"A" WORK BUT PLAGIARISM FREE

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Introduction Children in child care facilities can trans- mit communicable diseases to other chil- dren, staff, and family members. In addition, child care facilities have a known history of increasing a child’s risk of contracting dis- eases. The incidence of diarrhea, for example, has been shown to be significantly higher in children in child care facilities (Reves et al., 1993). Similarly, the use of child care facili- ties is a major factor contributing to trans- mission of respiratory tract diseases (Collet et al., 1991; Fleming, Cochi, Hightower, & Broome, 1987). Administrators of child care centers need to have effective infection con- trol procedures in place to prevent and con- trol outbreaks (Lee & Greig, 2008).

In 2007, the Washoe County Health Dis- trict and the Washoe County Department of Social Services responded to the increas- ing number of illnesses from outbreaks of

norovirus, influenza, and strep throat at child care centers by setting a goal to strengthen the Washoe County child care regulations on communicable diseases. Washoe County is located in northern Nevada and includes the cities of Reno and Sparks. The proposed regu- lations covered all licensed child care facili- ties in Washoe County. The Washoe County Health District also set a goal of developing an education, evaluation, and inspection pro- gram at child care facilities. Due to resource availability, however, the education, evalua- tion, and inspection program was only imple- mented at larger child care facilities licensed to care for 13 or more children.

Amending the Child Care Regulations Child care regulations are designed to pro- tect children by striving to prevent the risk of the spread of diseases (National Association for the Education of Young Children, 1997).

As a result of the collaboration between the Washoe County Health District and the Washoe County Department of Social Ser- vices, a number of communicable disease pre- vention requirements were adopted into the Washoe County child care regulations. These regulatory requirements were designed to reduce the number and severity of outbreaks and included 1) requiring exclusion of care- givers and children when they exhibit spe- cific symptoms; 2) requiring a hand-washing training program for children and caregivers; 3) requiring that caregivers monitor chil- dren’s hand-washing activities; 4) requiring specific hand-washing procedures be fol- lowed; 5) requiring a cleaning and sanitiz- ing schedule for specific items; 6) requiring additional steps to the diaper-changing pro- cedure, and 7) requiring all caregivers to take a Washoe County–approved communicable disease prevention course at least once every three years. Overall, the caregivers were very receptive and supportive of these proposed regulations. After a feedback period, these requirements were formally adopted in 2009.

The Education, Evaluation, and Inspection Program The education, evaluation, and inspection program at child care centers began on Feb- ruary 1, 2009. This program was designed to evaluate and provide educational feed- back on communicable disease prevention concepts to child care administrators. The program was also designed to familiarize the child care administrators with the symptoms of communicable diseases, such as diarrhea, vomiting, fever, cough, and sore throat. In

A b s t r a c t From 2005 to 2008, Washoe County, Nevada, child care centers experienced an increase in illnesses from communicable disease

outbreaks. The number of ill children and caregivers from these outbreaks

went from 26 in 2005 to 266 in 2008, an increase of 923%. A clear need to

reverse this trend existed. Therefore, in 2009 Washoe County strengthened

its regulations for child care facilities by adding numerous communicable

disease prevention standards. In addition, in 2009 a two-year education,

evaluation, and inspection program was implemented at Washoe County

child care centers. Following the implementation of this program, a decline

occurred in the number of illnesses. The number of ill children and caregivers

from outbreaks went from 266 in 2008 to 13 in 2011, a decrease of 95%.

Jordan Wagner, RN Altru Health System

Sharon Clodfelter Renown Health

Preventing Diseases and Outbreaks at Child Care Centers Using an Education, Evaluation, and Inspection Method

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addition, this education, evaluation, and inspection program was designed to deter- mine if any improvements in specific cat- egories of the administrators’ knowledge of communicable disease prevention concepts transferred into observed improvements in the child care centers’ communicable disease prevention practices.

Previous education and evaluation pro- grams have been effective in reducing ill- nesses. For example, hand-washing promo- tion is associated with significantly reduced absenteeism in school (Bowen et al., 2007). Hand-washing monitoring practices and hand-washing training programs also have played a role in reducing infections in chil- dren attending daycare centers (Carabin et al., 1999). Hand washing has proven to be one of the most important ways to limit the transmission of diseases in child care centers (Australian Government National Health and Medical Council, 2005). The critical role of hand washing to prevent disease transmis- sion cannot be overemphasized (Mink & Yeh, 2009). Hand washing alone, however, does not always appear to be sufficient to pre- vent the spread of disease at child care cen- ters. A hand-washing intervention program that resulted in an approximate threefold increase in hand washing among preschool children did not reduce illness absenteeism or overall absenteeism (Rosen et al., 2006). This suggests that a need exists for enhanced approaches for reducing illnesses in pre- school settings (Rosen et al., 2006).

