Recommendations for Outbreak Prevention and Control in Institutions and Congregate Living Settings

Recommendations for Outbreak

Prevention and Control in Institutions

and Congregate Living Settings

Ministry of Health

Effective: April 2024

ISBN 978-1-4868-7976-2 [PDF]

Citation: Ontario. Ministry of Health. Recommendations

for outbreak prevention and control in institutions and

congregate living settings. Toronto, ON: King’s Printer for

Ontario; 2024.

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

Table of Contents

Introduction ................................................................................................................................................. 7

How to Use This Guide .............................................................................................................................. 8

Acronyms .................................................................................................................................................... 9

Glossary ..................................................................................................................................................... 11

Section 1: Roles and Responsibilities..................................................................................................... 14

Role of PHU ......................................................................................................................................................................... 14

Role of Institutions ............................................................................................................................................................ 16

Role of Ministries with respect to Institutions and Congregate Living Settings (e.g., IAO, MCCSS,

MLITSD, MLTC, MMAH, MOH, MSAA, OMAFRA, SolGen)

.................................................................................. 19

Role of Public Health Ontario ....................................................................................................................................... 19

Role of IPAC Hub ............................................................................................................................................................. 20

Section 2: Preparing for Potential Outbreaks ...................................................................................... 20

Outbreak Preparedness Plan........................................................................................................................................ 21

Outbreak Preparation Resources ................................................................................................................................ 21

Section 3: Managing a Suspect Outbreak ............................................................................................. 21

3.1 IPAC Measures ....................................................................................................................................................... 22

3.2 Administrative Measures .................................................................................................................................... 27

3.3 Client/Patient/Resident Restrictions ............................................................................................................ 27

3.4 Restrictions on Affected Units/Sites.............................................................................................................. 29

3.5 Admissions/Transfers from Acute Care Setting to an Institution ....................................................... 29

3.6 Transfers from an Outbreak Institution to an Acute Care Setting ...................................................... 30

3.7 Group/Social Activities and Other Events .................................................................................................... 31

3.8 Nourishment Areas/Sharing of Food ............................................................................................................. 31

3.9 Visitors and Essential Caregivers ..................................................................................................................... 32

3.10 HCW/Staff Outbreak Control Measures (including volunteers, students, and physicians) 33

3.11 Specimen Collection ....................................................................................................................................... 34

3.12 Enhanced Environmental Cleaning and Disinfection ......................................................................... 34

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

Section 4: General Recommendations for Confirmed Outbreaks ...................................................... 37

Roles and Responsibilities for Confirmed Outbreaks......................................................................................... 37

Reporting to the Local PHU ......................................................................................................................................... 37

Reporting Worker Illness to MLITSD ........................................................................................................................ 37

Declaring an Outbreak ................................................................................................................................................... 38

4.1 IPAC Measures ....................................................................................................................................................... 38

4.2 Administrative Measures .................................................................................................................................... 40

4.3 Client/Patient/Resident Restrictions ............................................................................................................. 41

4.4 Restrictions on Affected Units/Sites............................................................................................................... 41

4.5 Admissions/Transfers from Acute Care to an Outbreak Institution .................................................... 41

4.6 Transfers from an Outbreak Institution to an Acute Care Setting ........................................................ 41

4.7 Group/Social Activities and Other Events .................................................................................................... 41

4.8 Nourishment Areas/Sharing of Food ............................................................................................................ 42

4.9 Visitors and Essential Caregivers ..................................................................................................................... 42

4.10 HCW/Staff Outbreak Measures (including volunteers, students, physicians) ......................... 42

4.11 Specimen Collection ....................................................................................................................................... 43

4.12 Enhanced Environmental Cleaning and Disinfection ......................................................................... 43

Section 5: Confirmed COVID-19 Outbreak ............................................................................................ 43

A. Declaring a COVID Outbreak............................................................................................................................. 43

B. Duration of outbreak ............................................................................................................................................ 43

C. Case Management ................................................................................................................................................ 43

D. Contact Management .......................................................................................................................................... 44

5.1 IPAC Measures ....................................................................................................................................................... 47

5.2 Administrative Measures .................................................................................................................................... 48

5.3 Client/Patient/Resident Restrictions ............................................................................................................ 48

5.4 Restrictions on Affected Unit/Site .................................................................................................................. 49

5.5 Admissions/Transfers from Acute Care Setting to an Outbreak Institution ................................... 49

5.6 Transfers from an Outbreak Institution to an Acute Care Setting ....................................................... 49

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

5.7 Group/Social Activities and Other Events ................................................................................................... 49

5.8 Nourishment Areas/Sharing of Food ............................................................................................................ 49

5.9 Visitors and Essential Caregivers ..................................................................................................................... 50

5.10 HCW/Staff Outbreak Measures (including volunteers, students and physicians) ................. 50

5.11 Specimen Collection ........................................................................................................................................ 51

5.12 Enhanced Environmental Cleaning and Disinfection ......................................................................... 52

Section 6: Confirmed ARI Outbreak ....................................................................................................... 52

A. Declaring an ARI Outbreak ................................................................................................................................. 52

B. Duration of Outbreak ............................................................................................................................................ 53

C. Case Management ................................................................................................................................................ 53

D. Contact Management .......................................................................................................................................... 54

6.1 IPAC Measures ....................................................................................................................................................... 58

6.2 Administrative Measures .................................................................................................................................... 58

6.3 Client/Patient/Resident Restrictions ............................................................................................................ 58

6.4 Restrictions on Affected Unit/Site .................................................................................................................. 58

6.5 Admissions/Transfers from Acute Care to an Outbreak Institution ................................................... 58

6.6 Transfers from an Outbreak Facility to an Acute Care Setting ............................................................ 58

6.7 Group/Social Activities and Other Events ................................................................................................... 59

6.8 Nourishment Areas/Sharing of Food ............................................................................................................ 59

6.9 Visitors and Essential Caregivers ..................................................................................................................... 59

6.10 HCW/Staff Outbreak Measures (including volunteers, students, physicians) ......................... 59

6.11 Specimen Collection ....................................................................................................................................... 59

6.12 Enhanced Environmental Cleaning and Disinfection ........................................................................ 60

Section 7: Confirmed Influenza Outbreak ............................................................................................ 60

A. Declaring an Influenza Outbreak .................................................................................................................... 60

B. Duration of Outbreak ........................................................................................................................................... 60

C. Case Management ................................................................................................................................................. 61

D. Contact Management ........................................................................................................................................... 61

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

7.1 IPAC Measures ........................................................................................................................................................ 61

7.2 Administrative Measures ..................................................................................................................................... 61

7.3 Client/Patient/Resident Restrictions ............................................................................................................ 62

7.4 Restrictions on Affected Units/Settings ....................................................................................................... 62

7.5 Admissions/Transfers from Acute Care to an Outbreak Institution/Setting .................................. 62

7.6 Transfers from an Outbreak Institution to an Acute Care Setting ....................................................... 62

7.7 Group/Social Activities and Other Events ................................................................................................... 62

7.8 Nourishment Areas/Sharing of Food ............................................................................................................ 62

7.9 Visitors and Essential Caregivers ..................................................................................................................... 62

7.10 HCW/Staff Outbreak Measures (including volunteers, students, physicians) ......................... 62

7.11 Specimen Collection ....................................................................................................................................... 63

7.12 Enhanced Environmental Cleaning and Disinfection ......................................................................... 63

Section 8: Confirmed Gastrointestinal Outbreak ................................................................................. 64

A. Declaring a Gastroenteritis Outbreak ............................................................................................................. 64

B. Duration of the outbreak ..................................................................................................................................... 64

8.1 IPAC Measures ....................................................................................................................................................... 75

8.2 Administrative Measures .................................................................................................................................... 75

8.3 Client/Patient/Resident Restrictions ............................................................................................................ 75

8.4 Restrictions on Affected Units/Site ................................................................................................................ 75

8.5 Admissions/Transfers from Acute Care to an Outbreak Institution ................................................... 75

8.6 Transfers from an Outbreak Setting to Acute Care .................................................................................. 76

8.7 Group/Social Activities and other Events .................................................................................................... 76

8.8 Visitors and Essential Caregivers ..................................................................................................................... 78

8.9 HCW/Staff Outbreak Measures ...................................................................................................................... 78

8.10 Specimen Collection ....................................................................................................................................... 78

8.11 Enhanced Environmental Cleaning and Disinfection ......................................................................... 79

Section 9: Closing an Outbreak .............................................................................................................. 79

Review the Outbreak ...................................................................................................................................................... 79

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

Complete the Outbreak Investigation File ............................................................................................................ 80

Appendix A: Outbreak Preparation Resources ..................................................................................... 81

Appendix B: Antivirals/Therapeutics .................................................................................................... 84

Appendix C: Sample Outbreak Line List ................................................................................................ 95

Appendix D: COVID-19 Case, Contact and Outbreak Management in non-LTCH/RH Institutions . 97

Appendix E: Instructions for COVID-19 Cases and Close Contacts Associated with LTCHs, RHs, and

Institutions

.............................................................................................................................................. 101

Appendix F: Summary of Screening Practices for Settings.............................................................. 104

References ............................................................................................................................................. 106

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

Introduction

Reference Documents are not enforceable; the aim of Reference Documents is to

provide professional staff employed by local boards of health, support in

operationalizing and implementing requirements outlined in the Standards and

related documents.

Specifically, this document has been developed to support

public health’s work in managing outbreaks and provides guidance on infection

control measures.

This guidance document is intended to be used as an operational guide for local

public health units (PHUs) investigating outbreaks in institutions, including long-term

care homes (LTCHs) and retirement homes (RHs). The document provides current

best practices and evidence-based guidance for control of respiratory (including

SARS-CoV-2) and gastrointestinal outbreaks in institutions under the Health

Protection and Promotion Act, and other congregate living settings in Ontario.

This

document also discusses the roles of ministry partners, PHUs and institutions. The

Roles and Responsibilities outlined for institutions may also be applied to facilities

that are not defined as institutions under the HPPA, such as shelters and other

congregate living settings, based on the risk of the population and setting, to

prevent and manage outbreaks.

Institutions may be at increased risk for infectious disease outbreaks due to

communal living and underlying health conditions of the individuals residing in

these spaces.

Effective outbreak management requires coordination of practices and policy to

ensure a quick and effective response. Under the HPPA (Section 25 (1) and (2)),

notification of a disease of public health significance (DOPHS) (including SARS-CoV-

2, respiratory and gastrointestinal outbreaks) to the local Medical Officer of Health,

or the PHU, is required by the physician or practitioner (definitions of “practitioner”

are listed in the HPPA). Health care worker (HCW) and staff training are essential to

the early detection of illness in a client/patient/resident and control of potential

outbreaks in these institutions.

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

NOTE: There are foundational infection prevention and control measures outlined in

this document that are applicable throughout the year. However, additional infection

prevention and control (IPAC) measures may be applicable during high-risk periods

of respiratory virus illness. Please refer to PHO’s Interim Infection Prevention and

Control Measures Based on Respiratory Virus Transmission Risk in Health Care

Settings for more information on the classification of periods of high-risk

transmission and non-high-risk transmission.

Additional measures (e.g., increased use of masking by staff/visitors, increased

frequency of infection prevention and control audits with feedback) to prevent

respiratory virus transmission during high-risk periods should be implemented

provincewide when identified by the Office of the Chief Medical Officer of Health,

Public Health, and may also be implemented based on local/regional context.

Additional measures, as described in PHO’s Interim Infection Prevention and Control

Measures Based on Respiratory Virus Transmission Risk in Health Care Settings,

during high-risk periods may be particularly applicable to settings where individuals

who are at higher risk of severe outcomes reside, and may not apply to all

institutions. Institutions should refer to any applicable sector-specific guidance for

further information/direction during high-risk periods.

Please note that PHUs have the discretion to modify or discontinue any activity in

the institution as part of their outbreak investigation and management (e.g., adult

day activities within the setting/affected unit, implementing universal masking).

How to Use This Guide

• This document was created for PHUs to use as a guide for preventing and

supporting the management of suspect and confirmed COVID-19, respiratory

and gastroenteritis outbreaks in institutions.

• The guide has been organized into ten sections, for user ease.

• Roles and responsibilities have been outlined for those who have a role in the

outbreak management process.

• Institutions (including long-term care homes (LTCHs) and retirement homes

(RHs) can use this document for guidance purposes to inform their policies and

procedures regarding the prevention and management of outbreaks. Due to the

wide-ranging nature of institutions, not all information under each section will

apply to every setting. The user fulfilling a specific role can determine which

guidance is applicable to their setting.

• Note: Settings should ensure they follow sector-specific requirements/guidance.

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

Acronyms

ABHR Alcohol-Based Hand Rub

ARI Acute Respiratory Infection

BOH Board of Health

CLS Congregate Living Setting

DONPC Director of Nursing and Personal Care

DOPHS Disease of Public Health Significance

FLTCA Fixing Long-Term Care Act, 2021

GI Gastrointestinal

HACCP Hazard Analysis Critical Control Point

HCW Health Care Worker

HCP Health Care Providers

HPPA Health Protection and Promotion Act, 1990

HCCSS Home and Community Care Support Services

IAO Indigenous Affairs Ontario

ICP Infection Prevention and Control Professional

IPAC Infection Prevention and Control

JHSC Joint Health and Safety Committee

LTCH Long-Term Care Home

MCCSS Ministry of Children, Community, and Social Services

MMAH Ministry of Municipal Affairs and Housing

MLTC Ministry of Long-term Care

MLITSD Ministry of Labour, Immigration, Training and Skills Development

MOH Ministry of Health

MSAA Ministry for Seniors and Accessibility

NACI National Advisory Committee on Immunization

OB Outbreak

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

OH Ontario Health

OHS Occupational Health and Safety

OHSA Occupational Health and Safety Act, 1990

OMAFRA Ontario Ministry of Agriculture, Food and Rural Affairs

OMT Outbreak Management Team

PCRA Point-of-Care Risk Assessment

PRA Personal Risk Assessment

PHAC Public Health Agency of Canada

PHU Public Health Unit

PHO Public Health Ontario

PIDAC Provincial Infectious Diseases Advisory Committee on Infection

Prevention and Control PIDAC-IPC

PPE Personal Protective Equipment

RH Retirement Home

RSV Respiratory Syncytial Virus

SDM Substitute Decision Maker

SolGen Solicitor General

WSIB Workplace Safety and Insurance Board

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

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 clients/patients/residents from other individuals and the use of Personal

Protective Equipment (PPE) (e.g., gowns, gloves, masks, eye protection) 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 transmit

the agent to others. More information can be found in PIDAC’s Routine Practices and

Additional Precautions in all Health Care Settings.

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 should

have an alcohol concentration between 70% and 90%.

Cohorting:

• Clients/Patients/Residents: Grouping of clients/patients/residents who are

colonized, infected or exposed to/with the same microorganism with staffing

assignments restricted to the cohorted group of patients;

• Staff: Grouping of staff to care for a specific group of

clients/patients/residents or to assign them to a floor/unit that either

contains or does not contain active cases.

Contact Precautions: A type of Additional Precaution 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 time that a disinfectant must be in contact with a surface or

device to ensure that disinfection has occurred. For disinfectants, the surface should

remain wet for the required contact time.

Control measure: Any action or activity that can be used to prevent or stop

transmission of infection and outbreaks. Control measures for gastroenteritis

outbreaks are primarily focused on reducing additional exposure.

Cross-contamination: The transfer of pathogens from one item to another item (e.g.,

during food preparation through cooking equipment, utensils, food contact surfaces,

the hands of food handlers or care providers).

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

Epidemiological Link: An epidemiological link can refer to, but is not limited to,

common unit/floor, common staff, shared activities or dining area, common visitors

etc., where there is evidence of transmission within the unit or site.

Food handler: A person who directly handles or prepares food.

Gastroenteritis: Inflammation of the stomach and intestines that usually causes

diarrhea and/or vomiting.

Hazard Analysis Critical Control Point (HACCP): A science-based, systematic

approach of identifying, evaluating, and controlling food safety hazards. HACCP is

designed to prevent, reduce, or eliminate potential biological, chemical, and

physical food-safety hazards, including those caused by cross-contamination.

Health care setting: Any location where health care is provided, including settings

where emergency care is provided, hospitals, LTCHs, outpatient clinics, community

health centres and clinics, physician offices, dental offices, and home health care.

Infection prevention and control committee: The Infection Prevention and Control

Committee is a multidisciplinary committee that serves the setting and is

responsible for verifying that the infection prevention and control recommendations

and standards are being followed in the health care setting.

Infection prevention and control professional (ICP)/IPAC lead: Trained

individual(s) responsible for a health care setting’s infection prevention and control

activities. Refer to sector-specific legislation for requirements of the ICP or IPAC

lead.

Just Clean Your Hands

: Is the evidence-based hand hygiene program that was

developed by Public Health Ontario to improve the hand hygiene compliance of

health care providers, reduce negative impacts on clients/patients/residents due to

health care associated infections, and increase the performance of Ontario’s health

system.

Joint Health and Safety Committee (JHSC): A committee formed in workplaces to

address health and safety concerns and improve health and safety in the workplace.

This committee is composed of employer and worker representative.

Joint Health and Safety Committee (JHSC) member: a worker representative

whose duties include ensuring Occupational Health and Safety Act, 1990,

requirements are met.

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

Line list: A table that summarizes information about suspect, probable, or confirmed

cases associated with an outbreak. It often includes identifying information,

demographics, clinical information, and exposure or risk-factor information.

Long-Term Care Homes: is a long-term care home within the meaning of

subsection 2(1) of the Fixing Long-Term Care Act, 2021.

OHS Workplace Designate: anyone or any service that assumes the responsibility

for the delivery of occupational health services to the setting.

Organizational Risk Assessment: An evaluation done by the organization or facility

in order to implement controls to mitigate identified hazards.

Performed by the employer to:

• Apply engineering controls;

• Apply administrative controls;

• Provide PPE as required.

Personal Risk Assessment (PRA): Staff/visitors conduct personal risk assessments

to identify controls (precautions, PPE) already in place and determine if additional

measures/PPE are required.

Point-of-care Risk Assessment (PCRA): Assesses the task, the patient, and the

environment to identify the most appropriate precautions (PPE) that need to be

taken for that particular interaction or task.

Performed by staff to:

• Identify controls already in place (e.g., access to ABHR, sharps container)

• Use additional measures, if needed

(e.g., selection of PPE)

Retirement Home: is a retirement home within the meaning of subsection 2(1) of the

Retirement Homes Act, 2010.

Routine Practices: The system of infection prevention and control practices

recommended by the Public Health Agency of Canada to be used with all

clients/patients/residents during all care to prevent and control transmission of

microorganisms in all health care settings. They are based on the premise that all

blood, body fluids, secretions, excretions, mucous membranes, non-intact skin, or

soiled items are potentially infectious. These practices are to be used with all

clients/patients/residents during all care to prevent and control the transmission of

micro-organisms. More information can be found in PHO’s Routine Practices and

Additional Precautions in all Health Care Settings.

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

Surveillance: The systematic and ongoing collection, collation, and analysis of data

and the timely dissemination of information so that appropriate action can be taken

to reduce the number of illnesses. For more information, please refer to PHO’s Best

Practices for Surveillance of Health Care-Associated Infections.

Section 1: Roles and Responsibilities

Managing outbreaks is a collaborative effort across public health and institution

partners. Depending on the scope of the outbreak and type of pathogen, different

partners may be involved in outbreak response and investigation.

Role of PHU

Act under the authority of the HPPA and in accordance with the Ontario Public

Health Standards.

The OPHS and accompanying protocols outline the minimum expectations for PHU

programs and services to be delivered by PHUs in Ontario.

Prevention and Preparedness

Assist institutions with creation of a prevention and preparedness plan for managing

cases, contacts, and outbreaks.

Provide information and training to institutions to encourage uptake of

immunizations and antivirals.

Support the development and implementation of outbreak management plans (in

conjunction with partners) per section 2.

