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Headlice Guidelines

PEDICULOSIS STATEMENT

Introduction
Pediculosis Humanus Capitis, commonly known as head lice, is a common parasitic infestation affecting all ages, races, genders, and socioeconomic levels. It affects six to twelve million people a year and is most prevalent in young girls between the ages of
four and ten. Literature reveals that head lice are the second most common childhood health condition, second only to the common cold1. Most distressing though, parents of school-aged children rank head lice as a more important concern than some more serious
health conditions. The facts show head lice to be more of a social issue than a serious health concern.

The following are recommended as best practices:
  1. Providing consistent information for schools, health agencies and social services agencies to effectively control the spread of head lice.
  2. Providing consistent education on safe and effective lice treatment.
  3. Providing consistent education for effective prevention.
  4. Providing an established process to respond to those families and students having difficulty with chronic or recurrent lice infestations (including practice and referral criteria).
Brief Overview of Head Lice2
Head lice are tiny parasitic insects that live, feed and breed only on the human head. They do not live on animals or birds and cannot survive for more than 48 hours off of the human head. The female head louse lays eggs (nits) in the hair, glued tightly to the hair shaft. An infestation of head lice can be symptom free and go undetected for several weeks. Symptoms may include itching, redness and scratch marks. Severe untreated infestations can lead to secondary infections caused by bacteria. Head lice themselves do not carry or transmit any diseases.
Head lice are primarily transmitted by direct head to head contact. An example of this would be siblings sharing the same bed and pillow. This contact forms a handy bridge for the head lice to cross over from one person to another. Hugging and cuddling are also forms of direct contact. Other forms of transmission are less direct, such as sharing of hairbrushes, combs, barrettes, hats, scarves, etc. One important thing to remember is that head lice are “obligate human parasites”. They want to stay on the same host throughout their life cycle. An infestation of head lice can bring on a wide range of emotional responses ranging from embarrassment to guilt to rage. Parents and caregivers can experience much frustration that can lead to anger and blame, especially to the school. For the school-aged child, an infestation with head lice can cause excessive absenteeism. For the caregivers, it can cause lost time in the workplace and lost wages. Schools are impacted by increased
staff time spent in screening for head lice, calling parents and other related matters that infringe on their usual duties. Current research indicates that most lice infestations are not contracted in the school setting.

Treatment
Treatment is a three step process.3, 4
  1. Use of a lice killing agent: There appears to be no satisfactory chemical or herbal treatment known to be 100% effective in the elimination of live lice and nits. Parents should be given accurate information regarding treatment. Their school nurse, health care provider or pharmacist can provide specific information regarding what treatment is best for a given family. It is very important to remember individuals react differently to different medications including alternative treatments. Therefore, a referral to a health care professional is sometimes necessary.
  2. Nit removal: Treatment should include daily lice and nit combing for 2 weeks. Daily head checks for all family members are imperative and should be continued until everyone has been clear of lice for 23 weeks.
  3. Environmental clean up: Written instructions should be given to families regarding home care. Use of sprays, fumigating agents and bug bombs should be discouraged. They are ineffective and can be a health hazard. Simple information regarding vacuuming, ironing, clothes drying, and or bagging items is appropriate. 