Methods The methods involved a two-part evalua- tion process consisting of questionnaires and visual inspections. These questionnaires and inspections were conducted by environmen- talists who are registered as environmental health specialists both by the state of Nevada and by the National Environmental Health Association. The environmentalists’ train- ing included being able to implement health and safety laws as they pertain to child care centers. Their training also equipped them on how to communicate with the child care operators on when to suspect an outbreak is occurring, what interdiction measures to take when a suspected outbreak is occurring, and how to prevent outbreaks.

A 24-item questionnaire was developed to ascertain each child care administrator’s base-

line knowledge regarding communicable dis- ease prevention concepts. This questionnaire was administered to the child care admin- istrators during the unannounced annual inspections by the Washoe County Health District environmentalists. If they were unable to answer a question or answered a question incorrectly, it was marked as a negative response. The correct answer was then discussed until the environmentalist determined that the child care administra- tor understood the communicable disease concept(s) and could now answer the ques- tion correctly. The questions were asked in an open-ended format.

After the questionnaire was completed, the environmentalist conducted a visual inspec- tion of the child care center to determine the extent of the center’s compliance with the regulations. The environmentalist recorded violations on a 20-point list. If any violation on that list was found to have occurred, then the child care center was marked out of com- pliance for that category.

Approximately one year following the ini- tial questionnaire and visual inspection, the process was repeated during the following year’s unannounced annual inspection. A follow-up questionnaire (identical to the one given during the first inspection) was again asked of the child care center’s administrator. In addition, another visual inspection was conducted and violations were once again marked on the 20-point list.

The differences between the first and sec- ond visit’s answers to the administrative questionnaire were evaluated. In addition, the differences between the first and second visit’s visual inspection were evaluated. The Pearson Chi-square test was used to deter- mine any statistically significant differences in the answers to the questions from the first to second visit. The Pearson Chi-square test was also used to determine any statistically significant differences in the visual inspec- tion from the first to the second visit. When a cell had a count of five or less, the Fisher’s exact test was used instead of the Pearson Chi-square test. A threshold of p < .05 was chosen to identify statistical significance.

The Washoe County Health District also reviewed the yearly number of outbreaks and the yearly number of ill children and caregivers from these outbreaks prior to, during, and after completion of this two

year education, evaluation, and inspection program. The tracking of these outbreaks and illnesses was used to determine whether or not changes occurred in the number of outbreaks and illnesses.

Results Questionnaires were given and visual inspec- tions were conducted at 111 licensed child care centers in Washoe County. Of these 111 licensed child care centers, 80 of the child care centers had questionnaires and visual inspec- tions conducted twice over a two-year period. Of the questions asked of the child care admin- istrators, 8 of the 24 questions on the ques- tionnaire had statistically significant different responses from the first to the second visits (Table 1). Administrators’ correct responses to all eight of these questions increased on the second visit. The questions that had statisti- cally significant different responses from the first to the second visit are as follows: 1) “Were there special precautions to prevent outbreaks in place?” (p ≤ .001). 2) “Did the administra- tor have knowledge of the reporting require- ments for suspected gastrointestinal (GI) out- breaks?” (p ≤ .038). 3) “Was the administrator aware of normal, baseline levels of illness?” (p ≤ .002). 4) “Was the administrator able to determine a suspected illness outbreak—How many sick kids and staff with the same symp- toms before they report to the health district?” (p ≤ .001). 5) “Was there a hand-washing training program for children and staff?” (p ≤ .002). 6) “Were hand-washing monitoring requirements in place (even when only one child uses the bathroom)?” (p ≤ .005). 7) “Was there a blood spill cleanup kit in place?” (p ≤ .001). 8) “Was the cleanup procedure from vomitus acceptable for norovirus prevention?” (p ≤ .001).

No statistically significant differences were found on the visual inspections of the child care centers from the first to the second visit (Table 2).

