Thank you for attending the Managing Head Lice in Schools webinar broadcast on October 20, 2015, a part of the School IPM Webinar series hosted by EPA’s Center of Expertise for School IPM. 

• Speakers
• Statistical information
• Questions and answers
• Resources
• Head lice resource links
• Upcoming school IPM webinars

Speakers

• Richard Pollack, Ph.D., Senior Environmental Health Officer, Harvard University 
• Nichole Bobo, Director of Nursing Education, National Association of School Nurses
• Deborah Pontius, Health Services Coordinator, Pershing County (Nevada) School District

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Statistical Information

Registration

• 2288 people from 49 states, plus Canada, Puerto Rico, New Zealand, Zimbabwe and Philippines
  • Top 7 states: TX (195), MO (192), NY (149),NJ (148), PA (147), VA (143), NC (130) 
  • Represented over 7 M students (7,068,908)
  • Registration breakdown:
  • 1963 school/ district / childcare center related 
    • 272 administration
    • 140 Facilities management
    • 1468 School nurses
    • 83 other school staff
  • 177 Health Departments
  • 47 Pest management professionals
  • 32 Tribes or tribe related organizations (IHS)
  • Others including government (56), University (32), Other 13 
• 78% (1822) preferred Webinars as the training venue of choice as opposed to all other choices: classroom/workshops (164), conventions (21), websites (191), or papers (86). 
• 519 registrant / attendees want more information on developing an IPM plan/program. 

Participation

• 43% (985) of those that registered, attended the webinar (total number and percent of attendees is unknown, as many attended in conference rooms with up to 30 attendees. The number recorded is only for computers connected).
  • Attendees were from 49 states plus Canada, Puerto Rico and Zimbabwe
  • Top 5 States in attendance: MO (88), TX (78), NY (74), PA (69), NC (68)
  • Attendees represented  2.4M+ children  (2,469,855)
    • 82.5% (813) of all attendees were schools/ districts / Childcare centers
      • 129 School administration  
      • 51 Facilities management 
      • 596 School nurses 
      • 37 other school staff 
    • 87 Health Departments 
    • 18 Educational –University 
    • 26 Pest management professionals    
    • 48 Other government entity 
    • 13 Tribes or tribe related (HIS) participants 

Teaching efficacy (measured by attendee feedback)

• 98% of attendees have a greater knowledge of IPM head lice action protocols. 
• 92% of attendees have a better insight about head lice prevention as a result of the webinar. 
• 99% of attendees would recommend this course to others.

IPM Related

• 53% registered have an IPM Coordinator at their school: Yes (1071), No (399), Don’t Know (534)
• 57% of registered School districts have and follow an IPM policy and/or plan?  Yes (1393) 

Outreach Effort (measured by how registrants learn about the webinar)

• 52% (1195) responded that they learned of the webinar from an EPA generated e-mail or website, as opposed to PMP (17), ESA (118), School District (494), or other source (460)(this invitation went out through the NASN
• 118 Educational Service Agency
• 494 School District 
• 460 Other source (this invitation went out through the NASN)

Comprehension

• 94% of attendees Identify the CDC, NASN justified response on finding head lice on a student, by sending students home at the end of the day with a letter or phone call to parents about head lice findings 
• 100% of attendees identified the one true head lice statement: ‘Head lice are insects that occur only on scalp hair and feed only on blood’. 
• 73% of attendees identified the role of the school nurse as the health professional and head lice expert include all of the choices given.

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Questions and Answers

The questions below were posed by the webinar participants. The responses may have been refined by the presenters following the webinar for clarification or to include additional resources.

General Questions

1. Will the presentation be available for download? Where?

   A PDF of the presentation will be made available on our website along with answers to attendees’ questions and statistics about the webinar. A recording of the webinar will be available on the School IPM website.

2. This would be an awesome presentation for our teachers!!!  Is it possible to obtain an electronic document of the slides covered today?

   (COE): Yes, the PDF of the powerpoint is on our website and the recording of the entire webinar will eventually be available for on-demand viewing.

3. Do we get any continuing education certificate for this training?

   (COE): You would need to contact your state or local agency to determine if that is allowed. Every agency and professional association has different requirements and guidelines. We do provide a certificate for attending the webinar. If you need further assistance in obtaining a course outline, usually a prerequisite for CEU’s, please contact me, I will be happy to help. Anderson.marcia@epa.gov.

Head Lice Management Questions

1. How about suffocation with mayonnaise, olive oil or use of tea tree oil?

   (Pollack): I’ve not seen any objective data to support the use of mayonnaise, olive oil or tea tree oil to suffocate head lice. Consider, instead, using FDA-registered pediculicides that have been tested for efficacy and safety.

2. Is tea tree oil effective in repelling head lice?

   (Pollack): I’m not aware of any convincing evidence that tea tree oil would be effective as a repellent of head lice on a person’s scalp.

3. Do any non-medication treatments such as "smothering the lice" with a heavy coating of thick lotion work?

   (Pollack): Viscous substances that completely coat or encase a louse may, indeed, cause the louse to suffer from hypoxia. A prescription formulation of benzyl alcohol is available that apparently functions in this manner. Other substances may possibly provide similar results.

