Outbreaks and Increased Absenteeism in Schools

Chain of infection

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Diagram showing the chain of infection for germs

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

Chicken pox reporting form

Chicken pox reporting form (PDF)

Cleaning and disinfection checklist

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 facility is experiencing an outbreak, cleaning and disinfection of these surfaces and items is required more often. Develop a checklist specific to your facility, using this checklist as a guide. Remember to always work from clean areas to dirty areas.

General areas:

Door knobs/frames/handles/other frequently touched areas on the door
Locker doors/cubby holes/storage bins for children
Desks/tables/chairs/counter tops
Hand railings
Light switches
Water fountains
Elevator buttons
Shared equipment (such as toys, sports equipment and musical instruments after each use, computer keyboards and mice, etc.)
Telephones/faxes/photocopiers/intercoms
Play areas and toy storage areas
Floors (especially where children play on them)

Kitchen/staff room:

Food preparation areas and equipment
Counter tops
Fridge handles
Microwaves
Coffee pots/kettles
Tables/chairs

Child and staff washrooms:

Stall door edges and locks
Coat hooks
Sanitary napkin dispensers
Paper towel dispensers
Soap dispensers
Taps/faucets
Flush handles
Toilet seats
Toilet bowls and urinals

Important points to remember:

Use single use cloths or disposable paper towels to clean sinks and toilets/urinals
Ensure an adequate supply of paper towels and soap
Do not top up partially empty dispensers; once empty, containers should be cleaned, disinfected, dried, and then refilled
Soap/detergent must be rinsed off prior to disinfection

For more information, call Ottawa Public Health at 613-580-6744

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)
Use a solution of 10 ml (2 tsp) sodium hypochlorite (household bleach) per 1 liter (4 cups) of water as a disinfectant. This solution requires a contact time of 10 minutes. Only mix bleach with water and never with other disinfectants or cleaners
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

For more information, call Ottawa Public Health at 613-580-6744.

Environmental cleaning and disinfection in child care centres and schools

Shared items and high touch surfaces can be sources for spread of infection, especially in child care centres 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 centre 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. A number of disinfectant products can be used in a child care facility on a regular basis. A different disinfectant may be required in outbreak situations. This may be discussed with your product supplier or with Ottawa Public Health as needed.

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. If gloves are indicated for handling a product, ensure they are single use and discarded between tasks.

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.

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

Concentration	Uses	Mixture	Contact time
100 parts per million (ppm)	To sanitize items such as combs, brushes and floors To sanitize kitchen utensils in a commercial dishwasher	2 mL of bleach with 1 litre of water OR ½ teaspoon (tsp) of bleach with 4 cups of water	1 minute
200 ppm	To sanitize dishes and utensils in place when they are too large to be washed in a dishwasher or submerged in a sink To sanitize kitchen surfaces such as counter tops and cutting boards	4 mL of bleach with 1 litre of water OR ¾ tsp of bleach with 4 cups of water	1 minute
500 ppm	To sanitize child care surfaces, diapering stations, toys, play areas, pet cages and high touch surfaces	10 mL of bleach with 1 litre of water OR 2 tsp of bleach with 4 cups of water	1 minute
5000 ppm	To disinfect surfaces or items that have been in contact with blood or body fluids, including blood spills, vomit or fecal (stool) contamination To sanitize surfaces or items during outbreaks of illnesses in child care or school settings	100 mL of bleach with 1 litre of water OR ½ cup of bleach with 4 cups of water	≥10 minutes

Hand hygiene for infants and young children

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

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

Cleaning Your Hands with a Hand Sanitizer

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

Washing a young child's hands

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

Cleaning a Young Child's Hands with Hand Sanitizer

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

For more information, call Ottawa Public Health at 613-580-6744

Hand hygiene resources

Learn more about preventing the spread of germs in the below resources prepared by OPH.

The information below is available in other formats. Contact Ottawa Public Health at 613-580-6744 to request the document in an accessible format.

