Guidance

Toolkit 6: principles for the management of outbreaks in specific settings

Published 21 January 2025

This toolkit provides additional guidance, beyond that contained within the main body of the communicable disease and outbreak management guidance, relating to the management of outbreaks in specific settings.

Many of the settings covered in this section include different forms of communal accommodation. Such settings are associated with an increased risk of infection transmission and the implementation of control measures in these settings may be complex. Inclusion health populations and wider populations experiencing health inequalities may be more likely to live in communal accommodation settings than the general population. As such, encouraging local partners to build relationships with these settings is important as this can support preparedness, early identification of outbreaks, and effective and equitable implementation of control measures.

Outbreaks in hospitals and other health and care premises

Outbreaks in healthcare settings

The main considerations for the management of outbreaks in hospital and health care premises include the following:

• the majority of hospital outbreaks will be dealt with using the hospital’s own internal outbreak plan. All hospital outbreak policies should stipulate that the local consultant in health protection (CHP) will be informed whenever a hospital incident management team (IMT) is convened, regardless of the circumstances
• if the outbreak is potentially linked or confirmed to be linked to food exposure, including how the food was handled, then the NHS in its capacity as a food business, has a legal obligation to immediately inform the local authority, who are required to then inform the Food Standards Agency (FSA) (Food Law Code of Practice section 5.2.2)
• the DPH and the local authority environmental health team should be informed in all instances where local environmental health support may be required
• the role of the UKHSA health protection teams (HPTs) with respect to healthcare associated infection (HCAI) outbreaks is mostly supportive, advisory, and facilitative, as NHS trusts will predominantly lead on investigation and response

The role of the UKHSA with respect to HCAI and outbreaks includes:

• discussing emerging issues with the trust infection prevention and control (IPC) team and supporting investigation and control through active membership of trust IMTs. Where an IMT is established, the role and activities of the UKHSA HPT should be defined at the first incident meeting, clarifying who is responsible for contact tracing
• co-ordinating investigations of outbreaks involving more than one NHS organisation. Where multiple NHS organisations are involved, UKHSA may be the appropriate organisation to lead, following agreement by the affected NHS trusts
• providing specialist epidemiological and infection control support and leadership in the event of a serious outbreak/infectious disease incident.  This may include working with trusts, supporting the trust to follow their own outbreak control plan, and ensuring early involvement of the UKHSA consultant in public health infection and the FSA, in the event of a food or feed-related outbreak

Outbreaks in adult social care (ASC) settings

The main considerations for the management of outbreaks in ASC settings include the following:

• ASC settings, such as care homes, are expected to report suspected outbreaks of illness to their local UKHSA HPT or another provider in line with local arrangements. These arrangements may mean that the UKHSA HPT is the sole or primary responder to the outbreak, alternatively the settings may receive initial support from their local system (ICB/local authority)
• where the outbreak is in relation to food, the local authority is required to inform the FSA  if the outbreak is localised to the care home but serious, or widespread (affecting more than one setting in another local authority, or several similar health care settings in the same local authority area)
• stakeholders involved in the management of the outbreak should use learning from outbreaks to inform quality improvement in the local health and social care system, and/or at regional and national level
• outbreak control advice must consider requirements of the Care Quality Commission (CQC) Fundamental Standards on Visiting and Accompanying (Regulation 9A) implemented in April 2024. This stipulates that care homes must support residents to receive visits safely in the event of an outbreak. It also requires that residents should not be discouraged from taking visits out of the care home. If necessary and proportionate, precautions should be put in place to enable visits to happen safely. UKHSA has published operational guidance to support alignment of outbreak management with this Regulation (Supporting safer visiting in care homes during infectious illness outbreaks)
• together with the care home, hospitals should assess the risk in the period before planned discharge. This applies to the discharge of individuals to a care setting with a known outbreak or when discharging an individual with known infection. The care provider should speak to the hospital to raise any concerns about a planned discharge. Advice can be sought from the IPC team, local authority public health teams, or UKHSA HPTs as appropriate

Further advice on the management of outbreaks in care settings can be found in Adult Social Care Guidance.