Case and Contact Management/Outbreak Management

Receive reports of suspected or confirmed cases and contacts of illness in

accordance with the HPPA.

Enter cases, contacts, and outbreaks into the provincial surveillance system, in

accordance with data entry guidance provided by PHO.

While assessing the scope, severity, population at risk and ability for the institution

to manage the outbreak, the PHU shall provide outbreak support as needed.

Provide guidance and recommendations to the facility on outbreak control

measures, IPAC best practices and provincial resources.

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

Support/consult with Infection Prevention and Control Professionals (ICP) and

provide representation on the Outbreak Management Team (OMT), when

appropriate.

Assist in ensuring collection of clinical, environmental, or other samples as

appropriate to assess, evaluate, confirm, and control the outbreak.

Ensure prophylaxis and/or vaccines are recommended and offered in outbreaks

where they would be considered a public health intervention.

For respiratory outbreaks, including COVID-19, shall assess, and where

epidemiological evidence supports it, review and evaluate infection prevention and

control practices in the institution, in accordance with the Institutional/Facility

Outbreak Management Protocol, 2018 (or as current).

For gastroenteritis outbreaks, shall assess the need for additional inspection of food

preparation and handling within the institution, in accordance with the

Institutional/Facility Outbreak Management Protocol, 2018 (or as current).

For Clostridioides difficile (CDI) outbreaks, shall assess and, where epidemiological

evidence supports it, inspect, and evaluate IPAC practices at the institution,

including antimicrobial stewardship programs in accordance with the

Institutional/Facility Outbreak Management Protocol, 2023 or as current.

Issue orders by the Medical Officer of Health (MOH) or their designate under the

HPPA, if necessary.

Declare an outbreak over.

Coordination and Communication

If a case or contact resides in a PHU that is different than that of the institution,

discussions between the respective PHUs should take place to coordinate contact

follow-up and delineate roles and responsibilities.

The PHU where the home is geographically located is typically the lead PHU for

home follow-up.

Request support from the Ministry of Health if coordination between multiple PHUs

is required for outbreak management.

Notify the Ministry of Health (IDPP@ontario.ca) of:

• Potential for significant media coverage or if media releases are planned by

the PHU and/or facility.

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

• Any orders issued by the PHUs MOH or their designate to the institution and

share a copy.

• Engage and/or communicate with relevant partners, stakeholders, and

ministries, as necessary.

Outbreak Management Team

• Facilitates lab testing by contacting the lab to discuss the appropriate specimen

collection and testing required.

• Recommends best practices for outbreak control measures to be implemented

including new admissions/transfers, immunization, and management of

HCWs/staff.

• Determines the frequency of receiving updated line lists as part of the ongoing

risk assessment of the outbreak which will influence the level of involvement by

the PHU in the management of the outbreak.

• Reviews line list received from institution, monitors outbreak progress, and

provides consultation to setting when necessary.

• Creates outbreak number for institution through Public Health Ontario (PHO) for

outbreak-related specimen tracking and provides this number to the institution

contact person.

Role of Institutions

• All institutions are responsible for reporting outbreaks of DOPHS to their local

PHU, as per subsection 27(2) of the HPPA.

Some institutions are to be

considered that are not under the HPPA (see Institutional/Facility Outbreak

Management Protocol, 2018 or as current).

2,11

• Institutions are to follow any outbreak reporting requirements required under

their respective legislation or authorities.

• All institutions as employers under the Occupational Health and Safety Act, 1990

(OHSA) and its regulations, have a duty to take every precaution reasonable in

the circumstances for the protection of a worker. This includes protecting

workers from the hazards of infectious diseases.

• Implement prevention measures found in this guidance, sector-specific

guidance or as directed by their local PHU.

• Coordinate with the local PHU and other stakeholders as appropriate, as part of

the investigation of cases, contacts, and outbreaks.

• Follow any directions of the local PHU and/or OMT if there is a suspect or

confirmed outbreak in the institution.

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

• Maintain accurate records regarding suspect and confirmed outbreaks that can

be made available to the local PHU in a timely manner for investigations and

communications.

• Develops and maintains communication plans to keep staff,

clients/patients/residents, and families informed about the outbreak status of

the institution, including frequent and ongoing communication during outbreaks.

IPAC Lead/Designate within Institution

Note: Depending on the nature of the institution, not all institutions will have an IPAC

lead/designate. Refer to: IPAC Standard for Long-Term Care Homes.

• Conducts routine auditing to identify educational/training needs.

• Ensures training and education of HCWs/staff/visitors regarding outbreak

management and IPAC principles.

• Where applicable, review infectious disease surveillance results regularly to

ensure that all staff are conducting infectious disease surveillance appropriately

and to ensure that appropriate action is being taken to respond to surveillance

findings.

• Reviews and updates internal policies and procedures for IPAC (Routine

Practices, Additional Precautions) and outbreak management as necessary,

including review of case definitions and reporting processes.

• Work with site personnel to ensure adequate PPE/hand hygiene (HH) supplies,

signage for outbreak management, and respiratory and stool specimen kits that

are not expired.

Institution Administration, Management or Designate

• Supports recommended immunization of clients/patients/residents, HCW/staff

and volunteers.

• Develop plan for implementing prophylaxis/therapeutics.

• Develop policies and procedures for outbreak prevention and management.

• Liaise with IPAC Lead/Designate to ensure policies and procedures are in place

for reporting of DOPHS by units/staff (where applicable).

• Liaise with IPAC Lead/Designate to ensure unit/HCW/staff have access to the

current outbreak management guidance as well as policies and procedure for

reporting outbreaks to the local PHU.

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

• Ensure HCW/staff/visitor awareness of symptoms as found in Appendix 1

for

reporting to PHU.

• Works closely with IPAC lead to report HCW/staff illness to setting management

and OMT where necessary.

• Liaise with Joint Health and Safety Committee (JHSC) or health and safety

representative to ensure Occupational Health and Safety Act (OHSA)

requirements are fulfilled.

• Supports/discusses any workplace-related health and safety concern with the

Joint Health and Safety Committee (JHSC).

• Ensure communication pathways between the PHU and institution are identified

during an outbreak such that the PHU can obtain outbreak information as

needed, even on weekends/holidays.

Onsite HCW (where applicable)/Staff

• Ensu

res ongoing monitoring and surveillance at the setting to identify and report

new symptomatic illness in residents according to

Appendix 1

• Works in collaboration with oth

er staff to facilitate outbreak investigations and

implement appropriate initial IPAC measures immediately.

o It is not necessary to await lab results from collected specimens to initiate

IPAC measures.

• Coordinates the collection of clinical specimens as appropriate, under direction

of OMT.

• Maintains clear communication with staff leads, administration and management

in the setting.

• Liaise with clinicians as necessary.

Occupational Health and Safety (OHS)

• The Occupational Health and Safety Act (OHSA

)

requires employers to take every

precaution reasonable in the circumstances for the protection of workers

(includes protecting workers from transmission of infectious disease in the

workplace).

Appendix 1: Gastroenteritis Outbreaks in Institutions and Public Hospitals

Appendix 1: Diseases caused by a novel coronavirus, including Coronavirus Disease 2019

(COVID-19), Severe Acute Respiratory Syndrome (SARS) and Middle East Respiratory

Syndrome (MERS) | Appendix 1: Respiratory Infection Outbreaks in Institutions and Public

Hospitals

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

• Joint Health and Safety Committee (JHSC) member information can be found at

Ontario’s Guide for Health and Safety Committees and Representatives page.

• Institutions may have an OHS workplace designate who will assist with

recommendations made by the JHSC;

• The OHS workplace designate would also work closely with IPAC lead to report

HCW/ staff illness to institution management and OMT where necessary.

• Assess and address any workplace-related health and safety concerns.

Role of Ministries with respect to Institutions and

Congregate Living Settings (e.g., IAO, MCCSS, MLITSD,

MLTC, MMAH, MOH, MSAA, OMAFRA, SolGen)

• Provide sector-sp

ecific guidance and policy oversight, where applicable.

• May have enforcement capabilities within their sector (i.e., MLTC, MLITSD).

Role of Public Health Ontario

• Provide scientific and technical advice to PHUs to support outbreak

management, case and contact management, and data entry.

• Develop evidence-informed resources, programs, and approaches.

• Advise on and support laboratory testing as needed.

• Work with MOH and other government and health system partners on a

coordinated approach to strengthening capacity.

• Provide scientific and technical advice to MOH and PHUs, including multi-

jurisdictional teleconferences.

• Supplies specimen collection kits as needed to PHUs.

• Test specimens to identify etiology.

• As needed, provides consultation to PHU/OMT on specimen type and testing

appropriate for outbreak.

• Ensures OMT and IPAC lead receive timely results of outbreak specimens.

• Track all samples and specimens submitted under the outbreak number.

Public Health Ontario Specimen Collection Guidance

•

For more information, refer to PHO’s Enteric Outbreak Kit Ordering Instructions

and Gastroenteritis –Stool Viruses webpage and the Respiratory Viruses

webpage.

15,16,17

Policies should also address receiving and reporting of laboratory

test results. Refer to the Laboratory Services section of PHO’s website for more

information.

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

Role of IPAC Hub

• Support implementation of infection prevention and control (IPAC) best practices

in applicable institutions.

• Educational supports are offered both remotely (virtually) or onsite and are

tailored to the unique types and needs of settings.

• Deliver education and training.

• Host communities of practice (CoP) to support information sharing, learning, and

networking to congregate living settings.

• Support the development and implementation of IPAC programs, policy, and

procedures within sites/organizations.

• Support assessments and audits of IPAC programs and practices.

• Mentor IPAC leads/staff to strengthen IPAC programs and practices.

• Mentor those with responsibilities for IPAC within institutions.

Section 2: Preparing for Potential

Outbreaks

It is the responsibility of the institution to be prepared for the possibility of a COVID-

19, respiratory or gastrointestinal illness (GI) outbreak. PHUs support outbreak

management by assisting these settings to develop their own policies and

procedures for outbreak prevention and management, including, but not limited to:

• Staff training on outbreak management principles.

• Routine Practices and Additional Precautions (related to outbreak

management), including passive screening and information for

staff/clients/patients/residents/visitors.

• Staff access to current outbreak management resources.

• Internal policies and procedures for outbreak management including

symptoms that require investigation, surveillance and reporting internally and

to the PHU.

• Adequate availability of supplies for outbreak management including PPE, HH

supplies, and respiratory/stool collection kits.

• Communications plans as part of outbreak management, including between

PHU and institution and to client/patients/residents, family member and

visitors.

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

Outbreak Preparedness Plan

Institutions should ensure measures are taken to prepare for and respond to an

infectious disease outbreak, including developing and implementing an outbreak

preparedness plan. The plan should include:

• Outbreak Preparedness Plans to support the operationalization of the

recommendations outlined in this guidance document and develop

contingencies as appropriate to their setting, in accordance with any setting-

specific guidance issued by their respective ministries. Refer to PHO’s COVID-

19 Preparedness and Prevention in Congregate Living Settings Checklist.

• Identifying members of the OMT.

• Identifying their local PHU and their contact information.

• Implementing and auditing of the IPAC Program, in accordance with relevant

legislation and sector specific guidance as applicable.

• Ensuring non-expired collection kits are available and stored appropriately,

and plans are in place for specimen collection (including training of staff on

how to collect a specimen.

• Ensuring sufficient PPE is available and that all staff and volunteers are

trained on IPAC protocols, as applicable, including how to perform a personal

risk assessment/PCRA and the appropriate use of PPE including how to don

and doff PPE.

• Ensuring policies and processes are in place for rapid deployment of

antivirals and prophylaxis, when applicable.

• Developing policies to manage staff who may have been exposed in an

outbreak and/or staff shortages.

• Developing and implementing a communications plan to keep staff,

clients/patients/residents, and families informed about the status of

outbreaks in the settings, including frequent and ongoing communication

during outbreaks.

• Identifying their local IPAC Hub and their contact information.

Outbreak Preparation Resources

Please see Appendix A for outbreak resources.

Please see Appendix C for a sample outbreak line list.

Section 3: Managing a Suspect Outbreak

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

Table 3.1: Initial information required by PHU from Institutions

Site name

Address

Telephone

Name of Manager/contact

person and email

Date

# ill residents and # total

residents per unit/area

# ill staff and # total staff

Do staff work in multiple

locations/sites?

First case’s symptom onset

date

# hospitalizations

# deaths

What control measures have

been initiated?

Request line list from Institution

3.1 IPAC Measures

• Routine Practices are based on the premise that all clients/patients/residents

are potentially infectious, even when asymptomatic, and that these standards of

practice should be used routinely during all care. Routine practices include but

are not limited to:

o PCRA: HCW conducting a point-of-care risk assessment (PCRA) prior to

client/patient/resident interaction to determine PPE use;

o PRA: Staff/visitors conducting personal risk assessment to identify controls

already in place and determine if additional measures are required;

o Hand hygiene: A general term referring to any action of hand cleaning. Hand

hygiene relates to the removal of visible soil and removal or killing of transient

microorganisms from the hands. Hand hygiene may be accomplished using

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

soap and running water or an alcohol-based hand rub. Hand hygiene includes

surgical hand antisepsis;

o PPE: The use of PPE (e.g., gloves, gown, mask, eye protection) to prevent staff

contact with a client’s/patient’s/resident’s blood, body fluids, secretions,

excretions, mucous membranes, non-intact skin, or soiled items;

o Control of the environment: Describes the structural design of an institution

and design measures (e.g., cleaning and disinfecting of equipment and

surfaces, bed placement in shared rooms, and location of ABHR dispensers);

o Administrative controls: Policies and procedures related to the IPAC program,

staff education, staffing levels, immunization, etc.;

o Engineering controls: Physical or mechanical measures put in place to help

reduce the risk of infection to staff and/or to clients/patients/residents (e.g.,

installation of ABHR at the point-of-care, installation of sharps containers at

the point-of-care, ventilation).

• Additional Precautions refer to IPAC interventions (e.g., PPE, accommodation,

additional environmental cleaning) to be used in addition to Routine Practices to

protect staff and clients/patients/residents by interrupting transmission of

suspected or identified infectious agent; Based on presenting symptoms, droplet

and contact or airborne precautions can be implemented.

• If a client/patient/resident develops symptoms in accordance with Appendix

IPAC measures including Additional Precautions should be implemented

immediately.

• Isolation of symptomatic clients/patients/residents:

o Symptomatic clients/patients/residents:

 Isolate immediately and implement Additional Precautions.

 HCWs/Staff to wear PPE as determined by their PCRA or PRA.

 Place signage outside client/patient/resident’s room, on the door,

indicating to HCWs/Staff/visitors that Additional Precautions are required.

• For symptomatic clients/patients/residents if COVID-19 or Influenza is

suspected, see early treatment/therapeutics recommendations in Section 6.2

and Section 8.2.

• Notify the local PHU.

• Notify all staff, clients/patients/residents, and families as soon as an outbreak is

suspected or confirmed.

• Encourage clients/patients/residents with suspect gastroenteritis to remain in

their rooms until 48 hours symptom-free and provide them with tray food

service.

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

• Begin a line list to track additional clients/patients/residents and staff that meet

the case definition (refer to Appendix C for a sample outbreak line list).

• Implement enhanced environmental cleaning and disinfecting (e.g., increased

cleaning and disinfecting of high touch surfaces, potentially switching

disinfectants, donning/doffing appropriate PPE).

• Staff are to follow routine practices when handling soiled clothing/linens and

waste and wear the appropriate PPE as indicated by a PCRA.

• Hand hygiene is the single, most important measure in preventing the spread of

infections.

o Hand hygiene should be performed in accordance with PHOs Best Practices

for Hand Hygiene in All Health Care Settings, 4

Edition

o The 4 moments for hand hygiene are:

 Before initial client/patient/resident contact and/or contact with their

environment.

 Before invasive/aseptic procedures.

 After body fluid exposure risk and contact with blood, body fluids,

secretions, and excretions.

 After client/patient/resident contact and/or contact with their

environment.

• Alcohol-based hand rubs (ABHR) are the first choice for hand hygiene when

hands are NOT visibly soiled.

o 70-90% ABHR should be used as this range is also more effective against

Norovirus.

o Must have a Natural Product Number (NPN) or Drug Identification Number

(DIN) from Health Canada.

o Must not be expired.

• Wash hands with soap and water when hands are visibly soiled.

o Liquid and foam soaps may become contaminated. Liquid products shall be

dispensed in disposable pump dispensers that are discarded when empty.

They should never be “topped-up” or refilled.

• Glove use is not a substitute for hand hygiene; hand hygiene is required before

donning and after doffing gloves.

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

Table 3.2: Additional Precautions

Additional Precautions Items Required

Contact Precautions

Gloves, gown (if skin or clothing may

come into direct contact with the

client/patient/resident or their

environment).

Droplet Precautions

Facial protection (medical mask, eye

protection).

Airborne Precautions Airborne infection isolation room; fit-

tested N95 respirator for airborne

pathogens.

For more fulsome details regarding the IPAC measures listed above, please refer to:

• The Best Practices for Hand Hygiene, April 2014.

• Routine Practices and Additional Precautions in All Health Care Settings,

November 2012.

• Annex B, Best Practices for Prevention of Transmission of Acute Respiratory

Infection, March 2013.

• Best Practices for Environmental Cleaning for Prevention and Control of

Infections, April 2018.

The most current PIDAC documents are available at: Provincial Infectious Diseases

Advisory Committee on Infection Prevention and Control (PIDAC-IPC).

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

Figure 3.1: Routine Practices and Additional Precautions

Implement Routine Practices and Additional Precautions as per PHO’s Routine Practices and

Additional Precautions in All Health Care Settings (3rd edition).

PCRA

• A PCRA assesses the task, the client/patient/resident, and the environment to identify the

most appropriate precautions that needs to be taken for that interaction or task.

Resident Placement and Signage

• Single room preferred.

• Maintain 2 metres between clients/patients/residents sharing a room.

• Use of physical barriers (curtains or portable wipeable screens) is recommended.

Face Mask (for respiratory outbreaks)

• Masking is recommended for staff, clients/patients/residents, and visitors during

respiratory outbreaks or seasonal increases in respiratory illness.

Eye Protection

• Eye protection is worn to protect mucous membranes of the eyes during procedures likely

to generate splashes or sprays of blood, body fluids, secretions, excretions or when within

two metres of a coughing client/patient/resident or client/patient/resident on Droplet

Precautions.

• Prescription eyeglasses are NOT appropriate for use as eye protection.

Gowns

• Gowns are worn to protect uncovered skin and protect clothing or uniforms during

activities likely to generate splashes or sprays of blood, body fluids, secretions, or

excretions.

Gloves

• Gloves protect the hands of HCWs from contact with the client’s/patient’s/resident’s body

fluids, bloods, excretions, secretions, tissue, mucous membranes or non-intact skin, or

equipment/surfaces which have been contaminated with the above.

Four Moments of Hand Hygiene

1. Before initial client/patient/resident contact and/or contact with their environment.

2. Before invasive/aseptic procedures.

3. After body fluid exposure risk and contact with blood, body fluids, secretions, and

excretions.

4. After client/patient/resident contact and/or contact with their environment.

Visitors

• Request visitors to report to administration desk or nursing desk to discuss precautions

before entering client’s/patient’s/resident’s room.

Environmental Control

• Institutions should ensure regular environmental cleaning (e.g., at least once a day) of their

institution is maintained and enhanced environmental cleaning and disinfection for

frequently touched surfaces is performed.

• Institutions should increase cleaning and disinfection to twice daily in suspect or confirmed

outbreaks.

• Confirm disinfectant being used is effective for identified pathogen (products effective

against one pathogen may not be effective against another).

*Please refer to PHO’s Routine Practices Fact Sheet for more detailed information.

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

3.2 Administrative Measures

• Ensure an organizational risk assessment is conducted to determine which

controls are already in place and which controls need to be implemented (this

includes administrative, environmental, and engineering controls).

• Ensure adequate availability of all supplies, such as hand hygiene products, PPE,

linen, cleaning products and specimen collection supplies for appropriate

departments.

