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Going to School on Head Lice

Going to School on Head Lice. New Approaches to an Old Nemesis. Getty Images/Digital Vision. US.IVE.13.03.021. Key Points to Cover Today!. Head Lice: Getting to Know You The Key Role of the Clinician in Head Lice Diagnosis and Treatment

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Going to School on Head Lice

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

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

  3. Head Lice: Getting to Know You

  4. Head Lice Infestation: A Common Pediatric Condition • Pediculosis is the most prevalentparasitic infestation among humans1 • Head lice infestations are pervasiveamong school-age children in theUnited States2,3 • ~6-12 million infestations occur eachyear in children 3-11 years of age3 • More common in females4 • All socioeconomic groups are affected2,4,5 • Contrary to myth, “head lice prefer clean, healthy hosts”4 Getty Images/Peter Dazeley. References: 1. Hodgdon HE, et al. Pest Manag Sci. 2010;66(9):1031-1040. 2.Frankowski BL, et al. Pediatrics.2010;126(2):392-403.3. Centers for Disease Control and Prevention (CDC). Head lice. Epidemiology & risk factors. http://www.cdc.gov/parasites/lice/head/epi.html. Accessed January 13, 2013. 4.Meinking T, et al. Infestations. In: Schachner LA, Hansen RC, eds. Pediatric Dermatology. 4th ed.Mosby Elsevier; 2011:1535-1583. 5. Meinking TL, et al. Int J Dermatol. 2013;52(1):106-112. 4

  5. Common Myths About Head Lice1 • 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 arole in head lice transmission. Reference: 1. Pontius DJ. NASN Sch Nurse. 2011;26(6):356-362. 5 CDC. Dr. Dennis D. Juranek.

  6. The Head Louse:A Closer Look • The adult louse is 2-3mm long (aboutthe size of a sesame seed)1 • Usually pale gray; color may vary1 • Red when engorged with blood • May adapt color to surroundings • The louse feeds by injecting smallamounts of saliva and taking tinyamounts of blood from the scalpevery few hours1 • Lice usually survive less than 24-48 hours away from the scalp at room temperature1,2 • 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 CDC. References: 1. Frankowski BL, et al. Pediatrics. 2010;126(2):392-403. 2. CDC. Head lice. Prevention and control. http://www.cdc.gov/parasites/lice/head/prevent.html. Accessed March 26, 2013. 6

  7. The Life Cycle of the Head Louse1,2 Female lays 1st egg 1-2 days after mating Become adults 9-12 days after hatching 3 Lays up to 10 eggs per day Female lives 3-4 weeks Without treatment, the cycle may repeat every 3 weeks Eggs tightly attached to hair, close to scalp 2 Eggs hatch in 7-12 days 3 nymph stages 1 Illustration by Penumbra Design Inc. References: 1. Frankowski BL, et al. Pediatrics. 2010;126(2):392-403. 2.Meinking TL, et al. Infestations. In: Schachner LA,Hansen RC, eds.Pediatric Dermatology. 4th ed. Mosby Elsevier; 2011:1535-1583. 7

  8. Know Your Nits! • Nits are tiny, teardrop-shaped eggs attached to 1 sideof the hair shaft with a waterproof, glue-like substance1-4 • Often found on nape of the neck and behind the ears5 • Viable nits with an egg inside may be tan to coffee-colored or darker1 • Nonviable nits are white or yellowishshells, or casings1 • Nits attached >1cm from the scalpare usually not viable2 • In some warmer climates, viable nitsmay be found several inches from the scalp3 • Close inspection is needed4 CDC/Dr. Dennis D. Juranek. • Nits may be confused with: • Dandruff1-5 • Dirt and other debris2,4,5 • Droplets of hair spray, gel2-4 • Hair casts (pseudonits) encircling the hair shaft1,3,5,6 • Plugs of skin cells5 • Fungal infection of the hair (piedra)1,3,5 • Psoriasis1,3 References: 1. Meinking TL, et al. Infestations. In: Schachner LA, Hansen RC, eds. Pediatric Dermatology. 4th ed. Mosby Elsevier; 2011:1535-1583. 2. Frankowski BL, et al. Pediatrics. 2010;126(2):392-403. 3. Paller AS, Mancini AJ, eds. Hurwitz Clinical Pediatric Dermatology. A Textbook of Skin Disorders of Childhood and Adolescence, 4th ed. New York, Elsevier Saunders; 2011:424-427. 4. CDC. Head lice. Diagnosis. http://www.cdc.gov/.parasites/lice/head/diagnosis.html. Accessed January 13, 2013. 5. American Academy of Pediatrics. Pediculosis capitis (head lice). In: Red Book. 2012 Report of the Committee on Infectious Diseases. Pickering LK, ed. 29th ed. Elk Grove Village, IL, American Academy of Pediatrics; 2012:543-546. 6. Franca K, et al. Int J Trichology. 2011;3(2):121-122. 8

