Scabies

Sharon · Oct 6, 2003

I have dealt with them in many different settings. In a residential setting of at risk individuals, if more then one resident has acquired them without being outside, then it is a major/primary indicator of abuse and investigation of possible sexual assault should occur.

All non-partner outbreaks with three or more individuals with limited outdoor exposure that I have investigated have had included at least one individual who was the victim of an assault. This has include the following outbreak locations: day care, elementary, high school, and college (especially hazing and parties where Rhopy was present), disaster rescue and relief shelters, disabled residential facilities including half way house and LTC.

If you see more then one case in a residential facility then the ill residents should be screened for all STD's including Hep A, B, C, and HIV. My last hospitalized pediatric patient was a 5-year-old admitted for an appendectomy in the middle of winter. She did have appendicitis. During the Emergency Department exam they did not fully undress here and missed the scabies rash on her buttocks. I requested further testing and was allowed to do a throat culture and add blood work to her pre-op orders. SANE was initially refused. Her throat culture came back positive for gonorrhea and her VDRL was positive. Once the throat culture came back positive a full evaluation was ordered and the police were brought in.

What needs to be considered when presented with a case of scabies?

Is this an isolated case?

Could the patient have acquired them on their own?

Was it a warm day and were they in prolong contact with the grass?

If all questions are "YES" then assault investigation is not indicated. If there are any are: "NO's", further investigation is indicted

Noney · Oct 6, 2003

I've seen pt's with scabies. In LTC is one or two residents end up with Scabies then usually there are some employees that get it then more pts get it.... Usually have to Kwell the whole facility. I hate that because we all know it's just pioson, but what can you do? You have to wash all linens and pt's clothes even the ones in their closets, because someone may have hung an infected sweater back in the closet. You also need to wash all the w/c's and mattresses. I worked at a facility that had an outbreak of scabies once and they ended up sending most of the linen out to be cleaned.

Are you having an outbreak of scabies?

I took care of a pt this weekend in acute care that I would bet money has scabies. Dr told one of the other "You nurse worry too much about scabies."

Noney

caffine addict · Oct 7, 2003

Boy I didn't expect so much information!

THANKS guys!

Yes we've had an outbreak> Good news is that it seemed to be confined to our locked dementia unit. Three roomates were the only ones identified with a rash. We think we tracked back to a staff member. We treated the whole unit. Beds, mattressess, linen, ALL clothes(in closet and on residents) Elemite cream for everyone including the employees. Lots and Lots of showers.

My orignal question was weather or not to wash ALL of the personal clothing, when I did'nt get an answer I just did it anyway. Always error on the side of caution! This was confirmed by the health department as well. Well in 7 more days we will have to start all over:o

Thank goodness the health department and the Medical Director dont want to treat the whole facility just know.

P.S. How did you take the clothes out to wash? Aren't they concidered contaminated?

Noney · Oct 7, 2003

Sorry I don't know how they sent them out. It was years ago. I just remember clothes being bagged up and sent out. You're lucky(and smart) you caught it so soon and took care of things before it got out of hand.

Noney

Sharon · Oct 7, 2003

So how did the employee come down with it since close intimate contact, (i.e. sexual contact, sharing of clothing and sleeping in the same bed) is required for transmission? Remember this is not lice and does not spread even as easily as lice.

caffine addict · Oct 8, 2003

An employee actually had the rash first on the forearms.

The resident was transfered manually by the employee repeatedly putting the forearms under her axilla and pulling her close and performing a pivit transfer.

The resident's room mates have dementia and travel from bed to bed all day.

"Merk Mannual" States that it can be transferred from clothes or bedding if someone immediatly puts on those clothes or uses the linen.

Another staff member comes onto the unit from another unit and perform the same transfer technique with those room mates who are affected and then goes onto other residents.

Many of the staff car pool and are cramped into the vehickle together for a 30-40 min ride home and back each day.

The Physical theripist uses the same Gait belt on several residents throughout the day and ties it around her own waist inbetween.

And so on, and so on, excetra:p

Sharon · Oct 8, 2003

Umm of all of 100's of cases I have dealt with none ever spread to another patient or employee through such casual contact. I have had iaotrogenic outbreaks of conjunctivitis and respiratory transmissible conditions like Chicken Pox, but never a parasite in the US (inculding at residential schools for the disabled).

