In the child care setting, operators, staff and families each have an important role to play in protecting children and one another from infections and illness.
There are measures individuals can take to prevent infections and outbreaks, including immunization, hand hygiene, respiratory etiquette, and cleaning and disinfection practices. Developing and following a comprehensive Infection Prevention and Control (IPAC) program, and ensuring that all staff receive training, can help to limit the spread of illness in child care centres.
In addition to immunizations for staff and children, an outbreak management plan, and administrative health policies and procedures, a comprehensive IPAC program includes the components outlined in the sections below:
IPAC measures should be made into routine practices at child care centres to stay safe and prevent the spread of illness.
In child care centres, staff may be exposed to infections through their everyday work. Routine practices are a set of strategies to prevent the spread of infection. Routine practices are based on the concept that all body fluids, secretions, excretions, mucous membranes, non-intact skin, blood, and soiled items are potentially infectious. Elements of routine practices include:
Microorganisms, too small to be seen with the naked eye, are everywhere around us, found in food, water, people, animals, air and soil. Many microorganisms are harmless and do not lead to infection, and some are even necessary for health.
Some microorganisms, however, can cause infection. We call these microorganisms pathogens, infectious agents or, more commonly, germs.
Germs cause a number of illnesses commonly seen in child care centres such as common colds, influenza (the flu), norovirus, strep throat and food-borne illness. For more information, see Toronto Public Health’s Communicable Disease Information for Schools & Child Care Centres.
The Chain of Transmission model helps to understand how germs are spread from person-to-person, and how IPAC measures can “break the links” and prevent illness.
Germs include any microorganism that is capable of causing an infection, including:
Break the chain: IPAC measures such as hand hygiene, cleaning and disinfection, and cooking foods to safe temperatures can break this link in the chain of transmission.
Reservoirs are places where germs live and grow, including people, animals, food, water and the environment.
Break the chain: IPAC measures, such as improving air filtration and ventilation, food safety measures, and staying home when sick can break this link in the chain of transmission.
The portal of exit is how the germs get out and leave the reservoir (e.g., sneezing and coughing).
Break the chain: IPAC measures, such as wearing Personal Protective Equipment (PPE), practicing respiratory etiquette and hand hygiene can break this link in the chain of transmission.
The mode of transmission refers to how germs spread from person-to-person. The following are the three main modes of transmission:
Contract transmission includes:
Droplet transmission occurs when an infected person coughs or sneezes into the air. Respiratory illnesses, including the common cold and the flu, can spread when droplets come in contact with the mucous membranes (e.g., the eyes, nose or mouth) of another person.
Droplets can be expelled up to 2 metres through the air. They can also land on surfaces, contaminating the environment. Many survive on surfaces for a long period of time.
Airborne transmission occurs when an infected individual expels tiny droplets (or aerosols) into the air, either by coughing, sneezing, singing, laughing or otherwise exhaling in some way. These aerosols remain suspended in the air, and may travel along air currents. Transmission occurs when aerosols are inhaled by another individual. Examples include chicken pox, measles and tuberculosis.
Break the chain: IPAC measures, such as improving ventilation, hand hygiene, covering our coughs and sneezes, and using PPE can break this link in the chain of transmission.
The portal of entry refers to how germs enter a new person. Portals of entry include the mucous membranes of our eyes, nose and mouth; the respiratory tract; the gastrointestinal track; and broken skin.
Break the chain: IPAC measures such as practicing hand hygiene, using PPE, and avoiding touching our eyes, nose or mouth with unwashed hands can break this link in the chain of transmission.
Anyone can develop an infection, however some individuals may be at higher risk of getting very sick. This may include the very young, the very old, pregnant people, unvaccinated people, and those with weakened immune systems or chronic health conditions.
Break the chain: IPAC measures such as keeping up-to-date with immunizations and taking measures to protect those who are at higher risk can help break this link in the chain of transmission.
Download the Break the Chain of Transmission poster.
Monitoring for illness includes observing for signs and symptoms of disease (i.e., surveillance) and maintaining records. This is an important part of IPAC, and is key to identifying and possibly preventing an outbreak. Record the following information as part of routine monitoring in a child care centre:
According to the Child Care and Early Years Act, child care centres must ensure that an observation is made of each child at the beginning of each day to detect possible symptoms of illness.
Hands carry and spread germs. Touching our eyes, noses or mouths without cleaning our hands, or sneezing or coughing into our hands, may provide an opportunity for germs to get into our bodies. Keeping hands clean through good hygiene is one of the most important steps to avoid getting sick and spreading germs. In child care centres, hand hygiene is one of the single most important measures to prevent the spread of infections.
