Summary of Results

A literature search for similar projects found one document, by Richardson et al. (2001), published in the Pediatric Infectious Disease Journal that had produced evidenced based exclusion policies for schools and preschools for a variety of illnesses.

A total of 25 other documents containing guidelines (evidence based and/or group consensus) were also identified. There are guidelines from other countries and from American medical journals, and their topics vary as to exclusion groups addressed.

Other categories of literature reviewed included journals: 43 reviews of evidence based literature, 101 reviews of outbreaks and their epidemiology, and one (1) editorial. 

Comments related to exclusion of persons in SOS were quoted in the summary documents as previously stated. Each comment was then rated for strength and quality adapted from the system used in the article by Guerrant et al (2001). A summary table (Table 1) located at the end of the methodology section provides the operational definitions for evidence strength and data quality.

The following summarizes the quantity and scope of evidence for each of the diseases under consideration:

Amebiasis Click Here for More Details >>

  • Grade I recommendations were unavailable from the literature reviewed.
  • Grade II recommendations were unavailable from the literature reviewed.
  • Grade III-A recommendations for exclusion of symptomatic individuals from SOS (preventive measures #1, 2, 5 and 7 under symptomatic heading).
  • Grade III-A evidence recommends excluding symptomatic children from day care settings (preventive measures 3 and 4 under symptomatic heading).
  • Grade III-A sources indicate asymptomatic individuals are a source of transmission (preventive measures 3 and 4 under asymptomatic heading).
  • Grade III-A recommendation support the treatment of asymptomatic carriers to prevent transmission (preventive measures 1 and 3 under asymptomatic heading).
  • Grade III-A recommendation for screening household contacts of a case (see preventive measures # 7 and 8 under symptomatic heading).
  • California Code of Regulations (CCR) CCR §2550

Campylobacter Click Here for More Details >>

  • Grade I recommendations were unavailable from the literature reviewed.
  • Grade II recommendations were unavailable from the literature reviewed.
  • Multiple sources provide Grade III-A recommendation for exclusion of all symptomatic workers in SOS with active Campylobacter infection (preventive measures #1, 8, 9, 11 under symptomatic heading). Recommendations for return to work range from when asymptomatic to 48 hours post symptom resolution (preventive measures #1, 5, 6, 8, 9, 11 under symptomatic heading).
  • Outbreaks are linked with infected food handlers (preventive measures #8 under symptomatic heading) but in general sources indicate person-to-person transmission is unusual (see preventive measures 3 and 7 under symptomatic heading).
  • Two Grade III sources recommend exclusion of children younger than five years old from day care until diarrhea resolves to 48 hours post treatment of diarrhea with antibiotics (preventive measures #2 and 10 under symptomatic heading).
  • Asymptomatic excretion of Campylobacter is unusual and not seen as risk in SOS as long as good hand hygiene is practiced Grade III-A (preventive measure #1, 2 and 3 under asymptomatic heading)
  • One grade III source make a recommendation for clearance testing of stool however according to all other evidence collected on disease the strength of that recommendation is D.

Shiga Toxin Producing Escherichia Coli Click Here for More Details >>

  • Grade I recommendations were unavailable from the literature reviewed.
  • Grade II and III sources advocate isolation of any child suspected to have a communicable disease in a day care setting (see preventive measures 8 and 10 under symptomatic heading).
  • Grade III-A recommendation to exclude workers in SOS who are symptomatic or asymptomatic until two negative stool samples collected 24 hours apart or 48 hours post antibiotics (preventive measures #1, 3, and 4 under symptomatic heading and 5 under asymptomatic heading).
  • Grade II-A and grade III-A recommendation to exclude symptomatic children younger than five years old from day care setting until two negative stools 48 hours apart. Evidence also endorses the cohorting of convalescent children within the center or the complete exclusion asymptomatic carriers (preventive measures 2, 4, 5, 7, and 9 under symptomatic heading as well as 4 and 6 under asymptomatic heading).
  • Grade III-A recommendation to exclude all asymptomatic carriers of E.coli O157:H7 because of the low infectious dose required and the possible severe sequelae (preventive measures #1 and 2 under asymptomatic heading).
  • Grade II-A evidence that transmission from asymptomatic infection occurs from person-to person contacts in household contacts preventive measures #3 under asymptomatic heading). 

