Sleep Tight!

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.

4. Outbreak – WHY NOW?? • Bed bug infestations are rapidly increasing worldwide (developed countries): • Increased international travel and immigration • Increased temperatures • Allowing used furniture & bedding w/o inspection • Changes in pest control practices and increased insecticide resistance • Ex: DDT used after World War II • 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 • Systemic reactions

8. Clinical Presentation:Cutaneous Manifestations 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 Stucki. Nejm Sept 2008. 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 • 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? • proper identification of the bed bug species present, because some bat-infesting species may be found inside homes. • education of people involved • thorough inspection of infested and adjacent areas • implementation of chemical and nonchemical control measures • 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 move your bedroom set or throw away. • Wherever you go, the bedbugs will follow. • DO NOT bomb or fog your apartment. • will send the bedbugs further into their hiding places, making them much harder to kill. • 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. • 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 remove clutter • 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: • 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. • 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 • 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 • 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. • Images in clinical medicine. Bedbug bites. Stucki A, Ludwig R. N Engl J Med. 2008 Sep 4;359(10):1047. • 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. • 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. • Reinhardt, K., and M. T. Siva-Jothy. 2007. Biology of bed bugs (Cimicidae). Annu. Rev. Entomol. 52: 352-374. • 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. • 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. • http://www.pestcentral.com/bedbugs/bedbug-dos-and-donts.html

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