prepared this edition, for public distribution. Dr Raed Aburabi, medical coordinator for the ICRC's health care in detention team, supervised the preparation of this edition. This guide is dedicated to all those ICRC expatriate and national staff members who died working to save the lives of others.Scabies, a parasitic disease, is a major public health problem in many resourcepoor parts of the world, but remains comparatively neglected. Health problems in a community tend to appear in concentrated form in prisons; it is not surprising therefore that in these regions, scabies outbreaks occur frequently in prisons, where overcrowding is a major risk factor. Outbreaks of scabies have been reported in industrialized countries as well -in long-term-care facilities, makeshift refugee camps, nursing homes and less commonly, in acute-care facilities. Scabies does not usually kill, but it causes great discomfort, often disrupting sleep: "We even scratch in our dreams, " sufferers report. And it may cause secondary infections and post-infective complications, such as acute glomerulonephritis. The objective of ICRC action is either to eradicate the disease or to control it, which will ease the discomfort of detainees and reduce the risk of complications. Coordination amongst the various stakeholders and actors, and teamwork, is of utmost importance during an outbreak of scabies. This guide is intended for detention teams and health professionals dealing with an outbreak of scabies or case clusters in prisons. There are chapters on the following subjects: conducting an initial assessment; responding to an outbreak; evaluating the measures taken; and preventing further outbreaks. These chapters provide information; the Annexes at the end contain practical tools for use during a scabies eradication/control programme. The Annexes include: protocols for step-by-step scabies treatment; guidelines for estimating the staff and drugs and other materials needed; timelines; and diagrams showing how to set up a scabies eradication/control programme. Despite the care that has gone into its preparation the guide might contain errors. The authors would be grateful for any corrections that readers might want to send. They would also welcome comments and suggestions for improvement, as the guide should evolve in step with changes in the field.# BACKGROUND INFORMATION
1.1. The mite parasite
Scabies is a dermatological disorder, the result of infestation by the mite parasite Sarcoptes scabiei, variety hominis. The sarcopte is an external parasite (like the louse), an acarid that lives in the human epidermis. It is too small to be visible to the naked eye. Away from its host, it cannot survive very long: 24 to 36 hours at 24C and 40-80% relative humidity. Lower temperatures and higher humidity levels prolong its survival. At 34C, mites survive for fewer than 24 hours, irrespective of the level of humidity. The incubation period is two to six weeks in scabies-naive persons, but only one to three days in cases of reinfestation. This early reaction during reinfestation is because of the immune response: that is, the persons in question have an allergy to mites, as it were.

# Reservoir and transmission
Scabies is a communicable disease. Human beings are the only reservoir. Transmission occurs via direct body contact -in 95% of cases -or via contaminated clothes, bedding, bedclothes, carpets, and so on.
Predisposing/Aggravating factors that may contribute to the high prevalence of scabies in certain communities, and especially in detention centres
Overcrowding, poor living conditions, limited access to water, climate favourable for scabies mites, restricted access to health care, delayed diagnosis and treatment, wrong or missed diagnosis, shortage of drugs: all these contribute to high prevalence and the likelihood of outbreaks. The importance of poor hygiene has, however, been exaggerated: mites burrowed in the epidermis are resistant to water and soap, and even to daily showers.