Hand Washing Poster only:

Hand Washing Poster and Factsheet:

Hand Sanitizing Poster only:

Hand Sanitizing Poster and Factsheet:

Cough Etiquette Poster only:

Cough Etiquette Poster and Factsheet:

Infection prevention and control measures during outbreaks

Exclusion of ill children and/or staff

Children and/or staff should stay at home when they have:

Symptoms of an enteric illness, including vomiting and/or diarrhea, and until their symptoms have been resolved for at least 48 hours
Symptoms of a respiratory illness, including fever, cough, sore throat, congestion, runny nose, or sneezing until they are fever-free for 24 hours and feeling better without the use of medication
Other symptoms as described in the Guidelines for Communicable Diseases and Other Childhood Health Issues for Schools and Child Care Centres (2017, or as current).

During an outbreak, staff should be vigilant about monitoring children for symptoms of illness. Children returning to the child care centre or school after illness should be able to resume all regular activities.

Cohorting of ill children

If possible, ill children should be kept in a separate, supervised area that can be easily cleaned and disinfected, until a parent or guardian takes them home.

Cleaning and disinfection

Routine cleaning and disinfection is essential to prevent the spread of germs. During outbreaks, you may need to take additional measures, including, but not limited to, the following:

Ensure that the disinfectant used during an outbreak is effective to kill Norovirus, a virus which often results in enteric outbreaks
Clean and disinfect high touch surfaces at least twice a day
Avoid sensory play during outbreaks (e.g. water or sand activities, use of play-dough)
Remove shared items such as toys that cannot be easily cleaned and disinfected for the duration of the outbreak

Hand Hygiene

Hand hygiene is essential for all staff and children to prevent the spread of germs. Infants and young children should be supervised when performing hand hygiene to ensure it is done properly. Hand hygiene includes both hand washing and hand sanitizing and should be done more frequently during outbreaks.

You must ensure that:

Hands are washed with liquid soap and running water for at least 15 seconds if visibly soiled
Hands should be rubbed with 70-90% alcohol-based hand sanitizers for at least 15 seconds if not visibly soiled

Signage

Appropriate notices and posters should be posted at all entrances to advise parents, guardians, and visitors of an outbreak at the child care centre or school.

For more information, call the Ottawa Public Health Outbreak Reporting Line at 613-580-6744 ext 26325

Outbreak signage

If possible, print the signs in colour and post, facing outwards, at the main entrance and all other public entrances.

Outbreak signage (PDF)

Reporting outbreaks to Ottawa Public Health

A school should report an outbreak of illness to Ottawa Public Health (OPH):

If there are more than 15% of children and/or staff absent with similar symptoms within the same classroom or program OR within the entire school on the same day.

Respiratory illness symptoms may include fever, cough, runny nose, congestion, sneezing, sore throat or difficulty swallowing. Other symptoms may include headache, sore muscles, fatigue, poor appetite and irritability.

Enteric illness symptoms may include diarrhea, vomiting, nausea and stomach cramps.

A school should also report unusual increases in absenteeism due to illness to OPH

Increases in absenteeism due to illness above usual rates are reportable to Ottawa Public Health. If children and/or staff are absent with similar symptoms at a rate that is higher than usual for your school, an outbreak may exist.

Report to OPH

If an outbreak is suspected, notify OPH at 613-580-6744, ext 26325, Monday to Friday from 8:30 am to 4:30 pm or 3-1-1 after hours.

If an outbreak is confirmed, OPH will provide recommendations to manage the outbreak and monitor the outbreak daily until absenteeism rates return to baseline

When an outbreak is suspected or confirmed, implement outbreak control measures

Clean and disinfect commonly touched surfaces and common areas
Post signs to alert staff and parents / guardians of increased absenteeism or outbreak
Clean and disinfect toys and play areas twice daily and when visibly soiled
Exclude ill children and staff
If possible, keep ill children in a separate supervised area until a parent or guardian takes them home
Be diligent to perform hand hygiene

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. If you do not have the guidelines, visit OttawaPublicHealth.ca or call OPH at 613-580-6744.

Outbreaks of respiratory and enteric illnesses are reportable to the local health unit under the Health Protection and Promotion Act (HPPA), 1990

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