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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:
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Burkhart, C., Burkhart, C. G., Pachalek, I., &
Arbogast, J.
(1998) . The adherent cylindrical nit structure
and its chemical denaturation in vitro:
An assessment with
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Clore, E., & Longyear, L.
(1993). A comparative study
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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
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Donnelly, E., Likin, J-, Clore, E.,
& Altschuler, D.
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Eckartz, B. , Schillat, S., & Greene, L. (1996).
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Fillo, M.
You
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Evolving
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Gentry, C.
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(1994).
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Ibarra, J.
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Back to school signals head lice
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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 -made throughout
be appreciated.
Total school population served
1-299 students
300-599 students
600+ students
Other, please specify.
Grades served
Kindergarten through third grade
Kindergarten through fifth grade
Kindergarten through sixth grade
_ Other, please specify---------
Staffing
Certified school nurses
Registered Nurses
Licensed Practical Nurses
Health Room Aides/Assistants
school nurse
Years of experience as an elementary
Part B:
69
Survey-
Please answer the following questions by either
circling or checking the correct responses. YoJ
choose
more than one response per question when needed
X
anSSaSd™
°
throughout the survey will also be
appr cClG. LtzU. .
l.What method is used to identify lice at your school?
a. :Inspection of a child's head in the classroom
using the natural lighting of theJ room,
B. Inspection of the child's head in the nurse's
office using a goose necked lamp.
C. Inspection of the child's head by the use of
a hand held magnified light.
D. Other, please specify
2.
What procedures do you follow when examining a child?
A.
B.
C.
D.
E.
3.
No gloves are worn.
No sticks are utilized.
Gloves are worn.
Sticks are utilized.
Gloves and sticks are utilized.
When are mass screenings done?
A. They are not done.
B. They are only done when there has been an
increased occurrence.
uAv+iv
C. They are done in early September shortly
after the new school year resumes.
D. They are done after the new school year
break. ,Z^ATresumes and after Christmas
C---E. They are> done after the new school year
yea
resumes, after
after Christmas
Christmas -- after spri g
break.
F. Other, please specify---------’ T
70
4.
Are parents notified prior
to the school wide
screenings?
A. Yes
B. No
5.
Are parents notified after a school wide
screening?
A. Yes
B. No
C. Not notified because no mass screenings are done.
6.
When are additional screenings done?
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.
D. As a precautionary/preventive measure.
E. Other, please specify
7.
If precautionary/preventive screenings are
done, what is the routine?
A. Screen 1 classroom per wk.
rooms are checked then the
B. Screen 1 classroom per day
rooms are checked then the
C. Not done at our school.
until
cycle
until
cycle
all class
resumes.
all class
resumes.
D. Other, please specify------ ---- ------8.
Who does the screening in your school?
A.
B.
C.
D.
E.
Trained volunteers.
Trained school aides.
school nurses only.
school nurses and trained vo?;u^eJ; •
school nurses and trained scho
9.
How are student coats ordinarily stored
in your
school?
71
A. They are stored in a c°at closet with
hooks
less than 8 inches apart.
B. They are stored in a coat closet with hooks
more than 8 inches apart.
C. They are placed in iarge garbage bags with
tie strings and the bags
L J are hung from the
the provided hooks.
D. They are placed in large garbage bags only on
a voluntary basis.
E They are kept in separate lockers.
F They are kept on the back of each child's
individual chair.
G. They are kept inside each child's own
individual book bag.
H. Other, please specify
10.
If large bags are used for storing coats:
A. This practice is used only on a temporary
basis after a repeated infestation in a particular
classroom has been identified.
B. This practice is started on the first day of
school and continued through out the year for
all students.
C. Other, please specify------ -------------
11.
When pediculosis is identified, do you give
parents any of the following?
A. Oral instructions.
B. Written instructions.
C. Both.
12.
curriculum
Do you provide school health
.
•
pediculosis?
grade level concerning
A. Yes
B. No
to each
13.
14.
Do you in service the teachers about
and prevention?
pediculosis
A. Yes
B. No
Does your school district have
and procedure?
12
an approved lice policy
A. Yes
B. No
15.
