CONTROL OF INFESTATIONS: SCABIES, HEAD LICE, PUBIC LICE, BODY LICE Edition No: Dated:
6 December 2015
ID Number: Review Date:
Document ID: Policy Document Type: Nursing Directorate: Category: Department(s) Infection Prevention and Control Author:
Infection Prevention and Control
Sponsor:
POLCGR044 December 2018 Corporate Governance & Risk
Director of Infection Prevention & Control
Policy Dissemination
Intranet Consultation Process
Title of Individuals Consulted Infection Prevention and Control Team Modern Matrons Senior Sisters Name of Committee / Group Consulted Infection Control Committee
Date December 2015
Corporate Approval & Ratification
Committee / Job Title Infection Control Committee
Date December 2015
Document Control / History
Edition No 1 2 3 4 5 6
Reason for Change Replacement for ICTAP Reviewed Reviewed Reviewed Reviewed; HPA removed and replaced with PH England Reviewed – some treatments now discontinued.
References:
Document: Ref No: Barrett NJ. Morse (1993) The Resurgence of scabies, Communicable Disease report 3 (2). British National Formulary March 2013 Maunder JW. 1992) Treating the twenty-year itch. Practice Nurse Jan. 469 – 473. Maunder JW, (1992) The Scourge of Scabies. Pharmacy update. Chemist & Druggist January 54 55. Maunder JW. (1992) Insecticides as Medicines. Postgraduate update November. 864 – 869. Maunder JW. (1992) The Scourge of scabies. Pharmacy update.
Edition No: 6
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CONTROL OF INFESTATIONS: SCABIES, HEAD LICE, PUBIC LICE, BODY LICE Chemist and Druggist. 54 – 55. Maunder JW (1997) Scabies. The Medical Entomology Centre. Cambridge 1 – 7. Robinson R. Banker Kess–Jones L. Sivayoham S. (1995) An outbreak of scabies in a school for children with learning disabilities. Communicable Disease Report 5 (6). The University of York NHS Centre for reviews and dissemination (1999). Effectiveness Matters. Vol. 4. Issue. 1 British National Formulary (BNF) – September 2010 Health and Social Care Act 2012 Public Health Medicine Environmental Group: Head Lice: EvidencedBased Guidelines Based on the Stafford Report 2012 Updated Quality Commission Essential Standards of Quality & Safety Trust Associated Documents: Isolation Policy for Patients Mattress Policy Arrangements for the Control of an Outbreak of Infection in Medway NHS Trust Policy for the Management of Viral Gastroenteritis due to Norovirus Policy for the Management of Suspected or Confirmed Tuberculosis (including MDR TB) Management of MRSA (Meticillin Resistant Staphylococcus aureus) Guidelines for the Management of Clostridium difficile Varicella Zoster Virus (VZV) Chickenpox and Shingles Viral haemorrhagic Fever (VHF) Policy for Investigating Hospital-Acquired Legionellosis Policy for Hospital-Acquired Aspergillosis and Nocardiosis Guidelines for Laundry Hand Hygiene Guidelines Cleaning/Disinfection Policy Guidelines for the Management of Transmissible Spongiform Encephalopathy (TSE) including Creutzfeldt-Jakob Disease (CJD) Policy for the Prevention of Blood Borne Viruses Preventing Infections Associated with Indwelling Urinary Catheters Meningococcal Meningitis/Septicaemia Control of Glycopeptide Resistant Enterococci (GRE) Policy for the Management of Risks Associated with Infection Prevention & Control Control of Multi-Resistant Gram Negative Bacilli Blood Culture Policy Principles of Asepsis and Aseptic Non Touch Technique (ANTT) Policy for the Prevention of Infections Associated with Vascular Access Devices
Edition No: 6
Outcome 8 & 9
POLCGR37 POLCGR38 POLCGR39 POLCGR40 POLCGR41 POLCGR42 POLCGR43 POLCGR45 POLCGR46 POLCGR47 POLCGR48 POLCGR50 POLCGR51 POLCGR52 POLCGR53
POLCGR54 GUCPCM011 POLCGR060 POLCGR66 POLCGR067 POLCGR068 POLCGR-069 POLCGR070 POLCCPM02 6
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CONTROL OF INFESTATIONS: SCABIES, HEAD LICE, PUBIC LICE, BODY LICE Guidelines for the Prevention of Infections Associated with the Insertion and Maintenance of Central Venous Devices Guidelines for the Prevention of Infections Associated with Peripheral Venous Catheters Guidelines for Flexi-seal Infection Control in the Built Environment Environmental Policies and Infection Prevention and Control © Medway NHS Foundation Trust [2011]
Edition No: 6
GUCPCM006 GUCPCM007 GUCGR017 POLCGR088 POLCGR091
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CONTROL OF INFESTATIONS: SCABIES, HEAD LICE, PUBIC LICE, BODY LICE Table of Contents
Section
Page
POLICY DISSEMINATION .................................................................................................................................1 CONSULTATION PROCESS .............................................................................................................................1 CORPORATE APPROVAL ................................................................................................................................1 DOCUMENT CONTROL / HISTORY .................................................................................................................1 REFERENCES: ..................................................................................................................................................1 TABLE OF CONTENTS .....................................................................................................................................4 1
INTRODUCTION ........................................................................................................................................6
