Cincinnati Health Department. Bed Bugs: Biology, Inspections & Treatments

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1 Cincinnati Health Department Bed Bugs: Biology, Inspections & Treatments

2 Cincinnati Health Department Presenting: Robert Smith RS

3 Adult Male - Cimex lectularius AKA bed bug, wall-louse, house bug, mahogany flat, red coat, crimson rambler

4 Description / Identification Small bodies 1/10 3/8 inch long, flat, & oval Adults reddish brown in color Nymphs (immatures) light yellow to brown Can crawl quickly in response to stimulus (heat, CO 2 )

5 Public Health Significance No evidence of disease transmission Quality of life pest Property loss, expense, mental stress Often considered most difficult pest to control

Why Control Is Difficult Size Thin, flat bodies, can hide in cracks and crevices to avoid detection/chemicals Prolific breeders Females lay ~10 eggs per

6 Why Control Is Difficult Size Thin, flat bodies, can hide in cracks and crevices to avoid detection/chemicals Prolific breeders Females lay ~10 eggs per feeding, 500 eggs in a lifetime Will produce for ~6 wks. per mating Piercing/sucking mouthpart Will not ingest chemicals Well-established pesticide resistance

7 Bed Bug Facts Feed only on blood mammals or birds Eggs hatch in 7-10 days, egg to adult development ranges from 5-8 weeks, optimal temperature F Bed bug lifespan is 6 months to over a year Adults can survive at least several weeks without feeding (longer in colder temperatures)

9 Where Are Bed Bugs Found? Since bed bugs are human parasites and excellent hitchhikers, they can potentially be wherever we congregate Most often a problem in multi-unit residential buildings Dispersal within building more common than reintroductions from outside Can travel along pipes and through walls Will often move around, even two rooms away and down the hall EARLY DETECTION IS KEY

10 Feeding - Several Instars

11 Signs of a Bed Bug Infestation Fecal spots in/around bed or chair Unexplained bites/welts (30-40% of people non-reactive) Insecticide containers Red marks on walls Cast skins Clusters of bugs (heavier infestation)

13 Where Are Bed Bugs Found? Primarily in bedrooms/sleeping areas--seams, tufts of mattress, box spring, crevices of headboard, bed frame (70%) Upholstered chairs & sofas (23%) Nightstands, dressers Edges of carpeting Any hidden crack, corner, or recessed area

14 Folds in Couch Fabric

15 Keep In Mind Bed bugs do not fly or jump Remain hidden and immobile during the day Bring in only what is needed Avoid placing items on beds, floors, sofas Use tabletops/hard surfaces away from sleeping areas Better to sit on non-upholstered chair Farther bbs are from a host, less likely they are to feed-have to be close to find us

16 Protect Yourself If entering places known to be infested, consider making a bed bug kit: Portable chair/stool Fanny pack Plastic storage container with sealed lid Change of clothes Gloves Simple shoes with minimal tread Garbage/Ziploc bags

17 Protect Yourself Lighter-colored, simple clothing tape around cuffs White cloth or mat for equipment/supplies Flashlight for visually inspecting dark rooms/surfaces PPE Personal protective equipment (severe infestations) Tyvek or Bed Bug Body Guard suits latex or nitrile gloves shoe covers

18 Bed Bugs in Office Settings Actual infestations uncommon Not a preferred habitat Low-level sightings, hitchhikers more likely Early detection more difficult Office workers rarely bitten Bugs rarely seen until feeding pattern is changed Visual inspection time consuming Can disperse into other areas Inappropriate to assign blame Re-introduction possible

19 Bed Bugs in Office Settings Disclosure of problem and communication with staff is key Licensed Pest Management Professional can play a role Visual inspection of surrounding area (within 20 feet) important Prime areas to check: Desks and chairs (where plastic meets cloth) Wall dividers (especially at base) Upholstered chairs, baseboards, coat rack, stacked papers, wherever people congregate Scent-detection canines?

