Download pdf - The prevention, identification and management of head · PDF fileThe prevention, identification and management of head lice ... and the general public is of paramount importance in

HEALTH PROTECTION AGENCY NORTH WEST

The prevention, identification and management of head lice infection in the

community

October 2007

(Review Date: October 2010)

There are other national guidelines available

This is recommended for use in the North West.

Membership of the Group includes: Evdokia Dardamissis, Steve Gee, Ed Kaczmarski, Jeanette Kempster

Lorraine Lighton, Ken Mutton, Ruth Philp, Jeff Scott and Tracey Wood, on behalf of the North West Policy Group

www.hpa.org.uk

http://www.hpa.org.uk/

P:\NW Policy Group\Policies and Guidance\Amended policies 2007\Word Documents\Headlice infection in the community.doc FINAL VERSION: 6/11/07 Page 2 of 25

INDEX Page1 Introduction 3

2 Aims and Objectives 4

3 Information about Head Lice 4

4 Prevention and Detection 6

5 Parasiticidal Treatments 6

6 Treatment 8

7 Contact Tracing 10

8 Evaluating Treatment 11

9 Wet Combing (“Bug Busting”) 12

10 Alternative Remedies 12

11 Responsibilities of Parent/Carers 13

12 Role of School Nurse/School Health Visitor 14

13 Role of Health Visitor 15

14 Role of School 15

15 Role of General Practitioner 16

16 Role of Community Pharmacist 17

17 References/Bibliography 19

Appendix 1 21

Appendix 2 (Notes and Guidance for primary

care professionals)

22

Appendix 3 (Notes and Guidance for Head

Teachers)

23

Lice Detection 25


1. Introduction

• This guidance has been developed to promote a co-ordinated approach to the control and effective management of head lice infection, and, to assist health professionals in reducing the anxiety that often surrounds this infection. Commitment between health professionals, schools, nurseries, parents/carers and the general public is of paramount importance in tackling the problem of head lice infection.

• Head lice infection is a community problem and is not, as many people think,

restricted to children. Adults may become long-term carriers due to a de-sensitisation to head lice over time, and adults are also likely to have fewer lice so this can make an infection more difficult to identify. Consequently adults may be an ongoing source of head lice infection, and unknowingly infect children during prolonged head to head contact.

• No data is routinely collected about the number of people with head lice

infection, but a number of local surveys in recent years have suggested no significant increase in the number of head lice infections. Nowadays most head lice infections are of only a few lice, whereas before effective treatments with insecticidal lotions became available, much ‘heavier’ infections were seen.

• The true prevalence of infection is probably lower than the public and

professional perception. Many supposed cases of head lice infection are not true infections, and are due to a variety of causes including psychogenic itch upon hearing of other cases (known as louse “phobia”), other causes of an itchy scalp (dermatitis etc.), and extinct infections with persistent itch or nits (empty egg cases). Consequently it is important that head lice infection is not diagnosed unless a living, moving louse is seen in the hair.

• The main symptom from head lice is itching. Head lice infection does not constitute a serious public health problem. Head lice infection does generate considerable anxiety and distress among parents and within schools, which is often due to myths and to unjustified stigma. Inappropriate blame may be attached to schools or to individuals. Health professionals have an important role in reducing the anxiety surrounding head lice infection, and in changing false perceptions about the infection.

• The problem must be tackled in the community. This requires the

involvement of all families within the community. Head lice will always be present in the community and in schools, and will probably never be eradicated. A sensible informed approach that reflects current evidence and national ‘best practice’ will help to control the infection and, effectively manage the problem when it does occur.

• Control of head lice is based on early detection of infection among

cases and close contacts, and effective treatment with an insecticidal lotion or liquid.


•

e effective support concerning the detection and treatment of head lice.

• lice infection, and to provide consistent information and advice to parents.

. Aims And Objectives

As with any other health-related problem detecting head lice is the responsibility of parents, although parents need to be provided with clear information and receiv

Health professionals need to adopt a co-ordinated approach to

2

The aims and objectives of this guidance are:

reducing the incidence and prevalence of head lice in the ommunity.

rofessionals involved.

the detection, prevention, and treatment of ead lice to health professionals.

de aware of the importance of eir responsibilities in controlling head lice.

. Information about head lice

• To assist in

c

• To create accountability by identifying and clarifying the roles of the p

• To promote a co-ordinated approach for the control of head lice infection by outlining the current information onh

• To assist health professionals in providing factual and consistent information to members of the public whereby they are math

3

.1 What to look for 3

6 legged insect which is between the size of a pin-head nd a sesame seed.

is greyish brown in colour.

he adult louse lives for about one month.

n the scalp and cannot jump or fly and has difficulty walking on flat surfaces.

.2 Facts about head lice

• A head louse is a tiny

a

• It

• T

• Each leg ends with a claw, which grasps the hair, enabling swift movement close to the scalp. It does not walk o

3

• blood, approximately 5 times per day. The “biting” is not painful

• males in the ratio 4:1 and lay 6-8 eggs daily (not all eggs are viable).

it does ing off the hair is not

It feeds only on human

Females out number

• Eggs are firmly glued to strands of hair close to the scalp, preferring temperature of 30 - 31°C which is favourable to incubation. Therefore, not matter whether hair is short or long. Shav an


• The incubation period is 7 - 8 days and within 10 days of hatching, the louse

acceptable treatment for head lice infection.

