INFECTIOUS DISEASES IN SCHOOLS

This document gives NUT guidance for members on the subject of infectious diseases in schools. It does not seek to provide detailed information about different infectious diseases but looks instead at general principles about how to manage cases of infectious illness, such as the principles governing children’s attendance and exclusion periods, and identifies the best sources of advice on individual cases.

When should children be absent from school?

The basic principle advocated by Public Health England (PHE) in guidance on this area, is that children who are unwell with an infectious disease should not be at school or nursery. When the risk of infection to others has passed and the children have recovered, they should return to school whether or not vestiges of the disease are visible. It is important that parents and school staff understand this principle in order that children do not return before they should do. It is also important that school staff know where they can find information and obtain advice about such matters as exclusion periods. The full PHE guidance “Infection Control in Schools and other Childcare Settings”, is available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/353953/Guidan ce_on_infection_control_in_schools_11_Sept.pdf.

Many local authorities have published guidelines for their schools, often in co-operation with the health authorities, on dealing with cases of infectious disease. Such guidelines may include information on steps to be taken when children appear to be suffering from infectious disease, exclusion periods for particular conditions and requirements for notifying the local authority about cases of “notifiable diseases” or outbreaks of other diseases. Where such local authority guidelines exist, they should in all cases be followed. The following sections outline the NUT’s guidance on these and other areas.

The situation is of course very different in hospital schools. Teachers who work in hospital schools should be given full guidance on working with pupils who have infectious diseases or other medical conditions. Teachers who are employed as home tutors should also be given appropriate guidance in any case where they are expected to visit pupils who are at home due to medical reasons.

What if you suspect a child is suffering from an infectious disease?

Children who attend school whilst suffering the early stages of infectious diseases can rapidly spread them among their fellow pupils. Clear directions should, therefore, be given to teachers and support staff in order that they know what to do when they suspect that a child is suffering some form of infectious disease.

The PHE guidance emphasises that diagnosis should only be undertaken by an appropriately qualified health professional. Teachers should, therefore, immediately notify the head teacher

NUT Health & Safety Briefing: Infectious Diseases in Schools Updated April 2015 Page 2 of 14 of their concerns. The head teacher should then make arrangements, in accordance with any local authority guidelines, for the child to be examined by a health professional. This may involve temporary exclusion of the child and, in some circumstances, of close contacts as well. In such circumstances parents should, of course, be fully consulted and involved wherever practicable.

What about exclusion periods?

As noted above, the PHE guidance advises that children should not attend school until after they have recovered and until the risk of infection to others has passed. The PHE guidance includes specific advice for schools on exclusion periods for individual infectious diseases and sets out recommendations on the length of time for which children suffering from particular infections should be kept away from school, once they are well again, to ensure that the risk of transmitting the illness to other pupils and adults has passed. It also includes information on other relevant matters such as hygiene control and immunisations.

The text of the PHE guidance is appended in full to this briefing. It is also available on the internet at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/353953/Guidan ce_on_infection_control_in_schools_11_Sept.pdf.

Links to further guidance on specific infectious diseases are available on the PHE website, at: https://www.gov.uk/health-protection/infectious-diseases.

Where can schools get individual advice about management of illness?

Schools should seek advice either from the school nurse or doctor or from the local authority’s Consultant in Communicable Disease Control (CCDC).

The Consultant in Communicable Disease Control must be contacted whenever there are any cases of “notifiable diseases” in the school among either pupils or staff. The CCDC should also be contacted if there appears to be an unusual number of cases of an infectious disease in a school or nursery. The CCDC’s advice should be sought urgently if a food handler in the school is suffering from diarrhoea or vomiting. The full list of ‘notifiable’ diseases is contained in Appendix 2 of this briefing, and can also be accessed at: https://www.gov.uk/notifiable- diseases-and-causative-organisms-how-to-report.

What about outbreaks of infectious diseases?

During outbreaks of infectious diseases, in particular serious conditions such as Meningitis, it is important that parents, pupils and staff are fully and regularly informed. It is sensible for schools to hold information on infectious diseases and on steps which may need to be taken if there are cases at the school. In the same way that all schools have a named individual to deal with accidents and injuries, it is also sensible for each school to have a named person who will co-ordinate the school’s response to this type of issue.

