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Going to School on Head Lice New Approaches to an Old Nemesis Getty Images/Digital Vision. US.IVE.13.03.021.

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Presentation on theme: "Going to School on Head Lice New Approaches to an Old Nemesis Getty Images/Digital Vision. US.IVE.13.03.021."— Presentation transcript:

1 Going to School on Head Lice New Approaches to an Old Nemesis Getty Images/Digital Vision. US.IVE

2 Key Points to Cover Today! 1.Head Lice: Getting to Know You 2.The Key Role of the Clinician in Head Lice Diagnosis and Treatment 3.The School Nurse’s Pivotal Roles in Head Lice Management 4.Strategies for School Nurses: When Lice Go to the Head of the Class 5.Background Information on Approved Head Lice Products 2

3 Head Lice: Getting to Know You

4 Head Lice Infestation: A Common Pediatric Condition Pediculosis is the most prevalent parasitic infestation among humans 1 Head lice infestations are pervasive among school-age children in the United States 2,3 ~6-12 million infestations occur each year in children 3-11 years of age 3 –More common in females 4 All socioeconomic groups are affected 2,4,5 –Contrary to myth, “head lice prefer clean, healthy hosts” 4 References: 1. Hodgdon HE, et al. Pest Manag Sci. 2010;66(9): Frankowski BL, et al. Pediatrics. 2010;126(2): Centers for Disease Control and Prevention (CDC). Head lice. Epidemiology & risk factors. lice/head/epi.html. Accessed January 13, Meinking T, et al. Infestations. In: Schachner LA, Hansen RC, eds. Pediatric Dermatology. 4th ed. Mosby Elsevier; 2011: Meinking TL, et al. Int J Dermatol. 2013;52(1): Getty Images/Peter Dazeley. 4

5 Common Myths About Head Lice 1 Reference: 1. Pontius DJ. NASN Sch Nurse. 2011;26(6):  MYTH: Head lice can fly or jump from head to head FACT: Head lice have no wings and can only crawl.  MYTH: Head lice are a health hazard and are more common in people with poor hygiene. FACT: Head lice prefer a clean, healthy head; they are not a health hazard and do not transmit disease.  MYTH: Transmission of head lice in the classroom is common. FACT: Classroom transmission is considered rare.  MYTH: You can get head lice from a house pet. FACT: Dogs, cats, and other house pets do not play a role in head lice transmission. CDC. Dr. Dennis D. Juranek.

6 The Head Louse: A Closer Look The adult louse is 2-3mm long (about the size of a sesame seed) 1 Usually pale gray; color may vary 1 –Red when engorged with blood –May adapt color to surroundings The louse feeds by injecting small amounts of saliva and taking tiny amounts of blood from the scalp every few hours 1 Lice usually survive less than hours away from the scalp at room temperature 1,2 Lice that fall off the head are usually dead or dying Must find a host to survive Eggs need warm temperatures (like those near the scalp) to hatch References: 1. Frankowski BL, et al. Pediatrics. 2010;126(2): CDC. Head lice. Prevention and control. Accessed March 26, CDC.

7 Female lives 3-4 weeks Lays up to 10 eggs per day Eggs tightly attached to hair, close to scalp Eggs hatch in 7-12 days Female lays 1st egg 1-2 days after mating Without treatment, the cycle may repeat every 3 weeks Become adults 9-12 days after hatching 3 nymph stages References: 1. Frankowski BL, et al. Pediatrics. 2010;126(2): Meinking TL, et al. Infestations. In: Schachner LA, Hansen RC, eds. Pediatric Dermatology. 4th ed. Mosby Elsevier; 2011: Illustration by Penumbra Design Inc. The Life Cycle of the Head Louse 1,2