2
AIM .............................................................................................................................................................6
3
OBJECTIVE................................................................................................................................................6
4
DEFINITIONS .............................................................................................................................................6
5
ROLES & RESPONSIBILITIES .................................................................................................................6
6
SCABIES ....................................................................................................................................................7
7
GENERAL PRINCIPLES ............................................................................................................................8
8.
TRANSMISSION OF SCABIES .................................................................................................................8
9
RECOMMENDED TREATMENT FOR SCABIES ......................................................................................8
10
INFECTIVITY ..............................................................................................................................................9
11
CONTACTS ..............................................................................................................................................10
12
STAFF CONTACTS .................................................................................................................................10
13
PUBIC AND BODY LICE .........................................................................................................................10
14
THE BODY LOUSE (PEDICULUS HUMANUS) ......................................................................................10
15
GENERAL PRINCIPLES ..........................................................................................................................11
16
TRANSMISSION OF BODY LOUSE .......................................................................................................11
17
PUBIC LICE (PTHIRUS PUBIS) ..............................................................................................................11
18
TRANSMISSION OF PUBIC LICE ...........................................................................................................12
19
TREATMENT OF PUBIC LICE ................................................................................................................12
20
THE HEAD LOUSE (PEDICULUS CAPITIS) ...........................................................................................12
21
GENERAL PRINCIPLES ..........................................................................................................................13
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CONTROL OF INFESTATIONS: SCABIES, HEAD LICE, PUBIC LICE, BODY LICE 22
CHECKING FOR HEAD LICE ..................................................................................................................13
23
TREATMENT OF HEAD LICE .................................................................................................................13
24
PREVENTING RE-INFECTION ................................................................................................................14
25
EQUALITY IMPACT ASSESSMENT STATEMENT ................................................................................15
26
MONITORING AND REVIEW ..................................................................................................................15
27
APPENDIX 1 EQUALITY IMPACT ASSESSMENT ................................................................................16
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CONTROL OF INFESTATIONS: SCABIES, HEAD LICE, PUBIC LICE, BODY LICE 1
Introduction
1.1
Scabies, head lice, pubic lice and body lice are ecto parasites that can infect the human skin. Most of these infections can be eradicated quite easily and the risk of healthcare workers or other inpatients acquiring these parasites is small.
1.2
Treatment of these infections can be undertaken with minimum precautions and sensitivity to those infected providing healthcare personnel have an understanding of how these parasites are transmitted.
1.3
Scabies, head lice, body lice and pubic lice are not a serious health problem, however, professional and public reactions can lead to unnecessary, inappropriate or ineffective action and a great deal of unnecessary distress and anxiety.
2
Aim
2.1
The aim of this policy is to ensure the timely recognition and treatment of patients with different types of ecto parasites.
3
Objective
3.1
To prevent transmission of ecto parasites to others.
3.2
To provide support and reassurance to patients and families/carers with ectoparasitic infections.
3.3
Ensure that staff are aware of necessary precautions and treatments for ectoparasitic infection.
4
Definitions
4.1
Scabies Scabies is a persistent pruritic skin eruption caused by cutaneous infestation by the mite Sarcopes scabi.
4.2
Lice All three species of human lice are bloodsucking insects which are host specific. The head and pubic lice are found in specific areas (scalp and pubic hair) but can also occur in axillae, chest, legs, beard and eyebrows.
