ARTICLE IN PRESS

American Journal of Infection Control ■■ (2017) ■■-■■

Contents lists available at ScienceDirect

American Journal of Infection Control American Journal of

Infection Control

j o u r n a l h o m e p a g e : w w w. a j i c j o u r n a l . o r g

Major Article

Management of a family outbreak of scabies with high risk of spread

to other community and hospital facilities
Manfredo Marotta MD a, Francesco Toni MD a, Laura Dallolio PhD b,*, Greta Toni MD a,
Erica Leoni MD b
a
Unit of Hygiene and Public Health, Local Health Authority of Romagna, Rimini, Italy
b
Department of Biomedical and Neuromotor Sciences, Unit of Hygiene, Public Health and Medical Statistics, University of Bologna, Bologna, Italy

Key Words: Background: In developed countries, scabies is observed sporadically or as institutional outbreaks in hos-
Scabies pitals and other health facilities. In the family context, outbreaks generally involve a limited number of cases.
epidemiologic investigation Methods: A local health authority in Emilia-Romagna (Northern Italy) carried out an epidemiologic in-
outbreak management
vestigation on a family outbreak of scabies that included an unusually high number of cases. Its possible
hospital infections control
connection with a nosocomial case in a long-term care facility (LTCF) and outbreak management are
discussed.
Results: Among the household members, 8 confirmed cases occurred (attack rate, 87.5%). Another case
was reported in a patient of an LTCF where one of the family cases worked as a sociosanitary operator.
In total, 244 contacts were placed under surveillance. The control strategy focused on a mass informa-
tion campaign addressed to all contacts and the training of health care personnel. In addition, specific
prophylaxis (permethrin 5%) was performed in 108 high-risk contacts and LTCF patients and staff.
Conclusions: The control measures were successful in preventing the spread of the outbreak. However,
misdiagnosis and the tendency of people to hide the symptoms caused the late recognition and under-
estimation of the cases, contributing to delayed control measures and increasing the economic and human
resources required for outbreak management.
© 2018 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier
Inc. All rights reserved.

Human scabies is a highly contagious infestation of the skin
caused by the mite Sarcoptes scabiei var. hominis, which can be easily
passed from an infested person to his or her household members
and sexual partners. Transmission is generally by direct, pro-
longed, skin-to-skin personal contact, but occasionally, the mite can
spread indirectly, via clothing, towels, or bedsheets. This indirect
spread occurs more easily when the infested person is affected by
unrecognized crusted (Norwegian) scabies, associated with the
extreme proliferation and spreading of mites.1,2
Scabies is a common condition found worldwide: the Global
Burden of Disease Study 2015 estimated a global prevalence of >204
million cases, with a significant percentage change between 2005
and 2015 of 6.6%.3 The worldwide prevalence ranges from 0.2%-
71.4%, with the highest rates in the Pacific and Latin American
* Address correspondence to Laura Dallolio, PhD, Department of Biomedical and
Neuromotor Sciences, Unit of Hygiene, Public Health and Medical Statistics, University
of Bologna, Via San Giacome 12, 40126, Bologna, Italy.
E-mail address: laura.dallolio@unibo.it (L. Dallolio).
Conflicts of interest: None to report.
regions. Except for Europe and the Middle East, all regions
include populations with a prevalence of >10%.4 Of 246 conditions
comparatively ranked by the Global Burden of Disease Study 2015,
scabies was 101 in age-standardized global disability-adjusted life-
years and was responsible for 0.21% of disability-adjusted life-
years from all conditions.5 The prevalence of infestation is also
influenced by changes in social attitudes, population movements,
wars, and seasonal variations, with an increasing incidence in the
winter, probably because of the tendency for more indoor
overcrowding.1
In developed countries, scabies is observed sporadically or as in-
stitutional outbreaks in hospitals,6-8 residential care homes for older
adults,7,9,10 and long-term care facilities (LTCFs).11-13 In nosocomial
outbreaks, the mean attack rates range between 11% and 38%.7-9,12
Institutions taking care of children are involved more rarely.14,15 In
Italy, all cases of scabies observed by family doctors and hospital
doctors must be reported to the local health authority (LHA), which
notifies them to central health care bodies only if they fall into an
outbreak (appearance of at least 2 concomitant cases or occurring
within 4-6 weeks of each other and with exposure to the conta-
gion). Over the last 20 years, about 400 to >1,000 scabies outbreaks

