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Lice and Scabies Procedure
Management of Lice and Scabies
Version Number:
V1.2
Name of originator/author:
Infection Prevention and Control Team
Name of responsible committee:
Clinical Governance Committee
Name of executive lead:
Chief Nurse and Director of Quality Assurance
Date V1 issued:
Oct 2013
Last Reviewed:
October 2013
Next Review date:
October 2017
Scope:
Trust wide
MMHSCT Policy Code
CL88
Page 1 of 16
Document Control Sheet
Document Title / Ref:
Management of Lice and Scabies Procedure
Lead Executive
Director
Author and Contact
Number
Type of Document
Document Purpose
Director of Nursing and Therapies
Infection Prevention and Control Team
Guidance
Broad Category
Clinical
This policy relates to all Manchester Mental Health and Social Care Trust
(MMHSCT) staff. Its purpose is to provide guidance for staff and to identify
the expected standard for staff that has contact with service users to
reduce the risk of health care associated infections.
Scope
Trust Wide
Version number
1
Consultation
IPC Committee, Matrons, Ward Managers
Approving Committee
Clinical Governance
Approval Date
Oct 2013
Committee
Ratification
Lead Executive Approval
Date of Ratification
and Date
May 2014
V1 Valid from Date
October 2013
Current version is valid from approval date
Date of Last Review
October 2013
Date of Next Review
October 2017
Procedural Documents to be read in
conjunction with this document:
Training
There are Training
Financial
There are no Financial resource
Needs
requirements for this
Resource
impacts
Analysis
procedural document
Impact
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Impact
ANNT Training/Assessment
Document Change History
Changes to this document in different versions must be detailed below. Rationale for the change
should also be given
Version Number
/ Name of
procedural
document this
supersedes
Type of
Change i.e.
Review /
Legislation /
Claim /
Complaint
Date
Details of Change and approving group or Executive Lead (if done
outside of the formal revision process)
External references used in the creation of this document:
If these include monitoring duties upon the Trust for this policy the specific details should be
recorded on the Monitoring and Compliance Requirements sheet
Privacy Impact
N/a
Assessment submitted
Fraud Proofing
N/a
submitted
If not relevant to this procedural document give rationale:
No
No
Page 2 of 16
Policy authors are asked to consider each of the nine protected characteristics under the Equality
Act 2010. We expect you to demonstrate that throughout the policy process you have had regard to
the aims of the Equality Duty:
1. Eliminate unlawful discrimination, harassment and victimisation and any other conduct
prohibited by the Act;
2. Advance equality of opportunity between people who share a protected characteristic and
people who do not share it; and
3. Foster good relations between people who share a protected characteristic and people who do
not share it.
Please provide a brief account of how you have done this, further work to be completed and any
support you have had in considering the aims and working in compliance with the Equality Duty.
If you are unclear on how to do this or would like further advice and support then you may contact
[email protected].
It is the responsibility of the approving group to ensure this statement reflects the Trusts objectives
and position with compliance as set out within the NHS Equality Delivery System
There are no particular issues with Equality and Diversity in relation to this procedure, all staff and
patients are equally considered.
In line with the Trust values we may publish this
document on our External Website. Is there any
reason you would prefer this is not done?
None
It is the Authors responsibility to ensure all procedural documents comply with the Trust
values
If you are unclear on any of the requirements in the document control sheet then please email
[email protected] before proceeding
Page 3 of 16
Monitoring and Compliance Requirements Sheet
For audit, Registration and NHSLA purposes all procedural documents must have monitoring requirements or key performance indicators set by the authors,
Committees or Lead Directors. This allows the Trust to routinely monitor the effectiveness and impact of their procedural documents on a regular basis.
Procedural Document Title:
Management of Lice and Scabies Procedure
Does this procedural document offer
Yes
Primarily
support or evidence for the Trusts
Outcome 8 Cleanliness & Infection Control
registered activities and outcomes?
