Ped i c uI os i s pr o toe oI for the eI ementar y sc hooI / by tti ng Constance J. Kozlowski. Thesis Nurs. 1999 K885p PEDICULOSIS PROTOCOL FOR THE ELEMENTARY SCHOOL SETTING By Constance J. Kozlowski RN, BSN Submitted in Partial Fulfillment of the Requirements for the Master of Science in Nursing Degree Edinboro University of Pennsylvania Approved by: Judith Schilling, CRNP, Committee Chairperson C PhD ' Date Alice Conway^ RN, ^JiD~ Committee Member J$an Went ling, RN, MSN/ -committee Member Greenville Area School District Date Abstract Pediculosis Protocol for the Elementary School Setting Literature indicates that pediculosis capitis is a common contagious communicable disease among school age children. cold. It is only exceeded in frequency by the common Presently, there is no pesticide treatment that is 100% effective. Recent studies have shown that some lice are becoming resistant to the recommended pesticides. To ensure effective treatment, three steps are involved: use of the lice killing product in the safest most effective way, meticulous removal of all nits (lice eggs) and the treatment of personal articles and the environment. This study, utilizing a self-administered researcher designed questionnaire, first gathered information regarding current occurrences, screening practices, policies, and protocols used by elementary school nurses in Mercer and Crawford Counties in northwestern Pennsylvania. The sample consisted of 17 practicing school nurses with a mean 14.7 years of experience in this field. The results from this study indicated that these school nurses were not currently implementing all of the interventions needed to make up an effective pediculosis prevention program. These survey results were then incorporated into the development of a protocol to be utilized by school nurses as a guideline for pediculosis preventive practices. ii Acknowledgements I would like to take this opportunity to express my sincere appreciation to all those people who helped to make this thesis possible. A special thanks to Dr. Judith Schilling for her time, energy, and direction as chairperson of this project. In addition, I would like to thank Dr. Alice Conway, and Joan Wentling for their assistance as members of my committee. Appreciation is also extended to Dr. Patricia Homer, Superintendent of Greenville Area School District, Janet Hoffman, Principal of Hempfield Elementary, and Sandy Rakar, Principal of East Elementary for their assistance and understanding during this project. I would also like to thank the school nurses of Erie County who helped to pilot my study and the school nurses of Mercer and Crawford Counties who completed the survey in such a timely and professional manner. And last, but not least, I would like to thank my husband, parents, and children for their unending support and patience throughout this long process. each and every one of you. My deepest appreciation to Table of Contents Content Page Abstract... 11 Ac knowl edgemen t s iii List of Tables viii List of Figures Chapter I: ix Introduction 1 Background of the Problem 1 Statement of the Problem 2 Theoretical Framework 3 Statement of the Purpose 7 Assumptions 7 Limitations 7 Definition of Terms 8 Summary 9 Chapter II: Review of Literature 11 11 Background History 11 Morphology 12 Biology 12 Transmission 14 Occurrence 14 16 Management Standard Chemical Treatment 18 Resistance Strategies iv Content Page Treatment Failures 22 Nonstandard Remedies 23 Role of the School Nurse Summary- 25 28 Chapter III: Methodology 30 Research Design 30 Ins trumentat i on 30 Pilot Study 31 Sample, Setting and Procedure 31 Protection of Human Rights 32 Data Analysis 32 Summary 33 Chapter IV: Results 34 Demographics 34 Methods of Identifying Pediculosis 37 Protective Practices 37 Frequency of Mass Screenings 39 Parental Notification of Mass Screenings 39 Additional Pediculosis Screenings 40 Screeners 41 Storage of Coats 41 Education of Parents, Students, and Staff 43 School Policy 43 Support to School Nurses 46 "Tips" by Nurses for Controlling Pediculosis.. . . 47 v Content Page Concern of Pediculosis 49 Summary 50 Chapter V: Summary, Conclusions, and Recommendations. 51 Summary of Findings 51 Demographics 51 Identification Methods 52 Protective Practices 52 Frequency of Mass Screenings 53 Parental Notification of Mass Screenings.... 53 Additional Screenings 54 Screeners 54 Storage of Coats 54 Education of Parents, Students, Staff 55 School Policy,/Assistance of Agencies 56 "Tips" by Nurses in Controlling Pediculosis. 58 Concern of Pediculosis 59 Supportive Theoretical Framework 59 Conclusions 60 Recommendations 60 Summary 61 62 References Appendixes A. .................... ....’• 66 Letter Accompanying Elementary School Nurse Survey 67 B. Survey for School Nurses 68 C. Survey Data. vi Page Content D. Pediculosis Protocol for the Elementary School 85 Setting vii List of Tables Table Page 1. Size of Total School Populations Served 35 2. Years of Experience as a School Nurse 36 3. Parental Notification of Mass Screenings for Lice. 40 4. Pediculosis Screeners in the Elementary School.... 42 5. Those Involved in Formulating Policies 44 6. Included in Policy 45 7. Support Service 47 8. Assistance to Those Unable to Afford Treatment. ... 48 viii List of Figures Figure Page 1. The Health Belief Model 2. Methods Used by School Nurse for Identification of Lice 38 6 ix Chapter I Introduction This chapter provides an overview of Pediculosis capitis and how it affects the school and the community. Because of an increased incidence of pediculosis reported in 1997 up almost 10% in just 2 years according to Surveillance Data Inc., -- there may be a need for an established protocol to be utilized by school nurses who deal with this problem (Conklin, 1998) . A descriptive survey was utilized to gather information regarding current screening practices, policies, and protocols used within the elementary schools in Mercer and Crawford Counties in northwestern Pennsylvania. Following assessment of the survey data, a protocol for the prevention, diagnosis, and management of pediculosis was developed. The Health Belief Model served as the theoretical framework for this study and is described (Becker, 1974; Becker, Haefner, Kasl, Kirscht, Maiman, & Rosenstock, 1977) . Assumptions, limitations, and definition of the terms are also provided. Background of the Problem Infestation with Pediculosis capitis is a problem unique to humans. The insect does not exist on any other species and is not transmitted by household pets (Sokoloff, 1994). Head lice live for approximately 30 days on a host and a female louse may lay up to 100 eggs (National Pediculosis Association, 1998a). Pediculosis can cause an infestation in a relatively short period of time. 2 Pediculosis has been a problem since early times (Sokoloff, 1994). Ancient Egyptian priests reportedly- shaved their entire bodies in an attempt to prevent lice infestations. The ancient Romans created special combs to remove the nits from hair. Head lice are most common among elementary school children ranging from 3 to 12 years of age (Halpern, 1994) . This group is most affected because children spend so much time in direct personal contact with each other. Indirect contact also occurs in this age group with sharing of hats, scarves, combs, and brushes, and coats that are hung close together. Although lice are not harmful, they are itchy, highly contagious, and difficult to eradicate (Conklin, 1998). Some studies now suggest that lice are becoming resistant to some of the chemicals used in treatment (Gentry, 1998) . Effective treatment of the child and the environment are necessary steps that are not always followed, thus, perpetuating the cycle of infestation (Brainerd, 1998) . Failure to solve the head lice problem frustrates the parents, school staff, school nurse, and the child (Ibarra, 1995) . Statement of the Problem Although pediculosis is not a serious health threat to £ very contagious communicable a child's well-being, disease among school age children. Head lice are exceeded in frequency only by the common cold in the school 3 population (Windome, 1998) . In recent years, outbreaks of pediculosis have become more frequent, more visible, and more stubborn to control (Windome, 1998). Incorrectly inflated claims of 100% product treatment effectiveness, along with continuing reports of lice resistance, complicate this already difficult health problem. Due to these factors of continuing resistance and occurrence, both the school and parent communities are becoming increasingly frustrated (Windome, 1998) . Outbreaks of head lice cause alarm to school officials because of the associated hysteria, loss of class time for frequent screenings, plus increased student absenteeism (Windome, 1998) . Additionally, parents and children feel unfounded embarrassment due to the continued social stigma that unnecessarily goes along with this condition (Windome, 1998) . Therefore, it is paramount that the school nurse act as an infection control agent to assist the school in the management of head lice infestations (Brainard, 1998) . Theoretical Framework The theoretical framework for this research project was the Health Belief Model (Becker, 1974). The likelihood that an individual will take disease preventive action, that is, perforin some health, related illness or sick-role behavior, depends directly on the outcome of the assessments they make (Becker, 1974) . One assessment relates to the threat of the health problem. The other 4 weighs the pros and cons of action. Several factors influence a persons perceived threat concerning a condition (Becker, 1974). First of all, is the perceived seriousness of the health problem. People consider how severe the organic or social consequences are likely to be should they develop the condition. The more serious they believe the effects will be, the more likely they are to take preventive measures. Another factor is their perceived susceptibility to the condition (Becker, 1974). People evaluate their likelihood of developing the problem. The more vulnerable they perceive themselves to be, the more likely they are to take preventive action. Cues to action are helpful in initiating preventive action (Becker, 1974). Some external cues to action are exposure to information such as videos, pamphlets, advertisements, and magazine articles about the health concern. A population that is reminded or alerted about a potential health problem is more likely to take preventive action than one that is not. In addition, three classifications of variables are implicated in an individuals' perceived threat of a problem (Becker, 1974). These variables include demographic, sociopsychological, and structural variables, Influential demographic variables include age, sex, race, and ethni variables There There are are also also sociopsychological including personality traits, social class, and social background. 5 pressure. Lastly, structural variables include the client's knowledge level about the health concern or prior contact with the health problem. Evaluating the pros and cons of implementing preventive action, people arrive at a decision as to whether the perceived benefits of the action exceed its perceived barriers or costs (Becker, 1974) A barrier involved in health behavior concerning lice may relate to the need to administer two doses of pediculosis treatment. It is recommended that nonprescriptive pesticide shampoo be reapplied in 7 to 10 days in an attempt to eradicate any lice that may have hatched out of viable nits remaining after the first treatment (Brainerd, 1998) . Patients may decide not to follow through with the second treatment due to inconvenience and the cost of the medication. In addition, a physical consideration such as lack of transportation to the pharmacy or clinician's office may be a barrier. Another possible barrier is reluctance to spend the time and energy needed to complete the treatment as prescribed. Several treatment steps must be followed including proper use of medication, absolute nit removal, and cleansing of the immediate environment. The outcome of contemplating the benefits against the barriers is the assesseo sum: the degree to which taking the actions is more beneficial than not taking the actions (Becker, 1974). The perceived threat of lice combines with the assessed sum of benefits and. barriers to determine the 6 likelihood of action. Individuals who feel threatened by pediculosis, and who have preventive knowledge, are more likely to undertake primary prevention measures. shows the Health Belief Model. Figure 1 Knowledge and dissemination of factual information are the responsibility of every health care provider (Sokoloff, 1994) . Modifying Factors Demographic variables (age, sex, race, etc.) Sociopsychologic variables (social class, etc.) Structural variables (knowledge about the disease & prior contact, etc.) Likelihood of Action Perceived benefits of preventive action minus Perceived barriers to preventative action INDIVIDUAL PERCEPTIONS Perceived susceptibility to Pediculosis Perceived seriousness of Pediculosis Perceived threat of Pediculosis Likelihood of taking recommended preventive health action Cues to action: Media Advice from others Newspaper or Magazine articles Figure 1 The health belief model. (Becker, Maiman, & Rosenstock,1977). Haefner, Kasl, Kirst, 7 Statement of Purpose A need for an established protocol for head lice prevention, diagnosis, and management was determined through the assessment of elementary school nurses' practices as infection control agents. A researcher written survey was distributed to identify control measures utilized by school nurses serving all elementary students in Mercer and Crawford Counties in northwestern Pennsylvania. Once these data were assessed and a need was determined, a suggested protocol was developed. Assumptions The assumptions of this study were as follows: 1. School nurses recognize pediculosis as a problem in their schools and community. 2. School nurses acknowledge that one of their roles is to act as an infection control agent for the school and community. 3 . School nurses will be able to read and understand questions on the survey. They will answer the questions honestly. Limitations Limitations of this study were identified as follows: 1. This study was limited to a small sample of school nurses representing two rural counties in northwestern Pennsylvania. Therefore, its findings may not be applicable to other school populations. 2. The survey tool was researcher-developed. 8 Definition of Terms The terms utilized in this study were defined as follows: 1. A head louse is! a type of insect known as Pediculosis capitis. The head louse is an external obligate parasite of the human host. millimeters in length (Halpern, 1994). It ranges from 2 to 4 The grayish brown insect has six claw-like legs, a pointed head, a flat and elongated and wingless body, Contrary to popular belief, head lice can not fly, jump, or hop (Clore & Longyear, 1990). The life cycle of lice begins when oval shaped eggs or nits are first laid by an adult female louse. Approximately 1 week after the female louse deposits nits, the nits hatch into a nymph stage, which immediately begins feeding on human blood. In another 8 to 9 days, the nymph becomes sexually mature and will reproduce until it dies. A female louse can reproduce 100 nits during its normal 3 0 day life span (National Pediculosis Association, 1998a). 2. The term nitpicking refers to manually removing the eggs or nits one by one using a fingernail to strip the egg from the hair shaft. 