SCABIES POLICY DOCUMENT CONTROL: Version: 7 Ratified by: Clinical Quality & Standards Group Date ratified: 4 th August 2015 Name of originator/author: Senior Clinical Nurse Specialist - Infection Prevention and Control Name of responsible committee/individual: Infection Prevention & Control Quality & Standards Committee Date issued: 2 September 2015 Review date: September 2018 Target Audience All Clinical Staff
CONTENTS SECTION PAGE NO 1 INTRODUCTION 3 2 PURPOSE 3 2.1 Definitions/Explanation of Terms Used 3 3 SCOPE 3 4 RESPONSIBILITIES, ACCOUNTABILITIES AND DUTIES 3 4.1 Board of Directors 3 4.2 Chief Executive 3 4.3 Director of Infection Prevention and Control (DIPC) (Deputy Chief 4 Executive/Director of Nursing) 4.4 Infection Prevention and Control Quality and Standards Committee 4 4.5 Infection Control Doctors/Consultant Microbiologists 4 4.6 Clinical Nurse Specialists - Infection Prevention & Control Quality & 5 Standards Team 4.7 Consultant Medical Staff/Medical Staff 5 4.8 Modern Matrons/Service Managers 5 4.9 Chief Pharmacist 5 4.10 Staff 6 5 PROCEDURE 6 5.1 Scabies information 6 5.2 Incubation period 6 5.3 Transmission 7 5.4 Symptoms 7 5.5 Diagnosis 7 5.6 Complications of Scabies 7 5.7 Treatment of Scabies (see appendix 1 for table 7 5.7.1 Permethrin (Lyclear) First Choice treatment 7 5.7.2 Malathion Aqueous 0.5% Liquid (Derbac M) 8 5.7.3 Ivermectin 8 5.7.4 Management of Additional Treatment Information 8 5.7.5 Additional Information for the Treatment of Children 9 5.8 Scabies within a group of patients 9 6 TRAINING IMPLICATIONS 10 7 MONITORING ARRANGEMENTS 10 8 EQUALITY IMPACT ASSESSMENT SCREENING 10 8.1 Privacy, Dignity and Respect 11 8.2 Mental Capacity Act 11 9 LINKS TO ANY ASSOCIATED DOCUMENTS 11 10 REFERENCES 11 11 APPENDICES 12 Appendix 1 List of Scabicides 13 Page 2 of 14
1. INTRODUCTION Scabies is a parasitic disease caused by the mite, Scarcopes scabei. Skin to skin contact (direct contact) is the mode of transmission. Hyperkeratotic scabies (also called Norwegian Scabies) is a more infectious variant, which can also be transmitted by fomites. 2. PURPOSE The purpose of this policy is to provide information to staff on the care of patients diagnosed or suspected to have Scabies. The policy content is based on sound infection prevention and control (IPC) principles and national guidance. 2.1 Definitions/Explanation of Terms Used 3. SCOPE Hyperkeratotic adjective - overgrowth and thickening of the outer layer of the skin Fomites - any material, such as bedding or clothing, that may harbour pathogens and therefore convey disease This policy applies to all staff having contact with patients under the care of the Trust, whether in a direct or indirect patient care role regardless of the care environment. Adherence to this policy is the responsibility of all staff employed by the Trust, including agency, locum and bank staff contracted by the Trust. This policy should be read in conjunction with other IPC policies, particularly Hand Hygiene, Standard Infection Prevention and Control Precautions. 4. RESPONSIBILITIES, ACCOUNTABILITIES AND DUTIES All staff working on Trust premises, outreach clinics and community settings including Trust employed staff, contractors, agency and locum staff are responsible for adhering to this policy. 4.1 Board of Directors The Board of Directors are responsible for having policies and procedures in place to support best practice, effective management, service delivery, management of associated risks and meet national and local legislation and/or requirements. 4.2 Chief Executive The Chief Executive is responsible for establishing and maintaining IPC arrangements across the organisation, but delegates the responsibilities to the Trust Board and the Director of Infection Prevention and Control. The Director with the lead responsibility is the Deputy Chief Executive and Lead Nurse. Page 3 of 14
4.3 Director of Infection Prevention and Control (DIPC) (Deputy Chief Executive/Director of Nursing) The DIPC acts on legislation, national policies and guidance ensuring effective policies are in place and audited and directly reports to the Chief Executive and the Board of Directors: Any identified cases of infections/alert organisms The organisations performance in relation to Healthcare Associated Infection s (HCAI) and provides regular reports, including an annual report and an annual IPC programme All incidents requiring post infection review (PIR) 4.4 Infection Prevention & Control Quality & Standards Committee (IPCQ&SC) The IPCQ&SC members oversee compliance with international and national standards/targets in relation to the prevention and control of HCAI, including the Health and Social Care Act 2008, NHS Litigation Authority (NHSLA) and the Care Quality Commission (CQC) Fundamental Standards. The main duties of the IPCQ&SC are to oversee key IPC issues in regards to: Policy development and review Audit Education and training compliance Communication with staff, patients and the public Horizon scanning for relevant IPC guidance and documents Monitoring of IPC incidents Ensuring that robust plans for the management of outbreaks of infection are in place and to monitor their effectiveness Reviewing PIR reports in order to identify lessons learnt, develop and monitor action plans Agreeing the annual IPC report and work programme prior to its submission to Clinical Governance Group (CGG) To inform the CGG of clinical risk issues relating to the Trust 4.5 Infection Control Doctors/Consultant Microbiologists Medical microbiologists hosted within the provider acute Trusts are available, through a contractual service level agreement to: Provide expert microbiology advice for the management and treatment of micro-organisms Advise on antibiotic policy/prescribing and challenge inappropriate practices Contribute to the PIR process and attend meetings as required Page 4 of 14
4.6 Clinical Nurse Specialists (CNS) Infection Prevention & Control Quality & Standards Team (IPCQ&ST) The IPCQ&ST CNS role is to: Provide expert professional advice and education on the prevention and control of infection to other professionals, multi-disciplinary groups, patients and carers Lead in the investigation of identified cases of infection/alert organisms and conditions Advise on control measures, delegating responsibility to Trust staff as appropriate Give advice on complex issues relating to IPC and report findings to the DIPC Report any breaches in policy compliance through the IR1 system and to the IPCQ&SC 4.7 Consultant Medical Staff/Medical Staff Consultant medical staff are responsible for the supervision of junior medical staff assigned to work with them and all staff must: Ensure compliance with IPC policies Liaise with the Consultant Microbiologist for advice if required Be aware of and comply with antibiotic prescribing guidance Contribute to and participate in relevant meetings as required 4.8 Modern Matrons/Service Managers All Service Managers and Modern Matrons are responsible for: Membership at the IPCQ&SC On-going compliance with this policy within their clinical areas and reporting non-compliance to the DIPC via the IPCQ&SC Reporting all matters relating to IPC to the DIPC Facilitating feedback of information related to surveillance data and identified cases of infection/alert organisms and conditions, including Scabies Reporting confirmed cases of infection/alert organisms and conditions to the IPCQ&ST Reporting any breaches in policy compliance through the IR1 system and to the IPCQ&SC 4.9 Chief Pharmacist The Chief Pharmacist will: Contribute to the PIR process when antibiotics have been prescribed Facilitate and evaluate antibiotic and proton pump inhibitor prescribing Undertake audit as requested by the IPCQ&SC Report findings to Medicines Management Committee and IPCQ&SC Page 5 of 14
4.10 Staff All staff must comply with this policy and related guidance. 5. PROCEDURE/IMPLEMENTATION 5.1 Scabies Information There are two types of scabies. These being Classical Scabies, which is found in people with normal immune systems and Hyperkeratotic Scabies (also known as Norwegian Scabies), which is often found in the elderly population or those with suppressed immune systems. In Norwegian Scabies the skin becomes thickened, scaled and crusted due to the large number of mites present and is highly contagious due to the number of mites present in the exfoliating skin scales. The scabies mite is extremely small, with the female measuring 0.4 mm in length and the male 0.2 mm. A scabies infestation starts when a mite burrows under the top layer of the skin. They may occur anywhere on the body and the burrows are usually about 5 mm long. 5.2 Incubation period The incubation period is up to 8 weeks. This extended length of incubation time can make the identification and control of scabies difficult, especially in residential social care settings. 5.3 Transmission Scabies mites are not able to jump or fly. The usual method of transmission is through direct and prolonged periods of contact (10-20 minutes) or intimate skin contact. It's unlikely that scabies will be transmitted through brief physical contact, such as shaking hands or hugging. Classical scabies mites can survive outside the human body for 24 to 36 hours, making infestation by coming into contact with contaminated clothes, towels or bed linen a rare possibility, unless they have been contaminated by the infested individual immediately beforehand. In addition to transmission by direct contact, Hyperkeratotic Scabies is easily transmissible via clothing, towels or bedding due to the large number of mites present in the exfoliating skin scales. Hyperkeratotic Scabies mites can survive outside the human body for up to 7 days as they are able to feed on skin scales in bedding, towels or clothing. 5.4 Symptoms The main symptoms of scabies infection are caused through an allergic response to the presence of the mite. This is thought to be caused by the immune system reacting to the mites and their saliva, eggs and faeces. Severe itching develops, especially at night. It may take four to six weeks Page 6 of 14