How can schools prevent the spread of infectious diseases?

The spread of some infectious diseases in schools, particularly diarrhoea and vomiting

NUT Health & Safety Briefing: Infectious Diseases in Schools Page 3 of 14 illnesses, including Dysentery and Hepatitis A, can be controlled through good hygiene procedures. Many local authorities give detailed guidance on hygiene control procedures and these should always be followed in every case.

These procedures include effective hand-washing with warm, running water and soap, after using the toilet and before eating. Paper towels or hand-dryers are best for drying hands. Spillages of body fluids e.g. blood, faeces, saliva or vomit, should be cleaned up immediately. Disposable gloves should always be worn. Surfaces on which body fluids have been spilled should be disinfected with household bleach, diluted one part bleach to ten parts water. The NUT is aware that some local authorities have banned the use of bleach. In such cases the alternative recommended by the local authority should be used. Whatever cleaning fluid is used must be stored securely, away from the reach of children. Secure disposal procedures must also be followed. All of the above should be the responsibility of support staff and teachers cannot be required to be involved in these matters.

Particular care needs to be taken to avoid transmission of infectious diseases to children from animals which are kept in schools or which are encountered during farm visits. The DfE and most local authorities produce detailed guidance on hygiene procedures in these areas which again should always be followed in every case.

How can teachers protect themselves against infection from pupils?

The most important measure is to ensure that children who are infectious are excluded as advised above. In the case of diarrhoea or vomiting, the hygiene measures described above are also essential. In other cases immunisation may be necessary. Due to the resurgence of TB in certain parts of the country, teachers may wish to consult their GP to discuss whether they are sufficiently protected against this disease. Teachers who work with children who are in high risk groups for Hepatitis B may also wish to discuss with their GP whether immunisation would be appropriate.

What if teachers themselves become ill with an infectious disease?

Teachers who become ill with an infectious disease should remain absent until they recover and no longer pose a risk of infection to others. In rare instances medical suspension may be necessary. Guidance on this and on the provisions of the teachers’ sick pay scheme is available from NUT regional/Wales offices and on the NUT website (http://www.teachers.org.uk).

What about pregnant teachers?

During pregnancy, certain infectious diseases can pose dangers to unborn babies. Pregnant teachers should contact their GP or ante-natal clinic if they are concerned about possible exposure to an infectious disease at school. Women teachers who are considering becoming pregnant should, of course, check with their GP that they have immunity to Rubella. Other diseases of possible concern include Chickenpox and Slapped Cheek Disease (Parvovirus). Information on precautions to be taken with regard to these diseases is contained in the separate NUT briefing on “Women’s Health and Safety”, which is available at: http://www.teachers.org.uk/node/12572.

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Medication and Pupils

Some children who are otherwise well may need to complete a course of medication during the school day. Detailed NUT guidance is available in the separate briefing on “Administration of Medicines” which in turn refers to the detailed DfE guidance on this area, and is available at: http://www.teachers.org.uk/node/12538. Administration of medication by teachers to pupils is entirely voluntary and the NUT will support members in their exercise of their professional judgement on this area.

Action Points for Safety Reps

Make sure that:

 your school has a copy of the PHE guidance on infection control; and

 your colleagues are aware of their responsibilities and rights in this area.

Further Guidance

Further NUT guidance on specific infectious diseases is available on the Health and Safety section of the website, and via the following links:

Dysentery: http://www.teachers.org.uk/node/12512

Hepatitis: http://www.teachers.org.uk/node/12525

Meningitis: http://www.teachers.org.uk/node/12539

Tuberculosis: http://www.teachers.org.uk/node/12566

NUT Health and Safety Briefing April 2015

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Appendix 1: Full Wording of PHE document: ‘Guidance on infection control in schools and other childcare settings’.

