The results of the bed bug bite survey we heard so much about are reported in this new article, The Sensitivity Spectrum: Human Reactions to Bed Bug Bites (PCT February 2010, Michael F. Potter, Kenneth F. Haynes, Kevin Connelly, Michael Deutsch, Erich Hardebeck, Don Partin, and Ron Harrison).
This is unprecedented stuff, so let’s take a very close look.
474 respondents, all with confirmed bed bug infestations, in Chicago, New York, Cincinnati, Louisville, Atlanta, LA and Miami. 66% living in apartments and 15% in single-family homes. All ages. 58% female, 42% male.
The breakdown for infestation level:
| Infestation level |
Bugs |
Respondents |
| Low |
≤10 |
34% |
| Moderate |
11-100 |
47% |
| High |
101-500 |
14% |
| Very high |
> 500 |
5% |
“Have you experienced any bites or skin reactions from the bed bugs in your dwelling?”
70% yes, 30% no.
Essentially the reverse of what was previously thought. Though there were also skeptics—see this note about last year’s article by Reinhardt and others.
The female/male differences were not statistically significant. And neither were ethnicity differences. The level of infestation was also not a factor.
Not so with age, however:
Significantly more people over the age of 65 reported no bites or skin reactions than those who were younger. Forty-two percent of the eldest individuals surveyed said they had no bites or reactions from bed bugs in their dwelling, whereas 26 percent of those aged 11 to 65 reportedly did not react.
This corresponds with an earlier survey where 76% of elderly tenants in one “severely infested” building did not react to bites (or reported not reacting). Possible reasons for this mentioned by the authors include reduced responsiveness to allergens in the elderly, medications that suppress the immune response (corticosteroids), and “diminished awareness due to other competing health issues.” For another discussion of a similar case, see the ASHES/Orkin white paper (PDF) from last year.
I think everyone is rightly worried about the elderly. Their infestations may go unreported, grow undetected, and then may be treated incorrectly.
Relationship to mosquito bites
The bed bug bite response reported in this survey corresponded with the level of mosquito bite response in the following way:
- “Barely visible” mosquito bite reactions = 53% reacted to bed bugs
- “Small (dime-size) welts” from mosquito bites = 77% reacted to bed bugs
- “Large (quarter-size)” / “severe (half-dollar size or larger)” mosquito bite reactions = 89% reacted to bed bugs
Characterizing the reactions of the 70%
- 72% had “itchy red welts”
- 50% had “redness or discoloration”
- 28% had “itching in the absence of welts”
- 21% had “a ‘pinprick’ or ’stinging’ sensation”
Okay, let me pause here. On this last point the authors say: “which may or may not be symptomatic of bed bugs.”
Personally I have to say I can’t count the times people have reported this. Bed bugs!
There’s a lot more about the reported reactions.
The public health question, etc.
This is remarkable:
Other oft-mentioned symptoms from respondents living with bed bugs included nervousness, paranoia, anger, frustration, embarrassment, devastation and depression. Anxiety, stress, sleeplessness and depression are medically important symptoms that can lead to other conditions. Dismissing bed bugs as “not a public health pest” on the grounds that they are unproven disease vectors ignores the pain, suffering and emotional distress inflicted on their victims. When government agencies finally concede this point, additional resources may be allocated to combat the problem, as they were years ago.
I may have to put that on a post-it.
I hope they’re right.
Not sure how I missed this but check out the CDC’s internal site search stats for 2009. Bed bugs rank #44 on the list of keywords, behind scabies, above smoking.
25,506 searches. Frustrated searchers to be sure.
I’m good for at least 20.
As previously noted, nothing but some journal articles and a key.
The Environmental Protection Agency has published Ohio Department of Agriculture’s Section 18 exemption request for propoxur in the Federal Register. The public comment period ends on January 21.
The docket is EPA-HQ-OPP-2009-0856.
The notice: Propoxur; Receipt of Application for Emergency Exemption; Solicitation of Public Comment (PDF)
ODA’s application and supporting documentation, including draft labels and supporting letters: Supporting and Related Materials (PDF)
The three products are:
- Prenbay 1% Oil Solution (Prentiss Incorporated)
- Invader HPX Residual with Propoxur (FMC Corporation)
- Prescription Treatment Brand 250 Propoxur (Whitmire Micro-Gen Research Laboratories)
From Matt Beal’s letter:
Ohio is requesting a Section 18 Exemption for the use of three formulations of Propoxur for the control of bed bugs in residential single or multiple unit dwellings, apartments, hotels, motels, office buildings, modes of transportation, and commercial industrial buildings in Ohio.