4. Do chemical hair processing (perms, color treatments...) kill lice? 

   (Pollack): Whereas some lice may suffer from contact with hair bleaching and colorants, I’m not aware of any study that objectively tested such treatments for efficacy against lice.

5. The recommendation to use conditioner is counter to the CDC recommendation to avoid any lubricant as it may prevent the pediculocide from reaching viable lice or eggs. How do you address this caution? 

   (Pollack): CDC does advise not to use conditioners prior to, and just after, treatment for lice because the conditioners may act as a barrier that reduces exposure to the pediculicide. Conditioners, however, can help lubricate the hair and ease the task of combing. 

6. I have tried mayonnaise before to a child's head and it was very successful in treatment of lice. Much cheaper than chemical treatments like RID, and non-irritating to a child’s scalp. Your advice?

   (Pollack): Although many have claimed success from using mayonnaise or other substances as means of treating head lice, these claims have not been objectively evaluated. Mayonnaise is not labeled as a pediculicidal treatment, and it would be irregular to rely upon unsubstantiated treatments for a medical condition. The over-the-counter (OTC) pediculicides tend to be quite affordable, even by those with modest financial resources.

7. Are there any home remedies that are effective in treating lice and nits versus using pesticides? I currently recommend using coconut shampoo/conditioner and green tea shampoo/ conditioner. This seems to have really worked for me. My daughter hasn't had lice for over 2 years by shampooing with these products every day. Comment?

   (Pollack): I’m not aware of any ‘home remedy’ that has been adequately evaluated for efficacy or safety as a pediculicide. The absence of head lice for any interval is not likely attributable to use of such products.

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Treatment Questions

1. Does there actually always need to be a treatment when live nits are found?

   (Pollack): No. Note that it requires an adequate microscope and some expertise to properly judge the viability of a louse egg (‘nit’). Even if viable eggs are present, means other than pediculicidal treatment are available to reduce and eliminate a head louse infestation.

   Some people have indicated using heated blow dryers on their children's hair to "cook" the eggs and lice that didn't die with pesticides. Any truth in this? Answer (Pollack): Yes. Heat and dry air can ‘cook’ and/or desiccate lice and their eggs. I dissuade folks from using hair irons and standard hair dryers as means of intervention against lice, as these methods can result in burns to the hair and scalp. FDA has approved a specific hot air device designed for this purpose. In skilled hands, this device has been demonstrated to effectively kill lice by desiccation without posing unnecessary risks to the scalp.

2. What treatment do you recommend 1st? 

   (Pollack): First and foremost, one should always confirm that a genuine living head louse exists on the scalp hair before considering any treatment. If the hair is readily combed, than use of a good louse comb may be a reasonable option to remove lice and their eggs. As a supplement or as an alternative to combing, applying an FDA-approved over-the-counter (OTC) formulation of pyrethrins or permethrin may offer benefit, with virtually no measurable risk to persons. If head lice persist despite such efforts, then a prescriber should be consulted to consider prescription or other treatments.

3. What about use of dimethicone as a treatment? It is less harmful to human health and the environment.

   (Pollack): Formulations of dimethicone (=dimeticone) are available to treat head lice. The manufacturers claim that these offer some amount of efficacy. If used according to label directions, they would likely provide greater benefit than risk, but they’re not necessarily safer than other products.

4. Do you have recommendations for families who cannot afford the pesticide treatments?

   (Pollack): Over-the-counter (OTC) treatments are, with few exceptions, affordable to almost anyone. Such treatments can easily be purchased for about $10 or less. If battling head lice that seem resistant to the OTC products, consider prescription pediculicides. Contact the manufacturers directly to inquire if they might help subsidize their products for those with financial needs.

5. What is considered over-exposure to treatment?

   (Pollack): Over-exposure to treatment would be any use of a product in a manner that exceeds the label directions. This would include applying a product in its concentrated form if the label instructs the user to dilute it. Similarly, over-exposure would include applying the product in a volume or for a duration that exceeds that defined on the label, or in a frequency exceeding the label instructions.

6. Last time I checked the CDC website, it still recommended bagging stuffed animals for two weeks for kids who had head lice. That seems unnecessary given some of the information today. Is it still recommended by Dr. Pollack? Do you still advise bagging items in the home for several days to "suffocate" the louse?

   (Pollack): I have never recommended bagging items for any amount of time as a means to ‘treat’ head lice. Such efforts not only are unnecessary, but they are also wasteful and counterproductive. It is unfortunate that such archaic recommendations persist on the CDC website.

7. If lice don't live off the head for long, then is it no longer recommended that the furniture and mattress be vacuumed, bedding be washed, stuffed animals be bagged up for weeks, etc.?

   (Pollack): Vacuuming and washing items may remove dead lice from the environment, but these efforts would not have any measurable effect on eliminating or preventing head lice on a person. The recommendation to bag toys, stuffed animals and other items is not justified for combatting head lice. Such recommendations are pertinent as interventions against a different creature, the body louse, but body lice would be exceptionally rare on a child in the Western world.

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Combs, helmets, etc. Questions

1. Can mechanical removal be as effective as chemical removal?

   (Pollack): A diverse array of methods and products is available to manage or treat infestations of head lice. In some cases, mechanical methods – such as specialized combs - are effective in removing head lice and their eggs. In other cases, as when the hair is not readily combed, mechanical means are impractical and reliance on formulated pediculicides would be more effective.

