1. Sleep Tight! By Roslyn Joinvil & Kedarry Ransome Mentor: Mary-Lee Wong, MD Tania Rivera, MD Co-Mentor: Shirley Gomez Department of Internal Medicine Allergy & Immunology Beth Israel Medical Center

2. Epidemiology Bed bugs = Cimex lectularius Cimex Roman for bug lectularius Latin for couch or bed They are part of an insect family called Cimicidae (bed bugs, bat bugs, and swallow bugs) The 91 species in this family are wingless, obligate hematophagous ectoparasites that feed on bats, birds, and mammals Attracted to human's high body temperature and carbon dioxide production

3. Epidemiology They generally avoid light, hide during the day, and feed at night. Hiding places are usually within 1 to 2 meters of suitable hosts: seams in mattresses crevices in box springs backsides of headboards spaces under baseboards or loose wallpaper behind hanging pictures will feed during the day if hungry and the light is dim. will feed during the day if hungry and the light is dim.

4. Outbreak – WHY NOW?? Bed bug infestations are rapidly increasing worldwide (developed countries): Bed bug infestations are rapidly increasing worldwide (developed countries): Increased international travel and immigration Increased international travel and immigration Increased temperatures Increased temperatures Allowing used furniture & bedding w/o inspection Allowing used furniture & bedding w/o inspection Changes in pest control practices and increased insecticide resistance Changes in pest control practices and increased insecticide resistance Ex: DDT used after World War II Ex: DDT used after World War II Reports of bed bug infestations in San Francisco doubled between 2004 and 2006 Reports of bed bug infestations in San Francisco doubled between 2004 and 2006 Goddard et al 2008 Romero et al 2007 Doggett et al 2004

5. Life Cycle Egg – The female lays her eggs, usually in clusters of 50 per day. Eggs hatch in 1-2 weeks. Nymph – The nymph must consume a blood meal before it can molt. It molts 5 times to reach adulthood. The nymph stage lasts 3 weeks in warm temperatures and months in cold temperatures. Adult – Adult bed bugs live about 10 months, and can survive up to 1 year without feeding

6. How to Recognized Them? Adult bed bugs are oval shaped, flat, and approximately 5 mm long They resemble unfed ticks or small cockroaches and are easily visible, even to the untrained eye. Adults are reddish brown (chestnut) in color. *immatures are smaller and light yellow. They have a pyramid-shaped head with prominent eyes, and slender antennae After a blood meal, the bugs may increase in length by 30% to 50% and in weight by 150% to 200%.

7. Clinical Presentations Cutaneous manifestations Cutaneous manifestations Systemic reactions Systemic reactions

8. Clinical Presentation: Cutaneous Manifestations Stucki. Nejm Sept 2008. Most common: 2-5 mm pruritic maculopapular erythematous lesions at bed bug feeding sites. Resolve within 1 week Complex cutaneous reactions: pruritic wheals (local urticaria) around a central punctum, papular urticaria, and diffuse urticaria at bite sites Definitive diagnosis depends on identification of the bedbug or positive skin test

9. Clinical Presentation: Cutaneous Manifestations The timing of cutaneous reactions to bed bugs may change with multiple exposures. This appears to reflect host immunological responses to salivary proteins. Three salivary proteins have been identified (play a role in host immunological responses) a nitric oxide–liberating heme protein [nitrophorin] 17-kDa anticoagulant [Factor X] 40-kDa apyrase-like nucleotidebinding enzyme

10. Clinical Presentation: Cutaneous Manifestations Bullous Allergic Hypersensitivity to bed bug bites mediated by IgE against salivary nitrophorin Bullous rashes may occur subsequent to biting events days later

11. Clinical Presentation: Systemic Reactions Asthma Generalized urticaria (hives) Hives presents with spontaneous weals anywhere on the body Hives presents with spontaneous weals anywhere on the body release of chemicals in the skin causes small blood vessels to leak and results in tissue swelling release of chemicals in the skin causes small blood vessels to leak and results in tissue swelling Anaphylaxis

12. Diseases Transmitted The role of bedbugs as a vector for disease transmission remains unclear. Transmission of more than 40 human diseases has been attributed to bed bugs, but there is little evidence that such transmission has ever occurred.

