Guidance

[Withdrawn] Flu in prisons and secure settings

Updated 6 April 2022

This guidance was withdrawn on 4 November 2022

The information of this guidance has been superseded by information in Acute respiratory illness, including flu and COVID-19 in prisons.

Applies to England

1. Introduction

Influenza (flu) is an acute viral infection of the respiratory tract, which includes the nose, mouth, throat, bronchial tubes and lungs. It is characterised by:

• a fever
• chills
• headache
• muscle and joint pain
• fatigue

For otherwise healthy people, flu is an unpleasant but usually self-limiting disease with recovery within 2 to 7 days. Flu is easily transmitted and even people with mild or no symptoms can still infect others.

The risk of serious illness from flu is higher among:

• children under 6 months of age
• older people
• pregnant women
• people with underlying health conditions (such as respiratory disease, diabetes, cardiac disease or immunosuppression)

Maintaining the operational effectiveness of prisons and other secure settings is essential to preserve a fully functional criminal justice and immigration removal system. So, minimising the impact of seasonal flu within these settings is important.

Prisons run the risk of significant and potentially serious flu outbreaks, with large numbers of cases and a higher rate of complications, including mortality. This is because:

• large numbers of people live close together with high degrees of social mixing during activities
• the population is constantly turning over with new receptions (people coming into prison), releases and transfers
• access to healthcare could be limited if demand is high and transfer out to hospitals is complicated with demands on custodial staff for bedwatch and escort services
• people in prison have a higher prevalence of respiratory illness (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
• increasing numbers of older people in prison have a high level of physical health needs, which may put them at risk of complications of flu

An important principle in managing seasonal flu is that people in prison should receive the same healthcare as people in the community. This includes access to antiviral treatment, although delivering such healthcare may differ from community models.

An essential element of reducing the impact of flu in prison is taking a whole setting approach to the prevention, early identification and notification of illness, and quick access to treatment, including antivirals.

Flu levels were extremely low globally during the 2020 to 2021 flu season and there were no confirmed flu outbreaks reported in prisons across England and Wales.

2. Preparing for the flu season, including vaccination

2.1 Planning for the flu season during the coronavirus (COVID-19) pandemic

In 2020 to 2021, as a result of non-pharmaceutical interventions in place for COVID-19 (such as wearing masks, physical and social distancing, and restricted international travel) flu levels were very low globally. So, there will likely be a lower level of population immunity against flu in 2021 to 2022. As social mixing and social contact return towards pre-pandemic norms, there will potentially be high levels of seasonal influenza virus (and other respiratory viruses) circulating alongside COVID-19 in winter 2021 to 2022.

Last year saw the biggest NHS flu vaccination programme ever, aiming to offer protection to as many eligible people as possible during the COVID-19 pandemic. This expanded flu vaccination programme will continue for the 2021 to 2022 flu season (see section on vaccinating prisoners and detainees).

Many of the groups who are vulnerable to flu are also more vulnerable to hospitalisation and death from COVID-19. Prisoners and staff over 50 years old and those in clinical risk groups are at higher risk of both severe flu and severe COVID-19 infection. As these 2 viruses are likely to be circulating together in the winter of 2021 to 2022, protecting high risk people from flu is vitally important.

Flu vaccine clinics may need to adjust their processes due to any COVID-19 social distancing requirements at the time of vaccination. You should consider a range of different ways for delivering the programme this year in line with national COVID-19 guidance for prisons and places of detention.

Flu immunisers should wear personal protective equipment (PPE) in keeping with the current advice on delivering the flu vaccine. Health Education England has produced a flu specific e-learning programme, which is available free of charge. Anyone who gives or advises on flu vaccines can do this e-learning programme, which consists of a core module and separate sessions on the inactivated and live flu vaccines.