From 2008 to 2010 the number of out- breaks at these child care centers decreased from nine to two. More importantly, ill- nesses associated with these outbreaks declined from 266 in 2008 to 61 in 2010, a decrease of 77%. Although data collection on the education, evaluation, and inspection program ended on February 28, 2011, the number of illnesses from outbreaks at these child care centers continued to decline. The

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number of ill children and caregivers from outbreaks went from 266 in 2008 to 13 in 2011, a decrease of 95% (Table 3).

These education and evaluation type of inspections of child care centers did not place excessive demands on the Washoe County Health District environmentalists. The time

required to conduct an education and evalu- ation type of inspection of a child care cen- ter was nearly identical to the time it took to conduct the previous observational type of child care inspection. It took a mean aver- age of 74 minutes for an environmentalist to complete an education and evaluation type of

inspection verses a mean average of 75 min- utes for an environmentalist to complete the observational type of child care inspection.

Discussion Inspections coupled with education and evaluation of the child care administrators’

Responses to Questionnaires by the Child Care Administrators

Question Environmental Inspection Visit 1 Environmental Inspection Visit 2 p-Value**

n # Correct Response

% Correct Response

n # Correct Response

% Correct Response

1. Facility has a history of outbreak(s)? 80 8 10.0 80 11 13.8 ≤.463 2. Special precautions to prevent outbreaks in place? 80 60 75.0 80 80 100 ≤.001** 3. Understanding of exclusion for gastrointestinal

(GI) illnesses? 80 73 91.3 80 78 97.5 ≤.167

4. Backup employee substitute plan in place? 80 70 87.5 80 77 96.3 ≤.079 5. Sick children isolated during wait for parent pickup? 80 75 93.8 80 80 100 ≤.059 6. Knowledge of reporting requirements suspected

GI outbreaks? 80 67 83.8 80 76 95.0 ≤.038**

7. Awareness of normal, baseline levels of illness? 80 68 85.0 80 79 98.8 ≤.002** 8. Illness tallied/tracked/or informally noted daily? 80 57 71.3 80 59 73.8 ≤.723 9. Able to determine suspected illness outbreak—“How

many sick kids and staff with the same symptoms before you report to the health district?”

80 67 83.8 80 79 98.8 ≤.001**

10. Have hand-washing training program for children, staff? 80 68 85.0 80 79 98.8 ≤.002** 11. Hand washing occurs at appropriate times? 80 75 93.8 80 79 98.8 ≤.210 12. Hand-washing monitoring in place (even when only

one child uses bathroom)? 80 67 83.8 80 78 97.5 ≤.005**

13. If hand sanitizer is used, is it used correctly?* 51 41 80.4 61 52 85.2 ≤.496 14. If gloves are used, does facility have hand-washing

policy for glove use?* 64 56 87.5 73 68 93.2 ≤.382

15. Review diaper change policy (get a copy, if possible)— adequate?*

52 41 78.8 56 44 78.6 ≤.927

16. Child’s hands are washed with soap/water or wipes after soiled diaper is removed prior to rediapering?

80 33 41.3 80 45 56.3 ≤.058

17. Caregiver washes hands after soiled diaper is removed before clean diaper and clothes are put on?*

47 33 70.2 56 42 75.0 ≤.586

18. Child’s hands washed at end of diaper change?* 51 48 94.1 56 52 92.9 ≤1.00 19. Caregiver washes hands at end of each and every

diaper change?* 48 48 100.0 55 53 96.4 ≤.497

20. Have blood spill cleanup kit in place? 80 13 16.3 80 31 38.8 ≤.001** 21. Cleanup procedure for vomitus acceptable for

norovirus prevention? 80 44 55.0 80 73 91.3 ≤.001**

22. Infant formula prepared by parents?* 42 32 76.2 45 36 80.0 ≤.667 23. Infant formula mixed or remixed by caregivers?* 39 21 53.8 44 21 47.7 ≤.578 24. If caregivers remix formula, are bottles adequately

cleaned?* 21 15 71.4 19 14 73.7 ≤1.00

*Those child care centers that were not involved in the procedure covered under this question were marked “not applicable” and their response was not used in the statistical calculations. If a “not applicable” response was given to any question not marked by an (*), it was treated as a negative response. 

