Methodology

The research team sought to systematically identify documents and relevant publications in an effort to reflect recent advances in practice and research. Initially a search was conducted to identify existing documents that provide exclusion criteria for those in SOS utilizing the internet (Google Scholar as a search engine). The following terms were used in the search:

  1. exclusion policies/criteria
  2. diarrheal disease
  3. acute diarrhea
  4. foodhandler
  5. health care personnel
  6. guidelines
  7. childcare
  8. children
  9. day-care
  10. preventing person-to-person spread.

A literature search was then conducted in PubMed, Academic Search Premier and all Ebsco databases using key word searches, title searches and text searches for the following terms: acute diarrhea, gastrointestinal illness, cholera, typhoid (acute and chronic), typhoid fever, Shigella, shigellosis, E. Coli O157:H7, Salmonella Typhi, giardiasis, salmonellosis, cryptosporidiosis, Cryptosporidium, Shigella toxin producing E. coli, Hepatitis A, amebiasis, Entamoeba histolytica, campylobacteriosis, campylobacter, norovirus, norwalk, viral gastroenteritis, Giardia lamblia, Giardiasis, vibriosis, and epidemic cholera. Other words that were combined with the terms above and each other, in searches included: exclusion criteria, outbreak, prevention, management, guidelines, childcare, children, and foodborne. A list of related definitions is found under the DEFINITIONS tab.

Initially we thought to limit the search to articles published between 2000 and 2007 but abandoned this, as we were unable to produce sufficient sources. We then expanded our search to include articles from the 1980- 2007. References from literature that were obtained in the initial review were evaluated to determine if they might provide further clarity on the topic. We also utilized an online evidence based review site (©UpToDate) for further information. Outbreaks data were also retrieved from Morbidity and Mortality Weekly Reports (MMWR) published summaries on each disease entity in the United States. Sources that contain specific exclusion recommendations from accepted consensus groups were also consulted including the American Public Health Association (APHA) and the American Academy of Pediatrics (AAP).

The compiled literature was examined to find any comment on exclusion criteria, along with information on specific disease features (disease trend in the U.S., modes of transmission routes, infectious dose, attack rates, incubation periods, carrier state, and methods of diagnosis).  The information specific to exclusion and clearance was then entered into an enteric disease EXCLUSION SUMMARY CHART. All evidence was graded for strength and quality using the method adapted from the Infectious Disease Society of America [Guerrant et al 2001]. Table 1 below provides the operational definitions for evidence strength and data quality. This chart summarizes the recommendations for exclusion of a case or contact that is symptomatic or asymptomatic. Some sections of the chart contain a diamond symbol ◊, which indicates that there is an exclusionary requirement listed for that disease in the California Code of Regulations, Title 17. The chart provides a consensus from the literature as to whether that case of a specific disease or their contacts need to be cleared by the local public health agency in order to return to work or sensitive setting. In particular it considers recommendations for exclusion of children younger than five years old who may be symptomatic or asymptomatic and who are cared for in a group setting.

Individual column summary pages are also provided to give detail on which sources provide the exclusion recommendation. These sources then are quoted, in most cases, to provide the reader an opportunity to read the original authors’ comments and draw their own conclusions (see preventive measures sections on summary pages). Outbreak summaries are provided so that the reader can gain insight to the role specific transmission modes have played in the past.

Category

Definition

Strength of evidence

 

A

Evidence bolstering the use of recommendation is strong

B

Evidence bolstering the use of recommendation is fair

C

Evidence is of low quality therefore no support given for or against use

D

Evidence in opposition to use of recommendation is fair

E

Evidence in opposition to use of recommendation is strong

Quality of evidence

 

I

Evidence from one or more well-designed randomized controlled trial

II

Evidence from one or more well-designed non-randomized clinical trial, from cohort or case controlled analytic studies, or striking results from uncontrolled experiments

III

 Evidence based on judgments of well-regarded authorities, expert clinical experience, or reports of comments by acknowledged authorities.

Table 1. Strength & Quality of Evidence Operational Definitions