This was a descriptive cross-sectional study conducted in a rehabilitation centre, which is responsible for the care of disabled and mentally retarted people of Iran for a period of two months (In July 27 2018 until September 28, 2018 year). This centre had five units (A, B, C, D and E) comprising of 46 employees (34 staff; 2 nurses and 10 service personnel), catering to 110 handicapped persons.

The index case of scabies in the disability centre was a 16-year-old boy with Down syndrome, who was in contact with the patients in Unit 5. In spring season 2018, symptoms of itching were caused in the person’s head and body, which according to the physician’s order, the patient were treated with permethrin shampoo 1% and leaves of the quarantine.

In July 27 2018, one outbreak of scabies was reported in a rehabilitation centre to one Centre Care Health (CCH) of Iran.

The patients and employees were examined by a team including entomologists and dermatologists and demographic information of the patients was collected by completing the questionnaire (with regard to the principles of medical ethics). Nineteen patients had symptoms of typical scabies including: skin itching; papule on testis and penis and generalised rash on the body and two patients (Norwegian) had thick crust on skin in armpit and anal. Four service personnel had papule on neck skin and two persons were pregnant. The clinical picture of Classic and Norwegian type of scabies seen in the body of mentally handicapped persons is shown in [Table/Fig-1]. In the present study, the five patient’s skin scrapings (because of the terrible behaviour of patients) were sent to the laboratory and mounted by potassium hydroxide (KOH). The mite microscope slide was analysed by entomologist. After receiving the laboratory results of the samples, simultaneous treatment of patients and non-patients was performed according to the choice drugs. All staff and nurses of this disability centre were also examined by a dermatologist.

[Table/Fig-1]:

The symptoms of Classic and Norwegian type scabies on the body of mentally handicapped person: a) Created rash in the armpit; b) Hand skin thickening; c) Skin lesion under armpit; d) Inflammation of the skin in the armpit; e) tiny burrows that can be seen in the skin; f) scabies blister on the skin (original picture).

On July 28, all mental patients were treated topically with 5% permethrin and for the chemo-prophylaxis of individuals residents in other units also used 5% permethrin (twice with one week interval), according to its protocol. The nurses, service personnel and staff of the centre received chemoprophylaxis and were treated by 10% crotamiton for two days, twice with one week interval, except for the pregnant woman’s service personnel who used 10% sulfur ointment for two or three weeks. As the disease was not found in other units, to prevent the epidemics, all disabled persons were cured with 5% permethrin cream twice with one week interval.

According to the opinion service staff, the risk factors for this disease were included:

In this research SPSS, version 20 was used to analyse the data and then the relationships between factors (dependent) and genus and age indices (independent) variables were assessed through stepwise multiple regression analysis. The data normality was examined by Kolmogorov-Smirnov test.

For univariate description of data, the median, percentiles, range and frequency were given, and 95% Confidence Intervals (CI) of relative frequencies were calculated. For categorical data, the chi-square-test statistic for statistical significance was calculated and binary logistic regression was used for assessing the significance of the effect risk factors on prevalence scabies. The likelihood ratio statistic was used to test for statistical significance. Linear correlations between the risk factors and the incidence of scabies were calculated by Pearson’s correlation method.

A total of 110 individuals with mental and physical disorders (23.6% males and 76.4% females) [Table/Fig-2] were resident in five units [Table/Fig-3] out of which 19% of individuals were exposed and 81% unexposed [Table/Fig-4]. The sex ratio of female to male was 3.2:1 [Table/Fig-2]. The mean age of patients was 27 years (SD=7.09, Range 14-48 years) and most affected age group was 21-30 years (45.4%), 92% of this group was females and 8% were males [Table/Fig-5]. In this study prevalence of scabies was 16.02%.

[Table/Fig-2]:

Frequency of gender disabled persons in care unit.

[Table/Fig-5]:

The frequency of disabled people based on age year and sex.

