BACKGROUND: Infection with shiga toxin-producing Escherichia coli(STEC) can cause severe illness and is highly contagious. STEC serotype O157:H7 results in severe illness, including hemolytic uremic syndrome. Many public health jurisdictions have childcare exclusion policies for STEC infection often based on O157 infections. Increased sensitivity of rapid tests for shiga toxin has resulted in an increased burden of non-O157 infections.
METHODS: A standard questionnaire in SurveyMonkey™ was emailed to each state health program. The survey addressed childcare attendee and caregiver illness screening practices, restrictions and exclusion practices, and childcare STEC outbreak investigation. In addition, we asked if these practices vary by serogroup (O157 versus other).
RESULTS: Thirty-eight (76%) states responded. Twenty-two (53%) states reported STEC case exclusion from childcare, sixteen do not. Only two states reported these were based on O157 serotyping. Thirty-four (89%) require negative stools for re-entry and nine only require negative stools for serotype O157. Thirty-five (92%) required these be collected > 24 hours apart, and 50% reported variation if on antibiotics. Eighteen states accept culture independent diagnostic tests for clearance, 74% accept shiga toxin testing. However, type of testing typically is generally not specified by law. Twenty-eight (74%) reported that asymptomatic positive children would not be allowed to return to care while 10 states would allow them to return. Definition of an outbreak varied across states; most states reported they use two incubation periods between cases to define an outbreak, others specified a range of days from 10-60. The majority (87%) of states screen any symptomatic children at the childcare with a case, while 7 states screen all attendees regardless of symptoms. Seventy-six percent screen symptomatic caregivers, and 6 states screen all caregivers in a childcare outbreak. Twenty states reported that these policies do not vary depending on the age of the child or if the child was in diapers, whereas 11 states vary their policies based on age.
CONCLUSIONS: Childcare exclusion policies for STEC cases vary among states. Newer, non-specific shiga toxin tests have increased the number of positive results, creating the need to re-evaluate exclusionary practices. Active screening and exclusion of symptomatic or asymptomatic shedders in childcare settings can be resource-intensive and burdensome to families. Public health control measures require a balance between preventing disease transmission and adding excessive burden to families while taxing public health resources. Research is needed to evaluate how these practices effect the overall STEC disease burden.