Guidance

Managing flu, COVID-19 and other acute respiratory infections (ARI) in prisons and other prescribed places of detention (PPDs)

Updated 25 March 2024

Applies to England

Main messages

This guidance covers influenza (flu), COVID-19 and other acute respiratory infections (ARIs) across adult prisons and places of prescribed detention (PPDs). It is drawn upon the best available evidence and experience base and is intended as a basis for consistent practice nationally, while also accounting for local resources and needs.

The main actions and recommendations within this guidance are to:

• offer all eligible residents flu and COVID-19 vaccinations
• encourage all eligible staff to get flu and COVID-19 vaccinations
• follow the guidance for people with symptoms of a respiratory infection including COVID-19 if prisoners, detainees and staff have symptoms of ARI and a high temperature or do not feel well
• if an outbreak is not suspected, but individuals have symptoms of ARI, only test for COVID-19 if the symptomatic individual is eligible for COVID-19 treatments
• if an outbreak is suspected, contact the health protection team (HPT), who will advise on the use of multiplex polymerase chain reaction (PCR) to test up to 5 linked cases with most recent symptom onset
• confirmed cases of flu or COVID-19 should avoid contact with other people
• consider the wider impacts on prisoners/detainees, staff, and the setting when recommending outbreak control measures

There is separate guidance for preventing and managing outbreaks of ARI in the children and young people’s secure estate.

What has changed

This guidance has been updated in line with changes to testing policy from 1 April 2024. During a suspected outbreak of ARI, settings can access multiplex PCR tests through their local HPT to help identify the infection responsible.

Who this guidance is for

This guidance provides operational recommendations to assist residential and healthcare staff, commissioners and providers in the adult estate, and UK Health Security Agency (UKHSA) HPTs.

This guidance describes measures to prevent and manage cases and outbreaks of ARI in these settings. Operational practices may vary due to setting specific considerations.

NHS commissioned services should also refer to the NHS England National infection prevention and control manual (NIPCM) for England.

Background

PPDs are considered higher risk for transmission of ARI and poor outcomes for the following reasons:

• large numbers of people live close together with high degrees of social mixing
• the population is constantly changing with new receptions (people coming into the PPD), releases and transfers
• people in PPDs have a higher prevalence of chronic respiratory disease (including asthma), immunosuppression (for example, due to HIV infection) and other chronic illnesses (such as cardiovascular disease, diabetes, or liver disease) than their peers in the community

Most people with ARI will have a relatively mild illness, especially if they have been vaccinated. However, the risk of serious illness from flu and COVID-19 is higher among:

• people with underlying health conditions (such as respiratory disease, diabetes, cardiac disease, or immunosuppression)
• older people
• those who are pregnant
• babies under 6 months of age
• those whose immune system means they are at higher risk of serious illness

People in prisons and other places of detention should receive healthcare equivalent to people in the community. This includes access to flu and COVID-19 vaccination and treatments in line with guidance published by the National Institute for Health and Care Excellence (NICE), UKHSA and NHS England commissioning policies.

As well as the clinical and public health considerations, minimising the impact of ARI outbreaks on the operational effectiveness of PPDs is essential to preserving a fully functional criminal justice and immigration removal system.

To reduce the impact of ARIs in prisons there should be a whole-setting approach, including prevention, early identification and notification, and timely access to treatment and prophylaxis (where applicable).

Definitions

Acute respiratory infections

The term ARI includes presentations both of influenza-like illness (ILI) and other acute viral respiratory infections.

Causes of ARI include SARS-CoV-2, the virus that causes coronavirus disease (COVID-19), influenza virus, respiratory syncytial virus (RSV), adenovirus, rhinovirus, parainfluenza and human metapneumovirus (hMPV).

Influenza-like-illness

Influenza-like illness (ILI), which can be caused by a variety of infectious agents, is a clinical diagnosis made on the basis of symptoms. The UKHSA definition of ILI is:
(i) oral or ear temperature ≥37.8C

and

(ii) one of the following:

• acute onset of at least one of the following acute respiratory symptoms: cough (with or without sputum), hoarseness, nasal discharge or congestion, shortness of breath, sore throat, wheezing, sneezing

or

• an acute deterioration in physical or mental ability without other known cause

Outbreak of acute respiratory infections

An outbreak of ARI is defined as 2 or more epidemiologically linked cases within 5 days.