2. For Dr. Pollack- Is there any evidence regarding the use of a robi comb for treatment?

   (Pollack): Many kinds of combs are marketed for removing lice and their eggs. A few kinds are designed as tiny ‘bug zappers’ that can electrocute a louse. Whereas these may kill lice that contact adjacent metal tines, these devices may not be any more effective than a non-electric louse comb used properly. 

3. Would you explain how to remove nit with conditioner? Do you comb with the conditioner in the hair or apply the conditioner after combing and rinse?

   (Pollack): The conditioner is merely a lubricant to help ease passing the comb through the hair. It may then reduce discomfort caused by the comb binding in tangled hair. The conditioner will not have any effect on loosening the eggs.

4. Can lice transfer through combs, brushes, and helmets by clinging onto loose strands of hair?

   (Pollack): Combs, brushes, helmets, headphones and other inanimate objects are of no significance in the transfer of head lice.

5. Do we need to disinfect helmets after used by children? How do we keep helmets free of cross contamination of head lice?

   (Pollack): Helmets are of no significance in the transfer of head lice. Hence, there is no need to dis-insect helmets. Yet other organisms (including some kinds of fungi and bacteria) may more likely be transferred between helmet users. To reduce those risks, helmets may be wiped out with an approved sanitizing agent or simply with a clean cloth.

6. Speakers seemed to conflict on whether sharing hair care items can transmit head lice? Comments?

   (DP) I think we all agree that hair care items are “potential” source of transmission, but extremely rare. The focus should not be on items but people.  The louse must be able to “hold on to” any item for it to be transmissible. Maybe a brush if a louse managed to get itself tangled up in a loose hair and another person immediately brushed her hair with it.  Or a fuzzy scrunches that a louse held onto.  But this would be very rare and there is no research evidence that this has ever happened.

   (Pollack): Combs, brushes, helmets, headphones and other inanimate objects are of no significance in the transfer of head lice. It would be far more relevant to ask how probable might be the event, not if it is ever possible.

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Nurse procedures

1. What will the nurse "check" for - upon a child’s return to school? If nits are allowed?

   (DP): My policy does allow for nurse to recheck to determine the need for further treatment. The nurse would check for live, moving lice. Answer (Pollack): A nurse might check a child’s scalp for evidence of head lice or other objects of any health concern. I’d recommend that this be done only if agreed by the nurse, the child’s care-givers and the child him/herself. In the case of head lice, the nurse should look for live (crawling) insects and then try to confirm that these are lice rather than some other kind of creature. I’d dissuade the nurse (or anyone else) from conducting mass or scheduled checks for head lice. 

2. Question: Should summer camps abandon head lice screening of each child who comes to camp?

   (DP): Yes, I do believe this practice should be abandoned.  There is no evidence this reduces or eliminates the spread of lice.

   (Pollack): Yes. Camps – and schools – should abandon such mass checks for head lice, as they are ineffective and counterproductive pursuits.

3. How easy is it for a school district without a school nurse to allow a student with a live louse infestation to remain in the school?

   (DP): That is up to the district.  While I strongly believe in the need for a school nurse for a number of issues, lice is not purely a school nurse issue.  District with a proactive staff, administrator or even community members can change school policy.

   (Pollack): With few exceptions, the presence of head lice is a trivial medical condition, and it never should be considered a public health concern. Hence, children should be encouraged – and required - to attend school, regardless of whether or not they have head lice. Districts that have adopted no-nits or no-lice policies should reevaluate the bases of those policies. An objective assessment will reveal that such policies are not justified on medical or scientific bases, and they’ve never been demonstrated to reduce the prevalence or incidence of head lice. Accordingly, such policies should be abandoned because they’re baseless and counterproductive. 

4. Do you have to send a student home due to Nits? Especially if there are chronic problems of head lice over weeks?

   (DP): No, you do not need to send home due to nits.  Ever. Nits are not evidence of current lice, only of past.  Sending them home will not cure the nits or lice.  Only treatment will. Answer (Pollack): No. There’s no basis for a no-nit policy. The vast majority of objects presumed to be nits (louse eggs) are actually bits of irrelevant debris. Those objects that are genuine louse eggs tend to be non-viable (already hatched or dead eggs). Hence, not only is it unjustified to send home a child because of nits, it is also unjustified to treat a child for head lice if the basis for the diagnosis rests solely upon the presence of nits or nit-like objects.

5. Does Deborah provide parent training for how to identify and treat head lice?

   (DP):I do. As long as I see the parent.  Most cases of lice never make it to my office.  Most parents find it themselves, and treat it via (nowadays). I provide education to every family I come in contact with about treatment as well as sending home treatment messages at least twice a year.

6. Should school nurses refer families to their pediatrician if head lice are discovered? First confirm it is actually lice?

   (DP): It often is not. No, most cases of lice can be managed by over the counter treatment. If after two failures, the child still has lice, they should be referred to a medical provider for an Rx.  This is current CDC recommendations.

   (Pollack): A child’s care-giver should be offered clear evidence-based guidance. This may include consulting with a prescriber or clinician if the head lice do not respond to standard OTC pediculicides or if there are other health-related questions or issues.

