cdc.gov/ncidod/dvrd/spb/mnpages/disinfo.htm (petechiae) with fever and weakness Cardiovascular Shock and difficulty Anthrax (inhalational) breathing Ricin Viral hemorrhagic fever - 51 - Early Clinical Manifestations Agents/Disease Links to more information Neurologic Blurred vision; slurred Botulism www.bt.cdc.gov/agent/botulism/factsheet.pdf speech; (descending) muscle weakness progressing to flaccid paralysis Headache, dizziness, nervous Encephalomyelitis system malfunction; seizures; Anthrax (inhalational) coma Plague (septicemic and pneumonic) Gastrointestinal Diarrhea Salmonella species www.cdc.gov/ncidod/dbmd/diseaseinfo/salmonellosis_g.htm Shigella dysenteriae www.cdc.gov/ncidod/dbmd/diseaseinfo/shigellosis_g.htm E. Coli O157:H7 www.cdc.gov/ncidod/dbmd/diseaseinfo/escherichiacoli_g.htm Vibrio cholerae www.cdc.gov/ncidod/dbmd/diseaseinfo/cholera_g.htm Cryptosporidium Vomiting, abdominal pain, Anthrax (gastrointestinal) bloody diarrhea Renal/Kidneys Blood clotting problem; renal E. Coli O157:H7 failure Shigella dysenteriae Renal failure, no urine output Viral hemorrhagic fever Hantavirus Other Painful, swollen glands Plague (bubonic) (lymph nodes) Red and inflamed eyes with Tularemia (oropharyngeal) pus (conjunctivitis); swollen glands in neck and in front of the ears Adapted from American Academy of Pediatrics, Table 2.1 Red Book 2003 Report of the Committee on Infectious Diseases - 52 - Part V Appendices - 53 - Appendix A County of Los Angeles Reportable Diseases and Conditions - 54 - County of Los Angeles Department of Health Services • Public Health Please post REPORTABLE DISEASES AND CONDITIONS Title 17, California Code of Regulations (CCR), § 2500 It shall be the duty of every health care provider, knowing of or in attendance on a case or suspected case of any diseases or conditions listed below, to report to the local health officer for the jurisdiction where the patient resides. Where no health care provider is in attendance, any indi- vidual having knowledge of a person who is suspected to be suffering from one of the diseases or conditions listed below may make such a report. "Health care provider" encompasses physicians, surgeons, veterinarians, podiatrists, nurse practitioners, physician assistants, registered nurses, nurse midwives, school nurses, infection control practitioners, medical examiners, coroners, dentists and chiropractors. Urgency Reporting Requirements: ¤ = Report immediately by telephone. u = Report by mailing, telephoning or electronically transmitting a report within 1 working day of identification of the case or suspected case. ¥ = Report by telephone within 1 hour followed by a written report submitted by facsimile or electronic mail within 1 working day. If no symbol, report within 7 calendar days from the time of identification by mail, telephone or electronic report. REPORTABLE DISEASES Acquired Immune Deficiency Syndrome (AIDS)* ¤ Hemolytic Uremic Syndrome Rubella (German Measles) u Amebiasis Hepatitis, Viral Rubella Syndrome, Congenital u Anisakiasias u Hepatitis A u Salmonellosis (other than Typhoid Fever) ¤ Anthrax Hepatitis B (Specify Acute Case or Chronic) ¤ Scabies (Atypical or Crusted)5 u Babesiosis Hepatitis C (Specify Acute Case or Chronic) ¤ Scombroid Fish Poisoning ¤ Botulism (Infant, Foodborne, Wound) Hepatitis D (Delta) u Shigellosis ¤ Brucellosis Hepatitis, Other, Acute ¤ Smallpox (Variola) u Campylobacteriosis Human Immunodeficiency Virus (HIV)* Streptococcal Infections Chancroid* Kawasaki Syndrome (Mucocutaneous Lymph u Outbreaks of any Type and Individual Cases Chlamydial Infections* Node Syndrome) in Food Handlers and Dairy Workers Only ¤ Cholera Legionellosis u Invasive Group A Streptococcal Infections ¤ Ciguatera Fish Poisoning Leprosy (Hansen Disease) including Streptococcal Toxic Shock Syndrome Coccidioidomycosis Leptospirosis and Necrotizing Fasciitis 5 (Do not report u Colorado Tick Fever u Listeriosis individual cases of pharyngitis or scarlet fever.) u Conjunctivitis, Acute Infectious of the Newborn, Lyme Disease Invasive Streptococcus pneumoniae 5 Specify Etiology u Lymphocytic Choriomeningitis u Swimmer's Itch (Schistosomal Dermatitis) u Cryptosporidiosis u Malaria u Syphilis* Cysticercosis u Measles (Rubeola) Tetanus ¤ Dengue u Meningitis, Specify Etiology: Viral, Bacterial, Toxic Shock Syndrome ¤ Diarrhea of the Newborn, Outbreaks Fungal, Parasitic Toxoplasmosis ¤ Diphtheria ¤ Meningococcal Infections u Trichinosis ¤ Domoic Acid Poisoning (Amnesic Shellfish Mumps u Tuberculosis* Poisoning) Non-Gonococcal Urethritis (report laboratory ¤ Tularemia Echinococcosis (Hydatid Disease) confirmed chlamydial infections as chlamydia)* u Typhoid Fever, Cases and Carriers Ehrlichiosis ¤ Paralytic Shellfish Poisoning Typhus Fever u Encephalitis, Specify Etiology: Viral, Bacterial, Pelvic Inflammatory Disease (PID)* ¤ Varicella: fatal cases only Fungal, Parasitic u Pertussis (Whooping Cough) Varicella: Hospitalized cases ¤ Escherichia coli O157:H7 Infection ¤ Plague, Human or Animal u Vibrio Infections u Foodborne Disease u Poliomyelitis, Paralytic ¤ Viral Hemorrhagic Fevers (e.g., Crimean-Congo, ¤ (2 or more cases from separate households with u Psittacosis Ebola, Lassa, and Marburg viruses) same suspected source) u Q Fever u Water-associated Disease Giardiasis ¤ Rabies, Human or Animal ¤ Yellow Fever Gonococcal Infections* u Relapsing Fever u Yersiniosis u Haemophilus influenzae, Invasive Disease Reye Syndrome ¤ OCCURRENCE OF ANY UNUSUAL DISEASE ¤ Hantavirus Infections Rheumatic Fever, Acute ¤ OUTBREAKS OF ANY DISEASE Rocky Mountain Spotted Fever Notification Required of Laboratories (CCR §2505) ¥ Anthrax & s u Hepatitis B, acute infection, by IgM anti-HBc ¥ Smallpox s ¥ Botulism s antibody test Streptococcus pneumoniae, Invasive 5 ¥ Brucellosis & s u Hepatitis B surface antigen positivity (specify gender) u Syphilis* u Chlamydial infections* Human Immunodeficiency Virus (HIV)* u Tuberculosis &* u Cryptosporidiosis u Listeriosis & ¥ Tularemia & s u Diphtheria & u Malaria & u Typhoid and other Salmonella species & u Encephalitis, arboviral u Measles (Rubeola), acute infection, by IgM antibody u Vibrio species infections & ¥ Escherichia coli O157:H7 or Shiga toxin-producing test or positive viral antigen test ¥ Viral Hemorrhagic Fevers (e.g., Crimean- Congo, E. coli O157:NM & ¥ Plague, animal or human & s Ebola, Lassa, and Marburg viruses) s u Gonorrhea* u Rabies, animal or human u Hepatitis A, acute infection, by IgM antibody test u Salmonella & or positive viral antigen test 5 Reportable to the Los Angeles County Department of Health Services. & Bacterial isolates and malarial slides must be forwarded to the DHS Public Health Laboratory for confirmation. Health-care providers must still report all such cases separately. s Laboratories receiving specimens for the diagnosis of these diseases must immediately contact the California Department of Health Services; for botulism testing call 213-240-7941, for bacterial testing call 510-412-3700, for viral testing call 510-307-8575. Non-communicable Diseases or Conditions Alzheimer's Disease and Related Conditions Disorders Characterized by Lapses of Consciousness ¤ Pesticide-Related Illnesses (Health and Safety Code, §105200) * For questions regarding the reporting of HIV/AIDS, STDs, or TB, contact their respective programs: HIV Epidemiology Program STD Program TB Control Program 213-351-8516 213-744-3070 213-744-6271 (for reporting) • 213-744-6160 (general) www.lapublichealth.org/hiv/index.htm www.lapublichealth.org/std/index.htm www.lapublichealth.org/tb/index.htm To report a case or outbreak of any disease contact the Communicable Disease Reporting System Hotline Rev. 2/04 Tel: 888-397-3993 • Fax: 888-397-3778 Appendix B Guide to Immunizations Required for School Entry - 56 - GUIDE TO IMMUNIZATIONS REQUIRED FOR SCHOOL ENTRY Grades K-12 REFERENCE Health and Safety Code, Division 105, Part 2, Chapter 1, Sections 120325-120380; California Code of Regulations, Title 17, Division 1, Chapter 4, Subchapter 8, Sections 6000-6075 INSTRUCTIONS Post this guide on a wall or desktop as a quick reference to help you determine whether children seeking admission to your school meet California's school immunization requirements. If you have any questions, call the Immunization Coordinator at your local health department. IMMUNIZATION To enter or transfer into public and private elementary and secondary schools (grades kindergarten through REQUIREMENTS 12), children under age 18 years must have immunizations as outlined below. VACCINE REQUIRED DOSES Polio 4 doses at any age, but... 3 doses meet requirement for ages 4–6 years if at least one was given on or after the 4th birthday1; 3 doses meet requirement for ages 7–17 years if at least one was given on or after the 2nd birthday.1 Diphtheria, Tetanus, and Pertussis Age 6 years and under (Pertussis is required) 5 doses at any age, but... 4 doses meet requirements for ages 4–6 DTP, DTaP or any combination of DTP or years if at least one was on or after the 4th birthday.1 DTaP with DT (diphtheria and tetanus) Age 7 years and older (Pertussis is not required) 4 doses at any age, but...3 doses meet requirement for ages 7–17 Td, DT, or DTP, DTaP or any combination years if at least one was on or after the 2nd birthday.1 If last dose of these was given before the 2nd birthday, one more (Td) dose is required. 7th grade 1 dose not required but recommended if more than 5 years have Td booster passed since last DTP, DTaP, DT, or Td dose. Measles, Mumps, Rubella (MMR) Kindergarten 2 doses2 both on or after 1st birthday.1 7th grade 2 doses2 both on or after 1st birthday.1 Grades 1–6 and 8–12 1 dose must be on or after 1st birthday.1 Hepatitis B Kindergarten 3 doses at any age 7th grade 3 doses3 at any age Varicella Kindergarten 1 dose4 Out-of-state entrants (grades 1–12) 1 dose for children under 13 years; 2 doses are needed if immunized on or after 13th birthday.4 1 Receipt of the dose up to (and including) 4 days before the birthday will satisfy the school entry immunization requirement. 2 Two doses of measles-containing vaccine required. One dose of mumps and rubella-containing vaccine required; mumps vaccine is not required for children 7 years of age and older. 3 Two doses of the 2-dose hepatitis B vaccine formulation along with provider documentation that the 2-dose hepatitis B vaccine formulation was used for both doses and both doses were received at age 11–15 years will also fulfill this requirement. 4 Physician-documented varicella (chickenpox) disease history or immunity meets the varicella requirement. EXEMPTIONS The law allows (a) parents/guardians to choose an exemption from immunization requirements based on their personal beliefs, and (b) physicians of children to elect medical exemptions. The law does not allow parents/guardians to elect an exemption simply because of inconvenience (a record is lost or incomplete and it is too much trouble to go to a physician or clinic to correct the problem). See the back of the blue California School Immunization Record (PM 286) for instructions and the affidavit to be signed by parents/guardians electing the personal beliefs exemption. For children with medical exemptions, the physician's written state- ment should be stapled to the CSIR. Schools should maintain an up-to-date list of pupils with exemptions, so they can be excluded quickly if an outbreak occurs. IMM-231 (5/03) Continued on the next page... PUPILS NOT Refer pupils who do not meet these State requirements to their physician or local health department. Give MEETING families a written notice indicating which doses are lacking. REQUIREMENTS DOCUMENTATION All children must present an immunization record. What is it? It is a written immunization record, either a personal record with entries made by a physician or clinic, or a school immunization record—the blue California School Immunization Record (PM 286) from a former school or another state's school record. It must include at least the month and year each dose was received; for measles, rubella, and/or mumps vaccine given in the month of the first birthday, month, day, and year are required. A record with check marks instead of dates or saying only "up-to-date," "all require- ments met," or "series complete" is inadequate. Also, parents cannot simply fill out a California School Immu- nization Record from memory but must present a written immunization record. Further, the record must show that all due vaccine doses have been received. Who must present it? All children under age 18 years entering school or transferring between school cam- puses. Kindergarten entrants and entrants from outside the U.S. must present a personal immunization record. (Kindergarten entrants can present a California School Immunization Record from a child care center they previously attended, but this record usually will not include the final "booster" polio and DTP or DTaP vaccine doses or the second measles-containing vaccine dose.) Children transferring from other schools in California or other states must present either a personal immunization record or a state school immunization record. As of July 1, 1999, students entering 7th grade must present a personal immunization record so that the 7th grade requirement immunization dates can be added to the student's school immunization record. When must it be presented? Kindergarten entrants, 7th grade entrants, and entrants from outside the U.S. must present the record at or before entry; no "grace period" of attendance is allowed for these pupils if they do not have a record. Children transferring from other schools in California or other states, or entering at other grade levels may be given up to 30 school days of attendance while waiting for