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Communicable Disease Reference Guide

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					COMMUNICABLE DISEASES IN SCHOOLS

A Reference Guide




                       Student Medical Services and District Nursing Services
                                Student Health and Human Services Division
                                          Los Angeles Unified School District
                                                                  3rd Edition
                                                                        2005
                            Table of Contents


PART I: INTRODUCTION TO COMMUNICABLE DISEASES IN SCHOOLS……………………...1
      Overview……………………………………………………………………………………………………… .2
      General Inclusion and Exclusion Criteria……………………………………………………..3
      Definition of Terms……………………………………………………………………………………….5

PART II: POLICIES ON THE CONTROL OF COMMUNICABLE DISEASE IN SCHOOLS……..7

PART III: COMMONLY ENCOUNTERED COMMUNICABLE DISEASES…………………………..12
      Chickenpox (Varicella-Zoster Infections)…………………………………………………….13
      Chlamydia…………………………………………………………………………………………………….14
      Common Cold (Upper Respiratory Infections)…………………………………………….15
      Conjunctivitis (“Pink Eye”)………………………………………………………………………….16
      Cytomegalovirus (CMV)………………………………………………………………………………..17
      Diphtheria…………………………………………………………………………………………………….18
      Fifth Disease (Human Parvovirus B19)…………………………………………………………19
      Foodborne Illness (Food Poisoning)……………………………………….…………………….20
      Giardiasis……………………………………………………………………………………………………..21
      Gonorrhea…………………………………………………………………………………………………….22
      Hand, Foot, and Mouth Disease (Commonly Enterovirus)…………………………..23
      Head Lice (Pediculosis)………………………………………………………………………………..24
      Hepatitis A, B, and C…………………………………………………………………………….……..25
      Herpes (Oral and Genital)…………………………………………………………………………….27
      HIV/AIDS……………………………………………………………………………………………………….28
      Impetigo (& MRSA)……………………………………………………………………………………….30
      Influenza (Flu)……………………………………………………………………………………………..31
      Lyme Disease……………………………………………………………………………………………….32
      Measles (Rubeola)………………………………………………………………………………………..33
      Meningitis………………………………………………………………………………………….…………34
      Molluscum Contagiosum………………………………………………………………………………35
      Mononucleosis……………………………………………………………………………………………..36
      Mumps………………………………………………………………………………………………………….37
      Pinworms……………………………………………………………………………………………………..38
      Pertussis (Whooping Cough)…………………………………………………………………………39
      Ringworm (Tinea)…………………………………………………………………………………………40
      Rubella (German Measles)……………………………………………………………………………41
      Scabies………………………………………………………………………………………………………….42
      Scarlet Fever…………………………………………………………………………………………………43
      Strep Throat………………………………………………………………………………………………….44
      Tetanus……………………………………………………………………………………………..………..45
      Tuberculosis………………………………………………………………………………………..….…..46
      Warts (Genital and Non-Genital)…………………………………………………………..…….47
      West Nile Virus (& Mosquito-borne Diseases)……………………………………………….48

PART IV: BIOTERRORISM AND COMMUNICABLE DISEASES AT SCHOOLS……………………49
PART V: APPENDICES……………………………………………………………………………………………….53
   Appendix A: County of Los Angeles Reportable Diseases and Condition………….54
   Appendix B: Guide to Immunizations Required for School Entry……………………..56
   Appendix C: LAUSD Policies and Bulletins…………………………………………………………59
      Bulletin 1645: Infection Control Procedures for the Prevention
                     And Spread of Communicable Diseases……………………………….60
      Bulletin 1937: Reporting Communicable Diseases……………………………………..67
      Bulletin 1660: Immunization Guidelines for School Admission………………….77
      Bulletin 1959: Tuberculosis Examination Requirements for
                      New Entering Students ……………………………………………………….83
      Bulletin Z-70: Students with HIV/AIDS Infection………………………………………..87
      Bulletin Z-69: Employees with HIV/AIDS Infection…………………………………….92
      Bulletin Z-72: Bioterrorism Preparedness Response:
                      Health Perspective………………………………………………………………96
      Reference Guide 1304: West Nile Virus Precautions………………………………….103
                   Part I


Introduction to Communicable Disease in Schools




                    -1-
                                       Overview

From a very young age through adolescence, students spend a great deal of time in
the school setting. Schools place a high priority on attendance which is necessary for
optimal student learning and achievement. Yet, the nature of schools (close,
confined contact among students and staff) make the transmission of infectious
disease possible. Determining the likelihood that an infection will spread from one
person to another requires an understanding of the ease and mechanism by which a
particular organism is transmitted, as well as some knowledge of the host immunity
(i.e., Has the student been vaccinated against the disease? Does the student have a
compromised immune system?). We must also recognize that many schools do not
have a full-time health professional on-site, and some students have limited access to
medical services. This makes it important to have some reference for administrators
and staff (including school nurses and physicians) to make informed decisions when
intervening in communicable disease cases.

This Reference Guide has been compiled using existing District publications along with
the most current available information from the American Academy of Pediatrics and
the Center for Disease Control and Prevention. In addition, current State, County and
Los Angeles Unified School District policies are reflected in this Reference Guide. The
changing nature and evolving understanding of communicable diseases, particularly
with the transmission of new disease entities between countries, makes it important
to stay abreast of local disease patterns and infection control policy. District
personnel are advised to contact Student Medical Services or District Nursing Services
(Communicable Disease Team) if there are any questions regarding the management
of communicable disease in schools.

The Reference Guide is designed to be a quick reference for LAUSD personnel. The
following sections describe general recommendations for inclusion/exclusion and
readmission to school due to illness. There is also a section defining the terms used in
this Reference Guide. Part II references the various policies that relate to the control
of communicable diseases in school. Part III catalogues common infectious diseases in
alphabetical order, offering general information as well as specific exclusion,
readmission and contact guidelines for school settings. Part IV gives a brief summary
of bioterrorism and includes a table describing early clinical signs of certain infectious
agents that could be used in a bioterrorist attack. The appendices found in Part V
give more specific information about communicable disease control, including District
bulletins and reference sheets and forms from other agencies. All of this is in an
effort to keep students, staff, and families healthy and able to participate fully in the
educational process.




                                       -2-
                      General Inclusion and Exclusion Criteria

Determining when to include and exclude students from school is a difficult decision,
particularly as there are different factors that influence the decision. On the one
hand, schools are inclusive institutions that accommodate children with a variety of
medical issues. Student attendance is linked to academic achievement, therefore
avoiding unnecessary exclusion is important for student success. On the other hand,
children and adolescents who attend school with a communicable disease put others
at risk. Fortunately, most of the commonly encountered infections in school-age
children (e.g., respiratory viruses) are relatively harmless. In some cases, children
exposed to certain infection through contact with other children develop immunity
that protects the children as they grow older.

This Reference Guide is designed to help staff make an informed decision about when
to exclude students from the school setting. While guidance of this type is helpful,
there are multiple different presentations of infectious diseases in children. School
personnel are not expected (nor qualified, in some cases) to make a diagnosis of a
communicable disease in a student. Staff are encouraged to use what is presented in
this Guide and their best judgment to help ensure a safe and healthy school
environment. Table 1 lists general conditions that need medical attention and are
referred to as “general exclusion criteria” in the Reference Guide. In addition,
California law requires exclusion if a student’s immunization status does not comply
with Health and Safety Code (Division 105) and Administrative Code (Title 17)
regulations. The laws address immunization against communicable diseases such as
polio, diphtheria, pertussis, tetanus, measles, mumps, rubella, Hepatitis B, and
varicella. The laws allow exemptions due to personal beliefs and certain medical
conditions. There are other situations where students can be admitted
“conditionally” (see Appendix B).

Remember, most illnesses do not require exclusion. Conditions and diseases not
listed in Table 1 generally do not require automatic exclusion.


Table 1: General Exclusion Criteria for Schools1
Call emergency
medical services      Has difficulty breathing or is unable to speak
for a student who:
                      Has blue, purple or gray skin or lips
                      Is increasingly less responsive, or unconscious
                      Is vomiting blood
                      Has signs of meningitis (stiff neck, fever2 and headache)
                      Is severely dehydrated (lethargic, sunken eyes, no urine)
                      Has a serious injury or is experiencing severe pain
                      Is acting very strangely, less alert or very withdrawn


1
  Adapted from: American Academy of Pediatrics, Managing Infectious Diseases in Child Care and
Schools. Aronson S and Shope T (Eds.) 2005
2
  See definition of fever
                                           -3-
Get immediate
medical attention                Has a fever and looks more than mildly ill
                                            2




(within one hour)
for a student who:
                                 Has a quickly spreading purple or red rash
                                 Has a large volume of blood in the stools
                                 Has an injury that may require medical treatment, such as a
                                 deep cut that may require stitches
                                 Has an animal or human bite that breaks the skin
                                 Has any medical condition that is outlined in the child’s care
                                 plan as requiring medical attention
Temporarily
exclude a student                An illness that prevents the student from participating
if there is:                     comfortably in school activities
                                 An illness that results in a need for care that is greater than
                                 the staff can provide without compromising the health and
                                 safety of other students
                                 An illness that poses a risk of spread of disease to others
                                 Fever1 and behavior change or other signs and symptoms
                                 (e.g., sore throat, rash, vomiting, diarrhea)
                                 Diarrhea3 or blood in the stool not explained by dietary
                                 change, medications or hard stool.
                                 Vomiting more than 2 times in the previous 24 hours, unless
                                 the vomiting is determined to be from a non-communicable
                                 condition and the child is not in danger of dehydration
                                 Abdominal pain that continues for more than 2 hours or
                                 intermittent pain associated with fever or other signs and
                                 symptoms
                                 Mouth sores with excessive drooling (in young children)
                                 Rash with fever or behavioral changes
                                 Pink or red conjunctiva (whites of the eyes) with white or
                                 yellow eye mucous drainage—until treatment has been
                                 started
                                 Impetigo—until 24 hours after treatment has been started
                                 Strep throat (or other streptococcal infection)—until 24 hours
                                 after treatment has been started
                                 Head lice—until after the first treatment (note: exclusion is
                                 not necessary before the end of the school day)
                                 Scabies—until after treatment has been given
                                 Chickenpox (varicella)—until all lesions have dried and
                                 crusted
                                 Whooping Cough (pertussis)—until 5 days after appropriate
                                 treatment (antibiotic)
                                 Any child determined by the local health department to be
                                 contributing to the transmission of illness during an outbreak

3
    See definition of diarrhea
                                                -4-
Readmission to school after exclusion for a communicable disease generally falls to
the school principal or principal’s designee. There may be instances where certain
readmission criteria should be met and these are delineated in the listings of each
communicable disease (Part III). In more serious cases of infection, the attending
physician or the local health department should clear the student before readmission.

                               Definitions of Terms

Bacteria: Organisms that may be responsible for localized or generalized diseases
and can survive in and out of the body. They can be treated effectively with
antibiotics.

Body fluids: Urine, stool, saliva, blood, nasal discharge, eye discharge and tissue
discharge (i.e., seepage from wound). Not all body fluids transmit all types of micro-
organisms.

Communicable disease: A disease caused by a micro-organism (e.g., bacteria, virus,
fungus, parasite) that can be transmitted from person to person by an infected body
fluid or respiratory spray. This may occur with or without an intermediary agent
(e.g., mosquito) or object (e.g., table surface).

Dermatitis: An inflammation of the skin caused by irritation or infection.

Diarrhea: More frequent loose or watery stools compared to the student’s normal
pattern (not associated with change in diet or use of medications). Exclusion may be
needed if diarrhea can not be contained in toilet or there are other signs, such as
blood or color change (black).

Fever: An elevation of the body temperature. While there are several definitions of
fever, for the purpose of evaluating a student in school, fever is defined as
temperature:
       >101°F (38.3°C) oral
       >102°F (39°C) rectally
       >100°F (37.8°C) axillary (armpit) or measurement by equivalent method
Fever is an indication of the body’s response to something, but is neither a disease
nor a serious problem by itself.

Fungi: Plantlike organisms such as yeasts, molds, mildews and mushrooms that get
their nutrition from other living organisms or dead organic matter.

Health care professional: Practices medicine by an established licensing body with
or without supervision. The most common types of health care professionals include
physician, nurses, nurse practitioners, and physician assistants.

Immunizations: Vaccines that are given to children and adults to help them develop
protection (antibodies) against specific infections. Vaccines may contain an
inactivated or killed agent or a weakened live organism.

                                      -5-
Incubation period: Time between exposure to an infectious microorganism and
beginning of symptoms.

Mantoux intradermal skin test: Involves the injection of a standard amount to
tuberculin protein under the skin. The reaction to the protein on the skin can be
measured and the result is used to assess the likelihood of infection with tuberculosis.

Parasite: An organism that lives on or in another living organism (e.g., tick, louse)

Universal precautions: Apply to blood and other body fluids containing blood, semen
and vaginal secretions-- but not generally stool, nasal secretions, sputum, sweat,
tears, urine, saliva, or vomitus, unless they contain visible blood or are likely to
contain blood. Universal precautions include avoiding injuries caused by sharp
instruments or devices and the use of protective barriers such as gloves, gowns, masks
and protective eyewear, which can reduce the risk of exposure of a worker to
materials that may contain blood-borne pathogens while the worker is providing first
aid or care.

Virus: A microscopic organism that may cause disease. Viruses can grow or
reproduce only in living cells.




                                      -6-
                   Part II


Policies on the Control of Communicable Disease
                    in Schools




                    -7-
Policies Concerning Communicable Disease in Schools

The health and safety of the students is guided by several policies, some are LAUSD-
specific and others are part of California health, administrative and educational
codes. Listed below are some of the pertinent policies for communicable disease
identification, reporting, treatment and prevention. While these are provided for
reference, it should be noted that policies can not cover every possible individual
scenario. It is each staff member’s responsibility to use good judgment when dealing
with communicable diseases. Student
Medical Services and District Nursing                   Student Medical Services
(Communicable Disease Team) are available                     213-763-8342
for consultation, and should be used as a
resource when there is any question regarding                District Nursing
communicable disease diagnosis, exclusion,           (Communicable Disease Team)
reporting, readmission and notification                       213-763-8372
criteria.


Exclusion of students with communicable disease

   “A pupil while infected with any contagious or infectious disease may not remain
   in any public school.” (California Code of Regulations, Title 5, Education, 202.)

   “The governing body of any school district may exclude children of filthy or viscous
   habits, or children suffering from contagious or infectious diseases.” (California
   Education Code, 48211)

   “Students showing signs and symptoms of communicable or infectious diseases
   shall be excluded from attending school. The Student Health Services Division, in
   cooperation with the County of Los Angeles, Department of Health Services, shall
   prescribe such measures as shall be necessary for the control of communicable
   diseases, including the exclusion and readmission of students. (For provisions
   relating to employees, see Board Rule 1942.) Students whose continued presence
   would constitute a clear and present danger to the life, safety, or health of other
   students or school personnel shall be exempted or excluded.” (LAUSD Board Rule
   2312)

   “It shall be the duty of the principal or other person in charge of any public,
   private or Sunday School to exclude therefrom any child or other person affected
   with a disease presumably communicable, until the expiration of the prescribed
   period of isolation for the particular communicable disease. If the attending
   physician, school physician, or health officer finds upon examination that the
   person is not suffering from a communicable disease, he may submit a certificate
   to this effect to the school authority who shall readmit the person.” (California
   Code of Regulations, Title 17, Public Health, 2526)



                                      -8-
    “A parent or guardian having control or charge of any child enrolled in the public
   schools may file annually with the principal of the school in which he is enrolled a
   statement in writing, signed by the parent or guardian, stating that he will not
   consent to a physical examination of his child. Thereupon the child shall be
   exempt from physical examination, but whenever there is a good reason to believe
   that the child is suffering from a recognized contagious or infectious disease, he
   shall be sent home and shall not be permitted to return until the school authorities
   are satisfied that any contagious or infectious disease does not exist.” (California
   Education Code, 49541)


Exclusion of school employees with communicable disease

   “… [regarding communicable disease]… applicants and employees with any acute
   or chronic (e.g., tuberculosis AIDS/HIV infection) communicable diseases which
   may endanger health or safety of self and/or others, shall be evaluated on an
   individual basis in relation to the successful performance of the core duties of the
   class for which applying or in which serving…” (LAUSD Board Rule 1942)


Reporting communicable diseases

 A list of reportable diseases for the County of Los Angeles is included in the
 Appendix A of this Reference Guide. All reporting of communicable disease
 within LAUSD is coordinated by the District Nursing Communicable Disease
 Unit and Student Medical Services. Please use the phone numbers listed above
 to receive information and assistance in the event of a communicable disease case
 on a school campus.

   “It shall be the duty of every health care provider, knowing of or in attendance on
   a case or suspected case of any of the diseases or conditions listed in [Appendix
   A], to report to the local health officer for the jurisdiction where the patient
   resides... Where no health care provider is in attendance, any individual having
   knowledge of a person who is suspected to be suffering from one of the diseases or
   conditions listed in [Appendix A] may make such a report.” (California Code of
   Regulations, Title 17, section 2500)

Please note: “Health care provider” includes physicians, surgeons, nurse
practitioners, physician assistants, registered nurses, school nurses, infection
control practitioners, dentists and others as specified in subsections (h) in Title 17
section 2500

   “It shall be the duty of anyone in charge of a public or private school,
   kindergarten, boarding school, or day nursery to report at once to the local health
   officer the presence or suspected presence of any of the communicable diseases.”
   (California Code of Regulations, Title 17, section 2508)



                                       -9-
Notification of communicable disease

   “The Director, Student Medical Services, and the Director, District Nursing
   Services, must be consulted before any notification (written or oral) to
   parent/guardian or school employees regarding possible exposure to any
   communicable disease.” (LAUSD Bulletin No. 1937, Reporting Communicable
   Diseases, September 2005)

Immunizations

Immunization is an important method of preventing certain communicable diseases,
especially in group settings such as schools and child care. The California School
Immunization Law requires children to have a series of immunizations before they
enter school (public and private elementary and secondary schools). See LAUSD
Bulletin No. 1660.2 “Immunization Guidelines for School Admission” and the
California Immunization Handbook (7th Ed. July 2003- most recent edition available
on the Los Angeles DHS website:

(http://www.dhs.ca.gov/ps/dcdc/izgroup/pdf/HandbookText.pdf).

A guide to the immunizations required for school entry is included in this Reference
Guide, Appendix B.

   “… the governing board of any school district shall cooperate with the local health
   officer in measures necessary for the prevention and control of communicable
   diseases in school age children. For that purpose the board may use any funds,
   property, and personnel of the district, and may permit any person licensed as a
   physician and surgeon, or any person licensed as a registered nurse acting under
   the direction of a supervising physician and surgeon … to administer an immunizing
   agent to any pupil whose parents have consented in writing to the administration
   of such immunizing agent.” (California Education Code 49403)

   “A ‘Health Record’ card and health history must be maintained for each student.
   Mandated health information such as immunization status, child health and
   disability prevention screening, visual activity, color vision testing, audiometric
   test results, scoliosis screening results, and tuberculosis test results must be
   recorded. Reports of school physicians and school nurses are also recorded.”
   (LAUSD Board Rule 2309)

   “Physicians of the County of Los Angeles, Department of Health Services, or school
   physicians or any school nurse under supervision of a school physician, may
   immunize students on school premises. The school nurse will notify the school of
   the date set for giving immunizations and will assist with the program. A parent or
   guardian consent slip, provided by the County of Los Angeles, Department of
   Health Services, shall be completely filled out and be on file at he school before
   an immunization may be given.” (LAUSD Board Rule 2313)




                                     - 10 -
Tuberculosis

   “Students who have never attended a California school must present written
   evidence of a Mantoux (PPD) skin test…
      (1) All Kindergarten students. Tests must be given within 1 year prior to school
      entry.
      (2) All other students in grades 1-12 who have never attended any school in
      California”
   (County of Los Angeles DHS, TB Test Requirements. See Appendix C- LAUSD
   Bulletin No. 1659)

   “A parent or guardian consent slip, provided by the District, shall be completely
   filled out and be on file at the school before a Mantoux Tuberculin Skin Test may
   be given. If the test is positive, it shall be followed by an X-ray of the chest. The
   skin test must be administered and read within 48 to 72 hours by a member of the
   staff of District Tuberculosis Prevention Services. (For tuberculin skin testing of
   employees, see Board Rule 1950.)” (LAUSD Board Rule 2313)


Exposure control plan and general sanitation

   “Universal precautions shall be observed to prevent contact with blood or other
   potentially infectious materials…” and “Each employee shall ensure that the
   worksite is maintained in a clean and sanitary condition.” (LAUSD, Bloodborne
   Pathogens—Exposure Control Plan, July 2005)

   “Clean all contaminated areas and materials first with soap/detergent and water.
   An LAUSD approved commercial product may be used for cleaning surfaces which
   are not contaminated with blood…” (See approved chemical product list for use in
   the District at http://www.lausd-oehs.org/productreview_chemical.asp) “For
   washable surfaces always use freshly made 1:10 bleach solution (1 part bleach to 9
   parts cold water) when cleaning up blood.” (LAUSD Bulletin No. 1645, Infection
   Control Guidelines for Preventing the Spread of Communicable Diseases, July
   2005)




                                      - 11 -
                Part III


Commonly Encountered Communicable Diseases




                 - 12 -
                         Chickenpox (Varicella-Zoster Infections)
1. What is chickenpox?
Chickenpox is an infectious disease caused by the varicella-zoster virus that results in a rash, most
often occurring in persons less than 15 years old.

2. What are the signs and symptoms of chickenpox?
The most obvious sign of chickenpox infection is the development of a blister-like rash. This rash
begins with small, red spots that develop into blisters (vesicles) after a few hours. It first appears on
the trunk and face, but can spread over the entire body. These blisters will become pus-filled after 3-
4 days, and then develop into scabs. Fever, itching, cough, runny nose, and/or headache commonly
accompany this rash.

3. Incubation period: Usually 14 – 16 days.

4. Contagious period: From 1 – 2 days before the rash appears until after the last crop of vesicles.
A person no longer spreads the virus when all blisters have scabs and no new blisters are forming.

5. How does infection with chickenpox occur?
Chickenpox is a highly infectious virus; it spreads from person to person by direct contact with an
infected person or by breathing in air containing germs that are released when the infected person
coughs or sneezes.

6. How can infection with chickenpox be prevented?
Chickenpox can be prevented with a vaccination that is required by law for school admission. There
are other methods to prevent chickenpox in immunocompromised children after exposure (such as
varicella-zoster immune globulin, VZIG). VZIG must be given very early after exposure to be effective.

7. Is there a treatment for chickenpox?
Antiviral medication and treatment should be considered for individuals at increased risk for moderate
to severe disease (e.g., >12 years old, chronic skin or lung infections, immunocompromised, etc.).
Antivirals are most effective when administered early in the course of the disease. Children that have
chickenpox should not be given aspirin, as it can lead to serious liver disease (Reye’s syndrome).

8. What are the circumstances in which chickenpox could be significant?
One in ten children has a complication that is serious enough to visit a health care provider.
Complications include: infected skin lesions, other infections (such as pneumonia), dehydration from
vomiting or diarrhea, and exacerbation of asthma. Adults, infants, adolescents, and people with weak
immune systems are more likely to have a serious illness with complications.

9. Can you get chickenpox more than once?
Yes, but it is very rare. Cases are generally mild with less fever and fewer blisters than the first time.

10. Exclusion: Yes – routine exclusion of infected children from school is warranted until they are
not longer contagious.

11. Readmission: When all blisters have scabs and there are no new blisters appearing (usually 6
days after the start of the rash in healthy individuals).

12. Contacts and reporting: Consider sending letters to parents and employees to protect
immunocompromised or pregnant individuals exposed to chickenpox. Call Nursing Services
Communicable Disease Unit before any notification to parents or staff.



                                               - 13 -
                                            Chlamydia
1. What is chlamydia?
Chlamydia is a common sexually transmitted disease that is caused by the bacterium Chlamydia
trachomatis. (C. trachomatis may also cause neonatal conjunctivitis, blindness and pneumonia in
young infants). Most people with chlamydia have no symptoms and may not seek health care for their
infection. When chlamydia is diagnosed, it can be easily treated and cured. Untreated chlamydia can
cause serious health problems and infertility.

2. What are the signs and symptoms of chlamydia?
While 75% of infected women and 50% of infected men will show no symptoms, those men and women
that do show symptoms experience pain and difficulty when urinating and abnormal discharge from the
penis or vagina. Men may also have swelling in the testicles. Some women experience abdominal pain,
lower back pain, nausea, fever, pain during intercourse, and bleeding between menstrual periods.

3. Incubation period: Varies with the type of infection, the average is 5 – 7 days.

4. Contagious period: Communicable until the organism is eradicated by appropriate antibiotic.

5. How does infection with chlamydia occur?
Chlamydia is passed from an infected person to a healthy person through anal, oral, or vaginal sexual
contact. In addition, it can be passed from a mother to her baby during birth.

6. How can infection with chlamydia be prevented?
Frequent examination of sexually active individuals and safe sex practices, including the use of latex
condoms during sexual contact are effective prevention measures.

7. Is there a treatment for chlamydia?
Chlamydia can be treated and cured with antibiotics.

8. What are the circumstances in which chlamydia could be significant?
If left untreated, chlamydia bacteria can spread into a woman’s uterus or fallopian tubes, and can lead
to the development of pelvic-inflammatory disease, which can cause chronic pelvic pain and infertility.
If chlamydia is passed to a baby during birth, an eye infection or pneumonia can result. In men,
untreated chlamydia typically causes a urinary infection and, potentially, infertility.

9. Exclusion: None unless they meet other exclusion criteria (see “General Exclusion Criteria”)

10. Readmission: No restrictions.

11. Contacts and reporting: All sexual contacts of patients with Chlamydia infection should be
evaluated and treated. Chlamydia is a reportable disease to the County. Call Nursing Services
Communicable Disease Unit if there is a need to report a case of chlamydia.




                                             - 14 -
                    Common Cold (Upper Respiratory Infection)

1. What is the common cold?
The common cold is a highly contagious viral infection of the upper respiratory tract that increases in
prevalence during the fall and winter.

2. What are the signs and symptoms of the common cold?
Symptoms of the common cold often include runny nose, sneezing, sore throat, cough, and headache.
Fever is usually slight but can climb to 102 degrees Fahrenheit in infants and young children. While
nasal discharge usually is watery and clear at the onset, it can become colored and thick after a few
days. This has no correlation with bacterial infections, although occasionally the common cold can
lead to ear or sinus infections that require treatment with antibiotics. High fever, significantly swollen
glands, severe facial pain in the sinuses, and a cough that produces mucus may indicate a complication
or more serious illness requiring a doctor’s attention.

