1. Bed Bugs Providing the infection prevention professional with information to assist in developing a program to detect, eliminate and prevent bed bugs in the long term care organization Ruth Anne Rye, RN, BS Infection Prevention Consultant: LTC

2. Learners Objectives  Discuss the historical perspective of bed bugs  Describe bedbug entomology  List elements of a bed bug management plan  Discuss anecdotal episodes of ved bug infestations in healthcare facilities in Michigan

3. http://video.nationalgeographic.com video/animals/bugs-animals/other bugs/cockroach_german/

4. History: THEN  Archeologists found fossilized bed bugs while excavating a 3,500 year old site in Egypt  Introduced into US and Canada by colonists, not native Americans  Early 20 th century rated in top3 in and around structure; 1 in 3 residences  After WWW2 with discovery and accepted use of DDT infestations greatly reduced  1972 EPA banned use of DDT  Resistance developed but controlled with pesticides – lindane and malathion

5. NOW  US experiencing alarming resurgence in bed bug population  Probably associated with Increased resistance to pesticides Greater national and international travel Lack of knowledge regarding control No “magic bullet” insecticides Continuing decline of effective programs at national, state, and local health agencies

6. Entomology  Belong to category of blood-sucking ecoparasites (external parasites)  Cimex lectuanus  Small, flat, reddish brown, wingless  Approximate length of apple seed  Seek warmth and carbon dioxide  Feed on blood of humans

7. Continued … Experts in hiding during the day in Seams of mattresses, box springs, headboards, Cracks or crevices of furniture Under any clutter or objects around beds Behind wallpaper Main means of room-to-room spread is through ventilation ducts

8. Epidemiology  Ability to spread near and far – can travel over 100 ft in one night  Local spreading called “active dispersal”, i.e. hitching a ride  Supported by the environment – many sleeping under one roof, persons moving between rooms and convening in common areas  Tend to live within 8’ of where people sleep. Referred to as “nest” parasite because they reside in human nest  Fear light

9. Identification/Manifestations  Bite injects an anesthetic and anticoagulant – person doesn’t feel, allows uninterrupted feeding up to 5 min.  Bite marks on person – face, neck, arms, hands, any other body part  Bite mark often circular, with central hemorrhagic crust or vesicle at bite site  Distribution may be linear, curve, or random – several to many

10. Manifestations, continued….  May be itchy, with or without macular wheal, slightly swollen, red – similar to mosquito or flea bite  Emit sweet, musty odor  Visible reaction may not appear for two weeks after bite  May show no reaction  May see live bugs, e.g in folds of mattresses and sheets, or exoskeleton  Rusty-colored blood spots from blood- filled fecal material on sheets, bed clothes

11. Manifestations, continued Mental health-related symptoms  Anxiety  Insomnia  May exacerbate previous mental health illness

12. Develop a PLAN!  Utilize the expertise and strength of a multidisciplinary TEAM representing Leadership/Administration Infection Prevention Maintenance/Plant engineering Safety Nursing Housekeeping And others as determined by organization – consider pest control company, local public health o Designate authority, establish chain-of-command, and mechanism to maintain clear and consistent communication

13. Organize Plan in logical order For instance divide into sections  Detect – Eliminate – Prevent or  Recognize – Report – Respond Remediate Consider using algorithm

14. Recognize  Refer to previous slides Manifestations/Identification

15. REPORT and REACT  Immediately and directly report to person with authority to act, who will put PLAN into place and  Notify pest control/management company

16. RESPOND Treat resident’s symptoms PRN  OTC antihistamines  Topical steroids if severe pruritis  Anaphylaxis can occur

17. Have you seen this at entry points?

18. Integrated Pest Management (IPM) Michigan Regulation 637 Pesticide Use, Rules 14, 15 (revised 2008) Michigan Department of Agriculture and Rural Development IPM is a coordinated process that uses the most appropriate pest control methoda sand strategies in an environmentally and economically sound manner. Assesses – considers options - implements

19. Integrated Pest Management Approach … is the most comprehensive program for control and elimination of bed bugs. This program incorporates knowledge of insect life cycle, environmental control, and pest control methods.

20. P.M Service agreement: Addendum that addresses specific bed bug services  Cost of service – detect and treat separate from other IPM services  Type & details of service to expect  Preparation required by the organization (you!)  Realistic expectations  Schedule for completion  Client education  Limitation of liability  Exclusion for damages – replacement and health- related issues  Recordkeeping (shared) – times and locations of found bugs, and all activities related to occurrence

21. Pest Management Company  Will inspect/detect identify eradicate  Recognize that bed bug infestation will not go away without intervention  Goal is to eliminate their source of food, water, shelter  Intervention will be most effective when bed bug population is low

22. Confirm infestation  Visual inspection – look for live bugs and viable eggs Tools - powerful flashlight, and others Collect specimen and submit for determination (either entomologist or IPM professional)  Canine detection (scent detection) Useful if no live bug found Locate all rooms/areas Confirm success of treatment Must be recognized by the National Entomology Scent Detection Canine Association

23. Treatment warranted? Pre-Treatment Resident o Bathe or shower o Change clothes o Transfer to another room – remain out of room until deemed “bug free”- not with another resident o If impossible to move, resident should not leave room until room deemed “bug free”

24. Pre-treatment, continued Environment  Remove resident bed linens – sheets, pillowcases, mattress pads, etc. and seal in bag. Immediately wash and dry on hottest settings - dry at least 30 minutes  Remove mattress from bed frame and box springs and stand straight up

25. Environment continued  Inspect baseboards, electrical outlets, carpeting, underside of furniture  Empty closets, bedside tables, dresser drawers – anything where bug could hide. Seal tightly in plastic bag  Remove all items from walls

26. Treatment options Physical – primary means  Vacuming  Steam  Heat  Cold “freeze” treatment  Fumigation Chemical (pesticides) – secondary If used incorrectly the toxic effects may be deleterious to persons and may spread bugs to unaffected areas.

27. Post-Treatment and PREVENTION  Monitor for early detection E.g. traps – passive, active, moat-style  Proper laundry handling  Aggressive housekeeping  EDUCATE personnel, residents, others include elements of plan - how to identify, report and plan  Regular skin assessment of residents  Destroy nearby bat and bird harborage  Caulk cracks and crevices in walls  Encase mattress and springs