1. Introduction The document provides guidance for schools and other childcare settings, such as nurseries, on infection control issues. It is an updated version of guidance that was produced in 2010. Prevent the spread of infections by ensuring:  routine immunisation  high standards of personal hygiene and practice, particularly hand washing  maintaining a clean environment

For further information and advice visit www.gov.uk/phe or contact your local health PHE centre. See Appendix 1 for contact details.

2. Rashes and skin infections Children with rashes should be considered infectious and assessed by their doctor.

Infection or Recommended period Comments complaint to be kept away from school, nursery or child-minders Athlete’s foot None Athlete’s foot is not a serious condition. Treatment is recommended Chickenpox Until all vesicles have See: Vulnerable Children and Female Staff – crusted over Pregnancy Cold sores, None Avoid kissing and contact with the sores. Cold (Herpes simplex) sores are generally mild and self-limiting German measles Four days from onset of Preventable by immunisation (MMR x2 doses). (rubella)* rash (as per “Green See: Female Staff – Pregnancy Book”) Hand, foot and None Contact your local HPT if a large number of mouth children are affected. Exclusion may be considered in some circumstances Impetigo Until lesions are crusted Antibiotic treatment speeds healing and and healed, or 48 hours reduces the infectious period after starting antibiotic treatment Measles* Four days from onset of Preventable by vaccination (MMR x2). See: rash Vulnerable Children and Female Staff – Pregnancy Molluscum None A self-limiting condition contagiosum Ringworm Exclusion not usually Treatment is required required Roseola None None (infantum) Scabies Child can return after first Household and close contacts require treatment treatment

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Scarlet fever* Child can return 24 hours Antibiotic treatment is recommended for the after starting appropriate affected child antibiotic treatment Slapped None (once rash has See: Vulnerable Children and Female Staff – cheek/fifth developed) Pregnancy disease. Parvovirus B19 Shingles Exclude only if rash is Can cause chickenpox in those who are not weeping and cannot be immune, ie have not had chickenpox. It is covered spread by very close contact and touch. If further information is required, contact your local PHE centre. See: Vulnerable Children and Female Staff – Pregnancy Warts and None Verrucae should be covered in swimming verrucae pools, gymnasiums and changing rooms

3. Diarrhoea and vomiting illness

Infection or Recommended period to Comments complaint be kept away from school, nursery or child-minders Diarrhoea and/or 48 hours from last episode vomiting of diarrhoea or vomiting E. coli O157 VTEC Should be excluded for 48 Further exclusion is required for Typhoid* [and hours from the last episode children aged five years or younger paratyphoid*] (enteric of diarrhoea. Further and those who have difficulty in fever) Shigella exclusion may be required adhering to hygiene practices. (dysentery) for some children until they Children in these categories should are no longer excreting be excluded until there is evidence of microbiological clearance. This guidance may also apply to some contacts who may also require microbiological clearance. Please consult your local PHE centre for further advice Cryptosporidiosis Exclude for 48 hours from Exclusion from swimming is the last episode of advisable for two weeks after the diarrhoea diarrhoea has settled

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Infection or Recommended period to be Comments complaint kept away from school, nursery or child-minders Flu (influenza) Until recovered See: Vulnerable Children

Tuberculosis* Always consult your local PHE Requires prolonged close contact for centre spread Whooping Five days from starting Preventable by vaccination. After cough* antibiotic treatment, or 21 days treatment, non-infectious coughing may (pertussis) from onset of illness if no continue for many weeks. Your local antibiotic treatment PHE centre will organise any contact tracing necessary

5. Other infections

Infection or Recommended period Comments complaint to be kept away from school, nursery or child minders Conjunctivitis None If an outbreak/cluster occurs, consult your local PHE centre Diphtheria * Exclusion is essential. Family contacts must be excluded until Always consult with cleared to return by your local PHE your local HPT centre. Preventable by vaccination. Your local PHE centre will organise any contact tracing necessary Glandular fever None

