School nurses' perceptions of and experiences with head lice

International recommendations for an effective control of head louse infestations

Head louse infestations continue to be a concern of public health in most countries, including the most developed ones. The present recommendations are intended to inform and stress the role and impact of the different authorities, institutions, industry, and the public in the control of head lice in order to reduce the prevalence of this parasite. We encourage health authorities to pursue more effective methods to correctly identify such infestations, and evaluate existing and new pediculicides, medical devices, louse repellents, and louse- and nit-removal remedies. Pediculicides and medical devices must have verifiable claims in the instructions for use and should be tested periodically to document current levels of resistance by lice to the active ingredients and to the formulated products. Where the prevalence of lice is claimed to be epidemic, children should be periodically evaluated objectively to document the actual level of prevalence. Continuing education for health providers and the general population promises to correct misinformation regarding the biology, prevention, and management of lice. Parents should regularly inspect their children for head lice and treat as necessary. Health authorities are encouraged to eliminate policies and practices that rely upon school exclusion as a means to reduce incidence and prevalence, e.g., the 'no-nit' policy which lacks scientific justification, and are counterproductive to the health and welfare of children.

Knowledge, Attitude, and Practice of Pediculus Capitis Prevention and Control and Their Predictors among Schoolchildren in Woreta Town, Northwest Ethiopia, 2018: A School-Based Cross-Sectional Study

Background

Pediculus capitis is a human head lice infestation, a major public health issue that is most prevalent in resource-limited countries globally. The current study aimed to assess the knowledge, attitude, and practice of pediculus capitis prevention and control and their predictors among schoolchildren in North West Ethiopia.

Methods

About 402 randomly selected schoolchildren from three schools in Woreta town participated in the study from April to June 2018. The outcomes of this study were knowledge, attitude, and self-reported practice of schoolchildren about pediculus capitis prevention and control. We used EPI Info 7.1 and SPSS 21 software for data entry and analysis, respectively. Binary logistic regression was employed to test the association of covariates with the outcome/response variables. Variables with a p value <0.2 during the bivariable binary logistic regression analysis were included in the multivariable binary logistic regression analysis. Variables with p value <0.05 were declared as significantly associated with outcomes.

Results

The mean age of the study participants was 10.19 (±1.62) years. About 58.8%, 45.8%, and 78.6% of the schoolchildren had better self-reported pediculus capitis prevention knowledge, attitude, and practice, respectively. Age of children [9 to 11 years (AOR = 2.24, 95% C.I (1.10, 4.55)) and>12 years (AOR = 3.84, 95% C.I (1.56, 9.46))], better practice (AOR = 2.93, 95% C.I (1.39, 6.18)), and those who were not infested (AOR = 2.25, 95% C.I (1.14, 4.44)) were predictors of knowledge regarding pediculus capitis prevention. Better practice (AOR = 4.33, 95% C.I (1.69, 11.09)) and absence of infestation (AOR = 2.97, 95% C.I (1.64, 5.36)) were predictors of attitude of schoolchildren about pediculus capitis prevention. Number of students in a class [51 to 56 students per classroom, AOR = 4.61, 95% C.I (1.83, 11.67); 57 to 58 students per classroom, AOR = 8.18, 95% C.I (2.73, 24.46)], less than five family size (AOR = 2.37, 95% C.I (1.24, 4.54)), better knowledge (AOR = 2.93, 95% C.I (1.32, 6.50)), desirable attitude (AOR = 4.24, 95% C.I (1.60, 11.23)), and absence of infestation (AOR = 3.52, 95% C.I (1.22, 10.15)) were predictors of self-reported pediculus capitis prevention practice.

Conclusion

The knowledge, attitude, and practice of schoolchildren regarding pediculus capitis prevention and control were not satisfactory. To bring change, intensive efforts on factors associated with the knowledge, attitude, and practice should be encouraged.

Stigma resulting from head lice infestation: A concept analysis and implications for public health

AIM

The aim of this concept analysis was to examine stigma in the context of head lice, illuminating its components and providing insights for the development of appropriate nursing interventions.

BACKGROUND

Stigma associated with the phenomenon of head lice management is pervasive, promulgating fear and influencing policy and treatment practices. Few studies have examined stigma in this context.

