Guidance

Preventing and managing cases and outbreaks of acute respiratory infection (ARI) in the Children and Young People Secure Estate (CYPSE)

Updated 23 December 2024

Applies to England

Main messages

This guidance has been developed to help staff manage acute respiratory infections (ARIs) in the Children and Young People Secure Estate (CYPSE). Recommendations are based on available evidence and expert opinion.

The main actions and recommendations are to:

• offer and encourage all eligible children and young people flu, respiratory syncytial virus (RSV) and COVID-19 vaccinations, and to take the opportunity to  encourage all children and young people to be up to date with their routine vaccination schedule
• encourage all eligible staff to get flu, RSV and COVID-19 vaccinations
• allow individual cases with mild symptoms of an ARI to continue with their usual routine
• ideally, provide single room accommodation for those with a high temperature and respiratory symptoms
• get the advice of the local UKHSA health protection team (HPT) before testing to identify the cause of an outbreak
• if an outbreak is not suspected, but individuals have respiratory symptoms, only test for COVID-19 if the symptomatic individual is eligible for COVID-19 treatments
• if children and young people or staff have respiratory symptoms and a high temperature or do not feel well enough to carry out their normal activities, they should avoid contact with other people – in line with the guidance for people with symptoms of a respiratory infection including COVID-19
• confirmed cases of flu or COVID-19 should avoid contact with other people

• when recommending outbreak control measures, consider the wider impacts on children and young people, staff, and the setting

• if children and young people, or staff, have respiratory symptoms and a high temperature or do not feel well enough to carry out their normal activities, they should avoid contact with other people – in line with the guidance for people with symptoms of a respiratory infection including COVID-19 - confirmed cases of flu or COVID-19 should also avoid contact with other people
• consider the wider impacts on children and young people, staff, and the setting when recommending outbreak control measures

What has changed

This guidance has been updated to:

• reflect the publication of the multi-agency contingency plan for the management of outbreaks of communicable diseases or other health protection incidents in prisons and other secure settings in England. Section on outbreak management  has been removed and a link to the new communicable disease outbreak guidance has been inserted.
• include information and guidance on the RSV vaccination programme

Who this guidance is for

This guidance provides operational recommendations to assist residential and healthcare staff, commissioners and providers in the CYPSE, and UKHSA HPTs.

The CYPSE may be considered higher risk for transmission of infection and poor outcomes. This is because:

• of the enclosed nature of the CYPSE and the fact that children and young people are often living close together and mixing with adults who work there or visit, with social mixing during activities
• children and young people in the CYPSE have a higher prevalence of long-term conditions (such as asthma) than their peers in the community
• staff who regularly move between the community and PPDs are a potential source of infection between the settings

During ARI outbreaks, children and young people in the CYPSE should receive the same healthcare as their peers in the community. This includes access to therapies, such as flu antiviral treatment, when appropriate, delivered by NHS commissioned services and in line with national guidance.

It should also be recognised that there are multiple competing priorities that exist during an ARI outbreak in the CYPSE that may influence the ability to implement control measures. For example, a child who is required to self-isolate may be at increased risk of self-harm. Therefore, consideration of alternative approaches that take these competing priorities into account are needed.

Definitions

Acute respiratory illness (ARI)

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, RSV, adenovirus, rhinovirus, parainfluenza and human metapneumovirus (hMPV).

Outbreak of ARI

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 children and young people displaying symptoms of ARI at the same time who are linked by personal contact.

Flu, RSV, and COVID-19 vaccination

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

Find information and resources relating to eligibility, ordering, prescribing and delivering vaccines at the following:

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

The COVID-19 booster and annual flu vaccinations can be given safely at the same time.  RSV guidance advises that pregnant girls can also receive the RSV vaccine at the same time.

Flu, RSV, and COVID-19 vaccination for children and young people

Healthcare teams should offer the annual flu and COVID-19 booster vaccinations to eligible children and young people. All school-aged children (including secondary school-aged children) are eligible for the annual flu vaccine. Staff involved in delivery of the vaccine should ensure they are aware of the eligibility criteria for the current flu season, which is updated each year. CYPSE care teams should encourage children and young people to take up the offer and support them to access the vaccinations to protect themselves. This is also an opportunity to encourage all children  and young people to make sure they are up to date with their routine vaccination schedule.

Only children and young people at increased risk from COVID-19 are eligible for the COVID-19 booster. Staff involved in delivery of the vaccine should ensure they are aware of the eligibility criteria.

• Healthcare teams should offer the RSV vaccination as per the RSV vaccination guidance. The vaccine should be offered to all pregnant girls from 28 weeks’ gestation.

Flu vaccination for staff

All staff based in the CYPSE should be offered the annual flu vaccine. Employers should encourage staff to take up offers of flu vaccination to protect themselves and  those who may be at increased risk of illness in the CYPSE.