Head lice None Treatment is recommended only in cases where live lice have been seen Hepatitis A* Exclude until seven In an outbreak of hepatitis A, your local days after onset of PHE centre will advise on control jaundice (or seven days measures after symptom onset if no jaundice) Hepatitis B*, C*, None Hepatitis B and C and HIV are HIV/AIDS bloodborne viruses that are not infectious through casual contact. For cleaning of body fluid spills see: Good Hygiene Practice Meningococcal Until recovered Meningitis C is preventable by meningitis*/ vaccination septicaemia* There is no reason to exclude siblings or other close contacts of a case. In case of an outbreak, it may be necessary to

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provide antibiotics with or without meningococcal vaccination to close school contacts. Your local PHE centre will advise on any action is needed Meningitis* due Until recovered Hib and pneumococcal meningitis are to other bacteria preventable by vaccination. There is no reason to exclude siblings or other close contacts of a case. Your local PHE centre will give advice on any action needed Meningitis viral* None Milder illness. There is no reason to exclude siblings and other close contacts of a case. Contact tracing is not required MRSA None Good hygiene, in particular hand washing and environmental cleaning, are important to minimise any danger of spread. If further information is required, contact your local PHE centre Mumps* Exclude child for five Preventable by vaccination (MMR x2 days after onset of doses) swelling Threadworms None Treatment is recommended for the child and household contacts Tonsillitis None There are many causes, but most cases are due to viruses and do not need an antibiotic

* denotes a notifiable disease. It is a statutory requirement that doctors report a notifiable disease to the proper officer of the local authority (usually a consultant in communicable disease control). In addition, organisations may be required via locally agreed arrangements to inform their local PHE centre. Regulating bodies (for example, Office for Standards in Education (OFSTED)/Commission for Social Care Inspection (CSCI)) may wish to be informed – please refer to local policy. Outbreaks: if an outbreak of infectious disease is suspected, please contact your local PHE centre.

6. Good hygiene practice

Hand washing Hand washing is one of the most important ways of controlling the spread of infections, especially those that cause diarrhoea and vomiting, and respiratory disease. The recommended method is the use of liquid soap, warm water and paper towels. Always wash hands after using the toilet, before eating or handling food, and after handling animals. Cover all cuts and abrasions with waterproof dressings.

Coughing and sneezing Coughing and sneezing easily spread infections. Children and adults should be encouraged to cover their mouth and nose with a tissue. Wash hands after using or disposing of tissues. Spitting should be discouraged.

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Personal protective equipment (PPE) Disposable non-powdered vinyl or latex-free CE-marked gloves and disposable plastic aprons must be worn where there is a risk of splashing or contamination with blood/body fluids (for example, nappy or pad changing). Goggles should also be available for use if there is a risk of splashing to the face. Correct PPE should be used when handling cleaning chemicals.

Cleaning of the environment Cleaning of the environment, including toys and equipment, should be frequent, thorough and follow national guidance. For example, use colour-coded equipment, COSHH and correct decontamination of cleaning equipment. Monitor cleaning contracts and ensure cleaners are appropriately trained with access to PPE.

Cleaning of blood and body fluid spillages All spillages of blood, faeces, saliva, vomit, nasal and eye discharges should be cleaned up immediately (always wear PPE). When spillages occur, clean using a product that combines both a detergent and a disinfectant. Use as per manufacturer’s instructions and ensure it is effective against bacteria and viruses and suitable for use on the affected surface. Never use mops for cleaning up blood and body fluid spillages – use disposable paper towels and discard clinical waste as described below. A spillage kit should be available for blood spills. Guidance on infection control in schools and other childcare settings

Laundry Laundry should be dealt with in a separate dedicated facility. Soiled linen should be washed separately at the hottest wash the fabric will tolerate. Wear PPE when handling soiled linen. Children’s soiled clothing should be bagged to go home, never rinsed by hand.

Clinical waste Always segregate domestic and clinical waste, in accordance with local policy. Used nappies/pads, gloves, aprons and soiled dressings should be stored in correct clinical waste bags in foot-operated bins. All clinical waste must be removed by a registered waste contractor. All clinical waste bags should be less than two-thirds full and stored in a dedicated, secure area while awaiting collection.

Sharps disposal Sharps should be discarded straight into a sharps bin conforming to BS 7320 and UN 3291 standards. Sharps bins must be kept off the floor (preferably wall-mounted) and out of reach of children.

