Lice and insecticide resistance ESCMID European Course
Marseille 2014
Pr Philippe BROUQUI & Rezack DRALI Unité de Recherche sur les Maladies Infectieuses et Tropicales Emergentes
URMITE, UM63, CNRS 7278, IRD 198, Inserm 1095,
IHU Méditérranée Infection , Marseille
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Executive summary
• Human Lice – Biology
• Definition and life style • Impact and epidemiology
– History • Ancient and modern history
– Medical importance • Typhus, recurrent fever, trench fever
– Pest control • Toward eradication
– Hygiene – Ivermectine – perythroid
– Resistance • Clinical resistance • Biology and genomic resistance
– Future direction – Evaluation of the presentation
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The Louse biology
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The Human Louse
– Head louse • Lives in hair
• Nits are glued to hair
– Body Louse • Morphologically identical
• Lives in clothes
– Crab Louse • Pubis
• Armpits
• Eyelashes
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Body Louse
• Reproductive Biology • Females lay about 8 eggs a day
• Daily mating is needed as there is no spermatheca
• A pair of mating lice can generate 200 lice during their live
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The Body louse
• Biology • Eggs laid in the folds of clothing
• Eggs hatch on day 6-9
• Eggs live never exceed 16 days
• Growing louse molts 3 times L1,L2,L3, at D3, D5 and D10
• Adults lives another 20 days
• Optimal temperature 29-32°C
• Optimal humidity 70-90%
• Feed exclusively on human – five times a day
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The Body Louse :diagnosis
• Homeless interview – Most of them denied be infested
by louse
• Look for scratch skin lesion – On the neck and trunk
• Search for nits, larvae and adults – In clothes folds
– Infestation can rank from few to more than 300 individuals
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The Body louse
• Epidemiology – Consequently
• Louse lives in clothes and not onto the skin
• Louse leaves febrile host
– Presence of lice are determined by
• Climate
– Low temperature
– Poverty
– Promiscuity
• The lack of clothing hygiene – which does not allow to change clothes
– War, refugee camps and homeless
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The Body Louse in the Laboratory
• Laboratory colony
– Breed on human skin
– Rabbit
– Bloody cotton
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The Head louse
• Factors for head louse infestation • Sex, age, socioeconomic status, poverty,
crowding but not length of hair.
• Prevalence of simultaneous Body/Head infection in Nepalese street Childs as high as 60%
• Ex vivo breeding
– Human Skin
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The Head louse
• Not yet recognized to transmit Infectious agent
• Bartonella quintana DNA in adults and nits
• Trans-ovarial transmission ?
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The Human Louse
• History and phylogenetics – Up to 3000 louse species
– Head lice prevalent in humans for thousand of years
– Body louse found in textile from Jewish revolt against Roman AD 66-73
– Found in pre-Columbian mummies
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The Body Louse Origin Debate
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18S rRNA
Peru B1
Peru B2
France H1
France H2
Thailand H1
Thailand H2
Portugal H1
Portugal H2
China H1
China H2 95
62
57
87
84
100
100
76
44
Algeria B2
Algeria B1
FranceB2
Russia B2
Russia B1
USAB2
FranceB1
USAB1
91
64
77
Zimbabwe B1
Zimbabwe B2
Rwanda B1
Burundi B1
Burundi B2
Rwanda B2
Burundi H1
Burundi H2
Rwanda H1
Rwanda H2 65
100
89
0.002
Bo
dy
lice
H
ead
lice
Sub
Sah
aran
lice
Li
ce f
rom
all
are
as e
xce
pt
sub
Sah
aran
Afr
ica
[Yong et al. 2003. C R Biol]
[Raoult et al. 2008. J.Infect.Dis] [Veracx et al. 2012. PLoS.One]
[Li et al. 2010. PLoS.Negl.Trop.Dis.]
Classification of Human Louse
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Four and five genes were missing from the body and head louse respectively. Control PCR was not able to recovered PHUM540560 in the head louse and the gene was expected to be present in the body louse only
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Are Head and body lice
distinguishable ?
18 Comparison of the transcriptional profiles of head and body lice [Olds et al. 2012]
4112 bp 14514 bp
1283054 130512522071 bp
1798 bp
752 bp898 bpP
HU
M5
40
560
PH
UM
54
05
50
PH
UM
54
05
70
PHUM540560 • 3 exons, 752 bp • non conserved hypothetic protein • 89 a.a • 8288 Da • unknown fonction
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Are Head and body lice distinguishable ?
