Health protection in children and young people settings, including education
SHPN guide to using the external guidance

The diaragram flows in a clockwise direction and outlines the steps in the chain of infection.

Step 1: the infectious agent

This is the microorganism (germ or bug) that can cause harmful infections and make you ill.

Common infections in children and young people settings can include colds, flu and stomach bugs like norovirus.

Step 2: the reservoir

This is where the germ lives and grows.

This can be:

• on a person, for example in their respiratory tract
• on equipment
• in the environment
• in food or water

Step 3: the portal of exit

The germ then needs to find a way out of the infected person so it can spread.

Ways out can be through sickness and diarrhoea and from the nose and mouth through sneezing and coughing.

Step 4: the Mode of transmission

Once the germ is out it can spread from one person to another by hands or on equipment such as toys or furniture, in the air by coughing or through other bodily fluids.

Step 5: the portal of entry

The germ then needs to find a way into another person.

This can be through the eyes and mouth, hands, cuts or grazes and any tubes put into the body such as a catheter or feeding tube.

Step 6: the susceptible host

This is the child or young person who is at risk of infection because they are unable to fight the infection.

Some children and young people have underdeveloped immune systems and catch infections more easily. Infections can spread quickly among children and young people.

What you need to know

Hand hygiene is one of the most important ways of controlling the spread of infections, especially:

• those that cause diarrhoea and/or vomiting (gastroenteritis)
• respiratory infections

Staff should follow local guidance and policies relating to uniform or dress code, including fingernail length and the wearing of artificial nails or polish, both of which may prevent effective hand hygiene and pose a safety hazard.

What you need to do

Ensure everyone has access to liquid soap, warm water, and paper towels.

Bar soap should not be used.

When there is no easy access to soap and water, a hand rub (alcohol or non-alcohol based) can be used if hands are not visibly dirty. It is important to note that hand rubs are not effective against all germs that cause gastroenteritis, such as norovirus.

It may be necessary to supervise the use of alcohol hand gel with young people and always with children. Manufacturer’s instructions should be followed.

There may be occasions where permanent hand hygiene fixtures such as sinks are out of use. Local decision and risk assessment will be required to ensure that staff continue to have access to appropriate facilities. This may include the temporary use of mobile units. Manufacturer or provider instructions for use should be followed.

Advise everyone to clean their hands:

• when arriving to work
• after using the toilet
• before eating or handling food
• after playtime
• after touching animals

Regular hand hygiene throughout the day, particularly when shared equipment/toys are in use, will help prevent the spread of infection.

All cuts and abrasions should be covered with a waterproof dressing.

To make sure hands are cleaned properly with soap and water, the steps in the World Health Organisation (WHO) poster ‘How hands should be washed’ should be followed.

This poster is also provided in the posters for display in settings section and should be printed off and displayed to ensure that all staff, children and young people are aware of and practice this hand hygiene method when required.

Free resources to support hand hygiene education for ages 3 to 16 are available from:

• 'Wash your hands of them' children’s pack, National Infection Prevention and Control Manual (NIPCM)
• e-bug.eu
• NHS 'how to wash your hands'

What you need to know

Covering the nose and mouth when sneezing and coughing can reduce the spread of infections.

Some common infections in children and young people that spread by the respiratory route include:

• rhinovirus (the common cold)
• COVID-19
• respiratory syncytial virus (RSV)
• influenza
• group A streptococcus (the cause of scarlet fever and 'strep throat')
• parvovirus B19 (slapped cheek syndrome)
• chickenpox
• hand, foot and mouth disease

Face coverings

There is no recommendation to use face coverings in children or young people settings in Scotland.

However, anyone who wishes to continue to wear a face covering should be supported to do so.

Careful attention should be given to individuals with additional support needs when implementing this measure.

The use of face coverings may have an impact on babies and young children, especially those with additional support needs.

The ability to see a person’s face clearly contributes to babies and young children’s communication and understanding. 

This is particularly the case for:

• children with hearing loss
• children who are learning English or another language
• those who rely on visual cues to enable them to be included in learning

Some children may need additional support and reassurance around the reasons for adults wearing face coverings, and the wellbeing and needs of children should remain a priority.

