Outbreaks in Child Care Centres

Respiratory outbreaks

A respiratory outbreak is an increase in respiratory illness among a group of people at the same time and place. Respiratory illnesses can be caused by bacteria or viruses that affect the respiratory system (e.g., nose, throat, and lungs).

Symptoms of a respiratory illness include fever, cough, runny nose, congestion, sneezing, sore throat, and difficulty swallowing. Other symptoms may include headache, sore muscles, fatigue, poor appetite, and irritability. COVID-19, influenza and respiratory syncytial virus (RSV) are examples of viruses that cause respiratory illnesses. Respiratory illnesses can spread:

• From person to person through contact with droplets of someone who has a respiratory illness. This can be spread from coughing, sneezing, and talking.
• Indirectly through contact with contaminated objects/surfaces.

Gastrointestinal outbreaks

Enteric outbreaks (or gastroenteritis outbreaks) is a sudden onset of gastrointestinal illness and may occur in schools throughout the year. Gastrointestinal illness (GI) is caused by bacteria, viruses, or parasites leading to symptoms such as nausea, vomiting and diarrhea.

GI illnesses can spread:

• From person-person through contact with bodily fluids
• Through consumption of contaminated food/water
• Indirectly through contact with contaminated object/surfaces

Chain of infection

Download PDF [429 kb]

Germs (agent)

• Bacteria
• Viruses
• Parasites

Where germs live (reservoir)

• People
• Animals/Pets (dogs, cats, reptiles)
• Wild animals
• Food
• Soil
• Water

How germs get out (portal of exit)

• Mouth (vomit, saliva)
• Cuts in the skin (blood)
• During diapering and toileting stool

Germs get around (mode of transmission)

• Contact (hands, toys, sand)
• Droplets (when you speak, sneeze or cough)

How germs get in (portal of entry)

• Mouth
• Cuts in the skin
• Eyes

Next sick person (susceptible host)

• Babies
• Children
• Elderly
• People with a weakened immune system
• Unimmunized people
• Anyone

Cycle repeats

A Child Care Setting should report an outbreak of illness to Ottawa Public Health (OPH):

• When there are three or more cases (children or staff) of gastrointestinal illness (e.g. nausea, vomiting, diarrhea) within a program, group, or the entire setting in a three-day period, even if cases occurred at home
  OR
• When your child care setting absenteeism rate increases above what the setting would typically experience and the absences are not perceived to be linked to other factors such as holidays, the operator/owner should notify OPH.
  OR
• If there are one or more case(s) of a reportable disease in the setting as per the Guidelines for Communicable Disease and Other Childhood Health Issues for Schools and Child Care Centres.

When an outbreak is suspected, follow the guidance in the outbreak control measures section below. 

Other infectious diseases

Do you have children absent with other illnesses?

Refer to the Guidelines for Communicable Disease and Other Childhood Health Issues for Schools and Child Care Centres. 

Child care centres follow infection prevention and control (IPAC) measures as part of their daily operations. During an outbreak, some measures need to be adjusted or enhanced. The outbreak control measures outline the measures that should be enhanced or implemented to prevent the spread of illness. 

Please refer to OPH's Outbreak Control Measures for Institutions, Congregate Living Settings, Child Care Centres and Schools for guidance of control measures based on your setting. 

Infection Prevention and Control (IPAC) in Child Care Centres Checklist 

Specimen identification is a critical part of outbreak investigations. Once the causative agent is known through specimen testing, the public health unit and the home can determine the appropriate next steps to mitigate transmission by implementing targeted interventions.

Specimen collection kits (stool) can be ordered through Ottawa Public Health using the Facility Stool Specimen Collection Request Form when an outbreak has been declared.

Kit contains two sterile containers:

Specimen identification is a critical part of outbreak investigations. Once the causative agent is known through specimen testing, the public health unit and the home can determine the appropriate next steps to mitigate transmission by implementing targeted interventions.