From Dr. Susan Jones’ supporting letter:
In my opinion, the current bed bug crisis represents an urgent, non-routine situation that warrants a FIFRA Section 18 emergency exemption.
The draft labels (restricted use for certified applicators) are included; all three are ready to use products and include a 14-day re-treatment restriction — and needless to say cannot be used for treating mattresses.
I would suggest to individuals and organizations in Ohio looking for guidance to contact the Central Ohio Bed Bug Task Force.
Not everyday that you read this:
Mental health impact
One aspect of the medical affects of bed bug bites that is almost never addressed is the significant psychological distress caused by the bites. This is a very real health problem and should not be ignored. There is an apparent stigma associated with bed bugs that relates the insect with poor housekeeping and hygiene,29 even though five star hotels do not escape infestations. Often when people learn that there is an insect in their bed that is biting them at night, they are horrified and disgusted. This can develop into a delusionary state, whereby the patient feels bites and insects crawling on them, even if the bed bugs have been eliminated for some time.30 As bed bugs often bite on the face and neck, the resulting bite marks can affect an individual’s self esteem and possibly interfere with employment performance or prospects. Another aspect of how bed bugs impact on the mental health of people relates to the trauma of the cost of eradication, which can be from hundreds to thousands of dollars per infestation.
Not to mention this:
[S]ince the mid 1990s there has been an unprecedented global bed bug pandemic.
Doggett, S.L., Russell, R. (2009) Bed bugs – What the GP needs to know. Australian Family Physician. 38(11). 880-884. (free PDF download)
The authors include several photos of bed bug bite reactions, including blister-like reactions. There is mention of the Canadian bed bug anemia report (see our interview with one of the authors here) and a brief discussion of bite sensitivity with reference to Reinhardt et al. 2009 (we discussed here) and Goddard/deShazo (JAMA 2009), and also to this other Goddard/deShazo article (Midsouth Entomologist 2009) which I suppose we should have discussed earlier but, well.
One more quote from Doggett and Russell:
As bed bugs are not known to transmit infectious diseases, most regional and local health authorities do not strictly consider them to be a health issue. Clearly, however, they are a community health problem. Bed bugs produce variable irritating skin reactions and are responsible for considerable mental anguish, as well as being a major economic imposition on the community. Unfortunately, such an apathetic stance by health authorities can allow the bed bug resurgence to continue and become an increasing problem in more communities. As a result, more medical practitioners will be consulted by more victims of bed bug bites.
I think the apathy of public health authorities has indeed been an agent of the spread. But this apathy would not have persisted so long were it not for the stigma. I’m not sure how this will play out in the years to come, given all current evidence that suggests bed bug problems will continue to increase. Some interesting times ahead for sure.
What has been your experience with doctors and bed bugs? I hope more doctors start to ask about bed bugs. In my experience it does pay to start the conversation yourself. Educate your doctor, for the next patient who seeks advice.
And what do you make of the p word and bed bugs? Can we finally start calling this a pandemic? I never properly understood the reluctance.
Finally, on a barely related note of wishful thinking, I have been intrigued by NYC’s public health detailing program. What a great idea. Could we possibly piggyback some bed bug literature in there?
Update: Federal Register notice published; public comment period ends January 21, 2010.
When we noticed the talk about the active consideration by EPA of Section 18 emergency exemptions for bed bugs, it wasn’t clear which pesticides were being discussed.
The Columbus Dispatch reported today that Ohio is in a position to get propoxur for bed bugs.
The story about today’s Central Ohio Bed Bug Summit has Matt Beal of the Ohio Department of Agriculture citing University of Kentucky trials:
In tests at the University of Kentucky, the chemical killed 100 percent of the bedbugs exposed to it within 24 hours and kept on killing after eggs hatched, Beal said. That compared with a 16 percent kill rate after 72 hours for a commonly used household insecticide against one strain found in Cincinnati, and 40 percent in another strain.
The stakes are high as we all know. “Overwhelmed” and “bleak” are the words from Paul Wenning and Susan Jones.
Will this happen?
Getting the U.S. EPA to sign off will be a high hurdle, Beal said.
I’m curious to know what you make of this.
A new article on bed bugs in health care facilities from Orkin and the American Society for Healthcare Environmental Services (ASHES) of the American Hospital Association is out:
Pulling Back the Sheets on the Bed Bug Controversy: Research, Prevention and Management in Hospital & Long-Term Care Facilities (PDF).