If you do have a ]_policy,
"'
who was involved in
formulating this policy?
' ’ - ’ Please check.
school
School
Principal
School
School
16.
nurses
physician
administrator
board
Other, please specify.
If your school does have a policy, please check
what is included.
Exclusion policy
Readmission policy
Transportation policy
Number of excuse
condition.
Other, please specify
17.
If you have a school policy, could you p ^ase
enclose a copy of your policy when you re urn
this survey?
A. Yes
B. No
13
18.
correct
A. The day they are sent home
B. The day they are sent home’plus the
following day.
C. An unlimited number of days until problem
resolved.
D. Other, please specify
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?
A.
B.
C.
D.
Children and Youth Services.
The Public Health Department.
The Attendance Officer of your district.
Never had this situation.
D. Other, please specify
20.
_
Do you feel supported by these agencies?
A. Yes
B. No
C. Not applicable
21.
Does your school district provide^any
the
assistance to those who can inot
— afford
treatment?
A. The district will provide the money f
parent to buy the prescribed ^edl^^er
B. The district provides the pes ici
receiving permission from the s
physician.
■ • that those on medical
C. The school nursestheitphys
suggests’ician for free
assistance call 1--- - medication.
D. None of the above. .
E. Other, please specify----
74
22.
Do you have any tips or suggestions that you
have found useful in your practice for controlling
pediculosis?
23 .
Do you feel pediculosis is a problem in your
school community?
A. Yes
B. No
Comments.
24.
Do you feel the school nurses is the infection control
agent at your school?
A. Yes
B. No
25.
Would a pediculosis protocol be helpful as a
guideline in evaluating and updating your
current program?
A. Yes
B. No
26.
Would youj. like a copy of the summary of the
results of
c this study? Please check the
appropriate response.
A. Yes
B. No
-- of the summary, please
If you would like a copy
would
like the summary sent to.
list the address you wcu
75
Appendix C
Survey Data
Total school population served
0% 1-299 students
5.88% 300-599 students
70.59% 600+ students
Other:
23.53% 1000 + students
Grades served
41.18%
5.88%
41.18%
Kindergarten through twelfth grade
Kindergarten through eighth grade
Kindergarten through sixth grade
Other:
5.88%
Daycare -6th
5.88%
Grades 1, 2, 9, 10, and 12
Staffing for population elementary populations:
35.29%
5.88%
23.53%
One Certified school nurse only
Two Certified school nurses
One Certified School Nurse and
Registered Nurse only
29.41%
Certified School Nurse with Health Room
Aide
5.88%
Two Certified School Nurses and One
Practical Nurse
Mean years of experience as school nurse 14.76 years.
76
l.What method is used to identify lice at your school?
A. Inspection of a child's head in the classroom
using the natural lighting of the room ..5(29.41%).
B. Inspection of the child's head in the nurse's
office using a goose necked lamp
. ..4(23.52%) .
D. Other, please specify
Inspection of child's head using the natural
lighting and goose-necked lamp
4(23.52%).
Inspection of the child's head by the use of
a natural lighting and magnifying lamp ..2(11.76%).
Use of the natural light, goose necked light and
magnified lamp used
1(5.88%).
Use of gooseneck lamp and magnified
lamp
2.
1(5.88%).
What procedures do you follow when examining a child?
A. No gloves are worn
B. No sticks or gloves are utilized
C. Gloves are worn
1(5.88%) .
7(41.18%) .
1(5.88%).
D. Sticks are utilized
4(23.53%).
E. Gloves and sticks are utilized
2 (11.76%) .
F. Other
Did not use aloves routinely just during mass
1(5.88%) .
screenings.
Did not use gloves or sticks routinely just
during mass screenings...............
3.
When are mass screenings done?
B. They are only done when there has been an
increased occurrence.................. k
''
C. They are done in early September shortly 4(23.53%)
after the new school year resumes.....
77
D. They are done after the r_
new school year
resumes and after 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
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:
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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
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Pediatric and Adolescent Medicine^—152 (7) , 711 712.
Clore, E., & Longyear, L.
