- Email: [email protected]
An observational study of frequency of provider hand contacts in child care facilities in North Carolina and South Carolina
American Journal of Infection Control 43 (2015) 107-11
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
journal homepage: www.ajicjournal.org
Major article
An observational study of frequency of provider hand contacts in child care facilities in North Carolina and South Carolina Angela Fraser PhD a, *, Kelly Wohlgenant MS b, Sheryl Cates BA b, Xi Chen MS a, Lee-Ann Jaykus PhD c, You Li PhD c, Benjamin Chapman PhD d a
Department of Food, Nutrition, and Packaging Sciences, Clemson University, Clemson, SC Food and Nutrition Policy Research, RTI International, RTP, NC Department of Food, Nutrition, and Bioprocessing, North Carolina State University, Raleigh, NC d Department of 4-H Youth Development and Family & Consumer Sciences, North Carolina State University, Raleigh, NC b c
Key Words: Child care providers Porous surfaces Nonporous surfaces Hand contact Observational study
Background: Children enrolled in child care are 2.3-3.5 times more likely to experience acute gastrointestinal illness than children cared for in their own homes. The purpose of this study was to determine the frequency surfaces were touched by child care providers to identify surfaces that should be cleaned and sanitized. Methods: Observation data from a convenience sample of 37 child care facilities in North Carolina and South Carolina were analyzed. Trained data collectors used iPods (Apple, Cupertino, CA) to record hand touch events of 1 child care provider for 45 minutes in up to 2 classrooms in each facility. Results: Across the 37 facilities, 10,134 hand contacts were observed in 51 classrooms. Most (4,536) were contacts with porous surfaces, with an average of 88.9 events per classroom observation. The most frequently touched porous surface was children’s clothing. The most frequently touched nonporous surface was food contact surfaces (18.6 contacts/observation). Surfaces commonly identified as hightouch surfaces (ie, light switches, handrails, doorknobs) were touched the least. Conclusion: General cleaning and sanitizing guidelines should include detailed procedures for cleaning and sanitizing high-touch surfaces (ie, clothes, furniture, soft toys). Guidelines are available for nonporous surfaces but not for porous surfaces (eg, clothing, carpeting). Additional research is needed to inform the development of evidence-based practices to effectively treat porous surfaces. Copyright Ó 2015 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
In 2010, 61% (12.2 of 20 million) of U.S. children under the age of 5 years were enrolled in child care, spending an average of 35 hours per week in the facilities.1,2 As dependency on out-of-home child care increases, the opportunity for children to experience acute gastrointestinal illness (AGI) also increases.3-5 Lu et al6 reported that children in child care facilities are 2.3-3.5 times more likely to experience AGI than children cared for in their own home. In child care environments, young children are in close proximity to one another and share toys and other items (eg, diaper change tables), which may result in transmission of pathogens that cause AGI.6 * Address correspondence to Angela Fraser, PhD, Department of Food, Nutrition, and Packaging Sciences, Clemson University, Clemson, SC 29634. E-mail address: [email protected] (A. Fraser). Funding/support: This work was supported by the United States Department of Agriculture under Agreement No. 2008-51110-04335, and the National Integrated Food Safety Initiative of the Cooperative State Research, Education, and Extension Competitive Grants Program. Conflicts of interest: None to report.
Hand contact with surfaces, particularly high-touch surfaces, has been reported to pose a great risk of pathogen transfer.7-10 Several studies have reported high rates of fecal coliforms on child care provider hands, suggesting the need to study hand contact events in child care facilities.11-13 Audits of the frequency of hand contact events have been performed in health care settings,14,15 but no published study has quantified child care provider hand contacts. The purpose of this study was to determine the frequency surfaces were touched by child care providers to identify surfaces that should be cleaned and sanitized.
METHODS All data collection protocols and instruments were approved by the Institutional Review Board of Clemson University, North Carolina State University, and RTI International. Data were collected between September 2010 and February 2011.
0196-6553/$36.00 - Copyright Ó 2015 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajic.2014.10.017
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Sample selection There were 508 child care facilities (115 in North Carolina, 393 in South Carolina) contacted up to 3 times via telephone to participate in the study. The South Carolina sample was recruited from a list of licensed child care facilities (n ¼ 393) in 10 upstate South Carolina counties. In North Carolina, the sample was recruited from a list of licensed child care facilities in 5 counties. The inclusion criteria were as follows: continuous operation for at least 1 year prior to study, not exclusive to drop-in service or special needs children, enrollment of at least 1 infant (0-12 months) and 3 toddlers (13 months-2 years), and provision of daily lunch and snack service to toddlers. There were 18 North Carolina and 22 South Carolina child care facilities that met the inclusion criteria and agreed to participate. Data collector training Seven individuals were trained on study protocols, including conducting practice observations. To assess the level of agreement among data collectors, observer interrater reliability testing was conducted. Each data collector viewed a 5-minute video of a child care provider and child and audio recorded surfaces touched by the provider and the location as specified by the study protocol. Each data collector was required to be at least 85% accurate to the gold standard observer, an RTI International research consultant who had experience conducting observations in child care classrooms. All data collectors passed the interrater reliability testing, with 4 of the 7 collectors completing a second round of testing. Observation protocol Child care providers were informed that data collectors would be observing them while they worked, but they were blinded to the purpose of the study, which was to record their hand contact with surfaces. One provider was observed in up to 2 classrooms at each facility and included an infant room, toddler room, preschooler classroom, and combined room if there were no separate infant and toddler rooms (common in family daycare homes). If >1 provider was present, the