Cuidado infantil en grupo durante el COVID-19: Una conversación de seguimiento

(En inglés)

Caring for Children in Group Settings During COVID-19: A Follow-up Conversation

Marco Beltran: Good afternoon and welcome. I want to start with some housekeeping prior to starting this webinar. Because almost 10,000 people registered for this webinar and we have such a large group today, we're not going to be able to answer everyone's questions, but we do want to hear from you. So please use the ask a question feature on the left side bar to ask the questions, submit comments. In addition to trying to answer some of the questions today, we also use the questions to help us in determining or coming up with future webinars. So please ask questions. You can also download a PDF copy of today's presentation. A recording of this webinar will be posted on the ECLKC. You can also use the webinar link that you use to join this broadcast to watch the recording again for up to a month.

Once again, good afternoon and welcome. My name is Marco Beltran and I am the Health Lead for The Office of Head Start. And I would like to welcome you to The Caring for Children in Group Settings During COVID-19, a follow-up conversation webinar. During the last webinar, we received many questions related to the spread of COVID-19, how to protect yourself and others, personal protective equipment, use of cloth face coverings, as well as cleaning and disinfecting. These questions are the foundation of this webinar.

And at this point, I want to introduce Dr. Michele Cheung, who will help us to address these questions and provide further guidance. Dr. Cheung is the medical officer with the Orange County Health Care Agency, the local health department in Orange County, California, where she provides clinical consultation to public health nurses and training for communicable disease search response. She is currently assisting with the search response to COVID-19, including the training and implementation of case and contact-tracing teams. She previously served as the Deputy Medical Director of Epidemiology and Physician Specialist for Infectious Disease Preparedness at the Orange County Health Care Agency, where her primary activities included physician education and providing clinical and epidemiological expertise for communicable disease surveillance, outbreak investigation, and public health emergency preparedness. Before coming to the Orange County Health Care Agency in 2004, she worked as the hospital-based pediatric infectious disease consultant, and also assisted with influenza surveillance at the state level. She is a board-certified – She is board certified in pediatric infectious disease and pediatrics and is a volunteer Associate Clinical Professor in Pediatrics at the University of California, UC Irvine. She completed a pediatric infectious disease fellowship at UC San Francisco, a preventative medicine residency at UC Berkeley, UCSF, and a pediatrics residency at UC Irvine. She received her MD from Jefferson Medical College, Pennsylvania, her MPH from UC Berkeley, and her BA from Princeton University. At this point, I want to welcome Dr. Michele Cheung, and I now want to let her take it over.

Dr. Michele Cheung: Hello, thank you for inviting me to present on this webinar, and to all of those listening, thank you so much for your interest in this topic. I'm quite amazed at the number of people who are online, and it really shows the great interest that you have in the health of the children and families that you serve. But most of all, I want to thank you for the work you do on a daily basis. Both of my children, who are now college age, are products of full-time child care, starting at age 5 weeks and 3 months, respectively. So I and many of my healthcare and public-health colleagues would have not been able to do our jobs without the work that you guys do on a daily basis.

So starting now on the topic at hand today: COVID-19. This slide shows – is a map of the number of COVID-19 cases in the US, by state or territory, as of two days ago. The map today is very similar except, the colors a little darker because the darker the color of each state, the more cases there are. And the number of cases overall has gone up a little bit as well to over 1,117,000 cases and over 68,000 deaths. The reason why I want to show this map is to show that it does differ by state. So I'm from California. I don't know where all of you guys are from, but each state and each local jurisdiction, each county, or even every city is having different numbers of cases. So each state in each county may have different recommendations for you too. So it's really important that you know what your local health recommendations are. And that, because if you have a case, they may have different recommendations for you.

The symptoms of COVID-19 – we've been learning a lot about them over the last several months. And what we've known has changed. And initially the main symptoms that were always talked about were fever, cough, shortness of breath, or difficulty breathing. Now, we've learned more that people can have some unusual symptoms, like new loss of taste or smell, and then other ones that may be associated with other viral illnesses, like chills, repeated shaking with chills, muscle pain, headache, sore throat. The symptoms generally occur two to 14 days after the exposure to an infectious person, although we don't always know who that infectious person is, so that may not be so helpful since some people may be infectious, even when they don't have symptoms. So these symptoms on this slide are mainly what they're talking about in adults, because most of our data comes from adults.

