| What are outbreaks? |
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 |
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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 |
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| IPAC measures during outbreaks or increases in illness |
| Schools 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.
| Screening |
- Symptom screening should occur at home to avoid any sick students or staff attending school.
- The Ministry of Health’s Self Screening Tool can be used to determine if children or staff experiencing illness should be staying home.
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| Management of symptomatic individuals |
- Individuals with respiratory symptoms or a positive COVID-19 test should self-isolate immediately until symptoms have been improving for 24 hours and no fever is present.
- Individuals who have enteric/gastrointestinal symptoms including vomiting and/or diarrhea, should be excluded until symptoms have been resolved for at least 48 hours.
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| Management of close contacts |
For individuals who have been in close contact with anyone who has tested positive for COVID-19, the following measures are recommended:
- For a total of 10 days after the last exposure to the COVID-19 positive case, the individual should:
- Self-monitor for symptoms. They should self-isolate immediately if symptoms develop.
- Wear a well fitted mask in public settings including child care and school, unless under 2 years old.
- Reasonable exceptions would include removal for essential activities like eating, while maintaining as much physical distance as possible.
- Participation in activities where masking can be maintained throughout may be resumed, but individuals should avoid activities where mask removal would be necessary (e.g., dining out; playing a wind instrument; high contact sports where masks cannot be safely worn)
- Avoid non-essential visits to anyone who is immunocompromised or at higher risk of illness (e.g., seniors); and
- Avoid non-essential visits to highest risk settings such as hospitals and long-term care homes.
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| Personal protective equipment (PPE) and hand hygiene |
- Review and promote hand hygiene with staff, students, and parents.
- PPE is made available to staff based on school board policies.
- Gloves worn by staff if there is possibility of contact with bodily fluids (e.g., during diaper changes).
- Encourage frequent hand hygiene and respiratory etiquette for all staff, students, and visitors. Provide supervision/ assistance to students as needed.
- Soap and water should be used when hands are visibly soiled.
- Alcohol based hand rub (ABHR) with a minimum 70 percent alcohol concentration must be available throughout the facility (including ideally at the entry point to each classroom) and/or plain liquid soap in dispensers, with sinks and paper towels.
- Ensure adequate hand hygiene supplies are available and are not expired.
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| Cleaning and disinfection |
| Refer to Cleaning and Disinfection in Childcare and School Settings for more details.
- Disinfectant contains a Drug Identification Number and is not expired.
- Use appropriate cleaner/disinfectant and follow the manufacturer’s instructions for use (MIFU) for contact time; products with shorter contact times (1 minute/3 minutes) are preferred to ensure the surface has been cleaned and disinfected appropriately.
- Do not apply cleaning chemicals by aerosol or trigger sprays (spray guns).
- Ensure the product is effective against Norovirus if there is gastrointestinal illness.
- Remove sensory play during outbreaks (e.g., water or sand tables).
- Fabric furniture should be removed or covered with a non-absorbent easy cleanable cover during outbreak.
- Enhanced cleaning and disinfection of high touch surfaces, washrooms, toys/other shared objects minimum 2x/day; immediate cleaning & disinfection of items used by ill student or as needed.
- Clean and disinfect high-touch surfaces at least twice daily and as needed using an enhanced cleaner/disinfectant (e.g., doorknobs, water fountain knobs, light switches, toilet, and faucet handles).
- Clean and disinfect diaper changing stations immediately after each use.
- Personal items (e.g., sippy cups, soothers, utensils) are not shared.
- Reusable (regular) dishware and utensils may be used during an outbreak provided there is an appropriate wash-rinse-sanitize process in place.
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| Sample communication during outbreaks or increases in illness |
| It is recommended to communicate with the school community (staff and families) when there is an outbreak or increase in absences due to illness to promote the ongoing measures that the community can do to prevent or slow down the spread of illness.
| Increased absences due to respiratory illness |
| Our school is currently experiencing a greater than usual number of students and/or staff absent with respiratory symptoms such as cough, fever, sore throat. To help slow and prevent the spread of illness and keep our school as safe as possible, please continue to follow these public health measures:
- Screening: Complete the provincial screening tool every day before school and childcare.
- Staying home when ill: Report absences to school and stay home if you are sick. Follow directions in the screening tool. Consider using a COVID-19 rapid antigen test if applicable. Children and staff with symptoms of respiratory illness must be fever free and with symptoms improving for 24 hours before returning to school.
- Masking: It is recommended to wear a mask when in public for 10 days following the start of respiratory symptoms or 10 days from the last contact with someone that has tested positive for COVID-19.