their records to arrive from the previous school. What do schools do with it? School staff must transcribe the immunization dates onto the California School Immunization Record (CSIR or blue card; PM 286), which is available from local health depart- ments. School staff should then review the blue card to determine whether all immunization requirements have been met. The blue card is part of the child's Mandatory Permanent Pupil Record and must be transferred to the child's new school when he/she leaves your school. Although some vaccine doses are not required, please record dates of all doses from the child's personal immunization record s on to PM 286. This information will be valuable should outbreaks of these diseases occur in your school. CONDITIONAL Children who lack one or more required vaccine doses that are not currently due may be admitted on ADMISSIONS condition that they receive the remaining doses when due, according to the schedule below. If the maximum time interval between doses has passed, the child must be excluded until the next immunization is obtained. VACCINE TIME INTERVALS BETWEEN DOSES Polio 2nd dose: 6–10 weeks after 1st dose 3rd dose: 6 weeks to 12 months after 2nd dose DTP, DTaP, DT, Td 2nd dose: 4–8 weeks after 1st dose Under 7 years (DTP, DTaP, DT) 3rd dose: 4–8 weeks after 2nd dose 4th dose: 6–12 months after 3rd dose Age 7 years and older (Td)* 2nd dose: 4–8 weeks after 1st dose 3rd dose: 6–12 months after 2nd dose MMR 2nd dose: 1–3 months after 1st dose Hepatitis B for 3-dose formulation 2nd dose: 1–2 months after 1st dose 3rd dose: 2–6 months after 2nd dose and at least 4 months after 1st dose for 2-dose formulation (7th grade entry for child 11 through 15 years old) 2nd dose: 4–8 months after 1st dose Varicella (unimmunized out-of-state entrants > 13 years old) 2nd dose: 4 weeks to 3 months after 1st dose * Note: DTP, DTaP, DT doses received previously are counted toward meeting the 3-dose tetanus-diphtheria immunization requirement for this age group. State of California • Department of Health Services • Immunization Branch • 2151 Berkeley Way • Berkeley, CA 94704 • 510/540-2065 • IMM-231 (5/03) Appendix C LAUSD Policies and Bulletins - 59 - Infection Control Guidelines For TITLE: Preventing The Spread Of Communicable Diseases ROUTING All Employees NUMBER: BUL-1645 All Locations ISSUER: Rowena Lagrosa, Deputy Superintendent Educational Services DATE: July 1, 2005 POLICY: Preventing the transmission of communicable disease must have the highest priority. This bulletin provides guidelines for all District personnel to prevent the spread of communicable disease. MAJOR This bulletin replaces Bulletin No. Z-1, "Guidelines for Preventing the Spread CHANGES: of Communicable Diseases." The title has been renamed and the content has been updated to clarify additional guidelines. GUIDELINES: Infected persons may not know they are infected or may not share this information with others. Infection can be transmitted directly or indirectly, depending on the nature of each disease. Direct transmission can occur in such ways as touching, droplet spray from sneezing/coughing and close physical contact with body fluids, excretions, secretions and discharges. Indirect transmission can occur through contaminated food, water and objects such as towels, toys, eating utensils, clothing, and diapers. Teaching and supervision of preventive measures for the control of communicable diseases is a school nursing function. School nurses on an individual basis or group sessions will conduct in-service instruction. District physicians are available as a resource. Orientation and training must be on going and include new personnel. Personnel involved in the care of students with medical conditions that require specialized physical health care procedures and/or assistance with hygiene or feeding will receive annual training in Bloodborne Pathogens and Universal Precautions. Transmission of disease occurs more readily in very young and/or disabled children who require close personal physical care. Strict procedures and techniques must be used at all times in all settings. Staff will be trained in the required procedures and techniques before care is given. A pregnant woman or a woman of child bearing age should consult with their private health care provider and be aware that some infectious agents such as those causing rubella, herpes simplex, Parvovirus B19, CMV (cytomegalovirus) infection, AIDS (Acquired Immune Deficiency Syndrome)/HIV (Human Immunodeficiency Virus) infections, syphilis, - 60 - toxoplasmosis, hepatitis B & C, and varicella (chickenpox) can be transmitted to the unborn child. PROCEDURES AND TECHNIQUES – UNIVERSAL PRECAUTIONS Special procedures and techniques that are part of an individual's medical protocol must be adhered to precisely. The following procedures and techniques relate to the care of all students. Hand washing This is the single most important procedure for preventing the spread of disease and physically removes microorganisms from the hands. 1. Facilities (running water, preferably warm) and supplies (soap and paper towels) for hand washing must be readily accessible to all school students and personnel. 2. Food handlers and staff providing physical care to students must have fingernails that are kept short and manicured. (No artificial nails and/or nail polish). Skin injuries must be covered with a band aide before gloving. Consult Employee Health Services (213) 241-6326 regarding any chronic nail or skin condition. 3. Hand jewelry except plain wedding bands should not be worn while giving physical care to others. Microorganisms may collect in jewelry settings. 4. Hands should be washed before food preparation or feeding, after removing gloves, cleaning up body fluids, excretions, secretions, discharges and after using the toilet. 5. Technique: a. Use liquid soap/detergent and running water (preferable warm). Bar soap can harbor microorganisms. b. Rub all areas of hands and wrists in a circular motion briskly for 10- 15 seconds. c. Clean fingernails. Food handlers are not to wear nail polish/acrylic nails and to keep their own nails short for easier cleaning. d. Rinse well under running water. e. Dry thoroughly with paper towels; turn off water using the paper towels; wipe surfaces around sink and then discard the towels. Use of gloves 1. ALWAYS WEAR SINGLE USE DISPOSABLE GLOVES WHEN CLEANING UP BLOOD SPILLS, PERFORMING SPECIALIZED PHYSICAL CARE PROCEDURES OR WHEN PERFORMING PERSONAL CARE. • Gloves must be changed after each procedure and between students. • Use gloves one time and then dispose of them in the proper manner. - 61 - • To remove gloves, grasp the cuff and then strip it off by turning it ins out and dispose in the trash. • Wash hands with soap and water immediately after removing the glov 2. If hands or other skin areas are contaminated with blood or other body fluids when gloves are not used, the skin should be properly washed at once with soap and water. The danger is greater when you have open lesions or breaks in the skin. (Refer to Post Exposure Procedures, Bloodborne Pathogens Exposure Control Plan) Clean up and disinfection 1. General guidelines • Treat all blood and body fluids (urine, feces, purulent discharges, vomitus, saliva, mucus, nasal discharge) as though they are infectious. • All supplies needed are to be made available in all schools, offices, and other workplaces. • Do not ask students or volunteers to help. • Call the plant manager for assistance when appropriate. 2. Cleaning procedure • Wipe up any possibly infectious materials with paper towels and dispose of it in the proper manner. If saw dust is used to clean up vomitus, dispose of it in the same manner as any other contaminated material. • Clean all contaminated areas and materials first with soap/detergent and water. An LAUSD approved commercial product may be used for cleaning surfaces that are not contaminated with blood. • FOR WASHABLE SURFACES ALWAYS USE FRESHLY MADE 1:10 BLEACH SOLUTION (1 PART BLEACH TO 9 PARTS COLD WATER) WHEN CLEANING UP BLOOD. a. Make bleach solution daily or as needed. b. After cleaning with soap/detergent and water, wipe soiled areas and materials with bleach solution. c. After the bleach solution has been in contact with the surface for 1 minute, rinse the area with water to prevent possible corrosion. d. Do not place bleach solution directly on large amounts of protein matter, such as blood, vomitus, or feces, because noxious fumes may be produced. e. If a mop, broom, or dust pan is used in the clean up, rinse it in the bleach solution. 3. Contaminated stuffed toys that cannot be placed into commercial washers dryers should be disinfected appropriately. - 62 - Note: Outside playing surfaces contaminated with blood should be washed dow with soap and water and disinfected. Disposal of contaminated materials 1. Special handling and disposal procedures are required for regulated medica waste. Waste produced from the spill may qualify as regulated medical was the waste is: a. Liquid or semi-liquid blood or other potentially infectious material (OPIM) b. Items which release liquid blood or OPIM, if compressed c. Items with caked blood or OPIM capable of releasing materials during handling 2. Regulated medical waste must be placed in a red biohazard labeled plastic bag which is closable; constructed to contain all contents and prevent leakage of fluids during handling, storage, transport, or shipping. It should be closed prior to removal to prevent spillage or protrusion of contents during handling, storage, transport, or shipping. ♦ Call Environmental Health and Safety Branch at (213) 241-3199 for regulated biohazard waste pickup. 3. Place needles, syringes, or lancets in a puncture-proof red 'sharps' container for disposal. Do not bend, break, or recap needles. The school nurse will arrange for disposal and replacement of the full 'sharps' container. 4. Place soiled clothing and materials possibly contaminated with blood or other body fluids in double plastic bags (regular household type plastic bag) and seal them before they are returned to the parent or disposed of in another manner. Never reuse bags. Do not use cloth laundry bags. 5. If a non-disposable smock used to protect clothing is soiled, seal it in a double bag for transport. Wash it using bleach according to directions on the bottle. A soiled disposable apron must be discarded in the proper manner. 6. Used disposable diapers are to be placed in double plastic bags for disposal. 7. Do not store soiled items, even temporarily, in areas used for storage of clean linen, clothing or supplies. Using precautions for CPR Administration and Instruction A resuscitation mouthpiece shield is recommended to prevent backflow of fluids from the mouth of a person being given CPR. Manikins used for CPR instruction must be equipped with individual mouth/nose pieces with attached air bags for each student. - 63 - POST EXPOSURE PROCEDURES A bloodborne pathogen exposure incident is defined as exposure to blood or body fluid from another person to the mucous membranes of the eye, nose or mouth and non-intact skin or situations in which mucous membranes or skin barriers are pierced while during performance of the employee's duties. Examples of exposure incidents are: a prick with a used needle or lancet, human bites which break the skin, blood splashing on the mucous membranes or blood splattering on skin with cuts or scrapes. Post Exposure Procedures for Employee 1. After vigorously washing the exposed area (skin surfaces) with soap and water or flush mucous membranes (eyes, nose, or mouth) with water for 10-15 minutes, NOTIFY YOUR SITE ADMINISTRATOR IMMEDIATELY. 2. The site Administrator shall follow current Workers Compensation procedures and immediately report the incident by telephone to: EMPLOYEE HEALTH SERVICES: (213) 241-6326. 3. The site administrator or designee will document the circumstances of exposure and give the employee: • Completed Medical Service Letter • Copy of the employee's job description • Completed Injury/Accident Investigation Report • Employee/Potential Transmitter Medical Evaluation Consent Form and send the employee to an Authorized Workers' Compensation Doctor, Clinic or Hospital. 4. All medical information must be forwarded to Employee Health Services. Medical information regarding the incident is CONFIDENTIAL and must not be included in the site's written report. Post Exposure Procedures for Student 1. After vigorously washing the exposed area (skin surfaces) with soap and water (Tincture of green soap is preferred) or flush mucous membranes (eyes, nose, or mouth) with water for 10-15 minutes, NOTIFY DISTRICT NURSING SERVICES IMMEDIATELY (213) 763-8374. 2. Notify parent 3. District Nursing will work with the Los Angeles County Department of Health Services and the student's private health care providers to assist students in obtaining appropriate follow-up. 4. Notify District Nursing Services IMMEDIATELY (213) 763-8374 regarding any syringes found on or near the schools for instructions. Follow post - 64 - exposure procedures for students for any suspected needle sticks or sticks from any sharp object that may have stuck more than one person. SUPPLIES The following supplies can be ordered from Supplies and Equipment Catalog, Los Angeles Unified School District. Refer to the current school year for prices or call (213) 241-3058. STOCK DESCRIPTION NUMBER 485-74-50670 Absorbent powder or granules to absorb liquid/body fluids/spills, and turn it into a clean up solid, 8 oz. 200-15-10930 Apron, plastic, disposable (100 to pkg.) 640-15-61103 Bags, disposable for sanitary napkin receptacles (500 to pkg.) 665-24-52120 Bags, polyethylene, 15x9x24" liner for 10 gallon waste basket (500 per case) 485-94-69050 Basket-with step-on lever, steel, white baked enamel finish, with hard plastic liner, 8 gallon capacity. 