# Clinical features, diagnosis and treatment
Itching, especially at night, is one of the main signs. The primary lesions are erythematous papules, vesicles, bullae and the tunnel or burrow, which is typical but rarely seen. The burrow looks like a short wavy line and is most commonly seen on the anterior part of the wrist, and on the fingers and penis. It is between 1 and 10mm long. The papules are small, may be sparse or numerous, and closeset. Over time, papules can turn into vesicles or even bullae. Common infection sites include the axilla, elbows, finger web, wrists, genitalia, buttocks, waist, knees, toes and navel. The scalp and the face are usually unaffected, except in infants, children and the elderly.
Scratching may cause lesions to develop a secondary infection with excoriation and crust. Coexistence of lesions is quite common; it can sometimes be mistaken for atopic dermatitis or eczema. Crusted scabies, another clinical form of scabies, is highly contagious, with many mites in each lesion. The skin is hypertrophied, hyperkeratotic or wart-like in appearance and can mimic psoriasis. The risk factors for this form of scabies include old age, diabetes mellitus and immunosuppression (patient under general or topical corticosteroids, HIV infection, haematological malignancy). Fingers and toenails are more significant reservoirs of mites than is often supposed. Skin-scraping is a well-established procedure for diagnosing scabies: the skin is scraped and the scrapings examined under a microscope for mites and their eggs or faeces. However this is of dubious value, being of low sensitivity; in addition, neither microscopes nor trained staff are available in many places of detention throughout the world.
In scabies cases, the patient and his or her bedding and clothes should receive adequate treatment. More details will be found in the chapter on the treatment of cases.

# Associated pathology
Superinfection may occur in approximately 10% of scabies cases. Staphylococci and streptococci are common causes and pyoderma is a typical complication. Acute post-streptococcal glomerulonephritis and septicaemia have also been described.

# Outbreaks
Outbreaks are quite frequent in detention and institutional settings (nursing homes, hospitals, and so on). Outbreaks are underreported and the frequency of their occurrence often underestimated; they are also often not addressed.

# INITIAL ASSESSMENT OF SUSPECTED OUTBREAK OR CLUSTER OF SCABIES CASES
Ideally, the initial assessment should involve the health authorities in charge, but that should be discussed with the prison director first.

# Confirm the diagnosis and the outbreak
In most prison settings, the diagnosis of scabies cannot be confirmed by microscopic examination. Health professionals will have to rely on their clinical knowledge of scabies lesions. Review the section on "Clinical features, diagnosis and treatment" in Chapter 1 if necessary.
For many outbreaks, 'typical case' , 'probable case' and 'contact case' should be clearly defined, usually as done below:
- - Typical case: One burrow or tunnel - - Probable case: Itching (especially at night) and several erythematous papules - - Contact case: Someone who has been in prolonged contact with a probable case or someone who shared confined space in close proximity with a probable-case patient for a prolonged period of time.
Usually, when a scabies outbreak or cluster is suspected, the health team will ask to see all the detainees complaining of pruritus, and check the lesions. A diagnosis of scabies may then be confirmed.
Once the presence of scabies has been established, it must be decided whether the cases represent an outbreak (epidemic) or a cluster of cases that is part of a chronic problem (endemic). An outbreak is generally defined as more cases of a particular disease than expected in a given area, or among a specific group of people, over a particular period of time. The cases are presumed to be related to each other or to have a common cause. 1 There is no clear criterion -the number of cases, for instance -for defining a scabies outbreak in the prison setting. In nursing homes and hospitals in industrialized countries, the existence of two 1 This is the definition provided by the United States' Centers for Disease Control and Prevention. Note that the terms 'outbreak' and "epidemic' have very similar definitions and are sometimes used interchangeably. However, 'outbreak' is more commonly used to characterize the situation in smaller areas or groups, such as villages, towns, or specific institutions such as prisons; 'epidemic' tends to be reserved for situations involving large numbers of people dispersed over a wide geographical area.
typical cases (with the burrow/tunnel), together with other probable cases, may constitute an outbreak. In poor communities in the developing world -urban and rural -scabies may be endemic and a few scabies cases may be nothing out of the ordinary. In these contexts, scabies is likely to be a constant presence in prisons; therefore the best criterion for defining a scabies outbreak may be an increase in the number of scabies cases each week.
If it is not an outbreak but a cluster of cases that is part of an endemic problem, the treatment of individuals will help to control the disease but will not eradicate it. While managing an outbreak -as described here -the aim is to eradicate the disease; but, bear in mind that a single case not treated on arrival may lead to cluster cases or an outbreak.