Specimen collection kits (stool) can be ordered through Ottawa Public Health using the Facility Stool Specimen Collection Request Form when an outbreak has been declared.

Collection:

• Check the expiration date on the sterile containers. DO NOT use expired kits
• If blood or mucus is present in the stool, take the sample from this part of the stool
• Stool specimens that have been in contact with water in the toilet are unable to be accepted due to contamination

Collection procedure:

*These first two steps are very important – if the label and/or form are missing information, illegible, or filled out incorrectly, the lab will not test the sample.

1. Label the sample containers with the child’s name, health card number (ID number on the label), and the date/time the stool sample is collected.     
2. Complete all of the required sections of the “General Test Requisition” form
• Patient information section
• Public health unit outbreak number
• Date stool sample collected
• Date of symptom onset (date symptoms started)
3. Collect the stool sample  
• Adults and toilet trained children: Defecate into a clean container (i.e. a disposable plate). Stool that has been in contact with water is cannot be accepted. TIP: Urinate first if needed.
• Children who are not toilet trained: Collect the stool sample from the soiled diaper or directly from the child's training "potty."   
• Using the individual "scoop" attached to each of the caps, transfer stool into the corresponding sterile containers. Fill the white cap container first.  
• Fill to the line indicated on the container. Do not overfill.   
• Tighten the caps. Do not use excessive force to tighten the caps as the containers may crack and leak.  
• Place the containers in the inner pocket of the plastic biohazard bag and seal the zip-lock bag.  
• Place the General Test Requisition form in the small outer pocket of the plastic biohazard bag. Do not place the form in the inner pocket.         
• Place the biohazard bag into the brown paper bag and refrigerate the sample(s) immediately after collection. Stool samples should be placed on the bottom shelf of a fridge and food should not be stored in the same fridge as the stool samples. A cooler with ice or an ice pack can be used if a separate fridge is not available. Do not freeze the sample.
• Perform hand hygiene. If hands are visibly soiled, use soap and water.
• Call Ottawa Public Health at 613-580-2424, ext. 26325 for stool sample pick-up and delivery to the Public Health Laboratory located in Ottawa. Deadline for same day pick up is 3:30 pm. Inform your child care and early years operator that a stool sample was collected.  

Labelling:

Label each container with the client's name, Date of Birth and date the stool sample was collected.
Samples that are incorrectly filled out, or packaged improperly will be discarded by Public Health Lab.

For resources related to communication about enteric illness, please refer to the following documents:

• Parent Stool Sample Information (pdf - 154 KB)
• Child Care Enteric Outbreaks (pdf - 236 KB)

Keeping children's hands clean is the best way to keep them from spreading germs. Young children need to be taught when and how to clean their hands.

It is important for children to clean their hands frequently, including, but not limited to:

• After going to the washroom
• Before eating
• After coughing, sneezing or blowing their nose
• After playing with shared toys
• After touching animals
• After outdoor activities

Hand hygiene techniques

Cleaning children's hands can be done by washing them with warm running water and soap or by using alcohol based hand sanitizers. Children may need assistance and supervision while washing their hands to ensure that they are washed correctly.

Washing your hands

1. Wet hands under running water
2. Apply liquid soap
3. Lather and rub hands for at least 15 seconds
4. Rinse hands
5. Towel or air dry hands
6. Turn taps off with a towel or your sleeve

Cleaning Your Hands with a Hand Sanitizer

1. Place a quarter-size drop of alcohol- based hand sanitizer in your palm
2. Rub hands together, palm to palm
3. Rub back of each hand with palm and fingers of the other hand
4. Rub around each thumb
5. Rub fingertips of each hand back and forth in the other hand
6. Rub until your hands are dry (at least 15 seconds)

Washing a young child's hands

1. Wet a paper towel with water and a small amount of liquid soap
2. Rub child's hands for 15 seconds
3. Rinse under running water
4. Dry hands with a paper towel

