J Arthropod-Borne Dis, March 2022, 16(1): 72–83 YH Hama-Karim et al.: Epidemiological Study of … 72 http://jad.tums.ac.ir Published Online: March 31, 2022 Original Article Epidemiological Study of Pediculosis among Primary School Children in Sulaimani Governorate, Kurdistan Region of Iraq *Yadgar Hussein Hama-Karim1, Pary Mohammad Azize2, Salar Ibrahim Ali1, Shahow Abdulrehman Ezzaddin3 1College of Health and Medical Technology, Chwarchra Qtr 2Sulaimani Technical Insitute, Bakhtiari Qtr 3College of Medicine: Sulimani University Old Campus, Majid Bag Main Street, beside Smart Health Tower *Corresponding author: Dr Yadgar Hussein Hama-Karim, Email: yadgar.hamakarim@spu.edu.iq (Received 7 Sep 2021; accepted 9 Mar 2022) Abstract Background: Pediculosis is a common parasitic public health issue. Many socio-demographic and economic factors affect the pattern and prevalence of pediculosis. It is widely spread among pupils, particularly those in elementary schools. This study aimed to determine the prevalence of Pediculus capitis infestation and its related risk factors in pri- mary school children in Sulaimani Governorate, Kurdistan Region of Iraq. Methods: This is a cross-sectional study, overall, 2064 primary school children (aged 5–14 years) during the period from October 2019 to February 2020 were randomly examined for the presence of any stage of Pediculosis capitis in both urban and suburban areas. The schools were selected by multistage sampling methods. A questionnaire was sent to the parents to get consent and fill in for every single pupil. The results were computed using the chi-square test and lo- gistic regression analysis. Results: The overall prevalence of head lice infestation was (9.16%). The study found a significant association of Pe- diculosis capitis infestation with gender, parents’ education level, mother’s employment, number of siblings, and previ- ous infestation. The older age of children (≥12 years old) and the higher-grade pupils (4th to 6th class) were more infested. Conclusion: Head lice remain a health problem for school children. It needs collaboration of many sectors for decreas- ing and early detection and treatment in both urban and suburban areas since they have a close rate of infestation. Keywords: Pediculosis capitis; Risk factors; Children; Primary schools; Sulaimani governorate Introduction Lice as compulsory ectoparasites have a long relationship with the human host, indi- cating co-evolution between hosts and para- sites (1). Blood sprinkling lice are wingless bugs that feed on sebaceous secretions and bodily fluids. The human body hosts three kinds of lice, including head louse, body louse, and pubic louse (2, 3). The head louse is an ecto- parasite of humans, and unfed lice will die within 2 to 4 days if they are kept away from people and are denied a blood meal (4, 5). Lice infection is considered as one of the world's public health problems and especially in developing countries. Depending on the cir- cumstances especially for school children and their developmental ages, this infection is of special importance. The distribution of lice infection occurs across the world and especially with a wide range of pediculosis has been observed in the developing countries (6, 7). In epidemiologi- cal studies in schools around the Middle East countries, the prevalence of head lice in Iran is 7.6% (8), Syria 14.3% (9), Turkey 13.1% (10), Saudi Arabia 64.2% (11), and Jordan 20.4% (12). The status of primary school children head lice infestation in Iraq varies from 3.6% in Bagh- Copyright © 2022 The Authors. Published by Tehran University of Medical Sciences. This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International license (https://creativecommons.org/licenses/by- nc/4.0/). Non-commercial uses of the work are permitted, provided the original work is properly cited. http://jad.tums.ac.ir/ mailto:yadgar.hamakarim@spu.edu.iq https://creativecommons.org/licenses/by-nc/4.0/ https://creativecommons.org/licenses/by-nc/4.0/ J Arthropod-Borne Dis, March 2022, 16(1): 72–83 YH Hama-Karim et al.: Epidemiological Study of … 73 http://jad.tums.ac.ir Published Online: March 31, 2022 dad (13) to 20.08% in primary schools in Kir- kuk (14) and 34.7% in secondary schools in the same city (15). The highest infestation was ever reported was 56% among prisoners in Erbil. In the Kurdistan Region of Iraq, the to- tal prevalence of the Pediculus capitis infes- tation