Guidance

Investigation and management of outbreaks of suspected acute viral respiratory infection in schools: guidance for health protection teams

Updated 6 September 2022

Summary of changes from 2021 influenza-like illness (ILI) guidance

Section	Change	Author or version
Glossary and note on terminology	New section added	3
1. Executive summary	Addition of contingency framework link and actions for school’s link to end of summary	3
1. Executive summary	Inclusion of epidemiological thresholds and definitions thresholds for outbreak management and escalation	3
1. Executive summary	Removal of COVID-19 guidance references to be read in parallel. Replaced with signposting to health protection guidance on education and childcare settings	3
3	Change of approach to COVID cases and outbreaks	3
4	Update in cluster and outbreak definitions	3
4. Definitions	Inclusion of broad ARI definition	3
4. Definitions	Incorporation of COVID-19 definition into ARI definition	3
5.1	WHO reference for influenza incubation period	3
6.1	Department for Education reference added.	3
6.2	Removal of COVID-9 testing protocols	3
6.3	Addition of thresholds for convening OCT	3
7	Change of approach to contact tracing in schools and contact isolation	3
7.1	Removal of COVID-19 specific guidance; signpost to school’s health protection guidance	3
7.2	Key response measures in line with living with COVID-19	3
7.4	Removed; Key response measures; contacts	3
Appendix 1	Bullet point reformat	3
Appendix 3 (previous)	Previous Appendix 3 removed as no longer relevant; replaced with contributor appendix	3
Appendix 3 (current)	Appendix of version contributors	3
References	Removed all references, apart from paper journals. Replaced with hyperlinks. Many covid references have been removed all together	3
Throughout	Removing reference numbers in text, and replace with hyperlink	3
Throughout	Removed sections relating to COVID-19	3

Glossary and note on terminology

‘Pupil’ should be read as pupil, student, or child depending on the context.

‘School’ is also used to mean college and nursery.

1. Executive summary

This document provides guidance for local health protection teams (HPTs) about assessing and managing outbreaks of suspected acute viral respiratory infection (ARI) in schools and colleges including special educational needs. Approaches to response, including recommendations on testing, may have applicability in related settings such as early years/nurseries and school holiday clubs.

Every autumn and winter, seasonal influenza viruses and other respiratory viruses like rhinovirus and respiratory syncytial virus (RSV) cause school outbreaks. Since early 2020, SARS-CoV-2, the novel coronavirus that causes coronavirus disease (COVID-19), has been in circulation within the UK, and has led to cases and outbreaks linked to schools. All these viruses can present with similar symptoms and so it is essential that suspected ARI outbreaks in schools are investigated and managed appropriately.

Central to the approach to this setting, is the communication of key preparedness messages to schools, including awareness of arrangements for reporting of outbreaks to local HPTs, exclusion advice for unwell children (which will vary depending on the respiratory diagnosis), as well as the national childhood immunisation programmes such as that for influenza.

Schools are experienced in management of cases of childhood respiratory viruses. Schools may escalate concerns to HPTs if they have concerns related to:

• a higher than previously experienced and/or rapidly increasing number of pupil or staff absences due to acute respiratory infection
• evidence of severe disease due to respiratory infection, for example, if a pupil or staff member is admitted to hospital
• a cluster of cases where there are concerns about the health needs of vulnerable staff or students within the affected group, including special educational needs schools
• control of transmission in boarding or residential school environments

Epidemiological definitions of cases and outbreaks are primarily used for surveillance purposes and should not be taken as indicating thresholds for HPT referral or public health action.

A key intervention to limit the transmission of flu in schools is to ensure successful delivery of the childhood influenza immunisation programme in eligible year groups. In influenza outbreak situations, antivirals may also be considered for unvaccinated exposed children in clinical risk groups, in line with national guidance, such as that published by the National Institute for Health and Care Excellence (NICE) and the UK Health Security Agency (UKHSA).

The main guidance relating to specific situations which should be read in parallel with this guidance includes UKHSA guidance on health protection in schools and other childcare facilities (for example, for exclusion advice).

Separate considerations will apply for residential educational settings and special schools (see Appendix 1 and Appendix 2).

2. Background

Seasonal influenza, COVID-19 and other acute respiratory infections may transmit rapidly between children of school age, prompting the occurrence of localised outbreaks within schools. It is important to note that localised influenza outbreaks in school settings may precede circulation of seasonal influenza in the wider population. Co-circulation of multiple viruses is possible in a school or community. Other common viruses causing acute respiratory infection in children include RSV, rhinovirus and parainfluenza.