Really, children have not been getting a lot of illness in general. They're less than 2% of the cases and the feeling is children, in general, have more mild illness. So a lot of them are just presenting with upper respiratory symptoms – you know, the runny nose, cough – and not as severe symptoms as some of these other ones. So the question comes up is how we differentiate the symptoms of COVID-19 from a cold or influenza. And that's actually pretty difficult, I think, especially in children because their symptoms, symptoms of COVID-19 in children can be very mild. So there's really no single way to differentiate the symptoms of these different illnesses. Realize, of course, that the unusual symptoms, such as new loss of taste or smell, we do not see those with general colds or flu, although children probably won't be able to tell you that they have a new loss of taste or smell, but for at least for a staff that might be helpful.

In general, with a common cold, we don't have the shortness of breath. With any of these three, the cold that you're – the COVID-19 or influenza – you could have chills and fever, but that's more likely to happen, of course, with flu or with the COVID-19. But once again, there's really no way to absolutely, 100% distinguished them. And so, while we have COVID-19 circulating, when people have those symptoms with fever and respiratory, we have to think of at least COVID-19 and then determine if we want to – we can consult with the medical provider and see if that's what we think the patient has.

So as far as who is at risk for getting severe illness from COVID-19, generally people 65 years or older. And really, the older they are – so the people 85 years and older are at even higher risk for severe illness, hospitalization, and death. People who live in a long-term care facility or a nursing home, they're the ones right now you hear a lot of – there's outbreaks in these centers as well as deaths. And, you know, a lot of these people are the elderly and have underlying conditions, which may constitute would be to their increased risk for severe illness as well.

And then, people with underlying medical conditions, particularly if not well controlled. So this includes people with asthma or other chronic lung disease, people who have a compromised immune system, whether from cancer, medications, or any other kind of issues that are causing their immune system to be weak. People with chronic heart and lung disease, diabetes. And this also includes children with these special health care needs. when they've looked at children who were hospitalized, the things that were at increased risk for the severe illness in children with asthma and heart disease, as well as the compromised immune system. Fortunately, children in general, as I mentioned before, do seem to have milder illness, although there does seem to be an increased risk of severe disease again in these children with other healthcare – chronic healthcare conditions. And then also, children under 1 year of age seem to have slightly increased risk of severe disease, but overall, again, less than we have – less severe than we have with adults.

So COVID-19 is spread mainly from person to person. And you've heard a lot in the news about 6 feet, social distancing, keeping 6 feet from people. And that's because the way that it's spread through these respiratory droplets, generally those droplets – they're coughed or sneezed out, they come out sometimes with people are talking or singing, and then they're large droplets and they fall generally in less than three to 6 feet. So that's why that 6 feet comes up. The droplets can land in the mouth or nose of the people who are nearby and possibly be inhaled. And that's how people get infected. It also can be that these droplets that settle on a surface. So some of the spread may be that the people touched a contaminated surface or objects and then touch their eyes, nose, or mouth and get infected that way.

There are a lot of people who may be infected who may not know because they don't have symptoms. So they may be contributing to the spread as well. So how do we protect ourselves and others? There's key things that are recommended every year for – there are everyday preventative actions during flu season, or to prevent other respiratory illnesses. So these things are not new. Washing your hands often – and I know this is part of the standards in the Caring For Our Children as well. Using soap and water at least 20 seconds. If soap and water is not available, we can use hand sanitizer, and yes this can be used in children. It should only be used if hands are not visibly soiled and it has to be used supervised. There has to be an adult supervising because it is toxic. We don't want it lying around. It has to be locked up, stored where the children can access it. So that's washing your hands.

We want to avoid close contact – staying home as much as possible. A lot of areas are having different recommendations about that right now. Where we are in California, we're still under a stay-at-home order, but stay at home as much as possible if you're under; that order includes not going out, except for essentials, realizing that essential do include essential work. So if, people have an essential job, they would still go to that, and then the child care may be essential for them to support those people who are essential workers. While you're out in public, that includes keeping that safe distance, at least 6 feet around others – putting that distance between you and others. And then if you're out and about in the public, you should be covering your mouth and nose with a cloth face, covering. This again – the recommendation differs by area. Some places, it's a mandate; some places, it's just a recommendation. So that's mainly when you're out in places in the public where you can't keep that safe distance. If you're just going out for a run or riding your bike, of course you would not need to wear that. But if you're going to be going to the grocery store, for example, that would be a time that you would be wearing a cloth face covering. Realize also that this is a cloth face covering and not a surgical mask or an N95, as we're trying to preserve those kind of personal protective equipment for our health care workers in front line responders.

If you're at home or in another setting not out in the public, and by chance you're not wearing your face covering because you're not out in public, if you do cough or sneeze, you should be covering those with a tissue, throwing the tissue away, and then washing your hands. Cleaning and disinfecting frequently touched surfaces is something that should be done on a regular basis, and that also again is recommended in our Caring For Our Children guidance. During a pandemic, there is call for increasing the frequency of some of that cleaning/disinfecting, especially of items that are commonly touched.

