Each year, an estimated 12.5 million children in the United States under the age of 5 utilize early care and education (ECE) facilities [1]. ECE settings provide care and education to children outside of their homes [2]. Types of ECE facilities include family care settings such as family child care homes and non-family care settings such as child care centers and preschool programs [3, 4]. ECEs provide a variety of benefits for both children and their families, including improved language and cognitive development, healthy social and emotional development, and motor skills [5–9].
Although children and families benefit from ECE facilities, infectious disease can spread easily in these settings. Outbreaks of various enteric infectious diseases, such as norovirus, giardiasis, and shigellosis, have been reported in ECE settings [10]. Spread of infectious disease in congregate settings, like ECE facilities, can be facilitated by crowding and being in extended and close contact with others [11]. In ECE facilities, other factors contribute to the spread of infectious disease. These include personal hygiene behaviors of children and staff, presence of diapered children and children who have incompletely developed toileting behaviors, the lack of cleaning and sanitation of the facilities, crowding, sharing of items, attendance policies, and the ratio of children to caregivers [12–15]. Children also frequently touch items, put objects in their mouths, are not able to wash hands independently, and have developing immune systems, which contributes to susceptibility of infectious disease [15].
To prevent and control infectious diseases in ECE settings, particularly gastrointestinal disease, evidence-based sanitation and hygiene-related practices should be implemented. This includes handwashing promotion, hygiene and sanitation training, separation of diapering areas from food handling or eating areas, and routine cleaning and disinfection [16]. Evidence-based best practices have been compiled to guide ECE facilities in safe operation for infection control and prevention. An example of complied best practices is Managing Infectious Diseases in Child Care and Schools, a reference guide that includes an overview of how infections are spread, symptoms of infection, inclusion and exclusion criteria of children and staff, strategies for communication, and infection control measures for the prevention and control of infectious diseases in ECEs [17]. Caring for Our Children (CFOC): National Health and Safety Performance Standards Guidelines for Early Care and Education Programs was developed through a collaboration with the American Academy of Pediatrics, American Public Health Association, and the National Resource Center for Health and Safety in Child Care and Early Education and is considered the gold standard on safety standard recommendations for ECE facilities [2]. CFOC includes topics related to health promotion, nutrition and food service, infectious diseases, and playground safety and has detailed information on Water, Sanitation, and Hygiene (WASH)-related practices such as how to change a diaper and when to practice hand hygiene.
To ensure the safe operation of ECE facilities, each state has an agency that has set licensing regulations for ECE facilities to be able to legally operate [18]. Licensed ECE facilities are regularly inspected to ensure compliance with licensing requirements. These requirements are developed by state and territorial governments and are frequently updated following new research, new legislation, provider feedback, and industry trends [19]. They include requirements related to a range of safe practices, such as maintaining building safety, immunization of staff and children, child-staff ratios, and the nutritional content of food served to children [20]. They also include requirements related to the prevention of infectious disease, including sanitation and hygiene-related practices. However, state ECE regulations do not always align with the recommended best practices for health and safety in ECE settings, such as those outlined in CFOC. For example, studies have found that few states fully address CFOC recommendations within their regulatory documents [21, 22]. In the Leone et al. policy scan, a review of state licensing regulations was conducted to determine alignment (fully, partially, did not address) with best practices to prevent norovirus infections in child care centers [22]. Although across all state regulations approximatively two-thirds of the 14 practices were partially or fully addressed, few were fully addressed [22]. Few studies have reviewed state ECE licensing regulations to determine alignment with sanitation and hygiene-related best practices in child care centers. To address this gap, this study aimed to evaluate the alignment of ECE licensing to recommendations in CFOC with regards to sanitation- and hygiene-related practices. The results of this study can be used by state policymakers to better understand the extent of which ECE licensing regulations includes sanitation and hygiene-related best practices and identify opportunities to strengthen state regulations to prevent and control the spread of infectious disease in ECE settings.