5.5 Diagnosis before the itching starts, however, if the person has had a previous scabies infection, the immune response is rapid and itching develops in hours to days. A rash may develop consisting of tiny red spots and scratching the rash may cause crusty sores to develop. Scabies is usually diagnosed through the presence of intense itching with a follicular papular rash and the burrow marks of the mite. However, as scabies is spread very easily, it's often possible to make a confident diagnosis if more than one family member has the same symptoms 5.6 Complications of Scabies Repeatedly scratching itchy skin may break the skin's surface which may lead to the development of a secondary skin infection. In this situation clinical review and antibiotic therapy may be required. Scabies has been known to make some pre-existing skin conditions, such as eczema, worse. However, other skin conditions should settle down after the scabies infection has been successfully treated. 5.7 Treatment of Scabies (see appendix 1 for table) 5.7.1 Permethrin (Lyclear) First Choice treatment. Permethrin Cream (Lyclear 5%) is currently the agent of choice for the treatment of scabies and also for prophylactic treatment for contacts and can be used in pregnancy Permethrin is licensed for use in children over 2 months of age. It is recommended that medical supervision should be sought before applying to children s skin under 2 years of age. Permethrin is a cream, which should be applied and left for 8-12 hours The treatment requires 2 applications 1 week apart In Hyperkeratotic Scabies more than 2 applications on consecutive days may be required. Advice must be obtained from medical staff/dermatology specialists Avoid contact with eyes due to irritation One tube of Permethrin is usually adequate for an average sized person however in obese patients more tubes will be required This is a vanishing cream and so disappears on application. It should be continuously applied until it remains detectable on the skin surface Page 7 of 14
5.7.2 Malathion Aqueous 0.5% Liquid (Derbac M) This medication is a lotion and should be left on the body for 24 hours It should not be used more often than once a week for a maximum of three consecutive weeks Avoid in children less than 6 months of age, seek medical advice Can be used in pregnancy Aqueous preparations are preferable to alcoholic lotions, as they are less of an irritant to the skin and respiratory tract 5.7.3 Ivermectin This is an oral medication that is only given on a named patient basis within the UK. The decision to prescribe should only be undertaken after consultation with the Dermatology Department. Topical treatments may also be applied in conjunction with the oral medication being given particularly in Hyperkeratotic Scabies that does not respond to oral topical treatment alone. 5.7.4 Management and Additional Treatment Information As the incubation period can be up to 8 weeks it is important to consider any person who has had prolonged skin to skin contact within the last 8 weeks, as requiring treatment. Ensure the skin is clean, dry and cool before application. A hot bath should be avoided as evidence suggests this could reduce its efficacy. All members of the affected household should be treated at the same time, as prescribed by their GP, to ensure that individuals do not re-infect one another. Apply the cream or lotion to the scalp, jaw line and all over the body including the genital area. Pay particular attention to the webbed areas of toes and fingers. Occasionally an application to the head may be recommended. Applying the cream at night before going to bed is usually the best time because it can be left on overnight. Healthcare staff applying the cream or lotion should wear disposable gloves and a disposable apron with each individual they are treating. In the case of treatment application/care of patients with Hyperkeratotic Scabies arm protection would be advisable. A second person is necessary when treating oneself, to ensure all the body is covered. Nails should be trimmed and medication applied with cotton wool buds Page 8 of 14
