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

Towards the eradication of head lice:

literature review and research agenda

TINATINA KOCHKOCH PhD, RN

RDNS Chair in Domiciliary Nursing, Flinders University of South Australia, 31 Flemington St,

Glenside South Australia 5065

MARINAMARINA BROWNBROWN BN, RN

Research Nurse, Royal District Nursing Service, 31 Flemington St, Glenside South Australia 5065

PAMPAM SELIMSELIM BA, RN

Research Nurse, Royal District Nursing Service, 31 Flemington St, Glenside South Australia 5065

CATHYCATHY ISAMISAM BA

Senior Project Of®cer, Royal District Nursing Service, 31 Flemington St, Glenside South Australia

5065

Accepted for publication 12 December 2000

Summary

· Head lice infestation is a public health issue. In the effort to compile an

evidence-base about the physiology, detection, treatment, effects and manage-

ment strategies of head lice infestations we reviewed current literature.

· This literature signalled signi®cant 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 uni®ed 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.

Keywords: community nursing, evidence, head lice, public health.

Correspondence to: Tina Koch, Flinders University of South Australia,31 Flemington St, Glenside South Australia 5065 (tel.: 08 8206 0006;fax: 08 8206 0010; e-mail: tina.koch@¯inders.edu.au).

Journal of Clinical Nursing 2001; 10: 364±371

364 Ó 2001 Blackwell Science Ltd

Introduction

A colleague in the Community Based Research Unit

disclosed that her children were infested with head lice.

Not only was it endemic in the primary school her

children attended but also at other neighbouring schools.

As researchers, we explored the literature and the Internet

for current treatments in an effort to ®nd evidence to

support eradication practice. We discovered that the

problem was trivialized, information sources were contra-

dictory, and research was lacking. The Australian evidence

suggests that it was usually mothers who spent hours each

week tediously and meticulously combing the hair of their

offspring and therefore it was seen as a feminist issue. As

community nurses working in the area of public health we

could not resist tackling this problem. We decided to

systematically review the literature and identify a research

agenda. In this paper we present the literature review and

forge a research agenda. Our ®rst intention is to raise the

consciousness of community nurses that the epidemic of

head lice is a public health issue for which we should take

responsibility. Our second intention is to seek collabor-

ation with like-minded community nurse researchers

around the globe towards the eradication of head lice.

Head lice

Pediculosis capitis, more commonly known as a head louse

or a nit, presents a perennial problem for individuals and

communities affected by it. There is a gap in the literature

reviewed in that often the number of people annually

infested with these parasitic insects is unclear. In many

countries, health authorities do not maintain records of the

incidence of head lice. However, it is possible that tens or

hundreds of thousands of Australians suffer from head lice

annually if we consider the statistics for the United States

of America (USA) and United Kingdom (UK).

In an attempt to obtain local data on the spread of nits

in an urban primary school in Australia, Speare &

Buettner (1999) inspected children for signs of infestation.

It was discovered that nits were present amongst the

children at a `hyperendemic level'. More than 450 children

were inspected and over one third of them had evidence of

infestation. Although patterns exist regarding populations

or subgroups within which they occur, nits are not

constrained within rigid boundaries. For example, head

lice may cause problems in other communities, such as

older residents in an aged care facility (Speare & Ahn,

1999). However, children of primary school age constitute

the largest group of people affected (Droogan, 1999).

Girls of primary school age are more likely to be

infested than boys (Droogan, 1999; Spear & Buettner,

1999), although this is not always the case (Mumcuoglu

et al., 1991). The higher incidence of infestation in girls

has been suggested to be due to girls having greater

physical contact than boys, and sharing personal articles

that may transmit head lice (Clore & Longyear, 1993). It is

not thought that girls are at a greater risk of catching head

lice because of their tendency towards having longer hair

than boys (Clore & Longyear, 1993). Debate exists

regarding the in¯uence, if any, of socio-economic status

on the incidence (Wegner et al., 1994; Vermaak, 1996;

Burkhart et al., 1998b). Wegner et al. (1994) found an

association between children with stubborn, repeated

re-infestation of head lice and large families, cold or no

water supplied to houses and parents with little education.

It has been proposed that in areas of high social

disadvantage, larger families may pay less attention to

hair care due to lack of support and ®nancial limitations

(Vermaak, 1996). Contrary to common belief, head lice do

not prefer dirty hair to clean; in fact the opposite is true

(Chunge et al., 1991). A healthy, clean scalp provides

them with a good supply of blood from which they feed.