20 Bed Bugs in Office Settings Immediately contain/kill any observed bugs Document where found Desks, tabletops, other common areas can be cleaned Use monitoring traps General pesticide treatments ineffective No pesticides should be applied unless by a licensed PMP

21 Inspection Thoroughly inspect all adjoining rooms around the initial infestation point (sphere surrounding the unit): Left and right Up and down Across and behind Possible Infestation Possible Infestation Infestation Possible Infestation Possible Infestation

22 Inspecting Furniture

23 Inspecting Furniture

24 Treatment Options Non-chemical Monitoring devices, pitfall traps, chemical lures Targeted vacuuming Laundering/drying at 120 or hotter Heat treatments (Containerized or whole-room) Steaming/freezing Chemical Professionally applied products with residual action Over-the-counter sprays and dusts Non-EPA registered products

25 Cincinnati Health Department QUESTIONS?

26 Head Lice in the School Setting Christina Gruber RN, BSN, MS Stark County Health Department

27 Schools & Head Lice A Nuisance NOT a Public Health Problem Fact of life for school aged children- especially those under the age 11. Most cases are not detected until infestation for at least 1 month

28 History of Head Lice Researchers believe that Head Lice has been around for hundreds of thousands of years. Most often found among children 3 11 years of age. CDC estimates that 6 to 12 million infestations occur each year in the US. Many experts believe this estimate is high due to misdiagnosis

Head Louse Adult head louse- 2-4 mm long Less commonly, lice can also be found on

Generally a dull yellow or tan to grayish-white in color Appear to be gray or almost

Eggs (nits) are attached usually 4-6 mm from base of the hair shaft.

29 Head Louse Adult head louse- 2-4 mm long Less commonly, lice can also be found on eye brows and eye lashes. Generally a dull yellow or tan to grayish-white in color Appear to be gray or almost black when full of blood. Louse may appear darker in a person with dark hair. Eggs (nits) are attached usually 4-6 mm from base of the hair shaft. Pale yellow or white color, may be dark if the embryo dies, or transparent after the louse emerges, or same color as hair. ODH-IDCM PEDICULOSIS Section 6 Revised 1/2014

30 Life Cycle- 3 Stages 1. Eggs (Nits)- Incubation of the egg takes 6-12 days. The most suitable temperature range for egg production and hatching is from 84.2 F to 89.6 F. 2. Nymph- Immature louse, looks like adult but smaller (size of a pinhead), must feed on blood to mature, reaches sexual maturity in 7-12 days 3. Adult- can lay 3-10 eggs per day; Eggs will only hatch if female has mated. Life span of adult louse is 30 days ODH-IDCM PEDICULOSIS Section 6 Revised 1/2014

Signs and Symptoms of Infestation 1. Itching- allergic reaction to the louse bite. People will often not experience symptoms; May take up to 4 to 6 weeks for itching to begin. 2.

31 Signs and Symptoms of Infestation 1. Itching- allergic reaction to the louse bite. People will often not experience symptoms; May take up to 4 to 6 weeks for itching to begin. 2. Tickling feeling in the hair or a sensation of something moving 3. Sleeplessness or irritability 4. Sores on the head caused by scratching (the sores can become infected with bacteria). Head lice do not transmit diseases. They do NOT jump or fly ODH-IDCM PEDICULOSIS Section 6 Revised 1/2014

32 What are most schools doing? Policies are by district Differences between licensed preschool/ school aged childcare/ public schools Advised to change to a NO LIVE LICE policy Social Stigma still exists NEOLA revised policy in 2012 ODH brochure What should I do if my child gets Head Lice hool%20nursing/headlice.pdf

33 Licensed Preschools & Daycares Management of communicable disease. A person trained to recognize the common signs of communicable disease -trained in prevention, recognition, and management of communicable diseases as required by paragraph (D) of rule of the Administrative Code. A child with evidence of lice, scabies, or other parasitic infestation immediately isolated and discharged to his parent or guardian: Effective: 07/03/2014 R.C review dates: 04/10/2014 and 07/03/2019 Promulgated Under: Statutory Authority: , Rule Amplifies: to Prior Effective Dates: 8/5/88, 5/28/04, 6/25/2009

