Ontario 3 Ministry of Health Guidance: School Outbreak Management Version 1 August 26, 2020 This guidance document provides information for local public health units (PHUs) investigating cases, outbreaks and suspected outbreaks associated with elementary or secondary school settings. It is intended to supplement existing public health guidance on the Manadement of Cases and Contacts of in Ontario. In the event of a discrepancy between this Guidance and a Directive of the Chief Medical Officer of Health. the Directive prevails. Please check the Ministry of Health (MOH) Guidance for the Health Sector website regularly for updates to this document, the case definition. reference document for testing guidance, guidance documents. and other related information. Sector specific guidance documents provide additional information about reopening Ontario?s schools, including: Guide to Reopenind Ontario?s Schools This guidance applies to all schools as that term is defined in the Health Protection and Promotion Act (H PPA), which includes private schools and a school as defined by the Education Act. This guidance also supports child care centers within schools. Roles Responsibilities Role of Public Health Unit (PHUs) Prevention and preparedness Advise schools and boards of education (BOE) on prevention (including hierarchy of controls) and preparedness for managing cases, contacts and outbreaks, in conjunction with advice provided through the Ministry of Education (EDU) and Ministry of Health (MOH). 1 Page Ontario 9 Case and contact management Receive, investigate, and manage reports of cases and contacts of including decisions on case and contact management, in accordance with public health guidance on the Management of Cases and Contacts of in Ontario and the HPPA. Consider notifying the school?s principal or designate and the Director of Education or designate if a case of is identified in a staff, student, or essential visitor associated with an elementary or secondary school setting. Have a dedicated communication process to allow for timely notification, which may include, at minimum, a dedicated email address for school reporting. Outbreak assessment and management Investigate clusters of cases associated with school locations, school transportation, in?person attendance or work at a physical school location, before/after school programs located at a school, or other facilities shared with the school). Determine if an outbreak exists and declare an outbreak. Provide guidance and recommendations to the school on outbreak control measures in conjunction with advice provided by EDU and MOH. Provide recommendations on cohort(s) isolation, and the potential need for full or partial school dismissal based on the scope of the outbreak. Make recommendations on who to test, in alignment with the province's broader testing strategy; where recommended, facilitate a coordinated approach to testing, in collaboration with Ontario Health, including provision ofan investigation or outbreak number. Conduct an on?site investigation as part of the outbreak investigation, where necessary, in coordination with the school and board of education (BOE), and other relevant stakeholders Ministry of Labour, Training and Skills Development Issue orders by the medical officer of health or their designate under the HPPA, if necessary. Declare the outbreak over. Surveillance Monitor and assess local epidemiology related to the burden of cases, transmission risks in the local community and absenteeism in schools. Enter cases, outbreaks and school exposures in the provincial surveillance system, in accordance with data entry guidance provided by Public Health Ontario (PHO). Coordination and communication In the event that a case or contact resides in a PHU that is different than that of the school, discussions between the respective should take place to coordinate 2 Page Ontario 9 contact follow?up. 0 The PHU of the school is typically the lead PHU for school follow?up. 0 Request support from the Ministry of Health?s Emergency Operations Centre (MEOC) if coordination between multiple PHUs is required for outbreak management. 0 Notify the MEOC of: 0 Potential for significant media coverage or if media releases are planned by the PHU and/or school. 0 Any orders issued by the medical officer of health or their designate to the school and share a copy. 0 Engage and/or communicate with relevant partners, stakeholders and ministries, as necessary. . Assist the school/BOE with development of key messages and communication tools that can be provided to members of the school community in the event of a case, outbreak, or suspected outbreak. . Coordinate public communications. including media. regarding school outbreaks with the school/BOE partners, and the MOH, as needed. Identifying a spokesperson in each organization should occur prior to an outbreak being publicly declared. Role of Ministry of Health (MOH) 0 Provide legislative and policy oversight to Boards of Health. 0 Issue guidance to PHUs on the management of cases, contacts and outbreaks, and provide clear expectations of roles and responsibilities. 0 Advise on regional and provincial level school interventions. 0 Provide ongoing support to PHUs with partner agencies, ministries, health care professionals, and the public, as necessary. 