Head lice infestation

The host may not immediately feel the physical effect of

having head lice. It may take a number of weeks after

infestation before a person becomes aware. The charac-

teristic itching, or pruritis, that accompanies infestation

may, in some cases, be complicated further by bacterial

infections which occur when the skin becomes excoriated

(Chunge et al., 1991; Forsman, 19951 ). Fortunately, ped-

iculosis capitis is not a species that transmits disease to

humans (Chunge et al., 1991; Burkhart et al., 1998b). In

this sense, there is often only a relatively minimal physical

inconvenience.

Head lice pose a signi®cant problem in part due to their

prevalence and social distress. The incidence of infestation

in the USA is greater than that for all childhood

communicable diseases combined, apart from the common

cold (Centers for Disease Control, 1985; Clore &

Longyear, 1993). Surveys have been conducted among

children all over the world and prevalence rates are

`mostly below 10% (for live lice and/or viable eggs), but

occasionally reach 40% or higher' (Chunge et al., 1991).

In Australia, as in other countries, there is often a more

serious consequence than physical problems for those

affected, because social stigma is associated with having

head lice. Whilst the physical effects are usually relatively

Towards the eradication of head lice 365

Ó 2001 Blackwell Science Ltd, Journal of Clinical Nursing, 10, 364±371

mild, `the anxiety which surrounds the problem justi®es

the public health concern' (Chunge et al., 1991). Indeed

they constitute a public health problem precisely because

they cause social distress and not because they transmit

disease (Chunge et al., 1991). Distress is exacerbated by

misconceptions surrounding the circumstances of infesta-

tion. Despite attempts to dispel the myths, there persists a

sense of shame and disgust surrounding infestation. Head

lice were a low priority for health professionals (Altschuler

& Kenney, 1986), whereas parents and teachers believed

that the problem necessitated greater attention.

Physiology of head lice

Head lice are species unique to the human head; they do

not reside on any other creature (Burkhart et al., 1998b),

so there is no risk of sharing head lice with the family dog

or cat. Three stages occur in the life cycle of head lice: egg

(or nit), nymph and adult. The adult head louse lives for

30±40 days but survival time away from the scalp is

estimated to be between 6 h and 3 days (Burkhart et al.,

1998b; Forsman, 19952 ; Speare, 1999). Adult lice do not

hop or ¯y, but move swiftly through dry hair aided by

clawed legs, which grip the hair shafts. Most often, fewer

than 20 adult lice are found on the head (Forsman, 19953 ;

Burkhart et al., 1998b). Although children's heads are not

regularly found to be `crawling with lice', approximately

5% of hosts will have more than 100 adult lice on their

scalp (Burkhart et al., 1998b).

The eggs, or `nits', are laid and ®rmly cemented by a

waterproof, glue-like substance to a hair shaft close to the

scalp (Burkhart et al. 1998a). Eggs can survive up to

10 days away from the scalp (Burkhart et al., 1998b). The

nits hatch into juvenile lice (nymphs) after 6±9 days (Pray,

1999) and then mature into adults within a matter of days.

Once hatched, nymphs cannot survive much longer than

24 h without having a meal of blood (Pray, 1999).

Detection of an infestation

Dif®culty can be encountered in accurate diagnosis.

Because the adult louse moves quickly through dry hair

it is useful to look for lice when the hair is wet (Ibarra,

1996; Burkhart et al., 1998a4 ). This has the effect of

slowing them down, which gives the examiner extended

time to ®nd them. Using a ®ne toothed comb, wet hair is

combed, a section at a time, and inspected for the presence

of lice or nits. This method of checking after wetting the

hair may have implications for schools and/or parents who

elect to use the less effective, yet more convenient, dry

detection method.

There are important factors about the eggs which re¯ect

their ability to be an infestation problem for humans.

Active infestation by head lice is evidenced by the

presence of adult lice, nymphs or live eggs, whereas

hatched or dead eggs point to inactive (previous) infes-

tation (Speare, 1999). The position of the egg's attachment

to the hair shaft, its colour, pressure within the egg and

shape all contribute to assessment of whether an egg is

alive, dead or hatched (Speare, 1999). Clearly, the state of

the eggs should be considered before declaring a person

`infested'. Indiscriminate equating of nits with an active

infestation brings research evaluating the effectiveness of

treatment products into question (Clore & Longyear,

1993).

An additional complication in diagnosis is the presence

of `pseudonits'. These are objects detected in the hair that

might be confused with nits, such as dandruff. Pray (1999)

offers the guideline that if an object can be easily ¯icked

from the hair then it is a pseudonit, because nits are ®rmly

glued to the hair shaft.

