South Staffordshire and Shropshire Healthcare NHS Foundation Trust 1 Document Version Control Document Type and Title: Authorised Document Folder: Policy for the Management of Parasitic Infestations YELLOW Clinical New or Replacing: Replacing C/YEL/ic/22 v1.0 Document Reference: C/YEL/ic/22 Version No. v1.1 Implementation Date: Author: Approving body: Approval Date: Ratifying body: Judy Carr, Cathy Riley, Maudie McHardy Quality, Effectiveness and Risk Committee May 2009 Minor amendments Full Trust Board Ratified Date: May 2009 Committee, Group or Individual Monitoring the Document: Clinical Policy Group Infection Control Committee Review Date: May 2015
Contents 1 Introduction 3 2 Purpose of Policy 3 3 Scope of Policy 3 4 Training 3 5 Related Policies 3 6 Scabies 3 7 Lice 4 8 Threadworms 6 9 Monitoring Compliance 7 10 References 7 Appendix 1 Protocol for suspected case of 8 scabies 2
1. Introduction Parasites are organisms that rely on a host to survive. Those found on the skin include scabies and lice, those found in the digestive tract include threadworms. 2. Purpose of the Policy The aim of this policy is to provide recommendations on the management of Parasitic Infestations 3. Scope of Policy This document applies to all employees of the South Staffordshire and Shropshire Foundation Trust SSSFT (SSSFT) and all those visiting SSSFT premises such as contractors, agency/bank/locum staff, students and volunteers. 4. Training The Trust recognises that there is a need to ensure awareness amongst employees on the relevance and application of this policy. The infection control team will provide training for staff. Ongoing training is addressed within the Infection control mandatory updates 5. Related Policies This policy should be read in conjunction with the following infection prevention and control policies, and related guidance Hand decontamination policy Standard precautions and personal equipment policy 6. Scabies Scabies rash is a reaction to the excreta and salvia of the small mite Saracoptes Scabiei (0.3 0.4mm) which burrows into the skin. The burrow may be visible as a line about 5 mm length. These mites burrow down to the deeper layers of the skin where the females lay eggs, which hatch in 50 to 72 hours. The larvae make new burrows, mature and the females lay new eggs. This process takes around 10 to 17 days and the mites live for approximately 30 to 60 days. At all stages the mites produce faecal pellets, which are glued down to the tunnel floor. An allergen seeps from these faecal pellets into the deeper parts of the body and into the blood system and from there it spreads all over the body. Because of this systemic involvement, the sites of the allergic reaction (i.e. rash) do not generally correspond with the sites where the mites may be found. Burrows may occur anywhere but are mainly on the hands and arms, particularly finger 3
Webs. Other areas which may be affected are inner wrists, elbow creases, axillae, around the umbilicus, the nipples in adult females and genitalia in men. Within 2-6 weeks the host becomes sensitised to the mites and its products and a wide eczematous rash is produced. A variety of itching sensations follows, giving way to severe irritation, often worse at night. Symptoms A widespread itchy rash on the body exacerbated when warm, i.e. at night or following a bath, which develops over a long incubation period of 2-6 weeks after the initial exposure. The rash rarely develops on the head unless the patient is immunocompromised. Spread Spread is via prolonged continuous skin to skin contact, usually sexual contact or holding/supporting patients. Mites cannot survive away from the body therefore bedding and clothing is not a source of infection. Diagnosis Close examination of the skin may demonstrate a characteristic burrow. However scabies is notoriously difficult to diagnose, therefore patients must be referred to the dermatologist. Staff must seek advice from Occupational Health Service. Infection Control Measures The Infection Prevention & Control Team must be informed of suspected cases. Skin to skin contact must be avoided until diagnosis is confirmed by the dermatologist and treatment with a recommended scabicidal preparation (See Trust Formulary) has been completed; this usually takes 8-24 hours dependent on the chosen preparation (refer to the manufacturer s instructions). It is important to leave the application in place for the correct time, and if washing occurs before the full time, then it should be reapplied. Application before going to bed may help achieve this. A repeat treatment should always be applied 7 days later, and the quantity prescribed or supplied initially should cover both treatments. Itching can continue for some weeks after successful treatment. Relief may be found if calamine lotion is applied. Anyone who has prolonged skin to skin contact with the confirmed case must also be treated at the same time in order to prevent re-infection. In the event of two or more linked cases confirmed by the Medical Team, the Infection Prevention & Control Team must be informed in order that control measures may be implemented (See Appendix 1). 7. Lice The most common species is the head louse Pediculus humanus capitis. Two other lice are the body louse, Pediculus humanus corporis and the pubic louse, Pthiris pubis. 4
