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MANAGEMENT OF SCABIES

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					 INFECTION PREVENTION & CONTROL


      MANAGEMENT OF SCABIES




Initiated by:   Infection Prevention & Control Team
Approved by:    Infection Prevention & Control Committee
Issue Date:     2009
Review Date:    2011
Version:        3
Doc Ref:        ScabiesPv3.09
Policy Title:             Scabies

Executive Summary:
                          Details what scabies are, how they spread and the management of
                          them within the hospital setting. How patients are assessed,
                          treated and managed.




Supersedes:               V2 2007
Description of          Minor Wording
Amendment(s):
This policy will impact on:

clinical practices, employees and health & safety


Financial Implications:

None


Policy Area:          Infection Control Trust    Document                SACBIESPv3.09
                      Wide                       Reference:
Version Number:       3                          Effective Date:         2009
Issued By:            Director of Infection      Review Date:            12.2011
                      Prevention and Control
Author:               Head of Infection          Impact Assessment       06.09
                                                 Date:
                      Prevention and Control

                                    APPROVAL RECORD

                                      Committees / Group                         Date
Consultation:                   Infection Control Committee                     06.09
                                Health Protection Unit                          06.09
Approved by Director:           Director of Nursing & Patient                   06.09
                                Care Standards
Received for information:




Scabies Policy 2009 v3                    2 of 10                  East Cheshire NHS Trust
                                    CONTENTS


                                                                   Page

1. Introduction                                                        4

2. Mode of Transmission                                                4

3. Life Cycle                                                          4

   3.1 Incubation Period                                               5
   3.2 Sites of Infection                                              5
   3.3 Recognition                                                     5
   3.4 The Rash                                                        5
   3.5 The Allergy                                                     5

4. Classification of Scabies                                           6

   4.1 Classical Scabies                                               6
   4.2 Crusted Scabies                                                 6

5. Single Case or Suspected Cases                                      6

6. Treatment                                                           6

7. Hospital Mangagement                                                7

8. Outbreak Control                                                    8

   Legislation, Guidance and References                                8

Equality and Human Rights Policy Screening Tool




Scabies Policy 2009 v3              3 of 10       East Cheshire NHS Trust
1. INTRODUCTION

    The condition of ‘scabies’ is caused by an allergic reaction to the faecal material of the
    mite Sarcoptes scabei var hominus. It is an exceedingly common disease of world-wide
    distribution. It is endemic in many developing countries. Although scabies is more
    common where overcrowded conditions prevail, it can affect any individual irrespective of
    social status, personal hygiene, profession, gender, age or ethnic origin. It is primarily
    characterised by itching, vesiculation and pruritis. Signs of reddish, slightly elevated
    tracts may also accompany this on the skin, especially where the skin is thin. Miniature
    papules, vesiculations, pustules and excoriations soon appear. Scratching of these
    areas may lead to secondary infection.

2. MODE OF TRANSMISSION

    Transmission is by direct personal contact, i.e. by prolonged skin-to-skin contact, sexual
    or social, when the adult mites pass from person to person. More rarely, in institutions,
    overcrowded conditions or when crusted scabies occurs, mites can be transmitted by
    clothing and bed linen. This is not usually the case in a person’s own home. Scabies
    tend to spread through any close community, particularly within the household. It is
    recognised that the spread is not limited to family members but included everyone who is
    living in close or intimate contact with possible affected individuals.

     • Infection occurs following transference of one or more pregnant female mites who
       burrow into the skin.

     • People who have acquired the infection for the first time are infectious in the 2-4
       weeks before the rash develops, so this can make spread of the disease difficult to
       contain.

3. LIFE CYCLE

     • Adult female burrows into skin
       The newly mated female selects a site on the skin for burrowing. This is usually in
       the vicinity of the hands, wrists, elbows, feet or groin. The female uses suckers on
       her legs (called ambulacral suckers) to attach herself to the skin surface and then
       cuts a channel into the skin using her jaws (termed chelicerae) as well as cutting
       edges on the tibiae of her first pair of legs. She burrows only in the top layer of skin
       (the cornified epithelium) and over her full life the burrow can reach a length of 2-3
       cm and can often be observed through the skin as a thin zigzag line.

     • Female lays her eggs
       The female starts laying eggs in the burrow a few hours after she has began
       burrowing and she continues to lay eggs at a rate of 2-3 per day for up to 2 months.

     • Eggs mature
       Larvae emerge from the eggs 3-4 days after they have been laid.