METHOD

The method followed was the Rodgers's evolutionary method.

DATA SOURCES

Health, education, and social sciences databases were searched and yielded 20 articles spanning 1996-2018 used to create a relevant literature review.

RESULTS

Stigma arising from head lice infestation is preceded by an actual or perceived case of head lice, negative perceptions of lice, negative perception of groups or persons with head lice, or being associated with a group or person of lesser status believed to be a carrier of head lice. Defining attributes include marks of infestation, negative and unfair beliefs, and shame. Consequences of stigma are economic costs, social costs, mistreatment, and overtreatment with pediculicides.

CONCLUSION

The concept of stigma in the context of head lice management is multifaceted. Further research is required to understand the magnitude of stigma as well as other factors associated with optimal treatment of children with head lice.

Knowledge, attitudes, and practices of parents/guardians regarding pediculosis in the Umm el-Jimal district of Jordan

The aim of this study is to assess the prevalence of pediculosis capitis in one district in Jordan, and to determine the knowledge, attitudes and practices of parents/guardians regarding head lice. The study was performed in Jordan’s Umm el-Jimal district from February 2010 to May 2010, and involved the surveying of 105 randomly selected households containing a total of 213 children. The households’ parents were interviewed for their knowledge, attitudes and practices regarding pediculosis, and afterward their children’s hair was checked for head lice via a 5-min visual scalp examination. Chi-square testing was used to analyse the data, with statistical significance assumed at p < 0.05. The prevalence rate of pediculosis among the 213 children was found to be 14.6%. Parental knowledge of head lice was found to be very limited; only 35.2% of the parents/guardians correctly answered 10 of the 20 questions (50%), and only 17.1% correctly answered 14 questions (70%). More than 94% of the parents reported feeling shame upon learning that their children were infested with pediculosis, and nearly 90% felt too ashamed to ask for help from a healthcare provider. Many parents used traditional/local techniques that they believed to be effective in managing pediculosis; 61% of the parents applied kerosene to the scalps of infested individuals, 39.9% used medical shampoo and 37.6% used special combs. There is a clear deficiency in Jordanian parents’ knowledge of, and practices concerning, pediculosis capitis. It is recommended that the Jordanian Ministry of Health and local health departments work together to ensure the dissemination of accurate and consistent head lice information to families.

Head lice treatments and school policies in the US in an era of emerging resistance: a cost-effectiveness analysis

BACKGROUND

Head lice are a common infection in school-age children worldwide. Several authorities in the US have recommended different treatments and school policies in order to control this disease. Recent concerns of emerging lice resistance worldwide raise the necessity to reassess the current recommendations.

OBJECTIVES

To perform a cost-effectiveness analysis (from the US caregiver perspective) of three head lice treatments commonly used in the US, permethrin 1%, malathion 0.5% and the lice comb, in order to evaluate the cost effectiveness of different treatments in the current era, and to explore the effect of different factors in this analysis.

METHODS

We used a decision-tree model to represent the costs and effectiveness of the different treatment strategies. A patient/caregiver perspective was applied, with a time horizon of 2 weeks. Probabilities of treatment success or failure of the three treatments were based on the literature. Effectiveness was measured as the successful eradication of head lice, and costs - including the costs of the treatment, the physician co-pay and the costs of days out of school - were calculated. One-way and multi-way analyses were performed using decision analysis software (Treeage Pro Healthcare 2008).

RESULTS

Combing was dominated by permethrin 1%. The incremental cost-effectiveness ratio of malathion 0.5% versus permethrin 1% was $US161.75 per cure. For caregivers whose willingness to pay is <$US161.75 per cure, permethrin 1% is the most cost-effective option. For those with a willingness to pay of > or =$US161.75 per cure malathion 1% may offer the highest net monetary benefit. Twenty percent of the uncertainty in the model is due to variation in permethrin 1% resistance, and approximately 73% of the total variability of the model is attributed to the number of days the student has to be out of school because of the school's policy.