In this outbreak two mental patients were infected by Norwegian and 19 persons infected by classic type scabies. More of infected patients (11 male) were in 30-35 age groups [Table/Fig-4]. Only 4 females out of 46 staff had the symptoms of classic type of scabies. Here was a significant difference between the age and sex of the infected persons (p=0.015). Risk factors of the disease incidence were summarised in five factors including: washing clothes of the disabled patients together, sharing towel between patient (p>0.05), sharing bathroom supplies (p=0.04), sleeping in a common bed (p>0.05), were significantly associated with scabies and sharing glove (p=0.77) were factors that were not significantly associated with having scabies [Table/Fig-6].

The result of logistic regression analysis is listed in [Table/Fig-6]. Using of sharing towels (odds ratio: 23.25, 95% CI: 8.91-60.64), sharing bathroom supplies (odds ratio: 3.31, 95% CI: 1.03-10.64), sleeping in a common bed (odds ratio: 23.25, 95% CI: 8.91-60.64) and sharing glove (odds ratio: 0.86, 95% CI: 0.28-2.18) were the most important risk factors of the scabies. In the study, three patients (2.7%) only had pruritic symptoms, 14 patients (12.7%) had pruritic and papular rash with excoriations, 2 patients (1.8%) were associated with pruritic, papular rash with excoriations and borrowed on skin and 2 patients (1.8%) had thick crusts [Table/Fig-7]. Twenty (95%) of the mental patients were treated with 5% permethrin cream for twice, within a week of each other and 5% were treated after three time and 100% of the staff that had symptom of scabies were cured with 10% crotamiton cream [Table/Fig-4].

[Table/Fig-7]:

The frequency of symptoms scabies in patients.

This is the first ever study done in a population with specific physical, mental and walking health conditions, which often have problems with the control of scabies disease in this group. Those who are not educated and whose control and care require special conditions [18,19]. In this research, to prevent the spread of disease to other units, we recommend: 1) identification of infected patients by expert clinician; 2) prophylactic treatment with permethrin cream 5% for all exposed person; 3) use of permethrin cream 5% for twice with one week interval for all cases of Norwegian and Classic scabies; 4) retaining isolation patients for 8 days and prevention of relapse of the disease for 72 hours after completing second treatment for the diagnosis of scabies [23].

Most of the published reports were including spread of scabies between nurses and patients admitted to infectious diseases, students of a school, in prisons and nursing home [5,23-25]. In this study, due to the timely action of the early warning system, the spread of disease to other units was prevented and the contamination of scabies was limited to one unit by implementing the method of isolating patients and the timely separation of clothing from infected people, the disease epidemic ended after two months.

This article presented a patient with a rare case of scabies, Norwegian scabies. Elderly debilitated and immunocompromised patients are exposed to the risk of more severe forms of scabies. The same mite causing more classic presentation of the scabies skin infestation is also present in Norwegian scabies; in this case, declined immune response of the host was probably the reason for more severe symptoms. Absence of itching indicates lack of proper immune response [7].

In an overview of the published institutional scabies outbreaks by Stoevesandt J et al., 55 outbreak of scabies were reviewed, out of which three report were in institution for the disabled [26].

One of the criticisms about the persons of unit E was, their clothes were washed in the same washing machine with mild water daily and then they were dehydrated in drying machine but they were not subjected to sun light. The other mistake about this unit was that they had one towel which was used by three persons, unlike the study by Raza N et al., which found that sharing of towels or clothes was not a risk factor for scabies, whereas sharing of beds was [27,28].

The washing method of the disabled patients was one of the recommended strategies, in a way that the clothes of persons of the unit E were boiled separately at first then they should be washed by washing machine and after drying with drying system, they should be subjected to sunlight for 24 hours. The clothes of other units with no case of disease, though were washed with each other but it was recommended to boil the clothes until complete cure of the patients and till the end of their treatment periods.

Washing machine was disinfected daily with sodium hypochlorite 1%. For the case of classic type, it was set to prepare one towel for each person entitled with their own names and for doing personal cleaning, the nurses of each unit should change their gloves. All surfaces, walls and fences which are special for the disable persons were disinfected with 10% sodium hypochlorite twice daily. The classic visits of the unit’s residents were limited.

