Enteric Outbreaks in Long-Term Care Facilities and Retirement Homes

To report an outbreak during regular business hours, please complete the Initial Outbreak Notification Form or call 613-580-2424 ext. 26325. Evenings, weekends or holidays, call 3-1-1 and ask to speak with the Public Health Inspector on-call.

Gastroenteritis outbreaks (or enteric outbreaks) occur in long-term care and retirement homes throughout the year. These outbreaks may be caused by bacteria, viruses or parasites through the consumption of contaminated foods or drinks, and through contact with contaminated items or infected persons. Gastroenteritis outbreaks are seen frequently in institutional settings. Such outbreaks can lead to substantial morbidity and mortality and are disruptive and costly. Long-term care and retirement homes often have elderly residents who may have chronic illnesses which weaken their immune systems, putting them more at risk of developing severe illness and complications. Infections also can be more easily transmitted in institutional environments, thus increasing the importance of early implementation of control measures. Early detection and timely implementation of outbreak control measures is essential to prevent further transmission of the infection to others, thereby reducing the length and impact of an outbreak.

The following resources can be used for the detection, management and implementation of such control measures for gastroenteritis outbreaks in long-term care and retirement homes. 

To report an outbreak during regular business hours, please complete the Initial Outbreak Notification Form or call 613-580-2424 ext. 26325. Evenings, weekends or holidays, call 3-1-1 and ask to speak with the Public Health Inspector on-call.

Activities in long term care and retirement homes during an outbreak

It is important for long-term care homes and retirement homes to assess and modify activities during the course of enteric and respiratory outbreaks to reduce the risk of transmission of infection amongst residents and staff. Each outbreak is unique and the Ottawa Public Health (OPH) investigator assigned to the outbreak will assist you with outbreak management and activity assessment.

Do all activities have to be cancelled during an outbreak?
No, but some activities may have to be cancelled. You should review your list of planned or scheduled activities to assess whether they can continue based on the likelihood that they can cause disease transmission and, if necessary, modify activities to minimize the risks. 
What criteria need to be considered when assessing whether an activity can continue during an outbreak?

You need to consider the following when assessing if an activity can continue during an outbreak:

  • Outbreak status (newly declared or close to termination)
  • Type of facility
  • Type of outbreak (respiratory or enteric)
  • Areas affected by the outbreak (number of units/floors affected or facility-wide)
  • Type of activity and likelihood of transmission through sharing of objects, air space or touching common surfaces
  • Likely source of exposure to illness (food, environmental surfaces, ill staff, visitors, etc.)
  • Effectiveness of outbreak control measures in place
  • Type of agent(s) identified
  • Number of residents and staff affected and requiring modified activities
  • Health status of residents affected
Do third party services such as physiotherapy, foot care, dental care, etc. have to be cancelled during an outbreak?
Third party services do not always have to be cancelled during an outbreak. Criteria to be considered include the status of the outbreak, types of services being provided, areas of the facility affected by the outbreak (facility-wide, floors, or units), and the health status of individuals receiving the service. Third party service providers must adhere to the outbreak control measures at the affected facility if providing service to residents during an outbreak.
Who can participate in activities during an outbreak?

Well residents (those who are not exhibiting any symptoms) may participate in activities that are considered low-risk for transmission of infection. 

Ill residents should be placed on isolation and must not participate in group activities until they are taken off precautions and are well enough to participate.

One-on-one activities can be provided to ill residents if they are feeling well enough to participate. Any items used during the activity should remain in the ill resident's room or be cleaned and disinfected after use or discarded. Ill residents should be encouraged to remain on their units within the home.

Well staff and volunteers can assist with activities as long as they wear appropriate personal protective equipment (PPE) and practice good hand hygiene.
Where can activities for well residents take place during an outbreak?

Activities can take place on unaffected floors and units.  Only well residents can participate in these activities.

Events scheduled to take place outside the facility should be rescheduled if the outbreak is facility-wide. If well residents participate in off-site activities, high-touch surfaces in the vehicles used to transport them should be cleaned and disinfected after each trip.
What are some examples of individual activities for those who are isolated but feeling well enough to participate?
Activities that include items that can be easily disinfected or discarded following the interaction can take place within the resident's room.
What are some examples of group activities that can be offered for well residents during an outbreak?

Activities that do not involve sharing of objects can continue for well residents, such as, but not limited to, religious gatherings, choirs, sing-a-longs, movies, crafts, group discussions, and trivia games.  Factors to be addressed include seating arrangements (e.g. distance between residents and position of residents) and enhanced cleaning of areas where activities take place. Activities involving shared items that cannot be easily disinfected between residents will likely have to be modified during an outbreak. Examples of activities that may have to be modified or cancelled include: visiting entertainers, bingo, card games, baking, board games, bean bag toss, fitness classes and physiotherapy. 

