7/8/2017 1 “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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7/8/2017
1
“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)
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
“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