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HEAD LICE MANAGEMENT IN HEAD LICE MANAGEMENT IN SCHOOL SETTINGS SCHOOL SETTINGS Shirley Gordon, PhD, RN Christine E. Lynn College of Nursing Florida Atlantic University February 7, 2009 FASN Conference © Shirley Gordon, 2009
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HEAD LICE MANAGEMENT IN SCHOOL SETTINGSnursingnetwork-groupdata.s3.amazonaws.com/NASN/Florida...HEAD LICE MANAGEMENT IN SCHOOL SETTINGS Shirley Gordon, PhD, RN Christine E. Lynn College

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Page 1: HEAD LICE MANAGEMENT IN SCHOOL SETTINGSnursingnetwork-groupdata.s3.amazonaws.com/NASN/Florida...HEAD LICE MANAGEMENT IN SCHOOL SETTINGS Shirley Gordon, PhD, RN Christine E. Lynn College

HEAD LICE MANAGEMENT IN HEAD LICE MANAGEMENT IN SCHOOL SETTINGSSCHOOL SETTINGS

Shirley Gordon, PhD, RNChristine E. Lynn College of Nursing

Florida Atlantic University

February 7, 2009FASN Conference

©

Shirley Gordon, 2009

Page 2: HEAD LICE MANAGEMENT IN SCHOOL SETTINGSnursingnetwork-groupdata.s3.amazonaws.com/NASN/Florida...HEAD LICE MANAGEMENT IN SCHOOL SETTINGS Shirley Gordon, PhD, RN Christine E. Lynn College

The Head louse is an Ancient Parasite That:

Needs to feed on human blood every 2-3 hours [1mg per feeding]

Is easily transmitted through head to head contact

Is present on 1% to 3% of the worlds general population at any given time (Roberts, 2002)

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Primary weapons used against the parasite areneuro toxic pesticidesLeading pesticide –originally developed as an agent for bio chemical warfare

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Costs

Direct: $90 million each year in the US–

Cost of treatment products -

Average 5 self treatments before seeking help

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Indirect Costs

Indirect:–

Lost school days = lost school funding

California –

10% children with lice/4 days =

$3.2 million •

NY -

$20-$40/day/child = $25-$35 million•

Nationwide $10-$40 per day per child/ 33.5 Million children in grades K-8 = $280 - $325 million in lost funding

Lost work days $2,720/wages per family per active infestation

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Now Imagine:

Your child has head liceYour entire family has head liceAnd despite repeated treatment attempts [sometimes over a period of years] you can’t get rid of it…

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Objectives:

Review current research related to head liceIdentify family centered lice treatment and prevention strategies Increase ability to recognize lice, eggs and nits

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Head Lice (Pediculosis Capitis)Common among children ages 2 to 12 years old

Widespread throughout the United States and the world

6-12 million cases a year in the US (CDC)

Elementary schools may reach 25% infestation. (Roberts, 2002)

Photo: © 2001-03, Johns Hopkins University School of Medicine: Dermatlas

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Head Lice:Head Lice:

Size of sesame seed (adult)Wingless - Do not jump or flyAre human parasites – host specificDo not live more than 24 hrs off their human host. Do not infest homes/schoolsAre highly stigmatized

Presenter
Presentation Notes
Adapts Color: Red or black lice are found on dark hair and skin Gray-white lice on light hair and complexions La Valle, A. (1999) Head lice: The truth, the myths, the update. School Nurse News, 17 (4). 34.( This was a presentation at the NASN Conference 1999) Hansen, R. C. & colleagues from Working Group on the Treatment of Resistant Pediculosis. (2000, August). Guidelines for the treatment of resistant pediculosis. Contemporary Pediatrics, (Suppl.), 6.
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Life Cycle:Life Cycle:Lifespan approximately 30 days

Females lay up to 5-10 nits (eggs) per day (150-400 in a lifespan)

Nits hatch within 7-10 days and release nymphs (immature louse)

Nymphs reach adult reproductive stage in 8 or 9 days

Presenter
Presentation Notes
La Valle, A. (1999) Head lice: The truth, the myths, the update. School Nurse News, 17 (4). 34.( This was a presentation at the NASN Conference 1999)
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Nits (Eggs)Nits (Eggs)

