Aims - Herefordshire CCG

Comments

Transcription

Aims - Herefordshire CCG
HPA West Midlands West
Information Pack
For the management of scabies
June 2011
Version 1.1 June 2011
1
Review
June 2011
June 2012
Date
30/6/11
By
Avril Weaver
Designation
HP Nurse
Amendments
V 1.1
Date
30/6/11
By
Avril Weaver
Comments
Details of Ivermectin
included
Version 1.1 June 2011
2
Contents
Page
Aims of policy
3
Clinical Signs and Symptoms
3
Diagnosis
4
Transmission
4
Treatment
4
Management of an outbreak in institutional setting
5
Post Treatment Rash
6
Appendix 1
Check List
Appendix 2
Sample letter to Care Home
Appendix 3
List for Residents
List for Staff
Appendix 4
Information letter for residents & their relatives
Information letter for staff
Appendix 5
Leaflet
Appendix 6
Sample letter for GP
Version 1.1 June 2011
3
Aims of this policy
To raise the level of awareness and understanding about the issues concerning infection with
scabies
To provide a reference document for the diagnosis, treatment and control of scabies
To provide information which will help prevent the development of resistance to scabiecides
used in the treatment of scabies?
To ensure a consistent approach is taken by all staff when dealing with cases of scabies
Scabies
Scabies is a contagious disease caused by a mite, Sarcoptes scabei, which lives just under
the top layer of the skin. This mite is transparent and too small to see with the naked eye.
Scabies appears all over the world, but is especially common in schools, care homes, and
amongst the poorer people of the world living in cramped and difficult conditions.
Clinical signs and symptoms
Classic:
First-time sufferers can carry scabies for up to six weeks before showing any sort of reaction
to it. Those who have had it before will react within 2-3 days.
Once there is a reaction, the patient will develop an intense itchy rash which is worse at night,
and when the body is warm. For small children and babies this may be when they have been
running about, or if they have a sleep during the day. Due to the irritation caused by the rash,
the patient will often have long scratch marks on their body and limbs.
The rash is an allergic reaction of the body to the mite, its waste products and the eggs
deposited by the mite as it burrows under the skin. Therefore the rash does not directly
correspond with the location of the mites. It is always bilaterally symmetrical, that is, it is found
equally on both sides of the body. However, it does not appear in the centre of the back or
chest.
Crusted (Norwegian):
This can occur in people who have an impaired immune system.
The itchy rash does not occur. Eventually areas of scaling and crusting may appear
anywhere on the body.
This form of the disease is very contagious and is often at the centre of an outbreak of
classical scabies amongst family members or residents in a nursing or residential home.
Atypical:
Classical and Crusted scabies are relatively easy to recognise but atypical scabies in an
intermediate form. Frequently itching is absent and there is no rash, scaling or crusting,
although the mites may be present anywhere including the head.
Version 1.1 June 2011
4
Certain groups are more susceptible to this form of scabies:

The very young (under 4yrs)

Downs Syndrome patients

The elderly

Alcoholics

People being treated with immunosuppressive drugs

Patient where topical steroids have been used to stop undiagnosed itching.

