Guidance

Management and prevention of group A Streptococcus (GAS and iGAS) wound infections in prescribed places of detention

Updated 27 March 2026

1. Who this guidance is for

This guidance is intended to support a collaborative approach to prevention, diagnosis and management of group A streptococcal (GAS) infections in secure settings including prisons and prescribed places of detention (PPD).

This guidance is targeted at:

• prison and other PPD settings healthcare staff
• national and regional NHS England (NHSE) Health and Justice commissioners
• UK Health Security Agency (UKHSA) regional health protection teams
• UKHSA Health and Justice Team

The settings in England covered by this guidance include:

• prisons and young offender institutions (YOIs) with residents aged 18 and above
• approved premises (APs)
• IRCs and residential short-term holding facilities (maximum stay for 7 days) and residential holding rooms (maximum stay for 96 hours)

It supersedes the previous guidance published by Public Health England (PHE) in 2019 and is intended for use in England only.

This guidance should be considered in conjunction with:

• Guidelines for prevention and control of group A streptococcal infection in acute healthcare and maternity settings
• Management of incidents and outbreaks of communicable disease in secure settings in England
• UK guidelines for the management of contacts of invasive group A streptococcus (iGAS) infection in community settings
• Infection prevention and control guidelines for adult prisons

2. What has changed since this guidance was last updated

The guidance has been updated to:

• align the guidance with organisational changes (PHE to UKHSA) and style format
• focus on infection control and case management of GAS and iGAS infections in PPD settings
• align the isolation and exclusion requirement for cases to 24 hours as recommended in other UKHSA GAS guidelines (community, healthcare and maternity settings)
• remove the requirement for infection typing unless in outbreak conditions or where a risk assessment has been conducted by health protection teams (HPTs)
• align with the latest infection prevention control (IPC) guidance for adult prisons

3. Background

3.1 Overview

GAS infections can lead to a wide range of diseases, presenting as non-invasive infections such as scarlet fever, pharyngitis and impetigo or invasive ones like necrotising fasciitis, bacteraemia or streptococcal toxic shock syndrome.

Wound infections are common among people in prison and often associated with injecting drug use, tattooing, or other causes of skin injury, including violence and self-harm. However, not all wound infections are caused by GAS.

Invasive GAS (iGAS) is defined as the isolation of GAS from a normally sterile body site. Clinical presentations are varied and include skin or soft tissue (for example cellulitis, necrotising fasciitis), joint (septic arthritis), respiratory (pneumonia) and non-focal bacteraemia. iGAS infections are associated with a high case fatality rate. Prompt recognition and early treatment are essential given the potentially rapid progression of infection. Evidence suggests that outbreaks of iGAS are known to occur in institutional care settings. Further epidemiological information, including case definitions, is available in Invasive group A streptococcal disease: managing close contacts in community settings guidance and an evidence review published in 2025.

4. Roles and responsibilities

The management of GAS incidents and outbreaks in secure settings requires close collaboration between all system partners, who are each responsible for different aspects of management within a secure setting. An overview of the roles and responsibilities of system partners is provided in Management of incidents and outbreaks of communicable disease in secure settings.

5. Recommendations

Controlling the spread of infection in PPDs will depend on the coordinated efforts of both health and custodial staff working with UKHSA HPTs to apply the general approach summarised below:

1. Healthcare teams should ensure that swabs are taken from all patients with skin and soft tissue infections in PPDs and sent for analysis to local microbiology services.

2. Clusters of GAS infection and single cases of iGAS infections identified in PPDs should be promptly notified to local HPTs by healthcare and samples should be forwarded for typing to the national reference laboratory by local microbiology teams. Please refer to the National infection prevention and control manual (NIPCM) for staff in NHS settings and Infection prevention and control guidelines for adult prisons for non-healthcare settings for further information on infection prevention and control.

3. HPTs may declare a formal incident or an outbreak control response to enable and support coordinated, collaborative efforts across organisations to achieve infection control, following national guidance.

4. Custodial or detention staff should work together with healthcare teams in PPDs to identify new clusters of GAS infection or single cases of iGAS infections, their subsequent isolation, clinical assessment and treatment.

5. Cell or room sharers should be provided with information about the signs or symptoms of GAS and iGAS, and be encouraged to contact Healthcare for assessment and swabbing (throat swabs and skin lesions or wounds) if they have symptoms.

6. Healthcare or UKHSA health protection staff should consider undertaking a detailed risk-assessment for all new cases (clusters of GAS infection or single cases of iGAS infections) identified in PPDs. Consider using a questionnaire, available from local HPTs, to collect information related to patients’ engagement in PPD activities, particularly gym and work, and other associated risk factors. Review and consider any known cases of or scarlet fever links in visitors, staff and other personnel to identify potential sources of infection.

