Ectoparasites: Lice and Scabies

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EctoparasitesLice and Scabies

• Infection Control at DIHS
• Epidemiology Unit DIHS

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What is an Ectoparasite?

• Organisms that require external contact with a
  human host
• Include, but are not limited to lice and scabies

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Lice

• Lice are insects
• Three species of lice affect humans
• Pediculus humanus capitus- head louse
• Pediculus humanus corporis- body louse
• Pthiris pubis- crab louse or pubic lice
• Can only survive on human blood
• Louse saliva and excrement cause a mild
  dermatitis in human host

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Lice

• Cannot survive for more than approximately 48
  hours without a human host.
• A hatched nit needs a human blood meal within 45
  minutes to survive

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Which Came Firstthe Itchin or the Egg?
1st Nymph
2nd Nymph
Female
Male
Egg (Nit)
Adult
Life Cycle of the Head Louse
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Scabies

• Caused by the mite (sarcoptes scabiei)
• Mites burrow under skin and deposit eggs
• Mite eggs and excreta cause intense itching
• Scratching causes skin excoriation weeks after
  infestation
• Scabies can affect the entire body but are
  commonly found on finger-webs, underarms,
  waistline and feet.

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Transmission

• Head lice do not hop, jump or fly. They migrate
  through direct contact with an infested person
  and their belongings.
• Head and body lice commonly transmit when people
  share combs, clothing and bed linens
• Scabies is transmitted through close personal
  contact

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Identifying Head Lice

• Lice are found on the scalp behind the ears and
  near the neckline at the back of the neck.
• Head lice hold on to hair with hook-like claws
  found at the end of each of their six legs.
• Head lice are rarely found on the body,
  eyelashes, or eyebrows.
• Nits adhere to hair and are found close to the
  scalp
•  

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Lice Diagnosis

• Itching
• Detection of lice and eggs (nits) with naked eye
• Nits of head lice (1mm long) found on hair shafts
  close to scalp
• Nits of body lice primarily found on clothing

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Lice
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Lice Size Lice Next To Dime
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Lice Nits on Hair
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Scabies Diagnosis

• Tiny red intensely itchy bumps on the limbs and
  trunk (differential dermatitis and hives)
• Burrow ink test
• Microscopic view of mites and eggs from skin
  scrapings is definitive
• Symptoms may not occur until weeks after
  infection.
• Someone who has had scabies before will itch
  within hours of a new infestation.

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Scabies Mite
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Scabies Rash
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Scabies Rash on infant
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Infection Control Measures
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Steps to Manage Infestation

• Screening/ Diagnosis
• Treatment/Education
• Contact Precautions
• Disinfection/housekeeping
• Contact Investigation
• Protection of health care workers

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• When possible, detainees with a suspected or
  diagnosed ectoparasitic infestation should be
  housed in a single-cell room and be restricted
  from work assignments and visitations until
  medical evaluation is conducted and treatment is
  initiated

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Contact Precautions

• In addition to standard precautions, health
  workers should use appropriate barrier
  precautions (gloves, gown) while performing
  detainee care, while screening detainees, or when
  it is necessary to handle personal items of the
  infested detainee (e.g. clothes)

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Treatment Considerations

• Detainees generally should not be treated for an
  ectoparasitic infection unless a positive
  diagnosis is made
• Choice of treatment should be based on condition
  of patient (pregnant, immunocompromised, open
  wounds, etc)

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Treatment of Scabies

• 5 Permethrin cream applied from the neck down
  and washed off after 8-14 hours
• An alternative oral treatment is ivermectin 200
  micrograms/kg, repeated in 2 weeks.
• Fingernails should be closely trimmed
• Antipruritic medication should be prescribed to
  minimize excoriations due to scratching.

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Treatment Procedure for Scabies

• Infected detainee should have warm shower with
  soap and dry body
• Apply medication according to manufacturers
  instructions
• Trim fingernails and apply thin layer of
  medication to fingernails
• Provide clean clothes and bedding
• Second course of treatment after 7 days
• Monitor detainee for secondary infections

Clean clothing and bedding should be provided
after medication applied and again after
medication is washed off.
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Treatment of Lice

• Pubic and body lice
• 1 Permethrin cream, applied and washed off after
  10 minutes
• Head Lice
• 1 Permethrin 1 (Nix) or 5 permethrin
• Pyrethrins Plus Piperonyl Butoxide (Rid) - A
  shampoo that can cause an allergic reaction
• Detainees should be retreated after 7 days (to
  get rid of nits that have hatched)

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Treatment Procedure for Lice

• Remove all clothing from the waist up.
• Wash hair with regular (non conditioner) shampoo,
  rinse with water and towel dry.
• Saturate hair and scalp with head lice shampoo
  avoid contact with eyes, nose and mouth.
• Leave on hair for 10-15 minutes.
• Rinse with water and use a fresh towel to dry.
• Comb hair with a fine-tooth comb to remove any
  remaining lice and nits.
• Put on clean clothing.