Nits, tiny teardrop shaped eggsAttached to one side of the hair shaft with water proof, glue-like substanceLaid 1/4 inch from the scalp. (In warmer climates, viable nits can be found as much as 6 inches or more from the scalp)

Presenter
Presentation Notes
Nits are often found: Nape of the neck Behind the ears Hansen, R. C. & colleagues from Working Group on the Treatment of Resistant Pediculosis. (2000, August). Guidelines for the treatment of resistant pediculosis. Contemporary Pediatrics, (Suppl.), 6.
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Active Infestation

Presence of at least one live louse –

or Live lice & viable nits

Screen the entire familyTreat only active cases

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Transmission:Transmission:

Direct head to head contactTheoretically, may be shared through fomits such as hats, combs, and towels, etc. (thought to play a minor role in transmission)

Presenter
Presentation Notes
Direct: Head to head contact with an infested person: During an embrace Close friend Sibling Indirectly: Through sharing personal items which come in contact with the head such as: hats combs and brushes head bands and scrunchies towels Brainerd, E. (1998). From eradication to resistance: Five continuing concerns about pediculosis. Journal of School Health, 68 (4), 146-150.
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Common Symptoms:Common Symptoms:Many children (50%) experience no symptoms.Symptoms take several weeks to developWhen symptoms occur, the most common are:–

Scratching -

Sleeplessness

Red, hive-like bumps on the head.–

Rash on back of neck

Presenter
Presentation Notes
Children have sleeplessness because: Lice are more active at night. Secondary bacterial infections such as, impetigo and swollen lymph glands, can occur when: Symptoms go undetected and untreated They are not common Hansen, R. C. & colleagues from Working Group on the Treatment of Resistant Pediculosis. (2000, August). Guidelines for the treatment of resistant pediculosis. Contemporary Pediatrics, (Suppl.), 6. Estrada, J. S., & Morris, R. I. (2000). Pediculosis in a school population. The Journal of School Nursing, 16 (3), 34.
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Head Lice are a Community Head Lice are a Community Problem:Problem:

Only 1 in 10 transmissions occur at school.

Common Outbreak Times:Common Outbreak Times:•

Start of the School Year

After Winter Vacation•

After Spring Break

Whenever children are in the community for extended periods of time

Presenter
Presentation Notes
Socoloff, F. (1994). Identification and management of pediculosis. Nurse Practitioner, 19 (8) 62-63. Clore, E. R., and Longyear, L. A. (1990). Comprehensive pediculosis screening programs for elementary schools. Journal of School Health, 60 (5), 212-214.
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Factors Contributing to Absenteeism

Exclusion PoliciesMisdiagnosis of Active Head LiceFailure to Treat / Treatment FailureFatiguePersistent head Lice

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Exclusion Policies

No Nit – Live Lice Only – Non Exclusion Florida School nurses reported that the number of days children were excluded from the 2002-2003 school year for head lice ranged from 0 to 100 days (Gordon, 2004)School Districts vary on the number of days children receive an excused absence for lice

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Conversion From Nits to Live Lice

In a CDC study:–

1700 Atlanta children screened

91 had evidence of nits or lice (5%)–

Only 28% (476) had active infestation

50 (10.5%) children diagnosed with nits (no live lice present) were followed for 2 weeks

18% (9) went on to develop live lice–

5 or more nits close to the scalp –

predictor

of

conversion to live lice»

Williams, Reichert , McKenzie, Hightower, & Blake, 2001

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Misdiagnosis of Active Infestation

Active Infestation: Live lice & viable nits–

In a research study in which participants were asked to gather samples from identified head lice cases:

555 samples were sent in •

57.5% of samples showed evidence of lice & eggs

teachers samples / 50% active–

relatives / 47.1% active–

nurses / 31.7% active–

physicians / 11% active»

Pollack,

Kiszewski,

Spielman, (2000)

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Failure to Treat / Treatment Failure

Children may be excluded from school because caregivers:–

Fail to treat their child’s head lice

Misuse products leading to treatment failure–

Do not complete follow-up

Lice and Nit removal–

Experience resistant lice

Overuse products–

Do not screen & treat other family members / contacts [contact tracing]

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Treatment Approaches: Pesticides

