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DISINFECTANTS, OSHA BLOODBORNE
PATHOGEN STANDARD
AND
OTHER TOPICS ON MANAGEMENT OF
COMMUNICABLE DISEASES
IN SCHOOLS
Scott Maag
Vice President of Research and Operations
Buckeye International, Inc.
TOPICS
 Disinfectants
 OSHA Bloodborne Pathogen Standard
 Influenza Viruses (Including Avian
Influenza)
 Norovirus
 Non-Polio Enterovirus
 Zika Virus
 Staphylococcus Aureus/MRSA
 Head Lice
 Scabies
 Giardia
DISINFECTANTS
Disinfectants
 Disinfectant Versus Sanitizer
 How Disinfectants Work
Disinfectant Vs. Sanitizer
 Disinfectant – “a substance, or mixture of substances, that
destroys or irreversibly inactivates bacteria, fungi and
viruses, but not necessarily bacterial spores, in the
inanimate environment.”1
 Sanitizer – “a substance, or mixture of substances, that
reduces the bacterial population in the inanimate
environment by significant numbers, (e.g., 3 log 10
reduction) or more, but does not destroy or eliminate all
bacteria.”1 - food contact surface sanitizers are used in
food service
 Disinfectants and sanitizers are also called antimicrobial
pesticides, and they are regulated by the U.S. EPA
Disinfectant Vs. Sanitizer
ORGANISM
D S
Acinetobacter baumannii
X
Acinetobacter calcoaceticus
X
Chlamydia psittaci
X
Enterobacter aerogenes
X
Enterobacter cloacae
X
Enterobacter cloacae - NDM-1
X
Enterococcus faecalis - Vancomycin resistant
(VRE)
X
Escherichia coli
X
Escherichia coli - NDM-1
X
Fusobacterium necrophorum
X
Klebsiella pneumoniae
X
Klebsiella pneumoniae - NDM-1
X
Legionella pneumophila
X
Listeria monocytogenes
X
Pasteurella multocida
X
Proteus mirabilis
X
Proteus vulgaris
X
Pseudomonas aeruginosa
X
Salmonella enterica
X
Salmonella enteritidis
X
Salmonella typhi
X
Salmonella typhimurium
X
Serratia marcescens
X
Shigella flexneri
X
X
ORGANISM (cont.)
Shigella sonnei
Staphylococcus aureus
S. aureus - Community Associated
Methicillin-Resistant (CA-MRSA)
S. aureus Methicillin resistant (MRSA)
S. aureus - Vancomycin Intermediate
resistant (VISA)
Staphylococcus epidermidis (antibioticresistant strain only)
Streptococcus faecalis
Streptococcus pyogenes
Adenovirus type 4
Hepatitis B Virus
Hepatitis C Virus
Herpes Simplex Virus Type 1
Herpes Simplex Virus Type 2
HIV-1
Human coronavirus
Influenza A Virus/Hong Kong
Pandemic 2009 H1N1 influenza A virus
Respiratory syncytial virus
Rotavirus
Rubella virus
SARS Associated Coronavirus
Vaccinia
Aspergillus niger
Candida albicans
Trichophyton mentagrophytes
D S
X
X X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
D=Disinfectant (Quat-based, Diluted 1:256)
S=Non-food Contact Surface Sanitizer (Citric Acid-based, Diluted 1:4)
How Disinfectants Work
 Can work in a variety of ways involving effects on
microorganism components including cell membrane,
cell proteins, enzymes, and DNA
 Quat disinfectants, for example, are known for
disrupting the cell membranes of bacteria – quats are
able to attach to bacteria to begin with because the
quats’ charge is positive and the bacterial cell surface
is negative
OSHA BLOODBORNE
PATHOGEN STANDARD
OSHA’s Bloodborne
Pathogen Standard