Is this an NHSLA
Document?
No
Which Standard does this relate
to?
3 - Competent & Capable
Workforce
Additional
Not Applicable
Additional
Choose an item.
Which
Criterion
Not Applicable
Choose an item.
Choose an item.
If other Monitoring requirements are necessary i.e. Health & Safety Act and you should include them here and record them in the External References section
Specify where the
The Health Act 2008 Code of practice on the prevention and control of
Additional Details i.e.
requirement
Section number, Code of
infections and related guidance
originates
Practice
Minimum Requirement / Standard /
Process for
Responsible Individual / Group
Frequency
Responsible Group for
Comments
Indicator to be monitored & Section of
monitoring
of
review of results / action plan
document it appears
Monitoring
approval / implementation
When patient is identified with Head
IPC Team
Yearly
IPC Committee
Lice/Scabies the IPC Team will monitor
adherence to guidance and record in Datix
IPC Interventions
NB: If you have selected audit you should complete the required audit registration form and standards document and submit these with your expected
timescales for completing the audit to [email protected] as soon as possible and no later than 4 weeks prior to the audit commencing.
The Group / Committee should also ensure the monitoring work is added to their yearly schedule of monitoring and action logs as appropriate.
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Contents Page
Section
1
2
3
4
5
6
7
8
9
10
11
12
Appx 1
Appx 2
Title
Introduction
Purpose
Scope of Practice
Duties and Responsibilities
Background
5.1
Classification of Lice
Head Lice
6.1
Nits
6.2
Nymphs
6.3
Adults
6.4
Clinical Features
6.5
Transmission
6.6
Diagnosis
6.7
Treatment of Head Lice
Body Lice
7.1
Clinical Features
7.2
Transmission
7.3
Diagnosis
7.4
Treatment of Body Lice
Crab (Pubic) Lice
8.1
Clinical Features
8.2
Transmission
8.3
Diagnosis
8.4
Treatment of Crab Lice
Scabies
9.1
Infection Control Precautions for Classical Scabies
9.2
Isolation
9.3
Personal Protective Equipment (PPE)
9.4
Linen
9.5
Hand Hygiene
9.6
Environmental/Domestic Cleaning
9.7
Treatment
Staff Contact
Norwegian Scabies
11.1
Infection Control Precautions for Norwegian Scabies
11.2
Isolation
11.3
Personal Protective Equipment (PPE)
11.4
Linen
11.5
Hand Hygiene
11.6
Environmental/Domestic Cleaning
11.7
Contact Tracing
11.8
Treatment
11.9
Outbreak Management
References
Crusted Scabies Patient Contact Tracing Form
Crusted Scabies Staff Contact Tracing Form
Page
Number
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Management of Lice and Scabies Procedure
1
Introduction
Lice are wingless insects that need human blood to survive.
Scabies is an inflammatory disease of the skin caused by the Sarcoptes scabiei. It is
associated with poor personal hygiene and overcrowding. It is more prevalent in
children, young adults, in urban areas and in winter. Outbreaks have occurred in
hospitals, nursing and residential homes where both patients and staff have been
affected (Hawker 2005).
2
Purpose
This document provides a framework for all members of staff within the trust. It has
been developed to provide information on how to care for and manage a patient with
Lice and/or Scabies and:
•
•
•
3
To outline the signs and symptoms of a patient with Lice and/or Scabies
To highlight the risks of cross infection from Lice and/or Scabies and identify
appropriate preventative measures to reduce the risk
Provide staff with information on who to contact for advice when caring for
patients with Lice and/or Scabies or staff that may have Lice or Scabies.
Scope of Practice
This policy applies to the care of any patient or member of staff with, or suspected of
having Scabies and/or Lice on Manchester Mental Health and Social Care premises
and to provide advice to community staff dealing with patients at home and in
community Trust premises.