There are two ways to clean our hands:
The purpose of hand washing is to physically remove soil, organic material and germs. The use of soap, warm running water, and friction is an effective way to remove germs from our hands.
When clean, running water is available, wash hands with soap and water and dry thoroughly. In child care centres, children and staff should use a sink that is dedicated for the purpose of hand hygiene.
Each room with a designated hand washing station (i.e., IPAC sink) must be equipped with:
Alcohol-based hand sanitizers are very useful when soap and water are not available. When hands are not visibly dirty, then a 70-90% alcohol-based hand sanitizer can be used. People who are involved in food preparation should not use hand sanitizers but instead, wash their hands with soap and water.
Alcohol-based hand sanitizers can be harmful if swallowed. To reduce the risk of ingestion, it is important to always have child care staff help and supervise children when they use alcohol-based hand sanitizers. Keep alcohol-based hand sanitizers out of reach of children when not in use.
Note: Child care centres must ensure products are not expired, appropriate for use and follow manufacturer’s instructions.
Note: Artificial nails, chipped nail polish, and jewelry can harbour germs. For this reason, it is recommended that staff at child care centres keep their nails short and clean.
Germs such as influenza and cold viruses, and even whooping cough, are spread by coughing or sneezing. When you cough or sneeze on your hands, your hands carry and spread these germs. When possible, keep your distance (more than two metres) from people who are coughing or sneezing.
Respiratory infections are spread easily in settings where people are in close contact, such as child care centres. To prevent the spread of germs that cause respiratory infections, proper respiratory etiquette should be taught and practiced regularly by children, staff and visitors.
Child care operators must provide education to staff and children regarding hand hygiene and respiratory etiquette. The following resources may be useful:
To support hand hygiene in a child care centre, implement a hand hygiene and respiratory etiquette program that includes the following elements at a minimum:
As part of routine practices, child care centre staff should continuously perform a risk assessment. During a risk assessment, staff assess and analyze whether there is a potential for exposure to body fluids or infectious diseases.
Based on this risk assessment, staff must then choose appropriate IPAC measures and Personal Protective Equipment (PPE). PPE refers to protective clothing that is used to prevent the transmission of illness, including gloves, gowns, masks and eye protection.
Proper glove use provides barrier protection. Wear gloves when it is anticipated that hands will be in contact with mucous membranes, broken skin, blood, body fluids, or contaminated surfaces or objects.
Some individuals may be allergic or sensitive to certain types of single-use gloves (e.g., latex). When selecting gloves, consider individual allergies and sensitivities.
To protect hands and reduce irritation, choose gloves that are comfortable, well-fitting, clean and dry. Clean and dry hands before and after wearing gloves. Ensure that any cuts or abrasions on hands are covered with a waterproof bandage prior to applying gloves.
Masks help to protect individuals from germs that may enter the mucous membranes of their nose or mouth. Wear a mask if there is a risk of becoming exposed to a cough, sneeze, spray, or splash.
Eye protection, including goggles or face shields, helps to protect the individual from germs that may enter through the mucous membranes of the eyes. Wear eye protection if there is a risk of becoming exposed to splashes or sprays of body fluids.
Wear gowns if there is a risk of clothing or uncovered skin becoming exposed to splashes or sprays of body fluids.
For guidance, see:
To protect themselves and others from infection, it is important that child care centre operators and staff apply IPAC measures and routine practices when there is a potential risk of exposure to body fluids, including during diapering and toileting.
Child care centres must have a written policy and procedure in place that clearly outlines IPAC measures for diapering and toileting routines.
To help prevent transmission of infection and reduce the risk of cross contamination during diapering and toileting, it is important to consider the location and set-up of the diaper change station:
Please refer to the Diaper Change Routine information sheet for diapering steps.
The use of potty chairs is generally not recommended because of concerns related to waste disposal, storage of the chairs themselves and potential for cross contamination. However, there may be times where a child requires the use of a potty chair based on their individual needs. In these circumstances, policies and procedures for potty use must be created to support staff. Potty chairs must be:
If used, potty chairs should be viewed as a transitional step. It is important for child care staff to partner with children and families, promoting toileting skills and helping children to become more comfortable and confident with the toileting process.
Please refer to the Toilet Routine information sheet for toileting steps.
