Bed Bugs, and Lice, and ScabiesBed Bugs, and Lice, and ScabiesOh My!Oh My!

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Rosmarie KellyPublic Health EntomologistGDPH

Bed Bugs, Lice, & ScabiesBed Bugs, Lice, & Scabies• What do these 3 things have in common?

– All three are arthropods.• bed bugs – Class Insecta• lice – Class Insecta• scabies mites – Class Arachnida

– All three are ectoparasites.• bed bugs & lice – feed on blood• scabies mites – feed on skin cells

– Little to no disease transmission– Control

• Complicated for bed bugs• Treatment, as well as contact isolation and personal

protection procedures, for lice & scabies

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BIOLOGY REVIEWBIOLOGY REVIEW

Phylum Arthropoda

• includes insects, spiders, mites, ticks, millipedes, centipedes, scorpions

•Characteristics:Jointed legsSegmented bodiesWings and antennae (presence & number vary)Exoskeleton

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What is the most common symptom?

• Rash and itching

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Public Health and “Bugs”

• In public health, the goal is to prevent disease or injury in a whole population—a city, state or country, for example. That's different from the goal of health care, which is to care for individuals.

• Does disease have to be possible or present for an insect or arthropod to be considered a public health issue?

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Are Bed Bugs a Public Health Issue?Are Bed Bugs a Public Health Issue?

• Bed bugs require blood in order to reproduce and complete their life cycle.

• There is no evidence that bed bugs are involved in the transmission (via bite or infected feces) of any disease agent, including hepatitis B virus and HIV, the virus that causes AIDS.

• However, the CDC & EPA issued a joint statement saying that “Although bed bugs are not known to transmit disease, they are a pest of significant public health importance.”

– Frequent feeding can disrupt people's sleep and make them irritable. – Seeing bites may cause emotional distress in some people. – Heavy rates of feeding can result in significant blood loss and eventually lead to anemia,

especially in malnourished children.

http://www.cdc.gov/nceh/ehs/publications/bed_bugs_cdc-epa_statement.htm

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Are Lice a Public Health Issue?Are Lice a Public Health Issue?• Head lice infestation is a social issue not a health threat.

They do not transmit disease.• Body lice infestation is a prominent public health problem in

communities with large populations dealing with poverty, overcrowding, and poor personal hygiene. The body louse is the vector of three human diseases:– epidemic typhus fever– epidemic relapsing fever – trench fever

• Pubic Lice cause a severe nuisance and are a social embarrassment, but do not transmit disease.

http://www.emedicinehealth.com/lice/article_em.htm

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Are Scabies a Public Health Issue?Are Scabies a Public Health Issue?

• Scabies mites are not know to carry disease.• However:

– Scabies infections have been linked to many serious health problems such as skin sores, serious bloodstream infections, kidney disease, and have possible connections to rheumatic heart disease.

– Scabies may also have links to broader health issues in children such as malnutrition, gastro infections and pneumonia.

http://1disease.org/documents/factsheet.pdf

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So, does disease have to be possible or present for an insect or arthropod to be

considered a public health issue?

• Depends on who you ask.• According to an editorial published in the Aug

2000 American Journal of Public Health, “Public health should develop capacities to deal in meaningful ways with social problems…”

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1446330/pdf/10936991.pdf

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A Closer Look

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All About Bed BugsAll About Bed Bugs

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LIFE CYCLE

I lay between 1 and 5 eggs every day!

Starting as an egg, it takes me 30 days to become an adult!

I’ll molt 5 times before I become an adult!

I’ll live about 10 months and lay between 300 and 500 eggs!

I may live up to a year without feeding

1. 1:1 sex ratio

2. 10 month life span

3. 4 eggs/day

4. 10 days to hatch

5. 60 days develop

Day 114: 5,000

Day 129: 10,000

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One Bed Bug

One Month - 61 Bed Bugs

Bed bugs were once a common public health

pest worldwide.

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•Bedbugs were originally brought to the United States by early colonists from Europe.

•Bedbugs thrive in places with high occupancy, such as hotels.

•Bedbugs were believed to be altogether eradicated 50 years ago in the United States and elsewhere with the widespread use of DDT.

They’re Back!Bed bugs are once again becoming a problem within residences of all kinds, including homes, apartments, hotels, cruise ships, dormitories and shelters.

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•The cause of this resurgence is still uncertain, but most believe it is related to increased international travel and the use of new pest-control methods that do not affect bedbugs.

Of the 90 or so species in the family Cimicidae, approximately 7 will feed on human blood, but only 2 are commonly found: Cimex lectularius (bed bug) and Cimex hemipterus (tropical bed bug).

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eggs

Know What You Are Looking For

nymph

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female male

http://ipm.ncsu.edu/AG369/keys.html

Key to Common Pests of Man and Animals

Not Bed Bugs

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Habits & Habitats

Bed bugs are active mainly at night; they reach peak activity before dawn.

During the daytime, they prefer to hide close to where people sleep.

Their flattened bodies enable them to fit into tiny crevices - especially those associated with mattresses, box springs, bed frames, and headboards.

Bed bugs do not have nests like ants or bees, but do tend to congregate in habitual hiding places.

Bed bugs do not fly, but can move quickly over floors, walls, ceilings and other surfaces.

Bed bugs will travel 5-20 ft. from an established harborage to feed on a host. Egg-laying females also wander.

