What can day-care workers do to minimize the dangers of infection caused by fecal contamination?

• Hand washing. As simple as it may seem, hand washing is, as Professor Pickering says, "the single most preventive measure in the day-care center." Indeed, one study showed that outbreaks could be cut in half simply by requiring staff and children to wash their hands after diaper changes and bowel movements;
• Providing separate diaper-changing areas, preferably with disposable cover sheets and smooth, nonabsorbent, easily cleaned surfaces;
• Cleaning and disinfecting the diapering area after each use;
• Keeping younger children--especially those in diapers--separate from older children during the day;
• Keeping children with diarrhea at home;
• Segregating children whose diarrhea has stopped but who may still be carriers;
• Providing staff education on preventive measures and regular follow-ups to be sure the measures are being taken.

The U.S. Centers for Disease Control describes proper hand washing as follows:

• Use soap and running water.
• Rub your hands vigorously as you wash them.
• Wash all surfaces (including backs of hands, wrists, between fingers, and under fingernails).
• Rinse well and leave the water running.
• Dry hands with a single-use towel.
• Turn off water using a paper towel covering freshly washed hands.

Day-care staff members should wash their hands when they start work, before preparing or serving food, after diapering a child or wiping his nose or cleaning up messes, and after a trip to the bathroom.

For children, the routine is much the same, CDC advises. Center staff should be sure that children's hands are washed when they arrive, before they eat or drink, and after they use the toilet or have their diapers changed.

It's also important that the diaper-changing area is located well away from food-serving areas and that a separate sink is used for preparing food and washing dishes.

CDC recommends that only washable, preferably hard-surfaced toys be used around children still in diapers. Toys should be washed daily. Stuffed toys, if they're used by children in diapers, should be washed at least once a week.

Obviously, the need for cleanliness is not limited to hands and playthings. All facilities and supplies at day-care centers should be washed with soap and water and then disinfected on a regular, frequent schedule. For disinfectants, CDC recommends either a commercial product that kills bacteria, viruses, and parasites such as Giardia or a bleach solution. To make the bleach solution, mix one-fourth cup of bleach with a gallon of water (or one tablespoon per quart). The solution should be made daily but can be stored in a spray bottle. Disinfectants must be kept out of the reach of children.

Any parent knows how disagreeable even a short bout of diarrhea can be in a young child. But public health workers know that diseases spread from day-care centers can have further, more ominous consequences. A day-care center child who contracts hepatitis A, for example, will probably develop only mild symptoms or none at all. Spread to adult family members, however, the infection carries the risk of more serious illness, as well as the possibility of further transmission to the community, particularly if the adult handles or prepares food. According to the National Restaurant Association, there are 8 million food service workers in 550,000 establishments in this country. It is easy to see how enteric disease in a day-care center child can have far-reaching effects into a wider world. In two studies, 13 percent to 40 percent of reported cases of hepatitis A in the community had some form of association with outbreaks in day-care centers.