8 Know Your Nits! Nits are tiny, teardrop-shaped eggs attached to 1 side of the hair shaft with a waterproof, glue-like substance 1-4 –Often found on nape of the neck and behind the ears 5 Viable nits with an egg inside may be tan to coffee-colored or darker 1 Nonviable nits are white or yellowish shells, or casings 1 Nits attached >1cm from the scalp are usually not viable 2 –In some warmer climates, viable nits may be found several inches from the scalp 3 –Close inspection is needed 4 References: 1. Meinking TL, et al. Infestations. In: Schachner LA, Hansen RC, eds. Pediatric Dermatology. 4th ed. Mosby Elsevier; 2011: Frankowski BL, et al. Pediatrics. 2010;126(2): Paller AS, Mancini AJ, eds. Hurwitz Clinical Pediatric Dermatology. A Textbook of Skin Disorders of Childhood and Adolescence, 4th ed. New York, Elsevier Saunders; 2011: CDC. Head lice. Diagnosis. Accessed January 13, American Academy of Pediatrics. Pediculosis capitis (head lice). In: Red Book Report of the Committee on Infectious Diseases. Pickering LK, ed. 29th ed. Elk Grove Village, IL, American Academy of Pediatrics; 2012: Franca K, et al. Int J Trichology. 2011;3(2): Nits may be confused with: Dandruff 1-5 Dirt and other debris 2,4,5 Droplets of hair spray, gel 2-4 Hair casts (pseudonits) encircling the hair shaft 1,3,5,6 Plugs of skin cells 5 Fungal infection of the hair (piedra) 1,3,5 Psoriasis 1,3 8 CDC/Dr. Dennis D. Juranek.

9 Head Lice: The Truth About Transmission 1-3 Transmission of lice typically occurs by direct head-to-head contact with an infested individual Children can get head lice anytime they come in close contact with others—during play at home or school, slumber parties, sports activities, or camp Indirect spread by contact with personal items (combs, brushes, hats, headgear) is less likely but can occur References: 1. Frankowski BL, et al. Pediatrics. 2010;126(2): CDC. Head lice. Epidemiology & risk factors. Accessed January 13, Meinking TL, et al. Infestations. In: Schachner LA, Hansen RC, eds. Pediatric Dermatology. 4th ed. Mosby Elsevier; 2011: Getty Images/Jamie Grill.

10 Typical Symptoms of Head Lice Infestation Itching is the most common symptom 1-3 –Caused by an allergic reaction to louse saliva If someone is infested for the first time, itching may take 4-6 weeks to develop 1 –If a person has had previous head lice episodes, itching may develop within 48 hours 3 Irritability, difficulty sleeping 1 –Lice are more active in the dark Sores, crusting, secondary bacterial infection on the scalp 1-3 –Not common; caused by excessive scratching In some cases, no symptoms are present 3 Getty Images/Westend61. References: 1. CDC. Head lice. Disease. Accessed March 28, Frankowski BL, et al. Pediatrics. 2010;126(2): Meinking TL, et al. Infestations. In: Schachner LA, Hansen RC, eds. Pediatric Dermatology. 4th ed. Mosby Elsevier; 2011: Gordon SC. Dermatology Nursing. 2010;22(4): Reprinted with permission of Jannetti Publications, Inc.

11 The Key Role of the Clinician in Head Lice Diagnosis and Treatment

12 00 The Traditional Approach to Head Lice 1,a Desire to avoid delay Easy access to over-the- counter (OTC) products Limited parent knowledge of Rx choices Desire to avoid delay Easy access to over-the- counter (OTC) products Limited parent knowledge of Rx choices Treat On Their Own Contact a Health Care Provider 70% of Households 30% of Households Reference: 1. Sanofi Pasteur Inc., Data on file (ICR Research; Excel Omnibus Studies H , I8823). July MKT Head lice suspected Office may treat “over the phone” by recommending an OTC option or calling in a prescription treatment a Independent market research conducted in the US; data shown are based on responses from 201 households.

