Definitions
Diagnosis of Scabies
Confirmation of Diagnosis
Treatment
Environmental Control Measures
Protocol For Assessment And Control Of Scabies
Outbreaks in Long Term Care Facilities
Institutional Treatment Plan: Selective vs Mass
Treatment
References
Introduction
Scabies is a contagious parasitic infestation of the skin caused
by the mite, Sarcoptes scabiei var hominis. Although not a reportable
disease, scabies outbreaks reported from long term care facilities
(LTCFs) have increased in recent years. In Maryland, 61 scabies
outbreaks were reported from 1986-1995, of which 57% (35/61) occurred
in nursing homes. Both care givers and residents of LTCFs are
at increased risk of exposure to scabies. The increased risk is
attributed to several circumstances of providing and receiving
care in a LTCF.
Scabies in residents of LTCF may often be atypical in appearance
and symptoms, causing a delay in diagnosis as well as heavy infestation.
An additional factor contributing to the increased risk of exposure
is the opportunity for direct skin contact between staff and residents
or residents and other residents. Such contact is increased with
LTCF residents who often require assistance with dressing or positioning
as well as other nursing care. Further opportunities for transmission
can occur through rotation of asymptomatic staff members to various
units within the LTCF.
Finally, environmental exposure to scabies can occur if residents
mistakenly occupy another infested resident's bed.
Definitions
Outbreak: An outbreak of scabies should be reported when
a LTCF experiences two or more concurrent cases of scabies affecting
residents and/or staff members. Two or more consecutive cases
of scabies occurring within four to six weeks of each other should
also be considered to be an outbreak.
Case: A confirmed case of scabies is defined as a person
who has a skin scraping with identified mites, mite eggs, or mite
feces. A probable case of scabies is a person with clinical symptoms
of a persistent pruritic rash.
Contact: A contact is defined as anyone with whom a case
has had skin-to-skin contact (e.g., staff member, physical therapist,
phlebotomist, family member who is a regular visitor, or other
residents with whom the case has had direct skin contact). Sexual
partners and roommates are also contacts.
Incubation Period: The time between contact with the mite
and the appearance of the symptoms of the pruritic rash varies.
If the individual has never had a previous infestation, the onset
of symptoms occurs two to six weeks following the initial infestation
by the mite. If the individual has had a prior infestation symptoms
can occur one to four days following mite infestation.
Period of Communicability: The infested individual may
be asymptomatic yet able to transmit the mite to others. After
infestation occurs, the mite deposits eggs under the skin of the
human host. After larvae hatch from the eggs, they travel to the
surface of the skin. Transmission can occur as early as two weeks
after the original infestation of the individual. A person is
considered to be no longer communicable 24 hours after start of
effective therapy.
Diagnosis of Scabies:
Typical scabies lesions consist of papules, vesicles, or linear
burrows containing the pinpoint mite; however, these may not be
present on an elderly or immunocompromised infested person. Erythematous
papules, excoriations, or occasionally vesicles are often located
between the fingers, on the upper back, wrists, elbows, thighs,
breasts, or genitalia. The lesions may also appear as eczematous
plaques, pustules, or nodules located in skin folds under the
breasts, around the naval, axillae, buttocks, scrotum, or at the
belt line on the abdomen. Infested individuals usually complain
of severe nighttime itching. The itching is often worse following
a hot shower or bath. The location of scabies lesions also differs
in the elderly or immunocompromised.
Residents and staff should have skin examination by inspection.
New residents or those accepted in transfer from another care
facility should be examined on the first day of arrival. If a
resident is undergoing treatment for scabies but requires transfer
to another care facility, the accepting facility must be notified
of the current diagnosis of scabies in this resident prior to
transfer.
Residents of LTCF are at risk for hyperinfestation with the scabies
mite. Crusted scabies, known as Norwegian scabies, is extremely
contagious. If even a single resident has crusted scabies, the
LTCF faces a significant risk of a scabies outbreak. Lesions resemble
psoriasis with heavy crusting and scaling. Fingernails and toenails
often appear discolored and thickened. Individuals diagnosed with
Norwegian scabies may have one of the following characteristics:
a history of treatment with steroids, an impaired ability to scratch
caused by neurological or psychological illness, or an otherwise
impaired immune response secondary to age or illness.
Confirmation of Diagnosis:
Suspicious lesions should be scraped with a sterile needle or
scalpel blade. Health care personnel can be trained to perform
skin scrapings according to the following procedure:
-
Choose lesions without significant excoriation.
A magnifying glass may be used to locate burrows. When a possible
burrow is detected, mark with a wide felt tip pen. Apply an
alcohol pad to remove the surface ink. If a burrow is present,
the ink will remain within the burrow. The burrow will then
appear as a dark, irregular line.
-
Apply sterile mineral oil to the surface of
the lesion to be sampled.
-
With a glass slide held at a 90 angle to the
surface of the lesion, scrape the lesion. Collect the scraping
on the glass slide. Scrapings from several lesions may be collected
onto a single glass slide.