So last webinar, which was about a week or two ago, they did go over in depth the guidance that the Centers for Disease Control has for child cares that are remaining opening. So I'm not going to go over those, but I really think – I would like to direct you to see them – see this guidance on the CDC website, and the link is on the slide and will be available after the presentation. But really those items in red here are the things that are new, and it changed from what you're usually doing, and something that you really should take a look at: how to implement the social distancing within a child care, how to intensify the cleaning and disinfection efforts, how to modify drop-off and pick-up procedures, implement screening procedures on arrival, and then maintain an adequate rate of staff to children to ensure safety, and then also to wear fairly space coverings for the children as if they're over age 2.

The question that comes up a lot is personal protective equipment, or PPE. And this is – these are items to protect the worker from being exposed if potentially a child or their parent does have an illness such as COVID-19. So, in the guidance from the CDC, it goes through different ways to do screening at check-in. And the first way was a way that you would not need to use PPE. And that is if you were able to have the parents screen at home, including taking the temperature and make sure that the child does not have fever, cough, or shortness of breath or other signs of illness. And then if you can maintain that 6 feet distance, when you're confirming

that with the parent at check-in, then you do not need to wear a PPE. And you can also visually inspect some from six over 6 feet away, then you would not – would need to wear that PPE.

However, the other option is to have a physical barrier available, like a plexiglass shield or some other barrier, so that you can visually inspect the child and you can stay behind the shield and obtain the temperature. Of course, washing your hands and putting on gloves before you take the temperature. So if you have that physical barrier, again, you do not need to use PPE.

However, if you can't do either of those two, the third option includes you assessing the child and being within 6 feet, and therefore you would need to use the personal protective equipment, which would include a face mask, eye protection, and gloves. And then also a gown, if you expect extensive physical contact, although really for the initial screening, you shouldn't need to have that extensive physical contact. If a child does become ill while they're at the center and you must be within 6 feet of the child, again, you would need personal protective equipment at that time, including the mask, eye protection and gloves, and the gown if extensive contact is expected. The use of the personal protective equipment is limited right now because of supply. And also, you need to understand how to use these items and take them on and off – to put them on and take them off safely. So training would be good to use the PPE. If you have not used it before, there's also links on the CDC website of how to don and doff the personal protective equipment. Because of the limitations on supply, there are some alternatives you can use, although the capability of these alternatives is not known – to protect people is not known. So, really use caution to use alternatives, but some ideas if you don't have a surgical mask is to use a homemade mask or a cloth face covering. If you don't have a gown that you could use a smock or oversized long-sleeve button down shirts. And then if you don't have the face shields, you could use sports goggles or safety glasses.

Face coverings is something that has been talked about a lot, and it's because of the close contact that often may be occurring in a child care setting that you're not able to always keep that 6 feet distance. It is recommended when feasible that the staff members and the older children wear face coverings while in the facility. It is not recommended that children who are they under the age of 2, for example, babies and young toddlers, they should not be wearing the face coverings because of the danger of suffocation. So the reason why we wear face coverings is to limit the spread from the person wearing them in case they have the virus and don't know that they have the virus. It's not actually meant as a protection for the person who's wearing it. It's to make it so that they don't spread to other people. They should be fit snugly and uncomfortably against the side of the face, allow for easy breathing, even while they're on, and be able to be laundered and machine dried without damage or changes to shape. And really, if people are wearing them regularly, they need to be washed and laundered regularly to keep them clean.

So for the facility, I mentioned as one of the key presented actions with cleaning and disinfecting. And in your Caring For Our Children standards, there's a whole section on this, and a schedule came in the back of that talks about this as well. But just to remind you, there's a difference between cleaning and disinfecting. Cleaning is physically removing this dirt debris

and sticky film by washing, wiping, and rinsing. And you can do that with soap and water. Disinfecting then kills nearly all the germs on the hard, nonporous surface. So with – for COVID-19 we always want to clean and disinfect. The cleaning may take away some of the – physically take away some of the virus, and then the disinfect will help to kill some of the virus left there. Some of the disinfectants don't work well unless you keep clean first. And so, that's why it's really important to do that cleaning and then disinfecting. Most of the household disinfectants available are effective against the virus causing COVID-19. There is a list on the EPA website that – so you can check your product. It's very easily sorted – sortable – so you can just look for your product that you use. And if you don't have a special product, you can also make a bleach solution with one third cup of bleach and a gallon of water. Realize that if you do use bleach, it has to be made fresh daily. And again, always make sure to store all these solutions in a place that's accessible to the teacher, but out of reach of any child. The recommendations during the COVID-19 pandemic is to intensify cleaning and disinfecting efforts. So I know in your schedules and Appendix K, you have a routine schedule that you do in your facility. So this intensified cleaning and disinfecting – there's no one number of how often. It really depends on how often certain items are touched. The things more frequently touched need to be more frequently disinfected.

