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«Control of Gastroenteritis Outbreaks in Long-Term Care Homes A Guide for Long-Term Care Homes and Public Health Unit Staff Public Health Division ...»

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Control of Gastroenteritis

Outbreaks in Long-Term

Care Homes

A Guide for Long-Term Care Homes and Public Health Unit Staff

Public Health Division

Ministry of Health and Long-Term Care

October 2013

This document reflects the committee’s consensus position on prudent practice and is made

available as a resource to public health and health-care providers.

All or part of this guide may be reproduced without permission with the following


Ministry of Health and Long-Term Care/Public Health Division Toronto, Canada, 2013 © Queen’s Printer for Ontario Ministry of Health and Long-Term Care Copies of this report can be obtained from INFOline: 1-866-532-3161 TTY 1-800-387-5559 Table of Contents Acknowledgements



1 Introduction

1.1 Purpose

1.2 The Role of Public Health

1.3 The Role and Responsibilities of the Long-Term Care Homes

1.4 Types of Gastroenteritis Outbreaks

1.4.1 Outbreaks Caused by Viruses

1.4.2 Outbreaks Caused by Bacteria and Parasites

2 Preparation – Infection Control and Outbreak Policies and Procedures.............. 21

2.1 Outbreak Preparedness

2.2 The Infection Prevention and Control Program – Disease Prevention

2.2.1 Routine Practices

2.3 Additional Precautions

2.3.1 Contact Precautions

2.3.2 Other Disease Prevention Strategies

2.3.3 Education of Staff and Volunteers

2.3.4 Education of Residents and Visitors

3 Surveillance and Outbreak Detection

3.1 Surveillance

3.1.1 Target Groups for Surveillance

3.2 Outbreak Detection

3.2.1 Infectious Gastroenteritis Case Definition

3.2.2 Outbreak Definition

3.2.3 Suspected Gastroenteritis Outbreak Definition

3.2.4 Gastroenteritis Outbreak Definition

4 Managing Gastroenteritis Outbreaks

4.1 Control Measures for a Suspected Gastroenteritis Outbreak

4.2 Steps in Outbreak Management

4.2.1 Assess the Outbreak

4.2.2 Implement General Infection Prevention and Control Measures

4.2.3 Consult with the Public Health Unit

4.2.4 Declare an Outbreak

4.2.5 Notify Appropriate Individuals/Agencies

4.2.6 Call an Outbreak Management Team Meeting

4.2.7 Monitor the Outbreak on an Ongoing Basis

5 Control Measures For Specific Groups

5.1 Control Measures for Residents

5.1.1 Admissions and Returns from Absences

5.1.2 Medical and Other Appointments

5.1.3 Transfer to Hospital, Other Facility or Urgent Appointment

5.2 Control Measures for Staff and Volunteers

5.2.1 Well Staff

5.2.2 Ill Staff

5.3 Control Measures for Visitors and During Communal Activities

5.3.1 Modified Visitor Access

5.3.2 Communal Meetings and Other Activities

6 Declaring the Outbreak Over and Termination of Outbreak Control Measures.... 46

6.1 Criteria for Declaring an Outbreak Over

6.2 Review the Outbreak

6.3 Complete the Outbreak Investigation File

7 Investigation and Management of Food-Borne Outbreaks

7.1 Recommended Food Handling Policies and Procedures

7.1.1 Food-Handling Staff

7.1.2 Records of Food Suppliers

7.1.3 Retaining Food Samples

7.1.4 Temperature Records of Potentially Hazardous Food

7.1.5 Catered Food and Food Brought in by Families

7.1.6 Common Servery or Kitchenette

7.1.7 Feeding Assistance

7.1.8 Dishwasher Temperature and Sanitizing Records

7.1.9 Kitchen Equipment Installation and Maintenance

7.2 Food-borne Illness Investigation

7.2.1 Questionnaires

7.2.2 Clinical Samples

7.2.3 Food Service Operation

7.2.4 HACCP Investigation

7.2.5 Provision of Alternative Sources of Food and Water

7.2.6 Summary Report

Appendix 1: Instructions for Feces Specimen Collection During Outbreaks

Appendix 2: Routine Practices, Additional Precautions, and reporting requirements for selected pathogens or conditions associated with gastroenteritis outbreaks

Appendix 3: Routine Practices for all Health Care Settings

Appendix 4: Signage for entrance to room of a resident requiring Contact Precautions in nonacute care facilities