CONCLUSIONS

Our study suggests that permethrin 1% was the most cost-effective treatment for those with a willingness to pay of <$US162 per cure. Sensitivity of lice to permethrin and the specific school head lice policy had major effects on the model. Thus, informing communities in a given geographical area about the degree of head lice resistance and sensitivity is necessary in order for the public to make a rational decision regarding treatment. Schools' head lice policies have a major effect on the cost of head lice treatments.

Fomite transmission in head lice

Control of various infestations requires an accurate understanding of transmission. After thousands of years of lice infestation, scientific documentation of indirect contact transmission has been substantiated. Lice can be transferred in the egg, instar, and adult stages. Lice have now been shown in the laboratory to be readily dislodged by air movements such as blow-drying one's hair, combing, and toweling. Moreover, passive transfer to adjoining fabric is also frequently observed. Louse transmission by fomites occurs more frequently than has been commonly believed. Close proximity suffices to increase the likeliness of a new infestation. Thus louse control measures should take account of fomite transmission and include screening of all individuals within an infested person's immediate circle of contact, laundering of everything within the infested individuals' bed or quarantining of such material for 10 days, thorough vacuuming of floors, carpets, upholstery, with a standard vacuum cleaner.

Therapy for head lice based on life cycle, resistance, and safety considerations

The timing of head lice maturation most favorable to their survival in the presence of anti-lice agents is the maximum time as an ovum (12 days) and the shortest possible time of maturing from newly hatched nymph to egg-laying adult (8.5 days). Pediculicides that are not reliably ovicidal (pyrethroids and lindane) require 2 to 3 treatment cycles to eradicate lice. Ovicidal therapies (malathion) require 1 to 2 treatments. Treatment with an agent to which there is genetic resistance is unproductive. In the United States, lice have become increasingly resistant to pyrethroids and lindane but not to malathion. Treatment with malathion has favorable efficacy and safety profiles and enables the immediate, safe return to school. Nit combing can be performed adjunctively. No-nit policies should be rendered obsolete.

Head louse infestations: the "no nit" policy and its consequences

Health authorities in the USA, Canada and Australia recommend a "no nit" policy, i.e. the immediate dismissal of all children who have head lice, eggs and/or nits on their hair from school, camp or child-care settings. These children would be readmitted to the institution only when all head lice, eggs and nits have been removed. The "no nit" policy assumes that all nits seen when examining the scalp are viable and therefore the infested individual should be treated for lice, and all nits must be removed from the scalp. However, it has been repeatedly shown that only a small number of children who have nits on their scalp are also infested with living lice. Accordingly, in the USA alone 4-8 million children are treated unnecessarily for head lice annually, which amounts to 64% of all lice treatments. In addition, 12-24 million school days are lost annually. The annual economic loss owing to missed workdays by parents who have to stay home with their children adds US$4-8 billion to the country's economy. The policy also results in serious psychological problems for children and their parents. Therefore, the "no nit" policy should be abandoned and alternative ways of examination and treatment for head lice should be found.

Head lice: Scientific assessment of the nit sheath with clinical ramifications and therapeutic options

Head lice, like many insects, produce a protective coating for their newly laid eggs that is essential to the survival of the species. Knowledge of the composition of the sheath, which is the glue by which the egg is attached to human hair, and the nit laying process could lead to production of agents that could be used to attack louse infestations by interfering with the normally protected environment of nymph development within the egg. The physical removal of nits has become an important part of treatment of head louse infestations given the "no-nit" policy in schools. Biochemical analysis has revealed that the nit sheath of the head louse is composed of 4 bands of protein, possibly cross-linked to aliphatic components with a tertiary structure of beta sheeting. Nature has protected the louse by making the nit sheath similar in composition to the hair; thereby, agents designed to unravel the nit sheath may also damage human hair. Possible targets to destroy the nit sheath include proteases, denaturants, beta sheet breaker proteins, and small protein inhibitors of sheath formation. Better understanding of insect glues may allow us to develop compounds so that the liquid secretions of the collateral glands of the female louse, which becomes the nit sheath, do not solidify by oxidation when placed with the louse egg onto human hair. Knowledge of insect behavior, such as oviposition, may also suggest methods for repelling female lice from laying eggs onto hair. Alternatively, agents that coat the nits and restrict the oxygen transfer to the developing larvae may prove beneficial.