• Ensure HCWs/staff are maintaining heightened surveillance to identify and

report newly symptomatic clients/patients/residents as per Appendix 1

• Consult with the ICP/IPAC lead or the OMT when making decisions about

cohorting HCW/staff assignments. Cohorting is recommended where

operationally feasible (i.e., symptomatic clients/patients/residents receiving

treatments after asymptomatic clients/patients/residents or having designated

HCW/staff treat symptomatic clients).

• Ensure policies and processes are in place for rapid deployment of antivirals and

prophylaxis, if applicable to be used as an outbreak control measure.

Consider:

• Cohorting HCW/staff to affected areas if practical or assigning HCW/staff to care

for asymptomatic clients/patients/residents before symptomatic

clients/patients/residents.

• Minimizing movement of HCW/staff, students, or volunteers between

floors/areas, especially if some areas are not affected.

• Cohorting clients/patients/residents with the same illness.

• Cohorting asymptomatic clients/patients/residents exposed to the same

infectious agent.

• Please see PHO’s Cohorting in Respiratory Virus Outbreaks for more information.

3.3 Client/Patient/Resident Restrictions

Note: The recommendations contained in this document are intended to protect the

health of client/patient/resident populations. Institutions should ensure that the

rights of the clients/patients/residents are fully respected and promoted. The

facility ICP IPAC lead should contact the PHU to balance the needs of the

client/patient/resident against the risk to the health of the other

clients/patients/residents.

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

• When providing outbreak management recommendations, PHUs assess the risk

of non-compliance to outbreak control measures on the general

client/patient/resident population.

• Generally, the PHU discusses outbreak control measures and decides on

appropriate measures to implement.

• The extent to which IPAC measures can be implemented and what is considered

reasonable throughout the course of each outbreak will vary. Examples of some

measures that may be reasonable depending on the context include:

o limiting visiting hours;

o limiting the number of clients/patients/residents with whom the visitor has

contact;

o requiring anyone providing direct care (including visitors, other

clients/patients/residents, etc.) to wear the necessary PPE;

o posting signs at entrances of facility and/or affected unit/area;

o limiting non-essential visitors during the outbreak period;

o limiting communal dining activities and day programming; and

o notifying clients/patients/residents, HCW/staff, and visitors of the outbreak.

• Implementing universal masking in the suspect outbreak area, for respiratory

outbreaks

• Asymptomatic clients/patients/residents outside of the suspect outbreak area

are able to participate in daily activities.

• Symptomatic clients/patients/residents are recommended to remain in their

rooms. Additional Precautions are required when entering a symptomatic

clients/patients/resident’s room (see Fig. 3.1). See Sections 5, 6, 7 and 8 for

specific guidance once an outbreak has been declared.

• During a suspect outbreak, symptomatic clients/patients/residents are

recommended to receive treatments such as physiotherapy or occupational

therapy in their rooms instead of common areas. For respiratory illnesses, they

are recommended to wear an appropriate mask (as tolerated).

• Symptomatic clients/patients/residents will be allowed to attend medically

necessary appointments or activities and it is recommended they wear a mask

(as tolerated for respiratory illnesses). Receiving facility should be notified of the

potential outbreak so appropriate precautions can be taken for the

client/patient/resident on arrival.

• For respiratory illnesses, if client/patient/resident chooses not to wear a mask,

or is unable to safely wear a mask, HCW/Staff should review their PCRA and

adjust PPE accordingly.

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

• Additional considerations for accommodations that may be supported for safe

movement of clients/patients/residents with dementia or cognitive impairment

who are in isolation, depending on the type of outbreak (respiratory vs.

gastrointestinal):

• Support client/patient/resident in leaving their room in ways that minimize

spread of infection (e.g., one-to-one support with client/patient/resident at all

times when outside of their room, putting on PPE, using ABHR, physical

distancing, avoid touching surfaces, etc.).

• Minimize contact with the isolated client/patient/resident (e.g., minimize the

possibility of other clients/patients/residents going into their room) by providing

or offering additional activities and interventions for non-isolated

clients/patients/residents in the unit.

• Support outdoor visits with caregivers and volunteers.

Note: for Norovirus, outdoor visits are not recommended until Additional

Precautions are discontinued. Alternatively, 1:1 visits with essential caregiver or

visitor can be encouraged as long as Additional Precautions are followed.

3.4 Restrictions on Affected Units/Sites

Restrictions on affected units/sites will depend on the type of outbreak, severity of

the outbreak and risk of non-compliance.

In the event of a disagreement between the institution and the MOH, the MOH has

the authority to determine if an outbreak of a communicable disease exists, for

purposes of exercising statutory powers under the HPPA.

3.5 Admissions/Transfers from Acute Care Setting to an

Institution

PHU approval is not required for admissions/transfers, but PHU consultation is

recommended when IPAC advice or risk mitigation is needed.

In general, mitigation measures should routinely be in place to facilitate the return of

clients/residents/patients to the institution and avoid unnecessary delays in transfer

from acute care.

Institutions are recommended to consult the PHU when:

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

• The client/resident/patient is from a health care facility in outbreak and is going

to an institution that is not in outbreak and there are concerns with compliance of

IPAC measures.

• The client/patient/resident is from the community or a health care facility not in

outbreak and going to an institution in outbreak and any of the following apply:

• New outbreak has been declared with an ongoing investigation;

• Outbreak is uncontrolled/uncontained;

• Admission/transfer to an area where many clients/patients/residents are unable

to follow IPAC measures or client/patient/resident is unable to isolate and/or

follow IPAC measures;

• Client/patient/resident is severely immunocompromised;

• Informed consent has not been obtained from the client/patient/resident.

• Additionally, for admissions or transfers from an acute care facility, the

discharging physician should agree to the admission or transfer to an institution

in outbreak.

3.6 Transfers from an Outbreak Institution to an Acute Care

Setting

• For LTCHs only, all inter-facility client/patient/resident transfer between

hospitals, physicians’ offices, dental clinics, and institutions should not take place

without the sending facility obtaining a Medical Transfer (MT) authorization

number from the Provincial Transfer Authorization Centre (PTAC). Life

threatening emergencies DO NOT require authorization.

o To arrange a transfer, the sending institution/facility should login to the online

PTAC portal, administered by Ornge at:

https://www.hospitaltransfers.com/transfer/ or call 1-866-869-PTAC (7822).

o If approved, an authorization number will be issued immediately and either

sent online or by fax depending on the method used to obtain the MT

authorization number from PTAC.

• Before sending an ill client/patient/resident to acute care, the facility should

notify the receiving healthcare facility and the PTAC that the institution is

experiencing an outbreak.

• The hospital ICP/IPAC lead must be provided with the details of the outbreak to

ensure control measures are in place when the client/patient/resident arrives at

the hospital. The hospital ICP/IPAC lead should be informed of whether the

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

client/patient/resident to be transferred has been identified as a case or a

contact of a case.

• Additionally, a client/patient/resident who is away from the LTCH on a medical

absence will have their bed held for them if the length of the medical absence

does not exceed 30 days. In the case of a psychiatric absence, the bed will be

held for up to 60 days. If the client’s/patient’s/resident’s medical or psychiatric

leave exceeds the maximum length identified above, the client/patient/resident

will be discharged by the LTCH. They will then be placed in the re-admission

category to return to that LTCH which will give the client/patient/resident

priority for re-admission to the LTCH when the client/patient/resident is well

enough to return. However, if a client/patient/resident cannot return to the

LTCH because of an outbreak of disease in the LTCH, the licensee of the LTCH is

not permitted to discharge the client/patient/resident and the

client/patient/resident will return to the LTCH when the outbreak is declared

over (O. Reg. 246/22 s. 158).

• All other institutions should notify Emergency Medical Services (EMS) when they

are in outbreak prior to transferring a client/patient/resident.

3.7 Group/Social Activities and Other Events

• Symptomatic clients/patients/residents or those on Additional Precautions are

not recommended to participate in in-person group or social activities with other

clients/patients/residents and institutions should discontinue group activities in

affected units.

o Symptomatic clients/patients/residents or those on Additional Precautions

may continue to interact with essential caregivers and visitors. This includes

going outdoors and participating in 1:1 activities as long as Additional

Precautions are followed (e.g., enhanced HH, masking, physical distancing).

o For clients/patients/residents with GI symptoms, social activities should be

postponed until Additional Precautions are discontinued.

o 1:1 visits with essential caregivers or visitors may continue if Additional

Precautions are followed.

3.8 Nourishment Areas/Sharing of Food

• Symptomatic clients/patients/residents or those on Additional Precautions

should receive tray meal service in their rooms, where possible.

• Other restrictions may be implemented depending on type and severity of

outbreak.

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

3.9 Visitors and Essential Caregivers

• General visitors should postpone all non-essential visits to

clients/patients/residents within the outbreak area for the duration of the

outbreak.

• Essential caregivers/visitors should be directed to the reception desk prior to

visiting clients/patients/residents.

• Essential caregivers/visitors should be educated on the potential risk of

exposure when visiting a symptomatic client/patient/resident.

• If an essential caregiver/visitor is symptomatic, they are recommended not to

enter the setting.

• In some circumstances, the setting, along with the OMT will need to determine if

the visitation is recommended when an essential caregiver/visitor is

symptomatic.

o Exemptions exist on compassionate grounds to support visitation by essential

caregivers/visitors of patients who are at end of life.

o In the case above, appropriate PPE (mask, gown, gloves, appropriate eye

protection, depending on symptoms) and HH should be performed by the

visitor.

• Encourage essential caregivers/visitors visiting symptomatic

clients/patients/residents to wear PPE (mask, gown, gloves, appropriate eye

protection, depending on symptoms) and to perform hand hygiene with ABHR

before donning and doffing PPE

. Please refer to Appendix N of the PIDAC

Routine Practices and Additional Precautions

document for more information on

PPE requirements.

• If education is needed, demonstrate for caregivers/visitors how to use PPE

appropriately.

Essential Caregivers

• Institutions are recommended to support the presence of essential caregivers

while balancing the safety of all clients/patients /residents, caregivers, and

HCWs/Staff.

• Essential caregivers are NOT recommended to be restricted from visiting their

loved ones, but limits may be required, and will be assessed on a case-by-case

basis by the OMT and the setting.

• Institution to contact family members and advise them of their relative’s illness.

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

3.10 HCW/Staff Outbreak Control Measures (including

volunteers, students, and physicians)

• HCWs/staff should monitor themselves for signs and symptoms of an infectious

disease.

• Symptomatic staff should self-isolate at home, and not go into work; staff should

report being ill to their employer (setting administration/management).

• Employers also have a duty to report workplace-related/occupational illness as

per the Occupational Health and Safety Act (OHSA)

and Ontario regulation

420/21.

For more information, please see the provincial web page on

Occupational Health and Safety compliance.

6,31

• HCWs/staff who develop respiratory symptoms at work are recommended to

perform respiratory hygiene practices (wear mask, cough into sleeve/elbow) and

leave work as soon as possible.

• For respiratory illness, staff should immediately leave and be directed to self-

isolate at their own home until symptoms have been improving for 24 hours and

no fever present.

o For 10 days after the date of specimen collection or symptom onset,

whichever is earlier/applicable, HCWs/Staff should adhere to workplace

measures for reducing risk of transmission (i.e., masking for source control)

and avoid caring for clients/patients/residents at highest risk of severe

respiratory illness, where possible.

• HCWs/staff who develop gastrointestinal symptoms at work are

recommended to perform hand hygiene and leave work as soon as possible.

• For gastrointestinal illness, depending on the policies of their employers, staff

may be asked to not return to work until symptom-free for 48 hours. This period

could be modified if the causative agent is known.

o Disease-specific exclusions may apply. See Appendix 1

• Cohort HCWs/staff to care for asymptomatic clients/patients/residents before

symptomatic clients/patients/residents when possible.

• Consider minimizing movement of HCWs/staff/volunteers/students between

units/ floors, especially if some units/floors are not affected.

• Volunteers:

o Educate volunteers on the importance of HH, Routine Practices and Additional

Precautions, and including a PRA.

o Symptomatic volunteers are recommended to NOT enter the setting.

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

o Volunteers are recommended to follow the same PPE recommendations as

HCWs/staff.

Note: Settings should ensure they follow sector-specific requirements.

3.11 Specimen Collection

• If respiratory or gastrointestinal illness case definition has been met, appropriate

samples should be collected:

o Respiratory illness: Confirmation of a respiratory outbreak is NOT dependant

on lab confirmation. Please see PHOs testing information for more details:

Respiratory Viruses (including influenza) | Public Health Ontario

. Refer to

Appendix 1a.

o Gastrointestinal illness: Confirmation of a gastroenteritis outbreak is NOT

dependent on lab confirmation. Please see PHO’s testing information for more

details: Gastroenteritis –Stool Viruses | Public Health Ontario

. Refer to

Appendix 1

 If the causative agent of the outbreak is suspected or confirmed to be

caused by norovirus, laboratory testing of food retention samples is not

recommended.

 For further information about human diagnostic testing, contact the Public

Health Ontario’s Laboratory.

 For more information regarding specimen collection and testing, please

refer to the Public Health Inspector’s Guide to Environmental Microbiology

Laboratory Testing.

 Please see Gastroenteritis Outbreaks in Institutions. and Public Hospitals

(under the Infectious Diseases Protocol

, for more info.

• If specimen collection is required, HCWs/staff should ensure correct collection

and labelling of specimens and lab requisition forms (D.O.B., name of

client/patient/resident, date of sample collection, outbreak number, etc.).

3.12 Enhanced Environmental Cleaning and Disinfection

• Clean and disinfect:

o Common areas

 At least once daily for low touch surfaces (shelving, windowsills,

white/message boards).

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

 Minimum twice daily for high touch surfaces (door handles/knobs, light

switches, handrails, phones, elevator buttons, etc.), treatment areas, dining

areas and lounge areas.

 Immediately for any visibly dirty surfaces.

 Surfaces and items in close proximity to vulnerable

client/patient/resident populations require more frequent cleaning and

disinfection than surfaces in close proximity to those who are less

vulnerable.

o Non-critical medical equipment (stethoscope, blood pressure cuffs) should be

dedicated. If unable to dedicate, shared equipment should be cleaned and

disinfected between client/patient/resident use.

o HCW/Staff equipment should be cleaned and disinfected at least twice daily

or when visibly dirty.

o Refer to manufacturer’s instructions for use (MIFUs) of cleaners and

disinfectants.

o Concerning dilution/mixing as well as contact time and expiry dates.

o Ensure staff are educated on cleaning and disinfection procedures and

following cleaning schedules.

• Areas that are not considered common areas (private offices, admin areas) do not

require enhanced cleaning and disinfection.

• Ensure to follow appropriate precautions when using chemicals for cleaning and

disinfection. Consult Safety Data Sheets (SDS) for further safety information.

Use

appropriate PPE and donning and doffing methods for cleaning and disinfection

practices.

• Upholstered furniture, rugs or carpets contaminated with body fluids (vomit,

diarrhea) are difficult to clean and disinfect. Consult MIFUs for instructions on

cleaning. Steam clean as soon as possible. Consider only using cleanable, non-

porous surfaces/equipment in settings that is compatible with the cleaners and

disinfectants used.

• HCW/Staff handling soiled linens are recommended to wear gloves and gown if

there is a risk of contaminating their clothing. Additional PPE may be

recommended depending on the causative organism and risk of aerosolization

from soiled linens.

• If the laundry machine has been used to clean soiled (vomit, diarrhea) laundry, a

bleach cycle of the laundry machine is recommended to be run (without laundry)

before washing the next load.

• Cleaning and disinfection principles:

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

o Cleaning should be performed using a health care grade cleaners as well as

disinfectants that have a drug identification number (DIN).

o Do not apply cleaning chemicals by aerosol or trigger sprays.

o Minimize the contamination levels of the disinfectant solution and equipment

by frequently changing the disinfectant solution and ensuring wiping cloths,

are not double dipped into the disinfectant solution.

o Move from clean areas to dirty areas and clean from top to bottom.

o Adhere to manufacturer’s instructions for use on preparation and storage of

disinfectant solutions and the recommended contact time.

• For more information on cleaning and disinfection, please see PHO’s Best

Practices for Environmental Cleaning for Prevention and Control of Infections in

All Health Care Settings, 3

Edition.

Each institution should have written policies and procedures for:

• Routine cleaning and disinfection.

• Enhanced environmental cleaning and disinfection during an outbreak and for

terminal cleaning.

These policies and procedures should be reviewed, evaluated and updated at least

annually to ensure they reflect current best practices. Policies and procedures

should include:

• Proper use of supplies for cleaning and disinfection;

• cleaning schedules and appropriate documentation;

• Staff training;

• Laundry-handling practices;

• Proper handling and disposal of waste;

• Responsibility and accountability of routine cleaning of all environmental

surfaces and non-critical client/patient/resident care items; and

• Staffing in Environmental Services (ES) departments to allow for surge capacity

(e.g., additional staff, supervision, supplies, equipment) during outbreaks.

Refer to the following for additional information:

• PIDAC Best Practices for Environmental Cleaning for Prevention and Control of

Infections in All Health Care Settings, 3

Edition.

• PIDAC Best Practices for Infection Prevention and Control Programs in Ontario

In All Health Care Settings.

• PIDAC Best Practices for Cleaning, Disinfection and Sterilization of Medical

Equipment/Devices in All Health Care Settings.

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

Section 4: General Recommendations

for Confirmed Outbreaks

Roles and Responsibilities for Confirmed Outbreaks

• See section 1.

Reporting to the Local PHU

• Reporting requirements vary in different settings. Outbreaks and diseases of

public health significance (DOPHS) are required to be reported to the Medical

Officer of Health or their designate (local PHU) by Institutions under the HPPA

• Local PHUs are required to report outbreaks to the Ministry of Health and to

PHO, using the integrated Public Health Information System (iPHIS), or any other

method specified by the ministry, within one business day of receiving

notification of an outbreak or of assessing that an outbreak is occurring but has

not been reported by the institution.

• If staff advise the setting that they are ill or have acquired an occupational illness,

the institution must report those cases to the MLITSD. Please see below section

on reporting to MLITSD for more information.

• The PHUs should notify, as appropriate:

o Physicians and nurse practitioners in the community

o Adjacent PHUs

o EMS

o Other institutions in the community

Refer to: Timely Entry of Cases and Outbreaks for Diseases of Public Health

Significance (DOPHS).

Reporting Worker Illness to MLITSD

• Workers who are unwell should report their illness-related absence to their

supervisor or employer.

In accordance with the Occupational Health and Safety Act (OHSA) and its

regulations.

If an employer is advised that a worker has an occupational illness

or that a claim has been filed with the Workplace Safety and Insurance Board

(WSIB) by or on behalf of the worker with respect to an occupational illness, the

employer must provide written notice within four days to:

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

o A Director appointed under the OHSA of the MLITSD.

o The workplace’s joint health and safety committee (or a health and safety

representative).

o The worker’s trade union, if any.

• This may include providing notice for an infection that is acquired in the

workplace.

• The information to include in a notice of occupational illness is prescribed by the

Ontario Regulation 420/21: “Notices and Reports, under sections 51 to 53.1 of the

Act – Fatalities, Critical Injuries, Occupational Illnesses and Other Incidents”.

• In accordance with the Workplace Safety and Insurance Act (WSIA), the

employer must also report any instance of an occupationally acquired disease to

the WSIB within 72 hours of receiving notification of said illness.

• For more information, please contact the MLITSD:

o Employment Standards Information Centre: Toll-free: 1-800-531-5551

o Health and Safety Contact Centre: Toll-free: 1-877-202-0008

o Reporting workplace incidents and illnesses | ontario.ca

• For more information from the WSIB, please refer to the following:

o Telephone: 416-344-1000 or Toll-free: 1-800-387-0750.

Declaring an Outbreak

• PHUs are responsible for notifying PHO’s Laboratory of the investigation and

providing the laboratory with the particulars of the suspected outbreak.

• The PHU completes PHO’s online OB reporting tool.