(1993). A comparative study
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Journal of Pediatric Health Care,7, 55 60.
(1990). Comprehensive
Clore, E., & Longyear, L.
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Journal of School Health/60, 212-214.
Conklin, J.
63
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Donnelly, E., Likin, J-, Clore, E.,
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Eckartz, B. , Schillat, S., & Greene, L. (1996).
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Evolving
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Gentry, C.
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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
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Ibarra, J.
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Millonig, V.
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64
(1991).
Back to school signals head lice
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(1998 a). Available Netscape:
Hostname: http:
//www.headlice.org.
National Pediculosis Association-Child care provider's
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(1998 b).
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(1995). Pediculosis-primary care protocol.
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Pediculosis: Battling a community health problem.
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Sokoloff,F.
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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 -made throughout
be appreciated.
Total school population served
1-299 students
300-599 students
600+ students
Other, please specify.
Grades served
Kindergarten through third grade
Kindergarten through fifth grade
Kindergarten through sixth grade
_ Other, please specify---------
Staffing
Certified school nurses
Registered Nurses
Licensed Practical Nurses
Health Room Aides/Assistants
school nurse
Years of experience as an elementary
Part B:
69
Survey-
Please answer the following questions by either
circling or checking the correct responses. YoJ
choose
more than one response per question when needed
X
anSSaSd™
°
throughout the survey will also be
appr cClG. LtzU. .
l.What method is used to identify lice at your school?
a. :Inspection of a child's head in the classroom
using the natural lighting of theJ room,
B. Inspection of the child's head in the nurse's
office using a goose necked lamp.
C. Inspection of the child's head by the use of
a hand held magnified light.
D. Other, please specify
2.
What procedures do you follow when examining a child?
A.
B.
C.
D.
E.
3.
No gloves are worn.
No sticks are utilized.
Gloves are worn.
Sticks are utilized.
Gloves and sticks are utilized.
When are mass screenings done?
A. They are not done.
B. They are only done when there has been an
increased occurrence.
uAv+iv
C. They are done in early September shortly
after the new school year resumes.
D. They are done after the new school year
break. ,Z^ATresumes and after Christmas
C---E. They are> done after the new school year
yea
resumes, after
after Christmas
Christmas -- after spri g
break.
F. Other, please specify---------’ T
70
4.
Are parents notified prior
to the school wide
screenings?
A. Yes
B. No
5.
Are parents notified after a school wide
screening?
A. Yes
B. No
C. Not notified because no mass screenings are done.
6.
When are additional screenings done?
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.
D. As a precautionary/preventive measure.
E. Other, please specify
7.
If precautionary/preventive screenings are
done, what is the routine?
A. Screen 1 classroom per wk.
rooms are checked then the
B. Screen 1 classroom per day
rooms are checked then the
C. Not done at our school.
until
cycle
until
cycle
all class
resumes.
all class
resumes.
D. Other, please specify------ ---- ------8.
Who does the screening in your school?
A.
B.
C.
D.
E.
Trained volunteers.
Trained school aides.
school nurses only.
school nurses and trained vo?;u^eJ; •
school nurses and trained scho
9.
How are student coats ordinarily stored
in your
school?
71
A. They are stored in a c°at closet with
hooks
less than 8 inches apart.
B. They are stored in a coat closet with hooks
more than 8 inches apart.
C. They are placed in iarge garbage bags with
tie strings and the bags
L J are hung from the
the provided hooks.
D. They are placed in large garbage bags only on
a voluntary basis.
E They are kept in separate lockers.
F They are kept on the back of each child's
individual chair.
G. They are kept inside each child's own
individual book bag.
H. Other, please specify
10.
If large bags are used for storing coats:
A. This practice is used only on a temporary
basis after a repeated infestation in a particular
classroom has been identified.
B. This practice is started on the first day of
school and continued through out the year for
all students.
C. Other, please specify------ -------------
11.
When pediculosis is identified, do you give
parents any of the following?
A. Oral instructions.
B. Written instructions.
C. Both.
12.
curriculum
Do you provide school health
.
•
pediculosis?
grade level concerning
A. Yes
B. No
to each
13.
