The Toronto District School Board has begun the process of reconsidering its strict policy on requiring children with head lice to remain home from school.
The Toronto District School Board ("TDSB") has begun the process of reconsidering its strict policy on requiring children with head lice to remain home from school.1 TDSB spokesperson Ryan Bird described the reconsideration process as geared towards inclusion in the classroom:
"I think that many people believe that as long as it's being treated, that shouldn't be a barrier to come to school for days at a time."
Commonly known as "no nit" policies, the strict exclusion of children with head lice from classes has been adopted by numerous schools throughout Canada, Australia and the United States. Such policies maintain strict caution against the spread of lice – requiring children found with traces of live head lice or lice eggs in their hair to remain at home until their scalps are completely lice-free.2 In many cases, children are sent home regardless of whether they are found with one louse or many, and regardless of whether the lice are viable or not. Even a single "nit" amounting to an empty egg casing with no live louse and presenting no possibility of transmission may result in a child being sent home from school. Depending on the course of treatment, the resulting exclusion from school usually ranges between 2 and 14 days.3 Up until 2006, health authorities in both Canada and the United States recommended such policies as a best practice among school boards.4
However, these recommendations have recently changed. This change has created a disparity in school boards' policies towards addressing lice infections – with some school boards continuing to maintain a strict "no nits" approach and others adopting more relaxed approaches.
A Similar Debate is Taking Place in the United States
As of 2004, approximately 60 percent of schools in the United States reported having adopted strict "no nit" policies.5
Research on the costs of maintaining such "no nit" policies in the United States has nevertheless challenged their value. One group of researchers estimated that parents missed an average of five working days when a child was sent home to be treated for lice. This resulted in lost wages of up to $2,720.00 per family per active infestation,6 and a total annual loss of approximately $6 billion in earnings across the United States.7 At the same time, children in the United States lost an estimated 12 to 24 million school days and,8 as a result, schools lost $280 to $325 million in funding due to absences attributable to head lice.9
For many Americans, however, these costs are unquestionably worthwhile — particularly when considered against the costs that would result from lice transmission becoming more common in classrooms. Parents who have endured the distress and effort involved in meticulously removing lice from children's hair and fabrics have attested to the importance of taking all possible measures to ensure that such experiences are avoided.10
Critics of "no nits" policies have nevertheless countered that simple treatment by insecticide shampoos and acid vinegar for the weeks after contamination is sufficient to remove lice from most children with minimal distress.11 However, Deborah Z. Altschuler, president of the United States National Pediculosis Association, states that policies allowing children with lice to attend classes give rise to a lack of vigilance on the part of parents and an overreliance on treatment by pesticides that may, in themselves, place children in further jeopardy.12 The Canadian Paediatric Society confirms that although commonly-used insecticides "have favourable safety profiles," stronger second-line insecticides such as Lindane have potential for neurotoxicity and bone marrow suppression.13
Changed Recommendations From The Medical Community In Canada
Following updates to international guidelines for the control of head lice infections in 2007,14 the Canadian Paediatric Society (CPS) adopted a revised position statement that favoured the inclusion of students with head lice in classrooms.15The most recent version of the CPS position statement sets out the basics of head lice infestations and transmission as follows:
An infestation with lice is called pediculosis, and usually involves less than 10 live lice. Itching occurs if the individual becomes sensitized to antigenic components of louse saliva that is injected as the louse feeds. On the first infestation, sensitization commonly takes four to six weeks. However, some individuals remain asymptomatic and never itch. In cases with heavy infestations, secondary bacterial infection of the excoriated scalp may occur. Unlike body lice, head lice are not vectors for other diseases.
Transmission of head lice
Head lice are spread mainly through direct head-to-head (hair-to-hair) contact. Lice do not hop or fly, but can crawl at a rapid rate (23 cm/min under natural conditions). There continues to be controversy about the role fomites play in transmission. Two studies from Australia suggest that in the home, pillowcases present only a small risk, and in the classroom, the carpets pose no risk. Pets are not vectors for human head lice.
Based on its assessment of the limited potential for head lice to spread between children in classrooms or to cause serious adverse side effects, the CPS adopts the view that schools' "no nit" policies do not have a basis in medicine:
Exclusion from school and daycare due to the detection of the presence of 'nits' does not have sound medical rationale. Even the detection of active head lice should not lead to the exclusion of the affected child. Treatment should be recommended and close head-to-head contact should be discouraged pending treatment. The American Academy of Pediatrics and the Public Health Medicine Environmental Group in the United Kingdom also discourage 'no nit' school policies.
Families of children in the classroom where a case of active head lice has been detected should be alerted that an active infestation has been noted, and informed about the diagnosis, misdiagnosis and management of head lice, and the lack of risk for serious disease. [emphasis added]
Similar positions have been adopted by the United States' Centre for Disease Control, and National Association of School Nurses.16
Responses From Community Stakeholders
Like their American counterparts, Canadians who support strict “no nit” policies have cited concerns over the potential for lice to spread in the classroom, and the resulting stress and lost work time for parents who are then required to treat their children and prevent the further spread of lice in their homes.
The Hastings and Prince Edward District School Board's recent revision of its formerly strict "no nits" policy received a "furious" response from some of the parents in its community.17 A Facebook page launched to protest the change of policy received the support of nearly 400 individuals who signed up as members over the course of a single weekend. In an interview with The Globe and Mail, the parent who launched the page stated, "now our children who don't have head lice are now prone to it on a daily basis... it's like our kids' rights have been taken away from them."18 As The Globe and Mail highlighted, however, not all parents who joined the online Facebook discussion shared a common point of view on the necessity of strict "no nits" policies. The disagreement is evident in the following two postings:
"This is ridiculous! Send them to school so they can give it to all the other students!"