HEAD LICE The head louse is a small wingless parasite that lives on the hair near the scalp. Infection is widespread in the population most commonly occurring in children. Symptoms Itching is common and the resulting scratching may give rise to secondary infection. Spread Spread is via prolonged head to head contact. Lice found in the environment are not viable and therefore not a source of infection. Diagnosis Female head lice lay approximately 8 eggs a day. These become attached to the hair shaft, hatching around 10 days later. The egg cases or nits remain on the hair and are easier to detect than the lice as white specs which cannot be removed by ordinary combing. The lice mature one week after hatching and live for approximately 30 days, they are difficult to detect as they hide when the hair is parted and develop the same colour tone as the host. Infection Control Measures Avoid head to head contact until diagnosis and treatment is completed. Once confirmed treat the patient with headlice preparation (see Trust Formulary) and ensure close contacts are informed. Lotions are the treatment of choice, but alcohol preparations are not recommended for very young or people with asthma or eczema (use aqueous lotions). The treatment should be repeated after 7 days. BODY LICE Are rarer and are most likely to be seen in patients with poor personal hygiene. Symptoms Early signs are a red itchy rash, with skin becoming excoriated with secondary infection as the infection persists. Lice can be found in clothing. Spread Spread is through direct contact with the person and shared clothing. Diagnosis Presence of lice on visible inspection. Infection Control Measures Contact precautions should be taken with the patient until treatment with a recommended preparation is completed; aqueous lotions of malathion or permethrin are recommended and should be applied to all surfaces of the body including the scalp, neck, face and ears (refer to manufacturer s information). Treatment should be repeated 5
after 7 days. Linen should be treated as infected. Patient s clothing should be treated as infected or dry cleaned or tumble dried on hot cycle to destroy eggs and lice, paying particular attention to seams where mites can survive. PUBIC LICE Are found in pubic hair but can be found in hair elsewhere on the body if left untreated. Symptoms Intense itching in the genital region and secondary infection from scratching. Spread Most frequently transmitted through sexual contact. Diagnosis Both eggs and lice may be seen on visible inspection Infection Control Measures Contact precautions with the patient until treated with a recommended preparation; aqueous lotions of Malathion or permethrin are recommended and should be applied to all surfaces of the body including the scalp, neck, face and ears (refer to manufacturer s information). Treatment should be repeated after 7 days. 8. Threadworms The only common helminth infection in the UK is caused by threadworms or pinworms, i.e. Enterobus vermicularis. Threadworm infection is very common and generally harmless. Two out of 5 children under 10 years of age are affected. The eggs are swallowed and worms develop in the small intestine. Adult worms are usually found in the colon and the female lays eggs, which are invisible to the naked eye, around the anus. Symptoms Intense itching around the anus particularly at night. Spread The eggs are picked up under the fingernails during scratching and returned to the mouth either directly or from clothing, carpets, towels, bed linen, house dust, garden soil, on unwashed vegetables and salads or from someone who already has threadworms. Because they are so widespread and small it is easy for them to be swallowed. The cycle then begins again and eggs pass into the bowel where they hatch. 6
Diagnosis Worms 8-13mm long may be seen at the anus or in the stool like threads of white cotton, alternatively eggs can be detected by using a special collector available from the Microbiology laboratory. Infection Control Measures Contact/faecal oral precautions and treat linen as infected until treatment is completed (see Trust Formulary). Public Health leaflets are available for further advice on preventing re-infection. Ensure the close family are informed to seek treatment at the same time. 9 Monitoring compliance This policy will be reviewed three yearly or earlier in light of new national guidance or other significant change in circumstances. Compliance with this policy will be monitored through the mechanisms detailed in the table below. Where compliance is deemed to be insufficient and the assurance provided is limited then remedial actions will be drawn together through an action plan. This progress against the action plan will be monitored at the specified