By Martin Hodgson

Introduction

The transmission of infectious diseases in early years is a significant risk. Coughs, colds and respiratory infections are relatively commonplace, especially at certain times of the year, and outbreaks of serious infections, such as E.coli, can cause severe illness.

Many infectious diseases have the capacity to spread rapidly within a care provision or nursery school. Early years staff must always be vigilant to this threat.

In some ways, childcare provisions are an ideal environment for the spread of infectious diseases because of the difficulties in maintaining hygiene with such a young age group.

Where children spend time together in close proximity, and share toys and equipment, the transfer of infection is hard to avoid. High standards of hygiene and infection control are therefore required if transmission is to be prevented.

The importance of infection control

Infection control is the name given to policies and procedures intended to prevent the spread of infectious diseases. Everyone in an early years provision is at risk of spreading infection if they do not take sensible precautions. Those who come into contact with bodily fluids, such as urine, faeces, vomit or sputum, are at most risk. Such substances may contain micro-organisms, such as bacteria and viruses. Also at risk of spreading infection are those involved in food preparation and handling.

To combat the spread of such diseases, early years managers must ensure that the environment is kept in a clean and hygienic state and that staff comply with effective hygiene practice.

It is important to have an up-to-date infection control policy in place. Find a template policy here.

Hygiene and the Early Years Framework

In England, hygiene is covered under Section 3: The Safeguarding and Welfare Requirements of the Early Years Foundation Stage (EYFS) Statutory Framework, updated in March 2017.

Section 3.54 requires providers to ensure that their premises are “fit for purpose” and comply with the requirements of relevant health and safety legislation. The framework specifies compliance with hygiene requirements.

Section 3.60 requires providers to ensure there are an adequate number of toilets and hand basins available and that there are suitable hygienic changing facilities for changing any children who are in nappies. The need for “clean bedding, towels, spare clothes and any other necessary items” to always be available is also specified.

Elsewhere, the framework provides guidance on the need to deal effectively with ill children and to minimise the spread of infectious disease by ensuring that the environment is kept in a clean and hygienic condition.

To support the framework, Public Health England published an updated guidance, Health Protection in Schools and Other Childcare Facilities, on the GOV.UK website.

In Scotland, the National Care Standards for Early Education and Childcare Up to the Age of 16 apply. Standard 2 states that children should be cared for in a safe and hygienic premises.

Handwashing

Unwashed or poorly washed hands provide an effective transfer route for micro-organisms such as bacteria. Effective handwashing is therefore perhaps the single most effective way to prevent the spread of disease. It removes the micro-organisms from the hands and prevents them being transferred to another person or to a toy or piece of equipment.

All staff and children should be encouraged to wash their hands regularly and thoroughly, including after going to the toilet, after handling any body fluids, waste or soiled items, before handling foodstuffs and after dirty play, indoors or outdoors.

Sinks and soap

To enable effective handwashing, managers should ensure that the premises are equipped with an adequate number of sinks that:

  • are easily accessible

  • have robust, easy-to-use dispensers for liquid soaps

  • have a supply of disposable towels.

Liquid soaps are preferable to bar soaps which can rapidly become soiled. Disposable paper towels are preferable to linen towels which can also become soiled and damp. Thorough drying of the hands should be encouraged after washing as this further reduces the number of micro-organisms that remain on the hands.

Staff are advised to:

  • keep nails short and clean

  • remove nail varnish

  • remove jewellery, ie rings with stones or ridges, wristwatches or bracelets before washing hands

  • cover visible cuts and abrasions with a water proof dressing.

It is recommended to place signs and posters by sinks reminding people of the importance of effective hand hygiene.

Alcohol rubs and gels

Antibacterial gels and rubs were originally introduced to provide higher levels of infection control in hospitals but these have now become popular as an additional form of defence against infections. However, they must be used with care.

Antibacterial gels or hand sanitisers are useful in circumstances where normal soap, water and paper towels are not available, such as during farm visits, or where additional protection is required. However, they should never take the place of routine handwashing with soap and water. Hand gels do not kill some disease carriers, for example Norovirus, and may give a false sense of security. They are also ineffective where hands are visibly soiled or where they are wet.

Where a gel is used managers should ensure it is compliant with BS EN1500: Standard for Efficacy of Hygienic Handrubs Using a Reference of 60% Isopropyl Alcohol.

Making handwashing fun

Young children can sometimes be reluctant to wash their hands and may need encouragement. Making handwashing fun by using foaming soaps is one idea, as is the use of songs or poems to ensure that they wash their hands for long enough. More sophisticated toy handwashing products are available from specialist providers which mix handwashing and play with health education.

Maintaining a clean environment

To combat the spread of infection, early years managers must ensure that the environment is kept clean. All staff have a responsibility to help keep the premises clean and tidy and to identify areas that fall below acceptable or safe standards.

Effective cleaning arrangements should be in place. These should be supported by regular quality assurance checks to ensure standards are being met.

Suitably trained cleaning staff should be employed, either directly or through a contractor arrangement. Schedules of cleaning should be set up.

Both kitchens and toilets require particular attention.