7. Notify any care givers, such as prison nurses and contacts of cases as they may be a reservoir of infection.

8. Management and Healthcare staff should work with regional HPTs and UKHSA’s national Health and Justice team to implement infection control measures, balancing public health risks with operational pressures on the PPD and the wider secure estate.

Public health action is required when cases of GAS or iGAS infections in wounds are reported in PPDs to ensure adequate case management and prevent spread of infection. This document is divided into 3 sections detailing specific actions recommended for:

• healthcare staff
• the custodial service (prison and immigration detention settings)
• the wider public health response system, such as local HPTs and microbiology services

5.1 Recommendations for healthcare staff

5.1.1 Case identification and assessment in PPDs

A case is defined as an individual who has an iGAS infection, which is defined as the detection of group A streptococcus (GAS), by culture or accredited molecular methods (such as polymerase chain reaction - PCR), from a normally sterile body site, such as blood, cerebrospinal fluid, joint aspirate, pericardial peritoneal-pleural fluids, bone, endometrium, deep tissue or deep abscess at operation or postmortem. For the purposes of these guidelines, it also includes severe GAS infections, where GAS has been isolated from a normally non-sterile site such as throat, sputum, vagina or wound in combination with a severe clinical presentation, such as streptococcal toxic shock syndrome (STSS), necrotising fasciitis, pneumonia, septic arthritis, meningitis, peritonitis, osteomyelitis, myositis, and puerperal sepsis.

All staff should be alert to the enhanced risk of wound infections in high-risk groups including:

• people who inject drugs (PWID) or those using other illicit drugs
• people with mental health issues at risk of self-harm
• people experiencing homelessness
• transfers from other PPDs with declared outbreaks of GAS infection

All staff should be extra vigilant with any transfers from specific wings with outbreaks and conduct a risk assessment as required.

Cases may be identified by notifications received from custodial or detention staff or local routes of access in individual PPD settings. The general approach outlined below can be followed to assess all potential cases in PPDs with additional information provided for specific groups (for example, transfers from establishments with reported clusters of infection) and for different stages of reception health screening.

5.1.2 Clinical assessment and management

Any prisoners or detainees showing signs or symptoms consistent with invasive infection should be urgently reviewed by a doctor and/or arrangements made for referral to Accident and Emergency (A&E) for assessment if signs of sepsis are present.

For incident management purposes in PPDs, wounds are defined as acute or chronic breaks in the skin, recent tattoo or injecting sites or sites of self-harm or injury.

A short clinical history should be taken to determine whether wounds are recent, if any associated systemic symptoms present, as well as to identify any possible risk factors (for example, risk behaviours, environmental (including participation in specific PPD regime activities, such as using the gym], close contact with other known cases). The management of the wound should be in line with normal clinical practice, including the decision to prescribe antibiotics at time of presentation, guided by the local microbiology department’s antibiotic treatment protocols and the National Institute for Health and Care Excellence (NICE) guidance on antimicrobial stewardship and wound management.

It is essential to seek consent from individuals prior to sample collection, such as taking swabs. For individuals who lack capacity to consent and adhere to oral chemoprophylaxis, for example those with dementia, discuss with the local microbiologist whether alternative regimens are available and could be administered, with appropriate delegated consent.

All wounds identified should have a sample of fluid taken from the wound bed using a moist swab, then cleaned and covered with a semi-permeable dressing. Throat swabs should also be taken. Staff collecting swabs should clean their hands and wear gloves as per either the IPC or NIPCM guidance.

Samples must be sent to local microbiology services for testing with information indicating if part of a confirmed or suspected outbreak [including Case and Incident Management System (CIMS) and Incident Log (iLOG) numbers if available]. Providing these numbers will ensure a transparent audit trail and better case management. To expedite sample processing, verbal notifications or discussions with the receiving laboratories are encouraged to provide context and awareness. Microbiology results should be followed up to ensure that patients with positive culture results receive appropriate treatment without delay as guided by the local microbiology department’s antibiotic and treatment protocols and antibiogram for the isolate, noting the potential for resistance to second line agents. A single course of antibiotics is not always sufficient, and consideration should be given for re-swabbing post treatment as per national iGAS guidelines.

5.1.3 Epidemiological information gathering

Details of cases of iGAS and outbreaks of GAS, including date of onset, date of reception into current prison, symptoms of illness and if cell or room-sharing with another case should be recorded by the prison healthcare team and reported to the responding HPT.