Prescription:LindaneMalathion

OTC:Pyrethroids

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Barrier

Dimeticone–

Showing great promise

Creates a physical barrier around the louse –

Does not act on the nervous system

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Contraindications

On children under 6 months: medical supervisionPreparations with an alcohol base should not be used on children under 5Pyrethroid based products are contraindicated in persons with allergy to chrysanthemum flowersPreparations with an alcohol base should not be used on persons with scalp dermatitis or asthma. –

Well ventilated rooms, away from heat sources like: open flames, stoves, cigarettes, hair dryers

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Alternative Treatments

Mechanical removalHerbal and essential oils–

Tea tree oil and lavender oil can be toxic in concentrates

Limited empirical evidence to determine effectiveness

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Importance of Contact Tracing ( 9 out 10 family members in 4 homes )

Referral case6 yo Female

Uncle 59 Mother/Fatherbrother (10) brother (8)

Aunt (no lice)cousin (4) / cousin (7)

Grandmother 89

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FatigueLice are more active at nightChildren with head lice report disrupted sleep patterns resulting in:–

Irritability

Diminished ability to concentrate–

Poor school performance

Sleepiness in class–

Children sent to health room for falling asleep in class should be checked for head lice

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Persistent Head Lice CasesA small number of children develop persistent cases: Diagnosis of live lice 3X in 6 weeks that are not amenable to treatment (Gordon, 2002, 2007)Children with persistent lice may be placed at risk:–

educationally due to excessive absences from school

physically from unsafe treatment strategies–

Emotionally from stigma & fear of transmission

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Grounded Theory Study of Families Experiencing Persistent Head Lice

Problem–

Caregiver Strain

Process–

Shared Vulnerability

Gordon, 2007

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Purposive Sample20 parents/caregivers caring for children with persistent head lice–

Mothers (75%)–

Grandmothers (15%)–

Foster father (5%)–

Stepmother (5%)Referral case recruited from–

Public Schools 35%–

Lice treatment facility 60%–

Word of mouth 5%

Age–

22-73 years –

Mean 33 yearsEthic background–

Caucasian 95%–

Hispanic 5%Marital Status–

Single 65%–

Married 35%Participants experiencing financial difficulty obtaining treatment 35%

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Children

# Children in the home–

Range 1 to 6

Median 3 children50% receiving Free/reduced lunch“Forced absences”from school for lice–

0 to 37 days

Mean 11 days

65% Spent time in more than one home30% of children slept in bed with others–

# persons in a bed

2 to 4 persons•

Median 3

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Problem: Caregiver StrainParents experienced stress from the moment their child was diagnosed with head lice, throughout treatment attempts and long after theinfestation had ended.

Caregiver Strain denotes the enduring nature of the perceived stress of caring for children with persistent head lice.

Stress associated with caring for children with persistent head lice was as persistent as the lice.

“You can’t imagine how stressful this is [lice] – it takes over your whole life!”

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Process of Shared Vulnerability ©

Shirley Gordon, 2007

Participants described suffering the same openness to injury as their child with persistent head lice. They were also susceptible to becoming infested with head lice themselves.

Shared Vulnerability

Stage I Being Ostracized

[Conditions]

Stage II Losing Integrity

Of the Self

[Consequences]

Stage III Struggling with

Persistence[Strategies]

Stage IV Managing Strain

[Consequences]

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Stage I Being OstracizedDescribes the conditions under which caregiver stain is experienced. Lice myths include:

Being unclean–

Living in poverty–

Poor parenting

Head lice is a stigmatizing condition –

Socially discredited–

Set apart from others–

Stigma increased if •

Treatment was unsuccessful•

Re-infestation occurred •

Infestation becomes chronic

“I over heard my son’s best friend’s mother say it wasn’t safe to come over to our house.”

Stage I Being Ostracized

Exaggerating meaning

Blaming the victim

Ruminating

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Stage I Being OstracizedExaggerating meaning and negatively evaluating ability to successfully treat lice.

Blaming the Victim. Persistent head lice is thought to be a curable condition that is allowed to become chronic by the parents/caregivers.

Ruminating–

Intrusion of unwanted thoughts that interfere with daily functioning.

“I’ve been trying to get rid of these things for 4 years! No matter what –they keep coming back. You start to believe you will never win.”

“They keep telling me I must be doing something wrong. I’m following all of the instructions to the letter. My house is clean. It [lice] just keeps coming back.”

“I think about it [lice] all the time. I can’t sleep. I feel them crawling even when they are not there.”