As most symptomatic COVID-19 testing has been removed, an outbreak may be suspected when there is an increase in the number of staff and/or prisoners/detainees displaying symptoms of ARI at the same time who are linked by personal contact.

Flu and COVID-19 vaccination

Vaccination helps to prevent serious illness associated with flu and COVID-19.

Information and resources, including relating to ordering, prescribing and delivering vaccines can be found at:

• annual flu programme
• COVID-19 booster
• Green Book

The annual flu and COVID-19 booster vaccinations can be given safely at the same time.

It is vital that healthcare staff not only protect themselves against flu and COVID-19 but recognise the importance of vaccination as part of infection prevention and control and protecting the prisoners or detainees in their care.

Vaccination for prisoners and detainees

Healthcare teams should offer the annual flu and COVID-19 booster vaccinations to eligible prisoners and detainees. Eligible prisoners and detainees should be encouraged to take up the offer and should be supported to access the vaccinations to protect themselves.

Healthcare providers should maximise opportunities to co-promote and co-administer vaccinations where possible and where clinically advised (for example COVID-19, flu and pneumococcal vaccination), especially where this improves patient experience and uptake. However, co-administration should not unduly delay administration of any vaccine.

Vaccination for healthcare and custodial staff

All establishments’ local outbreak plans should include clear information on how all appropriate healthcare and custodial staff groups can access flu and COVID-19 vaccinations, and how the employer will facilitate uptake.

Employers should encourage all staff to take up offers of flu and COVID-19 vaccination to protect themselves, their families and those they care for from severe illness.

Flu vaccination for HMPPS staff

His Majesty’s Prison and Probation Service (HMPPS) offers an e-voucher scheme for flu vaccines or onsite flu clinics in public sector prisons for all HMPPS staff aged 18 to 64. Through the e-voucher scheme, HMPPS employees can book their flu vaccine at another outlet if required.

HMPPS staff aged 65 and over have access to the flu vaccine for free via the NHS flu vaccine scheme.

Flu vaccination for other staff

Private-sector PPDs should offer the annual flu vaccine to all custodial staff as part of their occupational health provision.

Sub-contracted employees and volunteers within PPDs should be encouraged to contact their own occupational services to find out how to access flu vaccinations.

COVID-19 vaccination for all staff

PPD staff who meet the national NHS eligibility criteria can access COVID-19 vaccination in the community via local vaccination services.

Recognising and responding to cases of acute respiratory infections

All staff should be aware of the symptoms of ARIs and should be advised to quickly report suspected cases to healthcare.

Custodial staff often have the most contact with prisoners and detainees, so are well-placed to recognise symptoms among those in their care. Clinical advice should be sought from the healthcare team if the person is unwell or has a high temperature.

Symptoms of acute respiratory infections

For up-to-date information on the symptoms of respiratory infections, including COVID-19, flu, and other common ARIs, please refer to people with symptoms of a respiratory infection including COVID-19. These symptoms include:

• continuous cough
• high temperature, fever or chills
• loss of, or change in, the normal sense of taste or smell
• shortness of breath
• unexplained tiredness, lack of energy
• muscle aches or pains that are not due to exercise
• not wanting to eat or not feeling hungry
• headache that is unusual or longer lasting than usual
• sore throat, stuffy or runny nose
• diarrhoea, feeling sick or being sick

Management of cases of acute respiratory infections

Staff, prisoners and detainees should be alert for signs and symptoms of ARI and know how to report these if they become unwell or develop a high temperature.

Prisoners, detainees and staff with symptoms of ARI  and a high temperature or who do not feel well should follow the guidance for people with symptoms of a respiratory infection including COVID-19.

It is particularly important that people with a high temperature or feeling unwell with symptoms of ARI try to avoid close contact with anyone at higher risk of becoming seriously unwell, especially individuals who have weakened immune systems which means that they are at higher risk of serious illness.

If prisoners, detainees or staff are unable to avoid contact with other people while they have a high temperature or are feeling unwell and have ARI symptoms, there are actions that will reduce the chance of passing on the infection to others. These include:

• wearing a well-fitting face covering made with multiple layers, or a surgical face mask
• covering mouth and nose when coughing or sneezing
• washing hands frequently with soap and water for 20 seconds, or using hand sanitiser, after coughing, sneezing and blowing their nose and before eating or handling food
• avoiding touching their face
• limiting prisoners and detainees working in essential services, or anywhere that is enclosed or poorly ventilated

Measures should be in place for transportation to reduce the risk of the infection spreading.