Treatment

The perspective taken towards insecticide use may

in¯uence the management of head lice. Concerns have

been raised about the exposure of people to toxic

chemicals used when treating an infestation (Willis,

19995 ; Community Hygiene Concern, 1999). However,

the literature reports these concerns anecdotally only. The

person or organization giving advice or providing treat-

ment, such as a pharmacist, mother, school or local doctor,

in¯uences whether chemicals or more natural methods are

used. `Mother' is speci®ed instead of parent since it is

mothers of children who have the responsibility for head

lice detection and treatment, as shown in a survey

returned by the parents of school children (Mumcuoglu

et al., 1990±91). It should be noted, however, that the

social norms for fathers are changing, so it may be that

fathers have taken on more of this responsibility in the

intervening years.

Treatment methods can be divided into three groups:

insecticides, manual removal, or herbal/home remedies.

As well as treating the head, the environment can be

treated by cleaning or spraying with insecticides. This

latter treatment is not advocated because it is unclear what

effect inhalation has on humans over a prolonged period

(Burkhart et al., 1998b; Pray, 1999). Speare (1999) reports

that tap water at 60 °C for 10 s causes 100% mortality of

lice and refers to this as heat treatment. Using heat, head

lice can be eradicated from the environment, for example,

by placing hats in a clothes dryer on a hot cycle. There are


366 T. Koch et al.

many advocates for treating objects such as furniture, bed

linen, hats, combs, bed toys and carpets (Burkhart et al.,

1998b; Colchamiro, 1998; Price et al. 1999). Methods

suggested for treating the environment include cleaning,

washing in hot water, vacuum cleaning and tumble-

drying.

There is some doubt over the much-advocated practice

of treating objects, apart from the head. Chunge et al.

(1991) believe there is a lack of evidence that transmission

of head lice occurs via shared articles such as hats and

combs, and they say that the evidence for spread through

inanimate objects such as furniture is even less conclusive.

A questionnaire returned by the parents of nearly 1000

primary school children found that there was no associ-

ation between infestation rates with head lice and the

sharing of brushes, combs, hats, towels and clothes

(Mumcuoglu et al., 199091). Speare (1999) believes that

it is an `unnecessary waste of time' to treat items such as

hats, bed toys, furniture and bed linen. He admits that

there is little solid evidence for this claim but offers some

rationale for his stance. His reasons include the following:

few lice fall off the head; those that do fall off are most

likely near death; and any healthy ones that fall off will

only live for a short time (6±24 h by his calculation;

Speare, 1999).

As previously mentioned, there are several ways of

treating the head. Research has only been conducted on a

number of insecticides used for this purpose. The

effectiveness of manual removal methods, such as ®ne

combing, herbal/natural or home remedies has been

researched recently. Roberts et al. (2000) compared wet

combing with Malathion for the treatment of head lice in

the UK using a randomized controlled trial. The cure rate

achieved was 38% for wet combing (12 out of 32) and

78% (31 out of 40) for Malathion. However, only 50% of

participants complied fully with treatment. Therefore, it

seems important to replicate this research design but to

give particular attention to compliance.

Among the often vocal advocates for non-evidence-

based methods are nurses, doctors, pharmacists, commu-

nity organizations and, of course, product manufacturers.

Questionable, even dangerous products have been used

by parents in treating their children. These include

¯ysprays, animal treatments, essential oil mixtures, head

shaving, ¯ammable liquids (e.g. gasoline) and industrial

strength pesticides (Willis, 1998; Pray, 1999). Some of

these treatments have resulted in severe injury, disability

or even death (Pray, 1999). In a survey of school nurses in

the US, Price et al. (1999) found that 4% recommended

home remedies such as vaseline or mayonnaise. Products

such as these are criticized because removing them from

the hair may cause irritation owing to the multiple

shampooing required, and may put the scalp at risk of

infection by leaving perishable products on overnight

(Price et al., 19996 ).

In Australia, insecticides are common products used for

the treatment. Insecticides can be divided into four

categories based on their active ingredient: pyrethrins,

synthetic pyrethroids, organophosphates (Malathion), and

herbal agents (Speare, 1999). In recent years there have

been two meta-analyses associated with treatments for

head lice. The ®rst, focusing on insecticide use, found

only seven trials that ful®lled the authors' criteria for

acceptable methodological quality (Vander Stichele et al.