lead provider was observed. In each classroom, the provider’s hand contacts were observed and recorded on a digital voice recorder (iPod, Apple, Cupertino, CA) for a 45-minute period. This method was chosen because narrative records are open ended and flexible, allowing us to record as much as possible about what occurred, whereas using a checklist would have limited us to predefined choices. Data collectors audio recorded the type of surface touched and the location in the room (eg, handwash sink, diaper change area). To allow providers to acclimate to the presence of observers, each observer conducted a classroom audit (generally 15 minutes in length) immediately before the observation. Results of the classroom audit data are reported in a separate publication.16 Green et al17 applied a similar method for an observation study of restaurant workers, allowing subjects 10-15 minutes to acclimate before observations began. Observation data were transcribed and coded by 2 trained research assistants. Each hand contact was initially categorized by type of surface (porous surface, nonporous surface, bare skin). Porous surfaces were defined as “surfaces that have tiny openings which allow liquid to be absorbed or to pass through,” and nonporous surfaces were defined as “surfaces that have no openings to allow liquid to be absorbed or pass through.”18 Bare skin and hair were defined as a body part not covered by clothes. Coders then assigned each hand contact to 1 of 38 object codes (20 nonporous surfaces, 12 porous surfaces, 6 bare skin and hair) to
describe the surface touched. Frequencies of hand contacts were computed by room type and surface type or item touched using SAS 9.2 (SAS Institute, Cary, NC). RESULTS Characteristics of participating child care facilities Table 1 shows the characteristics of the 37 child care facilities that participated in the study. Of the child care centers, 43% (n ¼ 30) were classified as for-profit and 48% were classified as nonprofit facilities; the remaining 10% did not answer this question. All family daycare homes (n ¼ 7) were for-profit and independently owned and operated. Most centers (83%-93%) provided initial training on hygiene and sanitation practices to new employees compared with only 43%-57% of homes, which is not surprising given that most homes reported having only 1 employee, usually the owner or operator. Among all the facilities in the study, most directors (78%) reported having policies or written procedures for surface washing. Hand contacts Observation data from 51 classrooms in 37 facilities were analyzed. Three of the 40 facilities visited were excluded from the analysis because of poor audio quality or the provider was not in the classroom for most of the observation period. Of the 37 facilities, 16 facilities were in North Carolina and 21 were in South Carolina; 30 were centers and 7 were homes. A total of 10,134 provider hand contacts were recorded. Of the contacts observed, 4,536 were with porous surfaces; 4,054 were with nonporous surfaces; and 1,544 were with bare skin or hair. The number of hand contacts per observation ranged from 6-437, with an average of 198.7 contacts/observation. Porous surfaces were the most commonly touched surfaces (89.5 contacts/observation) followed by nonporous surfaces (78.9 contacts/observation) and then bare skin or hair (30.3 contacts/observation) (data not shown). Table 2 shows the total hand contacts by classroom type and type of surface touched. Porous surfaces were most commonly touched across all 4 classroom types except for the preschooler rooms (children ages 3-4 years) where nonporous surface contacts were the most commonly touched. Total hand contacts (n ¼ 4,219) were highest in toddler rooms and lowest in preschooler rooms (n ¼ 764). Figure 1 shows the mean frequencies of hand contact by surface in all 37 facilities. Of the 10 most commonly touched surfaces, 5 were porous surfaces (children’s clothes, papers or books, porous cleaning items, child care providers’ clothes, children’s hands), and 5 were nonporous surfaces (food contact surfaces, physical education shared, hard surface toys or games, nonporous shared classroom, hard fixtures). Of the 10 least touched surfaces, 8 were nonporous, 1 was bare skin, and 1 was porous. Children’s clothes were touched most frequently (34.2 contacts/observation). Food contact surfaces were the second most frequently touched surface (18.6 contacts/observation). Children’s hands were the most frequently touched bare skin or hair surface (9.8 contacts/ observation). Examining results by room type, the most frequently touched surface in infant, toddler, and combined rooms was children’s clothes (629 contacts, 630 contacts, and 382 contacts, respectively), whereas in preschooler classrooms the most frequently touched surface was providers’ clothes (85 contacts). For the infant and toddler rooms, the next most frequently touched surfaces were porous cleaning items, such as wet wipes and tissues (n ¼ 236 and n ¼ 358, respectively). In combined rooms, the most frequently
A. Fraser et al. / American Journal of Infection Control 43 (2015) 107-11
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Table 1 Characteristics of participating child care facilities All (N ¼ 40) No. of Percentage facilities of facilities
Characteristics of facilities Training on sanitation practices Initial training provided to new employees On-going training provided to employees Has policy or written procedure Handwashing Food preparation Diaper changing Surface cleaning Sick children Business type For-profit chain For-profit independently owned and operated Nonprofit No answer Participate in CACFP Mean no. of children by age group <12 months (infants) 12-<24 months (toddlers) 24-<36 months 3-5 years >5 years All children
North Carolina (n ¼ 18)
South Carolina (n ¼ 22)
No. of facilities
Percentage of facilities
No. of facilities
Percentage of facilities
Center (n ¼ 31)
Home (n ¼ 9)
No. of Percentage No. of Percentage facilities of facilities facilities of facilities
34 32
85.0 80.0
14 15
77.8 83.3
20 17
90.9 77.3
29 27
93.5 87.1
5 5
55.6 55.6
33 18 35 32 39
82.5 45.0 87.5 80.0 97.5
14 7 15 14 17
77.8 38.9 83.3 77.8 94.4
19 11 20 18 122
86.4 50.0 90.9 81.8 100.0
26 15 27 25 30
83.9 48.4 87.1 80.6 96.8
7 3 8 7 9
77.8 33.3 88.9 77.8 100.0
1 22 14 3 17
2.5 55.0 35.0 7.5 42.5
0 13 4 5 13
0 72.2 22.2 25.6 72.2
1 9 10 2 4
4.5 40.9 45.5 9.1 18.2
1 13 14 3 10
3.2 41.9 45.2 9.7 32.3
0 9 0 0 7
0 100.0 0 0 77.8
Mean
SD
Mean
SD
Mean
SD
Mean
SD
Mean
SD
5.1 8.5 8.9 27.2 10.7 60.4
5.8 9.1 9.3 29.2 15.0 49.8
2.6 5.0 4.4 21.2 8.3 41.4
3.1 5.6 5.4 26.0 16.2 42.5
7.3 11.5 12.8 32.4 12.8 76.8
6.7 10.5 9.6 31.3 13.9 50.7
6.4 10.6 11.2 34.7 13.6 76.6
6.0 9.4 9.0 29.3 16.0 45.6
0.6 1.4 1.3 2.1 1.1 6.7
0.7 1.1 1.0 1.5 1.3 2.6
CACFP, Child and Adult Care Food Program.