committee/group. The results of the annual audit will be escalated to the appropriate committee/group where appropriate Aspect of compliance or effectiveness being monitored Compliance with Infection Prevention and control policies and practices Monitoring method Annual Infection Prevention and control audits Individual or department responsible for the monitoring Audit Department Frequenc y of the monitorin g activity Group/committee/ forum which will receive the findings/monitorin g report Yearly Infection Control committee Committee/ individual responsible for ensuring that the actions are completed Matrons and ward managers Organisation s expectations in relation to staff training, as identified in the training needs analysis Training Reports Learning and Development Department Monthly HR&OD Subcommittee HR&OD Subcommittee 7
10 References Maunder J W, (1997). SCOPE; Scabies A war in the skin. Sept 4-5 Benenson A S, (1995) Control of Communicable Disease Manual. 16 th Edition. American Public Health Association. Wilson, J. (2001) Infection Control in Clinical Practice. 2nd Edition. Baillere Tindall. London With thanks to Mid Staffordshire NHS Foundation Trust and Telford and Wrekin PCT 8
PROTOCOL FOR SUSPECTED CASES OF SCABIES Action to be taken for a single suspected case: (patient or staff) Appendix 1 Report: Patient case to the Infection Prevention & Control Team (IPCT), report staff case to Occupational Health Services (OHS) Confirm: Diagnosis with Medical staff (via Trust OHS for staff) Patient: Treat confirmed case with scabicidal preparation recommended by the dermatologist (see Trust formulary). Recommend close contacts, e.g. family or others who have had prolonged skin to skin contact, to see their local pharmacist or GP for treatment. Staff: Treat confirmed case with scabicidal preparation, issued by OHS, at the same time close contacts will require treatment (OHS/IPCT will advise). Staff members can return to work after the treatment is complete (usually the following morning). NB. Whenever possible staff with suspected scabies should see a dermatologist (via Trust OHS) as soon as possible and take contact precautions when working with service users and completed treatment if required. Otherwise, contact OHSS, a member of the IPCT or, out of hours, the Consultant Microbiologist for advice. Observe for any further rashes on the ward in patients or staff during the following 6 weeks. Report any suspected or confirmed cases to the IPCT/OHSS. Action to be taken for more than one linked case: Report to the Infection Prevention & Control Team. Confirm diagnosis with Medical staff (via Trust OHS for staff) The IPCT will consider a co-ordinated mass treatment of all patients and staff. The symptoms of scabies can take several weeks to appear and close contacts (skin to skin contact) can become infected before the disease is suspected. Therefore anyone who has had prolonged skin to skin contact, where there is more than one linked case, will need treatment whether they have symptoms or not. Once the treatment is complete the person can return to work the following day. All staff will receive treatment on the same day as the patients on the ward. This may take a few days to organise but will be done as soon as possible after diagnosis is confirmed. (See Plan/Action). Ensure close contacts of the index case and of those staff diagnosed with scabies are also treated. It is not usually necessary to treat family contacts of staff or patients unless the patient or staff member has a confirmed rash. 9
PLAN Inform Ward Manager/Directorate Manager/Clinical Director/OH/Pharmacy/ Plan treatment programme and set date. Inform patient s clinician Inform Principal Pharmacist and request treatments for all staff members (defined by the OH/IPCT) and patients defined by IPCT OH to send request for staff treatment to SGH pharmacy stating number of individual treatments required including number of close contacts of staff with confirmed rashes (defined by the OH/IPCT) Pharmacy to confirm date when treatments will be available. Provide a list of all staff working on the ward including physiotherapy/ots and the number of patients. Identifying those with rashes and date if staff already treated, for the OH/IPCN to collect. Arrange staff education session on treatment and management. Provide information leaflets for staff and patients. Inform relatives of all ward patients and supply Public Health Leaflet. Ensure adequate staffing to ensure patients and staff will be treated on the same evening. Patients treatments must be prescribed on their treatment sheets by the ward doctor prior to the date of application. Staff treatment must be issued by the OHS (or a designated representative) and a record kept. Staff with confirmed rashes requiring treatment for close contacts will be advised by OHSS/IPCT. Inform staff members GP s by letter ACTION Infection Prevention & Control Nurse (IPCN) Infection Prevention & Control Nurse/Ward Manager or Nurse in Charge Ward Manager/Nurse in Charge OHS/IPCT OHS Pharmacy Ward Manager/Nurse In Charge Infection Prevention & Control Nurse Infection Prevention &Control Nurse Ward Manager/Nurse in Charge Ward Manager/Nurse in Charge Ward Manager/Nurse in Charge OHS OHS/Staff member 10
