Epidemiologic Notes and Reports Scabies in Health-Care Facilities -- Iowa

Scabies continues to occur among residents and staff of Iowa nursing homes and hospitals. For the 8-year period July 1979-June 1987, the Iowa Department of Public Health confirmed scabies in 25 nursing homes, 1 hospital, 1 state institution, and 1 county residential care facility. Reports of scabies were received from 11 other facil- ities. A report of the investigation of this problem in three nursing homes follows.

Facility 1. In September 1985, scabies mites were found on three of seven nursing home patients with lesions suggestive of the disease. Skin scrapings from one of these patients yielded mites and eggs. He was successfully treated with an appropriate regimen of lindane lotion. The three visiting physical therapists who had treated the patient were also evaluated. Two had pruritic lesions compatible with scabies. A live mite was recovered in skin scrapings from one therapist, who was referred to her personal physician for treatment. Additional scabies cases were confirmed in this facility in December 1985 (1 of 3 positive) and November 1986 (5 of 19 positive).

Facility 2. In September 1985, skin scrapings from a 90-year-old nursing home patient with a persistent skin rash yielded 23 mites. The patient had been hospitalized briefly 3 weeks prior to this assessment, and evidence of transmission to hospital personnel was reported. The condition persisted, and the patient received monthly maintenance treatments until she died during a subsequent hospitalization.

Facility 3. In April 1987, an investigation revealed seven residents and three staff members with confirmed or probable scabies. All but two residents were confined to a ward of patients with Alzheimer's disease. The index patient, who had a rash of long duration, had transferred from another nursing home and probably had scabies upon arrival. Twice during 1986 the state health department had investigated the previous nursing home, which was the probable source of infestation, and had found rashes compatible with scabies but no positive scrapings. The index patient had been included in these investigations. Reported by: RW Currier, DVM, C Christie, BSN, LA Wintermeyer, MD, State Epidemiologist, Iowa Dept of Public Health. Div of Host Factors, Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note: Scabies becomes pandemic at approximately 30-year intervals (1,2). Evidence suggests that community scabies peaked in the mid-1970s but has persisted at high levels for the past 10 years (University of Minnesota, unpublished data).

Scabies is caused by infestation with the mite Sarcoptes scabiei and is a major problem in nursing homes, particularly among patients who are debilitated and require extensive hands-on care. Because treatment failure is common with approved scabicides (10% crotamiton cream/lotion, 1% lindane cream/lotion, and 10% sulfur in petrolatum), lengthy, intensive retreatment may be necessary.

These reports from Iowa suggest that the scabies mite is introduced when infested patients are transferred between institutions. The quantity of mites carried by these patients expedites transmission, which can occur directly, through contact between residents, or indirectly, through contact with staff. Thus, for such institutional settings, it may be appropriate to screen new patients routinely, preferably before admission, if they have a pruritic rash.

Skin scraping is the only consistent means of detecting mites, assessing the degree of transmissibility, and evaluating treatment when skin lesions persist or reappear (3). Any red, raised, pruritic skin lesions (especially on the upper back) that are not obviously due to other causes are suspect and should be scraped. Scraping will often yield Demodex folliculorum mites, which may produce lesions without extensive pruritis, in addition to S. scabiei. Treatment of residents, especially those with atypical, crusted rashes, should be aggressive (e.g., lindane lotion for 1 day, followed by 10% crotamiton lotion for 5 days, followed by a second lindane treatment). Treatment should include the entire body from the neck down, with special attention to the underside of well-trimmed fingernails.

Mass prophylaxis will not totally eliminate scabies, and the decision to use it should be based on the prevalence of scabies infestation in the facility. Follow-up examinations are recommended to assess overall control. Patients who cannot be successfully treated should receive monthly maintenance treatments for an extended period (e.g., applications of 10% crotamiton lotion for 2 days each month). Use of protective clothing and gloves by the nursing staff and isolation of patients would not serve any useful purpose since treatment failures usually reflect inadequate application of the scabicide to all appropriate body surfaces and not reinfestation from other patients or staff. Treatment failures occasionally result from resistance of mites to scabicides; failure for elderly, institutionalized persons may reflect concurrent cell- mediated immunodeficiency (3).

Nursing personnel frequently acquire scabies, especially on the upper arms and abdomen, but rarely on the hands and wrists (4,5). Recovering mites in scrapings from these persons is difficult because they usually carry a small number of adult mites. Occasionally, personnel experience psychogenic scabies or acarophobia, especially after recent treatment. Standard treatment will usually eliminate the problem and should be given to the staff's family members. Health-care workers with persistent complaints are best managed by emotional support and repeated skin scrapings to demonstrate the absence of mites (6).

References

1. Orkin M. Resurgence of scabies. JAMA 1971;217:593-7.

2. Orkin M, Maiback HI. Current concepts in parasitology: this scabies pandemic. N Engl J Med 1978;298:496-8.

3. Juranek DD, Currier RW, Millikan LE. Scabies control in institutions. In: Orkin M, Maiback HI, eds. Cutaneous infestations and insect bites. New York: Dekker, 1985:139-56.

4. Lerche NW, Currier RW, Juranek DD, Baer W, Dubay NJ. Atypical crusted "Norwegian" scabies: report of nosocomial transmission in a community hospital and an approach to control. Cutis 1983;31:637-42,668,684.

5. Cooper CL, Jackson MM. Outbreak of scabies in a small community hospital. Am J Infect Control 1986;14:173-9.

6. Currier RW. Scabies and pediculosis: hospitalized mites and lice. crusted "Norwegian" scabies: report of nosocomial transmission in a community hospital and an approach to control. Cutis 1983;31:637-42,668,684.

7. Cooper CL, Jackson MM. Outbreak of scabies in a small community hospital. Am J Infect Control 1986;14:173-9.

8. Currier RW. Scabies and pediculosis: hospitalized mites and lice. Asepsis -- The Infection Control Forum 1984;6:13-21.

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