was approximately 14% among school children (16–19). The variance in infection rate might be attributed to a variety of variables, including eradication methods, the number of head-to-head interactions, diagnostic proce- dures, school head lice policy (no-nit policy), pesticide resistance, and general head lice aware- ness (20). Direct contact with infected people is the main route of transmission of lice. In addition, the disease is transmitted indirectly through contact with infected personal items such as combs or brushes, hats, and pillows (21). Al- so, various factors such as personal hygiene, parents' job, parent's education, hair length, and frequency of bathing per week can affect the prevalence of infection (22). The ectopar- asite is found mainly in crowded places where close contacts occur, including schools, nurse- ries, sports facilities, playgrounds, camps, and prisons (2). The highest incidence is observed among children aged from five to thirteen years old. Nevertheless, the incidence among the 24– 36-year age group is increasing due to their exposure to infected children. Pediculosis is more common in younger girls and those in crowded families (23, 24). The itching scalp is already caused by lice bites, saliva, and fecal matter. Depression, sleep- lessness, exhaustion, educational failure, men- tal problem, a decline in social stigma, and al- lergic responses are some of the additional symp- toms that might occur. Because of the societal shame associated with infestations and the vast majority of cases are unreported (5, 25). No thorough study on head lice infestation has been conducted over recent years in Sulai- mani Governorate and considering the rising trend in pediculosis frequency among children in Sulaimani schools; therefore, this study was conducted to determine the prevalence of P. capitis infestation and the associated risk fac- tors among primary school children. Materials and Methods Study setting and participants The school-based, cross-sectional study was performed in the primary schools (classes 1–6) inside and outside the Sulaimani gover- norate. The study was performed in the Sulai- mani Governorate/ Kurdistan Region of Iraq between October 2019 and February 2020. At the time of the study, 333045 children were enrolled in primary schools. Sampling and data collection A pre-test of about 3000 children was ex- amined and semi-structured questionnaires were sent to the children's parents to fill in and get their consent. Only the respondent and com- pleted forms were considered in the study. The sample size was estimated via using this formula: , where n is the sample size, z is the confidence level at 95% (1.96), P is the expected prevalence (50%), and margin of error (d), at 5%. Based on this formula, the minimum sample size needed was 385 pupils; however, the sample size was increased to in- clude all eligible pupils in the selected schools to increase the power and validity of the study. A total of 2064 primary school children (aged 5–14 years), in which 1046 boys and 1018 girls were included in this study from nine primary schools of both urban and suburban areas. Multi-step, stratified, cluster sampling was used. The total number of children in the pri- mary schools was divided into urban and sub- urban. Inside the urban areas (Sulaimani City) was also divided into western and eastern zones. The number of chosen schools was determined proportionally to the whole population. The schools were selected randomly among the areas. When a school was selected it was con- sidered as a cluster and all the children’s heads http://jad.tums.ac.ir/ J Arthropod-Borne Dis, March 2022, 16(1): 72–83 YH Hama-Karim et al.: Epidemiological Study of … 74 http://jad.tums.ac.ir Published Online: March 31, 2022 from the first to the sixth classes were exam- ined. Special attention was given to the back of the ears and neck area. The examination was done by the researchers and by at least nurses that manage the school health of that area. The infested child was recorded secretly and checked in the questionnaire form. The ques- tions in the form were designed about sex, age, class, education levels of parents, moth- er’s workplace, family size, and income. Hy- giene-related questions were also added, which include frequency of head washing, combing, bathing, hair length and style, head wash ma- terials, sharing bed and tools, and history of infestation. Statistical