Preventing the Spread of Influenza (the Flu) in Child Care Settings: Guidance for Administrators, Care Providers, and Other Staff

Symptoms

Symptoms of flu include fever (usually high), headache, extreme tiredness, dry cough, sore throat, runny or stuffy nose, and muscle aches. Nausea, vomiting, and diarrhea also can occur, but are much more common in children than adults.

Spread of the Flu

Flu viruses are thought to spread mainly from person to person through coughing or sneezing of people with influenza. Sometimes people may become infected by touching something with flu viruses on it and then touching their mouth or nose. People with influenza can potentially infect others beginning 1 day before symptoms develop and up to 5 days after becoming sick. That means that you may be able to pass on the flu to someone else before you know you are sick, as well as while you are sick.

Preventing Spread of the Flu in Child Care Settings

Yearly flu vaccination is the first and most important step in protecting against this serious disease. Two kinds of flu vaccine are available in the United States:

• The "flu shot" — an inactivated vaccine (containing killed virus) that is given with a needle, usually in the arm. The flu shot is approved for use in people older than 6 months, including healthy people and people with chronic medical conditions (such as asthma, diabetes, or heart disease). See also Questions & Answers: Seasonal Flu Shot.
• The nasal-spray flu vaccine — a vaccine made with live, weakened flu viruses that do not cause the flu (sometimes called LAIV for "live attenuated influenza vaccine" or FluMist®). LAIV (FluMist®) is approved for use in healthy* people 2-49 years of age who are not pregnant. See also Questions & Answers: Nasal Spray Flu Vaccine.

Yearly flu vaccination should begin as soon as vaccine is available and continue throughout the influenza season, into December, January, and beyond. While influenza outbreaks can happen as early as October, influenza activity peaks most often in February.

About 2 weeks after vaccination, antibodies that provide protection against influenza virus infection develop in the body. Vaccination, along with other measures, also may help to decrease the spread of influenza among children in the child care setting and among care providers.

Recommend influenza vaccination for children and care providers in child care settings.

Vaccination is the best method for preventing flu and its potentially severe complications in children.

CDC recommends that all children aged 6 months up to their 19th birthday get a flu vaccine.

Certain groups of children are at increased risk for flu complications. For more information about children at greater risk of serious flu-related complications visit Children and the Flu Vaccine.

CDC also recommends that people in contact with certain groups of children get a flu vaccine in order to protect children from the flu.

For more information about those recommended for vaccination visit Persons for Whom Annual Vaccination is Recommended.

Children 6 months up to 9 years of age getting a flu vaccine for the first time will need two doses of vaccine the first year they are vaccinated. If possible, the first dose should be given as soon as vaccine becomes available. The second dose should be given 28 or more days after the first dose. The first dose "primes" the immune system; the second dose provides immune protection. Children who only get one dose but who need two doses can have reduced or no protection from a single dose of flu vaccine. Two doses are necessary to protect these children. It usually takes about two weeks after the second dose for protection to begin. For more information see CDC"e;s Childhood Immunization Schedule.

Remind children and care providers to wash their hands or use alcohol-based hand cleaners, and make sure that supplies are available to prevent the spread of germs.

• Encourage care providers and children to use soap and water to wash hands when hands are visibly soiled, or an alcohol-based hand cleaner when soap and water are not available and hands are not visibly soiled.
• Encourage care providers to wash their hands to the extent possible between contacts with infants and children, such as before meals or feedings, after wiping the child"e;s nose or mouth, after touching objects such as tissues or surfaces soiled with saliva or nose drainage, after diaper changes, and after assisting a child with toileting.
• Encourage care providers to wash the hands of infants and toddlers when the hands become soiled.
• Encourage children to wash hands when their hands have become soiled. Teach children to wash hands for 15-20 seconds (long enough for children to sing the "Happy Birthday" song twice).
• Oversee the use of alcohol-based hand cleaner by children and avoid using these on the sensitive skin of infants and toddlers.
• Rub hands thoroughly until the alcohol has dried, when using alcohol-based hand cleaner.
• Keep alcohol-based hand cleaner out of the reach of children to prevent unsupervised use.
• Ensure that sink locations and restrooms are stocked with soap, paper towels or working hand dryers.
• Ensure that each child care room and diaper changing area is supplied with alcohol-based hand cleaner when sinks for washing hands are not readily accessible. Alcohol-based hand cleaner are not recommended when hands are visibly soiled.

Keep the child care environment clean and make sure that supplies are available.

• Clean frequently touched surfaces, toys, and commonly shared items at least daily and when visibly soiled.
• Use an Environmental Protection Agency (EPA)-registered household disinfectant labeled for activity against bacteria and viruses, an EPA-registered hospital disinfectant, or EPA-registered chlorine bleach/hypochlorite solution. Always follow label instructions when using any EPA-registered disinfectant. If EPA-registered chlorine bleach is not available and a generic (i.e., store brand) chlorine bleach is used, mix ?? cup chlorine bleach with 1 gallon of cool water.
• Keep disinfectants out of the reach of children.

Remind children and care providers to cover their noses and mouths when sneezing or coughing.

• Advise children and care providers to cover their noses and mouths with a tissue when sneezing or coughing, and to put their used tissue in a waste basket.
• Make sure that tissues are available in all nurseries, child care rooms, and common areas such as reading rooms, classrooms, and rooms where meals are provided.
• Encourage care providers and children to wash their hands or use an alcohol-based hand rub as soon as possible, if they have sneezed or coughed on their hands.

Observe all children for symptoms of respiratory illness

Observe closely all infants and children for symptoms of respiratory illness. Notify the parent if a child develops a fever (100˚F. or higher under the arm, 101˚F. orally, or 102˚F. rectally) or chills, cough, sore throat, headache, or muscle aches. For children 4 months or younger, the lower rectal temperature of 101˚F or under the arm of 100˚F is considered a fever threshold. Send the child home, if possible, and advise the parent to contact the child"e;s doctor.

• Infants and young children can become quite ill with influenza very quickly, and might require urgent medical attention and possibly hospitalization. If a child has difficulty breathing, is lethargic, or appears to be worsening rapidly, consider calling a physician or 911 in addition to notifying a parent.

Encourage parents of sick children to keep their children home. Encourage sick care providers to stay home.

• Encourage parents of sick children to keep the children home and away from the child care setting until the children have been without fever for 24 hours, to prevent spreading illness to others. Similarly, encourage sick care providers to stay home.

Consult your local health department when increases in respiratory illness occur in the child care setting.

• Consult with your local or state health department for recommendations to prevent the spread of respiratory illness.

Resources

The following resources provide information about flu that may be adapted for use in the child care setting:

CDC Resources

• Seasonal Flu Information for Schools & Childcare Providers
• About the Flu: Questions & Answers
• Persons for Whom Annual Vaccination is Recommended
• Persons Who Should Not Be Vaccinated

State and Local Health Departments

• Some state and/or local health departments have information for child care centers. Contact the local or state health department by phone or the state health department through the state"e;s web site.

Other Resources

• The National Resource Center for Health and Safety in Child Care has developed guidance for child care programs: Caring for Our Children: National Health and Safety Performance Standards Guidelines for Out-of-Home Child Care Programs, Second Edition.

* "Healthy" indicates persons who do not have an underlying medical condition that predisposes them to influenza complications.