"I am outraged!!! I have been through this x 5 and wasted an entire summer picking nits and had to cut all my girls hair off short...nuisance my ass!"
Faced with such competing views, school boards have been left to determine the appropriate policy measures to balance medical recommendations against many parents' voiced concerns and lived experiences.
The Differing Approaches of School Boards Across Canada
Across Canada, a single, consistent policy approach for addressing head lice remains elusive, as different school boards continue to adopt different approaches to striking the balance between the views of medical professionals and their community stakeholders. While most school boards continue to maintain some form of a "no nits" policy, the strictness of enforcement varies. On the strict end of the spectrum, the Simcoe County District School Board requires children with head lice to be removed from school and, before the child may return, parents must to sign a form confirming that recommended head lice treatments have been completed.19 Toward the opposite end of the spectrum, Vancouver public school boards notify parents when lice or nits are spotted in the classroom but do not otherwise require students to be kept out of school.20 Closer to the center of the spectrum, school boards in Calgary and Halifax encourage parents to remove their children from classes but do not expressly require them to do so.21
The possibility that Canada's largest school board may relax its own "no nits" policy may serve to significantly shift the balance in this spectrum of approaches.
Considerations For Striking An Appropriate Balance
In developing a balanced approach to policies addressing head lice in the classroom, the minimization of harm is key. The challenge for school boards is to strike a balance that assigns appropriate weight to sorts of harms that concern the medical community as against the sorts of harms that concern their community stakeholders.
An entry point in this respect may be both communities' shared concern over ensuring against (i) unnecessary harm to the health of children; and (ii) unnecessary time away from school.
These shared concerns may be best reflected in head lice policies designed to avoid misdiagnosis and overdiagnosis of head lice infections. As stated by Sciscione:22
Misdiagnosis of head lice infestation occurs frequently and causes inappropriate exclusion from school and unnecessary treatment with pediculicides [i.e., insecticides].
Indeed, research cited by Kosta Mumcuoglu estimates that, in the United States, 4.2 to 8.3 million children are unnecessarily sent home each year to be treated for lice infections that they do not have. Such uninfected children are just as likely as infected children to be treated with strong insecticides.23 In Canada, the CPS policy statement similarly cites concerns over research finding that head lice is frequently overdiagnosed and misdiagnosed when the strict application of "no nits" policies are not matched with investment in necessary resources for ensuring that lice infections are accurately diagnosed.24
One solution to these concerns is to provide training that enables school staff to take proper care in determining whether a child is truly infected with live lice that may be passed on to others. The United States' National Pediculosis Association, while supporting policies to send children with lice home from school, also supports prevention efforts to ensure that such outcomes are as rare as possible. Included among these prevention efforts is a "comprehensive" policy of continuous community education to ensure that parents and others play a role in detecting lice and minimizing the risk of infections in the first place.25 As described by Deborah Altschuler, such education ensures against the sort of complacency that may adversely impact on children who experience its consequences:
The mentality that head lice are only a nuisance keeps children unnecessarily vulnerable and chronically infested.
While medical professionals and community stakeholders have differed in the weight they attach to different harms arising from the application of "no nits" policies, all sides agree that the safety and well-being of children must be paramount in any policy addressing head lice in the classroom.
1 Alison Auld (Jan 13, 2016) "Toronto school board's plan to review head lice policy sparks debate" The Globe and Mail [Globe and Mail].
2 Kosta Y Mumcuoglu, Terri A Meinking, Craig N Burkhart and Craig G Burkhart, "Head Louse Infections: the "no nit" policy and its consequences" (2006) 45 International J Dermatology 891 [Mumcuoglu].
3 JH Price JH, CN Burkhart CN, CG Burkhart CG, et al. "School nurses' perceptions of and experiences with head lice." (1999) 69 J Sch Health 153.
5 Patricia Sciscione, "No-Nit Policies in Schools: Time for Change" (2007) 23 J Sch Nursing 13 at 16 [Sciscione].
6 S Gordon “Shared vulnerability: A theory of caring for children with persistent head lice” (2007) 23 J Sch Nursing 283 [Gordon].
7 Mumcuoglu, supra at 893.
8 Sciscione, supra at 13.
9 Gordon, supra.
10 For example, see Tamara Flannagan, "Send Students With Lice Home Before it Gets out of Control" (October 15, 2015)New York Times.
11 Mumcuoglu, supra at 894.
12 Deborah Z. Altschuler, "No Nits or Lice, No Chemicals, No Excuses" (October 15, 2015) New York Times [Altschuler].
13 CPS Policy Statement, supra.
14 "Pediculosis Management in the School Setting," National Association of School Nurses Position Statement (Revised 2017)
15 J Finlay, NE MacDonald; Canadian Paediatric Society (CPS), " Head Lice Infestations: A Clinical Update" (Originally issued in 2008, reaffirmed in February 2016).
16 Centers for Disease Control and Prevention, Head lice information for schools (2010); " Pediculosis Management in the School Setting;" National Association of School Nurses Position Statement (Revised 2017).
17 Luke Hendry (January 12, 2016) " Parents furious over head lice decision" The Belleville Intelligencer.
18 The Globe and Mail, supra.
19 Cheryl Browne, "Debate brewing is students suffering from head lice should be nit-free when they return to class," (January 14, 2016) Barrie Examiner.
20 Hannah Hoag (April 11, 2015) "The new lice wars" Macleans; See also The Globe and Mail, supra.
21 The Globe and Mail, supra.
22 Sciscione, supra at 16.
23 Mumcuoglu, supra at 893.
24 CPS Policy Statement, supra.
25 Altschuler, supra.