    •   Larvae mature
        After emerging from the egg, the larva moves out of the burrow onto the skin and
        wanders around till it finds a suitable hair follicle within which to shelter and find food.
        It lives here, passing through two moults before becoming adult.

    •   Adult male and female mate
        Mating probably takes place on the surface of the skin.

        The entire life cycle can be completed in 10-14 days.
Scabies Policy v3 2009                      4 of 10                      East Cheshire NHS Trust
    3.1 Incubation Period

        The incubation period for a first contact is usually 4-6 weeks in people without
        previous exposure, as the dung (Scybala) takes anything up to this time to cause an
        allergic reaction. Subsequent contacts with the mite will cause an allergy within one
        week. Scabies is easily cured provided treatment is performed properly. The
        asymptomatic carrier has time to transmit the mite in any prolonged close skin-to-skin
        contact within these weeks.

    3.2 Sites of Infection

        The most common site for mites to be found is between the folds in the skin,
        especially where skin is thin. The typical appearance is of tiny raised burrows or
        small red slightly elevated papules or vesicles particularly on the wrists, back of the
        hands and between the fingers. Further spread is usually confined to the elbows,
        armpits, beneath the breasts, waist, groin, genitals, buttocks, knees and ankles. In
        infants the face and scalp are also involved. It should be recognised, however, that
        scabies is an allergy and the itch and the rash may not always coincide with the site
        of the mite.

    3.3 Recognition

        This can be difficult.      The mites are only just visible to the naked eye.
        Yellowish/white in colour, they are almost spherical in shape. Recovering the mite
        from its burrow and identifying it microscopically may establish diagnosis. Prior
        application of mineral oil facilitates collecting the scrapings. Scabies should be
        suspected in the presence of:

        ♦ itching, particularly at night
        ♦ a symmetrical rash
        ♦ burrows and other lesions in the sites of mite predilection

        Other clinical conditions may make diagnosis difficult and need to be eliminated, e.g.
        eczema.

    3.4 The Rash

        The rash in scabies is due to two factors:

        i)   The classic burrows and vesicles of scabies are related to direct infection with the
             mite and are normally found on the hands and wrists only.

        ii) The generalised eczema and itching is an allergic response to the excreta and
            saliva, egg cases and other waste proteins of the parasitic mite Sarcoptes
            scabiei.


    3.5 Allergy

        ♦ The allergic response is generated in response to the presence of faecal pellets:
             the protein from which eventually diffuses into the bloodstream.

        ♦ The allergic reaction does not always correspond with the site where the mite
             may be found.

        ♦ The appearance and severity of symptoms varies from person to person and can
             in some cases depend on the status of the patient’s immune system.
Scabies Policy v3 2009                      5 of 10                    East Cheshire NHS Trust
4. CLASSIFICATION OF SCABIES

    There are two types of scabies, both caused by the same mite.

    4.1 Classical scabies

        ♦   Found in people with normal immune systems.
        ♦   Mites may be few in numbers.
        ♦   Itch starts about 2-6 weeks following infection.
        ♦   Sites of the rash may not correspond to sites of the mites.

    4.2 Crusted scabies

        ♦ A rare form of the disease, also known as Norwegian Scabies.
        ♦ It affects individuals with severely impaired immune systems.
        ♦ It is also commonly found in people with Downs Syndrome. Numerous mites are
            found in crusted scabies.
        ♦ There may be an absence of the generalised itchy rash.
        ♦ Skin becomes scaled, crusted and unsightly due to the number of mites present..

5. SINGLE CASE OR SUSPECTED CASES

    Unless the original source of infection and ALL contacts are identified, the disease will
    continue to spread with the possibility of re-infecting those already treated. For further
    advice contact the Infection Prevention & Control Team.

    The purpose of contact tracing is to alert anyone who may be infected. All those with
    whom skin contact was made for a prolonged period of time within the previous two
    months must be informed. If the patient is from a Nursing or Residential home the
    Community IPCT should be informed telephone 01606 564091.

6. TREATMENT

    Scabies occasionally presents in hospitalised patients as a single case or sometimes as
    small outbreaks in ward areas. Once the diagnosis of scabies has been made, the
    patient should be informed and treatment commenced (treatment should be applied as
    per manufacturers instructions).

    Further advice can be sough from the Infection Prevention & Control Team

    All staff having close contact with an index case may require treatment even in the
    absence of symptoms. In many institutions this will involve all staff identified being
    treated simultaneously.

    All members of the household should be treated even in the absence of symptoms. It is
    important that all members of the household are treated at the same time. It is important
    to stress that this is not limited to family members but should include everyone who is
    living in close or intimate contact with possible affected individuals.