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Both head and body louse are infested with B quintana
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Table 1: Head lice haplotypes distribution identified in this study within different haplogroups
Polymorphisms specific to haplogroup A
Polymorphisms Specific to haplogroup B
Polymorphisms specific to haplogroup C
Nonsynonymous mutations
Haplotypes A
Haplotypes X
Haplotypes B
Haplotypes C
376379384385393397405414415423426429444445447453465468475477480483486492501502505506507508510513516519525540543546549550555557564565570582591597601608609619621623624637639
X37 A G A A G A T G T T A T A C A T T A G C A A A T T G A T T C T C T G C G G G T T C G A G T C A T T G T T A T T G T
A1 A G A A G A G G T T A T G C G T T A G C A G G T C A A T T C C C C A T A A G T T T G A G T C A T C G T T A T T A T
A5 A G A A G A G G T T A T G C G T T A G C A G G T C A A T T C C C C A T A A G T T T G A G T C A T T G T T A T T A T
A52 - G A A G A G G T T A T G C G T T A G C A G G T C A A T T C C C C A T A A G T T T G A G T C A T T G T T A T T A T
A15 A G A A G A G G T T A T G C G T T A G C A G G T C A A T T C C C C A T A A G T T T G A G T T A T T G T T A T T A T
A16 A G A A G A G G T T A T G T G T T A G C A G G T C A A T T C C C C A T A A A T T T G A G T C A T T G T T A T T A T
A17 A G A A G A G G T T A T G T G T T A G C A G G T C A A T T C C C C A T A A G T T T G A G T C A T T G T T A T T A T
A18 - G A A G A G G T T A T G T G T T A G C A G G T C A A C T C C C C A T A A G T T T G A G T C A T T G T T A T T A T
A19 A G A A G A G G T T A T G T G T T A G C A G G T C A A T T C C C C A T A A G T T T A A G T C A T T G T T A T T A T
A53 - G A A G A G G T T A T G T G T T A G C A G G T C A A T T C C C C A T A A G T T T G A G T C A T T G T T A T T A T
A12 A G A A G A G G T T A T G C G T T A G C A G A T C A A T T C C C C A T A A G T T T G A G T C A T T G T T A T T A T
A24 A G A A G A G G T T A T G T G C T A G C A G G T C A A T T C C C C A T G A G T T T G A G T C A T T G T T A T T A T
A21 A G A G G A G G T T A T G T G T T A G C A G G T C A A T T C C C C A C A A G T T T G A G T C A T T G T T A T T A T
A22 A G A A G A G G T T A T G T G T T A G C A G G T C A A T T C C C C A T G A G G T T G A G T T A T T G T T A T T A T
A23 A G A A G A G G T T A T G T G C T A G C A G G T C A A T T C C C C A T G A G T T T G A G T T A T T G T T A T T A T
X25 A G A G G A G G T T A T G T G C T A G C G G G T C A A T T C T C C A C G G G G C T G A G T C A T T G T T A T T A T
X27 A G A A G A G G T T A T G T G C T A A C G G G T C A A T T C T T C A C G A G G C T G A G T C A T T G T T A T T A T
X28 A G A G G A G G T T A T G T G C T A A C G G G T C A A T T C T T C A C G A G G C T G A G T C A T T G T T A T T A T
X26 A G A G G A G G T T A T A T G C T A G C G G G T C A A T T C C C C A C G G G G C T G A G T T A T T G T T A T T A T
X29 A G A G G A G G T T A T A T G T T A A C G G A T C A A T T C T T T A C G G G G C T G A G T C A T T G T T A T T A T
X30 A G A G G A G G T T A T A T G C T A A C G G A T C A A T T C T T C A C G G G G C T G A G T T A T T G T T A T T A T
B32 A G A G G A G G T T A T A T G C T A A C A G A T C A A T T C T T T A C G G G G T T G G G T T A T T T T T G T T G C
B33 A G A G G A G G T T A T A T G C T A A C A G A T C A A T T C T T T A C G G G G C T G G G T T A T T T T T G T T G C
B34 A G A G G A G G T T A T A T G C T A A C A G A T T A A T T C T T T A C G G G G C T G G G T T A T T T T T G T T G C
B31 A G A G G A G G T T A T A T G C T A A C G G A T C A A T T C T T T A C G G G G C T G G G T T A T T G T T A T T A C
