Scabies: A creepy bug strikes fear in workers

Nosocomial mite outbreaks on the rise

Forget antibiotic-resistant pathogens and even bloodborne infections. If you want to strike fear in the heart of health care workers, mention scabies.

Scabies is a transmissible infestation of the skin with a real bug, the burrowing microscopic mite Sarcoptes scabiei. Even after you kill them, they stay under your skin until it sloughs off.

"We have had employees take care of people with tuberculosis and meningitis, but you have something like this, and the panic was unbelievable," says Alexis Raimondi, RN, infection control practitioner at Beth Israel Medical Center in New York City. "They would be coming up to me, pulling up their sleeves and saying, Do you think this could be it?’ I felt really bad for them. The itching, especially at night, is intense."

Raimondi relays a cautionary tale about a nosocomial problem that appears to be on the increase, although scabies is not a reportable condition.

According to information from the Centers for Disease Control and Prevention (CDC): "In recent years, there has been an increase in the occurrence of crusted scabies among immunocompromised patients, particularly persons with HIV, which has led to the transmission of scabies among personnel, patients, and their families."1

The first signs at Beth Israel were in a general warning from New York health officials that scabies outbreaks were occurring in long-term care. "Then it hit the hospitals," she says.

In October 2002, the hospital admitted two patients through the emergency department (ED) with skin rashes that were not initially recognized as scabies. The index case was an elderly, immune-compromised female nursing home resident who came in with what eventually would be diagnosed as Norwegian scabies, a particularly dastardly presentation of the mite.

"It has more flaking and scales and a very heavy mite infestation," Raimondi says.

"The problem was that it wasn’t originally recognized as scabies. She was immunocompromised and had gone through various treatments. The elderly, because of their skin, can have other things going on, and they did not recognize it as scabies," she adds.

Unrecognized, the bug and its burrowing brethren found their way under the skin of 27 health care workers, including those in nursing, housekeeping, engineering, physical therapy, and physicians. "There was spread from various departments and to different areas of the hospital," she said.

As the infected patients scratched their skin, flakes containing mites traveled and alighted on other surfaces. "Skin flakes can be on linen, clothing, floors, furniture," she says. "For example, the flakes might be in the linen and when you pull it off the bed, they go flying and land on the bedrail or on the furniture."

Rigid infection control measures were instituted, including contact isolation of known or suspected patients and education of health care workers.

"The first thing was education because the staff went into a total panic," Raimondi says. "Basically, you would think they were going to die. But it’s kind of creepy. You read about it and think about it and want to start scratching."

Intensive skin assessments were done in the ED, looking for any other incoming cases. Patients who had been in contact with the index cases were treated empirically with permethrin.

No other patients developed infection, but workers were suffering as the wave of initial transmission — gradually emerging from an incubation period of up to six weeks — began to create pruritic rashes. In some cases, the mites found their way to uncovered skin between gloves and clothing.

"We noticed that right above the glove line between the sleeve of the scrubs you would actually see the demarcation of where the glove ended and the rash began," she says, adding that workers were advised to wear long-sleeved gowns with all suspect cases.

Health care workers were treated with permethrin, which was effective but did not immediately end the torment.

"It is a cream that is applied all over the body from the neck down," Raimondi says. "They keep it on over night and wash it off in the morning. It will kill the mites; but your skin has to keep sloughing off, so you still are itchy. The mites will be dead but they have burrowed under your skin."

Unfortunately, before the outbreak was contained, some workers spread scabies to family members, who also were treated to kill the bugs. The outbreak was disturbing and disruptive, with almost 240 health care workers being evaluated for possible infestation.

The medicine alone was $28 a tube. "It would have been a good time to buy stock it," she says.

"It was disruptive because the staff were very upset about it. There was a lot of anxiety about taking it home to their families. This went on for weeks. It started in October, and our last employee was diagnosed in December," Raimondi adds.