Scabies and Body Lice Outbreak Among I.V. Homeless

Fast, effective, and pre-emptive;

Doctors Without Walls – Santa Barbara Street Medicine volunteers mobilize on a moment’s notice to successfully contain an outbreak of scabies and body lice among the homeless of Isla Vista before the opening of the warming centers.

By Jason Prystowsky MD, MPH, volunteer physician and medical director of DWW-SBSM

Dr Jason Prystowsky reflects on an outbreak of scabies and body lice among the homeless community in Isla Vista just before Thanksgiving and how Doctors Without Walls – Santa Barbara Street Medicine quickly and creatively contained it.

“It’s far more important to know what person the disease has than what disease the person has” Hippocrates

As the cold descends upon our Santa Barbara community, we begin to add layers of clothes and wrap up in blankets. We spend more time in closer proximity to others in our community – partly to stay warm, and to share a dry roof to wait out the storm. These conditions are the foundation for disease epidemic. Whether influenza, the common cold, or parasitic infestation, cold and scared people huddled together to endure the elements is often the first step to outbreak.

It was a cold and dark Monday evening. Since “day light savings” time ended, the darkness of night has fallen ever sooner every evening. As always, we with Doctors Without Walls – Santa Barbara Street Medicine follow the food. And as the homeless community of Isla Vista came from the parks, from behind dumpsters, from parked cars for a Monday evening meal. . .we opened our clinic for business. Our volunteer outreach workers scurried along the line yielding flashlights and head torches, talking to people as they waited for dinner. With smiles and gifted socks in hand, they greeted old familiar faces and asked if anyone needed to see the doctor. Just another night of street medicine. Routine. It was not long before we had diagnosed our 3^rd case of scabies and body lice. It was difficult to distinguish between the two parasites in the cold and the dark. Our patients were reluctant to remove their warm coats to show me their skin because of the cold wind. Part of the challenge of practicing medicine in the streets instead of a hospital or clinic. Since the treatment for both parasites is permethrin.. . it was an academic question. . .scabies or lice? . . .we treated both the same. After our fourth case diagnosed in under an hour, we became concerned about the pattern. Father Jon and I walked over to the Isla Vista Neighborhood clinic and asked our colleagues what they had been seeing in clinic that day. Their coordinator told us what we had suspected: they had diagnosed and treated four cases of scabies/body lice that day. That is eight confirmed cases. My first thought was how to appropriately measure the size, scale, and complexity of the problem before us. Eight cases of scabies and body lice in one small, confined geographical location- Isla Vista, the most populated square mile west of the Mississippi. And that is an epidemic (or an outbreak). Epidemics are like an iceberg. You only see a small part of it, but you know that there is much much more under the surface, and that is where the damage comes from. With the warming centers opening three days later. . . our response to this epidemic needed to swift, decisive, and effective.

The warming centers are an amazing collaborative effort of the faith based and humanitarian community. Different churches are on call to host the warming center if the forecast predicts an evening where the temperature drops below 35 degrees, where there is 50% chance of rain on two consecutive nights, or if there is a 50% chance for rain and the temperature is below 40 degrees.  Various churches open their doors to the homeless community to stay warm, dry, and to wait out the storm. Bedding is provided. And we with DWW-SBSM are fortunate to have the privilege to provide medical support. We needed to contain this epidemic before the warming centers opened. Otherwise we would have many infected people sleeping alongside vulnerable people in a closed and confined space. We knew what we had to do.

Dr. Prystowski examines a patient

Before we can talk about the outbreak. Some background. . .  Pediculus humanus capitus (the head louse), Pediculus humanus humanus (the body louse), and Sarcoptes scabiei (scabies), have evolved with human beings for thousands of years. Scabies hit pandemic levels around the world in the 1980s and as many as 300million people have it worldwide. It is caused by a microscopic mite too small to be seen by the naked eye which burrows into the skin and lays eggs causing intense itching. Patients who have had scabies often describe it as the worst itching they have ever had. Scabies tends to be more common in the winter months due to physical crowding in addition to the mite living longer off the body during the colder weather. Transmission occurs from close and prolonged person to person contact. You cannot get it from pets. It rarely transmits by casual physical contact such as shaking hands or sharing a seat on the bus. Occasionally when clothing and bedding is heavily contaminated, it can be transmitted by sleeping in the same bed, sharing clothing, or rarely handling clothing.

