1. Introduction

This guidance aims to support integrated care boards (ICBs) in planning and commissioning services to manage infectious disease outbreaks. With over 10,000 outbreaks managed annually in England, these incidents can strain NHS resources and exacerbate health inequalities, especially among vulnerable populations.

ICBs are responsible for developing health plans, managing budgets, and arranging services. The guidance emphasises the importance of activities like diagnostic testing, clinical assessment, vaccination, and post-exposure chemoprophylaxis to prevent illness and reduce transmission.

Clear prior arrangements with providers are crucial for timely responses and minimizing disruptions to routine services.

This guidance is intended to help ICBs prepare their response to infectious disease threats up to and including NHS incident response level 2, ranging from individual exposures to localised outbreaks.

It should be used alongside national legislation and policy and operationalised through commissioning arrangements with local providers in conjunction with local outbreak plans and multiagency memorandums of understanding.

The guidance does not override established and functional operating practice at local level but should be used to inform the development of consistent outbreak management practice over time.

Local systems are expected to implement this guidance over the 2025/26 financial year.

1.1 What are infectious disease outbreaks and incidents?

For the purposes of this guidance, an infectious disease outbreak is defined as:

• an incident in which 2 or more people affected by the same infectious disease are linked by time, place, or common exposure
• a greater than expected rate of infection compared with the usual background rate for the place and time where the outbreak has occurred

Other situations may not fit into the above outbreak definition, but nonetheless require a rapid and comprehensive response. For the purposes of this document, such are referred to as infectious disease incidents and include:

• a single case of certain rare or high-consequence disease
• a single exposure to a suspected or confirmed high consequence infectious disease
• a suspected, anticipated, or actual event involving microbial contamination of food or water

1.2 The ICB’s role in infectious disease outbreaks and incidents

Having multiple actors with different commissioning arrangements carries a risk of gaps in service provision, leading to delays in responding to and controlling outbreaks and incidents of infectious disease.

As the local commissioners of NHS-funded community and secondary care services, ICBs are best placed to lead the NHS’s preparation for and response to local infectious disease incidents.

ICBs are responsible for planning and funding NHS community and secondary care services, enabling them to integrate resources, align priorities, and address gaps across providers.

ICBs are also responsible for developing integration and collaboration within the local system, ensuring a coordinated response which combines clinical expertise, infection prevention, testing, vaccination, and treatment capabilities.

As Category 1 responders under the Civil Contingencies Act 2004, ICBs must assess the risk of emergencies and use this to inform contingency plans, put in place emergency plans and business continuity arrangements, and share information and co-operate with other local responders to enhance coordination and efficiency.

This role includes assessing the risks of infectious disease incidents and outbreaks for the local population and putting in place plans to respond to and mitigate these risks.

This applies to all community settings within the ICB footprint, including sites managed by the Ministry of Defence for Afghan entitled persons and by the Home Office for people seeking asylum.

Infectious disease outbreaks have the potential to incur substantial healthcare costs. Financial constraints are a recognised challenge in ICB’s commissioning functions, and NHS England acknowledges the significant budgetary pressures on local systems who have numerous population health priorities to consider.

Clinical control measures are widely established to be effective and cost-saving. Preventing additional cases through rapid implementation of clinical and public health control measures is therefore anticipated to be economically beneficial to local NHS organisations.

There are also broader benefits of effective infectious disease control to the local system, and responsibility for health protection activities is shared amongst numerous local partners.

ICBs should consider whether the required arrangements could be made more efficiently through mechanisms such as pooling budgets with other partners, such as local authorities, under section 75 of the NHS Act 2006.

1.3 Principles of commissioning for infectious disease incidents

Commissioning of clinical services for infectious disease incidents involves the strategic planning, procurement, and management of services to protect the population from health threats.

