M i t t d bi tb k iManaging a protracted scabies outbreak in a residential care facility for adults with ‘special needs’ in Grampian, Northeast Scotland: 

Challenges and Lesson learnedg

E Okpo,  Consultant in Public Health MedicineFiona Browning, Health Protection Nurse SpecialistDiana Webster, Consultant in Public Health MedicineHelen Corrigan, Health Protection Nurse SpecialistJayne Leith, Health Protection Nurse SpecialistLynn Byers, Health Protection Nurse SpecialistMaria Rossi, CPHMJohn Hewitt, Consultant Dermatologist  

How did it all start?……………………..How did it all start?……………………..

• Member of HPT Contacted by a GP ‐29/9/2016• Ongoing problem in a residential home since July ?? Scabies.

• Contacted care home management‐ different accounts of previous treatmentaccounts of previous treatment

• Options for treatment‐ Treat only symptomatic or treat all –(blanket treatment).

• Need to involve dermatologist, others • PAG

What is scabies?• Common skin disease• Caused by Sarcoptes Scabieiy p• Transmission

• Female scabies mite, skin to skin contact minimum 1min.

• Crusted minimal contact required 

• Symptoms• Symptoms• Intense pruritus, scratching, encrustation, impetiginisation, secondary bacteria infection

• Diagnosis • Clinical

Light microscopy image of Sarcoptes Scabiei• microscopic evidence of mites, eggs, or• evidence of mites obtained by dermatoscope

Light microscopy image of Sarcoptes Scabiei Source: Dressler C, Rosumeck S, Sunderkötter C, Werner RN, Nast A: The treatment of scabies—a systematic review of randomized controlled trials. Dtsch Arztebl Int 2016; 113: 757–62.

Current common treatment options in the UK…..

Ivermectin• Unlicensed in the UK but available on a named patient basis for theUnlicensed in the UK but available on a named patient basis for the treatment of scabies that has not responded to topical treat and crusted or Norwegian scabies

• Growing evidence suggesting effectiveness over routinely used topical agents

Management of the outbreak 1

• One PAG & 2 IMT’s, several visits to the home

• PAG (virtual 29 September 2016) • Mainly to gather more information re‐situationMainly to gather more information re‐situation• Residents and staff affected• Situation confirmed as an outbreak of scabies• IMT planned for early October (06/10/16)

Management of the outbreak 2h• 1st IMT (6th October 2016)

• Assessment/Actions: Who to treat? collate information on staff, family and visitors to home, organisation y gof treatment, how to treat, timing of treatment, liaise with pharmacy re‐supply of medication, develop  Qs and As and Permethrin information sheets 

• Management Bl k t t t t f t ff/ id t / i it l d i h i J lBlanket treatment of staff/residents/visitors planned‐ anyone in home since JulyPSD developed (staff/residents). GP’s to prescribe the topical agent relatives/some staffResidents & their visitors, staff and staff relatives ‐ treated with topical agentsResidents & their visitors, staff and staff relatives  treated with topical agents (Permethrin 5%). Support to care home to administer treatment to residents

• Communication• Permanent/Agency staff of residential home• Residents and their families, visitors, NHS HCW’s• All GP/GP practices/GMED• Media holding statement

• Monitoring of completion of treatment (residents and staff)

Management of the outbreak 3• 15th November 2016, phone call from residential home‐re ongoing scabies 

• Referral to dermatologist • Visit to home by HPT & Dermatologist (on diff occasions)

id i b i d f h iresidents given Derbac M instead of Permethrin. 1 staff member with rashes not treated previously b/cos on holidayResidents significant disabilities e.g. bed bound, incontinent etc.Residents significant disabilities e.g. bed bound, incontinent etc.Dermatologist confirms scabies ?? Treatment failure. Recommends Ivermectin for residents and permethrin for staff and relatives.

• 2nd IMT (01 December 2016)New Agency staff identified –details requestedg y qRx Ivermectin‐ resident, Permethrin –staff & household contacts

Management of the outbreak 4• June 2017, phone call, rashes one resident affected• Assessment – unlikely to be treatment failure as over 4 months since last RxAssessment  unlikely to be treatment failure as over 4 months since last Rx.• Dermatologist –re‐infection• Rx planRx plan

• All residents & staff (with skin to skin contact with residents) to be offered Ivermectin (2 doses) (if not contraindicated).doses) ( ot co t a d cated)

• All household members of (at risk) staff ‐ treat with permethrin cream (even if asymptomatic).

• All visitors of residents if they have had skin to skin contact treat with permethrin cream• All visitors of residents, if they have had skin to skin contact ‐treat with permethrin cream (even if asymptomatic). If symptomatic, treat self and all their household members.

• Visiting HCW information and advice (if symptomatic treat self & all their household• Visiting HCW ‐information and advice (if symptomatic, treat self & all their household members with permethrin cream. If asymptomatic, no treatment.)

And 6 weeks later just when we thought everything was overwas over……………………….

• Phone call from the home…………  rashes again!                                                     

However, Dermatologist confirms the rash is dermatitis 

So what went wrong?So what went wrong?     

GP ib d l thi i t d f th i ( t)• GP prescribed malathion instead of permethrin

• Insufficient cream given to some staff body surface

(prompt)

• Insufficient cream given to some staff – body surface

Whereas 2 tubes would be sufficient forWhereas 2 tubes would be sufficient for 

It definitely would be insufficient forIt definitely would be insufficient for

• The timing of treatmente t g o t eat e t

Challenges and lessonsChallengesg• Managing anxiety of Residential home management, their staff, residents and relatives of residents

Lessons• Topical treatment & contact timeresidents. 

• Coordinating the timing of treatment of over 60 staff, residents and their family members and 

p• Number of tubes required per individual –some staff were large so one tube, even 2 tubes of cream would not be enoughvisitors 

• staff on holiday etc.• Staff registered with various agencies 

tubes of cream would not be enough• Clear instruction on how to apply cream very important.g g

• Staff and family members have  different GP’s • Need for PSD to allow coordinated treatmentVi i h i id i /C H i• Complaint from Management of Residential home

C t f di ti I ti £6K h

• Visit to the incident site/Care Home is important

• Input from Dermatologist was crucial• Cost of medication e.g. Ivermectin – over £6K‐ who pays ?

Input from ermatologist was crucial• Communication ‐ crucial

ConclusionConclusion

S bi tb k b t t d d diffi lt t• Scabies outbreak can be protracted and difficult to manage

/• Requires significant resources/time

• Requires multidisciplinary interaction with relevant stakeholders –e.g. Dermatologist, GP, pharmacist, Home management 

AcknowledgementsAcknowledgements

• NHS Grampian Health Protection Admin support Team (Bev Miller, Fiona Anderson, Senga Smith)

• GP practice‐ Practice Nurse, Advanced Nurse Practitioner 

• Community Pharmacist

• Management of Residential Home