Gastrointestinal Outbreak Management in Child Care Centres

Identifying an Outbreak

Early recognition of an outbreak, along with IPAC measures, will help limit the spread of illness and the number of children or staff who become ill.

Gastrointestinal Illness

Gastrointestinal (enteric) illness refers to inflammation or infection of the gastrointestinal tract. Symptoms of gastrointestinal illness may occur suddenly, and include:

• Vomiting
• Diarrhea
• Abdominal pain
• Headache
• Fever, chills and/or myalgia

Gastrointestinal illness may be due to:

• Viruses, such as Norovirus, Rotavirus or Adenovirus;
• Bacteria, such as E. coli, Salmonella, Cambylobacter, Shigella, C. Difficile, or Staphylococci; or
• Parasites, such as Cryptosporidium, Giardia, or Amoeba.

In child care centres, gastrointestinal illness is most often caused by viruses, such as norovirus. These viruses are very contagious; they can spread person-to-person by direct contact, or through indirect contact with surfaces or objects in the ill person’s environment. For example, infection may be spread through:

• Touching contaminated surfaces or objects.
• Caring for a person with the illness.
• Changing diapers, or shared diapering equipment that is not effectively cleaned between uses.
• Sharing food, utensils, toys or items with someone who is infected.
• Eating food or drinking liquids contaminated with the virus (contamination of food or water may occur at the source or during transportation, preparation, handling or storage).

An outbreak of gastroenteritis is defined as two or more cases meeting the following case definition with a common epidemiological link (e.g., the same room or program, or same child care provider) with initial onset within a 48 hour period.

A case (child or staff) of gastrointestinal illness can be defined as:

• Two or more episodes of diarrhea within a 24-hour period, or;
• Two or more episodes of vomiting within a 24-hour period, or;
• One or more episodes of diarrhea and one or more episodes of vomiting within a 24-hour period.

If the number of children or staff experiencing gastrointestinal symptoms increase:

• Review your surveillance data, communication books or daily logs.
• Identify similar symptoms of illness in children/staff.
• Review recent child/staff absenteeism records.
• Consider other possible reasons for symptoms (new medications or diet changes).

Reporting an Outbreak

Child care centres must report suspected outbreaks and/or reportable diseases (Diseases of Public Health Significance) to TPH, as outlined in the Health Protection and Promotion Act, R.S.O. 1990, c.H.7, Regulation 135/18.

Child care centres must develop and maintain written policies and procedures in preparation for reporting diseases or suspected outbreaks.

Contacting TPH:

• If an outbreak is suspected or if you are unsure if there is an outbreak, call the TPH Communicable Disease Notification Unit (CDNU) for further guidance: 416-392-7411, Monday to Friday, 8:30 a.m. to 4:30 p.m.
• After hours, call 311
• Fill out the Reportable Disease Notification Form and fax it to: 416-392-0047
• Use the TPH Gastrointestinal Outbreak Reporting Form to report a gastrointestinal outbreak. TPH will use this information to determine if an outbreak exists.

When calling TPH have the following information ready when you call:

• Date and time of the first case
• Date and time of the most recent case
• Total number of ill children and staff per room and total number for the child care centre
• Signs or complaints of symptoms of illness (e.g., diarrhea, vomiting)

If TPH declares that there is an outbreak, a unique outbreak number will be assigned. It is important to include the outbreak number on all outbreak-related documentation.

Working with Toronto Public Health

After reporting a gastrointestinal outbreak, a TPH outbreak investigator (public health nurse or public health inspector) will follow up to conduct an outbreak investigation. During a gastrointestinal outbreak, it is important to work with TPH to minimize further illness spread.

The outbreak investigation may include:

• Assessing the outbreak
• Declaring the outbreak
• Reviewing the Line Lists
• Providing exclusion directions for ill children and staff
• Assisting in the collection and transportation of specimens to the Public Health Ontario Laboratory
• Interpreting laboratory reports
• Reviewing outbreak control measures
• Declaring the outbreak over

In many cases, a public health inspector may also be assigned to conduct an on-site visit to review IPAC measures, confirm outbreak control measures are in place, and provide consultation and education.

Communicating Updates to TPH

It is important to notify the TPH outbreak investigator if:

• A positive test result is received,
• There is spread of illness to another group or cohort,
• There is a change in symptoms experienced,
• There is a hospitalization or death of a child or staff,
• There is a parental concern or a difficult question, or
• There is media interest or concerns.