2.2 Preparing for the flu season: principles and arrangements

The public health principles guiding preparation for the flu season for prisons are the same as those in the wider community. This includes:

• prisons appointing flu leads (one to be appointed in health care and one for custodial staff) to oversee preparations, including the seasonal flu vaccine campaign
• vaccinating everyone in clinical risk groups (refer to the influenza chapter in the Green Book)
• vaccinating people in the expanded age group of 50 to 64 (refer to the latest national flu immunisation programme plan)
• vaccinating prison healthcare staff according to national guidance in the Green Book
• using legal mechanisms and national guidance to supply and administer the vaccine and antivirals, such as a patient specific direction (PSD) (like a prescription), a patient group direction (PGD) or written instruction for staff
• good infection control practice and resources

All directly employed public sector staff working for Her Majesty’s Prisons and Probation Service (HMPPS) are eligible for a free flu vaccine this year. HMPPS staff based in public sector prisons will have access to on-site flu clinics through occupational health. Alternatively, HMPPS staff can get a flu vaccine from a community pharmacy and claim the cost on expenses.

Prison healthcare teams should share clear arrangements with their local health protection team (HPT) and NHS England health and justice commissioners to make sure they can:

• order vaccine supplies in good time before the annual vaccination period (usually in the spring)
• identify and coordinate vaccination of eligible people (staff and prisoners or detainees)
• record, monitor and make available on request local information on numbers or percentages of staff and prisoners or detainees who have received vaccination
• recognise possible outbreaks and report them quickly to local HPTs (see guidance on managing outbreaks in prisons)
• access public health advice and support from local HPTs, both in and out of office hours
• collect respiratory specimens when there is a case of a flu-like illness to get quick diagnosis (including assessing whether it is an outbreak and making sure there is effective and appropriate care)
• rapidly access respiratory virus testing (including access to swab kits and procedures for sending them for testing) to support the need for quick diagnosis
• rapidly access and supply antiviral medication, including having a current PGD or PSD in place with a process of reviewing and updating them for the current season
• ensure there is enough PPE in stock

2.3 Vaccination for prisoners and detainees

The immunisation programme protects people from serious illness and reduces transmission of the infection, so it contributes to the protection of other people. Healthcare teams should make a register of prisoners and detainees eligible for immunisation to make sure enough vaccine is ordered in advance. They can then invite these people to planned immunisation sessions or appointments.

Healthcare teams should offer vaccination to the groups outlined in the annual flu letter before flu starts to circulate. This includes:

• people aged 50 years and over
• people under 50 years in a clinical risk group (see the chapter on influenza in the Green Book), including babies aged 6 months and older in clinical risk groups on mother and baby units
• pregnant women
• close contacts of immunocompromised people (in prison, these are people who expect to share accommodation with an immunocompromised person on most days over the winter, so continuing close contact is unavoidable)

In cases where the cell or roommate declines vaccination, healthcare staff should discuss with custodial staff and consider changing the cell or room-sharing arrangements.

The list of clinical risk groups in the Green Book is not exhaustive. A healthcare professional should apply clinical judgement to consider the risk of flu exacerbating any underlying disease a prisoner or detainee may have, as well as the risk of serious illness from flu itself.

Healthcare staff should reoffer vaccination to prisoners and detainees who have declined. The offer and reoffer should be recorded.

2.4 Healthcare and custodial staff

All establishments’ flu strategies should include clear information on vaccine coverage for all appropriate healthcare and custodial staff groups. The strategy and processes must include information about how the vaccination can be recorded in the person’s GP record if they are vaccinated in the prison or secure setting.

Healthcare staff

Employers should offer all healthcare staff a flu vaccination. This should form part of an establishment’s flu policy and should link directly to their occupational health policy.

NHS guidance on administering the seasonal flu vaccine provides advice for healthcare providers on vaccinating their staff using a peer-to-peer approach. It is vital that healthcare staff not only protect themselves against seasonal flu, but recognise the importance of infection prevention and control, and protecting prisoners in their care.

Custodial staff

Each establishment should assess which custodial staff (non-HMPPS staff) perform a similar role to a health and social care worker. This means their role requires close contact with prisoners who may have flu, such as accessing healthcare appointments or close personal care.

You should offer staff the flu vaccine in line with the NHS programme and the establishment or provider’s occupational health policy. Occupational health providers should provide aggregate data to a prison’s senior leaders on the number of staff in clinical risk groups and their vaccine status (without providing patient identifiable information).