3. Incubation period: From 2 – 14 days

4. Contagious period: Usually few days before signs and symptoms appear and while clear runny
nasal secretions are present. Viral shedding is most abundant in the first few days of infection and
usually ceases within 7 – 10 days.

5. How does infection with the common cold occur?
The common cold is passed person-to-person through direct or close contact with mouth and nose
secretions, including inhalation of tiny droplets containing the virus. Transmission can also happen
indirectly when a healthy person touches an object or surface that has been soiled by nasal or oral
discharges from the infected person and then touches his or her eyes or nose.

6. How can infection with the common cold be prevented?
General hygiene measures, such as frequent hand washing, covering the mouth and nose with tissues
when coughing or sneezing, and proper disposal of tissues are the best methods of prevention. If
possible, one should avoid close, prolonged exposure to persons who have colds.

7. Is there a treatment for common cold?
Only the symptoms can be treated, there is no cure or vaccine for the common cold at this time.
Children that have a viral infection should not be given aspirin, for they run the risk of developing a
rare but serious illness called Reye’s syndrome.

8. Exclusion: Generally none for children with the common cold, unless they meet other exclusion
criteria (see “General Exclusion Criteria”)

9. Readmission: Upon recovery, by school principal or principal’s designee.




                                             - 15 -
                                 Conjunctivitis (“Pink Eye”)

1. What is conjunctivitis?
Conjunctivitis is a condition in which the conjunctiva, the clear membrane that covers the eye,
becomes inflamed. Conjunctivitis is caused by bacteria, viruses, chemicals, allergies, etc. Infectious
conjunctivitis is commonly known as “pink-eye”.

2. What are the signs and symptoms of conjunctivitis?
Signs and symptoms vary according to the kind of conjunctivitis:
        Bacterial Conjunctivitis is characterized by redness, itching and pain in the eyes, with
        discharge containing mucus and or pus. It may affect one or both eyes.
        Viral Conjunctivitis is characterized by redness, watery eyes, sensitivity to light and may
        affect only one eye.
        Allergic Conjunctivitis is characterized by itching, redness and excessive tearing usually of
        both eyes.
        Chemical Conjunctivitis is characterized by red, watery eyes especially after swimming in
        chlorinated water.

3. Incubation period: Depends on the type of conjunctivitis.

4. Contagious period: Allergic and chemical conjunctivitis are not contagious. Bacterial
conjunctivitis contagious period ends when the course of medication is started. Viral conjunctivitis
contagious period continues while the signs or symptoms are present.

5. How does infection with conjunctivitis occur?
Conjunctivitis caused by bacteria or viruses can be passed from an infected person to a healthy person
through direct contact, or through indirect contact with articles, such as those used for eye makeup,
that are freshly soiled with infectious discharge. Conjunctivitis caused by an allergy is not contagious.

6. How can infection with conjunctivitis be prevented?
Strict personal hygiene, careful hand washing, use of separate towels, prompt treatment of bacterial
infected eyes, and avoiding contagious individuals can help prevent the spread of conjunctivitis.

7. Is there a treatment for conjunctivitis?
Bacterial conjunctivitis can be treated with antibiotics that are usually given in the form of eye drops.

8. What are the circumstances in which conjunctivitis could be significant?
If left untreated, conjunctivitis can create serious complications, such as infection in the cornea, lids,
and tear ducts. One type of conjunctivitis, caused by the bacterium Chlamydia trachomatis, can lead
to blindness.

9. Exclusion: Yes, for bacterial conjunctivitis; and no, for other forms except on recommendation
of health department or the child’s health professional for epidemic viral conjunctivitis.

10. Readmission: After exclusion for bacterial conjunctivitis, the child may return after treatment
has begun with antibiotic eye drops or ointment.




                                              - 16 -
                            Cytomegalovirus Infection (CMV)

1. What is CMV?
Cytomegalovirus (CMV) is a common virus that infects 50%-85% of adults in the United States by 40
years of age. CMV is the most common infection among those transmitted from a pregnant mother to
her baby.

2. What are the signs and symptoms of CMV?
For most healthy persons who acquire CMV after birth, there are few symptoms and no long-term
health consequences. Some adolescents and adults may have a mononucleosis-like infection with a
prolonged fever and a mild hepatitis.

3. Incubation period: Unknown

4. Contagious period: Unknown. Virus continues to be excreted and urine and saliva for many
months and sometimes for several years.

5. How does infection with CMV occur?
Transmission of CMV occurs through various modes: close contact with a person excreting the virus in
saliva, breast milk, urine, blood, and tears; sexual contact; blood transfusions; organ transplants; and
from a mother to her baby before, during and after birth. CMV has been shown to spread in households
and day care centers.

6. How can infection with CMV be prevented?
To decrease the transmission of CMV, good personal hygiene is recommended. This includes care when
handling children and items like soiled diapers, avoidance of contact with oral secretions, and simple
hand washing with soap and water, which is effective in removing the virus from the hands. This is
especially important for women of childbearing age working with young children.

7. Is there a treatment for CMV?
Treatment consists of an antiviral medication that is used for certain patients, depending on age,
disease, and mode of transmission. Treatment decisions are reserved for experienced health care
professionals.

8. Should children infected with CMV stay home from school to prevent spreading
the disease?
CMV infection without symptoms is common in infants and children. There is no need to either screen
or exclude CMV-excreting children from schools or institutions because the virus is frequently found in
many healthy children and adults. Absence from school should only occur if symptoms are severe
enough to prevent attendance.

9. What are the circumstances in which CMV could be significant?
Infection can be significant in infants born to women whose first infection with CMV occurs during
pregnancy. In addition, people with weak immune systems, such as organ transplant recipients and
persons infected with HIV, may experience pneumonia, eye infections, gastrointestinal disease, or even
death due to CMV. Hence, these groups should take extra hygienic precautions to prevent infection.

10. Exclusion: Generally none for children with CMV, unless they meet other exclusion criteria (see
“General Exclusion Criteria”)

11. Readmission: Upon recovery, by school principal or principal’s designee.


                                             - 17 -
                                             Diphtheria

1. What is diphtheria?
Diphtheria is an acute disease caused by a toxin produced by the bacterium Corynebacterium diphtheriae.
Diphtheria was once a major cause of death in children, but due to the development of an effective
vaccine in the 1920s, cases of diphtheria in the United States are very rare today. However, diphtheria
still occurs in other parts of the world, and most recently caused an epidemic in the former Soviet Union.

2. What are the signs and symptoms of diphtheria?
Diphtheria begins with symptoms such as sore throat, loss of appetite, and low-grade fever. It most
commonly affects the throat and tonsils or skin.
       Diphtheria of the throat and tonsils causes a bluish-white membrane to form at the back of the
       mouth (on the soft palate) within 2-3 days. This membrane sticks to the tissues and attempts
       to remove it cause bleeding. Its color can change to grayish green or black if bleeding occurs.
       The membrane may cause an airway obstruction and prevent the ability to breathe, which can
       lead to serious complications.
       Diphtheria of the skin causes a scaling rash or ulcers with clearly marked edges.
       Diagnosis of diphtheria is determined by taking a culture from these lesions or membranes.

3. Incubation period: From 2 – 5 days.

4. Contagious period: Varies. The average is 2 - 6 weeks if untreated; less than 4 days if
appropriately treated.

5. How does infection with diphtheria occur?
Infected persons may shed the bacteria to others through their respiratory secretions by coughing or
sneezing and from their infected wounds. Ill persons can remain contagious for 2-6 weeks without
antibiotic treatment. Individuals who are chronic carriers of diphtheria, i.e. those who carry the bacteria
but do not manifest signs or symptoms of diphtheria, may remain contagious for up to 6 months.

6. How can infection with diphtheria be prevented?
The diphtheria vaccine can prevent this disease. It is usually combined with the tetanus vaccine (Td)
or with both tetanus and pertussis vaccines (DTaP). Persons of all ages should be vaccinated against
diphtheria, and it is required for school admission.

7. Is there a treatment for diphtheria?
Antitoxin and antibiotics are used in cases of throat and tonsil infection. Antibiotics are used for skin
infections.

8. What are the circumstances in which diphtheria could be significant?
Most complications of diphtheria are due to the effects of the toxin. The toxin can spread through the
blood to other parts of the body and can cause ear infections, pneumonia, heart failure, paralysis,
respiratory failure, and death.

9. Exclusion: Immediate isolation and exclusion in the case of the disease.

10. Readmission: Student and contacts are readmitted only by written permission of the County of
the Los Angeles, Department of Health.

11. Contacts and reporting: Identification, surveillance and treatment of close contacts in
congruence with County of the Los Angeles, Department of Public Health policy. Diphtheria is an
immediately reportable disease, call Nursing Services Communicable Disease Unit.



                                              - 18 -
                         Fifth Disease (Human Parvovirus B19)

1. What is fifth disease?
Fifth disease is a mild rash illness caused by human parovirus B19 that occurs most commonly in
children.

2. What are the signs and symptoms of fifth disease?
A child infected with fifth disease has a characteristic “slapped-cheek” rash on the face, followed by a
lacy red rash on the trunk and limbs. Occasionally, the rash may itch. The illness usually starts 7 to 10
days before the appearance of the rash with a low-grade fever, muscle aches and headache, but some
children may be asymptomatic. The rash usually resolves in 7-10 days, but can reappear after exposure
to sunlight or heat.

3. Incubation period: From 4 – 14 days but can be as long as 21 days.

4. Contagious period: Healthy individuals are contagious until the rash appears.

5. How does infection with fifth disease occur?
During the early part of the illness, before the rash appears, the virus can be passed from an infected
person to a healthy person through direct contact with saliva, sputum, or nasal mucus. The virus may
also spread through blood products and from a mother to her unborn baby.

6. How can infection with fifth disease be prevented?
There is no vaccine or medicine that prevents fifth disease at this time. Frequent hand washing is
recommended as a practical and effective method to decrease the chance of becoming infected.

7. Is there a treatment for fifth disease?
Treatment of symptoms such as fever, pain, or itching is usually all that is needed, unless a more
serious condition develops.

8. Does keeping an infected child home from school help prevent the spread of
fifth disease?
Excluding persons with fifth disease from work, child care centers, or schools is not likely to prevent
the spread of the virus, since people are contagious before they develop the rash and are no longer
contagious once the rash appears.

9. What are the circumstances in which fifth disease could be significant?
Fifth disease is usually a mild illness that resolves on its own among children and adults who are
otherwise healthy. However, fifth disease may cause a serious illness in persons with sickle-cell
disease or similar types of chronic anemia. Persons with weak immune systems, due to leukemia,
cancer, organ transplants, HIV, etc. are also risk for serious illness due to fifth disease infection and
should seek medical care if exposed. Pregnant women who may be exposed to fifth disease should
consult their health professional about their immune status and risk of infection.

10. Exclusion: Generally none unless the child has sickle cell disease or compromised immune
system or they meet other exclusion criteria (see “General Exclusion Criteria”)

11. Readmission: Upon recovery, by school principal or principal’s designee.

12. Contacts and reporting: Non reportable, but consider sending letters to parents and
employees to protect immunocompromised or pregnant individuals exposed to fifth disease. Call
Nursing Services Communicable Disease Unit before any such notification to parents or staff.



                                              - 19 -
                           Foodborne Illness (Food Poisoning)

1. What is foodborne illness?
Foodborne illness, or food poisoning, is caused by consuming contaminated food or beverages. Many
different microbes can contaminate foods. More than 250 different foodborne illnesses have been
described. Most of these diseases are infectious, caused by a variety of bacteria, viruses, and parasites.
Harmful toxins and chemicals can also contaminate food, such as those found in poisonous mushrooms.

2. What are the symptoms of a foodborne illness?
Symptoms vary based on the cause of food poisoning; hence there is no one “syndrome” caused by
foodborne illness. In all types of foodborne disease, the microbe or toxin enters the body through the
gastrointestinal tract, and often causes nausea, vomiting, abdominal cramps, and diarrhea.

3. Incubation period: May begin within hours to days of food ingestion, depending on the
organism.

4. Contagious period: Varies according to the organism.

5. What are the most common microbes that cause foodborne illness?
Bacteria causing foodborne illness include Salmonella, E. Coli, Shigella, Clostridium botulinum, and
others. Viruses include hepatitis A and Calicivirus or Norwalk-like virus, while parasites like Giardia
lamblia (see chapter on Giardiasis) and Cryptosporidia can also cause foodborne diseases. There is so
much overlap that it is rarely possible to say which microbe is likely to be causing a given illness unless
laboratory tests are done to identify the microbe, or the illness is part of a recognized outbreak.

6. How can foodborne illness be prevented?
Thoroughly cook all foodstuff (i.e., meat, poultry, eggs). Avoid cross-contamination by washing hands,
utensils and cutting boards after contact with raw meat or poultry. Refrigerate prepared foods and
leftovers. Protect food against contamination by washing hands and rinsing vegetables.

7. Is there treatment for foodborne illnesses?
There are many different types of foodborne illnesses and they may require different treatments
depending on the symptoms they cause. Fluids and electrolyte replacement are important. Medical
attention may be necessary if symptoms are severe. Antibiotics are not always needed.

8. What are the circumstances in which foodborne illness could be significant?
While some foodborne illnesses are self-limited in nature, others are, or can become, serious illnesses.
Certain strains of E. Coli can result in bleeding disorders and kidney failure. Botulism can result in
paralysis and death, particularly in infants. Immunocompromised individuals may be at greater risk for
severe disease in some cases. All persons suffering from foodborne illness may become dehydrated,
and possibly septic.

9. Exclusion: Yes, if person is symptomatic or meets other exclusion criteria (see “General Exclusion
Criteria”). In cases of salmonella infections, symptomatic employees (including food handlers) should
be referred to employee health for assessment, treatment and readmission

10. Readmission: By school nurse or physician, the County of Los Angeles, Department of Health
Services or other licensed physician.

11. Contacts and reporting: Many foodborne illness pathogens, as well as commercial food
products suspected of causing illness are reportable to the County. Call Nursing Services Communicable
Disease Unit if there is a need to report a foodborne illness or outbreak.



                                              - 20 -
                                             Giardiasis

1. What is Giardiasis?
Giardiasis is an intestinal infection caused by a parasite (Giardia lamblia). The organism is common in
the stools of young children in child care programs and schools, and outbreaks in these settings can
occur.

2. What are the signs and symptoms of Giardiasis?
        Acute watery diarrhea
        Excessive gas
        Abdominal pain and cramps
        Decreased appetite
        Weight loss
        Individual can be infected and infectious without signs and symptoms. The asymptomatic
        carrier state is more common in children than adults.

3. Incubation period: One to 4 weeks after exposure.

4. Contagious period: Highly variable, but infected individuals can be contagious for months.

5. How does infection with Giardia occur?
Ingestion of contaminated water or food, contamination of water supply by human or animal feces, and
hand- to- mouth transfer of cysts from feces of infected individuals. Individuals may contract the
organism while drinking from streams or lakes while camping. Outbreaks can occur with contamination
of the public water supply. Asymptomatic carriers probably are more important to the spread of
disease than persons with active disease.

6. How can infection with Giardia be prevented?
       Practice careful and frequent hand-washing, especially after the use of the toilet or changing
       soiled clothing
       Identify and treat family members, staff and children who have symptoms.
       Exclude people with diarrhea until they are symptom-free.
     Note: Treatment and exclusions of asymptomatic carriers is not effective for outbreak control.

7. Is there a treatment for Giardiasis?
Treatment generally consists of an anti-parasitic drug and correction of any electrolyte imbalances or
dehydration. Treatment for asymptomatic carriers is generally not recommended.

8. Exclusion: Yes, if diarrhea is present or the child is unable to participate and staff determines
that they cannot care for the child without compromising their ability to care for the health and safety
of the other children in the group
     Note: For caregivers/teachers and children without symptoms (i.e. recently recovered or exposed)
     testing stool cultures, treatment and exclusions are not necessary.

9. Readmission: Once exclusion criteria (diarrhea) has resolved.

10. Contacts and reporting: Giardiasis is a reportable disease to the County. Call Nursing
Services Communicable Disease Unit if there is a need to report a case of Giardiasis.




                                             - 21 -
                                            Gonorrhea

1. What is gonorrhea?
Gonorrhea is a common sexually transmitted disease caused by the bacterium Neisseria gonorrhoeae.

2. What are the signs and symptoms of gonorrhea?
In males, signs and symptoms include a burning sensation when urinating and a yellowish white
discharge from the penis. Painful or swollen testicles may also occur. In females, gonorrhea may be
asymptomatic or painful or burning sensation when urinating, and a yellowish or occasionally bloody
vaginal discharge. Women with no or mild gonorrhea symptoms are still at risk for developing serious
complications from the infection (PID, ectopic pregnancy, or infertility). Symptoms of rectal infection
in both men and women include painful bowel movements, discharge, anal itching, soreness, and
bleeding. Infections in the throat cause few symptoms.

3. Incubation period: 1 – 30 days, usually 3 – 5 days following exposure.

4. Contagious period: Weeks or months if untreated, even if asymptomatic. Communicable period
ends with appropriate antibiotic therapy.

5. How does infection with gonorrhea occur?
Gonorrhea is spread through sexual contact: vaginal, oral, or anal. It can also be spread from mother
to child during birth. An infected person can spread gonorrhea even if they are not showing symptoms.

6. How can infection with gonorrhea be prevented?
Abstinence and safe sex practices such as the use of latex condoms are the most effective prevention
measures.

7. Is there a treatment for gonorrhea?
Antibiotics can successfully cure gonorrhea in adolescents and adults.

8. What are the circumstances in which gonorrhea could be significant?
Untreated gonorrhea can cause permanent problems in both men and women. In women, gonorrhea is
a common cause of pelvic inflammatory disease, which can cause severe abdominal pain and infertility.
In men, gonorrhea can cause a painful condition of the testicles that can also result in infertility.
Gonorrhea can in some instances cause a life-threatening infection. In addition, persons with
gonorrhea are more likely to contract and transmit HIV. Lastly, the infant of a pregnant woman with
gonorrhea can contract the disease and develop a life-threatening infection, which may lead to
blindness.

9. Exclusion: None unless they meet other exclusion criteria (see “General Exclusion Criteria”)

10. Readmission: No restrictions.

11. Contacts and reporting: All sexual contacts of patients with gonorrhea infection should be
evaluated and treated. Gonorrhea is a reportable disease to the County. Call Nursing Services
Communicable Disease Unit if there is a need to report a case of gonorrhea.




                                             - 22 -
           Hand, Foot, and Mouth Disease (Commonly Enterovirus)


1. What is hand, foot, and mouth disease?
Hand, foot, and mouth disease (HFMD) is a common illness caused by a virus (most commonly
Enterovirus 71 and Coxsackievirus A16) in infants and children. It is rarely serious. Although it mainly
occurs in children under 10 years old, adults may also be at risk. HFMD is not to be confused with foot-
and-mouth disease of cattle, sheep, and swine, which is unrelated.

2. What are the signs and symptoms of HFMD?
HFMD begins with a mild fever, poor appetite, a sore throat, and general signs of a “cold.” A few days
after the fever begins, sores develop in the mouth. The sores appear as red spots that turn into
blisters on the tongue, gums, and inside of the cheeks. A skin rash may also occur which develops over
1-2 days and is characterized by flat or red raised spots that may blister. The rash does not itch and
usually occurs on the palms of the hands and soles of the feet. A person with HFMD may have only the
rash on the body or the mouth ulcers. Nearly all patients recover without medical treatment in 7-10
days.

3. Incubation period: 3 – 6 days.

4. Contagious period: Virus may be shed for several weeks after the infection starts; respiratory
shedding of the virus is usually limited to < 1 week.

5. How does infection with HFMD occur?
HFMD is moderately contagious, and infection is spread from person to person by direct contact with
nose and throat discharge or the stool of an infected person. HFMD is not transmitted to or from pets
or other animals. A person is most contagious during the first week of the illness.

6. How can infection with HFMD be prevented?
A vaccine for the HFMD virus does not exist at this time; hygiene is the best prevention measure. This
includes frequent hand washing, especially after diaper changes, and disinfection of contaminated
surfaces with household cleaners. Children are often excluded from childcare programs, schools, or
other group settings during the first few days of their illness, but these measures will not reduce
disease transmission because some children shed the virus without symptoms, and other children may
shed virus for weeks after recovery.

7. Is there a treatment for HFMD?
HFMD cannot be cured by medication, but treatment is available for symptoms such as fever or pain in
the mouth from ulcers.

8. What are the circumstances in which HFMD could be significant?
Rarely, HFMD may be associated with serious infections such as: viral meningitis/encephalitis with
fever, headache, stiff-neck; or a polio-like paralysis. The individual may need to be hospitalized.

9. Exclusion: None for children with the HFMD, unless they meet other exclusion criteria (see
“General Exclusion Criteria”)

10. Readmission: Upon recovery, by school principal or principal’s designee.

11. Contacts and reporting: Non reportable, but consider sending letters to parents when
there is an outbreak of HFMD. Call Nursing Services Communicable Disease Unit before any such
notification to parents or staff.



                                             - 23 -
                                   Head Lice (Pediculosis)

1. What are head lice?
Head lice are parasitic insects called Pediculus humanus capitis that must feed on blood to live.
Having head lice is very common; as many as 6-12 million people worldwide get head lice each year.

2. What are the signs and symptoms of head lice?
Signs that head lice are present include: a tickling feeling of something moving in the hair; itching
caused by an allergic reaction to the bites; irritability; and, sores on the head from scratching that
may become infected. Head lice lay eggs, called nits, that are hard to see and are often confused for
dandruff or hair-spray droplets. Once hatched and full grown, a live louse is about the size of a
sesame seed, and they are tan to grayish white.

3. Incubation period: 6 – 10 days from laying to hatching of eggs

4. Contagious period: Until treated with a chemical that kills lice and viable eggs have been
killed or removed

5. Who is at risk for getting head lice?
Anyone who comes in close contact with someone who already has head lice, or with contaminated
clothing and other belongings, is at risk for getting head lice. Preschool and elementary-age children
are most often infested.

6. How does infestation with head lice occur?
Infestation with head lice occurs by direct contact with an already infested person, which is common
during play at school and at home. Infestation can also occur by the wearing of infested clothing such
as hats, scarves, etc.; by using infested combs or brushes; or, by lying on a bed or a couch that has
been in contact with an infested person. Presence of nits alone does not indicate active infestation.

7. How can infestation with head lice be prevented?
It is probably impossible to totally prevent head lice infestations. Avoiding contact with an infested
person or objects as mentioned above is the best prevention measure. Inspection of children
demonstrating symptoms, especially in areas where head lice are prevalent, is also helpful.

8. Is there a treatment for head lice?
Over the counter treatments and prescription drugs are available for treating head lice. Treatment
often entails combing out the eggs and casings (nits) attached to the hair shaft with a specialized or
fine-toothed comb. It is important to treat the infested person and any infested family members;
wash or dry clean all clothing and bed linens; store stuffed animals and comforters in a plastic bag for
2 weeks; clean combs and brushes; and vacuum the floor and furniture.

9. What are the circumstances in which head lice could be significant?
Head lice rarely pose a serious problem. Sores that occur due to scratching can become infected, in
which case a physician should be consulted.

10. Exclusion: Yes, when a student has the signs and symptoms of infestation (the most specific
being the presence of a live louse). The condition does not warrant immediate exclusion. Inform
parents of suspected infestation and avoid any activity that involves the child in head-to-head contact
with other children or sharing of any head gear until the end of the school day.

11. Readmission: After the child has received the proper treatment they may return to school.
While the removal of nits is desirable to avoid diagnostic confusion, the presence of nits alone (after
treatment) is not sufficient criteria to exclude children from school.


                                             - 24 -
                                      Hepatitis A, B, and C

1. What are hepatitis A, B, and C?
Hepatitis A, B, and C are liver diseases caused by the hepatitis A, B, and C virus, respectively.

2. What are the signs and symptoms of hepatitis A, B and C?
All three viruses can cause asymptomatic infection, and adults are more likely to have symptoms than
children. Symptoms common to the three viruses are as follows: fatigue, loss of appetite, nausea,
vomiting, abdominal discomfort, jaundice (yellowing of the skin and eyes), and dark urine. In addition,
hepatitis A is usually more abrupt in onset; hepatitis B may cause joint pains and rash.

3. Incubation period:
        Hepatitis A: 15 – 50 days; average 25 – 30 days
        Hepatitis B: 45 – 160 days; average 90 days
        Hepatitis C: 14 – 180 days; average 45 days

4. Contagious period:
        Hepatitis A: 2 weeks before onset of signs and symptoms, infectivity is minimal one week after
        onset of jaundice
        Hepatitis B: As long as the virus is present in the blood of the infected person
        Hepatitis C: Unknown

5. How does infection with hepatitis A, B, and C occur?
        Hepatitis A is found in an infected person’s feces, thus it is usually spread from person to
        person by putting something in the mouth that has been contaminated with the feces of a
        person with hepatitis A.

        Hepatitis B is found in bodily fluids and blood, and it is spread from person to person through
        unprotected sex, needle sharing, or blood transfusion. It can also be spread from mother to
        infant.

        Hepatitis C is found in bodily fluids and blood, and is usually spread through needle sharing,
        needlesticks or sharps exposure, and blood transfusions. It can also be passed from a pregnant
        mother to her baby during birth. Rarely spread through sexual contact.

6. How can infection with hepatitis A, B, or C be prevented?
        Hepatitis A: A vaccine is available for persons 2 years of age and older. Major methods of
        prevention include general sanitation and personal hygiene. There is an immune globulin for
        exposed individuals who meet specific criteria.

        Hepatitis B: A vaccine is available for all ages. Other methods of prevention include
        sanitation, universal precautions and the use of latex condoms.

        Hepatitis C: There is no vaccine to prevent hepatitis C available at this time. Avoidance of
        needle sharing by injection drug users or people receiving tattoos or body piercing is a helpful
        preventative measure, as is using latex condoms during sexual contact.

 Note: Students with Hepatitis B, Hepatitis C or HIV are generally not required to be identified to
 school personnel. Universal precautions should be taken when handling any blood or body fluids in
 school settings to acknowledge the risk of exposure to all types of unrecognized disease.

                                                                            Continued




                                              - 25 -
7. Is there a treatment for hepatitis A, B, or C?
Treatment is generally supportive. No cure exists at this time for hepatitis A or B, but medication for
chronic hepatitis B infection is available. For hepatitis C, a combination of drug therapy is available to
treat chronic infection.