Table 2 Frequencies of hand contacts by surface and type of classroom (N ¼ 51) in child care facilities (N ¼ 37)* in North Carolina and South Carolina Type of classroom Infant (n ¼ 18) Toddler (n ¼ 18) Combined (n ¼ 11) Preschooler (n ¼ 4)
Hand contacts with nonporous surfaces 1,284 1,772 622 346
(32.0) (44.0) (15.0) (10.0)
Hand contacts with porous surfaces 1,538 1,823 906 296
(34.0) (40.0) (20.0) (6.5)
Hand contacts with bare skin 534 624 267 122
(35.0) (40.0) (17.0) (7.9)
Hand contacts across all surface types 3,356 4,219 1,795 764
NOTE. Values are n (%), where percentage refers to the frequency of surface contacts on nonporous surfaces in 1 type of classroom or the frequency of surface contacts on nonporous surfaces in all classrooms during a 45-minute observation period. *Three facilities were excluded for data analysis because the quality of the recorded observation audios in these 3 facilities were poor and could not be transcribed.
touched surface was also provider clothes (n ¼ 144). In preschooler rooms, it was children’s clothes (n ¼ 69) (data not reported). DISCUSSION
Fig 1. Mean frequencies of hand contacts by the type of surface in child care facilities (N ¼ 37) in North Carolina and South Carolina.
To determine the frequency providers touch surfaces in the child care environment, an observational study was conducted in 37 child care facilities in North Carolina and South Carolina. Observational data were used to quantify the types of surfaces touched during a 45-minute observation period. Overall, porous surfaces were touched most often (88.9 contacts/observation) across all classroom types except for preschooler rooms where nonporous surfaces were touched more frequently. Of the porous surfaces touched, children’s clothes were contacted most frequently (34.2 contacts/observation). Providers also had more frequent contact with children’s hands than any other bare skin surfaces (9.8 contacts/observation). Laborde et al11 reported that frequent hand contact between providers and children may increase the risk of pathogen transmission. These researchers also reported that classrooms with high coliform counts on providers’ hands had high coliform counts on children’s hands. Additionally,
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Goldmann19 and Hall et al20 identified touching infants infected with respiratory syncytial virus or surrounding fomites as a risk factor for developing respiratory syncytial virus infection in nurses. In our study, we also observed providers making frequent hand contact with hard-surface (nonporous) toys or games (14.8 contacts/observation) and soft surface (porous) toys or games (8.4 contacts/observation). Toys are known to be a source for pathogens. The handling of contaminated toys by children and providers could increase risk for AGI.21 Food contact surfaces (eg, counter tops, cutlery, cups) were the most frequently touched nonporous surfaces in all facilities (18.6 contacts/observation), presumably because of the frequent service of infant formula, meals, and snacks within the classroom. Surprisingly, the least-touched surfaces were those commonly labeled high-touch surfaces (doorknobs, common telephones, light and fan switches, handrails), suggesting the need to identify high-touch surfaces by setting to be certain cleaning and sanitizing are properly directed. Because the providers in our study had frequent contact with children’s clothes (34.2 contacts/observation), the risk of transferring pathogens from contaminated fabric to hands is constantly present, especially from wet fabric to hands.22-26 Spreading enteric pathogens may increase when providers contact children’s clothing contaminated by leaking diapers, spit up, or saliva. Unfortunately, we do not know if it is a common practice for providers to change children’s clothes after clothes become soiled or how those soiled clothes are handled because there is no clear guidance. Because contact with clothing and other porous surfaces may be an important point of contamination, guidelines or regulatory provisions detailing how to handle these surfaces after contamination events, if available and followed, could reduce the risk for AGI. At present, all 50 states plus the District of Columbia have child care regulations that provide guidelines on cleaning of nonporous surfaces (eg, food contact surfaces).27 Daily sanitation of food contact surfaces is a well-known prevention strategy for AGI and is therefore required by regulation.25,28-31 However, guidelines for cleaning porous surfaces (eg, clothing, fabric, carpet) are unclear in many state regulations. For example, in North Carolina, the only porous surfaces that must be cleaned and sanitized are bed linens and toys. This is also the case in South Carolina with furniture and toys. Although these items are required to be cleaned and sanitized, the guidelines for doing so are not clear.32-35 To illustrate how widespread this problem is, in a review of child care regulations across the United States, no state provides detailed guidelines for cleaning porous surfaces other than bed linens.27 Limitations There are several limitations to this study. The observations could have been confounded by the Hawthorne effect, also known as reactivity bias.36 Participation in the study was voluntary, leading to potential selection bias that could have favored participation by high-performing child care facilities and the exclusion of those having less stringent compliance with recognized hygiene and sanitation best practices. Finally, our sample size (37 facilities) was not sufficiently large to generalize the results. CONCLUSION This study quantifies the frequency that types of surfaces were touched by child care providers in a convenience sample of child care facilities in North Carolina and South Carolina. The most commonly touched surface across all classrooms was clothing, either the child’s clothes or the provider’s clothes. Contact with clothing and other porous surfaces may facilitate the transmission of enteric pathogens in the child care environment. Guidelines for