2.5 Vaccination targets, coverage and recording

Planning for flu vaccination should continue as usual this autumn and the 2021 COVID-19 booster vaccine programme should not disrupt or delay the flu vaccination programme. COVID-19 and flu vaccines can be co-administered and systems should seek to give both vaccines where this will improve patient experience and the uptake of both vaccines, and will help to reduce administrative burdens.

Department of Health and Social Care (DHSC) vaccination targets for 2021 to 2022 include:

• at least 85% of those aged 65 years and over
• at least 75% of those in clinical risk groups, including pregnant women
• at least 75% of those aged 50 to 64 years
• offering vaccination to 100% of healthcare and custodial staff with at least an 85% uptake

For prisoners and detainees, both the offer and uptake of the flu vaccine should be recorded. Healthcare providers are encouraged to hold a register so that they can identify all people eligible for the flu vaccine. Updating the eligibility register throughout the flu season will help with coordination of the local flu vaccination programme. Clinical risk group status should also be recorded on SystmOne, paying particular attention to women who become pregnant and people who enter one or more clinical risk groups during the flu season.

All healthcare staff should be included in their employers’ seasonal flu vaccination programme in line with national guidance for healthcare staff given the additional concern about flu outbreaks in closed institutions.

Individual employers should tell their custodial staff about the need to be vaccinated and how to access vaccination through occupational health or other services. Staff in clinical risk groups should receive vaccines through their GP or local pharmacies participating in the NHS seasonal flu programme, free of charge. People who are not eligible through their employer or GP should be encouraged to consider accessing vaccination privately and then claim the fee back on expenses.

The NHS-commissioned healthcare provider in the prison cannot vaccinate custodial staff.

2.6 Accessing vaccine supplies

Healthcare providers access flu vaccines in the same way as GP practices. This is detailed in:

• the chapter on influenza in the Green Book
• the national flu immunisation programme 2021 to 2022 letter
• the annual flu programme document collection on GOV.UK

Vaccine supplies

Healthcare providers in prisons should routinely order vaccine supplies directly from manufacturers in the spring to secure supplies in line with NHS seasonal flu planning publications. They should order enough vaccine based on past and planned performance and expected demographic increase. These orders are delivered just before the autumn and winter vaccination programme. A list of vaccines is published in the annual flu letter for England. Information about ordering vaccines from manufacturers is given in the chapter on influenza in the Green Book.

During an outbreak of seasonal flu, additional vaccine stock can be sourced in priority order from:

• vaccine manufacturers
• pharmacy service providers via individual patient prescriptions
• pharmaceutical wholesalers contracted to the prison

Administrating flu vaccines

Vaccines can be administered via a prescription or a PGD. A PGD is for vaccinating a number of people, for example, as part of nurse or pharmacist-led vaccination clinics. A PGD must be used in line with legislation and National Institute for Health and Care Excellence (NICE) guidelines on PGDs.

PGDs should be in place at all times and should be reviewed before the flu season to use in vaccination clinics for the vaccine.

NHS England usually shares a copy of an authorised flu vaccine PGD through their regional teams. This can be used by GP practices and health and justice providers in that region or local area. Where providers cannot access the authorised PGD (for example, private prisons where the healthcare is not commissioned by the NHS), Public Health England (PHE) published a template PGD for the vaccine. Healthcare providers can use this to either authorise the vaccine’s use within their organisation (for NHS trusts) or to gain NHS England authorisation to use it in health and justice sites (for non-NHS healthcare providers).

Prisons that have healthcare delivered under contract to the Ministry of Justice must have the PGD authorised by the relevant prison staff rather than NHS England (see Medicines and Healthcare products Regulatory Agency advice on PGDs in the private, prison and police sectors).

3. Diagnosis and recognising a case

3.1 Flu symptoms

You need to act quickly if there is suspected flu. It is important that all staff (custodial and healthcare) are aware of the symptoms of flu-like illness and of the need to quickly report suspected cases to healthcare. Custodial staff often have the most contact with prisoners and detainees, so are well-placed to recognise cases.

If someone has flu, they will usually have an oral or tympanic (eardrum) temperature of 37.8°C or higher, and 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

Flu can also cause an acute deterioration in a person’s physical or mental ability without other known cause.

