Scabies Control

1. Scabies Control Massachusetts Department of Public Health Presented by: Elizabeth Land, MS November 2006

2. Presentation Objectives • Provide an overview of scabies • Description • Transmission • Symptoms • Diagnosis and treatment • Control measures • Examine the Department of Mental Retardation (DMR) protocols for scabies prevention and control

3. Scabies Description • Contagious infestation of the skin • Caused by human mites (Sarcoptes scabiei subsp. hominis) • Distributed worldwide • Reported incidence increasing in US since 1970’s • Humans are the reservoir

4. Scabies Infestation: Mites burrow under skin to feed and lay eggs Can burrow beneath skin in 2.5 minutes Adult female mite .3 - .4 mm long

5. Scabies Transmission • Direct, prolonged, skin–to-skin contact • Sexual contact • Household contact • Indirect transfer from clothing, towels and bedding, only if contaminated immediately before contact • Communicable • while infested and untreated • during incubation period

6. Scabies Symptoms • Symptoms caused by reaction to mites • Pimple-like rash or burrows between fingers, on wrist, elbows, armpits, belt line, navel, abdomen, and/or buttocks • Intense itching over most of the body, especially at night • Sores on the body caused by scratching • Incubation period: • 2-6 weeks without previous exposure • 1-4 days after re-infestation (usually milder)

7. Scabies Rash

8. Scabies Diagnosis • Confirmed by skin scrapings of papules or intact burrows • Burrows and mites may be few in number (only 10-12) and difficult to find

9. Scabies Treatment • Applicaton of scabicide over entire body below head: • 5% permethrin cream (wash after 8-14 hrs) • 1% lindane cream (wash after 8-12 hrs) • Ivermectin, single dose, orally • Itching may continue for several weeks despite successful treatment • In ~5% of cases, 2nd treatment may be necessary after 7-10 days.

10. Applying Prescription Creams • Follow package insert • Apply thin layer over whole body from neck down, paying particular attention to folds in skin • Trim fingernails and toenails, apply under nails • Reapply after handwashing • Leave on for at least 8 hours, but not longer than maximum time recommended for product • Wash off with warm, soapy water and dry skin

11. Scabies Control • Prompt diagnosis and treatment of patients • Simultaneous, prophylactic therapy: • household members, • sexual contacts, and • caregivers with prolonged skin-to skin contact • Launder all clothing worn within 48-72 hrs. of treatment in hot water and dry in hot dryer • Thorough vacuuming of carpets and upholstered furniture

12. DMR Protocols for Scabies • Who should be treated? • Who should be prophylaxed? • Who should be notified? • Who should be isolated and for how long? • Who should be monitored and for how long? • What environmental treatment is needed? • Who is responsible for follow-up?

13. DMR Protocol forSuspect Scabies Case • Staff reports suspect scabies case to their supervisor • Primary care physician or dermatologist is contacted for appointment • Case remains at home to minimize exposure to others until medical clearance is obtained • Physician completes the Scabies MD Treatment Form

14. DMR Notification Protocol for Confirmed Scabies Case • Day and residential program directors, as applicable • Area office nurse • Day program and/or residential program nurse • Primary care physician for all others living in household of confirmed case • Family/guardian • Residential staff, if applicable • Transportation staff, if applicable

15. DMR Treatment Protocol • Confirmed case • All people living in the household of a confirmed case • All residential staff • Exposed day program individuals and staff do not need to be treated, but will be monitored for rash for 6 weeks

16. DMR Follow-up Protocol • Isolation of treated, confirmed cases at home is determined by physician • For confirmed or suspect cases – signed doctor’s note is required to return to any day program • For exposed individuals - family members and residential staff may sign note that treatment has been completed or is not indicated • Exposed individuals are monitored for 6 weeks • Area office nurse tracks additional cases

17. DMR Environmental Protocol • Wash all bedding and towels used by case during last 4 days in hot water and dry on hot cycle • Wear gloves to launder and discard after • Store items that cannot be washed in plastic bag for 14 days • Clean all washable surfaces • Vacuum rugs, furniture, and mattresses • Clean and vacuum all vehicles

18. DMR Scabies Control • Educate clients about personal hygiene, including handwashing • Increase awareness and surveillance for scabies with program staff • Report any suspect cases promptly to program nurse or area office nurse • Seek medical visit as soon as possible, if indicated • Conduct contact investigation as soon as possible, if indicated

19. Prevention and Handwashing • Germs are everywhere: • People carry millions of germs on their hands. • Germs are on also on objects that we touch every day (doorknobs, handrails) • “30 second solution” • Least expensive way to stay healthy • Forming good habits early in life keeps us healthy • Biggest factor in preventing spread of infectious diseases!

20. How to Wash Your Hands • Use warm running water • Lather with soap (liquid preferred) • Scrub, including between fingers, for 20 seconds • Rinse with water • Dry thoroughly with a clean dry towel or paper towel • Turn off faucet with towel

21. References • American Academy of Pediatrics. Summaries of Infectious Diseases. In:Pickering LK, ed. Red Book: 2006 Report of the Committee on Infectious Diseases. 26th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2003:584-587. • Heymann, DL, Control of Communicable Diseases Manual. Washington DC: American Public Health Association; 2004:473-476.  • Isada, C. et al. Infectious Diseases Handbook. 6th ed. Hudson, Ohio: Lexi-Comp, Inc.; 2006:293-294. • http://www.cdc.gov/ncidod/dpd/parasites/scabies/default.htm