A questionnaire developed by UKHSA and available from local HPTs can be used to facilitate this process. The assessment should consider:

• the patient’s movements in the 7 days prior to symptom onset; if new to the prison, note residential history (for example, hostel, homeless, fixed address) or name of previous PPD; if current resident note cell or room movements and any cell or room sharers
• participation in PPD activities; in particular, participation in high-risk activities for transmission of infection such as needle use, exercise (for example, use of gym or sports facilities and sharing towels), employment (for example, kitchen or laundry staff), religious or cultural (for example, use of prayer rooms), education or training and others (for example, peer mentoring)
• associated risk factors: intravenous drug use or other illicit drug use, engagement in tattooing while resident in the PPD, self-harming, contact with other infected or high- risk persons and external visitors. Consider also if they have been in contact with healthcare workers providing wound care to other individuals who might have an infection

Clusters of GAS wound infections and/or incidents of invasive GAS infection identified in PPDs should be notified to local HPTs and UKHSA Centre Health and Justice leads as soon as possible in line with IPC guidance.

5.1.4 Transfers from establishments with reported clusters of GAS infection

Clear and timely communication between sending and receiving prisons about the transfer of individuals from sites that have experienced outbreaks is essential, particularly as not all cases will result in Incident Management Meetings (IMT) or Outbreak Control Meetings (OCT) where information can be discussed. PPDs admitting persons without signs of infection from establishments with declared outbreaks should be notified to this effect. Healthcare in the receiving establishment should be made aware of these individuals in line with the outbreak management guidance to enable appropriate assessment of any wounds if needed. For new prisoners, Healthcare should follow routine procedures for reception screening.

1. Reception screening

Assess for any signs of wound infection on entry to the establishment and before allocation to a cell/room.

At reception screening, undertake assessment for any wounds, skin lesions or sore throat and swab accordingly as described above before allocation to a cell or room. If required, wounds should be covered with an appropriate dressing.

Ideally, patients presenting with wounds could be allocated to single cell or room accommodation if available and if first night isolation poses no risk to their mental wellbeing. For more information, please refer to the Section 3 of the IPC guidelines.

If the patient is not reporting any symptoms, then isolation is not necessary unless swab results are returned as positive. Where symptoms are present, proceed as per clinical management advice detailed in Clinical assessment and management.

2. Secondary screening (up to 7 days from reception)

Follow-up on any skin or soft tissue wounds identified at reception screening, check for signs of new or worsening infection and review microbiology results for patients who were swabbed. Positive microbiology results should be actioned as per control measures stipulated in section 5 of national iGAS guidelines.

Plan a follow-up healthcare review at a suitable time based on clinical judgement, considering the length of sentence.

5.1.5 Isolation and cohorting of cases

Cases should be isolated in single cell accommodation until 24 hours of compliance with antibiotic treatment.

The complexity of symptoms and treatment will inform duration of isolation, and an individual risk assessment should be undertaken with input from custodial or detention staff to account for safeguarding and security considerations.

Isolation of cases in single accommodation is advised given the high likelihood of cross-transmission of infection to asymptomatic cellmates.

5.1.6 Treatment

Infections should be treated by clinicians with appropriate antibiotics, including topical treatments, based on microbiology results. Consider a discussion with the microbiology team about treatment alongside the iGAS guidelines. Refer to section 2 of the national iGAS guidelines when making a recommendation on the choice of antibiotics. Completion of antibiotic treatment is important to prevent re-infection, onward spread to other people and antimicrobial resistance. Ensure adherence to NICE guidelines for dosage and agents, particularly if a second line agent is used.

5.1.7 Infection control measures in PPDs

 All staff should be familiar with and follow proper hand hygiene protocol as described in either the IPC or NIPCM guidance. For further information on infection control measures, please refer to the IPC guideline.

Healthcare staff should request that PPD custodial staff ensure that all prisoners are provided with access to hand soap in their cells, particularly for infected patients. They should also request access to facilities to enable enhanced personal hygiene and good wound care (see access to showers in Isolation and cohorting of cases in Recommendations for PPD custodial staff).

Healthcare staff and patients should ensure that wounds are appropriately dressed and covered.

Infected patients may need to attend PPD Healthcare facilities for wound dressings and the administration of medications. A risk assessment should be undertaken to determine the most appropriate setting for wound dressings. Patients should either be brought to healthcare facility alone and last on the list to facilitate cleaning of the healthcare environment or if this poses other risks, dressings may be undertaken in the cell if the environment is cleaned as per the standards for environmental cleanliness and equipment cleaning in place in the healthcare setting.