1.4 Summary of ICB responsibilities

The expected responsibilities of ICBs in relation to the clinical response to outbreaks and incidents of infectious disease in the local area are to:

• develop pathways and ensure that services are in place for the diagnosis of infectious diseases in the community, including timely clinical assessment and collection, storage and transport of clinical specimens
• develop pathways and ensure that services are in place for prescribing and dispensing post-exposure chemoprophylaxis to contacts of infectious disease, including out-of-hours
• arrange for timely provision of post-exposure vaccination of contacts of infectious disease and reactive vaccination of individuals and groups in response to an unfolding outbreak across a range of local settings
• develop local immunoglobulin pathways which are clearly defined and available to treat contacts of infectious disease when recommended by the Health Protection or National Immunisation teams, including for immunocompromised patients and children
• develop local pathways for the assessment and management of patients with suspected high consequence infectious diseases up to the point of diagnosis
• develop policies for decontamination of premises and homes as appropriate
• develop internal escalation and accountability pathways for health protection to ensure that issues reported by partners can be escalated appropriately
• consider the needs of different populations in relation to infectious diseases and making appropriate plans to meet these needs in the event of an incident or outbreak

2. Clinical services: testing and diagnostics

Accurate, reliable, and timely diagnostics are essential for identifying cases and enabling prompt and appropriate management.

England has a comprehensive laboratory infrastructure consisting of NHS diagnostic laboratories, UK Health Security Agency (UKHSA) public health laboratories, and reference laboratories for specialist investigations such as genetic typing, whole genome sequencing, and high-consequence infectious disease investigations.

Local commissioned services should have the capability to collect, store and transport clinical specimens to the most appropriate location for processing and to perform clinical assessment of symptomatic individuals.

Local arrangements and pathways should be agreed for reporting of results of testing to partners within the health protection system to inform public health action. Staff should be appropriately trained in collecting respiratory, cutaneous, blood and stool samples, and effective use of personal protective equipment (PPE).

Providers should have appropriate infection prevention and control (IPC) arrangements in place and be able to supply suitable PPE to their staff, including FFP3 face masks and relevant fit testing where indicated.

As discussed further in the logistics section, outreach capability is important for screening and diagnostics, particularly where an individual is required to stay at home due to symptoms of infectious disease or where testing is most usefully conducted in a setting such as a school or care home.

2.1 Swabbing

Swabbing is one of the most common sampling methods for diagnosing infectious disease, most commonly for respiratory infections but also for a variety of other pathogens.

Respiratory samples include nasal, nasopharyngeal, throat, and mouth swabs, which are used to diagnose infections such as COVID-19, influenza, scarlet fever and measles. Swabbing of skin and skin lesions is used in the diagnosis of conditions such as MRSA, Mpox and cutaneous diphtheria.

Swabbing can be conducted by any suitably qualified medical or nursing staff, and many social care staff are now proficient at performing respiratory swabs.

Staff should be familiar with the type of swab required for different pathogens and appropriately trained to perform these methods.

Providers should stock or be able to rapidly procure the required equipment and should have suitable pathways in place for timely sampling with appropriate IPC measures.

2.2 Blood tests

Certain pathogens are most effectively detected through blood samples, either because they primarily reside in the bloodstream, or because the presence of the pathogen or its biomarkers in the blood provides the most accurate or timely diagnostic information.

Blood tests can also be used to determine susceptibility of an individual to certain pathogens, assisting in clinical decision-making regarding post-exposure prophylaxis.

Providers should have the capability to perform blood tests through capillary or venous sampling, with appropriate IPC, and to perform point-of-care testing including pre and post-test counselling for blood-borne viruses.

2.3 Faecal sampling

Stool samples may be required to diagnose the cause of an outbreak of gastrointestinal illness or follow up individuals after their illness to ensure clearance.

Depending on the setting and local arrangements, investigations into incidents and outbreaks of gastrointestinal illness may be led by local authority environmental health officers (EHOs), local IPC teams, NHS trusts or UKHSA.

Samples may be collected by care workers at the affected setting, or by the affected individuals using pots provided by a healthcare provider or EHO.

ICB-commissioned providers are most likely to be involved in faecal sampling where there are symptomatic individuals who require diagnostic testing.

As these individuals often also require clinical assessment, it is usually most appropriate for faecal sampling to be arranged via the patient’s GP.

