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Patient-Source Scabies among Hospital Personnel -- Pennsylvania

In early January 1982, a 60-year-old woman with severe diabetes mellitus and multiple end-organ complications was admitted to a Pennsylvania hospital with bacterial sepsis and shock; she had previously been a custodial nursing home patient. The patient died 5 days after admission. During her hospitalization, she was comatose and required total nursing care, including repeated physical contact by the floor nursing and support staffs. On admission, the patient had an excoriated, crusted rash covering her entire body that had been present for many weeks; retrospectively, it was believed to be crusted or Norweigan scabies. No other patients requiring extensive care contact had dermatologic problems on this unit during the same period.

Approximately 3 weeks after the patient's death, unit staff members began to report to the employee-health service with itching and red, scaly, skin lesions primarily on the anterior trunk and volar side of the arms. Epidemiologic investigation revealed that all the ill individuals had had frequent, close contact with the deceased. Staff members at risk of physical contact were identified, and on examination, 10 had skin rashes clinically compatable with scabies. Some of these individuals had already been treated with a scabicide by their private physicians. All had onset of rash about 2 weeks after the death of the index patient; the remaining 20 at-risk individuals without rash had considerably fewer intense physical contacts with her. There were no cleaning or food service personnel or orderlies, transporters, or other nonnursing-care staff in either the skin-rash or at-risk groups.

All individuals with rash were examined. Four had been previously treated, and their lesions were resolving. Five had lesions suitable for scrapings to detect mites; three of these had positive scrapings.

All 10 individuals were treated with lindane lotion and noted prompt relief of symptoms and resolution of rash. Surveillance over the next 8 weeks identified one possibly late primary case with the same clinical features as the original 10 and one suspected secondary case with hand-dominant localization. Both patients were treated by private physicians, with immediate symptom resolution.

After a year of total follow-up, no additional cases were reported. Reported by SJ Pancoast, MD, JJ Kishel, Mercy Hospital, Scranton, Pennsylvania; Div of Vector-Borne Viral Diseases, Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note: Each patient in this outbreak had a rash distribution that included mainly the anterior trunk, upper legs, and volar arms. Classic hand involvement was conspicuously absent. The predominance of trunk and arm distribution reflects the mode of probable acquisition (body contact acquired by lifting and positioning the index patient). All affected staff members had repeated, close body contact without protective outerwear, frequently with bare arms and forearms. The lack of hand involvement can be partly attributed to frequent post-patient handwashing.

In many custodial, close-confinement situations with disabled patients, scabies is an endemic problem. When skin-rash outbreaks are reported among hospital personnel, even with an atypical distribution of skin lesions as in this case, scabies should be considered. The usual mode of transmission in such instances may be predominantly body-to-body contact.

All persons admitted to patient-care institutions should be examined for skin lesions. Those positive for scabies should be managed as having an infectious disease and isolated until cured to prevent spread among staff and other patients. This includes the use of gloves and, if indicated, gowns, while actually in contact with suspected or positive cases.

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