Head Lice in the School Setting
Although head lice are transmissible, their potential for epidemic spread in the school setting is minimal. Thus major health organizations such as the American Academy of Pediatrics, the Harvard School of Public Health, and the American Public Health Association have recommended against excluding children from school as an intervention against head lice infestation. From a medical perspective, infestation with head lice is a mild health condition without serious health consequences for a child, and should not be considered a major health threat to those infected or those potentially exposed. No convincing data exists that demonstrates that enforced exclusion policies are effective in reducing the transmission of lice. One study executed and reported by L. Keoki Williams, MD in Lice, Nits and School Policy is illustrative. This study involved
screening 2,094 children in Atlanta schools. The researchers found that 74 (3.6%) of the children screened had nits but no live lice. Live lice subsequently appeared in only 9 of the children with nits. This study shows that the likelihood that nits will develop into an infestation with live lice is low. It also suggests that excluding all children with nits from school and requesting they be treated for lice is a “shotgun” approach. For each child and family who could actually benefit from such an approach, several children and their families will experience unnecessary pesticide exposure and lost school and work days. Other research, done by Dr. Richard Pollack at the Harvard School of Public Health, highlighted the following three points regarding the diagnosis and management of head lice infestations:
  1. Health care professionals as well as those without a health care background frequently over-diagnose lice infestation.
  2. Non-infested children are quarantined as often as infested children.
  3. Traditional pediculicides and alternative formulations are frequently over-applied. Such research has led to a consensus among experts to discourage policies that broadly target children with nits for exclusion from school for treatment of lice. For example, the position of the National Association of School Nurses states “…nit free policies disrupt the education process and should not be viewed as an essential strategy in the management of head lice.”
Recommended Head Lice Procedures in a School Setting
The following guidelines will assist in the prevention and spread of head lice:
A. Instruction
  1. Head Lice education shall be implemented by the school nurses at the request of individual classroom teachers and shall include general head lice information and specific prevention measures.
  2. There should be yearly in-service training for school staff to review measures to prevent the spread of head lice.
  3. Parents and guardians should be:
    *Informed of school policies regarding head lice management procedures at the beginning of the school year (especially at the elementary school level)
    *Provided with access to information on appropriate management of head lice infestation
    *Reminded to wash clothes removed from the lost and found
B. Screenings5
  1. Criteria for screening individuals for lice are: persistent itching and scratching, known exposure to sibling or other close contact with head lice (e.g. locker mates, overnight sleep activities, scouts, etc.), self (student or parent referral).
  2. Three non-related cases of head lice in a classroom within ten consecutive school days requires that all children in the classroom be screened by the following school day.
  3. If there is an infestation among three percent of the entire student population within ten consecutive school days, there should be a screening of all students in the school within one week. (Multiple cases within the same household count as one case for purposes of calculating the percent of children infested.)
  4. The school should notify parents and/or guardians whenever individual or group screenings are planned or performed.
C. Building Prevention
  1. Carpeted areas of schools should be vacuumed daily or carpets removed. Kindergarten and primary classes are highest priority.
  2. When acquiring furniture for classrooms and the front office, avoid furniture with cloth upholstery.
  3. Students should not pile jackets, scarves, or hats in classrooms, playgrounds, or cafeterias.
  4. Coats should be place in the student’s backpack or in a student’s locker.
  5. Commercial insecticide sprays should never be used on furniture or mats.
  6. Clinic cots should have the cot sheet changed between students or be wiped down with an appropriate cleaner between students.
  7. Headphones should be wiped between student uses with appropriate cleaner.
  8. Students should not share helmets.
  9. Avoid sharing of hats, pillows, stuffed toys or dress-up clothes. Wash all of these items in the event of a classroom outbreak.
  10. Nap towels used in the kindergarten classrooms should be stored in large Ziploc bags and laundered weekly.

Students with Head Lice
Students with live lice will be excluded from school. Although uncommon, transmission of live lice can occur between pupils at school. Exclusion from school in this circumstance is an almost universal practice in the United States. Parents should be advised to return to school with the student for re-admittance. It may be necessary to further exclude a student when they attempt to return to school if live lice remain present.
The following statements are recommended guidelines for readmission to school:
  1. Students found with live lice shall be excluded from school.
  2. Students who present with no live lice may return to school even if nits are present. However, we strongly encourage the removal of nits especially within 1 cm of the scalp since they are more apt to be viable and to help eliminate misdiagnosis.
  3. Students will be rechecked at seven and fourteen days. If live lice are present, the student is excluded from school again.
  4. After fourteen days if live lice remain present, absence of both live lice and nits is required for readmission to school.
  5. Students with nits only should not be excluded from school but be rechecked in seven and fourteen days for the presence of live lice.