If prisoners or detainees with symptoms of an ARI also have a high temperature or do not feel well enough to carry out normal activities, they should try to stay in their room and avoid contact with other people. They can return to usual activities when they no longer have a high temperature (if they had one) or when they no longer feel unwell.

Staff who have a high temperature or feel unwell and have symptoms of an ARI should try to stay at home, avoid contact with other people and report the absence to their employer. They can return to work when they no longer have a high temperature (if they had one) or when they no longer feel unwell.

More information on how to limit the spread of ARIs in PPDs is provided in the section on limiting the spread of ARI below.

Healthcare staff employed by the NHS or other healthcare providers should follow guidance on managing healthcare staff with symptoms of a respiratory infection, including COVID-19.

Staff should be mindful of the potential for the infection to spread and for an outbreak to start.

Testing to identify the cause of infection

Testing for COVID-19 and flu is only recommended if it is required for clinical management (for example a prisoner/detainee is symptomatic and eligible for COVID-19 treatment), or if there is an outbreak. If an outbreak is suspected, contact the local HPT who will conduct a risk assessment. The HPT will advise on the use of multiplex PCR to test up to 5 linked cases with most recent symptom onset (see the section on testing to identify the cause of infection in an outbreak for more information).

Prisoners or detainees eligible for COVID-19 treatments

Prisoners or detainees who are eligible for COVID-19 treatments should have access to NHS COVID-19 testing, for use if they are symptomatic.

If a prisoner or detainee is experiencing COVID-19 symptoms (even if the symptoms are mild) and is eligible for COVID-19 treatments, they should take a lateral flow device (LFD) test immediately. If the result is positive the healthcare service should follow the guidance on COVID-19 treatments. They should also follow the guidance for people with a positive COVID-19 test result, found below.

If all of the individual’s LFD test results are negative, they can return to their usual activities once they are well enough to do so, and they do not have a high temperature. If there are concerns about someone’s health, they should undergo clinical assessment.

Management of prisoners, detainees and staff with a positive test result for COVID-19 or flu

All PPDs should have a plan in place to identify appropriate facilities where prisoners and detainees who have tested positive for flu, COVID-19 or another ARI can be supported to isolate appropriately.

Confirmed cases of flu and COVID-19 should avoid contact with other people. Where possible, prisoners and detainees with confirmed flu or COVID-19 should be supported to isolate in single occupancy accommodation. See the cohorting cases section for guidance about cohorting in an outbreak.

Prisoners and detainees who are isolating away from others should have regular opportunities to discuss their wellbeing and any anxieties with a member of staff.

Testing residents to decide whether to end isolation is no longer required for symptomatic or confirmed COVID-19 cases.

If the health of a prisoner or detainee is worsening, of if they remain unwell after 10 days or longer, the PPD should arrange for the prisoner or detainee to get medical advice.

Duration of isolation (prisoners, detainees and non-healthcare staff)

Confirmed cases of flu should continue to isolate until their symptoms resolve (usually 3 to 5 days from onset but may be longer in people with underlying medical conditions).

Confirmed cases of COVID-19 should isolate for 5 days after the day the test was taken. They can return to normal activities after 5 days if they feel well enough and no longer have a high temperature.

Healthcare staff cases

Healthcare staff employed by the NHS or other healthcare providers who have tested positive for COVID-19 should follow guidance on managing healthcare staff with symptoms of a respiratory infection, including COVID-19.

Reporting COVID-19 test results

Under Regulation 4A of The Health Protection (Notification) Regulations 2010, PPDs are still required to report positive, negative and void LFD test results where they have assisted prisoners or detainees to take an LFD.

To support PPDs in being able to meet their Regulation 4A duty, the UKHSA multiple registration spreadsheet will remain available for PPDs to report COVID-19 LFD test results. PPDs are still able to use this route to report the result of LFD tests that have not been provided to the PPD directly by UKHSA.

It is important to note that the registration of a positive COVID-19 LFD test result will not lead to a COVID-19 treatment being prescribed. To access COVID-19 treatments, follow the guidance issued by the NHS.