underneath the nails and around the nail bed area. If hands are subsequently washed, then further treatment needs to be applied. If any part of the body requires washing/cleaning during the treatment time schedule the cream/lotion will need to be reapplied after each wash e.g. after changing continence products. The treatment should be left on for the manufacturers recommended time period. Remove the treatment by thorough washing of all areas of the skin to which it has been applied. Once the treatment has been applied and washed off, wash all bedding and clothing immediately on a hot wash cycle. In healthcare settings, bedding and clothing should be treated as infected linen and red alginate bags should be used (refer to the Laundry Policy). Itching and rash may persist or even become slightly worse for a few days following treatment due to the continuing presence of dead mites and the dead mites faeces in the skin. Antihistamine medication may be useful in this situation. Exclude from school/workplace until 24 hours after treatment has been started. Prolonged skin to skin contact should be avoided wherever possible until 24 hours after treatment. Notify Public Health England on 01143 211177 when there is an outbreak of scabies. An outbreak of infection is defined as the occurrence of two or more related cases of the same infection, or where the number of infections is more than would normally be expected (Wilson, 2001). Seek additional advice from the IPC team if required. A Consultant Dermatologist or Consultant Microbiologist can advise on the choice of agent for treatment. 5.7.5 Additional Information for the Treatment of Children Children under the age of two may also have mites on the face, neck, scalp, ears and the soles of their feet. It is therefore important to pay particular attention to the head, neck, flexor areas and the soles of the feet. Special care must be taken in the selection of the scabicide. 5.8 Scabies Within A Group Of Patients If there is a single case of scabies within a healthcare setting the patient does not require isolation (except with Hyperkeratotic Scabies due to exfoliating skin scales) and can be left in the usual area whilst being treated. Staff Page 9 of 14
should however be extremely vigilant for signs and symptoms of scabies in other patients or clients during the following weeks. If there appears to be more than one case of scabies, diagnosis must be confirmed by a Dermatologist before commencing treatment of patients. Treatment will be carried out in consultation with the IPCQ&ST. The Occupational Health Department should be informed of the situation though staff are to contact their own General Practitioner for advice/treatment. 6. TRAINING IMPLICATIONS There are no specific training needs in relation to this policy, but the following staff will need to be familiar with its contents: All clinical staff having face to face contact with patients and any other individual or group with a responsibility for implementing the contents of this policy. As a Trust policy, all staff need to be aware of the key points that the policy covers. Staff can be made aware through: A number of a variety of means such as; Team Brief Trust wide mail drop Team meetings One to one meetings / Supervision Posters CPD sessions Weekly Newsletter Trust wide email Special meetings Group supervision Practice Development Days Local Induction 7. MONITORING ARRANGEMENTS Area for Monitoring How Who by Reported to Frequency Noncompliance to policy Monitor breaches in policy via IR1 reporting system. IPCQ&S CNS IPCQ&SC Bi-monthly 8. EQUALITY IMPACT ASSESSMENT SCREENING The completed Equality Impact Assessment for this Policy has been published on the Equality and Diversity webpage of the RDaSH website click here Page 10 of 14
8.1 Privacy, Dignity and Respect The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi s review of the NHS, identifies the need to organise care around the individual, not just clinically but in terms of dignity and respect. Indicate how this will be met No issues have been identified in relation to this policy. As a consequence the Trust is required to articulate its intent to deliver care with privacy and dignity that treats all service users with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity and respect, (when appropriate this should also include how same sex accommodation is provided). 