0196-6553/© 2018 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.ajic.2017.12.004
 ARTICLE IN PRESS
2 M. Marotta et al. / American Journal of Infection Control ■■ (2017) ■■-■■
have been reported annually in Italy, with a number of cases ranging
from 2,000-5,800 per year. However, the nonreporting of sporadic
cases and the frequent lack of accuracy and standardization in clin-
ical diagnosis of scabies make it difficult to estimate the actual
number. As in other industrialized counties, scabies in Italy tends
to occur in cyclical outbreaks, particularly within institutional living
situations, such as hospitals, nursing homes for older adults, and
LTCFs.16,17 The nosocomial outbreaks contribute to the epidemiol-
ogy of scabies, involving a larger number of cases, but the greatest
number of outbreaks concerns the family context where the number
of cases is generally circumscribed.
This article describes a family outbreak of scabies that oc-
curred in the district of Rimini, Emilia-Romagna Region (Northern
Italy). This study aimed to identify the chain of transmission of the
scabies epidemic and to describe the outbreak management and
the adopted measures of surveillance and control, which pre-
vented the diffusion of the outbreak from the family members to
other communities.
METHODS
Setting
Rimini is the chief city of an important tourist area on the Adri-
atic Sea, in the Emilia-Romagna Region. The province of Rimini has
a population of around 390,000 resident inhabitants and an annual
influx of tourists of around 15 million, mainly from April-September.
Between March 14, 2016, and March 15, 2016, 2 people with a clin-
ical picture compatible with scabies referred to the dermatologic
unit of the city’s public hospital: a 2-year-old boy (on March 14)
who had been suffering from generalized itch since the start of Feb-
ruary, especially at night, and a 60-year-old man (on March 15),
staying over the previous 2 months in the rehabilitation unit of an
LTCF (nosocomial case), who similarly complained of pruritus present
for around a month, with evidence of micropapules in the axillary
region and hips. The dermatologist made a clinical-dermatoscopic
diagnosis of scabies and reported the 2 cases to the LHA. After the
reporting of other cases belonging to the same family of the af-
fected child, LHA constituted a multidisciplinary operating group
composed of dermatologists, public health physicians, and nursing
staff with the aim of carrying out an epidemiologic investigation
and adopting the necessary surveillance and control measures. To
frame the outbreak in the context of the Rimini district, a retro-
spective analysis of the notification sheets of scabies outbreaks and
cases reported in the previous 3 years was carried out.
Epidemiologic investigation and surveillance of contacts
The epidemiologic investigation and contacts surveillance was
carried out according to the regional and national regulations,18,19
adopting the following definitions of cases and contacts. A proba-
ble case was defined as a person with symptoms and signs consistent
with scabies (generalized itch with nocturnal predominance,
Table 1
Cases of scabies reported in the Rimini district in the period 2013-2015
Family outbreaks Provisional accommodation centers
Years Outbreaks Cases Outbreaks Cases
2013 4 10 0 0
2014 11 22 4 28
2015 10 23 0 0
Total 25 55 4 28
NOTE. Values are n.
LTCF, long-term care facility; RCH, residential care homes.
erythematous papules, and/or secondary lesions such as pustules,
vesicles, and excoriations) who had direct contact with a con-
firmed case in the 2 months preceding their onset. A confirmed case
of scabies was defined as a person affected by the characteristic
itching and skin signs, with evidence of the typical skin lesions
(burrows), eggs, or mites by dermatoscopy or microscopic exami-
nation of skin scraping. High-risk contacts were defined as
cohabitants, sexual partners, and people with frequent skin contact
with any one case. Low-risk contacts were persons with indirect
contact through objects or other materials.
All the cases were interviewed. As well as general information
and date of onset of symptoms, details were collected on contacts
in the previous 2 months, in their home, work, and community
context. Data collection was done using structured sheets and clin-
ical reports of dermatologists who visited the patients. The
epidemiologic investigation and surveillance included the follow-
ing steps: (1) identifying all high-risk contacts and interviewing them
personally or by telephone and, if symptomatic, proceeding to the
assessment of the case through dermatologic examination; (2) iden-
tifying the greatest possible number of low-risk contacts and, if
possible, interviewing them to verify the presence of symptoms con-
sistent with scabies; (3) inspecting any risk communities frequented
by the cases (schools, hospital settings, and workplaces) and alert-
ing school health care managers, company occupational physicians,
and hospital health managers; and (4) implementing information
campaigns for the staff working in these structures, in particular
health care workers, about the prevention measures to adopt. Fur-
thermore, suspected and confirmed cases were treated, and the
administration of specific prophylaxis to all high-risk contacts was
recommended.
RESULTS
Incidence of scabies in the Rimini district
Table 1 shows the scabies outbreaks reported in the Rimini dis-
trict from 2013-2015, with the corresponding number of cases.
Table 1 reports the total number of confirmed cases, also includ-
ing sporadic cases. The outbreaks occurred above all in family
settings, with an average of 2 cases per outbreak. The higher number
of cases reported in 2014 is because of 4 outbreaks in provisional
accommodation centers for non-European migrants. In the 3-year
period considered, outbreak cases represent more than half of the
total cases. The incidence rate ranges between 0.9 and 2.0 per 10,000
resident inhabitants.
Outbreak
After the first case reported to the LHA on March 14, 2016, 7 other
cases were identified among the family contacts of the 2-year-old
boy (index case). The child had suffered from itch since the start
of February, but his symptoms and signs were previously misdiag-
nosed. Table 2 shows the index case and the secondary cases that
RCH and LTCF outbreaks Other Total cases included
Outbreaks Cases Outbreaks Cases in outbreaks Total confirmed cases
0 0 0 0 10 35
1 2 2 8 60 78
0 0 1 2 25 64
1 2 3 10 95 177
 ARTICLE IN PRESS
M. Marotta et al. / American Journal of Infection Control ■■ (2017) ■■-■■ 3