8. What are the circumstances in which hepatitis A, B, or C could be significant?
        Hepatitis A: There is no long-term infection risk associated with hepatitis A, and one cannot
        get the disease again after having it once, although upon initial infection prolonged or
        relapsing symptoms may occur for 6-9 months.

        Hepatitis B has more serious implications for chronic infection in infants, children, and adults.
        Persons who have hepatitis B are at risk for developing chronic hepatitis with its complications
        at advancing age, including liver cancer.

        Hepatitis C: Persons who have hepatitis C are at risk for developing chronic hepatitis with its
        complications at advancing age, including liver cancer.

9. Exclusion:
        Hepatitis A: Yes,
           o children should be excluded for 1 week after onset of illness; refer to health
               professional
           o staff with the illness, especially food handlers, should also be excluded for 1 week
               after onset of illness
        Hepatitis B: Yes, if the child with known Hepatitis B exhibits any of the following:
           o weeping sores that cannot be covered
           o biting or scratching behavior
           o a bleeding problem
           o generalized dermatitis that may produce wounds or weepy tissue fluid that can not be
               covered
        Hepatitis C: (Same as Hepatitis B)


10. Readmission:
        Hepatitis A: One week after the onset of illness and upon recovery from symptoms
        Hepatitis B: When skin lesions are dry or covered; when the child is clear to return by a health
        professional
        Hepatitis C: When skin lesions are dry or covered; when the child is clear to return by a health
        professional

11. Contacts and reporting: Reportable to the County (only acute cases are investigated);
outbreaks of Hepatitis A may require immune globulin shots given by the health department. Call
Nursing Services Communicable Disease Unit if there is a need to report a case of viral hepatitis.




                                              - 26 -
                                 Herpes (Oral and Genital)

1. What is herpes?
Herpes is an infection caused by two different but closely related viruses– herpes simplex virus type 1
and herpes simplex virus type 2. Both can cause sores in the mouth (oral herpes), genitals (genital
herpes), or skin that comes in contact with these areas. Genital herpes is considered to be a sexually
transmitted disease. More serious complication of herpes infection can occur in the newborn and when
there is involvement of the eyes.

2. What are the signs and symptoms of herpes?
Symptoms of oral herpes include “cold sores” or “fever blisters” that appear on the lips or inside of the
mouth. They are common in young children, and harmless in children and adults. Symptoms of genital
herpes include blistery sores that appear on the genitalia and buttocks that can be accompanied by
pain in the infected area and flu-like symptoms. Sores can also be found on the skin, as in the case of
wrestlers (herpes gladiatorum) or those with eczema (eczema herpeticum). After the primary
infection, the virus persists for life and can result in occasional “flare-ups” or recurrence.

3. Incubation period: 2 days to 2 weeks

4. Contagious period: The primary infection is generally communicable for 1 to 2 weeks after
signs or symptoms appear. In recurrent infections the largest amount of virus is shed for 3 to 4 days
after signs or symptoms appear. There may be a low level of viral shedding when infected individuals
have no signs or symptoms

5. How does infection with herpes occur?
Herpes is spread by touching, kissing, and sexual contact. It can be passed from one person to
another, or from one part of the body to another, even when sores are not present.

6. How can infection with herpes be prevented?
Sores in the mouth or genital area should not be touched, and if they are, prompt hand washing should
follow. People with sores in the mouth should avoid kissing and sharing food or drink with other
people, especially infants, children, and pregnant women. Covering open herpes skin lesions is
advisable. Wrestlers may need to have mats washed/disinfected between matches if there is suspicion
or known herpes gladiatorum.

7. Is there a treatment for herpes?
Antiviral medications, such as acyclovir, can be prescribed to help speed up the healing of sores and
weaken the virus. Individuals with more than six episodes a year may be advised to take daily antiviral
medications to prevent episodes.

8. What are the circumstances in which herpes could be significant?
Herpes infections are much more serious in newborns. It is possible for a mother to pass herpes to her
baby during birth, but the risk is much higher with primary infection of the mother.

9. Exclusion: No, unless the child has mouth ulcers and blisters and does not have control of
drooling, or the child meets other exclusion criteria (see “General Exclusion Criteria”).

Note: Athletes with exposed herpes lesions participating in close contact sport (e.g., wrestling) may
need to be excluded from practice or competition until lesions heal or clearance from a physician
declaring the condition noninfectious.

10. Readmission: Upon recovery and exclusion criteria resolved (no drooling or exposed open
sores).



                                             - 27 -
                                              HIV/AIDS

1. What are HIV and AIDS?
Human immunodeficiency virus (HIV) is an infection that destroys the body’s immune system and can
cause a broad spectrum of disease. Acquired immunodeficiency syndrome (AIDS) represents the most
severe end of the clinical spectrum of HIV infection.

2. What are the signs and symptoms of HIV and AIDS?
    HIV: While many HIV-infected people may not have any symptoms, they may experience rapid
    weight loss, dry cough, recurring fever or profuse night sweats, profound and unexplained fatigue,
    and swollen lymph glands. HIV infected persons can also have diarrhea that can last for more than
    a week, white spots on the tongue, and pneumonia. However, no one should assume that they are
    infected if they have any of these symptoms. The only way to determine whether one is infected is
    to be tested for HIV.
    AIDS: HIV destroys certain blood cells (T-cells) that are crucial to immune system function, and
    this damage can lead to the development of AIDS. Signs of AIDS include certain opportunistic
    infections that are generally rare, such as Pneumocystis carinii pneumonia and Kaposi’s sarcoma.
    Diagnosis of AIDS requires a T-cell count below a certain level, which may or may not be
    accompanied by the presence of an opportunistic infection.

3. Incubation period: Clinical symptoms after HIV infection have appeared in less than 1 year to
longer than 10 years. Average is 2 – 4 years. The incubation period is shorter in children.

4. Contagious period: Lifelong in infected persons who may or may not be symptomatic

5. How does infection with HIV occur?
HIV is passed from one person to another by having sexual intercourse (anal, vaginal, or oral) with an
HIV-infected person, by sharing needles with an injection drug user who is infected with HIV, or by
having blood or bodily fluid contact with a person infected with HIV. In addition, the virus can be
passed from an HIV-infected mother to her baby before or during birth and through breast-feeding.
HIV is not transmitted by casual contact such as handshaking, hugging, sneezing, or sharing toilet seats
and is not acquired from saliva, tears, or urine.

6. How can infection with HIV be prevented?
Education on the methods of transmission of HIV is an important component of prevention. Prevention
of HIV transmission by sexual contact can be accomplished by abstinence and safe sex practices such as
the use of latex condoms. Universal precautions and standard procedures should be followed in the
handing of potentially infectious material (see LAUSD Bulletin No 1645, “Infection Control Procedures
for the Prevention and Spread of Communicable Diseases,” July 2005 and LAUSD “Bloodborne
Pathogens—Exposure Control Plan,” July 2005)

7. Is there a treatment for HIV or AIDS?
There is no cure or vaccine for HIV or AIDS at this time. However, early intervention and treatment
with antiretroviral drugs can slow the disease progression and prolong and improve the quality of life.

                                                                                              Continued




                                              - 28 -
8. What are the policies surrounding HIV/AIDS and school attendance?
A child or adult infected with HIV should not be isolated or excluded from any activity that their health
status permits them to participate in. Their diagnosis of HIV/AIDS must remain confidential by law.
Students and/or families are not required to disclose HIV infection status to anyone in the
education system. No information regarding a person’s HIV status will de divulged to any individual
or organization without a Court Order or informed written, signed, and dated consent of the
person with HIV infection (or the parent or guardian of a legal minor). For more information, see
LAUSD Bulletins No.Z-70 and Z-69, “Students with HIV/AIDS Infection” and “Employees with HIV/AIDS
Infection,” August 2001.

9. Exclusion: No, unless the child meets other exclusion criteria (see “General Exclusion Criteria”)
or has bleeding problems or weeping skin lesions that cannot be covered. In such cases, school
attendance will be decided on an individual basis with consideration given to any risk for the infected
person and any possible risk to others. Age, maturity level, physical condition, neurological
development, behavior, psychological needs and requirement for special environment or physical care
will be considered.

10. Readmission: Children who are known to be infected with HIV and have been excluded because
of risk of exposure to infections posed by group settings may return to school upon clearance from the
child’s health professional who is knowledgeable about HIV infection. Skin lesions must be dry and
covered and bleeding must be controlled. Complex cases of admission/readmission will be evaluated
on an individual basis involving a collaborative decision making process, which should include the
school principal, family and medical personnel.

11. Contacts and reporting: AIDS (cases meeting the criteria) is a reportable condition, but
school personnel will generally not be involved with disease surveillance. Remember confidentiality of
HIV/AIDS status is a legal requirement and any questions regarding students with HIV/AIDS should be
directed to Student Medical Services or Nursing Services Communicable Disease Unit.




                                             - 29 -
                                     Impetigo (and MRSA)

1. What is impetigo? What is MRSA?
Impetigo is a skin infection caused by bacteria (Group A streptococci or Staphylococcus aureus).
Impetigo typically affects school-aged children, most often during the hot and humid summer months.
It has a preference for skin that has already been injured by other skin problems, such as eczema or
poison ivy. A potentially more serious strain of the bacterium S. aureus has emerged in recent years
that is resistant to certain antibiotics (Methicillin-resistant S. aureus, or MRSA). Community-associated
MRSA will be discussed with impetigo, but they are clinically distinct entities.

2. What are the signs and symptoms of impetigo? MRSA?
Impetigo can affect skin anywhere on the body, but it most often affects the face. It causes itchy skin
with tiny blisters especially around the mouth and nose. Blisters will eventually burst to reveal areas
of red skin that may weep fluid. Gradually, a tan or yellowish-brown crust will cover the infected
area. Community–associated MRSA usually presents as pimples, boils or abscesses. They may be
painful and may be misdiagnosed as “spider bites.” School personnel will generally only know that a
student is infected with MRSA if given the diagnosis by a health care provider as it may be difficult to
distinguish from other common skin infections.

3. Incubation period: Skin sores develop in 7 – 10 days after bacteria attach to the skin.

4. Contagious period: Until the skin sores are treated with antibiotic for at least 24 hours or the
crusting lesions are no longer present.

5. How does infection with impetigo occur?
Impetigo (and MRSA) can be passed from person to person. When someone in a household has
impetigo, the infection can be passed to other family members on clothing, towels, and bed linens that
have touched the infected person’s skin. Impetigo can also be spread from one area of the skin to
another by scratching. On the face, the infection usually spreads along the edges of an affected area,
but it may also spread to more distant parts of the body on contaminated fingers.

6. How can infection with impetigo be prevented?
Good general hygiene practices, such as a daily bathing with soap and water can help prevent
impetigo. Areas of skin that have been injured should be kept clean and covered. Covering sores with
gauze, loosely to allow airflow, can help prevent spreading the bacteria in group settings. If a family
member is infected, all family members should use different towels.

7. Is there a treatment for impetigo? MRSA?
Impetigo is usually treated with antibiotics, which may be given by the mouth. In very mild cases, a
topical antibiotic may be used. Community-associated MRSA is best treated with good wound care
(incision and drainage by health care provider), coverage with a clean, dry bandage, and in some cases
antibiotics (to which the organism is susceptible).

8. Exclusion: Yes, as soon as impetigo is suspected. If the family is unable to pick up the child
promptly, wash affected area with soap and water and cover it with a clean, dry bandage. Exclusion
for MRSA is only recommended if the student is unable to cover skin lesion and control body fluids.

9. Readmission: After 24 hours of appropriate (antibiotic) treatment for impetigo or when lesions
are healed, by school principal or principal’s designee.




                                             - 30 -
                                          Influenza (Flu)

1. What is the flu?
The flu is a contagious disease caused by the influenza virus that attacks the nose, throat, and lungs.
Most people recover in 1-2 weeks, but some develop serious complications.

2. What are the signs and symptoms of the flu?
Fever, chills, headache, tiredness, dry cough, sore throat, nasal congestion, and body aches are all
common flu symptoms. Children can have nausea, vomiting and diarrhea.

3. Incubation period: Usually from 1 – 4 days.

4. Contagious period: From the day before signs or symptoms appear until 7 days after the onset
of flu. Children can be contagious longer.

5. How does infection with the flu occur?
The flu is spread when an infected person coughs, sneezes, or speaks and another person inhales this
virus. The flu can also be spread when a person touches a surface that has the flu virus on it, such as a
door handle, and then touches his or her nose or mouth.

6. How can infection with the flu be prevented?
A flu shot can be obtained each fall, before flu season, for prevention. The elderly, people with
chronic medical conditions or who are immunocompromised, and very young children (6 – 23 months)
are recommended to get the flu shot as they are more likely to develop complications. Persons who
care or work with these high-risk groups may also be eligible for the flu shot. Please check with a
school/CD nurse or the Department of Public Health regarding current indications for the
immunization. Good personal hygiene such as hand washing can also help prevent infection.

7. Is there a treatment for the flu?
The flu cannot be cured by medication, although some antiviral drugs taken within the first two days of
illness can reduce the duration of the disease. Rest, drinking plenty of liquids, avoiding alcohol and
tobacco use, and taking nonprescription medication to relieve symptoms can help. A child or teenager
with flu-like symptoms, particularly fever, should not be given aspirin without first consulting a
physician, as a rare but serious illness called Reye’s syndrome can result.

8. What are the circumstances in which the flu could be significant?
While most people recover from the flu in 1-2 weeks, some people develop life-threatening
complications. People ages 65 years and older, people of any age with chronic conditions, and very
young children are more likely to get complications from the flu such as sinus and ear infections,
bronchitis, and pneumonia. The flu can also make chronic health problems worse; for example, people
with asthma may experience asthma attacks while they have the flu, and people with chronic
congestive heart failure may experience a worsening of their condition. Unusual strains of flu (avian
flu) may pose greater risk to populations. The management, exclusion and readmission of students
and/or staff with avian flu may be different than the guidelines below.


9. Exclusion: None, unless the child meets other exclusion criteria such as fever with behavior
changes, or if the child appears to be severely ill and also when the child is unable to participate
comfortably in activities as determined by the school staff (see “General Exclusion Criteria”).

10. Readmission: Upon recovery, by school principal or principal’s designee.



                                              - 31 -
                                           Lyme Disease
1. What is Lyme disease?
Lyme disease is an infection caused by the bite of ticks infected with Lyme disease spirochetes (a type
of bacteria). There are other tick-borne diseases, but the discussion will focus on Lyme disease since it
serves as a general model for tick-borne disease prevention, exclusion, and readmission in school
settings.

2. What are the signs and symptoms of Lyme disease?
Most patients will have a red, slowly expanding “bull’s eye” rash accompanied by general tiredness,
fever, headache, stiff neck, muscle aches, and joint pain. If untreated, more serious complications
can result.

3. Incubation period: 3 – 31 days from tick bite to appearance of rash.

4. Contagious period: Lyme disease is not contagious except through blood transfusion.

5. How does infection with Lyme disease occur?
Infection occurs after a bite by a tick infected with Lyme disease bacteria (the tick usually has to be
attached for greater than 36 hours). Lyme disease cannot be spread from person to person (i.e. one
cannot become infected from touching or kissing a person who has Lyme disease, from a health care
worker who has treated someone with the disease, or by sexual contact).

6. How can infection with Lyme disease be prevented?
Avoiding a tick bite is the most effective measure of prevention. This can be aided by wearing
appropriate clothing when in tick-infested areas (e.g., tall grassy, bushes, wooded areas), daily tick
checks, and quick removal of attached ticks. The use of insect repellants should be used on children
only as directed by the manufacturer and according to Center for Disease Control (CDC) instructions.

7. Can a person be reinfected with Lyme disease?
Yes. Having had Lyme disease once does not protect against reinfection.

8. Is there a treatment for Lyme disease?
Antibiotic treatment for 3-4 weeks is generally effective in early disease. Later disease may require
intravenous antibiotics. In later disease, treatment failures may occur and retreatment may be
necessary.

9. What are the circumstances in which Lyme disease could be significant?
If Lyme disease is untreated, weeks to months after infection some patients may develop arthritis
including intermittent episodes of swelling and pain in the large joints and neurologic abnormalities
such as meningitis and facial palsy may occur. Rarely, heart problems, including an enlarged heart,
can result.

10. Exclusion: None, unless they meet other exclusion criteria (see “General Exclusion Criteria”)

11. Readmission: Upon recovery, by school principal or principal’s designee.

12. Contacts and reporting: Lyme disease is reportable to the County. Call Nursing Services
Communicable Disease Unit if there is a need to report a case of Lyme disease.




                                             - 32 -
                                      Measles (Rubeola)
1. What is measles?
Measles is an acute, highly contagious viral disease. The disease can be severe with complications such
as pneumonia and inflammation of the brain leading to death in about two of every thousand cases.

2. What are the signs and symptoms of measles?
The infected person first experiences a fever lasting about 2-4 days that can peak as high as 103-105
degrees Fahrenheit. This is followed by the onset of a cough, runny nose, conjunctivitis (pink eye) and
Koplik spots (small red spots in the mouth). The rash (dusky, red blotchy) usually begins at the
hairline, and then involves the face and upper neck. Over the next 3 days, the rash gradually proceeds
downward on the body, reaching the hands and feet. Diagnostic testing for measles should be
undertaken by a qualified health professional and the state public health laboratory.

3. Incubation period: 8 – 12 days from exposure to onset of signs and symptoms.

4. Contagious period: From 1 – 2 days before the first signs or symptoms appear until 4 days after
the appearance of the rash.

5. How does infection with measles occur?
The disease is highly contagious, and can be transmitted prior to and after the appearance of the rash.
The virus resides in the mucus in the nose and throat of the infected person. When the infected person
sneezes, coughs, or speaks another person can inhale this virus from the air and become ill. Touching
an infected surface can also spread the virus, which remains active and contagious on infected surfaces
for up to 2 hours. Measles spreads so easily that anyone who is not immunized may get it.

6. How can infection with measles be prevented?
The measles vaccine can prevent this disease. The vaccine is usually given as part of a combination
vaccine, called MMR that protects against measles, mumps, and rubella. There is an immune globulin
that can be given after exposure to measles, usually for immunocompromised and unimmunized
patients.

7. Is there a treatment for measles?
There is no cure or treatment for measles; only its symptoms can be treated.

8. What are the circumstances in which measles could be significant?
Complications of measles are more common among children under 5 years of age and adults over 20
years old, and can include ear infection, pneumonia, encephalitis (brain inflammation), and death.
Measles in pregnant women can result in miscarriage, premature birth, or a low-birth-weight baby.

9. Exclusion: Yes, measles is highly communicable illness for which routine exclusion of infected
children is warranted. Unimmunized children (exempted from measles immunization for medical,
religious, or other reasons) if not immunized within 72 hours of exposure, should be excluded from
school until at least 2 weeks after the onset of rash in the last case of measles.

10. Readmission: Four days after beginning of rash and with clearance from County of the Los
Angeles, Department of Health or other treating physician.

11. Contacts and reporting: Measles is reportable to the County. Call Nursing Services
Communicable Disease Unit if there is a need to report a case of measles.




                                            - 33 -
                                             Meningitis

1. What is meningitis?
Meningitis is an infectious disease causing swelling and inflammation of the membranes and the fluid
surrounding the brain and spinal cord. Meningitis can be caused by a bacterium or a virus. Knowing
whether meningitis is caused by a virus or bacterium is important because the severity of illness and
the treatment differ. Viral meningitis is generally less severe and resolves without specific treatment,
while bacterial meningitis caused by meningococcal bacteria is a serious disease and can be fatal.
Unlike viral meningitis, bacterial meningitis must be treated with antibiotics.

2. What are the signs and symptoms of meningitis?
Often, the symptoms of viral meningitis and bacterial meningitis are the same. High fever, headache,
and stiff neck are common symptoms of meningitis in anyone over the age of 2 years. These symptoms
can develop over several hours, or they may take 1-2 days. Other symptoms may include nausea,
vomiting, discomfort looking into bright lights, confusion, and sleepiness. As the disease progresses,
patients may have seizures. Children infected with the meningococcal bacteria can have a quickly
progressing course that includes a dusky-purple rash and shock or coma.

3. Incubation period:
        Viral Meningitis: 3 – 6 days
        Bacterial Meningitis: Less than 4 days

4. Contagious period:
        Viral Meningitis: Varies with causative organism
        Bacterial Meningitis: Until after 24 hours of antibiotics

5. How does infection with meningitis occur?
Most viruses and bacteria that cause meningitis spread through person to person contact and
respiratory secretions. Some viruses are spread through fecal-oral routes.

6. How can infection with meningitis be prevented?
There are safe and effective vaccines against some of the bacteria that cause meningitis. One
effective method of prevention both viral and bacterial infections is to wash hands thoroughly and
often. In institutional settings such as schools and child care centers, washing objects and surfaces
with a District-approved disinfectant (e.g., dilute bleach solution) can be a very effective way to
inactivate a virus. In some cases of bacterial meningitis, antibiotic prophylaxis may be indicated for
close contacts to the infected individual.

7. Is there a treatment for meningitis?
Bacterial meningitis can be treated with a number of effective antibiotics, but no specific treatment
exists for viral meningitis at this time. Individuals with meningitis may be managed in the hospital
based on their general condition and the severity of their disease.

8. Exclusion: Yes, as soon as it is suspected.

9. Readmission: When the child is cleared to return by a health professional.

10. Contacts and reporting: Meningitis is a reportable condition. Call Nursing Services
Communicable Disease Unit before any reporting and to discuss if there is a need for notification to
parents or staff.




                                              - 34 -
                                   Molluscum Contagiosum

1. What is molluscum contagiosum?
Molluscum is a benign skin disease caused by a virus, somewhat similar to warts. Humans are the only
known source of the virus. While infectivity is generally low, there are occasional outbreaks that have
been reported, including in child care centers.

2. What are the signs and symptoms of molluscum contagiosum?
Molluscum only affects the skin and not other parts of the body. It is characterized by small, flesh-
colored bumps on the skin, often with a tiny, hard, indented, seed-like center. Lesions commonly
occur on the trunk, face, arms and legs, but rarely are generalized over the entire body. The
exceptions are with eczema or immunocompromised people, who tend to have more intense and
widespread eruptions.

3. Incubation period: Usually between 2 and 7 weeks, but may be as long as 6 months.

4. Contagious period: Unknown

5. How does infection with molluscum contagiosum occur?
The virus is spread person-to-person through close contact or through inanimate objects such as
towels. Infectivity is generally considered low.

6. How can infection with molluscum contagiosum be prevented?
Although molluscum contagiosum bumps represent a viral infection, they are very mildly contagious
and most often are spread to other areas of the affected child’s body, rather than to other children.
Children should avoid scratching the bumps, as they can become infected with bacteria or further
spread the virus to another site. As with other communicable disease, hand washing is important and
not sharing personal objects (towels) with infected individuals. Molluscum contagiosum bumps do not
need to be covered like shingles or other oozing sores.

7. Is there a treatment for molluscum contagiosum?
Treatment is a personal choice and not an infection control issue for a group care setting. The bumps
usually go away on their own in a few months as the person develops antibodies to the virus.
Alternatively, treatments may be used; however, there is little agreement on effective treatments.

8. Exclusion: No

9. Readmission: No restrictions




                                             - 35 -
                                          Mononucleosis
1. What is mononucleosis?
Mononucleosis is an infectious disease caused by the Epstein-Barr Virus (EBV) commonly known among
the general public as “mono.” Most people become infected with EBV some time during their lives, but
do not necessarily develop mononucleosis.

2. What are the signs and symptoms of mononucleosis?
Symptoms of infectious mononucleosis include fever, sore throat, swollen lymph glands, and fatigue.
Sometimes, a swollen spleen or liver involvement may develop. Heart problems or involvement of the
central nervous system occur only rarely.

3. Incubation period: Estimated to be 30 – 50 days

4. Contagious period: Unknown, but probably before symptoms appear and many months after
infection symptoms.

5. How does infection with mononucleosis occur?
Most individuals exposed to people with infectious mononucleosis have previously been infected with
the virus and are not at risk for infectious mononucleosis. Transmission of the virus requires intimate
contact with the saliva of an infected person; transmission through the air or blood does not normally
occur, although infection has been reported through blood transfusion.

6. How can infection with mononucleosis be prevented?
Avoiding direct contact with the saliva of an infected person may help prevent transmission. However
the fact that many healthy people can carry and spread the virus intermittently for life, and that they
are usually the primary reservoir for person-to-person transmission, makes the transmission of the virus
almost impossible to prevent. As a general measure, people with signs and symptoms of mononucleosis
should not donate blood or prepare food for others.

7. Is there a treatment for mononucleosis?
Only the symptoms of mononucleosis may be treated. No vaccine or antiviral drugs are available at
this time.

8. What are the circumstances in which mononucleosis could be significant?
Rupture of an organ is a risk in patients with an enlarged spleen or liver who plays contact sports. In
rare instances bleeding disorders or testicular or cardiac inflammation can lead to more severe
complications of EBV infection. EBV has also been associated with distinct types of cancer.

9. Exclusion: No, unless they meet other exclusion criteria (see “General Exclusion Criteria”).
However, contact sports should be avoided until patient has fully recovered and the spleen is no longer
enlarged/palpable.

10. Readmission: Upon recovery, by school principal or principal’s designee.




                                             - 36 -
                                              Mumps

1. What is mumps?
Mumps is an acute illness caused by the mumps virus. After a vaccine was introduced in 1967, the
incidence of mumps decreased rapidly. In 1986 and 1987 there was a relative resurgence of mumps in
young adults, indicating a need for two doses of the vaccine to confer immunity. Since 1989, there has
been a steady decline in reported mumps cases as a result of implementation of the second dose
recommendation for the mumps vaccine.

2. What are the signs and symptoms of mumps?
Mumps begins with a low-grade fever, headache, loss of appetite, muscle aches, and a generalized sick
feeling. Mumps most commonly affects the parotids glands in front and below the ear or under the
jaw. Within 2 days, the infection in the salivary glands begins to be marked with an earache and/or
jaw pain. Symptoms tend to decrease after one week and usually resolve in 10 days. Some infections
show no symptoms, while others may show only non-specific or respiratory symptoms. In teenage boys,
painful swelling of the testicles may appear; girls may have swelling of the ovaries which may cause
abdominal pain.

3. Incubation period: 16 – 18 days

4. Contagious period: From 1 – 2 days before to 5 days after the swelling of glands

5. How does infection with mumps occur?
Transmission of mumps virus occurs when a healthy person comes in contact with an infected person’s
saliva, or when an infected person spews airborne droplets containing the virus by coughing, sneezing,
or talking, and a healthy person breathes them in.