4
Duties and Responsibilities
The Role and Responsibilities of named individual within the organisation, with
regard to their duty to comply with this policy and to protect patients from the risks of
acquiring a Healthcare Associated Infection are identified in the overarching Infection
Prevention Policy.
5
Background
There are about 500 different species of lice but only three of these use humans as
their host, and each lives on a specific part of the body.
5.1
Classification of Lice
•
Pediculus humanus capitis (head louse),
Page 6 of 16
6
•
Pediculus humanus corporis (body louse, clothes louse)
•
Pthirus pubis ("crab”)
Head Lice
There are three forms of head lice:
6.1
Nits are head lice eggs. The oval, yellowy white eggs are hard to see and may be
confused with dandruff. They attach themselves to the hair shaft and take about a
week to hatch. The eggs remain after hatching and many nits are empty egg cases.
6.2
Nymphs hatch from the nits. The baby lice look like the adults, but are smaller. They
take about 7 days to mature to adults and feed on blood to survive.
6.3
Adults are about the size of a sesame seed. They have six legs and are tan to
greyish-white. The legs have hook-like claws to hold onto the hair with. Adults can
live up to 30 days and feed on blood.
6.4
Clinical Features
•
Itchy scalp - this is due to an allergic reaction. Not always present, particularly
in adults.
•
Louse droppings may fall onto the pillow and be visible as black specs.
•
Living lice are visible on the hair.
•
Nits - the egg cases may be present but that does not necessarily imply an
active infection.
•
Egg cases will stick to hair even when you have got rid of the lice, and
eventually grow out.
6.5
Transmission
Lice can walk from one head to another only when heads have sustained, immediate,
contact for a minute or so. They cannot swim, jump, hop or fly.
6.6
Diagnosis
Misdiagnosis of head lice infestation is common. The diagnosis of head lice
infestation is best made by finding a live nymph or adult louse on the scalp or hair of
a person.
Because adult and nymph lice are very small, move quickly, and avoid light, they
may be difficult to find. Use of a fine-toothed louse comb may facilitate identification
of live lice.
If crawling lice are not seen, finding nits attached firmly within ¼ inch of the base of
hair shafts suggests, but does not confirm, the person is infested. Nits frequently are
seen on hair behind the ears and near the back of the neck. Nits that are attached
more than ¼ inch from the base of the hair shaft are almost always non-viable
(hatched or dead).
Page 7 of 16
Head lice and nits can be visible with the naked eye, although use of a magnifying
lens may be necessary to find crawling lice or to identify a developing nymph inside a
viable nit. Nits are often confused with other particles found in hair such as dandruff,
hair spray droplets, and dirt particles.
If no nymphs or adults are seen, and the only nits found are more than ¼ inch from
the scalp, then the infestation is probably old and no longer active -- and does not
need to be treated
6.7
7.
Treatment of Head Lice
•
Only active infections require treatment.
•
Treat affected individuals with insecticide as prescribed. Follow instructions
carefully. Alcohol based lotions are normally preferred. Aqueous based
lotions must be used for asthmatics and persons with eczema or dry skin
conditions.
•
Repeat treatment after 7 days. Do not use the lotion more than once a week
and for not more than 3 consecutive weeks.
•
'Wet-combing' can be carried out to assist with removal of the lice. (This
involves washing the hair, covering the hair with large amounts of conditioner,
combing the hair through with the ordinary comb, then thoroughly and
precisely with a detector comb, wiping the comb between each combing
action and removing any lice present). Compliance is imperative if insecticide
is not used, and must be repeated for a minimum of 2-3 times a week for 2-3
weeks to be effective.
•
Treatment should be performed on all family members/contacts who have an
active infection at the same time.
•
Isolation precautions are not necessary but may help maintain privacy during
treatment.
Body Lice
Body lice are parasitic insects that live on clothing and bedding used by infested
persons.
Body lice frequently lay their eggs on or near the seams of clothing. Body lice must
feed on blood and usually only move to the skin to feed.