Table 2
Family outbreak, cases, and their contacts

Degree of relationship
Cases with index case Age (y) Sex Occupation High-risk contacts Low-risk contact
1 Index case 2 M Mother, father, grandparent’s Children and staff of the kindergarten,
family members noncohabitant relatives
2 Mother 22 F Esthetician Noncohabitant partner Staff and customers of the beauty
center, 4 friends who often attended
the house
3 Father 29 M Pizza maker Lived alone Pizzeria staff
4 Maternal grandmother 55 F Sociosanitary operator of a Household members Patients and health care workers of the
LTCF, volunteer of the psychiatric unit of the LTCF,
Italian Red Cross colleagues of the local section of the
Italian Red Cross
5 Partner of maternal 67 M Entrepreneur Lived alone
grandmother
6 Paternal grandmother 45 F Cashier of the pizzeria Household members Pizzeria staff
7 Paternal grandfather 46 M Pizza maker Household members Pizzeria staff
8 Paternal uncle 13 M Student Household members Classmates

F, female; LTCF, long-term care facility; M, male.

Fig 1. Reconstruction of the chain of infection.

occurred in the same family, all confirmed, and the contacts of the
cases, divided into low- and high-risk contacts. The dates of onset
of the secondary cases were distributed between mid-February and
the last week of March. Figure 1 describes the family outbreak and
the link between the involved people belonging to 3 distinct nuclei
that had very close contacts. Figure 1 also shows a possible, but not
confirmed, link between the family outbreak and the nosocomial
case. The nosocomial case was hospitalized in the rehabilitation unit
of the same LTCF where the grandmother of the index case worked.
However, according to the information collected, these 2 cases had
never come into direct contact because the woman worked in the
psychiatric unit. Over the previous 2 months, the possible con-
tacts of the nosocomial case, besides the health operators and other
patients, included the family members who visited him. Among these
relatives, a brother had for some time been complaining of itch on
his hands and arms (reported by the patient), but a specific diag-
nosis by dermatoscopy or microscopy analysis was not possible
because the brother denied having any itch symptoms. The brother
was a hairdresser and worked in the same beauty center of the
mother of the index case.
 ARTICLE IN PRESS
4 M. Marotta et al. / American Journal of Infection Control ■■ (2017) ■■-■■

Active surveillance and control measures
All the family cases were treated with topical permethrin 5%, with
the treatment repeated daily for 3 days, then 7 days without, and
repeated daily for another 3 days. The nosocomial case was treated
with the protocol repeated daily for 4 days, then 7 days without,
and repeated daily for another 4 days. The cases that worked in close
contact with other people were kept away from work, and the minors
(the index case and his 13-year-old uncle) were kept away from
school until the completion of treatment and negative dermatoscopic
examination.
Table 3 shows the measures adopted for the contacts and the
measures taken to communicate the risk and to train staff. Among
contacts, certain communities were given particular attention: the
kindergarten attended by the index case, the secondary school at-
tended by the 13-year-old paternal uncle of the index case, the work
environments of cases, and the health facilities, in particular the LTHF
and the first aid unit of the local committee of the Italian Red Cross,
where the maternal grandmother also did voluntary service.
The high-risk contacts and all the contacts in the LTCF were
treated with topical permethrin 5% following the recommenda-
tions of the regional guidelines,18,19 and were told to report any
appearance of symptoms immediately to the LHA operating group.
The control strategy adopted for the low-risk contacts focused on
surveillance and information-centered measures and did not include
prophylaxis with permethrin. In the case of suspected symptoms,
the low-risk contacts were treated as a precautionary measure with
permethrin 5%, even if their dermatoscopic examination was
negative for scabies. The surveillance involved a total of 244 con-
tacts, 108 of whom underwent prophylaxis. The medication cost of
prophylaxis was around €24 per person.
The inspection of the work places (beauty center and pizzeria)
revealed that the workers all had their own lockers for personal be-
longings. There was no sharing of clothing. The beauty center
company physician (not specialized in dermatology) examined the
workers and did not report any dermatologic diseases. The family
health unit of the LHA and community pediatricians were in-
volved in the active surveillance in the school setting.
All the relative health care managers, physicians, and nursing staff
of the LTCF and the Red Cross committee took part in the staff train-
ing process and were instructed on the modalities of surveillance
inside the nursing home and on the protocols to follow in the case
of suspected scabies. The measures proposed for the prevention of
contamination were in accordance with the guidelines of the Emilia-
Romagna Region,18,19 which are consistent with the European
guidelines and those proposed by the U.S. Centers for Disease Control
and Prevention.20,21 The nosocomial case remained in a double room
because of the nonavailability of a single room, but an adequate
spatial separation was ensured, >1 m, and a partition was placed
between the beds to minimize the chances of contact.
No secondary cases of scabies occurred in the school commu-
nities and health facilities surveyed (LTCF and Red Cross). One month
after the notification of the index case, all cases had completed the
treatment without any significant adverse events and had re-
turned to work or to school. No new cases were reported, and the
outbreak was considered ended after 2 months from the index case.

