Clinical Parasitic Infestations, SOP Document Control Summary Replacement. Status: Replacing: Policy for the Management of Parasitic Infestations Version: V 1.0 Date: August 2015 Author/Owner: Judy Carr Approved by: Policy and Procedures Committee Date: 15/10/2015 Ratified: Policy and Procedures Committee Date: 15/10/2015 Related Trust Strategy and/or Strategic Aims Provide high quality services, built on best known practice and evaluated through service user and carer feedback and clear process and outcome measures Implementation Date: September 2015 Review Date: September 2018 Key Words: Associated Policy or Standard Operating Procedures Lice, Scabies, Threadworm Hand decontamination SOP Standard precautions and personal equipment SOP Contents 1. Introduction... 2 2. Purpose... 2 3. Scope... 2 4. Related Policies... 2 5. Scabies... 2 6. Lice... 3 6.1 Head Lice... 4 6.2 Body Lice... 4
6.3 Pubic Lice... 5 7. Threadworms... 5 8. Process for Monitoring Compliance and Effectiveness... 6 9. References... 6 Appendix 1... 7 Protocol for Suspected Cases of Scabies...7 Application of Treatment... 9 Further Information.. 10 Change Control Amendment History Version Dates Amendments 1. Introduction Parasites are organisms that rely on a host to survive. Those found on the skin include scabies and lice, those found in the digestive tract include threadworms. 2. Purpose The aim of this Standard operating procedure (SOP) is to provide recommendations on the management of Parasitic Infestations 3. Scope This document applies to all employees of the South Staffordshire and Shropshire Foundation Trust SSSFT (SSSFT) and all those visiting SSSFT premises such as contractors, agency/bank/locum staff, students and volunteers. 4. Related Policies This SOP should be read in conjunction with the following infection prevention and control SOPs, and related guidance Hand decontamination SOP Standard precautions and personal equipment SOP 5. Scabies Scabies rash is a reaction to the excreta and salvia of the small mite Saracoptes Scabiei (0.3 0.4mm) which burrows into the skin. The burrow may be visible as a line about 5 mm length. These mites burrow down to the deeper layers of the skin where the females lay eggs, which hatch in 50 to 72 hours. The larvae make new burrows, mature and the females Page 2 of 11
lay new eggs. This process takes around 10 to 17 days and the mites live for approximately 30 to 60 days. At all stages the mites produce faecal pellets, which are glued down to the tunnel floor. An allergen seeps from these faecal pellets into the deeper parts of the body and into the blood system and from there it spreads all over the body. Because of this systemic involvement, the sites of the allergic reaction (i.e. rash) do not generally correspond with the sites where the mites may be found. Burrows may occur anywhere but are mainly on the hands and arms, particularly finger Webs. Other areas which may be affected are inner wrists, elbow creases, axillae, around the umbilicus, the nipples in adult females and genitalia in men. Within 2-6 weeks the host becomes sensitised to the mites and its products and a wide eczematous rash is produced. A variety of itching sensations follows, giving way to severe irritation, often worse at night. Symptoms A widespread itchy rash on the body exacerbated when warm, i.e. at night or following a bath which develops over a long incubation period of 2-6 weeks after the initial exposure. The rash rarely develops on the head unless the patient is immunocompromised. Spread Spread is via prolonged continuous skin to skin contact, usually sexual contact or holding/supporting patients. Mites cannot survive away from the body therefore bedding and clothing is not a source of infection Diagnosis Close examination of the skin may demonstrate a characteristic burrow, However scabies is notoriously difficult to diagnose, and therefore patients must be referred to the dermatologist. Staff must seek advice from Occupational Health Service Infection Control Measures The Infection Prevention & Control Team must be informed of suspected cases. Skin to skin contact must be avoided until diagnosis is confirmed by the dermatologist and treatment with a recommended scabicidal preparation (See Trust Formulary) has been completed; this usually takes 8-24 hours dependent on the chosen preparation (refer to the manufacturer s instructions). It is important to leave the application in place for the correct time, and if washing occurs before the full time, then it should be reapplied. Application before going to bed may help achieve this. A repeat treatment should always be applied 7 days later, and the quantity prescribed or supplied initially should cover both treatments. Itching can continue for some weeks after successful treatment. Relief may be found if calamine lotion is applied. Anyone who has prolonged skin to skin contact with the confirmed case must also be treated at the same time in order to prevent re-infection. In the event of two or more linked cases confirmed by the Medical Team, the Infection Prevention & Control Team must be informed in order that control measures may be implemented (See Appendix 1). 6. Lice The most common species is the head louse Pediculus humanus capitis. Two other lice are the body louse, Pediculus humanus corporis and the pubic louse, Pthiris pubis. Page 3 of 11