Employers should tell staff how to access vaccines as follows:

• youth custody services (YCSs) - all staff, including non-directly employed staff, can access a free annual flu vaccine if they are not eligible for the free NHS flu vaccine. Staff should check with their onsite Immunisation Coordinator for details of how to access vaccination
• secure training centres (STCs) - residential and care staff should be offered the flu vaccine via their operator
• secure children’s homes (SCHs) and secure schools - staff should be offered the flu vaccine through relevant occupational health services or as children’s homeworkers

COVID-19 vaccination for staff

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

RSV vaccination for staff

Employers should encourage eligible staff to take up the offer of the RSV vaccination.

 The vaccine should be offered to:

• all pregnant women from 28 weeks’ gestation

The RSV vaccine should be offered throughout the year as this is a year-round programme.

Further information is available in the RSV vaccination guidance.

Recognising and responding to cases of ARI

ARIs are common in children and young people, particularly during the winter months.

All staff should be aware of the symptoms of ARIs in children and young people and should be advised to quickly report possible cases to the healthcare team.

Residential and care staff often have the most contact with children and young people, so are well-placed to recognise an increasing number of cases.

Symptoms of ARI

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

The CYPSE should contact their HPT if they observe signs of severe disease resulting from respiratory infection. This includes instances such as hospital admission for a child, young person, or staff member, or if there is a rapid increase in the number of children displaying symptoms, suggesting a potential outbreak.

Managing cases of ARI

Follow the general guidance for children and young people who have symptoms of a respiratory infection. The guidance recommends that:

• children and young people with mild symptoms (for example runny nose, sore throat, or slight cough) who are otherwise well can continue with their usual routine
• children and young people who have symptoms and who are unwell and have a high temperature should be supported to stay away from others, in a single room accommodation as far as possible. They should be clinically assessed by the healthcare team if staff or the child or young person are concerned about their health
• children and young people can resume normal activities when they no longer have a high temperature and are well enough to participate in normal activities
• all children and young people with symptoms should be encouraged to cover their mouth and nose with a disposable tissue when coughing and/or sneezing and to wash their hands after using or disposing of tissues

Staff with symptoms and a high temperature or who do not feel well enough to carry out normal activities should follow the guidance for people with symptoms of a respiratory infection including COVID-19.

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.

Treatment and care

Most children will recover from an ARI within a few days.

When flu is suspected or confirmed, healthcare staff should use flu antivirals to treat children and young people who are eligible for flu antivirals according to National Institute for Health and Care Excellence (NICE) guidance for treating flu and UKHSA guidance on using antivirals. UKHSA recommends considering antiviral treatment even if the child or young person has been vaccinated.

If the individual is eligible for COVID-19 treatments, refer to the guidance on testing and accessing treatments immediately below.

Testing to identify the cause of infection

Testing is only recommended if it is required for clinical management (for example a child or young person is symptomatic and eligible for COVID-19 treatment), or if there is an ARI outbreak in which it is important to identify the cause of infection and guide management - see the section on outbreak management below.

Children and young people eligible for COVID-19 treatments

Staff should identify any children and young people who are eligible for COVID-19 treatments and ensure they can access COVID-19 testing, if required. The healthcare provider should keep a stock of LFD tests for this purpose. They can be purchased via NHS Supplies or from the usual pharmaceutical wholesaler.

If a child or young person is eligible for COVID-19 treatments and is experiencing COVID-19 symptoms (even if the symptoms are mild), they should be supported to take a lateral flow device (LFD) test immediately, have a clinical assessment and follow the guidance for those eligible for COVID-19 treatments, which advises on the use of further LFD tests. They should also follow the guidance for a person who tests positive for COVID-19, below.

A child or young person in the at-risk group for COVID-19 treatments who tests positive for COVID-19 should be urgently referred to the local Integrated Care System’s (ICS) COVID-19 therapeutic service. The healthcare service should have a referral pathway in place for these cases. If the service access details are not known, NHS 111 can provide information for the referral to the local service.

The service will arrange for the child or young person to be assessed, and prescribed and supplied with a COVID-19 treatment. Note that if the child or young person requires parenteral treatment, they will need to be urgently transferred to a hospital or clinic to receive the treatment. Close collaboration with between healthcare services and custodial teams is needed to facilitate a prompt transfer in these cases . 

If the LFD test results are negative, the child or young person can return to their usual activities once they do not have a high temperature and are well enough to do so.

Positive test result for COVID-19 or flu in children and young people

Where possible, and balanced against an assessment of other health and wellbeing needs, children and young people with confirmed flu or COVID-19 should avoid contact with other people for 3 days from the date when the test was taken. They can return to normal activities after 3 days if they feel well enough and no longer have a high temperature.