Table 3
Active surveillance and control measures

Health personal involved No. of contacts Specific treatment

Place of contact in the active surveillance High risk Low risk of contacts Other control measures
Family Operating group of the public 9 (persons cohabitating or 4 (for the cases of the Permethrin 5% Distribution of information
health service of the LHA in close contact with the family outbreak) both in high-risk (3:7:3) leaflets
Family doctors of patients index case; 7 were 6 (for the nosocomial and low-risk contacts Counseling
confirmed as secondary case) (1:7:1)
cases)
Kindergarten Family health unit of the LHA 43 children and staff No specific treatment Distribution of information
Community pediatricians leaflets to parents and
Coordinator of the teachers
kindergarten Counseling
Secondary Family health unit of the LHA 25 children and staff No specific treatment Distribution of information
school Community pediatricians leaflets to children, parents,
School head teacher and teachers
Counseling
Health and Officer of the Public health 18 employees Medical visit
beauty center service of the LHA Inspection of the work
company’s occupational doctor environment
Distribution of information
leaflets to the workers
Counseling
LTCF Health care manager of the Psychiatric unit: Permethrin 5% Staff training with ward
LTCF 20 patients 1:7:1 meetings
17 health care workers Distribution of operational
Rehabilitation unit: guidelines with instructions
30 patients on management of suspected
27 health care workers cases, preventive measures,
and alert system
Italian Red Manager of the local section of 50 employees and Permethrin 5% Staff training
Cross staff the Italian Red Cross volunteers 1:7:1 in 2 cases with itch, Distribution of information
even if negative to leaflets Counseling
dermatoscopic
examination
Pizzeria Officer of the public health 4 employees No specific treatment Inspection of the work
service of the LHA environment
Distribution of information
leaflets Counseling