Body lice infestations can spread rapidly under crowded living conditions where
hygiene is poor
Body lice generally are found on clothing and bedding used by infested people.
Sometimes body lice are be seen on the body when they feed.
Body lice eggs usually are seen in the seams of clothing or on bedding. Occasionally
eggs are attached to body hair.
Page 8 of 16
7.1
Clinical Features
Bite marks usually occur opposite seams such as under collar or waistband and are
extremely itchy. Usually result in characteristic long, linear scratch marks on the
torso.
If the host is sensitised to louse faeces, this may cause a generalised rash and
sneezing may sometimes result.
7.2
Transmission
This occurs in overcrowded conditions by contact with infested clothing. To survive,
body lice depend on the same clothes being worn for prolonged periods, washed in
cool water and then re-worn immediately.
7.3
Diagnosis
Body lice can be seen by the human eye on the body and clothes.
7.4
Treatment of Body Lice
All clothing and bedding should be removed and washed in hot water (60°C or more)
and be changed at least once a week, fifteen minutes in a hot tumble dryer is
sufficient to destroy both lice and eggs.
No treatments of the skin or isolation precautions are necessary.
8
Crab(Pubic)Lice
Crab (Pubic) Lice are far more common than head lice. They live on the coarse body
hair, particularly pubic and axillary hair, but also on chest and facial hair and the
eyelashes.
They are much broader and flatter than head or body lice.
8.1
Clinical Features
It can take 4-6 weeks for the host to react to the bite of the lice during which time
they usually remain undetected.
Once sensitised, itching around the anus and vagina is severe.
8.2
Transmission
Crab lice are transmitted by close physical contact and sexual contact. They may be
passed easily where people are living in crowded conditions but cannot be
transmitted on inanimate objects except perhaps on shared towels.
8.3
Diagnosis
Crab lice can be seen by the human eye on coarse body hair.
8.4
Treatment of Crab Lice
Treat the affected individuals with an aqueous based insecticide. Treat all hair except
for the hair.
Page 9 of 16
All bedding and clothing should be removed and washed in hot water (60oC or
more).
Isolation precautions are not necessary, but may help maintain privacy during
treatment.
9
Scabies
Scabies (Sarcoptes scabiei) is a contagious skin infestation caused by a parasite.
The scabies mite can cause Classical (typical) or Norwegian (crusted) scabies.
Norwegian Scabies may require a diagnosis by a dermatologist, as patient
management is different for each condition. In-patients will require medical
assessment.
Scabies is transmitted by skin to skin contact, most likely to occur when immature
mites crawl from one person to another. This typically occurs within families, sexual
partners and between patients and care givers.
Symptoms often take 2-4 weeks to develop after initial exposure when allergy
develops to mite saliva and faeces and an itchy symmetrical rash appears. The
rash comprises of small red papules and can be seen anywhere on the body. If the
person has had scabies, before the rash may appear within a few days after of reexposure.
The elderly, immunocompromised patients, infants and young children at
particularly at risk and can develop the rash on the face neck, scalp and ears
(Hawker 2005).
The Scabies mites burrow into the epidermis, where the females lay eggs that
hatch between 50 to 72 hours. The larvae mature and the females lay new eggs.
Once away from the human body, mites do not survive more than 48-72 hours.
The main symptom of scabies in healthy individuals is itching, particularly at
night. Burrows may be visible as a line about 5cm in length. They can occur
anywhere on the body but are often more easily identified on the wrists and
hands, particularly within the finger webs.
Positive diagnosis is made by finding and identifying the mite or its eggs. This can be
done by skin scraping between the papular lesions. Patients will require medical
assessment and possible referral to a Dermatology Department for a formal
diagnosis.
If mites are present they can be identified under a microscope.
Page 10 of 16
Scabies Mite (viewed under a microscope). Their actual size 0.3mm long.
