DOH Memorandum: Control of Scabies in Health Care Facilities

Series: Health Facilities Series: H-11, RHCF-8 96-14
Subject: Control of Scabies in Health Care Facilities
Date: 09/03/96

This memo is intended as a guide for infection control and employee health staff in health care facilities and replaces Public Health Series Memo 83-44. Although scabies is not a severe or life-threatening disease, when it occurs the risk of spread and the disruptions to health care facilities are considerable. The information that follows was developed in response to scabies outbreaks reported to the New York State Department of Health. Prompt diagnosis, proper treatment of cases and exposed individuals and education of staff are the most important elements of scabies control in health care facilities.

  1. Clinical Characteristics and Epidemiology

    Scabies is an infestation or parasitic disease of the skin caused by the mite, Sarcoptes scabiei. The mite is primarily transmitted by direct skin-to-skin contact. Transmission by contaminated undergarments, bedclothes, or linens is possible but uncommon.

    Scabies appears as papules, vesicles, or tiny linear lesions which contain the mites and their eggs. The usual distribution of lesions include the interdigital folds, wrists, elbows, breasts, waist, perineum and buttocks. Complaints of itching that becomes worse at night are typical.

    In the elderly, unusual presentations of scabies can often be confused with other dermatologic conditions. The distribution of lesions may differ considerably from younger persons and may include the back, shoulders, neck and scalp. In the chronic stage, eczematization may occur.

    Norwegian scabies is an unusual clinical presentation involving hyperkeratinization and crusting of the skin. Its "scaly skin" appearance is frequently misdiagnosed as psoriasis.

    In persons without previous exposure, the incubation period may range from two to six weeks before onset of itching. Persons who have been previously infested (sensitized) have a much shorter incubation period and develop symptoms one to four days after re-exposure.

    The period of communicability may persist until patients are treated (occasionally two courses are necessary). Following treatment, patients or staff may resume routine activities.

    Twenty to 30 nosocomial outbreaks are reported each year in New York State. Sporadic, community-acquired cases are not reportable in New York.

  2. Control Measures

    When outbreaks of suspect scabies occur, the following control measures should be considered:

    1. Place all patients with a suspected scabies rash on contact precautions until treated with an appropriate scabicide.

      • Use gloves when having direct contact with the patient.
      • If more extensive contact is likely (e.g., turning the patient, bathing), a gown should be worn.
      • Hands must be washed before entering and leaving the room.

    2. Linen should be regarded as contaminated and handled according to facility policies. Personnel should wear gloves and gowns when handling and bagging contaminated linen.

    3. Confirm the diagnosis.

      1. Laboratory Diagnosis

        The diagnosis can be established by identification of the mite, ova, or feces in skin scrapings of burrows or papules. The following method should be used:

        • Place a drop of sterile mineral oil on the lesion.
        • Place a drop of sterile mineral oil on a sterile scalpel blade.
        • Scrape the lesion until tiny flecks of blood appear in the oil.
        • Place oil on slide or coverglass.
        • Examine under microscope.

      2. Epidemiologic Diagnosis

        If skin scrapings fail to establish the diagnosis or cannot be performed, there are three highly suggestive, if not pathognomonic, indicators:

        • The presence of burrows;
        • Complaints of itching which becomes worse at night; and
        • Clustering of cases.

    4. Define the extent of the problem

      1. Check all floors by nursing unit to determine the incidence of rashes in both the patient and employee populations.
      2. Survey other staff members who have direct contact with patients, or patients' laundry, for the presence of an itchy rash. Be sure to include hairdressers, physical and occupational therapy staff, and laundry service staff. Dietary employees do not usually have the direct patient contact necessary for transmission.

    5. Determine which patients and personnel were exposed to symptomatic persons.

    6. Outbreaks must be reported to the New York State Department of Health (NYSDOH) Infection Control Program by phone at (518) 473-4439 or fax at (518) 474-7381.

    7. Conduct in-service training for staff. Handouts and training materials are available through the New York State Department of Health, Bureau of Communicable Disease Control, at (518) 473-4439.

  3. Deciding Who to Treat

    Effective control depends upon treatment of exposed individuals concurrently with symptomatic persons. Because some asymptomatic persons may be incubating scabies, all exposed persons must be treated. Treating only symptomatic persons is not likely to result in control.

    1. Treatment of patients and staff may be limited to a particular nursing unit or floor if

      • All suspected or confirmed cases (patients and employees) are contained on one particular unit or floor, and
      • None of the affected staff have worked on other units.

    2. If cases are scattered throughout the facility, then all patients and exposed staff should be treated.

    3. All patients and exposed employees (both symptomatic and asymptomatic) should be treated on the same day.

    4. Stop staff crossover and group activities until staff and patients have been treated. It is also advisable to discontinue special services (occupational therapy, physical therapy, hairdressers, etc.) until everyone has had at least one course of therapy.

    5. Treatment Protocol

      Patients

      • The patient should receive a complete bath, or shower prior to the administration of therapy. Personnel assisting the patient should wear a gown and gloves.
      • Apply scabicide (e.g., Elimite, Kwell, Eurax). Follow the manufacturer's instructions for method of application and number of courses required. Do not dilute the product.
      • Itching should subside but may persist for one to two weeks even with successful treatment.
      • Clean clothes should be provided and bed linens changed.
      • Topical steroids may alter the immune response in infested individuals resulting in inapparent cases and potentially increased mite reproduction. Therefore, if the patient has been on topical steroids, they should be discontinued for at least 24-48 hours prior to the administration of a scabicide and until the rash has completely cleared.

      Employees

      • Both symptomatic and exposed asymptomatic employees should be treated.
      • The employee may return to work 8 hours after the first application of the scabicide.
      • Household members and sexual contacts of symptomatic employees must be treated at the same time as the symptomatic employee. This is critical to avoid reinfestation.

    For further information on scabies, contact the Bureau of Communicable Disease Control at (518) 473-4439.

    References:

    1. Control of Communicable Diseases in Man - Abram S. Benenson, Editor Sixteenth Edition, 1995, pp. 415-417.
    2. Green, M.; Epidemiology of Scabies, Epidemiologic Reviews; 1989; 11: 126-150.
    3. Pasternak, J., et al. Scabies Epidemic: Pride and Prejudice. Hospital Epidemiology 1994; 15: 540-542.
    4. Degelan, J. Scabies in Long-term Care Facilities. Hospital Epidemiology 1992; 13: 421-425.

    Endorsement:
    David Ackman
    Bureau of Communicable Disease

    Dale Morse
    Division of Epidemiology

    Kenneth Spitalny
    Center for Community Health

    Dennis Whalen
    Director, Office of Health Systems Management

    Distribution:
    Regional Offices of Public Health
    Area Offices of Health Systems Management
    Local Health Units
    Residential Health Care Facilities
    County Nursing Services
    District Health Offices
    Hospitals