When there are special

concerns such as severity of illness, extent of illness in institution and/or

community, suspicion of unusual agent, or other special testing considerations

the PHU should phone PHO to discuss additional testing considerations.

• Institutions should discuss with the PHU how specimens will be collected,

stored, and submitted to the laboratory, using as reference current PHO

specimen collection instructions in the relevant Test Information Sheet on the

PHO website.

This will ensure that the most up-to-date instructions, proper

laboratory requisitions, and appropriate collection kits are used.

• The PHU is responsible for declaring the outbreak over, completing and closing

the outbreak file.

4.1 IPAC Measures

See section 3.1 for IPAC measures.

Additionally, other IPAC measures that may be recommended by the PHU/OMT:

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

• IPAC measures for all visitors and essential caregivers.

• Universal masking in outbreak areas for respiratory outbreaks.

• High risk activities suspended in affected units (large group activities, bus

outings).

• For respiratory outbreaks, physical distancing in communal areas/dining areas,

where possible.

• HCWs/staff active screening for symptoms prior to each shift during the

outbreak.

• Active screening of visitors and essential caregivers prior to entering the setting.

• Restrictions on non-essential visitors.

• Client/patient/resident screening upon return from absences.

• Active screening for client/patient/residents’ admissions upon return from other

health care settings that are in active outbreaks.

• During a COVID-19 outbreak close contact identification and management of

clients/patients/residents or HCW/staff may be implemented to control the

outbreak.

Additional Precautions

Additional Precautions refer to IPAC interventions (e.g., PPE, accommodation,

enhanced environmental cleaning) to be used in addition to Routine Practices to

protect staff and clients/patients/residents by interrupting transmission of

suspected or identified infectious agents. Additional Precautions include Contact,

Droplet, and Airborne Precautions.

Contact and Droplet Precautions

Contact and Droplet Precautions should always be used in addition to Routine

Practices with all clients/patients/residents who have signs and symptoms of

respiratory illness and in all respiratory outbreaks.

The following strategies help decrease the risk of transmission during an outbreak:

• Clean, disinfect, and record cleaning of all devices/equipment/surfaces.

• Devices/Equipment must be dedicated to the client/patient/resident whenever

possible. If devices/equipment cannot be dedicated to client/patient/resident it

must be cleaned, disinfected immediately after use.

• All devices/equipment designated to be used by an ill client/patient/resident

should be identified and dedicated to prevent the use by others. If a lack of

equipment or storage space makes this unfeasible, then do not use the

equipment until it has been thoroughly cleaned and disinfected.

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

• Wear mask, eye protection, gloves, and gown in providing direct care to an ill

client/patient/resident. A fit tested sealed checked N95 may also be required.

• Store clean supplies outside the rooms of infected residents to prevent

contamination.

• Provide appropriate waste receptacles with lids in clients/patients/residents’

rooms for PPE disposal.

• Reinforce the importance of HH and respiratory etiquette with

clients/patients/residents, staff, and visitors.

• Instruct visitors including essential care givers on additional precautions they

should follow while in the institution/facility.

• Essential caregivers who provide direct care to clients/patients/residents should

use the same PPE as staff and be instructed on how to properly do so.

For additional resources on Contact Droplet Precautions, refer to PIDAC’s Routine

Practices and Additional Precautions In All Health Care Settings

and COVID-19

Guidance: Personal Protective Equipment (PPE) for Health Care Workers and Health

Care Entities.

4.2 Administrative Measures

See section 3.2 for administrative measures.

• Establish OB case definition.

• Assemble OMT and initiate an OMT meeting to discuss OB and IPAC measures

taken/to be taken.

• Ensure adequate availability of all supplies by notifying necessary departments.

• Notify Environmental Cleaning Services regarding the increased need for

supplies and services. and/or change in cleaning product or disinfectant if

required.

• Notify all relevant partners of the outbreak.

• Ensure all HCWs/Staff (inclusive of all departments) are aware of

recommendations during confirmed outbreak and work restrictions if applicable.

• Ensure outbreak signage has been posted on all entrances to facility, advising all

staff and visitors that the institution is experiencing an OB.

• Inform client/patient/resident families/essential caregivers of outbreak status at

the institution.

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

4.3 Client/Patient/Resident Restrictions

See section 3.3.

• Continue all measures noted in section 3.3 including isolation of symptomatic

clients/patients/residents and Additional Precautions.

• Symptomatic clients/patients/residents are allowed to attend medically

necessary activities or appointments. For respiratory outbreaks, they are

recommended to wear an appropriate mask, as tolerated. Ensure transportation

staff and staff at receiving medical setting are notified of the outbreak so

appropriate precautions can be implemented for client/patient/resident on

arrival. Where possible, virtual visits are encouraged.

• Symptomatic clients/patients/residents should avoid contact with other

clients/patients/residents.

• Please refer to sector-specific guidance on absences for

clients/patients/residents; the PHU/OMT may provide guidance for absences

during an outbreak to minimize risk of spread.

4.4 Restrictions on Affected Units/Sites

See section 3.5.

4.5 Admissions/Transfers from Acute Care to an Outbreak

Institution

See section 3.5.

4.6 Transfers from an Outbreak Institution to an Acute Care

Setting

See section 3.6

4.7 Group/Social Activities and Other Events

See section 3.7

Additionally:

• Consult the OMT for recommendations on whether routine group activities may

continue for asymptomatic clients/patients/residents to support physical and

mental well-being and with mitigation measures in place to prevent spread of

infection.

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

• For respiratory illnesses or outbreaks, measures such as physical distancing,

masking, HH, and enhanced surveillance may be used for low-risk group

activities.

• The following should be implemented during an outbreak:

o Reschedule communal meetings on the affected unit/floor. However, other

meetings or activities may proceed in non-affected units/floors;

o Discontinue group outings from the affected unit/floor;

o The OMT should discuss restricting meetings or activities in the entire facility if

the outbreak transmits to two or more units/floors;

o Exceptions involving non-outbreak units/floors should be discussed with the

OMT involving outside groups such as entertainers, volunteer organizations,

and community groups;

o Conduct on-site programs such as physiotherapy and foot care for

clients/patients/residents in their rooms, if possible. Precautions should be

taken for ill clients/patients/residents; and

o Ensure there is no interaction between staff/clients/patients/residents of the

affected floor/unit and participants in on-site childcare or other day programs.

4.8 Nourishment Areas/Sharing of Food

• Symptomatic clients/patients/residents should receive tray meal service in their

rooms.

• Some other measures/modifications related to nourishment areas and sharing of

food during a confirmed outbreak:

o Close buffet lines and have food plated by staff.

o Encourage staggered eating times for diners.

o Pre-set tables with utensils to minimize client/patient/resident handling.

o Single service/disposable utensils may be encouraged depending on

severity of outbreak.

o Limit/close communal food or snacking areas and sharing of foods between

residents or staff.

o Individually wrapping snacks, and use of single packet condiments.

4.9 Visitors and Essential Caregivers

• See section 3.9.

4.10 HCW/Staff Outbreak Measures (including volunteers,

students, physicians)

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

• See section 3.10.

4.11 Specimen Collection

• See section 3.11.

4.12 Enhanced Environmental Cleaning and Disinfection

• See section 3.12.

Section 5: Confirmed COVID-19

Outbreak

A. Declaring a COVID Outbreak

For case definition please see Appendix 1: Diseases caused by a novel coronavirus,

including Coronavirus Disease 2019 (COVID-19), Severe Acute Respiratory

Syndrome (SARS) and Middle East Respiratory Syndrome (MERS).

Refer to Appendix E for more information on case and contact management in

LTCH/RH settings.

Refer to Appendix D for more information on COVID case and contact management

in non-LTCH/RH institutions.

B. Duration of outbreak

In consultation with the OMT and institution, the outbreak may be declared over

when no new cases, which were reasonably acquired in the setting, have occurred

for 7 days, and there is no evidence of ongoing transmission.

• For example, in the circumstance of a case in a roommate of a case, where the

roommate had already been in isolation prior to testing positive and therefore did

not pose a risk for ongoing transmission, the roommate should be counted as

part of the outbreak but would not extend the duration of the outbreak.

C. Case Management

• Clients/patients/residents who are identified as a confirmed or a probable

COVID-19 case and are unable to wear a mask, should self-isolate on Additional

Precautions for at least 10 days from symptom onset or date of specimen

collection, if asymptomatic (whichever is earlier/applicable) and until symptoms

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

have been improving for 24 hours (or 48 hours if gastrointestinal symptoms) and

no fever is present.

• Clients/patients/residents can leave their room for walks in the immediate area

with staff wearing appropriate PPE, to support overall physical and mental well-

being. See section 5.1 for information on contact management.

• Clients/patients/residents who are identified as a confirmed or a probable

COVID-19 case and are able to independently and consistently wear a mask,

should self-isolate on Additional Precautions for at least 10 days from symptom

onset or date of specimen collection, if asymptomatic (whichever is

earlier/applicable). Clients/patients/residents may leave their room to

participate in activities and join others in communal areas provided they meet

the following criteria:

o It has been a minimum of 5 days from symptom onset or positive test

(whichever is earlier/applicable);

o They are asymptomatic or their symptoms have been improving for 24 hours

(or 48 hours if gastrointestinal symptoms) and no fever is present; and

o They wear a well-fitted mask at all times outside of their room, they do not join

in communal activities where they would need to remove their mask within

the setting (e.g., group dining), and they continue to follow additional

precautions for 10 days after their symptom onset or positive test.

• Clients/patients/residents who test positive for COVID-19 should be assessed as

soon as possible to determine if COVID-19 therapeutics are within their goals of

care, and if so, to determine eligibility. Refer to Appendix B for more information

on COVID-19 therapeutics.

D. Contact Management

• Client/patient/resident close contacts (for the definition of close contacts,

please refer to p. 11 of the Coronavirus Case Definitions and Disease-Specific

Information (ontario.ca)) who remain asymptomatic do not need to be placed on

Additional Precautions.

However, the following risk reduction measures should

be recommended by the PHU for the duration of the outbreak:

o Even if not under Additional Precautions, exposed clients/patients/residents

within the outbreak area of the institution/facility should be cohorted

separately from non-exposed clients/patients/residents.

o Should symptoms develop, promptly isolate the client/patient/resident on

Additional Precautions and testing for COVID-19 and other respiratory viruses.

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

• All roommate close contacts should be placed on Additional Precautions.

Individuals who remain asymptomatic may discontinue isolation after a minimum

of 5 days of isolation (based on 5 days from when the case became symptomatic

or tested positive if asymptomatic). Roommate close contacts should then wear

a well- fitting mask, if tolerated, when receiving care and outside of their room,

and physically distance from others when outside of their room until day 7 from

last exposure to the case.

• Ideally, roommate close contacts are placed in a separate room to isolate away

from the case. When this is not possible, the use of physical barriers (e.g.,

curtains or a cleanable barrier) to create separation between the case and the

roommate is recommended.

Note: Institutions cannot restrict or deny absences for medical, palliative, or

compassionate reasons at any time. This includes when a client/patient/resident is

in isolation or when an institution is in an outbreak.

When a client/patient/resident who is self-isolating on Additional Precautions is

required to leave the institution for a medical absence, institutions should notify the

health care facility so that care can be provided to the client/patient/resident with

the appropriate Additional Precautions in place.

• Roles and Responsibilities for Confirmed COVID-19 Outbreaks

Note: Only those actions above and beyond those discussed in previous sections

are listed in this section. See Section 1 Roles and Responsibilities for additional

details.

OMT

• Provides direction on restrictions to admissions/transfers/discharges to the

outbreak unit/institution.

• Provides direction on isolation of client/patient/resident cases.

• Provides direction on management of HCWs/Staff.

• Provides direction on changes to activities (if applicable) within the

unit/institution.

• Provides direction on IPAC measures to be implemented upon declaration of

outbreak.

Specific actions for OMT in a confirmed COVID-19 outbreak:

• Defining the outbreak area of the institution (i.e., floor or unit) and cohorting

based on COVID-19 status (i.e., infected or exposed and potentially incubating);

• Assessing risk of exposure to residents/staff based on cases’ interactions.

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

IPAC Lead/Designate

• Advises on isolation of clients/patients/residents.

• Communicates with PHU for outbreak management and status updates

(including line lists, review of IPAC measures, etc.).

• Identifies high risk activities which are recommended to be stopped during the

outbreak.

• Initiate Additional Precautions for all symptomatic clients/patients/residents and

those with suspect or confirmed COVID-19.

• Post appropriate additional precaution signage outside the

client’s/patient’s/resident’s room.

• Facilitate assessment of IPAC and outbreak control measures, as needed.

• Weekly IPAC audits should be conducted for the duration of the outbreak. The

results of these audits should be reviewed by the OMT.

• Ensure dedicated staff conduct IPAC Audits for hand hygiene, PPE usage and

cleaning and disinfection and report rates to staff.

• Ensure training/education of staff, volunteers, essential care givers and visitors

on applicable IPAC measures.

Facility Administration/Facility Management or their Designates

• Supports assessment of client/patient/resident cases to determine if institution

meets outbreak definition.

• Manages impact of HCW/Staff exclusion on institution operations.

• Ensures if there are recommendations to restrictions/transfers/discharges to the

outbreak institution, they are implemented.

• If institution has restrictions to admissions/transfers/discharges, oversees

administrative paperwork for client/patient/resident moves (Provincial Transfer

Authorization Centre [PTAC]).

• Communicates outbreak status to partners and stakeholders.

Setting/Unit Manager/Designate

• Report worker's occupational illnesses as outlined in section 52 (2) of the

Occupational Health and Safety Act (including agency staff).

• Provides information to OMT/MLITSD about HCW/Staff shifts to determine

when they were last on site or when they were onsite during communicable

period.

• Collects info about HCW/Staff as well as resident/client /patient immunization

status; and shares this information with OMT.

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

• Supports assessment of client/patient/resident cases to determine if unit meets

outbreak definition.

• Manages impact of HCW/Staff exclusion on unit operations.

• Ensures if there are recommendations to restrictions/transfers/discharges to the

outbreak unit, they are implemented.

• If unit has restrictions to admissions/transfers/discharges, oversees

administrative paperwork for client/patient/resident moves (PTAC).

• Communicates status of unit to/with partners and stakeholders.

• Ensure that line list includes occupational illness in agency workers.

On site HCW/Staff

• Each HCW/Staff person is responsible for reporting their immunization status to

facility administration/management.

• Complies with work restrictions, if applicable.

PHO

• Completes testing of samples submitted by institutions/PHUs to identify variants

of concern.

5.1 IPAC Measures

• See section 3.1.

• All HCWs should conduct a PCRA before every client/patient/resident

interaction and task.

• A PCRA is the first step in Routine Practices assesses the task, the

client/patient/resident and the environment to identify the most appropriate

precautions that need to be taken for the particular interaction or task.

• All HCWs should wear appropriate PPE based on their PCRA, when assessing

clients/patients/residents with acute respiratory infections.

• At minimum, institutions should conduct enhanced symptom assessment

(minimum once daily) of all clients/patients/residents in the outbreak area to

facilitate early identification and management of ill clients/patients/residents.

• If feasible, clients/patients/residents should be assessed twice daily when the

client/patient/resident is symptomatic, has tested positive for COVID-19, or is a

close contact, to identify and monitor new or worsening symptoms of COVID-19.

• All HCWs or essential caregivers providing direct care to or interacting with a

suspect or confirmed case of COVID-19 should wear eye protection (goggles,

face shield, or safety glasses with side protection), gown, gloves, a well-fitted

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

medical mask (surgical/procedure) or a fit-tested, seal-checked N95 respirator

(or approved equivalent).

• HCW who are not yet fit-tested for an N95 respirator (or approved equivalent)

should wear a well-fitted surgical/procedure mask or a non-fit-tested N95

respirator (or approved equivalent), eye protection (goggles, face shield, or

safety glasses with side protection), gown and gloves.

• HCWs/staff should report any PPE breaches to IPAC lead/designate or

supervisor, who should then report to the institution as appropriate.

• For information on COVID-19 case and contact management in an institution,

refer to Appendix E.

5.2 Administrative Measures

• Employers of HCW should make reasonable efforts to ensure HCW obtain

respirator fit testing at the earliest opportunity.

• Institutions should have policies in place to address the use of COVID-19

therapeutics.

• COVID-19 therapeutics may be available and health care providers should

discuss potential treatment options (i.e.: Paxlovid, Remdesivir) with

client/patient/residents and caregivers in advance of a potential COVID-19

infection.

• Once an outbreak is declared, frequency of reporting of cases to the local PHU

will be determined through consultation with the PHU as per the

Institutional/Facility Outbreak Management Protocol, 2018 (or as current).

• Post outbreak signs at all entrances to institution to advise that setting is in

outbreak (see Figure 1).

• COVID-19 vaccination is one of the most effective ways to prevent severe illness

and death due to COVID-19, and institutions should have policies in place for

staff, clients/patients/residents and visitors’ immunizations. *Please refer to

sector-specific requirements regarding vaccine.*

• New admissions to institutions who are not up-to-date with their COVID-19

vaccinations should be offered a complete series of a COVID-19 vaccination or

their remaining eligible doses as soon as possible.

5.3 Client/Patient/Resident Restrictions

See Section 3.3 and 4.3.

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

5.4 Restrictions on Affected Unit/Site

• See Section 4.4.

5.5 Admissions/Transfers from Acute Care Setting to an

Outbreak Institution

• See section 3.5.

5.6 Transfers from an Outbreak Institution to an Acute Care

Setting

• Inter-facility transfer requires the sending facility to obtain a Medical Transfer

(MT) authorization number from the PTAC (1-866-869-PTAC (7822)).

• This policy also applies to clients/patients/residents being transported from a

healthcare setting to and from a private doctor’s or dental office for treatment.

• NOTE: life threatening emergencies DO NOT require authorization to transfer.

• Acute care setting ICP must be provided with details of the outbreak.

5.7 Group/Social Activities and Other Events

• See section 3.7 and 5.7.

Additionally:

• Group activities should be conducted such that the outbreak unit is cohorted

separately from unexposed clients/patients/residents and units. At the

discretion of the PHU/OMT, group activities for cohorts (exposed separated from

unexposed) may resume. Wherever possible, continuing group activities for

exposed cohorts is recommended to support mental health and wellbeing.

5.8 Nourishment Areas/Sharing of Food

• See section 3.8 and 4.8.

• The OMT can provide direction with any modifications based on the outbreak

(e.g., moving to single service utensils, if possible, discontinuing group dining).

• Communal dining should be conducted so that the outbreak unit is cohorted

separately from unexposed clients/patients/residents and units. At the

discretion of the PHU/OMT, communal dining for cohorts (exposed separated

from unexposed) may resume.

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

• At the discretion of the PHU, communal dining and group activities may be

paused completely in the case of a facility-wide outbreak where transmission is

uncontrolled, the rate of increase in cases or severity of illness is significant or

unexpected and the benefits of closure of communal activities are deemed to be

greater than the harms caused to client/patient/resident wellbeing. This

decision should be revisited as the outbreak progresses.

• At the discretion of the institution, in consultation with the PHU, resumption of

day programming may occur during an outbreak. However, all staff and

clients/patients/residents who are part of the outbreak should be cohorted to

be kept separate from participants and staff of day programs.

5.9 Visitors and Essential Caregivers

• Visitors should be made aware of the screening and masking policies for the

setting.

• It is recommended, but no longer required, that visitors and caregivers wear a

mask in LTCHs, RHs, and other institutions. Visitors are required to comply with

any masking/PPE requirements as appropriate during outbreaks or if the

client/patient/resident is on Additional Precautions.

• General visitors who test positive for COVID-19 and/or have symptoms

compatible with COVID-19 should avoid non-essential visits to anyone who is

immunocompromised or at higher risk of illness (e.g., senior) as well as highest

risk settings such as hospitals and LTCHs for 10 days following symptom onset

and/or positive test date (whichever is earlier/applicable).

• Where visits cannot be avoided (e.g., essential caregiver visits), visitors should

wear a medical mask, maintain physical distancing, and should notify the setting

of their recent illness/positive test. If the individual being visited can also wear a

mask, it is recommended they do so.