History
Pathogens
Infectious Materials
Modes of Transmission
Prevention
Cleaning Procedures
History
 December 6, 1991
Federal Register
29 CFR 1910.1030
Established in March 1992
 “…reasonably be anticipated to come into contact
with blood or other OPIM as a result of doing their job
duties.”2 (OPIM = Other Potentially Infectious
Materials)
 Limit occupational exposure to blood and other
potentially infectious materials since any exposure
could result in transmission of bloodborne pathogens
which could lead to disease or death.
Pathogens
 Hepatitis B (HBV)
 “Inflammation of the liver” - can cause cirrhosis and
cancer of liver
 HBV vaccine available - routine for children and
healthcare workers
 No cure for chronic HBV – medications reduce
chance of developing severe liver diseases
 50-100 times more infectious than HIV3, easily
spread by sex or injection drug use
 Very durable
can survive in dried blood for at least seven days
 Tens of thousands per year are infected (19,200 in
2014)3
Pathogens
 Hepatitis C (HCV)
 “Non-A, Non-B Hepatitis.”
 No vaccine to prevent HCV. Cure may be achievable with
medications taken daily for months.
 Leading cause of cirrhosis & the leading cause of liver
transplantation in the US
 Of 100 persons infected with HCV about4:
75-85 persons develop long-term infection (chronic)
15-25 persons develop acute HCV and recover
 Virus can survive on environmental surfaces for up to 3 weeks
 2.7-3.9 million Americans estimated to have chronic infection4
Pathogens
 Human Immunodeficiency Virus (HIV)
 Attacks CD4 cells (T cells) in the immune system
 Causes AIDS – Acquired Immunodeficiency





Syndrome
People who are infected carry the virus for many
years before AIDS symptoms develop
Testing is the only way to know if you are infected
1.2 million people in US are living with the virus –
13% are unaware they are infected (2013
information)5
No cure, treatment is improving
Very fragile virus
Pathogens
Directive Number: CPL 02-02-069
Effective Date: November 27, 2001
Subject: Enforcement Procedures for the Occupational Exposure to
Bloodborne Pathogens
(Purpose: This instruction establishes policies and provides clarification
to ensure uniform inspection procedures are followed when conducting
inspections to enforce the Occupational Exposure to Bloodborne
Pathogens Standard)
"Bloodborne Pathogens": While HBV and HIV are specifically identified in
the standard, the term includes any pathogenic microorganism that is
present in human blood or OPIM and can infect and cause disease in
persons who are exposed to blood containing the pathogen. Pathogenic
microorganisms can also cause diseases such as hepatitis C, malaria,
syphilis, babesiosis, brucellosis, leptospirosis, arboviral infections,
relapsing fever, Creutzfeldt-Jakob disease, adult T-cell
leukemia/lymphoma (caused by HTLV-I), HTLV-I associated myelopathy,
diseases associated with HTLV-II, and viral hemorrhagic fever.
Other Potentially
Infectious Materials
(Aside from blood) semen, vaginal secretions,
cerebrospinal fluid, synovial fluid, pleural fluid,
pericardial fluid, peritoneal fluid, amniotic fluid,
saliva, any body fluid visibly contaminated with
blood and all body fluids in situations where it is
difficult or impossible to differentiate between
body fluids…
Transmission of Pathogens

Normally, unbroken skin forms an impervious
barrier against bloodborne pathogens
 Open sores, cuts, abrasions, acne, sunburn,
blisters
 Mucous Membranes: eyes, nose and mouth
 (i.e. a splash of contaminated fluid to your
eye, nose, mouth or open sore could result in
transmission)
Prevention

Treat all potentially infectious material as if it
were contaminated
 Personal Protective Equipment (PPE)
 3 Step Cleaning – contain, clean, decontaminate
 Handwashing
soft, antibacterial soap (if possible)
avoid harsh, abrasive soaps
Hard Surface Clean - Up









Use gloves, gowns and eye protection
To clean up the spill:
Apply an absorbent to soak up the infectious material.
Contaminated broken glassware shall NOT be picked up by
hand. Use a brush and dust pan, tongs or forceps.
Pick up the moist absorbent.
Place the absorbent into a regulated waste container (if it
would be capable of releasing infectious material if
compressed or during handling). Any brush, dust pan, tongs
or forceps must be discarded or decontaminated before
reuse.
Clean the spill area with a general purpose cleaner or
disinfectant cleaner to remove gross filth.
Decontaminate area with disinfectant with HIV, HBV& HCV
claim, with TB claim or with bleach.
Place the towel which was used for cleaning into the
regulated waste container.
Appropriate Disinfectant Products
 OSHA letter June 30, 1989
Clarifies use of HIV claimed disinfectant
 OSHA letter February 28, 1997
Clarifies use of HIV & HBV claimed disinfectants
EPA's Registered Sterilizers, Tuberculocides, and Antimicrobial Products Against
HIV-1, and Hepatitis B and Hepatitis C Viruses.
(Updated March 14, 2016)
http://www.epa.gov/pesticide-registration/selected-epa-registereddisinfectants
Directive Number: CPL 02-02-069
Subject: Enforcement Procedures for the Occupational Exposure to Bloodborne Pathogens
Any of the above products are considered effective when used according to the manufacturer's
instructions, provided the surfaces have not become contaminated with agents or volumes of or
concentrations of agents for which higher level disinfection is recommended.
NOTE: Fresh solutions of diluted household bleach made up daily (every 24 hours) are also
considered appropriate for disinfection of environmental surfaces and for decontamination of
sites following initial cleanup (i.e., wiping up) of spills of blood or other potentially infectious
materials. Contact time for bleach is generally considered to be the time it takes the product to air
dry.
Bleach