3. xA "No Nit" policy consists of the removal of all lice, lice eggs, and egg cases following the application of a pediculicidal agent. 4. The school nurses, at the minimum, is a registered nurse with a Bachelor of Science Degree in Nursing and a 9 school nurses certification from the State of Pennsylvania. 5. An infection control agent is anyone who acts to prevent the spread of infection or infestation (Brainerd, 1998) . 6. An elementary community consists of all children attending school in kindergarten through sixth grade. Summary Pediculosis has been a public health problem since the beginning of time with an increased incidence in the United States today (Sokoloff, 1994) . Pediculosis is a major communicable problem in elementary schools throughout our nation. Infestations of lice touch all socioeconomic groups (Donnelly, Likin, Clore, & Altschuler, 1991). Pediculosis affects students, their classmates, families, neighbors, teachers, principals, and health care providers. The Health Behavior Model was the conceptual framework utilized for this study. The framework defines the individual's likelihood of taking preventive health action, The purpose of this study was to gather information regarding current practices and methods of control of pediculosis at the elementary school level in Mercer and Crawford Counties in northwestern Pennsylvania. Once these data were assessed, and a need was established, a protocol was developed utilizing this information for prevention, diagnosis, and management. The development of this protocol for the prevention of pediculosis will assist 10 school nurses in acting as effective infection control agents in order to decrease occurrence and improve management of this condition. The assumptions, limitations, and definition of terms for this study were also discussed. 11 Chapter II Review of Literature This chapter reviews the current literature on pediculosis. It provides the reader with a selective overview of the history, morphology, biology, transmission, occurrence, and resistance to current treatment regimens for pediculosis. Management strategies, treatment failure, nontraditional remedies, and the role of the school nurse in the elementary school setting are then discussed. Background Pediculosis has been a problem since early times (Ross, 1990; Sokoloff, 1994). Although lice are not harmful, they are itchy, highly contagious, and difficult to eradicate (Conklin, 1998). Failure to solve the head lice problem continues to frustrates parents, school staff, school nurses and infested children (Ibarra, 1995). History. Archaeological parasitologists have reported that the Egyptians and Romans had evidence of louse infestations. About 40% of scalp and hair samples examined from Nubian mummies (circa 350-550 AD) were found to be infested with head lice (Slonka, 1977) . Nits were also discovered on the scalps of pre-Colombian Peruvian mummies, and all stages of the louse (adult, nymph, and egg) were found on prehistoric North American Indian mummy scalps. Examinations of the organic specimens have revealed no change in louse morphology over the past 2,000 years. 12 Aristotle is said to have studied lice and found them puzzling (Roberts, 1983). Thomas A. Beckett was severely infested at his time of death. Lice have been described during periods of famine, pestilence, and war for centuries. Morphology. The head louse is a blood sucking insect that lives its entire life on the human host and survives only by feeding on human blood (Halpern, 1994) . The egg or nit is yellowish to brownish-white, and is less than 1 millimeter long (Slonka, 1977). It has a cap at one end through which air is admitted during development of the embryo. the egg. This cap allows the young insect to emerge from The egg is incubated by heat from the human body and hatches in about 1 week. Following the incubation period, the young nymph emerges from the nit through the cap (Slonka, 1977) . The parasite remains in the nymph stage for 8 to 9 days before it develops to sexual maturity. The nymph looks like an adult but does not have a developed reproductive system. When the nymph reaches adulthood, mating occurs approximately every 10 hours and continues until death (Slonka, 1977). Head lice live approximately 30 days on a 100 nits during her host and a female louse can lay up to life cycle (National Pediculosis Association, 1998a). Biology. Lice depend on human blood for sustenance (Slonka, 1977). When ready to feed, the louse anchors its mouth to the skin, stabs an opening through the skin, pours 13 saliva into the wound to prevent clotting, -and pumps blood from the wound into its digestive system, The bloodsucking process will continue throughout its life span if the louse is not disturbed. The effects of louse bites vary greatly according to the individual's sensitivity (Slonka, 1977). symptoms appear to be allergic in nature. The principal When persons previously unexposed to lice are bitten, there is at first only a slight sting and little or no itching. week, the individual may become sensitized. After 1 With increased sensitivity, irritation leads to scratching and these scratch sites may become infected. Eventually, with time and exposure, individuals develop some form of immunity to the bites and persons long infested become oblivious to them. Adults and nymphs are found on the hair and on the scalp (Slonka, 1977). They seem to be more prevalent on the back of the neck and behind the ears. Generally, a single child will harbor 10 to 20 lice, although infestations with hundreds of parasites have been reported. The life cycle of the louse is dependent on availability of a blood meal and moderate temperature (Sokoloff, 1998). However, lice can live away from the host for up to 48 hours. Nits can survive for as long as 10 days,, provided that the environmental temperature comfortable to the remains constant and in the normal range human host ("Pediculosis"/ 1992). 14 Transmission. 1977) . Lice do not hop, jump, or fly (Slonka, They are crawling insects. Transmission is by direct or indirect means, but it is thought that the most common method is by direct contact with an infested person. Lice can also be transmitted by indirect contact through combs, brushes, bedding, wearing apparel, and upholstered furniture containing viable eggs or lice (Sokoloff, 1994) . Since lice only feed and breed on humans, they are not transmitted by household pets. Occurrence. Presently, the head louse seems to have maintained itself well, since it is found world wide and in significant numbers (Slonka, 1977). Slonka writes that there has been an increase in incidence of pediculosis in widely scattered parts of the globe. In the United States, it is estimated that approximately six to twelve million individuals are affected each year (Millonig, 1991) . This is reflected in an increasing number of articles in the popular media as well as by the skyrocketing sales of over-the-counter lice shampoos, lotions, cream rinses, and other remedies, It is estimated that sales in the United States are now approaching $100 million annually (Windome, 1998) . Pennsylvania According to Surveillance Data Inc., a firm that surveys school nurses nearly 80% of school lice outbreak districts around the country had at least one (Fillo, 1998). One in during the 1996 to 1997 school year This number,. every four children had.pediculosis. 15 some experts say, affirms their belief that a more tenacious strain of the louse is evolving. In a study conducted by the Centers for Disease Control, epidemiologists collected data from their investigations of outbreaks in New York, Georgia, and Florida schools (Juranek, 1985). Children were examined for the presence of head lice by one of the investigators or a trained public health nurse. Additional epidemiologic information was obtained by written questionnaire and review of the students' health records. From this investigation, it was reported that the incidence was higher for girls than boys and for women than men apparently because females exhibit more physical contact and share more personal articles that directly and indirectly transmit head lice (Juranek, 1985) . No relationship was found between the length of hair and the incidence of infestations. It was also found that 59% of all infested persons had at least one other infested family member. Pediculosis afflicts all socioeconomic levels and races within the United States with the exception of African Americans. North American lice prefer the round hairs of children of European ancestry to the oval shaped hairs of African American children (Windome, 1998). This incidence of pediculosis is an explanation for the higher among Caucasian American families (Clore and Longyear, 1990) . 16 Management Once the diagnosis of pediculosis has been established, the goal is to eradicate all lice and nits. Management of this problem can be undertaken in numerous ways. There are standard chemical treatments, manual nit removal, and nonstandard remedies. The following is a overview of current management strategies and their effectiveness. Standard Chemical Treatment. Once a child is identified as having pediculosis, the initial step in the treatment is eradication of all lice and nits. Three types of chemicals are available to treat pediculosis infestations: pyrethrin shampoo, permethrin cream rinse, and lindane shampoo. Pyrethrin shampoos contain a natural chemical insecticide extracted from the pyrethrum flower (Sokoloff, 1998) . A number of pyrethrin shampoos are available overthe-counter such as Rid, Pronto, A-200, and generic brands. These over-the-counter shampoos are felt to be effective in killing the crawling lice, but not in eradicating the unhatched nits (Windome, 1998) . A second application of the shampoo is recommended in 7 to 10 days after the first treatment to kill any new lice that have hatched from the nits that had not been combed out. A permerthrin cream rinse is another cormnonly used product for the treatment of pediculosis (Windome, 1998). Permethrin is a synthetic insecticide similar to the 17 natural pyrethrins.- It is most common ly sold under the brand name of Nix as well as store brands. Permethrin has the ability to coat the hairs and provide residual insect­ killing activity for a week or more after the treatment. According to Taplin and Meinking (1990) , the permethrin cream rinses have been found to have the greatest efficacy and widest margin of safety. However, like the pyrethrins, treatment failures are common (Windome, 1998) Therefore, a second treatment is advisable with the permethrin cream rinses in 7 to 10 days. The active ingredients of these standard over-the- counter chemical lice treatment are poorly absorbed through the skin, although minor amounts are retained (Sokoloff, 1998) . Any absorbed active ingredients are rapidly metabolized to a water-soluble compound and eliminated. Lindane (Kwell) is available only by prescription (Sokoloff, 1994). Its insecticidal properties are based on its lethal effect on the insect's nervous system. The potential for human central nervous system toxicity with excessive application is high and the relative efficacy is This presents a danger to not only the patient but 1994) . also to the person applying the medication (Halpern, In addition, this toxic drug should not be used due to low. reports of resistance and because it has been shown to be ic products (Altschuler, less effective than other less toxic 1998). 18 Pediculicide exposure of any kind is not advised by the National Pediculosis Association (NPA) for any child under the age of 2, and to nursing and/or pregnant women (Donnelly et al., 1991). The NPA recommends that a physician be contacted for these populations. Resistance. A Harvard University research team has confirmed a widely held suspicion that lice in the United States are now resistant to permethrin (Gentry, 1998) . Permethrin is sold as the creme rinse product Nix. This is the leading treatment for louse infestation. In the Harvard study, lice collected from Cambridge, Massachusetts and Boise, Idaho, were placed on permethrin-soaked paper. They showed a lack of sensitivity to the chemical (Conklin, 1998) . By contrast, lice collected from the Phillipines, where such products are not used, all died quickly when exposed to permethrin. Entomologists noted that the chemicals in leading products (permethrin-Nix and pyrethrin-Rid) are so closely related that if the lice are resistant to one, they are resistant to the other (Gentry,. 1998) . According to Surveillance Data Inc., the number of reported cases of head lice went up 10% in 1997 from just 2 years previously based on a survey of (Conklin, 1998). This finding was It affirmed some school nurses in 208 United States cities, strain of the louse experts' belief that a more tenacious This study also supported the is evolving (Fillo, 1998). strains of lice that can observation that there are now 19 survive pyrethrin and permethrin (Conklin, 1998) Unfortunately, no pesticide has been found to be 100% effective. Leaving nits in the hair can definitely lead to misdiagnosis or reinfestation (Sokoloff, 1994). Strategies. According to the National Pediculosis Association Newsletter (1989), elimination of lice and nits involves three steps. Treatment includes use of a lice- killing product on the infested person in the safest and most effective way. The next step is removal of all nits. The third step is treatment of personal articles and the environment. Nit removal is the most essential step (Sokoloff, 1994) . This is a time consuming process that many parents and children do not have the patience or determination to endure (Windome, 1998). The nits are combed out with difficulty due to the glue-like substance the louse applies to the hair shaft. Several products such as Clear Lice Egg Remover Gel, Step 2, and a fifty/fifty mixture of vinegar and water have been suggested as beneficial in nit removal, However, no clinical benefit has been documented in the research literature (Burkhart, Burkhart, Pachalek, & Arbogast, 1998). While the physical structure of the nits are difficult to break down researchers believe that it may be possible According to Burkhart et to remove nits by chemical means. denatured by acids in al. (1998)., the nit structure can be a possibility in the vitro. While chemical nit removal is 20 future, mechanical combing is still the only successful method at present. ' A comparative study was designed by Clore and Longyear (1993) to evaluate the combined efficacy of seven pediculicidal agents with their supplied nit removal combs in the treatment of head lice. Results of this study determined that complete nit removal depended on the degree of infestation. Also, differences in combing technique and varying degrees of thoroughness of the individual comber were found to be significant factors in complete nit removal. Clore's and Longyear's (1993) purpose was to determine the efficacy of the various combs used for nit removal. A sample of 4,271 children were screened at various elementary schools in Florida. Each infested child was randomly assigned to one of seven treatment groups. Each treatment group contained at least 30 subjects. Each subject was examined over a 2 week period (Clore & Longyear, 1993). evaluation. The first examination was the baseline Subsequent evaluations occurred on days 7 and Clore & Longyear found that the comb packaged with Nix was significantly more effective in removing the nits after 14. 