NORTH LINCOLNSHIRE PRIMARY CARE TRUST
CLINICAL POLICY
Issued:May 2005
For Review:May 2007
Reviewer:Primary & Community Care Directorate
NORTH LINCOLNSHIRE PRIMARY CARE TRUST
HEAD LICE POLICY
1. AIM
This policy aims to provide guidance on the detection, treatment and prevention of head lice infestations and to co-ordinate control measures within the North Lincolnshire area.
2. OBJECTIVES
- To educate relevant professional staff and the public on the detection, treatment and prevention of head lice infestations.
- To encourage parental or self-inspection of hair for early identification of infestation.
- To minimise the social stigma associated with infestations.
- To ensure that consistent information and advice is available.
- To provide accurate information on head lice and methods of control to the public.
3. Head Louse iNFESTATION
Infestation with head lice affects all sections of the community. Infestation is more common among those aged between five and eleven years but can affect people of any age. Head lice are a community problem with social rather than health or educational implications. The problem therefore requires community action.
Head lice (pediculus humanus capitis) are flesh coloured insects about 3mm long whose bodies darken after feeding. They can only be passed from one host to another by direct, still and prolonged head to head contact. They cannot fly, jump or swim and are found on all types of hair. Because of this, spread is likely to occur from contact with other household or close family members rather than by social contact (i.e. school friends or work colleagues).
Head lice feed on human blood by biting into the scalp but no report of any blood borne infection such as Hepatitis B and C or HIV has been recorded by the spread of head lice. Head lice infestations may cause itching (pruritis), redness (erythema) and swelling (oedema) of the scalp. However these signs are also seen in other scalp conditions such as dandruff and eczema.
Head lice stay and lay their eggs close to the scalp. This provides the warmth, which the eggs need to incubate. Live eggs are very small, dull and flesh coloured; they are attached to the hair shaft just above the root. The incubation period is 7-10 days after which the young louse emerges. By the time the hair has grown 1cm the eggs have either hatched or died. Old egg shells known as “ nits” are usually white and shiny and are harmless.
The presence of nits does not necessarily mean there is a live infestation on that head.
4. DETECTION OF HEAD LICE
The diagnosis of infestation can only be made when live lice are identified.
Finding apparent nits is insufficient evidence of infestation. Wet combing is the preferred method of detection. This is described in Appendix 2.
5. TREATMENT
The evidence base for all types of treatment for head lice is weak, with no good quality trials from the developed world being available on which to base policy. There is no local audit data or routine surveillance of head lice infestation given its low health impact.
An approach of treating by the “Bug Busting” method was agreed and adopted locally in 1997. This is based on wet combing every fourth day for two weeks. Appendix 1 contains the local “Bug Busting” leaflet.
The reasons for adopting the policy were:
- Concerns over toxicity of insecticides, especially when used repeatedly (although the evidence for this is weak)
- Concerns over head lice insecticide resistance
- Bug busting helps to de-medicalise the problem and empower parents to manage the problem themselves.
Since taking this approach it appears, anecdotally, that it is no less effective than the use of insecticides. During the trial period of bug busting sales and prescriptions for insecticides reduced, showing that it was possible to reduce reliance on these preparations. There is local commitment to continue with “Bug Busting”.
Both insecticide application and “Bug Busting” require a commitment by the person responsible for treating and it is likely that both will fail when families with multiple social problems are the target.
6. MANAGEMENT OF CONTACTS
If a person is found to be infested then all close contacts should be informed and examined for evidence of infestation by the responsible adult (usually a parent) and treated as described if live lice are found i.e. by the wet combing method.
7. PREVENTION OF INFESTATION
Good hair care as part of personal hygiene and grooming should be encouraged, although there is no evidence with regard to its effectiveness in prevention. Insect repellent sprays and electronic combs should not be used as a means of preventing or controlling infestations.
The use of school nurse time to detect infestations has been discontinued for some years because it has been shown to be ineffective in the control of infestations. Head lice are a community problem, not an educational problem, and parents should take responsibility for being aware of any problems with their children’s hair in the same way as they are over any other health problem.
APPENDIX 1
WET COMBING
The technique is described in the South Humber Bug Busting leaflet. The hair should be washed in the normal way with ordinary shampoo and, after rinsing; conditioner is applied and combed through. The hair should then be combed with a wide toothed comb to remove any tangles. The application of conditioner makes the hair more slippery and difficult for the lice to hang on to.
The hair should then be combed thoroughly with a fine headlice toothed comb.