# Epidemiological description
The number of persons affected and their location, together with all defining characteristics (gender, accompanying children, underlying known disease), should be recorded, as well as the names of the contact persons. In overcrowded cells or prisons, especially where there is a lack of fresh air, all the detainees should be regarded as either probable cases or contact cases. Changes in the number of cases can be analysed if a reliable consultation record book is available.

# Living conditions
Living conditions must be assessed in order to decide on the approach to treatment, and to estimate the time needed. The factors to consider are listed below:
- Number and state of showers or shower areas (this will have the greatest impact on the pace of the treatment) 

# Preliminary conclusions
The health team must prepare a report that should answer the following questions:
- Are the skin problems scabies?
- Is there an outbreak (epidemic) or are the scabies cases part of a chronic problem (endemic)? (Compare the prevalence of the disease in the prison setting with that in the community. How has prevalence evolved over time?) 
- Is there a likely specific source (new arrivals from another facility, for instance)?
- What needs to be done and how?
The report should also contain a brief description of the health-care system in prison settings, and at the national and local levels.

# GENERAL APPROACH TO MANAGING AN OUTBREAK OR CLUSTER OF SCABIES CASES
Managing an outbreak of scabies at a prison is a multidisciplinary team exercise. Also, remember that it is essential to ensure the availability of the resources necessary for an effective response.

# Stage 1: Forming a crisis committee
An outbreak committee with one coordinator should lead the management of the outbreak. It should be created quickly once the outbreak has been recognized. Ideally, the coordinator should be a representative of the prison health authorities (usually someone from the ministry of public health or the doctor in charge of detainees' health). The committee should consist of representatives of: The committee should consist of people with expertise in these areas: health, water and hygiene, logistics, security and coordination.
The members of the committee should first decide upon the objective: whether to eradicate the disease or control it. Depending on the objective, the committee must choose a strategy and allot tasks within teams (Table 1). To eliminate the disease, it is necessary to treat the whole population (irrespective of whether individual detainees have skin lesions or not), as well as all the interior of the prison. To control the disease, only scabies sufferers and their belongings have to be treated. Another option would be to treat only the block where the outbreak occurred (if only one block was affected) -in elimination campaign mode, as it were -and to control the spread of the disease in the other blocks by treating only scabies sufferers and their belongings. Where overcrowding is an issue, the elimination mode is preferable. However, if there is no space outside cells or blocks -in the form of prison yards, for example -and if detainees have a lot of belongings (carpets, blankets), the elimination mode will be impracticable. The objective then would be to control the disease, not to eliminate it. Give detainees all necessary information before starting treatment

# Ensure financial resources
Table 1 In most instances, the following teams will have to be assembled:
- Cleaning and hygiene promotion: in charge of cleaning the cells when empty, and corridors, latrines and showers at the end. The detainees themselves can be trained for this task. The hygiene promoter(s) will have to conduct one or more sessions for detainees.
- Disinfection of belongings: in charge of putting anti-scabies powder in the bags in which clothes and blankets have been deposited and on bedding and carpets. If the committee has chosen the washing instead of the permethrin strategy, then this team -consisting mainly of detainees -will be in charge.
- Medical: in charge of anti-scabies (topic or oral) treatment and treatment of superinfection.
- Detainee flow control: usually done by the guards and or cell leaders.
The committee should decide who will pay for each activity undertaken, and who will be carry out these activities. It should also decide on the drugs to be used (topical scabicides, ivermectin, antibiotics for superinfections), the method for treating clothing and bedding (permethrin or something else) and the disinfectant for walls, floors and other surfaces (chlorine, for example). It should also raise the question of treatment for prison guards and their families.
If insects in the prison are also an issue, that may be an opportunity to fumigate the cells in addition to cleaning them. However, if this option is exercised, it must also be borne in mind that detainees will then have to spend more time outside their cells because of the potentially toxic effects of the insecticides.
It is important to decide if detainees should receive new sets of clothing and blankets each or if they may treat existing sets of these before the start of the campaign. New items are the easiest option but, depending on the number of detainees, may add considerably to the budget. Treating existing clothing and blankets will prolong the campaign; it will also require additional bags and permethrin for the treatment as well as more people to treat the bags and put them outside for 24 hours. It will also add to the flow of materials once the campaign is under way; additional manpower will be required as well, to ensure that each detainee receives the correct bag of pre-treated clothing, and at a set time.
The response will be free of charge for the detainees, the guards and their families if they also require treatment.
The committee should draw up a budget with the following in mind: The ICRC can carry out all the activities required and pay all the costs if the health authorities are unwilling or unable to do either.