B47 A G A G G A G G T T A T A T G C T A A C G G A T C A A T T C T T T A C G G G G C T G G G T T A T T G T T G T T G C
B48 A G A G G A G G T T A T A T G C T A A C G G A T C A A T T C T T T A C G G G G C T G G G T T A T T T T T G T T A C
B36 A G A G G A G G T T A T A T G C T A A C G G A T C A A T T C T T T A C G G G G C T G G G T T A T T T T T G T T G C
B49 A G A G G A G G T T A T A T G C T A A C G G A T C A A T T T T T T A C G G G G C T G G G T T A T T T T T G T T G C
B35 A G A G G A G G T T A A A T G C T A A C G G A T C A A T T C T T T A C G G G G C T G G G T T A T T T T T G T T G C
B50 A G A G G A G G C T A T A T G C T A A C G G A T C A A T T C T T T A C G G G G C T G G G T T A T T T T T G T T G C
39C G G G A G A G A T C A C C T A T C G A T G G G G T A G T T C C T T G C A G G A T T G A G C T T C T G C C A C C A T
C51 A G G A A A G G T T G C C T A C C G A T G G G G C A A T C C C T T A C A G G A T T G A G C T A C T G T T A T C A T
40C A A G A G A G G T T G C C T A C C G A T G G G G T A A T T C C T T G C A G G A T T G A A C T C C T G T T A T C A T
41C A G G A A A G G T T G C C T A C C G A T G G G G T A A T C C C T T G C A G G A T T G A A C T C C T G T T A T C A T
42C A A G A G A A G T T G C C T A C C G A T G G G G T A A T C C C T T G C A G G A T T G A A C T C C T G T T A T C A T
43C A A G A G T G G T T G C C T A C C G A T G G G G T A A T C C C T T G C A G G A T T G A A C T C C T G T T A T C A T
44C A A G A G A G G T T G C C T A C C G A T G G G G T A A T C C C T T G C A G G A T T G A A C T C C T G T T A T C A T
Polymorphisms Positions on the targeted cytb gene fragment (nucleotide positions 370-642)
Haplotypes
Haplotyping the mitochondrial genes of human louse
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Haplotyping the mitochondrial genes of human louse
• Paris is a cosmopolitan area
• Nucleotide recombination between mitochondrial genes ?
• African lice as well as those of Paris are found in all clade while Asian louse are found in clade A only and American one in clade A and B
• Identification of a new clade in “Pygmee” clade D
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D37
A12
A18
A16
A16
A17
A5
A15 A1
A22
A23
A24
A21
X27
X28
X25
X26
X29
X30
B48
B47
B50
B49
B35
B32
B34
B33
B31
C51
C39 C42
C44
C43
C41
C40
A53
B36
A52
Africa
Asia
Europe
America
Oceania
Paris
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The new concepts on the origin and evolution of Human Louse
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THE HUMAN LOUSE AND LOUSE BORNE DISEASES
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Head Pediculosis
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Body Pediculosis
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Louse borne diseases (Body louse only)
Bartonella quintana
Rickettsia prowazekii
Borrelia recurrentis
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Bartonella quintana
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Bartonella quintana (BQ)
• Bartonella quintana
Trench fever (IC individuals)
Bacillary angiomatosis and
peliosis
(ID individuals)
Endocarditis
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Trench fever History
• Older disease than expected
– BQ in dental pulp of 4,000 Y-O man
– BQ in Napoleon soldiers in Vilnius
• Discover World War 1
– Estimated morbidity : • 1,000,000 soldiers
– Re emergence in World War 2
– Describe 1918
• Re discovered – homeless in Marseille
– homeless in Seattle
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Excavations of mass graves in Vilnius, Lithuania.