Application of Treatment 1. The skin needs to be cool and dry before applying the cream. 2. Apply the prescribed treatment over the whole body, including face neck and ears (take care to avoid the eyes). Make sure that the finger webs and all body creases are carefully treated. Cut the fingernails short, scrub them clean then apply the lotion or cream under the nails. If hands or other parts are washed during the evening, then re-apply the treatment again to the washed areas. Babies under 2 years of age, the compromised and resistant cases should have the scalp and face treated as well, sparing the skin around the eyes, nose and mouth. 3. The application should be applied at night before going to bed and must be reapplied to areas that are washed, e.g. hands, during the treatment period, usually 8-24 hours (check the manufacturer s instructions). 4. When the treatment period is over, shower or bath to wash off the preparation. 5. The application should be repeated 7days after the first treatment. 6. Itching may continue for a few weeks after a successful treatment which can be soothed with lotion, e.g. calamine. Information/and or treatment request letters for relatives, staff GPs and pharmacists Follow 11
To All Staff You may be aware that a number of patients (and staff) have reported skin rashes on the ward. The Medical Team has confirmed that this is due to scabies. Scabies is a very common infection and spreads from person to person by touch. People are infectious whist they are incubating scabies and because the incubation period can be very long it is easy to see why it can be spread so easily. Therefore it is essential we treat everyone involved at the same time. We have discussed with Occupational Health and the Infection Prevention and Control Team how best to manage this. If you have a rash you will be given a letter by the Nurse or Ward Manager to ask your GP to confirm you have scabies. When you have been diagnosed you will be offered two treatments, each one week apart. The scabicide preparation will be provided by the Pharmacy on a named person basis. It is absolutely essential that all your household contacts be treated when you receive your first treatment. If you do not ensure this happens then you may become re-infected from a member of your household. Staff with rashes will also be given letters to show the GP who cares for their household contacts, explaining why treatment is necessary. If you do not have a rash you will be given one treatment from the Pharmacy on a named person basis, but we will not expect your household contacts to be treated. Your cooperation in this is essentially and greatly appreciated. A copy of the Scabies Policy is available on the Trust website or you may contact me If you have any queries. Yours sincerely Designation: 12
GP Staff with Symptoms Dear Dr Management of a Scabies Outbreak on..ward Hospital The Medical Team and the Infection Prevention and Control Team are advising the above ward where cases of scabies have been diagnosed. Both patients and members of staff are affected. Your patient, DOB of Address is complaining of a rash and or irritation. If following examination you believe this may be due to scabies please could you sign and date this letter below and return it to your patient, who will then be provided with a scabicide preparation by the Trusts pharmacy department. Your cooperation is greatly appreciated. If you have any queries about this letter please contact the ward. Yours sincerely Designation: I confirm that I have examined and diagnose that he/she is infected with scabies. Signature: Print Name: Date: 13
GP Patient Close Contact Dear Dr Management of a Scabies Outbreak on..ward Hospital The Medical Team and the Infection Prevention and Control Team are advising the above ward where cases of scabies have been diagnosed. Both patients and members of staff are affected. Your patient is a close contact of a member of staff who has a rash and symptoms of scabies. The staff member is receiving treatment via the Trust. We would therefore be very grateful if your patient, as a close contact could be treated With an appropriate scabicide. As you know scabies has a long incubation period up to five weeks and patients who are incubating can pass the infection on before a rash appears. To manage and control scabies it is essential all close contacts of those with rashes are treated once, even when they have no symptoms. Your cooperation is greatly appreciated. If you have any queries about this letter please contact the ward. Yours sincerely Designation: 14
Dear Pharmacist Management of a Scabies Outbreak on..ward Hospital I confirm that..is a member of staff and a close contact of an infected patient on the above ward Please dispense a topical scabicide. Your cooperation is greatly appreciated. If you have any queries I can be contacted on Yours sincerely Designation: 15
