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Infection Prevention and Control in the School Setting
In Schools and Early Childhood programs, a variety of actions can be used every day to prevent the spread of infectious diseases, including the virus that causes COVID-19.
Many factors increase the risk of transmission of communicable diseases at school. These include close contact to others, sharing of objects that may serve as vehicles of transmission, inadequate personal hygiene supplies or routines to use them, and students or staff who attend school with symptoms of infectious disease.
The following topics are covered:
Transmission of Communicable Diseases
Knowing how communicable diseases are spread is key to implementing proper infection prevention and control practices. The spread of an infectious disease requires:
- a source of infection (places e.g., sinks or surfaces or people e.g., human skin or respiratory secretions)
- a route of transmission
- a host (person) susceptible to the infection
Germs travel in a few general ways: through contact (e.g., touching), sprays and splashes, inhalation, and sharps injuries (e.g., when someone is accidentally stuck with a used needle or sharp instrument).
- Contact moves germs by touch. For example, peoples' hands become contaminated by touching germs present on high touch surfaces. If proper hand hygiene is not performed, the germs on the person's contaminated hands spread to a susceptible person.
- Sprays and splashes occur when an infected person coughs or sneezes, creating droplets which carry germs short distances (within approximately 6 feet). These germs can land in mucous membranes (e.g., eyes, nose, or mouth) and can cause infection in people who are susceptible.
- Inhalation occurs when germs are aerosolized in tiny particles that survive on air currents. These particles can be carried great distances and reach a susceptible person. Airborne transmission can occur when an infected person coughs, talks, or sneezes germs into the air.
- Sharps injuries can lead to infections when bloodborne pathogens enter a person through a skin puncture from a used needle or sharp instrument.
Infection Control Measures
The spread of communicable diseases can be controlled. Standard Precautions are common sense practices to prevent the spread of infection between people. Standard precautions include the following: proper hand/respiratory hygiene and cough etiquette; appropriate personal protective equipment; cleaning and disinfecting; and proper handling of needles and other sharps. These are all effective methods for preventing the spread of most infectious diseases and should be implemented and practiced consistently in schools.
CDC Standard Precautions are the minimum infection prevention practices that apply to all settings providing direct care, regardless of suspected or confirmed infection status of the person. This includes the school health office where healthcare is delivered. In addition, Standard Precautions can be applied to personal care services provided to students such as toileting, diapering or feeding. These practices are designed to minimize the spread of infection among school health personnel, students, and staff)
Hand/Respiratory Hygiene and Cough Etiquette
The number one way to prevent the spread of communicable diseases is frequent and thorough hand washing using soap and water or hand sanitizer with at least 60% alcohol (soap and water are preferred when hands are visibly dirty). When done correctly, hand washing will help students, school staff and visitors avoid spreading and receiving germs.
- Everyone should perform hand hygiene regularly and especially before eating, after recess, after using the restroom, and after coughing or sneezing into a tissue.
- In addition, school health personnel should perform hand hygiene:
- Before and after working with a student including medication administration or treatments.
- Immediately after touching blood, body fluids, nonintact skin, mucous membranes, or contaminated items (even when gloves are worn during contact).
- Immediately after removing gloves, after touching objects or using equipment in the health office.
Everyone should engage in respiratory hygiene to decrease the risk of spreading respiratory illnesses by covering the mouth and nose with a tissue when coughing or sneezing and disposing the of use of tissues in a wastebasket. Provide instructional signage or handouts at throughout the school and in the school health office.
Respiratory hygiene also has an environmental component, so as space permits, physically distance those students with respiratory symptoms from others as soon as possible in the health office as well as having these students' mask.
Personnel Protective Equipment
Personal Protective Equipment (PPE) refers to wearable equipment that is intended to protect school health personnel from exposure to or contact with infectious agents. Examples include gloves, gowns, face masks, respirators, goggles, and face shields. The selection of PPE is based on the nature of the health care interaction and potential for exposure to blood, body fluids or infectious material.
All school health personnel or those assigned to provide health care services should have on-going training for proper use of PPE. This will include identifying situations with potential risk for exposure, and how to properly put on, take off and dispose of PPE in a manner that protects themselves, the person receiving care, and others.
Related to COVID-19, policies for use of masks in school nurse offices should follow recommendations outlined in the Infection Control: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) guidance | CDC.
Transmission-Based Precautions are the second tier of basic infection control practices. These practices are to be used in addition to Standard Precautions with persons who may be infected or colonized with certain infectious agents requiring additional precautions to prevent infection transmission.
CDC states some procedures performed on patients are more likely to generate higher concentrations of infectious respiratory aerosols than coughing, sneezing, talking, or breathing. These aerosol generating procedures (AGPs) potentially put healthcare personnel and others at an increased risk for pathogen exposure and infection. In the school setting, open suction of airways is an Aerosol Generating Procedure (AGP) but there is limited data regarding nebulizations as an AGP. Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic
School health personnel should implement additional precautions (i.e., Contact, Droplet, and/or Airborne Precautions) for those with documented or suspected diagnoses (e.g., COVID-19, influenza or influenza like illness, RSV) when there is risk of contact with respiratory droplets by someone who is coughing, sneezing, or talking or performing respiratory procedures as appropriate.
Specific information about the types of Personal Protective Equipment and consideration for use within the school setting is available.
Environmental Cleaning and Disinfection
Schools and ECE programs should clean surfaces at least once a day to reduce the risk of spreading germs by touching surfaces. Cleaning with products containing soap or detergent reduces germs on surfaces by removing contaminants and decreases risk of infection from surfaces.
Disinfecting using U.S. Environmental Protection Agency (EPA)'s List N disinfectants, kills any remaining germs on surfaces, which further reduces any risk of spreading infection. School nurses should work with their custodial staff to develop protocols for the proper use of cleaning and disinfecting products by school staff. Only school staff who are properly trained should be using these products; students should not be using these cleaning and disinfecting products at school. Schools should also avoid products brought from home for school use.
Since the school health office is likely to have sick persons with potential infectious diseases like COVID-19 or influenza, the health office space should be cleaned and disinfected daily. In addition, you may need to clean and disinfect surfaces more frequently based on the volume of persons seen daily and/or the degree of soiling or the risk of severe illness for specific students (e.g., immune compromised) seen in the health office. Equipment used for direct care needs to be cleaned with a disinfectant after each use. For more information:
- CDC When and How to Clean and Disinfect a Facility
- Hennepin County Infectious Disease Manual: Cleaning, Sanitizing, Disinfecting (Section 2 - Guidelines: environment)
Ventilation is a key component impacting the environment within the school health office to help reduce transmission of infectious disease. One strategy includes the use of portable air cleaners that use high-efficiency particulate air (HEPA) filters to enhance air cleaning wherever possible, especially in higher-risk areas such as a school health office or sick/isolation room.
Although the use of needles in the health office may not be a common practice, standard precautions should always be used. Examples include using needles and syringes for a single person only (this includes manufactured prefilled syringes and cartridge devices such as insulin pens) and the availability of appropriate sharps disposal.
The Healthcare Infection Control Practices Advisory Committee (HICPAC) which is an advisory group to CDC has described a core set of infection prevention and control practices that are required in all healthcare settings, regardless of the type of healthcare provided and are applicable across the continuum of healthcare settings.
- Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings –Recommendations of the HICPAC.
One of the additional items included in the core practices is to provide job-specific, infection prevention education and training to all healthcare personnel for all tasks.