Strep A – Guidance on Management and Prevention in Prisons

On 12th June 2019, Public Health England issued further guidance around the management and prevention of bacterial wound infections in Prisons and Immigration Removal Centres.

This latest publication offers guidance for both healthcare and custodial staff along with those within the responding health protection services in managing and preventing the spread of skin and soft tissue infections. Within prisons and secure settings the most prevalent of those infections is group A streptococcal (GAS).

An increase in cases of bacterial infections caused by Group A streptococci (GAS) among people in prisons has been reported across England in early 2019. Clusters of infection, primarily wound infections, were initially reported in prisons in Yorkshire and Humber, the North West, the East and West Midlands and the South West. Affected prisons has been associated with infections in people who inject drugs (PWID) and homeless people in recent community clusters and there are links between prison cases and these risk groups.

The following provides some of the more selected aspects that I found interesting:

Controlling the spread of infection in prisons will be contingent on the coordinated efforts of both health and custodial staff working with PHE Health Protection Teams (HPT’s) in these more specific areas:

  • Healthcare teams to ensure that swabs are taken from all patients with skin and soft tissue infections.
  • Custodial/detention staff should work together with prison healthcare teams to enable the identification of new cases and their subsequent isolation, clinical assessment and treatment.
  • Any cell/room sharers of identified cases should be encouraged to contact healthcare in the event they develop signs of infection for assessment and swabbing (nose and throat swabs if no skin lesions but any wounds should be swabbed on finding).
  • Prison management and healthcare staff should work alongside regional HPTs and PHE’s national Health and Justice team to implement the infection control recommendations described herein while balancing public health risk against any operational pressures on those establishments and the wider secure and detained estate in England.

Reception Screening – Health and Custodial Staff

All reception custodial staff should be alert to the enhanced risk of wound infections in people who inject drugs (PWID) or those using other illicit drugs, people with mental health issues at risk of self-harming, homeless people admitted from the community and transfers from other establishments with declared clusters of GAS infection.

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

Persons should be assessed for any signs of wound infection on first entry to the establishment and before allocation to a cell/room.

At first reception screening, undertake assessment for any wounds, skin lesions or sore throat and swab accordingly as described above before allocation to a cell/room. Where possible, patients presenting with wounds should be allocated to single cell/room accommodation if available and if first night isolation poses no risk to their mental wellbeing.

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

Movement Restrictions – Health and Custodial Staff

The advice is that cases are not transferred to other prison establishments until 48 hours of compliance with antibiotic treatment. Medical holds are discouraged and will require individual risk assessment and agreement from both the establishment Governor/Director and population management unit (PMU) before they can be enacted.

No regime restrictions normally necessary for individuals post 48 hours antibiotic treatment with appropriately dressed wounds.

It may be advisable to restrict social mixing of prisoners/detainees between wings with high and low numbers of cases so as to limit cross-transmission of infection. This could entail limiting association activities for example, education, training and exercise; but practicability of implementation is dependent on both operational and security risk assessments.

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).

Inter-Prison Transfers

Prisons admitting persons without infection from other establishments with declared outbreaks should be notified to this effect. Healthcare in the receiving establishment should be made aware of these individuals to enable appropriate assessment of any wounds if needed.

Infection Control Measures – Health and Custodial Staff

All healthcare staff should be familiar with proper hand hygiene protocol as described in national guidance for prisons and make use of available liquid soap dispensers, paper towels and foot-operated pedal bins.

Any cuts should be kept clean and covered and healthcare staff should be mindful that patients may require support with wound management particularly for very deep lesions. Advice around personal hygiene and wound care will be a priority for infected patients and security staff should be made aware of the importance of regular access to shower blocks.

Consideration should be given to the need for dressing wounds and administering medications in the prison healthcare facility. Where the infected prisoner needs to attend the healthcare facility to do this, they should be seen as ‘last on the list’ and appropriate cleaning of the treatment room should be undertaken straight after.

All custodial staff should be familiar with proper hand hygiene protocol as described in national guidance for Prisons. All people (including staff, prisoners/detainees, visitors, etc.) should be encouraged to wash hands often and every time they use the toilet and before eating.