Economic considerations associated with Pediculus humanus capitis infestation

An estimated 6 to 12 million head lice infestations occur in the United States annually, with children ages 3 to 12 most likely to be affected. There are significant direct costs associated with treatment and indirect costs due to lost time from school. Anecdotal reports suggest that direct costs of treatment are in the hundreds of millions of dollars annually. Indirect costs are also substantial but more difficult to quantify. Examples of indirect costs include missed days from schools that use a "no nit" policy, lost wages for parents who must stay home with children, and costs of daycare for parents who cannot miss work. Contributors to the expense of treating head lice include misdiagnosis, and, consequently unneeded treatment; treatment failure due to misuse of pediculicides or other agents; and developing resistance, particularly to over-the-counter pyrethroid agents. An overview of direct and indirect costs of infestation are included in this review, along with a discussion of factors that lead to misuse and overuse of pediculicides. More accurate diagnosis of head lice infestation may provide the most effective means of controlling the costs of care and ensuring proper use of pediculicides.

Treatment of pediculosis capitis with thiabendazole: a pilot study

BACKGROUND

Despite the improvement of health standards, head lice infestation remains a problem worldwide. In addition, there is increasing evidence that head lice are becoming resistant to common pediculocides.

AIM

To test the potential effectiveness of thiabendazole, a potent and broad-spectrum antiparasitic and scabicidal agent, for the treatment of pediculosis capitis.

METHODS

Twenty-three female patients, aged 7-12 years, who had active head lice infestation, were treated with oral thiabendazole, 20 mg/kg twice daily for 1 day, with repeat treatment after 10 days.

RESULTS

On the 11th day, meticulous hair examination showed that 21 patients had responded to treatment [91%; 95% confidence interval (CI), 71-98%], with 14 showing complete responsiveness (61%; 95% CI, 40-78%). The only adverse reactions observed were nausea and mild dizziness, which occurred in four patients, three of whom took the drug on an empty stomach.

CONCLUSIONS

Thiabendazole may be a promising treatment for head lice infestation. The primary action of this drug seems to be the inhibition of parasite microtubule polymerization by binding to beta-tubulin. In addition, thiabendazole may interfere with the synaptic transmission of lice through its probable cholinergic effect. As pediculosis capitis is a very communicable disease, the unresponsiveness to thiabendazole could largely be attributed to new infestations during the drug-free interval. Therefore, massive and simultaneous rather than individual and isolated treatments should be used to achieve the epidemiologic control of this ectoparasitosis. As this is a preliminary study, the performance of double-blind, randomized controlled trials on this subject is warranted. Thiabendazole, either alone or in combination with other agents, may prove to be of particular use in areas in which head lice show resistance to common pediculocides.

Towards the eradication of head lice: literature review and research agenda

Head lice infestation is a public health issue. In the effort to compile an evidence-base about the physiology, detection, treatment, effects and management strategies of head lice infestations we reviewed current literature. This literature signalled significant evidence gaps and these gaps provide incentives for further research. Our conclusions from the literature are that parents of children are responsible for head lice detection and treatment but have varying access to advice about how best to treat this condition. Concern is exacerbated by misconceptions surrounding the circumstances of infestation. Head lice are a low priority for health professionals in Australia, whereas parents and teachers believe the problem necessitates greater attention. It is important to provide a unified evidence-based approach to good information. It is timely for health care professionals to re-examine and prioritize this public health issue. They should research and work collaboratively towards the eradication of head lice.

Head lice: is there a solution?

Head lice is an old problem that won't go away. Infestation with the head louse Pediculus capitis is still common in school-aged children. The majority of information about this condition is based on anecdotal evidence. There is a definite need for the standardization of detection methods for diagnosis and epidemiological purposes, and for properly designed trials to ascertain the effectiveness of the different treatment methods available.

Effects of a small monetary incentive and follow-up mailings on return rates of a survey to nurse practitioners

The purpose was to examine the effectiveness of a modest monetary incentive ($1) and none in increasing the response rate of a mail survey to 600 nurse practitioners. The response rate in the incentive group was 81% and 66% in the control group, significant by chi-square test. The most cost effective survey technique for increasing the response rate of nurse practitioners was to code the envelopes and eliminate the monetary incentive.