-
Place a coverslip over the scrapings and examine
with a microscope under low power. The presence of a mite, eggs
of a mite, or mite fecal material confirms the diagnosis of
scabies.
Treatment:
The recommended treatment for scabies is 5% permethrin
cream. Application of this cream to the skin of an infested resident
should be supervised by the staff of the LTCF. Usually the cream
is best applied prior to bedtime. The cream must cover all skin
areas from the neck down.
In the case of an incontinent resident, the LTCF staff
must ensure that any cream that is removed during bouts of incontinence
is promptly replaced. Following 8-14 hours of skin contact, the
cream should be removed by shower or bath. Treatment may need to
be repeated in seven days if there is evidence of persistent or
recurrent lesions.
An infested individual should be considered contagious
until 24 hours after start of effective treatment. Itching often
persists in spite of treatment and may require additional therapy
for symptomatic relief.
Alternative treatments are occasionally prescribed.
These may include 1% lindane cream or lotion, 6% precipitated sulfur
in petroleum, or 10% crotamiton cream or lotion.
Environmental Control Measures:
While scabies is readily transmissible with skin to
skin contact, the mite can only survive in the environment for 48
hours without a human host. The bedding and clothing of an infested
individual may contain viable mites, but exposure to a human host
must occur within a short period of time for transmission to occur.
In general, vacuuming and general cleanliness should
provide adequate environmental control. Fumigation is not necessary;
furniture should not be discarded. Clothing or bedding that were
used by an infested individual during the seven days before effective
treatment should be laundered and dried with the hot cycle or dry
cleaned. Items that cannot be laundered or dry cleaned should be
placed in a plastic bag and sealed for seven days to allow time
for mites and eggs to die.
Cohort Measures:
During an identified scabies outbreak, staff members
who have been providing care to an identified case should not be
rotated to other resident care units until 24 hours after completion
of the staff member's scabicidal treatment. The case should also
be isolated from other residents for 24 hours. Treatment of cases
and contacts in a coordinated manner according to the attached protocol
will minimize the inconvenience of these cohort measures.
Protocol For Assessment And
Control Of Scabies Outbreaks in Long Term Care Facilities
The following protocol provides guidance for surveillance,
diagnosis, and treatment of cases and contacts in LTCFs and management
of outbreaks.
-
Make a line list of all cases and contacts.
Include roommates, staff members (permanent and rotating), providing
care, and regular visitors as contacts
-
Confirm the diagnosis when possible; refer
to dermatologist or physician for diagnostic evaluation.
-
. Institute mass education regarding scabies
outbreaks. Educate staff; consider community meetings for residents
and family members, printed fact sheets (see attachment), and
newsletters to families of staff and residents.
4. Educate staff and residents (if possible) on:
-
Mode of transmission
-
Communicability
-
Potential for widespread epidemic if prompt
action not begun
-
Need for prophylactic treatment of even asymptomatic
contacts
-
Need for coordinated timing of treatment
-
Proper application of treatment medication
-
Environmental control measures: Laundry, dry
cleaning, or isolation of clothing in plastic bags for seven
days
Categorize cases and contacts for treatment assignment
as follows:
Management: Group I: Confirmed
or Suspected Scabies and Contacts
1. Action:
Isolate case (Contact precautions) for 24 hours after
start of effective therapy.
Perform environmental control measures:
- Laundry, dry cleaning, or isolation of clothing in plastic bags
for seven days.
- Exclude case from work (or school, day care center, if applicable)
until the day after treatment.
- Do not transfer patient without notifying the accepting facility
of the diagnosis of scabies.
2. Treatment:
- Day 1 (PM) Clip nails. Bathe or shower. Apply 5% permethrin
cream to all skin areas from the neck down and under nails. (Staff
member should apply permethrin to the skin of the resident.)
- Day 2 (AM) Bathe or shower to remove the cream. Inform
person that itching may persist for weeks.
- Day 14 Reexamine; retreat if persistent or recurrent
lesions.
- Day 28 Reexamine; retreat if persistent or recurrent
lesions.
Group II: Crusted Scabies or
Norwegian Scabies (Hyperinfestation)
Note: These individuals have a long
term rash and are very heavily infested. They are very contagious.
Repeat treatments with 5% permethrin cream are usually necessary.
1. Action:
- Isolate case (Contact precautions) until dermatology consult
determines that case's rash is no longer transmissible.
- Perform environmental control measures:
- Laundry, dry cleaning, or isolation of clothing in plastic bags
for seven days.
- Cohort staff so that only one group cares for a resident/in-patient
case until case is no longer transmissible.
- Exclude symptomatic cases (those with a rash) from work (or
school, day care center, if applicable) until dermatologist, in
consultation with Health Officer approves resumption based on
lack of risk of transmission.
- Do not transfer patient without notifying the accepting facility
of the diagnosis of scabies.
2. Treatment:
- Day 1 (PM) Clip nails. Bathe or shower. Apply 5% permethrin
cream to all skin areas including scalp, temples, forehead, and
under nails. (Staff member should apply permethrin to the skin
of the resident.)