6.1 Head Lice The head louse is a small wingless parasite that lives on the hair near the scalp. Infection is widespread in the population most commonly occurring in children. Symptoms Itching is common and the resulting scratching may give rise to secondary infection. Spread Spread is via prolonged head to head contact. Lice found in the environment are not viable and therefore not a source of infection. Diagnosis Female head lice lay approximately 8 eggs a day. These become attached to the hair shaft, hatching around 10 days later. The egg cases or nits remain on the hair and are easier to detect than the lice as white specs which cannot be removed by ordinary combing. The lice mature one week after hatching and live for approximately 30 days, they are difficult to detect as they hide when the hair is parted and develop the same colour tone as the host. Infection Control Measures Avoid head to head contact until diagnosis and treatment is completed. Once confirmed treat the patient with headlice preparation (see Trust Formulary) and ensure close contacts are informed. Lotions are the treatment of choice, but alcohol preparations are not recommended for very young or people with asthma or eczema (use aqueous lotions). The treatment should be repeated after 7 days. 6.2 Body Lice Are rarer and more likely to be seen in patients with poor personal hygiene Symptoms Early signs are a red itchy rash, with skin becoming excoriated with secondary infection as the infection persists. Lice can be found in clothing. Spread Spread is through direct contact with the person and shared clothing. Diagnosis Presence of lice on visible inspection. Infection Control Measures Contact precautions should be taken with the patient until treatment with a recommended preparation is completed; aqueous lotions of malathion or permethrin are recommended and should be applied to all surfaces of the body including the scalp, neck, face and ears (refer to manufacturer s information). Treatment should be Page 4 of 11
repeated after 7 days. Linen should be treated as infected. Patient s clothing should be treated as infected or dry cleaned or tumble dried on hot cycle to destroy eggs and lice, paying particular attention to seams where mites can survive. 6.3 Pubic Lice Are found in pubic hair but can be found in hair elsewhere on the body if left untreated. Symptoms Intense itching in the genital region and secondary infection from scratching. Spread Most frequently transmitted through sexual contact. Diagnosis Both eggs and lice may be seen on visible inspection Infection Control Measures Contact precautions with the patient until treated with a recommended preparation; aqueous lotions of malathion or permethrin are recommended and should be applied to all surfaces of the body including the scalp, neck, face and ears (refer to manufacturer s information). Treatment should be repeated after 7 days.. 7. Threadworms The only common helminth infection in the UK is caused by threadworms or pinworms, i.e. Enterobus vermicularis. Threadworm infection is very common and generally harmless. Two out of 5 children under 10 years of age are affected. The eggs are swallowed and worms develop in the small intestine. Adult worms are usually found in the colon and the female lays eggs, which are invisible to the naked eye, around the anus. Symptoms Intense itching around the anus particularly at night. Spread The eggs are picked up under the fingernails during scratching and returned to the mouth either directly or from clothing, carpets, towels, bed linen, house dust, garden soil, on unwashed vegetables and salads or from someone who already has threadworms. Because they are so widespread and small it is easy for them to be swallowed. The cycle then begins again and eggs pass into the bowel where they hatch. Diagnosis Worms 8-13mm long may be seen at the anus or in the stool like threads of white cotton, alternatively eggs can be detected by using a special collector available from the Microbiology laboratory. Page 5 of 11