cleaning and sanitizing nonporous surfaces in child care facilities are available, but guidelines are absent for cleaning and sanitizing porous surfaces (eg, carpets, clothing, soft toys). Universal guidelines are needed to clean and sanitize porous surfaces and need to be incorporated into state regulations. Finally, surfaces commonly identified as high-touch surfaces (ie, light switches, handrails, doorknobs) were touched the least, suggesting the need to identify high-touch surfaces by type of setting. Acknowledgments We thank all participating child care facilities and their staff for supporting the observational study. References 1. Child Care Aware of America. Child Care in America: 2012 state fact sheets. Available from: http://www.naccrra.org/publications/naccrra-publications/2012/6/ child-care-in-america-2012-state-fact-sheets. Accessed January 15, 2014. 2. Howden LM, Meyer JA. Age and sex composition: 2010. In: U.S. Department of Commerce Economics and Statistics Administration. Washington, DC: U.S. Census Bureau; 2011. p. 16. 3. Bartlett AV, Moore M, Gary GW, Starko KM, Erben JJ, Meredith BA. Diarrheal illness among infants and toddlers in day care centers. II. Comparison with day care homes and households. J Pediatr 1985;107:503-9. 4. Brady MT. Infectious disease in pediatric out-of-home child care. Am J Infect Control 2005;33:276-85. 5. Cote SM, Petitclerc A, Raynault MF, Xu Q, Falissard B, Boivin M, et al. Short- and long-term risk of infections as a function of group child care attendance: an 8year population-based study. Arch Pediatr Adolesc Med 2010;164:1132-7. 6. Lu N, Samuels M, Shi L, Baker S, Glover S, Sanders J. Child day care risks of common infectious diseases revisited. Child Care Health Dev 2004;30:361-8. 7. Bhalla A, Pultz NJ, Gries DM, Ray AJ, Eckstein EC, Aron DC, et al. Acquisition of nosocomial pathogens on hands after contact with environmental surfaces near hospitalized patients. Infect Control Hosp Epidemiol 2004;25:164-7. 8. Dancer SJ. Importance of the environment in methicillin-resistant Staphylococcus aureus acquisition: the case for hospital cleaning. Lancet Infect Dis 2008;8:101-13. 9. Oelberg DG, Joyner SE, Jiang X, Laborde D, Islam MP, Pickering LK. Detection of pathogen transmission in neonatal nurseries using DNA markers as surrogate indicators. Pediatrics 2000;105:311-5. 10. Rampling A, Wiseman S, Davis L, Hyett AP, Walbridge AN, Payne GC, et al. Evidence that hospital hygiene is important in the control of methicillinresistant Staphylococcus aureus. J Hosp Infect 2001;49:109-16. 11. Laborde DJ, Weigle KA, Weber DJ, Kotch JB. Effect of fecal contamination on diarrheal illness rates in day-care centers. Am J Epidemiol 1993;138:243-55. 12. Holaday B, Pantell R, Lewis C, Gilliss CL. Patterns of fecal coliform contamination in day-care centers. Public Health Nurs 1990;7:224-8. 13. Petersen NJ, Bressler GK. Design and modification of the day care environment. Rev Infectious Dis 1986;8:618-21. 14. Smith SJ, Young V, Robertson C, Dancer SJ. Where do hands go? An audit of sequential hand-touch events on a hospital ward. J Hosp Infect 2012;80: 206-11. 15. Huslage K, Rutala WA, Weber DJ. A quantitative approach to defining “hightouch” surfaces in hospitals. Infect Control Hosp Epidemiol 2010;31:850-3. 16. Wohlgenant K, Cates S, Fraser A, Chapman B, Jaykus LA, Chen X. J Environ Health. Pending. 17. Green LR, Radke V, Mason R, Bushnell L, Reimann DW, Mack JC, et al. Factors related to food worker hand hygiene practices. J Food Prot 2007;70:661-6. 18. Montana State University. Pesticide glossary. Available from: http://www. pesticides.montana.edu/Glossary.htm. Accessed January 15, 2014. 19. Goldmann DA. Transmission of viral respiratory infections in the home. Pediatr Infect Dis J 2000;19(10 Suppl):S97-102. 20. Hall CB, Douglas RG Jr, Schnabel KC, Geiman JM. Infectivity of respiratory syncytial virus by various routes of inoculation. Infect Immun 1981;33:779-83. 21. Jiang X, Dai X, Goldblatt S, Buescher C, Cusack TM, Matson DO, et al. Pathogen transmission in child care settings studied by using a cauliflower virus DNA as a surrogate marker. J Infect Dis 1998;177:881-8. 22. Mackintosh C, Hoffman P. An extended model for transfer of micro-organisms via the hands: differences between organisms and the effect of alcohol disinfection. J Hyg (London) 1984;92:345-55. 23. Rusin P, Maxwell S, Gerba C. Comparative surface-to-hand and fingertip-tomouth transfer efficiency of gram-positive bacteria, gram-negative bacteria, and phage. J Appl Microbiol 2002;93:585-92. 24. Sattar S, Springthorpe S, Mani S, Gallant M, Nair R, Scott E, et al. Transfer of bacteria from fabrics to hands and other fabrics: development and application of a quantitative method using Staphylococcus aureus as a model. J Appl Microbiol 2001;90:962-70. 25. Scott E, Bloomfield SF. The survival and transfer of microbial contamination via cloths, hands and utensils. J Appl Microbiol 1990;68:271-8.
A. Fraser et al. / American Journal of Infection Control 43 (2015) 107-11 26. Sidwell RW, Dixon GJ, Mcneil E. Quantitative studies on fabrics as disseminators of viruses III. Persistence of vaccinia virus on fabrics impregnated with a virucidal agent. Appl Microbiol 1967;15:921-7. 27. Leone C, Cates S, Wohlgenant K, Jaykus LA, Fraser AM. Analysis of child-care regulations for the presence of strategies to prevent and control noroviruses. In process. 28. Bloomfield S, Scott E. Cross-contamination and infection in the domestic environment and the role of chemical disinfectants. J Appl Microbiol 1997;83:1-9. 29. Cosby CM, Costello C, Morris W, Haughton B, Devereaux M, Harte F, et al. Microbiological analysis of food contact surfaces in child care centers. Appl Environ Microbiol 2008;74:6918-22. 30. Reynolds KA, Watt PM, Boone SA, Gerba CP. Occurrence of bacteria and biochemical markers on public surfaces. Int J Environ Health Res 2005;15:225-34. 31. Staskel DM, Briley ME, Field LH, Barth SS. Microbial evaluation of foodservice surfaces in Texas child-care centers. J Am Diet Assoc 2007;107:854-9. 32. North Carolina Administrative Code. Title 10A - health and human services. Chapter 9 - child care rules. Available from: http://www.reports.oah.state.nc.
33.
34.
35.
36.
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us/ncac.asp?folderName¼/Title%2010A%20-%20Health%20and%20Human%20 Services/Chapter%2009%20-%20Child%20Care%20Rules; 2013. Accessed October 3, 2013. North Carolina General Statutes. Article 7. Child care facilities. Available from: http://www.ncleg.net/EnactedLegislation/Statutes/PDF/ByArticle/Chapter_110/ Article_7.pdf; 2012. Accessed October 3, 2013. North Carolina Administrative Code. Title 15A - Department of Environment, Health, and Natural Resources. Chapter 18 - environmental health. Subchapter 18Aesanitation. Section .1900esewage treatment and disposal systems. Environmental Health. Available from: http://ehs.ncpublichealth.com/oswp/ docs/rules/August-2007.pdf; 2007. Accessed October 3, 2013. South Carolina Department of Social Services. 2005 South Carolina Code of Regulations - chapter 114 - Department of Social Services. Available from: http://law.justia.com/codes/south-carolina/2005/114/114.html. Accessed October 3, 2013. Bernard HR. Participant observation. In: Social Research Methods: qualitative and quantitative approaches. Sage Publications; 2013. p. 324.
