Infection Control in Child Care: Preventing Outbreaks and Protecting Children

Children are uniquely susceptible to infectious diseases. Their immune systems are still developing; they have frequent close contact with peers; they touch surfaces and then their faces; and young children in diapers spread gastrointestinal pathogens efficiently. When you bring dozens of children together in enclosed spaces for hours each day, you create conditions where respiratory viruses, gastrointestinal infections, and skin infections spread rapidly unless rigorous infection control measures are in place.

This is not theoretical. Child care settings experience regular outbreaks of influenza, respiratory syncytial virus, norovirus, strep throat, hand-foot-and-mouth disease, and other common infections. Before COVID-19, these outbreaks were often managed quietly, with parents keeping sick children home until the wave passed. The pandemic changed that calculation entirely. Concerns about COVID-19 transmission forced nationwide child care closures, led some parents to withdraw children indefinitely, and drove staff to leave the field. The disruption revealed how dependent families, employers, and the economy are on functioning child care, and how vulnerable the system is to infectious disease threats.

As New York expands child care capacity with over $2.2 billion in investments, infection control must be treated as core infrastructure rather than an afterthought. Programs that cannot manage infectious disease risks reliably will experience frequent closures, high staff turnover, and eroded family trust. This post examines the policies, protocols, and systems New York needs to prevent outbreaks and maintain operational continuity as the system scales.

Vaccination: The Foundation of Infection Control

Vaccination remains the most effective tool for preventing infectious disease outbreaks in congregate settings. New York State and New York City both mandate that children be vaccinated against high-priority diseases before entry into licensed child care. The current list of required vaccinations includes diphtheria, hepatitis B, measles, mumps, pertussis, polio, rubella, tetanus, and varicella. In New York City, children must also receive the seasonal influenza vaccination annually.

After a large measles outbreak in 2019 concentrated in Brooklyn and Rockland County, New York State eliminated religious and personal belief exemptions for vaccines, leaving only documented medical exemptions available. This policy change was critical. Before the elimination of non-medical exemptions, some child care programs and schools had developed clusters of unvaccinated children whose families held similar beliefs, creating pockets of vulnerability where outbreaks could spread rapidly. The 2019 measles outbreak infected over 600 people in New York, primarily in communities with low vaccination rates, and required extraordinary public health resources to contain.

The combination of strict requirements and rigorous enforcement has helped New York maintain high immunization levels in child care settings, often above 95 percent. This threshold is important because it provides what epidemiologists call “herd immunity” or “community protection,” where enough people are immune that disease transmission is interrupted even for those who cannot be vaccinated due to medical reasons such as immune system disorders or allergies to vaccine components.

The New Threat to Vaccination Rates

New York’s child care settings are at high risk of losing these protective immunization levels due to actions by the federal government and some states to reduce vaccine access and uptake, combined with the resurgence of highly infectious vaccine-preventable diseases such as measles and pertussis. Federal agencies have recently scaled back vaccine promotion efforts, some states have reinstated non-medical exemptions, and public discourse around vaccines has become increasingly polarized.

Measles is particularly dangerous in this context. The virus is among the most contagious pathogens known; a single infected person in a room can infect up to 90 percent of unvaccinated people present. Before widespread vaccination, measles killed approximately 400 to 500 people annually in the United States, most of them young children. When vaccination rates drop below the herd immunity threshold, outbreaks return rapidly.

New York must remain vigilant about enforcement of its vaccination requirements, ensure that programs verify immunization records within the required 14-day window after enrollment, and maintain inspection systems that flag non-compliance quickly. State and local health departments should also track vaccination coverage at the facility level to identify programs where coverage is slipping before outbreaks occur.

Beyond Vaccines: Hygiene and Sanitation Protocols

Vaccines prevent some infections, but child care programs must also implement rigorous hygiene and sanitation practices to reduce overall pathogen exposure. Licensing standards in New York cover handwashing facilities and practices, toilet and diapering procedures, toy sanitizing, cleaning schedules, and protocols for screening and excluding ill children. These are adapted from the national “Caring for Our Children” guidance developed by the American Academy of Pediatrics, the American Public Health Association, and the National Resource Center for Health and Safety in Child Care and Early Education.