 Asymptomatic contacts

 Contacts of flu cases

Where there are 2 or more people in a cell and one has flu, custodial staff should isolate all cellmates from the general population for 48 hours, starting from their last contact with the case to ensure the contact hasn’t acquired the infection. Contacts do not need to be tested. If they develop symptoms, they need to be managed as a case (see the above section on the management of cases of acute respiratory infections).

Practical operational considerations, such as the number of spare cells available, will inform whether the prisoner or detainee stays in their current cell or is moved to another location away from the ill cellmate.

Contacts of COVID-19 cases

There is no need for contacts of a case of COVID-19 to undertake testing. This applies to prisoners, detainees and staff. Routine contact tracing is not currently being undertaken in PPDs.

Close contacts of a confirmed case of COVID-19 should be supported to:

• minimise contact with the case
• avoid contact with anyone with a weakened immune system, which means they are at higher risk of serious illness, despite vaccination
• follow relevant guidance if they develop symptoms of COVID-19

Limiting the spread of acute respiratory infections

There are actions that settings can take to limit the spread of ARIs. Operational practices may vary due to setting-specific considerations.

 Vaccination

As outlined in the above section on flu and COVID-19 vaccines, all eligible prisoners, detainees and staff are strongly encouraged to be vaccinated to protect themselves and others from flu and COVID-19. This is especially important given the vulnerabilities of people in PPDs.

Vaccination for flu and COVID-19 is not effective for post-exposure prophylaxis due to the time taken for immunity to develop.

Ventilation

Bringing in fresh air to occupied spaces, while still maintaining appropriate levels of security, can help to reduce the concentration of respiratory particles, lowering the risk of airborne transmission of respiratory viruses. See further guidance on how to ventilate indoor spaces.

Infection prevention and control

Hand and respiratory hygiene are important components of infection prevention and control (IPC) and essential to reduce cross-contamination and infection.

Suitable hand washing facilities should be available including running water, liquid soap and paper towels or hand driers. Hands should be cleaned after removing PPE or handling contaminated surfaces or laundry.

If a flu or COVID-19 case needs to pass through areas where other people are waiting, then they should wear a fluid repellent surgical mask.

Cleaning

When a person has an infection, chlorine-based products should be used to disinfect the environment. Products that contain both detergent and chlorine may be used to give a measured dose of chlorine in solution for a one-stage clean and disinfection. HMPPS has approved the procurement of chlorine-based products for use across the prison estate.

Waste

Waste visibly contaminated with respiratory secretions from a person with an ARI infection should be sealed in a waste bag before removal from the accommodation and placed into a waste bin as soon as possible. There is no need to store waste for a time before collection. Dispose of routine waste as normal.

Waste produced by healthcare should follow appropriate guidance in the National Infection Prevention and Control Manual from NHS England.

Laundry

Wash items in accordance with the manufacturer’s instructions. Use the warmest water setting and dry items completely.

Used laundry that has been in contact with an unwell person can be washed with other people’s items. To minimise the possibility of spreading virus through the air, do not shake used laundry prior to washing.

Visitors

Visitors should follow the guidance for people with symptoms of a respiratory infection including COVID-19 if they experience symptoms.

Prisoners, detainees or visitors who are isolating because they have symptoms of an ARI, or because they are a confirmed case of COVID-19 should not participate in visits. They can participate in visits again once their symptoms have resolved and they have satisfied the relevant criteria for starting to participate in normal activities.

Custodial staff should keep visitor access to unwell, symptomatic prisoners or detainees to a minimum. They should also provide any visitors with hand and respiratory hygiene advice. Non-urgent visits should be rescheduled until after the outbreak is over.

Outbreaks

Contacting the local health protection team

If an outbreak is suspected, staff should contact the local HPT.

The PPD should highlight to the HPT if there are specific issues of concern. For example, if:

• there is a high number of hospitalisations or unexpected deaths among prisoners or detainees
• there is a rapid increase in the number of prisoners detainees or staff with symptoms of an ARI
• there is a suspected outbreak of another infection in addition to an ARI

Outbreak control team

Following initial risk assessment by the HPT with the setting, the HPT may convene an outbreak control team (OCT) to support management and help coordinate the outbreak response.