Strategies to improve ventilation can also help prevent infections in child care centres. Given the various types of settings that child care centres operate from, not all strategies may be applicable. Below are some strategies to consider:
Infections can spread when a person touches a contaminated surface or object and then touches their mouth, nose or eyes. Some germs can survive for long periods of time on surfaces, including doorknobs, faucet handles, toys, and diapering tables. Frequent cleaning and disinfection is an important measure to prevent the spread of infections in child care centres.
Child care centres must:
It is important to remember that cleaning and disinfection are two separate processes. To be effective, cleaning must be done before disinfection.
Cleaning describes the physical removal of debris and contaminants from a surface, and is accomplished using warm water, soap and friction (e.g., scrubbing). Cleaning reduces the number of germs on a surface, and removes dirt, dust, grease, body fluids and other organic materials. Organic material such as dirt and grease may coat and protect microorganisms. For this reason, cleaning is an important first step prior to disinfection:
Cleaning equipment may include multi-use gloves (e.g., rubber gloves), masks, eye protection (e.g., goggles), paper towels or cloths, and mops.
Disinfection describes the process of killing most germs on surfaces or objects (such as activity tables, diaper change tables or toys), using a chemical solution called a disinfectant. Apply disinfectants to a surface or object after it has first been cleaned.
Disinfectants must:
When using cleaning and disinfection products, there are several important safety considerations, including:
Carpets and floor mats can be more heavily contaminated for prolonged periods than non-carpeted floors and can be a potential source of microorganisms during outbreaks. Child care centres that use carpets and floor mats must ensure that:
Frequently-touched surfaces are those with frequent hand contact and include but are not limited to sinks, faucet taps, toilets, railings, floor mats, high chairs, feeding tables, plastic bibs, doorknobs, light switches and electronic devices that are touched frequently by hands. These surfaces require frequent cleaning and disinfection.
| Frequency | Method | |
|---|---|---|
| Toys | ||
| Mouthed toys | After each use | Clean & disinfect |
| Infants (< 18 months) |
Daily | Clean & disinfect |
| Shared plastic toddler toys | Daily | Clean & disinfect |
| Toddlers (18 months to 30 months) |
Weekly | Clean & disinfect |
| Pre-school (30 months to 5 years of age) |
Weekly | Clean & disinfect |
| Kindergarten & school age | Monthly | Clean & disinfect |
| Plush toys and dress-up clothes | Weekly | Launder |
| Sensory Materials | ||
| Water sensory play bins | After each session | Drain, clean & disinfect |
| Used homemade playdough/slime | After each use | Discard |
| Sand play bins and toys | Weekly | Discard sand, clean & disinfect play bin and toys |
| Activity table | After each use | Clean & disinfect |
| Water play toys | After each session | Clean & disinfect |
| Play Areas & Surfaces | ||
| Carpets – infant rooms | Every three months | Shampoo or steam clean |
| Carpets – all other rooms | Every six months | Shampoo or steam clean |
| Floors (including carpets) | Daily | Vacuum and/or wet mop |
Toys and play-based learning are essential to each child’s well-being, growth and development. However, toys may become contaminated from unwashed hands or saliva, and increase the risk of spreading infections. It is important that child care centres implement a toy cleaning and disinfection program.
Child care centres must:
When a toy is mouthed or becomes contaminated by a child’s cough, sneeze or runny nose, or if the toy appears dirty, it must be removed from use and not handled by another child until it has been properly cleaned and disinfected. For mouthed toys, check products to confirm they are appropriate for use on food contact surfaces OR use a mechanical dishwasher. Mouthed toys must be thoroughly rinsed with water following disinfection.
The frequency of cleaning and disinfection varies depending on the age group and the amount of handling:
Designated cupboards and storage containers used to store toys must be emptied, cleaned and disinfected as necessary.
Indoor play structures (e.g., playhouses/climbers) must be cleaned and disinfected as often as necessary. A thorough cleaning of the entire play structure must be done according to schedule. Frequency of cleaning is determined by the age group using the play structure.
| Toys | Frequency | Method |
|---|---|---|
| Mouthed toys | After each use | Clean & disinfect |
| Infants (< 18 months) | Daily | Clean & disinfect |
| Shared plastic toddler toys | Daily | Clean & disinfect |
| Toddlers (18 months to 30 months) | Weekly | Clean & disinfect |
| Pre-school (30 months to 5 years of age) | Weekly | Clean & disinfect |
| Kindergarten & school age | Monthly | Clean & disinfect |
| Plush toys and dress-up clothes | Weekly | Launder |
To disinfect toys, always clean and rinse prior to disinfection. Use the three-compartment sink method.
Please refer to the Toy Cleaning & Disinfection information sheet.
