REVIEWS

Fomite transmission in head lice

Craig N. Burkhart, MD, MSBS,a and Craig G. Burkhart, MD, MPHb
Chapel Hill, North Carolina, and Toledo, Ohio

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. ( J Am Acad Dermatol 2007;56:1044-7.)

L ice are bloodsucking, wingless insects belong-
ing to the order Anoplura. With more than 12
million cases per year in the United States
alone, a head lice epidemic persists and resistance to
standard treatment is rising. As resistance to pyre-
throids increases, treatment with prescription pro-
ducts, such as malathion and ivermectin, is becoming
essential in these resistant cases, requiring more
physician involvement.
Head lice are more than merely a nuisance in our
society. All the various types of lice harbor various
organisms within their gut, and several recent articles
suggest head lice have been overlooked as vectors
for various human pathogens.1-4 Additionally, lice do
transmit coagulase-positive Staphylococcus aureus
and group A Streptococcus pyogenes by carrying
these organisms on their external surfaces.
Arguably the most important component of a
host/parasite relationship in controlling spread of
infestations involves transmission function. Our in-
terest in head lice was precipitated by an elementary
school epidemic in which 17 teachers were infested.
All of the teachers denied head-to-head contact with
any of their students nor fellow teachers. Present
dogma emphasizing direct contact for louse trans-
mission failed to explain this paradox. A national
From the Department of Dermatology, University of North
Carolina at Chapel Hill,a and Medical University of Ohio at
Toledo.b
Funding sources: None.
Conflicts of interest: None declared.
Reprint requests: Craig G. Burkhart, MD, MPH, 5600 Monroe St,
Suite 106B, Sylvania, OH 43560. E-mail: cgbakb@aol.com.
Published online December 30, 2006.
0190-9622/$32.00
ª 2007 by the American Academy of Dermatology, Inc.
doi:10.1016/j.jaad.2006.10.979
survey of school nurses revealed that 82% strongly
believed in fomite transmission and that difficulties
in eliminating head lice infestations relates to not
taking satisfactory precautions to clear the environ-
ment of lice and eggs.5 In that vein, 95% of school
nurses suggest vacuuming of floors and furniture to
prevent reinfestation.6
The disagreement regarding the role of fomite
transmission has previously been controversial be-
cause there has been little experimental work on this
question, and there are no clinical studies that have
been specifically designated to test this hypothesis.
However, there is now adequate, quantitated in vitro
research to quell any naysayer.
EPIDEMIOLOGIC, BIOLOGIC, AND
ANATOMIC CONSIDERATIONS IN
LICE TRANSMISSION
Head lice have infested mankind for thousands
of years with nits having been found on the hair of
both Egyptian and Peruvian mummies. Head lice
are found worldwide with no strict limitations as to
age, sex, race, or socioeconomic class. Children aged
3 to 11 years have the highest incidence, being more
frequent in girls, probably due to their predilection
for longer hair, as well as the common exchange
of brushes, barrettes, and other hair accessories.
Although prevalent in African black persons, head
lice are distinctly uncommon in African Americans.
Anatomic differences in the lice in America do not
allow proper ovipositioning of the female to lay her
eggs in coarse curly hair.7
The head louse, Pediculus capitis, is a highly host-
specific insect approximately the size of a sesame
seed. These obligate human parasites feed exclu-
sively on the blood of the host approximately every 4
to 6 hours. The female louse lives for 30 days, during

1044
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VOLUME 56, NUMBER 6
which time she lays between 5 and 10 eggs a day.
There are 3 nymphal instars (or stages) each lasting
less than a week, from which a mature adult is
formed. All nymphal instars structurally resemble the
adult save for smaller size and underdeveloped sex
organs. The oval egg capsules (nits) are usually laid
close to the scalp for warmth. Generally eggs located
within one-quarter inch of the scalp are unhatched.