Wall-mounted liquid soap dispensers, paper towels and foot-operated pedal bins should be made available and accessible in key areas such as toilets, showers, the gym, the canteen and any other ‘high traffic’ communal areas to facilitate regular hand hygiene. Staff should assess whether these fixtures don’t pose a self-harm risk to residents prior to their installation.

Simple gym ‘instructions for use’ should be in place and visible to all gym users advising:

  • not to use the gym with open wounds/sores unless covered with a water-proof dressing
  • to wash hands with warm water and liquid soap and dry with paper towels before entering the gym or using any gym equipment
  • wearing of clean cotton clothes for gym/sports workouts
  • not to share gym clothes, towels and personal items including t-shirts, socks, etc.
  • to wipe surfaces of shared equipment before and after use with detergent wipes or detergent spray (wall-mounted dispensers in gyms are recommended) and disposable paper; focus should be on surfaces which are in contact with skin for example, handles, benches, seating pads, etc
  • to shower and wash with liquid soap and water after training
  • to wash personal items such as towels, underwear and sports clothing after every session at the highest possible temperature (refer to ‘Laundry’ section above) Laundry or food handing orderlies with proven infections should be transferred to other duties until their wounds have healed.

Staff are advised that the risk of infection to themselves from contact with cases is very low, as is the risk of carrying the bacteria from prison to home, as long as general hygiene precautions are in place. This includes:

  • regular hand hygiene with soap and water or alcohol hand-rub.
  • keeping any cuts clean and covered.
  • seeking advice from occupational health services on proper wound management if they have any doubts.

Should a staff member come into contact with someone who has an infected wound, for example by touching an infected site or being exposed to any exudate (ooze) that it produces, they should wash their hands thoroughly using warm water and soap or alcohol hand gel if soap and water is not available. Gloves can transfer infection from one person to another and if custodial staff are wearing gloves for prisoner/detainee movement/handling, gloves should be changed between case contacts.

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.

Isolation/Cohorting of Symptomatic Persons – Health and Custodial Staff

All cases are to isolated in single cell accommodation until 48 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/detention staff to account for safeguarding and security considerations.

Ideally, isolation of cases in single accommodation is advised given the high likelihood of cross-transmission of infection to asymptomatic cellmates. If such accommodation is not available cases should be held alone in higher occupancy accommodation, or, if this is not possible, cohorted with other cases with wound infections (cases with GAS infection can be cohorted in the same cells/rooms even if they don’t have the same emm type).

Asymptomatic cell/room sharers of cases should be assessed and monitored for any signs of infection and isolated/cohorted if necessary. Cell/room sharers should be swabbed at the earliest clinical opportunity; nose and throat swabs should be taken if no evidence of superficial wounds.

Isolated cases should take all their meals in their cell/room and not in communal dining areas during the isolation period (48 hours for most cases as per directions received from Healthcare). Healthcare workers or prison/centre staff should enter the room to administer treatment, bring food and beverages, change linen etc.

Regular access to shower facilities by isolated cases will be important to manage infection. Where the isolation cell/room does not have adjacent bathing facilities, the case should use the nearest facilities separately before or after the block/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/detainees en route to the toilet should be avoided.

Isolated prisoners/detainees with infections will need to receive regular changes of their bed linen and towels.

Recommendations For Healthcare Staff

All staff should be alert to the enhanced risk of wound infections in groups including people who inject drugs (PWID) or those using other illicit drugs, people with mental health issues at risk of self-harm, homeless people admitted from the community and transfers from other prisons with declared clusters of GAS infection.

Cases may be identified by notifications received from custodial/detention staff, other prisoners/detainees, self-referral, at reception screening or through other means.

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


Cases with infected wounds should be isolated in a single cell/room until 48 hours of compliance with antibiotic treatment plus/minus topical treatment as advised by local microbiology department.

More complex presentation (for example, Staphylococcus coinfection) may necessitate extended isolation/treatment periods as per individualised treatment plan advised by Healthcare.

Recommendations For Custodial Staff

Environmental Cleaning and Laundry

Staff and other persons, particularly those with cleaning/washing duties, should familiarise themselves with the general environmental cleaning protocols as outlined in national infection prevention and control guidance for custodial envirnments.

Thorough and regular (at least twice daily) cleaning of surfaces in communal areas must be undertaken with hot water, detergent and chlorine-based disinfectant agents; this will include ‘high-touch’ surfaces such as handrails, cell door handles, communal chairs and tables etc., and should extend to any communal bathrooms and showers.