Appendix 5: Hand Hygiene Fact Sheet for Health Care Settings

Appendix 6: Recommended steps for putting on and taking off personal protective equipment (PPE)

Appendix 7: Donning and removal of personal protective equipment (PPE)

Appendix 8: Cleaning checklist for an ill resident’s room during an outbreak

Appendix 9: Sample screening-policies sign to use during outbreaks

Appendix 10: Sample surveillance sheet

Appendix 11: Quick reference guide: suspected outbreak

Appendix 12: Steps in the prevention and management of gastroenteritis outbreaks.................. 79 Appendix 13: Gastroenteritis outbreak: sample line-listing form

Appendix 14: Position Statement: Recommended Length of Exclusion for Cases Associated with Norovirus Outbreaks and When to Declare Norovirus Outbreaks Over

Executive summary Gastroenteritis outbreaks in institutions became a Reportable Disease under the Health Protection and Promotion Act in 1991. The increased person-to-person contact and presence of a population with weakened immune systems increases the risk of gastroenteritis outbreaks in Long-Term Care Homes (LTCHs). Gastroenteritis outbreaks continue to occur and to control them; LTCHs require the development of effective infection control programs.

Control of Gastroenteritis Outbreaks in Long-Term Care Homes (MOHLTC, 2013) replaces Control of Gastroenteritis Outbreaks in Long-Term Care Homes (MOHLTC, 2011). The purpose of the guide is to assist LTCHs before, during, and after a gastroenteritis outbreak and to minimize illness, hospitalization, and death, related to gastroenteritis outbreaks in LTCHs.

This guide will provide useful and practical information that will help LTCHs:

1. Develop outbreak management policies and procedures and infection control programs.

2. Understand the importance of surveillance, early identification, and isolation of cases to prevent disease spread.

3. Educate their staff on policies and procedures and the importance of Routine Practices.

4. Respond to and manage a gastroenteritis outbreak should one occur.

5. Develop procedures for managing outbreaks associated with food.

The recommendations presented are based on the most current, evidence-based literature, clinical knowledge, trends, and expert consensus on prevention, detection, management, and control of gastroenteritis outbreaks. Included are quick reference appendices that outline procedures for managing specific micro-organisms (pathogens) and summaries of what to do if an outbreak is suspected and what to do during an outbreak.

Acknowledgements The Ministry of Health and Long-Term Care would like to acknowledge the contribution and expertise of the working group that developed Control of Gastroenteritis Outbreaks in LongTerm Care Homes in 2011 and provided updates to the 2013 version.

Revised and updated material in this version is shaded in the text Karen Beckermann Scheduling and Logistics Supervisor East York, Vaccine Preventable Diseases Toronto Public Health Risa Cashmore Infection Control Consultant, Central West Infection Control Network Public Health Ontario Joanne Dow Public Health Nurse, Infectious Disease Control Team Middlesex-London Health Unit Lisa Fortuna * Director, Communicable Disease Prevention and Control Public Health Ontario David Fraser Food and Rabies Coordinator, Health Protection Service Simcoe-Muskoka District Health Unit Edwina Gracias Manager, Health Protection Peterborough County-City Health Unit Judy de Grosbois Public Health Inspector Perth District Health Unit Lucie Imbiscuso Public Health Inspector Wellington Dufferin Guelph Public Health Unit/Canadian Institute of Public Health Inspectors (Ontario Branch) Manisa Jiaravuthisan Associate Director, Communicable Diseases Control Toronto Public Health Lois Lacroix Manager, Infectious Disease Program Niagara Region Public Health Department Andre LaFlamme Manager, Environmental Health Niagara Region Public Health Department Joseph Y. Lam Supervisor, Outbreak Management Ottawa Public Health Bill Limerick Retired, Director of Environmental Health, Director of Health Protection Northwestern Health Unit Marina Lombos Head Technologist, Laboratory Enteric & Molecular Surveillance Public Health Ontario Anne Maki Manager, Enteric, Environmental, Molecular Surveillance and STI Public Health Ontario Roman Malancyzj Senior Public Health Inspector Durham Region Health Department Dr. Dean Middleton * Senior Public Health Epidemiologist, Enteric, Zoonotic and Vector-Borne Diseases Public Health Ontario Francine Paquette Infection Control Consultant, South Western Ontario Infection Control Network Public Health Ontario Brenda Smith Network Coordinator, Central West Infection Control Network Public Health Ontario Dave Stronach Retired, Manager Halton Region Health Department Debbie Valickis Infection Control Specialist, Communicable Disease Division Peel Public Health Yvonne Whitfield * Senior Program Consultant, Enteric, Zoonotic and Vector-Borne Diseases Public Health Ontario Anne-Luise Winter Senior Epidemiologist, Communicable Disease Prevention and Control Public Health Ontario * At the time of the development of the original document in 2011 these contributors were affiliated with the Ministry of Health and Long-Term Care, Public Health Division.