• Live eggs are skin coloured and very difficult to see.

becomes a mature adult and is able to mate.

• Nits are empty egg cases. After a louse has hatched the empty egg case becomes white. If you have nits it does not always mean that you have a current head lice infection. Nits remain stuck to the hair and grow out as the

• You only have head lice if you can find a living, moving louse (not a

hair grows, at a rate of about 1 cm per month.

nit). 3.3 Information on head lice infection

• Lice will live on hair that is dirty or clean, short or long, adult or child. .

• High standards of personal hygiene do not

Short hair may make it easier for them to get from one head to another

necessarily prevent head

• thod of transmission (person to person spread) is walking from

head to head. The heads must touch for a duration of at least one minute or

• spread

through a population. It is much less infectious than some other common

ot

lice infection.

The me

more.

Head lice infection is not highly contagious, taking time to

infections in children, such as chickenpox and impetigo.

• Lice cann hop, jump, fly or be drowned. Should a louse be found on a

weak to hang on to the hair. Adult lice can live apart from humans for only a short period of time, therefore it is rare for infection to be caught in

• Lice do not keep still and move very rapidly when disturbed

• Most head louse infections are asymptomatic, but about one third of

• For a first infection, it can take up to 8 weeks for itching to start, with

• Sometimes the appearance of a rash at the back of the neck is the first indication of infection.

hat,collar, pillow, chair back etc it will either be a dead louse or a damaged louse that is too

this way.

e.g. when undertaking detection combing.

cases experience itching. The itching is due to sensitisation.

subsequent infections itching will occur sooner.


4. Prevention and Detection

G• ood hair care will not prevent head lice infection but it may help to identify head lice at an early stage and so help control the spread of the infection

• When hair is washed, damaged lice will float on the surface of the water. Also, the presence of lice may be indicated by finding a black powderp

.

on the

when you know that head to head contact with an infected person has occurred or when members of the

• louse repellents should be discouraged, as they do not deal existing

illow in the morning. This is a mixture of black faecal powder and cast skins which can also make collars become dirty more quickly than normal C• hildren should be provided with their own brush/comb and be encouraged to adopt good hair grooming habits.

• Weekly detection combing of children is recommended (please see Appendix 1 ‘Have you got Head Lice?’).

• Detection combing is especially important

household have been named as contacts.

The use of with the control of lice in the population, and they do not treat

infection. 5. Parasiticidal treatments

P• arasiticidal lotion or liquid formulations are recommended for the treatment of head lice infection

• Adv liquid to use can be obtained from:

’

tions one week apart.

•

ed mosaic’ system of treatment should be followed, whereby, if a course of treatment fails to cure, secticide is used for the next course

ice about which lotion or

- The pharmacist - The school nurse - The health visitor - The General Practitioner - The practice nurse

• Primary Care Trust’s may develop Patient Group Directions (PGDs) to enable supply and/or administration by nurses & health visitors. Non-medical prescribers should prescribe treatment rather than use a PGD. Malathion andphenothrin are included in the Commu ranity P ctitioner Nurse PrescribersFormulary and carbaryl may be prescribed by suitably competent nurses and pharmacist independent prescribers. A single treatment is considered as two applica• NB. Two applications is unlicensed use of these products (see BNF) butindicated in the BNF as accepted best practice.

The old practice of rotating insecticides is now out-moded, and a ‘structur

a different in


should be used in preference to aqueous products in the first instance.

• Insectic e sha

Group\Policies and Guidance\Amended policies 2007\Word Documents\Headlice infection in the community.doc FINAL VERSION: 6/11/07 Page 7 of 25

should be used in preference to aqueous products in the first instance.

• Insectic e sha

• In the absence of contra-indications alcohol based products• In the absence of contra-indications alcohol based products

id mpoos are not recommendedid mpoos are not recommended for two reasons:

They are susceptible to consumer abuse. - - Shampoos are diluted too much to be effective

is from the surviving eggs that resistance will appear.

5.1 Sa

- They have low efficiency in killing eggs. It

fety of parasiticidal products and contra-indications

Current recommended products are ones which contain Carbaryl, Dimeticone, Malathion, Permethrin and Phenothrin.

• Parsiticidal products have a good track record of safety and the ones

y only medicines.

safety

• A particular parasiticide should not

selected for use on human beings are among the safest insecticides available.

• Carbaryl based products are available as Prescription only Medicines.

Dimeticone, Malathion and Phenothrin are Pharmac

• The dose levels contained in a single treatment are well within the margins put forward by international organisations.

be used more than once a week for

• The solvents used do not readily permit absorption through human

• Preparations with an alcohol base are contra-indicated for people

• Dimeticone is a product, with no conventional insecticide activity. It is a clear (two

• Dimeticone is a product which coats head lice and interferes with water

gainst

• Head lice parasiticidal treatments should only be used in children

currently exists to contra-indicate the use of head lice

three weeks at a time (see the current advice in the British National Formulary).

skin. Aqueous formulations are less likely to encourage transdermal absorption of the insecticide

with scalp severe eczema, asthma and should not be used in very young children.