1:7:1, treatment repeated daily for 1 day, then 7 days without, and repeated daily for another 1 day; 3:7:3, treatment repeated daily for 3 days, then 7 days without, and
repeated daily for another 3 days; LHA, local health authority; LTCF, long-term care facility.
 ARTICLE IN PRESS
M. Marotta et al. / American Journal of Infection Control ■■ (2017) ■■-■■
DISCUSSION
The family outbreak described in this article is of interest for the
high number of persons involved, atypical for a family outbreak in
this area. Another particularity is that the people involved were not
marginalized members of society, but persons without those eco-
nomic and social barriers that could represent an obstacle to early
detection. Considering the 2-year-old child as the index case, the
attack rate was 87.5%, with 7 secondary cases among the 8 family
contacts. This high attack rate was mainly because of the delayed
diagnosis of the index case, which favored the infestation trans-
mission to many household members and amplified the risk of the
outbreak spreading to different settings. Misdiagnosis is a common
feature of scabies, particularly in institutional settings such as
hospitals,11 residential care homes,9 and schools.14 The late recog-
nition is because of scabies diagnosis difficulty when skin lesions
are minimal, or symptoms and signs are atypical, but can also be
explained by the low knowledge and experience of general
practitioners.22 In this outbreak, all cases presented signs and symp-
toms consistent with classic scabies,2 but it cannot be excluded that
other atypical cases may have occurred. These atypical cases, along
with crusted scabies, are identified as major contributors to scabies
outbreaks in the nosocomial setting.7
This family outbreak is also interesting for the presence, among
the family cases, of 2 people at high risk of spreading scabies to other
critical environments: a beauty center where the modality of working
(massaging with the bare hands, body care, etc) involves frequent
skin contact,23 and an LTCF, a nosocomial setting known to be at high
risk for diffusion during scabies outbreaks.11,12 It was not possible
to link the family outbreak to the LTCF case with any certainty, but
the link is strongly suspected (Fig 1). The fact that it was not pos-
sible to ascertain the source and the path of infection of the
nosocomial case represents a limit to the epidemiologic investigation.
Regarding the control measures, in the nosocomial setting, efforts
were concentrated on the training of staff and the implementa-
tion of a mass treatment management, as recommended by several
guidelines,10,24 and in accordance with the protocol suggested by
the regional regulations.18,19 These recommend topical treatment with
permethrin 5% on the basis of scientific evidence showing that
permethrin is highly effective and is related to adverse effects more
rarely than other topical treatments and oral ivermectin.8,24,25 No
cases of those treated in this outbreak showed adverse effects of
particular relevance.
In the case of workplace and school, the control measures were
focused on surveillance of all operators and scholars by the com-
petent health authorities and removal of cases from school and work
environments where other people might be at risk. This measure
was adopted in accordance with a recommended precautionary prin-
