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Lead Executive Click here to enter text. 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 Click here to enter text. 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. Page 4 of 16 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 6 6 6 6 6 6 7 7 7 7 7 7 7 8 8 9 9 9 9 9 9 9 9 9 10 11 11 11 11 11 11 11 12 12 13 13 13 13 13 13 13 13 14 14 15 16 Page 5 of 16 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. Page 12 of 16 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