Outbreaks in Child Care Centers

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

Outbreak Definition

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

• When there are three (3) 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 (3)-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. 

Control Measures During Outbreaks or Increase in Illness 

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. 

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 or NP) 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:

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)

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

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)

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.