**Statistically significant at p < .05.

TABLE 1

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knowledge on communicable disease con- cepts appear to be more effective than inspec- tions alone in reducing illnesses at child care centers. Experts recommend that health departments provide training, written infor- mation, and technical consultation to child care programs (American Academy of Pedi- atrics, 2009). Small, targeted health interven- tions in child care centers have been associ- ated with improved health knowledge and healthful behavior (Gupta, Shuman, Taveras, Kulldorff, & Finkelstein, 2005). Since pre- school-aged children spend increasing time in structured daycare settings, their risk for some communicable diseases has increased

(Thacker, Addiss, Goodman, Holloway & Spencer, 1992). Education about infection control, as a means of reducing transmission of diarrhea, appears to be effective (Roberts et al., 2000).

Child care administrators’ increased under- standing of a number of communicable dis- eases prevention concepts likely played a role in reducing the number and severity of out- breaks at Washoe County child care centers. This was evidenced by the administrators’ significant improvement in correct responses to a number of questions on the question- naire. To answer these questions correctly the administrators needed to understand the fol-

lowing communicable disease prevention con- cepts: 1) special precautions to take, includ- ing exclusion of ill individuals, to prevent outbreaks from occurring; 2) when to suspect an outbreak is occurring, including under- standing the baseline level of illness, and 3) what interdiction measures the administrator should immediately take, including calling the health department when he or she suspects an outbreak is occurring. These communicable disease prevention concepts are not likely to be observed being implemented during rou- tine inspections.

Since environmentalists conducting routine inspections will normally not observe if a child

Risk-Based Activities Observed

Risk-Based Activity Environmental Inspection Visit 1 Environmental Inspection Visit 2 p-Value*

n # Compliant % Compliant n # Compliant % Compliant I. Observed diaper change process

a. Is facility policy being followed? 35 30 85.7 33 25 75.8 ≤.363 b. Is there special prep for table (liners, etc.)? 39 20 51.3 34 16 47.1 ≤.719 c. Are gloves in use? 38 36 94.7 34 32 94.1 ≤1.00 d. Are gloves taken off immediately after diaper is

removed and wipes are used? 32 24 75.0 30 21 70.0 ≤.659

e. Are child’s hands washed with soap or wipes after diaper is removed before rediapering?

38 18 47.4 33 20 60.6 ≤.265

f. Are child’s hands washed with soap or wipes at end of diaper change?

37 29 78.4 33 28 84.8 ≤.551

g. Does employee wash hands with soap/water or wipes after removing soiled diaper before rediapering?

35 22 62.9 33 22 66.7 ≤.743

h. Are employee hands washed at end of diapering? 38 33 86.8 31 31 100 ≤.060 i. Is sanitizer used on changing table after each child? 38 35 92.1 31 30 96.8 ≤.622 j. Can items such as sanitizer bottle, wipes container,

etc., be indirectly contaminated during this procedure? 39 22 56.4 30 15 50.0 ≤.597

k. Are the soiled diapers correctly disposed of? 39 38 97.4 33 29 87.9 ≤.172 l. Is a wash/rinse step for table included if there is

visible soil? 29 22 75.9 30 25 83.3 ≤.532

m. Is correct hand wash technique used? 41 38 92.7 33 32 97.0 ≤.624 n. Is child hand washing monitored by caregivers? 41 36 87.8 35 33 94.3 ≤.442

II. Observed general hand washing a. Done after every diaper change? 32 29 90.6 31 30 96.8 ≤.613 b. After wiping child’s nose, etc.? 25 24 96.0 23 21 91.3 ≤.601 c. After wiping potentially contaminated surfaces? 29 28 96.6 28 27 96.4 ≤1.00 d. Before giving formula/food prep? 31 30 96.8 35 35 100 ≤.470 e. At other necessary times? 40 39 97.5 40 39 97.5 ≤1.00

III. Observed food handling a. Handling empty formula bottles, snack dishes,

etc., correctly? 31 29 93.5 37 35 94.6 ≤1.00

*Statistically significant at p < .05.

TABLE 2

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care center is implementing the three com- municable disease prevention concepts listed above, it is important to incorporate method(s) into the child care center inspections to teach and evaluate the administrators’ understand- ing of these concepts. One method to teach and evaluate administrators’ understanding of communicable disease prevention concepts is to have the health department environmental- ists ask them questions on these concepts and educate them on the correct responses to these questions when their answers are either incor- rect or vague. These questions should also be incorporated into the inspection forms.