5
Roles & Responsibilities
5.1
Consultant Dermatologist/Dermatology Nurse Specialist • •
Clinical diagnosis and treatment (scabies). Advice to nursing/medical staff.
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CONTROL OF INFESTATIONS: SCABIES, HEAD LICE, PUBIC LICE, BODY LICE 5.2
Microbiology Department •
5.3
Clinical Directors/Consultants • •
5.4
Organisation and record keeping of staff requiring treatment or advice from Infection Control Doctor.
Senior Sisters • • •
5.7
Education and training of staff. Advice on isolation/placement of patients. Management of close contact patients. Inform Public Health England (Kent) if patients have been admitted from nursing/ residential homes.
Occupational Health •
5.6
Management of clinical cases. Appropriate treatment.
Infection Prevention and Control Team • • • •
5.5
Laboratory diagnosis
Inform Infection Prevention and Control Team. Daily management of cases. Allocation of single rooms.
Clinical Site/Bed Managers •
Allocation of single rooms.
6
Scabies
6.1
General Information Scabies is primarily an allergic reaction caused by a tiny parasitic mite known as Sarcoptes Scabiei. The mites burrow into the top layer of skin, on which they feed and through which they tunnel and lay eggs. The mites produce faecal pellets, from which an allergen diffuses into the deeper skin and eventually enters the bloodstream and causes the symptoms of scabies. As with all allergies the appearance of symptoms is delayed usually appearing four to six weeks after infestation. During the incubation period the person may be infectious without having any signs or symptoms of scabies. This can make the spread very difficult to contain and is the reason for treating contacts and cases at the same time.
6.2
The severity of symptoms and the nature of the infection are dependent upon the immune status of the individual.
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CONTROL OF INFESTATIONS: SCABIES, HEAD LICE, PUBIC LICE, BODY LICE 6.2.1 Classical scabies: The common form found in healthy individuals. The major symptom is a rash that is extremely itchy, especially at night. Burrows (if seen) may appear anywhere, but mainly on the hands, particularly the finger webs and arms. 6.2.2 Crusted scabies: This form of scabies (also known as hyperkeratotic or Norwegian scabies) is extremely rare and occurs in those whose immune systems are severely impaired. Because there is no allergic response, the itchy rash does not appear and the disease is not uncomfortable. The mites are numerous and may be anywhere on the body including the head. Areas of the skin may crumble away. This form of the disease is extremely contagious and is often at the centre of an outbreak. 6.2.3 Atypical scabies: Occurs in individuals with immature or impaired immune response. Common in long term care environments. Symptoms are variable, scaling or crusting may be present, but is usually slight. Itching may also be very slight or absent, and it may be some time before the infection is diagnosed. 7
General Principles
7.1
Those individuals suffering from suspected or confirmed scabies should be nursed using Standard Isolation precautions (see Isolation Policy POLCGR37, Section 2) until the first treatment is completed. They should not be nursed on Oncology wards.
7.2
Where scabies is suspected an opinion should be sought from a Dermatologist/or Dermatology Nurse Specialist at the EARLIEST convenience. (However, if Scabies is indicated treatment can commence before this review.)
8.
Transmission of Scabies
8.1
Scabies is spread from one person to another, by prolonged close skin to skin contact with an infected person e.g. holding hands/intimate contact. Scabies mites rapidly dry out away from the human body; therefore, the environment does not present a risk of transmission; this includes bedding and towels which should be managed normally.
9
Recommended Treatment for Scabies
9.2
PREMETHRIN 5% (Lyclear Dermal Cream) Very low toxicity, high cure rates, however, the treatment should be washed off after 8-12 hours.
9.3
Two treatments are recommended, the second treatment should be given 7
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CONTROL OF INFESTATIONS: SCABIES, HEAD LICE, PUBIC LICE, BODY LICE days after the first treatment as eggs are relatively more resistant than mites. Patients with crusted scabies and those with HIV disease are often difficult to treat and may require repeated applications of treatment.
NB: All members of the affected household should be treated simultaneously. 9.4
The treatment should be applied to cool dry skin and NOT after a hot bath.
9.5
It is essential that THE WHOLE SKIN AREA OF THE BODY IS TREATED, paying particular attention to the ears, between the fingers and toes, under the finger/nails, the soles of the feet, around the buttocks/genitals. AVOID THE EYES AND AROUND THE MOUTH.