Play is essential for every child’s development. However, sensory play materials can become contaminated with germs. It is important that child care centres take measures to create a safe, healthy environment for children during play.
Child care centres must have a written policy and procedure in place that clearly identifies IPAC measures for sensory play activities:
Gardening can be a wonderful learning experience for young children, giving them an opportunity to care for something over time and to develop an appreciation for nature.
Child care centres must:
When planning a garden it is important to consider previous and current land use practices of neighbouring properties. Some actions to consider include:
Child care centres must have written policies that clearly outline IPAC measures for safe use, handling and storage of personal items.
Sleep is an essential part of children’s physical, mental and emotional health, and many child care centres schedule nap or sleep time as part of their programming.
Sleep equipment includes cribs, crib mattresses, sleeping cots, mats and bedding/linens. To ensure these items are not a potential source of infection, it is important that child care centres take IPAC measures:
Dirty clothing, linen and bedding can be a potential source of infection in child care centres. It is important to take appropriate precautions.
If laundry is done on-site or if an off-site laundering service is used, child care centres must ensure that policies and procedures include directions for the collection, transport, handling, washing, and drying of linen, bedding and soiled items (e.g., clothing contaminated with body fluids).
Staff must always complete a risk assessment and wear appropriate PPE when handling contaminated items, including bedding, linen or soiled clothing.
Proper food handling practices within child care centres reduce the risk of foodborne illness, which is caused by eating or drinking foods that have been contaminated by bacteria, viruses, moulds or parasites. The symptoms of food borne illness may vary, but the most common symptoms include fever, stomach cramps, nausea, vomiting and diarrhea. Usually, these symptoms begin within hours after eating contaminated food, although in some cases may take days or weeks to appear.
Children are considered a high risk population because they do not have a fully developed immune system, and therefore are at a higher risk of experiencing severe health complications if they experience food borne illness. Learn how to report food poisonings to Toronto Public Health.
To help keep children safe and healthy, it is important that child care centres take measures to ensure that food is prepared, handled and stored safely. Child care centres must have written policies and procedures in place regarding food safety and safe food handling practices.
All food products purchased or brought in to the centre must be from an approved source (e.g., restaurants, supermarkets, bakeries) that is inspected or graded. Inspection results in the City of Toronto can be viewed on the Dine Safe webpage.
Child care centres should maintain a record of:
Centres that are not catered should have recipes, menus and proof of purchase from an inspected facility for all food brought into the centre.
Parents can provide food for their own child, for example, expressed breast milk or food required for special dietary restrictions. Food containers sent in with a child must be clearly labelled with the child’s name and date of delivery.
Child care centres that are catered must ensure that the caterer is an inspected premise and should obtain a copy of the inspection report from the catering company.
Upon receiving catered food, child care settings must record the temperatures of hazardous foods in a log book. This temperature must be checked again prior to serving. Below are some questions to consider when looking for a catering company for your child care centre:
The “Danger Zone” is a temperature range in which bacteria that cause foodborne illness can multiply at its quickest. This range is between 4°C (40°F) and 60°C (140°F). To prevent bacteria from growing to dangerous levels, every effort must be made to prevent food from being stored within this temperature range.
To effectively clean and disinfect utensils and dishes, use either the manual dishwashing method or a mechanical dishwasher.
The manual dishwashing method can be conducted in two ways:
Centres equipped with a mechanical dishwasher must ensure that it is in compliance with O. Reg 493/17 Food Premises. Mechanical dishwashers must be equipped with accurate and easily readable thermometers to determine effective wash and rinse cycle temperatures:
Operators must be aware of the foods that are being served to children within their child care centre. Toronto Public Health advises child care operators to subscribe for Health Canada’s Recalls and Safety Alerts. Food recall warnings and allergy alerts can prevent food borne illnesses or a serious allergic reaction.
Severe allergic reactions (e.g., anaphylactic reaction) occur when the body’s immune system reacts strongly to a particular substance. These reactions may be caused by food, insect stings, latex and medications. Health Canada and the Canadian Food Inspection Agency (CFIA) have identified common food allergens including: eggs, milk, mustard, peanuts, crustaceans and molluscs, fish, sesame seeds, soy, sulphites, tree nuts and wheat.
