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Associate Professor of Sociology, University of Virginia 

More Daycare Disease

Bryce J. Christensen and Nicole M. King

An indispensible part of the feminist program for taking young mothers out of the home, the daycare center exposes young children to a troublingly long list of diseases. Adding one more disease to that list, Pablo Yagupsky of Israel’s Soroka University Medical Center recently published two studies identifying daycare centers as the prime location for the spread of Kingella kingae, a pathogen implicated in “clusters of serious infections, including osteomyelitis, septic arthritis, bacteremia, endocarditis, and meningitis.”  

Yagupsky explains that Kingella kingae is a Gram-negative bacterium usually carried “asymptomatically in the oropharynx and disseminate[d] by close interpersonal contact.” And nowhere is such transmission more likely than in daycare centers.  Noting that daycare center outbreaks of Kingella kingae have been documented in Israel, France, and the United States, Yagupsky assesses such outbreaks as part of a broader pattern. The Israeli scholar underscores the consequent health risks for the “growing number of children receiving care outside the home.” “The incidence of infectious diseases in general, and of those caused by respiratory pathogens in particular, has substantially increased among daycare center attendees,” he remarks. 

The linkage between infectious diseases and daycare centers is obvious to Yagupsky, who traces the spread of pathogens “within daycare centers by child-to-child transmission; they colonize the upper respiratory tract surfaces, from which they can disseminate to other attendees. From the upper airways, pathogens may invade adjacent structures such as the lungs, middle ear, or nasal sinuses, and may penetrate into the bloodstream, causing invasive diseases.”  

Because the respiratory germs that spread in daycare centers are typically enclosed by polysaccharide capsules, they may elude some of the body’s simpler immune responses, so surviving in the bloodstream and deep-body tissues. The survival of these pathogens poses a particularly great risk for very young children, Yagupsky points out, because “maturation of the T-cell independent arm of the immune system in humans is delayed until the age of 2–4 years; thus, young children are prone to colonization and infection by encapsulated bacteria.”  

Of course, children can contract diseases in crowded settings other than the daycare center. They can even contract dangerous germs at home. But Yagupsky stresses the singularly pathogenic character of the daycare center as a setting that brings together relatively large numbers of young children of “approximately the same age . . . [with] similar degrees of immunologic immaturity and susceptibility to infectious agents.”  “This epidemiologic setting,” he insists, “substantially differs from that of large families in that the latter include children of different ages and therefore, at any given time, only a fraction of . . . siblings belong to the age group at enhanced risk for bacterial colonization and invasion, which limits the chances to acquire and transmit the organism.” 

Limning the health perils at the daycare center, Yagupsky remarks on how “respiratory organisms spread easily [in such a setting] through large droplet transmission among young children with poor hygienic habits, who share toys contaminated with respiratory secretions or saliva.” “Introduction of a virulent bacterium in a crowded daycare facility attended by immunologically naïve children,” he warns, “may result in prompt dissemination of the organism and initiate outbreaks of disease such as those caused by pneumococci, Haemophilus influenza type b, or Neisseria meningitidis.”

Dispelling doubt about the role of daycare in spreading Kingella kingae are data collected from 1,277 children younger than five who had been referred to an Israeli pediatric emergency center. Analysis of these data established a strong independent statistical relationship between K. kingae colonization and out-of-home care. Compared to children cared for at home, children who were cared for outside the home were almost ten times as likely to have been colonized by this pathogen (Odds Ratio of 9.66; p < 0.001). 

Examining relevant recent reports from Israel, Western Europe, and the United States, Yagupsky finds “high disease attack rates [related to Kingella kingae] among [daycare-center] attendees, ranging from 14% to 21%.” To be sure, Yagupsky acknowledges that “with the exception of patients with endocardial involvement, children with K. kingae diseases often show only mild symptoms and signs,” reassuring his readers that “if adequately and promptly treated, invasive K. kingae infections with no endocardial involvement usually run a benign clinical course.”  

However, Yagupsky sees reason for concern in data collected from six daycare center K. kingae outbreaks, outbreaks involving a troubling number of “documented or presumptive K. kingae infections, including fatal endocarditis and meningitis.” Yagupsky thus fears that “the risk of acquisition of K. kingae with progression to a severe and even life-threatening infection appears to be greatly increased among youngsters in daycare.” 

In his conclusion to the more recent of his two articles on the issue, Yagupsky frankly admits that “many issues remain unsettled” in trying to deal with K. kingae. Physicians do not yet know whether the diagnosis of one K. kingae case in a daycare center should trigger the administration of antibacterial drugs to other asymptomatic daycare center attendees and to asymptomatic siblings. Nor do they yet know just what regimen of antibiotic drugs would be most effective in combatting this pathogen.  

What is becoming increasingly clear, however, is that the millions of children in daycare centers face serious health risks. No plan for administering antibiotics will do as much to eliminate those risks as will measures that get children out of such centers and back into their own homes with their mothers.    

(Pablo Yagupsky, “Outbreaks of Kingella kingae Infections in Daycare Facilities,” Emerging Infectious Diseases 20.5 [2014]: 746-53; Pablo Yagupsky, “Kingella kingae: Carriage, Transmission, and Disease,” Clinical Microbiology Reviews 28.1 [2015]: 54-79.)