Another area of significant improvement was in administrators’ responses that they had implemented hand-washing training programs and hand-washing monitoring practices. The increase in hand-washing training programs and hand-washing monitoring practices could have also played a role in reducing the number and severity of outbreaks at Washoe County child care centers. Implementing these train- ing programs and monitoring practices, how- ever, did not translate into observed signifi- cant changes in the following: 1) proper hand washing in general, 2) proper hand washing after diaper removal, and 3) proper monitor- ing by caregivers of children’s hand washing. This suggests that the hand-washing portion of the intervention program was not the pri- mary cause of the decrease in the number of outbreaks and illnesses at child care centers during this study period.

The limitations of our study are inherent in its design. After the education, evalua- tion, and inspection program was completed, a significant increase occurred in the child care administrators’ knowledge on a number of communicable disease prevention con- cepts. Other factors, however, both known and unknown, could have played a role in the increase in their knowledge. For example, the 2009 amendments to Washoe County’s child care regulations contained a number of requirements designed to help prevent com- municable diseases from occurring, including the requirement that all caregivers take a com- municable disease prevention class at least once every three years. These new regulations and perhaps other unknown factors could have played a role in reducing the number and severity of outbreaks in child care centers.

In addition, a limitation of our study was its small sample size. A decrease occurred in

the number and severity of outbreaks follow- ing the education, evaluation, and inspection program. It would require a larger sample size, however, to determine if this trend was statistically significant.

Finally, of the 111 child care centers inspected, only 80 had their questionnaires and surveys conducted twice. The remaining 31 child care centers had their questionnaires and surveys conducted only once due to a variety of factors, including the following: 1) a newly licensed child care center opened from one annual inspection to the next, 2) the child care center went out of business from one annual inspection to the next, and 3) the environmentalist only conducted one questionnaire and one 20-point visual inspection during the child care center’s two annual inspections.

Recommendations The Washoe County Health District makes the following recommendations for other health departments to consider. 1) Review current regulations governing

child care centers in your jurisdiction to ensure they adequately set standards for hand washing, for exclusion of ill indi- viduals, and for the appropriate interdic- tion measures to be taken if a suspected outbreak occurs.

2) Develop communicable diseases preven- tion questions for the child care adminis- trators to answer, with an emphasis placed on the administrators’ understanding of the correct answers to the following questions.

a. What special precautions (including isolating and excluding ill individuals) do they have in place to prevent out- breaks from occurring?

b. When to suspect an outbreak is occur- ring (including understanding the baseline level of illness)?

c. What interdiction measures (including calling the health department) would they immediately take when they sus- pect an outbreak is occurring?

3) Place these communicable diseases pre- vention questions on the routine child care inspection report forms and docu- ment the administrators’ responses.

Conclusion Benefits exist in conducting an education and evaluation type of child care inspection when compared to conducting the traditional type of observational inspection. For one, it is an excellent method to evaluate the child care administrator’s knowledge of communicable disease prevention concepts. This increase in knowledge on specific communicable dis- ease prevention concepts, as determined in our study, likely played a role in reducing the number and severity of outbreaks at Washoe County child care centers. Some of these concepts, such as knowing when to exclude a child and when to suspect an outbreak is occurring, are not readily observable through the traditional observational type of child care inspections. If the child care administra- tor is not educated on these concepts dur- ing these inspections, then they may end up

Washoe County Child Care Center Outbreaks and Number Ill From Outbreaks

Year Outbreaks Number Ill Mean Average Ill per Outbreak

2005 3 26 9 2006 7 243 35 2007 6 375 63 2008 9 266 30 2009* 3 49 16 2010 2 61 31 2011** 3 13 4

*February 1, 2009: education, evaluation, and inspection program begins. **February 28, 2011: education, evaluation, and inspection program ends.

TABLE 3

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being educated on these concepts during an outbreak at their child care center.

Lastly, the education, evaluation, and inspection program was cost-effective. The time it took an environmentalist to conduct an education and evaluation inspection was almost identical to the time it took to con- duct the traditional observational type of child care inspection. While the Washoe County Health District does not quantify the time spent on responding to outbreaks at licensed child care centers, the time spent in

responding to an outbreak can be extensive, depending on the number of ill people and the length of time the outbreak continues. It has been documented that the reduction in direct medical costs and costs associated with lost parental working time could more than offset the cost of implementing an infection control, education, and evaluation program in preschool settings (Ackerman, Duff, Den- nehy, Mafilios, & Krilov, 2001). Therefore, a reduction in the number and severity of out- breaks can save substantial resources.