Symptoms of acute viral respiratory infections (see Definitions) in children are difficult to distinguish between causative agents. Public health virological testing is not routinely undertaken for school outbreaks but may be considered by the consultant in health protection or other senior health protection staff if circumstances suggest utility. For a subset of more complex ARI outbreaks, such as: i) those involving children in clinical risk groups in special schools, or ii) when there is a high attack rate, iii) multiple cohorts are affected, iv) there are reports of hospitalisations or deaths; HPTs should pursue rapid multiplex testing for a range of respiratory viruses (for example, SARS-CoV-2, influenza A, influenza B, and RSV). This will provide useful information for the management of these outbreaks but will also provide important intelligence for surveillance purposes.

Influenza and COVID-19 vaccines are offered to many children by the NHS. Schools may have a direct role in facilitating delivery, including promotion, of influenza vaccination for their pupils. The national flu immunisation programme letter includes detailed information on plans for the forthcoming season. The childhood influenza vaccination programme which has undergone a phased introduction since 2013, is now an integral part of the national seasonal influenza vaccination programme.

As in previous influenza seasons, seasonal influenza vaccination is also available for individuals aged 6 months and older in clinical risk groups, as specified in the Green Book and the national flu immunisation programme letter. National recommendations on childhood COVID-19 vaccination are summarised in the Green Book.

HPTs should be aware that when they receive a report of acute respiratory infection in school-age children during the influenza season, some of those in the affected school may have already received seasonal influenza vaccination.

3. Preparedness measures

Achieving high uptake of the seasonal childhood influenza vaccination programme in schools is a key component of influenza preparedness. The aim is to reduce the public health impact of flu by:

• providing indirect protection by interrupting flu transmission from children and averting cases of severe flu and flu-related deaths in older adults and people in clinical risk groups
• providing direct protection to children, helping to prevent a large number of cases of flu in children

Research by the UK Health Security Agency (UKHSA) suggests that co-infection of both flu and COVID-19 is associated with a greater risk of more severe illness and death in adults (1). Therefore, during the winter season, influenza vaccination will be even more important in reducing related morbidity and mortality.

Many schools have existing arrangements to identify acute respiratory infection among pupils, such as monitoring of related absences. Schools should be aware of the most up to date information on local mechanisms for seeking advice in relation to observed increases of acute respiratory infection, including risk assessment of potential outbreak situations. Response arrangements will continue to be reviewed during the COVID-19 pandemic. However, in most localities this will involve the local health protection team (HPT).

Schools may also be aware of individual pupils who are in clinical risk groups (as part of the schools’ health and welfare arrangements), and this information will be important for the rapid provision of information to families of these children during an outbreak.

It is useful for schools to be signposted to guidance on health protection in schools and other childcare facilities, including exclusion advice, prior to the beginning of the influenza season.

4. Definitions

The term acute respiratory infection (ARI) includes presentations both of influenza-like illness (ILI) and other acute viral respiratory infections (AVRI). Other causal pathogens can include SARS-CoV-2, RSV, adenovirus, rhinovirus, parainfluenza and human metapneumovirus (hMPV).

See Appendix 1 and Appendix 2 for additional considerations in residential educational settings and special schools.

Epidemiological definitions of cases and outbreaks are primarily used for surveillance purposes and should not be taken as indicating thresholds for HPT referral or public health action.

4.1 Symptoms of ARI

Symptoms of influenza, COVID-19 and other common respiratory infections can include:

• continuous cough
• high temperature, fever or chills
• anosmia, ageusia or dysgeusia (loss of, or change in, sense of smell or taste)
• shortness of breath
• malaise (unexplained tiredness, lack of energy)
• myalgia (muscle aches or pains that are not due to exercise)
• anorexia (not wanting to eat or not feeling hungry)
• headache that is unusual or longer lasting than usual
• sore throat,
• coryza (stuffy or runny nose)
• diarrhoea
• nausea or vomiting

4.2 Case definition for influenza-like illness (ILI)

Influenza-like illness (ILI) is defined in an education or early years setting as:

• acute onset of fever and
• acute onset of cough (in the absence of other diagnoses)
• if measured, fever is defined as ≥37.8°C

It is acknowledged that influenza may vary in presentation in children, such as without fever or with diarrhoea, among others. These would not meet the ILI definition above, therefore if there is a suspicion of influenza in such children with these other clinical presentations, they would only be regarded as a case with a positive laboratory testing result for influenza.