• A randomised controlled equivalence trial (Burgess et al, 2005) has identified

the use of Dimeticone 4% as a successful treatment for head lice infection.

odourless fluid and is applied in the same way as other head lice lotionsapplications one week apart).

balance in lice by preventing the excretion of water. It is less active a eggs than other parasiticidals.

under the age of six months with medical supervision.

• No evidence


parasiticidal treatments in pregnancy, but as with all medicines these products should be used with caution. Use of an aqueous based liquid is advised.

• Care must be taken when using alcohol based lotions. They must be used

room, well away from sources of flame and heat such as res, stoves, cigarettes and hair dryers.

the

(permethrin and phenothrin) are

contra-indicated in persons with an allergy to chrysanthemum

5.2 esistance to parasiticides

in a well-ventilated fi

• Care should also be taken to prevent lotion/liquid from running over face into the eyes.

• Pyrethroid based preparations

flowers, as these flowers contain a natural pyrethroid insecticide.

R

health care professionals, the

mended products?

d treatment 7 days after the initial treatment applied? atment used (minimum of

ontacts identified and appropriately treated at the

If resistance to parasiticides are reported tofollowing issues need to be discussed with the patient/parent.

a. Was the product one of the recomb. Was the product applied properly? c. Was a second. Was sufficient quantity of insecticide tre

50mls per head per application)? e. Were household c

same time? f. Was contact tracing undertaken properly? g. Is this a re-infection from an untreated contact? - are they adult or

If true resistance is suspected by the health professional then lice can be sent

to the Insect Research and Development Centre in ertfordshire. A copy of the protocol (dated February 2005) can be obtained

mixed stage lice? h. Have living, moving lice been seen or is the report based upon

symptoms such itching? - query a scalp irritation or psychogenic itch?

for resistance testing Hat www.insectresearch.com

5.3 Mousse

There is currenthe treatment of head

tly only one mousse product (Full Marks Mousse) available for lice in the UK. This product is not recommended for the

. Treatment

treatment of head lice infection in the British National Formulary.

6

The importance of compliance with the chosen treatment regimen cannot be

.1 Diagnosis and treatment

emphasised enough, if a successful outcome is to be achieved.

6

• To diagnose head lice infection you must see a living moving louse

(please see Appendix 1).


rolonged head to head contact (e.g. grandparents, childminders) so that they can check their

• Only treat those with living, moving lice present.

r/practice nurse or pharmacist can advise on which lotion to use.

n on

• ust be noted that the information insert for many of the recommended

econd e week after the initial application, is a crucial lement of treatment.

-

• Check the heads of everyone in the household.

• Inform others who may have had very close and p

heads for signs of infection and treat appropriately.

• The GP/school nurse/health visito

• Apply the lotion carefully following the manufacture's instructio

the information sheet in the pack.

It m products do not state that a second application is required. The

s application one

The initial application will kill off the living, moving lice but will not kill all of the eggs.

ce ut are still

to immature to breed themselves).

- It is only by completing the two applications one week apart will the

• Ensure hair is dry before commencing treatment.

e prior to applying the insecticidal treatment.

fficient lotion - at least one small bottle for each

- The second application is required as it kills off the immature li

which have ‘hatched out’ from the remaining viable eggs (b

infection be treated (see current British National Formulary)

• If hair is braided or plaited then this must be undon

• Use su head (50 mls) but

more may be needed for longer / thicker hair.

g care to avoid the eyes e.g. hold a cloth over the eyes.

• Let the lotion dry naturally on the hair - do not use a hair dryer.

• During final shampooing, most dead lice will rinse out. Eggs, however

d out, or left to grow out as the hair grows.

• Apply lotion or liquid, takin

• Make sure all of the hair, particularly the scalp, is thoroughly wetted, then rub the lotion in well.

Alcohol based lotions are flammable and must be kept well away from flames, cigarettes, stoves and other sources of heat.

will remain attached to the hair even when dead. They cause no harm and can be either picked out, combe


• using the

, ask your school nurse/health

• No treated person should go swimming until after the first recommended

nd normal shampooing routines will not affect the efficiency the insecticides.

• A transient itch reaction may occasionally occur when the lotion is first

.2 Treatment with a pre-existing scalp irritation

A second application of lotion must be repeated one week late same method and the same lotion.

• Check all the heads treated a day or two after the second application. If you still find living moving licevisitor/GP/practice nurse or pharmacist for advice.

application time is completed. • Following the treatment, swimming a

applied, but this will soon disappear. 6

ove if the head lice infection is treated.

extremely bad or chronic scalp irritation, such as

. Contact Tracing

• If a person has a mild scalp irritation alongside a head lice infection, then the

condition will normally impr

• If a person has an dermatitis, then advice should be sought from their GP or a referral made to a Consultant Dermatologist.

