Scabies Guidance for the Management of Scabies Infestation in the Community and Community Hospitals Reference No: Version: 5 Ratified by: G_IPC_27 Date ratified: 10 th October 2017 Name of originator/author: Name of responsible committee/individual: Infection Prevention and Control Committee, Infection Prevention Team Date issued: October 2017 Review date: August 2019 Target audience: Distributed via: Infection Prevention & Control Committee All staff Website 1
Version V2 Section/Para/ Appendix Infection Prevention and Control Version Control Sheet Version/Description of Amendments Document reviewed Title amended Training & responsibilities updated Whole document; infection replaced with V3 All document Replace Lincolnshire Community Health Services in document with the Trust Date infestation 7 th Jan 2011 10 th May 2013 All document Remove My Mail 10 th May 2013 All document Replace Learning Academy 10 th May throughout document with 2013 Workforce Development Team All document Replace Link Persons throughout document with Link Champions 10 th May 2013 Author/Amended by Cheryl Day: Countywide IP&C Advisor L Roberts L Roberts L Roberts L Roberts All document Inclusion of Monitoring 10 th May L Roberts procedure 2013 All document Updated Equality and Diversity analysis 10 th May 2013 L Roberts All document Remove header except 10 th May L Roberts from front page 2013 All document Change HPA to Public 10 th May L Roberts Health England (PHE) 2013 V4 All document Changed Footer April 2015 L Roberts All document Changed Workforce April 2015 L Roberts Development Team to Education and Workforce Team Appendix K Update Equality Analysis April 2015 L Roberts V5 Page 11 Monitoring Change to Bi annually April 2015 L Roberts Whole Removed strap line July 2017 L Roberts document Section 3.1 Changed review time to July 2017 L Roberts every 2 years instead of 3 Whole Renamed Education and July 2017 L Roberts document Work force to Workforce Section 23 Removed Contribution July 2017 L Roberts section Copyright 2017 Lincolnshire Community Health Services NHS Trust, All Rights Reserved. Not to be reproduced in whole or in part without the permission of the copyright owner. 2
Guidance Statement Background The purpose of this guidance is to advise on the best practice required around the management of scabies infestation thus minimising the risk of healthcare associated infections to patients, visitors and staff in health care settings. Statement This guidance is comprehensive, formally approved, ratified and disseminated through appropriate channels. It will be implemented for all staff within the Trust Responsibilities Compliance with this guidance will be the responsibility of all The Trust staff and invited contractors. Training The Infection Prevention Team, Clinical Educators and Workforce Team will support/facilitate any training associated with this guidance. Dissemination Website. Resource implication This guidance has been developed in line with the NHS Litigation Authority guidelines, recent Department of Health Policy and Best Practice Evidence to provide a framework for staff within the organisation to ensure appropriate production, management and review of organisation wide policies. 3
Scabies Guidance for the Management of Scabies Infestation in the Community and Community Hospitals Contents Version Control Sheet... 2 Guidance Statement... 3 1. Introduction... 6 2. Scope of the guidance... 6 3. Key Responsibilities... 6 3.1 The Infection Prevention Team... 6 3.2 Infection Prevention Link Champions... 6 3.3 Managers... 6 3.4 Employees... 6 3.5 Workforce Team... 6 4. General information about Scabies... 7 5. Source of infestation... 7 6. Mode of Transmission... 7 7. Incubation period... 7 8. Signs and Symptoms of Scabies Infestation... 7 9. Types of Scabies Infestation... 8 10. Diagnosis... 8 11. Treatment of Scabies... 9 11.1 Staff... 9 11.2 Patient /Carers /Visitors... 9 11.3 Obtaining treatment... 9 12. Single Cases of Scabies... 9 13. Multiple cases / Outbreak Situation in health care settings...10 14. Additional Infection Prevention and Control Precautions...10 15. Post treatment observations / monitoring...10 16. Treatment of Contacts...10 17. Restrictions around Work...10 18. Re-occurrence of Infestation...10 19. Education...10 20. Monitoring...10 21. Resources...11 22. Evidence...11 Appendix A Leaflet...12 APPENDIX B: Types of Scabies Infestation...14 4
APPENDIX C: Treatment of Scabies Infestation...15 APPENDIX D: Management of Single and Multiple / Outbreak cases of Scabies in Community...16 APPENDIX E: Management of Scabies Outbreak - Checklist...17 APPENDIX F: Management of Scabies - Monitoring Form (Patient / Client)...18 APPENDIX G: Management of Scabies - Monitoring Form (Staff)...19 APPENDIX H: Letter to relatives of residents...20 APPENDIX I: Letter to carers/staff...21 APPENDIX J: Letter to GP...22 APPENDIX K: Equality analysis...23 5