Other symptoms associated with influenza can include malaise (tiredness), headache, myalgia (muscle pain), diarrhoea, nausea/vomiting, sore throat and shortness of breath.

4.3 Case definition for confirmed influenza

A confirmed case of influenza is an individual with laboratory detection of influenza virus from a respiratory sample (usually a nose or throat swab).

4.4 Case definition for acute viral respiratory infection (AVRI)

Sudden onset of symptoms and at least one of the following 4 respiratory symptoms:

• cough
• sore throat
• shortness of breath
• coryza (nasal symptoms such as congestion or discharge)

With no non-infectious cause suspected.

4.5 Definition for acute respiratory infection (ARI) outbreak

A suspected ARI outbreak in a non-residential school or educational setting is defined as:

• the occurrence of 2 or more cases of ARI symptoms (including ILI or AVRI symptoms) within a 14-day period
• with an epidemiological link to the school or educational setting
• without laboratory confirmation

Epidemiological evidence of transmission within the school includes both cases having attended the school on at least one of the 7 days before onset in the absence of a known, alternative source of infection (for example, a household member reported to have influenza-like illness).

The epidemiological likelihood of a respiratory outbreak being due to influenza is increased if influenza has been declared to be circulating in the general community and particularly if there is evidence of local influenza transmission. Cases coming to the attention of school authorities and HPTs may not represent all cases as there may be unobserved transmission within school settings.

Epidemiological definitions of cases and outbreaks are primarily used for surveillance purposes and should not be taken as indicating thresholds for HPT referral or public health action.

For residential settings, assement should take into account residential geographies and other mixing patterns.

4.6 Definition for confirmed influenza outbreak

Two or more laboratory confirmed cases of influenza among individuals (students or staff) with an epidemiological link to the educational setting, arising within a single 7-day period.

4.7 Definition for other confirmed AVRI outbreaks

Two or more laboratory confirmed cases of the same AVRI pathogen (including any typing or sequencing, if done) among individuals (students or staff) with an epidemiological link to the educational setting, arising within a single 14-day period.

4.8 End of cluster or outbreak

The end of a test-confirmed influenza outbreak is defined as a single 7-day period following symptom onset of the last outbreak case, during which there are no new cases of ILI or confirmed influenza cases within the same school group.

The end of an ARI outbreak where influenza has not been confirmed by laboratory testing is defined as a single 14-day period following symptom onset of the last outbreak case, during which there are no new cases of ARI within the same school group.

5. Epidemiological parameters

5.1 Influenza

Incubation period: The median incubation period of influenza is 2 days (range 1 to 4 days).

Infectious period: For influenza the period of infectiousness (that is communicability) starts with the onset of ILI symptoms and lasts for the duration of symptoms.

5.2 COVID-19

Incubation period: The median incubation period of COVID-19 is 5 days (range 1 to 14 days).

Infectious period: The infectious period is from 2 days prior to symptom onset (or 2 days prior to positive test if asymptomatic) and extend for up to 10 days post onset of symptoms (or positive test date if asymptomatic).

5.3 Other common respiratory viruses

These include:

• respiratory syncytial virus (RSV)
• rhinovirus
• adenovirus
• parainfluenza
• human metapneumovirus

All may have similar symptoms to other ARI.

Incubation periods vary between respiratory viruses, but are usually between 12 hours and 5 days, extending up to 8 days for RSV and parainfluenza.

6. Investigation of outbreaks

6.1 Risk assessment

When an ARI outbreak is initially notified to an HPT, the information listed in section 6.1.1 below will be useful to inform a risk assessment. This will help the HPT conduct an assessment of the likelihood of influenza and COVID-19, the severity and extent of the outbreak, and guide control measures. Equivalent local checklists may be deployed. This information should be captured on the HPT’s outbreak or situation record. It is appreciated that schools commonly experience periods when respiratory viruses readily circulate amongst their children and staff, and respond to these within their usual practices. School management are most likely to contact HPTs when they have specific concerns such as high absence rates, severe cases, or setting specific concerns such as as residential or special need.