“Titan-Chlor®” tablets are the only chlorine-based disinfectant product authorised for use in the prison estate in England and guidelines on its use can be found in existing health protection guidance issued by PHE’s Health and Justice team.

A ‘deep clean’ of cells occupied by any occupant diagnosed as having a wound infection once they have moved from the cell or after the decolonisation period is over, is necessary. This should be undertaken by specially trained prisoners or cleaning staff and is defined as follows:

  • cleaning of surfaces using hot water and detergent.
  • disinfection of these surfaces using a chlorine-based disinfectants.
  • allowing surfaces to dry before use.
  • checking that mattress and pillow covers are intact and, if not, ensuring that the damaged items are replaced.

Ideally, orderlies cleaning affected areas should not visit other parts of the establishment so as to avoid cross-contamination. If this is not possible, cleaning orderlies must ensure the appropriate use of personal protective equipment (PPE) and be aware of the importance of washing their hands with warm water and liquid soap after removal of PPE and before returning to their own cells/rooms.

All laundry staff should be familiar with washing protocols as outlined in national infection prevention and control guidance for prisons.

To limit the possibility of re-infection in prisoners/detainees with infected skin lesions, it is recommended that linen (for example, bedsheets and towels) is changed daily during the infectious period. Used linen must be placed into a soluble bag and then into a linen bag and tied promptly, half full bags should never be left lying about. The linen bag must be highlighted as ‘infected’. The linen that is contained in the soluble bag can be placed straight into an industrial washing machine. All linen should be washed and dried at the highest temperature setting possible.

Infected prisoners/detainees should be encouraged to send their clothing to laundry services for regular washing and made aware of the potential risks of doing their own laundry. Advice on the appropriate use of on-wing washing facilities (where applicable), including the importance of using high heat wash/dry cycles, should be given. Establishments should ensure appropriate maintenance of all on-wing laundry facilities is being undertaken to meet manufacturers’ guidance.

Where on-wing washing is necessary, laundry from infected prisoners/detainees should be done at the end of the day (N.B. consider risks to laundry orderly, wounds/cuts must be covered at all times), with high-temperature wash of empty machine after potentially infected laundry is processed. Articles of clothing should be placed in a soluble bag and tied in cell for transportation to the laundry facility by the prisoner/detainee or for collection by the laundry orderly, as appropriate. The entire laundry bag should be placed in the washing machine and washed at the highest temperature possible for the clothing; advisable that temperature settings above 60°C are used but lower temperatures may be suitable if the washed clothing is appropriately dried. After placing laundry in the washing machine, it is important that the handler (for example, prisoner/detainee, laundry orderly, etc.) wash their hands with soap and water and dry them at the first opportunity to prevent potential cross-transmission of infection.

Restrictions on visits

Consistent with patient welfare, visitor access to symptomatic prisoners/detainees should be kept to a minimum and any visitors should be provided with hygiene advice whilst ensuring patient confidentiality is maintained. Symptomatic visitors should avoid visiting the establishment.

If practicable, non-urgent visits should be rescheduled until 48 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 (e.g video-link) should be explored wherever possible.

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

Full Guidance Here

Photo by Claudio Schwarz on Unsplash

Strep A Guidance For Prisons

On 14th May 2019, the Government published some information and guidance around Group A Streptococcal Disease (GAS). Amongst prisoners, officers and healthcare staff, this is more commonly referred to as Strep A. This guidance was jointly created by Public Health England (PHE) and HM Prison and Probation Service (HMPPS).

What is Strep A?

Strep A is a type of bacteria often found in the throat and on the skin. The most invasive GAS (iGas) infections happen when the bacteria get past the skin and other bodily defence. The less common, but more severe cases on the invasive disease could be life threatening.

Over the past 18-24 months this bacteria has caused infection with ever increasing frequency amongst the prison population and across the wider prison estate. Local prisons are the most at risk of infections, given the correlation with those who are part of the homeless community (also a high risk area) and those active within the drug sub-culture being the most common.

Strep A – Signs And Symptoms.

Signs and symptoms of invasive group A streptococcal disease include:

  • High fever
  • Severe muscle aches
  • Localised muscle tenderness
  • Redness at the site of a wound

Where any of these symptoms develop, seek medical advice immediately. If anyone you know develops these symptoms, they should also seek medical advice immediately.