If an OCT is required, it will consider the:

• number and distribution/spread of cases within the PPD
• timeline of the outbreak
• severity of infection
• results of testing
• vaccination status of prisoners or detainees, and staff
• local and national epidemiology of respiratory viruses
• clinical vulnerability of prisoners, detainees and staff (including both physical and mental health considerations)
• capacity and staffing pressures within the PPD
• infection and outbreak control measures taken so far

The OCT will make recommendations on:

• infection prevention and control (IPC) (jump to the infection prevention and control section)
• outbreak control measures (jump to the outbreak control measures section)
• any additional testing
• contact tracing
• any additional information required to inform decisions and effective control measures
• flu antiviral use
• communications (to prisoners, detainees, staff, visitors, local stakeholders and media)

Testing to identify the cause of infection in an outbreak

It is important to identify the infection at an early stage of an outbreak to aid public health management, for example, to distinguish between COVID-19 and other ARIs such as flu. This will also ensure access to appropriate clinical care for those who need it.

If an outbreak is suspected, the HPT will advise on the use of multiplex PCR to test up to 5 linked cases with most recent symptom onset to establish which infection the individuals have.

Any individual who is eligible for COVID-19 treatments should also be tested as soon as possible if they develop symptoms of an ARI using COVID-19 LFD tests obtained for this purpose, even if they are also tested by PCR. Further testing of other symptomatic cases is not required unless testing is instructed by the local HPT.

If settings are advised to test in response to an outbreak, they will be expected to record the results and provide a summary to the HPT.    

If a flu outbreak is confirmed, the need for any additional testing will be considered by the HPT and/or an OCT.

Management of additional cases

During the outbreak, PPD and healthcare staff with ARI symptoms should be managed by their GP. They should seek testing for flu and/or COVID-19 based on the risk assessment of the OCT and their eligibility for COVID-19 treatments.

Antiviral treatment for flu

Healthcare staff should follow the guidance on the use of antiviral agents for the treatment and prophylaxis of seasonal influenza, supported by NICE guidance (TA168), for the treatment of individuals with flu.

HPTs can provide additional advice on the use of antivirals for the treatment of flu in an outbreak situation.

Antivirals should only be used for the treatment of flu in people in specific at-risk groups or those presenting with complications of flu.

In line with guidance, if someone with symptoms meets the criteria for receiving antivirals and the diagnosis of flu is considered to be highly probable based on the available clinical and epidemiological information, antivirals should be started promptly without awaiting the results of flu testing.

Antiviral post-exposure prophylaxis for close contacts of people with flu

Following advice from the HPT or the OCT, certain prisoners, detainees or staff may be offered antivirals for post-exposure prophylaxis (medicines taken soon after a possible exposure to flu) if they are close contacts of a case and are in a clinical risk group. Where there is an extensive outbreak, the OCT should consider offering antiviral post-exposure prophylaxis to all people in clinical risk groups in affected parts of the PPD.

Any recommendations for the use of antivirals as post-exposure prophylaxis should be in line with the guidance on the use of antiviral agents for the treatment and prophylaxis of seasonal influenza, supported by NICE guidance (TA158).

Prescribing and accessing antivirals

PPD winter plans should include details of the ordering and supply processes for flu antivirals. These plans must consider the need for patients to start antivirals within 48 hours of symptoms beginning (or within 48 hours of contact if being used for post-exposure prophylaxis).

Antivirals may be prescribed by issuing an individual prescription or a Patient Group Directive (PGD). The type of individual prescription required (FP10 or Patient Specific Direction (PSD)) will depend on whether the Chief Medical Officer and Chief Pharmaceutical Officer have issued the annual letter stating that flu is circulating.

PGDs can help healthcare staff quickly access antivirals. PGDs should only be used in line with legislation and NICE guidance on PGDs. 

Template PGDs for prescribing antivirals area available on GOV.UK. The templates were designed to be used in care homes, but they can be adapted for secure settings. The PGDs cover treating those with flu-like symptoms, and for prophylaxis for people at risk of getting flu and who meet specific criteria.

Antivirals for prisoners or detainees should be accessed from the PPD contracted pharmacy.

Any staff requiring antivirals should access these via their own GP and community pharmacy, or through occupational health.

Use an out of hours pharmacy for all urgent supplies.