Guidance for the Management of Scabies Infestation in the Community and Community Hospitals 1. Introduction Scabies infestation is common throughout the world and an estimated 300 million cases occur each year. It is not a notifiable disease and thus the true prevalence in the United Kingdom is unknown. It can affect any individual irrespective of age, gender, race, social class and geographical location. Scabies is frequently misdiagnosed in the elderly as the clinical features in this group may differ from those seen in younger people or as stated in some text books. This may lead to delayed diagnosis and consequentially outbreak situations within community hospitals or care homes. As there is the potential for large numbers of residents and staff to be affected before the diagnosis is made, it is important when dealing with outbreaks that the situation is effectively managed and that simultaneous treatment is achieved. NB. The principles of the care and management of scabies infestation as stated within this guidance are the same irrespective of where the patient may reside i.e. Home, Community Hospital or Care Home. 2. Scope of the guidance This guidance is for all staff working within The Trust. 3. Key Responsibilities 3.1 The Infection Prevention Team The Infection Prevention Team will: Review the guidance in response to the publication of any urgent communications from the Department of Health. Review the guidance every 2 years. Provide support and any relevant training associated with the implementation of this guidance. 3.2 Infection Prevention Link Champions Infection Prevention Link Champions are responsible for cascading the relevant training to staff within their team, clinical area and department. 3.3 Managers Managers have the responsibility for the standards of clinical practice by their staff in the health care setting. They must: Ensure all individuals are appropriately trained. Inform new employees of their responsibilities under this guidance. Ensure that all employees within their area of responsibility comply with this guidance. 3.4 Employees All employees have a responsibility to abide by this guidance and any decisions arising from the implementation of them. Any decision to vary from this guidance must be fully documented with the associated rationale stated. 3.5 Workforce Team The Workforce Team have a responsibility to ensure the coordination of any relevant staff education as identified within the training matrix. In relation to this guidance they will: 6
Evaluate the education sessions. Follow up non attendance. 4. General information about Scabies Scabies is a parasitic infestation of the skin, characterised by tiny burrows, papules or vesicles and intense itching (Appendix A). The symptoms may be variable in presentation and can mimic other skin conditions. It is caused by a parasitic mite, Sarcoptes scabiei var. hominis, an obligate human parasite which is approximately 0.3-0.4 mm in length which burrow under the epidermis of the skin. Burrows maybe visible as a line about 5mm in length and can occur anywhere on the body; this is where the mite lives and lays its eggs. The number of mites in classical scabies is approximately 10-15 per person. Crusted (Norwegian) scabies is a hyper-infestation with up to two million mites present in exfoliating skin scales. Scabies may be variable in presentation and may mimic other skin conditions. 5. Source of infestation The source of the mite is humans. Animal scabies will not reproduce in humans, though may cause irritation if there is contact with the skin. 6. Mode of Transmission Scabies is passed from an infested person to another via prolonged skin contact e.g. hand holding and/or sexual contacts. Close contacts may also include: family members, nurses and carers. Infestation occurs following transference of one or more pregnant female mites who then burrow into the skin. Scratching of burrows may expose the mite on the skin surface and prolonged skin contact at this time is a common source of transmission. Personal hygiene is not a factor in transmission. However, frequent washing may soften the skin, making access easier for the mite to move. Transmission via fomites, clothing and linen is uncommon. 7. Incubation period The timescale from acquiring the mite to the onset of symptoms is usually from 2 6 weeks, but may be up to 3 months in previously un-infested people. In those who have had scabies in the last few months, the onset of symptoms may be as short as a few days. 8. Signs and Symptoms of Scabies Infestation Scabies infestation may be variable in presentation and may mimic other skin conditions. The main symptoms typically are: An intense, itchy symmetrical rash particularly affecting fingers, hands, wrists, waist, groin, umbilicus, buttocks and soles of feet (and on the breasts of females, and male genitalia (see figure 1). The itch appears worse at night time. 7