5.1.8 Restrictions on movement of people in prison or detainees

It is advisable that cases are not transferred to other prison establishments until at least 24 hours of antibiotic treatment has been completed. Inappropriate medical holds (holds longer than 24 hours after commencement of antibiotic treatment) are discouraged and will require individual risk assessment and agreement from both the PPD governor or director and population management unit before they can be enacted.

No regime restrictions are normally necessary for individuals post 24 hours antibiotic treatment with appropriately dressed wounds, however, healthcare staff should consider the implementation of additional isolation protocols in case of non-compliance with prescribed antibiotics. Please refer to the IPC guidance for further information.

5.2 Recommendations for PPD custodial staff

All staff should ensure they follow infection prevention measures as recommended in the IPC guideline, such as the use of appropriate personal protective equipment (PPE). All reception custodial staff should be alert to the enhanced risk of wound infections in PWID or those using other illicit drugs, people with mental health issues at risk of self-harming, people experiencing homelessness, admitted from the community and transfers from other PPDs with declared clusters of GAS infection.

5.2.1 Reception screening

Persons presenting to reception staff with visual signs of wound infection should be referred to Healthcare immediately for appropriate follow up at the next clinical opportunity; all information relating to prisoners’ or detainees’ health is confidential and must be dealt with in the strictest confidence.

5.2.2 Isolation and cohorting of cases

All cases should be isolated until 24 hours after the commencement of treatment or per directions received from healthcare. Isolated cases should take all their meals in their cell or room and not in communal dining areas during the isolation period. Healthcare workers or prison or centre staff can enter the room to administer treatment, bring food and beverages, change linen, or for other necessary activities.

Given the high risk for the cross-transmission of infection, patients should not participate in gym activities or sports where there is prolonged skin-to-skin contact unless their wounds are covered adequately (seek advice from Healthcare if in doubt). It is advisable that cases are not transferred to other prison establishments until 24 hours of compliance with antibiotic treatment.

No regime restrictions necessary for non-infected individuals with appropriately dressed wounds.

Regular access to shower facilities by isolated cases will be important to manage infection. Where the isolation cell or room does not have adjacent bathing facilities, the case should use the nearest facilities separately before or after the block or wing prisoners or detainees have showered. If the isolation room does not have adjacent toilet facilities, a toilet should be designated for sole use by the case, wherever possible. Contact with other prisoners or detainees en route to the toilet should be avoided.

Isolated prisoners or detainees with infections will need to receive regular changes of their bed linen and towels and discouraged from sharing these with others. Bed linen and towels used by cases should never be used by other prisoners. Staff should ensure bed linen and towels are changed when prisoners are moved from cells to ensure new residents have unused supplies. Laundry arrangements are addressed in the IPC guidance.

5.2.3 Infection control measures in PPDs

Refer to Infection control measures in PPDs for information on enhanced personal hygiene.

Any staff presenting with signs or symptoms of wound infection, or throat infection, should seek medical attention immediately and be excluded from work until no longer infectious. They should advise their general practitioner (GP) of occupational risk and appropriate swabs should be carried out to determine if GAS is the cause of the symptoms.

Staff and other persons, particularly those with cleaning or washing duties, should familiarise themselves with the general environmental cleaning protocols as outlined in the Infection prevention and control guidelines for adult prisons guidance. All laundry staff should be familiar with protocols as outlined in the Infection prevention and control guidelines for adult prisons guidance.

5.2.4 Considerations for restrictions on movement of people in prison or detainees

On the recommendation of the outbreak control team (OCT), it may be advisable to restrict social mixing of prisoners or detainees between wings with high and low numbers of cases, or wings with medically vulnerable individuals to limit cross-transmission of infection, dependent on both operational and security risk assessments.

Restrict PPD activities such as those listed in Epidemiological information gathering that could result in cross-contamination of infection until 24 hours after the commencement of antibiotic treatment.

It is advisable that cases are not transferred to other prison establishments until 24 hours of compliance with antibiotic treatment. No regime restrictions are necessary for non-infected individuals with appropriately dressed wounds.

5.2.5 Restrictions on visits

With consideration for patient welfare, visitor access to people in prison or detainees who are symptomatic should be kept to a minimum during the isolation and exclusion period.

All visitors should be provided with hygiene advice whilst ensuring patient confidentiality is maintained. Additionally, they should be provided with the iGAS information leaflet for awareness and self-monitoring for 30 days. Symptomatic visitors should avoid visiting the PPD.

If practicable, non-urgent visits should be rescheduled until 24 hours after patient compliance with antibiotic treatment and following an individual risk assessment by Healthcare. Legal visits may be a requirement if preparing for court and alternatives to face-to-face meetings (for example, via tele or videoconferencing) should be explored wherever possible. Refer to the IPC guideline for further information.