Infection Control Measures Contact/faecal oral precautions and treat linen as infected until treatment is completed (see Trust Formulary). Public Health leaflets are available for further advice on preventing reinfection. Ensure the close family are informed to seek treatment at the same time. 8. Process for Monitoring Compliance and Effectiveness This SOP will be reviewed three yearly or earlier in light of new national guidance or other significant change in circumstances. Compliance with this SOP will be monitored through the mechanisms detailed in the table below. Where compliance is deemed to be insufficient and the assurance provided is limited then remedial actions will be drawn together through an action plan. This progress against the action plan will be monitored at the specified committee/group. The results of the annual audit will be escalated to the appropriate committee/group where appropriate Aspect of compliance or effectiveness being monitored Monitoring method Individual or department responsible for the monitoring Frequency of the monitoring activity Group/committe e/forum which will receive the findings/monitor ing report Committee/individu al responsible for ensuring that the actions are completed Compliance with Infection Prevention and control policies and practices Annual Infection Prevention and control audits Audit Department Yearly Infection Control committee Matrons and ward managers Organisation s expectations in relation to staff training, as identified in the training needs analysis Training Reports Learning and Development Department Monthly HRODE Committee HRODE Committee 9. References Maunder J W, (1997). SCOPE; Scabies A war in the skin. Sept 4-5 Benenson A S, (1995) Control of Communicable Disease Manual. 16 th Edition. American Public Health Association. Wilson, J. (2001) Infection Control in Clinical Practice. 2nd Edition. Baillere Tindall. London With thanks to Mid Staffordshire NHS Foundation Trust and Telford and Wrekin PCT Page 6 of 11
Appendix 1 Protocol for Suspected Cases of Scabies Action to be taken for a single suspected case: (patient or staff) Report: Patient case to the Infection Prevention & Control Team (IPCT), report staff case to Occupational Health Services (OHS) Confirm: Diagnosis with Medical staff (via Trust OHS for staff) Patient: Treat confirmed case with scabicidal preparation recommended by the dermatologist (see Trust formulary). Recommend close contacts, e.g. family or others who have had prolonged skin to skin contact, to see their local pharmacist or GP for treatment. Staff: Treat confirmed case with scabicidal preparation, issued by OHS, at the same time close contacts will require treatment (OHS/IPCT will advise). Staff members can return to work after the treatment is complete (usually the following morning). NB. Whenever possible staff with suspected scabies should see a demotologist. (via Trust OHS) as soon as possible and take contact precautions when working with service users and completed treatment if required. Otherwise, contact OHSS, a member of the IPCT or, out of hours, the Consultant Microbiologist for advice. Observe for any further rashes on the ward in patients or staff during the following 6 weeks. Report any suspected or confirmed cases to the IPCT/OHSS. Action to be taken for more than one linked case: Report to the Infection Prevention & Control Team. Confirm diagnosis with Medical staff (via Trust OHS for staff) The IPCT will consider a co-ordinated mass treatment of all patients and staff. The symptoms of scabies can take several weeks to appear and close contacts (skin to skin contact) can become infected before the disease is suspected. Therefore anyone who has had prolonged skin to skin contact, where there is more than one linked case, will need treatment whether they have symptoms or not. Once the treatment is complete the person can return to work the following day. All staff will receive treatment on the same day as the patients on the ward. This may take a few days to organise but will be done as soon as possible after diagnosis is confirmed. (See Plan/Action). Ensure close contacts of the index case and of those staff diagnosed with scabies are also treated. It is not usually necessary to treat family contacts of staff or patients unless the patient or staff member has a confirmed rash. Page 7 of 11
Plan Inform Ward Manager/Directorate Manager/Clinical Director/OH/Pharmacy Action Infection Prevention & Control Nurse (IPCN) Plan treatment programme and set date. Inform patient s clinician Inform Principal Pharmacist and request treatments for all staff members (defined by the OH/IPCT) and patients defined by IPCT OH to send request for staff treatment to SGH pharmacy stating number of individual treatments required including number of close contacts of staff with confirmed rashes (defined by the OH/IPCT) Pharmacy to confirm date when treatments will be available. Provide a list of all staff working on the ward including physiotherapy/ot s and the number of patients. Identifying those with rashes and date if staff already treated, for the OH/IPCN to collect. Arrange staff education session on treatment and management. Provide information leaflets for staff and patients. Inform relatives of all ward patients and supply Public Health Leaflet. Ensure adequate staffing to ensure patients and staff will be treated on the same evening. Patients treatments must be prescribed on their treatment sheets by the ward doctor prior to the date of application. Staff treatment must be issued by the OHS (or a designated representative) and a record kept. Staff with confirmed rashes requiring treatment for close contacts will be advised by OHSS/IPCT. Inform staff members GP s by letter Infection Prevention & Control Nurse/Ward Manager or Nurse in Charge Ward Manager/Nurse in Charge OHS/IPCT OHS Pharmacy Ward Manager/Nurse In Charge Infection Prevention & Control Nurse Infection Prevention &Control Nurse Ward Manager/Nurse in Charge Ward Manager/Nurse in Charge Ward Manager/Nurse in Charge OHS OHS/Staff member Page 8 of 11