7

gement of head lice infection and, its importance cannot be over emphasised.

of treatment as it is necessary to treat the likely source of the infection and to prevent re-infection.

• This is an essential element of effective control and mana

• It is also an essential element

• Contact tracing is the responsibility of the family and not the school or school nurse/health advisor.

means telling anyone who has had ‘head to head’

contact with the case for more than one minute (e.g. parents, brothers, school) about

the head lice infection, so they can do detection combing and treat if

• Contact tracing sisters, grandparents, other relatives, friends, playgroup,

necessary.

• A suggested checklist for identifying contacts includes: Mother Cousins Father Close Neighbours Siblings Playmates Grandparents Best Friend(s) Aunts and Uncles Childminders


Cubs/Brownies/Scouts

. Evaluating Treatment

After school clubs

• All contacts with living moving lice should be treated at the same time. This is required to break the ‘chain of infection’. 8

examined ys after

• All persons who have received treatment should have their heads

using a detection comb two or three da completing a course of treatment (two applications of treatment 7 days apart).

een killed.

e e

head lice are resistant to the lotion. These immature lice will be killed

• rue resistance to insecticides is relatively uncommon and is not currently a major problem. True re-infection is usually from close • contact in the community rather than in school, and results from failure

to trace and treat infected contacts.

• Many cases of ‘treatment failure’ are due to either misdiagnosis or inadequate treatment. Nits (empty egg cases) will continue to be found long after the lice have b

• Young lice may be found after the initial application, and before th second application of lotion. This is expected and not a sign that th off by the second application.

T

DETECTION COMBING

NO LICE FOUNDTreatment successful

Regular detection combing tofind any reinfection quickly

LICE FOUND Treatment failure

A few large lice found

Re-infection from acontact likely

Educate about thoroughcontact tracing

Mixed stages of lice found

Either treatment usedincorrectly or resistance

Determine if treatmentwas used correctly.

Educate patients

Re-treat with another product (2 applications, 7 days apart)

Flow chart to show the correct procedure for evaluating treatment after two treatment applications, seven days apart*

*North West (Liverpool) Drug Information Service, July 1998

P:\NW 007\Word Documents\Headlice infection in the community.doc FINAL VERSION: 6/11/07 Page 12 of 25

Policy Group\Policies and Guidance\Amended policies 2

9. Wet Combing (‘Bug Busting’)

• This is uggested as se

a physical (mechanical) method of removing lice

b through the hair in a similar manner to

every three days for a minimum of two weeks - extended by 4 days every time an adult lice is found.

eople who

g’ as

ubt about it ole population

• Kits’ are prescribable on the NHS.

• head lice in the UK (2000)*, identified that malathion was twice as effective.

should not be advocated as the first line of

, Morgan DA, Petrovic M, Comparison of wet combing with malathion for treatment headlice in the UK: a pragmatic randomised trial. The Lancet Vol356 12th Aug 2000)

from th hair.

• The technique involves applying conditioner or oil to the damp hair and usinga plastic detection comb to comdetection combing.

• A treatment session takes approximately 20 -30 minutes and has to be repeated

• Combing works for just over a third of people. So for every 10 p

use combing, only four will be clear of head lice after two weeks (Kmietowitz, 2003).

he efficacy of ‘wet-combin• There is continuing debate around t

treatment for head lice infection. It is time consuming, and while it may work well for individual families, there is do effectiveness as a treatment method for the wh It should be used as an alternative when a parent / patient declines to

use proprietary insecticides or has exceeded the safe use of insecticides (see the current BNF).

‘Bug Buster

A randomised trial comparing wet combing with malathion for treatment of

‘Bug Busting’ or wet combing treatment.

*(Roberts RJ, Cassey Dof

10. Alternative Remedies 10.1 Essential Oils

A number of cosmetic shampoo preparations containing herbs or

ve product licences, and there are little

s being

ate

aromatic oils are being promoted as effective ways to prevent or treat head lice infections.

These preparations do not ha or no efficacy data to support their use.

ived a Although “natural” products such as these are often perce totally safe, concentrated oils such as tea tree oil or lavender oil can be

toxic if used inappropriately.

Recipes for the control of head lice can be found in books and on the internet but, it is difficult to find any scientific papers that demonstr

the effectiveness of essential oils in head lice treatment.


Parents / patients may access information from the internet about ‘wonder’ lice infection. It is important to inform parents / patients not always be legitimate products and will not have

urchasing

products to treat head that these products willhad proper scientific trials to ensure their safety record.

Though health professionals cannot prevent parents / patientsthese products it is important that they do not

p recommend their use.

10.2 lectronic CombsE

These will kill live lice but not eggs, therefore they cannot completely

y eradicate a head lice infection. They should be used on clean, dr hair. They are expensive and general use is not recommended.

10.3 Repellent Sprays

There are a number of commercial products available that claim to be a

fection). These of ingredients

ss se is not

repellent to head lice (they do not treat an active inusually come in a spray form and contain a range including piperonal, tea tree, geranium and rosemary oils. At the present time there is no research evidence to support the effectiveneof these products. They are expensive and their general u recommended.