7. Should school nurses be picking out nits or identifying lice/nits only?

   (DP): I would like to say only identification, but reality, sometimes, when looking at a head and you see a louse, why not just remove it?  I have done some louse picking in my time. I do not nit-pick unless I manage to see what looks like a viable nit close to the head of a kid I know has chronic live lice.

   (Pollack): If the nurse has the time and inclination, s/he may certainly remove a few lice or louse eggs to help to confirm the identity of presumed lice and viability of nits. School nurses have far more important health tasks to perform that should take precedence over nit-picking as a means of management.

8. What is wrong with mass screening all students in the beginning of the school year to see if and where cases are so as to assist families with clearing their child of the lice?

   (DP): Because research says it makes absolutely no difference in the transmission of lice in school.  It takes away from education time for something not dangerous and not readily transmissible in school. It also will pretty much guarantee the child with lice will be labeled as a lice child and confidentially is done for.

   (Pollack): Mass screening for head lice is unjustified, wasteful and counterproductive. Such efforts have not been shown to reduce the incidence or prevalence of head lice.

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Social Interaction Questions

1. Have you seen any increase in the incidence of lice among older children because of the popularity of taking "selfies" head to head with friends?

   (DP): No. 

   (Pollack): The alleged association between taking ‘selfies’ and transmission of head lice is purely imagined. There’s no substance, whatsoever, to support the suggestion. Indeed, the story seems to have originated from a commercial ‘nit picker’ who might have wanted to enhance the client base by spreading rumors and fomenting fear. 

2. Would any of the presenters have any recommendations on head lice management and policy for private schools and early childhood centers for children under 5 years of age where children are more likely to come in head-to-head contact based on their age and environment?

   (Pollack): My recommendations would be the same regardless of whether the school is public or private, or is a facility that serves preschool-aged kids, those in college, or anyone between. I’ve summarized my guidance for schools into a one-page flow chart and offer it here: https://identify.us.com/idmybug/head-lice/head-lice-documents/lice-mgmnt-chart-school.pdf(1 pg, 96 K, About PDF) Exit

3. The children in our school are 18 months to 5 years old and have lots of free play time together. Is there an adjustment of policy to reflect this difference from school age children?

   (DP): Both questions. In areas like this, you may need to screen more children when one is identified.  Notes home when one is identified are still inappropriate, but regular education throughout the year and recommending to families who do have lice to contact any close contacts.  I recommend girls with long hair, as well as teachers, keep their hair up, and having cots for any naps at least two feet away from each other. If you hold children on your lap, do not drape your hair across the head of a child, or hold your heads close together. 

   (Pollack): Head lice are most prevalent (in North America) amongst children in the K-4th grade levels. Prevalence is far lower for persons of other ages. Let the kids engage in normal social activities. Should head lice be discovered on a child, then focus efforts on the scalp hair of that child? That child’s care-givers might be advised to check all others in the home. If multiple cases are confirmed in a single childcare room, temporary efforts might be pursued to reduce direct head-to-head contact.  

4. We have a Residential Hall consisting of K to 8th grade. What would be the best solution to minimize head lice in our hall?

   (DP): As long as the children are sleeping in their own beds, there should not be a problem.  If you are having a problem, identify how the children relate to each other and that should give you an idea how to control transmission.  Remember they must have time for the lice to crawl from one head to another.

5. Are there times when a bunch of kids are laying on the floor with their heads together watching a movie?  Or on a couch?  Not that the couch is the transmission site, but that the kids are very close together. When else are their heads close together?  Work on education of student about this.

   (Pollack): First, objectively confirm that any presumed case of head lice is based upon the discovery of a living (crawling) head louse. Adhering to that case definition will better ensure that non-infested children are not unnecessarily burdened by unnecessary interventions. If live lice are discovered, concentrate interventions just on those who are confirmed to be infested. It would be rarely justified to check roommates of those infested or anyone beyond immediate close contacts.

6. Since lice is transmitted head to head, how important is it to teach parents about cleaning the home environment, like throwing away stuffed animals or putting linen in the dryer for 30 minutes?

   (DP): Not important at all.  These are no longer risk related items. The only really risky areas are bed linen and perhaps clothing worn in the last 24 hours.

   (Pollack): A clean home may be aesthetically pleasing and it may reduce the abundance of dust, carpet beetles and other potential irritants. But, the cleanliness of the home has no bearing, whatsoever, to the presence of head lice or their transmission in the home. Discarding stuffed animals because of fear of head louse transmission would simply cause distress to the child, and would offer no benefit.

7. Can head lice be acquired from sleeping in a bed/sharing a bed of an infested person? Absolutely.  This is one of the most common transmission areas.

   (Pollack): Risk of acquiring head lice is greatest by means of direct head-to-head contact with an infested person. Sharing a bed with an infested person would likely pose such risk. But, simply using a bed that had previously been used by an infested person would pose only minimal risk. Any head lice left on the linens would likely be injured, ill or geriatric and would, consequently, not likely survive if they actually encounter a person.