Anaphylaxis is a serious, potentially life-threatening medical emergency that must be recognized and responded to promptly. Work closely with the child and parent/legal guardian to gather as much detail as possible regarding the allergen(s), the child’s reaction to the allergen(s), and the steps to take if an allergic reaction occurs. As per the Ontario Regulation 137/15 made under the Child Care & Early Years Act (CCEYA), each child care centre must have an anaphylactic policy that includes the following:
For more information regarding the above information, contact the Ministry of Education by calling 416-325-2929 or visit the following webpages:
To prevent foodborne illness from occurring, child care centres can follow four simple steps for food safety:
Safe drinking water is essential to public health. Child care centre operators are responsible for providing safe and potable water to children and staff.
Under the Ontario Safe Drinking Water Act, child care centres are identified as being a designated facility. This means that drinking water within child care centres is regulated by the Ministry of the Environment, Conservation and Parks, and there are specific sampling, testing, treatment and reporting requirements that apply. For questions, contact the Ministry of the Environment, Conservation and Parks.
If a child care centre becomes aware of an adverse water quality incident, they must contact:
In the event of a Boil/Drinking Water Advisory or a water disruption/shortage, have a contingency plan. This plan should include:
In the event of a water interruption during hours of operation, child care centres should consider:
Breast milk supports the optimal growth and development of infants, and is a complementary addition to a young child’s diet beyond one year.
Support parents/caregivers in their decision to provide expressed breastmilk for their infant or child. Develop policies for safely storing, thawing, warming and administering expressed breast milk (EBM). For more information, refer Toronto Public Health’s Breastfeeding webpage.
Follow safe practices when handling EBM:
Exposure to pests such as mice, flies, rats and cockroaches pose a potential health risk as they are known to carry disease, contaminate food supplies and trigger or worsen asthma symptoms in some individuals. In some cases, pests can also cause structural damage.
It is important that child care centres implement and follow an integrated pest management (IMP) system. An IPM system emphasizes pest prevention and recognizes that pests may only survive and thrive if access to food, water and shelter is available.
Implement an IPM system which includes the following practices:
Interacting with animals can be a joyful and valuable learning experience for young children, but it is important child care centres take steps to ensure children stay safe and healthy during these interactions:
West Nile virus (WNV) is a potentially serious illness that is transmitted to humans through the bite of an infected mosquito. Although the risk of becoming infected with WNV in Toronto is low, protecting ourselves against mosquito bites can help reduce the risk even further. While anyone can be infected with WNV, the chances of having a severe illness are greater as you get older or if you have a weakened immune system. For more information, visit Toronto Public Health’s West Nile Virus webpage.
Lyme disease is transmitted through the bite of an infected blacklegged tick. Tick populations are expanding in Canada, and blacklegged ticks have been found in Toronto, which suggests that these ticks are becoming established here. However, the risk of getting Lyme disease in Toronto is considered to be low. For more information, visit Toronto Public Health’s Lyme Disease webpage.
From spring to fall, when participating in outdoor activities, follow these simple steps to help protect children against WNV and Lyme disease:
If a tick is found, prompt removal is essential to reduce the spread of Lyme disease. Contact the child’s parents/guardians if a tick is found on a child to discuss removal of the tick and to pick up their child if necessary.
For information regarding tick removal, identification and follow up, visit Toronto Public Healths Lyme Disease webpage. Additional information is available from Health Canada’s Lyme Disease: How to Remove and Identify a Tick.
Occupational health and safety involves health and safety aspects in the workplace. The Ministry of Labour (MOL), Training and Skills Development directly oversees and enforces all matters relating to occupational health and safety in workplace settings.
Infection Control Practitioners employed by the MOL review requirements and provide consultation on IPAC issues in the workplace. Their work includes occasional audits of “Health Care Facilities,” and, although child care centres are not defined under the Health Care and Residential Facilities Regulation, the MOL has set precedent by applying this regulation to work settings where IPAC is a key component of that work setting. In order to comply with occupational health and safety legislation, activities in the child care centre may require the use of PPE, including gloves, masks, eye protection and gowns. Operators may also be required to report staff cases to the MOL.
Additionally, the Health Protection and Promotion Act (HPPA), as well as sections of the Ontario Public Health Standards, require local public health units to investigate and alert the MOL with respect to occupational health hazards.
Under the Occupational Health and Safety Act (OHSA), employers must take every precaution reasonable in the circumstances to protect the health and safety of workers. This includes precautions to protect workers from exposure to infectious diseases:
Biting incidents can occur among young children in child care centres during play or if they become upset. Most bites do not break the skin and are unlikely to cause infection. In addition, the risk of Hepatitis B, Hepatitis C or HIV transmission in child care centres is extremely low. When bites do break the skin, both children involved in the incident need proper assessment and management.
If the skin is not broken, clean the wound with soap and water, apply a cold compress and sooth the child who was bitten.