Post-Panel Contributors Jane Carruthers Long-Term Care Homes Inspector Ministry of Health and Long-Term Care Richard Hayden Long-Term Care Homes Inspector Ministry of Health and Long-Term Care Dr. Zsuzsanna Rajda Senior Program Consultant, Public Health Policy and Programs Branch Public Health Division, Ministry of Health and Long-Term Care Dr Erika Bontovics Manager, Public Health Policy and Programs Branch Public Health Division, Ministry of Health and Long-Term Care Stephen Moore Manager, Enteric, Zoonotic and Vector-borne Diseases Public Health Ontario Dr. Doug Sider Medical Director, Infectious Diseases Public Health Ontario Abbreviations ABHR Alcohol-Based Hand Rub CDI Clostridium difficile Infection CHICA Community Health and Infection Control Association HACCP Hazard Analysis Critical Control Point HAI Health Care-Associated Infections HPPA Health Protection and Promotion Act ICP Infection Prevention and Control Professional IPC Infection Prevention and Control LHIN Local Health Integration Network LTCH Long-Term Care Home LTCHA Long-Term Care Homes Act


Ministry of Health and Long-Term Care OHA Ontario Hospital Association OHSA Occupational Health and Safety Act OMA Ontario Medical Association OMT Outbreak Management Team PIDAC Provincial Infectious Diseases Advisory Committee PHAC Public Health Agency of Canada PHI Public Health Inspector PHF Potentially Hazardous Food PHN Public Health Nurse PPE Personal Protective Equipment RICN Regional Infection Control Network Glossary Additional Precautions – These precautions (i.e. Contact Precautions, Droplet Precautions and Airborne Precautions) are carried out in addition to Routine Practices when infections caused by organisms transmitted by these routes are suspected or diagnosed. They include the physical separation of infected or colonized residents from other individuals and the use of barriers (e.g. gowns, gloves, masks) to prevent or limit the transmission of the infectious agent, from colonized or infected individuals, to those who are susceptible to infection or to those who may spread the agent to others.

Alcohol-based hand rub (ABHR) – A liquid, gel or foam formulation of alcohol (e.g., ethanol, isopropanol) which is used to reduce the number of micro-organisms on hands in situations when the hands are dry and not visibly soiled. ABHRs are less time-consuming to use than washing with soap and water.

Attack rate – The occurrence of disease observed among a defined population over a limited period of time.

Baseline – The normal level or presence of a disease or infectious agent within a given geographic area or a population group and time period.

Case – A person with the particular illness or disease, usually fitting the case definition.

Case definition – A set of criteria for determining who should be classified as a case. The definition is comprised of clinical information and should include epidemiological information related to time, place, and person.

Cohorting – Cohorting of residents: Grouping of residents who present either with the same set of symptoms or are asymptomatic. Cohorting of staff: Grouping of staff to care for a specific group of residents or to assign them to a floor/unit that either contains or does not contain active cases.

Common-source outbreak – A type of outbreak that occurs when individuals are exposed to a point-source of infection at the same time.

Contact Precautions – A type of Additional Precautions to reduce the risk of transmitting infectious agents via contact with an infectious person. Contact Precautions are used in addition to Routine Practices.

Contact time – The length of time a surface is exposed to a disinfectant in order for the disinfectant to be effective against micro-organisms.

Contract worker – Workers from an outside agency. These workers include health-care workers, maintenance and other workers or those who carry on activities in resident-care areas or come into contact with residents, such as hairdressers.

Control measure – Any action or activity that can be used to prevent or stop an outbreak. Control measures for gastroenteritis outbreaks are primarily focused on reducing additional exposure.

Cross-contamination – The transfer of pathogens from one food item to another during food preparation through cooking equipment, utensils or the hands of food handlers.

Employees (on payroll) – This includes all persons who receives a direct paycheck from the reporting facility (i.e., on the facility’s payroll), regardless of clinical responsibility or patient contact. This category should not include staff on long-term leave (e.g. maternity, paternity, disability).

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