In the units with scabies infection, the patients were isolated until complete treatment. About the classic bedspread and pillow cases of the nurses, it was suggested each nurse to use his own personal sleeping supplies [29]. The uniform of all service personnel were washed twice in one week and they were replaced with the clean uniform. Two pregnant service personnel were treated with 10% sulfur ointment instead of 10% crotamiton and their contacts with the patients of other units were banned. All the patients’ were treated, with 5% permethrin cream twice, with one week interval and in order to reduce the itching; 5 mg prednisolone was prescribed to the mental patients (having scabies) daily for one week. The 16.02% initial prevalence rate of scabies were detected in this study compared with Fiji (18.5%), Vanuatu (24%), the Solomon Islands (25%), Timor-Leste (17.5%) and Malaysia (31%) [30-33].

In terms of control measures for the nosocomial setting, efforts have been mainly focused on staff training and conduction of mass treatment management suggested by various guidelines based on the regional regulations protocol. Recommendation of permethrin 5% topical treatment indicates high efficacy of permethrin and its rare adverse effects in comparison with other topical treatments and oral ivermectin. No adverse effects were recorded in patients treated in our study [34].

In a scabies outbreak (Leppard B et al.,), that happened in a prison in Tanzania, many prisoners were infected within four weeks. To cure these persons, 66 liters of Benzyl Benzoate were needed but it was too costly. Even application of lindane lotion and permethrin cream were more costly. The alternative drug was ivermectin. In this outbreak, actellic insecticide with 80 mg amount in 20 liters of water was sprayed on the floor and the walls of the rooms, where the patients were living [19].

Arlian LG et al., explanted that away from their hosts, mites are able to survive and remain infective for 24-36 hours at 21°C and 40-80 % relative humidity. Therefore, according to this theory, we did not use insecticides in our study [35]. In a study of Leppard B et al., the personnel of the prison were cured with 1% lindane but in our study, 10% crotamiton cream was applied. The age group of the patients was between 20 to 30-year-old and they were males which were in accordance with our study. An 88% of the prisoners were treated with ivermectin within four weeks but in our study, 95% of the patients were treated with 5% permethrin cream [19].

Andersen BM et al., explained a scabies outbreak that occurred in five months (October 1998–February 1999) influencing 19 people related to a nursing home in Oslo. Thirteen patients were diagnosed with scabies including six long-term patients and five short-term patients who were treated at home [5]. Chosidow O described an outbreak in an HIV-positive patient with crusted scabies led to development of scabies symptoms in 14 out of 19 staff. A total of 32 patients out of 33 patients of a closed nursing home were diagnosed with scabies, and some of them had crusted scabies. Long-term failures by repeated treatments of permethrin, gamma-benzene hexachloride, benzyl benzoate etc., resulted in application of oral treatment with ivermectin (an anti-parasitic drug) which showed effectiveness [12].

In a literature analysis of 44 scabies epidemics over the years 1976-1996, the authors found six factors that contributed to transmission and recurrent scabies in healthcare institutions: a) among residents in health care institutions a considerable number are, once infested, at risk of developing crusted scabies; b) many people are exposed through close contact; c) the generally long diagnostic delay; d) insufficient survey of the epidemiological problem; e) treatment failures; and f) incomplete post-intervention monitoring [36].

According to the patient’s physical and mental disabilities that were aggressive, we could not collect skin scrapings scabies of all patients. Due to the lack of funds at the centre, common supplies were used for the care of the people, which caused an outbreak. Another was the lack of required service personnel, which made it difficult to take care of the patients.

According to the findings, the delay in treatment and reported case scabies in a child with Down syndrome led to the epidemics among the disabled persons. So, it can be inferred that there is an urgent need in social places, including hospitals, centres for the care of the elderly and mentally handicapped people, the nurses and service personnel to get trained about the importance of urgent report of epidemic diseases especially scabies to Health care centres and it is too necessary to isolate the infected persons with scabies and to avoid their touch with healthy persons until their complete recovery.