Viral Gastroenteritis Click Here for More Details >>

  • Grade I recommendations were unavailable from the literature reviewed.
  • Grade II recommendations were unavailable from the literature reviewed.
  • Grade III-A recommendation supports confining symptomatic residents in institutional settings for at least 24 to 48 hours after symptom resolution (preventive measures 3 and 4 in symptomatic section).
  • Grade III-A recommendations support exclusion of food handlers from work until 48-72 hours after symptoms resolve (preventive measures #6, 7, 8 and 11 in symptomatic section). Multiple outbreaks caused by ill food handler, at least one from a pre-symptomatic and asymptomatic food handlers (preventive measure #11 symptomatic and 6 and 7 in asymptomatic).
  • Grade III-A recommendations propose exclusion of patient care staff from work and patient environment at least 24 hours from symptom resolution (preventive measures 4 and 5 in symptomatic section).
  • Grade III-A recommendations advocate for the isolation of symptomatic patients in sensitive settings until 24 hours after symptoms resolve (preventive measures 1 and 10 in symptomatic section). One source tested patient stool and kept the patient in isolation until negative (preventive measures #1 in symptomatic section).
  • Grade III-A recommendation not to transfer asymptomatic contact patients from a ward during incubation period (preventive measures 8 and 9 in asymptomatic section)
  • Grade III source promotes excluding any symptomatic person from recreational water sources (preventive measures #9 in symptomatic section). Recommendation is supported by outbreak trends in recreational settings.

Giardiasis Click Here for More Details >>

  • Grade I evidence supports the recommendation to exclude symptomatic persons but not asymptomatic persons in day care setting (preventive measures 8).
  • Grade III-A evidence supports exclusion of workers in SOS with symptomatic infection until diarrhea ceases or 48 hours post diarrheal resolution (preventive measures 1, 4 and 9).
  • Grade III sources provide broad general guidelines for several bacterial and parasitic infections and recommend exclusion for workers in SOS until 2 negative stools and 48 hours post symptom resolution (preventive measures #1 and 6), however these recommendations are considered of strength D in light of above evidence.

Hepatitis A Click Here for More Details >>

  • Grade I recommendations were unavailable from the literature reviewed.
  • Grade II-A and III-A recommendation to exclude symptomatic workers especially food handlers from SOS one to two weeks from onset of symptoms or onset of jaundice (preventive measures 1, 2, 3, 4, 5, 15). Also recommend post exposure prophylaxis for susceptible contacts (co-workers of food handler and patrons) (preventive measures 1, 4, 5, 9, 10 14). Surveillance of uninfected susceptible contacts recommended (preventive measures 1).
  • Grade III-A recommendation to exclude symptomatic children in day care setting for seven to fourteen days from onset of illness or seven days from onset of jaundice with IG for close contacts (preventive measures 2, 4, 6).
  • Grade II and III evidence points out that the exclusion of school aged children may be ineffective as the majority of Hepatitis A infections in these individuals may be mild or asymptomatic. However these sources recommend exclusions in preschool and day-care setting involving younger children (preventive measures 7, 8 and 13).