The other question that comes up a lot is "who should we exclude?" So we – in your Caring For Our Children, you have guidance on which children to exclude for illness in general. But if during COVID-19, we also have to think about anyone with a known COVID-19 diagnosis, as well as children with fever – at least 100.4 degrees Fahrenheit or higher – children with cough, shortness of breath, or any other signs of illness that may suggest that they have fever or other underlying illness. So for children with a known or suspected COVID-19 diagnosis, the duration of exclusion is until at least 72 hours of no fever without using fever reducing medications and at least 10 days after symptoms have started – and symptoms are improving. So it's the longest of all those time periods. So the minimum would be 10 days from onset of symptoms until – and it could be longer depending on how long their fever and other symptoms last. Every health department has – may have a different recommendation as well. This is the CDC guidance, and that's what we're using in our county. But really consult with your local health department and what the local requirements are. There are a lot of places where you can find good, reliable information. I really encourage you to seek one of these reputable sources because there's a lot of misinformation on the website as well. So the centers for disease control has guidance for both telecare programs in general as well as guidance for child care programs that remain open. And then your local health department is a great resource. They – not only for information, but they have the authority of – to close child cares if necessary or would take – exclude child cares or staff from a from the child care facility. So, you need to know what the recommendations are going to be in your local jurisdiction for COVID-19. And they also are the ones tracking and monitoring the cases and contacts. The American Academy of Pediatrics, on their website, has guidance related to child care during COVID-19. And then the one that I'm sure you know already, Caring For Our Children, has the National Standards. And remember, of course, that your state child care licensing authority has specific regulations on staffing and all that – that are – that you still must follow. So with that, I will open it up for questions. And I think Marco will be helping with that.

Marco: Yes. Yes. Thank you so much, Dr. Cheung. The first question that we have is – that just came in – was "should playground equipment be sanitized?"

Dr. Cheung: So, it is recommended that playground equipment be disinfected. Generally, things outdoors – people don't think about disinfecting, but you realize that all these children are touching it, maybe coughing/sneezing, so they – after children are using it, that would be a good time to disinfect. The thing about both playgrounds and the playtime in general in the child care facility – it is because we're trying to do the social distancing – really, it's recommended that you only let children's – because they're going to be in classroom groups – that you stagger the playground time. So, you only have that one classroom group at a time, then you would disinfect it before the next group comes onto it. The other thing of course to remember is that everyone should be washing their hands after playing outside.

Marco: Great. We've got several questions that have come in regarding low temperature, actually. And you just indicated in a previous slide related to the temperature, folks were asking if they could – if they need to exclude a child that has a low temp of 100 or 100.2 degrees.

Dr. Cheung: So the recommendation that CDC has right now is 100.4. Realize that if they have a 100.2 and they have other signs of illness that might be a time that you would need to exclude them or at least recheck them maybe an hour later to see if their temperature is going up. I do also want to call your attention to one of the other recommendations in the Caring For Our Children guidance about having a child healthcare consultant. So that person, if you have one, would be a great resource if you had specific cases, you wanted to run by them and also to help you develop your plan, especially now during COVID, of what you're going to do if people have these mild symptoms and how you're going to communicate with their provider. It's also very important that – in your plans – that you've communicated to the parents ahead of time, that what your criteria are for exclusion, and that they may be called at any time if the child's ill and they need to come promptly could pick them up.

Marco: A follow-up question to that, actually, that just came in is that "if that is the case and you need to call the parents to come and pick up the child, where should you put them – the child – until the parent arrived?"

Dr. Cheung: So, in your planning right now, you should think about exactly that. So is there a place where you could put a child, like a separate room, that – of course, they need to be supervised still – but that they can be where they're at least 6 feet away from other people? The best would be if there was a separate room where someone could be watching them. Again, the staff person should try to keep the 6-feet distance as well. But if there's not a separate room where they could be supervised and kept separately, then within the same room that you have, is there a way to designate an area that they can still – you can still have eyes on them, but they're 6 feet away from other children? And then, part of that plan also would be again to make sure that the parent realizes that they're going to need to come pick them up promptly.