13 A New Approach: Getting Clinicians More Involved 1 The American Academy of Pediatrics (AAP) calls for a new approach to diagnosis and treatment of head lice The rationale: –Self-diagnosis by families, plus easy availability of OTC products, have removed clinicians from the treatment process –The potential for misdiagnosis leading to improper use of pediculicides raises concerns about unsafe use of these products, especially when no lice are present or when products are used excessively –Emergence of resistance to some head lice products and introduction of new products call for increased provider involvement in the diagnosis and treatment of head lice Reference: 1. Frankowski BL, et al. Pediatrics. 2010;126(2):

14 A New Approach: Getting Clinicians More Involved (cont) According to the AAP, clinicians should: –Be knowledgeable about head lice infestations and the range of treatment options, both OTC and Rx 1 –Take an active role as information resources for families, schools, and community agencies 1 –Take time to instruct families in the proper use of head lice products 1 The AAP and National Association of School Nurses (NASN) support collaborative efforts to educate communities and develop sensible, evidence-based approaches 1,2 14 References: 1. Frankowski BA, et al. Pediatrics. 2010;126(2): Pontius D, Teskey C. Pediculosis management in the school setting. NASN position statement, Accessed March 28, 2013.

15 An Alternative to Self-Treatment Diagnosis confirmed by clinician Treatment choices made 15 School nurse identifies head lice, communicates with family Family contacts their health care provider Rx and OTC options discussed Instruction given on proper use of product Treatment unsuccessful Treatment successful

16 Who Needs to be Treated? Treatment should never be initiated without a clear diagnosis of head lice 1,2 Definitive diagnosis is made by finding a live louse or nymph on the scalp or head 2,3 Misdiagnosis is common 3-5 If no nymphs or adults are seen, and the only nits are >1/4 inch from the scalp, infestation is probably old and no longer active 3,a When 1 member of a household is diagnosed, everyone in the household—and other close contacts—should be checked 1 –Anyone with evidence of active infestation should be treated –All such persons should be treated at the same time a Some authorities use a guideline of >1cm from the scalp. 2 References: 1. CDC. Head lice. Treatment. Accessed March 26, Frankowski BL, et al. Pediatrics. 2010;126(2): CDC. Head lice. Diagnosis. diagnosis.html. Accessed April 4, Pollack RJ, et al. Pediatr Infect Dis J. 2000;19(8): Burkhart CG. Mayo Clin Proc. 2004;79(5):

17 Guidance on Managing Infestations In recommending treatment, the clinician should consider the product’s: 1 Effectiveness Safety Ease of use Cost Local patterns of resistance (if known) There is no scientific evidence that home remedies are effective 1,2 –Remedies not based in science can be expensive and frustrating, leaving the child and family ineffectively treated –Treatment recommendations should be evidence-based and come from medical, public health, and nursing experts rather than anecdotal experience or commercial advertisements 3 References: 1. Frankowski BL, et al. Pediatrics. 2010;126(2): Takano-Lee M, et al. J Pediatr Nurs. 2004;19(6): Pontius D, Teskey C. Pediculosis management in the school setting. NASN position statement, Accessed March 28,

18 Guidance on Managing Infestations (cont) Resistance to some head lice products has been reported, but the prevalence is not known 1 According to the AAP, 1% permethrin or pyrethrins (OTC products) can be used to treat active infestations— unless resistance has been noted in the community 1 If a treatment does not seem to be working, possible causes include incorrect use of the product or resistance 2 Newer prescription treatment options are available to help families resolve head lice episodes References: 1. Frankowski BL, et al. Pediatrics. 2010;126(2): CDC. Head lice. Treatment. Accessed March 28,

19 Careful Instruction: Key to Avoiding Misuse, Overuse The clinician should offer families careful instruction in the proper use of head lice products 1 –Need for second treatment? Use of nit comb? Products vary; families should be advised to follow the specific instructions that accompany the product Parents should not use extra amounts of any lice medication unless instructed to do so by their health care provider 2 –Drugs used to treat head lice can be dangerous if misused or overused An infested person should not be treated more than 2-3 times with the same medication if it does not seem to be working 2 –In such situations, it is important to seek the advice of a health care provider, who may recommend an alternative medication References: 1. Frankowski BL, et al. Pediatrics. 2010;126(2): CDC. Head lice. Treatment. Accessed March 28, Getty Images/Photodisc.