Nontyphoidal Salmonellosis Click Here for More Details >>

  • Grade I recommendations were unavailable from the literature reviewed.
  • Grade II recommendations were unavailable from the literature reviewed.
  • Grade III-A recommendation to exclude children under five years old who are symptomatic. Requires at least one stool to test negative before returning the child to the setting (preventive measure 5).
  • Grade III-A recommendation to exclude symptomatically ill workers in SOS with majority of sources in agreement to require clearance with two negative stools 24 hours apart and 48 hours after antibiotics (preventive measures 1, 3, 4, 5, 7, 8 and 9).
  • Outbreaks have been linked to ill food handlers (preventive measures 6).
  • Grade III sources state that asymptomatic carriers employed as food handlers can return to work as long as strict hygiene measures are employed (preventive measures 4 and 9). Carriers in this setting still pose some risk therefore strength of this recommendation is rated as C.
  • California Code of Regulations (CCR) CCR §2612

Shigellosis Click Here for More Details >>

  • Grade I recommendations were unavailable from the literature reviewed.
  • Grade III-A recommendation to exclude workers in SOS while symptomatic and require two negative stools 24 hours apart 48 hours post diarrhea resolution (preventive measure 1, 2, 3, 4, 7, and 8).
  • Infected food handlers have been implicated in several outbreaks (preventive measures 6 and outbreak trends section).
  • Grade III-A recommendation to exclude symptomatic children. (Preventive measures 2 and 5). Grade III-B recommendation to culture all symptomatic contacts of an infected child in the day-care setting (staff, children and household contacts). Exclude and treat any positive individual. Do not allow them to return until treated and stools test negative for Shigella (preventive measures 2).
  • Grade III sources state asymptomatic carriers may return to work as long as outbreak is concluded and person practices rigorous hand hygiene (preventive measures 4 and 9). Although asymptomatic carriers can transmit infection and infectious dose is very small, strength of this recommendation is C.
  • Grade II-A recommendation for cohorting of asymptomatic convalescing children in day-care center (preventive measure
  • California Code of Regulations (CCR) CCR §2613

Acute Typhoid fever Click Here for More Details >>

  • Grade I recommendations were unavailable from the literature reviewed.
  • Grade II recommendations were unavailable from the literature reviewed.
  •  Grade III-A recommendation excluding anyone with acute symptoms from patient environment and care, as well as food handling (see preventive measures #10).
  • Grade III-A recommendation for the exclusion of any food handler who is symptomatically ill with a gastrointestinal infection (see preventive measures #8).
  • Grade III-A recommendation endorsing the exclusion of children younger than 5 years of age from day-care setting who have active S. Typhi diarrhea until their symptoms stop and three negative cultures are obtained (see preventive measures #1, 2, 7, 9, and 11).
  • Grade III-A recommendation for the exclusion symptomatic staff of a childcare setting (preventive measures #1, 3, and 11). Two recommend obtaining three negative stools before returning to SOS (preventive measures 1 and 3) and the other recommends returning the person to the environment after 24 hours without a diarrheal stool (preventive measure 12). This specific part of the recommendation would be grade III-D as evidence from outbreak showcases that asymptomatic individuals could still serve as reservoirs of infection. The evidence from outbreaks demonstrates the role asymptomatic carriers and chronic carriers play in the spread of disease and reinforce the need for exclusion.
  • One grade III source emphasizes the need for exclusion of asymptomatic food handlers by stating: the evidence is clear that asymptomatic excreters have been a source of transmitting S. Typhi infection to others through food (see preventive measures #8).
  • Grade III-A recommendation to culture household and all other contacts of a case (see preventive measures 5 and 6). One requires restriction of household contacts from working in SOS until two consecutive urine and stool cultures are obtained at least 24 hours apart (see preventive measures #5). The other source recommends culturing all contacts to the case that were exposed the month preceding the onset of illness in the case (see preventive measures #6).
  • California Code of Regulations (CCR) CCR §2628

Chronic typhoid carrier: Click Here for More Details >>

  • Grade I recommendations were unavailable from the literature reviewed.
  • Grade II recommendations were unavailable from the literature reviewed.
  •  Grade III-A recommendations support the exclusion of carriers (see preventive measure # 7 and 12 on chronic typhoid) barring the person from preparing or serving foods and patient care. These sources further recommend carriers have three negative stools samples (six in the case of foodhandler) at least one month apart before returning to work; they also advise adherence to regulations for clearance from local and state health agencies.
  • Disease outbreak trends demonstrate the ease with which an asymptomatic carrier can spread this illness.
  • California Code of Regulations (CCR) CCR §2628

