Outbreak Reporting & IPAC for Congregate Living Settings

Under Ontario's Health Protection and Promotion Act, outbreaks of respiratory and gastrointestinal infections in institutions must be reported to the local Medical Officer of Health.

If an outbreak is suspected, report it to Hamilton Public Health Services. A Public Health staff member will work closely with facility staff to declare and manage the outbreak, helping to prevent further spread of illness.

By following these steps, congregate living settings can detect potential outbreaks early and take prompt action to prevent the spread of infections.

Steps for Early Outbreak Identification

1. Daily Resident Monitoring and Surveillance
   • Screen residents daily for respiratory and gastrointestinal symptoms:
     • Respiratory symptoms: Runny or stuffy nose, cough, congestion, sore throat, difficulty swallowing, fever, chills, difficulty breathing, loss of appetite, malaise, muscle pain, or headache.
     • Gastrointestinal symptoms: At least two unexpected episodes of diarrhea and/or vomiting within 24 hours.
2. Staff and Visitor Screening
   • Screen staff, visitors, and returning residents upon entry/re-entry for symptoms or potential exposures.

When to Report Outbreaks to Public Health

Respiratory Outbreaks

• Two patient/resident cases of acute respiratory illness occurring within 48 hours, with a common epidemiological link (such as same unit or floor) suggestive of transmission within the setting; or
• Two or more patient/resident cases of test-confirmed acute respiratory illness occurring within 48 hours, with a common epidemiological link (such as same unit or floor) suggestive of transmission within the setting

Molecular testing is the preferred method for symptomatic individuals in high-risk settings. While rapid antigen tests should ideally not be used for symptomatic clients, if they are, molecular testing should be conducted in parallel to confirm the results.

Gastrointestinal Outbreaks

• Symptoms of gastrointestinal illness occurring in two or more residents within 48 hours, with a common epidemiological link (such as same unit or floor)

General Directions for Outbreak Management

• Consult with Hamilton Public Health Services about following IPAC best practices (see Infection Control Measures section) and implementing outbreak control measures to reduce further transmission of illness
• Refer to the Ministry of Health and Long-term Care outbreak management documents:
  • Ministry of Health Recommendations for Outbreak Prevention and Control in Institutions and Congregate Living Settings
  • Appendix 1: Case Definitions and Disease-Specific Information Disease: Respiratory Infection Outbreaks in Institutions and Public Hospitals
  • Appendix 1: Case Definitions and Disease-Specific Information Disease: Gastroenteritis Outbreaks in Institutions and Public Hospitals
• Start an outbreak line list for residents and staff(PDF, 141.63 KB)
• Submit outbreak line listing to Hamilton Public Health Services Infectious Disease Program via
  • Fax 905-974-9847
• Consult with Hamilton Public Health Services before collecting outbreak specimens for laboratory testing (NP swabs for respiratory symptoms, stool samples for gastrointestinal symptoms)
• Maintain regular contact with Hamilton Public Health Services to review the outbreak status (new cases, hospitalizations, deaths, emerging challenges, etc.)

Reporting

Regular Business Hours Reporting
Call 905-546-2063 or Fax 905-546-4078

After Business Hours Reporting
Call 905-546-2489 and ask to speak with the infectious disease public health inspector on-call.

IPAC for Long-Term Care Homes: Summary of Key Principles and Best Practices (PHO)

Hand Washing

• How to Hand Rub (PHO)
• How to Hand Wash (PHO)
• Your 4 Moments for Hand Hygiene (PHO)
• List of hand sanitizers authorized by Health Canada

Personal Protective Equipment

• Putting on PPE (PHO)
• Taking off Full PPE (PHO)
• Recommended Steps for Putting On and Taking Off Personal Protective Equipment (PHO)
• Infographic – Recommended Steps: Personal Protective Equipment
• Recommended Steps for Putting On and Taking Off Personal Protective Equipment(PDF, 348.12 KB) (Hamilton Public Health Services and St. Joseph’s Healthcare Hamilton)

Cleaning and Disinfecting

• Cleaning involves the physical removal of dirt and microorganisms from surfaces by wiping or scrubbing with soap and water. In contrast, disinfection specifically refers to the process of killing microorganisms using chemical solutions. Both cleaning and disinfection are essential components of infection prevention and control.
• It’s important to note that some products are designated solely for cleaning, others for disinfection, and some can serve both purposes. Always refer to the manufacturer's instructions to ensure you use the product correctly. This includes understanding how long the surface should remain wet, proper mixing guidelines, and safety precautions.
• High-touch surfaces are frequently contacted by hands, making them prime areas for the accumulation of microorganisms. As a result, these surfaces require routine cleaning and disinfection to minimize the risk of infection. Common examples of high-touch surfaces include doorknobs, call bells, bedrails, light switches, toilet handles, handrails, and keypads.
• Best Practices for Environmental Cleaning for Prevention and Control of Infections in All Health Care Settings, 3rd Edition, 2018 (PHO)
• Chlorine Dilution Calculator (PHO)
• Key Elements of Environmental Cleaning in Healthcare Settings – Fact Sheet (PHO)

Construction, Renovation, Maintenance and Design

• Public Health Ontario – Construction, Renovation, Maintenance and Design (CRMD)

Ventilation

• Public Health Ontario - Heating, Ventilation and Air Conditioning (HVAC) Systems in Buildings and COVID-19
• Public Health Ontario - Use of Portable Air Cleaners and Transmission of COVID-19

When visiting your loved ones in a Long-Term Care Home (LTCH) during an outbreak, it's essential to take precautions to protect residents, staff, and yourself. Outbreaks in these settings can be stressful for families and caregivers, but by following these steps, you can help keep everyone safe. 

