SANITATION CLASSIFICATION, HANDWASHING
AND DIAPER CHANGING
3 CEU credits
Welcome to Module 1, the first of four On-Line Training
Modules sponsored by the Guilford County Department of Public
Health, Children’s Environmental Health Section. Before we begin,
make sure that you have read the Welcome Page for specific
instructions on where to mail your test once you have finished the
module. If you haven’t printed your test yet go back to the Module
selection page and select Module One Test. You will be answering
these questions as you read through the following material.
Sanitation inspections are required every six months in accordance
with our General Statute 15A NCAC 18A.2800. After our inspection
a sanitation card is posted (see below).
Classifications are as follows:
Superior 0-15 demerits
(no 6 point demerits)
Approved 16-30 demerits
(no 6 point demerits)
Provisional 31-45 demerits or any
6 point demerit
Disapproved 46 or more
demerits, or failure to improve a
Children’s Environmental Health does not license a Childcare facility.
The Division of Child Development is the licensing agent.
Hand washing is the single most important step in the prevention
and spread of diseases. Studies have shown that proper hand
washing reduces the spread of germs and bacteria, which keeps the
staff and children healthier. In the January 2006, revision of the
Rules Governing The Sanitation Of Child Care Facilities a total of 10
demerits may be deducted for hand washing during an inspection.
Five demerits for improper procedure and an additional 5 demerits
for not washing hands at the proper times. We will review the proper
procedures and times to wash hand a little later on. First, we are
going to cover what harmful pathogens can be spread when hands
are not washed properly.
Ever wonder why your Childcare Nurses, Consultants or
Environmental Health Specialists are so hung up on hand washing?
We know what may be lurking on those hands, under those
fingernails and behind those rings that you can’t see and we are
There are several types of bacteria, viruses and/or parasites that may
be transferred through improper or no hand washing. These are most
often referred to as pathogens. For this training, we will be covering
the ones most common to a childcare setting. There are four modes
of transmission in which pathogens can be passed from one person
to another. They are;
1) Respiratory or airborne (like coughing or sneezing)
2) Fecal-Oral Contact (contaminated hand with human waste)
3) Contact (touching)
4) Contact with infected blood and secretions ( like urine or
The most common form of transmission in a childcare setting is by
fecal-oral contact. Which means human waste is on your hands and
they are not properly washed. The contaminated hands then touch
someone else, a toy or food which is then ingested by the other
person. The most common illnesses that are transferred through
Fecal-oral contact are, E. Coli 0157, Hand-Foot and Mouth disease,
Salmonella, Shigellosis and Rotavirus. Any of these sound familiar?
We are going to look at Shigellosis and Rotavirus in detail because
these harmful pathogens are most common in childcare settings in
the United States.
Shigella or Shigellosis was discovered over 100 years ago by a Japenese
scientist named Shiga. This is where the name Shigellosis comes from.
There are four different types of species, but the symptoms are all the
same. The onset of symptoms can occur within one day to one week
of exposure and include stomach cramps, diarrhea, vomiting, fever
and headache. The illness usually lasts between 5-7 days. You can
carry the disease and not even know it. This is often referred to as
being asymptomatic which means that you have no symptoms.
Shigellosis is transmitted strictly by human feces and the infective dose
is between 10-100 organisms. That would barely cover the tip of a
ball point pen!
This is a picture of a single Shigella bacteria as
shown under an electron microscope magnified
This is a cluster of Shigella bacteria
under an electron microscope
magnified 1,000 times.
Each of the little purple rods
indicates one organism.
There are enough organisms in this
picture to be an infective dose.
Remember that it only takes about
10-100 organisms to give someone
According to the CDC there are about 14,000 confirmed cases of
Shigellosis every year in the Unites States. Confirmation is obtained
from collecting a stool sample (fecal) and analyzing it for Shigellosis.
Remember you can not see this harmful pathogen and it takes such a
small amount to infect either you or another child. That’s why hand
washing is so important!
The name for Rotavirus comes from the shape of the virus. It has a
wheel like appearance and the name comes from the latin word rota
meaning wheel. According to the CDC almost all children are
infected with Rotavirus during the first few years of life. They
estimate that 20-70 deaths per year are due to Rotavirus.
The symptoms include severe fever, diarrhea, vomiting all leading to
severe dehydration. The primary way this virus is spread is through
fecal-oral contact. Do these symptoms sound familiar? They are not
that different from Shigellosis, except that Rotavirus can not be treated
with antibiotics. Rotavirus has a seasonal pattern with annual
outbreaks occurring between November through May.
This is a computer generated picture of a
Rotovirus. Remember that this is a virus.
Viruses can not be treated with
antibiotics. The only way to be sure it is a
virus is to have the child or caregiver see
a doctor and have a stool sample
Remember that you can’t see this virus so it very important to be
aware of the symptoms. Early detection is critical with rotavirus
because it can lead to severe dehydration and hospitalization.
Now that you know about two of the main pathogens found in
childcare centers you know why hand washing is so very important!