505-25-38151 Bleach, liquid (2 qt). 485-42-13000 Disinfectant cleaner (Dispatch) for use on environmental surfaces and medical equipment (32 oz trigger spray bottle) 485-43-13040 Disinfectant cleaner (Dispatch) refill (64 oz) 485-74-20365 Emergency Clean-Up Kit for bodily fluids and wastes. 345-64-47330 Glasses-Safety: universal fit, clear lens, with side shields (cannot be worn over glasses). 475-14-70598 Gloves, disposable, vinyl, non-sterile, small size (100 per pkg). 475-41-47079 Gloves, disposable, vinyl, non-sterile, medium size (100 per pkg). 475-41-47119 Gloves, disposable, vinyl, non-sterile, large size (100 per pkg). 435-70-38040 Hand cleaner: germicidal rinse, provides hand wash when water is not available (4oz. Bottle) 345-72-51110 Mask-Filter: disposable, to provide relief from nuisance dust (50/ box) 345-10-51570 Resuscitation Aid, Portex mouthpiece shield for mouth-to- mouth resuscitation (disposable) 435-72-15050 Soap, green tincture, U.S.P. (pt.) 485-86-80135 Soap, hand, liquid (for use in liquid soap dispenser) (6 to a carton – 1 gal each) 640-75-72295 Towel, paper, hand 250/pkg. (12 pkg/carton) 640-85-10330 Towel, paper, wiping, disposable, 13"x18", Teri-Towels, 50 per bundle (18 bundles per case) - 65 - AUTHORITY: This is a policy of the Bloodborne Pathogens Standard, Title 8, California Code of Regulation, Section 5193; the Business and Professions Code Section 2725, Nurse Practice Act; the California Education Code Section 49426, Definition of School Nurse; the California Administrative Code, Title 16, Consumer Affairs. RELATED • Bloodborne Pathogens Exposure Control Plan, Los Angeles Unified School RESOURCES: District, Environmental Health and Safety Branch, January 1997. (Detailed information on the Bloodborne Pathogen Standard) • Communicable Diseases in Schools, Los Angeles Unified School District, Student Health and Human Services Division, 3rd Edition, 2005. (Information regarding individual diseases) • Techniques for Preventing the Spread of Infectious Diseases, California State Department of Education, 1983. (Detailed information on procedures and techniques) ASSISTANCE: For assistance or further information please contact Director, Student Medical Services, at (213) 763-8342; or Director, District Nursing Services at (213) 763-8374. - 66 - TITLE: Reporting Communicable Diseases ROUTING All Employees NUMBER: BUL-1937 All Locations ISSUER: Rowena Lagrosa, Deputy Superintendent Educational Services DATE: September 1, 2005 POLICY: "It shall be the duty of anyone in charge of a public or private school, Infant Care Center or Children's Center to report at once to the local Health Office the presence or suspected presence of any communicable disease. "CAC, Title 17, Health Section 2508. MAJOR This bulletin replaces Bulletin Z-2 "Reporting Communicable Diseases" dated CHANGES: September 4, 2002, Student Health Services Division. The content has been updated to reflect current reporting procedures. GUIDELINES: I. POLICY A. Cooperation with the County of Los Angeles- Department of Public Health. CEC 49403: Anything to the contrary notwithstanding, the governing board of any school district shall cooperate with the local Health Officer in measures necessary for the prevention and control of communicable diseases in school-age children . . . B. Notification of Communicable Disease to County of Los Angeles – Department of Public Health CAC, Title 17, Health Section 2508, Reporting by Schools, indicates it shall be the duty of anyone in charge of a public or private school, Infant Care Center or Children's Center to report at once to the local Health Office the presence or suspected presence of any communicable disease. C. Exclusion of students for communicable disease "A pupil while infected with any contagious or infectious disease may not remain in any public school." (California Administrative Code, Title 5, Education, 202.) "The governing body of any school district may exclude children . . . . suffering from contagious or infectious diseases." (California Education Code 48211) "The Principal or designee is not required to send prior notice of exclusion to the parent/guardian if the student is excluded because: a) he/she is exempt from a medical examination but suffers from a contagious disease; b) it is determined that the presence of the student would constitute a clear and present danger to the life, safety, or health of students or school personnel. The parent/guardian has a right to meet with the governing board of the school - 67 - district to review all documents leading to the exclusion of their child and the decision to exclude is subject to periodic review." (California Education code 48213) II. REPORTING AND NOTIFICATIONS A. Reporting Communicable Disease by School The following figure identifies the appropriate sequence for reporting issues of communicable disease in schools. This sequence is recommended to avoid unnecessary reporting and to ensure that all appropriate parties are notified in the case of serious disease outbreak. Who Notifies: School notifies District Communicable Nurse/Administrator Disease Nurse notifies Director, District Nursing District Communicable Services Disease Nurse notifies Local District Nursing Administrator notifies Director, Student Medical District Communicable Services Disease Nurse / Director, notifies County Department of Public District Nursing Services Health notifies Other District Offices (OEHS) In outbreaks of any illness affecting over 10% of students enrolled, the school nurse must telephone the office of the Director, District Nursing Services before 4:00 p.m. on the day of occurrence; the Director, District Nursing Services/CD Nurse will in turn notify the Director, Student Medical Services (SMS) and the County Department of Public Health. SMS Director may intercede to expedite the process by liaising with the County Department of Public Health and/or student's physicians, as deemed necessary. Problems related to tuberculosis control in students are reported to District Nursing Services, Communicable Disease Nurse at (213) 763-8374. The District Nursing Services in turn relates to the Director, Student Medical Services on a real-time basis. Problems related to tuberculosis control in employees are referred to Employee Health Services, Personnel Division, at (213) 241-6326. Reporting requirements in the event of possible food poisoning are addressed in the most recent version of Business Services Division, Bulletin No. C-32 (Rev.), "Emergency Procedures – Possible Food Borne Illness or Contamination," February 14, 2001. - 68 - B. Notification of Parents and School Employees The school's responsibility to notify school employees and the parent/guardian of children exposed to a communicable disease is based on several factors determined by school health personnel such as: - Is the disease likely to be spread by school contact? - Is the disease serious enough to warrant investigation or prophylactic treatment by the student's private physician or the County Department of Public Health? - Is there an action the parents or school employees should or could be taking? The Director, Student Medical Services, and the Director, District Nursing Services must be consulted before any notification (written or oral) to parent/guardian or school employees regarding possible exposure to any communicable disease. General guidance on reporting and notification of specific diseases and conditions is addressed in the current communicable disease reference guide (Communicable Disease In Schools, 3rd ed. 2005). Request for support services for employees is available on the request of the administrator. Requests should be made to the Director, Student Medical Services (213) 763-8342 or the Director, District Nursing Services, (213) 763-8374. III. SPECIFIC CONDITIONS AND COMMUNICABLE DISEASE A. Incomplete Immunizations In the case of exposure to a vaccine-preventable disease, students with incomplete immunization status may be excluded from school at the discretion of the County of Los Angeles-Department of Public Health. These may include exposures to pertussis, measles, and mumps. Refer to the Immunization Guidelines for School Admission BUL-1660.2 (August 1, 2005) B. Chickenpox Informational letters are to be sent to parent/guardian of all students (Attachment A) and to all employees (Attachment B) when chickenpox is first identified in the school, for each new semester. The treating physician and the parent/guardian of each student for whom chickenpox presents a particular hazard (i.e., students with immune system defects, or those taking certain medications for leukemia, organ transplants or steroid dependent asthma, etc.) are to be notified promptly by telephone whenever school exposure to chickenpox occurs. Outbreaks of chickenpox, (5 cases during a 3- week period) must be reported to the District's Communicable Disease Nurse (213) 764-8374. The school nurse should review the immunization record of each of the children and note the date of varicella immunization (if immunized) before reporting the outbreak. - 69 - C. Head lice The informational fact sheet for head lice (Attachment C) should be sent to the parents/guardians of students in classrooms with two or more identified cases. Students may be excluded for head lice at the end of the school day, but readmitted after appropriate treatment is instituted. The presence of nits alone (after treatment) is not an absolute indication for exclusion and children should not be absent from school for extended periods of time due to this treatable condition. ### - 70 - LOS ANGELES UNIFIED SCHOOL DISTRICT Student Health and Human Services (SAMPLE CHICKENPOX NOTIFICATION LETTER – STUDENTS) (Please use School Letterhead) Date _____________________ Dear Parent/Guardian: This letter is to inform you that you child may have been exposed to chickenpox in the school. Chickenpox is caused by a virus that leads to an itchy rash. The rash begins with small, red spots that develop into blisters which become scabs in 4-5 days. The rash may be the first sign of illness, sometimes coupled with fever. The virus spreads from person to person by direct contact or through air. Although chickenpox is usually mild, it may be a serious illness in infants, adults and persons with weak immune systems, such as those on medications for leukemia or organ transplant. The chickenpox (varicella) vaccine is effective in preventing the illness or it can help lessen the disease if given within 3-5 days of exposure. If you have any children or adults in your home with a weak immune system or who are not immunized against chickenpox disease, please talk to your physician regarding this exposure. If your child develops chickenpox, he/she will be excluded from school until the rash has completely scabbed over and there are no new blisters appearing (usually 6 days after the start of the rash for healthy children). Please do not let him/her expose other persons in the neighborhood. Thank you for your continued cooperation. Sincerely, _____________________ Principal _____________________ School Nurse - 71 - DISTRITO ESCOLAR UNIFICADO DE LOS ANGELES Oficina de Salud Estudiantil y Servicios Humanos (SAMPLE CHICKENPOX NOTIFICATION LETTER – STUDENTS) (Please use School Letterhead) Fecha _____________________ Estimado padre, madre o tutor: El motivo de esta carta es informarles que su niño(a) puede haber estado en contacto con el virus de la varicela en el plantel escolar. La varicela se contrae a través de un virus y se caracteriza por síntomas tales como fiebre durante 3 a 4 días y un sarpullido que pica, el cual luego se transforma en ampollas que se secan y se convierten en costras al cabo de 4 a 5 días. El sarpullido puede ser la primera señal de la enfermedad, a veces junto con la fiebre. El virus se transmite de una persona a la otra por contacto directo o a través del aire. A pesar de que la varicela es generalmente leve, puede ser grave en los bebés, los adultos y las personas con inmunodeficiencia tales como aquellas que reciben medicamentos para la leucemia y/o el transplante de órganos, entre otros. La vacuna contra la varicela es eficaz para prevenir la enfermedad o reducir la gravedad de la misma si se administra dentro de los 3 a 5 días de haber sido expuesto a la enfermedad. Si usted tiene niños o adultos en su casa con inmunodeficiencia o que no están vacunados contra la enfermedad de la varicela, por favor consulte a su médico en lo que concierne al contacto. Si su niño(a) contrae varicela, será dispensado por motivos de salud durante 7 días como mínimo. Por favor evite que esté en contacto con otras personas en su vecindario. Muchas gracias por su constante colaboración. Atentamente, ______________________________ Director _______________________________ Enfermera escolar - 72 - LOS ANGELES UNIFIED SCHOL DISTRICT Student Health and Human Services (SAMPLE CHICKENPOX NOTIFICATION LETTER – EMPLOYEES) (Please use School Letterhead) Date ___________________ Dear Employee: This letter is to inform you of the presence of chickenpox in this school. Chickenpox is caused by a virus and is characterized by an itchy rash, which then forms blisters that dry and become scabs in 4-5 days. The rash may be the first sign of illness, sometimes coupled with fever. Chickenpox develops within 10-21 days after contact with an infected person and is contagious 1-2 days before the rash appears and until all blisters have formed scabs. The virus spreads from person to person by direct contact or through air. Although chickenpox is usually mild, it