Where providers arrange faecal sampling for their patients as part of a wider outbreak or incident response, pathways should be agreed with the ICB and other partners in the health protection system as to the communication of the results of this testing; for example, through the use of ILOG incident numbers to identify relevant specimens.

Following the diagnosis of certain high risk gastrointestinal pathogens, such as E. coli O157, clearance sampling may be required for patients in some higher-risk groups. This is arranged by local EHOs and does not require NHS providers to request or facilitate sampling.

However, local diagnostic laboratories should ensure pathways are in place for reporting the results of these investigations to relevant partners, including the EHO and local UKHSA health protection team.

During community gastrointestinal illness incidents, asymptomatic contacts may also require testing to identify spread and inform control measures in affected settings, such as nurseries or care homes.

This testing is arranged by the local UKHSA health protection team via the regional public health laboratory, and does not require input from ICB-commissioned providers.

2.4 Clinical assessment

Clinical assessment by medical professionals is vital during incidents and outbreaks of infectious diseases to enable accurate diagnosis and effective treatment for individuals.

GPs and pharmacists are often the most appropriately placed to provide first-line assessment and treatment during normal weekday hours, with emergency departments available for assessment and treatment of patients with symptoms of severe or life-threatening illness.

Out-of-hours clinical assessment should be available for symptomatic individuals via out-of-hours GP services and emergency departments depending on clinical urgency.

Registered medical practitioners are legally obliged to notify the local HPT of suspected cases of certain infectious diseases, as detailed in the UKHSA guidance on notifiable diseases.

General practices, pharmacies and secondary care services should have agreed IPC arrangements and pathways in place to assess patients presenting with indications of infectious disease.

General practices are responsible for procuring their own PPE and ensuring that staff are appropriately trained and equipped to use this.

Where diagnosis or ongoing treatment surpass the capabilities of primary care, referral pathways should be in place for further investigation, for example community dermatology input for persistent scabies outbreaks in care homes.

Clinical assessment for suspected high-consequence infectious diseases (HCIDs) should not be conducted in primary care.

Patients should be referred to local emergency departments for isolation and assessment using appropriate PPE, and advice sought from local infection services with the support of the Imported Fever Service.

ICBs should have appropriate pathways in place to ensure patients can be transferred for assessment of HCIDs and returned home.

Local exceptions to this pathway may be arranged; for example, in the case of mildly symptomatic contacts of avian influenza, for whom clinical assessment may be provided remotely and swabbing undertaken at the patient’s home while in isolation.

ICBs should ensure pathways are in place for management of patients presenting to healthcare with suspected HCIDs, including procedures for patient transport, isolation, and decontamination, as well as handling and transport of clinical specimens.

HCID centres are commissioned by NHS England; they are regarded as a retained, highly specialised service. The pathway to the point of a confirmed HCID diagnosis is an ICB commissioning responsibility.

Following a formal HCID diagnosis, NHS England will co-ordinate the transportation of individuals to a designated HCID facility.

NHS England will be responsible for treating those individuals formally diagnosed with a HCID who are admitted to a designated HCID facility as well as those who can safely isolate at home.

3. Clinical services: vaccination and immunisation

3.1 Post-exposure vaccination

Post-exposure vaccination is a time-sensitive intervention administered to contacts of infectious disease with the aim of modifying or precluding the development of disease.

This is not included under section 7A, which is concerned with routine vaccination services associated with the national immunisation schedule and commissioned by NHS England.

Vaccination is included as an essential service under Part 8 of the GMS contract, and GPs may be the most appropriate provider in more common, isolated incidents such as individual contacts of hepatitis A or B, or individual exposure zoonotic diseases.

However, operational challenges exist in delivery through this mechanism, especially where administration is required out-of-hours and where vaccines are difficult to source.

Furthermore, during a local outbreak, demand is likely to rapidly outstrip GPs capacity to prescribe and administer post-exposure vaccination.

Commissioning arrangements should ensure local and rapid access to post-exposure vaccination for all relevant diseases, including capability to prescribe and administer more unusual vaccines, such as rabies or mpox.

ICBs should make general practices aware of the expectation for post-exposure vaccination to be provided within their services and develop local agreements regarding the boundaries of this work and associated remuneration.