# Stage 2: Preparing a campaign to eliminate or control scabies
After settling on the strategy, make an inventory of the resources available and of those that can be mobilized; the crisis committee should plan the campaign.
The first task is to set up a time frame and draw up a list containing all the activities to be carried out (and when), as well as the persons who will be in charge of each. Planning should take into account visitors' days and national holidays. Ideally, family visits should be forbidden during the campaign, but it is seldom recommended because it may interfere with the well-being of the detainees. A scabies outbreak is not an emergency and it is advisable to take time to assess the situation carefully and plan accordingly. The time frame will also allow the committee to follow the progress of the campaign (see the example in Annex 6).
If possible, schedules for court hearings (names and dates) should be acquired in advance, to make sure those detainees will not be forgotten during the treatment process.
The flow of the detainees (packing their belongings, showering, medical treatment, transporting their own bags outside, staying outside until their cells have been cleaned, returning with only clean clothes and carpets) should be very clear to the prison director (Annexes 5.1 and 5.2).

# Stage 3: Providing information for detainees
Detainees should be given information on the disease and on what is going to be done to eliminate or control it. They should also know what the crisis committee expect from them.
The information on the treatment should include the flow of people during the period in question and instructions in connection with the treatment (see Annex 7). If ivermectin is chosen, detainees should be told that they must not eat or drink anything for two hours before and after the treatment. If BB is chosen, detainees should be shown how to apply it; they should be aware that they may feel a burning sensation and should be encouraged not to take a shower 24 hours before application. If they wash their hands and/or feet during those 24 hours, they should re-apply the BB on their hands and/or feet. It is crucial to draw attention to this in Muslim countries in particular, because of the numerous prayers and ablutions involved. Cultural usage makes it difficult to apply BB correctly in every particular (showering together or in public is not common in a lot of countries). Therefore, the process of application must be explained several times (the steps in the right order, and other matters as well).

# Stage 4: Organizing an elimination campaign
The campaign will vary according to the treatment chosen.
- Topical anti-scabies treatment (see Annex 5.1) Cell by cell, block by block, the detainees put their belongings in bags (see Annex 9 on the treatment of clothing and bedding). They receive one bar of bath soap and go to the showers wearing their bath towels. They take a shower. Afterwards, wearing their towels, they proceed to the treatment area. They drop their clothing and the towel in their medium-sized plastic bags. Then they receive their treatment. They get a new set of clothing and towels or a clean set (that was washed or treated with permethrin a few days before). They then proceed to the courtyard and stay there until their cells have been disinfected. They have a session on hygiene promotion while they wait. On returning from the yard, they receive new blankets for the night or their own blankets that were treated a few days ago. The next day, they take a shower and receive the second application of BB. Then they go to the courtyard to retrieve their bags and, shake out their clothes, after which they put their cells in order. Cell by cell, block by block, the detainees put their belongings in bags (see Annex 9 on the treatment of clothing and bedding). They receive one body bar of bath soap and go to the showers wearing their bath towels. They take a shower. Afterwards, they drop their clothes and the towels in their mediumsized plastic bags and get new sets of clothing and towels or a clean set (that was washed or treated with permethrin few days before). They swallow the tablet with some water (direct observed treatment). They then proceed to the yard and stay there until their cells have been disinfected. They have a session on hygiene promotion while they wait. On returning from the yard, they receive new blankets for the night or their own blankets that were treated a few days ago. The next day, they go to the yard to retrieve their bags and shake out their clothes, after which they put their cells in order.

