1. Bed Bugs and Long-Term Care: Emerging Healthcare Issue A primer for providers By: Erik Foster, MS Medical Entomologist Michigan Department of Community Health

2. DISCLAIMER The following presentation presents a grim and often discouraging picture of a very unwelcome insect pest. However, bed bug management IS possible. Through education, training, cooperation, and persistence facilities can keep bed bugs at bay or at levels that are controllable.

3. What you will learntoday Why are bed bugs a problem now? What are bed bugs? What are the health concerns with bed bugs? Can you tell if bed bugs are present? Provider guidance for bed bug prevention and control How to prevent bed bugs from going home with you Resources

4. Brief History of Bed Bugs The human bed bug is thought to have evolved from bat feeding relatives during the time early humans were living in caves There are dozens of species in the genus, most feeding on birds and bats Early bed bug control method

5. Brief History of Bed Bugs Pre WWII estimates placed bed bug infestation rates in the U.S. as high as 1/3 homes Over the past 50 years, the human bed bug was rarely encountered in the U.S. due to improvements in living standards and the use of residual insecticides such as DDT

6. NY Daily News. July 10, 2010 Media Frenzy -2010 Drives public perception New York –Theaters –Clothing Stores –Transportation Michigan –High-rises in Detroit –Public Housing –Hospitals Business Insider. Aug 18, 2010 WWJ Radio News Room. Aug 24, 2010 WILX.com. Sept 9, 2010

7. Why the Resurgence? Bed bugs never truly went away Increases in global travel Lack of institutional knowledge due to rarity of bed bugs in the U.S. Reported resistance of bed bugs to currently used classes of insecticides Lack of public knowledge Expense of treatment

8. Are Bed Bugs a Public Health Issue? YES! Bed bugs are a HUMAN PARASITE – they live ONLY on human blood –Head lice and scabies are other examples of public health “nuisance pests” “Measurable physical and mental health effects from prolonged infestations” (CDC/EPA) Bed bugs are spread through human travel, contact, and commerce – environmentally communicable Bed bugs often affect vulnerable populations disproportionately Citizens and agencies look to public health authorities for information and guidance on health issues

9. The Bed Bug Resurgence Pest Management Survey Bed bug infestations are not required to be reported in most jurisdictions Survey of 950 pest management firms of various size worldwide The pest management industry provides valuable data on the distribution and trends of bed bug infestations Potter et al. 2010

10. Frequency of Bed Bug Infestations Worldwide Potter et al. 2010

11. Most Commonly Infested Locations Potter et al. 2010

12. Public Concern Potter et al. 2010

13. Perception of Government Officials Potter et al. 2010

14. Bed Bug Emergence in Michigan First public health indication in 2006 – Detroit –WSU: Mother brings in mattress left outside Noticeable increase in public concerns/complaints to MDCH beginning in 2008 Realization of lack of available educational resources for local agencies Housing and tenant/landlord issues difficult to resolve MDCH acknowledgment that bed bugs are a public health issue

15. Public Health and Pest Management Industry Findings County with increased bed bug infestations as reported by the local health department survey County where pest management firms have confirmed bed bugs and are seeing increased requests for treatment Legend

16. Risk Factors for a Bed Bug Infestation-Demographic Infestations primarily urban - for now: Low-income rental housing Multi-unit rental housing Adult foster care facilities Long-term care facilities Homeless shelters Single family homes Hotels Schools and Childcare Facilities

17. Risk Factors for a Bed Bug Infestation-Behavioral Lack of knowledge about bed bugs! Acquiring Used Furniture/Bedding International and Domestic Travel Transient lifestyle Tenant/client fear of reporting infestations Institutional lack of protocol/proactive response

18. Biology of the Bed Bug Small - 3/16 inch long, oval, flat, reddish - brown insects Obligate human ectoparasite Nocturnally active, and feed almost painlessly Normally found within 5- 20 feet of host Give off a distinctive “musty, sweetish” odor MALE FEMALE

19. Biology of the Bed Bug Undergo metamorphosis through 5 nymphal stages requiring a blood meal at each stage (feed within 3- 15 minutes) Life cycle takes 4-5 weeks (egg-to-egg) in ‘good’ conditions [ 75-80% RH; 83-90o F] Female may lay 200-500 eggs in her lifetime Do not fly or jump

20. Life Cycle Unfed Fed Bed bugs progress through five stages. Optimal conditions = 5weeks egg to egg.

21. Can be confused with… Ticks Cockroach nymphs Other kinds of bug bites Other insect bites Tick Bat Bug Cockroach Nymph

22. Bed Bug Biology Sense and seek warmth and CO2 Adults can survive >1 yr. without feeding (Nymphs: 3-4 mo.) Can remain fully active at <45o F “Prefer” humans but feed on other hosts, too! Becoming resistant to many commonly available pesticides

23. Bed Bug Behavior Live indoors amongst our belongings Will infest cluttered AND pristine environments Easily hide in cracks, crevices in bed frames, mattresses, personal electronics, and baseboards, etc. Normally found within two meters of host Transmitted through the movement of people and their belongings Nocturnally active, attracted to heat and carbon dioxide Infestations can quickly build to extremely high levels due to rapid reproduction, difficulties in initial detection, and lack of knowledge about how to treat

24. 24 Where bed bugs live In the building In any crack or crevice where a credit card edge could fit In anything near where people rest Bed bug crawling into a screw hole to hide Bed bugs using ceiling light fixture as harborage