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“Biting Bad”The Bed Bug

Ted Rosen, MD Professor of Dermatology

Baylor College of Medicine Houston, Texas

Ted Rosen, MD

F018: Infectious Disease and Infestations

in Returned Travelers: The Americas

DISCLOSURES

I do not have any relevant relationships with industry.

DISCLOSURE OF RELATIONSHIPS WITH INDUSTRY

The Panic Started in 2010: NYC!

Bedbugs Are Not Limited to Cheap Motels!

• Hotels and motels

• Homes and apartment buildings

• College dormitories, Public school classrooms

• Workplaces (eg. law office in NYC)

• Commercial property (eg. Niketown)

• Movie theaters (eg. AMC in Manhattan)

• Airplanes, Cars, Buses, Trains and Taxicabs

• Police squad cars!J Environ Health 2014;76:6-7

BedBugRegistry.com

Self-reported bites and infestations

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2016 Top Cities for Bedbugs (Orkin)(with any movement from 2015)

1. Baltimore (+9)

2. Washington, D.C. (+1)

3. Chicago (-2)

4. New York

5. Columbus, Ohio

6. Los Angeles (-4)

7. Detroit

8. Cincinnati

9. Philadelphia (-3)

10.San Francisco-Oakland, CA (+4)

11.Richmond-Petersburg, Va. (-2)

12.Raleigh-Durham, N.C. (-1)

13.Cleveland-Akron-Canton, Ohio (-1)

14.Indianapolis (+1)

15.Dallas-Ft. Worth (-2)

16.Atlanta (+3)

17.Houston

18.Buffalo, N.Y. (+2)

19.Charlotte, N.C. (-3)

20. Norfolk-Portsmouth-Newport News, VA. (+10)

2016 Top Cities for Bedbugs (Orkin)(with any movement from 2015)

1. Baltimore (+9)

2. Washington, D.C. (+1)

3. Chicago (-2)

4. New York

5. Columbus, Ohio

6. Los Angeles (-4)

7. Detroit

8. Cincinnati

9. Philadelphia (-3)

10.San Francisco-Oakland, CA (+4)

11.Richmond-Petersburg, Va. (-2)

12.Raleigh-Durham, N.C. (-1)

13.Cleveland-Akron-Canton, Ohio (-1)

14.Indianapolis (+1)

15.Dallas-Ft. Worth (-2)

16.Atlanta (+3)

17.Houston

18.Buffalo, N.Y. (+2)

19.Charlotte, N.C. (-3)

20. Norfolk-Portsmouth-Newport News, VA. (+10)

2016 Top Cities for Bedbugs (Orkin)(with any movement from 2015)

1. Baltimore (+9)

2. Washington, D.C. (+1)

3. Chicago (-2)

4. New York

5. Columbus, Ohio

6. Los Angeles (-4)

7. Detroit

8. Cincinnati

9. Philadelphia (-3)

10.San Francisco-Oakland, CA (+4)

11.Richmond-Petersburg, Va. (-2)

12.Raleigh-Durham, N.C. (-1)

13.Cleveland-Akron-Canton, Ohio (-1)

14.Indianapolis (+1)

15.Dallas-Ft. Worth (-2)

16.Atlanta (+3)

17.Houston

18.Buffalo, N.Y. (+2)

19.Charlotte, N.C. (-3)

20. Norfolk-Portsmouth-Newport News, VA. (+10)

Global Problem!

http://registry.bedbugs.net/countries/

Are Bedbugs SPREADING?

• Recent report of bedbug activity in far

Southern Chile

• The bugs have never before been reported

this far south

• Can they adapt to new climates?

Temperatures? Water availability?

• Is there such a thing as a bedbug domain?