34 School Age Child Care Programs (5-14 years of age) Management of communicable disease. A person trained to recognize the common signs of communicable disease or other illness as required by paragraph (L) of rule of the Administrative Code, shall observe each child daily as the child enters the group. A child with evidence of lice, scabies, or other parasitic infestation shall be isolated immediately. Decisions regarding exclusion from the program either immediately or at some later time in the day shall be determined by the program coordinator or team leader and the parent. Effective: 01/22/2010 R.C review dates: 11/03/2009 and 01/22/2015 Promulgated Under: Statutory Authority: , , Rule Amplifies: to Prior Effective Dates: ;

35 NEOLA SCHOOL POLICY- Pediculosis ( ) Examine students exhibiting scratching or evidence of live bugs Contact parent if live lice are visualized Factors influencing pick up: severity of infestation, child s age, or other health concerns influence professional judgment regarding parent pick-up and recommended treatment options. Close household contacts should be inspected. Students remaining at school will be discouraged from direct head-to-head contact with other students in the classroom. If nits only are visualized, the student may remain in school and the parent will be notified at the end of the school day. Nits located closer than one-half (½) inch on the scalp require parental action at home. Nits farther than one-half (½) inch are not considered to be viable. Revised 4/15/14 NEOLA

36 NEOLA continued- Returning to School The student, accompanied by an adult, will return to school the next day. School nurse will examine student upon return to school. If no live bugs are visualized, and no nits closer than one-half (½) inch from the scalp are present, the student may return to class. Students with live bugs or nits closer than one-half (½) inch from the scalp shall return home for further removal. The school nurse may re-inspect child s scalp in seven to ten (7-10) days to assist with control measures. School-or classroom-wide screening is not merited. School nurse shall exercise professional judgment when requests for classroom checks arise. Revised 4/15/14 NEOLA

Licensed Daycare/Preschool Licensed School Aged Daycare Public School

recognize Identify child with head lice Immediately isolate Call parent

child with head lice Immediately isolate Decision to call parent for early

examine for potential head lice If live lice DO NOT isolate.

37 Licensed Daycare/Preschool Licensed School Aged Daycare Public School Difference between daycare/school Person checking must be trained to recognize Identify child with head lice Immediately isolate Call parent for immediate pickup Person checking must be trained to recognize Identify child with head lice Immediately isolate Decision to call parent for early pickup is left up to Program Coordinator If child is itching/ scratching examine for potential head lice If live lice DO NOT isolate. Contact parent at end of day to discuss treatment options- child NOT sent home until end of school day

38 National Association of School Nurses Position Statement It is the position of the National Association of School Nurses that head lice management not disrupt the educational process. Children found with live lice should remain in classroom until the end of the school day, but be discouraged from close contact with others. School nurses should contact parents and discuss treatment options. Classroom wide and school wide screenings are not recommended. National Association of School Nurses-

American Academy of Pediatrics (AAP) Recommendations Recommends that a healthy child should not be restricted from attending school because of head lice or nits (eggs).

working, call pediatrician for a prescription medication such as spinosad or topical ivermectin. Once a family member is identified with head lice, all household members should be checked.

39 American Academy of Pediatrics (AAP) Recommendations Recommends that a healthy child should not be restricted from attending school because of head lice or nits (eggs). Use of OTC medications containing 1 percent permethrin or pyrethrins, unless resistance has been seen in the community In areas with known resistance to OTC products, or when parents' efforts are not working, call pediatrician for a prescription medication such as spinosad or topical ivermectin. Once a family member is identified with head lice, all household members should be checked. AAP does not recommend excessive environmental cleaning. However, washing pillow cases and treating natural bristle hair care items that may have been in contact with the hair of anyone found to have head lice are reasonable measures. Updates-Treatments-for-Head-Lice.aspx

40 ODH REPORTING INFORMATION While pediculosis is not an individually reportable condition in Ohio, outbreaks are required to be reported. ODH-IDCM PEDICULOSIS Section 6 Revised 1/2014

41 Steps to Treatment Treat infested individual Examine all close contacts Environmental control

42 STEP 1 Treat infested individual Never initiate treatment unless there is clear diagnosis with live lice. Apply medication that will kill live lice and most nits. Parents should be advised to remove pediculicides over a sink not in bath or shower to avoid skin irritation As a general rule - children under 2 should not be treated with pediculicides (remove lice and nits by hand) although there are a few products licensed by the FDA for use in children under 2 years of age.