8. What is suggested protocol for schools that have a nap time and have students with live lice?

   (DP): As long as the students are not head to head and close enough for hair to touch each other, it should not be a problem.  Just make sure your students are separated by a foot or more, as on their on their mats or cots. Answer (Pollack): Space the students so that they are not in direct head-to-head contact.

9. If the primary method of transmission is through hair to hair contact which doesn't occur often at school why is there a significant increase of children getting lice?

   (DP): There isn’t, that is the point.  School is where lice is identified, often because we look for it.  Where it is identified and where it is transmitted is not the same thing. We FIND lice at school, but we don’t GET lice at school. Answer (Pollack): The question is based upon the flawed assumption that incidence of head lice is increasing. There is no basis to believe that incidence or prevalence today is significantly different than it was a decade or three ago.

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Product Related Questions

1. How effective are the products on the market now that state they prevent head lice?

   (Pollack): I’m not convinced of any of the product claims regarding ‘prevention’. In fact, the FTC (Federal Trade Commission) has taken an interest in several such claims and found them to be lacking substance.

2. Is Dr. Pollack aware of an oral medication for elimination of head lice?

   (Pollack): In the U.S., no FDA-approved oral pediculicides are available. Some clinicians have prescribed, off-label, various antibiotics and anti-parasitic formulations. I would dissuade their use because they’ve not been sufficiently evaluated for efficacy against head lice, and some may pose safety concerns.

3. A parent wants the classroom teacher to spray the rugs and chairs with a "natural" spray supplied by a local Lice treatment center. I informed them this is not necessary due to lice needing a blood supply and lose viability. In addition we have students who have asthma and don't need added chemicals to breathe...and we have students who are allergic to essential oils. The teacher continues to insist on using the spray. My concern is if a student gets a hold of the spray and we would not have an emergency Materials Safety Data Sheet on this "natural spray". What can we do in addition to educating and dispelling the myths?

   (Pollack): Applying any product – whether ‘natural’ or synthetic – in the school environment to treat, repel or otherwise manage head lice is unnecessary, unwise and potentially could violate state and/or federal regulations. I’d suggest you ensure that the school administrators immediately halt this practice

4. Dr. Pollock, have you used or heard of the product Vamouse?

   (Pollack): Yes. This product (Vamousse) is now on the market in the US. The active ingredient is ‘natrum muriaticum’. That’s the homeopathic term for sodium chloride (table salt). The manufacturer claims that this product somehow removes the outer protective layer of lice and their eggs and leads to their demise by dehydration. That is an interesting claim, but I doubt it can be supported by a good objective study. I am more than skeptical that it would be effective on a person’s scalp.

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Chronic head lice infestations

1. All of this is great information for the parents that are interested in doing the work required to rid the issue.  Am I hearing all say that for the parents that will not do the work required for their children we should just ignore these children and tell the educators to do the same?  Protective service says this is not an issue they will deal with. Your thoughts?

   (Pollack): An infestation of head lice is, with rare exceptions, a trivial health issue. When head lice are discovered, it would make sense to try to eliminate them using appropriate means. Encourage the child’s care-givers to pursue those evidence-based methods. But, what if they refuse or just don’t have success? Take a deep breath and relax. Put your time and energy into battling more significant issues, such as ensuring that kids are properly vaccinated, well nourished, etc. Those kids who seem to be chronically infested with head lice tend to be without symptoms, and they pose virtually no risk to themselves or to others. There’s a good chance that these kids will simply outgrow the infestations; that is, the lice will eventually fail to thrive as the kids age. I cannot conceive of any reason to recruit protective services because of head lice. If a child with head lice is beaten, denied necessary medical care or food, etc., then by all means call protective services because of those other concerns. Don’t even mention head lice in those cases, as this will remove the focus of the true needs.

2. My concerns is for those students who have chronic/persistent/and untreated lice and how to deal with that in the school setting?

   (Pollack): From my perspective, it matters not if the child has had head lice for one day or one year. See my answer immediately above.

3. We have families that send children to school with live lice repeatedly, to date this year approximately every 5-8 days.  These cases have continued over 8 years.  Education has been extensive, CPS involved, social workers in the home and multiple family members involved.  We do not have a no nit policy.  We only screen symptomatic students, "itchy" How do you propose we help these students when they are repeatedly subjected to lice shampoo, and sprays, but the families REFUSE to remove the nits from the hair? The eggs hatch and the process starts all over again. Please advise.

   (Pollack): See my answer above. I’d also question the basis for the diagnoses. It is highly unlikely that a child will present every week with head lice for eight years. In many such instances, the diagnosis has incorrectly been based upon the finding of nits or nit-like objects. The case definition should require the finding of a genuine living (crawling) head louse on the scalp hair. Should kids who are seen scratching their heads be screened for head lice? I think not. Most kids who have itchy scalps don’t have head lice, and most kids with head lice don’t suffer more itching than do those who don’t have head lice.  Answer for the above questions (DP): Yes, it does end up that way.  I myself have two families with chronic head lice.  But they never infest others in the school. Keep helping the family.  In some cases, the lice are actually resistant and need RX so getting them to health care professional is important, and getting the HCP educated on what is the right treatment. Removing nits is not necessary.  You usually only see the old nits, so it does no good.  Removal of nits is no guarantee the lice are gone. The bad news is the kids will probably have lice until they are in MS or HS and care for their own hair, sleep in their own bed and are responsible for themselves.  But nothing will be gained if they are excluded from school as they will still have the lice, but no education.