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Treatment Procedure for Lice (2)

• Comb hair everyday, continuing to check for lice
  for 2-3 weeks.
• Nits may need to be removed by hand
• If lice are still found in 7 days, apply second
  application of lice shampoo to target lice that
  hatch after the initial treatment.
• Wash brushes and combs in hot sudsy water, soak
  in a bleach solution of one part bleach to 10
  parts water.

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Post Treatment of Ectoparasites

• Patient may still experience itchiness for some
  time after treatment because of hypersensitivity
  of the host to the ectoparasite.
• HCW should educate detainee regarding contact
  precautions

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Screening at Intake

• Because early prevention is critical in the
  detention environment, clinicians should maintain
  high index of suspicion of ectoparasitic
  infections.
• Clinician should symptom screen detainees at
  intake
• Health care worker should examine head for lice
  and or nits when symptoms are described/observed
  or during epidemic.
• Detainee should be carefully examined when
  scabies symptoms are described or observed

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Definition of Ectoparasitic Outbreak

• several (e.g. three or more) cases which are
  epidemiologically associated by person, time, or
  place, or
• a substantial increase in number of cases in a
  facility.
• Each facility must decide the criterion to define
  an outbreak.

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Outbreak Management

• Screen all detainees who slept in the same pod as
  the index case (s)
• Detainees without infestation should not be
  housed with infested detainees until infested
  detainees have received a first treatment.
• In a widespread outbreak, treatment of all
  roommates may be considered.

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Laundry

• All clothing, sheets, towels and any other
  launderable items of a detainee with a confirmed
  ectoparasitic infection should be hot water
  washed and dried (at least 130 0 fahrenheit)
• Alternatively items can be bagged and sealed and
  left untouched for 5 days.
• Detainees should be treated simultaneously with
  disinfection of personal items and laundry.

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Disinfection

• Treat infested patients simultaneously for the
  infestation
• Launder and clean all potentially infested items
  at the same time that the patient is treated
• Mattresses, furniture, carpets should be well
  vaccuumed and cleaned
• Place vacuum bag in plastic bag and discard
• Fumigation/room sprays are not recommended

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Housekeeping

• Daily, routine cleaning must be done in all
  patients areas to reduce parasitic load.
• Cleaning must be done with a disinfectant
  registered with the EPA and performed in a
  sanitary manner as is done in all rooms.
• Equipment should be routinely cleaned,
  disinfected or sterilized per hospital policy.

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Prevention Precautions

• ICO should inform barber in camp of lice outbreak
  and educate on cleaning practices
• Discard and replace torn mattresses
• Advise detainees with infestation to cut hair or
  wear hair in braids/buns
• Detainees should be instructed not to share
  combs, brushes, hats, coats, towels or other
  articles that come in contact with the head, neck
  and shoulders.

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Release/Removal/transfer of Detainee

• Diagnosis of ectoparastic infestation is not a
  reason to recommend holding of a detainee from
  release/removal or court visits.
• Clinical staff should document diagnosis in
  transfer summary
• Clinical staff may recommend that transfer of
  infested detainee to another facility be delayed,
  when possible, to allow initiation of treatment.

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Role of Each DIHS Site

• Develop local operating procedure to carry out
  management and treatment guidelines
• Coordinate with ICE laundry staff, kitchen staff,
  housekeeping, and security staff to handle
  detainees with ectoparasitic infestations
• Establish notification process of medical staff
  to local ICE authority
• Establish procedures with ICE for provision of
  fresh clothing, linens, cleaning of area.
• Prepare needed forms (i.e. special needs form) to
  formalize process with ICE for issuing fresh
  clothes, linens, cleaning mattresses, etc.

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Sources

• http//www.cdc.gov/ncidod/dpd/parasites/lice/defau
  lt.htm
• http//www.dpd.cdc.gov/DPDx/HTML/HeadLice.htm
• http//www.cdc.gov/ncidod/dpd/parasites/scabies/de
  fault.htm
• APIC text of Infection Control and Epidemiology,
  2005