Resistant Lice? A Crisis for the Kids

The National Pediculosis Association has issued an alert to warn American families. The NPA reports that a worst-case scenario is emerging, as head lice appear to be resistant to commercially available chemical treatments. With resistance to the prescription chemical lindane already documented, it is likely that the over-the-counter pediculicides have followed suit. Lice resistance to permethrin was anticipated in 1990 by doctors John D. Edman, Medical Entomologist and John M. Clark, Insecticide Toxicologist, both at the University of Massachusetts at Amherst.

For the past year, the NPA has been averaging 50 calls a day from parents and health professionals reporting product treatment failure. Frustrated parents have responded to persistent infestations by using treatment products repeatedly, or by resorting to dangerous alternatives such as treatments containing lindane, lice sprays, dog flea and tick shampoo, and kerosene.

Many diseases affect our child population today, but few are as communicable and as widespread as pediculosis capitis, and few involve the repeated direct exposure of young children to pesticides. Parents and health professionals nationwide have reported treatment failures as consumers use "everything on the drug store shelf," only to continue finding adult-sized crawling lice. Everyone has a different opinion; even experts disagree. Dr. Sanford Matthews told Atlanta's television viewers that this years head lice have become drug resistant: "lice have developed an appetite for the various remedies and are having them for lunch." In a Boston television interview, Dr. Charles Brown, a pediatrician at the Newton Wellesley Hospital, unfortunately responded to treatment failure questions by recommending that parents "Treat the entire family."

There are many elements that can play a role in treatment failure. While there is more than sufficient reason to seriously consider insect resistance, we must also acknowledge other possible contributing factors such as noncompliance with nit removal, failure to follow product treatment instructions, and false hope generated by product marketing. A 1986 NPA commentary may have said it best: "Assured by the manufacturers that pediculicides constitute fully effective treatment. Physicians have deemed pediculosis of low importance both as a topic of research and in clinical practice. At the same time, parents are desperate to believe in any promised cure-all. As a result, we have all been fair game for misleading pharmaceutical information. We have proceeded on the basis of too little consideration for safety and too much faith in efficacy claims." (Arch Dermatol - Vol 122)

Until the treatment failure crisis is addressed by the scientific and medical community as well as the product manufacturers, the NPA is focusing its efforts on getting parents "BACK-TO-BASICS." The crisis in effectiveness comes at a time when possible louse borne disease is reported (New England Journal of Medicine, February 16, 1995) in the U.S. among the homeless.

Jill Reynolds, a registered nurse working in the public schools in Kalamazoo, Michigan and authority on head lice management views this crisis as a call to action for parents. "The stigma of head lice infestation divides friends and damages families. 'Back-to-basics' means revisiting a philosophy of friends and neighbors helping each other, parents supporting the school with volunteerism and backing it up with similar efforts at home. Outbreaks of lice can bring schools to their knees. A crisis intervention approach to head lice outbreaks is an impediment to education. Instead, head lice prevention and education should be part of every school health program."

A Massachusetts mother recently drove over three hours to the NPA offices to insist that we contact the manufacturers of products being advertised in magazines and on television. She was deeply distraught yet angry at the same time. "The ads give moms false hopes that by buying a lice shampoo you can kill all the lice and their eggs. My doctor recommended to use these products over and over again, even though I told him that they were not working. I treated myself and my family at least eight times. I have bad eyesight. No one will help me check my own head. I called my insurance company, HMO Blue in Massachusetts, to see if I could get a visiting nurse to help me. And while they paid for one visit, it just wasn't enough. When I requested additional help I was told that lice do not represent a medical problem worthy of reimbursement for a visiting nurse. I don't know about lice being a medical problem but I do know that I cannot continue applying these chemicals to myself and family, especially on my little 4-year old daughter." She has called the manufacturer and asked for a refund.

While treatment failures have been reported for all of the commercially available pediculicides, the majority of reports have involved the two largest selling products, NIX and RID. On October 5, 1995, the NPA contacted the manufacturers Warner-Wellcome (marketers of NIX) and Pfizer (makers of RID) to report the NPA's growing perception of a national crisis regarding product treatment failure. Warner-Wellcome expressed concern and offered to help the NPA collect and compile treatment failure reports. Pfizer declined to participate with the NPA but offered assistance to consumers via its own toll-free number.

The NPA does not claim to have all the answers to the serious question of possible lice resistance. However, in the meantime, we are offering the following suggestions for those who use a lice treatment product and experience treatment failure:

• Discontinue use at the earliest sign of treatment failure. Do not reuse the same product in the hope of killing the lice. Remember that lice treatment products are pesticides. Repeated use of such pesticides pose a variety of serious health risks as adverse reaction reports to NPA's national registry have indicated.
• Never resort to dangerous remedies such as lindane, kerosene, or pet shampoos.
• Never use a lice spray. Lice sprays are pesticides marketed for use on children's bedding, cars, rugs, garments, and furniture. Vacuuming is the safe and effective alternative to spraying. Head lice are human parasites and will not survive without human blood. Parents need not exhaust their physical and emotional selves by obsessive housecleaning and "bagging." They should save their energies for that which pays the most benefit: manual removal of both lice and eggs from the infested individuals.
• Manual removal is crucial. Since head lice move quickly throughout the head, it may be helpful to have two people checking an infested person at the same time. Even under the best of conditions, a few lice or nits may be missed. Use a nit removal comb to screen the infested person every day and regularly thereafter.
• Continue to check your children often. Screen for lice and nits. Early detection is the best prevention. Make checking for lice and nits part of routine hygiene.

David Satcher, Director of The Centers for Disease Control and Prevention told the NPA, "CDC does not have resources for surveillance or applied research programs regarding pediculosis or scabies." Instead, CDC refers callers to local and state health departments. These are the same state officials who are also desperate for answers to this emerging public health crisis.

The low priority assigned to this parasitic condition by the CDC has helped to create this climate in which there continues to be no collective will to address it.

The $100 million dollar a year pediculicide industry is a growing one. Brisk sales of lice treatments spell good news for profit margins but bad news for- the public's health, especially when too many products are repeat purchases and therefore represent repeat chemical exposures for a family suffering with treatment failure.

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