0 Support PHUs during investigations, through the MEOC and/or Office of the Chief Medical Officer of Health (OCMOH), with respect to coordination, policy interpretation, communications, etc., if requested. . Support and coordinate teleconferences if needed if multiple PHUs are involved) via the MEOC. . Receive notification through the MEOC: If the PHU believes there is potential for significant media coverage or if media releases are planned by the PHU and/or school. 0 If orders are issued by the medical officer of health or their designate to the school. 3 Page Ontario 9 Role of Ontario Health Coordinate local planning among health system partners for testing to ensure the availability of testing resources. Deploy testing resources and modalities to meet the testing needs identified by the PHU. Collaborate with PHU, school boards and schools to monitor testing demands and access. Work with testing centres to optimize sample collection and distribution to reduce turnaround times. Role of Public Health Ontario (PHO) Provide scientific and technical advice to the PHU to support case and contact management, outbreak investigations, and data entry. Advise on and support laboratory testing as needed. Provide scientific and technical support to MOH and PHUs, including during multi? jurisdictional teleconferences. Produce provincial epidemiological and surveillance reports related to in schools to support public health units and provincial ministries. Role of Ministry of Education (EDU) Provide legislative and policy oversight to BOEs. Communicate expectations and provincial level guidance on related policies. measures and practices for schools to BOEs. Ensure that BOEs are aware of their duties as employers under the Occupational Health and Safety Act (OHSA) and its regulations, including to report occupational illness to the Provide ongoing support and communication to BOEs with partner agencies, ministries, and the public, as necessary. Support the procurement of supplies of personal protective equipment (PPE). Role of School Administrators and Boards of Education All schools are required to report a communicable disease to their local PHU, as per 3.28 of the HPPA. Employers have a general duty under OHSA to take every precaution reasonable in the circumstances for the protection of a worker, including in respect of infectious disease. Under OHSA, an employer must provide written notice to within four days of being advised that a worker has an occupational illness and must report to WSIB within 72 hours of receiving notification of said illness. 4 Page Ontario 9 Implement prevention measures found in guidance or as directed by the EDU, MOH, and their local PHU. Coordinate with the local PHU and other stakeholders as appropriate, as part of the investigation of cases, contacts, and outbreaks. Maintain accurate records of staff and students? attendance, for all common school locations attended by staff and students school transportation, in?person attendance or work at a physical school location, before/after school programs located at a school, or other facilities shared with the school) for the last 30 days, as well as up to date contact information for staff and students. This information should be available to be accessed and shared with the local PHU in a timely manner (within 24 hours) for investigations and communications. 0 Facilitate access for PHUs to staff lists for staff not directly employed by the school board transportation staff, before/ after school program staff). Keep a log ofall visitors essential volunteers, contractors, parents/guardians, etc.) who enter the school, location(s) visited and dates/times of visit to facilitate contact follow?up if needed. Provide PHU with the name(s) and contact information of a designated point of contact for use during and/or after business hours, to ensure timely investigation and follow up cases, contacts and outbreaks. In collaboration with the PHU, communicate proactively with the school community about prevention measures and about how ill individuals, cases, and outbreaks will be handled. . Develop a communication plan, in collaboration with the local PHU, for managing concerns in the school setting, and use this proactively and responsively as needed in schools. Provide training to school staff with respect to outbreak prevention and control measures, including infection prevention and control (IPAC) measures and the use of personal protective equipment (PPE). Role of Ministry of Labour, Training and Skills Development (M LTSD) Develops, coordinates and implements strategies to prevent workplace injuries and illnesses and set standards for health and safety training. Proactively inspects workplaces to monitor compliance with the OHSA and its regulations. investigates occupational illness notifications under ss. 52(2) of the OHSA to determine if the employer is in compliance with the Act and that appropriate measures have been taken to prevent further illnesses. Investigate unsafe work practices, critical injuries, fatalities, work refusals and occupational illness, all as related to worker health and safety. This includes investigation of reports of by employers to 5 Page Ontario 3 0 Issue orders under the OHSA. Operates the Health and Safety Contact Centre (1?877?202?0008). available for anyone to report health and safety concerns. complaints or to provide notices of occupational illnesses. While this document focuses in part on the role of the health and safety program. the ministry also administers the Employment Standards Act. If workplace parties request information regarding employment standards, they can be referred to the Employment Standards Information Centre: 1?800?531? 