Guidance

Preventing and controlling outbreaks of COVID-19 in prisons and places of detention

Updated 15 March 2021

Please note

This guidance is of a general nature and should be treated as a guide. In the event of any conflict between any applicable legislation (including the health and safety legislation) and this guidance, the applicable legislation shall prevail.

What you need to know

• any prisoner or detainee with symptoms of coronavirus (COVID-19), should be placed in protective isolation for at least 10 days (in accordance with relevant powers). Arrangements should be made to have them tested for the infection immediately
• any member of staff or visitor who develops symptoms of COVID-19 should be sent home and they should arrange to have a test. They should follow the Stay at home guidance
• if a member of staff lives in a household where someone else is unwell with symptoms of COVID-19 then they must stay at home and follow the Stay at home guidance
• possible and confirmed cases of COVID-19 amongst prisoners, detainees or staff should be notified by prison or prescribed place of detention (PPD) healthcare teams as soon as possible to local Public Health England (PHE) Health Protection Teams (HPTs)
• prisoners or detainees, members of staff and their household contacts, who are clinically vulnerable or clinically extremely vulnerable, should be supported as they follow the recommendations on social distancing and shielding
• prisoners or detainees and members of staff should be reminded to wash their hands more frequently with soap and water for at least 20 seconds, or use hand sanitiser, and catch coughs and sneezes in tissues
• objects and surfaces that are touched regularly should be frequently cleaned and disinfected using standard cleaning products
• prisoners or detainees who have symptoms of COVID-19 but are clinically well enough to remain in the PPD do not need to be transferred to hospital
• people whose illness requires assessment, treatment or care that cannot be provided in the PPD may be transferred to appropriate healthcare facilities with usual escorts and following advice on safe transfers
• staff should wear specified personal protective equipment (PPE) for activities requiring sustained close contact with possible or confirmed cases (see below for detail)
• staff should follow social distancing guidelines (when not performing duties requiring close contact), maintaining 2 metre distance from other members of staff and prisoners or detainees wherever possible
• in the event of a suspected outbreak of COVID-19 in a PPD, the first step is for the PPD leader to refer to the local HPT in line with outbreak control plans that are in place for all infectious diseases
• PPD leaders should be assessing their estate for suitable isolation and cohorting (such as a gathering of potentially infected cases or vulnerable groups into a designated area) provision

Background

This guidance will assist custodial, detention and healthcare staff in addressing COVID-19 in PPDs. It provides operational recommendations to assist staff, local PHE HPTs and other stakeholders in the event that an incident or outbreak of COVID-19 is reported in a PPD.

The following establishments in England are included within the definition of PPDs used in this guidance:

• prisons (both public and privately managed)
• immigration removal centres (IRC)
• children and young people’s secure estate (CYPSE) young offender institutions (YOI), secure training centres (STC) and secure children’s homes (SCH)

Recommendations made here may also be relevant to Prison Escort and Custodial Services (PECS) staff, particularly environmental cleaning recommendations and advice to staff. Controlling the spread of infection and managing outbreaks in PPDs will rely on coordinating healthcare and custodial staff working with HPTs and other stakeholders at both the local and national level. Other stakeholders may include:

• NHS England and Improvement Health and Justice Commissioners
• the Home Office
• establishment managers and their teams
• the Population Management Unit and others

PHE HPTs are advised to convene an incident or outbreak control team (ICT/OCT) in response to notification of a possible, probable incident or outbreak of COVID-19 to ensure effective management in a complex environment across different organisations mindful of operational, logistical and security challenges of outbreak management in PPD.

PHE’s National Health and Justice Team will provide expert advice and support to responding ICT/OCTs, conduct surveillance at national level, share intelligence with key partners, and develop national guidance for use in preventing and managing outbreaks.

This guidance may be updated in line with the changing situation.

Symptoms

The most important symptoms of COVID-19 are recent onset of any of the following:

• a new continuous cough
• a high temperature
• a loss of, or change in, your normal sense of taste or smell (anosmia)

For most people, COVID-19 will be a mild illness. However, if anyone has any of the symptoms above they must be isolated and testing arranged.