4. If students are treated properly, why do some families continually get head lice?

   (DP): Most likely because it was not treated properly.  For example, not doing the second treatment is the most common reason, or when more than one child in the family has lice, but they are not treated and the bed linen is not washed on the same day. They reinfest each other.  Everyone with lice must be cleared at the same time, or it will reinfest.

   (Pollack): In some cases, the problem is attributed to incorrect diagnosis. When genuine head lice actually are present, it may be that someone else (child or adult) in the child’s home environment is endowed with head lice. In such cases, it makes sense for everyone in the home to be checked for head lice, and efforts pursued to eliminate head lice from each infested family member.

5. Child care centers often enroll multiple children from the same family. Can his be interpreted as an outbreak in a small environment?

   (DP): No, just that family has lice.  Lots of kids have lice.   There is always lice.  They are a family with lice, you are not a child care center with lice.

   (Pollack): Concentrate efforts just to those individual children who are confirmed infested by head lice. If multiple members of the same family are affected, certainly work with the family. Invoking the term ‘outbreak’ to describe head louse transmission amongst those in the home or in a classroom is not particularly helpful.

6. What do you do with parents that are non-compliant and have been educated numerous times?

   (Pollack): Be supportive and arm them with good information. Then, smile (being assured that you’ve done all that is necessary) and refocus your efforts on more productive pursuits.

7. When a family that has chronic head lice, what do you recommend that school nurses do to help them get rid of the lice when they have tried OTC treatments as well as prescription?

   (DP): Help them identify what may be the failure point.  Most likely one of the following:  everyone in the family with lice was not treated at the same time, bedding was not washed at the same time, and second required treatments were not done.  Kids were not checked daily for two weeks to catch any linger-oners, then weekly, kids returned or went to an area where they were reinfested, like spending the night at friends or back and forth from one parent to another.  I have found my chronic parents just are not as diligent as they need to be. All you can do is keep plugging away.  I have the same problems myself.  I just keep remembering if I excluded these kids, they would still have lice, just not be education.  Once in a while, the thread of exclusion will work to get treatment.  In my own experience, this only temporarily eliminates the problem.  The lice come back. Answer (Pollack): Ensure that: 1) the child was actually infested with living head lice (not just ‘nits’); 2) the care-givers were using an appropriate product and following the label directions; and 3) others in the home were checked to ensure that they were not contributing to the problem. There’s no reason why head lice should persist if these steps are followed.

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School Head Lice Policies

1. For Deb: If a District has no lice policy - you stated that they should not create a policy.  Would it be best to prepare an action plan or protocol instead based on evidence-based practice?

   (DP): If you can get away with doing nothing, do that.  A protocol is really nothing more than a policy. Some districts just provide information about lice one their website or written.  But don’t have any formal procedure for handling.

2. What modifications might you make in the policy when considering younger children who may be in a preschool setting within the school?

   (DP): These children are much less likely to maintain body space! My policy allows for me to screen the preschool class if I feel it is warranted.  I make sure I check all close contacts in the classroom whenever there is a noted case.  I suggest to parents (and teachers) to keep long hair up. If there is napping, make sure the mats are 1-2 feet away from each other.

   (Pollack): I see no reason to have a ‘policy’ relating to head lice other than to provide the child’s care-givers with good information. The age of the child shouldn’t really have much, if any, bearing on how to manage the situation.

3. Do you have advice for preparing families and communities for elimination of no-nit policies and allowing students with live lice to remain in school until the end of the school day?

   (DP): Start slow.  Talk to teachers first, they may be your biggest opponent.  Show them the evidence.  Compare it to evidence based teacher.  Do your own research on students and how no one else in the class gets it from them.

   (Pollack): Begin trying to educate the educators. I see no reason why teachers (unless they are medical professionals) should have any say, whatsoever, regarding most health policies. If a teacher perceives a health concern for a child, that child should be seen by a nurse or by a clinician of the parent’s choice. The teachers should not be looking for head lice, and – with rare exceptions - they should not be informed as to the health status of any child. Efforts to eliminate a failed policy in the school might begin by documenting the basis for that policy, assessing whether it is justified (it is not), enumerating the costs (e.g. lost school time), and then concluding the obvious: that such policies are flawed and counterproductive.

4. Do most schools have a nit-free policy?

   (DP): Yes, unfortunately, policies are slow to change, but they are.

   (Pollack): Sadly, most schools do still seem to burden their students and their care-givers with such unjustified and counterproductive policies. But, increasingly, those policies are being abandoned as the school administrators realize that these policies were never justified, and that they consistently fail to reduce incidence or prevalence of head louse infestations.

5. Should head lice no longer be a subsect of a school's IPM plan/or policy?

   (Pollack): Head lice are obligate human parasites. They survive and thrive solely upon a person’s scalp, but nowhere else. Hence, they are a medical concern (and a trivial one), NOT an environmental pest management challenge. The contribution of IPM to managing head lice should be limited to helping ensure proper diagnoses, disseminating good evidence-based practice guidance, eliminating efforts to treat classrooms and buses for head lice, and discarding unjustified exclusion policies.

