Acute respiratory infections: outbreaks in higher-risk communal accommodation settings
This guidance provides information on Acute Respiratory Infections (ARIs) in higher-risk settings.
Main messages
This guidance provides information on Acute Respiratory Infections (ARIs) in higher-risk communal accommodation settings.
It is drawn upon the best available evidence and experience and is intended as a basis for consistent practice nationally, while also accounting for local resources and needs.
Staff, residents and service users do not need to be routinely tested if they have symptoms of an ARI. The exceptions to this are:
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if short term symptomatic testing is recommended as part of a health protection team (HPT) led outbreak response. In this case, multiplex polymerase chain reaction (PCR) testing should be conducted in up to 5 linked symptomatic cases in a suspected outbreak of ARI to inform outbreak response actions
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if the symptomatic staff member or service user is eligible for COVID-19 treatments, in which case symptomatic COVID-19 testing should be carried out to support access to treatments
Who this guidance is for
This guidance is for commissioners, providers and staff working with higher risk communal accommodation settings. These settings are accommodation venues for vulnerable adults (and sometimes their dependent children) without onsite clinical teams. Residents often share rooms, bathrooms and/or other facilities. Examples include:
- accommodation for people seeking asylum, for example contingency or initial accommodation centres
- accommodation for people experiencing homelessness, for example, hostels and night shelters
- domestic abuse refuges
- other communal settings used to house individuals for emergency or temporary accommodation
Additional guidance on outbreak management in short term asylum seeker accommodation settings and broader public health guidance on operating night shelters is also available.
This guidance does not apply to adult social care, prisons and places of detention (PPDs), secure children’s homes, secure schools, secure training centres and Young Offenders Institution units for those aged under 18 years. For these settings, guidance on the management of COVID-19 and other acute respiratory infections is available for:
- adult social care
- prisons and places of prescribed detention (PPDs)
- the Children and Young People Secure Estate
Background
The settings included in this guidance are considered higher risk for transmission of ARIs and poor outcomes for the following reasons:
- there is a higher risk of ARI transmission due to crowding, people sharing rooms, shared facilities, staff turnover and less adequate ventilation
- individuals within these settings may be at higher risk of severe illness from ARIs due to poorer health, barriers to accessing healthcare, and/or lower vaccination coverage
- individuals in these settings may be less able to isolate or take other actions to prevent the spread of ARIs
As a result, outbreaks in these settings may have a greater impact than in other settings.
Testing and infection prevention and control (IPC) measures in this guidance are focused on reducing severe outcomes and reducing transmission risk in individuals who are at higher risk from ARIs.
Definitions
Acute respiratory illness (ARI)
ARI is defined as the acute onset of one or more specific respiratory symptoms and a clinician’s judgement that the illness is due to a viral ARI (for example COVID-19, flu, respiratory syncytial virus (RSV)).
Outbreak of ARI
An ARI outbreak is defined as 2 or more positive or clinically suspected linked cases of ARI, within the same setting within a 5-day period. This means the cases may be linked to each other and transmission within the setting may have occurred.
Additionally, an ARI outbreak may be suspected when there is an increase in the number of residents displaying symptoms of a respiratory infection.
Symptoms of acute respiratory illness, including COVID-19: management of staff and service users
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, your 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
Individual testing for COVID-19 in higher-risk settings is now only offered to people experiencing symptoms of ARI who are eligible for COVID-19 treatment.
Staff and service users with symptoms of ARI should be supported to follow guidance for people with symptoms of a respiratory infection, including COVID-19 If staff, volunteers or service users have symptom of ARI and have a high temperature or do not feel well enough to go to work or carry out normal activities, they should be encouraged to stay at home or in their room and avoid contact with other people. If possible, service users with symptoms of ARI should be provided with single room accommodation. They can return to work or usual activities when they no longer have a high temperature (if they had one) or when they no longer feel unwell.
It is particularly important they try to avoid close contact with anyone known to be at higher risk of becoming seriously unwell if they are infected ARIs, especially those whose immune system means that they are at higher risk of serious illness, despite vaccination.