Body lice are commonly referred to in history especially in the context of war and as a vector for disease such as epidemic typhus, trench fever, and relapsing fever. These diseases are of historical interest and may be seen currently in the developing world, but rarely in Europe and North America. It is said that epidemic typhus killed more of Napoleon’s troops than Russians did during his retreat from Moscow in 1812. The cold, crowded, unhygienic conditions of military barracks were ideal for the body louse to thrive.  The body louse (about 2-4mm in length) lives in the clothing and lays its eggs along the seams. The louse visits the host’s skin to feed and can survive for up to three days without a meal. Risk factors for having body lice is similar to scabies: having a communal bed, poverty, poor hygiene, and being homeless. It is not hard to imagine how homelessness- with the poor access to showers, sinks, laundry, and methods to clean and decontaminate their clothes, bedding and bodies can make them vulnerable to parasitic infestation. We (the housed and the sheltered) tend not to get body lice since we bath every day, change our clothes every day, and live a much more clean, healthy, and stable lifestyle.

The treatment for both organisms is the same. A shower – with soap and water. Washing the clothes and bedding in hot water and dried on high heat. A topical cream called “permethrin” which is a neuro-toxin to both lice and the scabies. Permethrin is a safe and effective treatment but it must be washed off within 8-12 hours after it is applied to the body. This is easy for us who have housing and 24 hour access to a bathroom with running water, but more of a challenge for the homeless. But as one of my mentors with Medicins Sans Frontieres/Doctors Without Borders once said, “you do not sign up for the job, you sign up for the constraints.” We had a problem before us with a myriad of challenges and constraints. So we got to work. And we had to be creative in our solutions.

We set a time and place. The following day at 3pm we would start our scabies/body lice epidemic containment. Cases would be categorized as “infested” or “exposed”. An infested case had objective findings of scabies/lice infestation. Either visible wounds, burrows, organisms, eggs, or the symptoms of itching. Given that we were operating within an epidemic our inclusion threshold for infested cases was low. An exposed case slept in the same bed, shared clothing, or was in close proximity to an infested case. Infested cases were to get a shower with soap and water, have all of their clothes and bedding washed on hot water cycle with high heat dryer, and then was treated with a dose of permethrin 5% topical cream. All exposed cases got a shower, and their clothes and bedding washed but no treatment of permethrin. We simply did not have enough permethrin to treat everyone. Our plan seemed simple enough. The next problem was logistics. Logistics is always the challenge.

Allie Clement, the leader of Street Health Outreach (SHO) was inspirational in her ability to round up UCSB student volunteers to do outreach, laundry, and facilitate logistics. She promised to show up the following afternoon with 8-10 student volunteers to go out into the community and find cases. The SHO students would also help do laundry and facilitate the showers- an essential part of the process. RicHovesepian, our MRC liason was able to get soap and towels donated by Mission Linen. The Isla Vista Neighborhood clinic has access to a shower, but we were unable to obtain a key to use it. The Isla Vista Redevelopment Agency has access to the key and was unable to allow us access to it within our timeline. Never to be done in by bureaucratic inconveniences, Father Jon set up a mobile camping shower using hot water from a cooler that we were able to obtain from his office. And Sandy Miller made individualized bags of clothing for all of the infested and exposed cases, so that the patients would have clean clothes to wear while their clothes were being laundered. Putting on dirty clothes after showering would only allow re-infestation. Everyone pitched in to make it work.

When Tuesday afternoon came around, we were as ready as we could ever be. Father Jon had set up his camping shower. Sandy had individualized bags of clean clothing and she kept the line moving of people waiting to shower. Allie was with a group of inspiring students with rolls of quarters for the local laundry mat and black plastic bags with labels for laundering clothing and bedding. Garrett, one of our logisticians, had almost our entire stock of permethrin. I and Dr Matti Jensen checked patients for objective findings of scabies or body lice. The students combed the streets of Isla Vista, asking the homeless community if they had any symptoms or had been exposed. The homeless community rose to the occasion and joined our outreach team side by side helping to find cases and helping to talk people into coming for a warm shower and letting us help with laundry. Allan, a consistently compassionate personality among the Isla Vista homeless community, enthusiastically led our outreach workers to the people who he knew had been complaining of itching the night before. He felt a sense of responsibility to his own homeless community and wanted to help in the ways that he could. He was an essential part of our outreach team.