may be severe in infants, adults and persons with impaired immune systems such as those on medications for leukemia and/or organ transplant. The varicella vaccine is effective in preventing illness or reducing the severity of the disease if administered within 3-5 days of exposure to the disease. If you have any children or adults in your home with an impaired immune response or who are not immunized against chickenpox disease, please consult your physician regarding this exposure. Sincerely, _____________________ Principal _____________________ School Nurse - 73 - LOS ANGELES UNIFIED SCHOOL DISTRICT Student Health and Human Services (SAMPLE HEAD LICE NOTIFICATION LETTER) (Please use School Letterhead) Date ____________________ Dear Parent/Guardian: Infestation with head lice is a common occurrence in the school community. School nurses check children for lice and exclude those who are infested. Your cooperation is essential in helping to control this problem. We strongly urge you to check daily your child's hair, clothes and the bedding for any signs of lice or nits. If you would like to consult the school nurse during school hours for screening or checking, please feel free to call. Adult lice are tan or grayish-white and the size of a sesame seed. The nits (eggs) are silver-gray in color and are attached to the hair. They cluster around the hairline at the back of the neck, around the ears, and across the front and top area of the head. Infestation by lice causes frequent itching of the scalp. If you suspect that your child or any family member has been infested by head lice, you may contact your physician. There are several over-the-counter treatments for head lice available from your pharmacist. It has been found that it may take more than one treatment to destroy the infestation. Carefully follow directions given on the package to ensure proper treatment. Do not use insecticides, gasoline or other home preparations on your child's hair. Shaving the hair is not necessary. Children with lice infestation may return to school after appropriate treatment. It is recommended that after treatment a special nit removal comb be used to remove all nits (eggs) from the hair. When using the comb, approximately one inch of hair should be combed at a time for successful removal of the nits. Removal of nits helps the school nurse determine whether or not infestation has been properly treated. A long absence from school is not necessary. Yours sincerely, ___________________ Principal ___________________ Available on: _____________________________ School Nurse Days - 74 - (SAMPLE HEAD LICE NOTIFICATION LETTER)- SPANISH (Please use School Letterhead) FECHA ______________________ Estimado Padre/Guardián: La infestatión de piojos en la cabeza ocurre comunmente en las escuelas. Las enfermeras escolares revisan a los niños en busca de piojos o liendres (huevos) y excluyen a aquellos que estan infestados. Su cooperación es esencial para ayudar a controlar este problema. Le urgimos a revisar diariamente el cabello de sus niños asi como su ropa y ropa de cama para cualquier senal de piojos o liendres. Si desea consultar a la enfermera escolar durante horas habiles para consultar o revisar a sus niños, hagalo con toda confianza. Las liendres son de color gris-plata y se pegan a los foliculos del cabello. Se acumulan donde termina el pelo en la parte trasera del cuello, alrededor de las orejas, y a traves del area frontal y superior de la cabeza. La infestación de piojos y liendres causa frecuente comezon en la craneo. Si usted sospecha que su niño/a a cualquier miembro de su familia esta infestado de piojos o liendres, puede llamar a su medico. En su farmacia encontrara varios medicamentos contra los piojos que no requieren receta. Por lo regular se requiere mas de un tratamiento para eliminar la infestación. Siga con cuidado las instrucciones que aparecen en el paquete. Cunado las liendres estan vivas se pegan al cabello; cuando muertas, son faciles de remover. Se recomienda que despues del tratamiento se utilice un peine especial para remover las liendres del cabello. Se sugiere que cuando use el peine, se peine el cabello una pulgada a la vez para asi remover con exito las liendres. Ausencia excesiva de la escuela no es necesaria. Atentamente. ___________________________ Director(a) _______________________ Disponible:_________________________ Enfermera Escolar Días - 75 - AUTHORITY: A pupil while infected with any contagious or infectious disease may not remain in any public school." (California Administrative Code, Title 5, Education, 202.) " The governing body of any school district may exclude children . . . . suffering from contagious or infectious diseases." (California Education Code 48211) ASSISTANCE: For assistance or further information please contact Director, Student Medical Services, at (213) 763-8342; or Director, District Nursing Services at (213) 763-8374. - 76 - TITLE: Immunization Guidelines ROUTING For School Admission Local District Superintendents NUMBER: BUL-1660.2 Administrators School Nurses ISSUER: Rowena Lagrosa, Deputy Superintendent SAA's Educational Services DATE: July 21, 2005 POLICY: Children must have required immunizations before they can attend school in California. Parent/Guardian must present their child's Immunization Record to school staff as proof of immunization prior to admission. MAJOR This bulletin replaces Bulletin No. Z-4, "Immunization Guidelines for School CHANGES: Admission," dated June 1, 2001 and Bulletin – 1660.1 of the same dated May 5, 2005. The content has been updated to reflect current immunization requirements. GUIDELINES: REQUIREMENTS FOR SCHOOL ENTRY The California Health and Safety Code Section, Division 105, Part 2, Chapter 1, Sections 120325-120380 and the California Code of Regulations, Title 17, Division 1, Chapter 4, Subchapter 8, Sections 6000-6075 requires the following immunizations prior to school entry. 1. All children entering a California school at pre-school or kindergarten level (or first grade if kindergarten was skipped) require immunization against polio, diphtheria, pertussis, tetanus, measles, mumps, rubella (MMR), hepatitis B and varicella. Students enrolled in a California school before July 1, 2001 are exempt from the varicella requirement. Acceptable varicella documentation includes either the immunization or documentation by a medical provider that the child has had the varicella (chickenpox disease). 2. In addition to these immunizations, all children below the age of four years, six months, require Haemophilus influenza type B immunization (see Attachment E). 3. Children seven years of age and older require immunization against polio, diphtheria, tetanus, measles and rubella but are not required to be immunized against pertussis and mumps. All children under 18 years of age from out of state or country who enter a California school for the first time after July 1, 2001 require immunization against varicella or acceptable documentation by a physician's office or clinic that the child has had the varicella (chickenpox) disease. 4. All children entering or repeating 7th grade must be immunized against Hepatitis B. In addition, these students are required to have two doses of a measles-containing vaccine, at least one of which must be MMR. 5. Refer to Attachments for specific requirements. These Attachments can be photocopied and used as quick references during registration. - 77 - Exemptions to the immunization requirement are provided for medical or personal reasons. (See California Administrative Code, Title 17, Title 17, Division 1, Chapter 4, Section 6051.) A medical exemption requires a written statement from a licensed physician to the effect that the physical condition of the pupil or medical circumstances relating to the pupil are such that immunization is not indicated. This statement will be attached to the California School Immunization Record (CSIR). A personal belief exemption is that the immunization(s) is contrary to the parent/guardian beliefs. The fact of the personal beliefs exemption shall be recorded on the CSIR. The Personal Beliefs Affidavit to be signed by the parent or guardian is located on the reverse side of the California School Immunization Record (CSIR). The California Administrative Code charges the administrator of each school with enforcing these immunization requirements. The school nurse is available to assist with this responsibility. Since verification of immunization must be shown at the time of enrollment, office personnel who register new students must be familiar with the requirements. Parents/Guardians who do not have a written immunization record for their child are to be referred to their physician or the health department to obtain the required immunizations and/or written immunization verification for their child prior to enrollment. No grace period is allowed. For exceptions refer to Bulletin 787: July 1, 2004 "Guidelines for School Enrollment of Students in Out of Home Placement," and Bulletin 1570: Feb. 8, 2005 "Enrollment of Homeless Children and Youth in Schools." FIRST ADMISSION TO SCHOOL Children entering school for the first time must possess a written immunization record showing receipt of each required dose of vaccine (see Attachment A). This record must show the date (at least the month and year) of each dose. Measles, mumps, rubella (MMR) records must have the month, day, and year if administered in the month of the first birthday. Unconditional Admission (K-12). Granted to students who have: 1. Met all immunization requirements. 2. Filed a medical exemption signed by a physician (if the need ceases to exist, the student must then meet immunization requirements). 3. A statement of personal belief against immunizations signed by parent or guardian. 4. Reached 18 years of age or older. Conditional Admission (Pre-K). Granted to students who have: 1. Completed all age-appropriate immunizations required to date (see - 78 - Attachment E). All pre-kindergarten students are admitted conditionally since immunization schedules cannot be completed because of age. 2. Haemophilus influenza type B immunization is required for first school entry for all students below the age of four years, six months. Conditional Admission (K-12). Granted to students who have been partially immunized and succeeding vaccine doses are not yet due (see Attachment E). Note: If the maximum time interval between doses has already been exceeded, the next required doses must be received before admission. Remaining required doses must be received according to the vaccine schedule. A primary immunization series does not have to be restarted if the interval between doses is prolonged. Follow-up of Conditional Admission Students who have been admitted conditionally must have their immunization records reviewed every 30 days until all required immunizations are completed. Parents are to be notified of the date the immunization is due. At this time, they are also to be notified of the date the student must be excluded if the immunization is not received within 10 school days. (See sample letter, Attachment C). ADMISSION OF TRANSFERRING STUDENTS Parents or guardians of students transferring within LAUSD must present a written immunization record prior to enrollment. LAUSD sending schools should give the parent/guardian a copy of the California School Immunization Record (CSIR) card to take to the receiving school. Receiving schools must request immunization documents directly from the parent to determine admission status and follow-up as indicated. In unusual circumstances only, a fax or telephone confirmation that immunizations are complete to date may be accepted from another LAUSD school for enrollment purposes, pending receipt of records. Follow-up must be done to assure that records are received and meet State requirements. Students from other countries must meet the same requirements as any student entering school for the first time. EXCLUSION A student who was admitted conditionally and fails to obtain the required immunizations within the time periods specified in Attachment E, Item 3 (Conditional Admission), must be excluded until he/she receives another dose of each vaccine required at that time. - 79 - The school administrator is charged by the California Administrative Code and Board Rule 2313 to exclude a student who does not meet the immunization requirements within the specified time periods when the following conditions are met: 1. Parent/Guardian has been informed of public sources of immunization administration. 2. Parent/Guardian has been notified at least 10 school days before the date of exclusion. When a student, who has not been completely immunized against a particular communicable disease, is believed to have been exposed to that disease, the school administrator must report this information immediately by telephone to the Director of Student Medical Services. The Director of Student Medical Services and the County Health Officer will determine whether the student is at risk of developing the disease, and, if so, may require exclusion of the student until the completion of the incubation period and the period of communicability of the disease. RECORD KEEPING Written personal immunization record 1. The physician or health agency performing the immunizations must give a written record to the student or parent/guardian containing the following information: • Name of child • Birth date of child • Type of vaccine(s) administered • Date of each immunization (month/year) or • Physician's written indication that the child had the disease or lab report indicating that the child has immunity for the disease • Name of physician or health agency administering vaccine(s) 2. A variety of written records may be used for this purpose but the Immunization Record, printed by the California State Department of Health Services, is most often used (see Attachment A). 