20 Cleaning Up: What’s Really Needed? 1 Use of pediculicides is part of an overall approach to head lice management that may also include: –Wash in hot water or dry-clean all clothing, hats, bed linens, and towels used by an infested person during the 2 days prior to treatment –Wash personal care items such as combs, brushes, and hair clips in hot water –Vacuum floors and furniture, especially where the infested person sat or lay Fumigant sprays or fogs are not needed to control head lice –These products can be toxic if inhaled or absorbed through the skin Reference: 1. CDC. Head lice. Prevention & control. Accessed March 26, Shutterstock. Photos.com. 20

21 The School Nurse’s Pivotal Roles in Head Lice Management

22 The School Nurse: First Responder to Head Lice Infestation School nurses are often the first to assess a child for the presence of head lice 1 The NASN encourages parents to talk to their school nurse about head lice When a case of head lice is suspected, school nurses should –Provide accurate information to families and –Encourage them to contact their physician or other health care provider to confirm the diagnosis and discuss treatment options Reference: 1. Schoessler SZ. Am J Manag Care. 2004;10(9 Suppl):S273-S

23 The School Nurse: Educator School nurses play an essential role in educating families, teachers, and school officials about head lice 1 –Calming fears –Dispelling myths and stigmas regarding pediculosis –Maintaining student privacy and confidentiality –Building awareness of effective head lice management “School nurses are in a pivotal position to dispel myths and stigmas regarding pediculosis by providing education on the life cycle of the louse, methods of transmission, treatment options, and care of the environment to the student’s family, school, and community at large.” —NASN 1 Reference: 1. Pontius D, Teskey C. Pediculosis management in the school setting. NASN position statement, Accessed March 28,

24 The School Nurse: Advocate School district policies on head lice management vary widely 1-3 –Not always based on science School nurses can be instrumental in championing evidence-based policies in their school districts and communities 1-5 References: 1. Weisberg L. Nasnewsletter. 2009;24(4): Sciscione P, et al. J Sch Nurs. 2007;23(1): Pontius DJ. NASN Sch Nurse. 2011;36(6): Pontius D, Teskey C. Pediculosis management in the school setting. NASN position statement, Accessed March 28, Schoessler SZ. Am J Manag Care. 2004;10(9 Suppl):S273-S “The school nurse is the key health professional to provide education and anticipatory guidance to the school community regarding best practice guidance in the management of pediculosis.” 4 Getty Images/Ariel Skelley.

25 The School Nurse: First Responder, Educator, Advocate The school nurse thus has a vital role to play in:  Facilitating an accurate assessment of the problem 1,2  Containing head lice infestations 1,2  Safeguarding family privacy and confidentiality 1,2  Advising affected students and families to contact their physician or other health care provider to discuss available treatment options 3  Preventing overexposure to potentially hazardous chemicals 1,2  Minimizing school absences 1,2 References: 1. Pontius D, Teskey C. Pediculosis management in the school setting. NASN position statement, Accessed March 28, Schoessler SZ. Am J Manag Care. 2004;10(9 Suppl):S273-S Burkhart CG. Mayo Clin Proc. 2004;79(5):

26 Strategies for School: When Lice Go to the Head of the Class

27 Managing Infestations in the School: NASN Guidance If a child in school has live head lice, he or she should remain in class but be discouraged from close direct head contact with others The school nurse should contact the parents to discuss treating the child at the end of the school day It is vital to prevent stigmatizing and maintain the student’s privacy and the family’s right to confidentiality It may be appropriate to screen others who have had close head-to-head contact with a student who has an active infestation –Classroom-wide or school-wide screening is not merited Students with nits only should not be excluded from school; however, it is appropriate to monitor for signs of active re-infestation Reference: 1. Pontius D, Teskey C. Pediculosis management in the school setting. NASN position statement, Accessed March 26,

28 Helping Kids Stay in School The AAP and NASN state: No healthy child should be allowed to miss school time because of head lice 1,2 “ No-nit” policies for return to school should be abandoned 1,2 School-based head lice screening programs have not had a significant effect on incidence of head lice in schools and are not cost-effective 2 References: 1. Pontius D, Teskey C. Pediculosis management in the school setting. NASN position statement, Accessed January 13, Frankowski BL, et al. Pediatrics. 2010;126(2): iStockphoto.