Sharps injuries and bites If skin is broken, encourage the wound to bleed/ wash thoroughly using soap and water. Contact GP or occupational health or go to A&E immediately. Ensure local policy is in place for staff to follow. Contact your local HPT for advice, if unsure.

Animals

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Animals may carry infections, so hands must be washed after handling any animals. Health and Safety Executive (HSE) guidelines for protecting the health and safety of children should be followed.

Animals in school (permanent or visiting) Ensure animals’ living quarters are kept clean and away from food areas. Waste should be disposed of regularly, and litter boxes not accessible to children. Children should not play with animals unsupervised. Veterinary advice should be sought on animal welfare and animal health issues and the suitability of the animal as a pet. Reptiles are not suitable as pets in schools and nurseries, as all species carry salmonella.

Visits to farms Please contact your local environmental health department, which will provide you with help and advice when you are planning a visit to a farm or similar establishment. For more information see http://www.face-online.org.uk/resources/preventing-or-controlling-ill-health- from-animal-contact-at-visitor-attractions-industry-code-of-practice

Vulnerable children Some medical conditions make children vulnerable to infections that would rarely be serious in most children; these include those being treated for leukaemia or other cancers, on high doses of steroids and with conditions that seriously reduce immunity. Schools and nurseries and child-minders will normally have been made aware of such children. These children are particularly vulnerable to chickenpox, measles or parvovirus B19 and, if exposed to either of these, the parent/carer should be informed promptly and further medical advice sought. It may be advisable for these children to have additional immunisations, for example pneumococcal and influenza.

Female staff – pregnancy If a pregnant woman develops a rash or is in direct contact with someone with a potentially infectious rash, this should be investigated according to PHE guidelines by a doctor. The greatest risk to pregnant women from such infections comes from their own child/children, rather than the workplace. Some specific risks are:

 chickenpox can affect the pregnancy if a woman has not already had the infection. Report exposure to midwife and GP at any stage of exposure. The GP and antenatal carer will arrange a blood test to check for immunity. Shingles is caused by the same virus as chickenpox, so anyone who has not had chickenpox is potentially vulnerable to the infection if they have close contact with a case of shingles  German measles (rubella). If a pregnant woman comes into contact with german measles she should inform her GP and antenatal carer immediately to ensure investigation. The infection may affect the developing baby if the woman is not immune and is exposed in early pregnancy  slapped cheek disease (parvovirus B19) can occasionally affect an unborn child. If exposed early in pregnancy (before 20 weeks), inform whoever is giving antenatal care as this must be investigated promptly  measles during pregnancy can result in early delivery or even loss of the baby. If a pregnant woman is exposed she should immediately inform whoever is giving antenatal care to ensure investigation. This advice also applies to pregnant students.

NUT Health & Safety Briefing: Infectious Diseases in Schools Page 11 of 14 7. Immunisations

Immunisation status should always be checked at school entry and at the time of any vaccination. Parents should be encouraged to have their child immunised and any immunisation missed or further catch-up doses organised through the child’s GP. For the most up-to-date immunisation advice see the NHS Choices website at www.nhs.uk or the school health service can advise on the latest national immunisation schedule.

Immunisation schedule

Two months old Diphtheria, tetanus, pertussis, polio One injection and Hib (DTaP/IPV/Hib) One injection Pneumococcal (PCV13) Given orally Rotavirus vaccine Three months old Diphtheria, tetanus, pertussis, polio One injection and Hib (DTaP/IPV/Hib) One injection Meningitis C (Men C) Given orally Rotavirus vaccine Four months old Diphtheria, tetanus, pertussis, polio One injection and Hib (DTaP/IPV/Hib) One injection Pneumococcal (PCV13) Between 12-13 months Hib/meningitis C One injection old Measles, mumps and rubella (MMR) One injection Pneumococcal (PCV13) One injection Two, three and four Influenza (from September) Nasal spray years old or one injection Three years and four Diphtheria, tetanus, pertussis, polio One injection months old or soon after (DTaP/IPV or dTaP/IPV) One injection Measles, mumps and rubella (MMR) Girls aged 12 to 13 years Cervical cancer caused by human Two injections papilloma virus types 16 and 18. HPV given 6-24 months vaccine apart Around 14 years old Tetanus, diphtheria, and polio One injection (Td/IPV) Meningococcal C (Men One injection C)