1995). They concluded that the permethrin was the only

insecticide that had suf®cient published researched to

show its ef®cacy. Malathion (see the study by Roberts

et al. 2000) requires more evidence, and lindane (not

permitted in Australia) and the natural pyrethrines were

not effective enough to justify their in use. Criticisms of

Vander Stichele's meta-analysis include the fact that it did

not address insecticide resistance, toxicity, or cost of the

products (Burgess, 19957 ; Stallbaumer & Ibarra, 1995;

Laekeman, 1996).

The second and most recent meta-analysis by Dodd

(1999) included only three trials (out of 70) in the analysis,

on the basis of having an appropriate methodology. The

author concedes that these trials were all carried out in

populations previously unexposed to insecticide treat-

ment, which has implications for countries where insec-

ticide has been used extensively. The insecticide products

examined in the few trials analysed (permethrin, synthetic

pyrethroid and malathion) were shown to be effective, but

local resistance requires further consideration. In addition,

Dodd concluded that there was no evidence to support the

effectiveness of physical methods (e.g. combing) or herbal

treatments for head lice control, and recommends that

further well designed research should address comparisons

between different treatment methods such as herbal,

chemical and physical methods.

Evidence supporting oral treatment was not identi®ed

in the published literature. However, Burkhart et al.

(1998b) believe that oral ivermectin is an effective drug

that may soon take the place of topical treatments. A single

dose of Ivermectin may be effective if removal of eggs

occurs at the same time (Speare & Ahn, 1999). It has been

suggested that the increased use of oral prescription drugs

increases the involvement of general practitioners in the

treatment of head lice (Burkhart et al., 1998a), thus

medicalizing a public health issue.

The resistance of head lice to insecticides is much

discussed in the literature. It is possible to tell whether



head lice are resistant by checking the effect of the

treatment (Speare, 1999). Resistance to insecticides is said

to have occurred in parts of the US (Pollack et al. 1999),

UK (Burkhart et al., 1998b8 ), Israel and France (Dodd,

1999). Resistance occurs in populations of head lice that

have had multiple exposure to insecticides (Dodd, 1999)

and is a problem because the range of products available is

limited. Rotation of insecticides is suggested as a means of

minimizing the risk of resistance to an insecticide

(Vermaak, 1996). Limiting any one insecticide has become

more dif®cult because they are increasingly available

without prescription (Dodd, 1999). Resistance to an

insecticide necessitates trying another from a different

group, which will have a different active ingredient

(Speare, 1999). However, there is no evidence that head

lice resistant to one insecticide group will be susceptible to

another (Ibarra, 1996).

Failure to treat head lice effectively with insecticide is

a common complaint. Speare (1999) gives the following

four reasons for treatment failure: inappropriate treat-

ment application; resistance to insecticides; failure to kill

newly hatched lice; and re-infestation by head lice. He

suggests that these four reasons should be addressed in a

systematic way if treatment is not successful. Some

manufacturers of insecticides advocate the need for only

one treatment; however, many people believe that no

product is 100% effective at killing the eggs and

therefore a second application is necessary after a week

in order to kill any lice hatched from the remaining eggs

(Burkhart et al., 1998b9 ; Speare, 1999). Vander Stichele

et al. (1995) recommends further research into the

ef®cacy of only one application of insecticide. At this

time, no chemical product has been identi®ed that is safe

and ef®cient in removing ®rmly attached eggs from

the hair (Burkhart et al., 1998a), although the under-

researched method of ®ne combing is said to remove eggs

(Pray, 1999).

Re-infestation can occur after a person is treated, and

this may lead to the assumption that the treatment itself

was at fault. Speare (1999) believes this can be ruled out

by carefully examining the hair combings after each

treatment to check that all the lice are dead. One

research study found that 64% of children with head lice

had another family member infested at the same time

(Clore & Longyear, 1993). Therefore, family and others

who have been in close contact must be considered when

re-infestation occurs. This identi®cation of contacts who

may be a re-infestation source can be dif®cult (Speare &

Ahn, 1999). The potential for the environment to be a

source of re-infestation, or infestation, has already been

discussed.

Management strategies

Different strategies are used throughout the world in the

treatment of head lice. Many of these programmes have as

their aim the management of head lice, but some go so far

as to say that they are committed to eradicating head lice

altogether.