Food provided during an activity should be served to each resident individually.  Buffet or self service options for food are not recommended.  Provide alcohol-based hand rub for residents to use prior to and after eating.  Residents should not be participating in food preparation during an outbreak.
Does the dining room have to be closed during an outbreak?
No. Eating in the dining room does not count as an activity.  Some facilities may re-locate dining of ill residents to an affected floor if they have the capacity to do so.  During an outbreak, hand hygiene should be performed by all residents prior to entering the dining room.  Tray service is to be provided to ill residents who are isolated in their rooms.

Please contact the OPH outbreak investigator assigned to the outbreak at your facility if you have any questions at 613-580-6744 or visit OttawaPublicHealth.ca
Family and visitor information during an outbreak

Outbreaks of illness sometimes occur in health care facilities and can be a stressful time for families and staff. Outbreaks are most often caused by common viruses that produce symptoms of gastroenteritis, such as nausea, vomiting and diarrhea, or respiratory illness, such as fever, cough and sore throat. These viruses are generally spread from person to person, or by touching contaminated surfaces, objects or equipment and then touching your eyes, mouth or nose or handling food or drink. For the health and well-being of everyone, it is important to implement measures to control the spread of infection as soon as possible.

Ways you can help stop the spread of illness:

  • Do not visit if you are ill
  • Follow the outbreak and infection control measures recommended
  • Limit your visit to your family or friend, as much as possible
  • If you are visiting an ill family member of friend, please check with the staff prior to entering his or her room
  • Clean your hands often with liquid soap and running water or alcohol-based hand sanitizer
  • Clean your hands
    • When entering the facility and before leaving
    • Before entering and after leaving a resident's room
    • Before eating or assisting your family or friend with his/her meals
    • After going to the washroom or blowing your nose
    • Get immunized against influenza every year

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)
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:
Stool specimen collection kit
Kit contains two sterile containers:
Container NumberColour of CapTransport MediaTest Required
#1 White cap Empty vial Virology
#2 Green cap Red transport medium Bacteriology

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
Identifying and reporting an enteric outbreak in long term care and retirement homes

Assess if you have an enteric outbreak

An enteric outbreak exists when you have:

  • Two or more cases meeting the case definition with a common epidemiological link (e.g. specific unit or floor, same caregiver) with initial onset within a 48 hour period.

Case definition:

Symptoms must not be attributed to another cause (e.g. medication side effects, laxatives, diet or prior medical condition) and at least one of the following must be met:

  • Two or more episodes of diarrhea (i.e. loose/watery bowel movements) within a 24-hour period

OR

  • Two or more episodes of vomiting within a 24-hour period;

OR

  • One or more episodes of diarrhea AND one or more episodes of vomiting within a 24-hour period.

If yes, report to Ottawa Public Health

Notify Ottawa Public Health (OPH) at 613-580-2424, ext 26325 from 8:30 am to 4:30 pm or 3-1-1 outside regular business hours, on weekends or statutory holidays

When an enteric outbreak is confirmed by OPH, fax the Enteric Outbreak Line Listing to OPH at 613-580-9649 on a daily basis, until the outbreak is declared over by OPH.

Identify pathogen

  • Collect stool samples from symptomatic residents as directed by OPH
  • Ensure samples have two resident identifiers on the sample bottle and requisition (for example, name and date of birth)
  • Ensure samples are kept refrigerated
  • Call OPH to pick up and deliver the samples to the Public Health Ontario Laboratory

Implement outbreak control measures immediately

  • Do not wait for confirmation of pathogen involved
  • Isolate ill residents
  • Exclude ill staff
  • Wear appropriate personal protective equipment (PPE) when providing care to ill residents
  • Ensure adequate and frequent hand washing
  • Notify internal and external partners of outbreak (including volunteers)
  • Ensure staff within the facility are aware of the outbreak
  • Post signs at the facility entrances and affected units
  • Enhance environmental cleaning and disinfection (at least twice daily)
  • Modify activities on affected units as appropriate
  • Discuss any transfers or new admissions of residents with OPH
  • Keep visitors and volunteers to a minimum
  • Ensure active surveillance for new cases and report all new cases on the daily line listing to OPH

Termination of an enteric outbreak

Upon consultation with OPH, declare an outbreak over if there is no new case 48 hours after the last case is symptom free.

Note: Norovirus outbreaks are declared over five days after the onset of the last case. 
Outbreak line listing 

Outbreak signage

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

We are experiencing an outbreak [PDF 138 kb]

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