13. How to Eradicate? 1. 1. proper identification of the bed bug species present, because some bat-infesting species may be found inside homes. 2. 2. education of people involved 3. 3. thorough inspection of infested and adjacent areas 4. 4. implementation of chemical and nonchemical control measures 5. 5. follow-up to evaluate the success of eradication Measurement to prevent?? Avoidance, because no repellents for the insects have been demonstrated conclusively

14. Don’ts DO NOT panic and move. This will only prolong your suffering. DO NOT panic and move. This will only prolong your suffering. DO NOT move your bedroom set or throw away. DO NOT move your bedroom set or throw away. Wherever you go, the bedbugs will follow. Wherever you go, the bedbugs will follow. DO NOT bomb or fog your apartment. DO NOT bomb or fog your apartment. will send the bedbugs further into their hiding places, making them much harder to kill. will send the bedbugs further into their hiding places, making them much harder to kill. DO NOT attempt to treat bed bugs yourself. DO NOT attempt to treat bed bugs yourself. if bed bugs are not thoroughly treated, the situation will not improve and you end up wasting your time and money. if bed bugs are not thoroughly treated, the situation will not improve and you end up wasting your time and money. Professional exterminators have certified knowledge, D.E.C approved chemicals that are restricted from public use, and the right mechanical tools to treat your infested property. Professional exterminators have certified knowledge, D.E.C approved chemicals that are restricted from public use, and the right mechanical tools to treat your infested property.

15. Do’s DO take notice of yourself and other people in your household who have mysterious bites, welts or unexplained itching. DO take notice of yourself and other people in your household who have mysterious bites, welts or unexplained itching. DO remove clutter DO remove clutter i.e. throw away unwanted materials. Bedbugs like wood and like to hide in clutter - clothes on floor, around bed, etc. i.e. throw away unwanted materials. Bedbugs like wood and like to hide in clutter - clothes on floor, around bed, etc. DO give a thorough inspection to your bedding area: DO give a thorough inspection to your bedding area: i.e., night table, bed, dresser and box spring. Look for white to light brown castings (skins) of the bedbugs. i.e., night table, bed, dresser and box spring. Look for white to light brown castings (skins) of the bedbugs. look for tiny blood droppings on mattress tufts, behind picture frames, and all wooden objects in the bedroom. look for tiny blood droppings on mattress tufts, behind picture frames, and all wooden objects in the bedroom. put bedding, clothing, etc. in a plastic bag to transport to the laundry room, and wash in hot water right away and in a hot dryer. put bedding, clothing, etc. in a plastic bag to transport to the laundry room, and wash in hot water right away and in a hot dryer. DO put isopropyl alcohol in a spray bottle DO put isopropyl alcohol in a spray bottle spray the braiding of the mattress, the headboard, and the box springs. Test on a small section of furniture to see if it stains. Alcohol kills on contact, but it does not remain on the surfaces to continue killing bedbugs. Remember that the alcohol is a temporary fix. spray the braiding of the mattress, the headboard, and the box springs. Test on a small section of furniture to see if it stains. Alcohol kills on contact, but it does not remain on the surfaces to continue killing bedbugs. Remember that the alcohol is a temporary fix.

16. References 1. 1. Who knows the bed bug? Knowledge of adult bed bug appearance increases with people's age in three counties of Great Britain. Reinhardt K, Harder A, Holland S, Hooper J, Leake-Lyall C. J Med Entomol. 2008 Sep;45(5):956-8. 2. 2. Images in clinical medicine. Bedbug bites. Stucki A, Ludwig R. N Engl J Med. 2008 Sep 4;359(10):1047. 3. 3. Romero, A., M. F. Potter, D. A. Potter, and K. F. Haynes. 2007. Insecticide resistance in the bed bug: a factor in the pest’s sudden resurgence? J. Med. Entomol. 44: 175-178. 4. 4. Doggett, S. L., M. J. Geary, and R. C. Russell. 2004. The resurgence of bed bugs in Australia: with notes on their ecology and control. Environ. Health 4: 30-38. 5. 5. Reinhardt, K., and M. T. Siva-Jothy. 2007. Biology of bed bugs (Cimicidae). Annu. Rev. Entomol. 52: 352-374. 6. 6. Goddard J, deShazo RD. Rapid rise in bed bug populations: the need to include them in the differential diagnosis of mysterious skin rashes. South Med J. 2008;101:854-855. 7. 7. Bullous allergic hypersensitivity to bed bug bites mediated by IgE against salivary nitrophorin. Leverkus M, Jochim RC, Schäd S, Bröcker EB, Andersen JF, Valenzuela JG, Trautmann A. J Invest Dermatol. 2006 Jan;126(1):91-6. 8. 8. http://www.pestcentral.com/bedbugs/bedbug-dos-and-donts.html http://www.pestcentral.com/bedbugs/bedbug-dos-and-donts.html

17. Acknowledgements Harlem Children Society Harlem Children Society Dr. Sat Dr. Sat Dr. Mary Lee-Wong Dr. Mary Lee-Wong Shirley Gomez Shirley Gomez Audience Audience