9.6
MOST TREATMENT FAILURES CAN BE ATTRIBUTED TO INADEQUATE APPLICATION OF TREATMENTS.
9.7
The head should be treated in adults whose hair is thinning. (Scabies mites are unable to burrow between hairs that are grouped closely together).
9.8
Children under two years should be treated under medical supervision and have the treatment applied to the scalp, face and ears AVOID THE EYES AND AROUND THE MOUTH.
9.9
The treatment should be left on for several hours (8-24 hours, depending on the preparation, see data sheet).
9.10
If the hands or other skin areas are washed during the treatment period the treatment should be re-applied to that area.
9.11
Staff must wear gloves when applying treatment to patients.
10
Infectivity
10.1
Once the treatment (classical and atypical scabies) has been completed the patient is considered non-infectious: PREMATHRIN 5% (Lyclear dermal cream) - 8 – 12 hours
10.2
Patients with crusted scabies are difficult to treat effectively and may require more than two treatments to kill all the mites/eggs; they should be isolated until completion of treatments.
10.3 Please contact the Infection Prevention and Control Team for advice and confirmation to discontinue isolation precautions. 10.4 The itch may persist for 1-2 weeks; application of calamine lotion is helpful. Oral antihistamines at night may also be helpful. As an alternative, the
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CONTROL OF INFESTATIONS: SCABIES, HEAD LICE, PUBIC LICE, BODY LICE application of Crotamiton (Eurax) after completion of treatment cream can be used to control itching.
11
Contacts
11.1
Treatment of close contact patients will be managed by the Infection Control Team.
11.2
All members of the affected household should be treated; (this will be arranged via the GPs).
11.3
If patient has come from nursing/residential home the Public Health England (Kent) must be informed by the Infection Prevention and Control Team (IPCT).
12
Staff Contacts
12.1 Occupational Health will organize treatment for members of staff on the advice of the Infection Control Doctor and keep records. A bulk prescription for treatment may be used to obtain treatment for staff. 12.2 The Infection Prevention and Control Team organize treatments for the staff who have been close contacts, and bulk prescription needs to be obtained by Infection Prevention and Control Team/Occupational Health. 12.3 A list should be retained by the Infection Prevention and Control Team of close contacts, treatment and treatment date. 13
Pubic and Body Lice
13.1 Lice are blood-sucking insects and specific parasites of human beings. Lice are 13mm long and have 3 pairs of legs with powerful claws. There are 3 species of lice which have adapted to live on humans:
Head Louse (Pediculous humanus Capitis)
Body Louse (Pediculus humanus)
Crab (or pubic) Louse (Pthirus pubis)
14
The Body Louse (Pediculus humanus)
14.1
Life Stages Body lice have three forms: the egg (also called the nit), the nymph and the adult.
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Nits are lice eggs. They are generally easy to see in the seams of an infested person’s clothing, particularly around the waist line and under
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CONTROL OF INFESTATIONS: SCABIES, HEAD LICE, PUBIC LICE, BODY LICE armpits. Body lice nits occasionally also may be attached to body hair. They are oval and usually yellow to white in colour. Body lice nits may take 1-2 weeks to hatch.
A nymph is an immature louse that hatches from the nit (egg). A nymph looks like an adult body louse, but is smaller. Nymphs mature into adults about 9-12 days after hatching. To live, the nymph must feed on blood.
The adult body louse is about the size of a sesame seed, has 6 legs, and is tan to greyish-white. Females lay eggs. To live, lice must feed on blood. If a louse is separated from its person, it dies at room temperature.
The eggs of the body louse are laid mainly in the seams of clothing. The lice visit the skin to feed. Diagnosis depends upon seeing live lice in the seams of clothing. Seams may also contain large numbers of eggs. 15
General Principles
15.1
Those individuals suffering from suspected or confirmed body lice should be nursed using Standard Isolation Precautions (see Isolation Policy POLCGR37). They should not be nursed on Oncology wards.
15.2
Where body lice are suspected an opinion should be sought from a dermatologist at the earliest convenience.
15.3
Treatment is of the clothing rather than the patient.
