Aug. 24, 2000 -- The start of the school year can mean more than just back-to-school shopping trips and first-day-of-class jitters; for many children, it also means creepy, crawly head lice. Even hearing the words makes most people wrinkle their noses in disgust. But are the strict measures taken against head lice -- such as the so-called "No Nits" policy that bars children with even one louse egg from attending school -- warranted, or are they overkill?
For one scientist from the Harvard School of Public Health, society has definitely gone overboard, overdiagnosing, overtreating, and overworrying about a minor nuisance that doesn't even qualify as a public health issue.
"We are dealing with head lice: They don't cause disease, they don't transmit anything, and we think they are much less contagious than people believe," says Richard Pollack, PhD, an instructor of immunology and infectious diseases.
Pollack and his team of researchers recently published a study in the Pediatric Infectious Disease Journal that showed that in about 40% of cases, head lice are incorrectly diagnosed, leading to unnecessary treatments and unnecessary absences from school.
Pollack invited people who visited a web site that provides information on head lice to submit specimens of items that they considered to be lice or nits. The researchers examined the samples under a microscope within two days of receiving them. Each sample was identified by the species of louse and its life stage (egg, nymph, or adult). A person was considered infected if their sample included at least one adult or nymph louse, or a louse egg capable of hatching.
The researchers received more than 600 samples, each containing from one to 100 or more objects. Lice or their eggs were found in 60% of the samples; other critters, such as beetles, mites, and bedbugs, were found in 5%. The rest contained other debris, including dandruff, scabs, fibers, dirt, and knotted hair.
Slightly more than half of the samples that actually did contain lice or nits had a living louse or egg capable of hatching (indicating an active infestation); the other half were either hatched eggs or dead eggs.
Pollack tells WebMD that almost everyone who submitted a sample believed they had active lice and were using treatments on themselves and their children. "Many of these children had been recently excluded from school," he says.
"We found, interestingly, that if you don't have lice, you are just as likely to use one or multiple over-the- counter [lice treatments] than if you do have lice," says Pollack.
Pollack and his colleagues also found that parents, school nurses, and teachers were the most accurate at spotting lice -- but failed to distinguish active from inactive cases just as often. Surprisingly, only 12% of the samples sent in by physicians contained active lice.
Pollack says he doesn't believe the "No Nits" policy is a good one because even a dead egg is seen as a bad egg and is enough to keep a child out of school. And treatment, he says, should be reserved only for cases of confirmed, active infestation.
"What I am saying is this: These things do not generally cause disease ... therefore, it is not a medical issue, it is not a public-health issue. Why are we invoking health policy if it is not a health issue?" he asks. "My view is a very unpopular one."
Pollack is certainly right about that. Deborah Z. Altschuler tells WebMD, "Yes, parents need help; yes, they don't always know what they are looking for; yes, they sometimes do the wrong thing. But no, they don't want kids to keep lice." Altschuler is the president of the National Pediculosis Association, a nonprofit organization that educates parents and others about head lice.
"I can appreciate what [Pollack] has to say," Carol Steltenkamp, MD, tells WebMD. "But both from a physician standpoint and as well as a mother of school-aged children, I think his suggestions are not reasonable " Steltenkamp is an assistant professor of pediatrics and the associate chief of staff at the University of Kentucky Medical Center.
"Medically this is not a problem, my physician mind tells me," Steltenkamp says. "But when my child got it, my mother mind freaked out. I knew that it was OK and nobody was going to die or get a horrible disease, but it was nasty!"
Family practitioner and Emory University instructor David Clifford, MD, agrees that there is much unwarranted hysteria over head lice. "But it is aggravating and the patient feels dirty," he says.
Both Clifford and Steltenkamp agree with Pollack that we probably overtreat head lice, but neither can see a way around it.
"If you are not going to treat them and you are going to send them to school, you'll have 20 more patients next week," says Clifford. "The bottom line is, you just have to treat it -- you can't always tell [if the case is active]. The eggs can be dead and it can take a while for the nits to disappear, but that is why it is important that you rinse the hair properly, that you use the comb. "