J Med Entomol 2014;51:1073-6

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Bedbugs Disappear

• By 1950’s bedbugs vanished

• Purported due to use of long-lasting insecticides

• DDT: 1945 USDA report it “phenomenal”

• Kills in place 6 mo to 3 years

Bedbug Resurgence

• Ban on potent chlorinated hydrocarbon, like DDT

• Bedbug habits changed: move more & don’t remain in one place

• Resistance to pyrethroids (more on this later)

• Reliance on “traps” and “baits”

• Cockroach eradication efforts

• Second hand “shabby chic” materials (Rename “flea market” to “bedbug market”)

• Globalization and travelJ Med Entomol 46:51, 2009

J Med Entomol 44:175, 2007

Thin flat body

Cimex lectularis

• True insect (6 legs)

• ¼ inch long, wingless, flattened and oval body

• Life cycle that requires a blood meal to molt and continue; nocturnal

• Attracted by CO2 and heat

• Will move 5 to up to 20 feet in order to feed

• Will bite every 2 days if host is available, but….

5 mm

Cimex lectularis

• A mature adult can live 1-3 months and possibly years without additional blood meal

• Gravid female lays 200-500 eggs in a lifetime (6-12 months)

• Rarely (Florida): tropical bedbug: Cimex hemipterus

BMC Genomics 13:6, 2012

Bedbug Genome: Sequenced!

Nat Commun. 2016 Feb 2;7:10165. doi: 10.1038/ncomms10165

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Resistant Bedbugs!

• Genetic mutations:

• Thicker cuticle (skin)

• ↓ Penetration insecticides

• Upregulated CYP450

• ↑ Metabolic degradation

• Stabilized neurons

• ↓ Tetanic firing of neurons

PLoS One. 2016;11(4):e0153302

Pest Manag Sci. 2015;71:914-22Sci Rep. 2013;3:1456

Arch Insect Biochem Physiol. 2010;73:245-57

Resistant Bedbugs!

• NEW approach: identify chemicals which are suitably toxic to bedbug but non-toxic to humans which can be incorporated into an oral bait

• Fipronil 43x more potent after oral ingestion than by spray application

• Clothianidin and abamectin also emerging candidates

Pest Manag Sci. 2017;73:521-27

Bedbugs live in groups, and group living accelerates

development of nymphs into adults! J Med Entomol 51:293, 2014

Do Bedbugs Die Off in Winter?

•NO

• Bedbugs can survive one week of continuous exposure to -120 C (10.40 F)

• J Econ Entomol 106:2433, 2013

Bedbug Bite: Part 1

• Dawn or dusk, primarily early morning

• Exposed skin: arms, legs, face, neck

• CLUSTERS of bites, not just single bites

• NOT ALL PEOPLE REACT TO BITE

• ~4% react to first bite

• ~70% react in infested environment

• Less reaction children and elderly

• Women > Men (but barely so)Med Vet Entomol 23:163, 2009

Bed bugs feeding at night!

Bedbug Bite: Part 2

• Bedbug saliva contains: anesthetic, vasodilatory, anticoagulant, and proteolytic compounds

• Insects can thus feed undetected for five to 10 minutes

• Three salivary compounds have been identified as instigators of the subsequent hypersensitivity reactions that may be noticed when the host awakens J Exp Biol 1998;201(pt 18):2659–2664

Exp Parasitol 1996;83(2):184–190

J Biol Chem 1998;273(46):30583–30590

Bed bugs feeding at night!

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John Steinbeck

“The bedbugs bothered him a little bit a first, but as they got used to the taste of him and he grew accustomed to their bites, they got along peacefully”

• Tortilla Flat, 1935

Bedbug Bites

Photos courtesy of Ted Rosen, MD

RARE Severe Bite Reactions

ARM

LEGVesiculobullous in ~5%

Am J Med 125:688, 2012

Upton Sinclair

“There were two bunks, one above the other, each with a straw mattress and a pair of gray blankets – the latter stiff as boards with filth and alive with bedbugs”

• The Jungle, 1906

Bedbug Detection: Where to Look

• Typically within 3 feet of the bed

• Headboard, Mattress, Bed frame

• Electrical outlets & cable plates near bed

• Edges of carpet, particularly near bed

• Newspapers, magazines near bed

• Torn wallpaper, peeling paint

• Cushions of chairs and sofas

• Door, window, picture and mirror frames

• Drawers, especially nightstands; Shleves

Mattress

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Undersurface of drawer

Drawers

Inside of drawer

Under peeling paint!

