Outbreaks (Child Care Manual)

Children and staff at your child care centre will experience some infectious diseases no matter how careful you are. It’s important that your staff and parents know in advance of an outbreak what these illnesses could be and what to do.

Awareness and identification
Roles and responsibilities
Gastroenteritis outbreak
Enteric outbreak kit
Respiratory outbreak

Awareness and Identification

Early awareness and action is critical in managing an outbreak at your child care centre:

Keep a daily log book to know if there's an increase in illness at the centre
Call Public Health when several children and / or child care providers become ill on the same day or successive days. Any delay can have an impact on managing the outbreak and collecting specimens.
Refer to your centre's written policies and procedures
Follow proper infection prevention and control measures

Identify a potential outbreak

Consider any of the following as a potential outbreak:

Significantly more cases of the same or similar illness among children and child care providers than normally expected
Two or more children in the same group suffering from vomiting and / or diarrhea within a short time period
A diagnosed Disease of Public Health Significance in a child or child care provider

Roles and Responsibilities

Public Health

Recommend measures for outbreak infection prevention and control
Inform staff about the specific illness
Collected stool specimens may be submitted to Public Health for laboratory testing to identify a possible cause for the illness
Help to identify children considered susceptible, such as unimmunized for certain diseases
Provide information for parent(s) / caregiver(s)
Provide information on medications and / or immunization for contacts when appropriate

Child care centre

Follow recommendations provided by Public Health
Report changes or provide updated information about the outbreak on a daily basis, such as line list
Provide information to the families of children attending the centre
Collect specimens from ill children after obtaining consent from parent(s) / caregiver(s). Parent(s) / caregiver(s) must consent to samples being collected from their child for submission to the lab for testing. Results from lab specimens are released only to the parent(s) / caregiver(s) of the child.

Gastroenteritis Outbreak

A gastroenteritis outbreak may be in effect when there are two or more related children or staff, such as same room or same age group, with similar signs and symptoms that:

Occur within 48 hours in the centre, or
When the number of ill staff / children exceeds what is normal in the child care centre within a short period of time

Typical symptoms of gastroenteritis:

Diarrhea
Bloody diarrhea
Vomiting
Nausea
Stomach cramps
Fever
General irritability
Headache

Managing a gastroenteritis outbreak

Step 1: Call Public Health at 905-688-8248 ext. 7330

Step 2: Work with Public Health to develop a case definition. A case definition identifies who is added to the line list. Public Health will assign an outbreak number.

Step 3. Create a line list. A line list identifies the number of new cases each day, including children, staff, volunteers and students.

List all ill persons who meet case definition chronologically in order of when the illness started
Complete all information required on the line list. You may have to contact the parent(s) / caregiver(s) to obtain accurate information.
Record those that may have been part of the outbreak and are not present at the centre and those that are admitted to hospital
Do not record the same ill person more than once
Update the line list daily and report new information to Public Health
Do not remove names of resolved cases from the line list; simply add each new case to the existing line list
Fax an updated line list daily to Public Health at 905-682-6470

Step 4: Review and implement outbreak infection prevention and control measures

Post outbreak signs at entrances and affected area. Signs are provided by Public Health.

Provide communication to parent(s) / caregiver(s), such as email, letters and communication board

Inform outside agencies that use the child care centre of outbreak
Separate ill children and arrange for prompt pick up
Minimize the movement of children and staff between age groups and rooms
Reinforce the importance of hand hygiene with staff, volunteers, students and children
Review the importance of proper glove use when toileting and diapering children with staff, volunteers and students
Initiate enhanced environmental cleaning and disinfection. Procedures will be reviewed by Public Health during the site visit:

All toys and high contact surfaces should be cleaned and disinfected daily
Use of a broad spectrum virucide is recommended for the disinfection of toys, change tables and high contact surfaces
Inform outside cleaning companies about the outbreak and review cleaning / disinfecting products
Soiled diapers and clothing must not be rinsed or washed at the centre. Soiled diapers and clothing should be emptied into the toilet, placed in a securely tied plastic bag and sent home with parent(s) / caregiver(s).

Exclude symptomatic children and staff / volunteers / students until symptom-free for 48 hours (exclusion period may vary based on cause of illness). This includes being fever-free without the use of fever reducing medicine for 24 hours before returning to child care.
Suspension of activities:

Activities between children should be limited to same age group / room
Visitation from outside groups should not be permitted
Discontinue group outings, including field trips
Suspend sensory play, such as wet / dry sensory tables, sand boxes and play dough

Inform parent(s) / caregiver(s) with new child enrolments of the outbreak
Staff, volunteers and students should only work at the outbreak centre, not other child care centres. If asymptomatic and they choose to work at another centre, they must wait 48 hours after working at outbreak child care centre.

Step 5: Collect specimen

In order to identify the source of a gastroenteritis outbreak, it's important to collect stool, water and / or food specimens
Parent(s) / caregiver(s) must consent to stool samples being collected from their child for submission to the lab for testing. Results from lab specimens will only be released to the parent(s) / caregiver(s) of the child.

Stool specimen collection

Encourage all people who meet the case definition to provide a stool sample. An enteric outbreak kit will be delivered to your child care centre by Public Health and instructions will be provided.

If ill children or staff are at home, contact parent(s) / caregiver(s) or staff to arrange for stool kit drop-off and pick-up by Public Health.

Fill out all information on each vial within the enteric outbreak kit and the information required on the outside packaging of the enteric outbreak kit.

