Control

A scabies outbreak suggests that transmission has been occurring within the institution for several weeks to months — thus increasing the likelihood that some infested staff or patients may have had time to spread scabies elsewhere in the community, including to other facilities. Measures to control scabies in an institution depend on factors such as how many cases are diagnosed or suspected, how long infested persons have been at the institution while undiagnosed and/or unsuccessfully treated, and whether any of the cases are crusted (Norwegian) scabies. Because it is so highly transmissible, crusted scabies requires rapid and aggressive detection, diagnosis, infection control, and treatment measures to prevent and control spread.

The local health department should be notified of any outbreak that may have community implications, including possible spread by patients or staff to other institutions.

Control measures for a single case of non-crusted scabies should consist of heightened surveillance for early detection of new cases, proper use of infection control measures when handling patients (e.g. avoidance of direct skin-to-skin contact, handwashing, etc.), confirmation of the diagnosis of scabies, early and complete treatment and follow-up of cases, and prophylactic treatment of staff, other patients, and household members who had prolonged skin-to-skin contact with suspected and confirmed cases. Skin-to-skin contact with scabies patients should be avoided for at least 8 hours after treatment.

Control measures for multiple cases of non-crusted scabies should consist of heightened surveillance for early detection of new cases, proper use of infection control measures when handling patients (e.g. avoidance of direct skin-to-skin contact, handwashing, etc.), confirmation of the diagnosis of scabies, early and complete treatment and follow-up of cases, and prophylactic treatment of staff, other patients, and household members who had prolonged skin-to-skin contact with suspected and confirmed cases. Skin-to-skin contact with scabies patients should be avoided for at least 8 hours after treatment. In addition, an institution-wide information program should be implemented to instruct all management, medical, nursing, and support staff about scabies, the scabies mite, and how scabies is and is not spread. Epidemiologic and clinical data should be reviewed to determine the extent of the outbreak and risk factors for spread.

Control measures for an outbreak involving one or more cases of crusted scabies should involve rapid and aggressive detection, diagnosis, infection control, and treatment measures because this form of scabies is so highly transmissible. Unrecognized crusted scabies often is the source of institutional outbreaks of scabies. Infection control personnel and dermatologists should be involved as soon as scabies is suspected in an institution. An institution-wide information program should be implemented to instruct all management, medical, nursing, and support staff about scabies, the scabies mite, and how scabies is and is not spread.

Until successfully treated, patients with crusted scabies should be isolated from other patients who do not have crusted scabies. Assigning a cohort of caretakers to care only for patients with crusted scabies can reduce the potential for further transmission. Direct skin-to-skin contact between a patient with crusted scabies and his/her caretakers and visitors should be eliminated by following strict contact precautions, including the use of protective garments such as gowns, gloves, and shoe covers. The patient’s room should be cleaned thoroughly. Bedding and clothing used by a person with scabies should be machine-laundered using the hot water and hot dryer cycles.

All staff, volunteers, and visitors who may have been exposed to a patient with crusted scabies, or to clothing, bedding, or furniture used by such a patient, should be identified and treated. Treatment should be strongly considered even in equivocal circumstances because of the complexity of controlling an institutional outbreak and the low risk associated with treatment. All suspected and confirmed cases, as well as all potentially exposed patients, staff, visitors, and family members should be treated at the same time to prevent reexposure. Remember that symptoms of scabies can take weeks to appear the first time a person is infested; however, the person still can spread scabies during this asymptomatic period.

Persons with crusted scabies generally require treatment at least twice, a week apart. Topical treatment with permethrin or oral treatment with ivermectin has been used successfully, although ivermectin currently is not FDA-approved for treatment of scabies.

Long-term surveillance for scabies is imperative to eradicate scabies from an institution. All new patients and staff should be screened and treated for skin conditions suggestive of possible scabies. The local health department and neighboring institutions should be notified of the outbreak and of any patients who may have been transferred to or of staff who may have worked in other institutions.