analysis The data were analyzed in the statistical software STATA v.14. Categorical variables were defined as the number and percentage (%) and analyzed using the chi-square test. For finding the relationship between the head lice infestation and potential predictors, the univariate logistic regression model was first used and then a multivariate logistic regres- sion was used to calculate the adjusted Odds Ratios (ORs) for compromising the risk fac- tors. Any variable having a P-value less than 0.20 was chosen to be entered in the multivar- iate logistic analysis. In both logistic regres- sion models besides OR 95% confidence in- tervals (95% CI) were presented. A P-value of less than 0.05 was considered statistically sig- nificant. Results Head lice infestation was found in 189 school children out of 2064 one examined; the overall infestation rate was 9.16%. The infes- tation was significantly more common among girls (18.7%) than boys (1.82%). The mean and median age of the infested pupils were 9.4 and 9 years old, respectively. The rate of pedicu- losis was increasing as the age group increased as shown in (Table 1). The prevalence of P. capitis was higher significantly among the 6th class and aged ≥ 12 as well as among those who had 4–6 siblings and housewife mothers, parents with primary education levels, long or wavy hair, and those with the previous infes- tation. However, family income, living in sub- urban areas were not significantly associated with head lice. Also, none of the hygiene fac- tors were found to have significant relation with head lice (Table 2). Univariate analysis showed that prevalence of head lice was related to sex, age group, class grade, father and mother’s education, mother’ employment, number of siblings, the income of the family, hair length, sharing the bed, and either if the child had the previous infestation of pediculosis or not (Table 3). However, in the multivariate logistic regression model, 12 var- iables were adjusted as it is shown in (Table 4). It was found that girls were 12 folds more at risk to get head lice than the boys (OR= 12.21, 95% CI= 2.46 to 60.51). The odds of developing pediculosis are two times higher among the second class when compared with the first class (OR= 2.18, 95% CI= 1.19 to 3.99). Surprisingly, children whose fathers complet- ed primary and secondary schools were 91% and twice more prone to have head lice than the illiterate ones (OR= 1.19, 95% CI= 1.08 to 3.38 and OR= 2.0, 95% CI= 1.09 to 3.67, re- spectively). In opposite, mothers who completed secondary school had their children were 42% less likely to have pediculosis compared to il- literate mothers (OR= 0.58, 95% CI= 0.35 to 0.98). Likewise, the employed mothers’ chil- dren had less likelihood of developing head lice 55% than the children whose mothers were housewives (OR= 0.55, 95% CI= 0.23 to 0.88). The greater number of siblings increases the greater risk of pediculosis; however, the sig- nificance level of those who live with more than six siblings was almost on the borderline. Pupils who had been infested with a previous attack of the parasite had two folds more like- ly to get it again than those who get it for the first time (OR= 2.31, 95% CI= 1.56 to 3.41). http://jad.tums.ac.ir/ J Arthropod-Borne Dis, March 2022, 16(1): 72–83 YH Hama-Karim et al.: Epidemiological Study of … 75 http://jad.tums.ac.ir Published Online: March 31, 2022 Table 1. Characteristics of pediculosis in the infested and noninfested primary school children, 2019–2020 Examined Pupils Infested pupils Characteristics n (%) n (%) P value Age (years) 0.023 6–8 870 (42.15) 65 (7.47) 9–11 920 (44.57) 89 (9.67) ≥ 12 274 (13.28) 35 (12.77) Sex <0.001 Boys 1046 (50.68) 19 (1.82) Girls 1018 (49.32) 170 (16.70) School Grade 0.032 1 425 (20.59) 21 (4.94) 2 346 (16.76) 34 (9.83) 3 337 (16.33) 33 (9.79) 4 345 (16.72) 36 (10.43) 5 305 (14.78) 30 (9.84) 6 306 (14.83) 35 (11.44) Residency 0.891 Urban 1126 (54.55) 104 (9.24) Sub-urban 938 (44.45) 85 (9.06) No of Siblings 0.001 0–3 1560 (75.58) 121 (7.76) 4–6 441 (21.37) 60 (13.61) ≥ 7 63 (3.05) 8 (12.70) Education level of the father < 0.001 Illiterate 261 (12.64) 19 (7.28) Primary 723 (35.03) 85 (11.76) Secondary 646 (31.30) 70 (10.84) Higher Education 434 (21.03) 15 (3.46) Mother Education level < 0.001 Illiterate 372 (18.02) 43 (11.56) Primary 659 (31.93) 80 (12.14) Secondary 565 (27.37) 43 (7.61) Higher Education 468 (22.67) 23 (4.91) Occupation