  9. Head Lice: The Truth About Transmission1-3 • Transmission of lice typically occursby direct head-to-head contact withan infested individual • Children can get head lice anytimethey come in close contact withothers—during play at home orschool, slumber parties, sportsactivities, or camp • Indirect spread by contact withpersonal items (combs, brushes,hats, headgear) is less likely butcan occur Getty Images/Jamie Grill. References: 1. Frankowski BL, et al. Pediatrics. 2010;126(2):392-403. 2. CDC. Head lice. Epidemiology & risk factors. http://www.cdc.gov/parasites/lice/head/epi.html. Accessed January 13, 2013. 3. Meinking TL, et al. Infestations. In: Schachner LA, Hansen RC, eds. Pediatric Dermatology. 4th ed.Mosby Elsevier; 2011:1535-1583. 9

  10. Typical Symptoms of Head Lice Infestation • Itching is the most common symptom1-3 • Caused by an allergic reaction to louse saliva • If someone is infested for the first time,itching may take 4-6 weeks to develop1 • If a person has had previous head liceepisodes, itching may develop within48 hours3 • Irritability, difficulty sleeping1 • Lice are more active in the dark • Sores, crusting, secondary bacterial infectionon the scalp1-3 • Not common; caused by excessive scratching • In some cases, no symptoms are present3 Getty Images/Westend61. Gordon SC. Dermatology Nursing. 2010;22(4):18-20. Reprinted with permission of Jannetti Publications, Inc. References: 1. CDC. Head lice. Disease. http://www.cdc.gov/parasites/lice/head/disease.html. Accessed March 28, 2013.2. Frankowski BL, et al. Pediatrics. 2010;126(2):392-403. 3. Meinking TL, et al. Infestations. In: Schachner LA, Hansen RC, eds. Pediatric Dermatology. 4th ed. Mosby Elsevier; 2011:1535-1583. 10

  11. The Key Role of theClinician in Head Lice Diagnosis and Treatment

  12. Desire to avoid delay Easy access to over-the-counter (OTC) products Limited parent knowledge of Rx choices 70% 30% of Households of Households The Traditional Approachto Head Lice1,a Head lice suspected 00 Treat On Their Own Contact a Health Care Provider • 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. 12 Reference: 1.Sanofi Pasteur Inc., Data on file (ICR Research; Excel Omnibus Studies H8824-26, I8823). July 2009. MKT26505.

  13. A New Approach: Getting Clinicians More Involved1 • The American Academy of Pediatrics (AAP) calls fora 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 13 Reference: 1. Frankowski BL, et al. Pediatrics. 2010;126(2):392-403.

  14. A New Approach: Getting Clinicians More Involved (cont) • According to the AAP, clinicians should: • Be knowledgeable about head lice infestations and therange of treatment options, both OTC and Rx1 • Take an active role as information resources for families, schools, and community agencies1 • Take time to instruct families in the proper use of head lice products1 • The AAP and National Association of School Nurses (NASN) support collaborative efforts to educate communities and develop sensible, evidence-based approaches1,2 References: 1. Frankowski BA, et al. Pediatrics. 2010;126(2):392-403. 2. Pontius D, Teskey C. Pediculosis management in the school setting. NASN position statement, 2011. http://www.nasn.org. Accessed March 28, 2013. 14

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

  16. Who Needs to be Treated? • Treatment should never be initiated without a clear diagnosis of head lice1,2 • Definitive diagnosis is made by finding a live louse or nymphon the scalp or head2,3 • Misdiagnosis is common3-5 • 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 active3,a • When 1 member of a household is diagnosed, everyone in the household—and other close contacts—should be checked1 • 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. http://www.cdc.gov/parasites/lice/head/treatment.html. Accessed March 26, 2013. 2. Frankowski BL, et al. Pediatrics. 2010;126(2):392-403. 3. CDC. Head lice. Diagnosis. http://www.cdc.gov/parasites/lice/head/diagnosis.html. Accessed April 4, 2013. 4. Pollack RJ, et al. Pediatr Infect Dis J. 2000;19(8):689-693. 5. Burkhart CG. Mayo Clin Proc. 2004;79(5):661-666. 16