Actions To Minimise Risk.

  • Prisoners should be encouraged to maintain clean cells.
  • Prisoners should have opportunities for clothing to be washed at the right temperature and dried fully.
  • Prisoner bedding should be regularly changed and washed. This should be more frequent for those who have wounds.
  • Prisoners should have opportunities to wash and shower at least daily.
  • Prisoners should be reminded of the importance of good hand hygiene – washing hands after using the toilet and before the eating or preparing of food.
  • For those prisoners who have infected wounds, the guidance is that they should not use the gym, until they have had 48 hours of antibiotics and/or the wound is covered or healed.

The concerns will rise where the this guidance is not adhered to, and the disease is allowed too become more prevalent as a consequence of denial, ignorance or complacency. In all reality, it is likely to a combination of all of these factors.

The full guidance is found here.

Photo by Brian Patrick Tagalog on Unsplash.

Hepatitis C Report – Prisons In England 2019

In this latest report (published on 9 April 2019), Hepatitis C in England 2019, Public Health England summarises the current data and the impact of action plans in England to drive down mortality from Hepatitis C Virus (HCV) and to reduce the number of new infections. Also included is an outline the actions required to make further progress. It is clear that progress is being made, but there is still much to do.

This post provides a summary of the key points relative to the levels of activity ongoing through the prison estate in England.

Latest modelled estimates suggest that around 143,000 people in England were living with chronic HCV infection in 2015. Prevalence is estimated to have fallen in recent years, and was predicted to decline to 113,000 in 2018 with the advent of new treatments. HCV affects a larger proportion of people in prison and other detention centres than the wider population, principally as a result of the relatively higher levels of injecting drug use that are observed among this population.

Partnership Working – HMPPS, NHSE and PHE.

Since 2013/14, PHE in partnership with NHS England and Her Majesty’s Prison and Probation Service (HMPPS) have overseen the rollout of BBV testing in adult prisons on an ‘opt-out’ basis. A significant milestone was reached in April 2018, when after more than 4 years of implementation, the programme was successfully rolled out across the entire adult prison estate.

Testing and Diagnosis.

Opt-out bloodborne virus (BBV) testing is now fully implemented across the prison estate, and among new receptions to English prisons, levels of testing have risen from 5% in 2010/11 to 19% in 2017/18. In the 2017/18 financial year, Health and Justice Indicators of Performance (HJIP) testing data suggest that, after excluding previously confirmed cases, 75% of new receptions and transfers were offered HCV testing, 26% were tested, 11% of those tested were found anti-HCV positive but less than half (46%) went on to have HCV Ribonucleic acid (RNA) testing. About 40% of those testing positive for HCV RNA received specialist referrals for their HCV infection.

Overall, these data suggest an increasing awareness of HCV in prisons with significant increases in testing, including Dried blood spot (DBS) testing. Whilst testing volumes remain sub-optimal, work is ongoing to move from the implementation of BBV testing to improving the quality of the offer and uptake of testing within prisons.

HJIP Metrics.

Prison Health Performance and Quality Indicators and HJIPs have shown a rise in HCV tests performed, from 5.3% in 2010/11 to 19.4% in 2017/18. It is likely that the recent increase in testing of people in prisons is due to the introduction of BBV opt-out testing, which was agreed in October 2013 by PHE, NHS England and HMPPS and is now fully implemented across the prison estate. While this increase in testing is welcomed, current levels are still below the lower BBV testing threshold proposed by NHS England (50-74%), and well below the target threshold of at least 75% uptake.

Performance in relation to the BBV opt-out testing programme is measured at the prison level by NHS England through the collection of data via HJIPs. These metrics include specific reports on:

  • the number of BBV tests offered within 72 hours of reception,
  • the number of tests undertaken,
  • the number of people newly diagnosed,
  • the number of patients referred for specialist treatment following diagnosis,
  • the number who received treatment.

These data are used by NHS England commissioners to performance manage healthcare providers in prisons and are important for identifying potential attrition points in the testing pathway.

In the 2017/18 financial year, HJIP testing data suggest that, after excluding previously confirmed cases, 75% of new receptions and transfers were offered HCV testing and of these 26% were tested. Of those tested, 11% were positive and 46% of these went on to have HCV RNA testing.