The World Health Organization defines flu as being “characterized by a sudden onset of fever, cough (usually dry), headache, muscle and joint pain, severe malaise (feeling unwell), sore throat and a runny nose”.

It is important to be aware that older prisoners may not always develop a fever with flu, COVID-19 or other respiratory viruses. You should suspect a flu-like illness if an older prisoner develops an acute deterioration in physical or mental ability without another known cause.

People with COVID-19 may have similar symptoms to flu. PHE published information on case definitions for COVID-19. It is likely that COVID-19, flu and other respiratory illnesses will need to be investigated and managed simultaneously this winter. So, outbreaks of acute respiratory illness in prisons should initially be managed by immediately implementing the infection control and isolation measures required for COVID-19 until COVID-19 has been excluded by viral testing.

Staff with signs and symptoms of flu should seek advice from their GP and inform their line manager and occupational health provider.

3.2 Isolating flu cases

Staff should isolate prisoners and detainees with flu-like symptoms in single cell accommodation where possible and they should be clinically assessed as soon as possible. Initially suspected cases should be assumed to be COVID-19 cases, so prisoners should remain isolated until they have had a healthcare assessment or had test results confirmed.

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

Different guidance applies to COVID-19, so it is important to get the correct diagnosis, and follow the appropriate guidance. Guidance on preventing and controlling COVID-19 outbreaks in prisons is available.

3.3 Swabbing to confirm infection

Healthcare teams should swab people who are symptomatic as soon as possible. They should request a full respiratory screen to include COVID-19 and flu on early cases in an outbreak (typically up to 5 cases but potentially more depending on the epidemiology of the outbreak and the distribution of the cases within the facility).

Multiplex platforms that include both flu and COVID-19 are available via pillar 1 regional labs. If multiplex testing is not available 2 swabs will be needed per case: one for COVID-19 testing and one for flu and other respiratory viruses. These swabs should be taken at the same time, and put into separate tubes of viral transport media, with the appropriate laboratory request forms.

If a flu outbreak is confirmed, the outbreak control team (OCT) will need to decide whether to test all other cases or treat other cases that meet the clinical case definition as suspected flu without further testing. This will depend on the current epidemiology of circulating respiratory viruses (including COVID-19), the availability of multiplex testing and other factors.

4. Outbreaks

4.1 Outbreak control team

If staff identify a cluster of 2 or more cases of flu-like illness, they should inform their local HPT who will conduct a risk assessment and decide whether to arrange an OCT meeting. You can find more information on managing outbreaks in the multi-agency contingency plan for disease outbreaks in prisons guidance.

The OCT will:

• review information with partners on the extent and severity of infection (including information on people requiring transfer to hospital)
• collect data to guide management of effective control measures
• review infection control practice for both prisoners and staff groups
• consider flu vaccine coverage among prisoners and staff
• consider flu antiviral treatment or prophylaxis for cases or contacts, including staff When holding an OCT meeting, you should invite:
• the national UKHSA health and justice team who can provide expert support (you can contact them by email at health-justice@phe.gov.uk)
• representatives from UKHSA’s field epidemiology services team and National Infection Service
• the HMPPS health liaison service (you can contact them by email at health@justice.gov.uk)

During an OCT meeting, you should consider the following questions:

1. Has testing for seasonal flu, COVID-19 and other respiratory infections been carried out (see section on swabbing)?
2. Is there a need to offer vaccination to prisoners or detainees, as well as staff?
3. Is flu antiviral prophylaxis needed? Who should receive it and how? This includes confirming that a current in-date PGD is in place.
4. What is the operational status of the prison or secure setting? This includes any restrictions that are in place, such as temporarily stopping transfers in and out of the prison. If required, this can be managed through the HMPPS Gold Command structure.
5. Should prisoners or detainees be isolated or cohorted (grouped together) as part of wider infection control practice?
6. Are the appropriate staff dealing with prisoners or detainees who either have flu symptoms or do not, but not both?
7. Is there a process for managing hospital admissions if needed?
8. Is there a process for dealing with communication (including prisoner and patient communications) and media issues?