Outbreaks in local authority premises

While local authorities often have a role in the management of outbreaks in their area, a conflict of interest may occur where a local authority is the relevant enforcing authority in relation to premises in which it also has an ownership or management interest. This situation could arise where local authorities are called upon to exercise their responsibilities as a health and safety regulator in leisure centres that are wholly owned, but not managed, by themselves.

A conflict of interest can either be an actual or a perceived conflict of interest. If this conflict is not dealt with appropriately, it can cause avoidable difficulties in the regulatory activities that may follow a work-related death or other serious incident.

Where the local authority has a management or ownership interest in premises for which it is the enforcing authority, it should consider whether that interest is so great that it should no longer act in a regulatory capacity. In some situations, transfer of enforcement authority to another local authority, the Food Standards Agency (FSA), or the Health and Safety Executive (HSE) may be appropriate. HSE’s ‘LA Enforcement in premises in which they may have an interest’ provides further information for local authorities where the local authority is the relevant enforcing authority.

Outbreaks in inclusion health settings

Inclusion health settings include, but are not limited to, hostels for people experiencing homelessness, accommodation for people seeking asylum, domestic abuse refuges, and respite rooms. Guidance for providers in relation to outbreaks within inclusion health settings can be found in the following:

• Outbreak management in short term asylum seeker accommodation
• Operating principles for night shelters

Important considerations for the management of outbreaks in inclusion health settings include the following:

• inclusion health settings do not usually have healthcare provision on site
• people in inclusion health settings can experience multiple barriers to accessing healthcare, including poor health literacy, language barriers, stigmatisation, and mistrust of healthcare or other professionals (often due to previous negative experiences)
• to reduce the risk of poor outbreak control measure implementation, trusted local partners, including voluntary, community, and social enterprises (VCSE) and healthcare professionals, should be involved in advising on the implementation of public health measures and the co-development of messaging

Outbreaks in prisons and places of detention

Guidance related to the management of outbreaks in secure settings can be found within Management of incidents and outbreaks of communicable disease in secure settings.

Prisons and places of detention include prisons, young offender institution (YOI) units for young people age 18 to 24 years of age, children and young people secure estates (CYPSE), which comprises YOI for those younger than 18 years of age, secure training centres (STCs), secure schools (SSs), secure children’s homes (SCHs), and immigration removal centres (IRCs).

Important considerations in relation to the management of outbreaks in prisons and places of detention include the following:

• in accordance with the 2015 UN standard minimum rules for the treatment of prisoners, each individual who resides in a secure setting should receive care equivalent to what is provided for the rest of the population
• the governor, director, centre manager or principal of each secure setting has a statutory responsibility to ensure the health and safety of residents, visitors and staff in their care and a duty to co-operate with appropriate agencies to ensure that any threats to health are identified and effectively managed. Outbreaks in secure settings will therefore usually require representation from the governor, director, centre managers, principal or head of healthcare of the secure setting and any private provider of healthcare services
• healthcare in secure settings is the responsibility of NHS England
• the lead responsible organisation will lead communications depending on the governance structure of the secure setting (Ministry of Justice for those under the responsibility of HM Prison and Probation Service (HMPPS), the Home Office for IRCs, and the relevant local authority or third sector organisation for secure children’s homes)
• establishments will be responsible for identifying contacts and implementing control measures, such as isolation

Important considerations for the management of outbreaks in prisons are that:

• the need for health protection interventions should be balanced with the need for security within the setting as well as the ability of the prison healthcare team to deliver the intervention. The governor (or deputy) or the head of healthcare should attend any IMT meetings to ensure the challenges within individual settings are fully understood and the security of the prison is not compromised
• it is legally not possible to hold people in prison past their release date even if they are isolating due to being in contact or testing positive for an infectious disease
• HMPPS will consider recommendations from the IMT to restrict transfers out of, and new receptions into, prisons at a regional level with reference to national population management and other headquarters functions as required. HMPPS is responsible for deciding how to respond to an IMT 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

Important considerations for the management of outbreaks in the children and young person’s secure estate include the following:

• children and young people within secure settings may be particularly vulnerable to the negative impact of certain control measures, such as isolation, on their mental health and wellbeing. In addition, these settings manage a number of significant competing risks of harm, including risks of serious self-harm and violence, which can be exacerbated by isolation and cohorting. Measures put in place to respond to outbreaks in these settings need to balance these competing risks through defensible decision-making and be proportionate to the likely risk of harm to the children, young people, and staff in these settings
• the Youth Custody Service (YCS) head of placements (for a YOI or STC) or the local authority or charity that operates an SCH would consider recommendations to limit arrivals or transfers or to close the setting, with the ultimate decision being made by the YCS head of placements or the SCH registered manager

Important considerations for the management of outbreaks in IRCs include the following:

• IRCs hold people who have no legal right to remain in the UK and who refuse to leave voluntarily. Close attention should be paid to the inequalities in access to healthcare (for example, the translation of resources)
• after initial notification to the local UKHSA HPT, if an outbreak is declared at an IRC, the director or centre manager must also notify the on-site Home Office Detention Services team who will send an initial notification email to an agreed distribution list
• the population within IRCs are more transient and they generally have more freedom of movement within the setting than the HMP estate, including more dormitory style accommodation. These factors may affect the levels of contact with other residents and their ability to isolate effectively
• individuals may only be in an IRC for a short period before removal to another country or returning to the community. These factors present challenges for contact tracing and data quality and data sharing.
• a national Home Office representative, as well as the centre manager and IRC healthcare team, should be present at the IMT
• IRC leads should provide information on whether cases or contacts are due to be deported or to leave the UK for another country. If the Home Office decide to remove individuals who have been diagnosed with an infectious disease from the UK, UKHSA’s International Health Regulations team should be notified on IHRNFP@ukhsa.gov.uk.
• the Home Office will consider recommendations from the IMT to restrict transfers out of, and new receptions into, IRCs at a regional level with reference to national population management. The Home Office is responsible for deciding how to respond to an IMT recommendation to limit or stop receptions and transfers. The Home Office has oversight of the wider prison estate and how any such decisions will affect overall prison population management

Outbreaks in children and young people’s settings, including education

Early years and educations settings include, but are not limited to, early years and pre-schools, child minders, education, settings working with people with special educational needs (SEN), additional support needs (ASN) or disabilities (SEND) and residential settings such as boarding schools, halls of residence and children’s homes.

Important considerations for the management of outbreaks in early years settings and education include the following:

• the role of the UKHSA HPTs with respect to early years and education settings outbreaks is mostly supportive, advisory, and facilitative. The settings will work with HPTs on identification of contacts within the settings and on communications with parents and carers
• measures put in place need to be considerate of the best outcomes for children and young people, these need to be proportionate and consider both impact to the individual and to their parents/carers.
• the Director of Public Health should be informed as soon as possible, if not already involved in the IMT, and consideration made to communication with ward councillors and elected members with responsibility for the children’s portfolio.
• make every effort to ensure a school remains open during an outbreak; exceptionally, decisions on closure of settings should be made in consultation with the IMT/UKHSA HPT and are the responsibility of the settings leaders or local authority
• if a child or young person is known to be vulnerable to neglect, abuse, or exploitation, and public health exclusion may increase this vulnerability, follow safeguarding procedures, including consideration of confidentiality, and the appropriate agencies or individuals involved in safeguarding the child or young person should be involved in decision making

Guidance for settings staff:

• Health protection in children and young people settings, including education
• Managing outbreaks and incidents
• Managing specific infectious diseases: A to Z
• Specific settings and populations: additional health protection considerations
• Children and young people settings: tools and resources

Outbreaks in military settings or of military personnel

Cases, incidents, and outbreaks involving UK service personnel or the Defence Estate will be managed by defence public health consultants and environmental health teams with input from UKHSA as required. Notwithstanding, the statutory requirement to report all notifiable conditions to the geographically responsible UKHSA HPT remains extant.

To reach the Defence Single Point of Contact for Infectious Diseases during working hours:

• phone +44 (0)300 1592060
• emailing the group mailbox at sg-dmed-med-dphu-gpmailbox@mod.gov.uk.

For urgent out of hours health protection issues, call the duty Defence Public Health Consultant on +44(0)1543406008.