16
Transmission of Body Louse
16.1
Transmission occurs in overcrowded conditions by contact with infested clothing. Body lice are easily eradicated as they will die if the clothing is not worn for at least 3 days. Clothing should be disposed of (with the patients consent) or washed in hot water (71oC) and tumble-dried. Contact the Laundry Manager to organise.
16.2 Isolation precautions can be withdrawn once clothing has been removed and washed. 17
Pubic Lice (Pthirus pubis)
17.1
Pubic lice are slightly smaller than head and body lice. They are crab-shaped, grey-brown in colour and about 2mm in length. The females lay eggs (smaller than a pinhead) on the hair-shaft near to the body. The eggs hatch after approximately 6-10 days. The empty egg-shells (nits) are tightly attached to the hair. The female louse lives for 1-3 months. Eradication from the body is unlikely unless treated. They are common amongst young adults. Shaving the infected areas does not provide protection from re-infestation because pubic lice need only a minimal length of hair on which to lay eggs.
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CONTROL OF INFESTATIONS: SCABIES, HEAD LICE, PUBIC LICE, BODY LICE 17.2
Survive on coarse body hair particularly pubic and axillary hair and may be found on chest and facial hair.
18
Transmission of Pubic Lice
18.1
Transmission occurs by close physical contact.
19
Treatment of Pubic Lice In general 2 applications are required, 7 days apart.
19.1
Consideration should be given as to whether the pubic lice infestation has been acquired via sexual or non-sexual contact. If acquired via sexual contact, a referral should be made to the Genito-Urinary Medicine (GUM) Clinic for treatment and screening for other sexually transmitted infections, and contact tracing. Topical Insecticide: Malathion 0.5% should be applied (i.e. Derbac-M or Prioderm), allowed to dry naturally and washed off after 12 hours.
19.2 The treatment should be applied to the whole of the trunk and limbs; the scalp should also be treated if there is evidence of scalp involvement. 19.3 Once the treatment has been completed isolation precautions can be withdrawn. N.B.
Insecticide lotions are not licensed for use on eyelashes. It is recommended to apply soft white paraffin to the eyelids and lashes 3 times daily for 2-3 weeks. This blocks the louses respiratory system and causes suffocation. Complications
Excoriation and skin infection due to scratching.
Blepharitis, conjunctivitis or corneal epithelial keratitis when the eye-lashes are affected.
20
The Head Louse (Pediculus capitis)
20.1
Head Lice are very small flat wingless insects, measuring 2-3 millimetres in length. Lice live close to the scalp where the surface temperature is 31%c or greater. They feed on blood. The female lays her eggs as close to the scalp as possible in order to ensure that they are at the optimum temperature for incubation. The eggs are glued to the hair strands and normally hatch within 7-10 days. The young louse is mature after 10 days, during which it will have moulted three times, and lives for 4-6 weeks.
20.2
The empty egg shell is called the ‘nit’ and is sometimes the first sign of infection. It
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CONTROL OF INFESTATIONS: SCABIES, HEAD LICE, PUBIC LICE, BODY LICE remains attached to hair and moves out from the scalp on the growing hair. On average an individual will have been infected for 4 months before lice are detected. 20.3
All reactions to lice take time to show, as it takes repeated bites for a person to become sensitised and start to itch. Children about 5 years of age become sensitised and start reacting to lice. Also individuals can carry lice and be a constant source of infection and re-infection in families and communities.
20.4
Transmission occurs when heads come into prolonged contact. They cannot jump, fly or hop.
21
General Principles
21.1
Adults with head lice do not need to be isolated. When in hospital, children should be isolated until the treatment has been applied, due to close contact with other children.
22
Checking for Head Lice
22.1
Examine the hair by combing damp hair with a fine-toothed detection comb.
22.2
Comb hair over a white paper or towel.
22.3
Look for lice on the comb or white surface. Look behind the ears, nape of neck and at the hair close to the scalp for nits. These are tiny cream coloured empty egg shells, glued to the hair.
22.4
Lice become dormant when wet. However, as they dry out on the tissue they start to move after 1-2 minutes. This is an easy way of detecting live lice.
22.5
Check pillows and collars for little black specks, which are the droppings and shed skin of lice.
22.6
A significant proportion of lice are damaged or killed by the action of a comb moving vigorously through the hair, this is a very important prophylactic measure. An ordinary grooming comb is recommended for this.