In the UK a method called `Bug Busting' is widely

advocated and endorsed by the UK Department of Health

(Community Hygiene Concern, 1999). The instigator of

Bug Busting is Community Hygiene Concern, a charitable

organization with a strong focus on eradicating head lice

without the use of insecticides (Ibarra, 1996). Bug Busting

is a detection and eradication method that involves using a

specially designed comb with normal shampoo and

conditioner. The method works by using the comb to

examine the head for lice and, if present, to remove them.

It is recommended that the comb be used four times over a

fortnight in order to `break the life cycle of the lice,

stopping them from spreading and reproducing' (Com-

munity Hygiene Concern, 1999).

Community Hygiene Concern (1999) believes that `by

explaining and co-ordinating Bug Busting at the school,

local authority and national levels, as well as to individual

families, we can work towards the goal of head lice

eradication'. Bug Busting has a primary school focus and

entails providing information for parents and encouraging

their signi®cant and ongoing participation (Ibarra, 1996).

The technique has the advantage of being non-toxic,

cheap and effective (Ibarra, 1996; Community Hygiene

Concern, 1999). Unlike other products that have to be

replenished, such as insecticides, the Bug Buster comb can

be re-used inde®nitely. Only Roberts et al. (2000) have

published research on Bug Busting vs. the application of

Malathion.

A `No Nit Policy' is recommended and publicised by a

US non-pro®t organization called the National Pediculosis

Association. It advocates that the spirit of the No Nit

Policy is to minimize head lice infestations as a public

health problem and to keep children in school (National

Pediculosis Association, 1999). The No Nit Policy, like

Bug Busting, advocates mechanical, non-toxic treatment

for head lice management. The National Pediculosis

Association markets its own comb called the `LiceMei-

ster'.

The National Pediculosis Association states that the No

Nit Policy incorporates community education regarding

policy and its purpose, and directs children to be excluded

from school until all head lice, eggs and egg cases have

been removed. Clore & Longyear (1993) believe that the

No Nit Policy helps to `eliminate diagnostic confusion':


368 T. Koch et al.

presumably this confusion surrounds the identi®cation of

viable or non-viable eggs. Other advantages of this policy

are that it allows health professionals to adopt a standard-

ized approach to management and through establishing

consistent guidelines it is argued that parental compliance

is encouraged. Understanding of head lice management

minimizes repeated insecticide treatments, improves the

self-esteem and hygiene standard of children and provides

the majority of children with uninterrupted education. In

addition, it avoids parents having to take time off work

(National Pediculosis Association, 1999). Support for the

No Nit Policy includes the majority of school nurses, with

two national surveys in the US ®nding that 60±61%

agreed with it as a school policy (Donnelly et al., 1991;

Price et al., 1999).

The National Pediculosis Association disagrees with

opponents of the No Nit Policy who argue that it is

`overzealous' in keeping children with eggs out of

classrooms (1999). They counter this accusation by

maintaining that `broader public health values and pref-

erences of the community' must be considered (1999).

However, the No Nit Policy does not include educating

health care providers, school staff or parents about the

varying viability of eggs found in the hair and their

potential, or inability, to cause re-infestation.

A different lice elimination programme was evaluated

and consequently recommended by Vermaak (1996).

There were two phases to the study: an initial elimination

programme for all schools on the Isle of Man and a long-

term follow-up strategy. A full prevalence survey was

conducted before the start of the programme and

prevalence continued to be monitored annually. The

programme included a lice elimination day and ongoing

health education. The lice elimination programme

involved all stakeholders, particularly parents, and was

dependent on knowable, committed health care profes-

sionals and the full support of managers. As a part of the

initial strategy, children were given stickers to reward

them for having had their parents inspect their heads for

lice. This programme advocated the use of insecticides

for treatment. A process of insecticide rotation was

advocated, which involved communicating to parents

what treatment product was currently being recommen-

ded. The bene®ts of the programme are reported as

follows: giving parents the responsibility and ability to

manage head lice; making better use of school nurse time;

reducing feelings of social stigma; monitoring the pro-

gramme's success; and lowering rates of infestation. The

stigma associated with head lice infestation was reduced

because parents were encouraged to notify the school of

an infestation. In addition, parents were informed when a

contact of their child was infested, as a warning of the

need for continued, or increased, vigilance. Vermaak

(1996) reported that children were observed discussing

their infestations `as they would discuss a cold or chicken

pox'.

A model of head lice treatment was reported by Son

et al. (1995), who compared two different methods used

with school children in South Korea. In one school all

children were treated with an insecticide (permethrin

shampoo) regardless of whether they had head lice, while

in the other school only those with an infestation were

treated. As the re-infestation rates were not signi®cantly

different at follow-up evaluations of the two groups, the

authors conclude that it is not necessary to undertake mass

treatment for head lice irrespective of actual infestation.