Atypical scabies often occurs in people already resident in long stay establishments.
Diagnosis:
Diagnosis is made via a history and clinical appearance.
Most commonly, the mite is found between the fingers and around the wrists, although it may
be transferred to other parts of the body through touch. Hence, it is also found on the outside
of the elbows and knees, and around the ankles, waist, breasts and genital area. On the very
young, elderly and those who are chronically ill, the mites can be found on the ears, face and
head.
Skin scrapings (to identify mites) can be obtained ideally from between the fingers. The
presence of a symmetrical rash on the body together with itching, which is worse at night, is
suggestive of scabies.
Transmission:
Scabies can be transferred by prolonged skin-to-skin contact with someone who already has
the infection e.g. by hand holding. The contact must be prolonged e.g. 2-6 minutes or more,
to give the mites time to transfer on to the new host.
Sarcoptes scabei is host specific i.e. it lives only on humans. Therefore, scabies cannot be
caught from pets or other animals. There is a similar disease in animals known as "mange",
but it is caused by a mite specific to the animal and cannot be transmitted to humans.
The scabies mite needs a humid environment in which to survive. This is provided by the
tunnels that it makes just under the skin. The humidity on the surface of the skin is not high
enough for the mite to survive any great length of time. Therefore, the mites do not crawl out
into clothing or bedclothes, and there is no need to change bed linen daily or boil, disinfect or
dispose of bedclothes or clothing. It would however be good practice for patient to change
into clean clothing and change bed linen on day of treatment.
Treatment:
The treatment is usually a cream, such as Lyclear Dermal Cream®, or a lotion like Derbac
M®. All treatments contain an acaricide, which is a substance that kills mites. The lotion or
cream should be applied to cool, dry skin. It is not necessary to take a hot bath or scrub the
body beforehand. Such action may result in the treatment being absorbed into the
bloodstream too quickly and being made harmless before the mites are affected.
Crusted scabies is more difficult to treat and usually requires several applications of a
scabicide (see: frequency of treatments). Advice should be sought from the Health Protection
Unit
Version 1.1 June 2011
5
Where crusted scabies are observed, softening and gently removing some of the crusts will
enable to topical treatment to be absorbed more easily. It may be necessary however, to
apply 2 or 4 applications on consecutive days to ensure that enough penetrates the skin
crusts to kill all of the mites.
Applying the treatment:
The cream or lotion should be applied all over the body including palms of hands, soles of
feet, under finger and toenails, around the pubic area and in the tummy button. For those
under two years old, the elderly and those with long-term illnesses, it is recommended that
the face, scalp, neck and ears should also be treated, being careful to protect the eyes and
mouth. It will take two people to ensure the whole body is adequately covered.
The lotion or cream should be allowed to dry before getting dressed. It should be reapplied
after washing hands or other areas (e.g. after changing nappies / incontinence pads) during
the treatment time. To prevent small children and babies sucking the treatment from their
hands, mittens can be worn.
After the treatment has been on for the required time, it should be washed off with clear
water. Treatments should be repeated as directed - usually again after 4 - 7 days.
Ivermectin (oral treatment for Scabies)
Ivermectin is an oral treatment used in cases of Crusted (Norwegian) Scabies. Usually
given in a single dose, it has proved successful in patients where response to topical
treatment alone has failed. It is only available for use in the UK on a named patient basis so
would need to be prescribed on individual assessment by GP or dermatologist. Where
possible this would be a coordinated treatment give in conjunction with a topical application of
a scabicidal treatment.
.Treatment of contacts:
It is important that close and intimate contacts should receive treatment, even though they
may not yet show signs of having scabies. This should include all other members of the
household. In the care home setting this would also include regular visitors to symptomatic
patients.
Frequency of treatments:
A person who has had contact with someone
infected with scabies but has no symptoms
1 treatment
A person with symptoms
2 treatments given 7 days apart
A person with crusted areas of skin or one where
treatment has previously failed
May need up to 4 treatment – this should
be clarified with the doctor in charge.
May need single oral treatment of
Ivermectin.
Management of outbreak in an institutional situation





Before commencing treatment a definite diagnosis should be made by a GP
(preferably a Dermatologist).
Assess the extent of the problem by identifying all residents and staff with recent
rashes or undiagnosed itching.
Two or more suspected cases would qualify as an outbreak
Inform the Health Protection Unit – Kidderminster office: 01562 756 300.
Mass treatments are recommended in outbreak situations and preparation and timing
is crucial for success. The HPA will advise on how best this should be approached for
optimum results.
Version 1.1 June 2011
6
Post-Treatment Rash
Itching can continue for 2-4 weeks after treatment even if the treatment has been successful.
Keeping the skin cool will help, however antihistamines may be prescribed to ease
discomfort.
In an institutional situation - monitoring of symptoms and observing for new cases should
continue for up to six weeks post treatment. If known cases show signs of new lesions or
new cases are identified the HPU should be contacted for further advice.
Version 1.1 June 2011
7
Appendix 1
HPA West Midlands West
SCABIES IN NURSING/RESIDENTIAL HOMES
CHECK LIST

Identify all patients and staff with symptoms of rash and/or itching, which is worse at
night.

Obtain details of:
Date of onset
Where nurse / working (check if agency staff)
General Practitioner
Confirmed diagnosis
Has treatment been prescribed / administered and when
Total number of residents and staff

Identify source case – has the person been transferred from another care setting?

Advise all staff on prevention of spread

Contact general practitioners and arrange treatment:
2 applications, 7 days apart for symptomatic cases
1 treatment for close contacts

Provide training for all staff to ensure all are aware of correct method of application

Regular visitors / relatives to be advised
Outbreak Situation

Detail list of: all patients / staff / close contacts

Set dates of treatment:
 Day 1 - treatment for all
 Day 7 - second treatment for symptomatic cases only

Contact and advise all residents GPs of plan

Prepare:
Version 1.1 June 2011
Information leaflets
Information sheets for staff
Information sheets for residents and relatives
Side-effect sheet
Letter of plan confirmation to Home Manager
Letter to all staff
Check list of all who have received treatment and type
8
Appendix 2
Sample letter
Dear Matron/Manager
Re: Management of Scabies Outbreak
I can confirm that in order to manage the situation regarding scabies, the
agreed plan of action is to be follows:

Make a list of all residents and staff, noting all of those with symptoms and
if they have received treatment (note date and type of cream used).