Strong odor
Corrosive to eyes and skin
Short shelf life, needs test paper to test
concentration
Can damage clothes and other fabrics
Phenolics
 Skin depigmentation
 Possible disposal problems down sanitary
sewers
 High cost
 Not to be used around neonatal area
“Texas public school districts are
required to implement bloodborne
pathogen exposure control
plans.”6
Influenza Viruses
Including Avian Influenza
Influenza Viruses



Types of virus
Preventing
Avian Influenza
The Influenza Virus


Virus which infects the respiratory tract
(nose, throat and lungs)
Three types that infect people
 Influenza A
 Influenza B
 Influenza C
Influenza A
 Tend to cause epidemics of disease almost
every winter
 Divided into subtypes based on two surface
proteins
 H (hemagglutinin) 18 types
 N (neuraminidase) 11 types
 Found in many different animals – ducks,
chickens, pigs, whales, horses, etc.
 Birds are thought to be the source of Influenza A
viruses in other animals
Influenza B
 Tend to cause epidemics almost every
winter
 No subtypes
 Circulates widely only among humans
 Influenza B and A (H1N1 & H3N2) are
included in each year’s Influenza
vaccine
Influenza C
Causes mild respiratory illness and not
thought to cause epidemics
Flu shot does not protect against type C
Influenza
Preventing Influenza
 Get vaccinated each fall
 Avoid close contact with individuals
 Stay home when you are sick
 Cover your mouth and nose
 Wash your hands
 Avoid touching eyes, mouth & nose
 Clean and disinfect frequently touched
surfaces (influenza virus on a surface
may be able to infect for up to 48
hours)
Avian Influenza A
Known as bird flu
Variety of strains with a variety of symptoms –
most cause no or mild symptoms
Low Pathogenic – may go undetected, cause mild
symptoms
Highly pathogenic – highly contagious and rapidly
fatal (90-100% mortality within 48 hours)
Avian Influenza A
Spreads through saliva, nasal secretions
and feces
Avian Influenza viruses don’t usually
infect humans
Avian Influenza A
 Strains of Concern Highly Pathogenic Asian
Avian Influenza A (H5N1) Virus in Africa, Asia,
Europe, and the Middle East and new Avian
Influenza A (H7N9) Virus in China – these have
caused most human illness worldwide
 Spread to humans from contact with infected
birds and droppings (there has been human-tohuman spread, but it has been rare)
 Avian Influenza A Symptoms in Humans
Flu like – fever, cough, sore throat, muscle aches
Eye infections, pneumonia, acute respiratory
distress, stomach illness, neurologic changes
Avian Influenza A
 Fear is: virus will change and infect humans easily
Spread easily between people
Influenza pandemic could begin
 BUT at this time Asian Avian Influenza A Virus
(H5N1) and new Avian Influenza A Virus (H7N9)
have not been detected in birds and humans in the
U.S.
A Few Notes on Pandemic
Preparedness