Burrows may be seen on the finger webs and wrists. They appear as slightly elevated pink or grey, straight or tortuous lines. Rash appears when the person becomes sensitised to the allergen (see incubation period). The clinical picture may be further complicated by secondary bacterial infection e.g. Staphylococcus aureus or Group A Streptococci (GAS). Infestation may manifest only as pruritic plaques and patches with faint scale and erythema. In the elderly burrows may be seen on unusual sites, and the back is frequently involved, in contrast to younger patients. N.B. Symptoms may be atypical in the elderly due to a different immunological response, and infestation may easily be mistaken for other disease such as psoriasis or eczema. Figure 1. Bodily Sites of Rash and of Mites 9. Types of Scabies Infestation Scabies can be classified into 2 main categories: Classical, Hyperkeratotic or Crusted (Norwegian) Scabies The main characteristics are displayed in Table, Appendix B. 10. Diagnosis It is vital that an accurate diagnosis is made before treatment commences. Diagnosis is usually based upon history and clinical appearance. 8
The GP should see the patient prior to confirming the diagnosis. Patient may be referred to a Consultant Dermatologist to confirm diagnosis. Other skin conditions look similar to the scabies rash and have the same associated itchiness and scratching. If there remains any doubt about diagnosis or complexity of the case, it is recommended that treatment is delayed and the advice of a Consultant Dermatologist is sought; in this way unnecessary treatment is avoided. 11. Treatment of Scabies Treatment of scabies infestation is in the form of a lotion or cream that is available on prescription or from a pharmacy and are summarised in Table (Appendix C). The recommended treatment is two applications one week apart. The points to note are: Treatment is applied to the whole body, paying attention to the webs of the fingers and toes and brushing lotion under the nails. The application should be extended to the scalp, neck face and ears in the elderly, the immunocompromised and those with history of previous treatment failure. Any residual lotion should be removed by bathing. At the same time, change all clothes, towels and bedclothes for clean ones and launder as normal. Patients with Crusted scabies may need more frequent applications and this should be performed under the guidance of a Consultant Dermatologist. Itching may persist for 3-4 weeks, despite successful treatment. Simple moisturisers, aqueous creams or antihistamines may help. For mass de-infestation, e.g. outbreaks, the treatment day should be planned well in advance and all service users / staff treated within the same 24hour period. 11.1 Staff Staff need only be treated from the neck downwards. Staff, not available on day of mass treatment, must have treatment before return to work. 11.2 Patient /Carers /Visitors All those who had intimate skin contact with an affected individual for a prolonged period of time within the previous 2-6 weeks must be identified. It is important that all staff and residents are treated simultaneously. Visitors generally do not require treatment but should be advised to observe for symptoms and as necessary to seek information and guidance from their family doctor, practice nurse, community pharmacist or where appropriate their occupational health department. 11.3 Obtaining treatment In institutions requiring mass de-infestation, it is advisable that the same insecticide is used. This can be obtained by prescription from the GP. The employer should consider funding the treatment necessary for all staff resulting in an occupational exposure to the mite. 12. Single Cases of Scabies Single cases among clients / patients or staff generally only require treatment of that particular individual. This should be followed by increased surveillance amongst all client / patients or staff for symptoms in the following weeks (Appendix D). 9
13. Multiple cases / Outbreak Situation in health care settings Where there are two or more suspected or confirmed cases of scabies, this will necessitate mass treatment, i.e. all close contacts, staff and clients / patients (Appendix D, F, G, H, I, J). Close liaison with the Community Infection Prevention Team and the Health Protection Agency is advised in this situation. 