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
journal homepage: www.ajicjournal.org
Major article
An observational study of frequency of provider hand contacts in child care facilities in North Carolina and South Carolina Angela Fraser PhD a, *, Kelly Wohlgenant MS b, Sheryl Cates BA b, Xi Chen MS a, Lee-Ann Jaykus PhD c, You Li PhD c, Benjamin Chapman PhD d a
Department of Food, Nutrition, and Packaging Sciences, Clemson University, Clemson, SC Food and Nutrition Policy Research, RTI International, RTP, NC Department of Food, Nutrition, and Bioprocessing, North Carolina State University, Raleigh, NC d Department of 4-H Youth Development and Family & Consumer Sciences, North Carolina State University, Raleigh, NC b c
Key Words: Child care providers Porous surfaces Nonporous surfaces Hand contact Observational study
Background: Children enrolled in child care are 2.3-3.5 times more likely to experience acute gastrointestinal illness than children cared for in their own homes. The purpose of this study was to determine the frequency surfaces were touched by child care providers to identify surfaces that should be cleaned and sanitized. Methods: Observation data from a convenience sample of 37 child care facilities in North Carolina and South Carolina were analyzed. Trained data collectors used iPods (Apple, Cupertino, CA) to record hand touch events of 1 child care provider for 45 minutes in up to 2 classrooms in each facility. Results: Across the 37 facilities, 10,134 hand contacts were observed in 51 classrooms. Most (4,536) were contacts with porous surfaces, with an average of 88.9 events per classroom observation. The most frequently touched porous surface was children’s clothing. The most frequently touched nonporous surface was food contact surfaces (18.6 contacts/observation). Surfaces commonly identified as hightouch surfaces (ie, light switches, handrails, doorknobs) were touched the least. Conclusion: General cleaning and sanitizing guidelines should include detailed procedures for cleaning and sanitizing high-touch surfaces (ie, clothes, furniture, soft toys). Guidelines are available for nonporous surfaces but not for porous surfaces (eg, clothing, carpeting). Additional research is needed to inform the development of evidence-based practices to effectively treat porous surfaces. Copyright Ó 2015 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
In 2010, 61% (12.2 of 20 million) of U.S. children under the age of 5 years were enrolled in child care, spending an average of 35 hours per week in the facilities.1,2 As dependency on out-of-home child care increases, the opportunity for children to experience acute gastrointestinal illness (AGI) also increases.3-5 Lu et al6 reported that children in child care facilities are 2.3-3.5 times more likely to experience AGI than children cared for in their own home. In child care environments, young children are in close proximity to one another and share toys and other items (eg, diaper change tables), which may result in transmission of pathogens that cause AGI.6 * Address correspondence to Angela Fraser, PhD, Department of Food, Nutrition, and Packaging Sciences, Clemson University, Clemson, SC 29634. E-mail address: [email protected] (A. Fraser). Funding/support: This work was supported by the United States Department of Agriculture under Agreement No. 2008-51110-04335, and the National Integrated Food Safety Initiative of the Cooperative State Research, Education, and Extension Competitive Grants Program. Conflicts of interest: None to report.
Hand contact with surfaces, particularly high-touch surfaces, has been reported to pose a great risk of pathogen transfer.7-10 Several studies have reported high rates of fecal coliforms on child care provider hands, suggesting the need to study hand contact events in child care facilities.11-13 Audits of the frequency of hand contact events have been performed in health care settings,14,15 but no published study has quantified child care provider hand contacts. The purpose of this study was to determine the frequency surfaces were touched by child care providers to identify surfaces that should be cleaned and sanitized.
METHODS All data collection protocols and instruments were approved by the Institutional Review Board of Clemson University, North Carolina State University, and RTI International. Data were collected between September 2010 and February 2011.
0196-6553/$36.00 - Copyright Ó 2015 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajic.2014.10.017
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Sample selection There were 508 child care facilities (115 in North Carolina, 393 in South Carolina) contacted up to 3 times via telephone to participate in the study. The South Carolina sample was recruited from a list of licensed child care facilities (n ¼ 393) in 10 upstate South Carolina counties. In North Carolina, the sample was recruited from a list of licensed child care facilities in 5 counties. The inclusion criteria were as follows: continuous operation for at least 1 year prior to study, not exclusive to drop-in service or special needs children, enrollment of at least 1 infant (0-12 months) and 3 toddlers (13 months-2 years), and provision of daily lunch and snack service to toddlers. There were 18 North Carolina and 22 South Carolina child care facilities that met the inclusion criteria and agreed to participate. Data collector training Seven individuals were trained on study protocols, including conducting practice observations. To assess the level of agreement among data collectors, observer interrater reliability testing was conducted. Each data collector viewed a 5-minute video of a child care provider and child and audio recorded surfaces touched by the provider and the location as specified by the study protocol. Each data collector was required to be at least 85% accurate to the gold standard observer, an RTI International research consultant who had experience conducting observations in child care classrooms. All data collectors passed the interrater reliability testing, with 4 of the 7 collectors completing a second round of testing. Observation protocol Child care providers were informed that data collectors would be observing them while they worked, but they were blinded to the purpose of the study, which was to record their hand contact with surfaces. One provider was observed in up to 2 classrooms at each facility and included an infant room, toddler room, preschooler classroom, and combined room if there were no separate infant and toddler rooms (common in family daycare homes). If >1 provider was present, the lead provider was observed. In each classroom, the provider’s