3. At the time of enrollment, school personnel should make a photocopy of the written record. The copy should be kept with the student's health card. School personnel will enter immunization data along with other enrollment information in the computer and on the student's health card. California School Immunization Record (CSIR) [PM 286 (1/02)] 1. It is mandatory that each new kindergarten student has his/her immunizations recorded by school personnel on the California School Immunization Record (CSIR) card. This card is part of the student's permanent record and must be filled with the Student's Cumulative Record file (see Attachment B). - 80 - The CSIR card is also required for each new admission at other grade levels through grade 12 for whom no previous permanent record exists. The requirement for immunization records on a CSIR card refers also to students in the Early Education Program and pre-school age children participating in school-based programs. LAUSD policy requires that school personnel review the CSIR card and certify the accuracy of the document information at school entrance and before entrance to 7th grade. 2. If a student was admitted conditionally, all immunizations received after the conditional admission must be entered on the student's CSIR card. 3. When an exemption on the basis of personal beliefs is claimed, the parent/guardian must sign the affidavit on the back of the CSIR card. 4. When a medical exemption is claimed, a signed physician's statement to this effect is required and must be attached to the CSIR card. The following information must be included: • Type of immunization(s) from which the student is medically exempt. • Reason(s) immunization(s) cannot be given. • Probable duration of medical condition or circumstances contraindicating the immunization(s). Reporting to the State of California Department of Health Services 1. The administrator of each school must ensure that a report is properly filed with District Nursing Services on the immunization status of new kindergarten entrants and all students entering or repeating 7th grade at the beginning of each school year. A District report will be compiled and sent to the State of California Department of Health Services and County of Los Angeles- Department of Health Services. 2. The County of Los Angeles Department of Health Services may request additional reports on the immunization status of students at any time. 3. A few schools will be selected at random annually by the State of California Department of Health Services, for monitoring of immunization record keeping, reporting, and follow-up procedures. AUTHORITY: This is a policy of the California Health and Safety Code Section, the California Code of Regulations, the LAUSD Board of Education to require immunizations prior to school entry. RELATED • California Immunization Handbook for School and Child Care Programs, 7th RESOURCES: Edition, July 2003. • Health and Safety Code, Division 105, Part 2, Chapter 1, Sections 120325- 120380 (formerly Sections 3380-3390). • California Code of Regulations, Title 17, Division 1, Chapter 4, Subchapter 8, Sections 6000-6075. • LAUSD Board Rule 2313 - 81 - ASSISTANCE: For assistance or further information please contact Director, Student Medical Services, at (213) 763-8342; or Director, District Nursing Services at (213) 763- 8374. - 82 - LOS ANGELES UNIFIED SCHOOL DISTRICT Policy Bulletin TITLE: TUBERCULOSIS EXAMINATION REQUIREMENT ROUTING FOR NEW ENTERING STUDENTS Local District Superintendents NUMBER: BUL-1659 Administrators School Nurses ISSUER: Maria Reza, Assistant Superintendent Student Health and Human Services DATE: March 31, 2005 POLICY: The guidelines are intended for the School Administrator and staff who enroll students new to California. The certificate must indicate the student is free of tuberculosis (TB). MAJOR This bulletin replaces Bulletin No. Z-21, "Tuberculosis Examination Requirement CHANGES: for New Entering Students," dated February 1, 1998. The content has been updated to reflect current policy of the District and the Los Angeles County Department of Health Services. GUIDELINES: The following guidelines apply. GENERAL INFORMATION The Director of the Los Angeles County Department of Health Services has implemented provisions of the California Administrative Code, Title 22, Division 2, New Chapter 9 (Articles 1-7, Sections 41301-41329, not consecutive) and is requiring that as of September, 1985, all students new to California schools must present a certificate which shows that they are free of tuberculosis (TB). School administrators of public and private elementary and secondary schools in Los Angeles County are charged with carrying out the requirements of the law. Parents should be advised that their children could obtain the tuberculosis examination and certificate at their local Department of Health Services, medical care provider, or at an appropriate health care facility. For all qualifications of this requirement, no verbal affirmation or parental recall can be accepted. The only approved tuberculosis skin test for meeting this requirement is the Mantoux Skin Test (in which the material is 0.1 cc of PPD containing 5 TU.) A chest x-ray is required if the skin test reaction is 10 mm induration or greater (positive reaction). (Under certain conditions less than 10 mm induration may be considered a positive reaction.) Policy Bulletin No. 1659 Office of Student Health and Human Services Page 1 of 4 March 31, 2005 LOS ANGELES UNIFIED SCHOOL DISTRICT Policy Bulletin FIRST ADMISSION TO SCHOOL Unconditional Admission Students entering at the kindergarten level or first-grade level who never attended kindergarten anywhere must present written evidence of having undergone a satisfactory skin test for tuberculosis within one year prior to school entry. All other students entering at any grade level who never attended any school in California must present documentation that they have had a satisfactory skin test for tuberculosis administered at any previous time. Students entering at any grade level from any other California school (public, private, or parochial) are exempt from the requirement. Students whose parents/guardians do not want them to have the tuberculosis examination on the basis of personal beliefs are exempt from the requirement. The parent/guardian must sign a waiver to this effect on the back of the California State Immunization Record (CSIR) card. Students whose medical practitioners certify in writing that they are undergoing or have already undergone preventive treatment for tuberculosis infection or treatment for tuberculosis disease are exempt from the requirement. Conditional Admission Students may be administered the tuberculosis skin test prior to or at the same time they are immunized against measles, mumps, rubella (MMR), and/or varicella; if, however, the skin test is not given at the same time or before these immunizations are administered, a period of 4 weeks must elapse before the skin test can and will produce valid results. Therefore, students in these circumstances may be admitted conditionally until it is medically possible for them to meet the requirement. Students who have had the tuberculosis skin test administered but who also require a diagnostic chest x-ray have 20 school days in which to comply with the requirement. Students who do not comply after 20 school days may be excluded from school. PRODEDURES FOR ENROLLMENT Review of Tuberculosis Examination Requirement Certificate A certificate signed by a physician or his/her designee, shall be given to the person tested or to his/her parent/guardian by the physician or health agency doing the tuberculosis examination which shall contain the following information: • Name of student • Birth date • Date of administration of Mantoux Skin Test Policy Bulletin No. 1659 Office of Student Health and Human Services Page 2 of 4 March 31, 2005 LOS ANGELES UNIFIED SCHOOL DISTRICT Policy Bulletin • Date of reading of Mantoux Skin Test • Name and title of person reading the skin test • Mantoux Skin Test reaction: Negative: 0 mm induration to 9 mm induration Positive: 10 mm induration or greater • Date of chest x-ray (when skin test reaction is 10 mm induration or greater) (X-ray must be done within 20 school days after the Mantoux Skin Test is read) • A negative chest x-ray or notation that the student is free of communicable TB if the skin test reaction is positive • Name of physician or health agency administering the examination The certificate shall be shown to the appropriate school personnel on admission to school and at any other time when requested. The school nurse or designee shall review the documents submitted by the parent/guardian or student showing compliance with this tuberculosis examination requirement. Recording Data Information regarding the Mantoux Skin Test shall be recorded on the student health record and CSIR card (California State Immunization Record) Form PM 286B (1/02). Include the date of Mantoux Skin test; test reaction; date of chest x-ray (if required) and results or notation that student is free of communicable TB; exemption because of personal belief, medical reasons, or transfer from another California school. For a personal belief exemption, the parent/guardian must sign to this effect on the back of the CSIR card. For a medical exemption, a physician's statement is required and must be attached to the CSIR card. The tuberculosis examination record shall be transferred with the mandatory permanent student records when the student leaves the school. Record Keeping A list of students conditionally enrolled shall be maintained and the school shall pursue follow-up of these students. A list of all students excluded by reason of noncompliance shall be maintained, and the school shall pursue follow-up of these students. EXCLUSION FROM SCHOOL A student admitted conditionally who fails to obtain the required tuberculosis Policy Bulletin No. 1659 Office of Student Health and Human Services Page 3 of 4 March 31, 2005 LOS ANGELES UNIFIED SCHOOL DISTRICT Policy Bulletin examination within the time periods specified should be excluded from school until the student provides written evidence that he/she has received the required tuberculosis examination. A student who may have tuberculosis shall be reported to District Nursing Services (DNS). DNS will contact the L.A. County Department of Health Services TB Control. The District Health Officer may require the exclusion of the student from school until certified to be free of communicable tuberculosis. Students whose medical practitioners certify in writing that they are undergoing treatment for tuberculosis disease and are free of communicable disease may be admitted. ANNUAL REPORT All school districts and private schools in the County are required to file a report by December 1 of each year on the new admissions from outside California who were enrolled in school by the preceding October 30. The report will include: • Total enrollment of Kindergarten and first time enrollees from outside California by grade and birthplace (U.S./non-U.S.) as of October 30th. • Number of new students by grade and birthplace who were admitted with positive skin test reactions (10mm induration or greater). • Number of new students exempted for personal beliefs. • Number of new students exempted for medical reasons. • Number of new students admitted conditionally. Information for the report will be collected from all schools and compiled by District Nursing Services. The report will then be filed with the Los Angeles County Department of Health Services TB Control. AUTHORITY: This is a policy of the California Administrative Code and the Los Angeles County Department of Health Services. RELATED The Director of the Los Angeles County Department of Health Services has RESOURCES: implemented provisions of the California Administrative Code, Title 22, Division 2, New Chapter 9 (Articles 1-7, Sections 41301- 41329 not consecutive), filed 3/11/82; effective thirtieth day thereafter (Register 82, No. 11). Authority cited: Sections 208 and 3409, Health and Safety Code. Reference: Sections 3400(a) and 3402(a). ASSISTANCE: For assistance or further information please contact Kimberly Uyeda, MD, Director, Student Medical Services, At (213) 763-8342; or Karen Maiorca, Director, District Nursing Services at (213) 763-8374. Policy Bulletin No. 1659 Office of Student Health and Human Services Page 4 of 4 March 31, 2005 FOR YOUR INFORMATION LOS ANGELES UNIFIED SCHOOL DISTRICT Office of the Deputy Superintendent, Instruction DISTRIBUTION: All Schools and Offices ROUTING Local Superintendents SUBJECT: BULLETIN NO. Z-70 Local District School Support STUDENTS WITH HIV/AIDS Directors INFECTION Administrators Principals DATE: August 1, 2001 Nurses DIVISION: Student Health and Human Services APPROVED: MARIA REZA, Assistant Superintendent For further information regarding students, please call the Director, Student Medical Services, at (213) 763-8342 or Director, District Nursing Services at (213) 763-8374. This is a revision of Student Health and Human Services Bulletin No. Z-47, dated August 4, 1998. This bulletin deals with issues specifically related to Students. For the bulletin regarding issues concerning employees and staff affected with HIV/AIDS, please see Bulletin No. Z-69. The Los Angeles Unified School District shall strive to protect the safety and health of children and youth in our care as well as their families, our employees, and the general public. I. BACKGROUND