Seasonal flu in prisons: the importance of vaccination coverage

Prevention and management of infectious disease is a key priority in prescribed places of detention (PPDs) where outbreaks can have a significant impact not only on the health of staff and detainees but also on the operational integrity of these settings. Previous experience has demonstrated that high vaccine coverage among vulnerable people and staff in PPDs can go a long way to preventing and/or controlling outbreaks of common infections like seasonal flu. In fact, PHE recommends the implementation of a seasonal flu vaccine campaign for vulnerable groups at risk of complications from flu in PPDs. Ideally, this includes holding a register of people in high-risk groups, those offered vaccine, and those vaccinated, thereby allowing an estimate of vaccine coverage to be calculated for the whole season or for points in time when there is an active outbreak. Flu vaccine should be offered before influenza viruses start to circulate to all prisoners/detainees aged 65 years or older and those in defined clinical risk groups as described in PHE seasonal flu guidance for PPDs.
 
The recent flu season (17/18) has been particularly impactful in the English and Welsh secure and detained estate, with a significant number of confirmed flu (both A and B) outbreaks reported, with some outbreaks running concurrently and some for several weeks. In total 18 confirmed outbreaks were reported, two of which were reported in prisons in Wales and three in immigration removal centres (IRCs). More than 250 prisoners and detainees reported influenza-like illness (ILI) and over 100 more were confirmed as having either influenza A or B, with about a dozen prisoners hospitalised following complications from flu. More than 80 members of staff were also affected and several hospitalised. Fortunately, despite the significant impact on the secure and detained estate, no one died secondary to their flu infection. Two outbreaks were also re-opened following recrudescence of infection in prisoners and/or staff shortly after they were declared closed.
 
The cumulative impact of so many outbreaks in PPDs resulted in more than 60 outbreak control team (OCT) meetings being convened and put substantial demands on the prison system and on responding PHE health protection teams (HPTs), prison healthcare teams and the National Health and Justice Team. Overall, a high degree of collaboration was observed between all partners and a sustained response was maintained throughout all outbreak periods. However, flu vaccine coverage varied across the prison estate with some affected prisons showing low coverage in vulnerable prisoner/detainee groups. A few protracted outbreaks, lasting more than two weeks, also had a high number of affected staff suggesting that community acquired infection by staff may have contributed to prolonging these outbreaks and that more stringent infection control measures should have been in place for this group.
 
During outbreaks the control team always endeavours to balance effective outbreak control with the operational needs of the PPD to protect health and avoid harm to both staff and detainees. The overall objective is to bring a flu outbreak under control quickly through rapid and effective action. This needs to take account of management of staff as well as prisoners/detainees.  Staff should be advised when there is an outbreak that if they become symptomatic with ILI that they should not report for work but inform line managers of illness. If they are themselves in high risk groups for complications of infection then they may require advice from their GP or Occupational Health Adviser. If they become symptomatic at work they should be sent home until fully recovered. To facilitate management of both staff and detainees, accurate and timely information is required to guide actions during an OCT and therefore daily line-listings of new cases provided by prison/IRC healthcare teams to regional health protection teams are necessary. Finally, for vaccine-preventable illnesses such as influenza, prisoners/detainees and staff groups in high risk groups for complications of influenza infection should be encouraged to take up offer of seasonal flu vaccine to prevent outbreaks, operational impact and illness.
 
While impactful, the last flu season also provides an opportunity for lessons learned from responding to demands in PPDs to inform planning for the 2018-19 flu season. As a rule of thumb, but particularly during periods of heightened flu activity, outbreak control team meetings should be convened as early as possible to assess the situation and agree on necessary infection control measures as early as possible thereby circumventing further transmission of infection and minimising health and operational impact. Healthcare teams in PPDs are also encouraged to have contingency plans in place at the local level to effectively manage any potential outbreaks. To this end, ‘desktop’ exercises simulating outbreak scenarios can go a long way to facilitate outbreak preparedness and ensure that things run smoothly during an actual outbreak, saving both time and resources. The key preventive and cost-effective approach to tackling flu in PPDs and other settings remains regular flu vaccination of older and clinically at-risk individuals and PPD healthcare teams should maintain up to date vaccination registers.

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