Contact GP’s and arrange prescriptions for all. Two treatments will be
required for those with symptoms but only one for those who have not.
(Letter to GP attached)

Obtain enough treatment for all staff (not necessary for kitchen staff). We
recommend that the home purchase this, as to wait for staff to attend their
own GP could delay the treatment date and also not ensure that they
would hold off application until the scheduled date.

Advise any staff with symptoms that their household contacts should
contact their own GP for treatment. (it is important to stress that their
treatment should be scheduled to coincide the homes schedule if this is to
be successful)

Visiting relatives of symptomatic patients should also be advised to visit
their own GP as detailed above.

Agree dates on which treatment will be given i.e. day 1 and day 7. This
needs to be a realistic date allowing time to obtain adequate quantities of
cream and ensure that enough staff are on site to complete the application
treatments.

Ensure all staff are provided with detailed advice on how to apply the lotion
effectively and precautions to prevent further spread.

First treatment will be for everyone(staff and patients/ symptomatic and
non-symptomatic)

Second treatment (7 days later) will be for those who have rashes

Patients who have been diagnosed with crusted (Norwegian) scabies will
need more intensive treatment and may require up to 3 or 4 applications
within the 7 day period. Where possible crusts can be softened and gently
removed to enable the treatment to penetrate and be successful. In some
areas GP’s will prescribe oral Ivermectin in conjunction with topical
treatment.
Version 1.1 June 2011
9

The situation should be carefully monitored for a further six weeks. Itching
can continue for up to 4 weeks following treatment - this does not
necessarily mean that the treatment has been unsuccessful.
In order for this treatment to be effective, timing is crucial. I have enclosed
sample information sheets for staff, residents and their relatives, which you
may find useful. If you need any further advice please do not hesitate to
contact me. I will keep in touch to monitor the situation.
Yours sincerely
Version 1.1 June 2011
10
Appendix 3
SCABIES LIST - RESIDENTS
NAME
G.P.
Version 1.1 June 2011
SYMPTOMS
(YES/ NO)
11
ONSET
DATE
SCABIES
TREATMENT
HISTORY AND
DATE/S
SCABIES LIST - STAFF
NAME
G.P.
Version 1.1 June 2011
SYMPTOMS
(YES/ NO)
12
ONSET
DATE
SCABIES
TREATMENT
HISTORY AND
DATE/S
Appendix 4
Information for residents and their relatives
You may already be aware that some of the residents have been diagnosed as
suspected of having scabies.
Scabies is an allergic reaction to a small mite, which burrows under the skin.
This mite is passed from person to person by close skin contact usually when
holding hands.
Healthy infected people will usually develop a rash, which is very itchy,
particularly at night. Sometimes elderly people do not develop this rash, so
therefore it is advisable to treat all of the residents at the same time to ensure
that the mite is controlled.
The treatment consists of an anti-scabies cream or lotion, which is applied all
over the body and is generally very effective. However, the itching may continue
for a few weeks following treatment.
If you or anyone in your family develops an unexplained itching or rash, please
seek advice from your doctor as soon as possible.
If you have any further questions please contact:
Version 1.1 June 2011
13
Information for Staff
Scabies is an allergic reaction to a small mite, which burrows under the skin.
The mite is transmitted during close and prolonged skin contact with someone
who is infected (e.g. holding hands).
Treatment is being coordinated by the home:
1.
All family contacts residing in the same house as the infected staff
member should be treated and any other close contacts thoroughly
checked for signs of scabies.
2.
If you are not infected you will still receive treatment but not your family.
3.
After treatment the rash will continue to itch for up to four weeks but
should gradually fade.
Your family doctor can prescribe cream to soothe the itching if severe.
4.
Since it can take up to six weeks from acquiring scabies to developing
symptoms, it is essential everyone is treated on the same day.
5.
The lotion or cream is applied all over the body:





Ensure nails are cut short
Pay particular attention to the areas between the fingers and toes
and under the nails
Reapply the lotion if you wash your hands
If hair is thin apply to head avoiding eyes
If hair is thick ensure you apply lotion/cream to hairline and all
around the ears and lobes.
6.
You will be advised if a second treatment is required.
7.
There is no need for any special treatment of clothing or bedding other
than washing on a hot washing cycle.
If you have any further questions please contact
Version 1.1 June 2011
14
WHAT IS SCABIES?
.
.
.... . .…
. ..
. ..
. .. ..
... …..
. . .... ..
. ….
.
.
.... . ... .
. ...... .......
Scabies is a very itchy skin rash, which is
an allergic response to a tiny mite smaller
than a pinhead.
The mite burrows
anywhere in the skin, mostly on the
hands and arms. The site of the rash may
not be the site of the mites.
Diagram 1
Scabies Rash
. .
.
. .
HOW IS IT CAUGHT?
WHO NEEDS TREATMENT?
The scabies mite can pass from person to
person when there is prolonged skin-toskin contact, approximately five to ten
minutes. It is unlikely to be caught by
brief contact such as shaking hands. It
can take up to two months after catching
the mites before itching begins, so mites
can pass on to someone else before the
rash appears.
 Everyone who has scabies
 Household family contacts
 Everyone who has had skin to skin
contact with a case for more than five
to ten minutes
 Doctors sometimes advise treatment
for suspected scabies, e.g. when no
burrows can be seen.
HOW DO YOU KNOW IF YOU
HAVE GOT SCABIES?
APPLYING THE LOTION
 Apply the lotion at night before going
to bed.
 Do not have a bath or shower just
before applying the lotion.
 Take off all your clothes including
jewellery.
 Apply lotion all over the body, from
the hairline to the toes. You may
need someone to help with the places
you cannot reach, e.g. centre of your
back.
You will have a very itchy rash, which is
worse at night. The rash usually only
appears in certain parts of the body
(diagram 1). Check with your doctor!
HOW CAN YOU GET
RID OF THEM?
Treatment is with a lotion or cream. Ask
your doctor or local chemist.
Version 1.1 June 2011
15
 Let the lotion dry before getting
dressed or it may rub off.
 Apply more lotion to any parts you
wash in the first 24 hours.
 If you need to wash your hands
often, use plastic gloves for dirty
work during the treatment period.
 A bath or shower can be taken the
day after treatment to remove any
traces of the lotion.
Pay special attention
to these areas when
you put on the lotion
or cream.
behind both ears
both armpits
underneath breasts
naval
between fingers and
under finger nails
groin and genital area
between the legs
back of knees
between all toes and under nails
soles of feet
HOW OFTEN DO YOU NEED TO
APPLY THE TREATMENT?
If the lotion has been applied correctly,
usually one treatment is enough to kill
the mites and their eggs.
For contacts of the person with scabies,
one treatment should be carried out at the
same time as that person or before further
physical contact with them.
WHAT IF YOU HAVE A SKIN
PROBLEM SUCH AS ECZEMA?
The lotions and cream are very gentle on
the skin. Only about one in a 1000 people
have irritation - usually minor, for up to a
day after using them.
CAN YOU CATCH IT AGAIN?
Yes. Once someone has the allergy, the
rash appears after a few days of
becoming re-infected.
WHAT ABOUT BABIES,
PREGNANT WOMEN AND
WOMEN WHO ARE
BREAST-FEEDING?
CAN YOU GO TO
WORK / SCHOOL?
If they require treatment, pregnant
women and those breast-feeding must
use malathion (Derbac-M).
You can return to work / school 24 hours
after starting the treatment. You will not
give scabies to anybody else.
Information leaflet on:
Scabies
For babies under six months, permethrin
(Lyclear Dermal Cream) should be used.
Itching can continue for up to four weeks
after treatment even if the treatment has
been successful. Do not allow yourself
to get too hot, as this will increase the
itching. Calamine lotion should help, but
if not ask you doctor or chemist for antiitch cream or tablets.
FURTHER INFORMATION
This leaflet gives general information. If
you require further details, please contact
your general practitioner or the Health
Protection Nurse.
WHAT SHOULD YOU DO ABOUT
LAUNDRY, CLOTHING ETC?
Kidderminster office: 01562 756 300
Normal washing of clothes and bedding
is sufficient. The mites die when they are
away from the body so it is unlikely that
they can spread this way.
Version 1.1 June 2011
HPA West Midlands West
16
May 2007
HPA West Midlands West
Elgar House
Green Street
Kidderminster
DY10 1JF
Tel: 01562 756300
Fax: 01562 756302
Email:
[email protected]
www.hpa.org.uk
Date:
Dear Doctor
RE: SCABIES OUTBREAK AT………………………………………………………………………….
Several clients at the above care home / day centre (Delete as appropriate) have been diagnosed as
having scabies. In an effort to bring this outbreak under control the Local Health Protection Unit
is co-ordinating simultaneous treatment for all clients, staff and their contacts.
We believe the following staff member(s)* /resident(s)* /contact(s)* (*Delete
registered with your practice (see attached list) (Home / day centre to provide lists)
as appropriate)
are
We would be grateful if you could prescribe the following to enable them to be treated:
* Derbac M lotion 200mls (one bottle / two bottles)
* Lyclear Dermal Cream 30g (one / two tubes)
*(HPU staff delete as appropriate)
An information pack advising them how and when to undertake treatment has been sent to the
home / day centre.
If you have any queries do not hesitate to contact the Health Protection Team on
01562 756300.
Thank you for your co-operation.
Yours sincerely
Health Protection Consultant / Practitioner

Similar documents