When you reported the outbreak to the Health Department how did they take it? If other employees contracted the scabies, how did the States Worker's Compensation Commission react? Did it spread to other family members of employees so opening your risk for additional worker compensation claims by the family members? How many months/years will you be doing follow up liver function studies if Kwell was used? Has your facility had retraining on infection control practices yet?

caffine addict · Oct 10, 2003

WOW so many questions,

And I was the one looking for answers. Now I have more to think about. I wish you were My infection control practitioner!!!!

The Health Department wasn't to concerned and walked us through what to do. As a matter of fact one of our sister facilities, maybe 2 have also reported scabies. The health dept. says that in this month alone they have had more reports than all of last year.

I didn't know we were supposed to report to the workers comp people?! That sounds like a can of worms. No employees have reported that their families have been affected.

As for casual contact, thats how it was explained to me by health dept. personel. Did they mis inform me? :confused:

P.S. we used Elimite cream. There was no recomendation to do liver fxn studies.

Sharon · Oct 10, 2003

Since Elimite is a permethrin insecticide (for human use) and can trigger asthma attacks I have not used it much. In mild case I have just waited it out and used good universal protection.

If any employees contracted scabies while at work then yes it is a reportable illness. Reportables are both injury and illness. If an employee were to file on their own and the commission or OSHA where to discover the company or facility did not file timely there could be consequences. Workers compensation commissions and OSHA expect the employers to know they have to file and hold them to higher standard then the individual employee.

As I mention before I have never seen casual contact spread scabies. Lice I have seen spread casually and I have seen lice confused with scabies. And I have seen many cases of chicken pox and shingles mistaken for scabies, especially if the outbreak is in the groin or under the arms.

The only group I know of who got scabies and initially appeared casual, was a high school and college group of Deaf/deaf students. The outbreak investigation actually tracked it back to an outdoor study group on a lawn. They had all manage to sit on a nest of scabies. We did not medically treat this group because of the high incidence of undetected renal problems in deaf individuals. We used housing isolation and daily cleansing of bedding and clothing. Once the student appeared to no longer have active scabies they were moved to a clean dorm room. And the old was treated.

caffine addict · Oct 11, 2003

It's funny that you mentioned Chicken pox and shingles. I've been questioning that!

We had another resident on the same unit with shingles a few weeks prior to the out break. He lived a few doors down and only came out to meals and returned back to his bed. How would this be transmitted to and only affect the 3 women room mates with the rash?

I didn't realize that you could pick up scabies outdoors and was just asking where they come from. I mean they just couldn't live from person to person continuously.

Im going to have to look into our workers comp. rules and ask some questions. No one ever taught me that step in all the years that I've been in management. Boy that makes me wonder what else I've missed. I was never mentored. I'm one of those people who was just thrown in to sink or swim and I'm still waiting for someone to throw me the life jacket.

Sharon · Oct 13, 2003

Zoster transmission is a much more likely culprit in an institution then scabies. Since both, Varicella Zoster and Herpes Zoster are fomites transmissible and therefore can be spread on clothing. I have seen outbreaks in which the subsequent patient developed symptoms as far away as separate buildings on. It s not uncommon in adults to skip units and floors. Who gets it and how it manifests itself depends on prior exposure history and current immune status. If any vesicle formation occurs, you should evaluate for zoster. To complicate matters people with lowered mental status have a tendency to scratch and change the rash pattern due to trauma before initial assessment and diagnosis.

When you think scabies think more of ticks then lice. It is much more common to pick up ticks from outdoors and close intimate (sexual contact) then from casual contact. Since I always have problems with identifying rashes, I use the DERM IS website (http://www.dermis.net/index_e.htm) to compare rashes when trying to identify them. This website is available in English, German,, French, Spanish and Portuguese. A portion of the DermIS website description for scabies:

"Contagious disorder caused by the mite Sarcoptes scabiei, which attacks infants and children as well as adults. Scabies is transmitted in the course of close physical contact, e.g. during sexual intercourse, as well as in camps and between children under unsanitary living conditions. Transmission by means of underwear or linen is rare . . ."

Most states have workers compensation web pages and links to the actual regulations. I hope yours does. If you do have trouble finding it out, you are welcome to PM me confidentially your location and I will try some resources I have through my professional memberships.