If staff or service users are unable to avoid contact with other people while they have symptoms of ARI, 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
- avoiding crowded places such as public transport, large social gatherings, or communal places, or anywhere that is enclosed or poorly ventilated
- taking any exercise outdoors in places where they will not have close contact with other people
- covering the 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; avoid touching their face
More information on how to limit the spread of ARIs n these settings is available.
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.
Service users eligible for COVID-19 treatments
Staff in the respective settings should identify service users who are eligible for COVID-19 treatments and ensure they can access COVID-19 testing if required. COVID-19 and other ARIs have similar symptoms.
If a resident or service user is experiencing COVID-19 symptoms (even if they 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 provider should follow the guidance on COVID-19 treatments.
If the test result is positive the provider should follow the guidance for people with symptoms of a respiratory infection including COVID-19..
Staff working in higher-risk settings should:
- make sure those who are eligible for treatment are registered with a GP
- confirm that the contact details for those eligible are up to date, and they or a representative are contactable
Staff and volunteers eligible for COVID-19 treatments
If a staff member is experiencing COVID-19 symptoms and is eligible for COVID-19 treatments they should follow NHS guidance on treatment for COVID-19.
How to access COVID-19 test kits
Service providers should support service users to access test kits for those eligible for COVID-19 treatments . These can be accessed from the NHS.
Reporting LFD test results
Under Regulation 4A of The Health Protection (Notification) Regulations 2010, higher risk settings are still required to report positive, negative and void LFD test results where they have assisted residents to take an LFD.
To support settings in being able to meet their Regulation 4A duty, the UKHSA multiple registration spreadsheet will remain available for settings to report COVID-19 LFD test results. Settings are still able to use this route to report the result of LFD tests that have not been provided to the setting 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 support service users to access COVID-19 treatments, follow the guidance issued by the NHS.
Positive ARI test result: managing staff and service users
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
If the service user tests positive, follow the treatment advice of the GP or, hospital and inform the HPT.
Staff and service users with a positive COVID-19 test result should be supported to stay away from other people 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 .
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).
Isolation
All higher risk residential settings should have a plan in place to identify appropriate facilities where service users who are unwell with an ARI can be supported to self-isolate appropriately.
If single occupancy accommodation is not available, confirmed cases with the same ARI may be cohorted (grouped and isolated) together.
Seeking further clinical input
If the health condition of a service user is worsening, settings are advised to seek clinical advice.
Management of confirmed cases where testing has been undertaken
People who are household or overnight contacts of someone who has a confirmed ARI should follow guidance for the general public set out in Guidance for people with symptoms of a respiratory infection including COVID-19.
Individuals do not need to be tested if they have been in contact with someone who has tested positive for an ARI.
Outbreak management
Contacting the local health protection team
If an outbreak of ARI is suspected, staff should undertake a risk assessment as soon as possible to determine whether the local HPT should be contacted.
The setting provider should contact the HPT if there are specific issues of concern. For example, if:
- there are a high number of hospitalisations or unexpected deaths among service users
- there is a rapid increase in the number of service users with ARI symptoms
- there is a suspected outbreak of another infection in addition to an ARI
Testing during 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, contact your 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 to establish which infection the individuals have.
Any individuals who are 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.
Outbreak measures
Following initial risk assessment by the HPT with the setting, HPTs may convene an Incident Management Team (IMT) to support management and help coordinate the outbreak response.
The IMT will make recommendations on:
- infection prevention and control
- outbreak control measures
- any additional testing
- contact tracing
- any additional information required to inform decisions and effective control measures
- antiviral use (only applicable for flu)
- communications (to service users, staff, visitors, local stakeholders and media)
After a risk assessment, and subject to discussion with the service managers, further temporary outbreak control measures that may be considered by IMTs include:
- proportionate reduction in communal activities
- cohorting of service users with suspected or confirmed infections into similar groups to help manage risk
- reintroduction of social distancing
- introduction of enhanced IPC and personal protective equipment (PPE) measures being used in the setting, including the use of face coverings
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 required.