hand contacts were observed and recorded on a digital voice recorder (iPod, Apple, Cupertino, CA) for a 45-minute period. This method was chosen because narrative records are open ended and flexible, allowing us to record as much as possible about what occurred, whereas using a checklist would have limited us to predefined choices. Data collectors audio recorded the type of surface touched and the location in the room (eg, handwash sink, diaper change area). To allow providers to acclimate to the presence of observers, each observer conducted a classroom audit (generally 15 minutes in length) immediately before the observation. Results of the classroom audit data are reported in a separate publication.16 Green et al17 applied a similar method for an observation study of restaurant workers, allowing subjects 10-15 minutes to acclimate before observations began. Observation data were transcribed and coded by 2 trained research assistants. Each hand contact was initially categorized by type of surface (porous surface, nonporous surface, bare skin). Porous surfaces were defined as “surfaces that have tiny openings which allow liquid to be absorbed or to pass through,” and nonporous surfaces were defined as “surfaces that have no openings to allow liquid to be absorbed or pass through.”18 Bare skin and hair were defined as a body part not covered by clothes. Coders then assigned each hand contact to 1 of 38 object codes (20 nonporous surfaces, 12 porous surfaces, 6 bare skin and hair) to
describe the surface touched. Frequencies of hand contacts were computed by room type and surface type or item touched using SAS 9.2 (SAS Institute, Cary, NC). RESULTS Characteristics of participating child care facilities Table 1 shows the characteristics of the 37 child care facilities that participated in the study. Of the child care centers, 43% (n ¼ 30) were classified as for-profit and 48% were classified as nonprofit facilities; the remaining 10% did not answer this question. All family daycare homes (n ¼ 7) were for-profit and independently owned and operated. Most centers (83%-93%) provided initial training on hygiene and sanitation practices to new employees compared with only 43%-57% of homes, which is not surprising given that most homes reported having only 1 employee, usually the owner or operator. Among all the facilities in the study, most directors (78%) reported having policies or written procedures for surface washing. Hand contacts Observation data from 51 classrooms in 37 facilities were analyzed. Three of the 40 facilities visited were excluded from the analysis because of poor audio quality or the provider was not in the classroom for most of the observation period. Of the 37 facilities, 16 facilities were in North Carolina and 21 were in South Carolina; 30 were centers and 7 were homes. A total of 10,134 provider hand contacts were recorded. Of the contacts observed, 4,536 were with porous surfaces; 4,054 were with nonporous surfaces; and 1,544 were with bare skin or hair. The number of hand contacts per observation ranged from 6-437, with an average of 198.7 contacts/observation. Porous surfaces were the most commonly touched surfaces (89.5 contacts/observation) followed by nonporous surfaces (78.9 contacts/observation) and then bare skin or hair (30.3 contacts/observation) (data not shown). Table 2 shows the total hand contacts by classroom type and type of surface touched. Porous surfaces were most commonly touched across all 4 classroom types except for the preschooler rooms (children ages 3-4 years) where nonporous surface contacts were the most commonly touched. Total hand contacts (n ¼ 4,219) were highest in toddler rooms and lowest in preschooler rooms (n ¼ 764). Figure 1 shows the mean frequencies of hand contact by surface in all 37 facilities. Of the 10 most commonly touched surfaces, 5 were porous surfaces (children’s clothes, papers or books, porous cleaning items, child care providers’ clothes, children’s hands), and 5 were nonporous surfaces (food contact surfaces, physical education shared, hard surface toys or games, nonporous shared classroom, hard fixtures). Of the 10 least touched surfaces, 8 were nonporous, 1 was bare skin, and 1 was porous. Children’s clothes were touched most frequently (34.2 contacts/observation). Food contact surfaces were the second most frequently touched surface (18.6 contacts/observation). Children’s hands were the most frequently touched bare skin or hair surface (9.8 contacts/ observation). Examining results by room type, the most frequently touched surface in infant, toddler, and combined rooms was children’s clothes (629 contacts, 630 contacts, and 382 contacts, respectively), whereas in preschooler classrooms the most frequently touched surface was providers’ clothes (85 contacts). For the infant and toddler rooms, the next most frequently touched surfaces were porous cleaning items, such as wet wipes and tissues (n ¼ 236 and n ¼ 358, respectively). In combined rooms, the most frequently
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Table 1 Characteristics of participating child care facilities All (N ¼ 40) No. of Percentage facilities of facilities
Characteristics of facilities Training on sanitation practices Initial training provided to new employees On-going training provided to employees Has policy or written procedure Handwashing Food preparation Diaper changing Surface cleaning Sick children Business type For-profit chain For-profit independently owned and operated Nonprofit No answer Participate in CACFP Mean no. of children by age group <12 months (infants) 12-<24 months (toddlers) 24-<36 months 3-5 years >5 years All children
North Carolina (n ¼ 18)
South Carolina (n ¼ 22)
No. of facilities
Percentage of facilities
No. of facilities
Percentage of facilities
Center (n ¼ 31)
Home (n ¼ 9)
No. of Percentage No. of Percentage facilities of facilities facilities of facilities
34 32
85.0 80.0
14 15
77.8 83.3
20 17
90.9 77.3
29 27
93.5 87.1
5 5
55.6 55.6
33 18 35 32 39
82.5 45.0 87.5 80.0 97.5
14 7 15 14 17
77.8 38.9 83.3 77.8 94.4
19 11 20 18 122
86.4 50.0 90.9 81.8 100.0
26 15 27 25 30
83.9 48.4 87.1 80.6 96.8
7 3 8 7 9
77.8 33.3 88.9 77.8 100.0
1 22 14 3 17
2.5 55.0 35.0 7.5 42.5
0 13 4 5 13
0 72.2 22.2 25.6 72.2
1 9 10 2 4
4.5 40.9 45.5 9.1 18.2
1 13 14 3 10
3.2 41.9 45.2 9.7 32.3
0 9 0 0 7
0 100.0 0 0 77.8
Mean
SD
Mean
SD
Mean
SD
Mean
SD
Mean
SD
5.1 8.5 8.9 27.2 10.7 60.4
5.8 9.1 9.3 29.2 15.0 49.8
2.6 5.0 4.4 21.2 8.3 41.4
3.1 5.6 5.4 26.0 16.2 42.5
7.3 11.5 12.8 32.4 12.8 76.8
6.7 10.5 9.6 31.3 13.9 50.7
6.4 10.6 11.2 34.7 13.6 76.6
6.0 9.4 9.0 29.3 16.0 45.6
0.6 1.4 1.3 2.1 1.1 6.7
0.7 1.1 1.0 1.5 1.3 2.6
CACFP, Child and Adult Care Food Program.
