P R A C T I C E FORUM

M a n a g e m e n t of an o u t b r e a k of Norwegian scabies Jean Clark, RN, CIC Douglas L. Friesen, MD, FACS Willis A. Williams, MD, FAAFP, FAFP Halstead, Kansas

An outbreak of Norwegian scabies in a 170-bed acute care hospital was controlled through an organized plan for delivering treatment to those affected: four patients, 50 staff members, and 14 family members of staff members. Health departments in two counties were notified and found four additional cases in the long-term care facility at which the index patient lived. Contact isolation was used for the index patient and any other patients with nosocomial scabies. Staff members infested with Sarcoptes scabiei were released from work until they had been treated with lindane. Staff members who had been in contact with infested persons and staff members' families were treated prophylacticallywith lindane. This aggressive treatment plan resulted in rapid resolution of the outbreak. (AJIC AMJ INFECTCONTROL1992;20:217-2)

Our acute care hospital was faced with the challenge of an outbreak of Norwegian scabies in April 1991. Norwegian or crusted scabies occurs in i m m u n o c o m p r o m i s e d patients and often does not have the usual symptoms of scabies. Patients m a y have thick, gray, hyperkeratotic crusts or scales on the palms, between fingers, and on the knees, elbows, a n d soles.1 Patients m a y also have a fine rash. S y m p t o m s typically associated with scabies, such as burrows, vesicles, and severe itching, can be m i n i m a l or absent in Norwegian scabies. In other reported outbreaks of Norwegian scabies, symptoms were often attributed to other causes until secondary cases occurred. The parasite, Sarcoptes scabiei, is the same mite responsible for typical scabies. Because of diminished i m m u n e response, however, these parasites can n u m b e r in the millions in patients with Norwegian scabies, c o m p a r e d with the small n u m b e r of parasites seen in scabies occurring in a healthy person. 2 Norwegian crusted or scabies is thus highly contagious. This paper describes an outbreak of Norwegian scabies and gives recommendations for rapid resolution.

From Halstead Hospital and the Hertzler Clinic, Halstead, Kansas. Reprint requests: Jean Clark, RN, CIC, Halstead Hospital, 328 Poplar, Halstead, KS 67056.

17/49/37600

CASES IN OUTBREAK

The index case was that of a patient with an i m m u n o c o m p r o m i s e d state unrelated to HIV infection. This patient lived in a long-term care facility housing m a n y mentally retarded persons. The index patient was admitted to the intensive care unit and later transferred to the inpatient psychiatric ward, where he had extremely limited contact with other patients because of his debilitated medical condition. The patient had a fine rash 3 weeks after admission while residing on the psychiatric unit. He was later transferred to a medical unit, where the rash became more generalized and crusting was noted. The diagnosis of Norwegian scabies was made a n d control measures were instituted immediately. Sixty-seven cases of nosocomial scabies were identified: 49 in hospital staff members, 14 in family m e m b e r s of staffmembers, 1 in an ancillary staff member, a n d 3 in patients. The hospital staff members infected were those with frequent contact providing direct patient care or services (nurses, n u r s i n g assistants, and respiratory therapists). Other hospital staff members with scabies were in social services a n d housekeeping departments (Fig. 1). Family members infested were spouses or children of staff members who h a d significant contact with the index patient, although two of the staff members who had infected family meml~ers had more limited contact (Fig. 2). 217

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Clark, Friesen, and Williams Psychlatr'm Unit staff 36.00%

Ancillary Staff 2.00% -'-LRespiratory Therapy Staff 6.00%

L

Medical Unit Staff

ICCU Staff

52.00%

4.0O% Fig. 1. Outbreak pattern among staff members.

Family of Psychiatric Unit Staff 36.00%

Family of Ancillary Staff 7.00%

Family of Medical Unit Staff 57.00% Fig. 2. Outbreak pattern among families of staff members.

The three hospital patients involved in the outbreak had rooms near that of the index case patient but had no actual contact. We identified no transmission to medical staff members, laundry workers, or other staff members. CONTROL MEASURES

Medical staff, hospital staff, and ancillary service personnel were immediately notified of the outbreak. Outside consultation with an infectious disease specialist confirmed our treatment plan for staff and patients. Although scabies is not a reportable disease, the local health department was apprised of the outbreak. No additional cases were identified in the community by the health department. The facility at which the index patient lived, which was located in another county, was also notified. Their local health department as-

sisted in their treatment of four facility residents with scabies. The index patient was treated with lindane, followed by a course of keratolytic agents to loosen the crusts. His care included gentle removal of loose scales and containment of shed scales. His skin scrapings contained viable S. scabiei under the hyperkeratotic crusts 6 days after initial treatment. The patient was scheduled for application of permethrin 1 week after initial treatment. Permethrin was chosen because of the patient's weakened condition and consequent concern about heightened susceptibility to the toxic effects of repeated lindane. The patient died of unrelated pulmonary complications before this projected treatment was completed. Hospital staff members, their family members, and patients with lesions and itching suggesting