In warm climates, however, viable nits may be found
15 cm (6 inches) or more from the scalp, especially
in the area above the nape of the neck. They are
cemented to individual hairs by means of a protein-
aceous matrix that closely resembles amino acid
constituents of the human hair shaft itself.8 Thus it
would appear unlikely that a simple compound
will be forthcoming that will easily dissolve the nit
sheath without damaging hair. Head lice rarely live
more than 36 hours away from the host without a
blood meal; however, given appropriate tempera-
ture (288C-328C/828C-908F) and humidity (70%-90%
relative humidity), nits can survive and hatch after
10 days away from the host.
Each louse leg has a terminal tarsus with a conspic-
uous, articulated hooked claw that is apposed to a
thumb-like extension of the tibia. The claw’s adapta-
tion allows the louse both to cling to the hairs of
the host and to move with excellent mobility. In fact,
the head louse is able to move 23 cm (9 inches) per
minute.9 However, wetting the hair considerably re-
duces their movement. The nonpesticidal ‘‘bug bust-
ing’’ treatment of head lice takes advantage of this
point by using hair conditioners before the weekly
laborious combing out of all adult lice and nymphs
from scalp hair.10 On passing, the pubic louse, in
contrast to the head louse, has a serrated edge on the
tarsal claw of the first leg, which is an adaptation for
movement on the skin of the host.11,12 This allows the
pubic louse to migrate to the trunk, legs, armpits,
beard, scalp, eyelashes, and eyebrows. This is in sharp
contrast to the head louse, which cannot move on
smooth surfaces, such as glass or plastic.
The joints of the extremities are made of soft chitin
and arthrodial membrane that is highly flexible and
stretchable. The joint space is actually made of more
chitin than the rest of the exoskeleton and affixed
with proteins that are not sclerotic. Sensory hairs,
conical pegs, and campaniform organs have been
identified on the legs that appear to be chemorecep-
tors, as well as proprioceptors and mechanorecep-
tors.11 Thus the louse is capable of detecting
environmental hazards such as wind, a comb brush-
ing through the hair, chemical signals, or a finger
scratching the scalp.
The antennae contain the scent organs, which
include the tuft organs (located within the tuft hairs
Burkhart and Burkhart 1045
on the dorsolateral surface on the external surface of
the fourth and fifth antennae segments), the peg
organs (located within the nostril holes of the
respective antennae), and the pore organs on the
dorsolateral surface of the fifth antennae segment.11
The tuft organs detect changes in humidity, whereas
the peg organs serve as olfactory organs. The louse is
attracted to the odor of ammonium that is found in
lice feces, and so it acts as an aggregation attractant.
Head lice are averse to the smell of piperonyl,
insecticides, anise, and lavender.
LICE TRANSMISSION IN GENERAL
Head lice transmission is by means of direct head-
to-head contact and fomite transmission. A fomite is
an object that can harbor a pathogenic organism for
possible transmission to other people. With lice, such
inanimate objects would include combs, brushes,
blow-dryers, hair accessories, bedding, helmets, and
other headgear.
Transmission can occur with adult lice, during the
nymphal or instar stages of development, or with the
eggs. For example, an average host carries a popu-
lation of about 20 adult female lice. During their
30-day life cycle, they have been demonstrated to
lay 2652 eggs.13 Such an accomplishment takes into
account that the female louse anatomically has two
ovaries, each with 5 ovarioles, and each of these
carrying 2 to 3 developed oocytes along its length.14
Nature has additionally allowed the female louse to
store sperm in a spermatotheca so that a single
mating is all that is required for lifetime fertility.15
Nature has therefore aided the dispersion of the
species by allowing a single female louse to have the
capabilities of starting a new population. The sheer
number of lice that hatch from one female louse
underlines the fact that many nymphs must be taking
chances of survival at sites besides their present
niches.