Face coverings are not the same as face masks being used as PPE. PPE is only used following an individual risk assessment, as set out in the next section.

What you need to do

Encourage all individuals – particularly those with signs and symptoms of a respiratory infection – to follow respiratory and cough hygiene specifically, to:

• cover their nose and mouth with a tissue when coughing and sneezing, dispose of used tissue in a waste bin, and then wash their hands
• cough or sneeze into the inner elbow (upper sleeve) if no tissues are available
• keep contaminated hands away from their eyes, mouth and nose
• wash hands with soap and water after contact with respiratory secretions and contaminated objects and materials

Staff should help all children and young people who need assistance with respiratory hygiene and ensure they are provided with tissues, a waste bin and hand hygiene facilities.

Staff, children, and young people should be reminded why respiratory hygiene is important to minimise the spread of infection.

Support resources for ages 3 to 16 and are available at e-bug.eu.

What you need to know

PPE can protect individuals from contamination with blood or bodily fluids, which may contain germs that spread infection.

Before doing any procedure or activity staff should always risk assess any likely exposure to blood and/or bodily fluids and in line with risk assessments. If PPE, is required, individuals, should ensure that it provides adequate protection against the risks associated with the procedure or task being undertaken.

Risk assessments should consider the risk and impact of infection occurring and may need to be adaptable if conducted in an emerging situation. This ensures that all people, including those with complex or additional health needs, are supported to continue their care and education in the setting, where it is safe to do so.

One example of where a risk assessment may be required is for an aerosol generating procedure (AGP). See below for further information.

What you need to do

It is the responsibility of the organisation to ensure that risk assessments are undertaken as/when required as part of safe working practices.

If there is a risk of splashing or contamination with blood or bodily fluids during an activity, wear single-use (disposable) gloves and a single use plastic apron. Gloves should be made of latex, nitrile or neoprene.

Wear a fluid-repellent surgical facemask and eye protection if there is a risk of splashing with blood or body fluids to the face.

For aerosol-generating procedures (AGPs)

Certain clinical procedures are rarely undertaken in the settings covered by this guidance.

An AGP is a medical procedure that can result in the release of airborne particles (aerosols) from the respiratory tract.

The AGP list differs slightly in Scotland than in England.

View the AGP list for Scotland.

AGPs from this list which may occur within children and young people settings can include:

• tracheotomy or tracheostomy procedures (e.g. open suction or removal)
• non-invasive ventilation (NIV):
  • bi-level positive airway pressure ventilation (BiPAP)
  • continuous positive airway pressure ventilation (CPAP)
• respiratory tract suctioning beyond the oro-pharynx (the base of the tongue)
• manual ventilation

Training should be in place to support staff to wear eye and face protection, apron, and gloves to protect against the splashing or spraying of blood and bodily fluids from AGPs.

Before undertaking any care, task or procedure staff should assess any likely exposure and ensure PPE is worn that provides adequate protection against the risks associated with the procedure or task being undertaken.

If you or a member of your staff is performing an AGP on an individual who is suspected of being infectious with a respiratory agent (for example RSV or COVID-19), use additional airborne PPE including a fit-tested filtering facepiece 3 (FFP3) respirator.

See this poster for information. 

Residential settings should plan for AGPs in a child with a suspected infection using the advice provided in this guidance. Typically, in non-residential settings, children showing signs of an infection should return home for further care, including AGP. Further advice from the local HPT can support a risk assessment in this situation. 

It is a Health and Safety Executive (HSE) requirement that staff who need to wear an FFP3 respirator must be fit tested. It is the employer’s responsibility to have this in place.

FFP3 respirators should not be worn by staff who are not trained in their use or who have not been fit tested.

All FFP3 respirators must be:

• fit tested (by a competent fit test operator) on all staff who may be required to wear a respirator to ensure an adequate seal/fit according to the manufacturers’ guidance
• fit checked (according to the manufacturers’ guidance) every time a respirator is donned to ensure an adequate seal has been achieved
• single-use (disposable) and fluid resistant
• compatible with other facial protection used such as protective eyewear so that this does not interfere with the seal of the respiratory protection. Regular corrective spectacles are not considered adequate eye protection
• put on before entry to the room where the AGP will be carried out and removed in a safe area once outside the room
• changed after each use

Signs that a change in respirator is required include:

• breathing becomes difficult
• the respirator is wet or moist
• the respirator is damaged
• the respirator is obviously contaminated with bodily fluids such as respiratory secretions

Further information regarding fitting and fit checking of respirators can be found from the Health and Safety Executive.