Vibrioses (Not Cholera) Click Here for More Details >>

  • Grade I recommendations were unavailable from the literature reviewed.
  • Grade II recommendations were unavailable from the literature reviewed
  • Grade III-A recommendation to restriction from patient care, patient environment or from food handling for workers with active gastrointestinal disease regardless of agent (see preventive measure 1, 5 and 6). Exclude until 48 hours after first normal stool. (see preventive measure 1).
  • Grade III-A recommendations state that children with diarrhea should be excluded from setting (see preventive measure #2 and 4). One source recommends exclusion until diarrhea stops (see preventive measure #6) and the other until diarrhea stops or stool deemed non-infectious by appropriate public health officials (see preventive measure #2).
  • Grade III document stated secondary spread is rare even when sanitary inadequacies exist. This is supported by the fact that within the outbreaks reviewed in the literature from the US there is a paucity of secondary transmission cases detailed (preventive measures #3).

Cholera (Vibrio cholerae O1 or O139) Click Here for More Details >>

  • Grade I recommendations were unavailable from the literature reviewed.
  • Grade II-and III-A recommendations state persons with active V. cholerae infections should not handle or prepare food (see preventive measure #1 and 7). Another grade II source cited the pivotal role food handlers could play in transmission (see preventive measures #7).
  • Two grade III-A recommendations are made that persons with active V. cholerae diarrhea should not work until 48 hours after diarrhea ceases (see preventive measure #1).
  • One grade III source stated asymptomatic carriers may not pose a significant risk in SOS if they are rigorous with hand hygiene (see preventive measure #5).
  • Grade III-A recommendations state that children with diarrhea should be excluded from setting (see preventive measure #2 and 6). One source recommends exclusion until diarrhea stops (see preventive measure #6) and the other until diarrhea stops or stool deemed non-infectious by appropriate public health officials (see preventive measure #2).
  • One grade III source in addressing any bacterial illness in health care workers and food handlers recommends clearance with two negative stools 24 hour apart and 48 hours after diarrhea resolution (preventive measures 4). Other grade III sources state where indicated, microbiological clearance would include two negative stools taken 24 hours apart (see Preventive measures #1).
  • Grade III-A recommendation to have contact who shared food or drink with a case be monitored for symptoms for five days from exposure (see preventive measure #3).
  • California Code of Regulations (CCR) CCR §2556

Cryptosporidiosis Click Here for More Details >>

  • Grade I recommendations were unavailable from the literature reviewed.
  • Multiple grade III sources recommend the exclusion of symptomatic individuals from the direct patient care of hospitalized patients and residents of other institutionalized settings (see preventive measures #3). Sources generally agree that persons in these specific SOS should be allowed to return to work once asymptomatic (three specifically requiring 48 hours after last diarrheal stool) but stress the need for rigorous hand hygiene (see preventive measure #3 and #7). Further evidence bolstering the return is found in the fact that an asymptomatic adult has a five percent chance of transmitting the infection (see preventive measure #4).
  • Multiple grade III sources and one grade II source recommend exclusion of symptomatic children from day care setting. The recommendation is for the return of the child to this setting once diarrhea resolves (see preventive measure #2). One grade III and one grade II source agree that it would be acceptable to cohort asymptomatic cases and contacts at care facility (see preventive measures #2 and 6). Children who are asymptomatic have been a source of infection and among household contacts of an asymptomatic child ten percent can acquire infection (see attack rates section and preventive measures #5).
  •  Grade II-A recommendation supports screening of children and staff exposed to a known or suspected case in the day care setting when infected and uninfected attendees are cohorted in the facility (see preventive measure #6).
  • Two grade III-A along with one grade II-A recommendation reinforces the practice of excluding any symptomatic food handler (see preventive measure 1, 8 and 9). Outbreak trends demonstrate how easily this infection spreads.