ciple, whereas the administration of specific prophylaxis was not
considered necessary.
The preventive measures taken were successful in limiting the
outbreak to only household members and in avoiding an institu-
tional outbreak in the LTCF. It was clear that the outbreak control
plan required considerable economic and human resources, espe-
cially in the nosocomial setting where the mass treatment proved
stressful for both patients and staff.
CONCLUSIONS
The noninstitutional outbreak described in this article high-
lights and confirms some aspects of scabies that should be improved:
(1) the delay in diagnosis or the misdiagnosis of index cases, mainly
because of the limited knowledge of scabies among general prac-
titioners; and (2) the underestimation of the actual number of
community cases because of the tendency to hide symptoms. Both
5
these factors contribute to delaying the adoption of control mea-
sures and increasing the risk of transmission, enhancing the
economic burden and the human resources required for the man-
agement of cases and their contacts. The strategy adopted here, based
on the surveillance of contacts, an information campaign, and the
appropriate administration of a specific prophylaxis, was success-
ful in preventing the spread of the family outbreak in the relative
school and work environments and also played a key role, togeth-
er with staff training, in controlling the spread of infestation in the
hospital setting.
Acknowledgments
We thank the hospital health manager, the medical and nursing
staff of the long-term care facility, the school managers and teach-
ers, the Red Cross staff, and the occupational physician of the beauty
center for the invaluable collaboration offered in the information
campaign and health care staff training.
References
1. Hengge UR, Currie BJ, Jager G, Lupi O, Schwartz RA. Scabies: a ubiquitous
neglected skin disease. Lancet Infect Dis 2006;6:769-79.
2. Chosidow O. Scabies and pediculosis. Lancet 2000;355:819-26.
3. GBD 2015 Disease and Injury Incidence and Prevalence Collaborators. Global,
regional, and national incidence, prevalence, and years lived with disability for
310 diseases and injuries, 1990-2015: a systematic analysis for the Global Burden
of Disease Study 2015. Lancet 2016;388:1545-602.
4. Romani L, Steer AC, Whitfield MJ, Kaldor JM. Prevalence of scabies and impetigo
worldwide: a systematic review. Lancet Infect Dis 2015;15:960-7.
5. Karimkhani C, Colombara DV, Drucker AM, Norton SA, Hay R, Engelman D, et al.
The global burden of scabies: a cross-sectional analysis from the Global Burden
of Disease Study 2015. Lancet Infect Dis 2017;17:1247-54.
6. Koene RP, Tjioe M, Hoondert K, Van De Vrie W, Olde Rikkert MG, Wulfen M,
et al. Scabies outbreak in a hospital and in 8 health-care institutions caused
by an elderly patient with scabies crustosa. Ned Tijdschr Geneeskd
2006;150:918-23.
7. Mounsey KE, Murray HC, King M, Oprescu F. Retrospective analysis of institutional
scabies outbreaks from 1984 to 2013: lessons learned and moving forward.
Epidemiol Infect 2016;144:2462-71.
8. Vorou R, Remoudaki HD, Maltezou HC. Nosocomial scabies. J Hosp Infect
2007;65:9-14.
9. Hewitt KA, Nalabanda A, Cassell JA. Scabies outbreaks in residential care homes:
factors associated with late recognition, burden and impact: a mixed methods