If lice are detected then this procedure should be continued every four days over a period of two weeks. This will ensure that any new lice that hatch from eggs will be detected and removed before they become mature. The cycle of mature lice being replaced is therefore broken. Lice, which are not removed, are often fatally damaged by the combing.
This method of treatment has been chosen for the area because of the concerns of possible carcinogenic links with insecticides.
All General Practitioners and Pharmacists have been asked not to prescribe or sell insecticides treatments at present.
If there is something found in the hair but its nature is unclear, then it should be attached to a piece of card and shown to an appropriate healthcare professional for possible identification.
APPENDIX 2
ROLES AND RESPONSIBILITIES
THE ROLE OF THE CONSULTANT IN COMMUNICABLE DISEASE CONTROL
- To provide advice, based on the evidence for the PCT and then revise / develop policies.
- To formulate a policy in consultation with others and disseminate the policy.
- To maintain and update the policy as necessary.
- The consultant in communicable disease control will not routinely undertake operational activity to control head lice.
THE ROLE OF THE community TRUSTS
- To develop operational policies on controlling lice infestations based on the agreed South Humber policy.
- The trust will not routinely undertake operational activity to control head lice but will ensure mechanisms to undertake this function are in place.
THE ROLE OF THE SCHOOL HEALTH SERVICE
- To ensure that approved local policies are followed
- To avoid promoting advice or action that is not locally approved
- To ensure that the school nurse designated for a school is contactable during normal working hours by parents and the school for information, advice and support
- To ensure that training programmes are in place to enable staff concerned to be kept fully informed and up to date with current knowledge and practice
- To encourage regular educational programmes by healthcare staff in school for children, parents and staff
THE ROLE OF THE SCHOOL NURSE
- To ensure that locally approved policies are followed
- To avoid promoting advice or action that is not locally approved
- To ensure that he/she is fully informed and up to date with current knowledge and practice
- To give consistent advice to parents, children and school staff and make them aware of means of transmission and of current treatment
- To discourage unnecessary or inappropriate treatment
THE ROLE OF THE EDUCATION DEPARTMENT
- To ensure that locally approved policies are followed
- To avoid promoting advice or action that is not locally approved
- To work with the health services towards preventing ill-health and minimising the effects of ill-health on school children and their education
- To disseminate information to schools in order that school staff are aware of locally approved policies in connections with lice infestations
THE ROLE OF HEAD TEACHERS
- To ensure that locally agree policies are followed within their school
- To avoid promoting advice or action that is not within the locally approved policy
- To inform the school nurse, in confidence, of cases of lice infestation
- To assist the school nurse in disseminating advice to parents and pupils. This should be an on-going, routine part of school life and preferably be part of dealing with other health issues
- To support the school health service in any health promotion events they wish to hold in school. Parents, pupils and staff should be encouraged to attend.
- To guide concerned parents to the most appropriate agency for dealing with their concerns. Professional advice is available from the school nurse, general practitioner or local pharmacist.
- To maintain confidentiality of health information on children and encourage the same in other staff
THE ROLE OF PRIMARY CARE TEAMS
- To ensure that locally approved policy is followed
- To avoid promoting advice or action that is not locally approved
- To provide advice on the management of lice infestations. Those advising should be knowledgeable and competent on the subject and be able to teach clients the technique of wet combing. Bug busting kits are also prescribable by Health visitors
- To discourage unnecessary or inappropriate treatment
ROLE OF COMMUNITY PHARMACISTS
- To ensure that locally approved policy is followed
- To avoid promoting advice or action that is not locally approved
- To promote advice on management of lice infestations. Those advising should be knowledgeable and competent on the subject and also be able to teach the technique of wet combing.
- To discourage unnecessary or inappropriate treatment
THE ROLE OF PARENTS/GUARDIANS
- The primary responsibility for the initial identification of ill health in a child lies with the parent or guardian. The same applies to the recognition of head lice infestations.
Appropriate advice may be sought from healthcare professionals who will offer information and support. The advice of the healthcare professional, which will follow local policy, should be followed.
- Parents or guardians should also ensure that they notify any close contacts and advise them of the need for wet combing for detection.
APPENDIX 3
GUIDANCE NOTES
GUIDANCE NOTES FOR SCHOOL NURSES
A professional assessment of reported cases of head lice infestations of any child in the school should be made. If the report is from a teacher of a child continually scratching or of live lice being seen, then the parent should be informed, and this may be done by the teaching staff, and wet combing advised for detection. If the report is from a parent or guardian then it may be necessary to make a home visit to ensure they know how to use the wet combing detection method and to advise on the procedure to be followed if live lice are found.