CNRS
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Trench fever BQ primary infection
• Quintane fever – Incubation 6-22 days
– A typical pain in the shin
– Dizziness
– Headaches
– HG fever
• Last 2 to 4 days
• Relapse every 4-6 days
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Trench fever Chronic bacteremia
• Recognized early 1950
• A third (5) of 14 the B.quintana infected louse feeders (typhus vaccine production) had prolonged bacteremia
• Among symptomatic carriers two third are infected de novo
• Asymptomatic carriers do not have antibodies
• In our experience • 5/11 homeless had prolonged chronic bacteremia
• Last up to 78 Weeks
• Without endocarditis ESCMID Online Lecture Library
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Bartonella Quintana In immunocompromised
• Immunocompromised situations – AIDS
– Organ transplant and other
• Cutaneous Bacilliary Angiomatosis • Histology : endothelial cell proliferation with
clumps of bacilli
• Liver and spleen peliosis • Systemic disease with bacteremia, visceral
involvement : liver, spleen, lymph nodes, bone, brain…
• Lobular proliferation of hepatic sinusoids + clumps of bacilli
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Bartonella Quintana endocarditis
• Culture negative Endocarditis – No previous valvulopathy
– Alcohol consumption
– Body louse infestation
• Homeless
– Diagnostic often delayed
– High mortality rate / Others IE
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Epidemic typhus
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Epidemic typhus the agent
• Rickettsia prowazekii
– Obligate intracellular
• BSL3 handling
– Main reservoir
• Humans but Flying squirrel possible option in the USA
– Transmission by Body Louse
• Ticks suggested option
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Epidemic typhus
• Epidemiology – Outbreaks associated with
• War famine, and refugee camps
• Cold weather poverty or gap in Public health management – In ancient time (Vilnius)
– In the last decades Burundi/Rwanda 1996, Russia
– Individual cases reported
• Homeless of Marseille, Alger and Houston,TX
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1812: La Grande Armée Napoléon
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Epidemic typhus re-emergence
• Body-louse as a cause of reemergence of typhus
Typhus
recover
« Healthy carrier »
Stress
Brill-Zinsser
OUTBREAK
R.prowazekii Infected Louse ESCMID Online Lecture Library
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Epidemic Typhus
• Life-threatening acute exanthematic illness • Fever, myalgia, headaches, prostration (tuphos)
• Rash on day 5
• Mortality without treatment 10-40% – but lower in youth (5%)
• Treatment : One dose of 200mg of Doxycycline®
Niang, Brouqui, Raoult. Emerg Infect Dis 1999
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Relapsing fever
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Relapsing Fever
• Borrelia recurrentis – Spirochete
• Almost Disappeared – But still endemic on highland of Ethiopia
• 25% hospitalization
– Outbreak notified • Sudan and rural Andean in Peru
– unnoticed cases in homeless
• Commonly reported – Slum dwellers – prisoners – and impoverished population
• Transmitted by the Body Louse
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Relapsing fever
• Clinical features
– Abrupt Chills, fever and headaches • Myalgia, arthralgia, abdominal pain , anorexia ,
• Prominent dry cough , hemoptysis and epitasis mimicking CAP
• Neurological involvement usual – Meningismus, encephalitis
– Physical signs
• Conjunctivitis, petechial skin rash of the trunk Jaundice
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Relapsing fever • Evolution
– Bleeding : purpura and epistasis • Hematuria, cerebral hemorrhages, bloody diarrhea…
– Relapses • 1-2
• Duration and severity decrease
– Mortality • 10-40% without TTT
• 2-3% if TTT
– Treatment • Jarisch-Herxheimer 75%
• 3 fold risk in patient >14YO
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Others louse-associated bacteria
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• Body Louse as a vector for Plague
– Classically : Xenopsylla cheopis • (Rat flea)
– Transmission by clothes • Observed first by Baltazar 1941
• Infected body louse collected from bacteriemic patient in Morocco 1940s
• Animal model
• Body Louse as vector for Acinetobacter baumanii?
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Prevention and control
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Delousing • Delousing
– Complete change of clothes – Clothes need to be washed up
to 50°C
– If not washed do not re-used until 6 days
– Powder dusting • 10%DDT,
• 1% malathion,
• 1% permethrin
Need for alternative treatment
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Follow up of louse infestation:
a 12 years follow up