Acknowledgements: The authors wish to thank the Washoe County Health District environmentalists for their diligence and commitment to protecting children’s health in Washoe County child care centers.

Corresponding Author: Jordan Wagner, Depart- ment of Telemetry, Altru Health System, P.O. Box 6002, Grand Forks, ND 58206. E-mail: [email protected].

Ackerman, S.J., Duff, S.B., Dennehy, P.H., Mafilios, M.S., & Krilov, L.R. (2001). Economic impact of an infection control education program in a specialized preschool setting. Pediatrics, 108(6), e102.

American Academy of Pediatrics. (2009). Respiratory children in out- of-home child care. In L.K. Pickering, C.J. Baker, D.W. Kimberlin, & S.S. Long (Eds.), Red book: 2009 report of the committee on infec- tious diseases (28th ed., p. 127). Elk Grove Village, IL: Author.

Australian Government National Health and Medical Research Council. (2005). Staying healthy in child care: Preventing infectious diseases in child care (4th ed.). Retrieved from http://www.nhmrc. gov.au/_files_nhmrc/publications/attachments/ch43.pdf

Bowen, A., Ma, H., Ou, J., Billhimer, W., Long, T., Mintz, E., Hoek- stra, R.M., & Luby, S. (2007). A cluster-randomized controlled trial evaluating the effect of a handwashing-promotion program in Chinese primary schools. The American Journal of Tropical Med- icine and Hygiene, 76(6), 1166–1173.

Carabin, H., Gyorkos, T.W., Soto, J.C., Joseph, L., Payment, P., & Collet, J.P. (1999). Effectiveness of a training program in reduc- ing infections in toddlers attending daycare centers. Epidemiology, 10(3), 219–227.

Collet, J.P., Ducruet, T., Floret, D., Cogan-Collet, J., Honneger, D., & Boissel, J.P. (1991). Daycare attendance and risk of first infectious disease. European Journal of Pediatrics, 150(3), 214–216.

Fleming, D.W., Cochi, S.L., Hightower, A.W., & Broome, C.V. (1987). Childhood upper respiratory tract infections: To what degree is incidence affected by daycare attendance? Pediatrics, 79(1), 55–60.

Gupta, R.S., Shuman, S., Taveras, E.M., Kulldorff, M., & Finkel- stein, J.A. (2005). Opportunities for health promotion education in child care. Pediatrics, 116(4), e499–e505.

Lee, M.B., & Greig, J.D. (2008). A review of enteric outbreaks in child care centers: Effective infection control recommendations. Journal of Environmental Health, 71(3), 24–32.

Mink, C.M., & Yeh, S. (2009). Infections in child-care facilities and schools. Pediatrics in Review, 30(7), 259–269.

National Association for the Education of Young Children. (1997). Licensing and public regulation of early childhood programs: A posi- tion statement. Retrieved from http://www.naeyc.org/files/naeyc/ file/positions/PSLIC98.PDF

Reves, R.R., Morrow, A.L., Bartlett, A.V., III, Caruso, C.J., Plumb, R.L., Lu, B.T., & Pickering, L.K. (1993). Child daycare increases the risk of clinic visits for acute diarrhea and diarrhea due to rota- virus. American Journal of Epidemiology, 137(1), 97–107.

Roberts, L., Jorm, L., Patel, M., Smith, W., Douglas, R.M., & McGil- christ, C. (2000). Effect of infection control measures on the fre- quency of diarrheal episodes in child care: A randomized, con- trolled trial. Pediatrics, 105(4), 743–746.

Rosen, L., Manor, O., Engelhard, D., Brody, D., Rosen, B., Peleg, H., Meir, M., & Zucker, D. (2006). Can a handwashing intervention make a difference? Results from a randomized controlled trial in Jerusalem preschools. Preventive Medicine, 42(1), 27–32.

Thacker, S.B., Addiss, D.J., Goodman, R.A., Holloway, B.R., & Spen- cer, H.C. (1992). Infectious diseases and injuries of child daycare. Opportunities for healthier children. Journal of the American Medi- cal Association, 268(13), 1720–1726.

References

?In its latest step to increase the safety of the American food supply, the Food and Drug Administration has issued the 2013 Voluntary National Retail Food Regulatory Program Standards. Visit www.fda.gov/Food/GuidanceRegulation/RetailFoodProtection/ProgramStandards for more information.Did You Know? JEH3.14_PRINT.indd 23 1/30/14 10:56 AM

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