6. How can infection with mumps be prevented?
The mumps vaccine can prevent this disease. The vaccine is usually given as part of a combination
vaccine, called MMR that protects against measles, mumps, and rubella.

7. What are the circumstances in which mumps could be significant?
Mumps can cause complications in the central nervous system, including meningitis. Testicular,
ovarian, and heart inflammation, as well as pancreatic infection, can also occur. Deafness caused by
mumps was significant in children in the pre-vaccine era.

8. Exclusion: Yes, mumps is highly communicable illness for which routine exclusion of infected
children is warranted. For outbreaks, exclude exposed children who have not been immunized until
they become immunized; or if they are not immunized because of an accepted exemption, continue to
exclude them until the health department determines it is safe for them to return.

9. Readmission: Nine days after onset of symptoms (swelling of glands) and with clearance from
County of the Los Angeles, Department of Health or other treating physician.

10. Contacts and reporting: Mumps is reportable to the County. Call Nursing Services
Communicable Disease Unit if there is a need to report a case of mumps.




                                            - 37 -
                                             Pinworms

1. What are pinworms?
Pinworm refers to an infection caused by small, white, threadlike worms ( 0.25” – 0.5” long ) that live
in the large intestine. It has been estimated that 5%-15% of the U.S. population is infected, and higher
rates are seen in pre-school and school aged children.

2. What are the signs and symptoms of pinworms?
Children with pinworm infections have itching and irritation around the anal or vaginal area. Worms
may be seen, especially after the child has been sleeping for a few hours, around the anus

3. Incubation period: 1 to 2 months or longer from the time of ingesting the pinworm egg until an
adult worm migrates to the anal area.

4. Contagious period: As long as the female worms are discharging eggs to the skin around the
anus.

5. How does infection with pinworms occur?
The transmission of pinworm eggs occurs by the fecal-oral route. This may occur directly or indirectly
by coming in contact with contaminated toys, bedding, clothing, toilet sheets, or baths. Pinworm eggs
remain infective for 2 to 3 weeks in indoor environments and infestation with pinworms commonly
cluster within families.

6. How can infection with pinworms be prevented?
Good hand hygiene is the most effective method of prevention. Parents may bathe the child in the
morning to remove a large proportion of eggs that are laid at night and frequently change underwear,
bedclothes, and bed sheets to decrease egg contamination. Wash toys frequently and clean and
sanitize surfaces used for eating, toileting, food preparation, and diapering.

7. Is there a treatment for pinworms?
Treatment with oral medication once or repeated in 2 weeks may be necessary for the whole family
and the group of children who share common environment.

8. Exclusion: No

9. Readmission: No restrictions




                                             - 38 -
                               Pertussis (Whooping Cough)
1. What is pertussis or whooping cough?
Whooping cough is an acute infection caused by the bacterium Bordetella pertussis. It is one of the most
common childhood diseases involving the throat and lungs, especially encountered in unimmunized populations.
Whooping cough is a serious illness in children and may result in complications and death. Adolescents and
adults who become infected with whooping cough, although contagious, usually have a milder illness.

2. What are the signs and symptoms of whooping cough?
The initial stage is characterized by a runny nose, sneezing, low-grade fever, and a mild cough. The
second stage begins with bursts of numerous, rapid coughs followed by a characteristic, long, high-
pitched inspiratory whoop. During such an attack, a patient may turn blue, especially children and
young infants. Vomiting and exhaustion commonly follow the episode, but the individual usually
appears normal between attacks. The second stage lasts for 1-6 weeks, but may persist for up to 10
weeks. In the last stage, the cough begins to subside and disappears over a period of 2-3 weeks.

3. Incubation period: 6 – 21 days; usually 7 – 10 days

4. Contagious period: From the beginning of symptoms until 2 weeks after the cough begins
depending on age immunization status. An infant who has no pertussis immunization may remain
infectious for 6 weeks or more after the cough starts.

5. How does infection with whooping cough occur?
Transmission of the whooping cough bacteria from one person to another usually occurs through direct
contact with or inhalation of airborne droplets of respiratory secretions. Less commonly, transmission
can occur through contact with freshly contaminated objects touched by an infected person.

6. How can infection with whooping cough be prevented?
The pertussis vaccine can prevent whooping cough. The immunization for pertussis is usually given
with one for diphtheria and tetanus (DTaP). Other measures include hand washing and prophylactic
antibiotics for exposed close contacts.

7. Is there a treatment for whooping cough?
Antibiotics can be used to treat whooping cough.

8. What are circumstances in which whooping cough could be significant?
Young infants are at highest risk for developing complications from whooping cough. The most
common complication is bacterial pneumonia. Neurologic complications such as seizures, etc. may also
occur as a result of a reduced oxygen supply to the brain due to coughing.

9. Exclusion: Yes, pertussis is highly communicable illness for which routine exclusion of infected children is
warranted. Exclude close contacts who are coughing until they receive appropriate evaluation and treatment.

10. Readmission: After 5 days of appropriate antibiotic treatment (which is given for a total of 14 days) and
with clearance from County of the Los Angeles, Department of Health or other treating physician. People who do
not receive appropriate antibiotic therapy should be excluded from school for 21 days after the onset of symptoms.

11. Contacts and reporting: Whooping cough (pertussis) is a reportable disease. Call Nursing
Services Communicable Disease Unit before any reporting and to discuss if there is a need for
notification to parents or staff.




                                            - 39 -
                                        Ringworm (Tinea)

1. What is ringworm?
Ringworm is a contagious fungal infection of the skin (tinea corporis), scalp (tinea capitis), feet (tinea
pedis), and the nails (tinea unguium). Despite its name, it has nothing to do with worms. The name
comes from the characteristic red ring that can appear on an infected person’s skin.

2. What are the signs and symptoms of ringworm?
        Ringworm of the body shows up as a flat, round patch anywhere on the skin except for the
        scalp and feet. The groin is a common area of infection. As the rash gradually expands, its
        center clears to produce a ring and there may be scales on the edges. More than one patch
        might appear, and the patches can overlap. The area is sometimes itchy.
        Ringworm of the scalp begins with a small pimple that becomes larger, leaving scaly patches of
        temporary baldness. Infected hairs become brittle. Yellowish crusty areas sometimes develop.
        Ringworm of the foot is also called “athlete’s foot.” It appears as a scaling or cracking of the
        skin, especially between the toes.
        Ringworm of the nails causes the infected nails to become thicker, discolored, and brittle, or
        to become chalky and disintegrate.

3. Incubation period: Approximately 10 – 14 days

4. Contagious period: Unknown, but likely infectious as long as lesions are present with viable fungus.

5. How does infection with ringworm occur?
People can get ringworm by direct skin-to-skin contact with an infected person or pet. People can also
get ringworm indirectly by contact with objects or surfaces that an infected person or pet has touched,
such as hats, combs, brushes, bed linens, stuffed animals, gym mats, and shower stalls. In rare cases,
ringworm can be spread by contact with soil.

6. How can infection with ringworm be prevented?
The fungus is very common and it is contagious even before symptoms appear. Steps to prevent
infection include the following: educating the public about the risk of ringworm from infected persons
and pets; keeping common-use areas clean, especially in schools, day-care centers, gyms, and locker
rooms; using District-approved disinfecting solutions on sleeping mats and gym mats; and, avoiding the
sharing of clothing, towels, hair brushes, or other personal items. Infected persons can prevent
infection from spreading by: completing treatment as instructed even after symptoms disappear;
avoiding sharing personal items with others; and, minimizing contact with others by covering lesions.

7. Is there a treatment for ringworm?
Ringworm can be treated with an anti-fungal medicine. The medicine can be in tablet or liquid form
taken by mouth, or as a cream applied directly to the infected area. Anti-fungal creams can be
purchased in a pharmacy, without a prescription, for ringworm of the skin and foot. More extensive
infections and ringworm of the scalp and nails usually require a prescription medication.

8. What are the circumstances in which ringworm could be significant?
Lack of or inadequate treatment can result in an infection that will not clear up.

9. Exclusion: Yes, at the end of the school day for treatment.

10. Readmission: Once treatment is started, reasonable effort should be made to cover exposed
skin lesions. Readmission may be granted by school staff or private physician.



                                              - 40 -
                                  Rubella (German Measles)

1. What is rubella?
Rubella, also called German measles, is an infectious disease caused by a virus. Although mild in
children, rubella can be associated with significant disease in adults. If a pregnant woman gets rubella
during the first 3 months of pregnancy, her baby is at risk of dying or of having serious birth defects.

2. What are the signs and symptoms of rubella?
Symptoms of rubella may include a rash, slight fever, aching joints, headaches, discomfort, runny nose,
and redness of eyes. A red or pink rash first appears on the face and spreads from head to toe. The
lymph nodes just behind the ears and at the back of the neck may swell, causing soreness and pain.
Many people with rubella have few or no symptoms, and only about half of the people who have the
disease get a rash.

3. Incubation period: Usually 16 – 18 days

4. Contagious period: May be spread 7 days before to 14 days after the appearance of the rash

5. How does infection with rubella occur?
Rubella is spread from person to person when an infected person coughs or sneezes and an uninfected
person comes in direct contact with these respiratory and throat secretions. In addition, a mother can
pass rubella to her fetus.

6. How can infection with rubella be prevented?
There is a safe and effective vaccine to protect against rubella. The vaccine is usually given as part of
a combination vaccine, called the MMR vaccine that protects against measles, mumps, and rubella.

7. Is there a treatment for rubella?
Only the symptoms of rubella can be treated.

8. What are the circumstances in which rubella could be significant?
If rubella is contracted in the early months of pregnancy it is associated with a high rate of serious
birth defects such as deafness, cataracts, heart defects, and liver or spleen damage.

9. Exclusion: Yes, rubella is highly communicable illness for which routine exclusion of infected
children is warranted. For outbreaks, exclude exposed children who have not been immunized until
they become immunized; or if they are not immunized because of an accepted exemption, continue to
exclude them until the health department determines it is safe for them to return.

10. Readmission: Six days after onset of rash and with clearance from County of the Los Angeles,
Department of Health or other treating physician.

11. Contacts and reporting: Rubella is reportable disease. Call Nursing Services Communicable
Disease Unit if there is a need to report a case of rubella.




                                              - 41 -
                                               Scabies


1. What is scabies?
Scabies is an infestation of the skin with a microscopic mite. Scabies spreads rapidly under crowded
conditions where there is frequent skin-to-skin contact between people, such as in childcare facilities.

2. What are the signs and symptoms of scabies?
Symptoms of scabies include pimple-like irritations, burrows, or rash of the skin, especially in the
webbing between the fingers; the skin folds on the wrist, elbow, or knee; the penis; the breast; or the
shoulder blades. Intense itching is common, especially at night. Sores can result due to scratching and
can sometimes become infected by bacteria.

3. Incubation period: 4 – 6 weeks for those who have never been infected. 1 – 4 days for those
who have been previously infested.

4. Contagious period: Until insect infestation is treated.

5. How does infestation with scabies occur?
Scabies is spread to a healthy person by direct, prolonged, skin-to-skin contact with a person already
infested with scabies. Infestation may also occur by sharing clothing, towels, and bedding. Infestation
is easily spread to sexual partners and household members.

6. How can infestation with scabies be prevented?
Health education regarding cleanliness of person, garments, and bedclothes, and the need to be
selective of intimate contacts can help prevent the spread of scabies. Having scabies once does not
prevent one from becoming infected again since the body does not build up an immune response to
scabies.

7. Is there a treatment for scabies?
Several topical treatments, such as creams and lotions, are available to treat scabies. Even when
treatment has eliminated the mites, itching may continue for 2-3 weeks and does not mean that one is
still infested. No new burrows or rashes should appear 24-48 hours after effective treatment. Close
contacts with the patient should be treated at the same time. Infested bedding and clothing should be
laundered (in hot water) and items that can not be laundered should be stored in a sealed plastic bag
for at least 4 days.

8. What are the circumstances in which scabies could be significant?
People with weakened immune systems, infants and the elderly are at risk for a more severe form of
scabies called Norwegian or crusted scabies.

9. Exclusion: Yes, until after treatment is completed.

10. Readmission: After treatment has been completed (usually complete overnight).

11. Contacts and reporting: Family members and close contacts to the infected individual
should be treated at the same time, even if they have no signs or symptoms are present. Scabies is
only reportable to the County in atypical cases. Call Nursing Services Communicable Disease Unit if
there is a need to report an atypical case.




                                             - 42 -
                                           Scarlet Fever

1. What is scarlet fever?
Scarlet fever is a rash that sometimes occurs in people with strep throat. Both scarlet fever and strep
throat are caused by the same bacteria called group A streptococcus. The rash of scarlet fever is
usually seen in children under the age of 18.

2. What are the signs and symptoms of scarlet fever?
A rash first appears as tiny red bumps on the chest and abdomen. This rash may then spread all over
the body. It looks like a sunburn and feels like a rough piece of sandpaper. It is usually redder in the
armpits and groin areas. The rash lasts about 2-5 days. After the rash is gone, the skin on the tips of
the fingers and toes often begins to peel. The face is flushed with a pale area around the lips. The
throat is very red and sore, and can have white or yellow patches. Fever, chills, swollen lymph nodes
and “strawberry tongue” can be seen. Other, less common, symptoms include nausea, vomiting,
headache, and body aches.

3. Incubation period: 2 – 5 days

4. Contagious period: Approximately 10 days if untreated. Uncomplicated cases are
communicable during incubation and clinical illness. Adequate treatment with antibiotic will decrease
the probability of transmission from patients or carriers within 24 hours.

5. How does infection with scarlet fever occur?
The illness can be spread to an uninfected person through contact with throat, mouth and nasal fluids
of an infected person. Also, drinking from the same glass or sharing utensils with an infected person
can spread the illness.

6. How can infection with scarlet fever be prevented?
There is no vaccine against the bacteria that causes scarlet fever available at this time. Thorough
handwashing and avoidance of contact with an infected person’s throat, mouth, or nasal secretions
are helpful prevention measures.

7. Is there a treatment for scarlet fever?
Scarlet fever can be treated with antibiotics. It is very important to finish the prescribed medication,
even when symptoms subside in order to prevent the development of complications or antibiotic-
resistance bacteria.

8. What are the circumstances in which scarlet fever can be significant?
If scarlet fever is not treated, or if prescribed antibiotics are not completed, rheumatic fever can
occur in a small percentage of people. Rheumatic fever is a disease characterized by pain and
swelling of tissues in various parts of the body and kidney problems.

9. Exclusion: Yes, until treatment has been initiated for 24 hours

10. Readmission: After a minimum of 24 hours of antibiotic treatment.




                                             - 43 -
                                            Strep Throat

1. What is strep throat?
Strep throat is an infectious disease characterized by a sore throat. It is called “strep” after the
bacterium that causes the infection (group A streptococcus).

2. What are the signs and symptoms of strep throat?
Signs and symptoms of strep throat include: a sore throat that is red from inflammation, white patches
on the tonsils or back of throat, swollen lymph nodes in the neck, fever, and headache. Children may
also experience stomach pain, nausea, or vomiting. Strep throat is usually not accompanied by a stuffy
nose or cough.

3. Incubation period: 2 – 5 days

4. Contagious period: Same as Scarlet Fever

5. How does infection with strep throat occur?
The bacteria that cause strep throat are spread through direct contact with mucus from the nose or
throat of persons who are infected or through contact with infected wounds or sores on the skin. Ill
persons, such as those who have strep throat or skin infections, are most likely to spread the infection.
Persons who carry the bacteria but have no symptoms are much less contagious. Treating an infected
person with an antibiotic for 24 hours or longer greatly decreases their ability to spread the bacteria.

6. How can infection with step throat be prevented?
Good hygienic measures, such as frequent hand washing and avoiding contact with mucus from an
infected person are the best prevention methods.

7. Is there a treatment for strep throat?
Strep throat can be treated with antibiotics. A throat swab is usually needed to test for the infection
and make the diagnosis. It is very important to finish the prescribed medication, even when symptoms
subside in order to prevent the development of complications or antibiotic-resistant bacteria.

8. What are the circumstances in which strep throat could be significant?
If strep throat is not treated, or if the prescribed course of antibiotics is not completed, rheumatic
fever can occur in a small percentage of people. Rheumatic fever is a disease characterized by pain
and swelling of tissues in various parts of the body and kidney problems. Other complication of strep
throat can include ear infections, sinusitis and abscess in the tonsils.

9. Exclusion: Yes, until treatment has been initiated for 24 hours

10. Readmission: After a minimum of 24 hours of antibiotic treatment. The untreated cases are
excluded until clinical recovery, not less than 7 days.




                                              - 44 -
                                             Tetanus


1. What is tetanus?
Tetanus is an acute, often fatal, disease caused by a toxin produced by Clostridium tetani. The
spores that produce the tetanus toxin usually enter the body through a wound. Although the
incidence of tetanus has declined since the introduction of a vaccine, the late 1990s saw an increase
in tetanus cases among young injection drug users in California.

2. What are the signs and symptoms of tetanus?
The most common form of tetanus is generalized tetanus. Symptoms of generalized tetanus usually
descend throughout the body; first there is a stiff jaw, then neck, and then problems swallowing
followed by rigidity of abdominal muscles. Other symptoms include fever, sweating, elevated blood
pressure, and rapid heart rate. Spasms may occur frequently and last for several minutes, and
continue for 3-4 weeks. Complete recovery may take months.

Another form of generalized tetanus is neonatal tetanus which occurs in newborn infants, often
through an infection of an unhealed umbilical stump. Neonatal tetanus is common in some developing
countries but is very rare in the United States.

3. Incubation period: Usually 3 – 21 days

4. Contagious period: Not directly transmitted from person to person

5. How does infection with tetanus occur?
Tetanus is not contagious from person to person. Transmission is usually by contaminated wounds. In
addition, tetanus may follow surgery, burns, animal bites, etc.

6. How can infection with tetanus be prevented?
The tetanus vaccine can prevent this disease. Primary immunization is commonly given to infants and
toddlers as a combined vaccine of diphtheria, tetanus and pertussis (DTaP). However, tetanus
immunity decreases 10 years after receiving the vaccine. Thus, additional booster doses of tetanus
vaccines are required every 10 years to maintain immunity. If a person experiences a major or
unclean wound, it may be necessary for them to receive a vaccine or immune globulin to protect them
from tetanus, even if they were vaccinated as an infant. A physician should be consulted in the event
of injury to determine what steps are necessary to prevent tetanus.

7. What are the circumstances in which tetanus could be significant?
Tetanus can cause spasms of respiratory muscles, which result in difficulty breathing. Pneumonia is a
common complication of tetanus. Elevated blood pressure and heart rate can also occur. In recent
years, tetanus has been fatal in approximately 11% of reported cases, with death occurring more
frequently in persons over 60 years of age and in unvaccinated individuals.

8. Exclusion: Yes, for the duration of illness

9. Readmission: Upon recovery, with clearance by the County of Los Angeles, Department of
Public Health or other licensed physician.

10. Contacts and reporting: Tetanus is reportable disease. Call Nursing Services Communicable
Disease Unit if there is a need to report a case of tetanus.




                                            - 45 -
                                           Tuberculosis

1. What is tuberculosis?
Tuberculosis (TB) is a disease caused by the bacterium Mycobacterium tuberculosis that classically
affects the lungs. TB infection (“inactive” or “latent”) is when a person has a positive TB skin test,
but no signs or symptoms of disease and a negative chest x-ray. Infected individuals are not
contagious, but they may develop active TB disease at some time in the future. TB disease refers to
those that have a positive TB skin test, an abnormal chest x-ray, and may spread TB to others.

2. What are the signs and symptoms of TB?
TB infection is without signs or symptoms. TB disease may cause a bad cough that lasts longer than 2
weeks, chest pain, coughing up blood or phlegm, weakness or fatigue, weight loss, poor appetite,
chills, fever, and night sweats.

3. Incubation period: TB can be carried in the body for many years without active disease.

4. Contagious period:
        Persons with latent TB infection are not contagious.
        While adolescents and adults with active TB disease are usually contagious, infants and young
        children are generally not. This is due to their unique disease process and the decreased
        ability to expel bacterium when they cough.

5. How does infection with TB occur?
The bacteria that cause TB are spewed into the air when a person with active TB disease coughs or
sneezes. People nearby may breathe in these bacteria and become infected.

6. How can infection with TB be prevented?
There is a vaccine for TB called BCG that is administered to infants and small children in countries
where TB is common. The BCG vaccine does not always protect people from TB and is not
recommended for routine use in the United States. Prevention of the progression from latent TB
infection to active TB disease is usually accomplished through a course of an anti-tuberculosis drug.
General public health measures are also instituted to prevent the spread of TB.

7. Is there a treatment for TB?
Various anti-tuberculosis drugs are available for the treatment of TB disease. The entire course of
drug treatment must be completed in order to prevent bacteria from becoming drug-resistant.

8. What are the circumstances in which infection with TB could be significant?
TB can be fatal if left untreated. However, it can be prevented and controlled once contracted. It is
important that the condition is diagnosed early in individuals with risk factors (i.e., HIV infection).

9. Exclusion:
        Yes, for persons with active TB disease who have not started appropriate therapy.
        No, for persons with latent TB infection, whether or not they are receiving treatment.

10. Readmission: Upon starting and adherence to effective therapy for TB disease, the student is
approved to return by local health professionals and considered non-infectious to others. Students
seeking readmission after exclusion for TB disease should be referred to the LAUSD Nursing Services
Communicable Disease Unit for readmission.

11. Contacts and reporting: Tuberculosis is reportable to the County. Contact investigation of TB
disease will be performed according to County of the Los Angeles, Department of Public Health policy.


                                             - 46 -
                            Warts (Genital and Non-Genital)
1. What are warts?
Warts are non-cancerous skin growths caused by a viral infection in the top layer of the skin. Viruses
that cause warts are called human papillomavirus (HPV). Common warts usually appear on the hands
and feet, while genital warts appear in the gential area and are considered to be a sexually
transmitted disease.

2. What are the signs and symptoms of warts?
Warts are usually skin-colored and feel rough to the touch, but they can be dark, flat, and smooth.
There are a variety of types:
        Common warts usually appear on the fingers and hands, and are most frequently found where
        skin has been broken. These are often called “seed” warts because the blood vessels to the
        wart produce black dots that look like seeds. Most often seen in young children.
        Plantar warts are found on the soles of the feet. Most do not stick up and they can be painful.
        Plantar warts are most commonly seen in school age children and teenagers.
        Flat warts are smaller and smoother than other warts, they tend to grow in large numbers
        (20-100 at a time), and they are common on the face. Most often seen in young children.
        Genital warts are clusters of wart-like lesions in the genital area (vulva, vagina, anus, cervix,
        penis, scrotum, groin, or thigh). They usually occur as soft, moist, pink or red swellings.
        They can be raised or flat, single or multiple, small or large. They can take weeks to months
        to appear after contact with an infected person.

3. Incubation period: Unknown, but estimated at 3 months to several years

4. Contagious period: As long as visible lesions are present. (Warts are only mildly contagious).

5. How does infection with warts occur?
Warts are spread person-to-person through direct or, sometimes, indirect contact. Many HPV
infections show no signs or symptoms, so people can pass the virus unknowingly to another person.
This is frequently the case in the spread of genital warts, when people unaware of their infection pass
HPV to a sex partner. Rarely, pregnant women can pass HPV to their babies during vaginal delivery.

6. How can infection with warts be prevented?
Avoidance of direct contact with another person’s warts is the best mode of prevention. Wash hands
after touching a wart and do not share towels. Genital warts can be prevented by abstinence and safe
sex practices. Use of condoms can reduce but not eliminate the risk of infection. Sexually active
women should have regular Pap smears to screen for cervical cancer.

7. Is there a treatment for warts?
Many warts disappear on their own over months or years. The lesions can be removed by a
dermatologist, with daily application of duct tape, or by over-the-counter treatments with salicylic
acid. (Note: salicylic acid is not to be used on genital warts).

8. What are the circumstances in which infection with warts could be significant?
Genital warts can cause cancer in the cervix, anus, and penis. Regular health check-ups, including Pap
smears in women, are important to screen for pre-cancerous conditions and cervical cancers.

9. Exclusion: None, unless they meet other exclusion criteria (see “General Exclusion Criteria”)

10. Readmission: No restrictions


                                             - 47 -
                   West Nile Virus (and Mosquito-borne Disease)

1. What is West Nile virus?
The West Nile virus is one of several viral diseases spread by infected mosquitoes. Other examples of
such viruses include eastern and western equine encephalomyelitis, and St. Louis and La Crosse
encephalitis. West Nile Virus will be discussed in more detail as it has received the most media
attention in recent years. West Nile virus is established as a seasonal epidemic in North America with
flares in months with more mosquitoes (summer-fall).

2. What are the signs and symptoms of West Nile virus?
The majority of people (80%) who are infected with West Nile virus will show no signs of illness. Up to
20% of people who become infected will develop West Nile fever and will experience mild symptoms,
including fever, headache, and body aches, with an occasional skin rash on the trunk of the body and
swollen lymph glands. The most serious symptoms occur in the small percentage with West Nile
encephalitis and meningitis: headache, high fever, neck stiffness, disorientation, coma, tremors,
convulsions, muscle weakness, and paralysis.

3. Incubation period: 5 - 15 days (West Nile); 2 - 15 days (others) after infected mosquito bite.

4. Contagious period: Not contagious to other persons through regular contact

5. How does infection with West Nile virus occur?
West Nile virus occurs through the bite of an infected mosquito. Mosquitoes become infected after
biting an infected bird (usually a crow or jay). West Nile virus may be transmitted rarely through
transplanted organs or blood transfusion, and from a mother to her fetus. There is no evidence that
West Nile virus can be spread from person to person under normal causal contact.

6. What can be done to reduce the risk of being infected with West Nile Virus?
Protective measures to prevent West Nile virus exposure include:
    Avoid activity outside when mosquitoes are most active, especially at dawn and dusk.
    When outdoors, wear long pants, long sleeve shirts, and other protective clothing.
    Fit doors and windows have tight fitting screens; repair or replace torn screens.
    Eliminate all sources of standing water that can support mosquito breeding.
    Contact your local mosquito and vector control agency if there is a significant mosquito problem
    (for school sites, please contact the Integrated Pest Management Unit at 213-745-1427).

7. Is there a treatment for West Nile virus?
There is no specific treatment for West Nile virus infection. In more severe cases, intensive
supportive therapy is indicated, often involving hospitalization.

8. What are the circumstances in which West Nile Virus could be significant?
Persons over 50 years of age have the highest risk of severe disease, i.e. developing encephalitis.

