To protect children, families and staff, it is important that child care centres and Toronto Public Health (TPH) work closely with one another in the prevention, early identification and control of infectious diseases. When a case or outbreak of an infectious disease is suspected, early identification is crucial in ensuring the prompt implementation and enhancement of infection prevention and control (IPAC) measures that can help prevent further spread.
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 (enteric) illness refers to inflammation or infection of the gastrointestinal tract. Symptoms of gastrointestinal illness may occur suddenly, and include:
Gastrointestinal illness may be due to:
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:
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.
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.
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.
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:
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.
It is important to notify the TPH outbreak investigator if:
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
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.
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.
During an outbreak, IPAC measures can help prevent further spread of illness.
During an outbreak, additional cleaning and disinfection measures are needed. For example:
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.
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.
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.