You should also consider these specific infection control measures:

1. Re-emphasise hand and respiratory hygiene measures.
2. Use chlorine-based bleach products for disinfecting and deep cleaning contaminated areas for infection control purposes. HMPPS has approved Titan Chlor tablets for use across the prison estate.
3. If a symptomatic or confirmed case needs to pass through areas where other people are waiting, then they should wear a fluid repellent surgical mask.
4. Prison and healthcare staff who are assessing people with suspected flu and coming into close contact (less than one metre) to provide care should wear appropriate PPE. Staff should also review guidance on investigating and managing suspected cases of COVID-19, and prison COVID-19 outbreak guidance and PPE recommendations.
5. During the outbreak, prison and healthcare staff with flu-like symptoms should be excluded from work and be managed by their GP. They should seek COVID-19 testing in line with national guidance.
6. If staff become ill at work, they should be sent home immediately or isolated until they can be sent home.
7. Report cases among staff as well as prisoners and detainees to the HPT.

You should also consider the following communications during an outbreak:

1. Make an information leaflet on the use of antiviral medication for treatment and prevention purposes available for staff .
2. Issue a letter to staff to inform them of the outbreak and provide relevant advice.

4.2 Cohorting cases

Where demand for single cell accommodation exceeds capacity, cases may be ‘cohorted’ or paired together in a shared cell.

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. Healthcare teams should cohort cases of flu separately from suspected or confirmed cases of COVID-19.

4.3 Asymptomatic contacts

Where there are 2 or more people in a cell and one is suspected or confirmed as having flu, the other cellmates can pose an infection control risk. This is because they could be asymptomatic or show no signs of being infected.

Custodial staff should isolate all cellmates from the general population for 48 hours starting from their last contact with a suspected or confirmed case. However, this should be reviewed if a COVID-19 test result is known. Practical operational considerations, such as the number of spare cells available, will inform whether the prisoner stays in their current cell or is moved to another location away from the ill cellmate.

4.4 Visiting

Custodial staff should prevent symptomatic visitors from entering the prison until they are no longer symptomatic. They should also discourage visitors with underlying health conditions and those at risk of more severe infection (as described in the chapter on influenza in the Green Book) from visiting during an outbreak.

To protect patient welfare, custodial staff should keep visitor access to symptomatic prisoners or detainees to a minimum. They should also provide any visitors with hygiene advice. Non-urgent visits should be rescheduled until after the outbreak is over.

5. Treatment and care

5.1 Flu antivirals

Healthcare staff should follow guidance on the use of antiviral agents for the treatment and prophylaxis of seasonal flu as also recommended in NICE guidance for preventing flu and NICE guidance for treating flu. These guidelines remain an integral part of flu control measures in prisons.

The HPT can recommend using antivirals in an outbreak situation following a local risk assessment, usually on the advice of the consultant on duty. If a risk assessment has supported using antivirals, it should not be delayed while waiting for flu testing results. This situation could be within the Chief Medical Officer-declared ‘flu season’, or outside the flu season when flu is known to be circulating in the local area.

You should only use flu antivirals for treatment and prophylaxis of people in specific at-risk groups, so it’s important to follow the guidelines (and any recommendations from the HPT) closely. UKHSA recommends considering antiviral treatment even in vaccinated prisoners. In the initial stages of the outbreak, it’s important to identify potential cases early and quickly administer antivirals where indicated. Treatment with antivirals should ideally start within 48 hours of symptoms starting.

5.2 Antiviral post-exposure prophylaxis of close contacts

Following advice from the HPT or the OCT, prisoners and staff should be offered antivirals for post-exposure prophylaxis (AV-PEP) if they are close contacts of cases and are in clinical risk groups. This is regardless of their flu vaccine status (although this lies outside of NICE guidance) and should be within 48 hours of exposure to confirmed cases for oseltamivir (commonly known by the brand name Tamiflu), and 36 hours of exposure to a case for zanamivir.