The image with this post illustrates the Hepatitis C testing cascade in the English prison estate (112 prisons).

World Hepatitis Day is held on 28 July 2019.

Read the full report Here

Eradicating Hepatitis C In Prisons

In March 2018, the All-Party Parliamentary Group published the report – Eliminating Hepatitis C in England. A report produced with the aim of moving towards achieving NHS England’s ambition to eliminate hepatitis C by 2025 at the latest. A target date some five years before the World Health Organization target of 2030.

One of the key risk factors was the acknowledgment that Hepatitis C disproportionately affects people who inject drugs (PWID) are the group most at risk of becoming infected with hepatitis C, with transmission occurring via shared syringes and other injecting equipment. Approximately 50% of PWID remain undiagnosed, and prevalence of hepatitis C among recent initiates in drug use was found to be 26%. PWID are a key target population for hepatitis C prevention, diagnosis, and treatment initiatives.

There is a high prevalence of hepatitis C among people in prison, due to a high population of PWID in prison, as well as unsafe injecting and tattooing taking place within prison.

Prisons, substance misuse services, and sexual health services have traditionally been the key settings to offer hepatitis C testing to high concentrations of at-risk populations. People in touch with these services are highly likely to have put themselves at risk for transmission, and the aim in these settings should be universal testing and regular re-testing of all service users. There are unique challenges and missed opportunities in each of these settings.

This report puts forward a series of desired outcomes and action-based recommendations to support objectives leading to elimination of hepatitis C, which are specific to prisons and prison healthcare providers:

Desired Outcomes:

  • Increased awareness of hepatitis C among PWID and people in prison.
  • Increased awareness of the ease and short duration of new direct acting antiviral (DAA) treatments among prisoners.
  • Increased awareness of the ease and short duration of new DAA treatments among PWID.
  • Prison staff are an effective source of information for prisoners on harm reduction and prevention.
  • Fewer new infections as a result of improved knowledge of transmission risks.
  • Increased coverage and uptake of testing in substance misuse services.
  • Increased coverage and uptake of testing in prisons.
  • Opt-out dry-blood spot testing for hepatitis C is fully implemented in substance misuse services and prisons.
  • A target of 20,000 people per year treated is set, incentivised, and monitored.

Recommendations & Actions:

  • Awareness-raising talks delivered by peers to be commissioned as an integral part of contracts for substance misuse services and in prisons.
  • Nationally-approved NHS England Health and Justice publicity highlighting the ease of new treatments to be rolled out across HM prison estate.
  • Peer programmes to be commissioned as an integral part of hepatitis C treatment services in commissioning contracts in prisons.
  • Nationally-approved publicity highlighting the ease of new treatments to be rolled out across substance misuse services.
  • Hepatitis C peer programmes to be commissioned as an integral part of commissioning contracts for substance misuse services.
  • BBV training to be made compulsory for prison staff.
  • Peer programmes to be commissioned as an integral part of hepatitis C treatment services in commissioning contracts for substance misuse services and in prisons.
  • Opt-out testing for hepatitis C to be commissioned by local authorities in substance misuse services.
  • Re-offer of testing to all those engaged with substance misuse services every six months to be mandated and commissioned.
  • Testing to be re-offered in prisons to those who did not receive a test at reception.
  • Opportunities to be provided for those who previously tested to re-test in prison.
  • Clear national protocol to be developed surrounding wording of opt-out test offer in prisons.
  • Commissioners to support access for prisoners to second reception screening.
  • Research to be conducted on transmission risk within prisons to determine impact of re-testing.
  • Commissioning contracts for substance misuse services and prisons to have clear mechanisms to hold services to account for failures to meet testing targets.
  • Unnecessary tests and appointments to be reduced, and the use of reflex tested dry blood spot samples, which necessitate only one sample and can be delivered in the community, to be mainstreamed.
  • Proportional prison treatment targets to be set for prisons specifically in every ODN depending on prison population.


The findings of this inquiry give us much cause for optimism, and the firm belief that elimination of hepatitis C in the very near future is an achievable national ambition. Given the concentration of this at-risk population within the prison setting, these suggested actions offer real opportunities for prisons and prison healthcare providers to make a positive contribution to society for the elimination of Hepatitis C.


Photo by Matthew T Rader on Unsplash.