5551. Local PHU Role in Managing Ill Individuals in the School Setting Ensuring schools have appropriate public health and infection prevention and control resources: . Ensure local school administrators and staff are aware of public health resources to enable them to safely manage individuals students, staff, and essential visitors) with signs or of in the school setting. 0 Examples of resources include: How to Wash Your hands Fact Sheet on Self?Isolation Self?Isolation: Guide for Caregivers, Household Members and Close Contacts How to put on and take off PPE videos Putting on and taking off PPE (poster) Non?medical masks and face coverind Environmental Cleaning in non?health care settings You were tested for what you should know Direct PHU involvement, in select circumstances: 0 In general. schools should not report all instances of ill individuals in the school setting to the PHU as these are frequent occurrences and typically students have non?specific 0 However, Section 28 of the HPPA outlines the responsibility of school principals to report to the medical officer of health of the health unit in which the school is located if they are of the opinion that a pupil has or may have a communicable disease. 0 Where there is sufficient concern that an individual may have school is informed by a parent/guardian that a student has been diagnosed with 6 Page Ontario 9 or informed by a staff that they have been diagnosed with or there are concerns about multiple ill individuals in a cohort. the school should report this to the PHU. or follow pre?established protocols from the local PHU. The PHU should provide advice to the school regarding identification of potential contacts staff and/or students in contact with the individual or in the 48 hours prior to onset) based on when the student attended school, the cohort(s) the student is a part of and other contacts based on the activity of the student. Management of a single ill individual known to the PHU, when test results are pending Note: PHUs do not need to be noti?ed of every ill student/staff; there are some instances they may become aware of ill persons with pending results, such as through investigations of cases and clusters of illness. 0 If PHUs are aware of an ill individual student/staff at a school) with test results pending: 0 Ensure that ill individual knows to self?isolate while testing is pending and when to seek further assessment or medical care as needed. 0 Where the risk (as determined by the PHU) of the person being a positive 19 case is not low (such as an individual who has a known exposure with a case during their infectious period). the PHU should ensure the school is collecting/preparing information on the cohorts and contacts of the ill individual, for sharing with the PHU. if required. to facilitate timely follow up. - Self?isolation and testing of contacts in the school of an ill individual pending test results is not generally recommended. - However, household contacts (roommates and family that live with the ill individual) should self?isolate as per the Ontario Self?Assessment Tool. Management of return to school for ill individuals who test negative or who are not tested . Staff and students with compatible with should be directed to get tested. In some circumstances, special efforts may be needed to facilitate access to testing to meet the needs of some staff or students/families. 0 Medical notes or proof of negative tests should not be required for staff or students to return to school. 7 Page Ontario 9 Management of ill individuals with a negative test: 0 If self?isolating after a high?risk exposure close contact of a known case or travel out of country): - Return to school only at end of their full 14?day self?isolation period. as they may be incubating up until then. 0 If no known high?risk exposure and not advised by the PHU or health care provider to self?isolate: - Return to school when are resolved for at least 24 hours. 0 Note: Mild known to persist in young children runny nose) may be ongoing at time of return to school if other have been resolved and there is a negative test. 0 If compatible with are persisting/worsening. advise to continue to stay home from school/work and seek medical attention; consider repeat testing. Management of ill individual with no laboratory test result: 0 If self?isolating after a high?risk exposure close contact of a known case or travel out of country): - This individual meets case definition for a Probable Case. Manage as per public health case and contact management guidance. Return to school is based on clearance from isolation. If the ill individual does not meet Probable case de?nition: - If there is a known alternative diagnosis provided by a health care provider. return to school can occur when are resolved for at least 24 hours. - If there is no known alternative diagnosis. and the ill individual has compatible with being recommended for testing for the individual should self?isolate from onset based on guidance on clearance from isolation. - Ifthere is no known alternative diagnosis. and the ill individual was NOT recommended for testing for by a health care provider. the individual may return to school when are resolved for at least 24 hours. - Self?isolation and testing of non?household contacts of an ill individual without a confirmed positive result is not generally recommended. However. household contacts (roommates and family that live with the ill individual) should self?isolate as per the Ontario Self?Assessment Tool. 8 Page Ontario 3 Management of Positive Case(s), Contacts, and Outbreaks Refer to