The subject of school attendance by students with Human Immunodeficiency Virus (HIV) infection and Acquired Immunodeficiency Syndrome (AIDS) was addressed at a regular meeting of the Board of Education in October 1985. The Board reaffirmed its existing policy on medical exclusion and readmission of students with communicable diseases as the means to deal with this new health issue. Subsequently, guidelines and procedures were developed for students that are consistent with Board policy. Similarly, guidelines and procedures were also developed for employees in accordance with Board Rule 1940- 1955 regarding employee health standards. With the growing number of individuals diagnosed to have HIV or AIDS infection it was desirable that the District develop a policy and guidelines/procedures relative to students and employees with HIV/AIDS. The risk of transmitting HIV is extremely low in school settings when current guidelines are followed. The spread of HIV infection in schools has not been documented and the fear of its communicability must be allayed by appropriate education of all school personnel. Participation in school provides a sense of normalcy for children and - 87 - Student Health and Human Services -2- BULLETIN NO. Z-70 August 1, 2001 adolescents with HIV infection and offers opportunities for socialization that are important for their development. Several laws such as Individuals with Disability Education Act (IDEA), Individual Family Service Plan (IFSP), Section 504 of the Rehabilitation Act of 1973, and Americans with Disability Act (ADA) have been enacted to improve the availability of services in schools to assist children with special health care needs to benefit optimally from the educational program, and to prohibit discrimination based on disability. II. CONFIDENTIALITY Confidentiality is a legal and medical requirement. Students (families) are not required to disclose HIV infection status to anyone in the education system. Disclosure of the child's HIV status is done only with the informed consent of the parents/legal guardian and age-appropriate consent of the child. No information regarding a person's HIV status will be divulged to any individual or organization without a Court Order or informed written, signed, and dated consent of the person with HIV infection (or the parent or guardian of a legal minor). The written consent must specify the name of the recipient of the information and the purpose for disclosure. A growing number of adolescents are choosing to exercise their right to be tested for HIV antibodies. Some of the youngsters also choose not to inform their parent(s) or guardian(s). In this case, if an HIV infected student informs a member of the school staff, that school staff person must be sure not to violate the student's right to keep this information confidential. Any disclosure of this information requires the student's specific, informed, written consent. Anyone disclosing the results of an HIV antibody test without the written authorization of the subject or parent/legal guardian is subject to civil, and in some cases criminal penalties, and can be liable for actual damages (California Health and Safety Code Sections 120980, 120975). III. GENERAL GUIDELINES 1. School Attendance Medical decisions relative to the attendance of students with HIV/AIDS at a school site will be based on the best medical knowledge available. HIV infected children should be admitted without restriction to childcare facilities and schools and allowed to participate in school activities to the extent their health permits. Children and youth with HIV/AIDS have the same rights as those without infection to attend school and participate in all programs and activities offered by the schools. These - 88 - Student Health and Human Services -3- BULLETIN NO. Z-70 August 1, 2001 students should have access to special education and other related services in accord with their needs. Continuity of education must be ensured for children and adolescents with HIV infection and encompasses the spectrum of traditional school, medical day treatment, and home teaching. 2. HIV Transmission HIV is not transmitted through casual contact. The HIV transmission may occur as follows: a) From a mother with HIV infection to her infant during pregnancy, delivery or breast feeding; b) Direct inoculation of infected blood or blood-containing tissues, including transfusion, transplantation of organ tissues, and use of contaminated needles or penetrating injuries with needles or sharp objects contaminated with blood, and c) Intimate sexual contact with an infected partner (between sex partners) by contact with infected semen, vaginal or cervical secretions, or blood with mucosal surfaces. 3. Infection Control / Universal Precautions In the best interest of health and safety concerns of all students and staff, it is imperative that proper measures for preventing the spread of all communicable diseases be practiced since the identity of persons with HIV/AIDS or other communicable diseases may not be known. All employees are required to consistently follow infection control guidelines in all settings and at all times, including playgrounds and school buses. Schools will follow the standards promulgated by the U.S. Occupational Health and Safety Administration for the prevention of blood-borne pathogens. All school personnel will be trained annually in the proper procedures for handling blood and body fluids and universal precautions and must strictly adhere to these procedures (See Student Health and Human Services Bulletin No. Z-1 (Rev), "Guidelines for Preventing the Spread of Communicable Diseases," dated June 1, 2001). 4. HIV Management in School Setting Students with chronic illnesses, including HIV, may need medications administered during the school day. Established policies and procedures must be followed and confidentiality must be ensured. Some medications have special requirements. Appropriate access to fluid and bathroom privileges should occur in response to physician requests. (See student Health and Human Services Bulletin No. Z-19 (Rev), "Assisting Students with Prescribed Medication at School," dated January 7, 1999. - 89 - Student Health and Human Services -4- BULLETIN NO. Z-70 August 1, 2001 Irrespective of whether a person has HIV/AIDS, infection control procedures and universal precautions should be strictly followed at all times and in all situations where there is a potential for contact with blood and/or body fluids. This includes playground injuries and classroom incidents involving blood or body fluids. In-service on infection control and universal precautions is provided annually. Contact District Nursing Services at 213- 763-8374 for additional information. In case of any illness and/or concerns regarding the student's health during school hours, the student should be referred to the school nurse for an assessment, who, in turn, may seek medical consultation from Student Medical Services. The student's physician may need to be consulted if necessary. 5. Exposure to Illness Parent/legal guardians should be informed when a possible exposure to a vaccine- preventable illness such as measles or varicella occurs in the school setting. Immuno- compromised students including those with HIV infection may need to be removed from school for their protection. 6. HIV and Athletics Athletes with HIV infection should be permitted to participate in competitive sports at all levels. The privilege of participating in elective physical education classes, extracurricular activities, competitive sports, and recess is not conditioned by a person's HIV status. Physical education programs suitable for the needs of a developmentally disabled or chronically ill child, including those with HIV, should be available. School authorities will make accommodations to allow students with HIV infection to participate in school-sponsored physical activities. Athletes with HIV infection interested in participating in contact sports such as wrestling or football should be evaluated on a case-by-case basis. The athlete's physician should be involved in the decision regarding participation. All employees must consistently adhere to infection control guidelines in locker rooms and all play and athletic settings. First aid kits and the infection control guidelines must be readily available. Student orientation about safety on the playing field will include guidelines for avoiding blood-borne pathogens. The guidelines for avoiding blood-borne pathogens should be included at the preseason "Rules Session" held at each school. Sports coaches must be aware of the guidelines regarding injuries that cause bleeding as indicated in the sports rulebooks. - 90 - Student Health and Human Services -5- BULLETIN NO. Z-70 August 1, 2001 IV. ADMISSION / READMISSION OF STUDENTS Students should be evaluated on an individual basis to determine health risks, benefits, and the most appropriate educational placement. Assistance in this evaluation may be obtained from the Director, Student Medical Services. The school physician may be requested to assist with the process. Open communication should be maintained between the District medical personnel and the student's private physician(s), especially after an absence due to illness or obvious health problems. V. DISTRICT/COMMUNITY RESOURCES Consultation and inservice on HIV/AIDS will be provided to the District personnel as needed. For additional information call: Director, Student Medical Services at (213) 763- 8342; Director, Student Nursing Services at (213) 763-8374 For community resources, contact Los Angeles Family AIDS Network at (323) 461-6606 or AIDS Service Center at (626) 441-8495. References: National Association of State Boards of Education: Someone at School has AIDS American Academy of Pediatrics: School Health Policy and Practice Nelson's Textbook of Pediatrics, 16th Edition Pediatrics, June 2000, Volume 105, Number 6: Education of children with HIV infection ### - 91 - FOR YOUR INFORMATION LOS ANGELES UNIFIED SCHOOL DISTRICT Office of the Deputy Superintendent, Instruction DISTRIBUTION: All Schools and Offices ROUTING Local Superintendents SUBJECT: BULLETIN NO. Z-69 Local District School Support EMPLOYEES WITH HIV/AIDS Directors INFECTION Administrators Principals DATE: August 1, 2001 Nurses DIVISION: Employee Health Services / Human resources Student Health and Human Services APPROVED: MARIA REZA, Assistant Superintendent For assistance regarding employees, please call the Medical Director, Employee Health Services, Personnel Division, at (213) 625-6326. This is a revision of Student Health and Human Services Bulletin No. Z-47 dated August 4, 1998. This bulletin deals with issues specifically related to employees and staff. For the bulletin regarding students affected with HIV/AIDS, please see Bulletin No. Z- 70. The Los Angeles Unified School District shall strive to protect the safety and health of children and youth in our care as well as their families, our employees, and the general public. I. POLICIES With the growing number of persons who have been diagnosed as having AIDS (Acquired Immune Deficiency Syndrome) or as having been infected with HIV (Human Immunodeficiency Virus), it is desirable that District policies, guidelines, and procedures related to employees with HIV/AIDS be stated and widely disseminated. At a regular meeting of the Board of Education in October 1985, the subject of school employees with AIDS was addressed. Subsequently, guidelines and procedures were developed for employees that are in accordance with Board Rules regarding employee health standards. Employees with communicable diseases (which includes HIV/AIDS) are to be treated as described in Board Rules 1940 – 1955. - 92 - Student Health and Human Services -2- BULLETIN NO. Z-69 August 1, 2001 II. CONFIDENTIALITY Confidentiality is a legal and medical requirement. Only with the written permission of the employee may District personnel be informed about the employee's health condition. In any case, dissemination of such information will be restricted. Under ideal circumstances, a small number of District personnel should be made aware of the diagnosis so that they can be active partners in seeing that the employee has the best possible care at school. The employee, however, has a legal right to withhold this information and to ask their physician(s) to do likewise. Anyone disclosing the results of an HIV antibody test without the written authorization of the subject is subject to civil, and in some cases criminal penalties, and can be liable for actual damages (California Health and Safety Code Sections 120980, 120975). III. GENERAL GUIDELINES A. Medical decisions related to the attendance of employees at school/work site will be based on the best medical knowledge available. Current resources include guidelines from the Los Angeles Department of Health Services, and the American Academy of Pediatrics. B. HIV/AIDS can be transmitted only by: (1) intimate sexual contact with an infected person, or (2) blood/blood products and organ transplants contaminated with the virus introduced into the body (i.e., needles used for IV drug use, blood transfusions, blood products), or (3) an infected mother to her baby before or during birth and after birth through breast milk. C. It must be assumed that some employees now working are infected with HIV/AIDS, with or without their personal knowledge. Since the identity of person with HIV/AIDS or other communicable diseases may not be known, it is imperative that proper measures for preventing the spread of all communicable diseases be practiced. Therefore, education regarding HIV/AIDS and the prevention of all communicable disease is of prime importance. (See Student Health and Human Services Division, Bulletin No.1, "Guidelines for Preventing the Spread of Communicable Diseases," dated July 1, 1996.) D. Employees returning from illness who are unable to perform the duties of their position should be referred to Employee Health Services for evaluation of their status. - 93 - Student Health and Human Services -3- BULLETIN NO. Z-69 August 1, 2001 E. The employee's progress should be monitored and open communication maintained between District medical personnel and the private physician(s) especially after an absence due to illness or obvious health problems at the school/work site. F. Physical care of the employee at the school/work site must include precautions for the clean up of blood spills/body fluids. (See Student Health and Human Services Division, Bulletin No. 1, "Guidelines for Preventing the Spread of Communicable Diseases," dated July 1, 1996). In-service by District Health personnel will be provided as needed. IV. ADMISSION/READMISSION OF EMPLOYEES A. Procedures related to employees: 1) Readmission of employees known to have HIV/AIDS will be considered on the recommendation of their private physician as in the case of any other medical condition, subject to their ability to perform the duties of their position as determined by District staff. Board Rules require that all employees must have the physical, mental, and emotional health needed to perform the core duties of their position and class and be free of any condition or disease detrimental to their own health and safety to the health and safety of other persons. 