9. Exclusion: No, unless they meet other exclusion criteria (see “General Exclusion Criteria”).

10. Readmission: Upon recovery, by school principal or principal’s designee.

11. Contacts and reporting: Dead birds may be a sign of West Nile virus disease, and they
should not be handled with bare hands. Contact the California Department of Health Services West
Nile Virus Hotline for information on disposal and reporting. See Reference Guide 1304 “West Nile Virus
Precautions” (September 16, 2004).



                                             - 48 -
              Part IV


Bioterrorism and Communicable Diseases
               in Schools




               - 49 -
                                          Bioterrorism

Since the September 11th attacks, there has been a heightened concern and
awareness of the use of biological agents in terrorist activities. Some of the agents
have already been described in this reference guide (e.g., food-borne illness,
influenza), but there are other, more rare agents that are classified as high priority
by the Center for Disease Control and Prevention (CDC) in the table below.

Category A                                           Category B
(easily disseminated; high rates of mortality;       (moderately easy to disseminate; moderate
may cause panic)                                     rates of morbidity and low mortality)
Anthrax                                              Q fever
Smallpox                                             Brucellosis
Plague                                               Eastern/western equine encephalitis
Tularemia                                            Ricin toxin
Botulism                                             Clostridia toxin
Viral Hemorrhagic Fevers (e.g., Ebola)               Food and water-borne illness (e.g.,
                                                     Salmonella, Shigella, E. coli O157:H7)

Children may be particularly vulnerable to a bioterrorist attack compared to adults.
This is due to their higher respiratory rate, increased skin absorption, high surface
(skin) to volume (weight) ratio, and the general crowded conditions of schools and
child care centers. The symptoms of illness caused by bioterrorism agents are similar
to symptoms of other common infectious diseases (e.g., fever, headache, vomiting,
diarrhea). Furthermore, the symptoms may not be evident immediately upon
exposure to the infectious agent. It may be very difficult to distinguish between
intentional infection and a naturally occurring outbreak.

Schools are where many children spend a good portion of their day, supervised by
teachers, administrators, and health professionals. This makes the school setting a
good place to monitor unusual signs and symptoms, or recognize patterns of illness
that may be occurring in a greater than average number of students (or staff).
Schools have become increasingly prepared for disasters and there are policies to
guide schools in crisis intervention (See LAUSD Bulletin 962 “Organizing for Crisis
Intervention” May 3, 2004). In acting as part of the many first-line responders, school
staff and District health professionals should have a basic understanding of
bioterrorism and the agents that may cause immediate and significant harm. LAUSD
Bulletin Z-72 “Bioterrorism Preparedness Response: Health Perspective” (September
3, 2002) describes the roles and responsibilities of district personnel in the unlikely
event of a bioterrorism attack directed at schools and school children.

The following table describes some of the early signs and symptoms that may help
distinguish the CDC’s Category A and B biologic agents. More complete descriptions of
each agent can be found using the links to CDC fact sheets available the CDC website
(www.bt.cdc.gov ).


                                            - 50 -
                          Prominent Early Clinical Manifestations After Exposure to Bioterrorist Agents
Early Clinical Manifestations Agents/Disease                     Links to more information
Respiratory
Flu-like illness with or        Tularemia                        www.bt.cdc.gov/agent/tularemia/pdf/tularemiafacts.pdf
without atypical pneumonia      Brucellosis                      www.cdc.gov/ncidod/dbmd/diseaseinfo/brucellosis_g.htm
(seen on chest radiograph)      Q fever                          www.cdc.gov/ncidod/dvrd/qfever/index.htm
                                Encephalomyelitis
Flu-like illness with cough     Anthrax (inhalational)           www.bt.cdc.gov/agent/anthrax/pdf/needtoknow.pdf
and difficulty breathing        Plague (pneumonic)               www.bt.cdc.gov/agent/plague/plaguefaq.pdf
                                Tularemia (inhalational)
                                Ricin                            www.bt.cdc.gov/agent/ricin/pdf/ricinfacts.pdf
                                Staph. enterovirus B (aerosol)
                                Hantavirus                       www.cdc.gov/ncidod/diseases/hanta/hps/noframes/FAQ.htm
Sore throat (with pus) and      Tularemia (oropharyngeal)
swollen lymph nodes (neck)
Dermatologic
Small red spots in the mouth, Smallpox                           www.bt.cdc.gov/agent/smallpox/overview/overview.pdf
progressing to vesicular rash
(fluid filled bubbles); fever,
headache and malaise
Small sore that develops into Anthrax (cutaneous)
blister, then a black ulcer
(all are painless)
Ulcers to the skin and mouth; Tularemia (ulceroglandular)
painful, swollen glands and
flu-like illness
Small purple spots              Viral hemorrhagic fever          www.cdc.gov/ncidod/dvrd/spb/mnpages/disinfo.htm
(petechiae) with fever and
weakness
Cardiovascular
Shock and difficulty            Anthrax (inhalational)
breathing                       Ricin
                                Viral hemorrhagic fever
                                   - 51 -
Early Clinical Manifestations   Agents/Disease               Links to more information
Neurologic
Blurred vision; slurred         Botulism                     www.bt.cdc.gov/agent/botulism/factsheet.pdf
speech; (descending) muscle
weakness progressing to
flaccid paralysis
Headache, dizziness, nervous    Encephalomyelitis
system malfunction; seizures;   Anthrax (inhalational)
coma                            Plague (septicemic and
                                      pneumonic)
Gastrointestinal
Diarrhea                        Salmonella species           www.cdc.gov/ncidod/dbmd/diseaseinfo/salmonellosis_g.htm
                                Shigella dysenteriae         www.cdc.gov/ncidod/dbmd/diseaseinfo/shigellosis_g.htm
                                E. Coli O157:H7              www.cdc.gov/ncidod/dbmd/diseaseinfo/escherichiacoli_g.htm
                                Vibrio cholerae              www.cdc.gov/ncidod/dbmd/diseaseinfo/cholera_g.htm
                                Cryptosporidium
Vomiting, abdominal pain,       Anthrax (gastrointestinal)
bloody diarrhea
Renal/Kidneys
Blood clotting problem; renal E. Coli O157:H7
failure                        Shigella dysenteriae
Renal failure, no urine output Viral hemorrhagic fever
                               Hantavirus
Other
Painful, swollen glands        Plague (bubonic)
(lymph nodes)
Red and inflamed eyes with     Tularemia (oropharyngeal)
pus (conjunctivitis); swollen
glands in neck and in front of
the ears

Adapted from American Academy of Pediatrics, Table 2.1 Red Book 2003 Report of the Committee on Infectious Diseases
                                     - 52 -
 Part V


Appendices




 - 53 -
                      Appendix A
County of Los Angeles Reportable Diseases and Conditions




                - 54 -
                                              County of Los Angeles Department of Health Services • Public Health                                                               Please post
                                    REPORTABLE DISEASES AND CONDITIONS
                                                       Title 17, California Code of Regulations (CCR), § 2500
     It shall be the duty of every health care provider, knowing of or in attendance on a case or suspected case of any diseases or conditions listed below,
     to report to the local health officer for the jurisdiction where the patient resides. Where no health care provider is in attendance, any indi-
     vidual having knowledge of a person who is suspected to be suffering from one of the diseases or conditions listed below may make such a
     report. “Health care provider” encompasses physicians, surgeons, veterinarians, podiatrists, nurse practitioners, physician assistants, registered
     nurses, nurse midwives, school nurses, infection control practitioners, medical examiners, coroners, dentists and chiropractors.
     Urgency Reporting Requirements:
     ¤ = Report immediately by telephone.
     u = Report by mailing, telephoning or electronically transmitting a report within 1 working day of identification of the case or suspected case.
     ¥ = Report by telephone within 1 hour followed by a written report submitted by facsimile or electronic mail within 1 working day.
     If no symbol, report within 7 calendar days from the time of identification by mail, telephone or electronic report.
                                                                           REPORTABLE DISEASES
            Acquired Immune Deficiency Syndrome (AIDS)*           ¤ Hemolytic Uremic Syndrome                                        Rubella (German Measles)
     u      Amebiasis                                                 Hepatitis, Viral                                               Rubella Syndrome, Congenital
     u      Anisakiasias                                              u Hepatitis A                                              u   Salmonellosis (other than Typhoid Fever)
     ¤      Anthrax                                                      Hepatitis B (Specify Acute Case or Chronic)             ¤   Scabies (Atypical or Crusted)5
     u      Babesiosis                                                   Hepatitis C (Specify Acute Case or Chronic)             ¤   Scombroid Fish Poisoning
     ¤      Botulism (Infant, Foodborne, Wound)                          Hepatitis D (Delta)                                     u   Shigellosis
     ¤      Brucellosis                                               Hepatitis, Other, Acute                                    ¤   Smallpox (Variola)
     u      Campylobacteriosis                                        Human Immunodeficiency Virus (HIV)*                            Streptococcal Infections
            Chancroid*                                                Kawasaki Syndrome (Mucocutaneous Lymph                         u Outbreaks of any Type and Individual Cases
            Chlamydial Infections*                                       Node Syndrome)                                                  in Food Handlers and Dairy Workers Only
     ¤      Cholera                                                   Legionellosis                                                  u Invasive Group A Streptococcal Infections
     ¤      Ciguatera Fish Poisoning                                  Leprosy (Hansen Disease)                                           including Streptococcal Toxic Shock Syndrome
            Coccidioidomycosis                                        Leptospirosis                                                      and Necrotizing Fasciitis 5 (Do not report
     u      Colorado Tick Fever                                   u   Listeriosis                                                        individual cases of pharyngitis or scarlet fever.)
     u      Conjunctivitis, Acute Infectious of the Newborn,          Lyme Disease                                                      Invasive Streptococcus pneumoniae 5
               Specify Etiology                                   u   Lymphocytic Choriomeningitis                               u   Swimmer’s Itch (Schistosomal Dermatitis)
     u      Cryptosporidiosis                                     u   Malaria                                                    u   Syphilis*
            Cysticercosis                                         u   Measles (Rubeola)                                              Tetanus
     ¤      Dengue                                                u   Meningitis, Specify Etiology: Viral, Bacterial,                Toxic Shock Syndrome
     ¤      Diarrhea of the Newborn, Outbreaks                           Fungal, Parasitic                                           Toxoplasmosis
     ¤      Diphtheria                                            ¤   Meningococcal Infections                                   u   Trichinosis
     ¤      Domoic Acid Poisoning (Amnesic Shellfish                  Mumps                                                      u   Tuberculosis*
               Poisoning)                                             Non-Gonococcal Urethritis (report laboratory               ¤   Tularemia
            Echinococcosis (Hydatid Disease)                             confirmed chlamydial infections as chlamydia)*          u   Typhoid Fever, Cases and Carriers
            Ehrlichiosis                                          ¤   Paralytic Shellfish Poisoning                                  Typhus Fever
     u      Encephalitis, Specify Etiology: Viral, Bacterial,         Pelvic Inflammatory Disease (PID)*                         ¤   Varicella: fatal cases only
               Fungal, Parasitic                                  u   Pertussis (Whooping Cough)                                     Varicella: Hospitalized cases
     ¤      Escherichia coli O157:H7 Infection                    ¤   Plague, Human or Animal                                    u   Vibrio Infections
     u      Foodborne Disease                                     u   Poliomyelitis, Paralytic                                   ¤   Viral Hemorrhagic Fevers (e.g., Crimean-Congo,
            ¤ (2 or more cases from separate households with      u   Psittacosis                                                       Ebola, Lassa, and Marburg viruses)
               same suspected source)                             u   Q Fever                                                    u   Water-associated Disease
            Giardiasis                                            ¤   Rabies, Human or Animal                                    ¤   Yellow Fever
            Gonococcal Infections*                                u   Relapsing Fever                                            u   Yersiniosis
     u      Haemophilus influenzae, Invasive Disease                  Reye Syndrome                                              ¤   OCCURRENCE OF ANY UNUSUAL DISEASE
     ¤      Hantavirus Infections                                     Rheumatic Fever, Acute                                     ¤   OUTBREAKS OF ANY DISEASE
                                                                      Rocky Mountain Spotted Fever
                                                            Notification Required of Laboratories (CCR §2505)
     ¥      Anthrax & s                                           u Hepatitis B, acute infection, by IgM anti-HBc ¥ Smallpox s
     ¥      Botulism s                                                    antibody test                                              Streptococcus pneumoniae, Invasive 5
     ¥      Brucellosis & s                                        u Hepatitis B surface antigen positivity (specify gender)     u   Syphilis*
     u      Chlamydial infections*                                     Human Immunodeficiency Virus (HIV)*                       u   Tuberculosis &*
     u      Cryptosporidiosis                                      u Listeriosis &                                               ¥   Tularemia & s
     u      Diphtheria &                                           u Malaria &                                                   u   Typhoid and other Salmonella species &
     u      Encephalitis, arboviral                                u Measles (Rubeola), acute infection, by IgM antibody         u   Vibrio species infections &
     ¥      Escherichia coli O157:H7 or Shiga toxin-producing             test or positive viral antigen test                    ¥   Viral Hemorrhagic Fevers (e.g., Crimean- Congo,
               E. coli O157:NM &                                   ¥ Plague, animal or human & s                                        Ebola, Lassa, and Marburg viruses) s
     u      Gonorrhea*                                             u Rabies, animal or human
     u      Hepatitis A, acute infection, by IgM antibody test     u Salmonella &
               or positive viral antigen test
     5 Reportable to the Los Angeles County Department of Health Services.
     & Bacterial isolates and malarial slides must be forwarded to the DHS Public Health Laboratory for confirmation. Health-care providers must still report all such cases separately.
     s Laboratories receiving specimens for the diagnosis of these diseases must immediately contact the California Department of Health Services; for botulism testing call 213-240-7941, for
       bacterial testing call 510-412-3700, for viral testing call 510-307-8575.

                                                                       Non-communicable Diseases or Conditions
            Alzheimer’s Disease and Related Conditions                Disorders Characterized by Lapses of Consciousness          ¤ Pesticide-Related Illnesses (Health and Safety Code,
                                                                                                                                      §105200)
            * For questions regarding the reporting of HIV/AIDS, STDs, or TB, contact their respective programs:
            HIV Epidemiology Program                                   STD Program                                                    TB Control Program
            213-351-8516                                               213-744-3070                                                   213-744-6271 (for reporting) • 213-744-6160 (general)
            www.lapublichealth.org/hiv/index.htm                       www.lapublichealth.org/std/index.htm                           www.lapublichealth.org/tb/index.htm


            To report a case or outbreak of any disease contact the Communicable Disease Reporting System Hotline
Rev. 2/04
                                                 Tel: 888-397-3993 • Fax: 888-397-3778
                  Appendix B
Guide to Immunizations Required for School Entry




             - 56 -
GUIDE TO IMMUNIZATIONS REQUIRED FOR SCHOOL ENTRY


Grades K-12
REFERENCE        Health and Safety Code, Division 105, Part 2, Chapter 1, Sections 120325-120380; California Code of
                 Regulations, Title 17, Division 1, Chapter 4, Subchapter 8, Sections 6000-6075

INSTRUCTIONS     Post this guide on a wall or desktop as a quick reference to help you determine whether children seeking
                 admission to your school meet California's school immunization requirements. If you have any questions, call
                 the Immunization Coordinator at your local health department.

IMMUNIZATION     To enter or transfer into public and private elementary and secondary schools (grades kindergarten through
REQUIREMENTS     12), children under age 18 years must have immunizations as outlined below.

                 VACCINE                                                   REQUIRED DOSES
                 Polio                                                     4 doses at any age, but... 3 doses meet requirement for ages 4–6
                                                                           years if at least one was given on or after the 4th birthday1; 3
                                                                           doses meet requirement for ages 7–17 years if at least one was
                                                                           given on or after the 2nd birthday.1
                 Diphtheria, Tetanus, and Pertussis
                   Age 6 years and under (Pertussis is required)           5 doses at any age, but... 4 doses meet requirements for ages 4–6
                     DTP, DTaP or any combination of DTP or                years if at least one was on or after the 4th birthday.1
                     DTaP with DT (diphtheria and tetanus)
                   Age 7 years and older (Pertussis is not required)       4 doses at any age, but...3 doses meet requirement for ages 7–17
                     Td, DT, or DTP, DTaP or any combination               years if at least one was on or after the 2nd birthday.1 If last dose
                     of these                                              was given before the 2nd birthday, one more (Td) dose is
                                                                           required.
                     7th grade                                             1 dose not required but recommended if more than 5 years have
                      Td booster                                           passed since last DTP, DTaP, DT, or Td dose.

                 Measles, Mumps, Rubella (MMR)
                   Kindergarten                                            2 doses2 both on or after 1st birthday.1
                   7th grade                                               2 doses2 both on or after 1st birthday.1
                   Grades 1–6 and 8–12                                     1 dose must be on or after 1st birthday.1

                 Hepatitis B
                   Kindergarten                                            3 doses at any age
                   7th grade                                               3 doses3 at any age

                 Varicella
                    Kindergarten                                           1 dose4
                    Out-of-state entrants (grades 1–12)                    1 dose for children under 13 years; 2 doses are needed if
                                                                           immunized on or after 13th birthday.4

                 1
                     Receipt of the dose up to (and including) 4 days before the birthday will satisfy the school entry immunization
                     requirement.
                 2
                     Two doses of measles-containing vaccine required. One dose of mumps and rubella-containing vaccine required;
                     mumps vaccine is not required for children 7 years of age and older.
                 3
                     Two doses of the 2-dose hepatitis B vaccine formulation along with provider documentation that the 2-dose hepatitis B vaccine
                     formulation was used for both doses and both doses were received at age 11–15 years will also fulfill this requirement.
                 4
                     Physician-documented varicella (chickenpox) disease history or immunity meets the varicella requirement.

EXEMPTIONS       The law allows (a) parents/guardians to choose an exemption from immunization requirements based on
                 their personal beliefs, and (b) physicians of children to elect medical exemptions. The law does not allow
                 parents/guardians to elect an exemption simply because of inconvenience (a record is lost or incomplete and
                 it is too much trouble to go to a physician or clinic to correct the problem). See the back of the blue California
                 School Immunization Record (PM 286) for instructions and the affidavit to be signed by parents/guardians
                 electing the personal beliefs exemption. For children with medical exemptions, the physician's written state-
                 ment should be stapled to the CSIR. Schools should maintain an up-to-date list of pupils with exemptions, so
                 they can be excluded quickly if an outbreak occurs.

IMM-231 (5/03)                                                                                                   Continued on the next page...
PUPILS NOT              Refer pupils who do not meet these State requirements to their physician or local health department. Give
MEETING                 families a written notice indicating which doses are lacking.
REQUIREMENTS

DOCUMENTATION All children must present an immunization record.
                        What is it? It is a written immunization record, either a personal record with entries made by a physician or
                        clinic, or a school immunization record—the blue California School Immunization Record (PM 286) from a
                        former school or another state's school record. It must include at least the month and year each dose was
                        received; for measles, rubella, and/or mumps vaccine given in the month of the first birthday, month, day,
                        and year are required. A record with check marks instead of dates or saying only "up-to-date," "all require-
                        ments met," or "series complete" is inadequate. Also, parents cannot simply fill out a California School Immu-
                        nization Record from memory but must present a written immunization record. Further, the record must
                        show that all due vaccine doses have been received.
                        Who must present it? All children under age 18 years entering school or transferring between school cam-
                        puses. Kindergarten entrants and entrants from outside the U.S. must present a personal immunization record.
                        (Kindergarten entrants can present a California School Immunization Record from a child care center they
                        previously attended, but this record usually will not include the final "booster" polio and DTP or DTaP
                        vaccine doses or the second measles-containing vaccine dose.) Children transferring from other schools in
                        California or other states must present either a personal immunization record or a state school immunization
                        record. As of July 1, 1999, students entering 7th grade must present a personal immunization record so that
                        the 7th grade requirement immunization dates can be added to the student's school immunization record.
                        When must it be presented? Kindergarten entrants, 7th grade entrants, and entrants from outside the U.S.
                        must present the record at or before entry; no "grace period" of attendance is allowed for these pupils if they
                        do not have a record. Children transferring from other schools in California or other states, or entering at other
                        grade levels may be given up to 30 school days of attendance while waiting for their records to arrive from the
                        previous school.
                        What do schools do with it? School staff must transcribe the immunization dates onto the California
                        School Immunization Record (CSIR or blue card; PM 286), which is available from local health depart-
                        ments. School staff should then review the blue card to determine whether all immunization requirements
                        have been met. The blue card is part of the child's Mandatory Permanent Pupil Record and must be
                        transferred to the child's new school when he/she leaves your school. Although some vaccine doses are not
                        required, please record dates of all doses from the child's personal immunization record s on to PM 286.
                        This information will be valuable should outbreaks of these diseases occur in your school.

CONDITIONAL             Children who lack one or more required vaccine doses that are not currently due may be admitted on
ADMISSIONS              condition that they receive the remaining doses when due, according to the schedule below. If the maximum
                        time interval between doses has passed, the child must be excluded until the next immunization is obtained.

                        VACCINE                                                      TIME INTERVALS BETWEEN DOSES
                        Polio                                                        2nd dose: 6–10 weeks after 1st dose
                                                                                     3rd dose: 6 weeks to 12 months after 2nd dose
                        DTP, DTaP, DT, Td                                            2nd dose: 4–8 weeks after 1st dose
                        Under 7 years (DTP, DTaP, DT)                                3rd dose: 4–8 weeks after 2nd dose
                                                                                     4th dose: 6–12 months after 3rd dose
                        Age 7 years and older (Td)*                                  2nd dose: 4–8 weeks after 1st dose
                                                                                     3rd dose: 6–12 months after 2nd dose
                        MMR                                                          2nd dose: 1–3 months after 1st dose
                        Hepatitis B
                        for 3-dose formulation                                       2nd dose: 1–2 months after 1st dose
                                                                                     3rd dose: 2–6 months after 2nd dose
                                                                                     and at least 4 months after 1st dose
                        for 2-dose formulation
                        (7th grade entry for child 11 through 15 years old)          2nd dose: 4–8 months after 1st dose
                        Varicella
                        (unimmunized out-of-state entrants > 13 years old)           2nd dose: 4 weeks to 3 months after 1st dose

                        * Note: DTP, DTaP, DT doses received previously are counted toward meeting the 3-dose tetanus-diphtheria
                          immunization requirement for this age group.

State of California • Department of Health Services • Immunization Branch • 2151 Berkeley Way • Berkeley, CA 94704 • 510/540-2065 • IMM-231 (5/03)
       Appendix C
LAUSD Policies and Bulletins




  - 59 -
              Infection Control Guidelines For
TITLE:        Preventing The Spread Of Communicable Diseases            ROUTING
                                                                          All Employees
NUMBER:       BUL-1645                                                    All Locations

ISSUER:       Rowena Lagrosa, Deputy Superintendent
              Educational Services
DATE:         July 1, 2005


POLICY:       Preventing the transmission of communicable disease must have the highest
              priority. This bulletin provides guidelines for all District personnel to
              prevent the spread of communicable disease.

MAJOR         This bulletin replaces Bulletin No. Z-1, “Guidelines for Preventing the Spread
CHANGES:      of Communicable Diseases.” The title has been renamed and the content has
              been updated to clarify additional guidelines.

GUIDELINES:   Infected persons may not know they are infected or may not share this
              information with others.

              Infection can be transmitted directly or indirectly, depending on the nature
              of each disease. Direct transmission can occur in such ways as touching,
              droplet spray from sneezing/coughing and close physical contact with body
              fluids, excretions, secretions and discharges. Indirect transmission can
              occur through contaminated food, water and objects such as towels, toys,
              eating utensils, clothing, and diapers.
              Teaching and supervision of preventive measures for the control of
              communicable diseases is a school nursing function. School nurses on an
              individual basis or group sessions will conduct in-service instruction. District
              physicians are available as a resource. Orientation and training must be on
              going and include new personnel.
              Personnel involved in the care of students with medical conditions that
              require specialized physical health care procedures and/or assistance with
              hygiene or feeding will receive annual training in Bloodborne Pathogens and
              Universal Precautions.

              Transmission of disease occurs more readily in very young and/or disabled
              children who require close personal physical care. Strict procedures and
              techniques must be used at all times in all settings. Staff will be trained in
              the required procedures and techniques before care is given.

              A pregnant woman or a woman of child bearing age should consult with their
              private health care provider and be aware that some infectious agents such
              as those causing rubella, herpes simplex, Parvovirus B19, CMV
              (cytomegalovirus) infection, AIDS (Acquired Immune Deficiency
              Syndrome)/HIV (Human Immunodeficiency Virus) infections, syphilis,

                                  - 60 -
toxoplasmosis, hepatitis B & C, and varicella (chickenpox) can be transmitted
to the unborn child.

PROCEDURES AND TECHNIQUES – UNIVERSAL PRECAUTIONS

Special procedures and techniques that are part of an individual’s medical
protocol must be adhered to precisely. The following procedures and
techniques relate to the care of all students.

Hand washing
This is the single most important procedure for preventing the spread of
disease and physically removes microorganisms from the hands.

1. Facilities (running water, preferably warm) and supplies (soap and paper
   towels) for hand washing must be readily accessible to all school students
   and personnel.

2. Food handlers and staff providing physical care to students must have
   fingernails that are kept short and manicured. (No artificial nails and/or
   nail polish). Skin injuries must be covered with a band aide before
   gloving. Consult Employee Health Services (213) 241-6326 regarding any
   chronic nail or skin condition.

3. Hand jewelry except plain wedding bands should not be worn while
   giving physical care to others. Microorganisms may collect in jewelry
   settings.
4. Hands should be washed before food preparation or feeding, after
   removing gloves, cleaning up body fluids, excretions, secretions,
   discharges and after using the toilet.

5. Technique:
   a. Use liquid soap/detergent and running water (preferable warm). Bar
      soap can harbor microorganisms.
   b. Rub all areas of hands and wrists in a circular motion briskly for 10-
      15 seconds.
   c. Clean fingernails. Food handlers are not to wear nail polish/acrylic
      nails and to keep their own nails short for easier cleaning.
   d. Rinse well under running water.
   e. Dry thoroughly with paper towels; turn off water using the paper
      towels; wipe surfaces around sink and then discard the towels.

Use of gloves

1. ALWAYS WEAR SINGLE USE DISPOSABLE GLOVES WHEN CLEANING UP
   BLOOD SPILLS, PERFORMING SPECIALIZED PHYSICAL CARE PROCEDURES
   OR WHEN PERFORMING PERSONAL CARE.