20 minutes of combing, The remaining combs were not effective in the removal of nits, This study did have a of the product and its limitation in that the combination effectiveness as a unit. packaged comb were studied i.or different combs had been Results may have been, different if 21 used with different pesticide. The National Pediculosis Association (Altschuler, 1998) advocated a new comb called the LiceMeister comb. Its cost is approximately $15 and can only be purchased through the National Pediculosis Association. The National Pediculosis Association concluded that the LiceMeister is not 100% effective but that it is a revolutionary improvement over any other combing tool currently available. This crucial second step of treatment may only reach 100% effectiveness through actual manual picking of the nits (NPA, 1998b). Unfortunately, if even a few nits are left they may be viable and restart the entire life cycle. Parents need to be informed that the "No Nit" policy requires a great deal of time and patience for removal of all nits from the hair, but that it represents major protection against reinfestation for their child. Nit removal must be done thoroughly along with the third step of treating the environment. Treatment of the environment surrounding the child is necessary to control the persistence and reinfestation of pediculosis (NPA, 1989). Combs and brushes should be cleaned in hot water (Krinsky, 1996) . All bed linen, should be machine washed in towels, clothing, and headgear item can not be hot water and dried in a hot dryer, If an garbage bag with a tie washed the article can be put into a from surviving. top for 10 days to. prevent any viable eggs 22 Also, the items can be placed in the freezer to interrupt the life cycle. Carpets, upholstered furniture, and car seats can be carefully vacuumed to pick up any living lice or nits attached to shed hairs. Fumigation with insecticides is unnecessary and can be potentially hazardous (Windome, 1998). Treatment Failures. The school nurse's lack of control over parental disinfection of the home environment contributes to reinfestation (Clore & Longyear, 1993). Instructions can be given in detail for completion of environmental treatment, however, the school nurse can not investigate every home to ensure that all of the prescribed environmental measures are indeed being instituted. Just as the school nurse can not be in each individual home to ensure that environmental treatment is completed, neither can the school nurse be in each home to ensure that proper treatment with the pesticide was undertaken and complete nit removal has occurred (Clore & Longyear, 1993). Also, it is difficult to determine if all contacts outside of the school environment have been inspected and treated appropriately. New transmissions by 1 person-to-person or fomite contact may have occurred in the child's environment. Parents often become upset when the school nurse notifies them of their child's infestation (Clore & the school as the Longyear, 1993). They frequently blame source of the infestation and demand that school officials 23 Preventing head lice is a parental responsibility as well as a school duty. The final reason for reinfestation or treatment failures--besides deceased efficacy of treatment products, control this problem. incomplete nit removal, and incomplete environmental is thau there may be altered family processes measures (Eckartz, Schillat, & Greene, 1996). The parents may be having drug dependency problems or ineffective coping mechanisms that disrupt accomplishing tasks and roles expected of them to treat this condition (Eckartz et al., 1996) . The perceived threat of lice combines with the assessed sum of benefits and barriers to determine the likelihood of action. Therefore, in some situations the barriers overtake the benefits and action is not undertaken properly. This is unfortunate for many children. Nonstandard Remedies. As stated previously, promises that products are 100% effective lull desperate and wishful thinking families into a false sense of security (Altschuler, 1998) . When products fail to do the job, people automatically think they did something wrong. Such treatment failure prompts consumers to leave chemical They may applications on the scalp longer than directed. also use products more often and resort to unnecessary pesticidal lice sprays or nonstandard treatment. Nonstandard remedies can be divided into two The first is remedies that are probably safe categories. is unsafe remedies. The second category but unproven. 24 A safe popular remedy is to soak the hair with olive oil and then cover the scalp with a shower cap overnight (Windome, 1998). Other variations on this strategy are to use mayonnaise or Vaseline. The Vaseline is applied to the hair coating every hair thoroughly (Windome, 1998). shower cap is then applied overnight. A The hair is washed once per day with regular shampoo for the next 10 days. The Vaseline is suppose to suffocate the live lice. When they go to feed they feed on the Vaseline thus blocking their respiratory tract and expiring. The residual Vaseline takes care of any hatching nits. Therefore, you do not want to use any grease cutting shampoos such as commercial dish washing liquid that will remove the Vaseline too fast. If the Vaseline is removed too quickly the residual nits may remain viable. This treatment causes embarrassment that far outweighs the seriousness of the condition (Windome, 1998) . Other 1 children immediately realize why this treatment was initiated and can be very cruel. Shaving the head is another alternative treatment that is equally safe but embarrassing for the child. The most hazardous home remedy for lice is kerosene It has caused (Halpern, 1994). Kerosene is a fire hazard, flash burns in some children who have come contact with a pilot light on treated. into close the stove while being Some children have been ingesting the kerosene when it was severely injured by sitting out in 25 preparation for application (Windome, 1998). Role of the School Nurse in the School The school nurse deals with head lice on two levels (Brainerd, 1998). On the school level, the nurse's responsibility involves diagnosing and managing individual cases and classroom or school outbreaks. On a second level, the public health level, the school nurse is responsible for educating the public so that transmission and reinfestation can be reduced. Brainerd (1998) described five major concerns that govern a school nurse's thinking in managing head louse infestations. The first two concerns are dispelling the misconceptions about lice and ensuring that infestations are not missed. The third concern is ensuring that parents understand instructions for effective treatment. The school nurse is also responsible for two additional concerns, educating the community about the correct usage of pediculicides and reducing the spread of infestations. Brainerd sees the school nurse as the infection control officer for the school and the community in managing head lice infestations. A similar view is held by Thompson (1977) who described the role of the school nurses in pediculosis, is indeed the key to She believed that the school nurse school setting, control of pediculosis in the inordinate amount of Unfortunately, this role is taking an time and effort in.schools today as it involves functioning 26 in health education, health servicp^ £vices, and environmental controls. The successful pediculosis program starts with a good plan (Thompson, 1977) . The school nurse must take the leadership role in developing policies and procedures. school nurse is a part of the team that would include The the school administrators, school physicians, and the health education staff. Being a part of the team that formulates policy and procedures implies that the school nurse must be knowledgeable about pediculosis — it's life cycle, the different modes of transmission, the diagnosing of the problem, and current acceptable treatment. Clore and Longyear (1990) also believed that it was essential that elementary schools develop a comprehensive pediculosis screening program. These programs provide an effective method for preventing epidemics by accomplishing early detection. These programs also promote education among elementary children, school officials, educators, and An effective program includes screening of the entire school population three times per year: in mid­ September, December, and near spring vacation. Clore and parents. Longyear (1990) recommended a "No Nit" policy, When a is successful approach to controlling pediculosis financial savings occur for the instituted, absenteeism and parents and the school district. A descriptive survey done by Donnelly et al. (1991) lice management was undertaken to determine specific 27 strategies of. schools and school nurses working in elementary, junior, and senior high schools across the country. A 20-item questionnaire was sent to 4,300 school nurses. A total of 543 individuals responded. Although, the majority of respondents believed that pediculosis was a health problem, over one half worked in schools without regularly scheduled lice screenings. Approximately 21% of these school nurses even worked without procedures or policies. Prevention is virtually impossible and control of lice infestation extremely difficult under such fragmented and unstructured conditions. Unresolved cases of infestation perpetuate this cycle of disease. This study done by Donnelly et al. (1991) came to the conclusion that efforts to prevent and control pediculosis should focus on two primary areas. The first area is establishment of appropriate policies. should focus on education. Secondly, efforts These authors noted that it is necessary for the school nurse to work closely with school officials to advocate changes in lice management strategies. Their recommendations also included the No Education is the major focus for students, teachers, and administrators. Prevention becomes Nit" policy. parents, the primary management strategy. The frequent transmission of pediculosis among children causes the nurse in the school setting to address daily (Donnelly et al., this public health problem almost initiate and 1991) . The school nurse is in a key role to 28 coordinate strategies. School nurses are challenged to educate parents so that the signs of infestation can be identified as early as possible and the spread < of pediculosis is controlled and checked. Although a review of the literature provided excellent recommendations concerning pediculosis, no example of an actual policy or protocol for a school setting was found. The only two protocols found (Pigott, 1997, Newland, 1995) were basic, vague, and geared to the hospital or medical office setting. Establishing a successful approach would result in numerous benefits to the school and community (Clore & Longyear, 1990). parent education and increased community awareness represent strategies for the prevention of lice (Donnelly et al., 1991) . Emphasis on policy and protocol development and other preventive strategies could reduce the occurrence of pediculosis, thereby optimizing the health of the school population. Summary This chapter has provided a review of the literature Pediculosis is an endemic public concerning pediculosis. health problem subjecting children to school exclusion, controversial pesticide treatment, and potential reinfestation (Donnelly et al., 1991). As the litera indicates, the incidence of pediculosis continues Attitudes and misconceptions currently interfe adequate diagnosis and treatment of pediculosis (Sokoloff, 1994) . 29 The importance of the school nurse was also noted. A standardized preventive approach is a critical link in dealing with this public health concern. Knowledge and dissemination of factual information and widespread education is the responsibility of every school nurse. i I 30 Chapter m Me thodo1ogy This chapter describes the! methodology that was utilized to determine the need for an established protocol for the prevention, diagnosis, and management of pediculosis. Based on a survey of 17 school nurses in northwestern Pennsylvania, a protocol was then developed, Included in this chapter are the research design, sample, setting, and procedures utilized for this study. Research Design This study utilized a descriptive survey research design. The goal of the survey was to gather information regarding current occurrences, pediculosis screening practices, and policies and protocols in all elementary schools in Mercer and Crawford Counties in northwestern Pennsylvania. Once rhe returned data were assessed, and a need was determined, a pediculosis protocol was then developed. Instrumentation A survey was utilized as the research tool. The tool was researcher-designed. The survey data was collected by a self-administered questionnaire (Appendix B) . The ■ sections. An accompanying Questionnaire consisted o± t-wo two secti described the purpose of the letter from the researcher study and gave instructions for completing the survey. The elicited demographic first section of the survey the respondent 's school population information concerning 31 size, nursing staffing patterns, ■ and number of years of service as a school nurse. The second section of.the survey contained 26 question: 25 closed ended questions with 11 dichotomous items, 14 multiple choice plus one open ended question. These questions were developed to gather information on current practice, lice identification methods, and control measures utilized by the target sample. Pilot Study The survey was pilot tested by four school nurses in Erie County, Pennsylvania and took an average of 15 minutes to complete. Two areas relating to demographic information were revised for further clarification. An additional option was added to questions 4, 6, 8, 18 and 19 for clarity. A new question number 5 was added to define whether or not parents were notified after a mass screening. Lastly, an additional space was added to obtain the address of respondents who wished to receive a summary of the results of the survey. Sample, Setting, and Procedure The targeted sample included all school nurses who were responsible for the health care of elementary populations in Mercer and Crawford Counties, Pennsylvania, They were twenty-three in number with 17 returned surveys, of the survey by The school nurses received a copy and return the survey mail. They were asked to complete A follow-up post card was within approximately 2 weeks. 32 sent to all members of the target group who had not replied after 1 week. The surveys were returned to the researcher in self-addressed, stamped envelopes provided by the researcher. The setting for this survey was in whatever location respondents chose to complete the questionnaire. Protection of Human Rights An introduction accompanied the survey to explain the purpose and importance of this study. The completion and return of the survey to the researcher constituted informed consent. All data remained confidential. required on the survey. No names were Only grouped data was reported. The researcher kept the returned surveys in a locked file. Data Analysis The survey data were analyzed by counting the frequency of responses on the dichotomous and multiple choice questions. They were then placed in a frequency distribution or percentage table reflecting the percent of specific responses. The response rate for each item in the survey was calculated. There was one open-ended question included in the survey. key words The responses from this question were examined for or phrases and categorized under meaningful headings. In addition, relationships between variables were item with investigated by comparing responses on one this information responses on other items. Analysis of relating to the determined the needs of this target group 33 problem of pediculosis'. After completion of this needs assessment, a recommended comprehensive protocol was developed to prevent, diagnose, and manage pediculosis (Appendix D). Summary The goal of this study was to determine if current pediculosis programs in elementary schools in Mercer and Crawford Counties, Pennsylvania were meeting the needs of school nurses. This was determined through analysis of data obtained in the needs assessment survey of school nurses in the designated Counties. The final step was to develop a recommended protocol for prevention, diagnosis, and management of pediculosis that could be utilized as a guideline for school nurses. 