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Recommendations for Inclusion or Exclusion from Daycare / School

Rationale, current evidence, and consensus statement:


There is no evidence based support for exclusion or isolation of children with bacterial or viral conjunctivitis.  Arguments in support of isolation include reports of epidemic outbreaks in enclosed populations such as college campuses and day care settings where outbreaks of bacterial disease affected 13 to 28% of the population.  Arguments against include the epidemiology of viral etiologies, unknown infectivity among contacts, self-limiting nature of untreated conjunctivitis and limited to no isolation recommendations for other contact transmitted infections including mild diarrheal illnesses and viral respiratory tract disease.  Cost is argued in both settings with isolation supporters identifying increased cost of missed school or work among patients infected with conjunctivitis in an outbreak setting that may have been prevented with early treatment and isolation of index cases; while alternative arguments identify increased cost of missed work and unnecessary medical costs for patients isolated with viral conjunctivitis requiring a visit to a medical provider to return to normal daily activities. 

The American Academy of Pediatrics in conjunction with the American Public Health Association published updated recommendations in 2002 for national consensus guidelines on child care exclusions including recommendations that otherwise healthy and well appearing children with suspected conjunctivitis including red watery eyes, not be excluded or isolated.  A 2010 publication in Pediatrics identifies that these recommendations are not routinely followed. 

The prospective trials on conjunctivitis by Patel et al (2007) and Meltzer et al (2010) both identified that contact with a household member with pink eye, daycare attendance or exposure to another patient with conjunctivitis did not increase the likelihood of a positive bacterial culture on patients suspected of conjunctivitis.

Finally, the 2015 Red Book discusses that most minor illnesses do not constitute a reason for excluding a child from childcare.  The specific example of a condition that does not necessitate exclusion includes a child with conjunctivitis without fever and without behavior change.  However, if two or more children develop conjunctivitis in the same period, it is recommended to seek advice from a health consultant.  Similarly, school aged children should be allowed to remain in school with spread of infection minimized by careful hand hygiene and minimal close contact with other students.  Recommendations do include exclusion or isolation of children with signs of systemic illness and indicated treatment should be initiated.

Based on current literature the Care Process Model team does not recommend that patients are routinely excluded from normal daily activities including school and daycare programs, but a pragmatic approach is warranted.

 

References:

Committee on Infectious Diseases. (2015). Red Book: Report of the Commitee on Infectious Diseases (2015) (Kimberlin DW, Brady, MT, Jackson MA, & Long, SS Eds. 30 ed.).

Hashikawa, A. N., Juhn, Y. J., Nimmer, M., Copeland, K., Shun-Hwa, L., Simpson, P., . . . Brousseau, D. C. (2010). Unnecessary child care exclusions in a state that endorses national exclusion guidelines. Pediatrics, 125(5), 1003-1009. doi:10.1542/peds.2009-

Lichtenstein, S. J., Dorfman, M., Kennedy, R., & Stroman, D. (2006). Controlling contagious bacterial conjunctivitis. J Pediatr Ophthalmol Strabismus, 43(1), 19-26.

Meltzer, J. A., Kunkov, S., & Crain, E. F. (2010). Identifying children at low risk for bacterial conjunctivitis. Arch Pediatr Adolesc Med, 164(3), 263-267. doi:10.1001/archpediatrics.2009.289

Oliver, G. F., Wilson, G. A., & Everts, R. J. (2009). Acute infective conjunctivitis: evidence review and management advice for New Zealand practitioners. N Z Med J, 122(1298), 69-75.

Patel, P. B., Diaz, M. C., Bennett, J. E., & Attia, M. W. (2007). Clinical features of bacterial conjunctivitis in children. Acad Emerg Med, 14(1), 1-5. doi:10.1197/j.aem.2006.08.006

These guidelines do not establish a standard of care to be followed in every case. It is recognized that each case is different and those individuals involved in providing health care are expected to use their judgment in determining what is in the best interests of the patient based on the circumstances existing at the time. It is impossible to anticipate all possible situations that may exist and to prepare guidelines for each. Accordingly these guidelines should guide care with the understanding that departures from them may be required at times.