Marco: We have a question related to face covering for children. And this is actually – a question that we've been getting a lot is "how safe is it to be working with toddlers, knowing that they're going to have difficulty keeping the mask on?”

Dr. Cheung: So, in general, we aren't seeing a lot of kids getting COVID-19, although they may be asymptomatic. Right now, we haven't seen a lot of transmission among children either, but this is all still developing – what we're knowing about this. But if you're using the guidance of screening for any symptoms beforehand as well as trying – for the older children – to keep the face coverings on. For those younger children, it is recommended that if you are going to have extensive contact with them in close contact, that you can wear – the staff member can wear their face covering, of course. And then wear a smock, and then if they're between children, they would change their smock and wash their hands.

Marco: We have one question in which an individual has received mixed messages and they're asking, "Is it best to keep children grouped by age or should family members be kept together?"

Dr. Cheung: So, yeah, it's a little complicated. Generally, the groups are by age because of the developmental status. But the reason why the recommendation for family members to be kept together is because they've had the same exposures already. So it really makes – it's going to be situation dependent. Of course, if you have an infant and a 5-year-old, they probably wouldn't be able to be in the same group. But if there is some leeway to be able to keep maybe a 2-year-old with a 3-year-old, that would be good to keep the family's children together. Or if you have, you know, multiple classrooms that are 2 to 3-year-olds together. I mean, instead of separating the two family members, you'd put them in the same group.

Marco: So, we've heard a lot about PPE, and you indicated some of that in your slides, but folks are getting really confused because when they hear PPE, they're saying N95 masks. What type of mask is recommended for use in a child care setting?

Dr. Cheung: So, the N95 masks are just for healthcare workers, who are – or frontline responders. If they're – if you're talking about everyday wear just to be wearing it, you know, the cloth face coverings is what's being recommended for everyone to be wearing, besides – except for the children less than 2. If you're talking about having contact, close contact with someone before you screen them or close contact with one of the children when they're sick, then that personal protective equipment includes the surgical masks, if you're able to get them. And then, as I mentioned before, there are alternatives to that if you're unable to get the surgical mask.

Marco: Just a couple more questions, since we're hitting that – the 1:30 mark. The question came in related to – "if a child in care is diagnosed with COVID-19, must all children and teachers then quarantine until they are tested?"

Dr. Cheung: So that, again, would be something every health department has different plans for that. So, I recommend that they talk to their local health department. When a case is reported to the health department, they are doing investigation, and so they would be looking at the

child care exposure and seeing what's needed to be done. Just to give you an example: So when we get a case, we would call the – and see if there's other cases, other people sick, and determine at that point whether we need to get other people tested, if we need to quarantine people. Like, who else had close contact? Was the child symptomatic while they were at an infectious – while they were at the facility, et cetera. So there's a lot of things that play into that. And really, the local health apartment is the one that's going to make that decision.

Marco: Dr. Cheung I really, really want to thank you for taking the opportunity and jumping on the webinar for us and answering some of the questions that have been coming in and responding to some of the questions that we received in the earlier webinars to help kind of form your particular – through your slide deck. So thank you very, very much. Since we've already reached the 1:30 mark and we know that folks have scheduled just 30 minutes for this particular webinar, we want to be respectful of that. And so, you know, many of you have sent questions to our National Center already. So thank you very much for doing that. And we use that to help plan our Ask the Experts Series with pediatricians.

Please check our upcoming events page, using the URL that's on this slide to find the dates and registration links for each of these webinars that are going to be up and coming. A lot of the questions that actually came in will help to – help us with those particular slide decks, and to answer those as well during those upcoming webinars.

So in addition, MyPeers is a collaborative platform for ECE programs to ask questions and share resources. Our national center regularly posts information and the health, safety, and wellness community – and many other communities on MyPeers. If you are not a member of MyPeers, you can use the link on this slide to set up an account. This information is also on the resource handout that you can download during this presentation or in the PDF slide deck that's available.

And finally, so you can find the resources about COVID-19 and many other health topics on the website. And you can also submit questions to our info line using the center's email address, which is health@ecetta.info.

And finally, I just kind of have wanted – I know that many of you are worried about providing safe services to children and families and that you're working hard to do that, and to also to try to and manage your own staff, your own health and wellness and your own staff, and your coworkers wellness and safety. So thank you for doing that, and thank you for thinking about how we move forward in making sure that we provide safe and healthy environments for everybody that enters into our environment. I want to thank Dr. Cheung for helping to address questions and for sharing her expertise. This concludes our presentation. Thank you for joining us today. And please continue to reach out to us with your questions and concerns. Stay healthy and safe.

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