European Journal of Cardiovascular Medicine

Head lice infestation, or pediculosis capitis, is a prevalent ectoparasitic condition predominantly affecting school-aged children. It is caused by Pediculus humanus capitis, a blood-feeding louse that primarily spreads through direct head-to-head contact, and to a lesser extent, through shared personal items such as combs, hats, and bedding [1,2]. Although not a vector for systemic infections, the infestation is associated with significant physical discomfort, persistent scalp pruritus, secondary bacterial infections, sleep disturbances, and social embarrassment, which can adversely affect a child’s psychosocial well-being and academic performance [3,4].

Globally, the prevalence of head lice infestation among children aged 5–13 years varies widely, with reported rates ranging from 20% to 70%, depending on geographic, socioeconomic, and hygienic conditions [1,5]. In low- and middle-income countries, particularly in densely populated and under-resourced settings, factors such as poor personal hygiene, infrequent hair washing, overcrowded households, and shared sleeping spaces significantly contribute to higher infestation rates [2,5,6]. Additionally, low parental literacy and limited awareness about preventive strategies exacerbate the risk of persistent or recurrent infestations [4].

Despite its public health relevance, pediculosis capitis remains underreported due to social stigma, absence of school-based screening programs, and reliance on ineffective home remedies [3]. Furthermore, commonly used diagnostic methods such as visual inspection lack sensitivity and may fail to detect early or asymptomatic infestations, especially in community-based settings [6]. This underscores the need for improved surveillance, standardized diagnostic practices, and educational interventions to manage and prevent head lice infestations effectively.

In this context, the present study was undertaken to estimate the prevalence of head lice infestation among primary school children in Amalapuram, Andhra Pradesh, and to identify associated behavioral and environmental risk factors. Additionally, the study compared the diagnostic accuracy of three commonly used methods visual inspection, wet combing, and microscopic examination to inform effective school-based screening protocols.

Study Design and Setting:
This was a school-based cross-sectional study conducted in Amalapuram, Andhra Pradesh. The study targeted school-going children aged 5 to 12 years enrolled in local primary schools. The study aimed to assess the prevalence of head lice infestation, identify associated risk factors, and evaluate the diagnostic accuracy of commonly used detection methods.

Study Population and Sampling:
A total of 200 children were selected using stratified random sampling to ensure representative distribution across age groups and schools. Inclusion criteria included children aged 5–12 years, attending school, present on the day of data collection, and whose parents/guardians provided written informed consent. Children were excluded if they were undergoing treatment for lice infestation within the previous 7 days, had scalp dermatological conditions (e.g., psoriasis), sustained scalp injuries, or had hypersensitivity to diagnostic tools.

Data Collection Tools and Procedure:
Data were collected through a structured, pre-validated questionnaire administered to parents or guardians. The questionnaire captured demographic data, hygiene practices, sharing habits (combs, hats), family size, and previous infestation history. Each child subsequently underwent clinical scalp examination using three diagnostic techniques:

Visual inspection: Performed under natural light to detect lice or nits.

Wet combing: Conducted using a fine-toothed lice comb on moistened hair.

Microscopic examination: Performed on lice/nits collected during combing to confirm the presence of infestation.

Ethical Considerations:
Ethical clearance was obtained from the institutional ethics committee. Written informed consent was secured from parents/guardians. Assent was obtained from children where appropriate.

Statistical Analysis:
Data were entered into Microsoft Excel and analyzed using SPSS version 24. Descriptive statistics were calculated for demographic and risk factors. Diagnostic accuracy of the methods was assessed using sensitivity and specificity analyses.

A total of 200 school-going children aged 5 to 12 years were included in the present cross-sectional study. The age- and gender-wise distribution is presented in Table 1, Figure 1. The majority of participants belonged to the 8–10 years age group, accounting for 38.5% of the total sample. Females constituted a slightly higher proportion (61.5%) than males (38.5%).

Table 1: Demographic Profile of Study Participants (N = 200)

Figure 1. Demographic Profile of Study Participants

The prevalence of head lice infestation was significantly associated with several behavioral and environmental risk factors (Table 2, Figure 2). Close contact at school emerged as the most prominent factor, reported in 75% (n = 150) of the children. Sharing of combs and hats was noted in 66.7% (n = 133), while poor hygiene was identified in 58.3% (n = 117). Children from larger families (defined as five or more members) represented 50% (n = 100) of the affected group. A previous history of lice infestation was present in 41.7% (n = 83), indicating potential reinfestation or suboptimal treatment in earlier episodes.