ICBs should ensure that commissioning arrangements are in place for instances where post-exposure vaccination via GPs is unfeasible; for example, incidents out-of-hours or at scale.

Alternative providers to consider include 7-day pharmacies, out-of-hours GP providers, and GP federations.

3.2 Reactive vaccination

Reactive vaccination aims to reduce the spread of an identified infection within a population, protect clinically vulnerable individuals, and prevent the outbreak from escalating.

It may include vaccines used within the routine immunisation schedule, such as pneumococcal, or other vaccines that are not routinely offered, such as hepatitis A.

Target populations are those at increased risk of exposure or illness; for example, classroom or workplace contacts of a confirmed case, those living in areas where the outbreak is occurring, or specific high-risk groups such as healthcare workers and people with underlying health conditions.

It may occasionally be appropriate for reactive vaccination to be organised through general practice; for example, outbreaks associated with GP waiting rooms or certain care homes where all residents are registered to a single practice.

However, drawbacks to this approach include lack of weekend capacity and the issue of how to treat staff members not registered with the practice.

The latter may be addressed by temporary registration arrangements or other local agreements, but the limitations of GPs’ capacity to provide such an intervention should be explored locally during commissioning discussions.

Reactive vaccination aims to reach as many of the target population as possible. As such, outreach capability is often fundamental to achieving sufficient uptake, and out-of-hours clinics may be required.

Providers with capability to provide these flexible services will vary by local area, but may include school-aged immunisation services, GP federations, out-of-hours GPs, and community-based health outreach teams.

3.3 Vaccine capabilities

Local systems should have the capability to provide all indicated post-exposure and reactive vaccinations in a timely and scalable manner. These capabilities include:

Vaccine supply chain management

Local systems need an efficient supply chain to ensure rapid and sufficient distribution of vaccines.

This includes secure storage facilities, cold chain management, and an effective distribution network.

Rapid deployment

Trained vaccinators should be readily available to administer vaccines swiftly during outbreaks, while minimising disruption to routine services.

Providers should ensure that vaccinators should be trained in vaccine storage, handling and administration, including intradermal injection, and should have access to appropriate PPE.

Prescribing and written instructions

Vaccinators require an appropriate legal mechanism against which to administer vaccines, which can include prescriptions, patient specific directions (PSDs) or patient group directions (PGDs).

Providers should have timely access to a suitable clinician(s) to support the use of any of these legal mechanisms. This can include assessing named patients, writing or signing off prescriptions or PSDs, and providing appropriate training and signoff for vaccinators.

Scalable infrastructure

Local systems should have the capacity to scale up vaccination efforts rapidly. This includes establishing temporary clinics to manage a surge in demand and as a way of meeting the needs of specific at-risk populations or underserved local populations.

Coherent data systems

Providers should ensure that vaccine administration and treatment plans are securely communicated to patients’ GPs so that clinical records are up-to-date, and coverage data is accurate and contemporaneous.

Community engagement

Providers should work with local directors of public health in local authorities and community organisations to effectively identify and access underserved groups.

Community engagement is essential for understanding and addressing any observed areas of low uptake.

Consistent vaccine messages should be agreed between all organisations involved in local delivery, and address any identified misinformation circulating.

3.4 Immunoglobulin and anti-toxin

Immunoglobulin is a time-sensitive intervention which may be used in the management of infections such as tetanus, rabies, hepatitis A and B, varicella-zoster, rubella and measles.

Pooled human immunoglobulin can be given as an intravenous infusion (IVIg), which is indicated for immunocompromised contacts.

Human normal immunoglobulin (HNIG) and disease-specific immunoglobulins are intramuscular or subcutaneous injections administered to immunocompetent contacts who are vulnerable to developing severe disease or complications from infection.

Further information on indications and use of immunoglobulin is available from the UKHSA guidance on the use of immunoglobulin and the Green Book on immunisation against infectious disease.

ICBs should ensure that local immunoglobulin pathways are clearly defined and available to treat contacts of infectious disease when recommended by the HPT or National Immunisation Team, including for those who are immunocompromised and children.