Limiting the spread of acute respiratory infections, including COVID-19
There are actions that settings can take to limit the spread of respiratory infections. Operational practices may vary due to setting-specific considerations.
Vaccination
All eligible service users and staff are strongly encouraged to be vaccinated to protect themselves and others from COVID-19, RSV and Flu. This is especially important given the vulnerabilities of people in high-risk inclusion health settings. Booster vaccinations are strongly recommended for individuals if they are eligible.
Information on the COVID-19 vaccination programme is available in the Green Book, chapter 14a (page 29 onwards), with further resources on the COVID-19 vaccination programme also available.
Information on the Flu vaccination programme is available in the Green Book, chapter 19.
Ventilation
Bringing in fresh air to occupied spaces can help to reduce the concentration of respiratory particles, lowering the risk airborne of airborne transmission of respiratory viruses.
Other ventilation measures should be determined by risk assessment and implemented appropriately.
Personal protective equipment
During an outbreak, IIR fluid-repellent surgical masks should be worn by staff to reduce transmission of ARIs particularly:
- if the person being cared for has symptoms of ARI
- when cleaning the room of a person with symptoms of ARI
- if there is an outbreak of ARI in the setting and the local risk assessment favours the introduction of universal masking as one of the outbreak control measures
- when caring for a person who is at high risk of becoming severely unwell if they are infected with an ARI
A local risk assessment should be undertaken by the service providers when considering how to support the personal preferences of staff and service users who wish to wear a face mask in situations beyond the above recommendations.
Providers should consider mitigations if a service user finds that the use of face masks impairs communication or is distressing. This may particularly be the case for people with learning disabilities, cognitive conditions such as dementia, or people who rely on lip reading or facial recognition. Providers should ensure that face masks are:
- well fitted to cover the nose, mouth and chin
- worn according to the manufacturer’s recommendations (for example checking the coloured side is worn outwards, unless the manufacturer states otherwise)
- worn by staff only following a risk assessment
- not allowed to dangle around the neck at any time, or rest on the forehead or under the chin
- not touched once they have been fitted
- removed and disposed of appropriately, with the wearer cleaning their hands before removal and after disposal
- replaced if moist, damaged, contaminated or soiled, or if it is uncomfortable to wear
- changed between break times and between visits to different people’s homes
- changed after providing care for an individual or a single cohort of several people with symptoms of ARI
Cleaning
Regular cleaning can help reduce the risk of spreading ARIs.
Standard cleaning products such as detergents are adequate to clean routinely.
Respiratory infections such as flu and COVID-19 can be spread from person to person through small droplets, aerosols and through direct contact. Surfaces and belongings can also be contaminated when people with infections cough or sneeze or touch them.
When a person is known or suspected to have an ARI, disinfect the environment using chlorine-based products. 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.
It is particularly important to clean and disinfect frequently touched surfaces in bathrooms and communal kitchens.
As a minimum, frequently touched surfaces such as door handles, light switches, work surfaces, remote controls and electronic devices should be cleaned at least once a day. Increased cleaning frequency will further reduce the risk of acquiring infection. . Cleaning should be more frequent depending on the number of people using the space, whether they are entering and exiting the setting and access to handwashing and hand-sanitising facilities. Suitable hand washing facilities should be available including running water, liquid soap and paper towels or hand driers. Clean hands after removing PPE or handling contaminated surfaces or laundry waste.
Waste products that are visibly contaminated with respiratory secretions from a person with suspected or confirmed ARI 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. If water-soluble (alginate) bags are available, use these to transport laundry from the unwell individual’s accommodation to the washing machine. To refrain from emptying these bags into the washing machine, instead to add the bag in the washing machine too (ensuring washing machines compatibility) as it will dissolve during the wash.
Used laundry that has been in contact with an unwell person can be washed with other people’s items. To minimise the possibility of dispersing virus through the air, do not shake used laundry prior to washing.
Visitors or volunteers
Visiting should not be stopped, but visitors should be made aware that they will be asked to adhere to infection prevention principles to minimise spread.
Visitors or volunteers should follow the guidance for people with symptoms of a respiratory infection including COVID-19 if they experience symptoms.