This is the complete routine immunisation schedule. Children who present with certain risk factors may require additional immunisations. Some areas have local policies – check with your local PHE centre. Staff immunisations – all staff should undergo a full occupational health check before starting employment; this includes ensuring they are up to date with immunisations, including MMR.

PHE centre contact details

North of England

Cheshire and Merseyside PHE Centre 5th Floor Rail House Lord Nelson Street Liverpool L1 1JF

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Tel: 0344 225 1295

Cumbria and Lancashire PHE Centre 1st Floor, York House Ackhurst Business Park Foxhole Road Chorley PR7 1NY Tel: 0344 225 0602

Greater Manchester PHE Centre 5th Floor 3 Piccadilly Place London Road Manchester M1 3BN Tel: 0344 225 0562

North East PHE Centre Floor 2 Citygate Gallowgate Newcastle-upon-Tyne NE1 4WH Tel: 0300 303 8596

Yorkshire and the Humber PHE Centre Blenheim House West One Duncombe Street Leeds LS1 4PL Tel: 0113 386 0300

Midlands and East of England

Anglia and Essex PHE Centre Eastbrook Shaftesbury Road Cambridge CB2 8DF Tel: 0303 444 6690

East Midlands PHE Centre Institute of Population Health Nottingham City Hospital Hucknall Road Nottingham NG5 1QP Tel: 0344 225 4524

South Midlands and Hertfordshire PHE Centre Beacon House Dunhams Lane Letchworth Garden City Herts SG6 1BE Tel: 0300 303 8537 West Midlands PHE Centre 6th Floor 5 St Philip's Place Birmingham B3 2PW Tel: 0344 225 3560

South of England

Avon, Gloucestershire and Wiltshire PHE Centre 2 Rivergate Temple Quay Bristol BS1 6EH Tel: 0300 303 8162

Devon, Cornwall and Somerset PHE Centre Richmond Court Emperor Way Exeter Business Park Exeter Devon EX1 3QS Tel: 0344 225 3557

Kent, Surrey and Sussex PHE Centre County Hall North Chart Way Horsham West Sussex RH12 1XA Tel: 0844 225 3861

Thames Valley PHE Centre

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Chilton Oxfordshire OX11 0RQ Tel: 0345 279 9879

Wessex PHE Centre Unit 8, Fulcrum 2 Solent Way Fareham Hampshire PO15 7FN Tel: 0345 055 2022

London

London integrated region and PHE Centre 151 Buckingham Palace Road London SW1W 9SZ Tel: 020 7811 7000/7001

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Appendix 2: List of notifiable diseases, as per the Health Protection (Notification) Regulations, 2010

Diseases notifiable to local authority proper officers under the Health Protection (Notification) Regulations 2010:

 Acute encephalitis  Acute infectious hepatitis  Acute meningitis  Acute poliomyelitis  Anthrax  Botulism  Brucellosis  Cholera  Diphtheria  Enteric fever (typhoid or paratyphoid fever)  Food poisoning  Haemolytic uraemic syndrome (HUS)  Infectious bloody diarrhoea  Invasive group A streptococcal disease  Legionnaires’ disease  Leprosy  Malaria  Measles  Meningococcal septicaemia  Mumps  Plague  Rabies  Rubella  Severe Acute Respiratory Syndrome (SARS)  Scarlet fever  Smallpox  Tetanus  Tuberculosis  Typhus  Viral haemorrhagic fever (VHF)  Whooping cough  Yellow fever

Report other diseases that may present significant risk to human health under the category ‘other significant disease’.

For more information, please visit: https://www.gov.uk/notifiable-diseases-and-causative- organisms-how-to-report.

NUT Health & Safety Briefing: Infectious Diseases in Schools