# Estimation of needs (materials, drugs and human resources)
Information on the estimation of needs can be found in the chapter on the treatment of cases, bedding, clothing and environment and in Annexes 3.1 and 3.2.

# Monitoring and follow-up during the campaign
The number of detainees leaving the treatment area should be counted, to make sure no one is forgotten and to order more supplies in a timely manner, in case more people than expected have to be treated. To ensure the availability of water throughout the campaign, its supply should be monitored closely. At the end of each day, the teams should meet to share and consolidate monitoring data on consumption and on the number of persons treated, and to prepare for the next day. What went wrong should be discussed to make adjustments the next day.

# Stage 5: Reporting
After the end of the campaign, a report should be prepared, with the involvement of at least the prison doctor. It will help to pass on information, internally and to stakeholders, on the outbreak and on what was done. It will also be useful for updating the guidelines with the lessons learnt (see Annex 11 for a template for the report).

# TREATMENT OF CASES, BEDDING, CLOTHING AND ENVIRONMENT

# Treatment of cases
There is insufficient evidence at present to make a recommendation in favour of either oral or topical treatment. However, its usability favours oral treatment, especially if the number of people to be treated is an important consideration. Annex 1 sets out the various possibilities.
Daily workers should be treated once they have finished their work; to avoid re-contamination they should be treated on the same day as their cellmates.

# BB (topical treatment)
Advantages: Available throughout the world (except in the United States) and economical (less than 1 USD/treatment). However, the cost of transporting it should be considered (as it is much heavier than ivermectin).

# Contra-indications, adverse effects, precautions
- It may cause a burning sensation that the detainees should be made aware of; Otherwise, they might be disinclined to go through the second application.
As it is an irritant, it might cause diagnostic uncertainty if signs or symptoms recur after treatment.
- Do not apply to mucous membranes (mouth, nose, rectum, vagina).
- Should it get into the eyes, wash with plenty of clean water.
- Never swallow! Ingesting BB is very dangerous, and may cause convulsions.
In case of accidental ingestion, refer the person to a doctor who will prescribe activated charcoal.
- In case of breast-feeding, do not apply to the nipples.
Preparation: 25% BB lotion (other preparations might be available, but this one is probably the least unwieldy for prison settings)
Use: Shake before use. For adults, the pure 25% BB lotion should be used. For children, it should be diluted by half (one part BB and one part clean water). For adults, the BB should be left on the skin for 24 hours; for children under the age of two it should be left on for only 12 hours; and for children under six months old, the BB should be left on for only six hours. For children under the age of two, bandages on the hands will help to prevent accidental ingestion. Children and the elderly often have lesions on the face; so BB should be applied on their faces, too. Health staff should apply the BB, using sprayers (five-litre sprayers). BB is sprayed on the body, and each detainee must spread it according to health staff's instructions. This should be supervised, as people, especially minors, tend not to do it carefully. Detainees can help spread the BB on each other's backs (see Annex 1 for more information on the use of BB). For pregnant women and children less than six months old, apply the solution only once (one-day treatment).
If necessary, a makeshift treatment area can be set up outside the blocks.

# Ivermectin (oral treatment)
Advantages: Much easier to use than BB. It is almost impossible to ensure that detainees will apply BB carefully all over their bodies, especially in the genital area. There is also no need to construct a treatment area if ivermectin is used.
Ivermectin has approval, in many countries, only for the treatment of nematode infections (for which also it is effective). However, its off-label use for parasitic skin diseases is common throughout the world.

# Contra-indications, adverse effects, precautions
- Transient new-onset pruritus or worsening of existing pruritus may occur.
- - It is not recommended for children weighing less than 15 kg (or under the age of five), or for pregnant or breastfeeding women.
- Do not eat for two hours before and after taking ivermectin.
Presentation: Ivermectin is available in 3 mg unscored and 6 mg scored tablets.