14. Additional Infection Prevention and Control Precautions It is essential that instructions/advice provided by the Community Infection Prevention Team or other healthcare advisors is followed to ensure efficacy of treatment. The standard infection prevention and control precautions apply and are detailed in Appendix E. 15. Post treatment observations / monitoring Many people experience continued itchiness following treatment. These symptoms may persist for many weeks. This does not necessarily indicate a treatment failure, but is caused by allergy to the mite residue. If this is the case, the GP may be approached for advice. Resistance to treatment is rare; where a rash persists it is due to either a failure in the treatment process, reintroduction of scabies to the home or misdiagnosis. If scabies is reintroduced to an individual the onset of symptoms is usually much faster within a week. 16. Treatment of Contacts A contact is defined as someone who has had prolonged (greater than 10 minutes on any one occasion) skin to skin contact over the previous two months. People who do not have a diagnosis of scabies, but who are contacts, should be treated at the same time as the confirmed case. 17. Restrictions around Work There are usually no restrictions surrounding work. Advice can be sought from the GP, Public Health England (PHE) or Department of health 18. Re-occurrence of Infestation Re-infestation can occur if the treatment is not carried out thoroughly, or by contact with someone else who is infested and has not been treated at the same time. There is no protective immunity to scabies, so multiple re-infestation can occur. 19. Education Mandatory training for this guidance is not applicable. The Infection Prevention Team will provide any training identified through management routes, including root cause analysis following an incident / Infection prevention and control outbreak (see Incident reporting and Serious Incident reporting policy P_RM_01). 20. Monitoring This guideline has been risk assessed as low priority for audit. As such the monitoring of the effectiveness of the guideline will be by critical review of clinical incidents and near misses. Minimum Process Responsibl Frequency of Responsible Responsibl Responsibl 10
requireme nt to be monitored for monitorin g e.g. audit e individuals / group/ committee monitoring/au dit individuals/ group/ committee (multidisciplinar y) for review of results e individuals/ group/ committee for developme nt of action plan e individuals / group/ committee for monitoring of action plan Compliance Audit Manager/ IP Team Biannually IC Committee IC Committee IC Committee 21. Resources Posters and Leaflets: Up to date information may be obtained from the Trust web site and from www.dh.gov.uk. 22. Evidence National Institute for Health and Care Excellence. Scabies https://cks.nice.org.uk/scabies [06/07/17] 11
Appendix A Leaflet 12
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APPENDIX B: Types of Scabies Infestation Type Person at Risk Transmission Symptoms Classical Healthy Individuals / Normal Immune system Close Skin Contact Infectious Rash. Intense itching (worse at night). Burrows may be seen. History of close contact with affected. Classical areas affected (see Fig 1). Crusted (Norwegian/ Hyperkeratotic) Atypical Those with impaired Immune System Susceptible Groups: The very young Down s syndrome Elderly Alcoholics Immunosuppressed Topical steroids Close Skin Contact Very Infectious Close Skin Contact Very Infectious Itching not present. Rash may be present. Areas of scaling and crusting of the skin. Often confined to one area of body therefore classical areas not affected. Infested for a long period of time e.g. months/years. Usually the centre of outbreak situations Diagnosis by Dermatologist essential. No rash No itching No scaling or crusting No classical areas affected May be seen in long term care facilities. 14
APPENDIX C: Treatment of Scabies Infestation Trade Name Malathion Permetherin Ivermectin Derbac-M liquid Lyclear cream Quellada-M liquid Treatment Strength 0.5% (100ml) 5% (30g) 200 microgrammes per kilogram Treatment Times 24 hours 8 12 hours Single dose Application To whole body including: scalp, neck, face, ears, toes and nails. Do not bathe before application To whole body including: scalp, neck, face, ears, toes and nails. Do not bathe before application Named patient basis only under guidance of the PHE / Consultant Dermatologist Apply to cool dry skin Apply to cool dry skin Where hands are washed frequently reapply treatment to hands Where hands are washed frequently reapply treatment to hands Do not apply more than once in one week Repeat treatment At 7 days More applications may be required in Crusted Scabies Consult GP/ Consultant At 7 days More applications may be required in Crusted Scabies Consult GP / Consultant Named patient basis only under guidance of the PHE / Consultant Dermatologist Cautions Avoid eyes Do not apply to broken skin / secondary infected skin Avoid eyes Do not apply to broken skin / secondary infected skin Named patient basis only under guidance of the PHE / Consultant Dermatologist Consult GP if: Children under 6 months Breast feeding, Pregnant Consult GP if: Children under 2 years Breast feeding, Pregnant 15
