Parents – Why It Is Now Legal to Put Your Child's Nappy in the Dustbin

Introduction

There are various diseases which are notifiable in England and Wales under the Public Health (Control of Disease) Act 1984 ¹ and the Public Health (Infectious Diseases) Regulations 1988. ¹ Notifiable diseases in England and Wales include cholera, plague, relapsing fever, smallpox, typhus and food poisoning. There are also various other disease which are “required to be notified”; these include anthrax, leprosy and tetanus.

Although food poisoning was not expressly defined in the Act, the Chief Medical Officer’s letter PL/CMO (92) 14 indicates that the definition is: “Any disease of an infectious or toxic nature caused by or thought to be caused by the consumption of food or water”. ¹ The letter adds that this definition includes “all food or waterborne illness regardless of the presenting symptoms and signs; thus it includes not only acute illnesses characterized by diarrhoea and/or vomiting, but also illnesses presenting with manifestations not related to the gastroenterital tract …”. ¹ This would include illnesses caused by toxic chemicals irrespective of origin but exclude illnesses due to allergies and food intolerances. Thus this definition would include most types of gastroenteritis.

Under s 26(1) of the Public Health (Control of Disease) Act 1984 Part II, it was a criminal offence to place material which is known to have been exposed to infection from a notifiable disease or one of a number of additional diseases, and which has not been disinfected, in a dustbin. ¹ Furthermore, s 26(2) of the 1984 Act placed the local authority under a duty to inform the occupier of a house in which they were aware that a person was suffering from a notifiable disease of this provision. Under s 26(3), the London Borough Council was even under a duty to remove and disinfect or destroy any rubbish that had been exposed to infection from such a disease if requested by the occupier of the house. ¹

One such potential infection risk that is often placed in dustbins is the disposable nappy, particularly from children who are suffering from gastroenteritis. Disposable nappies are increasingly used by parents in the UK for children who are not “potty trained”, often aged under two years. In this country, nearly 3 billion nappies are thrown away every year, comprising about 4% of household waste. ²

Gastroenteritis in children is characterized by a sudden onset of diarrhoea with or without vomiting. It is caused by a range of enteric viruses, bacteria and protozoal pathogens. ³ Rotavirus is the most common responsible pathogen in the developed world. In infants and children, gastroenteritis is often a relatively mild illness lasting for only a few days, managed at home with appropriate professional advice. In rare instances, however, children may require admission to hospital.

In order to estimate the incidence of gastroenteritis, a prospective observational study was undertaken in the UK and selected Western European countries of children younger than five years who received medical treatment in a range of settings. ⁴ It found that about 10% of children younger than five years present to health-care services with gastroenteritis each year, with rotavirus infection comprising 28–52% of cases identified. In another study from the UK, diarrhoeal illness accounted for 16% of medical presentations to a major paediatric accident and emergency department. ⁵ Therefore, we can surmise that nappies containing infectious material from a notifiable disease are discarded in dustbins on a regular basis.

Methods

To answer the question of whether discarded nappies pose a real infectious threat, a literature search using PubMed was undertaken on the relationship between nappies and the transmission of infectious disease. Two separate queries were conducted for the MeSH terms “Diapers, Infant” and “Disease Transmission”. The two queries were combined using the Boolean operator “AND” to concentrate on articles that contained both terms. This process was repeated for the keyword “Nappy” and the MeSH term “Disease Transmission”. It was considered that using these terms would cover all citations. Terms that focused on a specific outcome (eg “Nappy and Disease transmission”) were not used so as to minimize search bias.

Results

These searches produced approximately 300 citations for “Diapers, Infant”, 100 for “Nappy” and 90,000 for “Disease Transmission”.

Combining the search terms resulted in 14 and four papers, respectively. Of the 18 papers identified, one was common to both searches. A review of abstracts for the 17 papers revealed that only 13 of these had some relevance to the research question. The majority of these papers involved spread of infection in child daycare centres/nurseries.