What to do if someone develops symptoms of COVID-19 in a PPD

In PPD settings, possible cases are likely to be identified by:

• custodial and detention staff
• other prisoners or detainees
• self-referral
• at reception screening or through other means

All staff should be alert to prisoners or detainees who have symptoms of COVID-19, and the prisoner/detainee should be placed in protective isolation (in accordance with relevant powers) in single occupancy accommodation (for example a cell or detention room) for at least 10 days and be tested for COVID-19.

Prisoners or detainees who have had symptoms of COVID-19 may end isolation after 10 days and return to their normal routine if they do not have symptoms other than a cough or a loss of, or change in, their normal sense of taste or smell, as these symptoms can last for several weeks after the infection has gone. If a prisoner or detainee still has symptoms other than cough or loss of sense of smell or taste after 10 days or longer, they must continue to isolate until they feel better. The ending isolation section in the Stay at home guidance has more information.

If single occupancy accommodation is not available, possible cases should be held alone in higher occupancy accommodation, or where demand exceeds capacity, cases may be cohorted together. The prisoner or detainee should wear a surgical face mask while being transferred to an isolation room. Escorting staff should follow the latest guidance on PPE and follow handwashing instructions.

Where there are 2 or more prisoners or detainees in a cell or room and one develops symptoms or is confirmed to have coronavirus, those prisoners or detainees sharing the room may be at risk of COVID-19 infection and should also be isolated away from the general prison population in accordance with relevant powers for 10 days.

Practical operational considerations will inform whether that means they stay where they are or can be moved to another location away from the unwell cell or room-mate. All PPDs should have a plan in place identifying an appropriate place to isolate prisoners or detainees with symptoms, preferably with input from an infection control specialist.

If appropriate, access to a language-line, or similar translation service, must be provided as soon as a person with possible or confirmed COVID-19 infection enters the establishment. This will ensure an accurate history can be taken.

Prisoners or detainees who have symptoms of COVID-19, but who are clinically well enough to remain in the PPD, do not need to be transferred to hospital.

People in protective isolation should have regular opportunities to discuss any anxieties with a member of staff. It is important to be aware of people who have underlying co-morbidities and fall into clinically vulnerable or clinically extremely vulnerable categories for COVID-19, as they are at higher risk of deteriorating, needing closer monitoring or hospital admission.

Where possible, any assessment should be done without entering the cell or room. Detailed guidance for prison healthcare on the management of COVID-19 in secure environments is available from the Royal College of General Practitioners (see ‘Secure Environments’ tab and select ‘COVID-19 Guidance for healthcare in secure environments’).

Healthcare staff are most likely to work directly with people with symptoms of COVID-19. Custodial staff, PECS and transport services may also be engaged especially when symptoms first present. Those who are clinically unwell and require hospitalisation should be transferred to appropriate healthcare facilities following safe escort and transfer protocols for the establishment.

Staff should wear appropriate PPE. The prisoner or detainee should be offered a surgical face mask to be worn during transportation, if tolerated, to minimise the dispersal of respiratory droplets. Staff at the receiving destination must be informed that the patient has possible or confirmed COVID-19. Prisoners or detainees presenting with symptoms of COVID-19 should be tested (swabbed) by healthcare staff wherever possible. The local HPT can provide additional advice on local testing capacity and procedures.

PPDs are high-risk settings for COVID-19. Given the high-risk setting, it is important to interpret negative results in symptomatic prisoners with caution and a clinical assessment should be undertaken before they are released from isolation. Prisoners who test negative but continue to have symptoms of COVID-19 should stay in isolation for at least 10 days from symptom onset. Their close contacts should complete their 10 day isolation period following discussion with the HPT.

If a member of staff has helped someone who was taken unwell with symptoms of COVID-19 they do not need to go home unless they develop symptoms themselves or have been advised to do so by the local HPT or NHS Test and Trace system.

If a member of staff becomes unwell with symptoms of COVID-19, they should be sent home immediately, follow the Stay at home guidance, self-isolate for at least 10 days from first onset of symptoms and arrange a test.

Staff without symptoms of COVID-19 but who share a household with symptomatic or confirmed cases of COVID-19 must follow guidance to stay home and self-isolate for 10 days.