Immunoglobulin is most effective when administered as soon as possible after exposure to the respective pathogen; therefore pathways for referral and administration of this treatment should be available over weekends and bank holidays.

Local arrangements should be made according to demand in the local area. For example, areas that encounter relatively high demand may consider establishing a bespoke immunoglobulin service in primary or secondary care, while those encountering fewer cases may choose to arrange access to immunoglobulin treatments via emergency departments or other appropriate 7-day access services.

4. Clinical services: treatment and chemoprophylaxis

Antimicrobial medications are used to prevent or treat infections. In outbreak situations, these may include antibiotics, antivirals, and antiparasitics.

Prescription of antimicrobial treatments to patients with suspected or confirmed infections is part of normal clinical practice for GPs and other medical professionals. However, during outbreaks and incidents, demand for treatments may require additional prescribing capacity.

Antimicrobial prophylaxis is used to prevent infection in patients who have been exposed to a pathogen. It is recommended only under specific circumstances and for populations where risk assessment indicates a heightened likelihood or severity of disease, and where the benefits to the individual and wider population outweigh the risks.

Antimicrobial treatment and prophylaxis may be recommended by the HPT based on national guidance or expert advice.

ICBs should ensure that local pathways are arranged for prescribing and dispensing antimicrobial treatment and chemoprophylaxis to cases and contacts of infectious disease, including weekend provision where appropriate.

4.1 Antivirals

Antiviral prophylaxis is indicated following exposure to certain viral pathogens in particular populations. Examples include those exposed to probable or confirmed H5N1 avian influenza without appropriate PPE, immunosuppressed people exposed to varicella-zoster, and a range of clinically vulnerable people exposed to influenza.

NHS England previously published a system letter clarifying the need for local arrangements to provide treatment and prophylaxis for community outbreaks of influenza through commissioning or mutual aid.

Individual cases requiring antiviral prophylaxis – for example, susceptible pregnant women and infants exposed to chickenpox – may be most appropriately and safely managed by the patient’s GP following advice from the HPT and any associated clinical specialists.

ICBs should discuss locally with GP practices to ensure that they are willing and able to prescribe for this indication, either as part of their usual service or as a locally enhanced service depending on demand and GP capacity.

For higher volumes of patients – for example, outbreaks of COVID-19 or influenza in community settings such as care homes – ICBs should ensure that commissioned services are in place to provide appropriate post-exposure antiviral prophylaxis.

4.2 Antibiotics

Antibiotic treatment for cases of infectious disease is a routine and essential service in both primary and secondary care.

The HPT may recommend post-exposure antibiotics for asymptomatic contacts to prevent secondary cases and onward spread of the infection. Examples include prophylaxis for invasive bacterial diseases, such as meningococcal disease, as well other potentially serious bacterial infections contracted from humans and animals.

As with antivirals, antibiotic prophylaxis is most effective when given as soon as possible following exposure. For individual contacts, it is usually safest to arrange post-exposure chemoprophylaxis via their GP, who has access to records of allergies and any interacting medications.

Exceptions to this include incidents where household contacts accompany the case to hospital, wherein dispensing a single dose of antibiotic from the hospital may be the fastest way of ensuring that contacts have access to rapid chemoprophylaxis.

Where the HPT recommends that multiple contacts or whole settings receive antibiotic prophylaxis, demand may rapidly outstrip the business-as-usual capacity of primary care.

GPs may remain the most appropriate provider in situations where many exposed contacts are registered at the same practice, for example residents of some care homes.

However, in this situation, care home staff are likely to be registered at different practices, creating a barrier to providing prophylaxis. This could be addressed by making alternative arrangements, such as temporary GP registration or using an alternative provider.

ICBs should consider these scenarios in their commissioning planning and ensure that system partners are willing and able to undertake the required activities.

4.3 Decolonisation

Decolonisation refers to the process of eliminating or reducing the presence of pathogenic micro-organisms from the body, particularly those carried on the skin or in the nose.

The aim of decolonisation is to prevent these microorganisms from causing infection in the individual or spreading to others, especially in health and care settings where vulnerable patients are at risk.