   •   Gloves must be changed after each procedure and between students.
   •   Use gloves one time and then dispose of them in the proper manner.
                   - 61 -
     •    To remove gloves, grasp the cuff and then strip it off by turning it ins
          out and dispose in the trash.
     •    Wash hands with soap and water immediately after removing the glov

2. If hands or other skin areas are contaminated with blood or other body
   fluids when gloves are not used, the skin should be properly washed at
   once with soap and water. The danger is greater when you have open
   lesions or breaks in the skin. (Refer to Post Exposure Procedures,
   Bloodborne Pathogens Exposure Control Plan)

Clean up and disinfection

1. General guidelines

     • Treat all blood and body fluids (urine, feces, purulent discharges,
       vomitus, saliva, mucus, nasal discharge) as though they are
       infectious.
     • All supplies needed are to be made available in all schools, offices,
       and other workplaces.
     • Do not ask students or volunteers to help.
     • Call the plant manager for assistance when appropriate.

2.       Cleaning procedure

     •     Wipe up any possibly infectious materials with paper towels and
           dispose of it in the proper manner. If saw dust is used to clean up
           vomitus, dispose of it in the same manner as any other contaminated
           material.
     •     Clean all contaminated areas and materials first with soap/detergent
           and water. An LAUSD approved commercial product may be used for
           cleaning surfaces that are not contaminated with blood.
     •     FOR WASHABLE SURFACES ALWAYS USE FRESHLY MADE 1:10 BLEACH
           SOLUTION (1 PART BLEACH TO 9 PARTS COLD WATER) WHEN CLEANING
           UP BLOOD.
           a. Make bleach solution daily or as needed.
           b. After cleaning with soap/detergent and water, wipe soiled areas
               and materials with bleach solution.
           c. After the bleach solution has been in contact with the surface
               for 1 minute, rinse the area with water to prevent possible
               corrosion.
           d. Do not place bleach solution directly on large amounts of
               protein matter, such as blood, vomitus, or feces, because
               noxious fumes may be produced.
           e. If a mop, broom, or dust pan is used in the clean up, rinse it in
               the bleach solution.

3.       Contaminated stuffed toys that cannot be placed into commercial washers
         dryers should be disinfected appropriately.


                       - 62 -
Note: Outside playing surfaces contaminated with blood should be washed dow
with soap and water and disinfected.

Disposal of contaminated materials

1. Special handling and disposal procedures are required for regulated medica
   waste. Waste produced from the spill may qualify as regulated medical was
   the waste is:
   a. Liquid or semi-liquid blood or other potentially infectious material
       (OPIM)
   b. Items which release liquid blood or OPIM, if compressed
   c. Items with caked blood or OPIM capable of releasing materials
       during handling

2. Regulated medical waste must be placed in a red biohazard labeled
   plastic bag which is closable; constructed to contain all contents and
   prevent leakage of fluids during handling, storage, transport, or
   shipping. It should be closed prior to removal to prevent spillage or
   protrusion of contents during handling, storage, transport, or shipping.
   ♦ Call Environmental Health and Safety Branch at (213) 241-3199
      for regulated biohazard waste pickup.

3. Place needles, syringes, or lancets in a puncture-proof red ‘sharps’
   container for disposal. Do not bend, break, or recap needles. The
   school nurse will arrange for disposal and replacement of the full
   ‘sharps’ container.

4.    Place soiled clothing and materials possibly contaminated with blood
     or other body fluids in double plastic bags (regular household type
     plastic bag) and seal them before they are returned to the parent or
     disposed of in another manner. Never reuse bags. Do not use cloth
     laundry bags.

5. If a non-disposable smock used to protect clothing is soiled, seal it in a
   double bag for transport. Wash it using bleach according to directions
   on the bottle. A soiled disposable apron must be discarded in the
   proper manner.

6. Used disposable diapers are to be placed in double plastic bags for
   disposal.

7.   Do not store soiled items, even temporarily, in areas used for storage
     of clean linen, clothing or supplies.

Using precautions for CPR Administration and Instruction

A resuscitation mouthpiece shield is recommended to prevent backflow of
fluids from the mouth of a person being given CPR. Manikins used for CPR
instruction must be equipped with individual mouth/nose pieces with
attached air bags for each student.
                    - 63 -
POST EXPOSURE PROCEDURES

A bloodborne pathogen exposure incident is defined as exposure to blood or
body fluid from another person to the mucous membranes of the eye, nose
or mouth and non-intact skin or situations in which mucous membranes or
skin barriers are pierced while during performance of the employee’s
duties. Examples of exposure incidents are: a prick with a used needle or
lancet, human bites which break the skin, blood splashing on the mucous
membranes or blood splattering on skin with cuts or scrapes.

Post Exposure Procedures for Employee

1.    After vigorously washing the exposed area (skin surfaces) with soap and
      water or flush mucous membranes (eyes, nose, or mouth) with water for
      10-15 minutes, NOTIFY YOUR SITE ADMINISTRATOR IMMEDIATELY.

2.    The site Administrator shall follow current Workers Compensation
      procedures and immediately report the incident by telephone to:
      EMPLOYEE HEALTH SERVICES: (213) 241-6326.

3. The site administrator or designee will document the circumstances of
   exposure and give the employee:

      •   Completed Medical Service Letter
      •   Copy of the employee’s job description
      •   Completed Injury/Accident Investigation Report
      •   Employee/Potential Transmitter Medical Evaluation Consent Form
          and send the employee to an Authorized Workers’ Compensation
          Doctor, Clinic or Hospital.

4. All medical information must be forwarded to Employee Health
   Services. Medical information regarding the incident is CONFIDENTIAL
   and must not be included in the site’s written report.

Post Exposure Procedures for Student

1.    After vigorously washing the exposed area (skin surfaces) with soap
     and water (Tincture of green soap is preferred) or flush mucous
     membranes (eyes, nose, or mouth) with water for 10-15 minutes,
     NOTIFY DISTRICT NURSING SERVICES IMMEDIATELY (213) 763-8374.

2.   Notify parent

3.   District Nursing will work with the Los Angeles County Department of
     Health Services and the student’s private health care providers to
     assist students in obtaining appropriate follow-up.
4. Notify District Nursing Services IMMEDIATELY (213) 763-8374 regarding
   any syringes found on or near the schools for instructions. Follow post
                     - 64 -
   exposure procedures for students for any suspected needle sticks or
   sticks from any sharp object that may have stuck more than one person.

SUPPLIES

The following supplies can be ordered from Supplies and Equipment Catalog,
Los Angeles Unified School District. Refer to the current school year for
prices or call (213) 241-3058.

    STOCK                       DESCRIPTION
   NUMBER
 485-74-50670 Absorbent powder or granules to absorb liquid/body
              fluids/spills, and turn it into a clean up solid, 8 oz.
 200-15-10930 Apron, plastic, disposable (100 to pkg.)
 640-15-61103 Bags, disposable for sanitary napkin receptacles (500 to
              pkg.)
 665-24-52120 Bags, polyethylene, 15x9x24” liner for 10 gallon waste
              basket (500 per case)
 485-94-69050 Basket-with step-on lever, steel, white baked enamel
              finish, with hard plastic liner, 8 gallon capacity.
 505-25-38151 Bleach, liquid (2 qt).
 485-42-13000 Disinfectant cleaner (Dispatch) for use on environmental
              surfaces and medical equipment (32 oz trigger spray bottle)
 485-43-13040 Disinfectant cleaner (Dispatch) refill (64 oz)
 485-74-20365 Emergency Clean-Up Kit for bodily fluids and wastes.
 345-64-47330 Glasses-Safety: universal fit, clear lens, with side shields
              (cannot be worn over glasses).
 475-14-70598 Gloves, disposable, vinyl, non-sterile, small size (100 per
              pkg).
 475-41-47079 Gloves, disposable, vinyl, non-sterile, medium size (100 per
              pkg).
 475-41-47119 Gloves, disposable, vinyl, non-sterile, large size (100 per
              pkg).
 435-70-38040 Hand cleaner: germicidal rinse, provides hand wash when
              water is not available (4oz. Bottle)
 345-72-51110 Mask-Filter: disposable, to provide relief from nuisance dust
              (50/ box)
 345-10-51570 Resuscitation Aid, Portex mouthpiece shield for mouth-to-
              mouth resuscitation (disposable)
 435-72-15050 Soap, green tincture, U.S.P. (pt.)
 485-86-80135 Soap, hand, liquid (for use in liquid soap dispenser) (6 to a
              carton – 1 gal each)
 640-75-72295 Towel, paper, hand 250/pkg. (12 pkg/carton)
 640-85-10330 Towel, paper, wiping, disposable, 13”x18”, Teri-Towels, 50
              per bundle (18 bundles per case)




                  - 65 -
AUTHORITY:    This is a policy of the Bloodborne Pathogens Standard, Title 8, California
              Code of Regulation, Section 5193; the Business and Professions Code Section
              2725, Nurse Practice Act; the California Education Code Section 49426,
              Definition of School Nurse; the California Administrative Code, Title 16,
              Consumer Affairs.


RELATED       •   Bloodborne Pathogens Exposure Control Plan, Los Angeles Unified School
RESOURCES:           District, Environmental Health and Safety Branch, January 1997.
                     (Detailed information on the Bloodborne Pathogen Standard)
              •   Communicable Diseases in Schools, Los Angeles Unified School District,
                     Student Health and Human Services Division, 3rd Edition, 2005.
                     (Information regarding individual diseases)
              •   Techniques for Preventing the Spread of Infectious Diseases, California
                     State Department of Education, 1983. (Detailed information on
                     procedures and techniques)

ASSISTANCE:   For assistance or further information please contact Director, Student
              Medical Services, at (213) 763-8342; or Director, District Nursing Services at
              (213) 763-8374.




                                 - 66 -
TITLE:        Reporting Communicable Diseases                              ROUTING
                                                                              All Employees
NUMBER:       BUL-1937                                                        All Locations

ISSUER:       Rowena Lagrosa, Deputy Superintendent
              Educational Services
DATE:         September 1, 2005


POLICY:       “It shall be the duty of anyone in charge of a public or private school, Infant Care
              Center or Children’s Center to report at once to the local Health Office the presence
              or suspected presence of any communicable disease. “CAC, Title 17, Health Section
              2508.

MAJOR         This bulletin replaces Bulletin Z-2 “Reporting Communicable Diseases” dated
CHANGES:      September 4, 2002, Student Health Services Division. The content has been updated
              to reflect current reporting procedures.


GUIDELINES:   I. POLICY

              A. Cooperation with the County of Los Angeles- Department of Public Health.

                CEC 49403: Anything to the contrary notwithstanding, the governing board of any
                school district shall cooperate with the local Health Officer in measures necessary
                for the prevention and control of communicable diseases in school-age children . . .

              B. Notification of Communicable Disease to County of Los Angeles – Department of
                Public Health

                CAC, Title 17, Health Section 2508, Reporting by Schools, indicates it shall be the
                duty of anyone in charge of a public or private school, Infant Care Center or
                Children’s Center to report at once to the local Health Office the presence or
                suspected presence of any communicable disease.

              C. Exclusion of students for communicable disease

                “A pupil while infected with any contagious or infectious disease may not remain in
                any public school.” (California Administrative Code, Title 5, Education, 202.)

                “The governing body of any school district may exclude children . . . . suffering
                from contagious or infectious diseases.” (California Education Code 48211)

                 “The Principal or designee is not required to send prior notice of exclusion to the
                parent/guardian if the student is excluded because: a) he/she is exempt from a
                medical examination but suffers from a contagious disease; b) it is determined that
                the presence of the student would constitute a clear and present danger to the life,
                safety, or health of students or school personnel.

                The parent/guardian has a right to meet with the governing board of the school
                                  - 67 -
  district to review all documents leading to the exclusion of their child and the
  decision to exclude is subject to periodic review.” (California Education code 48213)

II. REPORTING AND NOTIFICATIONS

A. Reporting Communicable Disease by School

  The following figure identifies the appropriate sequence for reporting issues of
  communicable disease in schools. This sequence is recommended to avoid
  unnecessary reporting and to ensure that all appropriate parties are notified in the
  case of serious disease outbreak.

Who Notifies:

  School                         notifies               District Communicable
  Nurse/Administrator                                   Disease Nurse

                                 notifies               Director, District Nursing
   District Communicable                                Services
   Disease Nurse                 notifies               Local District Nursing
                                                        Administrator

                                 notifies               Director, Student Medical
   District Communicable                                Services
   Disease Nurse / Director,     notifies               County Department of Public
   District Nursing Services                            Health
                                 notifies               Other District Offices
                                                        (OEHS)

  In outbreaks of any illness affecting over 10% of students enrolled, the school nurse
  must telephone the office of the Director, District Nursing Services before 4:00
  p.m. on the day of occurrence; the Director, District Nursing Services/CD Nurse
  will in turn notify the Director, Student Medical Services (SMS) and the County
  Department of Public Health. SMS Director may intercede to expedite the process
  by liaising with the County Department of Public Health and/or student’s
  physicians, as deemed necessary.

  Problems related to tuberculosis control in students are reported to District Nursing
  Services, Communicable Disease Nurse at (213) 763-8374. The District Nursing
  Services in turn relates to the Director, Student Medical Services on a real-time
  basis. Problems related to tuberculosis control in employees are referred to
  Employee Health Services, Personnel Division, at (213) 241-6326.

  Reporting requirements in the event of possible food poisoning are addressed in the
  most recent version of Business Services Division, Bulletin No. C-32 (Rev.),
  “Emergency Procedures – Possible Food Borne Illness or Contamination,”
  February 14, 2001.



                     - 68 -
B. Notification of Parents and School Employees

  The school’s responsibility to notify school employees and the parent/guardian of
  children exposed to a communicable disease is based on several factors determined
  by school health personnel such as:
  - Is the disease likely to be spread by school contact?
  - Is the disease serious enough to warrant investigation or prophylactic treatment by
  the student’s private physician or the County Department of Public Health?
  - Is there an action the parents or school employees should or could be taking?

  The Director, Student Medical Services, and the Director, District Nursing Services
  must be consulted before any notification (written or oral) to parent/guardian or
  school employees regarding possible exposure to any communicable disease.

  General guidance on reporting and notification of specific diseases and conditions
  is addressed in the current communicable disease reference guide (Communicable
  Disease In Schools, 3rd ed. 2005). Request for support services for employees is
  available on the request of the administrator. Requests should be made to the
  Director, Student Medical Services (213) 763-8342 or the Director, District Nursing
  Services, (213) 763-8374.

III. SPECIFIC CONDITIONS AND COMMUNICABLE DISEASE

A. Incomplete Immunizations
  In the case of exposure to a vaccine-preventable disease, students with incomplete
  immunization status may be excluded from school at the discretion of the County of
  Los Angeles-Department of Public Health. These may include exposures to
  pertussis, measles, and mumps.


  Refer to the Immunization Guidelines for School Admission BUL-1660.2 (August
  1, 2005)

B. Chickenpox
  Informational letters are to be sent to parent/guardian of all students (Attachment
  A) and to all employees (Attachment B) when chickenpox is first identified in the
  school, for each new semester.

  The treating physician and the parent/guardian of each student for whom
  chickenpox presents a particular hazard (i.e., students with immune system defects,
  or those taking certain medications for leukemia, organ transplants or steroid
  dependent asthma, etc.) are to be notified promptly by telephone whenever school
  exposure to chickenpox occurs.

  Outbreaks of chickenpox, (5 cases during a 3- week period) must be reported to the
  District’s Communicable Disease Nurse (213) 764-8374. The school nurse should
  review the immunization record of each of the children and note the date of
  varicella immunization (if immunized) before reporting the outbreak.



                     - 69 -
C. Head lice
  The informational fact sheet for head lice (Attachment C) should be sent to the
  parents/guardians of students in classrooms with two or more identified cases.
  Students may be excluded for head lice at the end of the school day, but readmitted
  after appropriate treatment is instituted. The presence of nits alone (after treatment)
  is not an absolute indication for exclusion and children should not be absent from
  school for extended periods of time due to this treatable condition.


                                            ###




                      - 70 -
                  LOS ANGELES UNIFIED SCHOOL DISTRICT
                       Student Health and Human Services


       (SAMPLE CHICKENPOX NOTIFICATION LETTER – STUDENTS)
                     (Please use School Letterhead)



Date _____________________

Dear Parent/Guardian:

This letter is to inform you that you child may have been exposed to chickenpox in
the school.

Chickenpox is caused by a virus that leads to an itchy rash. The rash begins with
small, red spots that develop into blisters which become scabs in 4-5 days. The rash
may be the first sign of illness, sometimes coupled with fever. The virus spreads from
person to person by direct contact or through air. Although chickenpox is usually
mild, it may be a serious illness in infants, adults and persons with weak immune
systems, such as those on medications for leukemia or organ transplant.

The chickenpox (varicella) vaccine is effective in preventing the illness or it can help
lessen the disease if given within 3-5 days of exposure. If you have any children or
adults in your home with a weak immune system or who are not immunized against
chickenpox disease, please talk to your physician regarding this exposure. If your
child develops chickenpox, he/she will be excluded from school until the rash has
completely scabbed over and there are no new blisters appearing (usually 6 days after
the start of the rash for healthy children). Please do not let him/her expose other
persons in the neighborhood.

Thank you for your continued cooperation.

Sincerely,


_____________________
Principal

_____________________
School Nurse




                      - 71 -
           DISTRITO ESCOLAR UNIFICADO DE LOS ANGELES
          Oficina de Salud Estudiantil y Servicios Humanos


       (SAMPLE CHICKENPOX NOTIFICATION LETTER – STUDENTS)
                     (Please use School Letterhead)


Fecha _____________________

Estimado padre, madre o tutor:

El motivo de esta carta es informarles que su niño(a) puede haber estado en contacto
con el virus de la varicela en el plantel escolar.

La varicela se contrae a través de un virus y se caracteriza por síntomas tales como
fiebre durante 3 a 4 días y un sarpullido que pica, el cual luego se transforma en
ampollas que se secan y se convierten en costras al cabo de 4 a 5 días. El sarpullido
puede ser la primera señal de la enfermedad, a veces junto con la fiebre. El virus se
transmite de una persona a la otra por contacto directo o a través del aire. A pesar de
que la varicela es generalmente leve, puede ser grave en los bebés, los adultos y las
personas con inmunodeficiencia tales como aquellas que reciben medicamentos para
la leucemia y/o el transplante de órganos, entre otros.

La vacuna contra la varicela es eficaz para prevenir la enfermedad o reducir la
gravedad de la misma si se administra dentro de los 3 a 5 días de haber sido expuesto
a la enfermedad. Si usted tiene niños o adultos en su casa con inmunodeficiencia o
que no están vacunados contra la enfermedad de la varicela, por favor consulte a su
médico en lo que concierne al contacto. Si su niño(a) contrae varicela, será dispensado
por motivos de salud durante 7 días como mínimo. Por favor evite que esté en
contacto con otras personas en su vecindario.

Muchas gracias por su constante colaboración.

Atentamente,


______________________________
Director


_______________________________
Enfermera escolar




                      - 72 -
                  LOS ANGELES UNIFIED SCHOL DISTRICT
                    Student Health and Human Services

    (SAMPLE CHICKENPOX NOTIFICATION LETTER – EMPLOYEES)
                (Please use School Letterhead)


Date ___________________

Dear Employee:

This letter is to inform you of the presence of chickenpox in this school.

Chickenpox is caused by a virus and is characterized by an itchy rash, which then
forms blisters that dry and become scabs in 4-5 days. The rash may be the first sign
of illness, sometimes coupled with fever. Chickenpox develops within 10-21 days
after contact with an infected person and is contagious 1-2 days before the rash
appears and until all blisters have formed scabs. The virus spreads from person to
person by direct contact or through air. Although chickenpox is usually mild, it may
be severe in infants, adults and persons with impaired immune systems such as those
on medications for leukemia and/or organ transplant.

The varicella vaccine is effective in preventing illness or reducing the severity of the
disease if administered within 3-5 days of exposure to the disease. If you have any
children or adults in your home with an impaired immune response or who are not
immunized against chickenpox disease, please consult your physician regarding this
exposure.

Sincerely,


_____________________
Principal



_____________________
School Nurse




                      - 73 -
                 LOS ANGELES UNIFIED SCHOOL DISTRICT
                     Student Health and Human Services
                 (SAMPLE HEAD LICE NOTIFICATION LETTER)
                      (Please use School Letterhead)

Date ____________________

Dear Parent/Guardian:

Infestation with head lice is a common occurrence in the school community. School
nurses check children for lice and exclude those who are infested. Your cooperation
is essential in helping to control this problem. We strongly urge you to check daily
your child’s hair, clothes and the bedding for any signs of lice or nits. If you would
like to consult the school nurse during school hours for screening or checking, please
feel free to call.

Adult lice are tan or grayish-white and the size of a sesame seed. The nits (eggs) are
silver-gray in color and are attached to the hair. They cluster around the hairline at
the back of the neck, around the ears, and across the front and top area of the head.

Infestation by lice causes frequent itching of the scalp. If you suspect that your child
or any family member has been infested by head lice, you may contact your
physician. There are several over-the-counter treatments for head lice available from
your pharmacist. It has been found that it may take more than one treatment to
destroy the infestation. Carefully follow directions given on the package to ensure
proper treatment. Do not use insecticides, gasoline or other home preparations on your
child’s hair. Shaving the hair is not necessary. Children with lice infestation may
return to school after appropriate treatment.

It is recommended that after treatment a special nit removal comb be used to remove
all nits (eggs) from the hair. When using the comb, approximately one inch of hair
should be combed at a time for successful removal of the nits. Removal of nits helps
the school nurse determine whether or not infestation has been properly treated. A
long absence from school is not necessary.

Yours sincerely,

___________________
Principal


___________________            Available on: _____________________________
School Nurse                                             Days




                     - 74 -
   (SAMPLE HEAD LICE NOTIFICATION LETTER)- SPANISH
                 (Please use School Letterhead)

FECHA ______________________

Estimado Padre/Guardián:

La infestatión de piojos en la cabeza ocurre comunmente en las escuelas. Las
enfermeras escolares revisan a los niños en busca de piojos o liendres (huevos) y
excluyen a aquellos que estan infestados. Su cooperación es esencial para ayudar a
controlar este problema.

Le urgimos a revisar diariamente el cabello de sus niños asi como su ropa y ropa de
cama para cualquier senal de piojos o liendres. Si desea consultar a la enfermera
escolar durante horas habiles para consultar o revisar a sus niños, hagalo con toda
confianza.

Las liendres son de color gris-plata y se pegan a los foliculos del cabello. Se
acumulan donde termina el pelo en la parte trasera del cuello, alrededor de las orejas,
y a traves del area frontal y superior de la cabeza.

La infestación de piojos y liendres causa frecuente comezon en la craneo. Si usted
sospecha que su niño/a a cualquier miembro de su familia esta infestado de piojos o
liendres, puede llamar a su medico.

En su farmacia encontrara varios medicamentos contra los piojos que no requieren
receta. Por lo regular se requiere mas de un tratamiento para eliminar la infestación.
Siga con cuidado las instrucciones que aparecen en el paquete.

Cunado las liendres estan vivas se pegan al cabello; cuando muertas, son faciles de
remover. Se recomienda que despues del tratamiento se utilice un peine especial para
remover las liendres del cabello. Se sugiere que cuando use el peine, se peine el
cabello una pulgada a la vez para asi remover con exito las liendres. Ausencia
excesiva de la escuela no es necesaria.

Atentamente.

___________________________
Director(a)

_______________________              Disponible:_________________________
Enfermera Escolar                                       Días




                     - 75 -
AUTHORITY:    A pupil while infected with any contagious or infectious disease may not remain in
              any public school.” (California Administrative Code, Title 5, Education, 202.) “ The
              governing body of any school district may exclude children . . . . suffering from
              contagious or infectious diseases.” (California Education Code 48211)

ASSISTANCE:   For assistance or further information please contact Director, Student Medical
              Services, at (213) 763-8342; or Director, District Nursing Services at (213) 763-8374.




                                   - 76 -
TITLE:        Immunization Guidelines                                      ROUTING
              For School Admission                                           Local District
                                                                              Superintendents
NUMBER:       BUL-1660.2                                                     Administrators
                                                                             School Nurses
ISSUER:       Rowena Lagrosa, Deputy Superintendent                          SAA’s
              Educational Services
DATE:         July 21, 2005

POLICY:       Children must have required immunizations before they can attend school in
              California. Parent/Guardian must present their child’s Immunization Record to
              school staff as proof of immunization prior to admission.

MAJOR         This bulletin replaces Bulletin No. Z-4, “Immunization Guidelines for School
CHANGES:      Admission,” dated June 1, 2001 and Bulletin – 1660.1 of the same dated May 5,
              2005. The content has been updated to reflect current immunization requirements.

GUIDELINES:   REQUIREMENTS FOR SCHOOL ENTRY

              The California Health and Safety Code Section, Division 105, Part 2, Chapter 1,
              Sections 120325-120380 and the California Code of Regulations, Title 17,
              Division 1, Chapter 4, Subchapter 8, Sections 6000-6075 requires the following
              immunizations prior to school entry.

              1. All children entering a California school at pre-school or kindergarten level (or
                 first grade if kindergarten was skipped) require immunization against polio,
                 diphtheria, pertussis, tetanus, measles, mumps, rubella (MMR), hepatitis B and
                 varicella. Students enrolled in a California school before July 1, 2001 are
                 exempt from the varicella requirement. Acceptable varicella documentation
                 includes either the immunization or documentation by a medical provider that
                 the child has had the varicella (chickenpox disease).
              2. In addition to these immunizations, all children below the age of four years, six
                 months, require Haemophilus influenza type B immunization (see Attachment
                 E).
              3. Children seven years of age and older require immunization against polio,
                 diphtheria, tetanus, measles and rubella but are not required to be immunized
                 against pertussis and mumps. All children under 18 years of age from out of
                 state or country who enter a California school for the first time after July 1,
                 2001 require immunization against varicella or acceptable documentation by a
                 physician’s office or clinic that the child has had the varicella (chickenpox)
                 disease.
              4. All children entering or repeating 7th grade must be immunized against
                 Hepatitis B. In addition, these students are required to have two doses of a
                 measles-containing vaccine, at least one of which must be MMR.
              5. Refer to Attachments for specific requirements. These Attachments can be
                 photocopied and used as quick references during registration.