Bedbugs and Stained Fabric

“Nightwatch” $400-450

7 days in 16x16 room; 99.8% detection rate J Econ Entomol 106:1802-11, 2013

J Econ Entomol 101:1389, 2008

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Bedbugs are competent vectors

Am J Trop Med Hyg 2015;92:331-5

In a laboratory setting….

Bedbugs and infected mice

Bedbugs acquired T. cruzi from mice

Bedbugs transmitted T. cruzi to mice

Therefore, it is possible, that

bedbugs can serve the same role as

vector for Chagas disease as do

reduviid bugs

Bedbug bites….Dangerous?

•“To date, there have been nodocumented cases of the transmission of disease from bedbugs to humans, including diseases caused by blood borne pathogens.”

• Health Information Letter IL-10-2008-011 Department of Veterans Affairs and CDC

Arch Dermatol Res. 2016;308:531-8

J Am Acad Dermatol. 2016;74:1261

Anemia!

Parasitol Res 2012;110:2577

Anxiety

Depression

Acute psychosis

Destabilizes existing

psychiatric pathology

Suicidal ideation

Int J Public Health. 2015;60:827-37.

Therapy: Environment

• Symptomatic care for bites (“Smearoids”)

• RARELY: oral steroids, antihistamines

• Search for infestation

• Sterilize bed: vacuum, steam, encasement

• Similar for furniture, frames, drawers

• Small objects: 4 days at 0oF (?effective)

• Pesticides: Propoxur & Chlorfenapyr

• Silica gel & boric acid: desiccant (dehydrates)

• Growth inhibitor (Gentrol® prevents maturation)Pest Manag Sci 69:1061-5, 2013

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“Therapy” Bedbug Resistance is Widespread in USA

Arch Insect Biochem Physiol 2010;73:245-57

John Dos Passos

“The bedbugs took the insect powder like snuff and found it very stimulating, but it got into my nose and burned, got into my eyes and blinded me, got into my nose and choked me.”

• Orient Express, 1927

What About Ivermectin?

• Bedbugs fed on humans three hours after the subject took 200ug/kg of ivermectin (n=22) vrs No Rx (n=21)

• 63% mortality by three weeks later (active)

• 8% bedbug mortality in controls

• Ivermectin may reduce the bedbug population in crowded living situations; but won’t likely abolish a heavy infestation

• J Emerg Med 45:433, 2013

Thermal Remediation

• High heat generators: 25,000 BTU/hour

• Obtain/maintain 120-1400F

• Circulate heated air w/ high capacity fans

• Monitor remotely

• 5-8 hours treatment

• Remove: pets & plants (die), candles & crayons (melt)

• EVEN HERE: there may be thermal refuges which allow for bedbug survival (eg.walls)

• http://www.thermalremediation.com/bed-bugs

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Thermal Remediation Getting Rid of Bedbugs?

Bedbug Elimination: A SURE Thing Advice for the Traveler

• Before travel: check for reported bedbug activity

• Check room: usual sites

• Baggage up high and well away from bed

• Hang clothes high (Maybe on shower rod?)

• Launder clothes before wearing again

• Sleep fully clothed?

• Sleep in bath tub?J Travel Med 19:373-9, 2012

Travel Med Infect Dis 10:281-2, 2012

Advice for the Traveler

• Interesting fact

• Study of luggage deliberately contaminated with bedbugs on the outside…what happens?

• 170 bedbugs exterior, over 24 hours only 3% moved inside (5) through closed zipper

• Message: keep luggage closed, zippered and on returning home, clean (steam, suction or just vigorous rubbing) the outside.

Pest Manag Sci. 2017;73:64-70

Two Final Thoughts

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Relax and Sing “The Bedbug Boogie”

• Bill and Bink, 1958

• Chizmo Charles, 1996

• Papa Joe Grappa, 2010

I got into bed

Turned off the light

About five minutes later

I felt something bite

Doing the bedbug boogey

Doing it all night long

Bedbug Resurgence Is……GOOD?

• Restoration of nature’s normal harmonic ecosystem

• 60 year absence of bedbugs was an aberration of nature

Irish Bedtime Verse

Night night, sleep tight!

Don’t let the bed bugs bite.

If they do, squeeze them tight,

And they won’t bite another night

SKINmed 2011;9:6-8