9.1
Infection Control Precautions for Classical Scabies
Prevention of scabies is dependent on early diagnosis and prompt effective
treatment.
9.2
Isolation
A patient with classical scabies may or may not need isolation, please discuss
with the Infection Prevention and Control Team (IPCT). However, where possible,
patients presenting with dry, flaking skin should be isolated until a positive diagnosis
is established.
9.3
Personal Protective Equipment (PPE)
Gloves and aprons must be worn for close contact with the patient and placed in
clinical waste after use.
9.4
Linen
Patients own clothing and hospital bed linen must be placed in red alginate bags.
(Refer to Laundry Procedure)
9.5
Hand Hygiene
Hands must be washed with soap and water once PPE is removed. Staff paying
strict attention to hand hygiene after contact with an individual will reduce the risk
of transmission. (Refer to Hand Hygiene Policy)
9.6
Environmental/Domestic Cleaning
Routine daily cleaning of the patients room/bed space is sufficient. Vacuuming of
fabric chairs and other soft furnishings will minimise environmental
contamination.
9.7
Treatment
A suitable parasitical preparation must be prescribed by the physician or
dermatologist. Staff will need to contact Pharmacy for up to date guidance on
treatment.
Treatment must be applied following manufacturer’s guidance and instructions. It is
important that compliance with the treatment is thorough.
Secondary bacterial infection may occur if left untreated or from constant
scratching.
Page 11 of 16
•
•
•
•
•
•
•
•
•
10
Ensure the patient’s skin is clean, dry and cool before application. Individuals do not
need to have a hot bath before treatment. All persons having treatment should do so
at the same time so as to not re-infect one another.
For adults and children under 2 years old; apply treatment to cover the whole body
from the neckline down including the genital area. Usually the best time to do this is
last thing at night before bed.
Children under 2 years old and the elderly should be treated with a thin film of the
treatment applied to the scalp, face and ears. Care must be taken to avoid the vicinity
of the mouth where it would be licked off, and the areas close to the eyes.
Nails should be trimmed and medication applied with cotton wool buds to the nails
and nail bed. If hands are subsequently washed re-apply treatment to hands
Remove medication by washing thoroughly with soap and water between 12 and 24
hours after application.
Repeat treatment may be considered after one week on patients with clinical
infection (not contacts) Bedding and all clothing worn should be changed an
laundered as normal at the end of treatment
Patients should be advised that itching will persist for a few weeks after treatment.
Refer to medics if problem persists and treatment is required to alleviate irritation.
Family contacts of infested patients should consult their GP for treatment even if they
are asymptomatic; this also applies to patients from nursing/residential homes or on
in-patient units, where the ward manager should be informed immediately.
Pregnant women and parents of young children should discuss treatment options
with their doctor or pharmacist.
Staff Contact
Staff can liaise with IPC Team or their General Practitioner for advice if they
develop symptoms or are concerned. We would not treat staff if there was only
one identified case on the ward.
If there has been contact with staff prior to a patient’s diagnosis, consideration
must be given to treating staff. This would be under guidance from IPC Team in
conjunction with the Microbiologist.
If a member of staff develops scabies, treatment is recommended for his or her
close household contacts and they may return to work once treatment has been
completed (Hawker 2005).
11
Norwegian Scabies (Crusted)
Norwegian scabies is caused by the same mite that causes classical scabies, but
usually occurs when the infested person is immunologically or neurologically
compromised and in the elderly.
In this form many more mites are present and the skin presents as thickened
with crusts, often mistaken for Psoriasis. Sometimes the presentation may be
atypical, with no crusted lesions or itching.
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Patients develop widespread grey/brown scales or crusted areas. Skin scales
and crusts are heavily contaminated with mites and in this form the infestation is
highly contagious.
11.1
Infection Control Precautions for Norwegian Scabies
Prevention of scabies is dependent on early diagnosis and prompt effective
treatment.