Table 2 Frequencies of hand contacts by surface and type of classroom (N ¼ 51) in child care facilities (N ¼ 37)* in North Carolina and South Carolina Type of classroom Infant (n ¼ 18) Toddler (n ¼ 18) Combined (n ¼ 11) Preschooler (n ¼ 4)
Hand contacts with nonporous surfaces 1,284 1,772 622 346
(32.0) (44.0) (15.0) (10.0)
Hand contacts with porous surfaces 1,538 1,823 906 296
(34.0) (40.0) (20.0) (6.5)
Hand contacts with bare skin 534 624 267 122
(35.0) (40.0) (17.0) (7.9)
Hand contacts across all surface types 3,356 4,219 1,795 764
NOTE. Values are n (%), where percentage refers to the frequency of surface contacts on nonporous surfaces in 1 type of classroom or the frequency of surface contacts on nonporous surfaces in all classrooms during a 45-minute observation period. *Three facilities were excluded for data analysis because the quality of the recorded observation audios in these 3 facilities were poor and could not be transcribed.
touched surface was also provider clothes (n ¼ 144). In preschooler rooms, it was children’s clothes (n ¼ 69) (data not reported). DISCUSSION
Fig 1. Mean frequencies of hand contacts by the type of surface in child care facilities (N ¼ 37) in North Carolina and South Carolina.
To determine the frequency providers touch surfaces in the child care environment, an observational study was conducted in 37 child care facilities in North Carolina and South Carolina. Observational data were used to quantify the types of surfaces touched during a 45-minute observation period. Overall, porous surfaces were touched most often (88.9 contacts/observation) across all classroom types except for preschooler rooms where nonporous surfaces were touched more frequently. Of the porous surfaces touched, children’s clothes were contacted most frequently (34.2 contacts/observation). Providers also had more frequent contact with children’s hands than any other bare skin surfaces (9.8 contacts/observation). Laborde et al11 reported that frequent hand contact between providers and children may increase the risk of pathogen transmission. These researchers also reported that classrooms with high coliform counts on providers’ hands had high coliform counts on children’s hands. Additionally,
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Goldmann19 and Hall et al20 identified touching infants infected with respiratory syncytial virus or surrounding fomites as a risk factor for developing respiratory syncytial virus infection in nurses. In our study, we also observed providers making frequent hand contact with hard-surface (nonporous) toys or games (14.8 contacts/observation) and soft surface (porous) toys or games (8.4 contacts/observation). Toys are known to be a source for pathogens. The handling of contaminated toys by children and providers could increase risk for AGI.21 Food contact surfaces (eg, counter tops, cutlery, cups) were the most frequently touched nonporous surfaces in all facilities (18.6 contacts/observation), presumably because of the frequent service of infant formula, meals, and snacks within the classroom. Surprisingly, the least-touched surfaces were those commonly labeled high-touch surfaces (doorknobs, common telephones, light and fan switches, handrails), suggesting the need to identify high-touch surfaces by setting to be certain cleaning and sanitizing are properly directed. Because the providers in our study had frequent contact with children’s clothes (34.2 contacts/observation), the risk of transferring pathogens from contaminated fabric to hands is constantly present, especially from wet fabric to hands.22-26 Spreading enteric pathogens may increase when providers contact children’s clothing contaminated by leaking diapers, spit up, or saliva. Unfortunately, we do not know if it is a common practice for providers to change children’s clothes after clothes become soiled or how those soiled clothes are handled because there is no clear guidance. Because contact with clothing and other porous surfaces may be an important point of contamination, guidelines or regulatory provisions detailing how to handle these surfaces after contamination events, if available and followed, could reduce the risk for AGI. At present, all 50 states plus the District of Columbia have child care regulations that provide guidelines on cleaning of nonporous surfaces (eg, food contact surfaces).27 Daily sanitation of food contact surfaces is a well-known prevention strategy for AGI and is therefore required by regulation.25,28-31 However, guidelines for cleaning porous surfaces (eg, clothing, fabric, carpet) are unclear in many state regulations. For example, in North Carolina, the only porous surfaces that must be cleaned and sanitized are bed linens and toys. This is also the case in South Carolina with furniture and toys. Although these items are required to be cleaned and sanitized, the guidelines for doing so are not clear.32-35 To illustrate how widespread this problem is, in a review of child care regulations across the United States, no state provides detailed guidelines for cleaning porous surfaces other than bed linens.27 Limitations There are several limitations to this study. The observations could have been confounded by the Hawthorne effect, also known as reactivity bias.36 Participation in the study was voluntary, leading to potential selection bias that could have favored participation by high-performing child care facilities and the exclusion of those having less stringent compliance with recognized hygiene and sanitation best practices. Finally, our sample size (37 facilities) was not sufficiently large to generalize the results. CONCLUSION This study quantifies the frequency that types of surfaces were touched by child care providers in a convenience sample of child care facilities in North Carolina and South Carolina. The most commonly touched surface across all classrooms was clothing, either the child’s clothes or the provider’s clothes. Contact with clothing and other porous surfaces may facilitate the transmission of enteric pathogens in the child care environment. Guidelines for