29 Easing the Stigma Head lice infestations can take a high emotional and psychological toll on some children and parents 1-3 People with head lice may feel: –Disgust, horror, panic, anger; feelings of being dirty or contaminated –Excluded from school and social activities Head lice infestations can be an emotional issue in schools –Parents may panic when they are told their child has head lice –Students may feel isolated Parents should rely on the experience and judgment of school nurses and other health professionals who are equipped to provide accurate information and recommend or prescribe treatment options References: 1. Gordon SC. J School Nurs. 2007;23(5): Parison J, et al. Int J Dermatol. 2013;52(2): Parison J, Canyon DV. Head lice and the impact of knowledge, attitudes and practices—a social science overview. In: Heukelbach J, ed. Management and Control of Head Lice Infestations. UNI-MED, Bremen, Germany; 2010:

30 Supporting Families The school nurse can help students and families cope with the anxiety and stress of head lice episodes 1,2 The nurse has an opportunity to establish ongoing relationships with students and families –Often perceived as an ally Offer support and encouragement through: –Fact-to-face conversations with families –Frequent phone contact –Written materials sent home with the student Nurse can serve as case manager –Educating families and providing helpful resources for dealing with infestations –Directing them to their physician or other health care provider to discuss treatment options –Following up with families References: 1. Gordon SC. J School Nurs. 2007;23(5): Schoessler SZ. Am J Manag Care. 2004;10(9 Suppl):S273-S

31 The School Nurse: Champion for Evidence-Based Policies School nurses can be successful in persuading school districts to adopt evidence-based approaches: 1-4 Case in point: Lovelock, Nevada 2 –School nurse used incremental approach to achieve change Individual conversations with teachers, administrators “Lice 101” presentation to school board Educational letters to parents; fact sheets on myths Case in point: 5 school districts in an Iowa county 3 School nurses were called upon to serve as “catalysts for change” –Disseminated information on evidence-based approaches to key stakeholders –Helped develop pediculosis toolkit—“best practice guideline” rather than “policy” –Enlisted local public health department as a key partner References: 1. Pontius D, Teskey C. Pediculosis management in the school setting. Position statement, NASN, Accessed March 28, Pontius DJ. NASN Sch Nurse. 2011;26(6): Andresen K, McCarthy AM. J Sch Nurs. 2009;25(6): Weisberg L. Nasnewsletter. 2009;24(4): “The school nurse, as a student advocate and nursing expert, should be included in school district-community planning, implementation, and evaluation of vector control programs for the school setting.” 1 —NASN 31 Getty Images/joSon.

32 Summary School nurses are important first responders to head lice infestations They play a key strategic role in supporting children and families, ensuring privacy, and combating myths and stigma associated with head lice School nurses can work collaboratively with parents, physicians, and other health care providers to help manage head lice outbreaks in a calm and professional manner 32

33 Summary (cont) School nurses can help their communities by advocating for evidence-based policies and encouraging an end to no-nit policies for school re-entry Professional associations such as the AAP are urging pediatricians and other clinicians to become more involved in head lice management and family education School nurses can support the AAP guidance by directing students and families to first contact their physician to discuss treatment options 33

34 For More Information … Selected References NASN. Pediculosis management in the school setting, 2011 NASN position statement. Pontius DJ. Hats off to success: changing head lice policy. NASN Sch Nurse. 2011;26(6): Frankowski BL, Bocchini JA Jr, AAP Council on School Health and Committee on Infectious Diseases. Clinical report—head lice. Pediatrics. 2010;126(2): Weisberg L. The goal of evidence-based pediculosis guidelines. Nasnewsletter. 2009;24(4): Gordon SC. Shared vulnerability: a theory of caring for children with persistent head lice. J School Nurs. 2007;23(5): Andresen K, McCarthy AM. A policy change strategy for head lice management. J Sch Nurs. 2009;25(6): Visit the Lice Lessons resources area at