11.2
Isolation
A patient with Norwegian scabies must be isolated until treatment has been
completed as transmission can also occur via skin scales on bedding, clothes
and soft furnishings and is more infectious than classical scabies.
11.3
Personal Protective Equipment (PPE)
Gloves and aprons must be worn for patient contact and placed in clinical waste
after use.
11.4
Linen
Patients own clothing and hospital bed linen must be placed in red alginate bags
and outer red bag and treated as infectious linen. After treatment the patient’s
bed linen must be changed. (Refer to Laundry Guidelines)
11.5
Hand Hygiene
Hands must be washed with soap and water once PPE is removed. Staff paying
strict attention to hand hygiene after contact with an individual will reduce the risk
of transmission. (Refer to Hand Hygiene Procedure)
11.6
Environmental/Domestic Cleaning
Routine daily cleaning of the patients room/bed space must be undertaken.
Vacuuming of fabric chairs and other soft furnishings will minimise environmental
contamination. The curtains in the side room must be changed, once treatment is
commenced.
11.7
Contact Tracing
A contact list of both patients and staff must be completed. This will include all
those who have been in contact with the affected patient e.g. patients in the
same bay and staff who have been nursing the patient.
This list must be given to Occupational health and The Infection Prevention and
Control Team (IPCT).
In the event of an outbreak of scabies, the IPCT will advise on the planned coordinated management of the situation.
11.8
Treatment
Treatment is as for classical scabies; however in the case of patients with crusted
scabies it may be necessary to increase the number and frequency of
Page 13 of 16
applications of treatments in order to eliminate all the mites. Infection control
precautions must continue until the treatment period has been completed.
11.9
Outbreak Management
If a diagnosis is made in more than one person the IPC Team and they will notify
Occupational Health teams if they need to be informed.
Treatment must be agreed with the medics and dermatologist and all close
contacts including patients and staff are advised to have treatment.
All close contacts must be informed. Treatment will be coordinated by the IPC
Team in conjunction with Microbiology, Occupational Health Department for staff and
medics and IPC Team for patients
Everyone identified as a close contact should receive treatment at the same time to
prevent re- infestation.
During the ensuing 6 weeks, observe for any further presence of scabies so that and
possible cases can be dealt with promptly.
The Infection Prevention and Control Team will inform the Public Health England
of the outbreak.
12
References
Head lice – Information Leaflet HPA 2009. The Prevention and Treatment of Head
lice. Department of Health, 2007
Diaz JH, Lice (pediculosis) Madell GG. Bennett JE, Dolin R eds. Principles and
Practice of Infectious Diseases 7th edition (2009)
Pubic lice, Clinical Knowledge Summaries, NHS Evidence 2007.
Burgess. I. (2003) Understanding scabies. Nursing Times Infection Control
Supplement Vol. 99 NO 7.
nd
Hawker J et al (2005) Communicable Disease Control Handbook . (2 Ed).
Blackwell publishing. Oxford.
Johnston G., Sladden M. (2005). Scabies: Diagnosis and Treatment British Medical
Journal. 331,619-622
nd
Wilson, J. (2001) Infection Control In Practice. (2 Ed). Baillier Tindall,
Edinburgh.UK.
Page 14 of 16
Appendix 1
Crusted Scabies Patient Contact Tracing
Name of Index Case
…………………………....................................................….
Date of confirmed diagnosis……………….......................................................…………..
Ward
…………………………..................................……………….
Please record names of patients that have been in contact with the index case. e.g. in
the same bay.
Name/DofB
Hosp Number
Date of
Admission
Date of
Discharge
GP Name & Tel No
Page 15 of 16
Appendix 2
Crusted Scabies Staff Contact Tracing
Name of Index Case
…………………………....................................................….
Date of confirmed diagnosis……………….......................................................…………..
.......................................... ..................................................
Ward
Name
DofB
Date of
Exposure
Name
DofB
Date of
Exposure
Page 16 of 16