TRANSMISSION BY NYMPH AND
ADULT LICE
In laboratory studies, nymph and adult lice were
consistently dislodged by using a hair dryer set at
either low or high setting.16 Lice were also easily
separated from hosts’ scalp by using a normal comb,
with lice falling to the ground and/or remaining on
the comb.16 Anyone who has vigorously combed the
hair of infested patients is aware of the high number
of lice that cover one’s shirt or blouse after perform-
ing the nit-picking combing session. Lice were also
easily transferred from wet hair to a towel.16,17
Additionally, 27% of lice passively transferred from
hair wristlets to adjacent fabric within 5 minutes
of observation.16 Of interest, a hand-held vacuum
1046 Burkhart and Burkhart
failed to remove lice from fabric; however, a carpet
vacuum was successful. As both nymphal and adult
lice can survive up to 3 days away from a human
host, and nits can live for 10 days, lice landing
on headwear, shared helmets, brushes, combs, ear-
phones, bedding, upholstered furniture, and rugs
have ample time to find a new host.
All stages of lice are quite mobile. The fastest lice are
third instar nymphs and young adults, which have
been shown to be the most likely to disperse under
laboratory conditions.9,16 Head lice move rapidly away
from any perceived peril, which could come in the
form of offensive odor, light, or agitation of hair. These
defensive strategies assist them in avoiding detection
or places them in a position from which they could
transfer from the host’s hair. This transfer response has
been designated the ‘‘flee response,’’ in which the
louse traverses to the periphery of a hair follicle unit
ready to drop off if the perceived danger warrants
evacuation.1 Peril detected either by the louse’s olfac-
tory senses on their antennae, caused by light, or
detected by their mechanoreceptors on their leg joints,
induces the louse to follow one of three plans to avoid
conflict. The first is to quickly scramble away from the
site of danger. Second, the louse may opt to go to the
root of the hair and firmly attach its claws to a hair and,
so to speak, weather the storm. The final option is the
flee response, in which the louse traverses to the ends
of hair follicle units, ready to drop off if the danger
warrants evacuation. This response seconds the belief
that lice themselves can be airborne and can be blown
in the wind for short distances.1,15 Another example of
the flee response is that in several field studies,
investigators have found lice on themselves despite
having no head-to-head contact after agitating the hair
of infested individuals.18,19 A similar response is also
seen in in-vitro experiments in which many lice drop
off from hairs that extended beyond agar plates in
search of a more favorable environment.1
Lice can walk across linens, clothing, upholstery,
and carpet and can even attach to our hands and
arms hairs without difficulty.1,11,18,20 This passive
transfer also supports the transfer of lice to numerous
objects including hats, upholstery, headphones, and
pillowcases, thus posing a risk of not only fomite
transmission, but also reinfestation.16,17 With the
nymph being one third the size of the adult louse,
it was previously suggested that it can be blown
about in the air.15 It has now been confirmed that
they be made airborne with hair dryers.16 Although
lice do not possess the anatomy for jumping or
flying, combing or removing one’s sweater has been
shown to build up enough static electricity to phys-
ically eject an adult louse from an infested scalp more
than a meter.18 Lice can live in water unless heated to
J AM ACAD DERMATOL
JUNE 2007
higher 508C21,22; thus transfer of the organism while
swimming in a pool is a possibility which needs
further study.
TRANSMISSION BY LOUSE EGGS
Lice lay eggs individually onto various types of
fibers as well as on upholstered furniture and bed-
ding.15,17,23 Although there were preferences, head
lice laid their eggs on all fabrics tested by all 3 of
these researchers. Additionally, there is a clear pref-
erence for laying eggs close to other eggs. Nuttall23
found that lice prefer to lay their eggs on the
underside, rather than the top side, of various fabrics,
even when there was no illumination. In his study,
lice, when given a choice, had a strong preference
for laying eggs on felt over different grades of silk,
wool, cotton, and linen.