Occupational health teams are responsible for providing antivirals to prison staff. Optima Health is the HMPPS occupational health provider. The HPT should inform Optima Health’s clinical advice line that a flu outbreak has been declared in the prison so that the telephone line can be activated to receive calls related to Tamiflu. The clinical advice line (0330 008 5906) will operate between 7am on Monday and 3pm on Friday. Between 3pm on Friday and 7am on Monday, please contact NHS 111 for advice. A prescription can be offered through this service if it’s clinically indicated.

In privately managed prisons, the custodial service provider is responsible for providing occupational health and arrangements may vary between sites.

Where there is an extensive outbreak, the OCT should consider offering AV-PEP to all prisoners in clinical risk groups in affected areas or throughout the prison.

You can download a leaflet with information for prison staff about using antiviral medication to prevent seasonal flu in people at high risk of complications.

5.3 Accessing supplies of flu antivirals and patient group directions

Flu plans should include the ordering process and supply of antivirals. When making these plans, you must consider that antivirals need to start within 36 to 48 hours of symptoms beginning, depending on the brand of antiviral used.

Healthcare staff should record all supplies of antivirals given to prisoners in their clinical records. Staff can give prisoners their antiviral medication ‘in-possession’ unless the prisoner is unable to manage their medicines. This means the prisoner keeps their medication in their cell. Occupational health services are responsible for providing the antivirals for prison staff.

There are 2 ways to access antivirals following a clinical assessment and diagnosis: individual prescriptions or a PSD, or a PGD.

Individual prescriptions or a patient specific direction

Healthcare staff can access antivirals by sending the prescription or PSD to the pharmacy for dispensing. This will be the pharmacy contracted to provide medicines to the prison or an out of hours pharmacy.

Healthcare staff can also use ‘over-labelled’ stock supplies that allow the prescriber or registered healthcare professional to add the patient’s name and date to the pack. This means they can give the antivirals directly to the patient without waiting for them to come from the pharmacy. Healthcare staff must get over-labelled supplies from a licenced provider. The label usually has the dose pre-printed on it. They should complete this using standard operating procedures developed and approved by the healthcare provider.

Patient group direction

Healthcare staff should only use a PGD in line with legislation and NICE guidance on PGDs. PGDs can help healthcare staff quickly access the flu vaccine and antivirals.

PHE produced PGD templates for flu AV-PEP and treatment. The templates were designed for care homes, but they can be adapted for custodial settings. The PGDs cover Tamiflu and zanamivir to treat eligible people with flu-like symptoms and for prophylaxis to prevent eligible people getting flu.

The healthcare professional who assesses the patient must hand them the in-possession medication supplied under a PGD. For non-in-possession supplies, the healthcare professional who assesses the person can supply the antiviral to healthcare staff (as the patient’s carer) for storage so that doses can be administered under supervision in line with local arrangements.

The antiviral supplied via a PGD must be from over-labelled stock and the name of the patient and the date must be added to the label by the healthcare professional.

During an outbreak, UKHSA may also recommend that the prisons and secure settings consider offering post exposure prophylaxis with antiviral medication for staff in clinical risk groups. This would be provided by HMPPS occupational health services.

During an outbreak, healthcare staff may need to give prophylaxis for high-risk people over a longer period. This includes staff as well prisoners or detainees. A healthcare professional can give a high-risk person Tamiflu for prophylaxis for up to 42 days according to the product licence, where there is the potential for ongoing or repeated exposure to confirmed cases.

If a PGD is not in place when an outbreak occurs, healthcare providers can write individual prescriptions for antivirals or flu vaccinations until a PGD is in place. NHS trust healthcare providers can authorise their own PGDs and so can fast track the development and authorisation of PGDs for flu vaccines and antivirals.

Non-NHS providers cannot authorise their own PGDs, but they should have mechanisms to write the PGD and submit it for authorisation by their local NHS England health and justice commissioner. The commissioner will need to identify who the PGD authoriser is for their local team and help the rapid PGD authorisation through this local process.

5.4 Stock access of flu vaccine and antivirals

Flu vaccine is supplied from the provider’s usual wholesaler or the manufacturer. Do not use the vaccine ordering portal ‘Immform’.