Given the high-risk setting, it is important to interpret negative results in symptomatic staff with caution and a clinical assessment should be undertaken before they start working. Staff who test negative but continue to have symptoms of COVID-19 should stay home for at least 10 days from symptom onset and should only return to work after that if they feel well enough to do so.

HPTs will contact PHE’s National Health and Justice Team and Centre Health and Justice leads in response to cases (possible and confirmed) in PPDs. The HPT and the National Health and Justice Team will decide whether to declare a formal incident and respond accordingly. This will support efforts across organisations to achieve infection prevention and control following the national contingency plan for outbreaks in PPDs.

As infection can be spread through both personal contact and environmental contamination, it is important to consider reviewing current infection prevention and control practices to ensure they follow national infection prevention and control guidance for PPDs.

Cohorting of symptomatic, clinically vulnerable and newly received detainees

Cohorting is a public health strategy for the care of large numbers of people who are ill, or who are vulnerable and present heightened risk of severe disease if infected. Cohorting involves gathering these groups of people together into a limited number of areas and establishing effective barrier control between these groups and the wider population.

Cohorting strategies should consider arrangements to protect those at risk of severe illness from COVID-19 (those who are clinically vulnerable and clinically extremely vulnerable), measures to isolate those who are symptomatic (and any cell or room-sharers) and provision to hold newly received prisoners or detainees separated from the main population. To minimise the risk to other prisoners or detainees during periods of sustained community transmission of COVID-19, all new and transferred prisoners or detainees should be isolated. This may entail compartmentalising establishments into at least 3 separate areas to achieve distance between those who are symptomatic, those newly arriving, and those who are most vulnerable in every PPD.

Where PCR testing on day 0/1 and day 5 to 7 is in place for new entrants, the prisoner or detainee may move out of isolation following 2 negative test results. If this falls before day 10 the prisoner or detainee should complete the remainder of the 10 days away from the general population, if possible (ie in a single cell). If testing on reception is not available or the prisoner or detainee refuses the test they must complete 14 days isolation.

Prison Governors, Directors and IRC Managers must survey their establishments for suitability for cohorting and conduct risk assessments on the co-location of people who would normally be kept separated. These leaders will also be able to provide details on the cohorting of individuals in their specific establishment. Plans to implement cohorting should be developed in conjunction with appropriate clinical and specialist public health advice.

Staff overseeing a cohorted population should limit movements to other parts of the PPD to avoid widespread transmission of infection. Where staff movement is unavoidable it should be minimised, and extra care taken to ensure that good hand hygiene and general cleaning and PPE measures are strictly adhered to (see below).

Transition of prisoners or detainees to the community

All individuals should be seen by healthcare services as part of normal preparations for release. Cases cannot be detained beyond their tariff.

Where applicable, the local HPT must be made aware of any cases or close contacts of known cases that are returning to the community (particularly those with no fixed abode) before completing a full period of protective isolation, for example at least 10 days for cases or 10 days for close contacts. The local authority must be made aware of any cases or close contacts of known cases with no fixed abode. People returning to the community need to be prepared and understand the actions required of them once in the community to reduce risks from COVID-19, including knowledge of social distancing and measures to take if they are in a clinically extremely vulnerable group.

Probation services and approved premises/hostels should also be advised to facilitate appropriate self-isolation if the person is symptomatic, or has had a positive test for COVID-19, or has had contact with a confirmed case.

Cleaning and waste

Guidance on cleaning and waste disposal is available.

Advice on the use of PPE for healthcare staff and custodial or detention staff

Staff should minimise any non-essential contact with possible or confirmed COVID-19 cases. Healthcare staff are most likely to work directly with such patients, and custodial staff, PECS and transport services may also be engaged especially when symptoms first present.

For activities requiring close contact with a possible or confirmed case of COVID-19, for example, patient assessment, interviewing people at less than 2 metres distance, or arrest and restraint, PHE guidance on PPE should be adhered to. For all staff, PPE must be changed regularly, depending on the nature of the activity and local context. An activity/context specific table summarising the recommended PPE for use by healthcare and custodial staff in PPDs is available for quick reference.

All used PPE must be disposed of as clinical waste. Scrupulous hand hygiene is an important component of infection prevention and control measures and essential to reduce cross-contamination and infection.