34 Chapter iv Results This chapter presents the results obtained from a mailed survey of elementary school nurses from Mercer and Crawford Counties in northwestern Pennsylvania (Appendix C) . A total of 23 surveys were mailed to this study group with 17 surveys returned and included in the results, A descriptive analysis of these data indicated to the researcher that a written protocol for the prevention, diagnosis, and management of pediculosis would be helpful in these elementary school setting. A protocol was then developed utilizing this information. Demographic s Of the 17 returned surveys, 9 were completed by school nurses from Mercer County (52.94%) and 8 were completed by Crawford County school nurses (47.06%). There were 7 school nurses who served grades kindergarten through 6th (41.18%) exclusively. There were 7 additional school nurses who served grades kindergarten through 6th grade plus 7th through 12th (41.18%). The remainder of the school nurses served varied populations: one school nurse (5.88%) was responsible for daycare through 6th grade, another (5.88%) served kindergarten through 8th grade, and consisted of grades one (5.88%) nurse's school population size of the total 1/ 2, 9, 10, 11, and 12 (5.88%). The 1,629 students school populations served ranged from 300 (Table 1) . 35 Table 1 Size of Total School Populations Served (N=17) Range of Number N of Students 300-599 students 600-1000 students >1000 + students 1 12 4 Respondents' years of experience as elementary school nurses ranged from 2 to 30 years (Table 2) . The mean years of experience was 14.76. The staffing patterns varied throughout the districts Six of the school nurses (35.29%) were certified for their school nurses who had total responsibility additional assistance. Four student populations with no staffed with a (23.53%) of the reporting schools were ; nurse. Five other certified school nurse and a registered of health room certified school nurses had the assistance surveyed. 36 Table 2 Years of Experience as a School Nurse (N=17) Years Completed N 2.0 1 2.5 1 4.0 1 7.0 1 8.0 1 11.0 1 12.0 1 15.0 1 16.0 1 17.0 18.0 19.0 26.0 28.0 30.0 3 1 1 1 1 1 37 aides (29.44%) in the care of their student populations. One school' s staffing pattern consisted of two certified school nurses (5.88%). Lastly, one school had a staff of two certified school nurses and one licensed practical nurse (5.88%) . Methods of Identifying Pediculosis Different methods were used to identify children with pediculosis in the respondents' schools. The most common methods utilized were examination of the scalp and hair under direct sun light in the classroom or use of a goose­ necked lamp in the nurse's office to aid with visualization. A smaller number used a magnifying hand­ held lamp to assist in identification of lice. Some of the school nurses used one method exclusively while others used a combination. Figure 2 shows the percentage of each identification method used by the sample population. Protective Practices Protective measures such as use of gloves or wooden sticks when screening are recommended in the Child Care Providers Guide provided by the National Pediculosis Association (1998b). It was found in this survey that 10 of the 17 responding school nurses did not use protective measures on a routine basis. Eight respondents (61.07%) indicated that they neither used sticks nor gloves. One respondent (5.88%) replied that she did not wear gloves routinely, but did so just during mass screenings. Another respondent (5.88%) indicated they did not use 38 30 ■ Light □ Light/neck O Neck □ Light/mag. H Neck/mag. Lt./neck/mag. P e r 20 c e n t a g e 10 ■ 0 methods Figure 2. Notes. I I Methods Used by School Nurses for Identification of Lice. Light=natural lighting.: lighting and goose-necked lamp. Light/neck=natural Neck=goose-necked lamp. Light/mag.=natural lighting and magnifying light. Lt. /neck/mag. ^natural lighting/ goose-necked lamp, magnifying lamp. Neck/mag. =Goose-necked lamp and magnifying lamp. 39 gloves or sticks routinely, but did so during mass screenings. The remaining seven school nurses who replied did use protective measures on a routine basis. One respondent (5.88%) indicated that she used gloves routinely. Four nurses (23.53%) responded that they used sticks exclusively on a routine basis. The final two respondents (11.76%) used both gloves and sticks routinely. Frequency of Mass Screenings Fifteen of the 17 responding school nurses did do a yearly mass screening in September. Four nurses (23.53%) did this screening in September with no additional mass screenings throughout the year. Four nurses (23.53%) completed mass screenings in September and after Christmas break. Two additional school nurses (11.76%) completed mass screening in September along with additional mass screenings when there was evidence of an increased occurrence of pediculosis. Four respondents (23.53%) indicated that they conducted screenings in September, after Christmas break, and after spring break. respondent (5.88%) One screened the children in September and at a parent or teacher's request, Two nurses (11.76%) only did mass screenings when there was evidence of increased occurrence in the school, or at a teacher's request. Parental Notification of Mass Screenings It is suggested in the literature that parents take an active part in the preventive screening process (National 40 Pediculosis Association, 1998) . Table 3 indicates the frequency of parental notification by the school nurse prior to and after mass screenings. Table 3 Parental Notification of Mass Screenings for Lice (N=17) Notified Parent Yes No Before After 6 2 11 15 Additional Pediculosis Screenings Screenings done in addition to the mass screenings were conducted at various intervals. Nine respondents (52.94%) indicated that they do additional screenings when a teacher or parents suspects a problem, when one child has been identified in the classroom, and when a sibling has been found to have pediculosis, One respondent (5.88%) did additional screenings only if an infested child was A total of seven respondents identified in the classroom. for the above reasons, (41.18%) did additional screenings a preventive screening program. plus they had set up 41 Of the seven who did preventive screenings, five of the nurses screened one classroom per day until all classrooms were done. One respondent indicated that she did screen one classroom per day until all classrooms were completed on a cyclic pattern, plus increased the frequency and number of preventive screenings with increased occurrences. One respondent (14.29%) did preventive screening on a prescribed cycle, but only on an as needed basis; additional screening had not been adopted as a permanent part of their preventive plan. Screeners The primary screener for lice in every school was the nurse. However, seven of the 17 respondents did receive some assistance from school aides or a volunteer. volunteers and aides were trained screeners. All Table 4 indicates the distribution and variety of screeners for the schools in this study area. Storage of Coats Pediculosis can be spread by indirect contact, Therefore, a review of the storage procedures for students' coats was included in this survey. It was found that in 12 schools (70.59%) coat closets all had hooks less than 8 inches apart. Thus, each coat was in close proximity to the next. one Of those schools with these crowded closets, placed the coats in large garbage bags on a mandatory continuous basis and nine placed coats in large garbage basis depending on the bags on a temporary mandatory 42 Table 4 Pediculosis Screeners in the Elementary Schools (N=17) Staff Members Involved in Screening Nurse N 10 Nurse and volunteer 1 Nurse and school aides 6 current occurrence of pediculosis. Two respondents (11.73%) from this temporary mandatory population also gave the children the option of keeping their coats inside their book bags. The remaining two respondents with inadequate storage did not list any additional precautionary measures and apparently continued to store childrens' coats in this crowded manner. Two respondents (11.76%) indicated they did have coat closet hooks that were greater than 8 inches apart. An additional three respondents (17.65%) were fortunate to have student lockers thus decreasing the chance of direct contact. 43 Education of Parents, Students, and Staff All of the school nurses (100%) stated that they gave parents oral and written instructions for the treatment of pediculosis when an infested child was identified. However, only six (35.28%) of the nurses participated in a school health curriculum for pediculosis at each grade level while eleven respondents (64.71%) did not provide any education concerning pediculosis to their elementary community. A total of nine (52.94%) of the schools received an educational inservice about pediculosis and prevention from the school nurses. The remaining eight respondents (47.06%) did not. School Policy Each school should have a written policy on lice (Thompson, 1977). Fourteen schools (82.35%) had a policy while three did not. Table 5 indicates those persons who were involved in formulating these policies. In addition, two respondents indicated that the school guidance counselor and lawyer also participated in developing their school policy. One respondent indicated that they utilized state guidelines, although this researcher has never found these state guidelines and a telephone call to the Pennsylvania Department of Education, School Nu ’ g available. Two Division, confirmed that none were ■ respondents replied "not applicable " in their cases. /r, nn\ submitted their written Eleven respondents (64.71%) s 44 pediculosis policies with thei completed questionnaire while six respondents (35.29%) did not. The policies varied in Table 5 Those Involved in Formulating Policies School Nurse School Physician x x SuperintendentI Principal School Board X X x X X X X X X Other 2 (GC/L) 2 2 X 1 X X 1 X 1 X Notes. 2 3 X X N (GC/L)=guidance counselor/ lawyer. applicable. (N/A) 2 (SG) 1 (N/A)=not (SG)=state guidelines. what was included. contained in Table 6 describes what was these policies. to correct a The number of excused days of absence schools. child's pediculosis infestation varied among 45 Three schools (17.65%) excused students for the day of dismissal and the following day. Five (29.41%) provided an unlimited number of excused days until the problem was Table 6 Included in Policy (N=17) Exclusion Reentry Transport Excused Days x x X X X X X X X X X X X X X X X X X No Other Policy NA N 1 X 6 2 4 1 1 X x 2 Notes. Other=State Guidelines. resolved. The remaining nine other options: NA=not applicable. schools (52.94%) gave parents the parents 3 days seven of the nine gave additional days being to resolve the problem wich any 3 excused days for unexcused; two of the nine (22.22%) gave 46 the first three occurrences of pediculosis occurrences, every day was then After three counted as unexcused. Support to School Nurses Frequent infestations and excessive absences related to pediculosis may be a signL or symptom of another underlying social problem. 'The reason for reinfestation besides deceased efficacy of treatment products, incomplete nit removal, and incomplete environmental measures may be altered family processes (Eckartz, Schillat, & Greene, 1996) . The parent may be having drug dependency problems or ineffective coping mechanisms that disrupt accomplishing tasks and roles expected of them to treat this condition. The agencies contacted to support the school nurses in treating the child included Children and Youth Services, the Department of Health, and the school attendance officer. One respondent listed home visits made by the school nurse to further assess these underlying problems as a needed support service. Table 7 shows the responses of the school, nurses relating to the agencies they currently have contacted for assistance. Seven (41.18%) of the school nurses responded that they did receive assistance from these agencies while eight (47.06%) did not feel assisted. Two respondents (11.76%) had mixed experiences with these agencies, both positive districts provided financial and negative. Most school assistance to children and parents who could.not afford the pediculosis medication.. Table 8 indicates what school 47 nurses were doing to assist children and parents in obtaining medication for treatment. Table 7 Support Service (N=17) CYS PHD Attendance Officer Home Visit School Nurse Not a Problem x N 3 x x x X X X X X X X X X 1 X 1 2 2 1 X X X Notes. CYS=Children and Youth Services. 1 6 PHD=Public Health Department. "Tips" by Nurses for Controlling Pediculosis.-- Ten of the respondents (58.82%) gave numerous suggestions or tips that they have found useful in their practice. The seven remaining respondents (41.18%) did not complete this question. Two respondents urged parents combing daily for several weeks. to continue checking and An additional two 48 respondents strongly suggested that once the children are Table 8 Assistance to Those Unable to Afford Treatment (N=17) District Assistance Suggestion Concerning Free with Approval of: Prescriptive Medication: Administration Physician Yes No 4 x X N 2 x X x 4 X 6 X 1 readmitted to recheck them frequently—if possible, daily for 1 week. Another suggestion given by two respondents was to check repeaters weekly. A suggestion was given to : through the use of the stay in contact with the parents had found it telephone or notes. Also, one respondent credit for their helpful to give the parents a lot of Another efforts and make them a part of the solution. notebook especially suggestion was to log all children in a with pediculosis. The school designated for tracking those 49 nurse used this log to track trends and to document her efforts. Finally, an important suggestion child first. dignity. was to always put the Treat them with privacy, kindness, and The respondent continued to advise that if absolutely necessary and time permitted in chronic cases, she did the nit removal herself; without her intervention she believed the job may have never been completed. Concern of Pediculosis Of the 17 responses to question 23 concerning the school nurses' perception of pediculosis as a problem in their school communities, eight (47.06%) of the responding school nurses felt that pediculosis was a problem in their school districts. Six (35.29%) did not feel that pediculosis was a problem in their school populations. The final three (17.64%) considered pediculosis only an intermittent concern, All of the elementary school nurses in Mercer and Crawford Counties indicated that they were the infection control agent in their schools. Fourteen respondents (82.35%) replied that they felt that a pediculosis protocol would be helpful as a guideline in evaluating and updating their current programs. Two (11.76%) of the responding nurses indicated that they did not think a protocol would be helpful. One (5.88%) replied All of the that "maybe" a protocol would be helpful. of the results of respondents wanted a copy of the summary this study. 