14.
Do you in service the teachers about
and prevention?
pediculosis
A. Yes
B. No
Does your school district have
and procedure?
12
an approved lice policy
A. Yes
B. No
15.
If you do have a ]_policy,
"'
who was involved in
formulating this policy?
' ’ - ’ Please check.
school
School
Principal
School
School
16.
nurses
physician
administrator
board
Other, please specify.
If your school does have a policy, please check
what is included.
Exclusion policy
Readmission policy
Transportation policy
Number of excuse
condition.
Other, please specify
17.
If you have a school policy, could you p ^ase
enclose a copy of your policy when you re urn
this survey?
A. Yes
B. No
13
18.
correct
A. The day they are sent home
B. The day they are sent home’plus the
following day.
C. An unlimited number of days until problem
resolved.
D. Other, please specify
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?
A.
B.
C.
D.
Children and Youth Services.
The Public Health Department.
The Attendance Officer of your district.
Never had this situation.
D. Other, please specify
20.
_
Do you feel supported by these agencies?
A. Yes
B. No
C. Not applicable
21.
Does your school district provide^any
the
assistance to those who can inot
— afford
treatment?
A. The district will provide the money f
parent to buy the prescribed ^edl^^er
B. The district provides the pes ici
receiving permission from the s
physician.
■ • that those on medical
C. The school nursestheitphys
suggests’ician for free
assistance call 1--- - medication.
D. None of the above. .
E. Other, please specify----
74
22.
Do you have any tips or suggestions that you
have found useful in your practice for controlling
pediculosis?
23 .
Do you feel pediculosis is a problem in your
school community?
A. Yes
B. No
Comments.
24.
Do you feel the school nurses is the infection control
agent at your school?
A. Yes
B. No
25.
Would a pediculosis protocol be helpful as a
guideline in evaluating and updating your
current program?
A. Yes
B. No
26.
Would youj. like a copy of the summary of the
results of
c this study? Please check the
appropriate response.
A. Yes
B. No
-- of the summary, please
If you would like a copy
would
like the summary sent to.
list the address you wcu
75
Appendix C
Survey Data
Total school population served
0% 1-299 students
5.88% 300-599 students
70.59% 600+ students
Other:
23.53% 1000 + students
Grades served
41.18%
5.88%
41.18%
Kindergarten through twelfth grade
Kindergarten through eighth grade
Kindergarten through sixth grade
Other:
5.88%
Daycare -6th
5.88%
Grades 1, 2, 9, 10, and 12
Staffing for population elementary populations:
35.29%
5.88%
23.53%
One Certified school nurse only
Two Certified school nurses
One Certified School Nurse and
Registered Nurse only
29.41%
Certified School Nurse with Health Room
Aide
5.88%
Two Certified School Nurses and One
Practical Nurse
Mean years of experience as school nurse 14.76 years.
76
l.What method is used to identify lice at your school?
A. Inspection of a child's head in the classroom
using the natural lighting of the room ..5(29.41%).
B. Inspection of the child's head in the nurse's
office using a goose necked lamp
. ..4(23.52%) .
D. Other, please specify
Inspection of child's head using the natural
lighting and goose-necked lamp
4(23.52%).
Inspection of the child's head by the use of
a natural lighting and magnifying lamp ..2(11.76%).
Use of the natural light, goose necked light and
magnified lamp used
1(5.88%).
Use of gooseneck lamp and magnified
lamp
2.
1(5.88%).
What procedures do you follow when examining a child?
A. No gloves are worn
B. No sticks or gloves are utilized
C. Gloves are worn
1(5.88%) .
7(41.18%) .
1(5.88%).
D. Sticks are utilized
4(23.53%).
E. Gloves and sticks are utilized
2 (11.76%) .
F. Other
Did not use aloves routinely just during mass
1(5.88%) .
screenings.
Did not use gloves or sticks routinely just
during mass screenings...............
3.
When are mass screenings done?
B. They are only done when there has been an
increased occurrence.................. k
''
C. They are done in early September shortly 4(23.53%)
after the new school year resumes.....
77
D. They are done after the r_
new school year
resumes and after 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