Confidentiality
All checks for head lice will be done in a confidential manner to respect the student’s right to privacy, and to the extent possible, to avoid embarrassment. Staff members are never to discuss an infestation among themselves, in the presence of other students or out in the community. Furthermore, staff members are to defer to the professional expertise of the school nurse concerning matters of exclusion and readmission of students with lice infestations.

Designated School Staff
It is desirable to have a school nurse responsible for lice identification. In the school nurses’ absence, the clinic assistant will check for lice. Consistent and standardized instruction should be given with frequent updates and reviews to avoid inaccurate positive results and possible over treatment. Treatment strategies must only be offered by school health professionals.

Conclusions
Health education and outreach to de-stigmatize Pediculosis in our community is strongly recommended and supported. The above guidelines are intended to help our school nurses make fair and consistent decisions relevant to our county’s population and its resources. These guidelines include a no-lice policy and a limited no-nit policy as outlined above.

Footnotes
1 Hansen, Ronald MD, et.Al Guidelines for the Treatment of Resistant Pediculosis, Contemporary Pediatrics, 2000(Supplement).
2 Pollack, Richard J., “Head Lice: Information and Frequently Asked Questions”, Department of Immunology and Infectious Disease, Harvard School of Public Health.
3 Pray, Steven W., “Head Lice: Perfectly Adapted Human Predators”, American Journal of Pharmaceutical Education 8/4/99.
4 Got Head Lice? Get Advice!, Head Lice Resource Team, Multnomah County Health Department and Multnomah Education Service District, 2001.
5 Quality Nursing Interventions in the School Setting: Procedures, Models and Guidelines, Multnomah Education Service District, Fifth Edition, 1996.

Reference Sources
1. Pollack, Richard J., “Head Lice: Information and Frequently Asked Questions”, Department of Immunology and Infectious Disease, Harvard School of Public Health.
2. Hansen, Ronald MD, et. Al. Guidelines for the Treatment of Resistant Pediculosis, Contemporary Pediatrics, 2000(Supplement).
3. National Association of School Nurses, Position Statement.
4. ABC’s of Safe and Health Child Care, A Handbook for Child Care Providers, Department of Health and Human Services, U.S. Public Health Service Centers for Disease Control and Prevention, 1996.
5. Head Lice Infestations: a persistent itchy “pest”, Infectious Diseases and Immunization Committee, Canadian Paediatric Society, 1996.
6. The No Nit Standard, A Healthy Standard for Children and their Families, National Pediculosis Association.
7. Dealing with Head Lice: A Practical Approach for Schools, Parents, and Communities, Public Information Office and Bureau of Epidemiology and Disease, Kansas Department of Health and Education.
8. Williams, Keoki L., Lice, Nits and School Policy. Pediatrics, Vol 107 No. 5 May 2001.
9. Recommended Guidelines for the Management of Pediculosis in School Settings, School Health Program, Bureau of Children’s Health, Texas Department of Health, April 2001.
10. Quality Nursing Interventions in the School Setting: Procedures, Models and Guidelines, Multnomah Education Service District, Fifth Edition, 1996.
11. Springfield Public Schools, Communicable Diseases Head Lice Treatment, procedure JHCCAR.
12. Dillenburg, Jack MPH, Head Lice: The Myth, The Facts, The Update. LA County Department of Health Services, June, 1999.
13. Roberts, Richard J., Head Lice, New England Journal of Medicine Vol. 346, No. 21, May 23, 2002.
14. Prey, Steven W., “Head Lice: Perfectly Adapted Human Predators, American Journal of Pharmaceutical Education, Aug., 1999.
15. Got Head Lice? Get Advice!, Head Lice Resource Team, Multnomah County Health Department and Multnomah Education Service District.
16. “Pediculosis Statement”. Head Lice Resource Team. Multnomah County Health Department and Multnomah Education Service District.