• Head and body louse prevalence in Homeless and louse-associated diseases
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4,7 4,9
11,4
3,4
8,4
3,3
0
2
4
6
8
10
12
2000 2001 2002 2003
year of investigation
Perc
en
tag
e o
f p
osit
ive h
om
ele
ss
B quintana antibodies IgG>=100
B quintana bacteremia
R prowazekii antibodies IgG >=64
B recurrentis antibodies IgG >=100
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Delousing with Ivermectin 1898
261
15
497
60
18,5
60,7
84,9
0
10
20
30
40
50
60
70
80
90
D-0 D-7 D-14 D-45
Pre
vale
nce o
f b
od
y l
ice i
nfe
ste
d i
nd
ivid
ual
(%)
0
200
400
600
800
1000
1200
1400
1600
1800
2000
Nu
mb
er
of
bo
dy l
ice i
n t
he c
om
mu
nit
y o
f h
om
ele
ss
number of lice Prevalence
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Permethrin resistance in the
body louse Is due to the presence of mutations in
the gene encoding the α-subunit of the sodium channel that provides the depolarization of nerve cells. Kdr : Knock Down
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Permethrin kdr haplotypes and allelic frequency before the study on 52 lice from 12 randomly sampled
homeless
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Clinical trial
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0.4% Permethrin Under wear
0 % Permethrin Under wear
Double blind randomized clinical trail
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Characteristics Permethrin
(n = 40)
Placebo
(n = 33) P Value
Age, mean (SD), y 56.4 (14) 57.62 (12) .69
Men, No. (%) 37 (92) 33 (100) .24
MV Shelter 36 (90) 31 (94) .68
Marginal homelessa, No. (%) 20 (50) 20 (61) .36
Homeless with more than 50 lice, No. (%) 18 (45) 19 (58) .28
Duration of homelessness ≤24 months, No. (%) 15 (38) 19 (58) .08
Pruritus, No. (%) 40 (100) 33 (100) -
Intention-To-Treat population Per-Protocol population
Outcome Measures Permethri
n Placebo OR (95% CI)
P Value
Permethrin
Placebo OR (95% CI) P
Value
Body lice-free homeless after 14
days, No./Total (%) 11/40 (28) 3/33 (9) 3.79 (.95–
15.00) .04 11/32 (34) 3/28 (11) 4.36 (1.07–17.74) .03
Body lice-free homeless after 45
days, No./Total (%) 11/40 (28) 9/33 (27) 1.01 (.36–
2.84) .98 11/27 (41) 9/24 (38) 1.14 (.37–3.54) .81
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Permethrin Placebo
Haplotype Day 1 Day 45 P Value Day 1 Day 45 P Value
Year 1 RRRa, No./Total (%) 17/44 (39) 31/43 (72) .002 18/47 (38) 17/53 (32) .51
RRRa,b, % (95% CI) 41.9 (40.4–43.4)
67.4 (66.4–68.4) 21.1 (20.8–
21.4) 26.2 (25.3–
27.0)
Year 2 RRRa, No./Total (%) 22/32 (69) 41/56 (73) .65 18/35 (51) 34/61 (56) .68
RRRa,b, % (95% CI) 77.8 (76.1–79.6)
75.0 (74.1–76.0) 56.9 (55.1–
58.6) 59.9 (58.8–
61.0)
All RRRa, No./Total (%) 39/76 (51) 72/99 (73) .004 36/82 (44) 51/114 (45) .90
RRRa,b, % (95% CI) 62.8 (61.9–63.7)
71.8 (71.3–72.3) 34.3 (33.8–
34.9) 44.8 (44.3–
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Permethrin Placebo
Mutation Day 1 Day 45 P Value Day 1 Day 45 P Value
M815I, No./Total
(%) 44/44 (100) 43/43 (100) - 47/47 (100) 53/53 (100) -
Year 1 T917I, No./Total
(%) 18/44 (41) 31/44 (72) .003 21/47 (45) 17/53 (32) .19
L920F, No./Total
(%) 43/44 (98) 43/44 (100) - 37/47 (79) 53/53 (100) P<.001
M815I, No./Total
(%) 32/32 (100) 56/56 (100) - 35/35 (100) 61/61 (100) -
Year 2 T917I, No./Total
(%) 22/32 (69) 45/56 (80) .21 18/35 (51) 34/61 (56) .68
L920F, No./Total
(%) 32/32 (100) 56/56 (100) - 34/35 (97) 61/61 (100) -
M815I, No./Total
(%) 76/76 (100) 99/99 (100) - 82/82 (100) 114/114 (100) -
All T917I, No./Total
(%) 40/76 (53) 76/99 (77) .008 39/82 (48) 51/114 (45) .69
L920F, No./Total
(%) 75/76 (99) 99/99 (100) - 71/82 (87) 114/114 (100) P<.001
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Future direction
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Bacterial Symbiotes, Their Presence in Head Lice, and Potential Treatment Avenues :J Cutan Med Surg. 2006 Jan-Feb;10(1):2-6. Within these insects reside symbiotic bacteria “Riesia pediculicola » that enable the insect to flourish on dietary sources of limited nutritional value. These symbiotic bacteria are essential to the survival of the insect. The symbiont is accessible as a target for pediculocidal and ovicidal therapy by altering its habitat and existence. Understanding of the nature of bacterial symbiotes of head lice might lead to alternative strategies for eradication or inhibition of these necessary bacteria, thereby controlling head lice with less toxic agents than conventional insecticides, to which the organism continues to increase its resistance.
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Acknowledgement
To the medical doctors, fellows, students and nurses
who help in snapshot investigation
Dr Badiaga Sékéné
Dr H Tissot Dupont
Pr J M Rolain
Dr P Delauney
URMITE CNRS/IRD UMR 6236/198
Funded by PHRC ESCMID Online Lecture Library
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