of the mother < 0.001 Housewives 1552 (75.19) 170 (10.95) Work outside 512 (24.81) 19 (3.71) Family Income 0.137 Low 178 (8.64) 21 (11.80) Medium 1218 (65.13) 129 (9.58) High 495 (26.47) 39 (7.30) Hair Length < 0.001 Short 1056 (51.16) 21 (1.99) Long 1008 (48.84) 168 (16.67) Hairstyle 0.018 Straight 1507 (73.01) 122 (8.10) Curly 158 (7.66) 21 (13.29) Wavy 399 (19.33) 46 (11.53) Previous infestation < 0.001 Yes 234 (11.34) 52 (22.22) No 1830 (88.66) 137 (7.49) Total 2064 (100) 189 (9.16) http://jad.tums.ac.ir/ J Arthropod-Borne Dis, March 2022, 16(1): 72–83 YH Hama-Karim et al.: Epidemiological Study of … 76 http://jad.tums.ac.ir Published Online: March 31, 2022 Table 2. Association between hygiene factors and the head louse infestation, 2019–2020 Characteristics Examined Pupils n (%) Infested pupils n (%) P value Frequency of body washing per week ≤ 1 time 2 times ≥ 2 times 0.448 60 (2.91) 3 (5.0) 912 (44.19) 81 (8.88) 1092 (52.91) 105 (9.62) Daily hair combing 0.753 Less than once 1179 (57.12) 110 (9.33) Once or more 885 (42.88) 79 (8.51) Sharing beds 0.169 Yes 725 (35.13) 75 (10.34) No 1339 (64.87) 114 (8.51) Sharing instruments 0.254 Yes 333 (16.13) 25 (7.5) No 1731 (83.87) 164 (9.47) Cleansing material for hair washing 0.860 Shampoo 1934 (93.70) 117 (9.20) Soap 16 (0.78) 1 (6.25) Both 114 (5.52) 11 (9.65) Table 3. Univariate logistic regression for predictors of head louse infestation among school children, 2019, 2020 Predictors Crude OR (95% CI) P value Sex Male Female 1 10.84 (6.69–17.56) <0.001 Age 6–8 9–11 ≥ 12 1 1.33 (0.95–1.85) 1.81 (1.17–2.80) 0.006 Class 1st 2ns 3rd 4th 5th 6th 1 2.10 (1.19–3.86) 2.09 (1.84–3.68) 2.09 (1.28–3.92) 2.10 (1.18–3.74) 2.49 (1.41–4.36) 0.006 Father’s education level Illiterate Primary Secondary Higher education 1 1.70 (1.01–2.85) 1.55 (0.91–2.63) 0.46 (0.23–0.91) 0.007 Mother’s education level Illiterate Primary Secondary Higher education 1 1.06 (0.71–1.59) 0.63 (0.40–0.98) 0.40 (0.23–0.67) <0.001 Mother’s Occupation Housewives Work outside 1 0.31 (0.19–0.51) <0.001 No. of siblings <0.001 http://jad.tums.ac.ir/ J Arthropod-Borne Dis, March 2022, 16(1): 72–83 YH Hama-Karim et al.: Epidemiological Study of … 77 http://jad.tums.ac.ir Published Online: March 31, 2022 ≤ 3 4–6 ≥ 7 1 1.87 (1.35–2.60) 1.73 (0.81–3.72) Income Low Medium High 1 0.79 (0.48–1.29) 0.59 (0.33–1.03) 0.046 Weekly Head washing Once 2 times > 3 times 1 4.54 (0.62–33.39) 4.87 (0.67–35.64) 0.256 Combing frequency Less than once Once or more 1 0.95 (0.70–1.29) 0.753 Cleansing material Shampoo Soap Both 0.66 (0.09–5.04) 1.06 (0.56–2.01) 0.914 Hair Length Short Long 1 9.86 (6.21–15.66) <0.001 Hairstyle Straight Curly wavy 1 1.18 (0.68–2.04) 0.68 (0.47–0.97) 0.015 Sharing instruments No Yes 1 0.78 (0.50–1.20) 0.256 Sharing bed No Yes 0 1.24 (0.91–1.68) 0.169 History of infestation No Yes 1 3.53 (2.48–5.03) < 0.001 Table 4. Multivariate logistic regression for predictors of head louse infestation among school children Predictors Adjusted OR (95% CI) P value Sex Male Female 1 12.21 (2.46–60.51) 0.002 Age 6-8 9-11 ≥12 1 1.11 (0.56–2.17) 1.80 (0.73–4.50) 0.772 0.204 Class 1st 2ns 3rd 4th 5th 6th 1 2.18 (1.19–3.99) 1.86 (0.91–3.82) 1.76 (0.72–4.32) 1.55 (0.62–3.88) 1.56 (0.57–4.25) 0.012 0.091 0.218 0.352 0.384 Father’s education level Illiterate Primary 1 1.91 (1.08–3.38) 0.026 Table 3. Continued ... http://jad.tums.ac.ir/ J Arthropod-Borne Dis, March 2022, 16(1): 72–83 YH Hama-Karim et al.: Epidemiological Study of … 78 http://jad.tums.ac.ir Published Online: March 31, 2022 Secondary Higher education 2.00 (1.09–3.67) 0.34 (0.23–1.75) 0.025 0.540 Mother’s education level Illiterate Primary Secondary Higher education 1 0.89 (0.57–1.39) 0.58 (0.35–0.98) 0.93 (0.44–1.96) 0.617 0.038 0.841 Mother’s Occupation Housewives Work outside 1 0.45 (0.23–0.88) 0.020 No. of siblings ≤3 4-6 ≥7 1 1.47 (1.01–2.13) 2.33 (0.99–5.47) 0.044 0.052 Income Low Medium High 1 1.79 (0.48–1.29) 0.59 (0.33–1) 0.859 0.438 Hair Length Short Long 1 0.92 (0.20–4.27) 0.913 Hairstyle Straight Curly wavy 1 1.08 (0.59–1.97) 0.99 (0.42–1.47) 0.798 0.973 Sharing bed No Yes 0 1.16 (0.82–1.63) 0.400 History of infestation No Yes 1 2.31 (1.56–3.41) < 0.001 Discussion Head louse infestation is a widespread health concern that is most frequent in elementary schools worldwide, particularly in developing countries such as Iraq's Kurdistan region (8). It is most often affects children between the ages of 5 and 13 (4, 