Manadement of Cases and Contacts of in Ontario as the primary source of case and contact management guidance. This guidance document provides school? specific advice on the management of cases, contacts and outbreaks. Case Acquisition Assessment Ensure relevant acquisition exposures in the 14 days prior to onset (or 14 days prior to positive specimen collection date if never are captured for cases in accordance with PHO data entry guidance, including: Family exposures School School transportation School before/ after school programs School extra?curricular activities 0000 Other potential acquisition exposures outside of school (in the community), including work exposures. It is important to determine if the student or staff member likely acquired their infection outside of the school. For example, if a parent of a student or partner of staff with a known occupational exposure is believed to be the source of infection to the student or staff member, this will influence the management of the case in the school. Contact Assessment Management of Case(s) in the School PHUs will need to work closely with the school, to determine who a case was in contact with in the school environment during their period of communicability. Schools should be able to produce information regarding the students and staff members in the case?s cohort(s) classroom, bus, before/after school programs, extra?curricular activities); those in the case?s cohort(s) would usually be considered close contacts of a case. 0 This information should include up?to?date attendance records and contact information for those groups and should be provided to the PHU within 24 hours to ensure timely follow?up. 0 Records should be kept for 30 days. Information on any other contacts (low?risk contacts) that a case may have in the school or school transportation environment, should also be made available (if known), in case they are needed. 9 Page Ontario 3 Table 1 provides a general approach to case, contact, cohort and outbreak management when there are one or more cases in the school. Table 1: Approach to case, contact, cohort, and outbreak management, including school closures, when there is one or more cases in the school Management of (a) Case(s) in a School Row Acquisition When was # source of case case in the school? 1 Known Case was in acquisition for school during case was their period of outside of communicabili school (e.g., ty. case was infected by their parent who had a known occupational exposure) Public health actions regarding the school • Dismiss case’s cohort(s) for self-isolation (e.g., classroom, bus, extracurricular activities, before/after school programs attended by the case) Note: There may be some exceptions to these recommendations on a case-bycase basis as determined by the PHU. For example, if the case was known to have acquired their infection outside of the school and had very short or limited contact with the school while infectious, the PHU may decide on more limited dismissal. • • • In some instances, the PHU may decide to do a further risk assessment of the cohort to determine if there may be members of the cohort, who could be classified as low-risk contacts, based on time spent together, proximity of individuals to the case, or if PPE was used. Given physical distancing may not be maintained in cohorts and timeliness, this may not be feasible or required for the majority of cases. Individual risk assessments within a cohort could also result in those in the cohort(s) being able to identify the case. Dismiss for self-isolation any additional persons not part of the case’s cohorts, who have been identified as having highrisk exposures to the case when the case was infectious, including siblings. Test those who have been dismissed as soon as possible. Note: Consideration can be given to swabbing 5-7 days after last exposure to the case, to minimize risk of false negatives and need for repeat testing in children, but may not be feasible due to timing of notification or logistics of testing. • • • Self-isolation period will be 14-days from last exposure to the case (unless the contact becomes a case, which would extend the isolation period in accordance with guidance on clearance from isolation). Monitor closely for other symptomatic persons in the school (in addition to those from the case’s cohort, who are selfisolating). Further actions may be required if secondary cases are identified among those who have been dismissed (see row 3, 2 No known acquisition source for case outside of school or acquisition likely to have been from school Case was in school during their incubation period and may also have been there during the period of communicabili ty • • • • • • 4 and 5) or there are other additional cases identified in the school (see row 2, 4 and 5) Dismiss case’s cohort(s) for self-isolation (e.g., classroom, bus, extracurricular activities, before/after school programs attended by the case) Dismiss for self-isolation any additional persons not part of the case’s cohorts, who have been identified as having highrisk exposures to the case when the case was infectious, including siblings. Test those who were sent home as soon as possible; if negative, retest if symptoms develop Self-isolation period will be at least 14-days from their last exposure to the cohort (or to the case for those who were identified as close contacts, but not part of the case’s cohort(s)). Monitor closely for other symptomatic persons in the school and discuss these with the PHU. Further action may be required if secondary