50 Summary This chapter has presented the results of the survey of elementary school nurses in Mercer and Crawford Counties in northwestern Pennsylvania. These results were interpreted through descriptive analysis and the percent of each response was provided. also provided. Analyses of one open ended was 51 Chapter V Summary, Conclusions, and Recommendations This chapter provides a summary of results of a survey of elementary school nurses in northwestern Pennsylvania to assess their current practices relating to pediculosis. The survey results were incorporated into the development of a protocol to he utilized hy school nurses as a guideline for prevention, diagnosis, and management of pediculosis. Conclusions and recommendations are also provided. Summary of Findings This section provides a summary of findings from this research project. These findings were compared to the recommendations concerning pediculosis found in the review of literature. Demographics. All 17 of the elementary school nurse respondents were from Mercer (9) and Crawford (8) Counties in northwestern Pennsylvania. The majority of respondents had a school population of 600 to 1000 students, All of the respondents were responsible for elementary children from kindergarten to sixth grade except for one who only had grades 1 and 2 along with a high school population. The average years of the nurses' experience was 14.76 years. Six of the 17 respondents had solo responsibility for their student populations. However, the remainder of another staff member such as the nurses had assistance irom . „. v-nHiqtpred nurse, licensed an additional certified nurse, r g 52 practical nurse, or health assistant, These demographics, along with the large number of completed returned surveys (17 of 23) indicated that the sample consisted of educated, experienced and interested school nurses. Identification Method Different methods were used to identify pediculosis in the schools, Thirteen of nurses exclusively (76.44%) utilized direct sun light or a goose necked lamp to identify lice. Four nurses (23.52%) used the magnifying hand-held lamp along with the use of natural lighting or goose-necked light to assist in identification. Even though no studies found in the literature indicated that any of these methods were superior to another, it is probable that the magnifying hand-help lamp is the most effective because the light is bright and uniform. head. It can also be directed close to the child's The magnification makes it much easier to spot the lice and nits since they are of minute size. Although, the lamp's cost is approximately $275 its effectiveness outweighs the cost. Protective Practices. Although protective measures such as the use of gloves and sticks are recommended by the National Pediculosis Association there was a low compliance Reasons for this may be that it is Also, difficult to separate a child's hair with gloves on. it is difficult to when using the magnifying hand-held lamp hold the lamp plus use the sticks or gloves with the among this study group. remaining free hand. If no protective measures are used, 53 good hand washing is important prior to and after the screening process. Frequency of Mass Screenings, Clore and Longyear (1990) believed that it was essential that elementary schools develop a comprehensive pediculosis screening program. An effective program includes screening of the entire school population three times per year: in mid- September, December, and near spring vacation. Unfortunately, the majority of this target sample did not comply with this recommendation. Only four (23.53%) of the school nurses surveyed followed this program with the remainder involved in variations of a lesser frequency. This finding definitely stresses the need for the development of a comprehensive screening program. Parental Notification of Mass Screenings., The school nurse is responsible for educating the public so that transmission and reinfestation can be reduced. al. Donnelly et (1991) wrote that school nurses are challenged to educate parents so that the signs of infestation can be identified as early as possible and the spread of pediculosis checked. Therefore, parents should be notified prior to and after mass screenings as recommended by the National Pediculosis Association, At this time they should also receive educational materials relating to pediculosis, of the school's It is important that the parents are aware active role in prevention and its expectation that parents will also be a part of this preventive team. 54 Additional Screenings. The majority of surveyed school nurses did screening, in addition to mass screenings, for three reason: when a teacher or parent suspected that a child has pediculosis, when a sibling had been identified, or when a child had been identified in the classroom. Seven of the nurses also had set up a preventive screening program. This practice is recommended because it identifies infestation as early as possible in order to check the spread of pediculosis. Screeners. Ten screeners (58.80%) of pediculosis were the school nurses. However, seven of the respondents did have the assistance of school health aides or a volunteer helper. This is indeed helpful because it can become very disruptive to be interrupted to attend to pediculosis while numerous other health duties are awaiting attention. These trained assistants can result in better compliance with a preventive program, under the direction of the school nurse. This researcher would advise all school nurses without assistance in pediculosis screening to document the need for additional help and approach their supervisors with conviction. Head lice are most common among 3 to 12 years of elementary school children ranging from in this age age (Halpern, 1994), Indirect contact occurs scarves, combs, brushes, and group with sharing of hats, Storage of Coats.±. coats that are hung close together. that lice transfer through indirect contact The fact 55 Twelve surveyed nurses (70.59%) revealed that their students coats were kept in crowded closets. Therefore, this continues to be a major problem. The school nurse must decide what additional actions need to be taken to decrease indirect contact of coats in the school is well known. population. The ideal intervention, besides lockers, would be to place the coats in large garbage bags throughout the year. However, the cost of bags and poor compliance with this policy tend to be a problem. Therefore, prior to instituting the use of bags, it is essential to explain the rationale to the teaching staff so that they will be cooperative in the implementation of this procedure. Education of Parents, Students, Staff. One hundred percent of the surveyed school nurses indicated that they gave parents oral and written instructions on the treatment of lice when an infested child was recognized. However, only six of the nurses provided a school health educational program for students at each grade level while eleven did not provide any education to students. unfortunate. This is As infection control agents, school nurses need to make students aware of this problem and the an essential possible signs and symptoms. The children are part of the preventive team. Nine of the nurses in the elementary schools surveyed provided inservice educational programing on pediculosis It is the school and prevention for their teaching staff. control agent to enlist the nurse's role as the infection 56 team to fight pediculosis. If teachers understand the disease etiology, teacher as an active part of the misconceptions, and treatment of pediculosis perhaps they will be more cooperative in ensuring that the preventive measures are utilized. In addition, they may be more watchful and alert to high risk children. Lastly, they will understand the importance of maintaining the confidentiality of these students. School Policy/Assistance of Agencies. Each school should have a written policy concerning pediculosis. Fourteen schools (82.35%) did have a policy while 3 did not. The school nurse must take the leadership role in developing policies and procedures. The school nurse should lead the team that would include the school administrators, school board, school physicians, and the health education teacher in the development of a well organized policy. When a school policy is developed by different members of the school community, they may take ownership, Plus, nurses will feel supported and not alone in this battle against pediculosis. Everyone will understand what the school nurse is doing to prevent pediculosis in the school community. Eleven respondents (64.71%) submitted their policies while 6 respondents (35.29%) did not. The pediculosis policies varied in what was included and we developing a final comprehensive protocol. helpful in The number of students' days of 57 excused absence following identification of pediculosis varied among the surveyed schools. At three schools (17.65%) children were excused for the day of dismissal and for the following day while 14 schools gave an unlimited amount of days or 3 excused days to correct the problem. Although there is no literature with specific recommendations, the shortest number of excused absences provides for a better outcome for the child. The majority of concerned, compliant parents can complete the pediculosis treatment plan on the dismissal day and the following day. For some parents, who may not feel that school or treatment of pediculosis is a priority, the more time that they have allotted the more time they will take. Therefore, the child does not accumulate unexcused days. This is unfortunate for children who have chronic pediculosis because agencies such as Children and Youth Services will only assist in controlling this problem if the child has excessive unexcused days. Also, the Public Health Department will only make a home visit if the case is extensive and is detrimental to the child s education and self-esteem. Seven of the surveyed nurses indicated that they d* not feel supported by Children Public Health Department, and officer. and Youth Services, the their school's attendance This is understandable, Pediculosis is not a life threatening illness and does not make the top of these 58 agencies' priority list for interventions. This is why it is so crucial to lessen the number of excused days so that these children will be helped by Children and Youth Services. It is a mandated state law in Pennsylvania that any child with excessive unexcused absences be reported to Children and Youth Services. They then become an open case that is investigated no matter what the reason for these absences. 21Tips" by Nurses in Controlling Pediculosis. The role of the infection control agent takes an inordinate amount of time and effort in the schools today. As noted by Thompson (1977), this role involves functioning in health education, health services, and environmental controls. can be exhausting and frustrating. It The tips or suggestions made by the school nurses in this survey were interesting in that all reflected similar concerns. A total of six respondents noted the importance of frequent checking for pediculosis. Monitoring known repeaters or the child with a recent history is the key to decreasing the occurrence of lice in any population. Unfortunately, pretending that the problem does not exist in the school population does not make it go away. Communication was another key area mentioned by one school nurse to increase prevention, The school nurse needs to communicate effectively with the parents, that the nurse must be teachers, and children. She states and make them supportive to all the members of the team 59 part of the solution. Concern of Pediculosis Fifteen of the respondents felt that a pediculosis protocol was needed to serve as a guideline for assessment and possible improvement of their current programs. All seventeen respondents requested a copy of the summary of the results of this study. The above responses were interesting since only eight of the surveyed nurses indicated that they definitely felt lice were a problem in their school population. Support of Theoretical Framework. The theoretical framework for this research project was the Health Belief Model (Becker, 1974). The likelihood that an individual will take preventive action against pediculosis, that is, perforin some health role behavior, depends directly on the outcome of the assessments they make (Becker, 1974) . One assessment relates to the threat of the pediculosis. The other weighs the pros and cons of action. The degree to which taking the actions are more beneficial than not taking the actions is the assessed sum (Becker, 1974) . Individuals who feel threatened by pediculosis, and who have preventive knowledge, are more likely to undertake primary prevention measures, School nurses who believe that pediculosis threatens their student populations are more likely to implement a more effective program to prevent, diagnose, and manag problem. that are armed with Elementary schools and communities 60 adequate knowledge may take the necessary steps to control pediculosis. To this end, a recommended protocol to prevent, diagnose and treat pediculosis capitus was developed (Appendix D ). It is hoped that this recommended protocol will increase the survey group's knowledge base, improve current pediculosis programs, and decrease the occurrence in Mercer and Crawford Counties. Conclusions This study indicated that school nurses did not implement all of the appropriate preventive interventions for the control of pediculosis in elementary school populations. protocol. This study did show a need for an established A protocol was then developed. Recommendations This study revealed that elementary school nurses in two northwestern Pennsylvanian Counties were not providing the most comprehensive preventive programs against pediculosis. Interventions need to be instituted to improve current programs in Mercer and Crawford Counties. Some actions to assist with improving these current programs are: 1. Distribution of the developed established protocol to all of respondents of this survey. 2. Utilization of the pediculosis protocol, as shown in Appendix D, with guidelines for prevention, diagnosis, and management in the elementary school setting. 61 3. Increased networking with this target sample through phone conversations and e-mail. 4. Increased attendance at the monthly Mercer County School Nurse Association Meetings to discuss this topic. Summary This chapter has provided a summary of this research proj ect. Data indicated that the responding elementary school nurses were not implementing all of the interventions needed to make up an effective pediculosis prevention program. developed. A recommended protocol was then Discussion of the implications of these findings, and recommendations, were provided. 