26). Worldwide, pedicu- losis has seen a considerable rise in recent dec- ades as a consequence of inappropriate appli- cation of pesticides, louse resistance to conven- tional pesticides, and misdiagnosis (27, 28). Ac- cording to the present research, the prevalence rate of head louse infection is 9.16 percent. Ac- cording to the National Pediculosis Association of the United States of America's definition of an epidemic, 5% of the children in the study re- gion are infected (9); hence, based on the find- ings of this research, head pediculosis will be- come epidemic in Sulaimani Governorate schools if ignored. The overall prevalence of P. capitis among primary school children in the Sulaimani gov- ernorate was 9.16%. Previous epidemiological studies in Iraq reported different prevalence rate, 14.52% and 14% in Erbil (19), 14% in Najaf (17), 14.4% in Kalar (29), 21.9% in Tikrit (14), 3.6% in Baghdad (13) and 5.4% in Basrah (30). Although the prevalence rate in this study is less than in other cities except for Baghdad and Basrah, it demonstrates that P. capitis remains a significant public health issue in the Sulai- mani governorate among school-aged children. Population density, school head lice policies, eradication techniques, number of close con- tacts per person, overcrowded housing, econom- Table 4. Continued ... http://jad.tums.ac.ir/ J Arthropod-Borne Dis, March 2022, 16(1): 72–83 YH Hama-Karim et al.: Epidemiological Study of … 79 http://jad.tums.ac.ir Published Online: March 31, 2022 ic conditions, family income, and lack of care for head louse infection may all influence the infestation rate (20). Girls had much greater infection rate than boys (16.1 and 1.82%, respectively); the asso- ciation between sex and head lice was extreme- ly significant, with a P-value of 0.002 in the final model of multivariate analysis. This find- ing corroborated the findings of many previous research papers (31–34). Probably the disparity in head lice frequen- cy is likely attributable to a variety of factors, including the behavioural differences between boys and girls, the appropriateness of female hair as a breeding ground for head lice, and girls have closer, prolonged, and more intimate head contacts in small groups (35, 36). Alt- hough, many studies suggested that may be the long hair in females is another reason, where- as a non-significant relationship was found be- tween long hair and pediculosis in the current study. The findings of this study are consistent with other research studies (10, 35, 37), which indicated that the prevalence of pediculosis was lower in children with educated parents than in children with uneducated parents, in- dicating that literacy plays a significant role in decreasing the prevalence of pediculosis. They also accord with our earlier observations, which showed that the children with mother's em- ployment outside the home were less liable to head lice infestation. This may be due to the mothers who work outside may have higher educational level and their health awareness status could be greater. In line with many prior researches, poor family incomes are predisposed to P. capitis (38, 39). However, this finding was not sig- nificant in the last model of analysis in the current study. A significant prevalence of infestation was found among school children from households with larger siblings. Larger families may pay less attention to their children's hair care, put- ting them at a greater risk of infestation due to interaction with their siblings and house over- crowding. Close contact between siblings and a crowded household facilitates head lice trans- mission, particularly if another family member has been involved (40). Moreover, the prevalence of P. capitis was directly associated with the history of the dis- ease. It seems possible that the recurrent in- festation is due to misdiagnosis, non-adherence to proper recommendations, poor product qual- ity, use of alternative traditional remises such as kerosene, and/or parasite resistance to the available product (41–43). Head louse infestation was more common among pupils with curly hair and long hair in the present study. However, in the multivari- ate analysis, they were not significant. In gen- eral, the lack of a major difference between the head louse prevalence rate and the hair length is consistent with previous publications. Con- trary to popular belief, hair cutting does not seem to lessen the incidence