cases identified among those who have been dismissed (see ‘Management if Secondary Cases identified from a Known Case’ row 3, 4 and 5) or other additional cases identified in the school (see row 2, 4 and 5) Management if Secondary Cases Identified from a Known Case 3 • Manage the secondary case as outlined in row 2 (this may or may not require additional cohorts to be dismissed and tested), including dismissal of affected cohorts and any additional high-risk contacts from the secondary cases • • • • Note: There may be some exceptions to these recommendations on a case-by-case basis as determined by the PHU. For example: 1) If the initial case was known to have acquired their infection outside of the school and the only secondary case was a close friend with contact outside as well as at school, the PHU may decide on more limited dismissal; 2) If the initial case was rapidly identified and the secondary case(s) had already been dismissed when they were likely to have been infectious, the PHU may decide on more limited dismissal. Recommend testing for all dismissed students as soon as possible after dismissal, recognizing that in many scenarios a few days will have already passed since exposure. Return to school for cohorts and contacts directed to self-isolate and/or be tested will be determined by the PHU depending on if/when additional cases are identified. Declare an outbreak (see row 4) and consider school closure (see row 5). Outbreaks 4 Outbreak definition: • An outbreak in a school is defined as two or more lab-confirmed COVID-19 cases in students and/or staff (or other visitors) in a school with an epidemiological link, within a 14-day period, where at least one case could have reasonably acquired their infection* in the school (including transportation and before/after school care). *Examples of reasonably having acquired infection in school include: • No obvious source of infection outside of the school setting; OR • Known exposure in the school setting Declare the outbreak over: • At least 14 days have passed with no evidence of ongoing transmission that could reasonably be related to exposures in the school; AND • No further ill individuals associated with the initial exposed cohorts with tests pending; Whole School Dismissal 5 • Whole school dismissal should be considered if: o There is evidence of potential widespread transmission within the school. Examples may include: o A number of cases in students, staff or essential visitors with no known source of acquisition outside of the school and no obvious epidemiologic links within the school. Dismissal would allow for break in contact and testing for students, staff, and essential visitors as part of case finding; OR o Many cohorts have been dismissed based on management of cases and secondary cases (as outlined in rows 1, 2, 3). • Testing when the school is dismissed: o If a school is dismissed due to widespread transmission, consideration can be given to recommending all school attendees be tested, as part of case finding, particularly if epidemiological links between cases cannot be established and there is evidence of transmission beyond contacts in a case’s cohort(s) o Given the large volume of testing this includes, coordination with Ontario Health Region will be needed to plan broader testing and ensure timey access and accessibility of testing options • Re-opening the school: o The outbreak does not necessarily need to be over to re-open the school. Cohorts without evidence of transmission can be gradually brought back to school as additional information and test results become available. Consideration should be given to implementing additional preventive measures and active surveillance as part of reopening. Note: Consideration may be given to allowing asymptomatic students in an unexposed cohort with special education needs to continue to come to school under strict precautions if allowed daily attendance. • Ontario 9 For assessment of staff to staff interactions or exposure to essential visitors contractors) and/or volunteers at school. refer to the most recent version of the Management of Cases and Contacts of in Ontario. 0 Staff who ONLY provided care/ interacted with a case while they (staff) consistently and appropriately used a surgical/procedure mask and protection are considered low risk and do not require 14?day isolation or testing. 0 No 14?day self?isolation or testing would be required for the cohort (or school) if acquisition for a case was known to have occurred outside the school and the student or staff never attended that cohort (or school) while communicable. Any additional close contacts of the case (outside of school) will also be identified and advised to self?isolate according to the Public Health Management of Cases and Contacts of in Ontario. . There may be situations when the PHU recommends more expansive testing. Testing: 0 The PHU may, in collaboration with the Ontario Health Region. help facilitate a coordinated approach to testing including provision of an investigation or outbreak number, requisitions and possibly testing opportunities on?site at the school. Advise anyone associated with the school who requires testing to use that requisition so that they are captured under that number. 0 Testing is voluntary. contacts with epidemiological links to a case or dismissed cohort should be strongly encouraged to get tested. and managed as Probable cases if testing does not occur. 0 A negative test does not reduce the 14?day self?isolation period from last exposure for those self?isolating. 