Application of Treatment 1. The skin needs to be cool and dry before applying the cream. 2. Apply the prescribed treatment over the whole body, including face neck and ears (take care to avoid the eyes). Make sure that the finger webs and all body creases are carefully treated. Cut the fingernails short, scrub them clean then apply the lotion or cream under the nails. If hands or other parts are washed during the evening, then re-apply the treatment again to the washed areas. Babies under 2 years of age, the compromised and resistant cases should have the scalp and face treated as well, sparing the skin around the eyes, nose and mouth. 3. The application should be applied at night before going to bed and must be reapplied to areas that are washed, e.g. hands, during the treatment period, usually 8-24 hours (check the manufacturer s instructions). 4. When the treatment period is over, shower or bath to wash off the preparation. 5. The application should be repeated 7days after the first treatment. 6. Itching may continue for a few weeks after a successful treatment which can be soothed with lotion, e.g. calamine. Page 9 of 11
Breaking the Chain of Transmission Parasitic Infestations, SOP/September 2015 Since the symptoms of scabies take several weeks to appear, it is easy for close contacts (household and sexual) to become infected before the disease is suspected. Therefore, anyone who is in close contact with the first patient should also be treated in case they too pass it on to someone else. These contacts will need treatment whether they are itching or not. Further Information This leaflet gives general information. In Normal working hours initial contact for Infection Control Advice should be through: Bugs Information Leaflet On: 24 hours after treatment has been undertaken, the patient may return to work, school or nursery. Directorate of Nursing Tel: 01785 221483 No special precautions need to be taken with used clothing and bed linen hot cycle in a washing machine is sufficient. What about going to School and Work? Enquiries will then be passed to the Trust s Infection Prevention and Control Nurses: Judy Carr e-mail judy.carr@sssft.nhs.uk Mobile 07971313156 Scabies You can return to school or work once treatment has been completed. Elizabeth Blackham e-mail elizabeth.blackham@sssft.nhs.uk Page 10 of 11
What is Scabies? Transmission of Scabies Scabies is an allergic response to the excreta and saliva of a parasitic mite which burrows under the skin. Site of Infection Transmission is by direct, prolonged skin to skin contact usually by holding hands. Mites never leave the body because they die if they are not kept warm and moist. Treatment of Scabies It is important to apply the cream to cover all skin in the webs between the fingers and toes and buttocks and to the groin and genital area. These burrows occur anywhere but are more common on hands (finger webs), inner wrists, elbow creases, under the armpits, and around the umbilicus, the nipples in adult females and the genitalia in men. Signs of Infection A number of creams/lotions are available ask your family doctor or local pharmacist. A hot bath is NOT necessary before treatment as the skin must be dry and cool before cream is applied. Cut the finger nails short, scrub them clean then brush the lotion or cream under the nails. The cream must be reapplied to the hands after hand washing. Allergens from the mites produce an exceedingly small itchy, red rash. Itching of the rash is intense, more so at night and during or following a bath. There may be small, raised pimples and patches of crusty skin. The sites of the rash may not correspond to the sites of the mites. Not everybody will have sensitivity to the mite, and so not everybody develops a rash. Apply the recommended cream gently over the skin to cover the whole body, including face neck and ears (take care to avoid the eyes). Babies under 2 years of age, the infirm and resistant cases should have the scalp and face treated as well, Page 11 of 11 sparing the skin around the eyes, nose and mouth. After the treatment period (8-24 hours depending on the preparation -see manufacturer s leaflet), a bath or shower should be taken to remove traces of the