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Stage II Losing Integrity of the Self

Participants described losing integrity of the self as a consequence of being ostracized.

“It [head lice] changes how people see you – how you see yourself”

Stage IILosing Integrity

of the Self

Enduring Social Isolation

Altered Family Interactions

Feeling Guilty

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Stage II Losing Integrity of the Self

Enduring isolation–

Social isolation is shared

Feeling guilty–

Expectation that “good”

parents can successfully treat lice

Altered family interactions–

Effects day-to-day family relationships

“They only let her come to school for the FCAT exam. They made her sit on a plastic chair away from her friends. It makes me cry to think about it”.

“My husband is clueless, he’s like What’s going on? Why can’t you just take care of this? Like it’s that easy. I don’t now why!”

“When I lay down at night to read to her, we both wear shower caps to keep our heads from touching”

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Stage III Struggling with Persistence

Participants described strategies developed to cope with caregiver strain and shared vulnerability experienced in caring for children with persistent head lice.

“It’s a struggle everyday. You get up knowing you have to deal with it [lice] and you go to bed dreading the next day.”

Stage IIIStruggling with

Persistence

Protecting AgainstExposure

Trying Everything

Seeking Help

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Stage III Struggling with Persistence

Protecting against exposure–

Lice secret–

transmission

Trying everything–

Feeling overwhelmed and desperate

Seeking help

“I don’t let her go to anyone’s house or have anyone over. I just can’t risk it.”

“I can’t remember what all I’ve used. This has been going on for years. Sometimes I got pretty desperate – I used bleach, hair dye, kerosene, bug spray. I needed real help.”

“I tried to see my son’s doctor – he said talk to the pharmacist. He didn’t want my son to come in the office!”

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Stage IV Managing StrainAs a consequence of struggling with persistence, participants managed strain day to day.

“You have to learn to deal with the stress on a daily basis. What else can you do? Some days are better than others.”

Stage IVManaging Strain

Gaining Perspective

Balancing Resources

Developing Trust

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Stage IV Managing StrainGaining perspective–

alternated between seeing head lice as a major health threat and a benign condition.

Balancing resources–

Financial & human

Developing trust–

Share the secret

“ Sometimes I think head lice never killed anyone – but then I think I will never live through this.”

“My husband and I trade off. Sometimes he stays home with the kids. I couldn’t do this alone.”

“At some point you just have tell people and trust they do the right thing by checking their own kids and not making a personnel issue out of it.”

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Implications for School Nurses:

↑ Understanding of potential effects of persistent head lice on the family as a whole–

Shift from blaming → supporting

Challenge existing approaches → Grounding nursing responses in “what matters most.” (Boykin &Schoenhofer, 2001, p. 59.)

What mattered most to participants in this study was caregiver strain.

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Family Centered Strategies - Working Together:

Conceptualize head lice as a family phenomena–

Focus on contact tracingRecognize the strain placed on caregiversShift from adversarial approaches–

Evaluate exclusion policiesEducational programs to reduce stigma–

Community and school basedOffer treatment options respectfully–

How can I help?Co-ordinate community efforts–

Increase referrals for lice treatment–

Seek funding opportunitiesEnhance participation in research studies

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References:

Burgess, C.G., Pollack, R. & Taplin, D. (2003). Cutting through the Controversy: Special Report on the Treatment of Head Lice.Morrristown, NJ: Premier Health Care Research.

Gordon, S. ( 2007). Shared Vulnerability: A theory of caring for children with persistent head lice. Journal of School Nursing, (in press)

Gordon, S. (2004). School nurse attitudes toward the standardization of head lice policies. Unpublished manuscript.

Gordon, S. ( 1999). Factors relating to the overuse of chemical pesticides in children experiencing persistent head lice. Journal of School Nursing, 15(5), 6-10.

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References:Pollack, R.J, Kiszewski, AE, Spielman, A. (2000), Over diagnosis & consequent mismanagement of head louse infestations in North America. Pediatric Infectious Disease, 19, 689-693.

Roberts, RJ, ( 2002). Head lice. New England Journal of Medicine, 346, 1645-1650.

Williams, LK, Reichert, A. MacKenzie, WR, Hightower, AW, Blake, PA. (2001). Lice, nits, and school policy. Pediatrics, 107, 1011-1015.