Occupational Health will give advice on Staff and family treatment if required.

    ♦ Treatment should be applied/administered as per manufacturer’s guidelines.

    ♦ People should be advised to avoid body contact until they and their partners and
        close contacts have been treated.


Scabies Policy v3 2009                      6 of 10                   East Cheshire NHS Trust
    ♦ Partners and close contacts should be treated simultaneously.

    ♦ Patients may need help to apply the treatment properly and special attention should
        be paid to armpits, flexor aspects of wrists and elbows, finger webs and under nails,
        beneath the breasts and around the nipples in females. Treatment will need to be
        reapplied to any areas washed during the course of treatment.

    ♦ Classical scabies is not transmitted on clothing, towels and bedding; therefore no
        special cleaning or laundering measures other than the usual are required when
        treating it.

    ♦ Patients, staff and contacts should be advised that itching could persist several
        weeks after successful treatment. In fact, the symptoms may become more
        pronounced. This is because the body reacts to the dead mite and its waste
        products, which remain in the skin. Skin becomes scaled, crusted and unsightly due
        to the numbers of mites present and for this reason, an antipruitic lotion may be
        helpful.

    ♦ Pregnant and nursing women should only be treated if it is absolutely necessary and
        always under medical supervision.

    ♦ The guiding principle is co-ordination of treatment to limit both spread of the disease
        and pesticide exposure. Successful treatment does not protect the person from re-
        infestation from undiagnosed contacts inside and outside the family.

7. HOSPITAL MANAGEMENT

    It is advisable for the hospital to adopt a precautionary, watchful stance that ensures:

    ♦ Staff are educated to recognise the signs and symptoms of scabies.

    ♦ Pro-active surveillance for new patients suspected of having scabies, examination
        repeated at 3 and 6 weeks.

    ♦ Swift diagnosis.

    ♦ Swift treatment for all staff (if indicated) since adequate and simultaneous treatment
        of cases and contacts is essential to prevent further spread.

    ♦ Access to dermatological consultation for patients and staff.

    ♦ Established care procedures for suspected and identified cases minimising the risk of
        transmission, being sensitive to the feeling of the patients.

    Fomites are important in the dissemination of crusted scabies. Contaminated bedding,
    towels and clothes should be bagged and laundered separate from other washing.
    Normal washing temperatures can be used and should be followed by thorough drying.
    Staff at the home do not need to stay off duty provided that they have received and
    applied their treatment. Where staff have responsibility for applying the lotion/cream to
    patients, they should wear disposable non-sterile gloves to do so.




Scabies Policy v3 2009                      7 of 10                     East Cheshire NHS Trust
8. OUTBREAK CONTROL

    In the event of a suspected outbreak in the hospital, contact the Infection Prevention &
    Control Team.

    A confirmed diagnosis must be made by a Consultant Dermatologist or an appropriately
    trained practitioner.

    Effective control requires early identification of index cases and adequate and
    simultaneous treatment of cases and contacts to prevent further spread.

    All Consultants of patients who are affected should be made aware of the problem and
    should be informed of the action to be taken.

    Co-ordinate with the Infection Prevention & Control Team the supply of scabicides for the
    agreed treatment dates, limiting the amount available to two thorough treatments per
    person to prevent over medication. If possible have one principle pharmacy co-
    ordinating the supply.

    Household contacts of symptomatic staff must be treated at the same time.

    Information leaflet ICL 32 available from photocopying.

    For any further advice, please contact the Infection Prevention & Control Team on 1597
    or bleep 3034.




LEGISLATION, GUIDANCE AND REFERENCES

Chin J., MD, MPH (Ed) (2000) Control of Communicable Diseases Manual (17th Edition)
American Public Health Association, United Book Press. BALTMORE

Department of Health The Health & Social Care Act 2008 Code of Practice for the
Prevention and Control of Health Care Associated Infection

Good Practices Policy 2009 Infection Prevention & Control Manual. East Cheshire NHS
Trust


Scabies Policy v3 2009                    8 of 10                   East Cheshire NHS Trust
                               Equality and Human Rights Policy Screening Tool

Policy Title: Scabies                                                  Directorate: Nursing & Patient
                                                                       Care Standards

Name of person/s auditing / authoring policy:

Service Manager Infection Prevention & Control & Infection Prevention & Control Committee

Policy Content:

•     For each of the following check whether the policy under consideration is sensitive to people of a
      different age, ethnicity, gender, disability, religion or belief, and sexual orientation?