62 References Altschuler, D., & Kenney, l. (1986). Pediculicide performance, profit and the public health. Arch Dermatology,122, 259-261. Altschuler, D. out comb out! • National Pediculosis Society-All [On-line] . (1998) . Available Netscape: Hostname: http://www. head lice. org. Becker, M. (1974) . The health belief model and personal health behaviors. Thorofare, NJ: Charles B. Black. Becker, M., Haefner, D., Kasl, S., Kirscht, J. , Maiman, L., & Rosenstock, I. and the health belief model. Brainard, E. (1977) . Social learning theory Medical Care,15(5), 27. (1998) . From eradication to resistance: Five continuing concerns about pediculosis. Journal of School Health, 68,146-150. Burkhart, C., Burkhart, C. G., Pachalek, I., & Arbogast, J. (1998) . The adherent cylindrical nit structure and its chemical denaturation in vitro: An assessment with therapeutic implications for head lice. Archives o.f_ Pediatric and Adolescent Medicine^—152 (7) , 711 712. Clore, E., & Longyear, L. (1993). A comparative study of seven pesticides and their packaged nit removal combs. Journal of Pediatric Health Care,7, 55 60. (1990). Comprehensive Clore, E., & Longyear, L. pediculosis screening programs for elementary schools. Journal of School Health/60, 212-214. Conklin, J. 63 (1998, August 12). Industry parents try to fight lice. Wall Street spawns as Journal p. Bl. Donnelly, E., Likin, J-, Clore, E., & Altschuler, D. (1991). Pediculosis prevention and control strategies of community health and school nurses: A descriptive study. Journal of Community Health Nursing, 8 (2), 85-95. Eckartz, B. , Schillat, S., & Greene, L. (1996). make the diagnosis. Fillo, M. You Nursing Diagnosis,7(3), 125-127. (1998, February 3). Cursed lice! Evolving strain of this embarrassing parasite is proving harder to kill. The Hartford Courant, p. Fl. Gentry, C. causes stir. Disclosure of lice data (1998, April 1). Wall Street Journal, New England Edition. [On-Line]. Available Netscape: Halpern, J. (1994). Hostname: http://wsj/com Recognition and treatment of pediculosis in the emergency department. Journal of. Emergency Nursing,2 0(2) , 130-133. Ibarra, J. (1995, September). treating head lice. A non-drug approach to Nurse Prescriber / Community Nurse, 1 (_8) , 25-27. Pediculosis capitis in school Juranek, D. (1985) children. In M. Orkin & H. Mailbach (Eds.), Cutaneous , iQQ-911). New York: infestations and insect bites (pp- Marcel Dekker. Krinsky, W.(1996). In J.C. Arthropods and leeches. of Medicine (20th Bennett & F. Plum (Eds.), feci 1 Textbgp__ ed.) (pp.1945-1951). Philadelphia: Saunders. Millonig, V. season. 64 (1991). Back to school signals head lice Journal of American Academy of School Nurses,3 , 136-137. National Pediculosis Association-Biology of head lice [On-line]. (1998 a). Available Netscape: Hostname: http: //www.headlice.org. National Pediculosis Association-Child care provider's guide for controlling head lice[On-1inel . Available Netscape: Hostname: (1998 b). http://www.head lice org National Pediculosis Association (1989). Progress, 4(4) , 2-3 . Newland, J. (1995). Pediculosis-primary care protocol. American Journal of Nursing, 95 (9) , 16A. Pediculosis: Battling a community health problem. (1992) . PMA-Two Minute Clinic, 19-20. Pigott, K. (1997). Lice and scabies-protocol. Lippincott Primary Care Practice,! (1) , 91-96. (1983). Roberts, A. The fifth little horseman. Nursing Times, 79 (44) , 70-76. Ross, P. (1990) . Nit picker: more than cosmetic purposes. Sarafino, E. (1990). An ancient comb served Scientific American,62, 15. Health psychology- New York: Wiley. Slonka, G. (1977) . Life cycle and biology of lice. Journal of School Health, 47. (6), 349-351. 65 (1994). Identification and management of American Journal of Primary Health Care, 19 Sokoloff,F. pediculosis. (8), 62-64. Tapi in, D. , & Meinking, T. (1990) . pyrethroids in dermatology. Thompson, V. Pyrethrins and Arch Dermatology,126. 213-221. (1977, June). Role of the school nurses. Journal of School Health,47(6)- 358-359. Windome, M. [On-line]. (1998). Head lice: Scratching for answers Available Netscape: www.msnbc.com Hostname: http:// 66 Appendixes 67 Appendix a Letter Accompanying Elementary School Nurse Survey Dear________________ _ Hello. J' is Connie Kozlowski, rI am a school nurse in Greenville Area School - District. I am also ——-0 a graduate student at Edinboro University For my - of pa. graduate thesis, I am r" 1 attempting to determine the need for an established protocol for^ lice prevention and control in the elementary school community, To obtain this information, I am asking for your help on a volunteer basis. I would appreciate you taking the time to complete the following survey. This survey does not cover all issues relating to pediculosis. It was designed to gain essential information to utilize in the development of the proposed protocol for lice prevention in the elementary school setting. The survey contains 26 questions and should take about 15 minutes to complete. Please indicate your answers to the questions by circling or checking the responses that are appropriate for your situation. Any additional comments made throughout the survey will also be appreciated. Return this survey to me by April 3, 1999 in the enclosed self-addressed. All information will be kept strictly confidential and will be presented as group data so that no individual respondent can be identified. ' t can be utilized My goal is to develop a protocol that of effectively to decrease the occurrence c pediculosis in elementary school children. Thank you very much for your cooperation and assistance in this en^eavor . if you have contact me at my e-mail any questions, please feel free to c~. Hempfield School address (kozlofam@toolcity.com) or at (724-588-1018). Sincerely, Connie Kozlowski R.N School Nurse Hempfield School 68 Appendix B Part A: Survey for School Nurses Demographics Please indicate circling or checking your situation, Any the survey will also your answers to the questions by thej responses that are appropriate for additional done after the new school year yea resumes, after after Christmas Christmas break 4(23.53%). E. They are done after the new new school school year resumes, after Christmas and after ---- ? spring break --------------- 4(23.53%) . F. Other In September along with additional mass m screening when there was evidence of .2 an increased occurrence...... . . . . . . .2(11.76%) . Screened children in September and at a parent or teacher's request .1(5.88%). 4. 5. 6. Are parents notified prior to the school wide screenings? A. Yes 6(35.29%). B.No 11(64.71%). Are parents notified after a school wide screening? A. Yes 2(11.76%) . B. No 15 (88.24%) . When are additional screenings done? A. B.and C 9(52.94%) . A. When a teacher or parent suspects that a child has pediculosis. B. When a child has been identified in the classroom. C. When a sibling has been identified. B. When a child has been identified in the classroom. One respondent only did additional screening at .......................... 1(5.88%). this time .... E. Other ’ . B. and C. Did additional screening for reasons^ precautionary/preventive plus had set up a i ............... 7(41.18%). screening program............................................... 78 7. If precautionary/preventive done, what is the routine? screenings are B. Screen 1 classroom rper day until all classrooms are checked then -- 1 cycle resumes.... 5(29.41%). C. Not done at our school 1(5.88%). D. Other Only on an as needed basis 6(35.29%) . Screen one classroom per day until all classrooms were completed on a cyclic pattern plus on an as needed basis 1(5.88%). Four respondents had no response 8. 4(23.53%). Who does the screening in your school? C. School nurses only D. School nurses and trained volunteers 10(58.82%). 1(5.88%). E. school nurses and trained school aides...6(35.29%). 9. How are student coats ordinarily stored in your school? A. They are stored in a coat closet with hooks less than 8 inches apart 12(70.59%). B. They are stored in a coat closet with hooks . more than 8 inches apart -2(11.76%) . C. They are placed in large garbage bags with tie strings and the bags are hung from the the provided hooks. . . (see response to question 10) . E They are kept in separate lockers.... 3(17.65%) . G‘ SlivSua^boo^bag 6.^ Spon^ question 10) . 10. If large bags are used for coats 12(70.59%) of? the total population used large bags for storage of of coats coats in various ways: 79 A. This practice is used only on a temporary basis after a repeated infestation in’cT particular classroom has been identified identified 9(52.94%). B. This practice is started on the first day of school and continued through out the year for all students students all 1(5.88%) C. Other Given the additional option to keep in book bag on a temporary mandatory basis instead of garbage bag if wanted 2(11.76%). 11. When pediculosis is identified, do you give parents any of the following? A. Oral instructions. B. Written instructions. C. Both 12. 13. Do you provide school health curriculum to each grade level concerning pediculosis? A. Yes 6 (35.29%) . B. No 11(64.71%). Do you in service the teachers about pediculosis and prevention? A. Yes B. No 14. 17 (100.00%). Does your school district have and procedure? A. Yes B. No . . . 9(52.94%). ...8(47.06%) . an approved lice policy ....14(82.35%) . 15. 80 If you do have a ]_policy, ’ ' who was involved in formulating this policy? School Nurse, Physician, Prineipal/Superintendent, School Board.............. ..................................... 2(11.76%). School Nurse, Principal/Superintendent,School Board, Guidance Counselor, School Lawyer 2(11 7 6%) School Nurse, Principal/Superintendent, School Board . . . .3(17.65%). School Nurse, Physician 2(11.76%). School Nurse, Prine ipal/Superintendent 2(11.76%) . School Nurse, School Board 1(5.88%). School Nurse 1(5.88%). Superintendent 1(5.88%). State Guidelines 1(5.88%). Not Applicable 16. 2(11.76%). If your school does have a policy, please check what is included? Exclusion, Readmission, Transport, Excused Days, Other- How to get home if parent not available 1(5.88%). ° Exclusion, Readmission, Transport, Excused Days ........................ . .6(35.29%) . Exclusion, Readmission, Transport Exclusion, Readmission Exclusion, Readmission, Excused Days 1(5.88%). Exclusion, Readmission, Excused Days, other\^°5Ngg%) . Policy............................. Not Applicable 81 17. If you have a school [policy, ’ ' could you please enclose a copy of your policy “when -- 1 you return this survey? A. Yes. • .11(64.71%) . B. No 18. .6(35.29%). How many days.is the child excused to correct tnis problem in your district’-5 B. The day they are sent home plus the following day 3(17.65%) . C. An unlimited number of days until problem resolved 5(29.41%) . D. Other 9(52.94%). Items listed: Three days to resolve the problem with any days 7 (77.78%). passed this ruled as unexcused Three unexcused days for the first 3 occurrences then everyday thereafter counted as unexcused 2(22.22%) . 19. Frequent infestations and excessive absences related to pediculosis may be a sign or symptom of other underlying problems. Who do you contact for assistance with your concerns? Children and Youth Services 3(17.65%) . Children and Youth Services, Public Health Department _____..... 2 (11.76%) . Children and Youth Services, Public Health Department, Attendance Officer 2(11.76-6). Children and Youth Services, Public Health Department, Attendance Officer, Other-Home Visits....... 1(5.88%). Children and Youth Services, Attendance Officer, Not Problem 1(5.88%) . Children and Youth Services, Public Health Dept. ..................................... 1(3.oo?) . Public Health Dept 82 Not Problem.... • • -6(35.28%). 20. Do you feel supported by these A. Yes. B. No agencies? ..7(41.18%). . .8(47.06%) . Other-- mixed experiences with these agencies -both positive and negative 2(11.76%) . 21. Does your school district provide any any assistance to those who can not afford the treatment? A. The district will provide the money or the medication for the parent with administrative approval 4(23.53%) . B. The district will provide the money or the medication with administrative approval plus the child's physicians approval prior to giving out the medication 2(11.76%) . C. The district will provide the money or the medication for the parent with administrative approval plus the suggestion is made regularly to those on medical assistance to call their physician for free medication 4(23.53%). D. The school nurses suggests that those on medical assistance call their physician for free medication 6(35.29%) . E. Other Did not assist in providing medication plus did not suggest to call physician if on 1(5.88%) . assistance 22. Do you have any tips or suggestions that^you controlling have found useful in your practice for f pediculosis? suggestions. 10(58.82%) — gave numerous this question. 7(41.18%) — did not respond to 83 Suggestions: (2)-Continue checking and combing for several weeks. (2)-Once readmitted to recheck frequently. (2)-Check repeaters weekly. (1) Stay in close contact with parents. (l)-Be supportive and give credit for their efforts. Make them part of the solution. (l)-Log all children in notebook designated for tracking those with pediculosis. (l)-Put the child first — treat with kindness, privacy, and dignity. (l)-If absolutely necessary do the nit removal yourself. 23 . Do you feel pediculosis is a problem in your school community? A. Yes 8(47.06%) . B. No 6(35.29%). Other 2(17.64%) . at times or no Considered pediculosis a concern more than anywhere else. 24. Do you feel the school nurses is the infection control agent at your school? A. Yes 25. . . .17(100.00%) . Would a pediculosis protocol be helpful as and updating your guideline in evaluating <---current program? A. Yes. . B. No. . . a 84 Other One respondent replied maybe. 26. • ••.1(5.88%). Would you like a copy of the summary of the results of this study? Please' check the appropriate response. A. Yes (100.00%). 85 Appendix D PEDICULOSIS PROTOCOL FOR THE ELEMENTARY SCHOOL SETTING Head Lice-Pediculosis Capitis Description: Head lice {Pediculosis capitis) are tiny insects that live only in human hair. They hatch from small eggs that are called "nits". The nits hatch in about 7 to 10 days and reach maturity in about 10 more days. As the louse feeds on the human host, it injects saliva into the wound causing local irritation and itching. Young children are most vulnerable to pediculosis and the dangers associated with the abuse of head lice treatments. For this reason, schools need to establish and follow a pediculosis prevention, diagnosis, and management protocol, including a "No Nit" policy. Physical Findings: 1. Presence of lice on the scalp and/or hair. 2. Presence of nits. Nits are small oval, whitish to brown specks, are about the size of a sesame seed, and are strongly adherent to the hair shafts. Head Lice Control Policy A policy should be developed1 and approved by the school community — the school following members of your attendance office^/ |he ^^the^iperintendent. nurse, the 1 Physician, a school board member, policy be passed by After approval, it is advised thwhere there are no your School Board. Conflicts ar -s clear policies in place concerning pedicui 86 Guidelines for Exclusion Exclusion: The following should exclude a child from attending school. 1. A child will be excluded from school■ as soon as evidence of nits or lice is found Exclusion will continue until after the child cl.Ll„ has been treated with a prescribed pediculicide and~all - -- lice and nits are removed. 