Cleaning a young child's hands with hand sanitizer

1. Clean your hands first using the method above
2. Place a dime size drop of hand sanitizer on your own hands
3. Rub child's hands until dry (at least 15 seconds)

Shared items and high touch surfaces can be sources for spread of infection, especially in child care settings and schools. Such surfaces may include door knobs, taps, handrails, phones, computer keyboards, elevator buttons, countertops, as well as shared sports equipment or toys. These surfaces and items can easily become contaminated by viruses or bacteria which can spread from one person to another. Developing policies and procedures for cleaning and disinfection is important to prevent the spread of infections in your setting or school.

Cleaning

Cleaning is the physical action of removing debris from a surface. Cleaning with soap or detergent, and water, will remove organic material such as food, body fluids, fecal matter, or soil from surfaces. Residue from the soap or detergent must be rinsed off prior to disinfection to prevent neutralization of some disinfectants.

Disinfection

Disinfection must occur after cleaning. Disinfection inactivates or kills microorganisms (germs) that may be present on surfaces and that cleaning does not remove.
All-in-one cleaning/disinfecting products must contain a drug identification number (DIN) from Health Canada. The disinfectant contact time, which is the time that a surface must remain wet for a disinfectant to be effective, varies between products. Follow manufacturers' instructions for disinfectant contact times, dilution and handling of products, including for pre-saturated disinfectant wipes.
Flip-top bottles are preferred to apply cleaning solution. If using a spray bottle, saturate the cloth first then wipe the surface. Avoid the use of aerosol cans as this can propel the germs and cleaning solution into the air.
Household bleach diluted in water is an inexpensive and effective disinfectant and can be used for most surfaces. It should be prepared daily. Ensure that surfaces are cleaned with a detergent or cleaning agent before the household bleach mixture is used as a disinfectant.
Mixing some cleaners and disinfectants (like chlorine bleach and ammonia) can be harmful, even deadly. Others can irritate your eyes, nose, or throat and cause breathing problems.

Guide for Preparation of Bleach Solutions

The following table can be used as a reference for preparing household bleach solutions:

*Based on household bleach solution of 5.25% sodium hypochlorite solution (50 000 parts per million)

**Product manufacturer’s instructions for use (MIFU)

The above table is also available for download: Disinfectant Reference Table for Child Care Centers (PDF – 300 KB)

Cleaning and disinfection schedule

Commonly touched surfaces and items should be cleaned and disinfected frequently (e.g. at least once a day) to limit the potential spread of germs. When the setting is experiencing an outbreak, cleaning and disinfection of these surfaces and items is required more often. This easy-to-use guide outlines the recommended frequencies and key considerations for cleaning and disinfection practices within your facility. This schedule supports child care centers with adhering to best practices, minimizing the risk of infection.

Cleaning and Disinfection of Toys

Infants and young children share toys and often place them in their mouths. This increases the risk of spreading infections. To reduce this risk, play areas and storage spaces should be cleaned and disinfected on a regular basis. Ensure that the disinfectant is safe and suitable for use on toys. Consult the manufacturer's recommendations for dilution and contact times for these disinfectants.

Cleaning and disinfecting hard plastic toys

• Remove toys from the play area after use and place them in a collection box for cleaning and disinfection
• Clean and disinfect the collection box at the same time that toys are being cleaned and disinfected
• Clean toys in hot soapy water prior to using a disinfectant
• Use a brush to clean crevices or hard to reach areas
• Rinse toys well under running water as soap may neutralize the disinfectant
• Soak toys in an appropriate disinfectant for required amount of time (contact time)
• Rinse toys with clean water to remove any disinfectant solution, if indicated on the label; bleach does not require rinsing
• Clean and disinfect dishwasher-safe, hard plastic toys in a commercial dishwasher with a sanitizer or a hot rinse cycle
• Completely air dry toys before they are returned to use
• Keep a record of when toys were cleaned and disinfected