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scabies were immediately examined. Employees with symptoms were restricted from w o r k until lindane had been applied. Contact isolation with disposable gowns was added for 24 hours after treatment of the three patients with nosocomial scabies. The index patient remained in contact isolation; precautions were scheduled to be stopped only when repeated skin scrapings showed no evidence of scabies. Staff members without symptoms contacting the index patient and asymptomatic family members of infected staff members were treated prophylactically with one application of lindane. American Public Health Association guidelines2 for dealing with outbreaks were used in deciding to treat contacts prophylactically. The long incubation period of persons without previous exposure (2 to 6 weeks) 2also entered into this decision because our goal was the prevention of new cases of scabies. Several staff members had no symptoms on initial questioning and examination but were assumed to have had early undetected infection when characteristic scabies lesions developed after lindane application. Because 5% of cases may have treatment failures with a single application, 3 we elected to reapply lindane 1 week after initial treatment for staff and family members with scabies. This option was chosen because of the significant number of employees involved and our wish to prevent reintroduction of scabies. There were no reported toxic effects of lindane. Several staff members requested additional doses of lindane because of continued itching typical of resolving scabies lesions. Additional lindane doses were not needed, however, and these staff requests were therefore handled with information and repeated examination. METHODS

All staff members who had worked on the medical unit during the index patient's stay were questioned regarding contact with the index patient. Staff members with lesions and itching were immediately released from work and examined by employee health. Psychiatric unit and intensive care unit staff members were similarly notified and questioned. Managers of the affected units assisted with initial questioning and the development of a contact list. Ancillary department and medical staff members were notified by memorandum and those with known contact were also questioned and examined. Staff members were

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considered to be infested only if they had skin lesions and itching. Skin scrapings were used when lesions were not typical or if there was question of infestation. Informationand treatment were offered on all shifts to encourage compliance and to ensure that all contacts were identified. Physicians were encouraged to maintain a high index of suspicion for scabies in their assessment of current and recent patients on the affected units. RESULTS

This aggressive treatment was effective in preventing new cases within 2 weeks of the outbreak. During the second week, the last two employees to be infested had symptoms: one employee who believed that contact with the index patient was not significant and was therefore not treated, and one who had considerable contact but did not complete prophylactic treatment. DISCUSSION

We believe that the significant number of staff members infested was a result of the delay in diagnosis of scabies because of the atypical symptoms of Norwegian scabies. Other factors contributing to the number of staff members infested were the index patient's severe illness and debilitated condition, which resulted in contact with most staff members in the affected units. Staff members reported iio previous experience with scabies, so the extended incubation period (2 to 6 weeks)2 delayed identification of the outbreak and gave added time for transmission. We believe that the low ratio of staff to patient transmission in this outbreak, compared with that in another reported outbreak (20 patients, 6 staff members, and 9 family members), 3 reflects compliance with universal precautions and good handwashing technique. Scabies lesions in staff members were typically seen above the glove line. One of the challenges posed by this outbreak was maintaining normal hospital operations with a significant portion of the work force temporarily excluded. This gave added incentive for rapid and complete resolution of the outbreak. In any outbreak, liability issues also dictate rapid resolution. There has been no indication of litigation as a result of this outbreak. Infection control personnel and the employee health physician believe that we had excellent cooperation from the staff and family members involved in this outbreak. Employee questions and

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concerns were a priority for both the employee health physician and infection control staff. One spouse summarized a commonly expressed feeling when he asked his wife, "Why do you put up with this kind of risk?" Despite repeated education of our health care workers, several staff members stated that this outbreak was the first time they had faced the reality of the occupational risk of illness in health care professions. Staff members' distress was increased because their family members were affected by either preventive treatment or infestation. Management of Norwegian or crusted Scabies outbreaks will continue to be a challenge for infection control and employee health personnel. The population of immunocompromised patients is increasing because of both induced hypoimmune states (oncology and posttransplant patients) and disease processes such as AIDS that result in diminished immune response. Several similar outbreaks associated with patients with AIDS have been reported in health care facili-

ties.2, 4 Because of the increases in these populations and the atypical symptoms o f Norwegian scabies, the level of suspicion for scabies should be high in the case of any immunocompromised patient with a skin rash, particularly if the rash is associated with crusting. Earliest possible diagnosis of Norwegian scabies lessens the potential for outbreaks. Once a scabies outbreak is suspected, rapid, aggressive therapy is essential for its control. References I. Habif T. Clinical dermatology. St. Louis: C V Mosby, 1990: 390-1. 2. Sirera G. Hospital outbreak of scabies stemming from two AIDS patients with Norwegian scabies [Letter]. Lancet 1990;335:1227. 3. Benenson A. Control of communicable diseases in man. 14th ed. Washington: Arncrican Public Health Association,

1985:341-3. 4. Dillon S. An HIV-infectedpatient with an extraordinary rash. Hosp Pract 1989;3:199-200.

Practice Forum articles should address infection prevention and control practices and related applications of epidemiology. Items should be limited to two to five typed double-spaced pages. Please send items to the Editor, Mary Castle White, RN, MPH, PhD, 155 Marston Ave., San Francisco, CA 94112.

Management of an outbreak of Norwegian scabies.

An outbreak of Norwegian scabies in a 170-bed acute care hospital was controlled through an organized plan for delivering treatment to those affected:...
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