Last pandemic was 2009 H1N1 pandemic
Most people will not be immune to a pandemic influenza
virus, and a vaccine may not be immediately available
A preparedness plan may consider communication with
public health department, emergency communication
with parents/students/staff, sick leave policies, methods
for continuing education and services in case of school
closures, etc.7,8
Daily influenza prevention measures such as hand
washing, cleaning/disinfecting surfaces, etc. should also
be relevant for prevention of pandemic flu
Having adequate supplies such as soap and tissues
would be important during a pandemic
NOROVIRUS
(PREVIOUSLY CALLED
NORWALK-LIKE VIRUS)
Norovirus
• Symptoms of Norovirus
• Spread of Norovirus
• Norovirus Prevention Measures
Source: CDC/Jessica A. Allen and Alissa Eckert (Illustrator), ID# 21348,
https://cdc.gov/phil/home.asp, accessed December 2016.
Symptoms of Norovirus
•
•
•
•
•
•
Illness is sometimes called “stomach flu,” though
norovirus is not related to influenza virus
Norovirus causes inflammation of intestines and/or
stomach
Most common symptoms: diarrhea, vomiting,
nausea, stomach pain
Less common symptoms: fever, headache, body
aches
Symptoms usually start 12-48 hours after exposure;
people generally feel better in 1-3 days
Norovirus illness can lead to dehydration if lost fluids
are not replaced
Spread of Norovirus

Norovirus-containing stool or vomit gets into
the mouth of an uninfected person, for
example




Contaminated food or drinks are consumed
A contaminated surface is touched and then
fingers are put into mouth
Direct contact is had with an infected person
Contagious period: before symptoms until 2
weeks after recovery (most contagious while
sick plus a few days after)
 Spread is quick in enclosed facilities
 Most US outbreaks November-April9
Norovirus Prevention
Measures
•
Wash hands with soap and water
•
•
•
•
•
•
•
•
After changing diapers
After using the toilet
Before preparing food
Before eating
Hand sanitizers may be used in addition to soap
and water, but they are not substitutes
Handle foods correctly (e.g., wash raw produce)
Clean and disinfect hard, nonporous surfaces
If infected, stay home and do not prepare food
when you are most contagious
Non-Polio Enterovirus
Non-Polio Enterovirus
 What Non-Polio Enteroviruses Are
 How to Prevent the Spread
What Non-Polio Enteroviruses Are
•
•
•
•
•
Viruses in the Enterovirus genus other than
polio virus
Can cause mild or no symptoms, especially
in adults
Can cause illness such as viral conjunctivitis;
viral meningitis; and hand, foot, and mouth
disease
Spread from exposure of eye, nose, or
mouth to an infected person’s mouth or nose
secretions, stool, or blister fluid
Enterovirus D68 caused an outbreak in 2014
How to Prevent the Spread of
Non-Polio Enteroviruses
•
•
•
•
•
•
Wash hands often with soap and water
Avoid touching eyes, nose, and mouth with
unwashed hands
Avoid close contact with someone who is
sick
Clean and disinfect frequently touched
surfaces
Encourage covering coughs and sneezes
Stay home when sick
ZIKA VIRUS
Zika Virus

Transmitted primarily through the bite of Aedes
species mosquitoes
 Most infected people have no symptoms or mild
symptoms
 Zika virus infection during pregnancy may lead
to microcephaly and other birth defects
 Schools may take measures to prevent
mosquito bites, for example:


Removing outside standing water sources where
mosquitoes can lay eggs (such as uncovered trash
cans)
Ensuring that opened windows have functioning
screens to keep mosquitoes out of classrooms
STAPHYLOCOCCUS
AUREUS /
METHICILLIN RESISTANT
(MRSA)
Staphylococcus
Aureus/MRSA






What is Staph
Where is Staph Found
What is MRSA
How Common is Staph
How is Staph Spread
How to Prevent Staph Infections
What is Staph
•Staphylococcus aureus
•Bacteria commonly carried on the
skin and nose of healthy people
•It is one of the most common cause
of skin infections in the U.S.
•These are simple infections that can
cause pimples and boils
Staph can also cause serious
infections such as surgical wound
infections and pneumonia
Where is Staph Found
In the air
On human bodies
In their noses
On objects
What is MRSA
 Methicillin-Resistant Staphylococcus aureus
Antibiotic resistance only!
Not resistant to disinfectants
 Found in serious infections
 Normally found in hospitals and healthcare
facilities
 Infections occurring in the wider community
among healthy people – Community-Associated
MRSA (CA-MRSA)
 Usually shows up as skin infections in
healthy people
How Common Is Staph/MRSA
 Tens of thousands of cases of severe
MRSA infections are estimated to occur
per year nationwide10
How is Staph/MRSA Spread
Person-to-person contact
Contact with contaminated surfaces such as:
 Towels, sheets, clothes, workout rooms,
gyms, sports equipment, mats, locker
rooms
 Student desks, lunch tables, lockers
 Restroom fixtures, door handles, sinks,
benches
Prevention of Staph/MRSA
 Wash hands frequently with soap and
water; use hand sanitizers
 Keep cuts and wounds clean and
bandaged
 Avoid touching other people’s cuts or
wounds
 Encourage showering and washing
clothes/uniforms after exercise
 Instruct not sharing items such as towels
 Routinely disinfect hard surfaces of
concern
HEAD LICE
Head Lice
 Description
 How Head Lice Are Spread
 Prevention
Description of Head Lice
 Pediculus humanus capitis (scientific




