Diarrhea Caused by Specific Types of E coli (Escherichia coli)—Child Care and Schools

What is Escherichia coli (E coli) diarrhea?

Although many types of E coli bacteria live normally in the intestinal tract, at least 5 types can cause diarrhea. Shiga toxin?producing E coli (STEC) has caused numerous outbreaks in early childhood education (ECE) settings and can lead to other severe problems, such as bleeding, kidney damage, and blood cell damage, also known as hemolytic uremic syndrome. Other diarrhea-producing types are enteropathogenic E coli, enteroinvasive E coli, and enteroaggregative E coli. In children and adults who travel to resource-limited countries, enterotoxigenic E coli is the most likely to be diagnosed. There are no readily available and reliable diagnostic tests for other strains.

What are the signs or symptoms?

• Loose stools, which may be watery and/or bloody

• Abdominal pain

• Signs of dehydration, including dry mouth, no tears, or no urine for 8 hours

• May have fever

• May have nausea and vomiting

What are the incubation and contagious periods?

• Incubation period: Average 3 to 4 days (range, 1?10 days) for STEC but ranges from 10 hours to 6 days for all types

• Contagious period: For STEC, at least 2 weeks and, in some cases, much longer

How is it spread?

• Ingesting the bacteria through food or water contaminated with human or animal (eg, cattle, sheep, deer) feces, undercooked ground beef, unpasteurized milk, or other products contaminated with cattle feces. Contamination has occurred in improperly treated apple cider, raw vegetables, yogurt, and drinking water in recreation areas.

• Fecal-oral route: Contact with feces from an infected child, typically when the child contaminates their fingers and touches an object another child then touches. Children who have contact with the contaminated surface may place their fingers into their own or another person's mouth.

• Exposure to animal feces by direct contact with animals, as in petting zoos, farms, or other contact between animals and people.

• Outbreaks in water parks have been reported.

How do you control it?

• Use good hand-hygiene technique at all the times listed in Chapter 2 of Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide, 7th Edition, especially after toilet use or handling soiled diapers and before anything to do with food preparation or eating.

• Ensure proper surface disinfection that includes cleaning and rinsing of surfaces that may have become contaminated with stool (feces) with detergent and water and application of a US Environmental Protection Agency?registered disinfectant according to the instructions on the product label. For guidance on disinfectants, refer to Selection and Use of a Cleaning, Sanitizing, or Disinfecting Product in Chapter 8 of Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide, 7th Edition.

• Ensure proper washing of raw fruits and vegetables.

• Ensure proper cooking, handling, and storage of food. Avoid using the same cutting boards or utensils for raw and cooked foods without proper cleaning in between. Cook all ground beef thoroughly so there is no pink meat. Use only pasteurized milk and juice products.

• Exclude infected staff members who handle food. See Safe Food Preparation and Service: Food Handlers in Chapter 2 of Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide, 7th Edition.

• Minimize communal exposure to water, such as water tables, which can increase the spread of germs. Using water tables with free-flowing fresh water or separate water bins for each child reduces this risk.

• Children with E coli diarrhea should not participate in water play activities for 1 week after diarrhea has resolved.

• Notify local public health authorities immediately if STEC is identified in a child or adult at an ECE facility, as it is a major public health concern. Local public health authorities will be involved and may close the facility to new enrollees.

• Prevent enrolled children from being transferred for care to other groups or facilities where they may expose other susceptible children.

• Exclude for specific types of symptoms (see the section Exclude from educational setting?).

What are the roles of the educator and the family?

• A child or staff member with STEC may have bloody diarrhea, which should trigger a medical evaluation.

• Outbreaks can occur in ECE settings.

• There are multiple causes of bloody diarrhea. The following recommendations apply for a child or staff member with diarrhea from any cause (see Diarrhea Quick Reference Sheet).

  • ? Report the condition to the staff member designated by the ECE program or school for decision-making and action related to care of ill children and staff members. That person, in turn, alerts possibly exposed family and staff members to watch for symptoms and notifies the Child Care Health Consultant.

  • ? Ensure staff members follow the control measures listed in the section How do you control it?

  • ? Report outbreaks of diarrhea (more than 2 children or staff members in the group) to the Child Care Health Consultant, who may report to the local health department.

  • ? Do not allow a staff member with diarrhea to be involved with food handling or feeding of children.

  • ? Avoid drinking milk that is not pasteurized and water that is not chlorinated.

• If you know a child or staff member in the program has Shiga toxin?producing E coli

  • ? Follow the advice of the child's or staff member's health professional.

  • ? Report the infection to the local health department. The health professional who makes the diagnosis may not report that the infected child is a participant in an ECE program or school, and this could lead to delay in controlling the spread.

  • ? Reeducate staff members about strict and frequent handwashing, diapering, toileting, food handling, and cleaning and disinfection procedures.

  • ? Follow the directions of the local health department. A potential outbreak with Shiga toxin?producing E coli is a public health emergency.

Exclude from educational setting?

Yes, if Shiga toxin?producing E coli is identified and for any type of E coli diarrhea if

• The local health department determines exclusion is needed to control an outbreak.

• Stool is not contained in the diaper for diapered children.

• Diarrhea is causing "accidents" for toilet-trained children.

• Stool is more watery and frequency exceeds 2 stools above normal for that child during the time the child is in the program because this may cause too much work for EC educators and make it difficult for them to maintain sanitary conditions.

• There is blood or mucus in stool.

• The stool is all black.

• The child has a dry mouth, no tears, or no urine output in 8 hours (suggesting the child's diarrhea may be causing dehydration).

• The child is unable to participate and staff members determine they cannot care for the child without compromising their ability to care for the health and safety of the other children in the group.

Readmit to educational setting?

Yes, when all the following criteria are met:

• For Shiga toxin?producing E coli: Test results from 2 stool cultures are negative. These stool tests should be performed more than 48 hours after antibiotics have been discontinued, if they were started. Public health professionals will need to review the situation and approve the child's readiness to return.

  • ? Stool cultures might be needed for children with symptoms who have contact with Shiga toxin?producing E coli. Contact is typically identified through public health investigation or reports of known exposure, such as shared classrooms, diapering areas, or household environments with a confirmed case. These children should be excluded while they have symptoms and the evaluation is pending.

  • ? Stool cultures are not required or recommended for other E coli strains.

• Once diapered children have their stool contained by the diaper (even if the stools remain loose) and when toilet-trained children do not have toileting accidents.

• Once stool frequency is no more than 2 stools above normal for that child during the time the child is in the program, even if the stools remain loose.

• When the child is able to participate and staff members determine they can care for the child without compromising their ability to care for the health and safety of the other children in the group.