2. The school.nurse or other designated school official will notify the parent or guardian of the head, lice infestation by telephone and by a conf inning letter that includes the school's exclusion policy (Handout A) . A written instruction sheet for treatment, Handout B, will also be sent home to the parent after giving detailed oral instructions. 3. The parent must provide transportation home for the child. If the parent can not be contacted or has no transportation, the school will provide transportation through the office of the principal. The child is not to be sent home on his/her regular school bus. 4. While the child is awaiting transportation, the child will be excluded from the classroom; an alternative study area will be provided health suite. 5. District policy allows for one day of absence in addition to the day a child is sent home for the treatment of lice. Additional days absent will be counted as unexcused/illegal and citations for absences may be filed as per the district attendance policy. Charges for illegal absences may be i e wi the District Magistrate. 6. Students will be allowed to make up all school work missed during their absence. 7. :nco of pediculosis, all Following the third occurrence for pediculosis. subsequent exclusions from ischool ---- 2 absences. Citations will be deemed illegal/unexcused -i will be filed as per for illegal/unexcused absences u. A letter will be given to district attendance policy.. — 7 that all days of the parent at this time indicating unexcused (Handout E). absence from this date will be i 87 8. In the event of recurrentrecmi-Tp a , ent.cases, the school may to readmitting th^chiM^icati°n of treatment prior Readmission: 1. . parent/guardian must provide documentation of the pediculosis treatment and the date it was used by. completing Handout B. The parent must also bring back the completed instruction/checklist sheet, bottom part of Handout B, upon readmittance (Handout B) . This completed sheet will then be placed into the child's medical record for documentation of occurrence, instructions, and completion of treatment. 2. No student who has been excluded, or has been absent from school, by reason of having or being suspected of having head lice, will be readmitted until after the school nurse checks him or her. Therefore the parent/guardian must bring the student to be checked by the nurse after the head lice are treated. Under no circumstances is the student to be permitted to ride the school bus or attend classes prior to being checked by the school nurse. 3. It may be necessary for the parent to take the child to a different school to see the nurse. 4. Children who still have nits will be sent home for nit removal. Follow Up: 1. Upon readmission to school, the parents are encouraged to repeat the pediculicide application 7 10 days. per product instructions — usually in 7-10 2. The school nurse will check all siblings of any _____ ____ infested child. Other school nurses in the district will be notified if the siblings are not in the same building. 3. 4. ‘ " 1 check all classmates and bus seat The school nurse will ofT the infested student. mates -_ T T-i region 11 T'pr*lnpck theThe readmitted child XC^7°days Com child will then he rechecked « weekly intervals until free fr„» infestation for at least two week . 88 5. If more than three children in a classroom are infested, all coats will be for a two week period?" PlaCed in plastic ba9s Awareness Program Parents, students, teachers, and school nurses must work together to ccontrol this problem. An "Awareness Program" should be developed to assist in implementingr a team approach for prevention. Communicate Custodians f Policy to etc. ) : Staff (Teachers, Substitutes , 1. All staff members should understand the reason for enforcing a head lice policy. A staff meeting will be held to inservice the staff on the school's policy and rationale behind this policy. 2. Staff should be prepared to respond to children's and parent's questions without violating others confidentiality. Staff must understand the importance of confidentiality regarding the occurrence of lice at the school, plus the need for individual student's confidentiality. Communicate Policy to the Parents; 1. When a child is enrolled, parents will be provided with the written policy and educational literature on the description of the problem, prevention, detection, and treatment of lice. 2. The student handbook will contain this policy and educational literature. 3. In addition, the policy will be distributed to each parent of an infested child when giving oral and written instructions for treatment. 4. Parents should understand how the policy will help protect the group as well as their own child. 89 Communicate Policy the Students: and Educational Information to 1. Students need to be educated about pediculosis. A film about pediculosis iWill 1 be shown at all grade levels. Explain that it is -J a communicable disease and why children at the elementary level --- are most prone to pediculosis. 2. Teach children preventive practices. 3. Encourage children to let their teacher or the nurse know if they have any symptoms of pediculosis, or if they have had a recent case of pediculosis that was identified at home. 4. Dispel the myth of shame, poor hygiene, and negligence. Announce Regularly Scheduled Screening Dates: 1. A school wide mass screening is recommended in early September at the beginning of the school year. Parents are notified prior to screening by Handout C, adapted from the National Pediculosis Association. 2. An additional mass screening is encouraged after Christmas and Spring break. Parental Involvement: 1. Encourage parents to make the management of pediculosis their responsibility, as well as the schools, by checking their children often. Parental assistance will help detect this parasite early and decrease occurrence. 2. Speak at P.T.O. meetings and, if. appropriate, at Kindergarten registration emphasizing how we can work together to control this problem. 3. Encourage parents to notify the schoolnurse if they have found lice on their child. The nurse will then assess the classroom and playmates in order to prevent further outbreaks. 90 Screening and Treatment of Pediculosis Group Inspections: 1. Group inspections should be done in a private area of t e nurse's office with the use of a goose-necked lamp or a magnifying hand-held light. 2. Group inspections should be done with disposable screening sticks or gloves. Look for nits. Contrary to some claims, nits found more than a one quarter inch from the scalp are not necessarily dead. Viable nits can be found anywhere on the hair. The diagnosis is made more often by seeing the attached nits than by seeing crawling lice. 3. Watch for lice. Again they are about the size of a sesame seed, are usually brown in color, and move quickly away from light. 4. Be sure not to confuse nits with hair debris such as desquamated epithelial cells and dandruff. You should be able to remove this from the hair easily unlike the nits that adhere to the hair. 5. Check the entire scalp, the hair. 6. If nits or lice are found quietly have the child sit aside to recheck more thoroughly and with greater privacy. Emphasize 1. 2. Nits may be found throughout Prevention: Promptly inform parents of any case of head lice found in their child's classroom. Send home a sample letter, Handout D -- adapted from the National Pediculosis Association, 1998. Alert those who are at greatest risk from the use of pediculicides: a.Women who are pregnantt or nursing should avoid physicians before exposure and contact their t administering treatment to themselves or to their children. b. Children under two years of age should be 91 treated only by manual removal. should not be used. Pediculicide 3. Advise against treating anybody who is not infested, Do not recommend prophylactic 1treatment. No treatment will prevent a child from getti^heariice. 4. Strongly discourage the use of products containing lindane. Lindane (Kwell) is a prescription lice product. . This pediculicide ingredient is potentially more toxic and has been associated with adverse reactions ranging from seizures to death. 5. Inform parents that none of the commercially available products kills 100% of nits. 6. Based on increasing reports of lice resistance on a national level, the National Pediculosis Association advises parents to discontinue the use of lice products at the earliest sign of treatment failure. Manual removal is the best option whenever possible and especially when treatment products have failed. 7. Warn against the use of lice sprays. Using lice sprays on bedding, furniture and carpets is unwarranted, and may pose personal health and environmental hazards. Remember pets do not harbor head lice. Recommend vacuuming as the safest and most effective alternative to spraying. 8. When dealing with head lice outbreaks, experts used to recommend bagging objects that could no e^was e for at least 7 to 10 days. Vacuuming is sufficient. Parents should know to save their energy or DwnvAT which benefits them the most: THOROUGH NIT REMOVAL. Treatment of Individual! using pediculicides. Safety must come first tirst . when all should be Before one family member is treacea, of infestation examined. Only those showing evi *---- -infested family members at Should be treated. Treat all one to another, the same time to prevent reinfestation rewfgatwnj & pediculicidal Individual treatment involves involves the uh use < 92 product and the use of a combing tool manufactured for the purpose of nit removal. 1. Remove the child's shirt and provide a towel to protect the eyes. Do not treat in the bath tub or shower, but have the child lean over the sink (this confines the lice product to the scalp/neck ) 2. Use a pediculicide :recommended -1 by your physician, No pediculicide should be used in the eye area, Avoid applying pediculicides when there are open wounds on the scalp of the person to be treated or on the hands of the person who will apply the product. 3. After using the pediculicide remove all of the nits to insure complete treatment and to comply with "No Nit " policy. Lice products do not kill all the nits, and survivors will hatch into crawling lice within 7-10 days, generating a cycle of selfreinfestation. Nit removal can be accomplished with a special combing tool or by picking them out with the fingernail. Nits can also be cut out with small safety scissors. 4. Work under good light, such as natural sunlight from sitting by a window or going outdoors. A strong lamp can be used also. 5. Divide and fasten hair into sections working on each section individually. 6. Use comb (LiceMeister Comb from National Pediculosis Association is more effective than standard combs) , going through each (.------ - section of hair from the scalp to the end of the hair. Dip comb into water or* use a paper towel to remove any lice or nits. Go C- on to next section until all has been completed. 7. Comb the child's hair every day until all lice and nits are removed. 8. Following nit nit removal, removal, have have, the child put on clean Following clothing and let the hair air dry. 9. Parent should do a daily nit check for at least 10 Make it a part of the days following treatment. .L child's daily hygiene routine. Repeat treatment with is evidence of the pediculicide in 7-10 days if th new nits or newly hatched lice. 93 10 ’ KiiftInce noreASin? ■ rep?rts of Possible insect resistance on a national level the National Pediculosis Association advises discontinue discontinue the the use use of a^h^a^rg^a^the a chemical THE BESTn o°pfTTnN aw«ent failure failure*. MANUAL REMOVAL PRODUCT Treatment A US of the TREATMENT Home Environment: 1. Machine wash all clothing and bed linens that have been in contact with the infested ------ 1 person during the last three days. Articles should be washed in hot water and dried in a hot dryer. Non-washables can be vacuumed or dry cleaned. 2. Wash all combs, brushes, and other devices used for hair care with soap and hot water. 3. If unable to vacuum an item, such as a stuffed animals, place it in a closed off plastic bag for at least 1 week. 4. Again, do not use insecticidal sprays because they are harmful and are of questionable benefit. Inspect Your School Facility: 1. Coats and hats should be hung separately and more than eight inches apart so they do not touch. Lice do not hop, jump, or fly and cannot crawl between coats if the spacing is adequate. A. Hats should be tucked into coat sleeves. B. Do not allow coats to be piled up. 2. Children should not share combs, brushes, hats or headgear. 3. Towels brought from home should be labeled and stored in separate cubbies and sent home for washing. 4. 5. Carpeting should be vacuumed daily by maintenance. extermination services for Never use sprays or pest do not get lice, people do. head lice. Buildings CL Vacuum only. 94 Parental Support 1. Reassure parents that head lice do not reflect unsanitary households or neglected children. Learning that their child is being sent home due to head lice infestation can be distressing, and can provoke feelings of shame or panic. 2. Be prepared to explain points contained in the treatment letter and answer all questions. Be supportive. Parents who have experienced prior infestations may feel unable to cope with a recurrence. 3. Warn against over treatment for children with repeated infestations. Encourage manual nit removal. 4. If allowed by your school budget, purchase nit removal combs such as the LiceMeister which is more effective than the combs that come with the pediculicide. They may be sent home with the parent and returned after completion of total nit removal. The combs are metal and can be boiled for sterilization and cleaning. Handout A Letter of Confirmation with 95 School Policy Incorporated Dear Parents, In the process of an examination on your child name date - showed evidence of head lice. We know that you will be very much concerned aboufc fchis circumstance and that you will want to use every means possible to correct the condition. We suggest that you see your family the best product to use. Follow the attached use. directions for treatment of lice. Medications are covered by Medications doctor as to the Medical Assistance Card. Treatment, including complete removal of all nits, should be completed by the second day following dismissal. If you can accomplish the entire procedure sooner, including the removal of all nits, your child may return to school. You, of course, will be anxious to have your child return to classes at the earliest time, but it will be necessary to have the approval of the school nurse prior to your child's readmission to classes. The school nurse, or a designated assistant, will be in the building daily to examine your child for readmission. NOTE: ALL NITS MUST BE REMOVED FROM YOUR CHILD'S HAIR PRIOR TO READMISSION TO SCHOOL. THIS IS NECESSARY TO PREVENT . REINFESTATION. NOTE: PARENTS MUST ACCOMPANY THEIR CHILD TO SCHOOL CHILDREN , ARE NOT PERMITTED TO RIDE THE BUS UNTIL THIS CONDITION IS CORRECTED. NOTE: YOUR CHILD WILL BE LEGALLY EXCUSED FOR THE DAY O_ COMPLETE TREATMENT OF THIS DISMISSAL AND THE FOLLOWING DAY TO absence will be unexcused.. CONDITION. any additional days of. Yours respectfully, principal Handout B 96 PARENTS INSTRUCTION AND checklist FOR TREATING HEAD LICE Dear Parent, It has been determined that your child i auucner cniicrs sweater or hatLice outbreaks are common among school children -u . , , . n y cniiaren and even the cleanest child may easily become infested. Because lice are so t-i™, / . . • 4_ e cire so tiny and reproduce so fast it is important that you treat your child IMMEDIATELY We have provided a checklist on the bottom of this note for ~ you to follow in order to help you adequately destroy all lice and their nits ((eggs), and to prevent further infestation of other family members, -, friends, relatives, and classmates. Please complete the checklist, sign it, and bring it and your child to school to be reexamined by the nurse. STUDENTS ARE NOT PERMITTED TO RIDE THE BUS UNTIL THE CHILD IS REEXAMINED BY THE SCHOOL NURSE. PLEASE NOTE THAT NO MORE THAN ONE DAY OF ABSENCE (PER INCIDENCE) FOR TREATMENT OF HEAD 1LICE IS PERMITTED. ADDITIONAL DAYS WILL BE COUNTED AS UNEXCUSED AND CHARGES FOR ILLEGAL ABSENCES MAY BE FILED WITH THE DISTRICT MAGISTRATE. Signature of Superintendent Superintendent of Schools *************************************************************** I have: 3. -____ _4. --------- 5. _____ 6. ——J. 8. Shampooed hair with medication recommended by physician, I have 1. (NAME foil owed di rec t i ons exac t ly.