name)
Parasitic insects that can be found on
the head, eyebrows, and eyelashes of
people – live close to the scalp
Feed off human blood
Do not spread disease
Have 3 stages: nit(egg), nymph, adult
Source: CDC/Dr. Dennis Juranek, ID#
19067, https://phil.cdc.gov/phil/home.asp, ,
accessed December 2016.
How Head Lice Are Spread
•
•
•
•
•
Movement of head lice is by crawling
Head-to-head contact with someone who
has head lice is usual means of transmission
Less likely, spread may arise from contact
with clothing or other personal items of an
infested person
Lice live only <1-2 days if they cannot feed;
nits cannot hatch and will die within a week if
not at temperature of scalp
Infestation most common among day
care/school children and their families11
Prevention of Head Lice
•
•
•
•
•
Treatment of infested person at home with
prescribed or OTC medicine (American Academy of
Pediatrics urges against excluding children with nonit policies12)
Vacuuming, laundering, sealing of non-machine
washable items into plastic bags for two weeks,
soaking of brushes and combs in hot water (these
activities might be most appropriate at infested
child’s home)
Urging against head-to-head contact
If possible, providing each student with a space to
keep jackets, hats etc. separate from those of others
Avoiding sharing of personal items such as
hairbrushes
SCABIES
Scabies
 What Is Scabies and How Is It Spread
 Prevention of Scabies
Photomicrograph Showing Changes in a Human Skin Sample from a Scabies Infestation
Source: CDC/Reed & Carnrick Pharmaceuticals, ID# 15386, https://phil.cdc.gov/phil/home.asp, accessed December 2016.
What Is Scabies and How Is It Spread






Human itch mite (Sarcoptes scabiei var.
hominis) burrows into the skin
Symptoms are itching and a rash
Passed usually by direct, prolonged skin-toskin contact with a person who has scabies
Less commonly may be transmitted by using
an article (e.g., towel) that was used by an
infested person
Infestations are often seen in crowded
facilities or places with frequent skin contact
Scabies mites don’t usually survive more
than 48-72 hours off a person
Prevention of Scabies
•
•
•
•
•
Avoiding direct skin contact with an infested
person or with the infested person’s items
Keep in mind: symptoms may not appear for
up to two months after infestation
People in the same household and close
contacts are often recommended to be
treated along with the diagnosed person
Bedding and clothing used by a person
during the three days before treatment
should be machine washed, dry cleaned, or
stored in a plastic bag for up to a week
Exclusion from school until treated
GIARDIA
Giardia
 Basic Information
 Prevention of Giardia Infection
(Giardiasis)
Source: CDC/Janice Haney Carr, ID# 8698,
https://cdc.gov/phil/home.asp, accessed December 2016.
Basic Information about Giardia





Giardia are protozoan parasites
(protozoan = a term used to describe certain
one-celled, microscopic organisms)
Giardiasis (Giardia infection) symptoms can include
diarrhea, stomach cramps, vomiting, weight loss,
failure to absorb nutrients
Giardia are passed in the stool of those infected
People get giardiasis when they swallow
contaminated food or water or touch contaminated
surfaces and then put their fingers in their mouths
Illness may not appear until at least one week after
exposure, and symptoms may last several weeks
Prevention of Giardiasis