The benefits of isolating the child or young person to protect others from infection should be weighed against the impact on their mental health and wellbeing. Factors to consider include the presence of others in the setting who are particularly susceptible to severe disease if infected, and the risks from isolation, such as self-harm. The local HPT will be able to provide support with a risk assessment if required.

Positive test result for COVID-19 or flu in non-healthcare staff

Staff with confirmed flu or COVID-19 should stay at home and avoid contact with other people. Staff with a positive COVID-19 test should follow the guidance for what to do if you have a positive COVID-19 test result.

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).

Healthcare staff who test positive for COVID-19

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 for surveillance purposes

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

To support CYPSE settings in being able to meet their Regulation 4A duty, the UKHSA multiple registration spreadsheet will remain available for CYPSE settings to report COVID-19 LFD test results. 

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 , as detailed in the section above.

Limiting the spread of ARIs and preventing ARI outbreaks

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

Vaccination

As outlined above, all eligible children and young people and staff are strongly encouraged to be vaccinated to protect themselves and others from flu and COVID-19.

Ventilation

Bringing in fresh air to occupied spaces can help to reduce the risk of transmission of infection. Improve ventilation where it is possible to do so and where appropriate security can be maintained. See further guidance on how to ventilate indoor spaces.

Hand and respiratory hygiene

Hand hygiene is important for preventing infections from spreading. Suitable hand washing facilities should be available including running water, soap and paper towels or hand-drying facilities. Children and young people should be encouraged to clean their hands after coughing, sneezing, or blowing/wiping their nose. Tissues should be made readily available where safe to do so, to encourage children and young people to cough and sneeze into a tissue to prevent spread to others.

Hands should be cleaned after removing personal protective equipment (PPE) or handling contaminated surfaces or laundry. If permitted, hand sanitiser can be used for hand cleaning as it is effective at reducing the spread of ARI.

Cleaning

ARIs 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, sneeze or touch them.

Regular cleaning can help reduce the risk of spreading infection. In healthcare rooms and areas, follow the national healthcare cleanliness standards  which specify a minimum of daily cleaning to maintain optimal hygiene levels. In non-healthcare areas of the setting, the following is applicable.

For routine cleaning (not during an outbreak), standard cleaning products such as detergents are adequate.

If a child or young person has an ARI, use chlorine-based products at 1,000 parts per million (ppm) available chlorine or other products effective against respiratory viruses to disinfect their environment, including the room, bathroom and shower room. Products that contain both detergent and chlorine may be used to give a measured dose of chlorine in solution, following manufacturer instructions, for a one-stage clean and disinfection .

Frequently touched surfaces, such as door handles, light switches, work surfaces, remote controls and electronic devices, should be cleaned regularly with compatible cleaning products. This is especially true in communal bathrooms and communal kitchens.

Cleaning should be more frequent depending on the number of people using the space, whether they are entering and exiting the setting, and whether they have access to handwashing and hand-sanitising facilities, as appropriate.

Waste

Waste visibly contaminated with respiratory secretions from a person with a suspected or confirmed infection should be sealed in a waste bag before removal from the accommodation and placed into a waste bin as soon as possible. If clinical or offensive waste bins are available these can also be used. 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.

Hand hygiene should be performed after handling waste.

Laundry

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

Clothes, bedding, towels, or other laundry items that have been used by someone with an ARI can be washed with other people’s items. All used linen items should be removed one by one and placed with care into the dedicated used linen hamper/stream. To reduce the risk of self-contamination, do not shake used laundry prior to washing.

Hand hygiene should be performed after handling used linen.

Visitors

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

Whether visits should proceed when the child or young person is unwell should be assessed on a case-by-case basis. A visit to an unwell child or young person could be facilitated by asking the visitor(s) to wear a face mask, comply with hand hygiene practices during the visit and ensure the venue is well ventilated.

Outbreaks

Contacting the local HPT

If an outbreak is suspected, contact the local HPT.

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

• there is a high severity of illness amongst the staff, children and young people in the setting, including hospitalisation or a death
• there is a rapid increase in the number of individuals with symptoms
• there are children and young people at high risk from severe illness
• a flu outbreak is suspected, either because flu is clinically suspected or national or local surveillance indicators suggest that there is flu in circulation

Testing to identify the cause of infection in an outbreak

Testing to determine the cause of the outbreak should only be carried out on the advice of the HPT. Following a risk assessment, the HPT may advise the use of multiplex PCR to test a small number of symptomatic individuals (usually up to 5 linked cases with most recent symptom onset) for different ARIs.

HPTs and/or the outbreak control team (OCT) will consider the need for any additional testing if an outbreak is confirmed. If settings are advised to do testing in response to an outbreak, they will be expected to record the results and provide a summary to the HPT.