43 Types of Treatment 1 Pediculicides Alternative Approaches Oral Agents- Not recommended Scabicides- Not recommended See Pediatrics Journal article below on Head Lice from May 2015 for details on #3 & #4 Head Lice; Pediatrics Vol. 135 No.5, May 1, 2015 pp. e1355-e1365

Types of Treatment Pediculicides- OTC 1.

on for 10 minutes then rinse, leaves a residue on hair that kills some nymphs Adverse reactions: pruritus, erythema, and edema.

Pyrethrins Plus Piperonyl Butoxide Neurotoxic to lice, low toxicity to humans Shampoo or mousse formulations applied to dry hair

44 Types of Treatment Pediculicides- OTC 1. Permethrin (1%) Least toxic to humans Crème rinse type treatment- applied to damp hair that is first shampooed, leave treatment on for 10 minutes then rinse, leaves a residue on hair that kills some nymphs Adverse reactions: pruritus, erythema, and edema. Does not cause reaction in people with plant allergies. Resistance reported in some studies Retreat at day 9 if live lice seen 2. Pyrethrins Plus Piperonyl Butoxide Neurotoxic to lice, low toxicity to humans Shampoo or mousse formulations applied to dry hair and left on for 10 minutes then rinse, no residual pediculicidal activity Do NOT use in patients who are allergic to chrysanthemums, or sensitivity to ragweed Head Lice; Pediatrics Vol. 135 No.5, May 1, 2015 pp. e1355-e1365

Types of Treatment Pediculicides- Prescription 3. Malathion (0.

previously due to prolonged treatment time and flammability, returned in 1999 US version

properties that delay resistance) Due to high alcohol content allow hair to dry

Benzyl Alcohol (5%) Approved by USDA in 2009- for children 6 months and up Kills lice by

45 Types of Treatment Pediculicides- Prescription 3. Malathion (0.5%) Lotion applied to dry hair then washed off after 8-12 hours Taken off market twice previously due to prolonged treatment time and flammability, returned in 1999 US version contains terpineol, dipentene and pine needle oil (all which have pediculicidal properties that delay resistance) Due to high alcohol content allow hair to dry naturally and do not smoke near child. 4. Benzyl Alcohol (5%) Approved by USDA in for children 6 months and up Kills lice by asphyxiation Apply topically to dry hair until scalp and all hair is saturated leave on for 10 minutes then rinse Head Lice; Pediatrics Vol. 135 No.5, May 1, 2015 pp. e1355-e1365

Types of Treatment Pediculicides- Prescription 5. Spinosad (0.

hair is saturated leave on for 10 minutes then rinse Safety not established in children younger than 4 years old. 6.

5%) Approved by FDA in 2012 for children 6 months and older Apply lotion topically to dry hair until scalp and all

46 Types of Treatment Pediculicides- Prescription 5. Spinosad (0.9%) Approved by FDA for topical use in children 6 months and older Apply topically to dry hair until scalp and all hair is saturated leave on for 10 minutes then rinse Safety not established in children younger than 4 years old. 6. Ivermectin (0.5%) Approved by FDA in 2012 for children 6 months and older Apply lotion topically to dry hair until scalp and all hair is saturated leave on for 10 minutes. Only one treatment needed (hatching lice are unable to feed due to pharyngeal muscle paralysis, therefore are not viable. 7. Lindane (1%)- NO LONGER RECOMMENDED Head Lice; Pediatrics Vol. 135 No.5, May 1, 2015 pp. e1355-e1365

47 Types of Treatment Topical Pediculicides for Head Lice Product Available Cost Estimate Age for use Kills Time left on hair Retreat Permethrin 1% lotion (Nix) Pyrethrins + piperonyl butoxide (A 200*, Pronto*, R&C*, Rid*, Triple X) Malathion 0.5% (Ovide) Benzyl alcohol 5% (Ulesfia) Spinosad 0.9% (Natroba) Ivermectin 0.5% lotion (Sklice) OTC OTC Prescription Prescription Prescription Prescription Minimal $< 30 Minimal $< 30 High $ High $ High $ High $ months and over 2 years and over 6 years and over Live Lice & residual may kill newly hatched for 1-2 days after treatment 10 min Day 9 Live Lice 10 min 9-10 days 8-12 hours 7-9 days if live lice Live Lice & some eggs 6 months and over Live Lice 10 min Day 7 6 months and over 6 months and over Live Lice & eggs Live Lice & hatching lice unable to feed therefore are not viable 10 min 10 min Day 7 if live lice Not required Head Lice; Pediatrics Vol. 135 No.5, May 1, 2015 pp. e1355-e1365