It is routinely used in the management of PVL-associated staphylococcus aureus infections, with national guidance available on various outbreak scenarios.

Decolonisation may be recommended by a clinical specialist, such as a microbiologist or dermatologist, for the families of patients with MRSA infections. In this instance, treatment should be requested and prescribed for each household contact by their GPs.

The process of decolonisation can usually be undertaken by the patient or their caregiver, although additional support through outreach may be required in the case of community clusters in people who inject drugs.

As discussed in section 6.4, ICBs should ensure that providers have the capability to work effectively with vulnerable populations who may experience healthcare exclusion.

4.4 Antiparasitics

The most common and important indication for antiparasitic medications in health and social settings is the treatment of scabies: a highly contagious itching skin condition caused by mites burrowing into the upper layer of the skin.

Outbreaks are common in communal settings such as care homes and migrant accommodation, and are typically managed by the affected setting with advice from local IPC teams.

Scabies is very infectious but can take up to 8 weeks to show symptoms from the time of infection.

Therefore effective outbreak management requires concurrent treatment of all close contacts, even if they do not have symptoms, followed by repeat treatment of originally symptomatic patients 1 week later.

Topical treatment is effective but logistically challenging due to the need for near-simultaneous treatment of all residents and staff, long duration of application, and co-morbidities such as dementia leading to impaired compliance.

Where all residents requiring treatment are registered at the same practice, GP prescription is usually the most appropriate way to arrange this.

However, to ensure timely prescription and co-ordinated administration of treatments, ICBs should ensure that commissioned arrangements are in place with an alternative provider that has the capability to provide whole-home prescriptions where residents are registered to multiple different GP practices.

Topical treatments for staff can be obtained from a pharmacy without a prescription and should be funded by the employer under occupational health arrangements.

ICBs should agree an escalation pathway with local partners for where initial management fails to eliminate an outbreak. This should include escalation of IPC advice and oversight, and referral pathways for specialist assessment to confirm the diagnosis and advise on further treatment.

Where prescribed treatment is recommended, the ICB should arrange for an appropriate provider to prescribe and dispense this for staff and patient contacts. The ICB may wish to agree funding arrangements for staff treatment with the setting.

5. Populations

The scale of a clinical outbreak response and the amount of resource required to mount an effective response will depend on the population(s) affected.

Different populations have varying levels of vulnerability according to factors such as age, pre-existing health conditions, socioeconomic status, or access to healthcare.

Identifying these groups allows for prioritisation and equitable distribution of appropriate resources to effectively plan for and respond to outbreaks, reduce overall mortality and morbidity, and decrease disparities in health outcomes.

5.1 Individuals and small groups

Isolated incidents of most common infectious diseases affecting small numbers of individuals should usually be managed under the BAU functions of health service providers.

Examples include routine diagnostic tests for individuals presenting with symptoms of infectious disease, prescription of post-exposure chemoprophylaxis for household contacts of invasive bacterial disease, or post-exposure hepatitis A and B vaccination for a family group.

ICBs should seek agreement from GPs and other relevant providers that they are willing and able to provide these services and negotiate local agreements where required.

Some incidents involving small numbers of people may require resources or specialist skills beyond the capacity of primary care BAU.

Examples include out-of-hours chemoprophylaxis, procurement and administration of uncommon post-exposure vaccines or immunoglobulins, and diagnostic testing requiring outreach or high levels of PPE.

ICBs should consider what services cannot be provided under BAU activity and make clearly defined arrangements with relevant providers to ensure these are available.

5.2 Larger groups

Larger groups refer to populations affected by an infectious disease incident in greater numbers than an individual contact or household group. Examples include nursery, school, or care home outbreaks as well as outbreaks affecting specific geographical, social, or religious groups.

Clinical outbreak management for large groups may be co-ordinated through primary care if all patients are registered with a limited number of practices, and the practice is willing to take this on.

However, significant outbreak management is not included in the GMS contract, and this will therefore require additional financial resource from the ICB to either fund contract variation with existing providers or commission an alternative provider.