APPENDIX D: Management of Single and Multiple / Outbreak cases of Scabies in Community SINGLE CASE SCABIES SUSPECTED SINGLE CASE SCABIES CONFIRMED Has the person had prolonged contact with other patients/clients/ staff. Inform Health Care Workers Continue communications with Consultant/GP where necessary Observe all patients/ clients for signs of excessive itching & rashes Refer to Consultant Dermatologist if appropriate Inform Occupational Health Services where staff are involved. Not Scabies Arrange treatment for non-scabies skin conditions Arrange for treatment of patient/ client and household contacts Treat case individual and contacts with scabicidal on day 1 and 7 Observe all patients/ clients over period of one month for symptoms of scabies No further cases - No action required TWO OR MORE SUSPECTED / CONFIRMED CASES OF SCABIES Further cases OUTBREAK Gather patient / client / staff information. Complete assessment of all patients/ clients. Contact Infection Prevention /PHE for Treatment Regime advice. Refer all staff to Occupational Health. Diagnosis to be confirmed by GP / Consultant Dermatologist Liaise with GP to obtain treatment. Treatment regime of two applications one week apart for all cases (patients and staff) Treat all patients / clients / staff at the same time. Advise treatment on day 1 for all contacts of cases. Monitor patient / client / staff post treatment Symptoms may persist for several weeks. Where there is a deterioration / concern regarding the patients / clients / staff skin condition refer to GP/ Dermatologist / Occupational Health for advice Document all interventions No further cases - No action required 16
APPENDIX E: Management of Scabies Outbreak - Checklist This check list is an aide memoire and to be used in the event of an outbreak situation where scabies infestation is suspected / confirmed. Care Facility. Date First cases diagnosed on By.. Interventions Communications and Monitoring N/A Date Signature Close the Health Care Facility to new admissions Management of Scabies Outbreak - Checklist (this document) Gather patient /client / staff details (Appendix F &G) Complete assessment of all patient /clients (Staff) Inform all GP s Inform Infection Prevention and Control Team Inform Health Protection Agency Inform Occupational Health Inform CSCI Re assess patient patients /client on : Week one Week two Week three Week four Week five Week six. Provided information to: Patients / clients : Relatives / Carers / Visitors : Staff Liaise with other health care facilities where patients / clients have been admitted to. Treatment Obtain treatments for all patients / carers Obtain all treatment for staff Direct all close contacts / family members to their GP Treat all patients / carers / staff on : day 1 Treat all patients / carers / staff on : day 7 Environmental Cleaning Enhanced the level of environmental cleaning throughout outbreak period. Additional Infection Prevention and Control Precautions Isolation - those patents clients with Crusted (Norwegian) scabies Transfer / Discharge Patients may be discharged after the application of the second treatment. Discontinuation of Monitoring All patients / client have had two treatments Terminal clean affected areas at the end of the Outbreak Re- Open Health Care Facility Discuss outbreak at team meetings Arrange additional education (if required) Signature. Date (Manager/ Owner) 17
APPENDIX F: Management of Scabies - Monitoring Form (Patient / Client) Page No. Patient / Client Name Room Symptoms GP Scabicidal Name Date of Treatment 1 Date of Treatment 2 Week 2 Date: (state appearance) Week 3 Date: (state appearance) Week 4 Date: (state appearance) Week 5 Date: (state appearance) Week 6 Date: (state appearance) 18
APPENDIX G: Management of Scabies - Monitoring Form (Staff) Page No. Staff Name Symptoms GP Scabicidal Name Date of Treatment 1 Date of Treatment 2 Additional comments 19
APPENDIX H: Letter to relatives of residents To Relatives of Residents at Re: Suspected Scabies You may be aware that a number of patients and staff at the home* / ward*<* delete> have reported skin rashes. There is a strong possibility that this is due to scabies. Scabies is a fairly common infestation in the community; it is an infestation that spreads from person to person by prolonged and frequent skin to skin contact. Discussions have been held between the Local Public Health England Team/Lincolnshire Community Health Services NHS Trust and the home / ward as to how best to manage the scabies in the care home. Because the incubation period is long (up to 8 weeks) and people are infectious before symptoms appear, it is essential that all residents / patients at the home/ ward and their carers are treated at the same time, even if they don t have symptoms. Frequent visitors who do not have a rash should observe for signs, reporting and problems to the GP where necessary. Carers and frequent visitors, who do have a rash that could be scabies should receive two treatments, each one week apart. In addition, it is important that all close members of your household are treated at the same time as yourself regardless of whether they have any symptoms. If this is not done then you may become re-infested from a member of your household. Carers and frequent visitors who need treatment may obtain it on prescription from their GP (we suggest that they show this letter to their GP) or buy it over the counter. The enclosed factsheet on scabies provides more detailed information and advice on treatment. Your co-operation in controlling this outbreak is vital and greatly appreciated. Yours sincerely 20