Here’s an excerpt of the discussion of bite reactions and the implications for detection and control:
In recent research conducted at Orkin’s Training Center in Atlanta, Ga., we introduced each of 900 volunteers to one to three bed bugs from a lab colony for a feeding. Volunteers were monitored closely for reactions to the initial bite. Almost immediately, 3.7 percent of participants reacted with mild to serious skin irritation. Within 18 days, an additional 0.8 percent exhibited some level of reaction. In total, fewer than 5 percent of the participants had a reaction to beg bug bites. In the affected group, there were no discernible correlations between the subjects’ race, age or gender and their reaction to bed bug bites.
Because so few people seem to react visibly to initial bed bug bites, the presence of visible bite reactions – or the lack thereof – may not be a reliable early indicator of bed bug presence. Instead, it would seem that many hosts will have no reaction when first bitten, leaving bed bugs undetected for a longer period.
Orkin recently witnessed this disconnect first-hand at an independent living facility when we were called to consult on a severe bed bug infestation. The source infestation was a colony of 500-1,000 bed bugs – in one room – in various growth phases. Most of these bugs were found in the resident’s bed. Upon further inspection, our Commercial Pest Specialists identified 10 other separate cases of bed bugs in the same facility. It was a severe infestation, but zero bite reactions were reported by the facility’s residents in the other affected areas. This finding was correlated by research at the University of Kentucky that found that the elderly have a diminished response to skin irritants and are less likely than other age demographics to exhibit a reaction.
Quite a lot to think about and evaluate, including new information. Given the paucity of resources, a must read. The authors are Ron Harrison and Bill Lawrence from Orkin.
Via PCT.
Dr. Stephen W. Hwang is a research scientist at the Centre for Research on Inner City Health, the Keenan Research Centre in the Li Ka Shing Knowledge Institute of St. Michael’s Hospital, and Associate Professor of Medicine and Director of the Division of General Internal Medicine, University of Toronto. He is lead author of the influential 2005 Toronto bed bug infestations study. Dr. Hwang graciously answered our questions about the recent anemia case report in the Canadian Medical Association Journal which has deepened our understanding of the health effects of bed bugs on vulnerable populations.
New York vs Bed Bugs: Can you tell us about the severity of the patient’s condition and why it was caused by bed bugs? This was a life-threatening condition?
Dr. Stephen W. Hwang: The patient had severe anemia (a very low level of red blood cells) because he had an extensive bed bug infestation in his apartment that had gone untreated for months. This man was losing a substantial amount of blood on a daily basis to the thousands of bed bugs living in his bed and mattress, to the point that he became iron deficient. His blood levels reached a very low level that could be described as potentially life-threatening, although fortunately he did not suffer any permanent damage to his health. As we describe in our report, we are quite certain that the bed bugs were the cause of his anemia because an extensive series of medical investigations did not reveal any other source of blood loss or an alternative explanation for his anemia. In addition, his anemia went away and did not return after his apartment was treated for bed bugs.
New York vs Bed Bugs: The patient’s bed bug infestation has been abated but not eradicated. Presumably he is still at risk should the infestation grow to previous levels. Have you any indications of the prevalence of persistent bed bug infestations in the vulnerable populations which are the subject of your research interests? And what are the implications for the care of individuals who are at higher risk for chronic bed bug infestations? What would you recommend to health care providers?
Dr. Stephen W. Hwang: We have not done a follow-up study to find out if bed bug infestations are more common than before among vulnerable populations such as people living in homeless shelters or residents in low-income housing. In my experience as a physician caring for patients who are homeless, I would say that the problem of bed bugs has become even more prevalent over the last 5 years. Although many people complain about bed bug infestations, and rightly so, I think that the main point of our case study is that we should be keeping our eyes open for those individuals who have bed bugs in their home and are not complaining about it, for whatever reason. I suspect that people who have severe mental illness, addictions, or cognitive impairment (such as dementia) are at highest risk of developing overwhelming bed bug infestations. Health care providers need to familiarize themselves with the symptoms of bed bug bites and infestations, and be prepared to give advice on how to deal with this problem.
New York vs Bed Bugs: Aside from severe allergic reactions, there is little evidence in the medical literature for any of the potential health risks that have been suggested for bed bug infestations. It’s an open question, however, whether there is awareness and capacity to detect effects. In the years since your Toronto survey of bed bug infestations, what has been the interest in and perception of bed bugs in the medical and social services communities?
