Cryptosporidiosis—Child Care and Schools

What is cryptosporidiosis?

Cryptosporidiosis is an intestinal infection caused by a parasite ( Cryptosporidium hominis or Cryptosporidium parvum ) and is the leading cause of water-associated disease in the United States.

What are the signs or symptoms?

• Acute nonbloody, watery, frequent diarrhea.

• Fever.

• Nausea and vomiting.

• Abdominal cramps.

• Signs of dehydration, including dry mouth, no tears, or no urine for 8 hours.

• Fatigue.

• Lack of appetite.

• Many individuals are infected and contagious without signs or symptoms.

• Illness may last 1 to 20 days (average of 10 days) in immunocompetent children and can last much longer (weeks to months) in immunocompromised children.

What are the incubation and contagious periods?

• Incubation period: 2 to 10 days; average of 7 days.

• Contagious period: In immunocompetent children, the parasite may pass in the stool for up to 2 weeks after symptoms resolve. In immunocompromised children, the parasite may persist in the stool for months.

How is it spread?

• Fecal-oral route: Contact with feces from an infected person, typically when a child contaminates their fingers and then plays in communal water (during water play) or touches an object that another person then touches. Children who have contact with the contaminated water or surfaces may place their fingers into their own or another person’s mouth. About 2% to 4% of children without symptoms in early childhood education (ECE) settings pass Cryptosporidium oocysts (eggs; the infectious form of the parasite) in their stools.

• Most commonly spread through contaminated swimming or wading water and other shared water sources. Transmission often occurs when young children release small amounts of fecal material into the water while playing. The largest outbreaks of waterborne disease occur in the summer and early fall months and affect children younger than 5 years. Contaminated municipal water supplies can also cause outbreaks.

• Cryptosporidium is resistant to chlorine, which is commonly used to prevent infections from recreational water. As a result, Cryptosporidium is the leading cause of treated recreational water–associated outbreaks of diarrhea. Cryptosporidium oocysts that spread diarrheal disease can remain infectious for more than 7 days in chlorine concentrations typically required for swimming pools.

• Outbreaks can occur in ECE settings and are thought to be spread person-to-person at high rates, as well as from contaminated water sources.

• Transmission can also occur from animals in petting zoos and contaminated feces on farms and in the wild.

How do you control it?

• Use good hand-hygiene technique at all the times listed in Chapter 2 of Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide, 7th Edition , especially after toilet use or handling soiled diapers and before anything to do with food preparation or eating. Alcohol-based hand sanitizers are not effective against Cryptosporidium . Wash hands with soap and water.

• Ensure proper surface disinfection that includes cleaning and rinsing of surfaces that may have become contaminated with stool (feces) with detergent and water and application of a US Environmental Protection Agency–registered disinfectant according to the instructions on the product label. For guidance on disinfectants, refer to Selection and Use of a Cleaning, Sanitizing, or Disinfecting Product in Chapter 8 of Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide, 7th Edition .

• Children with Cryptosporidium diarrhea should not participate in water play activities for 2 weeks after diarrhea has resolved.

• Use a combination of water disinfection and proper pool maintenance to reduce the risk of contamination. For children younger than 8 years, consider restricting communal water play to water contact above the waist (eg, water tables), or limit play in bodies of water where children get wet below the waist to 1 child at a time before replacing the water with fresh water (eg, a portable wading pool).

• Advise swimmers and waders to use the toilet before using recreational water to reduce the risk of releasing feces into the water. Encourage all water users to shower before and after use and avoid swallowing the water. Some recreational pools implement a policy requiring children younger than 8 years to leave the pool for a toilet break at 2-hour intervals.

• Ensure thorough washing of raw fruits and vegetables.

• Ensure proper cooking and storage of food.

• Exclude infected staff members who handle food. See Safe Food Preparation and Service: Food Handlers in Chapter 2 of Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide, 7th Edition .

• Exclude for specific types of symptoms (see the section Exclude from educational setting?).

What are the roles of the educator and the family?

• There are multiple causes of diarrhea. Until the cause of the diarrhea is identified, apply the recommendations for a child or staff member with diarrhea from any cause (see Diarrhea Quick Reference Sheet).

  • – Report the condition to the staff member designated by the ECE program or school for decision-making and action related to care of ill children and staff members. That person, in turn, alerts possibly exposed family and staff members to watch for symptoms and notifies the Child Care Health Consultant.

  • – Ensure staff members follow the control measures listed in the section How do you control it?

  • – Do not allow a staff member with diarrhea to be involved with food handling or feeding of children.

  • – Report outbreaks of diarrhea (more than 2 children and/or staff members in the group) to the Child Care Health Consultant, who may report to the local health department.

• If you know a child or staff member has a cryptosporidiosis infection

  • – Follow the advice of the child’s or staff member’s health professional.

  • – Report the infection to the local health department. The health professional who makes the diagnosis may not report that the infected child is a participant in an ECE program or school, and this could lead to delay in controlling the spread.

  • – Reeducate staff members about strict and frequent handwashing, diapering, toileting, food handling, and cleaning and disinfection procedures.

  • – In an outbreak, follow the directions of the local health department.

Exclude from educational setting?

Yes, if

• The local health department determines exclusion is needed to control an outbreak.

• Stool is not contained in the diaper for diapered children.

• Diarrhea is causing “accidents” for toilet-trained children.

• Stool is more watery and frequency exceeds 2 stools above normal for that child during the time the child is in the program because this may cause too much work for EC educators and make it difficult for them to maintain sanitary conditions.

• There is blood or mucus in stool.

• The child has a dry mouth, no tears, or no urine output in 8 hours (suggesting the child’s diarrhea may be causing dehydration).

• The child is unable to participate and staff members determine they cannot care for the child without compromising their ability to care for the health and safety of the other children in the group.

• The child meets other exclusion criteria (see Conditions Requiring Temporary Exclusion in Chapter 4 of Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide, 7th Edition ).

Note: For children and staff members without symptoms (eg, recently recovered or exposed), testing or retesting stool cultures, treatment, and exclusion are not necessary.

Readmit to educational setting?

Yes, when all the following criteria are met:

• Once diapered children have their stool contained by the diaper (even if the stools remain loose) and when toilet-trained children do not have toileting accidents

• Once stool frequency is no more than 2 stools above normal for that child during the time the child is in the program, even if the stools remain loose

• When exclusion criteria are resolved, the child is able to participate, and staff members determine they can care for the child without compromising their ability to care for the health and safety of the other children in the group

Note: It is not necessary to demonstrate negative Cryptosporidium stool test results to be readmitted to the educational setting.