23
Treatment of Head Lice
23.1
The most important aspect of treatment is making the correct diagnosis. Live head lice should be seen before a definite diagnosis of infection with lice is made. Finding nits (empty egg shells) is not an indication for treatment.
23.2
Treatment of head lice is two-fold and involves: 22.2.1 The correct use of insecticide. 22.2.2 Effective contact tracing.
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CONTROL OF INFESTATIONS: SCABIES, HEAD LICE, PUBIC LICE, BODY LICE 23.3
TREATMENT SHOULD ONLY BE CARRIED OUT IF LIVE LICE ARE AROUND
23.4
There is no need to treat the entire family if head lice are detected in one person (see below).
23.5
Shampoos are not effective and must not be used.
23.6
In general, 2 applications are required, 7 days apart.
23.7.1 The hair should be clean and dry before applying treatment (free from chlorine, conditioner, gels and mousse) Treat with an aqueous Malathion product (Derbac-M or Quellada-M). (Dimeticone lotion 4% (Hedrin) rubbed into the scalp, allowed to dry naturally for a minimum of 8 hours before shampooing off has been shown to be effective.) (BNF 2010.) 23.7.2 Use lotion ensuring a minimum of 50ml is applied to each head (more if the hair is very long and/or thick). Apply the lotion to dry hair. 23.7.3 Part the hair into sections and rub in the lotion all over the scalp with fingers. All the hair and the scalp must be soaked. Gloves should be worn by healthcare workers. 23.7.4 Make sure that the back of the neck and the areas behind the ears are treated. 23.7.5 Leave the hair to dry naturally. DO NOT dry with a hair dryer. Leave the lotion on for a minimum of 12 hours before washing off.
23.7.6 Combing wet hair meticulously 4 times a day (30 minutes each time) with plastic detection comb (ensuring the comb is taken down to the scalp), continued for a minimum of 2 weeks can help to mechanically remove lice.
23.7.7 Inpatients with long term problems with head lice who have eczematous areas due to scratching, the eczemas area should be treated prior to head lice application 24
Preventing Re-infection
24.1
Prevention of recurrence is based mainly on identifying and treating relatives and other contacts of the family who are unsuspecting carriers who may pass infection back to treated individuals.
24.2
Individuals and families should be encouraged and advised to positively look for the
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CONTROL OF INFESTATIONS: SCABIES, HEAD LICE, PUBIC LICE, BODY LICE source of head lice infection. 24.3
This should include checking all those people who have social close contact with the infected person with whom they could have had moderately close head to head contact. Wherever possible this exercise should go back two to four weeks.
25
Equality Impact Assessment Statement
25.1
All public bodies have a statutory duty under the Race Relation (Amendment) Act 2000 to “set out arrangements to assess and consult on how their policies and functions impact on race equality.” This obligation has been increased to include equality and human rights with regard to disability, age and gender.
25.2
The Trust aims to design and implement services, policies and measures that meet the diverse needs of our service, population and workforce, ensuring that none are placed at a disadvantage over others. This strategy was found to be compliant with this philosophy.
25.3
Equality Impact Assessments will also ensure discrimination does not occur on the grounds of Religion/Belief or Sexual Orientation in line with the protected characteristics covered by the existing public duties.
25.4
Refer to appendix 1.
26
Monitoring and Review
What will be monitored
How/Method/ Frequency
Lead
Reporting to
Deficiencies/ gaps Recommendations and actions
Isolation room audits
As required
Head of Infection Control
Deputy Directors of Nursing
ICC
Review of Policy
Three yearly or when new guidance issued
Head of Infection Control
ICC
ICC
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Implementation of any required change
Required changes in practice will be identified and actioned within a specified time frame and lessons will be shared
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Appendix 1 Equality Impact Assessment Yes/No
1
Comments
Does the policy/guidance affect one group less or more favourably than another on the basis of:
Race
No
Disability
No
Gender
No
Religion or belief
No
Sexual orientation including lesbian, gay and bisexual people
No
Age
No
2
Is there any evidence that some groups are affected differently?
No
3
If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable?
No
4
Is the impact of the policy/guidance likely to be negative?
No
5
If so can the impact be avoided?
No
6
What alternatives are there to achieving the policy/guidance without the impact?
No
7
Can we reduce the impact by taking different action?
No
END OF DOCUMENT
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