---- ------ ------ --------OF SHAMPOO USED) . Used ,2 . a special metal comb to comb out all nits (browimsh white egg masses) . ALL NITS MUST BE REMOVED, Check especially around The nits look like tiny the back of the neck and over the ears, — . They must be slid dandruff flakes but are difficult to remove, Sometimes the nit is more easily off the entire length of hair. L--removed by your fingernail. treated as above. Checked all family members for nits or Washed all sheets, blankets, and pillowcases 3 Washed or dry-cleaned all clot^g."°^iors, carpets, upholstered Vacuumed pillows, mattresses, furniture, etc. used for hair care Washed all combs, brushes, and other devices with soap and very hot water. closed plastic bag for at Placed any stuffed animals in < least 1 week. PARENT/GUARDIAN SIGNATURE date ■ SAVE THIS IMPORTANT NOTICE! Handout C 97 Head lice infestations continue to be a problem in our community. Lice are highly communicable and difficult often, these parasites can be dtpv j j deal with, but the following inZSationshouTd and thoroughly to CHECK A HEAD and screen the entire family a"d COntr?lled' This is often a frustrating problem to T You t0 identify and treat your child for head lice safely How Do You Get Lice? Head lice have been a parasite of humans since recorded time. Many people associate lice with unclean people or homes. This is not true in the case of head lice. Frequent bathing or shampooing will not prevent lice nor eliminate them once they are established. Lice cannot jump or fly, and are usually transmitted by contact with infested per­ sons, their clothing, or their comb or brush. Children should be warned against sharing hats, clothing or grooming aids with others. Household pets do not transmit lice. What To Look For______________________________ Lice are small insects about the size of a sesame seed. They are usually light brown but can vary in color. They move quickly and shy away from the light, making them difficult to see. Diagnosis is more often made on the basis of finding nits (eggs). Nits are tiny, yellowish-white oval eggs attached to the hairshafts. Note: The old quarter-inch from the scalp rule has given way to new evidence sug­ gesting that viable (live) nits may be found at any distance from the scalp. As she deposits her eggs (3-5 per day), the female louse cements them to the hairs, and unlike lint or dandruff, they will not wash off or blow away. Haircasts or pseudo-nits are often mistaken for lice eggs. (Photo on reverse shows the difference.) Nits may be found throughout the hair, but are most often located at the nape of the neck, behind the ears, and at the crown. A magnifying glass and natural light may help when looking for them. Distinguishing dead nits from live nits is non­ productive since the presence of ten dead nits does not guarantee that the eleventh won’t be viable. Symptoms of Infestation________________________ The itching that occurs when lice bite and suck blood from the scalp is a primary symptom of infestation, although not everyone will experience the itching. Children seen scratching their heads should be examined at once. Often red bite marks or scratch marks can be seen on the scalp and neck. In severe infestations, a child may develop swollen glands in the neck or under the arms. Treatment of the Individual______________________ Safety must come first when using pesticides. Before one family member is treated, all should be examined. Only those showing evidence of infestation should be treated. Treat them at the same time to prevent reinfestation from one family member to another Individual treatment in­ volves the use of a pediculicidal product and the use of a combing tool manufactured for the purpose of nit removal. Proceed as follows: 1. Remove child’s shirt and provide a towel to protect the eyes. Do not treat in the bathtub or shower, but have the child lean over the sink (this confines the lice product to the scalp/neck.) 2 Use one of several louse remedies available at your pharmacy. Some are available by prescription;* some over the counter. Consult your pharmacist or physician if you are pregnant, nursing, have allergies, using medication, or discover lice/nits in the eyebrows or eyelashes. No pesticide should be used in the eye area. Avoid applying pesticides when there are open wounds on the scalp of the person to be treated or on the hands of the person who will apply the product. Adult female louse on hairshafts highh magni DO NOT USE THESE PRODUCTS ON INFANTS.** AVOID PERSONAL AND ENVIRONMENTAL PESTICIDE SPRAYS. READ ALL PACKAGE INFORMATION BEFORE USING LICE-KILLING PRODUCTS!*** 3. Although it can take time and sometimes be difficult, remove all nits to insure complete treatment and to comply with No Nit Policies.**** Louse products do not kill all the nits, and survivors will hatch into crawling lice within 7-10 days, generating a cycle of self-reinfestation. Even dead nits will cling to the hair and cause uncertainty about reinfestation. Nit removal can be accomplished with a special combing tool or by picking them out with the fingernails. Nits can also be cut out with small safety scissors. Note: Some so-called lice combs are actually cradle cap combs and are ineffective against nits. Nit combing is best accomplished with hair which is slightly damp. Note: Even if your lice comb fails as a nit removal tool it can be used to screen for adult lice and is particularly helpful for the person screening him or herself. 4. Following nit removal, have child put on clean clothing and let hair air dry. 5. A daily nit check is advisable for at least 10 days following treatment and then checking should become part of routine hygiene. You may have to retreat in 7-10 days if there is evidence of new nits or newly-hatched lice (Regardless of precautions taken at home, reinfestation from others can still take place.) Treat­ ment itself can cause itching; do not retreat on the basis of itchiness alone. I \ HEAD UCE |_______ r Enlarged photo of hair debris, nits and head lice. ^3! The nit is always oval-shaped and glued at an angle to the side of the hair shaft. Note the differences between hair debris and actual nits in the photo. A Rased on increasing reports of possible insect resistance on a national level, the NPA advises parents to discontinue the use of a chemical product at the earliest • of treatment failure. Manual removal is the best option when a lice treatment product has failed treatment of personal articles and ENVIRONMENT ----------------------------------- _______ 1 Machine wash all clothing and bed linens which have been in contact with the infested person during the last three days. Articles should be washed in hot water and dried in a hot dryer. Non-washables can be vacuumed or dry cleaned. 2 “Bagging” is not necessary. Rugs, upholstered furniture, mattresses, and car seats (and any personal items that cannot be washed, e.g. stuffed animals, can be carefully vacuumed to pick up living lice or nits attached to fallen hairs. The use of insecticidal sprays is not recommended and strongly discouraged by the NPA and the Centers For Disease Control because they may be harmful to family members and pets and are of questionable benefit. NOTICE! Handout D 98 Today, your child’s classroom was screened for T u classmates These children are being treated and will b Were found °n SOme of your child’s lice. Lice spread easily, so you will want to check >° retUrn t0 sch°o1 when they no longer have check should become part of your daily hyaiene Re™ T” C“. d s head for signs of lice, frequently. A daily others can still take place. We need your cooperation 6SS of p^ecautl0ns taken at home, reinfestation from message carefitlly to team how to recognize !i« I “eat read ,his "»ire How Do You Get Lice? ______ Head lice have been a parasite of humans since recorded time. Many people associate lice with unclean people or homes. This is not true in the case of head lice. Frequent bathing or shampooing will not prevent lice nor eliminate them once they are established. Lice cannot jump or fly, and are usually transmitted by contact with infested per­ sons, their clothing, or their comb or brush. Children should be warned against sharing hats, clothing or grooming aids with others. Household pets do not transmit lice. What To Look For Lice are small insects about the size of a sesame seed. They are usually light brown but can vary in color. They move quickly and shy away from the light, making them difficult to see. Diagnosis is more often made on the basis of finding nits (eggs). Nits are tiny, yellowish-white oval eggs attached to the hairshafts. Note: The old quarter-inch from the scalp rule has given way to new evidence sug­ gesting that viable (live) nits may be found at any distance from the scalp. As she deposits her eggs (3-5 per day), the female louse cements them to the hairs, and unlike lint or dandruff, they will not wash off or blow away. Haircasts or pseudo-nits are often mistaken for lice eggs. (Photo on reverse shows the difference.) Nits may be found throughout the hair, but are most often located at the nape of the neck, behind the ears, and at the crown. A magnifying glass and natural light may help when looking :1 for them. Distinguishing dead nits from live nits is non­ productive since the presence of ten dead nits does not guarantee that the eleventh won’t be viable. Symptoms of Infestation_______ The itching that occurs when lice bite and suck blood from the scalp is a primary symptom of infestation, although not everyone will experience the itching. Children seen scratching their heads should be examined at once. Often red bite marks or scratch marks can be seen on the scalp and neck. In severe infestations, a child may develop swollen glands in the neck or under the arms. Treatment of the Individual______________________ Safety must come first when using pesticides. Before one family member is treated, all should be examined. Only those showing evidence of infestation should be treated. Treat them at the same time to prevent reinfestation from one family member to another. Individual treatment in­ volves the use of a pediculicid'al product and the use of a combing tool manufactured for the purpose of nit removal. Proceed as follows: 1 Remove child’s shirt and provide a towel to protect the eyes. Do not {real in the bathtub or shower, but have the child lean over the sink (this confines the lice product to the scalp/neck.) 2 Use one of several louse remedies available at your pharmacy. Some are available by prescription;* some over the counter. Consult your pharmacist or physician if vou are pregnant, nursing, have allergies using medication, or discover lice/nits in the eyebrows or flashes No pesticide should be used in the eye area 7 ;. nnnlvms pesticides when there are open wounds Sp X'luli temaic louse :.jirshal’t< hly ma; or °n ,ht tond5 J NOT USE THi.SE PRODUCTS ON INFANTS. DO NOTPERSONALAND Ubfc. in a -x AVOID ENVIRONMENTAL PESTICIDE ERSONAL AND ENVIRO1 . SPRAYS. READ ALL PACKAGE — GE INFORMATION —iking LICE-KILLING PRODUCTS!*** BEFORE USING LICE-KILL.. ind sometimes be difficult, 3. Although can take time ai-----remove allitnits to insure complete treatment and1 to comply with No Nit Policies.**** TLouse products do not kill all the nits, and survivors will hatch into crawling lice within 7-10 days, generating a cycle of self-reinfestation. Even dead nits will cling to the hair and cause uncertainty about reinfestation. Nit removal can be accomplished with a special combing tool or by picking them out with the fingernails. Nits can also be I 1XV7W ----------- 1 XX* - ------- cut out with small safety scissors. Note: Some so-called lice combs are actually cradle cap combs and are ineffective against nits. Nit combing is best accomplished with hair which is slightly damp. Note: Even if your lice comb fails as a nit removal tool it can be used to screen for adult lice and is particularly helpful for the person screening him or herself. 4. Following nit removal, have child put on clean clothing and let hair air dry. 5. A daily nit check is advisable for at least 10 days following treatment and then checking should become part of routine hygiene. You may have to retreat in 7-10 days if there is evidence of new nits or newly-hatched lice. (Regardless of precautions taken at home, reinfestation from others can still take place.) Treat­ ment itself can cause itching; do not retreat on the basis of itchiness alone. i HAIR DEBRIS NITS HEAD LICE ___________________ * t n Enlarged photo of hair debris, nits and head lice. The nti is always oval-shaped and glued at an angle to the side of the hair shaft. Note the differences between hair debris and actual nits in the photo. dfecominue the use of a chemical product at the X of treatment failure. Manual removal is the best option when a lice treatment product has failed treatment of personal articles and ENVIRONMENT___________________________ 1 Machine wash all clothing and bed linens which have been in contact with the infested person during the three days. Articles should be washed in hot water and dried in a hot dryer. Non-washables can be vacuumed or dry cleaned. 2 "Bagging” is not necessary. Rugs, upholstered furniture, mattresses, and car seats (and any personal items that cannot be washed, e.g. stuffed animals, can be carefully vacuumed to pick up living lice or nits attached to fallen hairs. The use of insecticidal sprays is not recommended and strongly discouraged by the NPA and the Centers For Disease Control because they may be harmful to family members and pets and are of questionable benefit. 99 HANDOUT E LETTER FOR CHRONIC CASES WITH EXCESSIVE ABSENTEEISM Dear Parents, In the process of an examination on your child was found to still show evidence of head lice. We are very concerned about this because: .Your child has been absent with this condition longer than the legally allowed dismissal day plus one additional day for treatment. Jour child has been absent repeatedly due to reinfestation with lice times this school year. We suggest that you see your doctor as to the best lice treatment product to use and that you follow the attached guidelines for treatment. of all nits. Treatment includes complete removal This is necessary to prevent reinfestation. You including the removal of can accomplish the entire procedure, (Medications are follow directions carefully. all nits, if you covered by the Medical Assistance Card). today AND ALL FUTURE DAYS, THAT YOUR COUNTED AS ILLEGAL DAYS because ABSENT WILL ^BE time to correct the condition. already been adequate CHILD IS there has Yours respectfully, Principal