Frequently wash hands with soap and water

Before eating

Before preparing food

After using the toilet

After changing diapers
Clean up after ill people (quats are thought to be effective, but
this is difficult to test in labs and the products do not have
claims to our knowledge – bleach also gets recommended13)
Exclude students with diarrhea from school
Shower before swimming and exclude people with diarrhea or
recent diarrhea from swimming
Do not drink water from pools, hot tubs, lakes, etc.
Wash with clean drinking water food that is to be eaten raw
QUESTIONS?
Endnotes
1Environmental
Protection Agency Office of Chemical Safety and Pollution
Prevention, “Product Performance Test Guidelines OCSPP810.2000 General
Considerations for Uses of Antimicrobial Agents (September 2012),”
https://www.regulations.gov/document?D=EPA-HQ-OPPT-2009-0150-0019,
accessed December 2016.
2Occupational Safety and Health Administration, “OSHA Fact Sheet OSHA’s
Bloodborne Pathogens Standard,”
https://www.osha.gov/OshDoc/data_BloodborneFacts/bbfact01.pdf , accessed
December 2016.
3Centers for Disease Control and Prevention ,“Hepatitis B FAQs for the Public,”
https://www.cdc.gov/hepatitis/hbv/bfaq.htm, accessed December 2016.
4Centers for Disease Control and Prevention, “Hepatitis C FAQs for the Public,”
https://www.cdc.gov/hepatitis/hcv/cfaq.htm, accessed December 2016.
5Centers for Disease Control and Prevention, “HIV Basics,”
https://www.cdc.gov/hiv/basics/, accessed December 2016.
6Texas Department of State Health Services, “Bloodborne Pathogen Control in
Texas Schools,” https://www.dshs.texas.gov/schoolhealth/bldbrnpt.shtm, accessed
December 2016.
7Centers for Disease Control and Prevention, “Administrators of Childcare and K-12
Schools Flu Prevention at School,” https://www.cdc.gov/nonpharmaceuticalinterventions/school/administrators-childcare-k-12-schools.html.
Endnotes cont.
8Centers
for Disease Control and Prevention, “Pandemic Flu Checklist: K-12 School
Administrators,” https://www.cdc.gov/nonpharmaceutical-interventions/pdf/pan-fluchecklist-k-12-school-administrators-item2.pdf, accessed December 2016.
9Centers for Disease Control and Prevention, “Norovirus,”
https://www.cdc.gov/norovirus/, accessed December 2016.
10Centers for Disease Control and Prevention, “Methicillin-resistant Staphylococcus
aureus (MRSA),” https://www.cdc.gov/mrsa/, accessed December 2016.
11Centers for Disease Control and Prevention, “Parasites-Lice-Head Lice,”
https://www.cdc.gov/parasites/lice/head/index.html, accessed December 2016.
12Barbara L. Fankowski and Joseph A. Bocchini, Jr., “Clinical Report-Head Lice,”
Pediatrics 126, no. 2 (August 2010): 399,
http://pediatrics.aappublications.org/content/pediatrics/126/2/392.full.pdf, accessed
December 2016.
13Centers for Disease Control and Prevention, “Parasites-Giardia,”
https://www.cdc.gov/parasites/giardia/, accessed December 2016.
Bibliography
Centers for Disease Control and Prevention. “Administrators of Childcare and K-12
Schools Flu Prevention at School.”
https://www.cdc.gov/nonpharmaceutical-interventions/school/administrators-childcare-k-12-schools.html,
accessed December 2016.
Centers for Disease Control and Prevention. “Hepatitis B FAQs for the Public.”
https://www.cdc.gov/hepatitis/hbv/bfaq.htm, accessed December 2016.
Centers for Disease Control and Prevention. “Hepatitis C FAQs for the Public.”
https://www.cdc.gov/hepatitis/hcv/cfaq.htm, accessed December 2016.
Centers for Disease Control and Prevention, “HIV Basics,”
https://www.cdc.gov/hiv/basics/, accessed December 2016.
Centers for Disease Control and Prevention. “Influenza (Flu).”
https://www.cdc.gov/flu/, accessed December 2016.
Centers for Disease Control and Prevention. “Methicillin-resistant Staphylococcus
aureus (MRSA).” https://www.cdc.gov/mrsa, accessed December 2016.
Centers for Disease Control and Prevention. “MRSA and the Workplace.”
https://www.cdc.gov/niosh/topics/mrsa/, accessed December 2016.
Centers for Disease Control and Prevention. “Non-Polio Enterovirus.”
https://www.cdc.gov/non-polio-enterovirus/, accessed December 2016.
Centers for Disease Control and Prevention. “Norovirus.”
https://www.cdc.gov/norovirus/, accessed December 2016.
Bibliography cont.
Centers for Disease Control and Prevention. “Pandemic Flu Checklist: K-12 School
Administrators.”
https://www.cdc.gov/nonpharmaceutical-interventions/pdf/pan-flu-checklist-k-12-school-administrators-item2.pdf,
accessed December 2016.
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