6.1.1 Information to be collected in the event of an ARI outbreak

6.1.1.1 Information about the school or educational setting:

• details of the contact person at the school, including their job title and direct contact number
• size of the school (number of staff and number of pupils), and the size of cohorts affected (for example, classes or year groups) if the illness is limited to specific cohorts
• type of school: day pupils only, boarders or both (see Appendix 1)
• whether the school is for pupils with special educational or disability needs (SEND) or whether there are SEND pupils within the mainstream school (see Appendix 2)
• dates of childhood influenza vaccination and coverage rates in the school students and staff, if relevant and readily available

6.1.1.2 Characteristics of the outbreak:

• nature of the symptoms
• number of cases among students and staff affected, both clinically suspected and laboratory confirmed (including specific laboratory results such as influenza subtype, if known)
• distribution of cases over time, including onset date of the first and most recent cases, and according to class or year group
• number of hospitalisations, ICU admissions and deaths associated with the outbreak
• information on whether there are any children or staff in clinical risk groups in the school, if known

6.1.1.3 Current control measures:

• current infection prevention and control measures
• actions taken in response to suspected outbreak
• communications with the school community to date

6.2 Laboratory investigation

Any sampling that is undertaken to identify the causative organism for an ARI outbreak in a school (other than COVID-19) should be informed by national and local surveillance data.

Routine virological investigation of school ARI outbreaks is not essential for every outbreak but should be considered in:

• outbreaks involving significant numbers of children in clinical risk groups, such as in some special schools
• complex outbreaks, such as those involving high attack rates, multiple cohorts, prolonged outbreak duration, reported hospitalisations, critical care admissions or deaths among school children or teachers

Laboratory confirmation of influenza in particular is most useful in the inter-seasonal period and early in the influenza season, when national surveillance schemes have not yet confirmed that influenza is circulating widely in the community. During these time periods, other respiratory viruses may be as likely as seasonal influenza to cause ILI presentations and so there is a role for laboratory confirmation to inform the risk assessment and subsequent public health advice for individuals in risk groups who may benefit from antivirals.

Testing for respiratory viruses

When complex ARI school outbreaks arise, the HPT should consider testing symptomatic individuals for a broad range of respiratory viruses including influenza A, influenza B, SARS-CoV-2 and RSV.

When swabbing is indicated HPTs should work with local system partners to arrange multiplex testing through local swabbing arrangements, including NHS and UKHSA laboratories as appropriate to their local context. This will provide useful information for the management of these outbreaks but will also provide important intelligence for surveillance purposes.

Sampling should be undertaken as close as possible to illness onset (and no more than 7 days after onset). Those aged 11 years or less should be swabbed by a parent or guardian, while self-swabbing can be considered for children and young people 12 years and older. When considering multiplex testing, it is particularly useful if swabs can be returned via a central point to the diagnostic laboratory (as per local arrangements) so that transport of samples can be co-ordinated and the timeline for reporting of the overall results can be estimated.

Further advice on testing during outbreaks can be sought from the local public health laboratory in the first instance. Local arrangements should be made with the regional laboratory for rapid turnaround of testing in response to outbreak investigation.

Expert epidemiological advice can be sought from the national flu team, for example, if wider testing is being considered to better understand the epidemiology of the outbreak.

During the winter, there may be simultaneous circulation of multiple pathogens within a single ARI outbreak.

6.3 Declaration of outbreak

Local HPT risk assessment as above will inform a decision as to whether the situation meets the definition of an outbreak (see section 4. Definitions).

Once an outbreak has been declared, local stakeholders (for example, directors of public health and local authority public health teams) should be informed as per local protocols, and in line with the overall public health risk assessment. Where necessary (for example, complex situations, with large numbers of cases) an outbreak control team (OCT) should be considered.

Consider the need for an OCT if:

• there has been a death at the school or college
• there are a large number of vulnerable children
• there are a high number of cases
• the outbreak has been ongoing despite usual control measures
• there are concerns on the safe running of the school
• there are other factors that require multi-agency coordination and decision making

7. Outbreak control and communications

7.1 Infection control

Infection prevention and control (IPC) measures (where appropriate) should be implemented according to Health protection in schools and childcare.

7.2 Key response measures: cases

Cases with mild symptoms such as a runny nose, sore throat, or slight cough, who are otherwise well, can continue to attend their education setting unless directed otherwise by the HPT. There may be lower thresholds for self-isolation in an ARI outbreak.

Cases who are unwell and have a high temperature should stay at home and avoid contact with other people, where they can. They can go back to school, college or childcare when they no longer have a high temperature and they are well enough to attend.