• General visitors should postpone non-essential visits to

client(s)/patient(s)/resident(s) who are symptomatic and/or self-isolating, or

when the LTCH/RH/institution is in outbreak.

5.10 HCW/Staff Outbreak Measures (including volunteers,

students and physicians)

• See sections 3.10 and 4.10.

• If HCWs/Staff work in multiple settings/locations, it is recommended that they

advise other settings/locations of the outbreak to determine if they should

continue working in multiple places.

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

• If HCWs/Staff are symptomatic, they should not be permitted entry into the

institution.

• HCWs/Staff who become symptomatic while at work should leave immediately

and be directed to self-isolate at their own home and see medical assessment as

required.

• If HCWs/Staff test positive for COVID-19, and are working at the institution,

they should immediately leave and be directed to self-isolate at their own home

until symptoms have been improving for 24 hours (48 if gastrointestinal

symptoms) and no fever present. HCWs/staff should report their illness to

management/OHS designate/JHSC member.

• For 10 days after the date of specimen collection or symptom onset,

whichever is earlier/applicable, HCWs/Staff should adhere to workplace

measures for reducing risk of transmission (i.e., masking for source control) and

avoid caring for clients/patients/residents at highest risk of severe COVID-19

infection, where possible.

• For asymptomatic close contacts, where feasible, additional workplace

measures for individuals who are self-monitoring for 10 days from last exposure

may include:

• Active screening for symptoms ahead of each shift, where possible

• Individuals should not remove their mask when in the presence of other staff

to reduce exposure to co-workers (i.e., not eating meals/drinking in a shared

space such as conference room or lunchroom.)

• Working in only one facility, where possible;

• Ensuring well-fitting medical mask for the staff to reduce the risk of

transmission.

5.11 Specimen Collection

• When a client/patient/resident is symptomatic with signs and symptoms

consistent with acute respiratory illness (ARI), they should self-isolate, be placed

on Additional Precautions, medically assessed and tested for COVID-19 and

other respiratory pathogens as soon as possible.

• For a COVID-19 outbreak, ALL symptomatic clients/patients/residents should be

tested.

• See PHO’s respiratory testing page for more information: Respiratory Viruses

(including influenza) | Public Health Ontario.

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

5.12 Enhanced Environmental Cleaning and Disinfection

• See section 3.12.

• Additionally, cleaning and disinfection practices should be conducted twice

daily, at minimum.

Ventilation and Filtration

• In general, ventilation with fresh air and filtration can improve indoor air quality

over time by diluting and reducing potentially infectious respiratory aerosols.

Ventilation and air filtration do not prevent transmission in close contact

situations and, as with other measures, need to be implemented as part of a

comprehensive and layered strategy against COVID-19.

• The risk of COVID-19 transmission is higher in indoor settings. Where appropriate

and possible, encourage outdoor activities.

• Indoor spaces should be as well ventilated as possible, through a combination of

strategies: natural ventilation (e.g., by regular opening of windows and doors),

local exhaust fans, (e.g., bathroom exhaust fan), or centrally by a heating,

ventilation, and air conditioning (HVAC) system.

• Directional currents can move air from one patient/client/resident to another.

Portable units (e.g., fans, air conditioners, portable air cleaners) should be placed

in a manner that avoids person-to-person air currents.

Expert consultation may

be needed to assess and identify priority areas for improvement and improve

ventilation and filtration to the extent possible given HVAC system

characteristics.

• For more information, see PHO’s Heating, Ventilation and Air Conditioning (HVAC)

Systems in Buildings and COVID-19 and Public Health Agency of Canada’s

guidance on Using Ventilation and filtration to reduce aerosol transmission of

COVID-19 in long-term care homes.

42,43

• The use of portable air cleaners can help filter out aerosols, especially where

ventilation is inadequate or mechanical ventilation does not exist.

Section 6: Confirmed ARI Outbreak

A. Declaring an ARI Outbreak

• For case definition please see Appendix 1: Respiratory Infection in Institutions and

Public Hospitals.

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

B. Duration of Outbreak

In consultation with the OMT and the local PHU, to declare an outbreak over, the

institution must not have had any new cases of infection in either

clients/patients/residents or staff, which meet the case definition for the time

period established by the OMT (i.e., predetermined decision rules that the OMT has

decided to use to declare the outbreak over). These decision rules are usually based

on the period of communicability, the incubation period or based on two incubation

periods.

For example, viral respiratory outbreaks may be declared over if no new cases have

occurred in 8 days from the onset of symptoms of the last resident case or 3 days

from last day of work of an ill staff, whichever is longer. This “8-day rule” is based on

the period of communicability (5 days) and an incubation period (3 days) for

influenza and in general may apply to many other respiratory viruses associated

with respiratory infection outbreaks as well. If symptoms in the last resident case

resolves sooner than 5 days, or if the last case is a staff member who was away

from work (according to exclusion policy) throughout their period of

communicability, the time until the outbreak can be declared over can be shortened

accordingly. Please refer to Appendix 1 for additional information on incubation

periods for other respiratory viruses.

C. Case Management

• All cases should be placed on Additional Precautions, tested for COVID-19 and

other respiratory viruses, and monitored once daily for symptoms. Refer to PHO’s

Infection Prevention and Control Core Competencies – Additional Precautions,

and PHO’s Additional Precautions Signage and Lanyard Cards.

44,45

• Cases (ill residents) should be encouraged to stay in their room and should be on

Droplet and Contact Precautions until 5 days after the onset of acute illness or

until symptoms have resolved (whichever is shorter).

• For some pathogens, the period of communicability may be longer than 5 days,

but for practical reasons, this could still be applied to outbreaks caused by

respiratory viruses other than influenza or in the case of outbreaks when the

pathogen is unknown.

• Cases may leave their room while on Droplet and Contact Precautions if they are

able to perform hand hygiene and consistently wear a well-fitted medical mask.

However, this strategy may not work with all populations and its application is

left to the discretion of the institution in consultation with the PHU.

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

• All clients/patients/residents in isolation should be supported to leave their

room for walks in the immediate area with staff wearing appropriate PPE, to

support overall physical and mental well-being.

D. Contact Management

• If cases are confined to one unit, all residents and staff from that unit should

avoid contact with residents and staff in the remainder of the institution.

Additional recreational activities/resources should be made available.

• Additional Precautions in the outbreak area should remain in place until there is

no longer a risk of transmission of the microorganism or illness. Please see PHO’s

Routine Practices and Additional Precautions, 3

Edition document for more

information.

• Ideally, roommate close contacts are placed in a separate room to isolate away

from the case. When this is not possible, the use of physical barriers (e.g.,

curtains or a cleanable barrier) to create separation between the case and the

roommate is recommended.

• Asymptomatic roommate close contacts should wear a well-fitting mask, if

tolerated, when receiving care and outside of their room, and physically distance

from others when outside of their room for 10 days from first day of symptoms in

the roommate case.

• The following risk reduction measures should be considered for non-roommate

resident close contacts in the outbreak unit to reduce the risk of transmission to

other residents, while balancing the resident’s mental and social well-being:

o Monitoring once daily for symptoms.

o Strongly encouraging the resident to wear a well-fitting mask, if tolerated, and

physically distance from others when outside of their room for 7 days

following their last exposure to the individual with ARI.

 This may include avoiding attending group dining and group activities that

involve unexposed residents where masking and physical distancing

cannot be maintained by the close contact.

o Encouraging the resident to wear a well-fitted mask, if tolerated, when

receiving care.

• If a close contact, or anyone in the outbreak area, develops symptoms, promptly

isolate under Additional Precautions and test for COVID-19 and other respiratory

pathogens (i.e., FLUVID).

Recommendations for Outbreak Prevention and Control in Institutions and Congregate Living Settings

Table 6.1: Organisms Commonly Associated with Respiratory Illness

Organism

Clinical

Presentation/Sympto

Infectious Substance/How it

is Transmitted

Incubation Period

Period of

Communicability

Prec

autions

Required

Influenza, Seasonal

Type A or B

Symptoms include,

but are not limited to,

new or worsening

cough, shortness of

breath, fever, sore

throat, headache,

myalgia, and lethargy.

Infections in children

may also be

associated with some

gastrointestinal

symptoms such as

nausea, vomiting and

diarrhea, while the

elderly may not mount

a fever response and

may present with an

exacerbation of

underlying conditions.

Influenza virus particles are

predominantly spread via

droplets which are released or

shed from infected persons

when they sneeze, cough, or

talk. These large droplets do

not stay suspended in the air

and usually travel less than

two metres (six feet). They

may enter the host’s eyes,

nose or mouth or fall onto

surfaces in the immediate

environment. Some of these

viruses may remain viable for

extended periods of time,

therefore contact transmission

can occur by touching

contaminated objects or

surfaces and then touching

one’s face or eyes.

1-4 days

5-10 days, peak at

24-48 hrs

Contact and Droplet

Recommendations for Outbreak Prevention and Control in Institutions and Congregate Living Settings

Organism Clinical

Presentation/Sympto

Infectious Substance/How it

is Transmitted

Incubation Period Period of

Communicability

Precautions

Required

Respiratory Syncytial

Virus (RSV)

Similar to influenza

including sudden

onset of fever, cough,

chills, headache,

fatigue, sore throat,

runny or stuffy nose,

muscle pain or body

aches.

Direct person-to-person

transmission and fomites.

3-7 days 3-8 days; up to 3-4

weeks in children

and

immunocompromis

Contact and Droplet

Parainfluenza Type 1-

Rhinorrhea, cough,

croup, bronchiolitis,

fever, and pneumonia.

Transmitted between humans

through direct person-to-

person contact. Also

transmitted by large droplet

spread.

2-4 days

Typically, 3-10 days,

in rare cases as long

as 3-4 weeks

Contact and Droplet

Human Metapneumo-

Virus (hMPV)

Cough, fever, nasal

congestion, and

shortness of breath.

Symptoms may

progress to bronchitis

or pneumonia.

Most likely spread from an

infected person to others

through secretions from

coughing and sneezing,

person-to-person contact, and

touching objects/surfaces

with viruses on them.

3-6 days, varying

depending on

severity of illness.

Immunocompromis

ed may shed virus

for months.

Contact and

Droplet

Recommendations for Outbreak Prevention and Control in Institutions and Congregate Living Settings

Organism Clinical

Presentation/Sympto

Infectious Substance/How it

is Transmitted

Incubation Period Period of

Communicability

Precautions

Required

Other Common

Respiratory Viruses,

such as:

Entero/Rhino Virus

Non-COVID-19

Coronaviruses

Adenovirus

Runny nose, sneezing,

sore throat, muscle

pain, fatigue, fever,

cough, chills,

headache, shortness

of breath, loss of taste

or smell,

gastrointestinal issues.

Direct person-to-person

transmission through close

contact and exposure to large

and small respiratory particles,

and fomites.

1-14 days 2 days – 3 weeks

depending on virus.

Contact and Droplet

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

6.1 IPAC Measures

• See section 3.1 and 4.1.

6.2 Administrative Measures

• See section 3.2 and 4.2.

6.3 Client/Patient/Resident Restrictions

• See section 3.3 and 4.3.

Additionally:

• Ill clients/patients/residents should be on droplet and contact precautions until

5 days after symptom onset or until symptoms have resolved (whichever is

shorter).

• If a client/patient/resident is in a shared room, contact and droplet precautions

can be implemented with privacy curtains drawn.

• Clients/patients/residents on Droplet and Contact precautions may leave their

rooms if they are able to comply with hand hygiene and wear a well-fitted

medical mask.

6.4 Restrictions on Affected Unit/Site

See section 4.4.

6.5 Admissions/Transfers from Acute Care to an Outbreak

Institution

• See section 4.5 and 5.5.

6.6 Transfers from an Outbreak Facility to an Acute Care

Setting

• See section 3.6.

Additionally:

• If necessary, clients/patients/residents who do not have an ARI may be

admitted or transferred to a floor/unit with an outbreak, provided the following

conditions are met:

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

o Client/patient/resident (or substitute decision-maker) is made aware of the

risks of the admission or transfer and consents to the admission or transfer. It

is important to note the client/patient/resident should not face any

unintended consequences in terms of placement should the

client/patient/resident (or substitute decision-maker) choose not to consent.

o Client/patient/resident is admitted or transferred to a private room.

o Attending physician should be consulted.

6.7 Group/Social Activities and Other Events

• See section 4.7.

6.8 Nourishment Areas/Sharing of Food

• See section 4.8 and 5.8.

6.9 Visitors and Essential Caregivers

• See section 5.10.

6.10 HCW/Staff Outbreak Measures (including volunteers,

students, physicians)

• See section 3.10, 4.10 and 5.10.

Additionally:

• Symptomatic staff should be excluded from the institution until afebrile without

the use of fever-reducing medication and symptoms have been resolving for at

least 24 hours (48 hours if GI symptoms).

• Staff should mask until day 10 from symptom onset.

6.11 Specimen Collection

• See section 3.11, 4.11 and 5.11.

Diagnostic Testing for ARI Outbreaks in institutions

• All symptomatic clients/patients/residents should be tested by a laboratory

method, where possible, for COVID-19 and other respiratory pathogens as soon

as symptoms present.

• Symptomatic staff are eligible for testing as part of an outbreak.

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

• PHO’s laboratory has expanded the eligibility for outbreak-related respiratory

virus FLUVID (influenza A, influenza B, RSV, and SARS-CoV-2) PCR testing to all

specimens from symptomatic clients/patients/residents and staff. A select

number (typically 4) specimens from an outbreak will also be tested by the

laboratory by multiplex respiratory virus panel testing to assess for other

respiratory viruses.

• PHUs are responsible for following usual outbreak notification steps to PHO’s

laboratory to coordinate/facilitate outbreak testing and ensuring an outbreak

number is assigned. See PHO’s Respiratory Outbreak Testing Prioritization

protocol for details.

6.12 Enhanced Environmental Cleaning and Disinfection

• See section 3.12 and 5.12.

Roles and Responsibilities for Confirmed Outbreaks

• See section 1 and 5.12.

Section 7: Confirmed Influenza Outbreak

A. Declaring an Influenza Outbreak

Confirmed Influenza outbreak is a confirmed ARI outbreak where Influenza is the

causative organism. See Appendix 1: Respiratory Outbreaks in Institutions and Public

Hospitals.

B. Duration of Outbreak

See section 6B.

In consultation with the OMT and the local PHU, to declare an outbreak over, the

institution must not have had any new cases of infection in either

clients/patients/residents or staff, which meet the case definition for the period of

time established by the OMT i.e., predetermined decision rules that the OMT has

decided to use to declare the outbreak over. These decision rules are usually based

on the period of communicability + the incubation period or based on two incubation

periods, which for influenza is 8 days (5 days period of communicability + 3 days

incubation period).

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

C. Case Management

See section 6C.

• Should the client/patient/resident close contact be taking influenza antiviral

prophylaxis as part of outbreak management, consideration should be given to

switch empirically to treatment dosage of influenza antivirals if symptoms

develop.

• Initiation of early empiric treatment with influenza antiviral medication should be

considered, as antiviral treatment works best when initiated within 48 hours of

symptom onset.

• Considerations for when to initiate influenza antiviral treatment empirically can

be found in PHO’s Antiviral Medications for the 2023-2024 Seasonal Influenza.

D. Contact Management

See section 6D

• In addition to the acute respiratory infection outbreak management

recommendations outlined above, antiviral prophylaxis should be started as soon

as an influenza outbreak is declared and continued until the outbreak is over.

• Consider a cautious approach to starting antiviral prophylaxis if suspect ARI

definition is met (e.g., consider initiating when one lab-confirmed influenza case

in a client/patient/resident or in the context of co-circulation of influenza and

COVID-19 in the same unit/area).

• For further details on the use of antiviral medication for prophylaxis in an

outbreak, please refer to PHO’s Antiviral Medications for Seasonal Influenza.

7.1 IPAC Measures

• See section 3.1 and 4.1.

7.2 Administrative Measures

• See section 3.2 and 4.2.

Additionally, the following are important interventions for an influenza OB:

• Antiviral prophylaxis for all clients/patients/residents – Appendix B

• Antiviral prophylaxis for unimmunized HCW/staff – Appendix B

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

7.3 Client/Patient/Resident Restrictions

• See section 5.3 and 6.3.

7.4 Restrictions on Affected Units/Settings

See section 6.4 and 7.6.

7.5 Admissions/Transfers from Acute Care to an Outbreak

Institution/Setting

• See section 4.5 and 5.5 and 7.6.

7.6 Transfers from an Outbreak Institution to an Acute Care

Setting

• See section 4.6 and 6.6.

Additionally:

• It is recommended that if client/patient/resident is entering an outbreak area

that is using antiviral prophylaxis as a control measure, the

client/patient/resident should be started on the antiviral prophylaxis prior to

coming into the outbreak area.

7.7 Group/Social Activities and Other Events

• See section 4.7.

7.8 Nourishment Areas/Sharing of Food

• See section 4.8 and 5.8.

7.9 Visitors and Essential Caregivers

• See section 6.9.

7.10 HCW/Staff Outbreak Measures (including volunteers,

students, physicians)

• See sections 3.10 and 4.10.

Additionally:

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

• Asymptomatic staff protected by either immunization (at least two weeks prior to

outbreak declaration) or antivirals have no restrictions on their ability to work at

other institutions. Unimmunized staff may resume work at the affected setting as

soon as they are taking antiviral prophylaxis. If issues arise regarding compliance

with work exclusions, options should be reviewed with the OMT.

• Unimmunized staff not receiving prophylactic therapy should wait one

incubation period (3 days) from the last day that they worked at the outbreak

institution/facility prior to working in a non-outbreak institution, to ensure they

are not incubating.

• Unimmunized staff on antiviral prophylactic therapy that wish to work at another

institution may do so, under the following considerations:

o They do not have a fever and/or other signs and symptoms of respiratory

illness.

o It does not conflict with the policies of the receiving institution.

o It does not conflict with direction provided by the PHU based on information

available to them about the epidemiology of the outbreak or other local

considerations.

• On a case-by-case basis, the PHU may consider exceptions to the staff exclusion

policy if there are staffing shortages that would compromise resident care.

• The institution should discuss possible barriers that staff have, to not being

vaccinated or accessing antivirals.

7.11 Specimen Collection

• See section 6.11.

7.12 Enhanced Environmental Cleaning and Disinfection

• See section 3.12.

Roles and Responsibilities for Confirmed Outbreaks

• See section 1.

Influenza-related resources

• NACI statement on seasonal influenza

• Annex B: Prevention of Transmission of Acute Respiratory Infection in all Health

Care Settings, March 2013

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

Section 8: Confirmed Gastrointestinal

Outbreak

A. Declaring a Gastroenteritis Outbreak

• Please see Appendix 1: Gastroenteritis Outbreaks in Institutions and Public

Hospitals

for a confirmed gastro outbreak definition. If an outbreak is suspected,

notify the local PHU to support the investigation and outbreak management.

B. Duration of the outbreak

In consultation with the OMT and the local PHU, to declare an outbreak over, the

institution must not have had any new cases of infection in either

clients/patients/residents or staff, which meet the case definition for the period of

time established by the OMT i.e., predetermined decision rules that the OMT has

decided to use to declare the outbreak over. These decision rules are usually based

on the period of communicability + the incubation period or based on two incubation

periods.

One incubation period plus one communicable period following onset of symptoms

in last identified case is a reasonable approach (e.g.: after 5 days where Norovirus is

suspected or confirmed), or 48 hours after symptoms have resolved (diarrhea or

vomiting has ended). Where the last case is an ill staff person, the last day worked at

the setting would be used as the last date of exposure.