Dr. Stephen W. Hwang: Over the last 5 years, I think bed bugs have changed from being a new and unfamiliar problem to one that many health care and social service providers are very accustomed to seeing. Since this is a problem that shows no sign of going away, we need to prepare ourselves for a continuous and sustained effort to improve the control of bed bugs, rather than expecting to “defeat” or eliminate them. The risk is that we can’t afford to become either complacent or hopeless in this ongoing struggle. I also believe that we need to devote more resources to ensure that people who don’t have the capacity or resources to deal with bed bug infestations in their home can get the assistance that they need.
Publications:
Pritchard, M.J. & Hwang, S.W., 2009. Severe anemia from bedbugs. CMAJ, 181(5), 287-288. doi:10.1503/cmaj.090482
Hwang SW, Svoboda TJ, De Jong IJ, Kabasele KJ, Gogosis E. Bed bug infestations in an urban environment. 2005. Emerging Infectious Diseases 11(4), 533-538. http://www.cdc.gov/ncidod/EID/vol11no04/04-1126.htm
A new Canadian Medical Association Journal article reports on a patient who was ultimately hospitalized with severe anemia “almost certainly caused by ongoing blood loss from multiple bedbug bites.”
Pritchard, M.J. & Hwang, S.W., 2009. Severe anemia from bedbugs. CMAJ, 181(5), 287-288. doi:10.1503/cmaj.090482
The patient, 60 years old, initially presented with fatigue and lethargy for a two-month period that coincided with the bed bug infestation in his apartment.
After his second hospitalization for anemia (his hemoglobin had dropped to 52 g/L), his doctor visited him at home and discovered the true extent of his infestation (thousands of bed bugs, some observed crawling on the patient).
The patient had other medical problems, including a substance abuse problem that “may have increased his risk of extreme bedbug infestation by rendering him apathetic and inattentive to conditions in his home.”
Because he was unable to prepare his apartment for treatment, he was put up temporarily in a shelter while his apartment was treated.
His hemoglobin rose to 132 g/L (the authors reference the normal range as 135–180 g/L) four weeks after he received bed bug treatment.
Dr. Pritchard and Dr. Hwang write that bed bug bites:
should be considered a possible cause of chronic blood loss and iron-deficiency anemia in people who have signs of bedbug infestation. The anemia in the patient we have described was almost certainly caused by ongoing blood loss from multiple bedbug bites. The attribution of his anemia to bedbug bites is supported by the absence of other identifiable causes of anemia and the return to normal of his hemoglobin level after treatment of the severe infestation in his apartment. The patient’s poor eating habits may have contributed to the severity of his anemia.
Sadly, six months later, his anemia is still gone but the bed bugs, in lesser numbers, are still in his apartment, though it seems he is not suffering as before:
He has reported seeing and killing a few bedbugs in his apartment on a daily basis, but he has not experienced new bedbug bites.
(Because he lives alone, I think he must be experiencing continued bed bug bites, but perhaps we may conjecture that the current level of his infestation is not producing the previous reactions or, indeed, the severe anemia.)
This is the most disturbing aspect of this case. Here is someone who cannot cope with bed bugs and who is at medical risk from a severe bed bug infestation.
And he still has bed bugs.
The authors note the higher risk of developing severe bed bug infestations for people with certain medical and substance abuse conditions who also may require significant health care and social services intervention for bed bug treatment and control.
Dr. M. Jane Pritchard practices at Leaside Health Centre in Toronto and Dr. Stephen W. Hwang is a homelessness and health research scientist whom you will recall from the 2005 Toronto bed bug study: Hwang SW, Svoboda TJ, De Jong IJ, Kabasele KJ, Gogosis E. Bed bug infestations in an urban environment. 2005. Emerging Infectious Diseases 11(4), 533-538. http://www.cdc.gov/ncidod/EID/vol11no04/04-1126.htm
I hope you are checking the website of the Central Ohio Bed Bug Task Force every now and then. If you live in a place, like we do, where there’s nothing like it, you can borrow and learn from them.
I just mentioned this document in a comment to someone, a NYC health services worker looking for guidance, and I want to share with the rest of you out there in similar circumstances, the Central Ohio Bed Bug Task Force’s Guidelines for Reducing the Risk of Transporting Bed Bugs (PDF), a guide for health care and social service workers making home visits.
People travel around in cars in Ohio. No matter, big city social and health care workers can adapt these recommendations.
You can find additional best practice resources on our resources page.
You may want to also check out our May interview with COBBTF Chair Paul Wenning.