Patient Has Rash - Relative Letter Dear Relative You will be aware that your has been complaining of a rash and irritation. The Medical team now think this may be due to scabies and we will be commencing treatment. Scabies as you know is an infectious condition and is passed from person to person by touch. People who are incubating the infection can pass it on. In a ward such as this all patients are treated just in case they are incubating the infection. If you have been in close contact with. then it is advisable for you to contact your GP to be prescribed appropriate treatment. A copy of the Scabies Policy is available on the Trust website or you may contact the ward if you have any queries. Yours sincerely Designation: 16
Patient with NO Rash - Relative Letter Dear Relative You may be aware that some patients on the ward have been complaining of skin rashes and irritation. The Medical Team now think this may be due to scabies and we will be commencing treatment. Scabies as you know is an infectious condition and although your does not have a rash, we would like us to treat all patients. This is because the incubation period for scabies is long and people are infectious whilst they are incubating even though there is no rash. A copy of the Scabies Policy is available on the Trust website or you may contact the ward if you have any queries. Yours sincerely Designation: 17
Scabies Skin Monitoring Form for ALL Staff and Patients Name Date rash appeared Appear ance of rash Symptoms e.g. itching, excoriation Areas affected Name of scabicide prescribed Number of times used and when Person with rash is immunocompromise d Person with rash is prescribed steroids, systemic or topical 18
BREAKING THE CHAIN OF TRANSMISSION Since the symptoms of scabies take several weeks to appear, it is easy for close contacts (household and sexual) to become infected before the disease is suspected. Therefore, anyone who is in close contact with the first patient should also be treated in case they too pass it on to someone else. These contacts will need treatment whether they are itching or not. 24 hours after treatment has been undertaken, the patient may return to work, school or nursery. No special precautions need to be taken with used clothing and bed linen hot cycle in a washing machine is sufficient. FURTHER INFORMATION This leaflet gives general information. In NORMAL working hours initial contact for Infection Control Advice should be through: Directorate of nursing Tel: 01785 221483 Enquiries will then be passed to the Trust s Infection Prevention and Control Nurses: Policy for the Management of Parasitic Infestations/C/YEL/ic/22/v1.1 BUGS INFORMATION LEAFLET ON: WHAT ABOUT GOING TO SCHOOL AND WORK? You can return to school or work once treatment has been completed. Judy Carr e-mail judy.carr@sssft.nhs.uk Ext no 5189 Mobile 07971313156 Elizabeth Blackham e-mail elizabeth.blackham@sssft.nhs.uk Ext no 5476 SCABIES 19
WHAT IS SCABIES? Scabies is an allergic response to the excreta and saliva of a parasitic mite which burrows under the skin. SITE OF INFECTION These burrows occur anywhere but are more common on hands (finger webs), inner wrists, elbow creases, under the armpits, and around the umbilicus, the nipples in adult females and the genitalia in men. SIGNS OF INFECTION Allergens from the mites produce an exceedingly small itchy, red rash. Itching of the rash is intense, more so at night and during or following a bath. There may be small, raised pimples and patches of crusty skin. The sites of the rash may not correspond to the sites of the mites. Not everybody will have sensitivity to the mite, and so not everybody develops a rash. TRANSMISSION OF SCABIES Transmission is by direct, prolonged skin to skin contact usually by holding hands. Mites never leave the body because they die if they are not kept warm and moist. TREATMENT OF SCABIES A number of creams/lotions are available ask your family doctor or local pharmacist. A hot bath is NOT necessary before treatment as the skin must be dry and cool before cream is applied. Apply the recommended cream gently over the skin to cover the whole body, including face neck and ears (take care to avoid the eyes). Babies under 2 years of age, the infirm and resistant cases should have the scalp and face treated as well, sparing the skin around the eyes, nose and mouth. It is important to apply the cream to cover all skin in the webs between the fingers and toes and buttocks and to the groin and genital area. Cut the finger nails short, scrub them clean then brush the lotion or cream under the nails. The cream must be reapplied to the hands after hand washing. After the treatment period (8-24 hours depending on the preparation -see manufacturer s leaflet), a bath or shower should be taken to remove traces of the cream. Itching may persist for two to three weeks after the successful treatment, but it can be treated with a soothing lotion like calamine. The application should be carried out at night, before going to bed. 20