As the evening progressed we bundled up from the cold weather. We all pitched in fetching warm water from Father Jon’s office and carting it back to the park where we had our shower. I recall making two trips with Allan, fetching warm water from an office sink and filling a cooler. We chatted about Allan’s story and how he went from being a military veteran to being homeless. I mostly listened as we carted warm water through the cold night to refill the shower in between patients. Sandy and I debated about standards of care. She is a nurse by trade, and we talked about how in a perfect world, we would be discarding the infested clothing and bedding and not merely cleaning it. She brought to our attention that everyone we were treating with permethrin may not have access to a sink or shower the following morning to wash off the medicine. I was reminded of the many discussions I had had back in Sudan, Uganda, Haiti, Guatamala. I continued to share with Sandy the timeless lessons I had learned in my travels, that sometimes, at best, we are providing an imperfect offering. That we are not able to provide the gold standard of care to our patients. This is a sad truth. That circumstances do not allow us to be surgically effective but we are doing the best with the resources we were able to assemble on short notice. In short, sometimes good enough has to be good enough. And instead of judging ourselves by our shortcomings we should criticize the circumstances that put us into this situation. At least we are doing something even if it is an imperfect offering. Sandy Miller is an inspirational spirit and a true humanitarian. I hope Isla Vista community knows how lucky we are to have her. She was our inexhaustible moral compass throughout the evening.

The camping shower set up to treat scabies patients

One member of the homeless community was resistant to taking a shower that night. He complained about the cold. Allan was able to find him hiding from our outreach workers. The persistent charm of our volunteers- Allie, Maia, Matti, in addition the heckling from Allan and myself finally convinced him to be treated. When he came out of the warm shower into the cold air he asked for his jacket. . . which was in this process of being washed. Father Jon ran to his office to find another warm coat. I took my fleece off my own shoulders and gave it to him. It was my fleece back when I used to work at UCLA and I had not worked there in over a year now. I was planning on tossing it out but it was just so comfortable. He put it on and said “this is a nice one, and it is already warm.” He looked at the name on the right breast of the fleece. “Jason Prystowsky MD, MPH, UCLA Ronald Regan Medical Center,” and he looked at me and smiled and said “at least if anyone asks me who my doctor is, I can just look at my coat.” And we both smiled.

I will always remember that cold Isla Vista evening. Our volunteers were amazing. Ordinary people rising to the occasion the circumstances demanded of them. We communicated our findings with Santa Barbara County Public Health in addition to the coordinators of the warming center. Everyone was on the same page. That cold Tuesday evening we treated eight infested patients and two exposed patients. The following morning we treated more. But more importantly is the humanitarian act of community. We were out there in the cold with the homeless community. Standing beside them. This was not an act of charity but act of humanitarian solidarity. We did not give alms to the poor from our luxurious heights. We got down on the ground and met members from our community where they are at. We said to them, you have a problem, therefore we as a community have a problem, and we are going to solve it together. Allan was exceptional in his help going out into the homeless community to find patients whom he knew had either been infested or exposed. The homeless community assisted us in finding those who needed our help the most. Everyone pitched in to the capacity by which they could contribute. There is no greater human connectedness and shared human experience than working together to improve the health of a community. I hope that all of my friends can one day feel this.

There were no cases of scabies or body lice reported at the Isla Vista warming shelter two nights later. In public health we acknowledge that if we do our jobs well, then nobody will ever hear of us. The epidemic will have been prevented, the illness and suffering thwarted, and we are confined to congratulate ourselves silently and humbly drinking warm beer around a hurricane lamp. Laughing about the disaster that almost was. That Tuesday November night was cold. The camping showers were less than ideal. The laundry was the best we could do. But the enthusiasm, warmth, and perseverance of our homeless volunteers side by side with our SHO and DWW volunteers was something experienced beyond words. No amount of cold from the coldest of nights could chill the warmth that was there that night. Some fires cannot be extinguished. Some warmth, the cold will never penetrate.
Special recognition to the champions of the event. . . Father Jon Stephen, Allie Clement, Garret van der Water, Allan, and Sandy Miller!! You are an inspiration to us all!!