# Dosage and duration:
Although many persons with classic scabies respond well to a single dose of the drug, its ineffectiveness against nymphal forms and eggs is an argument for a 200 mcg/kg-dose regimen, the doses separated by approximately one week. The tablets should be swallowed in the presence of health staff (direct observed treatment).
Most individuals with crusted scabies will required combination therapy: topical scabicide plus oral ivermectin plus topical keratolytic. Other possibilities for topical treatment Malathion (two consecutive nights), sulphur 2% to 10% in white petroleum jelly (three consecutive nights), 5% permethrin cream (one application for 8 to 14 hours and a second one, seven days later), 1% lindane lotion/cream (one application for 24 hours on two consecutive days or a second application one week after the first -also for 24 hours). Permethrin takes effect more quickly and with fewer side effects than BB, but its widespread use is limited by its cost. Lindane can have severe effects on the central nervous system (restlessness, anxiety, trembling and convulsions), especially when applied on broken skin or to epileptic or underweight adults; as broken skin and epileptic or underweight adults are common features of places of detention, this topical drug should be avoided.

# Ivermectin doses according to body weight in kg

# Additional treatment in case of superinfection
Usually, oral anti-streptococci and anti-staphylococci are required to treat cases of superinfection. Ideally, a seven-day treatment with macrolide (for adults, 2 g/day of erythromycin, divided into two doses) or cloxacillin (for adults, 3 g/day divided into three doses) should be started one or two days before the anti-scabies treatment. However, in heavily populated prisons, it is seldom possible to screen all the inmates for superinfection. Therefore, cases of superinfection will be discovered during the application of BB, or detainees will have to be checked for it when or before they are given ivermectin. When BB is being used, the medical team in charge of spraying detainees with it should check for superinfection and give tokens to those who need antibiotics; these detainees will then be referred to the medical staff in charge of treating the superinfection. When ivermectin is used, the medical team can examine detainees when they get out of the shower and give tokens to those who need antibiotics.

# Contact-case management
A 'contact person' is someone who has had prolonged skin contact with a scabies sufferer. The contact case should receive the same treatment as people suffering from scabies. Ideally, in overcrowded blocks or cells, all the detainees should be treated whether they are affected or not, as it should be assumed that they are all contact cases or scabies sufferers. However, because of the lack of space it might not be possible to treat all of them with all their belongings.
With regard to treatment for guards and their families, the crisis committee should decide whether to treat them, based on the type of contact they have with the detainees.

# Treatment of clothing, bedding and the environment
Whenever possible, for each detainee, a set of clothes, a large towel and a blanket should be washed at 60C (at least) or in boiling water, and ironed, or treated with permethrin in advance and kept safe, out of range of re-infection, before the campaign starts. The additional time and resources required must be taken into account during the planning phase. In spite of such planning and preparation, some detainees may still find themselves without a spare set of clothes, a towel or a blanket. These things should be provided to them on the first day. They should be given their towels before they go to the showers, and the clothes and blankets just after the treatment (see Annexes 2, 5.1 and 5.2). Even when most of the detainees have spare sets of clothes, there will always be some without. It would therefore be prudent to buy a few sets of new clothes in advance. The same may apply for towels and blankets. Disinfection of clothing and bedding should be done on the same day that the detainees receive treatment (see protocol in Annex 2). Permethrin should be put into the bags outdoors, as it is toxic. Daily workers should wear masks. If rain is forecast and the yard has no roof, a tarpaulin should be set up. Bedding and clothing should be left in the bags with the permethrin for 24 hours.
The cells should be disinfected on the same day as the detainees; the corridors, common rooms, showers and latrines should be disinfected on the last day.
(See protocol in Annexes 2 and 8)