Nesti and Godbaum ⁶ found that children cared for in child daycare facilities exhibited up to a three times greater risk of acquiring infections. Thompson ⁷ described the major risk factors for transmission of enteric pathogens in preschool children cared for in daycare centres. One of these was staff combining nappy changing with food preparation duties. Other researchers noted that the high proportion of children in nappies and staff members whose hands were contaminated in nurseries was certainly a factor in disease transmission in these institutions. ⁸

In terms of specific infections, Hadler and McFarland ⁹ looked at hepatitis A outbreaks in daycare centres and discovered that those adults having contact with one- or two-year olds (ie those wearing nappies) had the greatest risk of acquiring an infection. Mohle-Boetani et al. ¹⁰ investigated risk factors for transmission of echovirus 30 infections from children to adult household members. Changing nappies was a risk factor for recent infection. Researchers in Norway reported on an outbreak of giardiasis in a child daycare centre. ¹¹ Although the origin of the infection was not found, one possible source identified was that staff who changed nappies also prepared food. Teresa Ortega et al. ¹² investigated a cryptosporidium outbreak in a child daycare centre. The wearing of nappies was one of two factors associated with an increased risk of disease. A group of investigators in the United States also looked at an outbreak of cryptosporidium involving 358 cases, but in a recreational waterpark. ¹³ They noted that one of the factors contributing to the outbreak was heavy use of the waterpark by children who wore nappies. Pessoa-Silva et al. ¹⁴ examined the dynamics of bacterial contamination of health-care workers’ hands during neonatal care in a large teaching hospital in Switzerland. They discovered that among other factors, nappy change was independently associated with an increased bacterial count. As part of an in-depth multidisciplinary study of carer and child hygiene in the domestic environment in the Wirral, UK, researchers took microbiological samples from household surfaces at sites thought likely to be involved in the transfer of faecal material. ¹⁵ Nappy changing took place mainly in living rooms. Contact with living room surfaces and objects during nappy changing was frequent and evidence of faecal contamination was found in 12% of living room samples.

In terms of control measures, Nesti and Godbaum ⁶ remarked that one of the measures effective for reducing transmission of infection included standardized routines for the changing and disposal of used nappies. Teresa Ortega et al. ¹² recommended taking more care with nappy-changing practices, especially with children suffering from diarrhoea. Reporting on an outbreak of rotavirus in a nursery in Taiwan, ¹⁶ researchers agreed that one of the most effective outbreak control procedures was careful management of nappies. Kotch et al. ¹⁷ investigated whether the installation of equipment for nappy changing, among other factors, would result in a decrease in the rate of diarrhoeal illness among children and their teachers in child daycare centres. They concluded that its use did indeed significantly reduce diarrhoeal illness. Evaluating the effect of two types of nappy on faecal contamination in a nursery, ¹⁸ investigators concluded that containment of faeces by overclothes and the type of nappy may be important in decreasing transmission of enteric pathogens. In their study of echovirus 30 infection, Mohle-Boetani et al. ¹⁰ noted that handwashing provided some protection, with a negative correlation between handwashing after nappy changes and infection among adults with infected children in nappies.

Discussion

Although these papers show that notifiable diseases can be transmitted via the use of and particularly the changing of nappies without adequate infection control procedures, no evidence was found of notifiable disease transmission through discarded nappies in dustbins. It should be borne in mind, however, that any contact between a properly discarded nappy in a rubbish bag and a refuse collector, or a member of the public, is minimal. In addition, a systematic literature review was not performed on this search question, only one database was searched, and there was no assessment of the quality of the studies found.

As it was increasingly recognized in the new millennium that many of the provisions of the Public Health (Control of Disease) Act 1984 were based on outdated legislation, the Welsh Assembly Government published a consultation paper in April 2007 which set out proposals for changes to key parts of the Act. ¹⁹

On completion of a consultation exercise, amendments to the Public Health (Control of Disease) Act 1984 were included in the Health and Social Care Bill, introduced to Parliament in November 2007. ¹⁹ Receiving Royal Assent in July 2008 and thus becoming an Act, this updated the powers in Part II of the Public Health (Control of Disease Act) 1984 for preventing and controlling the spread of disease, and extended the powers to cover radioactive or chemical contamination.

Conclusions

It can be seen that s 26 (1) of the Public Health (Control of Disease) Act 1984 made it a criminal offence to place material which is known to have been exposed to infection from a notifiable disease or one of a number of additional diseases, and which has not been disinfected, in a dustbin. A literature review has not revealed any evidence of notifiable disease transmission through discarded nappies in dustbins. Fortunately, Part II of the Public Health (Control of Disease) Act 1984 has now been replaced by Part IIA by virtue of the Health and Social Care Act 2008, and so s 26(1) no longer applies. This is both an evidence-based decision and more importantly, decriminalizes thousands of parents who decide to discard their babies’ nappies in the dustbin.