Settings should designate a room for undertaking AGPs. Designated rooms should be of adequate size and any non-essential equipment or furniture should be removed to allow for ease of cleaning. The room should have a door that can be closed and window that can be opened for ventilation.

Where it is not possible to designate a room, ensure all other staff, volunteers, children and young people are at least 2 metres distance away with a window(s) open for ventilation.

Clear signage should be used that indicates the timing of the last AGP.

Time is required after an AGP is performed to allow the aerosols still circulating to be removed/diluted. This is referred to as the post AGP fallow time (PAGPFT) and is a function of the room ventilation.

Where possible, allow one-hour PAGPFT with a window open before accessing the room without PPE, cleaning the room, or using the room again for an AGP.

Follow local policies or contact your local health protection team for support and advice.

What you need to know

Settings and equipment should be kept clean to reduce the risk of germs spreading.

Cleaning and disinfection are important in all settings, particularly when food preparation is taking place.

Cleaning with detergent and water is generally sufficient in order to remove most germs that can cause infection.

In the event of an outbreak of infection in your setting, your local health protection team should be contacted for support and advice regarding cleaning regimes and any additional products required.

Do not refill spray containers for cleaning products. This is because the tube and pump elements cannot be effectively cleaned and dried which may lead to bacterial growth and therefore, a risk of contamination.

What you need to do

Regularly clean and disinfect all areas or surfaces in contact with food, dirt, or bodily fluids.

Cleaning schedules should clearly:

• describe the cleaning methods
• describe the areas and items to be cleaned
• describe the frequency of cleaning
• state who has responsibility for cleaning

Toys and equipment should be safe for use, easily cleaned and well maintained to reduce the risk of germs spreading.

Toys and equipment should be cleaned:

• regularly as part of a cleaning schedule
• if visibly contaminated
• between use (where possible)
• before or after any servicing or repair

Soft toys should be regularly cleaned following manufacturers’ instructions. It is recommended that all soft toys in the setting are machine washable. Soft toys that are not machine washable should be hand washed using general-purpose detergent and hand-hot water, rinsed and dried.

Plans should be developed for situations where additional cleaning will be required (for example in the event of an outbreak) and how the setting might carry this out without delay.

Staff should be aware of their environmental cleaning schedules and individual responsibilities.

Where applicable, ensure staff are appropriately trained in the use of cleaning products and have access to the appropriate personal protective equipment (PPE) and cleaning equipment. If cleaning is being undertaken using a detergent solution only, vinyl gloves are appropriate for use. Where cleaning requires the use of a chemical disinfectant product, gloves should be made of latex, nitrile or neoprene.

Cleaning equipment used should be disposable or, if reusable, disinfected after each use. Keep all cleaning equipment well maintained, for example check and change vacuum cleaner filters regularly.

Do not refill spray containers for cleaning products as there is a risk of contamination.

Store cleaning solutions in accordance with Control of Substances of Hazardous to Health (COSHH).

What you need to know

Ventilation is the process of introducing fresh air into indoor spaces while removing stale air. Letting fresh air into indoor spaces dilutes air that contains infectious particles. It is recognised that good ventilation supports learning through fewer sick days off from work or school and improves concentration and sleep.

HSE provides guidance on ventilation in the workplace that is relevant to children and young people settings: Ventilation in the workplace.

School settings as a minimum should ensure that ventilation and temperatures are in line with the School Premises Regulations, e.g. avoid leading to cold discomfort.

All workplaces should refer to the Workplace (Health, Safety and Welfare) Regulations 1992 requirements.

As part of the COVID-19 pandemic response, the Scottish Government provided funding to support local authorities to equip education and childcare settings with carbon dioxide (CO2) monitors to help them assess how well-ventilated their spaces were.

CO2 monitors tell us how well-ventilated a room is, but they do not tell us the overall risk of infection.