Lice lay eggs on all surfaces tested often within
5 minutes, with overall hatching averaging 58%.17
More hairlike substrates such as charmeuse, hair,
and faux fur were preferred to smoother material
such as felt and denim. More eggs were laid on
charmeuse than on felt or denim. The preferred
location of laying was on the frayed ends of the
fabric.
Where the fibers were not secured, lice tried to lay
their eggs as close to the ends of the fiber as possible.
Investigating the preference of lice when presented
with single strands of different fabrics, wool was the
favorite fiber, followed by cotton, polyester, nylon,
silk, and aluminum. The order fits the subjective
ranking of the strands in order of hairiness.
Aluminum is a single smooth fiber and was the least
preferred fabric. Silk has a tightly woven structure
with a smooth surface, and eggs were laid mostly on
the cut ends. Nylon and polyester have many loose
fibers projecting from their tightly woven surface.
The cotton has a more loosely woven structure with
many loose fibers sticking out from the surface. The
wool has a very open structure with a great many
loose fibers being available for oviposition sites.
In short, lice are quite capable of laying eggs on
most fabrics, even aluminum, but when presented
with a choice, will prefer the substrate with the more
open and hairy structure. A small amount of roughness
is necessary before eggs can be laid on a surface.
With egg laying, the glue is secreted as a homo-
geneous fluid which is spread by the movements of
the abdomen tip of the head louse.15,24 At the very tip
of the abdomen, there is a pair of projections, called
the terminal lobes, that help the louse locate suitable
sites for oviposition. This structure also manipulates
glue secreted by colleterial (glue) glands so that
its eggs properly adhere to hair. There is a pair of
gonopods on the ventral surface of the terminal
J AM ACAD DERMATOL
VOLUME 56, NUMBER 6
segment. These are flat and triangular in shape with a
strongly chitinized median border set with a row of
strong hairs. The sexual orifice lies under the anterior
border of the gonopods. Muscle fibers in the
gonopods can raise them from the body surface,
exposing the genital pore ready for copulation or
oviposition. At the very tip of the abdomen, there is
a pair of projections, called the terminal lobes. They
help the louse to locate suitable sites for oviposition
and have been shown to play an important role in
manipulation the egg glue before it sets.
The gonopods have to work against the cohesive
forces of the fluid in order to spread it over the
hydrophobic surface. The gonopods form a mold
around the hair in which the glue is retained until set.
The setting process of the glue depends on oxidation
of the glue substance,8,24 which results in a rapid
increase in glue viscosity. When the egg is being laid,
it passes through an oviduct containing glue, onto a
glue-covered surface. If the glue is allowed to flow over
the whole surface of the egg, any respiratory opening
will be covered by a layer of glue. The only part of the
egg which is not wetted by the glue is the cap. If the
embryo is to avoid suffocation, either the glue has to
be permeable to gases, or there must be respiratory
opening passing through the cap. Given the elaborate
mechanism used to keep the cap free from glue, the
latter seems the most plausible explanation.15,24
The main differences between egg laying by body
lice and head lice is the amount of glue secreted, and
the way head lice draw the glue into a tube before the
egg is secreted. The movement of the abdomen over
the area to be glued is similar, but head lice have a hair
enclosed between the gonads, while clothing lice are
merely rubbing the surface of the fiber. Clothing lice
do not spread the glue with a pumping action of the
terminal lobes. The flexing of the end of the abdomen
is still apparent, but it looks more like an attempt to
pump the glue out of the abdomen rather than a
method of spreading the glue after secretion.
In conclusion, there are now scientific data to
confirm fomite transmission by adult lice, instars,
and eggs. Indeed, 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; laun-
dering of everything within the infested individual’s
bed or quarantining of such material for 10 days; and
thorough vacuuming of floors, carpets, upholstery,
with a standard vacuum cleaner.
Finally, after thousands of years of infestation, a
clearer view of indirect contact transmission has been
Burkhart and Burkhart 1047
clarified; however, numerous entomologic and epide-
miologic issues continue to warrant scientific scrutiny.
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