# Estimation of needs Drugs
Estimation of needs is based on the initial assessment and on the number of cases. Experience shows that when BB is used, each patient or contact person will require between 150 and 200 ml of it (for the two doses). If ivermectin is used, between 8 and 12 tablets of 3 mg will be needed for each person (for the two doses). Most of the time, about 10% of all those affected also have superinfections. There should always be a stock of these drugs in reserve, as new cases will have been registered or new detainees will have arrived by the time the campaign gets under way. This reserve stock should be bigger when treating cluster cases (where there may be more uncertainty about the number of cases) than when conducting an elimination campaign. As a rule, while treating cluster cases, reserve stocks should run to 25%, and while conducting an elimination campaign, to 10%.
Example: For a scabies elimination campaign (treatment for all whether affected or not) using BB 

# Water, showers, and soap
As far as we know, the consumption of water during an elimination campaign has never been measured. We may assume that the quantity of water requested, per person treated, is comparable to that for an IPD facility: 40-60 litres per person per day. As each person will undergo two days of treatment, we may assume the amount of water to be 80-120 litres per treated person, or 40-60 litres/person/day for two days. Sometimes water trucking has to be organized.
The more showers that are available, the faster the pace of the campaign.
Although the ICRC recommends one shower per 50 persons, this is often impracticable. But if it is available, it will be possible to treat 35-40 detainees per hour per team. Makeshift showers can be set up in the yard. With one shower per 27 persons, the pace of treatment can be as much as 70 detainees per hour per team. Where there are more showers, more teams will be needed. When hot tap water is not available in a cold country or during cold weather, water will have to be heated. Temporary water boilers will have to be installed, and buckets for carrying the hot water made available. More daily workers will be needed (see Annex 3.1 for HR needs)
Each detainee will receive one bar of bath soap when going to the showers.
A reserve stock of soap should be considered. If BB is being used (with two doses), it might be better to give detainees one bar of soap on the first day and a second on the second day. Some detainees will lose their bar of soap between the first and second days of treatment. Giving them two bars of soap will also provide hygiene materials for after the campaign: in some contexts, soap is a rare commodity in places of detention.

# Permethrin
Experience shows that 150 g of permethrin are needed per detainee, for both medium-sized and large bags. A reserve stock of permethrin should be set aside (10% for elimination mode, 25% for control mode). It is helpful to have a plastic cup marked with a line, to let daily workers know how much powder to put in each bag. It will be a rough estimate but will ensure that enough, but not too much, permethrin is used; and it will also reduce the possibility of running out of it.

# EVALUATION
The evaluation of the campaign will analyse its quality, effectiveness and reactivity, as well as resources, safety and costs. It should be carried out one month or six weeks after the end of the campaign, as itching can last for a few weeks after treatment. A report should be prepared and the findings communicated to the prison director and to all those interested parties who were involved in the campaign.

# Indicators

# Data necessary for indicators

# Data: Sources and collection methods

# Comments

# Effectiveness and quality
People still itching at night 

# PREVENTION OF OUTBREAK
Certain things are needed to prevent scabies outbreaks in prison settings: medical screening of detainees upon arrival, good topical treatment and supply chain of disinfectants, fair access to health care, and a health staff that is familiar with scabies. Their absence will increase the likelihood of outbreaks.
And certain things will put detainees at more risk: overcrowding, lack of water and hygiene, and lack of fresh air and exercise.

# Medical screening upon arrival
A single detainee can, without proper and prompt treatment, contaminate a lot of other inmates. The SMR 2 and numerous domestic laws require that every detainee be examined by a medical professional as soon as possible after his admission to a place of detention (Rule 24 of the SMR). The BPP 3 states the same (Principle 24). The latter states also that the examination must be provided free of charge. When those principles or rules are respected, the detainee can be treated promptly on arrival, which can also help to prevent a scabies outbreak.