- Vaccination: Stay up to date with routine vaccinations, including the flu shot, to help reduce the risk of illness.
- Hand hygiene: Wash your hands often with soap and water or alcohol-based hand sanitizer.
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| Increased absences due to gastrointestinal illness (outbreaks) |
| *Note: An OPH investigator will share a letter when an enteric outbreak has been declared. Our school is experiencing a greater than usual number of students and/or staff absent with gastrointestinal symptoms, such as vomiting, diarrhea, or fever. To help slow and prevent the spread of illness and keep our school as safe as possible, please continue to follow these public health measures:
- Hand hygiene: Wash your hands often with soap and water or alcohol-based hand sanitizer.
- Screening: Complete the provincial screening tool every day before school and childcare.
- Staying home when ill: Report absences to school and stay home if you are sick. Follow directions in the screening tool. Children and staff with symptoms of gastrointestinal illness must be free of vomiting and diarrhea for 48 hours before returning to school.
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| Specimen kits and collection |
| Collecting stool samples will tell us which organism or germ is making people sick. This will help ensure the right measures are put in place to stop and prevent more people from getting sick. Only ill students or staff may be asked to collect a stool sample. Kits are not for parents or other household members. Gastrointestinal (GI) symptoms like vomiting, diarrhea, and nausea can be symptoms of COVID-19, which continues to circulate in the community. It is highly recommended that individuals who are experiencing symptoms complete both a Rapid Antigen Test and a stool sample. How to Collect a Stool Sample Step 1: Get the kit Get a stool sample kit from the school if you have had GI symptoms within the last 48 hours. The kit should include two sterile containers. The container with the WHITE cap is empty and will test for viruses. The container with the GREEN cap has a red liquid called transport medium and will test for bacteria. DO NOT drink the red liquid! You will put a stool sample into both containers using the individual lids of the containers that have a scoop on the inside.
- Check the expiration date on the sterile containers. DO NOT use expired kits. Contact the school for another kit.
Step 2: Label the sample containers and fill in the requisition form. ***This step is very important. If the label and/or form are missing information, or is illegible, or filled out incorrectly, the lab will not test the sample.
- Label the sample containers with the individual’s name, health card number (ID number on the label), and the date/time the stool sample is collected.
- Complete all the required sections of the “General Test Requisition” form provided
- Patient information section
- Public health unit outbreak number – This number can be found on the Increased Illness Letter or by calling the school
- Date stool sample collected
- Date of symptom onset (the day symptoms started)
Step 3: Collect the stool sample Do not allow the stool to come in contact with the toilet water. If the stool touches the toilet water, it is no longer an acceptable sample. If blood or mucus is present in the stool, always take a sample from this part of the stool 1. Adults and toilet trained children can defecate into a clean container (i.e. a disposable plate). TIP: Urinate first if needed. Children who are not toilet trained, the stool sample can be taken from the soiled diaper or directly from the child's training "potty." 2. Using the individual "scoop" attached to lid of each container, transfer stool into the corresponding sterile container. Fill the white cap container first.
- Fill to the line indicated on the container. Do not overfill.
- Tighten the caps. Do not use extra 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.
3. 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 where the sample containers are. Place the biohazard bag into the brown paper bag and refrigerate the sample(s) immediately after collection. 4. Stool samples should be placed on the bottom shelf of a fridge that does NOT contain food.
- A cooler with ice or an ice pack can be used if a separate fridge is not available.
- DO NOT freeze the sample.
5. Perform hand hygiene. If hands are visibly soiled, use soap and water. 6. Call your school for stool sample pick-up and delivery to the Public Health Laboratory located in Ottawa. The deadline for same-day pick up is Monday to Friday before 3 pm.
- Please ensure you provide verbal consent to the school so they may provide your name and address to OPH for stool sample pick up.
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| 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 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:
| 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 |
2 minutes |
| 1000 ppm |
During outbreaks, to sanitize child care surfaces, diapering stations, toys, play areas, pet cages and high touch hard surfaces. |
20 mL of bleach with 1 litre of water OR 4 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 |
100 mL of bleach with 1 litre of water OR ½ cup of bleach with 4 cups of water |
≥10 minutes |
*Note: The contact time, also known as the wet time, is the time that the disinfectant needs to stay wet on a surface to make sure it can kill all the germs. It is the length of time you leave the solution on the surface before wiping it down. |
| 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 setting 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
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| 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
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| Signage, posters and factsheets |
| Outbreak signage |
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| Hand hygiene |
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For signage in additional languages, please refer to Ottawa Public Health’s Hand Hygiene webpage. |
| Personal protective equipment (PPE) |
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| Physical distancing |
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