2) If readmission or the ability to work is questioned by the employee's supervisor, the employee will be evaluated by Employee Health Services at (213) 625-6329. Decisions related to an employee's work assignment will be made in conjunction with the employee's personal physician and will be based on: a. Health risks to the employee—physical condition, immune status, stamina, degree of any handicap, potential exposure to communicable diseases, and ability to perform job-related duties in the assigned environment. b. Possible health risks to others – open lesions, communicable infections (such as tuberculosis, shingles), inimical behavior. - 94 - Student Health and Human Services -4- BULLETIN NO. Z-69 August 1, 2001 V. RESOURCE PERSONNEL Consultation and in-service for District personnel regarding HIV/AIDS will be provided as needed. For employee health issues, call the Medical Director, Employee Health Services at (213) 625-6326. ### - 95 - FOR YOUR INFORMATION LOS ANGELES UNIFIED SCHOOL DISTRICT Office of the Senior Deputy Superintendent, Educational Services DISTRIBUTION: All Schools and Offices ROUTING Local District Superintendents SUBJECT: BULLETIN NO. Z-72 Local District School Support BIOTERRORISM PREPAREDNESS Directors RESPONSE: HEALTH PERSPECTIVE Administrators Principals DATE: September 3, 2002 Physicians Nurses DIVISION: Student Health and Human Services APPROVED: MARIA REZA, Assistant Superintendent For further information regarding students, please call the Director, Student Medical Services, at (213) 763-8342 or Director, District Nursing Services at (213) 763-8374. I. PURPOSE The Student Medical Services (SMS) and the District Nursing Services (DNS) have been working in collaboration with the LAUSD Safety Managers including School Operations and the Office of Environmental Health and Safety to coordinate preparedness plans and response procedures in the event of biological or chemical terrorist incidents. In addition to the Safe School Plan and other Emergency and Disaster Manuals developed by these offices, this bulletin is developed to inform the District staff and share with them the outline of the bioterrorism preparedness and response plan developed by SMS and DNS to address health issues. A separate manual developed by the DHS Emergency Medical Services (EMS) has been provided to school physicians and nurses. While these plans are being developed, it is important to know that in the event of a terrorist incident, the law enforcement and public health agencies are the leaders and we will look to them for direction and guidance. II. BACKGROUND Bioterrorism (BT) is the use of biologic agents such as bacteria, viruses, parasites or biological toxins to intentionally produce disease or intoxication in a susceptible population to meet terrorist aims. Chemical terrorism (CT) employs certain classes of chemical compounds as weapons of mass destruction. BT or CT acts may range from dissemination of aerosolized anthrax spores to food product contamination, and predicting when and how such an attack might occur is not possible. Although paramedics, emergency room (ER) physicians, primary health care providers and the local health department will probably be the first to observe and report unusual illnesses - 96 - Student Health and Human Services -2- BULLETIN NO. Z-72 September 3, 2002 or injuries, school physicians and nurses may occasionally encounter such cases in school settings. Early detection of and response to biological or chemical terrorism are crucial, and preparedness for terrorist-caused outbreaks and injuries are an essential component of the U.S. public health surveillance and response system. Terrorists might use combination of agents. The Center for Disease Control (CDC) has developed a list of critical BT and CT agents, the details of which are available in the EMS manual provided to school physicians and nurses. A. Environment Where Exposure May Have Occurred Law enforcement and public health officials work together to investigate the environment including envelopes and packages suspected of containing anthrax or other biological agents. Powder and other specimens collected from these sources usually are analyzed through the Public Health Laboratory Network. As a part of the investigation, environmental sampling may be necessary where the exposure may have occurred. Testing of the environment is useful for detecting trace amounts of anthrax spores. Specimens obtained may include samples of air and/or swabs of material on various surfaces. The law enforcement and public health agencies will arrange for processing these samples. B. Clean-up of Contaminated Areas The U.S. Environmental Protection Agency with the help from other federal agencies and departments, including the CDC is responsible for environmental and clean-up issues. Federal agencies in conjunction with local and state agencies will determine the best approach to the cleanup. C. Biological (BT) Agents BT agents include bacteria, viruses and toxins among others. Anthrax, Small Pox, Plague, Botulinum Toxin are some of the examples of BT agents. BT incidents are more likely to be covert because of the delay between exposure and onset of illness, known as the incubation period. Thus, BT agents present different challenges, as there is no immediate impact. For example, persons are unknowingly exposed and an outbreak is suspected only upon recognition of unusual disease clusters or symptoms. BT may also occur as announced events in which persons are warned that an exposure has occurred. D. The Following are Some of the Examples of Indicators of a BT Attack: 1. Large numbers of ill persons with similar diseases or syndromes. 2. Unexplained disease, syndrome or death(s). - 97 - BULLETIN NO. Z-72 -3- Student Health and Human Services September 3, 2002 3. Unusual illness in a population. 4. Single case of disease caused by an uncommon agent. 5. Multiple unexplained diseases in the same patient. 6. Diseases transmitted through aerosol, food or water suggestive of sabotage. E. Detection of BT-Related Outbreaks The possibility of a BT event should be ruled out with the assistance of the FBI and state and local health officials. Rapid response to a BT-related outbreak requires prompt identification of its onset. The most critical step in response is early recognition that something unusual is occurring. Response to a BT event will require a concerted effort of physicians, the health department, health care facilities, laboratories and others to: identify the BT agent used; treat affected individuals; prevent additional transmission; and bring the situation under control. Primary care providers and emergency room physicians will likely be the first medical responders. F. Chemical (CT) Agents CT agents that might be used by terrorists range from warfare agents to toxic chemicals commonly used in industry. Like other substances, CT agents may exist as solids, liquids or gases, depending on temperature and pressure. These are six types of chemical agents, which include nerve agents, cyanide, vesicants or blistering agents, Mustard and Lewisite. CT incidents are more likely to be overt attacks but can also be delivered covertly through contaminated food and water. The effects usually are immediate and obvious because CT agents are absorbed through inhalation or by absorption through the skin or mucous membranes. Such attacks elicit immediate response from police, fire and EMS personnel. Biological effects such as eye or skin injury, and injury to lungs and other systemic effects can occur following exposure to chemical agents dispersed as solids, liquids or vapor. Evacuation and triage are integral to the response along with decontamination and medical management. In the event of a biological or chemical emergency, the state and local public health departments will inform the public about the action(s) they should take. CDC does not recommend hoarding antibiotics or buying a facemask. G. Radiation Accident Radioactive materials are among many kinds of hazardous substances emergency responders might have to deal with. Radiation is energy that comes from a source and travels through some material or space. Light, heat, etc., are types of radiation. Unstable atoms produce ionizing radiation. Unstable atoms are said to be radioactive. Alpha, Beta and Gamma are three types of ionizing radiation. Alpha is highly - 98 - Student Health and Human Services -4- BULLETIN NO. Z-72 September 3, 2002 penetrating and personal protective equipment can provide some protection. Gamma rays are very penetrating and can be produced from radioactive decay and a nuclear weapon explosion or reactor accident. Regardless of how radiation accident happens, three types of radiation-induced injury can occur: 1. External radiation: when all or part of the body is exposed to penetrating radiation from an external source. 2. Radiation contamination occurs where material containing radioactive material is deposited on skin, clothing or other places where it is undesirable. Contamination means that radioactive materials in the form of gases, liquids or solids are released into the environment and contaminate people externally on skin, internally in lungs, gut or wound, or both. 3. The third type of radiation injury is incorporation of radioactive material, which refers to the uptake of radioactive materials by body cells, tissues and organs. These injuries can occur along with illness or physical injury and in such instances serious medical problems have a priority over concerns about radiation. Law enforcement and public health and safety agencies are involved in responding to these emergencies. III. ROLES AND RESPONSIBILITIES A. Schools 1. Review disaster and emergency response plans, and assure appropriately designated staff is familiar with their content and strategies. 2. Conduct periodic practice drills and tabletop exercise. 3. Establish internal and external lines of communication. 4. Assess emergency call-up plans including activating 911 and assure that these are supported with communication and transportation strategies. 5. Report suspicious cases of illnesses, unusual illness clusters to the CD nurse (213) 763-8381, who, in turn, would notify the situation to the Directors of Student Medical Services (SMS) and District Nursing Services (DNS). 6. Employee situations are to be referred to the Medical Director, Employee Health, at (213) 241-6326, after logging with the CD nurse (213) 763-8381 at the Central Office. The following are some examples of unusual illness/occurrence: a) Atypical patterns of hospitalization that are known to you such as sepsis or shock. - 99 - BULLETIN NO. Z-72 -5- Student Health and Human Services September 3, 2002 b) Sudden unexplained deaths in healthy students/employees. c) Aberrations in absenteeism due to illness among students/employees. d) Emergency transfers for illness/injuries occurring during the routine school day. e) In the event of a suspected chemical /biological terrorist incident at a school site, follow the directions of the public health and law enforcement agencies either provided directly to schools or coordinated by your district/school administrative staff. f) Coordinate with Crisis teams for debriefing sessions as needed. For additional information on school safety plans, please refer to the Safety Grams and the Safe School Planning Guide issued by the LAUSD Office of Environmental Health and Safety. As of December 3rd, 2001, some of the Safety Grams available are: a) Safe Mail Handling Procedures (October, 2001). b) Short Terms Actions on Emergency Preparedness for Schools (October, (2001). c) Response to Discovery of Suspicious Substances (white powder, etc.) (October, 2001). d) Procedures for Responding to Toxic Air Release (November, 2001). B. District Health Care Providers – School Physicians and Nurses: 1. Develop an increased awareness of the ongoing threat of bioterrorism. 2. Build capacity with knowledge and skills to address emerging BT agents and the clinical syndromes. 