Check-in at the Front Desk and/or Nursing Station

• Upon arrival, stop by the front desk or nursing station. Infection control measures may change during an outbreak, and the staff will provide you with the latest guidelines to follow during your visit. They are there to answer any questions you have, so don’t hesitate to ask for clarification. 

Keep Your Hands Clean

• Hand hygiene is one of the most important steps you can take to protect your loved one:
• Wash your hands with soap and warm water, or use an alcohol-based hand rub (ABHR) immediately when entering and before leaving the facility.
• Clean your hands before entering and after leaving a resident’s room.
• Wash your hands before and after helping with meals or providing care, after using the washroom, and whenever your hands feel dirty.

Do Not Share Food or Other Items

To prevent the spread of illness, only bring essential items with you. Avoid sharing food, drinks, or personal belongings with other residents, visitors, or staff. 

Know How to Use Personal Protective Equipment (PPE)

• You may need to wear personal protective equipment like gloves, masks, gowns, and eye protection to prevent the spread of infection. PPE is important if you’re helping with tasks such as bathing, feeding, or toileting. If you’re unsure what PPE is needed, ask the staff for guidance.
• For more information on using PPE, you can watch instructional videos on
  • Putting on PPE
  • Taking off PPE

Practice Physical Distancing, Masking, and Cough Etiquette

• Keep a distance of two metres (six feet) from others whenever possible.
• Only provide direct care to your loved one, and avoid interactions with other residents.
• Always follow the infection prevention and control guidelines provided by the facility.
• Cough or sneeze into your elbow or a tissue, dispose of the tissue immediately, and clean your hands afterward.

Do Not Visit if you are Sick

• Visiting a resident when you aren’t feeling well puts everyone in the facility at risk. Stay home and do not visit the resident if you have any of the following symptoms, even if they are mild::
  • Fever, cough, runny nose, sneezing, stuffy nose, sore throat, or rash
  • Diarrhea, upset stomach, vomiting, or nausea (gastrointestinal symptoms)
• You may visit the home once you have no fever and your respiratory symptoms have been improving for 24 hours and no fever and your gastrointestinal symptoms have been improving for 48 hours.
• Consider wearing a medical mask until respiratory symptoms have fully resolved; avoid high-risk settings (e.g. LTCHs, RHs) for 10 days after symptoms start. If you must visit, wear a medical mask, maintain physical distancing, visit only in the resident’s room, and inform the high-risk setting of your recent illness.

Visiting a Sick Resident? Stay in Their Room

• Sick residents should remain in their rooms. Avoid taking a sick resident to any common areas (e.g., dining rooms, lounges) during your visit.
• While visiting a sick resident, follow the facility’s infection prevention and control instructions, such as wearing personal protective equipment (e.g., masks).
• Additionally, after visiting with a sick resident, leave the facility immediately. To protect other residents, avoid common areas (e.g., dining rooms) if possible.
• To protect yourself and others, remember to clean your hands with soap and water or ABHR when leaving the resident’s room and when leaving the facility.

Stay Up-to-date with Your Vaccinations

• Respiratory diseases, such as COVID-19 and influenza, can cause serious health complications and even death among older adults and other high-risk individuals. You can pass these viruses to others before you start to show symptoms. Even if residents have received their vaccinations, studies have shown that immunity wanes over time among older adults. Therefore, to protect yourself and your loved ones, stay up-to-date with your vaccinations.

Follow the Facility’s Infection Prevention and Control Instructions

• Hamilton Public Health Services and the local Infection Prevention and Control Hub works with facilities to prevent and control outbreaks. Follow the facility’s instructions for additional precautions or personal protective equipment (e.g., masks) if required. If followed by everyone, these measures can help control an outbreak.

How Long are Outbreaks?

• The duration of an outbreak can vary depending on several factors, including the type of illness, and the effectiveness of infection control measures. In general, outbreaks are usually considered over when there are no new cases for a specified period, based on public health guidelines. This can be longer if additional cases continue to emerge. 
• The quicker and more effectively infection control measures are implemented, such as isolation of sick individuals, use of personal protective equipment (PPE), and limiting visitors, the shorter the outbreak may last. 
• It’s important to follow the facility’s guidance closely, as they will update visitors when the outbreak is declared over.

Public Health Ontario – Infection Prevention and Control Online Learning Portal
Resources and online learning modules for both health care workers and non-clinical staff seeking education and training on IPAC and environmental cleaning.

Public Health Ontario – Infection Prevention and Control for Environmental Cleaning in Health Care
These resources and online learning modules are for individuals seeking education and training on IPAC and environmental cleaning. These items are intended for both frontline environmental service workers and management, as well as infection control professionals working in all health care settings.