Management of Gastrointestinal Outbreaks

Identifying an Outbreak

Symptoms of gastrointestinal illness may include vomiting, diarrhea, abdominal cramps and fever.

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

• two or more episodes of diarrhea within a 24-hour period
• two or more episodes of vomiting with a 24-hour period
• one or more episodes of diarrhea and one or more episodes of vomiting within a 24-hour period

If more children or staff are experiencing gastrointestinal symptoms than expected:

• 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)

An outbreak of gastroenteritis is defined as two or more people (children or staff) with the same symptoms, in the same room within 48 hours.

Reporting an Outbreak

Child care centres must report outbreaks of gastroenteritis to TPH. If an outbreak is suspected or if you are unsure if there is an outbreak, call the TPH Communicable Disease Surveillance Unit (CDSU) at 416-392-7411.

Have the following information when you call:

• date and time of the first case
• date and time of the most recent case
• total number of children and staff per room
• total number of ill children and staff per room
• signs or complaints of symptoms of illness (e.g., diarrhea, vomiting)

Use the Toronto Public Health Enteric Outbreak Reporting Form for Child Care Centres to report an enteric outbreak. TPH will use this information to determine if an outbreak exists. A unique outbreak number will be assigned when an outbreak is declared. It is important to include the outbreak number on all outbreak-related documentation.”

Infection Prevention and Control Measures during Outbreaks

Prompt implementation of control measures will help to minimize the risk of further spread of the infection in the child care centre. Some control measures are:

• Exclusion of ill children and/or staff: Ill children and staff must stay at home until they have been symptom-free of vomiting and/or diarrhea for 48 hours.
• Cohorting of ill children: Children who become ill while attending the child care centre should be isolated from other children until a parent or guardian can take them home.
• Cleaning and disinfection: Routine cleaning and disinfection is important to prevent the spread of infections. During an outbreak additional cleaning and disinfection measures are needed including, but not limited to:
  • Cleaning and disinfecting common areas, high touch surfaces and toys more frequently.
  • Ensuring that the disinfectant used during an outbreak is effective to kill norovirus (a virus that commonly causes outbreaks in child care centres).
• Avoiding sensory activities (e.g., water or sand play, play-dough).
• Limit the movement of staff and children from room to room as much as possible.

Hand Hygiene

Proper hand hygiene is the most effective way to prevent the spread of infections.

• Infants and young children should be supervised when performing hand hygiene to ensure it is done properly.
• Hand hygiene should be done more often during an outbreak.
• Ensure adequate supplies are available to perform hand hygiene.

Communication

Toronto Public Health (TPH) will provide a letter to inform parents/guardians of the outbreak and what actions are necessary should their child become symptomatic. TPH will provide an outbreak notice that should be posted at all entrances to inform parents, guardians and visitors of the outbreak.

Maintaining a Line List

A line list is a table that summarizes information about staff and children associated with the outbreak.

• Information on ill children and staff should be collected, reviewed and documented each on the line list.
• Maintain one line list for staff and one line list for children.
• A case is only listed once during the outbreak.
• New cases are added to the existing line list.
• TPH should be notified when:
  • the child care centre is aware of positive results from a stool specimen
  • spread of illness to another group/room
  • change in symptoms
  • hospitalization/death of child care attendee/staff
  • parental concern/difficult questions
  • media interest

You can use the Enteric Outbreak Line List to get you started.

Sampling

Specimen sampling is used to identify the cause of the outbreak – this could include stool samples and/or food samples. TPH staff will ensure stool sampling kits and instructions are available. A Public Health Inspector will collect food specimen samples if needed.

If an organism is identified in one stool specimen and only one stool specimen was submitted, then permission from the parent to release the results will be obtained prior to releasing the results to the child care centre operator. If an organism is identified when multiple stool specimens were submitted, the child care centre can be informed of the results such as the organism (e.g., norovirus) but not the case’s identity.

It is important to ensure consent to obtain and submit a stool specimen to PHOL is provided by parents/guardians of children. In the event that an opportunity to collect a stool specimen presents itself prior to notifying the parents/guardians, the specimen can be collected but not be sent to the lab until parental consent has been provided. Results from stool specimens are provided to the parent/guardian by TPH.

Here is information on How to Collect a Stool Sample.

Declaring the Outbreak Over

The end of an outbreak of gastroenteritis must be declared by TPH. 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.