Recommendations for Outbreak Prevention and Control in Institutions and Congregate Living Settings

Table 8.1: Organisms Commonly Associated with Gastrointestinal Illness

Organism

Clinical Presentation/

Symptoms

Infectious Substance/How it is Transmitted

Incubation

Period

Outbreak

Restrictions/

Recommendation

for Sites

Bacillus cereus

(Bacterial toxin)

a) Diarrheal syndrome: acute diarrhea,

nausea, and abdominal pain

b) Emetic syndrome: acute nausea, vomiting

and abdominal pain and sometimes

diarrhea

Ingestion of food that has been stored at

ambient temperatures after cooking, permitting

the growth of bacterial spores and toxin

production. Many outbreaks (particularly those

of the emetic syndrome) are associated with

cooked or fried rice that has been kept at

ambient temperature. Foods involved in

clude

starchy products such as boiled or fried rice,

spices, dried foods, milk, dairy products,

vegetable dishes, and sauces.

a) Diarrheal

syndrome:

8-16 hours

b) Emetic

syndrome:

1-5 hours

Refer to Section 9.

Campylobacter jejuni

Campylobacter coli

Fever, severe abdominal pain, nausea, and

diarrhea which can vary from slight to

profuse and watery sometimes containing

blood or mucus.

Principally through ingestion of contaminated

food. Main food sources are raw milk and raw

or un

dercooked poultry. Spread to other foods

by cross-contamination or contamination with

untreated water; contact with animals or birds.

Other sources of transmission are contact with

live animals (pets and farm animals). Person-to-

person transmission occurs during the

infectious period that ranges from several days

to several weeks. Foods involved include raw

milk, poultry, beef, pork and drinking water

2-5 days (may

persist 1-2

weeks)

Refer to Section 9.

Recommendations for Outbreak Prevention and Control in Institutions and Congregate Living Settings

Organism Clinical Presentation/

Symptoms

Infectious Substance/How it is Transmitted Incubation

Period

Outbreak

Restrictions/

Recommendation

for Sites

Clostridium botulinum

Vomiting, abdominal pain, fatigue, muscle

weakness, headache, dizziness, ocular

disturbance (blurred or double vision, dilated

pupils, unreactive to light), constipation, dry

mouth and difficulty in swallowing and

speaking, and ultimately paralysis and

respiratory or heart failure.

Ingestion of toxin pre-formed in food. This may

occur wh

en raw or

der- p

rocessed foods are

stored in anaerobic conditions that allow

growth of the organism. Most outbreaks are

due to faulty preservation of food (particularly

in homes or cottage industries), e.g., canning,

fermentation, curing, smoking, or acid or oil

preservation. Foods involved include

vegetables, condiments (e.g., pepper), fish and

fish products, meat and meat products, honey,

fruit and vegetable juices. Several outbreaks

have occurred as a result of consumption of

un-eviscerated fish, garlic in oil, and baked

potatoes.

12-36 hours,

or up to

several days

(foodborne),

4-14 days

(wound), up to

30 days

(intestinal)

Refer to Section 9.

Recommendations for Outbreak Prevention and Control in Institutions and Congregate Living Settings

Organism Clinical Presentation/

Symptoms

Infectious Substance/How it is Transmitted Incubation

Period

Outbreak

Restrictions/

Recommendation

for Sites

Clostridium

perfringens

Abdominal pain, diarrhea, rarely vomiting and

fever.

Illness usually caused by cooked meat and

poultry dishes subject to time/temperature

abuse. Dishes are often left for too long at

ambient temperature to cool down before

storage or cooled inadequately. This allows

spores that survive the cooking process to

germinate and grow, producing large numbers

of vegetative cells. If a dish is not reheated

sufficiently before consumption, the vegetative

cells can cause illness. Foods involved include

meat and poultry (boiled, stewed, or

casseroled).

8-24 hours

Refer to Section 9.

Cryptosporidium

parvum

Persistent diarrhea, nausea, vomiting and

abdominal pain, sometimes accompanied by

an influenza-lik

e illness with fever

Spread through the fecal-oral route, person-to-

person contact or consumption of fecal-

contaminated food and water, bathing in

contaminated pools. Foods involved include

raw milk, drinking water and apple cider.

1 to 12 days

with an

average of 7

days

Refer to Section 9.

Recommendations for Outbreak Prevention and Control in Institutions and Congregate Living Settings

Organism Clinical Presentation/

Symptoms

Infectious Substance/How it is Transmitted Incubation

Period

Outbreak

Restrictions/

Recommendation

for Sites

Cyclospora

cayetanensis

Watery diarrhea (this is the most common

symptom), abdominal bloating and gas,

fatigue, (tiredness), stomach cramps, loss of

appetite, weight loss, mild fever and nausea.

Cyclosporiasis is unlikely to spread directly

between people. This is because the parasite

can only infect others once it leaves your body

through feces. To be able to spread, the

parasite needs to be outside the body for about

7 to 15 days. Food can be a source of

cyclosporiasis for Canadians when imported

from countries where Cyclospora is common.

Foods imported to Canada that have been

linked to the Cyclospora parasite include: basil,

cilantro, raspberries, blackberries, mesclun

lettuce, snow and snap peas and pre-packaged

salad mix.

2-14 days with

an average of

7 days

Refer to Section 9.

Recommendations for Outbreak Prevention and Control in Institutions and Congregate Living Settings

Organism Clinical Presentation/

Symptoms

Infectious Substance/How it is Transmitted Incubation

Period

Outbreak

Restrictions/

Recommendation

for Sites

Escherichia coli

a) Enteropathogenic E.

coli (EPEC)

b) Enterotoxigenic E.

coli (ETEC)

producing a heat-

labile (LT) and a

heat-stable (ST)

enterotoxin

c) Enteroinvasive E.

coli (EIEC)

d) Enterohaemorrhagi

c E. coli (EHEC) or

verocytotoxin

producing E. coli

(VTEC), also

referred to as

Shiga-toxin

producing E. coli

(STEC), of which the

most recognized is

E. coli O157

EPEC adheres to the mucosa and

changes its absorption capacity, causing

vomiting, diarrhea, abdominal pain, and

fever.

b) ETEC mediates its effects by enterotoxins.

Symptoms include diarrhea (ranging from

mild to a severe, cholera-like syndrome),

abdominal cramps and vomiting,

sometimes leading to dehydration and

shock.

c) EIEC causes inflammatory disease of the

mucosa and submucosa by invading and

multiplying in the epithelial cells of the

colon. Symptoms include abdominal pain,

vomiting and watery diarrhoea (in <10% of

cases stools may become bloody and

contain mucus).

d) EHEC causes abdominal cramps and

watery diarrhea that may also develop

into bloody diarrhea (hemorrhagic colitis).

Fever and vomiting may also occur.

(a-c) EPEC, ETEC, EIEC: consumption of

food and water contaminated with fecal matter.

Time/temperature abuse of such foods

increases risk of illness. Up to 25% of infections

in infants and young children in developing

countries are due to E. coli, in particular ETEC

and EPEC (10 – 20% and 1 – 5% of cases at

treatment centres, respectively). ETEC is a

major cause of traveller’s diarrhea in

developing countries.

d) EHEC is transmitted mainly through

consumption of foods such as raw or

undercooked ground-meat products and raw

milk from infected animals. Fecal contamination

of water and other foods, as well as cross-

contamination during food preparation, will also

lead to infection.

Foods involved include ground (minced) meat,

raw milk, and vegetables. Secondary

transmission (person-to-person) may also occur

during the period of excretion of the pathogen

which is less than a week for adults but up to 3

weeks in one-third of affected children

EPEC: 1 –

6 days; as

short as 12

– 36 hours

b) ETEC: 1 – 3

days; as

short as

10–12

hours

c) EIEC: 1 – 3

days; as

short as

10–18

hours

d) EHEC: 3 –

8 days,

median of

4 days

Refer to Section 9.

Recommendations for Outbreak Prevention and Control in Institutions and Congregate Living Settings

Organism Clinical Presentation/

Symptoms

Infectious Substance/How it is Transmitted Incubation

Period

Outbreak

Restrictions/

Recommendation

for Sites

Giardia lamblia

Diarrhea (which may be chronic and

relapsing), abdominal cramps, fatigue,

weight loss, anorexia, and nausea. Symptoms

may be caused by a protein toxin.

Infected individuals excrete Giardia cysts in

large numbers. Illness is spread by fecal-oral

route, person-to-person contact or fecal-

contaminated food and water. Cysts have been

isolated from lettuces and fruits such as

strawberries. Infection also associated with

drinking-water from surface waters and

shallow wells. Foods involved include water,

home-canned salmon, fruit and vegetables and

noodle salad.

3-24 days or

longer, with a

median of 7-

10 days

Refer to Section 9.

Hepatitis A

Loss of appetite, fever, malaise, abdominal

discomfort, nausea and vomiting, followed

by symptoms of liver damage (passage of

dark urine, pale stools, jaundice).

Spread by fecal-oral route, primarily person-to-

person. Can also be transmitted through food

and water as a result of sewage contamination

or infected food handlers. Risk of transmission

is greatest during the second half of the

incubation period until a few days after the

appearance of jaundice. Foods involved include

shellfish, raw fruit and vegetables, bakery

products.

15-50 days

with an

average of

28-30 days

Refer to Section 9.

Listeria

monocytogenes

Influenza-like symptoms such as fever,

headache and occasionally gastrointestinal

symptoms.

A substantial proportion of cases of listeriosis

are foodborne. Foods involved include raw

milk, soft cheese, meat-based paste, jellied

pork tongue, raw vegetables and coleslaw.

1-70 days

Refer to Section 9.

Recommendations for Outbreak Prevention and Control in Institutions and Congregate Living Settings

Organism Clinical Presentation/

Symptoms

Infectious Substance/How it is Transmitted Incubation

Period

Outbreak

Restrictions/

Recommendation

for Sites

Non-typhoid

Salmonella serotypes

The principal symptoms are fever, headache,

nausea, vomiting, abdominal pain and

diarrhea.

Main route of transmission is by ingestion of the

organisms in food (milk, meat, poultry, eggs)

derived from infected food animals. Food can

also be contaminated by infected food-

handlers, pets and pests, or by cross-

contamination as a result of poor hygiene.

Contamination of food and water from the

feces of an infected animal or person may also

occur. Problems caused by initial contamination

may be exacerbated by prolonged storage at

temperatures at which the organism may grow.

Direct person to person transmission may also

occur during the course of the infection. Foods

involved include unpasteurized milk, raw eggs,

poultry, meat, spices, salads and chocolate.

6 – 48 hours,

occasionally

up to 4 days

Refer to Section 9.

Salmonella typhi and

Salmonella paratyphi

types a-c

Systemic infections characterized by high

fever, abdominal pains, headache, vomiting,

diarrhea followed by constipation, rashes

and other symptoms of generalized infection.

Ingestion of food and water contaminated with

fecal matter. Food-handlers may carry the

pathogen and be a source of food

contamination. Secondary transmission may

also occur. Foods involved include prepared

foods, dairy products (e.g. raw milk), meat

products, shellfish, vegetables, and salads.

10 – 20 days

(range 3 days

to 8 weeks)

Refer to Section 9.

Recommendations for Outbreak Prevention and Control in Institutions and Congregate Living Settings

Organism Clinical Presentation/

Symptoms

Infectious Substance/How it is Transmitted Incubation

Period

Outbreak

Restrictions/

Recommendation

for Sites

Shigella dysenteriae,

S. flexneri, S. boydii,

S. sonnei

Abdominal pain, vomiting, fever, diarrhea

ranging from watery (S. sonnei) to dysenteric

with bloody stools, mucus and pus

(S. dysenteriae and, to a lesser extent S.

flex

neri and S. boydii).

Food and water contaminated with fecal

matter. Person-to-person transmission through

the fecal–oral route is an important mode of

transmission. Food can be contaminated by

food-handlers with poor personal hygiene or by

use of sewage/wastewater for fertilization.

Foods involved include uncooked foods that

have received extensive handling, such as

mixed salads and vegetables, water and raw

milk.

1 – 3 days, up

to 1 week for

S. dysenteriae

Refer to Section 9.

Staphylococcus

aureus

Intoxication, sometimes of abrupt and violent

onset. Severe nausea, cramps, vomiting and

prostration, sometimes accompanied by

diarrhea.

Consumption of foods containing the toxin.

Foods are contaminated by food-handlers. If

storage conditions are inadequate, the bacteria

may multiply to produce toxin. Intoxication is

often associated with cooked food e.g. meat, in

which competitive bacteria have been

destroyed. Foods involved include prepared

foods subject to handling in their preparation

(ham

, chicken and egg salads, cream-filled

products, ice cream, cheese).

2-6 hours

Refer to Section 9.

Recommendations for Outbreak Prevention and Control in Institutions and Congregate Living Settings

Organism Clinical Presentation/

Symptoms

Infectious Substance/How it is Transmitted Incubation

Period

Outbreak

Restrictions/

Recommendation

for Sites

Vibrio cholerae O1 and

O139

Profuse watery diarrhea, which can lead to

severe dehydration, collapse and death

within a few hours unless lost fluid and salt

are replaced; abdominal pain and vomiting.

Food and water contaminated through contact

with fecal matter or infected food handlers.

Contamination of vegetables may occur

through sewage or wastewater used for

irrigation. Person-to- person transmission

through the fecal-oral route is also an important

mode of transmission. Foods involved include

seafood, vegetables, cooked rice and ice.

A few hours to

5 days, with

an average of

2-3 days

Refer to Section 9.

Vibrio

parahaemolyticus

Profuse watery diarrhea, abdominal pain,

vomiting, and fever. A dysenteric syndrome

has been reported from some countries,

particularly Japan.

Associated with consumption of raw or

undercooked fish and fishery products or

cooked foods subject to cross contamination

from raw fish.

9–25 hours,

up to 3 days

Refer to Section 9.

Vibrio vulnificus

Profuse diarrhea with blood in stools.

Organism is associated with wound

infections and septicaemia may originate

from the gastrointestinal tract or traumatized

epithelial surfaces.

All known cases are associated with seafood,

particularly raw oysters,

12 hours – 3

days

Refer to Section 9.

Yersinia enterocolitica

Abdominal pain, diarrhea, mild fever,

sometimes vomiting.

Associated Foods Illness is transmitted through

consumption of pork products (tongue, tonsils,

gut), cured or uncured, as well as milk and milk

products.

3-7 days,

generally less

than 10 days

Refer to Section 9.

Recommendations for Outbreak Prevention and Control in Institutions and Congregate Living Settings

Organism Clinical Presentation/

Symptoms

Infectious Substance/How it is Transmitted Incubation

Period

Outbreak

Restrictions/

Recommendation

for Sites

Viral gastroenteritis

Note: Many different

viruses can cause viral

gastroenteritis,

including

adenoviruses,

coronaviruses,

rotaviruses,

parvoviruses,

caliciviruses and

astroviruses. Those

viruses most

associated with

foodborne outbreaks

are norovirus and

hepatitis A.

Diarrhea and vomiting, which is often severe

and projectile with sudden onset.

Gastroenteritis viruses usually spread by fecal–

oral route. Food and drinking-water may be

contaminated either at source when exposed

to sewage/wastewater in the environment or

used for irrigation, or by an infected food-

handler. Filter-feeding shellfish most common

food contaminated at source, but a wi

de range

of different cooked and uncooked foods have

been implicated in secondary contamination by

food-handlers.

15-50 hours

Refer to Section 9.

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

8.1 IPAC Measures

• See sections 3.1 and 4.1.

8.2 Administrative Measures

• See sections 3.2 and 4.2.

8.3 Client/Patient/Resident Restrictions

• See sections 3.3 and 4.3.

8.4 Restrictions on Affected Units/Site

• See section 4.4.

Additionally:

• Decisions on restrictions for clients/patients/residents on affected units/sites

will be made by the OMT in consultation with the institution.

• If restrictions are lifted by the OMT, but some clients/patients/residents

continue to exhibit symptoms of gastrointestinal illness, isolation precautions for

ill clients/patients/residents should remain in effect to prevent further spread.

• The scope of restrictions on the affected unit are usually dependent on the

affected areas and severity of the outbreak.

• Restrictions typically remain in place until the outbreak has been declared over

by the PHU.

• Timeframes for declaring the outbreak over may vary depending on the

organism but usually follow whichever comes first:

o 48 hours from symptom resolution in the last case; OR

o No new cases after one infectious period plus one incubation period. For

example, Norovirus can be declared over after 5 days.

8.5 Admissions/Transfers from Acute Care to an Outbreak

Institution

• See section 4.5 and 5.5.

Additionally:

• New admissions are generally not advised during gastrointestinal outbreaks.

• If a client/patient/resident is returning from absence, due diligence should be

observed in protecting them by IPAC measures/precautions.

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

• It is important to weigh risk to the individual returning to the facility (health status,

etc.) and to consult with medical staff on a case-by-case basis to ensure the

returning client/patient/resident is protected.

8.6 Transfers from an Outbreak Setting to Acute Care

• The acute care setting should be notified of the outbreak and provided details to

ensure control measures are in place upon the client/patient/resident’s arrival.

• Institution to institution transfer during an outbreak is NOT recommended, but

this is evaluated by the OMT and settings on a case-by-case basis.

• For LTCHs, the PTAC, Paramedic Services and others may be notified about the

outbreak if the transfer has been approved.

8.7 Group/Social Activities and other Events

• See section 3.7 and 4.7.

 Nourishment Areas/Sharing of Food

• See section 3.8.

Food safety plays a role in controlling gastrointestinal illness, and all food areas

located within institutions are subject to Ontario Regulation 493/17.

The following safe food handling practices are required:

• Facilities should have policies and procedures on safe food handling, including:

o those related to staff who are certified food handlers;

o records of food suppliers;

o retention of food samples;

o temperature records of potentially hazardous foods;

o catered food;

o food brought in by families;

o common kitchens/serveries;

o feeding assistance;

o dishwasher temperature/sanitizing records and

o kitchen equipment installation and maintenance.

• Feeding assistance would require those providing it to follow proper HH

procedures before and after assisting with feeding. Clients/patients/residents

should also have an opportunity to perform HH before and after each meal. If

staff/volunteers are experiencing symptoms (diarrhea or vomiting), they should

be excluded from providing feeding assistance.

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

• A certified food handler must be on site to champion safe food handling

practices.

• Catered food and food brought in by families should be discussed with setting

staff. Food for one client/patient/resident should not be shared with other

clients/patients/residents without staff knowledge (some

clients/patients/residents cannot consume certain foods). Food should be

labelled with date prepared and client/patient/resident’s name. Families should

be directed on where to store this food.

• Families should be educated on potentially hazardous foods (deli meats and

potential for Listeria).

If it is suspected that the outbreak source is a food source or an infected food

handler, the following are also recommended:

• Staff should be familiar with exclusion criteria for food handlers related to the

Infectious Disease Protocol, 2018 (or as current).

• PHUs may provide recommendations on the screening of ill staff for enteric

diseases if it is strongly suspected that the outbreak source is an infected food

handler.

• Food samples (including food that is brought from outside of the facility) should

not be discarded once a potential outbreak has been identified. Food retention

policies should be in place including:

o Types of food to be retained.

o Date of production.

o Retention period (or date of discard).

o Location of retained food samples.

o Type of retention container.

o Quantity of food to be retained.

o Labeling requirements such as: date, type of food, and time of meal.

o Food samples should be kept frozen solid for 10 days.

•

Retain 200-gram samples of suspect food for collection and testing by a public

health inspector. Refer to the Public Health Inspector’s Guide to Environmental

Microbiology Laboratory Testing and Considerations for Food Safety

Investigations at Food Premises During an Outbreak for more information.

Contact PHOL for consultation, if necessary, at 416-235-6556 or toll free 1-877-

604-4567.

32,51

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

8.8 Visitors and Essential Caregivers

• See section 4.9.

8.9 HCW/Staff Outbreak Measures

• HCWs/staff should monitor themselves for signs and symptoms.

• Symptomatic staff should self-isolate at home, and not go into work; staff should

report being ill to their employer (setting administration/management).

• Staff can return to work after 48 hours if symptom-free.

• Employers also have a duty to report workplace-related illness as per the

Occupational Health and Safety Act (OHSA).

For more information, please see

the provincial web page on Occupational Health and Safety compliance.