# Availability of treatment and health staff
Shortage of drugs can result in widespread infection. International rules, especially the SMR, require that the quality of care in prison be at least equivalent to that in the community. The BPP states also that drugs should be provided free of charge. In many countries, scabies is a public health problem and health facilities are supplied with topical scabicidal agents, but so should health facilities in places of detention. It should also be noted that most of the time, topical treatment is provided for people but their bedding and clothes are left untreated. In a prison setting, it is of the utmost importance to treat patients and their belongings, because of people's proximity to one another and, often, the overcrowded conditions.

# Access to health care
Both the SMR and the BPP state that detainees who complain that they are feeling unwell should have access to medical care (Rule 25 and Principle 24). An effective system is one that allows sick people access to health facilities. 

# Health staff: Familiarity with scabies
Wrong or missed diagnoses can lead to the high prevalence of infection. Too often, scabies is not recognized and confused with other pruritic dermatoses: eczema, tinea and atopic dermatitis. Pyoderma could hide a scabies infection and crusted scabies can resemble psoriasis. Health personnel should receive training in this area, to prevent new outbreaks; the training should be a combination of lectures and discussion of cases (illustrated by photographs).
On-the-job training, where possible, is also very useful. Distribute three bags to each detainee: 110-litre bag for blankets, 35-litre bag for clothing, and a small plastic bag, of a different colour if possible, for things that will not be treated (books, watch, toothbrush, etc.)

# ANNEXES
Distribute one piece of string to each detainee to close small bags, and take great care over the handling and placement of these bags as they may contain religious materials Distribute labels and markers for the bags (to mark with names and cell numbers)
Information for detainees

# D1
Cell by cell, detainees should put their belongings in labelled bags
They should keep only one large towel, to wrap around themselves when they go to shower and to dry themselves afterwards
The towel should then be dropped into the 35-litre bag Hygiene team bring bags outside and pour the required amount of permethrin into them, seal them with the strings and shake them Sealed bags remain outdoors for 24 hours Cell by cell, sweep the floor, remove dust from the bars, the doors, the beds, the pillars, and the walls up to a height of one metre With a wet brush, clean the things mentioned above -only with water or with water and detergent; remove excess water with mop
To disinfect, spray an active 0.2% chlorine solution or chloroxylenol all over the floor, the doors, the beds, the bars, the pillars, and on the walls up to a height of one meter (from top to bottom)
When everything is dry, the detainees may return to their cells If fumigation has to be done at the same time, the detainees will have to be out of their cells for two hours; this needs to be considered while planning Preparation of an active 0.2% chlorine solution using the most easily available products
Remember that the concentration of chlorine solutions declines over time (1% per day). To avoid corrosion, never use a metal container. Medical supplies and drugs       The mites that cause scabies cannot be seen with the naked eye. They are about 1/4 of a millimetre in length and can be seen only with a microscope.
Scabies mites, unlike fleas, cannot jump from one person to another. However, they can be spread by direct body contact between people. Also, scabies mites may be transmitted through clothes and bedding, and when people live in close quarters. Clean cells in this order:

# Preventive measures
1. Clean from up to down. 2. Clean from the back to the front.
Clean in this order: the cell, the internal corridor, the showers and toilets, and the external corridor.   

# The internal corridor

# Cost and budget
Conclusions and recommendations for preventing recurrence

# Main localizations of the signs of the disease
Be sure that all these areas are covered with the benzyl benzoate lotion Few days to few weeks before symptoms, but you are already contagious

# Explain the treatment chosen and what it will involve
The symptoms may persist for two to four weeks after the treatment; the mites will be killed; and you will no longer be contagious. 

# MISSION
The International Committee of the Red Cross (ICRC) is an impartial, neutral and independent organization whose exclusively humanitarian mission is to protect the lives and dignity of victims of armed conflict and other situations of violence and to provide them with assistance. The ICRC also endeavours to prevent suffering by promoting and strengthening humanitarian law and universal humanitarian principles. Established in 1863, the ICRC is at the origin of the Geneva Conventions and the International Red Cross and Red Crescent Movement. It directs and coordinates the international activities conducted by the Movement in armed conflicts and other situations of violence.