Many of these monitors will still be in place in learning, teaching and play spaces in Scotland. Where a monitor is not available this can be raised with the owner of the setting or the local authority.

Childminders and those in other children and young people settings were not provided with monitors but should aim to ventilate their setting following the advice below.

What you need to do

Prioritise natural ventilation by opening windows and doors to let fresh air in unless it is unsafe to do so, for example, do not keep fire doors open, or where there is any danger of children leaving the setting unnoticed. Try and open higher-level windows to improve airflow without creating draughts, especially in colder weather.

During the colder months, you may consider opening windows more when the room is unoccupied e.g. in between sessions or lessons. This is known as a purge ventilation.

Those settings with access to CO2 monitors can continue to use them as a tool to assess and manage ventilation, sitting alongside other protective measures, such as cleaning, vaccination, hand washing and staying home when unwell.

General guidelines on how levels of CO2 can be used and potential actions to increase ventilation are set out in the HSE guidance on using CO2 monitors. Each setting should review the options and determine how best to make changes to improve ventilation in their setting.

HSE recommend that CO2 levels consistently higher than 1500ppm in an occupied room indicate poor ventilation. Reaching the maximum level should not be the point at which action is taken. Settings should aim to maximise ventilation before they reach this point and maintain lower levels of CO2.

Consistently improving CO2 levels will benefit the health of staff, young people and children.

Remember however that CO2 measurements are only a broad guide to ventilation rather than demonstrating 'safe levels'.

What you need to know

The UKHSA guidance on the safe management of linen and soft furnishings provides general advice for staff on the management of linen and soft furnishings in children and young people settings that is relevant to Scotland.

Childminders working from their own homes should ensure they utilise safe practices in relation to linen management where food preparation also takes place (i.e., domestic kitchen).

What you need to do

Under the waste management duty of care, settings must ensure that all waste produced is dealt with by a licensed waste management company.

Sharps waste (such as insulin needles) must be disposed of into an approved sharps waste bin. Bins should be stored safely and securely to prevent injury.

Childminders should contact their local primary care health team to discuss arrangements.

In areas where food is handled or prepared

Follow food hygiene standards from Food Standards Scotland (FFS).

Educate children and young people on their role in improving food hygiene. Resources for ages 3 to 16 and are available at e-bug.eu and Food Standards Scotland.

Further information can be found at:

• Scottish Government 'Duty of care: code of practice for managing controlled waste'
• Waste carriers and brokers (Scottish Environmental Protection Agency (SEPA))
• Information for childminders who provide food as part of their service (FSS)

What you need to know

Blood and bodily fluids may contain germs that cause infection. It is not always known whether a person has an infection or not, sometimes there are no symptoms. Therefore precautions should always be taken.

What you need to do

Clean any blood or bodily fluid spillages immediately.

Wear single-use (disposable) gloves and an apron when cleaning any blood or bodily fluid spillages.

A fluid-repellent surgical facemask and eye protection should be worn if there is a risk of splashing with blood or body fluids to the face.

Use disposable paper towels or cloths to clean up blood and bodily fluid spills first.

These should be disposed of immediately and safely after use.

Clean using a product that combines detergent and disinfectant.

The manufacturer’s guidance for the preparation of any solution should always be followed.

Cleaning with detergent followed by a disinfectant is also acceptable.

Chlorine-based disinfectants should not be poured directly onto urine spills as this can release chlorine gas.

Soak up urine spills first with disposable paper towels before using a disinfectant solution.

A spillage kit should be available and used for bodily fluids like blood, vomit, and urine.

Further information on the safe management of blood and body fluid spills is available from the Health and Safety Executive:

• cleaning up body fluids
• What are blood bone viruses?
• management of blood and body fluid spillages poster

This includes needlestick or sharps injuries, cuts, bites, nose bleeds and bodily fluid spills.

What you need to know

An exposure is an injury from a used needle or a bite which breaks the skin, and/or exposure of blood and body fluids onto:

• broken skin
• the eyes, nose or mouth

Injuries of this type including human bites that puncture the skin, are a potential source of exposure to blood borne infections and should be managed promptly and in accordance with guidance and/or local policies.

What you need to do

Be aware of the local health and safety policies and manage incidents such as cuts, bites, bleeds, and spills accordingly.