• HCWs/staff who develop gastrointestinal symptoms at work are

recommended to perform hand hygiene and leave work as soon as possible.

• Cohort HCWs / staff to care for asymptomatic residents before symptomatic

residents when possible.

• Consider minimizing movement of HCWs/staff/volunteers/students between

units/ floors, especially if some units/floors are not affected.

• For gastrointestinal illness, staff can return to work after 48 hours symptom

free. This period could be modified if the causative agent is known.

• Disease-specific exclusions may apply. See Appendix 1 for more details.

• All ready-to-eat (RTE) foods prepared by dietary staff that became ill while

working on shift, should be discarded.

8.10 Specimen Collection

• Not all clients/patients/residents will require specimen collection for outbreak

management.

• Confirmation of a gastroenteritis outbreak is NOT dependent on lab confirmation.

• If the causative agent of the outbreak is suspected or confirmed to be caused

by norovirus, laboratory testing of food retention samples is not

recommended.

• If gastrointestinal illness case definition has been met, appropriate samples may

be collected.

• If clinical specimen collection is required, HCWs/staff should ensure correct

collection and labelling of specimens (D.O.B., name of client/patient/resident,

date of sample collection, etc.).

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

• For further information about human diagnostic testing, contact PHO’s

Laboratory.

• For more information regarding collection and testing of environmental

samples, please refer to the Public Health Inspector’s Guide to Environmental

Microbiology Laboratory Testing.

• Please see Gastroenteritis Outbreaks in Institutions and Public Hospitals for

more info.

8.11 Enhanced Environmental Cleaning and Disinfection

• See section 3.12 and 4.12.

• During gastrointestinal illness/outbreaks, the following is recommended for

disinfecting surfaces and equipment:

o Use a hard surface disinfectant with efficacy against the identified/suspected

pathogen (e.g., norovirus) and reasonable contact time (not something with a

30 min CT) and compatible with the surface to be disinfected.

o Consultation with PHU for more information on cleaning and disinfection

practices.

Roles and Responsibilities for Confirmed Outbreaks

• See section 1.

• See ON-FIORP, 2023 or as current for further information on multi-jurisdictional

roles and responsibilities in gastrointestinal outbreaks.

Section 9: Closing an Outbreak

Review the Outbreak

The OMT should meet to review the management of the outbreak, including:

• What was handled well and what could be improved in managing future

outbreaks.

• Identifying recommendations for future preventive actions and/or necessary

policy/protocol changes

• Possible reasons for the outbreak and steps to prevent similar outbreaks in the

future.

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

Complete the Outbreak Investigation File

The PHU should review the outbreak file to ensure it contains full documentation

including:

• Copies of laboratory and other results.

• Copies of all meeting minutes and other communications.

• All other documents specific to the investigation and management of the

outbreak, including notes and line lists.

• A summary report.

Note: Setting administration/management or IPAC lead/designate should store

copies of all documents related to the outbreak. The PHUmay also maintain file

copies of all documents related to the outbreak and may report details of the

outbreak to the MOHs Office of the Chief Medical Officer of Health – Public Health

using the integrated Public Health Information System (iPHIS), Case and Contact

Management System (CCM) or any other method specified by the ministry and

within timelines specified by PHO.

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

Appendix A: Outbreak Preparation

Resources

General:

• Ontario Investigation Tools: Ontario Investigation Tools | Public Health Ontario

• Contact precautions: sign-ltc-caution-contact.pdf (publichealthontario.ca)

• Routine practices and additional precautions for all health care settings: bp-rpap-

healthcare-settings.pdf (publichealthontario.ca)

• Best practices for infection prevention and control programs in Ontario: bp-ipac-

hc-settings.pdf (publichealthontario.ca)

• Best practices documents: Best Practices in IPAC | Public Health Ontario

• Public health inspector’s guide to environmental microbiology laboratory testing:

Public Health Inspector’s Guide to Environmental Microbiology Laboratory

Testing (publichealthontario.ca)

• Donning and Doffing PPE: https://www.publichealthontario.ca/-

/media/documents/l/2013/lanyard-removing-putting-on-ppe.pdf?la=en

• Performing a risk assessment related to routine practices and additional

precautions

• IPAC core competencies and resources

o Routine Practices and Additional Precautions

, including use of PPE, cleaning

and disinfecting requirements, and environmental cleaning, as per Provincial

Infectious Disease Advisory Committee (PIDAC) documents.

o Just Clean Your Hands

, including your Four Moments for Hand Hygiene

o Chain of transmission: modes of infection transmission

o PHO’s IPAC online learning modules

• OPHS: Ontario Public Health Standards

• Ontario Regulation 493/17 (Food Premises Reg.): O. Reg. 493/17: FOOD

PREMISES (ontario.ca)

• Ontario Regulation 246/22 (General) under the Fixing Long Term Care Act: O.

Reg. 246/22: GENERAL (ontario.ca)

• Personal Protective Equipment Use Tracking Tools | NIOSH | CDC

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

Figure 1: Outbreak Signage

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

Respiratory:

• Interim Infection Prevention and Control Measures based on COVID-19

Transmission Risks in Health Care Settings (publichealthontario.ca)

• Influenza (flu) | Public Health Ontario

• Ontario Respiratory Virus Tool

GI:

• Gastro stool viruses: https://www.publichealthontario.ca/en/laboratory-

services/test-information-index/enteric-gastroenteritis-stool-viruses

• Enteric OB kit: https://www.publichealthontario.ca/en/laboratory-services/kit-

test-ordering-instructions/enteric-outbreak-kit

• Considerations for Food Safety Investigations at Food Premises During an

Outbreak

COVID:

• COVID-19 Specific Guidance for Health Sector

• COVID-19 Guidance: Personal Protective Equipment (PPE) for Health Care

Workers and Health Care Entities

• COVID-19 General Webpage

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

Appendix B: Antivirals/Therapeutics

Antivirals as Part of an Outbreak Preparedness Plan

An outbreak plan should include measures that will expedite the administration of

antiviral medication for staff and clients/patients/residents. A plan is required to

begin antivirals quickly not only because treatment is most effective when started

within 48 hours of symptom onset, but also because prophylaxis should begin as

soon as possible to stop the progression of the outbreak. This plan should include

measures to ensure rapid access to antiviral medications from local pharmacies.

Every eligible client/patient/resident in any setting could be a candidate for

antiviral prophylaxis. For outbreak management purposes, only some settings

would be eligible for antiviral prophylaxis for use as an outbreak control measure.

The following recommendations should be addressed in institution/facility policies

in preparation for an outbreak to ensure that there are no delays in providing

immunization and/or antiviral medication:

• Consent for antiviral medication use during the entire respiratory season should

be obtained from clients/patients/residents (or SDM) in advance of each

respiratory season. This may be obtained at the same time consent is obtained

for immunization.

• Advance medical orders for influenza antiviral medication for

clients/patients/residents should be obtained from medical staff at the

beginning of each respiratory season, or a plan should be in place to obtain

physician’s orders quickly in the event of an outbreak. Advance medical orders

can substantially expedite administration of antiviral medications.

• Staff who are unimmunized for any reason should be informed that in the event

of an outbreak, they may be given the option of taking antiviral medication for

the duration of the outbreak in order to continue their duties. If staff are unable or

refuse to take antiviral medication for the duration of the outbreak, the PHU and

institution should determine staffing needs for the setting on a case-by-case

basis.

• To facilitate antiviral treatment during outbreaks, staff who are unable to receive

vaccinations should be assessed for eligibility for antiviral drugs prior to the

respiratory season. A record of this information should be kept on-hand at the

institution/facility to expedite timely implementation of antiviral prophylaxis. In

addition, staff who are not immunized, who conduct activities in the

institution/facility, and who are assessed as being able to take antiviral

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

medication, may wish to obtain and keep prescriptions on hand to assist with

timely commencement of antivirals, in the event of an outbreak.

• During the respiratory illness season, institution/facility administration should

keep a current list of staff working in the institution/facility who are not

immunized, to promptly implement control measures, such as antiviral

prophylaxis and cohorting staff. Other control measures, such as non-

client/patient/resident care work arrangements or staff exclusions, may also be

considered.

• The PIDAC document Annex B: Prevention of Transmission of Acute Respiratory

Infection in all Health Care Settings, March 2013 recommends: “Annual influenza

vaccination should be a condition of continued employment in, or reappointment

to, health care organizations”.

• As soon as a vaccine-preventable respiratory outbreak is suspected,

unimmunized clients/patients/residents and staff carrying on activities in the

institution/facility, who do not have contraindications to the vaccination, should

be offered the vaccine. When an outbreak is declared, immunized persons

carrying on activities in the institution/facility may continue to work without

disruption of their work pattern. Those who have not provided documentation of

receipt of vaccine should be managed as unimmunized.

• Unimmunized staff carrying on activities in the institution/facility who refuse

antivirals during an outbreak should not provide client/patient/resident care or

conduct activities where they have a potential to acquire or transmit infections.

The institution/facility may choose to exclude from work unimmunized staff

carrying on activities in the institution/facility unless they take antivirals.

Unimmunized staff carrying on activities in the institution/facility who agree to

be immunized during an outbreak but do not take antivirals may return to work

14 days, or as indicated, following receipt of vaccine (the duration required to

achieve vaccine-induced immunity). They may return earlier if they begin a

course of antiviral prophylaxis.

• Newly immunized (within 2 weeks) or unimmunized staff taking antiviral

prophylaxis could continue their work without interruption.

• Antiviral drugs for staff carrying on activities in the institution/facility require a

prescription. All staff should try to use their own physician or health care

provider; however, in the event of an outbreak, to facilitate eligible staff with

timely antiviral medication (in situations where the medical assessment does not

contraindicate such) the institution/facility may wish to discuss with the

institution/facility physician(s)/nurse practitioners the opportunity for

institution/facility staff to access their medical services, as applicable.

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

• Unimmunized staff working in an outbreak institution/facility can work in a non-

outbreak or alternate healthcare setting if three or more days (one incubation

period) have passed since their last day of activities in the outbreak

institution/facility.

Influenza Antiviral Prophylaxis

Antiviral prophylaxis does not replace annual influenza immunization.

PHUs should be aware that clinical recommendations for the use of antiviral

medications may change from season-to-season, as additional evidence becomes

available. Decisions regarding influenza antiviral prophylaxis or treatment should be

made at the discretion of the attending physician/health care provider based on

current data of circulating influenza strains, including antiviral resistance.

It is important to ensure that the most current guidelines/publications/product

monographs are accessed as they can be updated yearly. Please refer to PHO’s Flu

Antiviral Guidance

. PHUs should be aware of the Association of Medical

Microbiology and Infectious Disease (AMMI) Canada’s current guidelines for the use

of antiviral drugs for influenza

In addition to AMMI, the current manufacturer’s

product monograph contains information regarding the use of the drug. The

manufacturer publishes an updated product monograph when changes relating to

recommended use of their products take effect. The Tamiflu™ product monograph

is located on the Roche Canada website and the Nat-oseltamivir product

monograph is on the Natco Pharma Canada website.

Antivirals for Prevention (Prophylaxis)

During a confirmed influenza outbreak, antiviral medication for prevention should be

offered to all clients/patients/residents in the outbreak-affected floor/unit who are

not already ill with influenza, whether previously vaccinated or not, until the

outbreak is declared over. When the circulating strain is not well-matched by the

vaccine, antiviral prophylaxis may be offered to all staff, regardless of vaccination

status, as determined by the OMT or in consultation with the PHU until the outbreak

is declared over. PHUs may consult with PHO regarding scientific and technical

support regarding evidence of a mismatch.

Antiviral prophylaxis should be initiated as soon as an influenza outbreak is declared.

In almost all situations, it is prudent to wait for laboratory confirmation of influenza

before initiating prophylaxis and treatment. Once the specimen reaches the

appropriate laboratory, rapid test results are usually available within one business

day. In some circumstances, the PHU may provide recommendations for

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

prophylaxis prior to laboratory confirmation. Institutions/facilities should consult

with PHU representatives on the OMT when starting antiviral prophylaxis and

treatment.

Recommendations regarding influenza antiviral prophylaxis:

• All unvaccinated asymptomatic staff who work in the area of the

institution/facility where the influenza outbreak is occurring should be advised to

take prophylactic antiviral medication until the outbreak is declared over.

• It is reasonable to allow unvaccinated staff to work with

clients/patients/residents on an outbreak floor/unit as soon as they start

antiviral prophylaxis. Unless there is a contraindication, consenting staff should

also immediately be offered immunization against influenza with the current

seasonal influenza vaccine.

• Staff who have been vaccinated for less than two weeks at the time the influenza

outbreak is declared should take antiviral prophylaxis for two weeks after

vaccination or until the outbreak is declared over (whichever comes first). Note:

Antiviral medications do not interfere with the immune response to vaccine.

• Staff should be alerted to the symptoms and signs of influenza, particularly

within the first 4 days after starting antiviral prophylaxis. Staff illness should

immediately be reported. Staff reporting signs and symptoms of influenza should

be excluded from working in any health care setting if symptoms develop.

• Prophylaxis may be discontinued once the influenza outbreak is declared over.

• Prophylaxis may also be given during influenza season in institutions/facilities

not experiencing an influenza outbreak to unvaccinated individuals at high-risk of

influenza-related complications, at the discretion of the treating physician or

health care provider.

• If a person taking a neuraminidase inhibitor (i.e., oseltamivir or zanamivir) for

prophylaxis of influenza develops symptoms of an influenza-like illness, the

neuraminidase inhibitor can be continued; however, the neuraminidase inhibitor

should be increased to the recommended treatment dose. Consideration should

be given to obtaining a nasopharyngeal specimen if the individual has been on

antiviral prophylaxis for more than four days to determine the presence of a

resistant strain or another respiratory virus.

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

Antiviral Prophylaxis to the Outbreak Floor(s)/Unit(s) Versus

the Whole Facility

The advantages and disadvantages of providing antiviral prophylaxis to the outbreak

floor(s)/unit(s) or to the whole facility may be evaluated based on the specific

characteristics of the outbreak and the design of the facility.

• Advantages of a whole-facility approach:

o Preventing the spread of the outbreak to other floors/units;

o Preventing the introduction from another outside source when influenza is

circulating in the community;

o Not needing to be as vigilant to detect the spread on another floor/unit as

would be needed if surveillance is being used as a trigger for prophylaxis; and,

o Preventing the need to manage an outbreak unit by floor/unit as new

floors/units are added.

• Disadvantages to the whole-facility approach:

o Logistics of using antiviral medication for a large number of residents;

o The theoretical potential for resistance if the drug is widely used for

prevention;

o Antiviral availability; and,

o The potential for side effects occurring in a larger number of residents.

PHUs may consult with PHO for scientific and technical support regarding the use of

antivirals for prophylaxis in outbreak unit(s)/facilities.

Antivirals for Treatment

Treatment decisions for the clients/patients/residents and staff are the

responsibility of the attending physicians or health care providers. Staff are

responsible for obtaining prescriptions for antiviral treatments.

Recommendations regarding antiviral treatment:

• Antiviral treatment should be started for ill clients/patients/residents (who meet

the outbreak case definition), as soon as possible and preferably within 48 hours

of symptom onset for maximum effectiveness. This may decrease complication

of influenza infection. As much as possible symptomatic residents should be

encouraged to remain in their rooms for the duration of antiviral treatment.

• Once an outbreak has been laboratory-confirmed as influenza, additional

laboratory confirmation of each new case is not required to initiate antiviral

treatment in individuals who meet the outbreak case definition.

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

Diagram 1, below, provides additional detail on actions to take in cases where

antiviral treatment is not initiated within 48 hours (Diagram 1), or in cases where

treatment has been completed but an outbreak is still ongoing (Diagram 2).

The algorithm in Diagram 2 would not apply if there was known to be two different

influenza strains in the same institution/facility. If this were the case, all

clients/patients/residents on treatment should switch to prophylaxis after

treatment completion, until prophylaxis is no longer indicated in the facility.

When Antivirals Do Not Control the Outbreak

It is prudent to wait for laboratory confirmation of the causative agent of an outbreak

before initiating antiviral prophylaxis or treatment. If new cases of influenza-like

illness continue to occur 96 hours or more after the initiation of antiviral use, one or

more of the following may be occurring:

• The new cases could be caused by an agent other than influenza (e.g., RSV);

• There may be compliance issues;

• The circulating strain may be resistant to the antivirals.

In the event that the outbreak is not controlled with antiviral use, the following

actions should be taken:

• Consult with the PHU

• The PHU should consult with PHOL about additional testing strategies.

• The PHU representative on the OMT should be consulted regarding continued

use of antivirals.

• Resistance testing on positive influenza specimens may be done in consultation

with PHOL if resistance is suspected and no other organism is identified in the

outbreak.

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

Obtaining Reimbursement for Antivirals for the Ontario Drug

Benefit (ODB) Program

Clients/patients/residents may be eligible for prescription drug coverage under the

ODB Program. Prescriptions for antiviral medications, as for all other medications,

are the responsibility of the medical directors or attending physicians of the

clients/patients/residents.

A searchable on-line ODB eFormulary database is available with information on the

conditions for reimbursement of the neuraminidase inhibitors oseltamivir and

zanamivir.

Staff are not eligible for prescription drug coverage under any circumstances from

the ODB Program. Staff that do not have insurance or have an insurance plan that

covers antivirals may be eligible for reimbursement through the Level-of-Care

envelope funding system allocated through the HCCSS. Prescriptions for antiviral

medications for staff, as for all other medications, are obtained from their physician,

health care provider, or another source, as appropriate.

General information regarding the ODB Program is available at the ODB Program.

Full details of the reimbursement criteria are below in Table 1. Reimbursement for

clients/patients/residents applies only during a confirmed influenza outbreak for

clients/patients/residents requiring treatment (up to five days of therapy) and for

clients/patients/residents requiring prophylactic therapy (up to six weeks of

therapy for prophylaxis).

Table 1: Reimbursement Criteria for Influenza Antivirals

LU Code

Drug

Clinical Criteria

371

Oseltamivir

(Tamiflu®)

30mg,

45mg, 75 mg

capsule

For the prophylaxis (max: 75 mg daily) of

institutionalized individuals during confirmed outbreaks

of influenza A or influenza B.

Supply is limited to a maximum of 6 weeks.

The outbreak must be confirmed by PHUs.

372

Oseltamivir

(Tamiflu®)

30mg,

45mg, 75 mg

capsule

For the treatment (max: 75 mg twice daily) of

institutionalized individuals during confirmed outbreaks

due to influenza A or influenza B.

Supply is limited to 5 days.

The outbreak must be confirmed by PHUs.

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

LU Code

Drug

Clinical Criteria

414

Zanamivir

(Relenza)

5 mg

inhalation

For treatment: 2 inhalations of 5 mg (10 mg) twice daily

for 5 days.

For the treatment of institutionalized individuals during

confirmed outbreaks due to influenza A or influenza B

when the predominant circulating strain is resistant to

oseltamivir

The outbreak must be confirmed by PHUs.

415 Zanamivir

(Relenza®)

5 mg

inhalation

For prophylaxis: 2 inhalations of 5 mg (10 mg) once

daily for 10 days

For the prophylaxis of institutionalized individuals

during confirmed outbreaks due to influenza A or

influenza B when the predominant circulating strain is

resistant to oseltamivir.

The outbreak must be confirmed by PHUs.

Antiviral Resistance

Testing of influenza isolates for antiviral resistance is performed as part of routine

laboratory surveillance at the National Microbiology Laboratory, and is reported by

PHO’s Ontario Respiratory Pathogen Bulletin, the Laboratory-Based Respiratory

Pathogen Surveillance Report and the national FluWatch report. HCWs are advised

to refer to updates on influenza activity and antiviral resistance patterns in ongoing

surveillance reports.

Resistance testing on positive influenza specimens may be done in consultation

with PHO if resistance is suspected and no other organism is identified in the

outbreak. The results, however, may not be received within a timeframe to influence

decision-making regarding the continued use of antivirals to control the outbreak.