Store the specimens in the refrigerator until they are ready for pick-up. It's very important to make sure that the filled enteric outbreak kit is not stored in a fridge that is used for food.

Food sample collection

Public Health will complete a food services inspection.

Food samples must be kept on hold and accumulated for the duration of the outbreak. If there's a suspected link between the outbreak and the food, food samples will be submitted to the Public Health laboratory for analysis.

Enteric Outbreak Kit

Instructions on how to collect and transport enteric specimens (feces)

Complete the general test requisition form

Check expiry date. Do not use expired kits.
Remove the specimen collection vial(s) from the biohazard bag
Complete the General Test Requisition Form. Form must include:

Full name and date of birth
Specimen collection date and illness onset date
Outbreak number assigned by Niagara Region Public Health

On each vial used, record:

Child's first and last name
Date of birth
Outbreak number assigned by Niagara Region Public Health

Collect the specimen

Feces that have been in contact with water in toilet are unacceptable.

Using the spoon from each vial, select different sites of the feces specimen, preferably blood, mucus or pus, and transfer to the vials as follows:

Virology / toxin (White capped vial which is empty) - Add feces up to the line indicated. Replace and tighten cap.
Bacteriology (Green capped vial with red-coloured transport medium) - Add 2 to 3 spoonfuls, mix into the transport medium. Replace and tighten cap.

Transport the specimen

Place all vials in the biohazard bag and seal bag. Place the completed requisition form in the outside pocket. Don't place the requisition inside the biohazard bag containing the specimens.
Refrigerate specimens immediately. Don't freeze specimens. It's very important to make sure that filled kits are not stored in a fridge that's used for food.
Call the Infectious Disease program at 905-688-8248 ext. 7330 as soon as possible to pick up specimens

Declaring a gastroenteritis outbreak over

Public Health shall declare whether an outbreak is over in consultation with the child care centre. The Medical Officer of Health retains the final authority to determine if an outbreak is over.

The outbreak may be declared over when certain criteria are met. The end of an outbreak is determined on a case-by-case basis. The specific period varies by micro-organism, but is often set at 48 hours after symptoms stop for the last case who attended the child care centre and all appropriate control measures were taken.

Respiratory Outbreak

A respiratory outbreak may be in effect when there are two or more children or staff, who are connected in the same child care setting, with similar signs and symptoms that:

Occur within 48 hours in the centre, or
When the number of ill staff / children exceeds what is normal in the child care centre within a short period of time

Typical symptoms of respiratory illness are:

Fever
Cough
Runny nose
Congestion (nasal and / or chest)
Generally unwell
Behaviour changes, such as not able to participate in normal activities
Joint or muscle pain

Managing a respiratory outbreak

Step 1: Call Public Health at 905-688-8248 ext. 7330

Step 2: Work with Public Health to develop a case definition. A case definition identifies who is added to the line list. Public Health will assign an outbreak number.

Step 3. Create a line list. A line list identifies the number of new cases each day, including children, staff, volunteers and students.

List all ill persons who meet case definition chronologically in order of when the illness started
Complete all information required on the line list. You may have to contact the parent(s) / caregiver(s) to obtain accurate information.
Record those that may have been part of the outbreak and are not present at the centre and those that are admitted to hospital
Do not record the same ill person more than once
Update the line list daily and report new information to Public Health
Do not remove names of resolved cases from the line list; simply add each new case to the existing line list
Fax an updated line list daily to Public Health at 905-682-6470

Step 4: Review and implement outbreak infection prevention and control measures

Post outbreak signs at entrances and affected area. Signs are provided by Public Health.

Provide communication to parent(s) / caregiver(s), such as email, letters and communication board

Inform outside agencies that use the child care centre of outbreak
Separate ill children and arrange for prompt pick up
Minimize the movement of children and staff between age groups and rooms
Reinforce the importance of hand hygiene with staff, volunteers, students and children
Encourage respiratory etiquette, such as covering coughs and sneezes, and use of tissue
Initiate enhanced environmental cleaning and disinfection. Procedures will be reviewed by Public Health during the site visit:

All toys and high contact surfaces should be cleaned and disinfected daily
Use of a broad spectrum virucide is recommended for the disinfection of toys, change tables and high contact surfaces
Inform outside cleaning companies about the outbreak and review cleaning / disinfecting products

Exclude symptomatic children and staff / volunteers / students until five days after onset of illness or until symptoms have resolved (whichever is shorter). This includes being fever-free without the use of fever reducing medicine for 24 hours before returning to child care.
Suspension of activities:

Activities between children should be limited to same age group / room
Visitation from outside groups should not be permitted
Discontinue group outings, including field trips
Suspend sensory play, such as wet / dry sensory tables, sand boxes and play dough

Inform parent(s) / caregiver(s) with new child enrolments of the outbreak
Staff, volunteers and students should only work at the outbreak centre, not other child care centres. If asymptomatic and they choose to work at another centre, they must wait 72 hours after working at outbreak child care centre.

Declaring respiratory outbreak over

Public Health shall declare whether an outbreak is over in consultation with the child care centre. The Medical Officer of Health retains the final authority to determine if an outbreak is over.

The outbreak may be declared over when certain criteria are met. The end of an outbreak is determined on a case-by-case basis. The specific period varies by microorganism, but is often set at 72 hours after the onset of symptoms of the last case who attended the child care centre and all appropriate control measures were taken.

Last updated: Sept. 10, 2020

Child Care Manual

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