Table 2: Distribution of Risk Factors Associated with Head Lice Infestation

Figure 2. Distribution of Risk Factors Associated with Head Lice Infestation

The diagnostic efficacy of the three assessment methods—visual inspection, wet combing, and microscopic examination—was evaluated and is summarized in Table 3, Figure 3. Microscopic examination demonstrated the highest diagnostic accuracy, with a sensitivity of 95% and specificity of 93%, establishing it as the most reliable reference method. Wet combing also showed robust performance (sensitivity: 91%; specificity: 88%) and was noted to be practical for field use. In contrast, visual inspection had lower accuracy, with a sensitivity of 75% and specificity of 70%, raising concerns about its reliability when used as a standalone screening method.

Table 3: Diagnostic Accuracy of Methods Used for Detection

Figure 3. Diagnostic Accuracy of Methods Used for Detection

Findings from different investigative approaches are outlined in Table 4. Clinical examination revealed visible lice or nits in many participants, while wet combing effectively retrieved lice from dampened hair. Microscopic confirmation provided definitive identification of the parasite species. Additionally, parental interviews captured frequent complaints of itching and scalp irritation among affected children, underscoring the symptomatic burden and social discomfort associated with the infestation.

Table 4: Investigations Performed and Findings

Figure 4. Investigations Performed and Findings

This cross-sectional study investigated the prevalence, associated risk factors, and diagnostic accuracy of various methods for detecting head lice infestation among 200 school-aged children in Amalapuram, Andhra Pradesh. The results revealed a significant burden of infestation linked to modifiable behavioral and environmental factors and highlighted the value of accurate diagnostic tools in school-based screening.

The most prevalent risk factor identified was close contact at school (75%), which is consistent with findings from Hama-Karim et al. [7], who observed high transmission rates in classroom settings due to overcrowding and prolonged proximity among peers. Similarly, sharing personal items such as combs and hats (66.7%) and poor hygiene (58.3%) emerged as major contributors. These are in line with the results of Kitvatanachai et al. and Bartosik et al., who reported that shared grooming tools and infrequent hair washing significantly increased the risk of infestation [8,9].

Large family size, noted in 50% of the cases, is often associated with shared sleeping arrangements and limited access to personal hygiene resources, corroborating the observations by Ghofleh Maramazi et al. [10]. Furthermore, 41.7% of children had a previous history of infestation, indicating recurrent episodes, possibly due to inadequate treatment or reinfestation within the household. These trends were similarly reported by Khamaiseh et al. and Najjari et al., who emphasized the need for routine follow-up and family-wide management strategies [11,12].

In terms of diagnostic accuracy, microscopic examination demonstrated the highest sensitivity and specificity (95% and 93%, respectively), confirming its status as the diagnostic gold standard. This is supported by studies from Abdul Aziz et al. and Zahirnia et al., who also reported superior performance of microscopy in confirming head lice presence [13,14]. Wet combing, with a sensitivity of 91% and specificity of 88%, was a reliable and practical alternative for community use. It was particularly noted for its utility in large-scale screening, as highlighted by Saraswat et al. [15].

Conversely, visual inspection yielded the lowest diagnostic performance (sensitivity: 75%, specificity: 70%). This method often fails to detect early or mild infestations, a limitation echoed in the work of Andrade et al. [16], who demonstrated that lice may be easily overlooked due to variations in hair characteristics such as thickness and length.

Limitations

This study had certain limitations. Being cross-sectional in nature, it could not establish causality between identified risk factors and infestation. The findings are limited to a specific geographic region and may not be generalizable to other populations with different socio-cultural practices. Self-reported data on hygiene practices and previous infestation history may have been subject to recall or social desirability bias. Additionally, resource constraints limited the use of advanced diagnostic modalities beyond microscopy for species-level identification

This study highlights a considerable burden of head lice infestation among primary school children, predominantly linked to modifiable factors such as close contact in schools, poor hygiene, sharing of personal items, and overcrowded living conditions. The findings underscore the importance of targeted health education programs, emphasizing personal hygiene and discouraging comb or hat sharing. Among diagnostic methods, microscopic examination demonstrated the highest accuracy, while wet combing emerged as a practical and sensitive alternative for large-scale screening. Visual inspection alone was insufficient for reliable diagnosis. Integrating routine screening and early intervention strategies into school health programs is essential to reduce infestation rates and prevent reinfestation in endemic settings.

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