48 Retreatment Usually is recommended No approved pediculicide is completely ovicidal. Retreatment should occur after all eggs have hatched but before new eggs are produced. (7-10 days after 1 st treatment) Retreatment schedule can vary depending on the pediculicide used.

49 Types of Treatment Alternative Approaches 1. Natural Products- Essential Oils Essential Oils have been used in traditional medicine for years but the effects on the treatment are not reproducible. Natural products are not required to meet FDA guidelines for efficacy and/or safety Safety and effectiveness are not known, therefore use in infants and children should be avoided 2. Occlusive agents- Petrolatum shampoo, mayonnaise, butter, margarine, herbal oils, and olive oil Applied to suffocate the lice Widely used but have no evaluated effectiveness 3. Desiccation- custom built machine that applies one 30 minute application of hot air in an attempt to desiccate the lice. Effectiveness still being studied. One study showed 100% effectiveness in killing eggs and 80% in killing live lice. 4. Manual Removal- Manual removal of nits and lice is always an option Head Lice; Pediatrics Vol. 135 No.5, May 1, 2015 pp. e1355-e1365

50 STEP 2 Examine all close contacts 1. All household members should be checked Anyone found with nits less than 1 cm from scalp should be treated 2. ODH recommends only treating those family members with active live lice infestations. American Academy of Pediatrics Clinic Report from May 2015 now recommends automatically treating anyone who shares a bed with the infected individual even if no live lice found. 3. Check anyone who might have had head-head contact with infested individual or shared lice-carrying fomites. (classmates, playmates, babysitters ect.) Entire classroom checks are not always necessary. Head Lice; Pediatrics Vol. 135 No.5, May 1, 2015 pp. e1355-e1365 ODH-IDCM PEDICULOSIS Section 6 Revised 1/2014

STEP 3 Environmental control Clean bedding and objects contacted by infested individual in the 48

Floors rugs, pillows and upholstered furniture should be vacuumed.

treatment in hot water (130 or higher) or place in freezer.

Seal items that cannot be washed, dried or placed in freezer, in plastic bag for two weeks.

51 STEP 3 Environmental control Clean bedding and objects contacted by infested individual in the 48 hr period before initial treatment. Floors rugs, pillows and upholstered furniture should be vacuumed. machine wash all clothing, linen, and cloth toys that infested individual handled 48 hrs prior to treatment in hot water (130 or higher) or place in freezer. Items that cannot be washed can be machine dried at hottest temperature for a minimum of 20 minutes Seal items that cannot be washed, dried or placed in freezer, in plastic bag for two weeks. Combs and brushes should be soaked in hot water (130 or higher ) for 1 hour. Spraying homes with insecticides is NOT RECOMMENDED. ODH-IDCM PEDICULOSIS Section 6 Revised 1/2014

52 Scabies Elizabeth Koch MD MPH&TM Director of Outbreak Response

Scabies Scabies is an intensely pruritic, highly contagious infestation of the skin by arachnid mite Sarcoptes scabiei Originally, scabies was a

53 Scabies Scabies is an intensely pruritic, highly contagious infestation of the skin by arachnid mite Sarcoptes scabiei Originally, scabies was a term used by the Romans to denote any pruritic skin disease In the 17th century, Giovanni Cosimo Bonomo identified the mite as the cause of scabies

or cut Latin Scabere: to scratch Today, the term

54 Sarcoptes scabiei & Scabies Sarcoptes scabiei is derived from Greek Sarx: the flesh Koptein: to smite or cut Latin Scabere: to scratch Today, the term scabies refers to skin lesions produced by the Sarcoptes scabiei mite