Local policies should include details of designated first aiders who are appropriately trained.

If an exposure, injury or bite occurs follow these steps.

1. Perform first aid to the exposed area immediately, based on the location of the exposure, injury, or bite.
   • If skin or tissue affected:
     • encourage the area to bleed
     • do not suck on the damaged skin or tissue
     • wash or irrigate with warm running water and non-antimicrobial (plain) soap
     • if running water is unavailable, use pre-packaged solutions, for example, sterile water or saline for irrigation
   • If eyes or mouth affected:
     • rinse or irrigate copiously with water
     • user eye/mouth washout kits, if available
     • if contact lenses are worn, remove then irrigate
2. Once first aid is carried out:
   • report and document the incident as per local procedures
   • ensure that any corrective actions or interventions are taken
   • ensure that the item that caused the injury is disposed of safely
   • assess if further medical assessment is needed

Use the SICPs to reduce the risk of unknown (and known) infection transmission.

These include:

• wearing single-use (disposable) gloves when in contact with blood, bodily fluids, non-intact skin, eyes, mouth, or nose (washing grazes, dressing wounds, cleaning up blood after an incident) and single-use (disposable) plastic apron
• carefully cleaning the wound under running water if possible or using a disposable container with water and wipes; carefully dab dry
• covering all exposed cuts and grazes with a waterproof dressing or plaster
• keeping the dressing or plaster clean by changing it as often as is necessary
• managing all spillages of blood or body fluids

The vaccination team will contact your setting to agree on suitable days for visits.

You should nominate someone in your setting to act as a link person for the vaccination team. This will help with early engagement ahead of the visit and support planning and set-up for the day of the visit.

The team will also provide the setting with a consent pack to send to parents and carers.

This contains:

• an invitation letter
• an informed consent leaflet
• a consent form to sign

Education packs to support teachers and staff to respond to questions or concerns will also be provided. 

Invite

Send the invitation to parents and carers of children and young people who are eligible, in good time and with a clear deadline for response.

Deadlines will be advised by the health board vaccination team.

Communicate

Communicate with children, young people and parents or carers to support return of consent forms.

This should include communication when consent packs are sent home and reminder communications, as well as actively assessing returns and following up where returns are low.

This is crucial to ensuring good uptake and smooth running of immunisation sessions on the day.

Encourage

Encourage parents, carers or staff who may be concerned or require additional guidance to refer to NHS inform or speak to a healthcare professional.

Plan

Consider what space could be made available and provide as much information as possible for the vaccination team so that they can plan their visit and be prepared on the day. Ideally, this should be a large, well-ventilated space – generally a sports hall or similar.

They will:

• set up the venue for the immunisation session
• check consent – if a young person wishes to be vaccinated and a consent form has not been returned, the vaccination team will work with the school to contact the parent/carer to seek verbal consent if necessary
• provide the immunisations to children and young people on the list provided
• remove any sharp, hazardous or medical waste

By law, some young people may be mature enough to provide their own consent.

The health professional will assess if a child under the age of 16 can be considered competent to understand the benefits and risks.

Read more about young people, immunisations and consent on NHS inform.

Ensure access

Ensure that the vaccination team can access the agreed space before the school day starts so they can set up.

Provide, if possible, access to:

• • a power supply with extension cables and anti-trip mats
  • separation screens
  • defibrillator
  • gym mats
  • tables and chairs

Provide easy wi-fi access for the vaccination team.

Clothing

Encourage children and young people to wear loose-fitting short-sleeved tops on the day of vaccination.

Support

Identify and support children and young people who may find the procedure stressful, in partnership with the vaccination team.

Support the vaccination team by providing parent/carer details to check consent as necessary.

Seek verbal consent

If a young person wishes to be vaccinated and a consent form has not been returned, every effort should be made to contact the parent/carer to seek verbal consent.

This is recommended but is not always necessary.

Environment

Help to keep disruption and noise to a minimum.

Ensure a steady flow of children and young people throughout the school day.

Avoid scheduling fire drills or other additional activities on the same day as vaccinations.

Non-clinical waste

Remove any non-clinical waste generated on the day. The vaccination team will deal with the clinical waste.