                                   - 77 -
   Exemptions to the immunization requirement are provided for medical or
   personal reasons. (See California Administrative Code, Title 17, Title 17,
   Division 1, Chapter 4, Section 6051.)
   A medical exemption requires a written statement from a licensed physician
   to the effect that the physical condition of the pupil or medical
   circumstances relating to the pupil are such that immunization is not
   indicated. This statement will be attached to the California School
   Immunization Record (CSIR).
   A personal belief exemption is that the immunization(s) is contrary to the
   parent/guardian beliefs. The fact of the personal beliefs exemption shall be
   recorded on the CSIR. The Personal Beliefs Affidavit to be signed by the
   parent or guardian is located on the reverse side of the California School
   Immunization Record (CSIR).
   The California Administrative Code charges the administrator of each
   school with enforcing these immunization requirements. The school nurse
   is available to assist with this responsibility. Since verification of
   immunization must be shown at the time of enrollment, office personnel
   who register new students must be familiar with the requirements.
   Parents/Guardians who do not have a written immunization record for their
   child are to be referred to their physician or the health department to obtain
   the required immunizations and/or written immunization verification for
   their child prior to enrollment. No grace period is allowed.

   For exceptions refer to Bulletin 787: July 1, 2004 “Guidelines for School
   Enrollment of Students in Out of Home Placement,” and Bulletin 1570: Feb.
   8, 2005 “Enrollment of Homeless Children and Youth in Schools.”

FIRST ADMISSION TO SCHOOL

Children entering school for the first time must possess a written immunization
record showing receipt of each required dose of vaccine (see Attachment A).
This record must show the date (at least the month and year) of each dose.
Measles, mumps, rubella (MMR) records must have the month, day, and year if
administered in the month of the first birthday.

Unconditional Admission (K-12). Granted to students who have:

1. Met all immunization requirements.

2. Filed a medical exemption signed by a physician (if the need ceases to exist,
   the student must then meet immunization requirements).

3. A statement of personal belief against immunizations signed by parent or
guardian.

4. Reached 18 years of age or older.

Conditional Admission (Pre-K). Granted to students who have:

1. Completed all age-appropriate immunizations required to date (see
                   - 78 -
    Attachment E). All pre-kindergarten students are admitted conditionally since
    immunization schedules cannot be completed because of age.

2. Haemophilus influenza type B immunization is required for first school
   entry for all students below the age of four years, six months.


Conditional Admission (K-12). Granted to students who have been partially
immunized and succeeding vaccine doses are not yet due (see Attachment E).

Note: If the maximum time interval between doses has already been exceeded,
the next required doses must be received before admission. Remaining required
doses must be received according to the vaccine schedule.

A primary immunization series does not have to be restarted if the interval between
doses is prolonged.

Follow-up of Conditional Admission

Students who have been admitted conditionally must have their immunization
records reviewed every 30 days until all required immunizations are completed.

Parents are to be notified of the date the immunization is due. At this time, they
are also to be notified of the date the student must be excluded if the
immunization is not received within 10 school days. (See sample letter,
Attachment C).

ADMISSION OF TRANSFERRING STUDENTS

Parents or guardians of students transferring within LAUSD must present a
written immunization record prior to enrollment.

LAUSD sending schools should give the parent/guardian a copy of the
California School Immunization Record (CSIR) card to take to the receiving
school.

Receiving schools must request immunization documents directly from the
parent to determine admission status and follow-up as indicated. In unusual
circumstances only, a fax or telephone confirmation that immunizations are
complete to date may be accepted from another LAUSD school for enrollment
purposes, pending receipt of records. Follow-up must be done to assure that
records are received and meet State requirements. Students from other countries
must meet the same requirements as any student entering school for the first
time.

EXCLUSION

A student who was admitted conditionally and fails to obtain the required
immunizations within the time periods specified in Attachment E, Item 3
(Conditional Admission), must be excluded until he/she receives another dose
of each vaccine required at that time.

                     - 79 -
The school administrator is charged by the California Administrative Code and
Board Rule 2313 to exclude a student who does not meet the immunization
requirements within the specified time periods when the following conditions
are met:

1. Parent/Guardian has been informed of public sources of immunization
   administration.

2. Parent/Guardian has been notified at least 10 school days before the date of
   exclusion.

When a student, who has not been completely immunized against a particular
communicable disease, is believed to have been exposed to that disease, the
school administrator must report this information immediately by telephone to
the Director of Student Medical Services.

The Director of Student Medical Services and the County Health Officer will
determine whether the student is at risk of developing the disease, and, if so,
may require exclusion of the student until the completion of the incubation
period and the period of communicability of the disease.

RECORD KEEPING
Written personal immunization record
1. The physician or health agency performing the immunizations must give a
   written record to the student or parent/guardian containing the following
   information:
   • Name of child
   • Birth date of child
   • Type of vaccine(s) administered
   • Date of each immunization (month/year) or
   • Physician’s written indication that the child had the disease or lab report
       indicating that the child has immunity for the disease
   • Name of physician or health agency administering vaccine(s)

2. A variety of written records may be used for this purpose but the
   Immunization Record, printed by the California State Department of Health
   Services, is most often used (see Attachment A).

3. At the time of enrollment, school personnel should make a photocopy of the
   written record. The copy should be kept with the student’s health card. School
   personnel will enter immunization data along with other enrollment information
   in the computer and on the student’s health card.

California School Immunization Record (CSIR) [PM 286 (1/02)]

1. It is mandatory that each new kindergarten student has his/her immunizations
   recorded by school personnel on the California School Immunization Record
   (CSIR) card. This card is part of the student’s permanent record and must be
   filled with the Student’s Cumulative Record file (see Attachment B).

                     - 80 -
                 The CSIR card is also required for each new admission at other grade levels
                 through grade 12 for whom no previous permanent record exists.
                 The requirement for immunization records on a CSIR card refers also to
                 students in the Early Education Program and pre-school age children
                 participating in school-based programs.
                 LAUSD policy requires that school personnel review the CSIR card and
                 certify the accuracy of the document information at school entrance and
                 before entrance to 7th grade.

             2. If a student was admitted conditionally, all immunizations received after the
                conditional admission must be entered on the student’s CSIR card.

             3. When an exemption on the basis of personal beliefs is claimed, the
                parent/guardian must sign the affidavit on the back of the CSIR card.
             4. When a medical exemption is claimed, a signed physician’s statement to this
                effect is required and must be attached to the CSIR card. The following
                information must be included:
                 • Type of immunization(s) from which the student is medically exempt.
                 • Reason(s) immunization(s) cannot be given.
                 • Probable duration of medical condition or circumstances contraindicating the
                   immunization(s).
             Reporting to the State of California Department of Health Services
             1. The administrator of each school must ensure that a report is properly filed
                with District Nursing Services on the immunization status of new kindergarten
                entrants and all students entering or repeating 7th grade at the beginning of
                each school year. A District report will be compiled and sent to the State of
                California Department of Health Services and County of Los Angeles-
                Department of Health Services.
             2. The County of Los Angeles Department of Health Services may request
                additional reports on the immunization status of students at any time.
             3. A few schools will be selected at random annually by the State of California
                Department of Health Services, for monitoring of immunization record
                keeping, reporting, and follow-up procedures.

AUTHORITY:   This is a policy of the California Health and Safety Code Section, the California
             Code of Regulations, the LAUSD Board of Education to require immunizations prior
             to school entry.

RELATED      •   California Immunization Handbook for School and Child Care Programs, 7th
RESOURCES:       Edition, July 2003.
             •   Health and Safety Code, Division 105, Part 2, Chapter 1, Sections 120325-
                 120380 (formerly Sections 3380-3390).
             •   California Code of Regulations, Title 17, Division 1, Chapter 4, Subchapter 8,
                 Sections 6000-6075.
             •   LAUSD Board Rule 2313
                                  - 81 -
ASSISTANCE:   For assistance or further information please contact Director, Student Medical
              Services, at (213) 763-8342; or Director, District Nursing Services at (213) 763-
              8374.




                                   - 82 -
          LOS ANGELES UNIFIED SCHOOL DISTRICT
          Policy Bulletin



 TITLE:            TUBERCULOSIS EXAMINATION REQUIREMENT ROUTING
                   FOR NEW ENTERING STUDENTS              Local District
                                                           Superintendents
 NUMBER:           BUL-1659                               Administrators
                                                          School Nurses
 ISSUER:           Maria Reza, Assistant Superintendent
                   Student Health and Human Services
 DATE:             March 31, 2005


 POLICY:           The guidelines are intended for the School Administrator and staff who enroll
                   students new to California. The certificate must indicate the student is free of
                   tuberculosis (TB).

 MAJOR             This bulletin replaces Bulletin No. Z-21, “Tuberculosis Examination Requirement
 CHANGES:          for New Entering Students,” dated February 1, 1998. The content has been updated
                   to reflect current policy of the District and the Los Angeles County Department of
                   Health Services.

 GUIDELINES:       The following guidelines apply.

                   GENERAL INFORMATION

                   The Director of the Los Angeles County Department of Health Services has
                   implemented provisions of the California Administrative Code, Title 22, Division 2,
                   New Chapter 9 (Articles 1-7, Sections 41301-41329, not consecutive) and is
                   requiring that as of September, 1985, all students new to California schools must
                   present a certificate which shows that they are free of tuberculosis (TB).
                   School administrators of public and private elementary and secondary schools in Los
                   Angeles County are charged with carrying out the requirements of the law.
                   Parents should be advised that their children could obtain the tuberculosis
                   examination and certificate at their local Department of Health Services, medical
                   care provider, or at an appropriate health care facility.
                   For all qualifications of this requirement, no verbal affirmation or parental recall can
                   be accepted.
                   The only approved tuberculosis skin test for meeting this requirement is the Mantoux
                   Skin Test (in which the material is 0.1 cc of PPD containing 5 TU.) A chest x-ray is
                   required if the skin test reaction is 10 mm induration or greater (positive reaction).
                   (Under certain conditions less than 10 mm induration may be considered a positive
                   reaction.)

Policy Bulletin No. 1659
Office of Student Health and
Human Services                             Page 1 of 4                                  March 31, 2005
          LOS ANGELES UNIFIED SCHOOL DISTRICT
          Policy Bulletin



                   FIRST ADMISSION TO SCHOOL
                   Unconditional Admission
                   Students entering at the kindergarten level or first-grade level who never attended
                   kindergarten anywhere must present written evidence of having undergone a
                   satisfactory skin test for tuberculosis within one year prior to school entry.
                   All other students entering at any grade level who never attended any school in
                   California must present documentation that they have had a satisfactory skin test for
                   tuberculosis administered at any previous time.
                   Students entering at any grade level from any other California school (public,
                   private, or parochial) are exempt from the requirement.
                   Students whose parents/guardians do not want them to have the tuberculosis
                   examination on the basis of personal beliefs are exempt from the requirement. The
                   parent/guardian must sign a waiver to this effect on the back of the California State
                   Immunization Record (CSIR) card.
                   Students whose medical practitioners certify in writing that they are undergoing or
                   have already undergone preventive treatment for tuberculosis infection or treatment
                   for tuberculosis disease are exempt from the requirement.
                   Conditional Admission
                   Students may be administered the tuberculosis skin test prior to or at the same time
                   they are immunized against measles, mumps, rubella (MMR), and/or varicella; if,
                   however, the skin test is not given at the same time or before these immunizations
                   are administered, a period of 4 weeks must elapse before the skin test can and will
                   produce valid results. Therefore, students in these circumstances may be admitted
                   conditionally until it is medically possible for them to meet the requirement.
                   Students who have had the tuberculosis skin test administered but who also require a
                   diagnostic chest x-ray have 20 school days in which to comply with the requirement.
                   Students who do not comply after 20 school days may be excluded from school.

                   PRODEDURES FOR ENROLLMENT
                   Review of Tuberculosis Examination Requirement Certificate
                   A certificate signed by a physician or his/her designee, shall be given to the person
                   tested or to his/her parent/guardian by the physician or health agency doing the
                   tuberculosis examination which shall contain the following information:
                    • Name of student
                    • Birth date
                    • Date of administration of Mantoux Skin Test
Policy Bulletin No. 1659
Office of Student Health and
Human Services                            Page 2 of 4                                  March 31, 2005
          LOS ANGELES UNIFIED SCHOOL DISTRICT
          Policy Bulletin



                   • Date of reading of Mantoux Skin Test
                   • Name and title of person reading the skin test
                   • Mantoux Skin Test reaction:
                     Negative: 0 mm induration to 9 mm induration
                     Positive: 10 mm induration or greater
                   • Date of chest x-ray (when skin test reaction is 10 mm induration or greater)
                     (X-ray must be done within 20 school days after the Mantoux Skin Test is read)
                   • A negative chest x-ray or notation that the student is free of communicable TB if
                     the skin test reaction is positive
                   • Name of physician or health agency administering the examination
                   The certificate shall be shown to the appropriate school personnel on admission to
                   school and at any other time when requested.
                   The school nurse or designee shall review the documents submitted by the
                   parent/guardian or student showing compliance with this tuberculosis examination
                   requirement.
                   Recording Data
                   Information regarding the Mantoux Skin Test shall be recorded on the student health
                   record and CSIR card (California State Immunization Record) Form PM 286B
                   (1/02). Include the date of Mantoux Skin test; test reaction; date of chest x-ray (if
                   required) and results or notation that student is free of communicable TB; exemption
                   because of personal belief, medical reasons, or transfer from another California
                   school.
                   For a personal belief exemption, the parent/guardian must sign to this effect on the
                   back of the CSIR card.
                   For a medical exemption, a physician’s statement is required and must be attached to
                   the CSIR card.
                   The tuberculosis examination record shall be transferred with the mandatory
                   permanent student records when the student leaves the school.
                   Record Keeping
                   A list of students conditionally enrolled shall be maintained and the school shall
                   pursue follow-up of these students.
                   A list of all students excluded by reason of noncompliance shall be maintained, and
                   the school shall pursue follow-up of these students.

                   EXCLUSION FROM SCHOOL
                   A student admitted conditionally who fails to obtain the required tuberculosis
Policy Bulletin No. 1659
Office of Student Health and
Human Services                            Page 3 of 4                                  March 31, 2005
          LOS ANGELES UNIFIED SCHOOL DISTRICT
          Policy Bulletin



                   examination within the time periods specified should be excluded from school until
                   the student provides written evidence that he/she has received the required
                   tuberculosis examination.
                   A student who may have tuberculosis shall be reported to District Nursing Services
                   (DNS). DNS will contact the L.A. County Department of Health Services TB
                   Control. The District Health Officer may require the exclusion of the student from
                   school until certified to be free of communicable tuberculosis. Students whose
                   medical practitioners certify in writing that they are undergoing treatment for
                   tuberculosis disease and are free of communicable disease may be admitted.
                   ANNUAL REPORT
                   All school districts and private schools in the County are required to file a report by
                   December 1 of each year on the new admissions from outside California who were
                   enrolled in school by the preceding October 30. The report will include:
                   • Total enrollment of Kindergarten and first time enrollees from outside California
                       by grade and birthplace (U.S./non-U.S.) as of October 30th.
                   • Number of new students by grade and birthplace who were admitted with
                       positive skin test reactions (10mm induration or greater).
                   • Number of new students exempted for personal beliefs.
                   • Number of new students exempted for medical reasons.
                   • Number of new students admitted conditionally.
                   Information for the report will be collected from all schools and compiled by District
                   Nursing Services. The report will then be filed with the Los Angeles County
                   Department of Health Services TB Control.

 AUTHORITY:        This is a policy of the California Administrative Code and the Los Angeles County
                   Department of Health Services.

 RELATED           The Director of the Los Angeles County Department of Health Services has
 RESOURCES:        implemented provisions of the California Administrative Code, Title 22, Division 2,
                   New Chapter 9 (Articles 1-7, Sections 41301- 41329 not consecutive), filed 3/11/82;
                   effective thirtieth day thereafter (Register 82, No. 11).
                   Authority cited: Sections 208 and 3409, Health and Safety Code. Reference:
                   Sections 3400(a) and 3402(a).

 ASSISTANCE:       For assistance or further information please contact Kimberly Uyeda, MD, Director,
                   Student Medical Services, At (213) 763-8342; or Karen Maiorca, Director, District
                   Nursing Services at (213) 763-8374.



Policy Bulletin No. 1659
Office of Student Health and
Human Services                            Page 4 of 4                                  March 31, 2005
FOR YOUR INFORMATION

                                 LOS ANGELES UNIFIED SCHOOL DISTRICT
                            Office of the Deputy Superintendent, Instruction

DISTRIBUTION:       All Schools and Offices                   ROUTING
                                                              Local Superintendents
SUBJECT:           BULLETIN NO. Z-70                          Local District School Support
                   STUDENTS WITH HIV/AIDS                     Directors
                   INFECTION                                  Administrators
                                                              Principals
DATE:              August 1, 2001                             Nurses

DIVISION:          Student Health and Human Services

APPROVED:          MARIA REZA, Assistant Superintendent

For further information regarding students, please call the Director, Student Medical
Services, at (213) 763-8342 or Director, District Nursing Services at (213) 763-8374.

This is a revision of Student Health and Human Services Bulletin No. Z-47, dated
August 4, 1998. This bulletin deals with issues specifically related to Students. For the
bulletin regarding issues concerning employees and staff affected with HIV/AIDS,
please see Bulletin No. Z-69.

The Los Angeles Unified School District shall strive to protect the safety and health of children
and youth in our care as well as their families, our employees, and the general public.

  I.    BACKGROUND

        The subject of school attendance by students with Human Immunodeficiency Virus (HIV)
        infection and Acquired Immunodeficiency Syndrome (AIDS) was addressed at a regular
        meeting of the Board of Education in October 1985. The Board reaffirmed its existing
        policy on medical exclusion and readmission of students with communicable diseases as
        the means to deal with this new health issue. Subsequently, guidelines and procedures
        were developed for students that are consistent with Board policy. Similarly, guidelines
        and procedures were also developed for employees in accordance with Board Rule 1940-
        1955 regarding employee health standards. With the growing number of individuals
        diagnosed to have HIV or AIDS infection it was desirable that the District develop a policy
        and guidelines/procedures relative to students and employees with HIV/AIDS.

        The risk of transmitting HIV is extremely low in school settings when current guidelines
        are followed. The spread of HIV infection in schools has not been documented and the
        fear of its communicability must be allayed by appropriate education of all school
        personnel. Participation in school provides a sense of normalcy for children and




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August 1, 2001

           adolescents with HIV infection and offers opportunities for socialization that are
           important for their development. Several laws such as Individuals with
           Disability Education Act (IDEA), Individual Family Service Plan (IFSP), Section
           504 of the Rehabilitation Act of 1973, and Americans with Disability Act (ADA)
           have been enacted to improve the availability of services in schools to assist
           children with special health care needs to benefit optimally from the
           educational program, and to prohibit discrimination based on disability.

     II.   CONFIDENTIALITY

           Confidentiality is a legal and medical requirement. Students (families) are not
           required to disclose HIV infection status to anyone in the education system.
           Disclosure of the child’s HIV status is done only with the informed consent of
           the parents/legal guardian and age-appropriate consent of the child.

           No information regarding a person’s HIV status will be divulged to any individual
           or organization without a Court Order or informed written, signed, and dated
           consent of the person with HIV infection (or the parent or guardian of a legal
           minor). The written consent must specify the name of the recipient of the
           information and the purpose for disclosure. A growing number of adolescents
           are choosing to exercise their right to be tested for HIV antibodies. Some of
           the youngsters also choose not to inform their parent(s) or guardian(s). In this
           case, if an HIV infected student informs a member of the school staff, that
           school staff person must be sure not to violate the student’s right to keep this
           information confidential. Any disclosure of this information requires the
           student’s specific, informed, written consent.

           Anyone disclosing the results of an HIV antibody test without the written
           authorization of the subject or parent/legal guardian is subject to civil, and in
           some cases criminal penalties, and can be liable for actual damages (California
           Health and Safety Code Sections 120980, 120975).

     III. GENERAL GUIDELINES

           1. School Attendance

              Medical decisions relative to the attendance of students with HIV/AIDS at a school site
              will be based on the best medical knowledge available. HIV infected children should be
              admitted without restriction to childcare facilities and schools and allowed to
              participate in school activities to the extent their health permits. Children and youth
              with HIV/AIDS have the same rights as those without infection to attend school and
              participate in all programs and activities offered by the schools. These




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August 1, 2001

         students should have access to special education and other related services
         in accord with their needs. Continuity of education must be ensured for
        children and adolescents with HIV infection and encompasses the spectrum of
        traditional school, medical day treatment, and home teaching.

      2. HIV Transmission

         HIV is not transmitted through casual contact. The HIV transmission may
         occur as follows:

         a) From a mother with HIV infection to her infant during pregnancy, delivery or breast
            feeding;

         b) Direct inoculation of infected blood or blood-containing tissues, including transfusion,
            transplantation of organ tissues, and use of contaminated needles or penetrating
            injuries with needles or sharp objects contaminated with blood, and

         c) Intimate sexual contact with an infected partner (between sex partners) by contact
            with infected semen, vaginal or cervical secretions, or blood with mucosal surfaces.

      3. Infection Control / Universal Precautions

         In the best interest of health and safety concerns of all students and staff, it is imperative
         that proper measures for preventing the spread of all communicable diseases be practiced
         since the identity of persons with HIV/AIDS or other communicable diseases may not be
         known. All employees are required to consistently follow infection control guidelines in
         all settings and at all times, including playgrounds and school buses. Schools will follow
         the standards promulgated by the U.S. Occupational Health and Safety Administration for
         the prevention of blood-borne pathogens. All school personnel will be trained annually in
         the proper procedures for handling blood and body fluids and universal precautions and
         must strictly adhere to these procedures (See Student Health and Human Services Bulletin
         No. Z-1 (Rev), “Guidelines for Preventing the Spread of Communicable Diseases,” dated
         June 1, 2001).

      4. HIV Management in School Setting

         Students with chronic illnesses, including HIV, may need medications administered during
         the school day. Established policies and procedures must be followed and confidentiality
         must be ensured. Some medications have special requirements. Appropriate access to
         fluid and bathroom privileges should occur in response to physician requests. (See
         student Health and Human Services Bulletin No. Z-19 (Rev), “Assisting Students with
         Prescribed Medication at School,” dated January 7, 1999.




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August 1, 2001


         Irrespective of whether a person has HIV/AIDS, infection control procedures
         and universal precautions should be strictly followed at all times and in all
         situations where there is a potential for contact with blood and/or body
         fluids. This includes playground injuries and classroom incidents involving
         blood or body fluids. In-service on infection control and universal
         precautions is provided annually. Contact District Nursing Services at 213-
         763-8374 for additional information.

         In case of any illness and/or concerns regarding the student’s health during
         school hours, the student should be referred to the school nurse for an
         assessment, who, in turn, may seek medical consultation from Student
         Medical Services. The student’s physician may need to be consulted if
         necessary.

      5. Exposure to Illness

         Parent/legal guardians should be informed when a possible exposure to a
         vaccine- preventable illness such as measles or varicella occurs in the school
         setting. Immuno- compromised students including those with HIV infection
         may need to be removed from school for their protection.

      6. HIV and Athletics

         Athletes with HIV infection should be permitted to participate in competitive sports
         at all levels. The privilege of participating in elective physical education classes,
         extracurricular activities, competitive sports, and recess is not conditioned by a
         person’s HIV status. Physical education programs suitable for the needs of a
         developmentally disabled or chronically ill child, including those with HIV, should be
         available. School authorities will make accommodations to allow students with HIV
         infection to participate in school-sponsored physical activities. Athletes with HIV
         infection interested in participating in contact sports such as wrestling or football
         should be evaluated on a case-by-case basis. The athlete’s physician should be
         involved in the decision regarding participation.

         All employees must consistently adhere to infection control guidelines in locker rooms
         and all play and athletic settings. First aid kits and the infection control guidelines
         must be readily available. Student orientation about safety on the playing field will
         include guidelines for avoiding blood-borne pathogens. The guidelines for avoiding
         blood-borne pathogens should be included at the preseason “Rules Session” held at
         each school. Sports coaches must be aware of the guidelines regarding injuries that
         cause bleeding as indicated in the sports rulebooks.




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August 1, 2001



  IV. ADMISSION / READMISSION OF STUDENTS

          Students should be evaluated on an individual basis to determine health
          risks, benefits, and the most appropriate educational placement. Assistance
          in this evaluation may be obtained from the Director, Student Medical
          Services. The school physician may be requested to assist with the process.
          Open communication should be maintained between the District medical
          personnel and the student’s private physician(s), especially after an absence
          due to illness or obvious health problems.


  V.   DISTRICT/COMMUNITY RESOURCES

       Consultation and inservice on HIV/AIDS will be provided to the District
       personnel as needed.

       For additional information call: Director, Student Medical Services at (213) 763-
        8342; Director, Student Nursing Services at (213) 763-8374

        For community resources, contact Los Angeles Family AIDS Network at (323)
        461-6606 or AIDS Service Center at (626) 441-8495.


References: National Association of State Boards of Education: Someone at School has AIDS

            American Academy of Pediatrics: School Health Policy and Practice

            Nelson’s Textbook of Pediatrics, 16th Edition

            Pediatrics, June 2000, Volume 105, Number 6: Education of children with HIV infection

                                                 ###




                                      - 91 -
FOR YOUR INFORMATION

                                LOS ANGELES UNIFIED SCHOOL DISTRICT
                           Office of the Deputy Superintendent, Instruction

DISTRIBUTION:      All Schools and Offices                        ROUTING
                                                               Local Superintendents
SUBJECT:           BULLETIN NO. Z-69                           Local District School Support
                   EMPLOYEES WITH HIV/AIDS                     Directors
                   INFECTION                                   Administrators
                                                               Principals
DATE:              August 1, 2001                              Nurses

DIVISION:          Employee Health Services / Human resources
                   Student Health and Human Services

APPROVED:          MARIA REZA, Assistant Superintendent

For assistance regarding employees, please call the Medical Director, Employee Health
Services, Personnel Division, at (213) 625-6326.

This is a revision of Student Health and Human Services Bulletin No. Z-47 dated August
4, 1998. This bulletin deals with issues specifically related to employees and staff. For
the bulletin regarding students affected with HIV/AIDS, please see Bulletin No. Z- 70.

The Los Angeles Unified School District shall strive to protect the safety and health of children and
youth in our care as well as their families, our employees, and the general public.

   I.   POLICIES

        With the growing number of persons who have been diagnosed as having AIDS
        (Acquired Immune Deficiency Syndrome) or as having been infected with HIV
        (Human Immunodeficiency Virus), it is desirable that District policies,
        guidelines, and procedures related to employees with HIV/AIDS be stated and
        widely disseminated.

        At a regular meeting of the Board of Education in October 1985, the subject of
        school employees with AIDS was addressed. Subsequently, guidelines and
        procedures were developed for employees that are in accordance with Board
        Rules regarding employee health standards.