study in England. Epidemiol Infect 2015;143:1542-51.
10. White LCJ, Lanza S, Middleton J, Hewitt K, Freire-Moran L, Edge G, et al. The
management of scabies outbreaks in residential care facilities for the elderly
in England: a review of current health protection guidelines. Epidemiol Infect
2016;144:3121-30.
11. De Beer G, Miller MA, Tremblay L, Monette J. An outbreak of scabies in a
long-term care facility: the role of misdiagnosis and the costs associated with
control. Infect Control Hosp Epidemiol 2006;27:517-8.
12. Utsumi M, Makimoto K, Quroshi N, Ashida N. Types of infectious outbreaks and
their impact in elderly facilities: a review of the literature. Age Ageing
2010;39:299-305.
13. Van Den Hoek JA, Van De Weerd JA, Bayen TD, Molenaar PM, Sonder GJ,
Van Ouwerkerk IM, et al. A persistent problem with scabies in and outside a
nursing home in Amsterdam: indications for resistance to lindane and
ivermectine. Euro Surveill 2008;13:pii: 19052.
14. Ariza L, Walter B, Worth C, Brockmann S, Weber ML, Feldmeier H. Investigation
of a scabies outbreak in a kindergarten in Constance, Germany. Eur J Clin
Microbiol Infect Dis 2013;32:373-80.
15. Ejidokun OO, Aruna OS, O’Neill B. A scabies outbreak in a further education
college in Gloucestershire. Epidemiol Infect 2007;135:455-7.
16. Belvisi V, Orsi GB, Del Borgo C, Fabietti P, Ianari A, Albertoni F, et al. Large
nosocomial outbreak associated with a Norwegian scabies index case undergoing
TNF-α inhibitor treatment: management and control. Infect Control Hosp
Epidemiol 2015;36:1358-60.
17. Capobussi M, Sabatino G, Donadini A, Tersalvi CA, Castaldi S. Control of scabies
outbreaks in an Italian hospital: an information-centered management strategy.
Am J Infect Control 2014;42:316-20.
18. Assessorato alla Sanità—Regione Emilia-Romagna. Circolare n. 21: Linee di
indirizzo per l’applicazione in Emilia-Romagna della Circolare del Ministero della
Sanità n. 4 del 13.03.1998 “Misure di profilassi per esigenze di sanità pubblica.
Provvedimenti da adottare nei confronti di soggetti affetti da alcune malattie
infettive e nei confronti di loro conviventi e contatti”. Bologna (Italy): Servizio
Sanitario Regionale; 1999. Prot. 48161 PRC PR-RR.
 ARTICLE IN PRESS
6 M. Marotta et al. / American Journal of Infection Control ■■ (2017) ■■-■■
19. Agenzia Sanitaria—Regione Emilia Romagna. Epidemie di infezioni correlate
all’assistenza sanitaria. Sorveglianza e controllo. Bologna, (Italy): Servizio Sanitario
Regionale; 2006. Dossier 123.
20. Scott GR, Chosidow O. European guideline for the management of scabies. Int
J STD AIDS 2010;22:3101-3.
21. Centers for Disease Control and Prevention (CDC). Scabies, resources for health
professionals: institutional settings. Available from: http://www.cdc.gov/
parasites/scabies/health_professionals/institutions.html Accessed May 9, 2017.
22. Lapeere H, Brochez L, De Weert J, Pasteels I, De Maeseneer J, Naeyaert JM.
Knowledge and management of scabies in general practitioners and
dermatologists. Eur J Dermatol 2005;15:171-5.
23. Veraldi S, Cuka E, Francia C, Persico MC. Scabies acquired in Chinese massage
centers. G Ital Dermatol Venereol 2014;149:627-8.
24. Salavastru CM, Chosidow O, Bofa MG, Janier M, Tiplica GS. European guideline
for the management of scabies. J Eur Acad Dermatol Venereol 2017;31:1248-53.
25. Johnstone P, Strong M. Scabies. BMJ Clin Evid 2014;2014: 1707.