3. Be available to the school/administrative staff in assigned district(s). Physicians may provide medical consultation, liaise with student/hospital physicians and facilitate referrals as indicated. 4. Become familiar with important emergency phone numbers and hospital referral sites. 5. Report suspicious cases to the SMS/CD office. 6. Know the school disaster and safety/emergency plans and participate in school disaster/emergency drills. 7. Clinicians (physicians/nurse practitioners) are not to prescribe prophylactic antibiotics unless otherwise directed by the Public Health Department via the SMS director. C. District Nursing Services (DNS): 1. Work closely with the Director of Student Medical Services (DSMS) in monitoring the disease patterns in schools by: - 100 - Student Health and Human Services -6- BULLETIN NO. Z-72 September 3, 2002 a) Forwarding a weekly update on the infectious disease data compiled for cases reported from schools. b) Apprising the DSMS of sentinel conditions and outbreaks on a real-time basis and with timely follow-ups. Examples of sentinel diseases are TB, meningitis and other highly contagious conditions. c) Notifying DSMS of any unusual clusters, atypical illnesses, increase in number of students with gastroenteritis, flu, rash with fever, etc. d) Monitoring communicable diseases, outbreaks and unusual illnesses in the District. 2. Conduct BT-related disease outbreak investigation in consultation with DHS, DSMS and DDNS. D. Student Medical Services: 1. Coordinate educational activities for the District physician and nursing staff. 2. Assist DHS with public educational activities when requested. 3. As necessary, assist DHS with surveillance activities for cases identified in the District. 4. Consult with/report to DHS any unusual disease events in the District when such reports are received from schools/CD nurses. 5. Monitor with DNS in the event of any the disease patterns in the District. 6. When requested by DHS, assist with monitoring of school absenteeism due to illnesses. 7. Work closely with the District's safety managers to coordinate activities. 8. Interface with the Office of Environmental Health and Safety (OEHS) to identify and address routine and atypical environmental health concerns; consult with DHS as necessary. 9. Communicate with student physicians/families as necessary. E. Role of School District in a Community-Wide Effort See Appendix A for possible roles of District staff and facilities as a part of community-wide effort in the event of a terrorist incident. For individual questions/instructions, please see Appendix B adapted from the Los Angeles County Health Department's Bioterrorism Preparedness and Response brochure. IV. HELPING CHILDREN, TEENS AND THEIR FAMILIES A. Be honest and give age-appropriate and developmentally appropriate explanations about the traumatic event. Recognize that a tragic event could elevate psychological or physical symptoms such as headaches, abdominal pain or chest pain in children and - 101 - BULLETIN NO. Z-72 -7- Student Health and Human Services September 3, 2002 teens, who are already depressed and anxious. Anger can be a sign of anxiety in children and teens. It is not unusual to see emerging post-traumatic mental/behavioral problems among students impacting their learning. Some children, teens and their families may need professional help and counseling. The following resources could be useful for additional information: 1. American Academy of Child and Adolescent Psychiatry: www.aacap.org Information on "Posttraumatic Stress Disorder", "Children and Grief", "Helping Children After a Disaster", etc., are available in English and Spanish. 2. National Association of School Psychologists: www.nasponline.org "Tips for Parents and Teachers on Helping Children Cope in Unsettling Times" 3. American Red Cross: www.redcross.org Counseling information and brochures in several languages. B. Additional Resource: For individuals seeking emotional or mental health assistance: Mental Health 24-Hour Crisis Hotline 1-800-854-7771 For individuals exposed to suspicious material (mail, powder, etc.: Refer to local law enforcement. If in school, follow the District procedure. For latest information on bioterrorism: Bioterrorism and Preparedness Response: www.labt.org For health alerts, advisories and updates on bioterrorism: CDC, Public Health Emergency Preparedness and Response: www.bt.cdc.gov C. Reference: The following reference materials were used for developing this bulletin: MMWR, April 21, 2000/Vol.49/No. RR-4 United States Army Medical Research Institute of Chemical Defense APIC Bioterrorism Task Force Document www.orau.gov www.nea.org www.bt.cdc.gov www.naspweb.org www.labt.org www.aap.org ww.childrennow.org www.aaets.org ww.childrensdefensefund.org www.fema.gov ### - 102 - LOS ANGELES UNIFIED SCHOOL DISTRICT REFERENCE GUIDE ROUTING Local District Superintendents TITLE: WEST NILE VIRUS PRECAUTIONS Local District Operations Coordinators NUMBER: REF-1304 Safety/Attendance Coordinators Local District Facilities Directors ISSUER: Office of Environmental Health and Safety, Principals Plant Managers Maintenance and Operations, and Student Nursing Administrators Medical Services Student Medical Services Employee Health Services DATE: September 16, 2004 PURPOSE: The purpose of this Reference Guide is to describe the responsibilities and specific actions of District offices in minimizing the risk of exposure to West Nile Virus (WNV) among LAUSD students and staff. MAJOR None CHANGES: INSTRUCTIONS: The County Department of Health Services reports that the WNV is spread to humans most commonly through the bite of a mosquito which has been infected with the virus. Most mosquitoes do not carry the virus and the risk of serious human illness is extremely low, with more than 80% of those exposed to the virus experiencing no symptoms at all. Those that develop symptoms may experience headaches, fever, body aches, skin rash or swollen lymph glands within 3 – 14 days after a bite from an infected mosquito and generally those symptoms last a few days. With the rare exception of transmission via blood donation or organ transplantation, individuals infected with WNV are not contagious to others. The elderly are at greatest risk for developing severe disease such as encephalitis and meningitis. The symptoms of severe infection include headache, high fever, stupor, disorientation, coma, tremors, convulsions, muscle weakness and paralysis. Less than 1% of those infected with WNV will develop severe disease. Among those who have developed a severe illness with WNV, between 3% and 15% have died and most of the deaths have occurred among the elderly. It is imperative that every effort is made to eliminate or avoid conditions conducive to mosquito breeding on school sites. These conditions include standing pools of water on athletic fields, in tree wells, or elsewhere on the grounds, small amounts of water in birdbaths, old tires, jars, cans, roof drains, air conditioning pans, etc. Mosquitoes will breed in as little as ½ inch of non- flowing water. Reference Guide No. REF -1304 Page 1 of 4 September 16, 2004 Office of Environmental Health and Safety LOS ANGELES UNIFIED SCHOOL DISTRICT REFERENCE GUIDE Following are the responsibilities and actions of school and central office personnel in reducing the risk of exposure to WNV among students and staff. Site Administrator The Site Administrator has overall responsibility for ensuring that site conditions do not encourage mosquito breeding, and that staff report any associated problems to M&O. Specifically, the Site Administrator will direct the Plant Manager to fully implement those actions specified under "Plant Manager" below, and will: Ensure staff keep unscreened doors/windows closed and report any broken screens, windows and doors to the Plant Manager. Encourage students and staff to stay indoors at dawn, dusk and in the early morning or evening, and to wear long-sleeved shirts and long pants when outdoors, and to use non-aerosol insect repellant before and after school in accordance with label instructions (staff should be informed that if repellant is used by students in a manner inconsistent with label instructions, it should be confiscated until retrieved by a parent or guardian). Report any health complaints potentially associated with mosquito spraying by County or City agencies to Student Medical Services at (213) 763-8342 or District Nursing Services at (213) 763-8374. Advise staff against the application of pesticides on campus (only the District's Pest Management Technicians are authorized to apply pesticides on campus in accordance with the Integrated Pest Management Policy). Plant Manager The Plant Manager is responsible for inspecting the school to ensure site conditions do not encourage mosquito breeding and taking necessary corrective action, such as reporting the problem to M&O. Specifically, the Plant Manager is responsible for: Inspecting the site frequently to report any non-flowing water problems, such as plumbing leaks, air conditioner condensation, standing or stagnant water to M&O Trouble Call Desk at (213) 745-1600. Using proper procedures to dispose of dead birds or squirrels using gloves or bag to pick up the carcass and double bagging the carcass (see OEHS Safety Alert No. 04-07, West Nile Virus Precautions) and reporting dead birds or squirrels immediately to the California Department of Health Services (CDHS) WNV Hotline at (877) 968-2473 Reference Guide No. REF -1304 Page 2 of 4 September 16, 2004 Office of Environmental Health and Safety LOS ANGELES UNIFIED SCHOOL DISTRICT REFERENCE GUIDE Ensuring grounds and tree wells are not being over-watered resulting in standing pools of water. If so, water schedules should be adjusted and/or a trouble call should be placed to have low areas filled in. Ensuring water runoff does not pool when hosing down lunch and other areas. A trouble call may need to be made to request fill for low areas. Ensuring that gutters, roof drains and underground drains are free of obstructions. Reporting any broken screens, windows and doors to the M&O Trouble Call Desk. Emptying or changing water at least every four days in birdbaths, fountains, and other decorative containers with standing pools of water. Requesting an inspection by the District's Integrated Pest Management Coordinator at (213) 745-1427 if there is a pond, spring, fountain, bird bath, etc., to ensure that there are no mosquito breeding conditions. Notifying the Greater Los Angeles County Vector Control District at (562) 944-9656 if potential breeding grounds (e.g., abandoned pools, drainage channels or street gutters with standing water) are observed on adjacent non-District properties. Maintenance and Operations (M&O) Branch The Maintenance and Operations Branch is responsible for corrective actions to address mosquito breeding concerns identified by school staff. Specifically, M&O is responsible for: Repairing broken screens or doors to prevent mosquitoes from entering occupied areas. Utilizing integrated pest management methodologies to avoid or eradicate mosquitoes and breeding conditions. Inspecting suspect ponds or standing water and implementing necessary action to minimize mosquito breeding. Office of Environmental Health and Safety (OEHS) The Office of Environmental Health and Safety (OEHS) is responsible for conducting periodic inspections to assess compliance with applicable health and safety standards. Specifically OEHS is responsible for: Inspecting school sites, noting conditions that may promote mosquito breeding, and reporting such conditions to the Site Administrator and M&O Trouble Call Desk at (213) 745-1600 while conducting routine inspections. Reporting any broken screens or doors to the Site Administrator and M&O Trouble Call Desk. Reference Guide No. REF -1304 Page 3 of 4 September 16, 2004 Office of Environmental Health and Safety LOS ANGELES UNIFIED SCHOOL DISTRICT REFERENCE GUIDE Responding to complaints or questions regarding WNV, and if necessary, referring these to the appropriate office or regulatory agency for follow-up action District Nursing Services District Nursing Services is responsible for tracking WNV incidents involving District students and staff and reporting these to the appropriate agencies. Specifically, District Nursing Services is responsible for: Responding to medical inquiries regarding WNV and if necessary referring these to Student Medical Services or appropriate agency for follow-up action. Serving as liaison between the District and County Department of Health Services. Referring to the Integrated Pest Management Coordinator at (213) 745- 1427 issues associated with pesticide spraying by City or County agencies. The Integrated Pest Management Coordinator may in turn contact agency representatives. RELATED OEHS Safety Alert No. 04-07, West Nile Virus Precautions may be RESOURCES: downloaded from http://www.lausd-oehs.org. "LAUSD Pest of the Month Program Publications Nos. 15, 17, and 18, West Nile Virus Information." These publications have been distributed to all Plant Managers. They are also available through the IPM Program Coordinator at (213) 745-1427. County of Los Angeles Department of Health Services West Nile Virus Website at http://www.lapublichealth/org/acd/index.htm/ Other helpful websites include: http://www.cdc.gov/ncidod/dvbid/westnile/ index.htm; http://www.westnile.ca.gov/; http://www.wipeoutestnile.com; http://vector.ucdavis.edu/arbo.html ASSISTANCE: Inquiries may be directed to OEHS at (213) 241-3199 or Pest Management at (213) 745-1435. Medical questions may be directed to Student Medical Services at (213) 763-8342 or District Nursing Services at (213) 763-8374. Reference Guide No. REF -1304 Page 4 of 4 September 16, 2004 Office of Environmental Health and Safety