        Employees with communicable diseases (which includes HIV/AIDS) are to be
        treated as described in Board Rules 1940 – 1955.




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August 1, 2001


   II.    CONFIDENTIALITY

          Confidentiality is a legal and medical requirement. Only with the written
          permission of the employee may District personnel be informed about the
          employee’s health condition. In any case, dissemination of such information
          will be restricted.

          Under ideal circumstances, a small number of District personnel should be
          made aware of the diagnosis so that they can be active partners in seeing that
          the employee has the best possible care at school. The employee, however,
          has a legal right to withhold this information and to ask their physician(s) to
          do likewise.

          Anyone disclosing the results of an HIV antibody test without the written
          authorization of the subject is subject to civil, and in some cases criminal
          penalties, and can be liable for actual damages (California Health and Safety
          Code Sections 120980, 120975).

   III.   GENERAL GUIDELINES

           A. Medical decisions related to the attendance of employees at
              school/work site will be based on the best medical knowledge available. Current
              resources include guidelines from the Los Angeles Department of Health Services,
              and the American Academy of Pediatrics.

           B. HIV/AIDS can be transmitted only by: (1) intimate sexual contact with
              an infected person, or (2) blood/blood products and organ transplants
              contaminated with the virus introduced into the body (i.e., needles used
              for IV drug use, blood transfusions, blood products), or (3) an infected
              mother to her baby before or during birth and after birth through breast milk.

          C.    It must be assumed that some employees now working are infected with
               HIV/AIDS, with or without their personal knowledge. Since the identity
               of person with HIV/AIDS or other communicable diseases may not be
               known, it is imperative that proper measures for preventing the spread
               of all communicable diseases be practiced. Therefore, education
               regarding HIV/AIDS and the prevention of all communicable disease is of
               prime importance. (See Student Health and Human Services Division,
               Bulletin No.1, “Guidelines for Preventing the Spread of Communicable
               Diseases,” dated July 1, 1996.)

          D.   Employees returning from illness who are unable to perform the duties of
               their position should be referred to Employee Health Services for
               evaluation of their status.

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August 1, 2001


         E.   The employee’s progress should be monitored and open
               communication maintained between District medical personnel and the
               private physician(s) especially after an absence due to illness or obvious
               health problems at the school/work site.

         F.   Physical care of the employee at the school/work site must include
               precautions for the clean up of blood spills/body fluids. (See Student
               Health and Human Services Division, Bulletin No. 1, “Guidelines for
               Preventing the Spread of Communicable Diseases,” dated July 1, 1996).
               In-service by District Health personnel will be provided as needed.

   IV.   ADMISSION/READMISSION OF EMPLOYEES

         A.   Procedures related to employees:

              1) Readmission of employees known to have HIV/AIDS will be considered
                 on the recommendation of their private physician as in the case of any
                 other medical condition, subject to their ability to perform the duties
                 of their position as determined by District staff. Board Rules require
                 that all employees must have the physical, mental, and emotional
                 health needed to perform the core duties of their position and class and
                 be free of any condition or disease detrimental to their own health and
                 safety to the health and safety of other persons.


              2) If readmission or the ability to work is questioned by the employee’s
                  supervisor, the employee will be evaluated by Employee Health Services
                  at (213) 625-6329.

                 Decisions related to an employee’s work assignment will be made in
                 conjunction with the employee’s personal physician and will be based on:

                      a.   Health risks to the employee—physical condition, immune
                           status, stamina, degree of any handicap, potential
                           exposure to communicable diseases, and ability to perform
                           job-related duties in the assigned environment.

                      b.   Possible health risks to others – open lesions, communicable
                           infections (such as tuberculosis, shingles), inimical
                           behavior.




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August 1, 2001



   V.   RESOURCE PERSONNEL

        Consultation and in-service for District personnel regarding HIV/AIDS will be
        provided as needed.

        For employee health issues, call the Medical Director, Employee Health
        Services at (213) 625-6326.



                                              ###




                                     - 95 -
FOR YOUR INFORMATION

                                LOS ANGELES UNIFIED SCHOOL DISTRICT
                   Office of the Senior Deputy Superintendent, Educational Services

DISTRIBUTION:      All Schools and Offices                   ROUTING
                                                             Local District Superintendents
SUBJECT:           BULLETIN NO. Z-72                         Local District School Support
                   BIOTERRORISM PREPAREDNESS                      Directors
                   RESPONSE: HEALTH PERSPECTIVE              Administrators
                                                             Principals
DATE:              September 3, 2002                         Physicians
                                                             Nurses
DIVISION:          Student Health and Human Services

APPROVED:          MARIA REZA, Assistant Superintendent

For further information regarding students, please call the Director, Student Medical
Services, at (213) 763-8342 or Director, District Nursing Services at (213) 763-8374.

I.    PURPOSE

      The Student Medical Services (SMS) and the District Nursing Services (DNS) have been
      working in collaboration with the LAUSD Safety Managers including School Operations
      and the Office of Environmental Health and Safety to coordinate preparedness plans
      and response procedures in the event of biological or chemical terrorist incidents. In
      addition to the Safe School Plan and other Emergency and Disaster Manuals developed
      by these offices, this bulletin is developed to inform the District staff and share with
      them the outline of the bioterrorism preparedness and response plan developed by SMS
      and DNS to address health issues. A separate manual developed by the DHS Emergency
      Medical Services (EMS) has been provided to school physicians and nurses. While these
      plans are being developed, it is important to know that in the event of a terrorist
      incident, the law enforcement and public health agencies are the leaders and we will
      look to them for direction and guidance.

II.   BACKGROUND

      Bioterrorism (BT) is the use of biologic agents such as bacteria, viruses, parasites or
      biological toxins to intentionally produce disease or intoxication in a susceptible
      population to meet terrorist aims. Chemical terrorism (CT) employs certain classes of
      chemical compounds as weapons of mass destruction.

      BT or CT acts may range from dissemination of aerosolized anthrax spores to food
      product contamination, and predicting when and how such an attack might occur is not
      possible. Although paramedics, emergency room (ER) physicians, primary health care
      providers and the local health department will probably be the first to observe and
      report unusual illnesses
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 September 3, 2002

 or injuries, school physicians and nurses may occasionally encounter such cases in
 school settings.

 Early detection of and response to biological or chemical terrorism are crucial, and
 preparedness for terrorist-caused outbreaks and injuries are an essential component of the U.S.
 public health surveillance and response system. Terrorists might use combination of agents.
 The Center for Disease Control (CDC) has developed a list of critical BT and CT agents, the
 details of which are available in the EMS manual provided to school physicians and nurses.


 A. Environment Where Exposure May Have Occurred

    Law enforcement and public health officials work together to investigate the environment
    including envelopes and packages suspected of containing anthrax or other biological
    agents. Powder and other specimens collected from these sources usually are analyzed
    through the Public Health Laboratory Network. As a part of the investigation,
    environmental sampling may be necessary where the exposure may have occurred. Testing
    of the environment is useful for detecting trace amounts of anthrax spores. Specimens
    obtained may include samples of air and/or swabs of material on various surfaces. The law
    enforcement and public health agencies will arrange for processing these samples.

 B. Clean-up of Contaminated Areas

    The U.S. Environmental Protection Agency with the help from other federal agencies and
    departments, including the CDC is responsible for environmental and clean-up issues.
    Federal agencies in conjunction with local and state agencies will determine the best
    approach to the cleanup.

 C. Biological (BT) Agents

    BT agents include bacteria, viruses and toxins among others. Anthrax, Small Pox, Plague,
    Botulinum Toxin are some of the examples of BT agents. BT incidents are more likely to be
    covert because of the delay between exposure and onset of illness, known as the incubation
    period. Thus, BT agents present different challenges, as there is no immediate impact. For
    example, persons are unknowingly exposed and an outbreak is suspected only upon
    recognition of unusual disease clusters or symptoms. BT may also occur as announced events
    in which persons are warned that an exposure has occurred.

 D. The Following are Some of the Examples of Indicators of a BT Attack:

    1. Large numbers of ill persons with similar diseases or syndromes.
    2. Unexplained disease, syndrome or death(s).




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September 3, 2002

          3.   Unusual illness in a population.
          4.   Single case of disease caused by an uncommon agent.
          5.   Multiple unexplained diseases in the same patient.
          6.   Diseases transmitted through aerosol, food or water suggestive of sabotage.

       E. Detection of BT-Related Outbreaks

          The possibility of a BT event should be ruled out with the assistance of the FBI and state
          and local health officials. Rapid response to a BT-related outbreak requires prompt
          identification of its onset. The most critical step in response is early recognition that
          something unusual is occurring. Response to a BT event will require a concerted effort of
          physicians, the health department, health care facilities, laboratories and others to:
          identify the BT agent used; treat affected individuals; prevent additional transmission; and
          bring the situation under control. Primary care providers and emergency room physicians
          will likely be the first medical responders.

        F. Chemical (CT) Agents

          CT agents that might be used by terrorists range from warfare agents to toxic chemicals
          commonly used in industry. Like other substances, CT agents may exist as solids, liquids
          or gases, depending on temperature and pressure. These are six types of chemical agents,
          which include nerve agents, cyanide, vesicants or blistering agents, Mustard and Lewisite.
          CT incidents are more likely to be overt attacks but can also be delivered covertly through
          contaminated food and water. The effects usually are immediate and obvious because CT
          agents are absorbed through inhalation or by absorption through the skin or mucous
          membranes. Such attacks elicit immediate response from police, fire and EMS personnel.
          Biological effects such as eye or skin injury, and injury to lungs and other systemic effects
          can occur following exposure to chemical agents dispersed as solids, liquids or vapor.
          Evacuation and triage are integral to the response along with decontamination and
          medical management.

          In the event of a biological or chemical emergency, the state and local public health
          departments will inform the public about the action(s) they should take. CDC does
          not recommend hoarding antibiotics or buying a facemask.

       G. Radiation Accident

          Radioactive materials are among many kinds of hazardous substances emergency
          responders might have to deal with. Radiation is energy that comes from a source and
          travels through some material or space. Light, heat, etc., are types of radiation.
          Unstable atoms produce ionizing radiation. Unstable atoms are said to be radioactive.
          Alpha, Beta and Gamma are three types of ionizing radiation. Alpha is highly




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September 3, 2002

          penetrating and personal protective equipment can provide some protection. Gamma rays
          are very penetrating and can be produced from radioactive decay and a nuclear weapon
          explosion or reactor accident.

          Regardless of how radiation accident happens, three types of radiation-induced injury can
          occur:

          1. External radiation: when all or part of the body is exposed to penetrating radiation
              from an external source.
          2. Radiation contamination occurs where material containing radioactive material is
              deposited on skin, clothing or other places where it is undesirable. Contamination
              means that radioactive materials in the form of gases, liquids or solids are released
              into the environment and contaminate people externally on skin, internally in lungs,
             gut or wound, or both.
          3. The third type of radiation injury is incorporation of radioactive material, which
              refers to the uptake of radioactive materials by body cells, tissues and organs.

          These injuries can occur along with illness or physical injury and in such instances serious
          medical problems have a priority over concerns about radiation. Law enforcement and
          public health and safety agencies are involved in responding to these emergencies.

III.   ROLES AND RESPONSIBILITIES

       A. Schools

          1. Review disaster and emergency response plans, and assure appropriately
             designated staff is familiar with their content and strategies.
          2. Conduct periodic practice drills and tabletop exercise.
          3. Establish internal and external lines of communication.
          4. Assess emergency call-up plans including activating 911 and assure that these
              are supported with communication and transportation strategies.
          5. Report suspicious cases of illnesses, unusual illness clusters to the CD nurse
             (213) 763-8381, who, in turn, would notify the situation to the Directors of
             Student Medical Services (SMS) and District Nursing Services (DNS).
          6. Employee situations are to be referred to the Medical Director, Employee Health, at
             (213) 241-6326, after logging with the CD nurse (213) 763-8381 at the Central Office.

             The following are some examples of unusual illness/occurrence:

             a) Atypical patterns of hospitalization that are known to you such as sepsis or shock.




                                      - 99 -
BULLETIN NO. Z-72                         -5-                Student Health and Human Services
September 3, 2002


              b) Sudden unexplained deaths in healthy students/employees.
              c) Aberrations in absenteeism due to illness among students/employees.
              d) Emergency transfers for illness/injuries occurring during the routine school day.
              e) In the event of a suspected chemical /biological terrorist incident at a school
                 site, follow the directions of the public health and law enforcement agencies
                 either provided directly to schools or coordinated by your district/school
                 administrative staff.
              f) Coordinate with Crisis teams for debriefing sessions as needed.

              For additional information on school safety plans, please refer to the Safety Grams
              and the Safe School Planning Guide issued by the LAUSD Office of Environmental
              Health and Safety. As of December 3rd, 2001, some of the Safety Grams available are:

              a) Safe Mail Handling Procedures (October, 2001).
              b) Short Terms Actions on Emergency Preparedness for Schools (October, (2001).
              c) Response to Discovery of Suspicious Substances (white powder, etc.)
                 (October, 2001).
              d) Procedures for Responding to Toxic Air Release (November, 2001).

     B. District Health Care Providers – School Physicians and Nurses:

           1. Develop an increased awareness of the ongoing threat of bioterrorism.
           2. Build capacity with knowledge and skills to address emerging BT agents and the
              clinical syndromes.
           3. Be available to the school/administrative staff in assigned district(s). Physicians
              may provide medical consultation, liaise with student/hospital physicians and
              facilitate referrals as indicated.
           4. Become familiar with important emergency phone numbers and hospital referral
              sites.
           5. Report suspicious cases to the SMS/CD office.
           6. Know the school disaster and safety/emergency plans and participate in school
              disaster/emergency drills.
           7. Clinicians (physicians/nurse practitioners) are not to prescribe prophylactic antibiotics
              unless otherwise directed by the Public Health Department via the SMS director.

      C.      District Nursing Services (DNS):

           1. Work closely with the Director of Student Medical Services (DSMS) in monitoring the
              disease patterns in schools by:




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 September 3, 2002

              a) Forwarding a weekly update on the infectious disease data compiled for cases
                 reported from schools.
              b) Apprising the DSMS of sentinel conditions and outbreaks on a real-time basis and
                 with timely follow-ups. Examples of sentinel diseases are TB, meningitis and other
                 highly contagious conditions.
              c) Notifying DSMS of any unusual clusters, atypical illnesses, increase in
                 number of students with gastroenteritis, flu, rash with fever, etc.
              d) Monitoring communicable diseases, outbreaks and unusual illnesses in
                 the District.

           2. Conduct BT-related disease outbreak investigation in consultation with
              DHS, DSMS and DDNS.

        D. Student Medical Services:

           1. Coordinate educational activities for the District physician and nursing staff.
           2. Assist DHS with public educational activities when requested.
           3. As necessary, assist DHS with surveillance activities for cases identified in the
              District.
           4. Consult with/report to DHS any unusual disease events in the District when such
              reports are received from schools/CD nurses.
           5. Monitor with DNS in the event of any the disease patterns in the District.
           6. When requested by DHS, assist with monitoring of school absenteeism due to
              illnesses.
           7. Work closely with the District’s safety managers to coordinate activities.
           8. Interface with the Office of Environmental Health and Safety (OEHS) to identify
              and address routine and atypical environmental health concerns; consult with
              DHS as necessary.
           9. Communicate with student physicians/families as necessary.


      E. Role of School District in a Community-Wide Effort


         See Appendix A for possible roles of District staff and facilities as a part of
         community-wide effort in the event of a terrorist incident.

         For individual questions/instructions, please see Appendix B adapted from the Los Angeles
         County Health Department’s Bioterrorism Preparedness and Response brochure.

IV.   HELPING CHILDREN, TEENS AND THEIR FAMILIES

      A. Be honest and give age-appropriate and developmentally appropriate explanations about the
         traumatic event. Recognize that a tragic event could elevate psychological or physical
         symptoms such as headaches, abdominal pain or chest pain in children and


                                       - 101 -
BULLETIN NO. Z-72                       -7-               Student Health and Human Services
September 3, 2002

       teens, who are already depressed and anxious. Anger can be a sign of anxiety in children
       and teens. It is not unusual to see emerging post-traumatic mental/behavioral
       problems among students impacting their learning. Some children, teens and their families
       may need professional help and counseling. The following resources could be useful for
       additional information:

       1. American Academy of Child and Adolescent Psychiatry: www.aacap.org
          Information on “Posttraumatic Stress Disorder”, “Children and Grief”, “Helping Children
          After a Disaster”, etc., are available in English and Spanish.
       2. National Association of School Psychologists: www.nasponline.org
          “Tips for Parents and Teachers on Helping Children Cope in Unsettling Times”
       3. American Red Cross: www.redcross.org
          Counseling information and brochures in several languages.

    B. Additional Resource:


       For individuals seeking emotional or mental health assistance: Mental Health 24-Hour Crisis
       Hotline 1-800-854-7771

       For individuals exposed to suspicious material (mail, powder, etc.: Refer to local law
       enforcement. If in school, follow the District procedure.

       For latest information on bioterrorism: Bioterrorism and Preparedness Response:
       www.labt.org

       For health alerts, advisories and updates on bioterrorism: CDC, Public Health Emergency
       Preparedness and Response: www.bt.cdc.gov

    C. Reference:

         The following reference materials were used for developing this bulletin:

         MMWR, April 21, 2000/Vol.49/No. RR-4
         United States Army Medical Research Institute of Chemical Defense
         APIC Bioterrorism Task Force Document

        www.orau.gov                          www.nea.org
        www.bt.cdc.gov                        www.naspweb.org
       www.labt.org                           www.aap.org
        ww.childrennow.org                    www.aaets.org
        ww.childrensdefensefund.org           www.fema.gov


                                                    ###
                                   - 102 -
               LOS ANGELES UNIFIED SCHOOL DISTRICT
                REFERENCE GUIDE


                                                                                   ROUTING
                                                                                   Local District Superintendents
TITLE:                          WEST NILE VIRUS PRECAUTIONS                        Local District Operations
                                                                                       Coordinators
NUMBER:                         REF-1304                                           Safety/Attendance Coordinators
                                                                                   Local District Facilities Directors
ISSUER:                         Office of Environmental Health and Safety,         Principals
                                                                                   Plant Managers
                                Maintenance and Operations, and Student            Nursing Administrators
                                Medical Services                                   Student Medical Services
                                                                                   Employee Health Services
DATE:                           September 16, 2004

PURPOSE:                        The purpose of this Reference Guide is to describe the responsibilities and
                                specific actions of District offices in minimizing the risk of exposure to West
                                Nile Virus (WNV) among LAUSD students and staff.

MAJOR                           None
CHANGES:

INSTRUCTIONS:                   The County Department of Health Services reports that the WNV is spread to
                                humans most commonly through the bite of a mosquito which has been
                                infected with the virus. Most mosquitoes do not carry the virus and the risk of
                                serious human illness is extremely low, with more than 80% of those exposed
                                to the virus experiencing no symptoms at all. Those that develop symptoms
                                may experience headaches, fever, body aches, skin rash or swollen lymph
                                glands within 3 – 14 days after a bite from an infected mosquito and generally
                                those symptoms last a few days. With the rare exception of transmission via
                                blood donation or organ transplantation, individuals infected with WNV are
                                not contagious to others.

                                The elderly are at greatest risk for developing severe disease such as
                                encephalitis and meningitis. The symptoms of severe infection include
                                headache, high fever, stupor, disorientation, coma, tremors, convulsions,
                                muscle weakness and paralysis. Less than 1% of those infected with WNV
                                will develop severe disease. Among those who have developed a severe
                                illness with WNV, between 3% and 15% have died and most of the deaths
                                have occurred among the elderly.

                                It is imperative that every effort is made to eliminate or avoid conditions
                                conducive to mosquito breeding on school sites. These conditions include
                                standing pools of water on athletic fields, in tree wells, or elsewhere on the
                                grounds, small amounts of water in birdbaths, old tires, jars, cans, roof drains,
                                air conditioning pans, etc. Mosquitoes will breed in as little as ½ inch of non-
                                flowing water.




Reference Guide No. REF -1304                          Page 1 of 4                                   September 16, 2004
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                                Following are the responsibilities and actions of school and central office
                                personnel in reducing the risk of exposure to WNV among students and staff.

                                Site Administrator

                                The Site Administrator has overall responsibility for ensuring that site
                                conditions do not encourage mosquito breeding, and that staff report any
                                associated problems to M&O. Specifically, the Site Administrator will direct
                                the Plant Manager to fully implement those actions specified under “Plant
                                Manager” below, and will:

                                     Ensure staff keep unscreened doors/windows closed and report any broken
                                     screens, windows and doors to the Plant Manager.
                                     Encourage students and staff to stay indoors at dawn, dusk and in the early
                                     morning or evening, and to wear long-sleeved shirts and long pants when
                                     outdoors, and to use non-aerosol insect repellant before and after school in
                                     accordance with label instructions (staff should be informed that if
                                     repellant is used by students in a manner inconsistent with label
                                     instructions, it should be confiscated until retrieved by a parent or
                                     guardian).
                                     Report any health complaints potentially associated with mosquito
                                     spraying by County or City agencies to Student Medical Services at (213)
                                     763-8342 or District Nursing Services at (213) 763-8374.
                                     Advise staff against the application of pesticides on campus (only the
                                     District’s Pest Management Technicians are authorized to apply pesticides
                                     on campus in accordance with the Integrated Pest Management Policy).


                                Plant Manager

                                The Plant Manager is responsible for inspecting the school to ensure site
                                conditions do not encourage mosquito breeding and taking necessary
                                corrective action, such as reporting the problem to M&O. Specifically, the
                                Plant Manager is responsible for:

                                     Inspecting the site frequently to report any non-flowing water problems,
                                     such as plumbing leaks, air conditioner condensation, standing or stagnant
                                     water to M&O Trouble Call Desk at (213) 745-1600.
                                     Using proper procedures to dispose of dead birds or squirrels using gloves
                                     or bag to pick up the carcass and double bagging the carcass (see OEHS
                                     Safety Alert No. 04-07, West Nile Virus Precautions) and reporting dead
                                     birds or squirrels immediately to the California Department of Health
                                     Services (CDHS) WNV Hotline at (877) 968-2473




Reference Guide No. REF -1304                          Page 2 of 4                                 September 16, 2004
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               LOS ANGELES UNIFIED SCHOOL DISTRICT
                REFERENCE GUIDE


                                     Ensuring grounds and tree wells are not being over-watered resulting in
                                     standing pools of water. If so, water schedules should be adjusted and/or a
                                     trouble call should be placed to have low areas filled in.
                                     Ensuring water runoff does not pool when hosing down lunch and other
                                     areas. A trouble call may need to be made to request fill for low areas.
                                     Ensuring that gutters, roof drains and underground drains are free of
                                     obstructions.
                                     Reporting any broken screens, windows and doors to the M&O Trouble
                                     Call Desk.
                                     Emptying or changing water at least every four days in birdbaths,
                                     fountains, and other decorative containers with standing pools of water.
                                     Requesting an inspection by the District’s Integrated Pest Management
                                     Coordinator at (213) 745-1427 if there is a pond, spring, fountain, bird
                                     bath, etc., to ensure that there are no mosquito breeding conditions.
                                     Notifying the Greater Los Angeles County Vector Control District at (562)
                                     944-9656 if potential breeding grounds (e.g., abandoned pools, drainage
                                     channels or street gutters with standing water) are observed on adjacent
                                     non-District properties.

                                Maintenance and Operations (M&O) Branch

                                The Maintenance and Operations Branch is responsible for corrective actions
                                to address mosquito breeding concerns identified by school staff.
                                Specifically, M&O is responsible for:

                                     Repairing broken screens or doors to prevent mosquitoes from entering
                                     occupied areas.
                                     Utilizing integrated pest management methodologies to avoid or eradicate
                                     mosquitoes and breeding conditions.
                                     Inspecting suspect ponds or standing water and implementing necessary
                                     action to minimize mosquito breeding.

                                Office of Environmental Health and Safety (OEHS)

                                The Office of Environmental Health and Safety (OEHS) is responsible for
                                conducting periodic inspections to assess compliance with applicable health
                                and safety standards. Specifically OEHS is responsible for:

                                     Inspecting school sites, noting conditions that may promote mosquito
                                     breeding, and reporting such conditions to the Site Administrator and
                                     M&O Trouble Call Desk at (213) 745-1600 while conducting routine
                                     inspections.
                                     Reporting any broken screens or doors to the Site Administrator and M&O
                                     Trouble Call Desk.


Reference Guide No. REF -1304                          Page 3 of 4                                September 16, 2004
Office of Environmental Health and Safety
               LOS ANGELES UNIFIED SCHOOL DISTRICT
                REFERENCE GUIDE


                                     Responding to complaints or questions regarding WNV, and if necessary,
                                     referring these to the appropriate office or regulatory agency for follow-up
                                     action

                                District Nursing Services

                                District Nursing Services is responsible for tracking WNV incidents involving
                                District students and staff and reporting these to the appropriate agencies.
                                Specifically, District Nursing Services is responsible for:

                                     Responding to medical inquiries regarding WNV and if necessary
                                     referring these to Student Medical Services or appropriate agency for
                                     follow-up action.
                                     Serving as liaison between the District and County Department of Health
                                     Services.
                                     Referring to the Integrated Pest Management Coordinator at (213) 745-
                                     1427 issues associated with pesticide spraying by City or County agencies.
                                     The Integrated Pest Management Coordinator may in turn contact agency
                                     representatives.



RELATED                         OEHS Safety Alert No. 04-07, West Nile Virus Precautions may be
RESOURCES:                      downloaded from http://www.lausd-oehs.org.

                                “LAUSD Pest of the Month Program Publications Nos. 15, 17, and 18, West
                                Nile Virus Information.” These publications have been distributed to all Plant
                                Managers. They are also available through the IPM Program Coordinator at
                                (213) 745-1427.

                                County of Los Angeles Department of Health Services West Nile Virus
                                Website at http://www.lapublichealth/org/acd/index.htm/

                                Other helpful websites include: http://www.cdc.gov/ncidod/dvbid/westnile/
                                index.htm; http://www.westnile.ca.gov/; http://www.wipeoutestnile.com;
                                http://vector.ucdavis.edu/arbo.html


ASSISTANCE:                     Inquiries may be directed to OEHS at (213) 241-3199 or Pest Management at
                                (213) 745-1435. Medical questions may be directed to Student Medical
                                Services at (213) 763-8342 or District Nursing Services at (213) 763-8374.




Reference Guide No. REF -1304                          Page 4 of 4                                 September 16, 2004
Office of Environmental Health and Safety

				
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