Limiting spread of COVID-19 in PPDs

Managers of PPDs can help reduce the spread of COVID-19 by ensuring adherence by all to best practice infection prevention and control and reminding everyone of available public health advice. Resources including posters, leaflets and other materials are available.

Keeping staff and prisoners or detainees socially distanced is helping limit the spread of COVID-19:

• staff should wear specified PPE for activities requiring sustained close contact with possible or confirmed cases
• staff and prisoners or detainees should be reminded to wash their hands with soap and water for 20 seconds more frequently than normal and to cover their mouths and noses with disposable tissues when they cough or sneeze. Dispose of tissues into a disposable rubbish bag. If they do not have a tissue, remind them to sneeze into the crook of the elbow, not into the hand and immediately wash hands with soap and water for 20 seconds or use hand sanitiser
• objects and surfaces that are touched regularly must be frequently cleaned and disinfected, using standard cleaning products

What to do if an outbreak of COVID-19 occurs in a PPD

An outbreak is defined as 2 or more prisoners or detainees or staff in the PPD who meet the case definition for COVID-19 or have a positive test result and among whom transmission was likely to have occurred within a 14-day period. In the event of a suspected outbreak of COVID-19 in a PPD, the first step is for the PPD leader to refer to the local PHE HPT in line with outbreak control plans that are in place for all infectious diseases.

Stakeholders responding to outbreaks must work through the formal structure of the OCT as detailed in the multi-agency contingency plan for disease outbreaks in PPDs. On advice from the OCT, an outbreak can be declared over 28 days after symptom onset in the last case or 28 days after the last positive test result, whichever is later. This refers to anyone working or living in the setting.

Testing (swabbing) of some or all prisoners or detainees and staff may be necessary when an outbreak has been declared, whether they are symptomatic or not. Following a risk assessment, the OCT will advise on an appropriate testing strategy.

A dedicated unit or area for the temporary isolation of cases who are unwell may be designated within the establishment to facilitate better monitoring or access to health services for these patients (also refer to cohorting recommendations).

Population management during an outbreak of COVID-19 in a PPD

Where an outbreak has been declared, the Governor or Manager should inform the HMPPS National COVID-19 reporting system (or equivalent in other PPD) in the first instance who will engage with the Population Management Unit through command arrangements. A dynamic risk assessment form should be completed by the Governor or Manager and the PHE Consultant in Health Protection leading the OCT. Outbreaks should be reported to HMPPS/Home Office by telephone in addition to written reports.

The OCT may consider recommending:

• restricting transfers out to other PPDs: this is to avoid seeding an outbreak in another PPD. Where required for security reasons, the receiving PPD should be notified of the outbreak. Avoid transferring symptomatic prisoners or detainees as a priority. All infection control advice should be followed if transfer is required
• restricting new receptions: this is to avoid feeding an outbreak by introducing new vulnerable cases to the PPD. If not possible to restrict completely, new receptions should be:
  • assessed to determine if they are in a high-risk clinical group
  • assessed for signs and symptoms of COVID-19, and any symptomatic new arrivals should be isolated/cohorted immediately

Note: From April 2020, routine inter-prison transfers have been discontinued by HMPPS. Movement of prisoners can proceed through exceptional arrangements agreed by HMPPS national command. It is not known at the time of writing how long these arrangements will continue.

Court appointments during an outbreak of COVID-19 in a prison

Courts should be informed of an outbreak of coronavirus in a prison and symptomatic patients should not attend court. Courts should be advised that a prisoner or detainee is ill with symptoms of COVID-19 as soon as possible and therefore may not be suitable for court appearance.

Video link to court should be the preferred method for undertaking a court appearance for all prisoners at this time.

Any court transfers of asymptomatic prisoners that cannot be avoided must follow safe escort and transfer protocols for the establishment and make reasonable consideration of community social distancing measures. If the person is remanded in custody in a different prison, the receiving prison should be notified of the outbreak in the original prison and advised to be alert to signs and symptoms of COVID-19 developing. A note should be placed on SystmOne for healthcare teams.

If the courts have allocated prisoners or detainees to a site affected by COVID-19 redirection to an establishment without an outbreak should be considered. In some circumstances and based on an establishment’s function, this may not be sustainable for more than a few days at most.