Toilets, washrooms and showers should be kept clean and free from dirt and grime at all times. Floors and walls should be impermeable and easy to clean and cracks and broken surfaces should be repaired as soon as possible.

Poor standards of cleanliness in kitchens are associated with ill health and can lead to food poisoning. Provisions must ensure high levels of kitchen cleanliness, and kitchen design should provide enough working space for staff to carry out all tasks hygienically.

Separate cleaning equipment should be used in kitchen areas and toilets and additional schedules of cleaning may be required during active outbreaks of disease in any community.

Cleaning toys and equipment

Playing with toys or using equipment such as climbing apparatus and slides is an important part of the child’s day in an early years provision. However, these items can quickly become soiled or unhygienic and a child’s habit of putting toys in their mouth can lead to a situation where disease can be spread.

Early years managers and staff should always ensure that toys and equipment are inspected and cleaned regularly. This should be done at the end of each working day and can be done with ordinary soap and hot water. Many settings have occasional “deep clean” sessions to ensure a thorough cleaning of toys and combine this with an audit of the toys.

Toys should be replaced when unhygienic, as should play sand and play dough.

Cleaning spillages

Early years managers should ensure that spillages of body fluid, such as urine, vomit, faeces or blood, are cleared up as quickly as possible. Staff should be encouraged to treat every spillage of body fluids or body waste with caution as potentially infectious.

An agreed process for spillage cleaning should be in place. In the case of maintained nurseries a set procedure may be specified by their local authority.

A typical procedure will include the following key steps:

  • staff should assess any spillage first and make arrangements to secure the area so that children and visitors do not enter it

  • they should wear appropriate personal protective equipment, such as disposable gloves and aprons

  • disposable paper towels and a suitable product that combines both a detergent and a disinfectant should be used to clean up the spill

  • used towels should be disposed of in a leak-proof plastic bag according to the services waste disposal policy.

Staff should note that chlorine-based disinfectants should not be applied directly to acidic bodily fluids, such as urine or vomit, as potentially dangerous chlorine vapour may be released. Such spills should be cleaned up with paper towels and washed with warm water and a general purpose detergent before being treated with a disinfectant solution.

In all cases, staff should follow the manufacturer’s instructions for any disinfectant product they are using.

Carpets and upholstery should be thoroughly cleaned with warm soapy water or a proprietary liquid carpet shampoo, rinsed and where possible, dried.

Mops should never be used for cleaning up blood and body fluid spillages.

Responding to infection outbreaks

Parents should be made aware that children who are unwell should be kept at home. Those with a temperature and other specific signs and symptoms should be excluded until they are better (48 hours from the last episode in the case of diarrhoea or vomiting).

Public Health England defines an infection outbreak as an incident in which two or more people experiencing a similar illness are linked in time or place.

Where two or more related cases of an infection occur, such as diarrhoea or vomiting, for example, it will be necessary to report the outbreak and obtain expert advice. Local health protection teams will be able to help and may have recommendations for improvement.

Childcare settings are asked to telephone their local team as soon as possible to report any serious or unusual illness, particularly for:

  • Escherichia coli (VTEC) (also called E.coli VTEC or E.coli 0157) infection

  • food poisoning

  • hepatitis

  • measles, mumps, rubella (also called German measles)

  • meningitis

  • tuberculosis

  • typhoid

  • whooping cough (also called pertussis)

During any infection outbreak, providers should:

  • increase environmental cleaning (especially toilets and door/flush handles)

  • ensure hot water, soap (preferably liquid soap) and paper towels are available in the toilets of both children and staff

  • reinforce good hand hygiene with children, especially after going to the toilet and before eating and drinking

  • ensure toys are cleaned and dried after use

  • exclude children with symptoms and advise staff members with symptoms to refrain from work until they have been symptom-free for 48 hours

  • suspend play with sand, water and plasticine/play dough until the outbreak is over — sand or play dough may have to be replaced as necessary.

Staff handling food or working in a food handling area should report to their manager if they have symptoms of diarrhoea and/or vomiting. Managers should exclude staff with these symptoms from food handling, in most cases for 48 hours from the natural cessation of symptoms.

Where several related cases of an infection occur, such as an outbreak of diarrhoea or vomiting, for example, it will be necessary to report the outbreak and obtain expert advice. Local community infection control teams or health protection units will be able to help and may have recommendations for improvement.

Further information

Infection control is a very wide topic area and some aspects are outside the scope of this article, for example, nappy changing, vaccinations and immunisations, first aid, pest control, food hygiene, waste disposal, bringing pets into the setting and visits to farms, etc.

Further information, including details of recommended exclusion periods, can be found in the following key guidance:

  • Health Protection in Schools and Other Childcare Facilities, published in September 2017 by Public Health England — updated in February 2018 and available on the GOV.UK website

  • Infection Prevention and Control in Childcare Settings (Day Care and Childminding Settings), published by Health Protection Scotland in September 2015

  • Infection Prevention and Control for Childcare Settings (0-5 years) Nurseries Child Minders and Playgroups All Wales Guidance, published in 2014 by NHS Wales

Last reviewed 21 May 2018