35 Background Information on Approved Head Lice Products

36 OTCPrescription Nix ®,a (permethrin, 1%)Lindane c 1% shampoo RID ®,b et al (pyrethrins with piperonyl butoxide) Ovide ®,d (malathion, 0.5% lotion) Ulesfia ®,e (benzyl alcohol, 5% lotion) Natroba ®,f (spinosad, 0.9% suspension) Sklice ®,g (ivermectin, 0.5% lotion) Treating Head Lice: Many Choices a Nix ® is a registered trademark of Insight Pharmaceuticals, LLC. b RID ® is a registered trademark of Bayer HealthCare, LLC. c Lindane is manufactured by Morton Grove Pharmaceuticals. d Ovide ® is a registered trademark of Taro Pharmaceuticals, U.S.A., Inc. e Ulesfia ® is a registered trademark of Shionogi, Inc. f Natroba ® is a registered trademark of ParaPRO LLC. g Sklice Lotion® is a registered trademark of Sanofi Pasteur Inc. 36 Please see Important Safety Information for Sklice Lotion at the end of this presentation. Full Prescribing Information for Sklice Lotion will be provided at this session. Important Safety Information for Sklice Lotion The most common adverse reactions for Sklice (<1%) are conjunctivitis, ocular hyperemia, eye irritation, dandruff, dry skin, and skin burning sensation.

37 Prescription Lice Products Lindane, 1% 1 Malathion, 0.5% (Ovide) 2 Benzyl alcohol, 5% (Ulesfia) 3 Spinosad, 0.9% (Natroba) 4 Ivermectin, 0.5% (Sklice Lotion) 5 Age indication Use with caution in those <110lb Safety not shown <6 y ≥6 mo≥4 y≥6 mo Dosage 1-2oz depending on hair length and density 2-oz bottles; apply enough to wet hair and scalp 4-48oz (varies with hair length) Up to 120mL (1 bottle) depending on hair length Up to 120mL ( 4-oz tube) Time of application 4 min; do not re-treat 8–12 hr; repeat treatment in 7-9 d if lice present 10 min; repeat treatment after 7 d 10 min; repeat treatment in 7 d if lice present 10 min; tube is intended for single use only; consult health care provider prior to re-treatment References: 1. Lindane [Prescribing Information]. Morton Grove, IL: Morton Grove Pharmaceuticals; Ovide [Prescribing Information]. Hawthorne, NY: Taro Pharmaceuticals; Ulesfia [Prescribing Information]. Florham Park, NJ: Shionogi Inc.; Natroba [Prescribing Information]. Carmel, IN:ParaPRO, Sklice Lotion [Prescribing Information]. Swiftwater, PA: Sanofi Pasteur Inc.; The comparison of product information has not been established in head-to-head trials. The clinical significance of this information has not been established. Please see Important Safety Information for Sklice Lotion at the end of this presentation. Full Prescribing Information for Sklice Lotion will be provided at this session.

38 Important Safety Information for Sklice Lotion Indication Sklice Lotion is a pediculicide indicated for the topical treatment of head lice infestations in patients 6 months of age and older. Adjunctive Measures Sklice Lotion should be used in the context of an overall lice management program: Wash (in hot water) or dry clean all recently worn clothing, hats, used bedding and towels. Wash personal care items such as combs, brushes and hair clips in hot water. A fine tooth comb or special nit comb may be used to remove dead lice and nits. Important Safety Information for Sklice Lotion In order to prevent accidental ingestion, Sklice Lotion should only be administered to pediatric patients under the direct supervision of an adult. The most common adverse reactions (incidence <1%) were conjunctivitis, ocular hyperemia, eye irritation, dandruff, dry skin, and skin burning sensation. Before administering Sklice Lotion, please see the full Prescribing Information provided at this session. 38


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