- Day 2 (AM) Bathe or shower to remove the cream after
permethrin has been on skin for 8-14 hours). Inform person that
itching may persist for weeks.
- Day 7 (PM) Repeat bath or shower. Repeat application
of 5% permethrin cream from the neck down.
- Day 8 (AM) Bathe or shower to remove cream. Day 14 Reexamine;
retreat if persistent or recurrent lesions.
- Day 28 Reexamine; retreat if persistent or recurrent
lesions.
Institutional Treatment Plan:
Selective vs Mass Treatment
Although scabies frequently presents as a widespread
outbreak within a LTCF, there are circumstances in which a more
selective treatment plan may be utilized. Selective Treatment Protocol
If a single case of scabies (Group I, above)
occurs within the population of residents or employees, a selective
treatment protocol may be utilized:
- Identify the case and make a line list of all contacts (roommate,
care providers including radiologists, physical therapists, etc.,
sexual contacts, family members, or regular visitors) for the
previous two months. Check contacts for rash or itching symptoms.
- Educate cases and contacts as previously described. Emphasize
the rationale for treatment of contacts.
- Evaluate case and contact for assignment to proper treatment
group (Group I or Group II,
above).
- Treat case and contacts to permit simultaneous treatment to
prevent reinfection and spread of the infestation
- Emphasize the need for follow-up / reexamination at 14 and
28 days.
- Employ environmental control measures for laundry and clothing
as previously described.
Mass Treatment Protocol
A more extensive treatment plan should be utilized
if any of the following occur:
- a single case of crusted or atypical scabies (Norwegian scabies,
Group II, above) is diagnosed within the resident
population and at least one employee is symptomatic;
- two or more residents have positive scrapings and at least
one employee on the same unit is symptomatic; or
- one asymptomatic resident has a positive scraping and other
residents or employees have exhibited symptoms of infestation
for a period exceeding a month.
The following actions should be taken:
- Designate an outbreak control officer. This should be a health
care provider or infection control professional who is able to
diagnose and treat cases and contacts.
- Make a line list of cases and contacts.
- Institute a facility-wide screening to detect skin lesions
or symptoms that may be present in residents, employees, or close
contacts of cases.
- Cohort employees to designated units until coordinated treatment
is completed.
- Educate the resident community, patients, employees, ancillary
personnel, and family members or frequent visitors as previously
described.
- Make assignment to appropriate treatment group (Groups I and
II, above).
- Perform mass treatment within a 24 hour period of all residents
and staff members employed within a defined area of the facility
.
- Perform followup examination and retreatment according to Group
assignment. 9. Perform environmental cleaning as previously described.
Summary
Prompt identification and treatment of scabies cases
and potential contacts remains the cornerstone of outbreak control.
Education of residents, staff, and family members or regular visitors
must be initiated immediately.
Finally, treatment of cases, contacts, and the environmental
control measures must be coordinated. If case and contact identification
is not complete or if treatment of cases and contacts does not occur
at the same time, transmission of the mite will continue.
Strict surveillance for possible cases should be performed
at time of resident admission or during times of skin care or bathing
assistance. The unique circumstances of the LTCF provide a population
that is extremely susceptible to outbreaks of scabies. Vigilant
and ongoing surveillance for cases is of paramount importance within
this setting.
References
- Maryland Electronic Reporting and Surveillance System (Unpublished
data).
- Jimenez-Lucho VE, Fallon F, Caputo C, Ramsey K. Role of prolonged
surveillance in the eradication of nosocomial scabies in an extended
care Veterans Affairs medical center. Am J Infec Control 1995;
23:44-49.
- Benenson, AS, ed. Control of Communicable Diseases Manual.
Washington, D.C.: American Public Health Association, 1995: 415-417.
- Maguire JH, Spielman A. Ectoparasite Infestations. In: Isselbacher
KJ, Braunwald E, Wilson JD, Martin JB, Fauci AS, and Kasper DL,
eds. Harrison's Principles of Internal Medicine. New York: McGraw-Hill,
Inc., 1994: 934-935.
- Centers for Disease Control. Scabies in health care facilities-Iowa.
MMWR 1988; 37: 178- 179.
- Degelau, J. Scabies in Long-Term Care Facilities. Infect Control
Hosp Epidemiol 1992; 13: 421-425.
- Wilson, BB. Scabies. In: Mandell GL, Bennett, JE, and Dolin
R, eds. Mandell, Douglas and Bennett's Principles and Practice
of Infectious Diseases. New York: Churchill and Livingstone, Inc.,
1995: 2560-2562.
- Yonkosky D, Ladia L, Gackenheimer L, and Schultz MW. Scabies
in nursing homes: an eradication program with permethrin 5% cream.
J Amer Acad Derm 1990; 16: 1133-1136.
- Collier, C. Guidelines for Scabies Prevention and Control .
Missouri Epidemiologist Nov-Dec 1994: 14
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