In practice, these standards are numerous and complex. Staff must know when a child with a fever can attend, when they are safe to return after strep throat, how to manage lice or bed bug exposures, and how to handle blood or bodily fluid spills safely. Diapering protocols alone involve multiple steps including handwashing before and after, proper cleaning of the changing surface, appropriate disposal of soiled materials, and documentation. Toys that go in children’s mouths must be sanitized after each use; surfaces must be cleaned with appropriate disinfectants on defined schedules; food preparation areas must be separate from diapering areas.

Ensuring that these standards are followed correctly and consistently at all times is challenging. Standards are detailed, new staff are constantly joining, existing staff are often overwhelmed by high child-to-adult ratios, and there is constant exposure to infectious agents. During a busy day, it is easy for protocols to slip: a staff member forgets to wash hands after helping a child use the toilet, a toy is not sanitized before another child picks it up, a sick child is allowed to stay because the parent cannot miss work.

The Critical Role of Child Health Care Consultants

To expand child care effectively and safely, New York must invest in building a large cadre of Child Health Care Consultants (CHCCs). CHCCs are experts in health and safety who help staff at facilities improve their adherence to recommended infection control protocols. Their primary focus is helping teams succeed, in contrast to child care inspectors whose focus is making legal determinations about whether a facility meets regulatory standards and should remain open.

CHCCs answer questions from staff and administrators about supplies and systems, observe routine operations and coach staff on how they can perform better, and provide refresher training on proper handwashing, diapering, and illness exclusion decisions. In a sector with high turnover and complex daily protocols, supportive coaching is one of the most scalable ways to promote adherence to standards between formal inspections.

CHCCs are required for Head Start and Early Head Start programs, where they have proven effective at reducing illness rates and improving protocol compliance. However, there is no current statewide mandate or dedicated funding stream in New York for CHCCs in all licensed providers, in contrast to states such as Washington, Colorado, and North Carolina that have established CHCC programs covering broader segments of the child care system.

The return on investment for CHCCs is substantial. Research from states with established programs shows that facilities receiving CHCC support experience fewer infectious disease outbreaks, lower rates of injury, better staff knowledge of health and safety protocols, and higher family satisfaction. For New York, which is adding thousands of new child care seats, CHCCs represent a mechanism to ensure that expansion does not dilute quality or increase health risks.

Exclusion Policies: Balancing Safety and Access

One of the most challenging infection control decisions child care providers face daily is whether to exclude a child who appears ill. Exclusion policies serve two purposes: protecting other children and staff from infection, and ensuring that sick children receive appropriate rest and care. But exclusion also creates significant burdens for families, particularly those without flexible work arrangements or backup care options.

New York’s regulations require child care programs to have written policies on when children must be excluded, based on symptoms such as fever, vomiting, diarrhea, rash, or difficulty breathing. For some conditions such as strep throat or conjunctivitis, children can return after starting antibiotic treatment and being fever-free for a specified period. For others such as chickenpox, exclusion continues until all lesions have crusted over.

The challenge is that these policies are often implemented inconsistently. Providers may feel pressure from parents who cannot miss work, leading them to accept children who should be excluded; conversely, some providers exclude children too aggressively out of fear of outbreaks or complaints from other families. Staff need clear guidance, confidence to enforce policies even when parents are upset, and support from program leadership.

During the COVID-19 pandemic, many child care programs adopted much stricter screening and exclusion protocols including temperature checks at entry, symptom questionnaires, and immediate exclusion for any respiratory symptoms. Some of these practices have continued, while others have been relaxed as COVID-19 has transitioned to endemic status. The key lesson is that exclusion policies must be evidence-based, clearly communicated to families at enrollment, applied consistently, and supported by backup care options or paid leave policies that reduce the financial penalty families face when children are excluded.

Outbreak Detection and Response Systems

Even with strong prevention measures, outbreaks will occur in child care settings. Rapid detection and response can limit the size and duration of outbreaks, but many programs lack systems to identify patterns early. A provider may notice that several children in one classroom have diarrhea, but not recognize that this represents an outbreak requiring reporting to the health department and enhanced cleaning protocols.

New York should establish clear requirements for child care programs to report suspected outbreaks to local health departments, along with technical assistance to help providers recognize when illness levels exceed normal background rates. Health departments, in turn, need staff capacity to investigate reported outbreaks, provide guidance on control measures, and follow up to ensure measures are implemented.