11. Responsibilities of Parents / Carers

• sh their own and their children’s hair routinely to help identify a head lice infection at the earliest possible stage.

k

hen members of the household ha

• esent).

NEVER

To comb / bru

• To inspect hair for head lice regularly i.e. once a wee

• To inspect hair for lice, especially if head to head contact with an infected ve been named person has occurred, or w

as contacts.

To promptly treat (at the same time) any members of the family who have head lice infection (has living, moving lice pr

• Only use insecticides as treatment when an infection is present - and

• To inform all contacts, both adult and children, to be vigilant for signs of infection, to inspect hair using a detection comb and to treat with head lice lotion if living moving lice are discovered.

r

as a preventive measure.

• To contact the School Nurse / Health Visitor / GP / practice nurse o pharmacist if advice and support is required.


12. Role of the school nurse / school health adviser

12.1 Old Role

• Research h head lice pr

-

-

as shown routine head inspections did little to reduce the oblem. The reasons are:

Lice are taken into school from the community and not the other way round

An effective head inspection requires damp hair and takes approximately 10 – 20 minutes to do – it is not possible to d

ent. o

isturbed and can go unnoticed during routine school inspections. Early light infection will usually not be easily visible to the naked

s.

ith a false curity

this in a school environm- Lice move rapidly when d

- eye and will easily be missed by routine school inspection

- A child who is louse free at the time of inspection can pick up infection later in the day.

- Routine inspections often provide parents/carers w sense of se

12.2 New Role

d lice

ponsibility of the family. School nurses should

rrent

the reception

rofessional assessment of reported head xamine an

been , and

nfidentiality. It must be

• The primary role of the school nurse is to provide education and dren, their families and teachers emphasising that heasupport for chil

ontrol is the resc be pro-active in this role.

• Continuing education should be provided for parents/ca head lice policy, during the child’s induction period into

rers on cu

class. The nurse will discuss and distribute to parents/carers an information leaflet on head lice, ensuring that the information is clearly understood.

• School nurses should be prepared to teach detection combing as required, and to give education on a ‘one to one’ or group basis on the treatment and prevention of head lice infection.

• The school nurse should make a p

louse infection of any child in the school. It may be necessary to eindividual child to make a diagnosis, once parental consent has

vironment if possibleobtained. This should be done in the home enshould be undertaken with sensitivity and coemphasised that this is done with the intention of supporting parents to enable them to continue with examination and treatment as appropriate, and will not replace parental responsibility.

• In the case of proven infection, the n contact tracing etc. This may require

urse will advise on treatment, telephone contact, a home visit or

using another health professional as appropriate.


• Resistant ethe carer/parent of the child to ascertain that treatment is being carried out correctly a t

Role of e

cas s of recurring infection will require that contact be made with

nd o offer further advice and support.

13. th Health Visitor

• As a key member of the Primary Health Care Team, Health Visitors play a vital role in:

- providing current information and education on head lice

treatment is the rents/carers.

ndix 1).

education approach within their eness.

new parents/carers on head lice

prevention. This should be included in discussion during the 18 einforced at the pre-school

stage.

essions and

14.

infection; - emphasising that prevention, detection, and

responsibility of the pa- Prescribing treatment as appropriate

• To provide clients with information, advice and support on detection combing and appropriate treatment when there is confirmed inf(Appe

• To teach clients the technique of detection combing when necessary.

• To pursue a vigorous health localities to raise public awar

• To introduce information to

month screening surveillance, and then r

• Health visitors are health educators and will undertake education s

‘one to one’ or group basis.

Role of the School

14.1 chool Nurse / Health Visitor roleS

ntified in schools, although it is more

as well as

vising pa n s of lice infection. T s parents of new pupils s

14.2 Action to

• Head lice infection is frequently ide common for the spread of lice to occur within the close family setting.

• ducation is the main role of the School Nurse/Health Visitor,Ead re ts/carers on contact tracing in recurring episode

ach year forhi should include a talk at the start of e in chools, nurseries and playgroups etc.

be taken in School

, the • If a member of the school staff suspects that a child has head lice school should ask the parent / carer:

- to assess their child as soon as is practicable;

onfirm (or deny) the diagnosis - to c


ild and undertake contact tracing as outlined in this guidance.

health

• Keep individual reports confidential and encourage your staff to do

14.3

- if confirmed to treat the ch

- if appropriate refer the child to the school nurse / advisor.

• Parents/carers who report cases of lice to the school should be advised to contact the School Nurse for advice and support.

likewise.

Exclusion of children from school

• There is provision under section 521-525 of the 1996 Education Act for ments to have pupils

However,

e management of head lice

ment) se as

). 15. itioner

the local education authority to make arrange inspected, excluded and if necessary, treated for head lice. such measures are extreme and are likely to cause as many problems

cept as they solve. It would be difficult to justify such measures, ex possibly as a last resort in very exceptional circumstances.

