Immediate Separation is Most Appropriate
Children with cystic fibrosis should be immediately separated and not allowed to play together, regardless of mask use, as person-to-person transmission of dangerous respiratory pathogens like Pseudomonas aeruginosa occurs between CF patients even with infection control measures. 1, 2
Why Separation is Critical
Evidence of Cross-Infection Risk
The Wisconsin Randomized Controlled Trial demonstrated that CF children who were not isolated from other CF patients acquired P. aeruginosa at a median age of 1.0 years, compared to 5.6 years for those who were isolated—a dramatic 4.6-year difference 3, 1, 2
Whole genome sequencing studies have confirmed frequent transmission of Mycobacterium abscessus between CF patients despite conventional infection control measures, proving that standard precautions are insufficient 1
Australian evidence further documented acquisition of P. aeruginosa from other CF patients cared for at the same center 3
Why Masks Are Inadequate
Masks alone do not adequately prevent cross-infection between CF patients, as they may reduce droplet transmission but cannot be relied upon to prevent transmission of antibiotic-resistant strains or new pathogens 1
Research shows that transmission of P. aeruginosa is possible beyond even 1 meter during both talking and coughing, with documented transmission occurring despite distance 4
The Cystic Fibrosis Foundation issued recommendations in 2003 specifically to segregate patients from each other to minimize person-to-person transmission 1
Minimum Distance Requirements When Contact Cannot Be Avoided
American Thoracic Society/European Respiratory Society guidelines recommend maintaining at least 3 feet (approximately 1 meter) distance from all others with CF in outpatient clinic settings 1, 5
However, even this distance is not completely safe—a study examining 336 samples from 42 CF patients found that transmission beyond 1 meter is possible, though the probability is lower at 1.7% 4
The conservative 6-foot distance represents a more protective approach to minimize cross-infection risk, particularly for P. aeruginosa and M. abscessus complex 1
Role of Influenza Vaccination
While annual influenza vaccination is critical for both children and should be administered as part of routine CF care, this does not address the cross-infection risk between CF patients 2, 6
Influenza vaccination prevents viral respiratory infections that increase risk of bacterial superinfection and pulmonary exacerbations, but it does not prevent bacterial pathogen transmission between CF patients 2
Both children should receive influenza vaccine annually per national guidelines, but this is a separate issue from preventing cross-infection 2
Clinical Bottom Line
The evidence strongly supports avoiding close contact between children with CF to prevent cross-infection 1, 2. Neither mask-wearing nor vaccination addresses the fundamental risk of bacterial pathogen transmission that occurs with proximity between CF patients. The most appropriate action is Option C: immediately separate them and educate families about maintaining distance of at least 3-6 feet from other CF patients in all settings 1, 5.