6. To all...what was your worst run in with resistance to changing policy (parents, teachers, admin etc.) and how did you address it?

   (DP): My worst was one teacher.  She is convinced she got lice from a student, and I am convinced she got it from her own child.  She still hates the idea that they stay in her class, but is no longer vocal about it.  She understands how much time they would be out of class if it were no nits or no live lice.  I actually use her as my evidence.  She had one student for two years in her classroom that probably had live lice at least 50% of the time. But no one else in her classroom for two years ever had lice. Her classroom is my home evidence.

   (Pollack): I’ve been the target of legal pressure by a self-proclaimed expert louse association in their efforts to prevent me from providing evidence-based insights and guidance. Despite having virtually no scientific or medical authority on this topic, they insisted that they should be the sole informational source. They continue to promote anti-scientific messages and aggressively argue for no-nit policies that rely on misinformation and fear-mongering techniques. My response has been to redouble my efforts to inform diverse audiences of the basis for my statements, to further the science, and to address naysayers in a polite and productive manner.

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Notification

1. If there is more than 1 child with lice in a classroom, do we continue with the NO LETTER home to parents?

   (DP): Yes.  There is no reason to send home a letter.  This reinforces that lice is transmitted in the classroom, otherwise why would you send the letter.

   (Pollack): Notification letters (‘a child in the classroom has head lice’) tend to incite a small amount of panic. Some parents who receive these letters seem encouraged to treat their kids presumptively or prophylactically, neither of which would be wise. Rather than sending letters to all when a child is suspected of being infested, I’d recommend that an informational letter or web resource be provided at the beginning of the school year. That letter would state the obvious: that head lice may be discovered on some kids in virtually any elementary school and at any time of the year. Then the letter might put this issue into a calm and proper perspective, and provide links to useful informational resources.

2. Sending a letter home instead of directly contacting family may not be the best way to approach this. One never knows how a family may react, and the onus is put on a child taking that letter home. I suggest always making direct contact as it offer the possibility of reassurance from an "authority/expert" person.

   (DP): I think you misunderstood me. I am not recommending a letter home to a specific student about lice.  Only written information in general in advance and written supplemental information for treatment.

   (Pollack): Contacting the parent / guardian of a presumably infested child would best be made at the end of the school day. Such communications may be made by phone, email or in person, and in a manner that would preserve the confidentiality of the child and his/her family. Be prepared to offer helpful advice and information sources.

3. On finding head lice on a child, I gather that you do not recommend any notification of other parents... or did I misunderstand? At what point is the education of parents undertaken in relation to an occurrence or is it a practice at start of school year?

   (DP): Yes, if I find lice, I do notify the parent. Just not immediately and the child does not go home. I do education about 2-3 times per year.  At the beginning of the year, after Christmas break and around spring break.  This is often when they have acquired lice in the community and it is identified at school where people are familiar with it.

   (Pollack): There’s no need to notify anyone other than that child’s care-giver. No one else – including the teacher, principal, guidance counselor, or parents of other students – need be informed. Despite their preferences and demands, it is not their business to be so informed regarding the situation with head lice at school. Head lice are neither highly contagious nor a significant health problem. Simply post a good informational link on the school’s website.

4. Are you advocating notifying teacher only with live lice and nits close to the scalp? Please explain.

   (DP): Sometimes I notify the teacher and sometimes not. Usually I do not.  If I need help in contacting parents I may involve the teacher.  If the teacher has referred a child to me, I will often follow up with her/him. Only if I know the teacher will not stigmatize the child in any way.

   (Pollack): There’s no reason for the teacher to be so informed. If the teacher has referred the child to the nurse, that teacher should be thanked for performing that service. At that point, it becomes a matter of confidentiality, and the teacher should not be informed whether or not the child has head lice.

5. Does promoting a hush-hush strategy regarding head lice further perpetuate the stigma and fear related to head lice?

   (DP):  I am not promoting a hush-hush strategy. Just treating lice like any other issue at school.  Not doing MORE for lice than I do for a cold or an injury.  I talk A LOT about lice to anyone who will listen

   (Pollack): Provide parents at the beginning of the year basic facts regarding head lice. Let parents know that the nurse will deal directly with parents of a presumptively infested child. This is far from a ‘hush-hush’ approach. Instead, it is an appropriate and direct response to a generally inconsequential health issue.

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Resource Questions

1. Nicole Bobo:  where would I find the 80% stats regarding schools still excluding for HL?

   (NB) The SHPPS Study came out in October 2015. The link is: http://www.cdc.gov/healthyyouth/data/shpps/pdf/shpps-508-final_101315.pdf(180 pp, 1.9 MB, About PDF). The discussion referred  to Table 4.16

2. Dr. Pollack - I love the photo on fatherly.com "invasion of super lice"- how would one get a copy of it?

   (Pollack): None of those images was mine. I’d recommend you contact the writer or editor of the site to inquire into use of those images.

3. Did I hear correctly that there was a study done on the rate of transmission of lice in school? I'm wondering about any statistics on where children get lice (sleepovers vs school vs community club)?