PHUs should contact PHO’s Customer Service Centre at 416-235-6556/1-877-604-

4567 in the event that they want to perform resistance testing. Influenza virus should

be detected from the clients/patients/residents of concern; only then can

sensitivity testing on the virus be performed. This testing usually requires that the

client’s/patient’s/resident’s influenza virus grows in culture.

If antiviral drug resistance is detected or suspected in an institution/facility outbreak

(e.g., if an outbreak appears uncontrolled despite proper antiviral use), or resistance

has been reported in local community, local and provincial health authorities should

be contacted for up-to-date advice on antiviral use.

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

COVID-19

Antivirals

Health care providers should discuss potential treatment options (i.e., Paxlovid,

Remdesivir) with residents and caregivers in advance of potential COVID-19

infection.

• This should include obtaining a clinical assessment, up-to-date renal function

tests and other relevant workup, medication reconciliation, and goals of care. A

physician or nurse practitioner must determine if treatment is right for a

client/patient/resident based on multiple factors such as clinical judgement,

goals of care, the potential for drug-drug interactions or other medication

contraindications, as well as other general considerations.

• Plans should also include steps for accessing treatment so it can be made

available as quickly as possible.

LTC homes are encouraged to pre-emptively:

• Determine if a client/patient/resident meets eligibility, including reviewing

medications for potential drug-drug interactions, and ordering a serum creatinine

while the residents are well.

• Connect with their contracted pharmacy about including Paxlovid in their

emergency box, especially if a home is in a remote area. (All long-term care

contracted pharmacies have access to Paxlovid and, in emergency situations,

homes may rely on their secondary pharmacy to access Paxlovid).

• If a patient is not eligible for Paxlovid, there are other therapeutic treatment

options (i.e., Remdesivir). Residents and their caregivers are encouraged to

proactively speak with their primary care provider.

• Health care providers and LTCHs should work with their Nurse-Led Outreach

Teams or OH regional contact to access Remdesivir through local pathways.

RHs and other institutions are encouraged to provide information on COVID-19

therapeutics and encourage residents and clients to speak with their primary care

provider to come up with a treatment plan in case they get sick, as appropriate.

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

Diagram 1: Antiviral treatment use recommendation in influenza outbreaks. If

treatment is not initiated within 48 hours of symptom onset

Is the outbreak still ongoing?

Are

antivirals still

being used for prophylaxis

on the line-listed

resident’s

unit?

Did the

line-listed resident

have laboratory confirmed

influenza?

Do not provide prophylaxis

The resident would now have

immunity to the influenza virus

that is causing the outbreak

Start on a prophylaxis does until the

outbreak is declared over

This is a precaution in case there is an

outbreak with more than one pathogen and

the line-listed resident may have previously

been infected with a non-influenza pathogen

Yes

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

Diagram 2: Antiviral prophylaxis recommendations in influenza outbreaks for

line-listed cases after completion of treatment with antiviral medication

Resident

meets outbreak

case definition

Was

antiviral treatment

initiated within 48 hours of

symptom onset?

Is the resident clinically

improving?

Provide antiviral treatment

Consider antiviral therapy for

individuals in high risk groups*, or

individuals with moderate,

severe, or complicated illness

*Note: please see AMMI Infuenza Guidelines (as current) for a definition of high-risk groups,

available at http://www.ammi.ca/guidelines

Yes

Recommendations for Outbreak Prevention and Control in Institutions and Congregate Living Settings

Appendix C: Sample Outbreak Line List

Facility Outbreak Line List

Facility Name Select ONLY one: Select ONLY one: Line List Outbreak #: Iphis?

Facility Address

Respiratory

☐

Resident

☐

Index Case Symptom

Onset Date: YYYY-MM-DD

Facility Phone and

Ext

Enteric

☐

Patient

☐

Control Measures Started

Date: YYYY-MM-DD

Contact Person #1

Children

☐

Submission Date: YYYY-

MM-DD

Contact Person #2

Staff

☐

Submitted By:

Respiratory

Enteric

Symptoms

Submit line list when:

(1) Two or more cases of acute respiratory

infections occur within 48hrs with a common

epi-link (i.e., unit, floor) in residents; OR

(2) One or more laboratory confirmed case(s) of

influenza in a resident; OR

(3) One or more positive tests for COVID-19 in

residents; OR

(4) Directed by local public health unit.

Submit line list when two or more people have:

(1) Two or more episodes of diarrhea (i.e.,

loose/watery bowel movements) within a 24-

hour period; OR

(2) Two or more episodes of vomiting within a

24-hour period; OR

(3) One or more episodes of diarrhea AND one or

more episodes of vomiting within a 24-hour

period.

(4) Directed by local PHU.

Fever (37.8ºC)

☐

Nausea/Vomitting

☐

Sore

☐

Headache

☐

Diarrhea

☐

Nasal

☐

Malaise/Fatigue

☐

Shortness of

Breath

☐

Loss of

taste/Smell

☐

New Cough

☐

Muscle Aches

☐

Other

Recommendations for Outbreak Prevention and Control in Institutions and Congregate Living Settings

Case Demographics

Isolation

Symptoms (new or worsening)

Speciment

Diagnostics

Vaccination /Treatment

Complications /Outcome

Case Name (Last, First)

Date of

Birth

(YYYY-

MM-

DD)

Unit/

Room#

(resident)

OR Unit

Worked

/Role

(Staff)

Isolation &

Additional

Precautions

start date or

date of last

shift MM-DD

Symptom onset date

MM-DD

Fever /Abnormal Temp (Celsius)

New /worsening cough

Shortness of Breath

Hoarseness /Shortness of Breath

Runny Nose/ Nasal Congestion

Headache

Fatigue /Malaise/ Myalgias

Loss of Taste /Smell

Vomiting # of episodes**

Diarrhea # of episodes**

Specimen Collection Date

MM-DD

Type of Test & Result (+ or

(RAT, PCR, MRVP, NAAT, Stool)

COVID

19 Vaccine (# of doses)

Influenza Vaccine

MM-DD

Antiviral Treatment

MM-DD

Antibiotic Treatment

MM-DD

Clinical/X

-RAY evidence of

pneumonia

MM DD

Hospitalization Date

MM-DD

Hospital Discharge Date

MM-DD

Death

MM-DD

Out of Isolation OR Return to Work

Date MM-DD

☐

**If client/patient/resident is experiencing new onset of diarrhea, collect stool sample using enteric outbreak stool kit for viral and bacteria testing.

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

Appendix D: COVID-19 Case, Contact and

Outbreak Management in non-LTCH/RH

Institutions

This section applies to higher risk institutions within the meaning of “institution” in

subsection 21(1) of the HPPA.

PHUs may provide outbreak management using principles outlined in this

document to other institutions that are not designated as an “institution” under the

HPPA but provide residential services to individuals who are medically and/or

socially vulnerable to COVID-19 when within their capacity to do so.

Institutions are recommended to develop Outbreak Preparedness Plans to support

the operationalization of the recommendations outlined in this guidance document,

and to develop contingencies as appropriate to their setting and in accordance with

any setting-specific guidance issued by their respective ministries. For more

information, refer to Public Health Ontario’s (PHO’s) COVID-19 Preparedness and

Prevention in Congregate Living Settings Checklist.

Management of Symptomatic Individuals:

• Any client who is exhibiting signs or symptoms consistent with COVID-19 should

be self-isolated and tested for COVID-19. Molecular testing remains the

preferred test for symptomatic individuals associated with a highest risk setting.

Ideally, rapid antigen tests (RATs) should not be used for symptomatic clients,

however, if they are used, parallel molecular testing should be done to confirm

results.

• Symptomatic clients should self-isolate away from others while awaiting test

results, ideally in a single room with access to a private washroom. Where this is

not possible, symptomatic individuals should be encouraged to physically

distance least 2 metres away from others as much as possible and wear a well-

fitting medical mask, if tolerated, around others while within the setting.

• When a staff or visitor is symptomatic, they should be directed to leave the

setting immediately and self-isolate at their own home. If they test positive for

COVID-19, they should self-isolate until symptoms have been improving for 24

hours (48 hours if gastrointestinal symptoms) and no fever present.

o Visitors: For a total of 10 days after the date of specimen collection or

symptom onset, whichever is earlier/applicable, visitors should avoid non-

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

essential visits to anyone who is immunocompromised or at higher risk of

illness (e.g., seniors). Additionally, avoid non-essential visits to highest-risk

settings such as hospitals and long-term care homes. Where visits cannot be

avoided (e.g., essential caregiver visits), visitors should wear a medical mask,

maintain physical distancing, and should notify the setting of their recent

illness/positive test. If the individual being visited can also wear a mask, it is

recommended they do so.

o Staff: For a total of 10 days after the date of specimen collection or symptom

onset, whichever is earlier/applicable, staff should adhere to workplace

measures for reducing risk of transmission (e.g., masking for source control,

not removing their mask unless eating or drinking, distancing from others as

much as possible) and avoid caring for patients/residents at highest risk of

severe COVID-19 infection, where possible.

Case Management

• If the case lives in a non-LTCH/RH institution, they should:

o Isolate in the setting (i.e., in a separate room away from others, with access to a

private washroom or disinfection of a shared bathroom between users) to limit

the transmission of COVID-19 to others who work/reside in that same setting,

o Remain isolated for at least 5 days after the onset of symptoms or date of

specimen collection (whichever is applicable/earlier), and until the case has

no fever and symptoms are improving for 24 hours (48 hours for

gastrointestinal symptoms).

o A client may also isolate away from the setting if alternative isolation facilities

are available.

o Until at least day 10 from symptom onset/positive specimen collection date

(whichever is applicable/earlier), client/patient/resident cases should

continue to wear a well-fitted mask at all times. Exceptions include eating and

sleeping, during which times the individual should maintain physical

distancing where possible.

• Setting-specific guidance only applies to individuals when they are physically

present in the institution. For individuals who leave the setting (e.g., for work,

school, other purposes), public health measures and any other setting-specific

guidance applies when they are outside of the setting. This means that an

individual may still be required to isolate away from others in their living situation

(e.g., shelter, group home), but once they are afebrile and their symptoms have

been improving for 24 hours (or 48 hours if gastrointestinal symptoms), they can

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

resume attending other settings in the community with precautions of masking

and avoiding vulnerable individuals and other highest-risk settings for 10 days

from their symptom onset or date of positive specimen collection. They should

also avoid contact anyone who is at higher risk of severe complications from

COVID-19 (e.g., immunocompromised and/or elderly) for 10 days from symptom

onset or date of specimen collection (whichever is applicable/earlier).

• Institutions should ensure that clients who test positive for COVID-19 have

access to the following, as applicable:

o Medical care, including Paxlovid or other approved COVID-19 therapeutics, if

eligible. For more information on eligibility, please see Ontario’s COVID-19

antiviral treatment screener.

o Routine medications, as applicable.

o Mental health supports, as applicable.

o Harm reduction supplies, as applicable.

Contact Management:

• While in the institution, all close contacts should wear a mask at all times (except

for eating/sleeping and maintain a distance of at least 2 metres from other

individuals) for 7 days from last exposure to the case.

• When outside of the institution, close contacts may follow community

guidance.

• All close contacts should self-monitor for symptoms, and promptly isolate and

get tested for COVID-19 if symptoms develop.

Outbreak Management:

Confirmed COVID-19 Outbreak

• For case definition please see Appendix 1: Diseases caused by a novel

coronavirus, including Coronavirus Disease 2019 (COVID-19), Severe Acute

Respiratory Syndrome (SARS) and Middle East Respiratory Syndrome (MERS).

• In institutions, clients/residents should be assessed at least once daily when the

client is symptomatic, has tested positive for COVID-19, or is a close contact, to

identify and monitor new or worsening symptoms of COVID-19.

• Outbreak management in institutions should follow the principles for outbreak

management in LTCHs and RHs, while recognizing that there are important

differences in settings and making modifications where necessary.

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

100

• For further information on how to modify outbreak measures to the unique

circumstances of an institution, please see PHO’s Checklist: Managing COVID-19

Outbreaks in Congregate Living Settings

Staff Exposure/Staff Illness

• Staff who test positive for COVID-19 should report their illness to their

manager/supervisor or to Occupational Health designate as per usual practice.

• The manager/supervisor or Occupational Health designate must promptly

inform the Infection Control Practitioner or designate of any cases or clusters of

staff including contract staff who are absent from work,

• Employers should help workers with symptoms and/or illness to self-isolate and

support them through the process.

• Staff who have COVID-19 symptoms or are a high-risk household contact of

someone who is COVID-19 positive should notify their manager/supervisor or

Occupational Health designate in consultation with their health care provider.

• Staff should report to Occupational Health designate prior to return to work.

Detailed general occupational health and safety guidelines for COVID-19 are

available on the MOH COVID-19 website and the MLITSD website.

64,72

o Symptomatic staff who decline testing should follow directions provided by

their employer, manager/supervisor, and/or Occupational Health.

o Staff who are returning to work after illness must follow their sector-specific

requirements or policy on test to work/return to work.

Recommendations for Outbreak Prevention and Control in Institutions and Congregate Living Settings

101

Appendix E: Instructions for COVID-19 Cases and Close Contacts Associated with

LTCHs, RHs, and Institutions

Scenario Self-Isolation Period Additional Instructions

LTCH/RH

client/patient/resident

case if able to

independently and

consistently wear a

mask

At least 10 days after the date of

specimen collection or symptom

onset (whichever is

applicable/earlier), and until

symptoms have been improving for

24 hours (or 48 hours if

gastrointestinal symptoms) and no

fever present.

After day 5, if the client/patient/resident is asymptomatic or their symptoms have been improving for

24 hours (or 48 hours if gastrointestinal symptoms) and no fever is present, the resident:

• May routinely participate in communal areas/activities but must wear a well-fitted mask at all times

when outside of their room; and

• May not participate in communal activities where they would need to remove their mask within the

setting (e.g., group dining).

LTCH/RH

client/patient/resident

case if unable to mask

At least 10 days after the date of

specimen collection or symptom

onset (whichever is

applicable/earlier), and until

symptoms have been improving for

24 hours (or 48 hours if

gastrointestinal symptoms) and no

fever present.

Client/patients/residents are able to leave their room for walks in the immediate area with a staff

person wearing appropriate PPE, to support overall physical and mental well-being.

Recommendations for Outbreak Prevention and Control in Institutions and Congregate Living Settings

102

Scenario Self-Isolation Period Additional Instructions

LTCH/RH

client/patient/resident

asymptomatic close

contact

Roommate close contacts: isolate

and place on Additional

Precautions. Individuals who remain

asymptomatic may discontinue

isolation after a minimum of 5 days

of isolation (based on 5 days from

when the case became

symptomatic or tested positive if

asymptomatic).

All other close contacts do not need

to self-isolate if asymptomatic but

should follow Additional

Instructions for risk reduction

measures.

For a total of 7 days after last exposure to the COVID-19 case (or individual with symptoms):

• Daily monitoring for symptoms;

• Wear a well-fitted mask, if tolerated, and physically distance from others as much as possible

when outside of their rooms; and

• Not visit other (unaffected) areas of the home or interact with residents who have not been

exposed.

Non-LTCH/RH

Institution client case

While in the setting: Isolate at least

5 days after the date of specimen

collection or symptom onset

(whichever is applicable/earlier),

and until symptoms have been

improving for 24 hours (or 48 hours

if gastrointestinal symptoms) and no

fever present.

When outside the setting: follow

community guidance.

For a total of 10 days after date of specimen collection or symptom onset (whichever is

earlier/applicable):

• Wear a well-fitted mask, if tolerated, and physically distance from others as much as possible while

in the setting.

Non-LTCH/RH

Institution client

asymptomatic close

contact

Does not need to self-isolate if

asymptomatic.

For a total of 7 days after last exposure to the COVID-19 case (or individual with symptoms):

• Daily monitoring for symptoms; and

• Wear a well-fitted mask, if tolerated, and physically distance from others as much as possible in

common areas of the setting.

Recommendations for Outbreak Prevention and Control in Institutions and Congregate Living Settings

103

Scenario Self-Isolation Period Additional Instructions

LTCH/RH/Institution

staff case

Follow community guidance when

community settings outside of the

LTCH/RH/Institution.

Staff may return to work if they are afebrile and their symptoms have been improving for 24 hours (48

hours if vomiting/diarrhea).

For a total of 10 days after date of specimen collection or symptom onset (whichever is

earlier/applicable), staff should:

• Strictly adhere to workplace measures for reducing risk of transmission (e.g., masking for source

control, not removing their mask unless eating or drinking, distancing from others as much as

possible); and

• Avoid caring for patients/residents at highest risk of severe COVID-19 infection, where possible.

LTCH/RH/Institution

visitor case

Follow community guidance when

community settings outside of the

LTCH/RH/institution.

•

For a total of 10 days after the date of specimen collection or symptom onset, whichever is

earlier/applicable, visitors should avoid non-essential visits to anyone who is immunocompromised

or at higher risk of illness (e.g., seniors) and avoid non-essential visits to highest-risk settings such as

hospitals and long-term care homes.

• Where visits cannot be avoided, visitors should wear a medical mask, maintain physical distancing,

and notify the setting of their recent illness/positive test. If the individual being visited can also

wear a mask, it is recommended they do so.

LTCH/RH/Institution

staff and essential

visitor/caregiver

asymptomatic close

contact

Does not need to self-isolate if

asymptomatic

•

Where feasible, additional workplace measures for individuals who are self-monitoring for 10 days

from last exposure may include:

o Active screening for symptoms ahead of each shift, where possible

o Individuals should not remove their mask when in the presence of other staff to reduce

exposure to co-workers (i.e., not eating meals/drinking in a shared space such as conference

room or lunch room.)

o Working in only one facility, where possible;

o Ensuring well-fitting source control masking for the staff to reduce the risk of transmission

(e.g., a well-fitting medical mask or fit or non-fit tested N95 respirator or KN95).

Recommendations for Outbreak Prevention and Control in Institutions and Congregate Living Settings

104

Appendix F: Summary of Screening Practices for Settings

General Visitors Staff, Students, Volunteers, and

Essential Visitors

Current Residents

What are the

recommended

screening

practices?

•

Provide individuals with information to monitor themselves for

COVID-19 symptoms and inform them they are not permitted to

enter the home if they are feeling ill.

• Signage at entrances and throughout the home listing signs and

symptoms of COVID-19, information on self-monitoring, and steps

that must be taken if COVID-19 is suspected or confirmed.

• All visitors entering the home should adhere to the home’s visitor

policies, where applicable.

•

For LTCHs and RHs: Conduct symptom assessments

of residents as per sector-specific guidance or

legislation to identify if any client/patient/resident has

symptoms of COVID-19. For a list of signs and

symptoms, refer to Appendix 1.

• For other institutions: Clients/residents should be

assessed at least once daily when the client

client/resident is symptomatic, has tested positive for

COVID-19, or is a close contact, in order to monitor

new or worsening symptoms of COVID-19.

• Symptom assessments should include temperature

checks only if the client/patient/resident is

symptomatic, has tested positive for COVID-19, or has

been exposed to COVID-19.

• Residents returning from absence can be screened at

their next daily symptom assessment rather than upon

arrival.

Recommendations for Outbreak Prevention and Control in Institutions and Congregate Living Settings

105

General Visitors

Staff, Students, Volunteers, and

Essential Visitors

Current Residents

What if someone

does not pass

screening (i.e.,

screens positive)?

Visitors who are showing

symptoms of COVID-19 or had

a potential exposure to COVID-

19, and have screened positive

should:

• Not enter the home

• Be advised to follow public

health guidance

Staff who are showing symptoms of

COVID-19 or had a potential

exposure to COVID-19, and have

screened positive should:

• Not enter the home (unless on

early return to work protocols),

• Be advised to follow public health

guidance

Residents with symptoms of COVID-19 (including mild

respiratory and/or atypical symptoms) should be self-

isolated on Additional Precautions and tested.

For a list of signs and symptoms, refer to Appendix 1

Recommendations for Outbreak Prevention and Control in Institutions and

Congregate Living Settings

106

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Congregate Living Settings

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