Stafford report on head lice

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See also head lice article.

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Contents

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Extracts from the Stafford Document

The "Stafford Group" of the Public Health Medicine Environment Group published detailed information on the control of head lice in 1988. A 2008 update is now available.[1] The full report, "Head Lice: a report for Consultants in Communicable Disease Control" is available here, or (with other editions) via the PHMEG website (follow "PHMEG documents (guidance, policy, consultation)" and "Head lice guidance (Stafford document)" links).

The remaining text in this article is taken directly (and with permission), unedited except for text in square brackets, from the 1998 version of the Stafford Group document.

Main points

  • Schools must remember that most lice are caught in the family and the local community, not in the classroom.
  • "Nitty Norah" head checks will not help, but the School Nurse can advise and support parents¬/carers to check their own families.
  • "Alert" letters should not be sent out. These can cause an “outbreak” of imaginary lice.
  • Children who may have lice should not be excluded from school; if they do have lice, they will probably have been there for weeks already. The School Nurse can help the parents/carers to make sure whether there really are lice there, and how to get rid of them if they are.
  • The school should give information on lice for parents/carers and staff including regular detection combing and how to do it. This should be on a regular basis, not just when there is thought to be an "outbreak", and should be done with the School Nurses.
  • Talks for parents/carers by the School Nurse can be helpful.

Notes and guidance for school nurses

(Or other responsible school health officer)

General

  • Please read [this] Statement carefully. It is your professional duty to ensure that you are fully informed and up to date with current scientific knowledge and practice.
  • Health professionals should make sure that they are able to identify a louse at all stages of its development. It helps to have a magnifying glass to hand.
  • Parents¬/carers and staff should be made aware that head lice are only transmitted by direct, prolonged, head-to-head contact.

Specific

  • Do not undertake routine head inspections as a screening procedure. Detection combing should be done by parents/carers, but it is important that you give them proper information, advice and support. This should be in accordance with the Statement.
  • Do especially always adhere to the following principles of control:
  • definite diagnosis; a living, moving louse found by detection combing
  • listing and examination of contacts by the family
  • simultaneous thorough and adequate treatment of all cases
  • repeat of the treatment after seven days
  • Do make a professional assessment of reported cases of head louse infection of any child in the school. If the report is from the child’s parent, make sure that the parents/carers are provided with information, advice and support. If the report is from a teacher, for example that the child is scratching continuously or that a moving louse has been seen on the head, it may be necessary to examine the child to establish a diagnosis. If your knowledge of the parents/carers is good, it may be sufficient to make contact with them to ensure that they know how to undertake detection combing and what to do if there are head lice present.
  • Do not diagnose head louse infection unless you yourself have found a living, moving louse, or you have physical evidence from the parents/carers; ask them to stick one of the lice on a piece of paper with clear sticky tape and bring it in to you or one of their other health advisors.
  • Do not recommend the head teacher to send out "alert letters" to other parents/carers. In fact, encouragement should be given not to do so.
  • Do yourself understand and teach your families and school staff that the correct use of insecticidal lotions is the scientifically confirmed way to treat head louse infections.
  • Do not ever recommend treatment unless a louse has been clearly identified (as described above). If you do recommend treatment, ensure that it is done adequately for the case and infected contacts.
  • Do make every effort to discourage unnecessary or inappropriate treatment with insecticides.
  • Do not assume that "reinfections" or "treatment failures" are truly infections. Make sure that a louse is found or produced.
  • Do not ever recommend retreatment without first of all establishing that living, moving lice are still present after two applications of lotion seven days apart and after a full professional assessment as to the ways in which the family may not have complied carefully with the first attempt.
  • Do resist the temptation to agree with parents’/carers’ suggestions 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 is not in the best interests of the family. There is no substitute for a proper professional assessment.
  • Do be prepared to do a domiciliary visit if that is the most tactful and effective way of dealing with a family problem, especially for a "problem family". You have the professional skills and training to educate, persuade, inform, guide and support them.
  • Do not recommend or support any mass action, including wet combing campaigns.
  • Do not support the use of electronic combs, repellent sprays, or chemical agents not specifically licensed for the treatment of head louse infections.
  • Do play an active part in providing regular accurate information about head lice to parents/carers and staff. This should be done in conjunction with your local Consultant in Communicable Disease Control and the head teacher, and should preferably be integrated into a package along with information on other health issues.
  • Do not wait until there is a perceived major outbreak and corresponding agitation in the school. A regular educational programme rather than a reactive "campaign" is more sensible.

Notes and guidance for head teachers

General

  • Please read [this] Statement carefully. You may worsen the problem in your school if you are under the same misapprehensions as many of your parents/carers.
  • Head louse infection is not primarily a problem of schools but of the wider community. The school cannot solve it, but the school can help the local community to deal with it.
  • Head lice are only transmitted by direct, prolonged, head-to-head contact.
  • Transmission of lice within the classroom is relatively rare. When it does occur, it is usually from a "best friend".
  • Head lice will not be eradicated in the foreseeable future, but a sensible, informed 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 infection with head lice. This is often between 0% and 5%, rarely more.
  • The perception by parents/carers and staff, however, is often that there is a serious outbreak with many of the children infected. This is hardly ever the case.
  • The "outbreak" is often an outbreak of agitation and alarm, not of louse infection. A societal problem not a public health problem.

Specific

  • Do have a written protocol on the management of the head louse problem, based on the Statement and this Appendix. If possible, agree a protocol for your area in consultation with the Local Education Authority, the local Consultant in Communicable Disease Control, Infection Control Nurses, the School Nurses, and, if appropriate, your colleagues in other schools.
  • Do make sure that your school nurse is informed in confidence of cases of head louse infection. The school 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 dealing 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 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, including instructions on proper diagnosis by detection combing, the avoidance of unnecessary or inappropriate treatments, and the thorough and adequate treatment of definitely confirmed infections and their contacts using an insecticidal lotion.
  • Do advise concerned parents/carers to seek the professional advice of the school nurse, the family practice, or the local pharmacist.

Key points for head teachers

  • Do not send out an “alert letter” to other parents/carers.
  • Do not exclude children who have, or are thought to have, head lice.
  • Do not recommend or support any mass action, including wet combing campaigns.
  • Do not agree with angry parents/carers that routine head inspections should be reintroduced. 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").

Have you got head lice? notes for families

Detection combing: how to do it

You need:

plastic detection comb (from the chemist)
good lighting
ordinary comb
  • Wash the hair well, then dry it with a towel. The hair should be damp, not dripping.
  • Make sure there is good light. Daylight is best.
  • Comb the hair with an ordinary comb.
  • Start with the teeth of the detection comb touching the skin of the scalp at 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.
  • Do this for several minutes. It takes 10 to 15 minutes to do it properly for each head.
  • If there are head lice, you will find one or more lice on the teeth of the comb.
  • Head lice are little insects with moving legs. They are often not much bigger than a pin head, but may be as big as a sesame seed (the seeds on burger buns).
  • Clean the comb under the tap. A nail brush helps to do this.
  • If you find something and aren’t sure what it is, stick it on a piece of paper with clear sticky tape and show it to your school nurse or family doctor. There can be other things in the hair which are not lice.

Notes

  • You can buy a plastic detection comb from the chemist.
  • If you need help and advice, ask your local chemist, health visitor, school nurse, or family doctor.
  • Don’t treat unless you are sure that you have found a living, moving louse

References