  17. Guidance on Managing Infestations • In recommending treatment, the clinician should considerthe product’s:1 • Effectiveness • Safety • Ease of use • Cost • Local patterns of resistance (if known) • There is no scientific evidence that home remedies are effective1,2 • 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 advertisements3 References: 1. Frankowski BL, et al. Pediatrics. 2010;126(2):392-403. 2. Takano-Lee M, et al. J Pediatr Nurs. 2004;19(6):393-398.3. Pontius D, Teskey C. Pediculosis management in the school setting. NASN position statement, 2011. http://www.nasn.org. Accessed March 28, 2013. 17

  18. Guidance on Managing Infestations (cont) • Resistance to some head lice products has been reported, but the prevalence is not known1 • According to the AAP, 1% permethrin or pyrethrins(OTC products) can be used to treat active infestations—unless resistance has been noted in the community1 • If a treatment does not seem to be working, possible causes include incorrect use of the product or resistance2 • Newer prescription treatment options are availableto help families resolve head lice episodes References: 1. Frankowski BL, et al. Pediatrics. 2010;126(2):392-403. 2. CDC. Head lice. Treatment. http://www.cdc.gov/parasites/lice/head/treatment.html. Accessed March 28, 2013. 18

  19. Careful Instruction: Key to Avoiding Misuse, Overuse • The clinician should offer families careful instruction in the proper use of head lice products1 • Need for second treatment? Use of nit comb? • Products vary; families should be advised to followthe 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 provider2 • Drugs used to treat head lice can be dangerous if misusedor overused • An infested person should not be treated more than 2-3 timeswith the same medication if it does not seem to be working2 • In such situations, it is important to seek the advice of a health care provider, who may recommend an alternative medication Getty Images/Photodisc. References: 1. Frankowski BL, et al. Pediatrics. 2010;126(2):392-403. 2. CDC. Head lice. Treatment. http://www.cdc.gov/parasites/lice/head/treatment.html. Accessed March 28, 2013. 19

  20. Cleaning Up: What’s Really Needed?1 • Use of pediculicides is part of an overall approachto 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 personduring 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 tocontrol head lice • These products can be toxic if inhaled or absorbedthrough the skin Shutterstock. Photos.com. Reference: 1. CDC. Head lice. Prevention & control. http://www.cdc.gov/parasites/lice/head/prevent.html. Accessed March 26, 2013. 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 childfor the presence of head lice1 • 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-S276. 22

  23. The School Nurse: Educator • School nurses play an essential role in educating families, teachers, and school officials about head lice1 • 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.” —NASN1 Reference: 1. Pontius D, Teskey C. Pediculosis management in the school setting. NASN position statement, 2011. http://www.nasn.org. Accessed March 28, 2013. 23

  24. The School Nurse: Advocate • School district policies on head licemanagement vary widely1-3 • Not always based on science • School nurses can be instrumentalin championing evidence-basedpolicies in their school districtsand communities1-5 Getty Images/Ariel Skelley. “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 References: 1. Weisberg L. Nasnewsletter. 2009;24(4):165-166. 2. Sciscione P, et al. J Sch Nurs. 2007;23(1):13-20. 3. Pontius DJ. NASN Sch Nurse. 2011;36(6):356-362. 4. Pontius D, Teskey C. Pediculosis management in the school setting. NASN position statement, 2011. http://www.nasn.org. Accessed March 28, 2013. 5. Schoessler SZ. Am J Manag Care. 2004;10(9 Suppl):S273-S276. 24

  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 problem1,2 • Containing head lice infestations1,2 • Safeguarding family privacy and confidentiality1,2 • Advising affected students and families to contact their physician or other health care provider to discuss available treatment options3 • Preventing overexposure to potentially hazardous chemicals1,2 • Minimizing school absences1,2 References: 1. Pontius D, Teskey C. Pediculosis management in the school setting. NASN position statement, 2011. http://www.nasn.org. Accessed March 28, 2013. 2. Schoessler SZ. Am J Manag Care. 2004;10(9 Suppl):S273-S276. 3. Burkhart CG. Mayo Clin Proc. 2004;79(5):661-666. 25