of head louse infestation in school children (44). Living inside and outside the city was not made a significant difference in the rate of P. capitis infestation. This can be explained by the number of pupils and the rate of infesta- tion in both urban and suburban schools were close. Besides, the living standards, medical care system regarding head lice, and availabil- ity of anti-pediculosis agents are almost equal in both regions. The sample did not involve rural schools except one, which may have a higher index of suspicion. None of the hygiene factors were found to be related to head louse infestation in this study. Some works of literature have shown that there is no significant association between head lice and inadequate cleanliness (3). Head louse trans- mission may readily occur through head-to-head contact, despite being sanitary. The increased incidence of pediculosis among individuals who were washed more often may be attribut- ed to severe itching owing to infestation (3). This study has some limitations. First, be- cause the visual screening was used to identi- http://jad.tums.ac.ir/ J Arthropod-Borne Dis, March 2022, 16(1): 72–83 YH Hama-Karim et al.: Epidemiological Study of … 80 http://jad.tums.ac.ir Published Online: March 31, 2022 fy an infestation, some students with very low levels of head lice may have gone unnoticed. Second, the lockdown of the school due to COVID-19 did not let us cover all the schools that had been planned. Therefore, the research- ers could not take any private schools. Also, because there were so many children who took part in this study, we didn't have access to some socioeconomic and cultural parameters. Third, like other cross-sectional studies, this study was not able to detect causation. The strengths of this study could be expressed as the first com- munity-based study in Sulaimani Governate. Secondly, the sample size of this study was relatively high. Fortunately, the examination of the students accompanied by educational advice on personal hygiene especially hair hygiene. Conclusion The prevalence of P. capitis infestation among primary school children was (9.16%). It is more common among girls (16.70%) than in boys (1.82%), and more frequent in 6th class grade (11.44%) and ≥12 years old children (12.77%). The rate of infestation was almost equal among pupils who live in urban and sub- urban areas. Parents’ illiteracy, housewife moth- er, crowded families, and history of infestation were considered as risk factors. For successful treatment of pediculosis, it is necessary to raise the awareness of the parents, teachers, and schools regarding the phenomenon through an educational program. Acknowledgements The authors would like to thank the Gen- eral Directorate of Education and Directorate of Preventive Health in Sulaimani for their encouragement and support. We would like to thank the nurses (school health staff in health centers) who helped us in the examination of the children and especially to Mr Hadi Mo- hammad. Special thanks to the teachers at the schools who were involved in contacting the pupils during the data collection. Ethical Considerations This study was reviewed and approved by the Ethical Committee of Technical College of Health, Sulaimani Polytechnic University (No. CH00026). The official permission was obtained from the General Directorate of Health and General Directorate Education, Principals of the schools, class teachers, and social work- ers. The signed letters of informed consent be- fore the study were obtained from the pupil’s parents. All pupils had the right not to partic- ipate in the study. Conflict of interest statement The authors declare that no conflict of in- terest exists. References 1. Demastes JW, Spradling TA, Hafner MS, Spies GR, Hafner DJ, Light JE (2012) Cophylogeny on a fine scale: Geomydoe- cus chewing lice and their pocket gopher hosts, Pappogeomys bulleri. J Parasitol. 98(2): 262–270. 2. Maramazi HG, Sharififard M, Jahanifard E, Maraghi E, Sourestani MM, Malehi AS, Rasaei S (2019) Pediculosis humanus capitis prevalence as a health problem in girl’s elementary schools, southwest of Iran (2017–2018). J Res Health Sci. 19 (2): e00446. 3. Mohammed A (2012) Head lice infestation in schoolchildren and related factors in Mafraq governorate, Jordan. Int J Der- matol. 51(2): 168–172. 