   (Pollack): I’m not aware of any study of head louse transmission in a school environment. There have been several studies – some published and some not - that examined the abundance of head lice on school desks, floors, swimming pools, and on diverse implements, such as combs, brushes, head phones and hats. The overall conclusion has been that inanimate objects are insignificant as means of transferring head lice. Head lice would most readily be acquired by direct head-to-head contact with an infested person. That may happen at home, play dates, camp, school or virtually anywhere such contact may occur.

4. Dr. Pollack - How long does it take for identifyUS to identify the pest that is submitted? 

   (Pollack): We (IdentifyUS, https://identify.us.com) strive to respond to every inquiry the same day it is received, whether it arrives as a physical specimen or digital image. Often, our turnaround time is measured in hours – and sometimes - in just minutes.

Hair type Questions

1. Some children have very thick oily hair. Are they less susceptible to lice infestation?

   (Pollack): A thick layer of oil or gel on the hair or scalp may provide a less conducive environment for head lice. 

2. Is it true that dirty/greasy hair is less likely to become infected because lice cannot grasp the hair?

   (Pollack): See response above.

3. Can anyone of the panel members comment on types of hair that head lice prefer? I understand certain types of hair, girth etc., and cannot be grasped by head lice.

   (Pollack): Head lice are well adapted to grasping the hair of the scalp. Some louse researchers have postulated that the relatively oval cross section shape of the hair of certain ethnic groups may explain a frequently observed difference in prevalence. Whereas that is an interesting hypothesis, it is merely conjecture. Any person with scalp hair may potentially acquire and host head lice. 

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Species Specific Questions

1. Where do head lice originate? I get asked this question by childcare providers in Kane County a lot.

   (Pollack): Head lice seem to have evolved along with human beings. Our ancestors had head lice, and so did theirs.

2. Do you need to vacuum carpets in classrooms on a daily basis to prevent head lice transmission?

   (Pollack): There’s no basis, whatsoever, to support the notion that vacuuming with any frequency will prevent or reduce transmission of head lice. Whereas it may be nice to have clean floors for other reasons, it would be an error to vacuum the floors with the intent to affect the transmission of head lice.

3. Dr. Pollack - did I understand you to say that a non-mated, non-pregnant female louse can still lay (non-fertile) eggs?

   (Pollack): Yes. Non-viable eggs are regularly produced by non-mated females, as well as by those females that had mated but have become geriatric (just a few weeks old). 

4. Is there a time of year that head lice are more prevalent and why?

   (Pollack): Despite claims to the contrary, there’s no reason to believe that the prevalence changes measurably as a function of the month or season. Head lice occur solely upon the scalp hair of human beings. Where would they go during the ‘off season’?

5. Do outside temperatures affect the life of them?

   (Pollack): The temperature of the scalp is a fairly constant and balmy ~30C regardless of the season. It may transiently get a bit cooler or warmer there while outside in winter or summer, but those brief intervals won’t likely burden the head lice. 

6. When Dr. Pollack says lice don't live long off the body, can he give us a better idea of the number of hours?

   (Pollack): Under ideal laboratory conditions, a few fully engorged female head lice may survive until the next day. But, that’s under ideal conditions. From a practical standpoint, a head louse that has been separated from a human host in school or at home will quickly begin to lose water and suffer from starvation. With few exceptions, the adult head lice should be expected to succumb in a matter of hours. Few, if any, will likely still be alive by the next day. Immature lice will perish far more quickly. To offer even better practical insight, any louse left on a desk or other surface at school at the close of the school day will almost certainly be dead by the time the school opens the next morning. Similarly, any louse left on a pillow case or stuffed animal at home in the morning should be expected to be dead or severely impaired by the time the child returns from school. 

7. While there are few known complications from a lice infestation, such as infection from scratching the area, what are the long term implications for chronic lice infestation?

   (Pollack): A person who chronically hosts head lice is almost invariably asymptomatic. The head lice don’t bother the person, and the host doesn’t bother the head lice. That chronically-infested person’s scalp won’t itch any more – or less – than that of a non-infested person. Hence, there’s really no long-term implication in terms of health, either to the person or to the lice. 

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Head Lice Resource Links The following links exit the site Exit

• Head Lice (American Academy of Pediatrics) 
• Pediculosis Management in the School Setting (PDF)(4 pp, 210 K, About PDF) (National Association of School Nurses, NASN) 
• Head Lice  (IdentifyUS) 
• Managing presumed head louse infestations at home (PDF)(1 pg, 120 K, About PDF) (IdentifyUS)  
• Head Lice Information for Schools (CDC)
• Head Lice – Pediculosis Capitis (NASN) 
• Headfirst Lice Lessons (NASN) 
• Lice Lessons (headfirst) 
• Demystifing Pediculosis. School Nurses Taking the Lead(10 pp, 2.4 MB, About PDF) (Continuing Nursing Education)  
• Over diagnosis and consequent mismanagement of head louse infestations in North America (PubMed)
• Managing Pests in Schools
• Webinars about Integrated Pest Management in Schools

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Upcoming School IPM Webinars

We welcome your participation in our upcoming webinars and ask you to encourage your peers to attend. These presentations are geared specifically to school and school district facility managers, buildings and grounds managers and staff, childcare facility managers, and school IPM practitioners. School nurses, school administrators, health officials, and pest management professionals are welcome to attend.

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