Taking local context into consideration, ICBs should consider whether alternative providers may be better situated to provide flexible outbreak responses without compromising routine services. Examples include sleeping contracts with GP federations or out-of-hours GP providers to stand up clinical responses when requested.

5.3 Workplace exposures

Many workplaces have specific infectious disease risks which should be considered in the organisation’s risk assessments. Examples include laboratory staff being exposed to airborne Brucella infection in veterinary laboratories, prison officers exposed to measles cases during an outbreak, and care home staff developing scabies following exposure at work.

Workplaces have legal obligations to protect the health and safety of their staff, including undertaking health surveillance and identifying and mitigating health risks.

To meet their legal obligations and prevent illness absences in their workforce, some organisations have an occupational health service which may be provided in-house or externally commissioned.

However, occupational health services may not have the capacity, skill mix, or logistical capabilities required to provide a comprehensive and robust response to infectious disease outbreaks in their settings.

Such services are often small, slow to respond due to limited working hours, difficult to contact, and may only see patients proactively; for example for health screening or immunisations.

Depending on the setting, they are unlikely to be specifically commissioned to participate in outbreak management and may lack crucial capabilities such as prescribing expertise and access to pharmacy stocks.

ICBs are not obliged to provide health services to private companies or other public sector organisations. However, they are responsible for planning health services for their local population, which is likely to include many of the staff employed in local care homes, prisons, and other workplaces with an increased risk of occupational exposure to infectious disease outbreaks.

This includes planning how the local health system should respond to incidents of infectious disease affecting local workplaces, and may include developing policies and draft contracts for the use of ICB resources in the event of incidents involving occupational exposures.

5.4 Health inequalities

Equity is an important consideration for NHS commissioners and providers, recognising public authorities’ duties under the Public Sector Equality Duty and the Health Inequality Duty.

These duties include the need to:

• pay due regard to eliminate unlawful discrimination, harassment, and victimisation
• reduce inequalities in the benefits which can be obtained from health services
• foster good relations between different parts of the community

Providers should demonstrate that they are aware of their legal duties to reduce health inequalities in relation to their services, be able to identify where inequalities may arise, and have actionable plans to address them.

Several factors exacerbate vulnerability to health harms from infectious disease. These include barriers to accessing and understanding information as it is typically presented; obstacles to taking action to reduce exposure risk; and challenges in accessing healthcare.

The CORE20PLUS framework

The NHS uses the CORE20PLUS framework to support structured consideration of ethical and equity aspects of outbreak response.

This framework identifies populations at increased risk of harm from infectious disease due to increased risk of exposure to pathogens, higher susceptibility to subsequent illness, and greater barriers to accessing appropriate healthcare. These include:

• the most socio-economically deprived 20% of the population, as identified by the Index of Multiple Deprivation (IMD)
• people experiencing poverty who are not living in areas classified as the most socio-economically deprived 20% by IMD
• people with protected characteristics under the Equality Act 2010, including people with disabilities, ethnic minorities, sexual minorities, and faith and minority belief groups
• people with long term health conditions that place them at increased risk of infection or increased vulnerability to external health hazards
• people providing and receiving social care
• people who are socially excluded (inclusion health groups)

Inclusion health

Inclusion health refers to several groups who experience social exclusion, including people experiencing homelessness, people with drug and alcohol dependence, vulnerable migrants, Gypsy, Roma and Traveller (GRT) communities, sex workers, people in contact with the justice system, and victims of modern slavery.

Inclusion health groups typically experience multiple overlapping risk factors for poor health such as poverty, violence, stigma, discrimination and complex trauma.

These groups are disproportionately affected by infectious disease outbreaks due to increased exposure risk, pre-existing health conditions, and healthcare exclusion.

NHS England has developed an inclusion health framework which provides recommendations to improve care pathways and accessibility of services for these groups, which should be considered when commissioning outbreak-related services and designing local outbreak plans.

Many infectious diseases disproportionately affect CORE20PLUS groups. For example, tuberculosis (TB) is most prevalent in socially excluded groups and ethnic minorities in the UK, while the 2022 mpox outbreak primarily affected gay, bisexual and other men who have sex with men (GBMSM) populations.