4. Rukke BA, Soleng A, Lindstedt HH, Ottesen P, Birkemoe T (2014) Socioeconomic sta- tus, family background and other key fac- tors influence the management of head lice in Norway. Parasitol Res. 113(5): 1847–1861. http://jad.tums.ac.ir/ J Arthropod-Borne Dis, March 2022, 16(1): 72–83 YH Hama-Karim et al.: Epidemiological Study of … 81 http://jad.tums.ac.ir Published Online: March 31, 2022 5. Gholamnia Shirvani Z, Amin Shokravi F, Sadat Ardestani M (2013) Evaluation of a Health Education Program for Head Lice Infestation in Female Primary School Students in Chabahar City, Iran. Arch Iran Med. 16(1): 42–45. 6. Gutiérrez MM, González JW, Stefanazzi N, Serralunga G, Yañez L, Ferrero AA (2012) Prevalence of Pediculus humanus capitis infestation among kindergarten children in Bahía Blanca City, Argentina. Parasi- tol Res. 111(3): 1309–1313. 7. Salehi S, Ban M, Motaghi M (2014) A study of head lice infestation (Pediculosis capitis) among primary school students in the villages of Abadan in 2012. Int J of Com Based Nurs Mid. 2(3): 196–200. 8. Hatam-Nahavandi K, Ahmadpour E, Pashaza- deh F, Dezhkam A, Zarean M, Rafiei- Sefiddashti R, Salimi-Khorashad A, Hos- seini-Teshnizi S, Hazratian T, Otranto D (2020) Pediculosis capitis among school- age students worldwide as an emerging public health concern: a systematic re- view and meta-analysis of past five dec- ades. Parasitol Res. 119(10): 3125–3143. 9. Ismail M, Kabakibi M, Al-Kafri A (2018) Epidemiology of pediculosis capitis among schoolchildren in Damascus, Syr- ia. Indian J Paediatr Dermatology. 19(4): 331–334. 10. Gulgun M, Balci E, Karaoǧlu A, Babacan O, Türker T (2013) Pediculosis capitis: Prevalence and its associated factors in primary school children living in rural and urban areas in Kayseri, Turkey. Cent Eur J Public Health. 21(2): 104–108. 11. Moussa S, El-edailli S, Alshammari R, Alobaidi S, Al-reshidi HF, Alshammari HN (2018) Knowledge and behavioral practice of pediculosis in Hail Region, Saudi Arabia. Int J Med. 4(5): 11–21. 12. Khamaiseh AM (2018) Head Lice among Governmental Primary School Students in Southern Jordan: Prevalence and Risk Factors. J Glob Infect Dis. 10(1): 11–15. 13. Al-Mendalawi, MD, Ibrahim JG (2012) Pattern of dermatoses in Iraqi children. EMHJ-Eastern Mediterr Heal J. 18(4): 365–371. 14. Suleiman AK, Magar EA (2014) Study of Distribution of Head Lice Pedicalus hu- manus Among The Students of Many Primary School in Kirkuk Province Pe- diculus humanus capitis De Geer (Ano- plura: Pediculidae). Tikrit J Pure Sci. 19 (6): 1–6. 15. Kadir MA, Taher HM, Ali IS (2017) Head lice infestation among local and dis- placed secondary school girls and its ef- fect on some haematological parameters in Kirkuk City. Kirkuk Univ Journal- Scientific Stud. 12(4): 1–10. 16. Khidhir KN, Mahmood CK, Ali WK (2017) Prevalence of infestation with head lice Pediculus humanus capitis (De Geer) in primary schoolchildren in the centre of Erbil City, Kurdistan Region, Iraq. Pak Entomol. 39(2): 1–4. 17. Salih HA, Shamran SJ, Al-shimerty DF (2017) Prevalence of pediculosis capitis (head lice) and treating among children in Al-Najaf City, Iraq. Al-Kufa Univ J Biol. 9(3): 179–183. 18. Obaid HM (2018) Home remedies for Pe- diculus humanus capitis infection among school children. Our Dermatology Online/ Nasza Dermatologia Online. 9(2): 131– 136. 19. Abdulla BS (2015) Morphological study and Prevalence of head lice (Pediculus humanus capitis) (Anoplura: Pediculidae) infestation among some primary school students in Erbil City, Kurdistan Re- gion. ZJPAS. 27(5): 29–36. 20. El-sayed MM, Toama MA, Abdelshafy AS, Esawy AM, El-naggar SA (2017) Preva- lence of pediculosis capitis among pri- mary school students at Sharkia Gover- norate by using dermoscopy. Egypt J Dermatol Venerol. 37(2): 33–42. http://jad.tums.ac.ir/ J Arthropod-Borne Dis, March 2022, 16(1): 72–83 YH Hama-Karim et al.: Epidemiological Study of … 82 http://jad.tums.ac.ir Published Online: March 31, 2022 21. Nejati J, Keyhani A, Tavakoli Kareshk A, Mahmoudvand H, Saghafipour A, Kho- raminasab M, Tavakoli Oliaee R, Mousa- vi SM (2018) Prevalence and risk factors of pediculosis in primary school children in south west of Iran. Iran J Public Health. 47(12): 1923–1929. 22. Moosazadeh M, Afshari M, Keianian H, Nezammahalleh A, Enayati AA (2015) Prevalence of head lice infestation and its associated factors among primary school students in Iran: a systematic review and meta-analysis. Osong public Heal Res Per- spect. 6(6): 346–356. 23. Meister L, Ochsendorf F (2016) Head Lice. Dtsch Arztebl Int. 113(45): 763–772. 