SCABIES: What, when, where

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SCABIES What, when, where how

• Gretha de Beer, RN, B.Sc,
  B.cur
• 10
  Dec 2003

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Introduction

• 2 500 years of infestation
• 300 million cases each year
• Incidence 15 years high, 15 years low
• Mite Sarcoptes scabiei var. hominis
• 0.4mm

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Life Cycle

• Adult female mite burrows to base of stratum
  corneum after mating
• Lays 3 eggs/d, hatch in 3 days
• Immature mites move to surface
• Maturation 10 days
• 1 4 months colony of mites, larvae eggs
• Life cycle 30 days

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Types of scabies

• Classic scabies 10 15 mites
• Crusted (Norwegian) scabies
• Thousands of mites

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Epidemiology

• Reservoir Humans
• Transmission Overcrowding, not hygiene
• Skin-to-skin contact
• Time of contact 2 10 min
• Role of fomites Bed linens, clothing
• Australian study

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• Risk population
• Close physical contact
• Incubation period
• 4 6 weeks without previous exposure
• 1 4 days with previous exposure
• Period of communicability
• Infected person untreated
• 24 hours after Tx
• 24 36 hours at room temperature

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Symptoms Signs

• Itching
• Characteristic sites Finger webs, axillae,
  buttocks, umbilicus, groin, breasts
• Clinical signs Pimples, burrows, signs of mites
  eggs. Hyperkeratotic crusted lesions in
  Norwegian scabies
• Secondary lesions Erythematious papules, edema
  excoriations

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But is it really scabies?

• Skin Scraping First line of Dx
• Mite, ova or fecal pellets present
• Biopsy Golden standard
• More invasive

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Old Scabies

• Skin changes Loss of epidermal undulation
  flattening of skin
• Atypical presentations Norwegian scabies
• Topical steroids suppress symptoms
• Dementia Prevent scratching or cause habitual
  scratching unrelated to scabies

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Treatment

• Topical
• Lindane 1
• Permithrin 5 (Nix 5, Kwellada-P)
• Benzyl benzoate
• Other
• Precipitated sulphur 5 10
• Crotamiton 10

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Treatment (cont)

• Oral
• Ivermectin Broad spectrum anti-parasitic agent
• Single dose for resistant scabies
• Anti-histamine for the itch

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Covering the cracks

• Application of scabicide
• Cool, dry skin
• Thin smear of lotion
• Special attention areas
• Behind ears, soles of feet, hair line, palms of
  hands, between fingers toes, buttocks groin
• At night, wash off am

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Outbreaks in long-term care

• Contact with resident/staff with Norwegian
  scabies
• Possibilities of differential Dx
• Misdiagnosis of unrecognized cases
• Inadequate application of scabicide
• Topical steroids commonly used

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Again again

• Reoccurrences in long term facilities
• Risk of developing Norwegian scabies
• Many people exposed through close contact
• Generally long diagnostic delay
• Insufficient survey of epidemiological problem
• Treatment failures
• Incomplete post-intervention monitoring

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The Maimonides outbreakAug 2003
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What happened?

• Residents treated 387
• Staff treated 700
• Treatment schedule recommended by Public Health
• Specific floors treated on specific dates
• No contact between treated and non-treated areas
• Infection control measures Gloves long
  sleeved gowns for 6 weeks after Tx
• Environment treated

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Is this an outbreak?

• Total number of possible cases of scabies 57
• Residents confirmed 15
• Staff confirmed 8
• Residents unconfirmed 27
• Staff unconfirmed 7

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Index cases

• 1. 83-year-old female admitted July 2002
• Oct 02 Start of symptoms treated with topical
  steroids
• Jan 03 Scabies Dx Nix 5 twice and repeated
  after 1week
• Environment companions treated
• Topical steroids continued for 1 month
• Mar 03 Rash treated with topical steroids for 2
  months
• Jun 03 Sulphur 10 topical steroids for 2
  months
• Aug 03 Scabies Dx treated as part of hospital
  initiative
• Sep 03 Ivermectin 12mg to prevent reoccurrence

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• 2. Staff member
• Mar 03 Start of symptoms
• Aug 03 Dx 5.5 months later with Norwegian
  scabies
• Treated Aug 1 8 with Kwellada-P
• Sep 03 Ivermectin 15mg

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Secondary cases

• 21 Confirmed cases between July and Aug 2003
• P3 10 Residents 7 nursing staff
• P4 2 Residents
• P5 1 Resident
• P6 1 Resident
• P7 1 Health care worker
• 5 Residents treated with topical steroids prior
  to Dx of scabies
• Dx on P3 Alzheimers dementia

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• 1. 75-year-old female room next to first index
  case
• Jan 03 Nix 5
• Apr 03 Transferred to another wing
• Jun 03 Rash treated with topical steroids
• Jul 03 Rash on groin treated with canestan
• Aug 03 Treated as part of hospital initiative

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• 2. 83-year-old female cared for by 2nd index
  case
• Apr 03 Start of symptoms treated with topical
  steroids
• Aug 03 Dx with scabies treated
• 3. 83-year-old female cared for by 2nd index
  case
• Apr 03 Start of symptoms treated with topical
  steroids
• Aug 03 Dx with scabies treated
• Husband in same room did not develop symptoms
  until Aug
• All other secondary cases, incl. residents
  staff developed symptoms at the end of July
  treated beginning of Aug

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From here to there in no time
P3
D
B
N
S
C
A
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The big picture
P3
D
B
N
S
C
A
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Was it successful?

• YES!!!
• NO reoccurrences after hospital eradication
  program
• 1 Suspected case on P7 treated with Kwellada-P in
  Sep
• 1 Staff member Dx in Nov

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Money, money, moneyCost of an outbreak

• Treatment
• Overtime and additional salaries
• Security
• Yellow gowns
• Gloves
• Cida Rinse
• Cleaning supplies
• Laundry
• Loss of Cafeteria revenue
• Miscellaneous
•  
• Total

• 40 000
• 56 000
• 22 000
• 55 000
• 12 000
• 5 200
• 3 600
• 6 300
• 8 400
• 3 800
• ________
• 212 300

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Some guidelines

• Educate staff on recognition of signs and
  symptoms of typical and atypical scabies
• Educate staff on measures used to prevent the
  transmission of scabies, incl. the correct
  application of scabicides
• Develop implement a plan to evaluate and
  categorize residents, staff and their contacts
  according to their probability of infestation
• Identify symptomatic residents and staff
• Use contact precautions for symptomatic residents
  until 24 hours after treatment is applied
• Identify symptomatic household contacts,
  significant others and visitors of residents
•  

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• Identify symptomatic household contacts and
  significant others of staff
• Treat symptomatic persons effectively
• Apply treatment to all identified persons within
  the same 24 48 hour period, whenever possible
• Restrict infested personnel from work until
  initial treatment is completed (after overnight
  application of scabicide)
• Re-examine confirmed or suspected scabies cases
  at 14 and 28 days after initial treatment to
  evaluate treatment success
• Identify follow up exposed residents and staff
  who are asymptomatic
• For continuing outbreak, prophylaxis for exposed
  residents and staff who are asymptomatic
• Develop an ongoing surveillance program

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THE END