Symptoms such as cough and anosmia can persist for weeks after the acute infectious episode and should not prevent return to school.

Those testing positive for COVID-19 should follow national guidance on preventing spread to others.

7.3 Communications

If applicable, the school should ensure effective communication to:

• raise awareness among parents and guardians of the ARI outbreak – this is often achieved through a written communication agreed and disseminated by the school through its existing mechanisms
• provide consistent messaging that symptomatic children should be excluded from school until theyare afebrile and well enough to attend
• publicising clear respiratory hygiene measures within the school such as regular handwashing and ‘Catch It, Bin It, Kill It’ type messages

7.4 Influenza antiviral treatment

Influenza antiviral treatment may be recommended for certain children during confirmed influenza outbreaks. Any decision to recommend influenza antiviral treatment:

• must be based on local risk assessment
• must be communicated clearly in outbreak-related communications to parents and guardians

Where influenza antiviral treatment is recommended, the local HPT may advise that:

• exposed children in clinical risk groups (see Green book chapter 19) who have not received seasonal influenza vaccination, or who received this vaccination less than 14 days prior to exposure, should be considered for antiviral prophylaxis with oseltamivir by a hospital health professional or paediatrician – this advice relates to exposure within the last 48 hours (or within 36 hours for zanamivir) if this risk assessment is likely to be feasible within this time period
• symptomatic children in clinical risk groups may be considered for antiviral treatment with oseltamivir within 48 hours of onset (or within 36 hours for zanamivir) in accordance with national guidance on influenza treatment and prophylaxis using anti-viral agents
• outside of the Chief Medical Officer (CMO) defined flu season, antivirals cannot be prescribed on the normal community prescription form (FP10 or electronic equivalent) but need to be prescribed on a Patient Specific Direction (PSD) (or could be a Patient Group Direction, PGD, for large groups). Local plans should be agreed in advance between the NHS clinical commissioning group (CCG) or Integrated Care System (ICS), the HPT and other relevant partners on how best to implement this and arrangements clearly communicated to all parties prior to the start of the flu season

When the number of children in clinical risk groups is thought to form a relatively small proportion of the school’s pupils and the CMO has not advised that antivirals may be prescribed in primary care, it may be possible for these to be prescribed by a hospital health professional such as a paediatrician. Consider writing a letter to parents or guardians to explain the situation. An alternative would be to telephone the parents directly, if this would expedite access to antivirals within the recommended time periods for starting prophylaxis (36 to 48 hours depending on the individual medicine).

Parents or guardians with an exposed child in a clinical risk group should then contact their specialist clinician looking after their child or be referred to paediatric Accident and Emergency (A&E) department to be considered for antivirals; the local HPT may need to facilitate this according to local processes. This is the preferable approach, as these health professionals will have the relevant medical history for these children.

If antivirals are indicated, the local HPT should discuss procurement with the local NHS commissioner as soon as possible.

The need for antivirals among staff in clinical risk groups should be addressed in a similar way to that outlined for children above.

7.5 Influenza vaccination

In a confirmed influenza outbreak, consideration should be given to wider influenza vaccination throughout the educational setting, especially in settings with low uptake of influenza vaccination to date.

The vaccination does not provide post-exposure prophylaxis. Two weeks are required for the immune response to vaccination to develop, and so this is unlikely to prevent secondary and tertiary cases. However, if an influenza outbreak is occurring in a school where flu vaccination has yet to be delivered, consideration may be given as to whether the vaccination session can be brought forward; this may help to prevent further transmission and shorten the duration of the outbreak. Local NHS services may also have catch up clinics that parents could be signposted to if the school vaccination session has been done and their child is not yet vaccinated.

7.6 Follow-up

Follow-up of individual outbreaks in schools should be undertaken according to local HPT processes.

Schools should be advised when to call the HPT, especially if there are any features of concern (such as those outlined for calling an OCT, see 6.3 Declaration of outbreak).

7.7 Temporary closure

It is anticipated that temporary closure of a school for public health reasons is likely to be an infrequent measure for ARI outbreaks. Any enquiry about potential closures on public health grounds should be discussed by the school management team directly with the local UKHSA HPT in the first instance, and school closure on public health grounds should be an OCT decision. Any decision to temporarily close for business continuity reasons, such as staff shortages, is a decision for the school management and local education authority, where applicable. However, it should be made clear to parents, guardians and staff that this decision has not been made on public health grounds.