Outbreak management

Full details on the principles of managing any health protection incident or outbreak in a secure setting, including the establishment and role of the Incident Management Team (IMT) are available in the Management of incidents and outbreaks of communicable disease in secure settings guidance). This guidance includes specific considerations for institutions within the CYPSE.

Management of additional cases

During the outbreak, staff with symptoms who require clinical care should be managed by their GP. Children and young people with symptoms and who are unwell should be seen by their healthcare team.  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.

Asymptomatic contacts

There is no need for contacts of (suspected or confirmed) cases of flu or COVID-19 to undertake testing.

Where multiple children and young people have had close contact and one is suspected or confirmed as having flu, their contacts can pose an infection risk. This is because they could have asymptomatic infection. Where children and young people stay in small groups or ‘cohorts’, the same may apply to the whole group or cohort.

Depending on the specific circumstances of the outbreak, including the size of the institution, the severity of the cases, the presence of people at higher risk of severe infection and the impact on staffing, the OCT may consider additional actions such as reducing social mixing or a proportionate reduction in daily activities for close contacts.  

Practical operational considerations, such as the number of spare rooms available, will inform any decisions about whether individuals may need to be moved to another location.

Antiviral treatment for flu

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

UKHSA recommends considering flu antiviral treatment for eligible children and young people even if they are vaccinated. 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), to treat individuals with flu.

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

In line with the above guidance, if a child or young person with symptoms of flu meets the criteria for receiving antivirals, and the diagnosis of flu is 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 children, young people 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 children and young people in clinical risk groups in affected parts of, or throughout, the setting.

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).

HMPPS provides a flu antiviral advice line for HMPPS employees.

Prescribing and accessing antivirals

CYPSE 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).

Healthcare staff should record all supplies of flu antivirals given to children and young people in their clinical records. They may be able to give the antiviral ‘in-possession’ (where the child or young person keeps the medication in their room) subject to an individual risk assessment and the policy of the individual secure setting.

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.

A prescription can be issued for the flu antiviral by a prescriber at the establishment, via the child or young person’s registered GP or via out-of-hours NHS services.

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 are 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 children and young people should be accessed from the setting’s contracted pharmacy.

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

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

There are multiple competing priorities that exist during an ARI outbreak in the CYPSE, such as balancing the risk of control measures with the risks to the mental health and wellbeing of children and young people or risking unintended changes in the setting that could increase levels of violence or self-harm. Therefore, any proposed control measures need to take these competing priorities into account.

Where an ARI outbreak has been declared, the governor, director or manager of the estate and the UKHSA consultant in health protection leading the OCT should complete a dynamic risk assessment. The assessment should balance the risk of infectious diseases against other risks.

Infection prevention and control (IPC)

During outbreaks, the importance of hand and respiratory hygiene should be re-emphasised among children, young people, staff and visitors.

Staff should follow the guidance for preventing and controlling infections in children and young people’s settings.

If a case needs to pass through communal areas, then they should consider wearing a fluid repellent surgical mask or face covering if appropriate and available.

Enhanced cleaning

During outbreaks, use chlorine-based products at 1,000 parts per million (ppm) available chlorine, or other products effective against respiratory viruses, to disinfect the environment, including shared areas. 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. Frequently touched surfaces, such as door handles, light switches, work surfaces, remote controls and electronic devices, should be cleaned regularly with compatible cleaning products. This is especially true in communal bathrooms and communal kitchens.

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

Laundry

If water-soluble (alginate) bags are available, use these to transport laundry from the case’s accommodation to the washing machine.

Visiting

Visitors should be made aware of existing outbreaks prior to attending, so they can make an informed decision about whether to visit. Those that decide to visit should be provided with hand and respiratory hygiene advice and encouraged to wear a face covering.  

Where possible, children and young people who have a high temperature and are too unwell to undertake usual activities should be supported to receive visits from close family/friends, if they wish these to go ahead, while reducing contact with other people as far as possible. Non-urgent professional visitors should be advised of the situation and a risk assessment should be undertaken to consider whether: the visit can be safely undertaken; should be rescheduled until after the outbreak is over; or whether the visits can be conducted virtually.

Population management

Full details on population management in the event of a health protection incident or outbreak in a CYPSE setting can be found in the Multi-agency contingency plan for the management of outbreaks of communicable diseases or other health protection incidents in prisons and other secure settings in England.

Transfers to court

In an outbreak situation, symptomatic children and young people may not be suitable for court due to clinical needs and infection control considerations. The court should be informed that a child or young person is ill with an ARI (or a specific pathogen if this has been diagnosed) and so may not be suitable for a court appearance.

Courts should consider a video link as an alternative to a personal appearance if a symptomatic child or young person needs to attend court.

If a personal appearance is required, appropriate infection prevention and control measures should be implemented following guidance to help court and tribunal users reduce the risk of catching an infectious disease.

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.