Antivirals supplied under a PGD are usually sourced already over-labelled from the provider’s usual supplier of pre-packs and over-labelled medicines. For urgent supply during an outbreak the antiviral can be supplied by adding the patient’s name, date and site name to the manufacturer’s pack. The healthcare professional will then need to give verbal instructions to the patient about the dose, advising them to read the patient leaflet in the pack and to contact healthcare staff if they have any queries while taking it. You can find more information on PGDs on the Specialist Pharmacy Service website.

In an outbreak, commissioners should check and confirm they have access to enough antiviral stock. Commissioners may need support to access urgent stock. Clinical commissioning groups are responsible for ensuring access to antivirals in response to outbreaks. UKHSA antiviral stocks are no longer available for this purpose.

Emergency regional stocks are a last resort. The pharmacy would need to hold the supply of antivirals and all costs and charges would be directly reimbursed by the commissioner. Not all stockholders of these emergency stocks may be able to accommodate such requests.

Where stock supplies of over-labelled antivirals are used, plans should include:

• agreed minimum stock levels based on the previous year’s use with plans to amend these during an outbreak
• processes to check the antiviral stock regularly for storage and expiry dates, audit the supplies made and reorder stock as it approaches minimum levels

6. Population management

6.1 Specific considerations for prisons about population management during an outbreak

Where an outbreak has been declared, the prison governor should inform the national incident management unit who will notify the population management unit (PMU). The governor and the consultant leading the OCT should complete a risk assessment form.

The OCT can consider recommending either restricting transfers to other prisons or restricting new receptions.

Restricting transfers to other prisons.

This is to avoid starting new outbreaks in other prisons. Your priority should be to avoid transferring symptomatic prisoners or detainees. If a transfer is required, follow all infection control advice.

If you cannot avoid moving prisoners, you should notify the receiving prison of the outbreak. This might be:

• for security reasons
• to ensure that HMPPS can continue to accommodate prisoners remanded by the courts
• to safely manage population or stability pressures

HMPPS will consider recommendations to restrict transfers in or out of an establishment at a national level. The HMPPS health liaison service will refer recommendations to HMPPS command and decide on such recommendations. You can contact them by email at health@justice.gov.uk.

Restricting new receptions.

This is to avoid making an outbreak worse by introducing new vulnerable cases to the prison. However, restricting new receptions at some sites can result in redirecting prisoners to other prisons, or to ‘lock-outs’ where prisoners remain in police cells. If it’s not possible to restrict new receptions completely, prisoners should be:

• assessed to determine if they are in a risk group and considered for AV-PEP and vaccination
• assessed for signs and symptoms of flu and symptomatic new arrivals should be isolated or cohorted immediately
• swabbed and considered for antivirals and isolation or cohorting if they are symptomatic and in a risk group, and it’s clinically appropriate

6.2 Restricting new receptions and transfers

The OCT will decide whether to recommend restricting new receptions coming into the prison or other secure setting and stop transfers in and out. Before changing the operational status of the prison, the OCT should consider whether it is proportionate and helpful to the management of the outbreak to limit receptions, transfers, or both. They should first assess whether there is an unaffected part of the establishment that can be used, so it can continue to accept new prisoners.

If the OCT decides that it’s necessary to restrict receptions or transfers, 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 a recommendation on movements for HMPPS Gold Command to consider.

Only the HMPPS Gold Commander or, if delegated, the prison group director, should take decisions on closing prisons to receptions and transfers. This is because they have oversight of a greater proportion of the prison estate and will understand how any decision to close will affect the prison population management generally.

6.3 Transfers to court

In an outbreak situation, symptomatic prisoners may not be suitable for court due to clinical needs and infection control considerations. Courts should be told that a prisoner is ill with flu in advance of their court appearance.

Courts should consider a video link as an alternative to a personal appearance. If a personal appearance is required, courts should implement appropriate infection control measures for the prisoner and staff members.

Asymptomatic prisoners can attend court. If they are remanded in custody in a different prison, the receiving prison should be told that there’s an outbreak in the original prison. You should tell the receiving prison to be alert to any signs or symptoms of flu and place a note on SystmOne for healthcare teams.

6.4 New allocations from court

You should consider redirecting new prisoners or detainees who are allocated by the court to an infected site. However, this may be only sustainable for a few days.