Routine head inspections in school as a screening procedure should not be undertaken. Parents or guardians should carry out detection combing but it is essential that the school nurse give them the correct advice, information and support. This should follow the approved policy
Assumption of a live infestation should not be made unless live lice are found, or there is appropriate evidence provided by parents. Parents may be asked to stick a louse on a piece of paper to show to the school nurse.
School nurses should ensure that parents are aware of how to wet comb properly and for the need for vigilance in the care of their children’s hair
School nurses should try to ensure that regular health promotion sessions are held in school rather than reactive campaigns to address problems with head lice.
Home visits may be necessary in cases where reinfestations are reported to ensure that the wet combing method is being carried out correctly.
GUIDANCE NOTES FOR HEAD TEACHERS
The anxiety and concern about head lice infestations may be greater than the true level of infestation warrant. At any one time many schools may have a few children who actually have live lice on their heads. This figure is often below 5% and very rarely more than this.
The number of children who actually have the dead or hatched eggshells on their heads may be higher, and it is often this that gives rise to concern among parents and teachers.
Transmission of head lice is by direct, still and prolonged contact of one head to another. Transmission in the classroom is rare.
Routine head inspections are not an effective method of controlling the problem.
The school nurse, the general practitioner or the local pharmacist most appropriately gives advice to parents about head lice, and teachers are asked to refer parents to the most appropriate source.
The matter should be discussed with the school health service before “ alert letters” are issued from school.
Children, who have or are thought to have head lice, should not be excluded from school for this reason.
GUIDANCE NOTES FOR PRIMARY CARE TEAMS
Head lice infestation is primarily a problem of the whole community not just of schools. As with any other infectious disease in their patients, primary care teams should have an appropriate level of knowledge and expertise in the control of head lice. They should be able to demonstrate to clients the technique of wet combing and should be able to offer up to date advice that is agreed by local policy.
It may be deemed necessary to have one or two members of the primary care team nominated to be responsible to offering advice and support to clients on head lice matters. This should be decided locally within teams.
A diagnosis of head lice infestation should only be made if a live louse is seen moving on the head or the client brings appropriate evidence. Some clients may be mistaken in thinking they are infested and other scalp conditions may be missed if it is assumed they are correct without any evidence being provided.
Clients of school age should not necessarily be referred to the school nurse as the sole means of dealing with the problem but the nurse should be notified of live cases to keep them up to date with the situation.
GUIDANCE NOTES FOR PHARMACISTS
Consideration should be given to having a nominated member of staff to be responsible for dealing with advising members of the public on head lice problems.
Clients should be made aware that head lice can only be transmitted by direct, still and prolonged head to head contact.
Clients of school age can be dealt with by any health care professional but the school nursing service should be notified of cases of live lice infestations.
Clients should not be assumed to having head lice unless lice are actually seen moving on the client’s head or appropriate evidence is shown. Other conditions of the scalp may be missed if it is taken that the client is correct in their assumptions.
Unnecessary or inappropriate treatment should not be recommended. The locally approved policy should be adhered to.
APPENDIX 4
HEAD LICE INITIAL IDENTIFICATION FLOW CHART
For further advice contact your school nurse, health visitor, general practitioner or pharmacist.
APPENDIX 5
HEAD LICE PERSISTENT PROBLEM FLOW CHART
APPENDIX 6
LETTER FROM THE SCHOOL HEALTH SERVICE
Dear Parent/Carer
We have had reports of live head lice infestations in your child’s class. We are therefore asking you to check your child’s hair.
It is vital that every child’s head is checked to determine whether or not there are lice present. The method we are advising is the wet combing method, which is detailed below.
Follow this procedure: -
- Wash the hair in the normal way with your regular shampoo.
- Check the water for any lice.
- While the hair is still wet comb through with conditioner and a fine toothed comb. Start at the roots of the hair and continue through to the end of the strands. At the end of every stroke check the comb for evidence of lice.
- The conditioner ensures that it is difficult for the lice to hang on to the hair and it is therefore easy to remove them with the comb.
- If any lice are found this routine should be continued every four days for a period of two weeks.
- It is advisable to use this routine on a regular basis so that any lice present can be detected early.
- If you find live lice please notify your child’s class teacher and also check all members of the family using the wet combing method.
- It is helpful if you also contact anyone whom your child has had close contact with e.g. Cubs, Brownies, Friends, Extended family etc.
If you require any further advice or help about the problem of head lice do not hesitate to contact your school nurse, or family doctor.
YOUR SCHOOL NURSE IS ………………………….
HER TELEPHONE NUMBER ………………………...
We thank you for you co-operation and prompt attention to this request.
Yours sincerely
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