We have learned why it’s important to
wash hands. Lets review the steps for
proper hand washing along with the
proper times for staff and for children to
wash their hands. Hand wash signs are
required to be posted at all hand wash
Steps for Proper Handwashing
1) using liquid soap and tempered water (80-110F);
2) rub hands vigorously with soap and tempered water for 15
3) wash all surfaces of hands, including the backs of hands, palms,
wrists, under fingernails and between fingers;
4) rinse well for ten seconds;
5) dry hands with a paper towel or other hand drying device; and
6) turn off faucet with paper towel or other method without
Remember that with the revised rules not following the proper
procedures may be a 5 demerit deduction on your inspection.
Finally, lets review when hand washing is required according the
Employees should wash hands:
¨ upon reporting for work;
¨ before and after handling food;
¨ before bottle feeding or serving food to children;
¨ before handling clean utensils or equipment;
¨ after going to the bathroom or handling any bodily fluids (e.g.
saliva, nasal discharge, vomitus, feces, urine, blood, etc);
¨ after diaper changing;
¨ after handling soiled items like garbage, clothes and mops;
¨ after being outdoors;
¨ after handling animals or animal cages;
¨ after removing gloves.
Children shall wash hands:
¨ upon arrival at the center;
¨ after diaper changing or visit to the toilet;
¨ before eating meals or snacks;
¨ before and after water play;
¨ after outdoor activity;
¨ after handling animals or animal cages.
Hand sanitizers may be used in place of hand washing but, only
outdoors when handwashing facilities are not available and not for
diapering. Children must wash hands upon returning inside.
When should you wear gloves? If your wearing fingernail polish and
handling food, and during diaper changing if your hands have cuts,
sores, or are badly chapped hands.
Not washing hands at the proper time is also a 5 demerit deduction.
Therefore, a total of 10 demerits may be taken during your inspection
if proper procedures are not followed and hands are not washed at
the proper times.
Be extra careful in your classrooms and make sure that everyone is
following the rules when it comes to hand washing!
The next part of this module is diaper changing. There have been a
few changes to diaper changing and what is needed in the diaper
changing area under the new rule revision.
The diaper changing surface is one of the most
contaminated surfaces in a childcare classroom.
All the pathogens that we mentioned earlier
that can be transmitted by fecal-oral contact
may be on that diaper changing surface!
Proper diaper changing procedures and disinfecting is extremely
important on the highly contaminated surface.
First we are going to talk about what is required at the diaper
changing area, then we will talk about the proper strength of
disinfecting solution, and finally we will review the proper diaper
Each center will need a designated area for diaper changing that has a
hand sink either next to or close by. The hand sink should be used
for washing caregiver hands and/or children’s hands that are
involved with the diaper changing process. Requirements are a little
bit different for centers than for centers in a residence.
The diapering surface must be smooth, intact and a non absorbent
surface. Don’t store anything on the diaper changing surface. That
means no boxes of wipes, gloves, diapers, toys, or used as a work
surface. The only items allowed are the supplies you need at the time
you are going to change a child. During our inspection 4 demerits
may be taken if we see anything stored on the diapering surface or
the changing pad/surface is in disrepair.
The diaper changing surface should be
cleaned with soapy water, wiped dry, and
then a disinfecting solution applied. The solution should be between
500-800 ppm of chlorine bleach (1/4 cup bleach per gallon water).
Make sure the bottle is labeled and stored out of reach (5ft. or
higher). If the diapering surface is not properly cleaned and
disinfected a deduction of 6 demerits may be taken causing the center
to be classified as provisional. When a center recieves a provisional
classification a re-inspection is required after 7 days.
Proper Diaper Changing Procedures.
1) gather supplies before placing child on diapering surface;
2) put on gloves (if needed or required by center);
3) remove clothes and soiled diaper, using a moist towelette or
moistened paper towel wipe front to back to clean child;
4) dispose of gloves if used, soiled towelettes and diaper in plastic-
lined, covered receptacle;
5) wipe hands with disposable towelette or moistened paper towel;
6) slide a clean diaper under child, apply any diapering products
using facial or toilet tissue, discard tissue in plastic-lined,
7) fasten diaper and redress child;
8) wash child’s hands following proper hand washing procedures,
or if child is unable to support their head, clean the childs
hands with a disposable towelette or moistened paper towel,
then dry their hands and return child to a supervised area;
9) spray entire diapering surface with soapy water and wipe clean,
using disposable paper towels;
10) spray entire surface with approved disinfecting solution and
allow to remain on surface for a minimum of two minutes, or
11) wash hands following proper hand washing procedures even if
disposable gloves are used.
Make sure that there are diaper changing posters and handwashing
signs posted at the diaper changing area. If you need any please
contact your consultant or environmental health specialists.
We talked about sanitation classifications and the amount of
deductions for each classification. Next, we addressed handwashing
and the importance of washing hands at the proper times and in the
proper manner. We also learned about two very harmful pathogens,
Shigella, and Rotavirus and what can spread these pathogens. Finally we
reviewed diaper changing and the proper procedures.
This ends Module 1. You might want to make a copy of your test
and mail us the original. Be sure to include a self addressed
stamped envelope in with your test so we can mail you your
certificate. Good Luck!
We appreciate your participation. We welcome your comments and
feedback either by email or filling out the bottom section of your test.