  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 shouldremain in class but be discouraged from close direct head contact with others • The school nurse should contact the parentsto discuss treating the child at the end of the school day • It is vital to prevent stigmatizingand maintain the student’s privacy and the family’s right to confidentiality • It may be appropriate to screen otherswho have had closehead-to-head contact with a student who has an active infestation • Classroom-wide or school-wide screening is not merited • Students with nits only shouldnot be excluded from school; however, it is appropriate to monitor for signs of activere-infestation Reference: 1. Pontius D, Teskey C. Pediculosis management in the school setting. NASN position statement, 2011. http://www.nasn.org. Accessed March 26, 2013. 27

  28. Helping Kids Stay in School • The AAP and NASN state: No healthy child should be allowed tomiss school time because of head lice1,2 • “No-nit” policies for return to school should be abandoned1,2 • School-based head lice screeningprograms have not had a significanteffect on incidence of head lice inschools and are not cost-effective2 iStockphoto. • References: 1. Pontius D, Teskey C. Pediculosis management in the school setting. NASN position statement, 2011. http://www.nasn.org. Accessed January 13, 2013. 2. Frankowski BL, et al. Pediatrics. 2010;126(2):392-403. 28

  29. Easing the Stigma • Head lice infestations can take a high emotional and psychological toll on some children and parents1-3 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 issuein 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):283-292. 2.Parison J, et al. Int J Dermatol. 2013;52(2):169-171. 3. 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; 2010:103-109. 29

  30. Supporting Families • The school nurse can help students and families cope with the anxiety and stress of head lice episodes1,2 • 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 discusstreatment options • Following up with families References: 1. Gordon SC. J School Nurs. 2007;23(5):283-292. 2.Schoessler SZ. Am J Manag Care. 2004;10(9 Suppl):S273-S276. 30

  31. The School Nurse: Champion for Evidence-Based Policies “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 • School nurses can be successful in persuading school districtsto adopt evidence-based approaches:1-4 • Case in point: Lovelock, Nevada2 • 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 county3 • 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 Getty Images/joSon. References: 1. Pontius D, Teskey C. Pediculosis management in the school setting. Position statement, NASN, 2011. http://www.nasn.org. Accessed March 28, 2013. 2. Pontius DJ. NASN Sch Nurse. 2011;26(6):356-362. 3. Andresen K, McCarthy AM. J Sch Nurs. 2009;25(6):407-416. 4. Weisberg L. Nasnewsletter. 2009;24(4):165-166. 31

  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 tono-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 … Visit theLice Lessons resources area at http://www.NASN.org Selected References • NASN. Pediculosis management in the school setting, 2011 NASN position statement. http://www.NASN.org • Pontius DJ. Hats off to success: changing head lice policy. NASN Sch Nurse. 2011;26(6):356-362. • Frankowski BL, Bocchini JA Jr, AAP Council on School Health and Committee on Infectious Diseases. Clinical report—head lice. Pediatrics. 2010;126(2):392-403. • Weisberg L. The goal of evidence-based pediculosis guidelines. Nasnewsletter. 2009;24(4):165-166. • Gordon SC. Shared vulnerability: a theory of caring for children with persistent head lice. J School Nurs. 2007;23(5):283-292. • Andresen K, McCarthy AM. A policy change strategy for head lice management. J Sch Nurs. 2009;25(6):407-416. 34

  35. Background Information on Approved Head Lice Products

  36. Treating Head Lice: Many Choices Important Safety Information for Sklice LotionThe most common adverse reactions for Sklice (<1%) are conjunctivitis, ocular hyperemia, eye irritation, dandruff, dry skin, and skin burning sensation. 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. 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 ofParaPRO LLC. g Sklice Lotion® is a registered trademark of Sanofi Pasteur Inc. 36

  37. Prescription Lice Products 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. References: 1. Lindane [Prescribing Information]. Morton Grove, IL: Morton Grove Pharmaceuticals; 2005. 2. Ovide [Prescribing Information]. Hawthorne, NY: Taro Pharmaceuticals; 2011. 3. Ulesfia [Prescribing Information]. Florham Park, NJ: Shionogi Inc.; 2012. 4. Natroba [Prescribing Information]. Carmel, IN:ParaPRO, 2011. 5. Sklice Lotion [Prescribing Information]. Swiftwater, PA: Sanofi Pasteur Inc.; 2012. 37

  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 MeasuresSklice 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 beddingand 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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