Debugging the system: Exterminating myths about lice

Jails and prisons, like schools and homeless shelters, need a solid plan for screening for and treating these tiny vampires


Little critters often hitchhike into our facilities, particularly head, body, and pubic lice. Once in the door, these vermin spread by direct physical contact among close-living humans or through sharing personal items like clothing and bedding. Are you getting itchy yet? Jails and prisons, like schools and homeless shelters, need a solid plan for screening for and treating these tiny vampires.

Pubic health entomologist Richard Pollack, PhD knows bugs. As a specialist on lice and other biting/infesting creatures, he provides consultations to a variety of public entities including correctional facilities. I recently interviewed him about the management of lice in jails and prisons. He had some surprising information, including this list of myths about lice that need to be exterminated from our practices.

Myth #1: Presumption of prevalence

Most jails and prisons seem to have a zero tolerance for lice because of the close communal living arrangements behind bars and the concern about the spread of parasites. However, lice are not nearly as prevalent as is generally believed and other creatures and objects on a person are frequently mistaken as lice.

The prevalence of lice (whether they be head lice, body lice or pubic lice) is quite low in the general community. But any of these lice might be somewhat more prevalent amongst prison inductees as a function of their attributes and contact with other infested persons. 

Head lice are most prevalent (~1 percent) amongst elementary school aged children, but they can and do occur with some lesser frequency on adults. Body (‘clothing’) lice are almost exclusively restricted to indigent adults, but even then prevalence is so low that most physicians will never likely see a case.  Pubic (‘crab’) lice mainly affect some promiscuous adults and these infestations generally are diagnosed by those visiting STD clinics.

Myth #2: Lice burrow into the skin, and can jump and fly

Lice remain on a person’s hair or clothing and wander to the skin to blood feed once or more often each day. They have tiny straw-like mouthparts – similar to those of mosquitoes – that they use to suck blood from skin capillaries. They’re unable to burrow into the skin. Lice never develop wings, so cannot fly.  They’re also incapable of jumping.

Myth #3:  Lice are a disease

Lice may cause an allergic reaction that results in some amount of itching. For head lice, the itching tends to be mild and temporary.  Body lice tend to cause far more itching, and even make the infested person feel ‘lousy’. Public lice tend to cause much itching in the affected area.  Whereas head lice and pubic lice are annoying, they do not transmit infections. Body lice sometimes do transmit infections. In North America, this is usually limited to a bacterial agent passed in the feces of the lice and able to infect via mucus membranes and wounds.  This trench fever-like infection may frequently lead to fever, headache, muscle and bone pain and endocarditis, amongst other symptoms.

Myth #4:  Lice are readily transmitted and will lead to outbreaks in a prison

Head lice are spread mainly by direct head-to-head contact with an infested person. Shared objects such as combs and hats play a very small part in this process. Body lice are spread by direct contact with an infested person or his/her contaminated clothing or bedding. Pubic lice are spread mainly by sexual contact. If separated from a human host, lice soon die from starvation and desiccation.

This may be just hours for head and pubic lice, or a day or so for body lice. Whereas an infested person might infest one or just a few others, outbreaks of any kind of louse in a prison in North America should be incredibly rare.

Myth #5: Anyone can diagnose head lice

A diagnosis of lice (regardless of the kind) should always be based upon the objective visual confirmation of a genuine living (crawling) louse. The discovery of a louse egg is generally not a sufficient basis to confirm an infestation. Because lice are relatively tiny (as small as a poppy seed and as large as a sesame seed), a screener must have good visual acuity, be close enough to see the creature, and have a magnifying lens and some expertise to identify and distinguish them from other kinds of beasts.

Other kinds of insects and even bits of debris are frequently mistaken to be lice, and this results in much misdiagnosis and unnecessary overtreatment. Persons suspected of being ‘with’ lice should be examined by a medical professional. Correction officers – or others – who do not have proper medical training should not be put in a position to make a determination for treatment.  Treatment for lice should be considered only if lice are present.

Myth #6: It is better to treat everyone

Because most persons at intake are not likely to be infested by lice, treating everyone who enters a facility generally constitutes poor medical practice, and it is not cost effective.  The standard medications used in prisons for lousing (removal of lice) contain the insecticides permethrin and pyrethrins.

These have become less effective as resistance to these insecticides have become fairly widespread. Furthermore, the manner of their application almost assures that they won’t be effective.  Various prescription-based formulations with other active ingredients are available, but their use should be restricted to a clinic because of the alcohol content or because of risks from overexposure and misuse.

Head lice can be treated with one or two 10-minute applications of a pediculicide.  Body lice usually require no treatment to the person. Instead, a person with body lice should bathe and change into prison-issued clothing. The infested clothing should be disinfected by proper laundering, or disposed. 

If body lice are detected on the body hairs of a person, a full-body treatment with a pediculicide is justified. Pubic lice would necessitate treatment to the affected area only.  Treatment focused just on those infested is consistent with sound medical practice.  It can also dramatically save time and precious funds, and it reduces the risk of lawsuit.


General Prevention Principles

Screening and treatment for injuries, skin lesions and parasites at intake is vital. Correction officers who observe any medically relevant problem should refer the prisoner to a medical professional.

Ongoing prevention measures for lice include frequent (at least weekly) laundering of clothing and linens, and early recognition and treatment of genuine infestations.  The Federal Bureau of Prisons Lice and Scabies Protocol of March 2011 recommends the following actions:

  • Be sure laundry temperatures are set to at least 130 degrees Fahrenheit to kill lice and their eggs on linens and clothing. Use a hot cycle for drying as well.
  • Educate inmates about lice and how to get treatment if they observe lice. The FBOP Protocol includes inmate education handouts that might be helpful.
  • Inmates should not be transferred to other facilities until 24 hours after initiation of treatment.  If moved before the 2nd treatment application (7 days), communication and continuation of treatment should be provided.

 

More information about lice and other tiny travelers can be found at Dr. Pollack’s website, including pictures of fleas, ticks, mites, lice, and bed bugs.

How are you managing lice in your facility? Share your thoughts in the comments section of this post.

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