Commissioning arrangements

Commissioning arrangements should specifically consider and address health inequalities, including identifying local priorities and building the resources and community links required to engage with underserved populations.

Local authorities are invaluable in this regard and should be included in plans and activities to reduce health inequalities in outbreak response.

6. Logistics

6.1 Out-of-hours capacity

While many infectious disease incidents can be managed within normal working hours, certain priority infections require rapid follow up and actions out-of-hours to protect the health of affected individuals and prevent ongoing spread of the pathogen.

Other than emergency presentations of illness and cases of suspected high-consequence infectious disease, very few health protection incidents require health service intervention overnight. However, there are several time-sensitive activities which may require services to be available on weekends and bank holidays, such as post-exposure prophylaxis through antimicrobials, immunoglobulin, or vaccination.

ICBs should ensure that their commissioned services are able to provide outbreak and incident response capabilities outside normal working hours; for example, through local out-of-hours services or the extended provisions of the PCN directed enhanced services.

ICBs should ensure that those on-call for the ICB have the appropriate training and access to the required information to manage the local health service response to an incident out-of-hours, including access to a local handbook or outbreak plan to assist in them contacting the relevant services to arrange the recommended clinical interventions – including referral pathways for specific clinical services such as immunoglobulin administration.

6.2 Outreach capacity

ICBs should ensure that commissioned services have appropriate outreach capabilities to meet the needs of the local population.

Timely and culturally competent outreach enables the effective dissemination of information and services to all segments of the population, particularly those who may be marginalised or otherwise excluded from routine health services.

By extending the reach of health services beyond traditional facilities, local health systems can improve early detection and intervention through provision of vaccines, testing, and medication which is crucial for treating individuals and preventing the spread of the disease.

Outreach capabilities should be adaptable to different pathogens, with the capacity to set up and operate in a variety of environments and the appropriate risk assessments in place.

Available staff should be PPE-trained and have access to the appropriate equipment.

6.3 Medicines management

Medicines management ensures that the right medicines are available to those who need them while preventing shortages and reducing waste.

Providers should be able to demonstrate appropriate medicines management capabilities, including maintaining stocks of essential drugs, vaccines, and other medical supplies, safe distribution mechanisms, and resilient procurement arrangements.

Providers should have the capability to use appropriate, clinically supported legal mechanisms for administering vaccines and other medications, including PSDs and PGD, with access to qualified clinical personnel to train and sign off staff, consent patients, and ensure compliance with the chosen mechanism.

Where vaccine or medication stocks are under pressure nationally, responsibility for procurement may be transferred to the ICB according to national directives.

In these instances, ICBs will be provided with a local protocol for procuring the restricted product from a regional or national centre on an as-needed basis, and should liaise with providers regarding local storage, transport, and administration.

6.4 Clinical governance

Effective clinical governance ensures high standards of clinical care, patient safety and accountability. Using BAU functions as far as possible for outbreak response facilitates good clinical governance by maintaining continuity of patient care and ensuring that medical records are kept appropriately.

Providers working on health protection responses outside of patients’ usual clinical pathways should demonstrate that they are able to maintain effective communication with patients’ primary care provider, recording and communicating all activities to prevent misunderstanding and duplication, and ensuring that follow-up care can be arranged as appropriate.

Providers and ICBs should demonstrate that they have robust escalation pathways and clear accountability in case of challenges or disruptions to health protection responses, including named members of staff who maintain assurance regarding their outbreak management capabilities.

7. Operational models for service delivery

Most local systems already have existing arrangements regarding response to infectious disease outbreaks and incidents.

ICBs should review these arrangements to identify gaps in provision and consider whether alternative delivery models may be required.

This should include reviewing the BAU functions of each commissioned service with a role in health protection, ensuring that agreed infectious disease interventions can be quickly activated without the need for ad hoc negotiations.

When planning for more complex local incidents, ICBs should consider the best model to meet the needs of the local population, with reference to the principles of flexibility, advanced planning, and resilience outlined in section 1.6.

Options include the following 3 models outlined in this section.

Publication reference: PRN01385
Classification: Official