Not mentioned in this study was the concern of placing

children at unnecessary risk through exposure to insecti-

cides.

Towards a research programme

for eradicating head lice

Published research literature is severely lacking regarding

the detection, treatment and control of head in individual

families and the wider community. Studies that have been

carried out are of a questionable quality or design. Often

the literature is advisory in nature and not based on sound

evidence. Con¯icting advice can be found concerning

almost all aspects of head lice management. There are

considerable gaps in the research that require serious

attention.

Notably, in all of the research literature surrounding

head lice, the experiences of certain key parties has been

excluded. There has been no opportunity for parents, in

particular mothers, to recount their experiences with head

lice management. No evidence has been reported on the

undoubtedly frustrating experiences of school teachers

who, in addition to parents and children, deal with the

problem on a ®rst hand basis. These central ®gures must

be considered in future research.

The situation regarding head lice in Australia is

disappointingly unclear. Only a few authors have pub-

lished limited amounts of research on the topic in this

country. There is a strong need for research, speci®cally

regarding the Australian experience, into all of the areas

mentioned previously. Statistics that relate to head lice in

Australian children are lacking and hence the extent and

implications of this problem can only be assumed.

Considering the effects of infestation on individuals and

communities, the need for further research cannot be

over-emphasized.



What can be done?

There is a need to move on two fronts. Firstly, there is a

need to work towards a model of best practice for the

eradication of head lice in primary school children.

Anecdotal information from education department and

media sources signals that the incidence of `nits' in the

hair of children is increasing markedly. The control of

head lice is regulated by the Public and Environmental

Health Act. In South Australia, individual local govern-

ment authorities have developed information materials and

management strategies, but the presence of head lice is not

a noti®able infectious condition. Parents of children have

varying access to advice about how to best treat this

condition, and concern is exacerbated by misconceptions

surrounding the circumstances of infestation. Information

is available from local government pamphlets, recently

published school guidelines, the Internet, other parents, or

advice from a pharmacist. Unfortunately, activity is

fragmented, whilst cohesive programmes are non-existent.

Head lice are perceived to be a community management

problem; however, there are no guidelines to shape

community action.

Because of this fragmented approach, the community

has not been able to resolve the problem and bug-busting

strategies need to be developed. The development of a

best practice model for the eradication of head lice in

primary school children is best orchestrated through

schools, local government and individual families.

Through explanation and co-ordination of best practice

strategies at the school, local authority and national levels,

as well as with individual families, it is possible to work

towards the goal of head lice eradication.

There are prototypes to guide the development of a best

practice model in Australia. The `Bug Busting' method

(Community Hygiene Concern, 1999) adopted in the UK

and endorsed by its Department of Health, and the No Nit

Policy led by the National Pediculosis Association in the

USA, provide useful models.

Secondly, it is important to establish a better evidence

base about the physiology, detection, treatment, effects

and management strategies of head lice infestations.

Already the literature reviewed has signalled signi®cant

evidence gaps and these gaps provide incentives for

further research. A range of quantitative and qualitative

research methodologies can be applied to advance infor-

mation and it is urgent that the myths surrounding head

lice are dispelled. Concerns have also been raised about

exposure to toxic chemicals used when treating an

infestation, and this must be a research priority. There

is a lack of evidence that the transmission of head lice

occurs via shared articles such as hats and combs and the

evidence that head lice spread through inanimate objects

such as furniture is even less conclusive. These concerns

form additional research agenda items. There are several

ways of treating the head for lice, but unfortunately many

treatments lack evidence and research has only been

conducted on some of the insecticides used. The effect-

iveness of manual removal methods, such as ®ne combing,

herbal/natural or home remedies is under researched. We

agree with Dodd (1999), who recommends that further

well-designed research should address comparisons

between different treatment methods such as herbal,

chemical and physical methods.

Further research needs to address social health issues.

The possible in¯uence of socio-economic status on the

incidence of head lice and the stigma associated with

having head lice are just two issues for social research.

Head lice seem to be a low priority for health professionals

in Australia, whereas parents and teachers believe the

problem demands greater attention. There is a need for

the development of clear policy and protocols.

It is important to provide good information, acknow-

ledgement and support for parents in these time

consuming tasks. The social distress that surrounds the

problem justi®es it as a public health concern. It is

timely for health care professionals to re-examine and

prioritize this community health problem, and to

research and work collaboratively towards the eradication

of head lice.

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