Prisoners with effectively dressed wounds but no signs of infection can continue to receive visitors.

5.3 Recommendations for the wider public health response system

5.3.1 Assessment

An outbreak is defined as 2 or more cases of probable or confirmed GAS or iGAS infection related by person, place and time. Outbreaks or clusters identified in PPDs should be notified to HPTs who will take necessary actions as per the outbreak management guidance. Prison leads are asked to raise awareness with prison healthcare to inform clinical investigation and ensure prompt reporting to HPTs.

5.3.2 Implications for microbiology services

Microbiologists should be alert to the increase in GAS in PPDs and ensure that all iGAS isolates are referred to UKHSA Colindale for emm typing and notify the local HPT. Non-invasive GAS isolates from suspected outbreaks in prison settings should also be sent to the Streptococcal Reference Laboratory in Colindale. Referral forms for these isolates should be clearly labelled with details such as prison name and the prison postcode to prioritise testing. Typing of these isolates will be free to NHS users. Microbiologists should alert their local HPT when they become aware of an apparent increase in non-invasive GAS or other bacterial disease.

6. Supporting evidence

The updates in this guidance are based on expert opinion and alignment with current case and incident management of GAS infections in other settings.

7. Further information

As infection can be spread through close personal contact and environmental contamination, particularly in shared facilities such as like gyms and showers or bathing facilities, it is important to consider reviewing current infection control practices to ensure they follow national guidance for prescribed places of detention (PPD).

Wound infection information pamphlets for people in prison have also been co-produced by UKHSA and HM Prison and Probation Service (HMPPS) for distribution in affected prisons. A similar pamphlet aimed at prison staff has also been produced and can be obtained on request from HMPPS Occupational Health services.

Multiple confirmed or probable cases of GAS wound infections, for which concerns have been raised by healthcare or invasive GAS infections should be notified by prison or immigration removal centre (IRC) healthcare teams as soon as possible to local HPTs.

Find your local team contact details online.

8. Feedback

Feedback

You can provide feedback on the Management and prevention of group A Streptococcus (GAS and iGAS) wound infections in prescribed places of detention at  healthequityinclusionhealth@ukhsa.gov.uk or by completing the short survey:

9. List of contributors

Editorial team

• Funke Usikalu, Public Health Registrar, UKHSA Inclusion Health Team
• Anjana Roy, Public Health Consultant, UKHSA H&J Team

Members of Health and Justice Task and Finish Group on GAS and iGAS in PPD

• Anjana Roy, Public Health Consultant, UKHSA - Chair
• David Tate, Consultant in Public Health Infection, UKHSA
• Elizabeth Smout, Consultant in Health Protection, UKHSA
• Lucy Thomas, Public Health Consultant, UKHSA
• Tanith Palmer, Consultant in Health Protection, UKHSA
• Theresa Lamagni, Lead Scientist and Head of Gram-Positive Team, UKHSA
• Memona Paracha, Health Equity and Inclusion Health Officer, UKHSA – Secretariat Support
• Sarah Dowle, Principal Health Protection Practitioner, UKHSA
• Steve Wilner, Health and Justice Episcientist, UKHSA

Wider stakeholder consultees prior to finalising guidance

• Abi Hamoodi, Head of Public Health, HMPPS
• Denise Farmer, National Pharmaceutical Adviser Health and Justice, NHS England
• Emily Nichol, Senior Policy Lead, Health and Justice Children Programme, NHS England
• Elizabeth Taylor-Diparno, NHSE National Lead for Specification 29 (Section 7A)
• Esther Taborn, Infection Prevention and Control Consultant Nurse, UKHSA
• Ian Palmer, Public Health Manager, H&J Team
• Lucy Harries Principal Public Health Manager, Children & Young People UKHSA
• Marina Sanchez-Perez, Senior IPC Clinical (Nurse) Specialist, UKHSA
• Mattea Clarke, Consultant in Health Protection, South East Health Protection Team (Thames Valley)
• Samihah Moazam, Consultant Health Protection, Cheshire & Lancashire HPT, UKHSA
• Stephanie Davis, Senior Infection Prevention and Control Clinical (Nurse) Specialist, UKHSA
• Susan Howes, Consultant in Health Protection, East Midlands Health Protection Team
• Susan Mein, Head of Safeguarding, UKHSA
• Terry Gibbs, Healthcare and Safer Detention Lead, Home Office Immigration Enforcement
• NHSE Health and Justice team
• UKHSA Health Protection Team Health and Justice Network