8.2 Mental Capacity Act Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individuals capacity to participate in the decision making process. Consequently, no intervention should be carried out without either the individuals informed consent, or the powers included in a legal framework, or by order of the Court Therefore, the Trust is required to make sure that all staff working with individuals who use our service are familiar with the provisions within the Mental Capacity Act. For this reason all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act 2005 to ensure that the interests of an individual whose capacity is in question can continue to make as many decisions for themselves as possible. Indicate How This Will Be Achieved. All individuals involved in the implementation of this policy should do so in accordance with the Guiding Principles of the Mental Capacity Act 2005. (Section 1) 9. LINKS TO ANY ASSOCIATED DOCUMENTS This policy should be read in conjunction with other Trust IPC and relevant clinical policies. All policies can be found in the Clinical Policies section of the intranet 10. REFERENCES British National Formulary and British National Formulary for children. April 2015. https://www.medicinescomplete.com/mc/bnf/current/ accessed 07.05.15 Chin J. (2002). Control of Communicable Diseases Manual American Public Health Association. Page 11 of 14
http://www.collinsdictionary.com/dictionary/english/infestation?showcookiepolicy=true accessed 08.05.15 National Institute for Health and Clinical Excellence (2012) Prevention and control of healthcare associated infections in primary and community care. NICE clinical guideline 139 Prodigy. Quick reference guide issued June 2005. www.prodigy.nhs.uk/scabies Sheffield District Infection Control Team (2003). Sheffield District Control of Infection Guidelines. Unpublished Wilson J. (2006). Infection Control in Clinical Practice. 3 rd ed. Baillere Tindall. London. http://cks.nice.org.uk/scabies#!topicsummary accessed 07.05.15 http://www.nhs.uk/conditions/scabies/pages/introduction.aspx Accessed 29.04.15 11. APPENDICES Appendix 1 List of Scabicides Page 12 of 14
LIST OF SCABICIDES: Appendix 1 First Choice Treatment: Permethrin (Lyclear Dermal Cream) Two applications of treatment are used 7 days apart Drug Age Dose Quantity Notes, Permethrin 5% dermal cream 2 months to 2 year Apply to the whole body, including the scalp, face, neck and ears. Leave on for 8-12 hours or overnight. Wash off. 2 to 11 years Apply to the whole body, including the scalp, face, neck and ears. Leave on for 8-12 hours or overnight. Wash off. Repeat after 7 days. 30g** 30g* Cautions/Contraindications Avoid contact with eyes Do not use on broken or secondarily infected skin Do not use in pregnancy or whilst breast feeding For children under 2 years medical supervision is required 12 years onwards Apply to the whole body, including the scalp, face, neck and ears. Leave on for 8-12 hours or overnight. Wash off. Repeat after 7 days. 60g* (may be required) *Two 30g tubes may be required for each application for an adult. For children up to the age of 2 years, one eighth to one quarter of a tube should be enough for each application. Children between 2 and 6 years need about a quarter of a tube per application, and children between 6 and 12 years need about half a tube per application. **A single application is usually sufficient for children under 2 years of age. Page 13 of 14
Second Choice Treatment: Malathion (Derbac M) Two applications of treatment are used 7 days apart Drug Age Dose Quantity Notes, Cautions/Contraindications 6 months to 1 Apply to the whole body, including the scalp, face, 100ml* year neck and ears. Malathion 0.5% aqueous liquid 2 years onwards Pregnancy and Breast Feeding: Malathion (Derbac M) Malathion 0.5% aqueous liquid Leave on for 24 hours. Wash off Apply to the whole body, including the scalp, face, neck and ears. Leave on for 24 hours. Wash off. Repeat after 7 days (unlicensed use see notes in BNF) 200ml* Avoid contact with eyes Do not use on broken or secondarily infected skin Do not use more than once a week for three weeks at a time For children under six months, medical supervision is required Drug Age Dose Quantity Notes, Cautions/Contraindications 12 years Apply to the whole body, including the scalp, face, 100ml onwards neck and ears. Leave on for 24 hours. Wash off If the person requiring treatment has broken skin areas e.g. ulcers, pressure sores, contact a Dermatologist for advice. Avoid contact with eyes Do not use on broken or secondarily infected skin Do not use more than once a week for three weeks at a time Ivermectin (available on a named patient basis from special-order manufacturers or specialist importing companies) in a dose of 200 micrograms/kg by mouth has been used, in combination with topical drugs, for the treatment of Hyperkeratotic Scabies that does not respond to topical treatment alone; further doses of 200 micrograms/kg may be required. Page 14 of 14