During the COVID-19 pandemic, some health departments developed dashboards showing illness and closure data for child care facilities, giving parents and policymakers visibility into outbreak patterns. These systems should be maintained and expanded to cover other infectious diseases. Transparency builds trust, and data-driven decision-making allows for targeted interventions rather than blanket policies.

Lessons from COVID-19: Airborne Transmission and Ventilation

One of the most important lessons from COVID-19 was recognition that many respiratory infections spread through airborne transmission, meaning small infectious particles can remain suspended in the air for extended periods and infect people beyond close contact distance. This understanding elevated the importance of ventilation and air filtration in preventing respiratory disease transmission in indoor spaces.

Traditional infection control in child care focused heavily on handwashing, surface cleaning, and direct contact precautions. These remain important for preventing gastrointestinal infections and some respiratory infections, but they are insufficient for airborne pathogens. Good ventilation and air filtration reduce the concentration of infectious particles in indoor air, lowering transmission risk for respiratory viruses including influenza, RSV, and COVID-19.

New York City public schools underwent substantial improvements to indoor air quality during the pandemic, including upgrading HVAC systems to include MERV-13 filters, installing portable air purifiers in classrooms, and modifying windows to allow natural ventilation. Child care facilities, particularly smaller and home-based programs, have not received similar investments. As the state expands child care capacity, basic ventilation standards should be incorporated into licensing and capital grant requirements. This connection between built environment and infection control will be explored in greater depth in a future post in this series.

Training and Workforce Preparedness

Infection control is only as strong as the workforce implementing it. Child care workers in New York are required to complete 30 hours of training every two years, which includes health and safety content, but the quality and relevance of this training varies widely. The state should mandate that a defined portion of these hours focus specifically on infection prevention and control, covering handwashing technique, respiratory hygiene, diapering protocols, cleaning and disinfection, and recognition of signs and symptoms requiring exclusion or urgent medical attention.

This training should be practical and scenario-based rather than abstract. Workers need to practice proper handwashing technique with feedback, see demonstrations of correct diapering procedures, and work through case studies about exclusion decisions. Training should also address the emotional and interpersonal challenges of enforcing health policies with upset parents, and provide language for communicating policies clearly and compassionately.

CHCCs can serve as key providers of this ongoing, practical training, reinforcing classroom learning with on-site observation and coaching. For new workers entering the field through New York’s expansion efforts, infection control training should be front-loaded during orientation rather than spread over two years, ensuring that foundational practices are established from day one.

Building Resilient Systems for the Future

New York’s $2.2 billion investment in child care expansion offers an opportunity to build infection control infrastructure into the system from the outset rather than retrofitting it after the next outbreak. This requires treating infection prevention not as a compliance checklist but as operational readiness that determines whether programs can stay open, whether families trust the system, and whether staff feel safe coming to work.

Concrete policy steps include establishing a statewide CHCC program with dedicated funding, incorporating ventilation and air quality standards into licensing requirements, strengthening inspection systems to verify infection control practices rather than just documentation, creating outbreak surveillance dashboards that provide transparency to families and accountability to providers, and ensuring that training requirements reflect the realities of preventing infectious disease transmission in congregate settings with young children.

The ultimate measure of success is not the presence of policies on paper but outcomes on the ground: fewer outbreaks, shorter outbreak duration when they occur, lower rates of illness-related closures, reduced staff absenteeism due to workplace infection, and family confidence that programs are managing health risks competently. These outcomes are achievable, but they require sustained commitment to infection control as foundational infrastructure rather than an afterthought.

As explored in the comprehensive framework for protecting health in child care expansion, infection control is one pillar of a three-domain approach that also addresses workforce health and built environment safety. In upcoming posts, we will examine how paid sick leave and health coverage for child care workers reduces disease transmission, how indoor air quality improvements prevent respiratory outbreaks, and how emergency preparedness systems ensure programs can respond to climate-related and public health threats. Together, these elements create a child care system that is not only larger but more resilient.

Dr. Jay K. Varma is Senior Vice President and Chief Medical Officer at Fedcap, a large global nonprofit organization, and a Senior Health Fellow at the Community Impact Policy Institute. He is a physician-epidemiologist with extensive experience in infectious disease control, public health emergency response, and health systems strengthening across the United States and internationally. The full report “Protecting Health in Child Care Expansion” is available at the Community Impact Policy Institute.