APPENDIX I: Letter to carers/staff To all Carers/Staff Suspected scabies at You may be aware that a number of patients and staff at the home /ward have reported skin rashes. There is a strong possibility that this is due to scabies. Scabies is a fairly common infestation in the community; it is an infestation that spreads from person to person by prolonged and frequent skin to skin contact. Discussions have been held between the Local Public Health England Team/Lincolnshire Community Health Services NHS Trust and the home / ward as to how best to manage the scabies in the home. Because the incubation period is long (up to 8 weeks) and people are infectious before symptoms appear, it is essential that all residents/patients at the home/ward and their carers/staff and frequent visitors are treated at the same time, even if you don t have symptoms. Frequent visitors who do not have a rash should observe for signs, reporting and problems to the GP where necessary. Carers/ Staff and frequent visitors who do have a rash that could be scabies should receive two treatments, each one week apart. In addition, it is important that all close members of your household are treated at the same time as yourself regardless of whether they have any symptoms. If this is not done then you may become re-infested from a member of your household. Frequent visitors and household members who need treatment may obtain it on prescription from their GP (we suggest that they show this letter to their GP) or buy it over the counter. Carers / staff who have acquired this infestation as a result of occupational exposure may obtain their treatment via their manager / occupational health department. The enclosed factsheet on scabies provides more detailed information and advice on treatment. Your co-operation in controlling this outbreak is vital and greatly appreciated. Yours sincerely
APPENDIX J: Letter to GP To the General Practitioner Suspected scabies at You may be aware that a number of patients and staff at the home / ward have reported skin rashes. There is a strong possibility that this is due to scabies. Scabies is a fairly common infestation in the community; it is an infestation that spreads from person to person by prolonged and frequent skin to skin contact. Discussions have been held between the Local Public Health England Team/Lincolnshire Community Health Services NHS Trust and the home / ward as to how best to manage the scabies in the home. Because the incubation period is long (up to 8 weeks) and people are infectious before symptoms appear, it is essential that all residents/patients at the home/ward and their carers/staff and frequent visitors are treated at the same time, even if they don t have symptoms. Please find a list attached of residents / patients / member of staff who are associated with the home / ward. We would be grateful if a prescription for treatment could be arranged for a staff member from the home / ward to collect. The treatment is due to take place for all residents /patients and carers/ staff on and on.. Many thanks for your help. Please do not hesitate to contact us should you require any further information. Yours sincerely 22
APPENDIX K: Equality analysis A. Briefly give an outline of the key objectives of the policy; what it s intended outcome is and who the intended beneficiaries are expected to be B. Does the policy have an impact on patients, carers or staff, or the wider community that we have links with? Please give details C. Is there is any evidence that the policy\service relates to an area with known inequalities? Please give details D. Will/Does the implementation of the policy\service result in different impacts for protected characteristics? To provide guidelines for staff on the management of Scabies infestation in the community and community hospital This has an impact on all staff, patients and careers. None Disability Sexual Orientation Sex Gender Reassignment Race Marriage/Civil Partnership Maternity/Pregnancy Age Religion or Belief Carers Yes If you have answered Yes to any of the questions then you are required to carry out a full Equality Analysis which should be approved by the Equality and Human Rights Lead please go to section 2 The above named policy has been considered and does not require a full equality analysis Equality Analysis Carried out Lynne Roberts by: Date: 04.08.15 No 23