Create and Maintain a Line List

A Line List is a tool that summarizes information about children and staff associated with the outbreak. The Line List allows the TPH outbreak investigator to assess and monitor the outbreak by keeping track of the number of cases each day. An Enteric Outbreak Line List template will be provided by the outbreak investigator for the child care centre to maintain.

Each new case that meets the case definition should be added to the Line List. Each case should only be listed once, and all cases should be listed in chronological order of when the symptoms began or when the illness started. A separate Line List should be maintained for children and for staff.

Update the Line List daily, and complete all information required. To gather and confirm information, the child care centre operator may be required to contact parents, guardians or staff members. If new information is received, update the Line List and report new information to the outbreak investigator

Collect Samples

Specimen sampling is used to identify the cause of the outbreak. This could include stool samples, food and/or water samples.

During a gastrointestinal outbreak, save any leftover food, if available, for analysis. The food should be dated and kept in the refrigerator. As this food may be a source of illness, the TPH outbreak investigator may arrange to have the food tested. All menus and catering information must be made available.

To help identify the source of the outbreak, it may be necessary to distribute stool kits to collect stool samples. TPH will provide the stool kits, along with a letter to parents instructing them on how to use the kits. Here is information on How to Collect a Stool Sample.

It is important to obtain consent from parents or guardians before submitting a stool specimen to the Public Health Ontario Laboratory. In the event that an opportunity to collect a stool specimen presents itself prior to notifying the parent or guardian, the specimen can be collected but not sent to the lab until consent has been provided. Results from laboratory specimens will always be provided to the parent or guardian of the child by TPH.

Communicating with Families and Staff

Once an outbreak is declared, TPH will provide a letter or fact sheet to be shared with parents and guardians, to inform them of the outbreak and what actions are necessary should their child become symptomatic. TPH will also provide an Outbreak Notification Sign that should be posted at all entrances to inform parents, guardians, staff and visitors of the outbreak.

Outbreak Control Measures

During an outbreak, IPAC measures can help prevent further spread of illness.

Routine Practices

• Routine practices such as hand hygiene, respiratory etiquette, and cleaning and disinfection must always be followed when there is a potential risk of exposure to body fluids.
• Child care centres must ensure that personal protective equipment (PPE) is worn during activities in which staff may be exposed to infection. For example, staff must wear appropriate PPE when they are required to handle soiled items, such as diapers; when they clean and disinfect surfaces or objects that have been contaminated by body fluids, such as vomit; or when they provide care to a child experiencing symptoms of illness.

Exclusion and Cohorting of Ill Children and Staff

• Separate sick children and staff at the child care centre from well children and staff.
• Children who become ill while attending the child care centre should be isolated from other children, and parents or guardians should be called to arrange for them to be picked up. Ensure that ill children are supervised and cared for by a designated staff member.
• During the outbreak, children and staff should be assigned to dedicated rooms (e.g., cohorting). As much as possible, limit the movement of staff from room-to-room.
• Children and staff who are experiencing gastroenteritis will be sent home and should not return to the child care centre until they are no longer infectious to others which means symptom-free for at least 48 hours.

Enhanced Cleaning and Disinfection

During an outbreak, additional cleaning and disinfection measures are needed. For example:

• Frequently-touched surfaces, objects and toys should be cleaned and disinfected more frequently, at a minimum of twice daily and as needed.
• The disinfectant used during an outbreak must be effective against common outbreak pathogens (e.g., norovirus). In some cases, a higher concentration of disinfectant is needed during an outbreak (e.g, “Outbreak Situation” level). Always follow the manufacturer’s instructions. If using chlorine (bleach) as a disinfectant, refer to Toronto Public Health’s Chlorine (Bleach) Solutions for Disinfecting information sheet.

Group Activities

During an outbreak, group activities such as sensory play should be stopped temporarily until the outbreak is declared over. Any sensory play materials (e.g., play dough) that were prepared and in use prior to an outbreak being declared should be discarded.

Hand Hygiene & Respiratory Etiquette

Practicing hand hygiene frequently is the most effective way to prevent the spread of infection. During an outbreak, it is important to provide frequent hand hygiene and respiratory etiquette reminders to all children and staff in the child care centre.

Declaring the Outbreak Over

The outbreak of gastroenteritis must be declared over by TPH. The outbreak will be declared over by the TPH outbreak investigator when the child care centre is clear of new cases for a specified period of time.

Generally, the outbreak is declared over 5 days from the onset of symptoms in the last case. This may change depending on the identification of a specific pathogen causing the outbreak.