AGEOutbreakGuidance

Guidance for Prevention of Acute Gastroenteritis (AGE) Outbreaks in Daycare Facilities and Schools

Source: Illinois Department of Public Health 12/20/2011 Memorandum

This guidance supersedes the previously issued “Guidance for Prevention of Norovirus Outbreaks in Daycare Facilities and Schools,” posted on November 17, 2010 in the intranet Communicable Disease Updates page.

The Illinois Department of Public Health Communicable Disease Control Section (CDCS) defines an AGE outbreak in a school or day care setting as a cluster of four or more persons with acute-onset of vomiting and/or diarrhea in a classroom or in an otherwise defined group of students; or cases in more than 10% of the school’s/daycare’s census in a single day. This definition differs from that of most other outbreaks; including viral AGE outbreaks in long-term care facilities or other locations where people gather such as restaurants, banquet halls etc.

Norovirus, formerly called Norwalk-like virus, is part of the Calicivirus family which is the most common virus that causes AGE in humans. Aside from acute onset of vomiting or diarrhea, other symptoms include nausea, abdominal cramps, low-grade fever, and body aches. Norovirus is very contagious, and humans are the only known reservoir. The virus can be spread through food, water, or by person-to-person transmission. The virus has an incubation period of 12-48 hours and symptoms typically resolve in 1- 3 days even without treatment. Norovirus outbreaks are common in schools and daycare facilities particularly in fall or winter months.

The following recommendations are key steps in investigation and response to AGE outbreaks in daycare facilities and schools from the Centers for Disease Control and Prevention (CDC) 2011:

1. Daycare facilities and schools are required to report all confirmed or suspected outbreaks of acute gastroenteritis to the local health department as soon as possible.

2. Initiate investigation promptly to help identify predominant mode of transmission and possible source.

It is recommended that schools and daycares maintain a daily log of the number of students and teachers absent due to AGE illness. A line list is available to log reports of absenteeism due to AGE illness.

3. Promote hand hygiene: good hand hygiene is the best way to prevent transmission of AGE.

Hands should be washed with warm water and soap for a minimum of 20 seconds.
Children should be taught good hand hygiene practices, and should wash their hands after using the bathroom and before eating.
Staff, especially staff responsible for caring for diapered children, should wash their hands frequently and particularly prior to contact with any diapered child.

4. During outbreaks, washing hands with soap and warm water is preferable to using alcohol-based hand sanitizers. Alcohol-based hand sanitizers should only be used when washing with soap and warm water is not possible but not as a substitute to soap and warm water hand washing.

5. Exclusion

Children and staff who are experiencing symptoms of AG should stay home from school or daycare until 24 hours after symptoms have stopped.
Staff involved in food preparation should be restricted from preparing food for 48 hours after symptoms stop. The staff may perform other duties not associated with food preparation 24 hours after symptoms have stopped until the 48-hour restriction for food preparation activities has ended.

6. Reinforce effective preventive controls and employee practices (e.g., elimination of bare-hand contact with ready-to-eat foods and proper cleaning and sanitizing of equipment and surfaces).

7. If a vomit or fecal spillage occurs, the area should be sanitized with an Environmental Protection Agency-approved disinfectant or a freshly prepared sodium hypochlorite solution. The hypochlorite (bleach) solution should be a 1:50 dilution; mix 1/3 cup bleach with 1 gallon water. For heavily soiled surfaces, use a dilution of 1:10, or 1 2/3 cup bleach to one gallon of water. Allow the solution to be in contact with the surface for 10-20 minutes or until it has air dried. Materials that may be put in children’s mouths (e.g. toys) should be rinsed. For porous surfaces such as upholstered furniture, carpets or clothing, clean visible debris with an absorbent, double-layer material. Steam clean or wash the contaminated surface at 158° F for 5 minutes or 212° F for 1 minute. Custodial staff should wear masks and gloves when cleaning areas contaminated by feces or vomitus. Throw away all disposable materials in sealed bags.

8. Bathrooms and other communal spaces should be cleaned more frequently during suspected Norovirus outbreaks. Frequently touched surfaces, such as door handles, classroom materials, and computer mice, should be disinfected with an approved product. For Day Care Centers, toys should be cleaned as often as possible. If a toy is not able to be cleaned by routine methods they should be put away during the course of the outbreak. Also toys which may fit in a child’s mouth should be put away during the course of the outbreak.

9. Facilities serving or sharing food should take these extra precautions:

Restrict sharing of foods brought from private homes.
Restrict students’ sharing of any communal food items in classrooms. Instead, the teacher should hand out items to be shared after washing his/her hands.
Stop using self-service food bars. Do not let children serve themselves in any manner which might promote direct hand contact with shared foods.

10. Assist the local health department in collecting whole stool specimens from at least two and no more than five persons during the acute phase of the illness (preferably <=72 hours from onset). The specimens can be submitted to a commercial laboratory for Norovirus testing or may be submitted to the IDPH lab assigned to test Norovirus in your area. Specimens should be collected in a clean container and shipped on cold packs. The specimen does not need to be frozen. Specimens should be kept cold and should not be sent to arrive on Fridays, weekends, or holidays. The facilities should assist in the completion and submission of a final report form no more than 30 days after the last onset of illness.