• ave a written school policy on thH(guidance issued by the local Primary Care Trust or based on this docu

Nurand ensure the school has access to advice from a School appropriate (see Notes and Guidance for Head Teachers - Appendix 3

Role of the General Pract

nt, eneral

ractitioner (GP) with whom the client is registered, as is advice and

therefore be knowledgeable and competent in the control of head lice, be able to

he primary care team, is convinced that living lice are present on at least one of the scalps of the family.

ith an insecticide is the only effective way to treat head lice infection as it has been clearly demonstrated to be effective,

• GPs (and other primary care prescribers) are encouraged to follow this

• eat only real infections and not the public reaction to perceived local

• Prescribe a lotion/liquid treatment, as appropriate, and not a

• The primary professional responsible for the diagnosis, manageme and treatment of an individual for any disease is the G

P support on disease prevention.

• GPs (or another member of the primary care staff) should

teach parents the technique of detection combing and be prepared to advise on appropriate treatment.

• Treatment should never be advised/prescribed unless the responsible member of t

• Treatment w

and is the treatment of choice when infection is definite.

guidance, by prescribing an appropriate insecticide.

Troutbreaks.

shampoo.

P:\NW Polic mended policies 2007\Word Documents\Headlice infection in the community.doc FINAL VERSION: 6/11/07 Page 17 of 25

• Prescribe in su to kill any resid

• Insecticides must not be used prophylactically as this will not prevent infectio

NOTE: GP Terms of Service require a separate prescription for each patient

ers.

•

ma or other skin conditions.

escribed for patients

y Group\Policies and Guidance\A

fficient quantity to repeat the treatment one week later, ual infection.

n and may encourage resistance.

or family member. This is also required of non-medical prescrib

An aqueous based lotion should be prescribed to treat:

- Patients with severe asthma, ecze- Patients with infection around the eyes e.g. eyebrows, eyelids. - Children under 5 years of age. - Pregnant and lactating women

A non-pyrethriod based lotion should be prwho are allergic to chrysanthemums e.g. Derbac M, Suleo M etc.

• If treatment failure is suspected, for example the presence of adult lice

nda nymphs 24 hours after a properly applied treatment, consideration should be given to prescribing an alternative insecticidal treatment .

6. Role of the community pharmacist1

of advice on the management of head louse infection. They can advise clients on the technique of detection

acists have an especially important role in limiting chemical treatment to true cases of infection, reducing unnecessary and inappropriate treatment

of lice.

• It has been shown that shampoos are less effective than lotions/liquids,

• Pharm s

access to t

• The sale o supervised y only” product.

• Advice should be offered to clients on the use of the product, while

Reg help to

ide In a ithin the household, the whole

fam uld be examined for lice. - Only those with living, moving head lice should be treated

• Pharmacists are an important source

combing and appropriate treatment (Appendix 1).

• Pharm

and thereby reducing the risk of the development of resistant strains

and therefore should not be sold or supplied.

aci ts should be aware of their local PCT policy, and should have he current PCT guidance

r supply of head lice medication should be personally by the pharmacist, since it is classed as a ”Pharmac

emphasising that:

- ular brushing and combing is important and may ntify a head lice infection at an early stage.

- case of confirmed head lice wily and other close contacts sho


Insecticides must not be used prophylactically as this will not

- Each purchase/supply of medication should include a copy of the

•

s. - Children under 5 years of age.

en

• Det ti

16.1 Pharm

prevent infection and may encourage resistance

current head lice leaflet.

An aqueous based lotion should be prescribed to treat:

- Patients with asthma, eczema or other skin conditions. - Patients with infection around the eyes e.g. eyebrows, eyelid

- Pregnant and lactating wom

A non-pyrethroid based lotion should be recommended for patients who are allergic to chrysanthemums.

ec on combs should be kept in stock, and their use promoted.

acy Prescribing Schemes Som P The Primary Care Trust negotiates with the Local Medical Committee to

These schemes have been developed to:

- Fully utilise the expertise and knowledge of community pharmacists in advising and supporting parents / patients in relation to head lice infection;

- To transfer the prescribing of the recommended head lice treatments (except Carbaryl) from busy GP practices to community pharmacists; To provide parents / patients with improved access to treatments, advice and support;

- To enhance the services provided by local pharmacies to their local population.

In areas where the schemes have been introduced patients, local GPs and the participating pharmacists have viewed them very positively.

e rimary Care Trusts have developed Pharmacy Prescribing Schemes.

transfer responsibility for head lice prescribing to community pharmacists.