0 Contacts should be re?tested if they develop compatible with 19 during self?isolation. Mechanisms should be established to ensure that the PHU is aware of all possible cases and positive laboratory results; PHUs are not responsible for tracking of negative results. Where a case has siblings/other household members who also attend the school (or another school or child care centre), the household member(s) must self? isolate and be recommended to be tested as a close (high?risk of exposure) contact. If the sibling/household member of the case tests positive or becomes a Probable case), follow?up of their cohort(s) and expanded contacts are required based on row 1. 14 Page Ontario 9 Outbreak Considerations (related to rows 4 and 5) Outbreaks may be identified based on: . Identification of a case or cases associated with a school, including in students, staff, essential visitors or volunteer. 0 Complaints of illness, associated with a school, from staff, students or parents/guardians (based on illness in the student/staff member or the student's/ staff member?s household) . Request for assistance from a school Application of Outbreak Measures 0 Outbreak measures may be scaled up/down based on the transmission risk and outbreak epidemiology in the school and the assessment of outbreak control measures, from dismissal of a single cohort through to consideration of school closures. Outbreak measures, particularly if the school remains open, may include: 0 OO Outbreak signage at entrances and affected area. Informing outside agencies that use the school/daycare of the outbreak; Only allowing essential visitors into the school. Further minimizing the movement of staff between cohorts. Limiting student activities to their required cohorts and discontinuing extra? curricular activities, as much as possible. Restricting all staff (including school, transportation, staff from home care agencies or others that provide medical services to those in school) from working in other schools. For social setting outside of the school recommend to staff, students and their families adherence to the social bubble (size based on current provincial recommendations). Reinforce masking of students for source control based on requirements for their age, mask and protection for staff members, hand hygiene for all, and maintaining physical distancing. Review the daily screening process for all staff/essential visitors and students and enhance if needed. Review of environmental cleaning and disinfection, and enhanced cleaning and disinfection for the outbreak area(s). Ensure families, including of any new child enrolments are aware of the outbreak. Enforce any orders issued by the medical officer of health or their designate under the HPPA, if necessary. 0 Return to school of cohorts deemed by the PHU to not be affected or not at high?risk of exposure, and who do not need to self?isolate may occur prior to the end of the 15 Page Ontario 9 outbreak if supported by the epidemiological investigation of the outbreak and implementation of follow up measures in the school, as recommended by the PHU. Occupational Health Safety Infection prevention and control 0 To minimize the risk of passing on novel coronavirus 2019 at work. employers should: 0 0 screen all individuals entering the workplace school). support workers with to self?isolate. take steps to support all individuals to maintain maximum physical distance. ensure proper environmental cleaning and disinfection of surfaces and objects. support hand hygiene. particularly handwashing. provide reminders about good cough and sneeze etiquette and to avoid touching their face. support or ensure the correct and consistent use of masks for source control or PPE, as appropriate. work with the local PHU if any workers have or are exposed to someone with 0 Where it is not possible to use other control measures to sufficiently reduce a worker's risk of exposure, personal protective equipment (PPE) will be needed. 0 Personal protective equipment (PPE) should be used in combination with other controls. 0 It is important that any PPE workers use is appropriate for the purpose. Where PPE for is needed it will likely consist of a surgical or procedure mask and protection (face shield or goggles) The effectiveness of PPE depends on the worker wearing it correctly and consistently. The employer must train workers on the care. use and limitations of any PPE that they use. Reporting staff illness Workers who are unwell should not attend at a workplace. They should report their illness?related absence to their supervisor or employer. In accordance with the Occupational Health and Safety Act 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 16 Page Ontario 9 worker with respect to an occupational illness. the employer must provide written notice within four days to: A Director appointed under the OHSA of the Ministry of Labour, Training and Skills Development: 0 The workplace?sjoint health and safety committee (or a health and safety representative): and The worker?s trade union, if any This may include providing notice for an infection that is acquired in the workplace. 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 Ministry of Labour, Training and Skills Development: 0 Employment Standards Information Centre: Toll?free: 1?800?531?5551 0 Health and Safety Contact Centre: Toll?free: 1?877?202?0008 For more information from the Workplace Safety and Insurance Board. please refer to thefoUomnng: 0 Telephone: 416?344?1000 or Toll?free: 1?800?387?0750 17 Page