During an outbreak, it is possible that individuals in at-risk groups may require antiviral prophylaxis over a prolonged period. Further details can be found in the NICE guidance.

Outbreak control measures

The decision to introduce any outbreak control measure must consider the potential for adverse impacts on the wellbeing, health and safety of prisoners, detainees and staff. They should be proportionate, targeted, and time limited.

In addition to the actions to limit the spread of ARI covered in limiting the spread of acute respiratory infections, measures which aim to limit person-to-person transmission of ARI include:

• reducing or stopping mixing between individuals from different wings or buildings, to prevent transmission between groups
• reducing or stopping communal activities
• reintroduction of social distancing
• cohorting staff to work on specific wings or buildings
• introduction of enhanced IPC and personal protective equipment (PPE) measures being used in the setting, including the use of face coverings

Additional outbreak control measures are detailed in the sections below.

More information on managing outbreaks can be found in the multi-agency contingency plan for disease outbreaks in prisons guidance.

Infection prevention and control

During outbreaks, the importance of hand and respiratory hygiene should be re-emphasised among prisoners, detainees, staff and visitors.

Staff should follow the guidance, which is specific to controlling the spread of ARI. Local stocks of PPE and suitable arrangements for safe disposal should be in place for this.

Follow the recommended PPE for staff in prisons and community offender populations.

During outbreaks, wider staff use of fluid repellent surgical masks (Type IIR) should be considered to reduce transmission of COVID-19, particularly in poorly ventilated or crowded areas. This is known as source control and prevents spread from the wearer to others. 

Cleaning

During outbreaks, chlorine-based products should be used to disinfect the environment. Products that contain both detergent and chlorine may be used to give a measured dose of chlorine in solution for a one-stage clean and disinfection. HMPPS has approved the procurement of chlorine-based products for use across the prison estate.

During outbreaks, the cleaning schedules should be adjusted to increase the frequency of cleaning and decontamination processes.

Laundry

If water-soluble (alginate) bags are available, use this to transport laundry from the individual’s accommodation to the washing machine. If an external contractor is used the items should be double bagged.

Visitors

Visitors should be made aware of existing outbreaks prior to attending, so they are fully informed and can manage their own risk.

Visitors with underlying health conditions and those at risk of more severe infection (as described in both the chapter on flu in the Green Book and the chapter on COVID-19) should be discouraged from visiting during an outbreak.

Cohorting cases

Where demand for single cell accommodation exceeds capacity, cases may be ‘cohorted’ or paired together in a shared cell. People with confirmed flu or COVID-19 should be cohorted separately from each other, and separately from confirmed cases of other ARIs.

Where cases are concentrated in a particular area or wing, the OCT might consider bringing all other cases into the same area and cohorting them, subject to operational and security assessments.

Population management

Where an ARI outbreak has been declared, the prison governor should inform the HMPPS Health Liaison Service by emailing health@justice.gov.uk who will notify the population management unit (PMU) and other headquarters (HQ) functions if required.

If an OCT is convened, the governor and the consultant leading the OCT should complete a dynamic risk assessment form.

The OCT can consider recommending restricting transfers out to other PPDs, restricting new receptions, or both. Before changing the operational status of the PPD, the OCT should consider whether it is proportionate and helpful to the management of the outbreak. If the OCT decides to go ahead with a recommendation, they should consider whether to recommend fully or partially limiting movement. They can ask for a governor’s advice on the potential impacts of any change. The OCT should then make the recommendation to HMPPS.

HMPPS will consider recommendations to restrict transfers to another PPD, transfer to court, and new receptions into a PPD at a regional level with reference to national population management and other HQ functions as required. HMPPS is responsible for deciding how to respond to an OCT recommendation to limit or stop receptions and transfers. HMPPS has oversight of the wider prison estate and how any such decisions will affect overall prison population management.

Lifting outbreak measures

Outbreak measures can be lifted 5 days after the last suspected or confirmed case.

Staff are recommended to remain alert for possible new cases between 6 to 10 days after the last suspected case.

As a precaution, infection control measures like hand washing, wearing PPE and social distancing can be maintained for longer than 10 days, if advised by the OCT.

Further information for specific settings

Immigration removal centres (IRCs)

Testing may be required for pre-departure for deportation according to the testing requirements of the receiving country and any other considerations regarding advice for travellers domestically.