Cleaning and disinfecting soft, porous toys or dress up clothes

• Launder fabrics or plush toys in a washing machine with hot water, and dry in a clothes dryer on a hot cycle
• Avoid using disinfectant products on porous surfaces

Cleaning other items

• Clean and disinfect other items (e.g., scissors, puzzles, storage bins, etc.) when they are visibly dirty
• Items such as books and some craft equipment may be difficult to clean, so consider discarding them once they are soiled
• Avoid sensory play during an outbreak, such as activities using play dough, sand or water
• Clean and disinfect computer keyboards, mice and other electronics between uses

Diaper changing

Diapering areas in child care settings are important to consider in preventing the spread of germs.

The following measures are important infection prevention and control practices for such areas:  

• Keep the diapering stations separate from food preparation, eating and activity areas
• Ensure the surface for diapering is made of a smooth, non-porous and cleanable material
• Dedicate a hand wash sink close to the diapering station with warm water, soap and disposable towels
• When diapering a child, it is important to ensure that staff wash their hands prior to putting on gloves and handling the soiled diaper
• Gloves should be removed after handling the soiled diaper, followed by hand washing
• Gloves are single use and should not be used for another task or for diapering another child
• Place soiled diapers immediately in a nearby garbage can with a secure lid and disposable liner; a foot operated garbage can is preferred
• Used cloth diapers (outer covering and liner) must be handled as little as possible to limit and prevent exposure to body fluids. Do not shake, scrape, or rinse the cloth diapers. However, formed stool may be released into a toilet if it can be done so with ease, then place soiled items into a plastic bag and return to parents. During an outbreak, children using cloth diapers should switch to disposable diapers for the duration of the outbreak
• Ensure personal diapering items are clearly labelled for each child (creams, wipes and diapers); do not use a child's dedicated items on another child
• If a child's clothing becomes soiled, place it in a plastic bag and send home for laundering
• Use an appropriate cleaner and disinfectant to clean the diapering surface between each use (e.g., after each diaper change)
• Assist children with hand washing after diapering

Potty chairs

• Potty Chairs Factsheet (PDF - 170 KB)

 How to dispose of expired alcohol based handrub (ABHR) 

• Do not pour expired ABHR down the sink or toilet as this can contaminate water systems and violates environmental regulations. 

Outbreak signage

• Ottawa Public Health - Signage - Outbreak alert (PDF 105 KB) 

Hand hygiene

• Ottawa's Health is in Your Hands Poster - English (PDF - 1.2 MB)
• Hand washing poster - English (PDF - 930 KB)
• Hand washing poster and factsheet - English (PDF - 606 KB)
• Hand sanitizing poster - English and French (PDF - 5.4 MB)
• Cough etiquette poster - English (PDF - 3 MB)

For signage in additional languages, please refer to Ottawa Public Health’s Hand Hygiene webpage.

Keeping your sick child home

• Should I keep my sick child home from school? Poster - English (PDF - 4 MB)

Personal protective equipment (PPE)

• Public Health Ontario: Poster - Recommended steps for putting on and taking off PPE 
• Public Health Ontario: Video - Putting on Full Personal Protective Equipment   
• Public Health Ontario: Poster - Donning PPE 
• Public Health Ontario: Poster - Doffing PPE Poster 
• Ottawa Public Health: Poster - Masks continue to be recommended in crowded spaces (PDF - 107 KB)  
• Ottawa Public Health: Poster - Safely putting on and taking off your mask (PDF - 7 MB) 
• Ottawa Public Health: Video - How to properly wear a mask video 
• Ottawa Public Health: Poster - COVID-19 Eye Protection Guideline (PDF - 139 KB)

Physical distancing

• Ottawa Public Health: Poster - Physical Distancing (PDF - 807 KB)