Public Health Strategies for Scabies Outbreaks in Institutional Settings

Overview

Scabies can spread easily under crowded conditions where close body and skin contact is frequent. Places where scabies outbreaks more commonly occur include:

• Nursing homes
• Extended care facilities
• Detention facilities including jails and prisons
• Childcare facilities
• Homeless shelters or encampments

Local and/or state health departments may be able to provide guidelines for preventing and controlling scabies outbreaks.

Below are suggestions for preventing, detecting, and responding to single or multiple cases of non-crusted scabies in an institution.

Prevention

Early detection, treatment, and implementation of appropriate isolation and infection control practices are essential in preventing scabies outbreaks. Institutions should maintain a high index of suspicion that undiagnosed skin rashes and conditions may be scabies, even if characteristic signs or symptoms of scabies are absent (e.g. no itching). New patients/residents and employees should be screened carefully and evaluated for any skin conditions that could be compatible with scabies. The onset of scabies in a staff person who has had scabies before can be an early warning sign of undetected scabies in a patient/resident. When there is concern for scabies in a person, skin scrapings should be obtained and examined carefully by a person who is trained and experienced in identifying scabies mites. Appropriate isolation and infection control practices (e.g., gloves, gowns, avoidance of direct skin-to-skin contact, etc.) should be used when providing hands-on care to patients/residents who might have scabies. Epidemiologic and clinical information about patients/residents with confirmed and suspected scabies should be collected and used for systematic review in order to facilitate early identification of and response to potential outbreaks.

Surveillance

Establish surveillance.

• Have an active program for early detection of infested patients/residents and staff.
• Maintain a high index of suspicion that scabies may be the cause of undiagnosed skin rash; evaluate and confirm suspected cases by obtaining skin scrapings.
• Screen all new patients/residents and staff for scabies.
• If there are multiple cases, notify the local health department of the outbreak; determine if there is evidence of an increase in scabies cases in the community; notify other institutions to or from which infected or exposed patients/residents may have transferred.

Diagnostic Services

Ensure that adequate diagnostic services are available.

• Consult with an experienced dermatologist for assistance in differentiating between skin rashes and scabies.
• Ensure a trained and experienced staff member can obtain and examine skin scrapings to identify scabies mites.

Control & Treatment

Establish appropriate procedures for infection control and treatment.

• Maintain records with patient/resident name, age, sex, room number, roommate(s) name(s), skin scraping status and result(s), and name(s) of all staff who provided hands-on care to the patient/resident before implementation of infection control measures: symptoms can take up to 2 months to appear in exposed persons and staff.
• Use epidemiologic data about the distribution of confirmed cases by building, room, floor, wing, occupation (for staff), dates of admission, and onset of scabies-like condition to determine:

1. levels of risk for patients/residents and staff;

2. extent of the outbreak (e.g., confined or widespread in the facility); and

3. temporal relationship among cases.

• Avoid direct skin-to-skin contact with any patient/resident with suspect or confirmed scabies.
• Use gloves when giving hands-on care to any patient/resident with suspect or confirmed scabies; wash hands thoroughly after providing care to any patient/resident.
• Avoid skin-to-skin contact with the individual with scabies for at least 8 hours after application of scabicide treatment.
• Identify and treat all persons (e.g., staff, relatives, patients/residents) having prolonged, direct skin-to-skin contact with an infected person before they were treated.
• Offer treatment to household members (e.g., spouses, children, roommates) of staff who are receiving scabies treatment.
• Staff generally can return to work the day after receiving a dose of treatment with permethrin or ivermectin; however, symptomatic staff who provide hands-on care to any patient/resident may need to use disposable gloves for several days after treatment until it is sure they are no longer infested.
• Use procedures that minimize the risk of transmission of secondary bacterial infections that may develop with scabies.

Environmental Disinfection

Establish appropriate procedures for environmental disinfection.

• Machine wash and dry bedding and clothing of scabies patients/residents using the hot water and hot dryer cycles. Temperatures in excess of 50°C or 122°F for 10 minutes will kill mites and eggs.
• Items that cannot be laundered can be disinfested by storing in a closed plastic bag for several days to a week.
• Routine cleaning and vacuuming of the room should be done if and when a patient/resident with non-crusted scabies leaves the facility or moves to a new room.
• Environmental disinfestation is neither necessary nor warranted.
• Discarding mattresses are generally not necessary.

Communication strategies

• Establish procedures for identifying and notifying at-risk patients/residents and staff who are no longer at the institution.
• Ensure a proactive employee health service approach to scabies. Include information about scabies to all staff and provide dermatologic consultation for employees and, when appropriate, their household members.
• Maintain an open and cooperative communication between management and staff.