7.8 Recording and surveillance

Outbreak reporting forms are not required for routine surveillance. Probable and confirmed outbreak surveillance data is obtained from HPZone. Information about acute viral ARI outbreaks in schools where the causative agent is identified should, in the first instance, be recorded on HPZone as per routine practice and data captured in the HPZone metrics when possible rather than as free text (see section 6.1.1). These data will then be extracted by the national surveillance team and reported on in the weekly surveillance reports.

References

1. Stowe and others. ‘Interactions between SARS-CoV-2 and influenza, and the impact of coinfection on disease severity: a test-negative design.’ International Journal of Epidemiology 2021: volume 50, issue 4, pages 1,124 to 1,133

2. Johnson and others. ‘Seroepidemiologic study of pandemic (H1N1) 2009 during outbreak in boarding school, England.’ Emerging Infectious Diseases 2011: volume 17, number 9

3. Chaves and others. ‘Patients hospitalized with laboratory confirmed influenza during the 2010-11 influenza season: exploring disease severity by virus type and subtype.’ The Journal of Infectious Diseases 2013: volume 208, pages 1,305 to 1,314

4. Keren and others. ‘Neurological and neuromuscular disease as a risk factor for respiratory failure in children hospitalized with influenza infection.’ Journal of the American Medical Association 2005: volume 294, number 17

Appendix 1. Additional considerations for residential educational settings

Transmission of respiratory viruses can be rapid in boarding schools and other residential educational settings, with high attack rates (2).

As a closed setting, for these settings:

• transmission may vary according to individual boarding houses, so extra sampling of symptomatic persons in different boarding houses should be considered, following discussion with the local Public Health Laboratory
• ensure a consistent case definition is used with healthcare providers and a consistent method of monitoring number of cases is agreed from the outset
• clarify seasonal influenza vaccination provision and uptake among pupils
• if the school hosts international students, determine if onset has occurred within 2 to 3 days of arrival from a foreign country
• consider if exclusion from the school is possible - if this is not possible, then advise restriction within residential accommodation until asymptomatic
• primary care health professionals assessing suspected or confirmed cases should advise the local NHS trust in relation to the outbreak, if referred for investigation, so that appropriate infection prevention and control measures can be taken
• maintain awareness of the possibility of other respiratory infections, and consider using locally agreed arrangements to swab up to 5 symptomatic cases in the inter-seasonal period or early in the influenza season, to inform risk assessment and outbreak management

Appendix 2. Additional considerations for special school settings

Special educational needs and disabilities (SEND) include 4 different areas of need, including communicating and interacting; cognition and learning; social, emotional and mental health difficulties and sensory or physical needs.

Many children and young people with special educational needs and disabilities have one or more conditions which place them at increased risk of severe influenza infection, and as such are likely to be members of clinical risk groups. Examples of relevant conditions include, but are not limited to, cerebral palsy, hydrocephalus, neuromuscular diseases (for example, spinal muscular atrophy, Duchenne muscular dystrophy) (3, 4).

Therefore, an influenza outbreak in a special school setting, where a significant proportion of the learners are members of clinical risk groups, has the potential for serious clinical illness.

Rapid public health intervention following a thorough risk assessment, is therefore justified in relation to outbreaks in such settings. Confirmation of the causative organism by rapidly testing recent symptomatic cases for COVID-19, influenza and other respiratory viruses can be useful to inform management. Advice on consideration of antivirals where influenza is strongly suspected or laboratory confirmed can be obtained from the UKHSA Clinical and Public Health Group, as required.

In order to support rapid public health action, when the CMO has advised that seasonal influenza is circulating in the community, local NHS commissioners should determine if central distribution of antiviral treatment or prophylaxis in confirmed influenza outbreaks would be more practicable than individual children’s families contacting their specialist health professionals and paediatric A&E. When flu is not circulating, the local HPT will need to work with NHS commissioners to identify alternative mechanisms for accessing and prescribing antivirals for treatment or prophylaxis in a timely way.

Individual children with special needs, attending other settings (for example, mainstream schools), should receive information as outlined in the control measures section. Centralised prescribing and distribution may not be required, as there may be a smaller number of children in clinical risk groups in these settings.

Appendix 3. Contributors

Version 3.0 was reviewed and updated in 2022 by Conall Watson in consultation with health protection and child public health specialists and the UKHSA Immunisation and Vaccine-preventable Diseases Division Influenza Scientific Advisory Forum.

Fernando Capelastegui provided scientific secretariat support.