•     The checklist below will help you to identify any strengths and weaknesses of the policy and to
      check whether it is compliant with equality legislation.

1. Check for DIRECT discrimination against any minority group of PATIENTS:
                                                                       Action                    Resource
Question: Does the policy contain any statements which  Response                                implication
                                                                      required
may disadvantage people from the following groups?
                                                        Yes    No    Yes    No                  Yes     No
1.0 Age?                                                        √            √                           √
1.1     Gender (Male, Female and Transsexual)?                           √               √              √
1.2     Learning Difficulties / Disability or Cognitive                  √               √              √
        Impairment?
1.3     Mental Health Need?                                              √               √              √
1.4     Sensory Impairment?                                              √               √              √
1.5     Physical Disability?                                             √               √              √
1.6     Race or Ethnicity?                                               √               √              √
1.7     Religious Belief?                                                √               √              √
1.8     Sexual Orientation?                                              √               √              √
2. Check for DIRECT discrimination against any minority group relating to EMPLOYEES:
                                                                         Action    Resource
Question: Does the policy contain any statements which  Response                  implication
                                                                        required
may disadvantage employees or potential employees from
any of the following groups?                            Yes    No     Yes     No Yes     No
2.0 Age?                                                        √              √          √
2.1 Gender (Male, Female and Transsexual)?                      √              √          √
2.2     Learning Difficulties / Disability or Cognitive                  √               √              √
        Impairment?
2.3     Mental Health Need?                                              √               √              √
2.4     Sensory Impairment?                                              √               √              √
2.5     Physical Disability?                                             √               √              √
2.6     Race or Ethnicity?                                               √               √              √
2.7     Religious Belief?                                                √               √              √
2.8     Sexual Orientation?                                              √               √              √
TOTAL NUMBER OF ITEMS ANSWERED ‘YES’ INDICATING DIRECT DISCRIMINATION = 0


      Scabies Policy v3 2009                      9 of 10                 East Cheshire NHS Trust
 3. Check for INDIRECT discrimination against any minority group of PATIENTS:
                                                                        Action                  Resource
 Question: Does the policy contain any conditions or     Response                              implication
                                                                       required
 requirements which are applied equally to everyone, but
 disadvantage particular people because they cannot      Yes    No    Yes    No               Yes    No
 comply due to:
 3.0 Age?                                                      √              √                       √
 3.1     Gender (Male, Female and Transsexual)?                   √                     √             √
 3.2     Learning Difficulties / Disability or Cognitive          √                     √             √
         Impairment?
 3.3     Mental Health Need?                                      √                     √             √
 3.4     Sensory Impairment?                                      √                     √             √
 3.5     Physical Disability?                                     √                     √             √
 3.6     Race or Ethnicity?                                       √                     √             √
 3.7     Religious, Spiritual belief (including other belief)?    √                     √             √
 3.8     Sexual Orientation?                                      √                     √             √

 4. Check for INDIRECT discrimination against any minority group relating to EMPLOYEES:
                                                                         Action      Resource
 Question: Does the policy contain any statements which  Response                   implication
                                                                        required
 may disadvantage employees or potential employees from
 any of the following groups?                            Yes    No     Yes    No   Yes     No
 4.0 Age?                                                        √             √            √
 4.1     Gender (Male, Female and Transsexual)?                       √                 √             √
 4.2     Learning Difficulties / Disability or Cognitive              √                 √             √
         Impairment?
 4.3     Mental Health Need?                                          √                 √             √
 4.4     Sensory Impairment?                                          √                 √             √
 4.5     Physical Disability?                                         √                 √             √
 4.6     Race or Ethnicity?                                           √                 √             √
 4.7     Religious, Spiritual belief (including other belief)?        √                 √             √
 4.8     Sexual Orientation?                                          √                 √             √
 TOTAL NUMBER OF ITEMS ANSWERED ‘YES’ INDICATING INDIRECT DISCRIMINATION = 0

Signatures of authors / auditors:
Chris McGinley Service Manager Infection Prevention & Control
Dr Alan Wills DIPC, on behalf of the IPCC                                          Date: 06.2009

                    Equality and Human Rights Compliance / Percentage Calculation
Number of ‘Yes’ answers for DIRECT discrimination.                    0

Number of ‘Yes’ for INDIRECT discrimination.                          0

Total answers for POLICY CONTENTS discrimination.                     0

Percentage content non compliant                                      = 0%




       Scabies Policy v3 2009                      10 of 10               East Cheshire NHS Trust

				
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