17. References / Bibliography Aston R, et al (2000), Head Lice: a report for Consultants in Communicable Disease Control (CCDCs), British National Formulary, March 2007, No.53, BMJ Publishing Group, London.

ntrol, Annu. Rev. Entomology,

se infestation

e degree ns

stigation, Vol.18 No.2, Pgs 105-115

lth

Burgess I F, Human lice and their coVol.49, Pgs 457-81 Burgess I F, Brown C M, Lee P N (2005) Treatment of head louwith 4% dimeticone lotion: randomised controlled equivalence trail, BMJ, Vol.330, 18th June 2005. De Berker D and Sinclair R (2000), Getting ahead of head lice, Australian Journal of Dermatology, Vol.41, Pgs 209-212. Dennis G A and Lee P N (1999), A Phase 1 Volunteer Study to establish thof absorption and effect on cholinesterase activity of four head lice preparatiocontaining malathion, Clinical Drug Inve Health Protection Agency, Head lice, Fact sheet for schools – Wired for Heawww.hpa.org.uk/topicsa_z/headlice Kmietowicz Z (2003), Commentary: Information for patients: removal of lice a

nd eggs by combing, BMJ, Vol.326 Clinical Review, Pg.1258.

mMenegaux F, Baruchel A, Bertrand Y et al (2006), Household exposure to pesticides

, OEM online, and risk of childhood acute leukaemia http://oem.bmjjournals.co

ational Prescribing Centre (1999), Management of head louse infection, rescribing Nurse Bulletin, Vol.10 No.5

orth West (Liverpool) Drug Information Service (1998), The Drug treatment of head lice,

oberts RJ, Cassey D, Morgan DA, Petrovic M, Comparison of wet combing with domised trial.

he Lancet, Vol.356, 12 Aug 2000.

e for Head lice Infection, r Stephen Woods, Prescribing Development Adviser, Salford PCT, March 2005.

eal L (2005), The potential effectiveness of essential oils as a treatment for head ifery.

Nash B (2003), Extracts from ‘Best treatments’ Treating head lice, BMJ, Vol.326 Clinical Review, Pgs 1256-57 National Prescribing Centre (1999), Management of head louse infection, Prescribing Nurse Bulletin, Vol.1 No.4. NP N

Drug Information Letter No.115, July 1998. Rmalathion for treatment of head lice in the UK: a pragmatic ran

thT Salford Primary Care Trust, Pharmacy Prescribing SchemM Vlice, Pediculus humanus capitis, Complementary Therapies in Nursing & Midw


With special thanks for their advice with this document to:

Ms Kate Brierley, Senior Health Protection Nurse, C&L HPU Mrs Christine Brown, Entomology Nurse Consultant, Insect Research & Development Limited, Hertfordshire. Dr Ian Burgess, Deputy Director, The Medical Entomology Centre, Cambridge. Ms Dianne Hogg, Non-medical Prescribing Fa litator, East Lancashire PCT. Mr Peter Morgan, Senior Health Protection Practitioner, GM HPU Mr Stephen Wood, Senior Prescribing Advisor, Salford Primary Care Trust.

ci


Appendix 1

HAVE YOU GOT HEAD LICE?

Detection Combing - How to do it

• You need warm water/towel/ordinary comb/detection comb/cocktail piece of kitchen tissue or toilet paper/good light.

stick/

Daylight is best.

detection comb

• Wet the hair well, then towel dry it. The hair should be damp, not dripping.

• Make sure there is good light.

• Comb the hair through with an ordinary comb so it is tangle-free.

• Start with the teeth of the touching the skin of the scalp at

remove them with a cocktail stick, or your nail, wiping them onto a piece of

• Head lice are little insects . They are often not much

bigger than a pin-head, but a sesame seed (the seeds on

• When finished clean the comb under the tap. A nailbrush will help to do

itor, GP Notes:

the top of the head. Draw the comb carefully towards the edge of the hair.

• Look carefully at the teeth of the comb in good light.

• Do this over and over again from the top of the head to the edge of the hair in all directions, working round the head.

• It takes approximately 10-20 minutes to do it properly for each head.

• If there are lice, you will find one or more lice on the teeth of the comb –

kitchen tissue or toilet paper.

• It may help to rub a small amount of conditioner into the hair. If you do, you will need to wipe it off the comb with tissue paper after each strokeand look for lice.

with moving legsmay be as big as

burger buns).

this.

• If you find something and are not sure what it is, stick it on a piece of paper with clear sticky tape and show it to your School Nurse, Health Vis

st, school nurse, health visitor, GP or practice nurse.

- You can buy a detection comb from the Pharmacist. - If you need help and advice, ask your local pharmaci

- Do not use head lice lotions unless you are sure that you have found a living, moving louse.Appendix 2


Appendix 2

NOTES AND GUIDANCE FOR PRIMARY CARE PROFESSIONALS

• Do not diagnose head louse infection unless you yourself have found a living moving louse, or have physical evidence from the parents; ask the parents to stick one of the lice on a piece of paper with clear sticky tape, and bring it to you or to another health primary care professional.

• Do not recommend treatment unless a louse has been cle

arly identified

ssume that “re-infections” or “treatment failures” are truly

atment without first of all establishing that moving lice are still o applications of lotion seven

days apart, and after a ful ssessment as to the ways in which the family may not have complied with the first attempt.

• Do resist the temptation to agree with the parents’ suggestion that a first

course of treatment has failed, that “it must be a resistant strain” and that a further course of treatment should be given. This may be an easier approach in a busy schedule, but it is not in the best interests of the family. There is no substitute for a proper professional assessment.

• Do not recommend or support any mass action, including wet combing

campaigns.