24. Albashtawy M (2017) Pediculosis in school sitting: What is the role of school nurs- es?. Iran J Public Health. 46(9): 1301– 1302. 25. Yousefi S, Shamsipoor F, Salim Abadi Y (2012) Epidemiological Study of Head Louse (Pediculus humanus capitis) Infes- tation among Primary School Students in Rural Areas of Sirjan County, South of Iran. Thrita J Med Sci. 1(2): 53–56. 26. Davarpanah MA, Kazerouni AR, Rahmati H, Neirami RN, Bakhtiary H, Sadeghi M (2013) The prevalence of pediculus capitis among the middle schoolchildren in Fars Province, southern Iran. Casp J Intern Med. 4(1): 607–610. 27. Hazrati Tappeh K, Chavshin AR, Moham- madzadeh Hajipirloo H, Khashaveh S, Hanifian H, Bozorgomid A, Mohammadi Bavani M, Jabbari Gharabag D, Azizi H (2012) Pediculosis capitis among prima- ry school children and related risk fac- tors in Urmia, the main city of West Azarbaijan, Iran. J Arthropod Borne Dis. 6(1): 79–85. 28. Boukan A, Mohebi L, Rashti R, Boukan A, Oshaghi MA (2022) Pediculosis capi- tis; the importance of accurate differen- tiation of nits and hair casts. Int J Trop Insect Sci. 42(1): 647–650. 29. Amin OM, Mahmood HF, Muhammed AA, Hussein SA, Mohammed LQ, Rostam BW (2019) Prevalence of head lice, Pedicu- lus humanus capitis L. and their relation to anxiety among primary school chil- dren in Kalar District, Kurdistan Region- Iraq. J Garmian Univ. 6(2): 330–338. 30. Al-Rubaiy KK, Habib OS, Ebrahim S (2004) Pattern of skin diseases among primary school children in Basrah, southern Iraq. Med j Basrah Univ. 22(2): 41–43. 31. Oh JM, Lee IY, Lee WJ, Seo M, Park S (2010) Prevalence of pediculosis capitis among Korean children. Parasitol Res. 107 (6): 1415–1419. 32. Oncu E, Vayisoglu SK, Guven Y, Onen E, Bulut ER, Cekic H, Ozturk F (2018) The prevalence of pediculus capitis in pri- mary schools in a city of Turkey and the efficacy of health education in treatment. Med Sci. 7(3): 469–475. 33. Nazari M, Goudarztalejerdi R, Anvari Pay- man M (2016) Pediculosis capitis among primary and middle school children in Asadabad, Iran: An epidemiological study. Asian Pac J Trop Biomed. 6(4): 367–370. 34. Khakshoor-Gharehsoo Z, Peyman N (2017) The effect of education to increase the awareness and preventive behaviors of pediculosis in female school students ac- cording to the health belief model in Mash- had. Health Education and Health Pro- motion. 5(2): 33–43. 35. Nor Faiza MT, Rampal L, Lye MS, Lim PY, Suhainizam MS (2018) Recurrent in- festation with pediculosis capitis among aged 10–11 students in Hulu Langat, Selangor. Int J Med Sci Public Health. 5 (4): 95–108. 36. Saghafipour A, Nejati J, Zahraei Rama- zani A, Vatandoost H (2017) Prevalence and risk factors associated with head louse (Pediculus humanus capitis) in Central Iran. Int J Pediatr. 5(7): 5245–5254. 37. Kokturk A, Baz K, Bugdayci R, Sasmaz T, Tursen U, Kaya TI, Ikizoglu G (2003) http://jad.tums.ac.ir/ J Arthropod-Borne Dis, March 2022, 16(1): 72–83 YH Hama-Karim et al.: Epidemiological Study of … 83 http://jad.tums.ac.ir Published Online: March 31, 2022 The prevalence of pediculosis capitis in school children in Mersin, Turkey. Int J Dermatol. 42(9): 694–698. 38. Karakuş M, Arici A, Töz SÖ, Özbel Y (2014) Prevalence of head lice in two so- cio-economically different schools in the center of Izmir City, Turkey. Turkiye Parazitol Derg. 38(1): 32–36. 39. Djohan V, Angora KE, Miezan S, Bédia AK, Konaté A, Vanga-Bosson AH, Kassi FK, Kiki-Barro PCM, Yavo W, Menan EI (2020) Pediculosis capitis in Abidjan, Côte d’Ivoire: Epidemiological profile and as- sociated risk factors. Parasite Epidemiol Control. 11: e00159. 40. Nordin RB, Che WA, Ibrahim NA, Naing L (2006) Prevalence and associated fac- tors of head lice infestation among pri- mary school children in Kelantan, Ma- laysia. Southeast Asian J Trop Med Pub- lic Health. 37(3): 536–543. 41. Jones KN, English JC III (2003) Review of common therapeutic options in the Unit- ed States for the treatment of pediculosis capitis. Clin Infect Dis. 36(11): 1355– 1361. 42. Gunning K, Pippitt K, Kiraly B, Sayler M (2012) Pediculosis and Scabies: A Treat- ment Update. Am Fam Physician. 86(6): 535–541. 43. Feldmeier H (2014) Diagnosis of Head Lice Infestations: An Evidence-Based Re- view. Open Dermatol J. 4(1): 69–71. 44. Kassiri H, Esteghali E (2016) Prevalence Rate and Risk Factors of Pediculus capitis Among Primary School Children in Iran. Arch Pediatr. 4(1): e26390. http://jad.tums.ac.ir/