cleaning and sanitizing nonporous surfaces in child care facilities are available, but guidelines are absent for cleaning and sanitizing porous surfaces (eg, carpets, clothing, soft toys). Universal guidelines are needed to clean and sanitize porous surfaces and need to be incorporated into state regulations. Finally, surfaces commonly identified as high-touch surfaces (ie, light switches, handrails, doorknobs) were touched the least, suggesting the need to identify high-touch surfaces by type of setting. Acknowledgments We thank all participating child care facilities and their staff for supporting the observational study. References 1. Child Care Aware of America. Child Care in America: 2012 state fact sheets. Available from: http://www.naccrra.org/publications/naccrra-publications/2012/6/ child-care-in-america-2012-state-fact-sheets. Accessed January 15, 2014. 2. Howden LM, Meyer JA. Age and sex composition: 2010. In: U.S. Department of Commerce Economics and Statistics Administration. Washington, DC: U.S. Census Bureau; 2011. p. 16. 3. Bartlett AV, Moore M, Gary GW, Starko KM, Erben JJ, Meredith BA. Diarrheal illness among infants and toddlers in day care centers. II. Comparison with day care homes and households. J Pediatr 1985;107:503-9. 4. Brady MT. Infectious disease in pediatric out-of-home child care. Am J Infect Control 2005;33:276-85. 5. Cote SM, Petitclerc A, Raynault MF, Xu Q, Falissard B, Boivin M, et al. Short- and long-term risk of infections as a function of group child care attendance: an 8year population-based study. Arch Pediatr Adolesc Med 2010;164:1132-7. 6. Lu N, Samuels M, Shi L, Baker S, Glover S, Sanders J. Child day care risks of common infectious diseases revisited. Child Care Health Dev 2004;30:361-8. 7. Bhalla A, Pultz NJ, Gries DM, Ray AJ, Eckstein EC, Aron DC, et al. Acquisition of nosocomial pathogens on hands after contact with environmental surfaces near hospitalized patients. Infect Control Hosp Epidemiol 2004;25:164-7. 8. Dancer SJ. Importance of the environment in methicillin-resistant Staphylococcus aureus acquisition: the case for hospital cleaning. Lancet Infect Dis 2008;8:101-13. 9. Oelberg DG, Joyner SE, Jiang X, Laborde D, Islam MP, Pickering LK. Detection of pathogen transmission in neonatal nurseries using DNA markers as surrogate indicators. Pediatrics 2000;105:311-5. 10. Rampling A, Wiseman S, Davis L, Hyett AP, Walbridge AN, Payne GC, et al. Evidence that hospital hygiene is important in the control of methicillinresistant Staphylococcus aureus. J Hosp Infect 2001;49:109-16. 11. Laborde DJ, Weigle KA, Weber DJ, Kotch JB. Effect of fecal contamination on diarrheal illness rates in day-care centers. Am J Epidemiol 1993;138:243-55. 12. Holaday B, Pantell R, Lewis C, Gilliss CL. Patterns of fecal coliform contamination in day-care centers. Public Health Nurs 1990;7:224-8. 13. Petersen NJ, Bressler GK. Design and modification of the day care environment. Rev Infectious Dis 1986;8:618-21. 14. Smith SJ, Young V, Robertson C, Dancer SJ. Where do hands go? An audit of sequential hand-touch events on a hospital ward. J Hosp Infect 2012;80: 206-11. 15. Huslage K, Rutala WA, Weber DJ. A quantitative approach to defining “hightouch” surfaces in hospitals. Infect Control Hosp Epidemiol 2010;31:850-3. 16. Wohlgenant K, Cates S, Fraser A, Chapman B, Jaykus LA, Chen X. J Environ Health. Pending. 17. Green LR, Radke V, Mason R, Bushnell L, Reimann DW, Mack JC, et al. Factors related to food worker hand hygiene practices. J Food Prot 2007;70:661-6. 18. Montana State University. Pesticide glossary. Available from: http://www. pesticides.montana.edu/Glossary.htm. Accessed January 15, 2014. 19. Goldmann DA. Transmission of viral respiratory infections in the home. Pediatr Infect Dis J 2000;19(10 Suppl):S97-102. 20. Hall CB, Douglas RG Jr, Schnabel KC, Geiman JM. Infectivity of respiratory syncytial virus by various routes of inoculation. Infect Immun 1981;33:779-83. 21. Jiang X, Dai X, Goldblatt S, Buescher C, Cusack TM, Matson DO, et al. Pathogen transmission in child care settings studied by using a cauliflower virus DNA as a surrogate marker. J Infect Dis 1998;177:881-8. 22. Mackintosh C, Hoffman P. An extended model for transfer of micro-organisms via the hands: differences between organisms and the effect of alcohol disinfection. J Hyg (London) 1984;92:345-55. 23. Rusin P, Maxwell S, Gerba C. Comparative surface-to-hand and fingertip-tomouth transfer efficiency of gram-positive bacteria, gram-negative bacteria, and phage. J Appl Microbiol 2002;93:585-92. 24. Sattar S, Springthorpe S, Mani S, Gallant M, Nair R, Scott E, et al. Transfer of bacteria from fabrics to hands and other fabrics: development and application of a quantitative method using Staphylococcus aureus as a model. J Appl Microbiol 2001;90:962-70. 25. Scott E, Bloomfield SF. The survival and transfer of microbial contamination via cloths, hands and utensils. J Appl Microbiol 1990;68:271-8.
A. Fraser et al. / American Journal of Infection Control 43 (2015) 107-11 26. Sidwell RW, Dixon GJ, Mcneil E. Quantitative studies on fabrics as disseminators of viruses III. Persistence of vaccinia virus on fabrics impregnated with a virucidal agent. Appl Microbiol 1967;15:921-7. 27. Leone C, Cates S, Wohlgenant K, Jaykus LA, Fraser AM. Analysis of child-care regulations for the presence of strategies to prevent and control noroviruses. In process. 28. Bloomfield S, Scott E. Cross-contamination and infection in the domestic environment and the role of chemical disinfectants. J Appl Microbiol 1997;83:1-9. 29. Cosby CM, Costello C, Morris W, Haughton B, Devereaux M, Harte F, et al. Microbiological analysis of food contact surfaces in child care centers. Appl Environ Microbiol 2008;74:6918-22. 30. Reynolds KA, Watt PM, Boone SA, Gerba CP. Occurrence of bacteria and biochemical markers on public surfaces. Int J Environ Health Res 2005;15:225-34. 31. Staskel DM, Briley ME, Field LH, Barth SS. Microbial evaluation of foodservice surfaces in Texas child-care centers. J Am Diet Assoc 2007;107:854-9. 32. North Carolina Administrative Code. Title 10A - health and human services. Chapter 9 - child care rules. Available from: http://www.reports.oah.state.nc.
33.
34.
35.
36.
111
us/ncac.asp?folderName¼/Title%2010A%20-%20Health%20and%20Human%20 Services/Chapter%2009%20-%20Child%20Care%20Rules; 2013. Accessed October 3, 2013. North Carolina General Statutes. Article 7. Child care facilities. Available from: http://www.ncleg.net/EnactedLegislation/Statutes/PDF/ByArticle/Chapter_110/ Article_7.pdf; 2012. Accessed October 3, 2013. North Carolina Administrative Code. Title 15A - Department of Environment, Health, and Natural Resources. Chapter 18 - environmental health. Subchapter 18Aesanitation. Section .1900esewage treatment and disposal systems. Environmental Health. Available from: http://ehs.ncpublichealth.com/oswp/ docs/rules/August-2007.pdf; 2007. Accessed October 3, 2013. South Carolina Department of Social Services. 2005 South Carolina Code of Regulations - chapter 114 - Department of Social Services. Available from: http://law.justia.com/codes/south-carolina/2005/114/114.html. Accessed October 3, 2013. Bernard HR. Participant observation. In: Social Research Methods: qualitative and quantitative approaches. Sage Publications; 2013. p. 324.