• Do not support the use s, repellent sprays, essential oils or chemical agents not s d for the treatment of head louse infections.

• School Nurses should recommend that head teachers do not send out

“alert letters” to other parents.

(as described above). If you do recommend treatment, ensure that this is done adequately for the case and for infected contacts.

• Do make every effort to discourage unnecessary or inappropriate

treatment with insecticides.

• Do not ainfections. Make sure that a louse is found or produced.

ot ever recommend re-tre• Do n

living, present after twl professional a

of electronic combpecifically license


Appendix 3

NOTES AND GUIDANCE FOR HEAD TEACHERS General Head louse infection is not primarily a problem of scho• ols but of the wider

ission of lice within the classroom is relatively rare. When it does occur, it

le, informed

a e

Specific

community. It cannot be solved by the school, but the school can help the local community to deal with it.

Head lice are transmitted by direct and prolonged head to head contact. •

Transm•

is usually from a ‘best friend’. Head lice will not be eradicated in the foreseeable future, but a sensib•

approach, based on fact not mythology, will help to limit the problem. • At any one time, most schools will have a few children who have active head lice

infection. This is often between 0% and 5%, rarely more. • The perception by parents/carers and staff, however, is often that there is

serious ‘outbreak’ with many of the children infected. This is hardly ever thcase.

• The ‘outbreak’ is often an outbreak of agitation and alarm, not a louse infection; a societal problem not a public health problem. • “Blitzing” a school after several cases of head lice have occurred is not effective

as a method of prevention and control of head lice. Success is more likely to be achieved by a consistent and thorough approach, as outlined in these guidelines.

• Do have a written protocol on the management of head louse problem, based on

the guidance issued by the local Primary Care Trust or on this policy. • Do make sure that the School Nurse is informed in confidence of cases of head

louse infection reported to you. The nurse will assess the individual report and may decide to make confidential contact with the parents/carers to offer information, advice and support.

• Do keep individual reports confidential, and encourage your staff to do likewise. • Do collaborate with your School Nurse in providing educational information to your

parents/carers and children about head lice, but do not wait until there is a perceived ‘outbreak’. Send out information on a regular basis, preferably as part of a package with other issues.

• Do consider asking your School Nurse to arrange a talk to parents/carers at the

school if they are very concerned. Be present yourself and encourage your staff


• to attend; they are just as likely to be just as misinformed about head lice as the parents/carers. You may prefer to arrange a separate talk for the staff.

• Do ensure, with the School Nurse, that your parents/carers are given regular

reliable information. This should include:

- Instructions on proper diagnosis by detection combing. - The avoidance of unnecessary or inappropriate treatments. - The thorough and adequate treatment of definitely confirmed infections using an

insecticide lotion.

• Do advise concerned parents to seek the professional advice of the School Nurse, the GP, or the local pharmacist.

• Do not send out ‘alert letters’ to other parents/carers. • Do not exclude children who have, or are thought to have head lice. • Do not organise wet combing campaigns such as ‘Bug Busting’. • Do not agree with angry parents/carers that routine head inspections should be

re-introduced. They were never effective. • Do not refer parents/carers directly to the Consultant in Communicable Disease

Control. The appropriate clinical advisors are the School Nurse, the local Pharmacist, the Health Visitor and the General Practitioner.

• Do not take, or support, actions simply ‘to be seen to be doing something’ (such

as sending out alert letters or organising Bug Busting campaigns).

p\Policies and Guidance\Amended policies 2 cuments\Headlice infection in the community.doc FINAL VERSION: 6/11/07 Page 25 of 25

ments\Headlice infection in the community.doc FINAL VERSION: 6/11/07 Page 25 of 25

007\Word Do

L I C E D E T E C T I O N L I C E D E T E C T I O N Live louse on the head

• Comb the hair through witha normal comb first, to getrid of any knots.

• With a fine tooth detection comb(“nit comb”), starting from the rootsof the hairs, draw the combcarefully along the complete lengthof the hair.

• After each stroke check the comb

for lice and wipe it clean

• Work systematically around thewhole head of hair.

• Do this for several minutes. Ittakes 10 to 20 minutes to do itproperly for each head.

• If there are head lice, you willfind one or more lice on the teethof the comb.

• If you see emptycases stuck on thehair it does notmean that theperson has lice.

Size of egg casingcompared with a pinhead

• Head lice are little insects with moving legs. They are not much bigger than a pinhead, but may be as big as a sesame seed.

• Remove any lice from the

comb with a cocktail stick or finger nail onto kitchen or toilet paper.

• Clean the comb under the

tap when finished. • If you find something and

are not sure what it is; stick it on the square below with clear sticky tape and show it to your Pharmacist, School Nurse or Doctor

• Do not treat unless youare sure that you havefound a living movinglouse.

• Wash the hair well and towel dry.The hair should be damp notdripping.

• If required apply a small amount ofconditioner, including the full lengthof long hair.

• Make sure there is good light.Daylight is best.

It is probably worth checking your child for head lice weekly. The best

way to check on the presence of lice, if you are not sure is to use the

following regime:

P:\NW Policy Grou