Sarcoptes scabiei Sarcoptes scabiei is transmitted through direct, prolonged skin-to-skin contact with a person who is already infested The mites

55 Sarcoptes scabiei Sarcoptes scabiei is transmitted through direct, prolonged skin-to-skin contact with a person who is already infested The mites burrow into the upper layer of the skin Since the mite remains viable for 2-5 days on inanimate transmission through bedding or clothing, is possible

56 Scabies Infestation Incubation Period 2-6 weeks for initial infestation 1-4 days for subsequent infestations Symptoms Papular Rash Pruritus often most severe at night

57 Scabies Diagnosis Definitive diagnosis is by direct visualization of Sarcoptes scabiei mite, eggs or feces Optimal skin scrapings are obtained from the end of a burrow where a black dot is visible

58 Scabies Treatment Permethrin 5% Most common treatment Crotamiton 10% Frequent treatment failure Sulfur 5% - 10% Oldest known treatment Lindane 1% Previous standard treatment Ivermectin Treatment for crusted scabies & special situations CDC Scabies Treatment Recommendations

59 Scabies Case Definition Confirmed Skin infection diagnosed by healthcare provider with laboratory confirmation of Sarcoptes scabiei Probable Skin infection diagnosed by healthcare provider as scabies Suspected Skin infection diagnosed by healthcare provider with epidemiologic link to a confirmed or probable case of scabies

60 Scabies Outbreaks 4 scabies outbreaks investigated by Columbus Public Health (CPH) additional scabies outbreaks reported in Ohio Disease Reporting System (ODRS) 2010

61 Outbreak Timeline 1 st Outbreak Confirmed First case onset date: March 17, 2010 Last diagnosed case date: March 26, suspected cases among residents No line listing available All suspected cases treated with Lindane, and if symptoms were still present after first treatment then treated with Permethrin

62 Outbreak Timeline 2 nd Outbreak Suspected First case onset date: August 4, 2010 Last diagnosed case date: Not Reported 18 suspected cases among residents and staff No line listing available All suspected cases treated with 2 rounds of Permethrin on August 4, 2010 & August 12, 2010

probable and 3 suspected) among residents Age range: 57-92 years

63 3 rd Outbreak Probable Outbreak Timeline First case onset date: March 29, 2011 Last diagnosed case date: May 26, cases (4 probable and 3 suspected) among residents Age range: years Mean age: 76 years Median age: 80 years Gender: 4 (57%) female & 3 (43%) male

probable cases among residents and staff Age range: 61-97 years

64 Outbreak Timeline 4 th Outbreak Probable First case onset date: July 19, 2012 Last diagnosed case date: September 19, probable cases among residents and staff Age range: years Mean age: 78 years Median age: 77 years Gender: 21 (78%) female & 6 (22%) male

5 th Outbreak Probable Outbreak Timeline First case onset date: October 1, 2012 Last diagnosed case date: December 10, 2012 11

65 5 th Outbreak Probable Outbreak Timeline First case onset date: October 1, 2012 Last diagnosed case date: December 10, probable cases among residents Age range: years Mean age: 81 years Median age: 80 years Gender: 6 (55%) female & 5 (45%) male

6 th Outbreak Probable Outbreak Timeline First case onset date: September 13, 2013 Last diagnosed case date: November 20, 2013 13 cases (12

66 6 th Outbreak Probable Outbreak Timeline First case onset date: September 13, 2013 Last diagnosed case date: November 20, cases (12 probable and 1 suspected) among residents and staff Age range: years Mean age: 72 years Median age: 77 years Gender: 9 (69%) female & 4 (31%) male

67 Epidemic Curve Outbreaks # 3-6

68 Epidemic Curve Outbreaks # 1-6

69 Scabies References Scabies Prevention & Control Manual Michigan Department of Community Health Scabies Prevention & Control Guidelines Los Angeles County Department of Public Health Atypical Presentation of Scabies Among Nursing Home Residents J Gerontol A Biol Sci Med Sci Jul;56(7):M

Head Lice Information for Parents from CDC

Head Lice Information for Parents from CDC You should examine your child's head, especially behind the ears and at the nape of the neck, for crawling lice and nits if your child exhibits symptoms of a