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Bed Bug FactsBed bugs respond to warmth and carbon dioxide when searching for a blood meal, but not to odors. All nymphal stages and adults of both sexes require blood for nutrition and development. Bed bugs ordinarily feed within 24 hours of hatching, once between each molt and once before egg deposition; an average period of 8 days is required between molts. Adult females will continue to take blood meals every 3-4 days depending on ambient temperature and humidity. Bed bugs take up to 10 minutes to complete a blood meal, and will consume 2-5 times their own body weight in blood during that time.

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More Bed Bug FactsIndividual bed bugs usually do not feed every night but at intervals of a few days to a week. Bed bugs do not remain on the host between feedings. Once a bed bug is finished feeding, it quickly retreats back to its hiding place. Bed bugs may also feed on small animals, such as pets.

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Really Weird FactBed bugs have a unique form of mating called “traumatic insemination”. The male penetrates the female’s abdomen with his external genitalia, inseminating into her body cavity. This sexual activity produces a wound in the female and probably endangers her longevity and productivity.

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Bed Bug Bites The bite of a bed bug is painless. The amount of blood loss due to bed bug feeding typically does not adversely affect the host. Bed bugs feed on any bare skin exposed while sleeping (face, neck, shoulders, arms, hands, etc). Skin reactions are commonly associated with bed bug bites, which result from the saliva injected during feeding. Some individuals do not react to bed bug bites, while others note a great deal of discomfort often with loss of sleep from the persistent biting.

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Reactions to Bites

Common allergic reactions include the development of large welts that are accompanied by itching and inflammation. The welts usually subside to red spots but can last for several days. Blister-like eruptions have been reported in association with multiple bed bug bites and anaphylaxis may occur in patients with severe allergies.

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More on BitesDepending on bite intensity and frequency, there are typically five post-bite effect stages: no reaction (no or too few antibodies developed), delayed reaction, delayed plus immediate reaction, immediate reaction only, and no visible reaction (due to excess circulating IgG antibodies).  Typical symptoms include a raised, inflamed, reddish wheal at each bite site, which may itch intensely for several days.  “Immediate” immune reactions may appear from one to 24 hours after a given bite and may last 1-2 days. "Delayed” immune reactions usually first appear one to three (up to 14) days after a bite and may last 2-5 days.  Humans who are frequently bitten by bed bugs may develop a sensitivity “syndrome” that can include nervousness, almost constant agitation (“jumpiness”), and sleeplessness. 

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Movement

Spending a night (or longer) in an environment which is already infested by bed bugs (hotels, homes, international flights, etc). Having someone visit from such an infested environment (bed bugs can be transported in luggage). Renting furniture or buying used furniture or bedding. Picking up discarded bedding or furniture from a curbside, trash collection point or dumpster.

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Some of the most common ways new bed bug infestations may be introduced include:

In a Hospital Setting• If you see a "creature" on your patient or their personal items, try to confirm it

by collecting the bug in a specimen container. – The lab or the facility's exterminator can confirm if the pest is a bed bug.– Showering the patient may help in assessing the presence of more bugs and the

condition of the patient's skin.• If there is evidence of bed bugs and the patient is being admitted, remove his

clothing and double bag in plastic. – Family members should be asked to remove the items. Reduce clutter in the

patient's room as well. – Mattresses on the unit should be checked regularly.

• If the patient is an outpatient, confine him to one area. – Do not use fabric-covered chairs and try to use a room without carpeting.– Double bag any items that the patient has with him.

• Notify the environmental services department so they can arrange to monitor the room and arrange for extermination services if necessary.

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Taking Precautions

Don’t bring bed bugs home with you.

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•If there is a reported bed bug issue:

•Assume beds, furniture, and other items in the room you are entering are infested and act accordingly.

•Bring a minimum of equipment into the room and place equipment in an open area away from walls and furniture.

•Avoid laying across, leaning against, or sitting on potentially infested beds or furniture and minimize direct contact with any potentially infested materials such as drapes, rugs, and dirty linens or clothes.

More Precautions

■Remove your clothes over a non-carpeted floor and be ready to immediately capture and destroy any bug you see.

■If you are concerned that your clothes might contain bed bugs, launder them in hot water as soon as possible.

■If you feel that you may have interacted with bed bugs, you may want to change and bag your clothes before leaving the site and have the clothes in question laundered.

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1. Cleaning of the room should be performed by appropriately trained cleaning staff.

2. Seal the linens and any other removable cloth (curtains, cushions, pillows, towels and so on) into a plastic bag and take them to the laundry room.

3. Wash the linens from the infested room as soon as possible in hot water with detergent and dry them. • Tie the bag closed in between loads and again before disposal.

4. Steam clean the mattresses and any other soft furniture in the infested room. • If the room is carpeted, steam clean it as well.

5. Wash down the room, especially crevices and floors, with the alcohol-based cleaner (or use a 50% ethanol/50% water solution). • This will destroy any eggs or adults that landed on the floor during linen

removal.

6. Clean your laundry room with the solution once all the infested linens have been washed.

Cleaning Infested Rooms

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BEDBUG CONTROL

REQUIRES

METICULOUS Treatment

of All Probable Harborage Sites

By Licensed Pest Control

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Key Control Facts• Clean and remove clutter • COOPERATE• Proper treatment preparation are vital

– Laundering: wash and dry all clothing and bedding on high heat

– Vacuuming– Removal of untreatable items: dispose of infested items so

that the bed bugs are not spread to other rooms• Get a written checklist from PCO• Successful eradication may require multiple chemical

and/or non-chemical treatments– Ongoing monitoring is essential– Need to use an IPM approach

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Bed Bugs - SummaryBed Bugs - SummaryGood night, sleep tight, don’t let the bed bugs BITE!

• How do I keep from getting bed bugs?– Keep your belongings out of a bedbug

infested area.• Signs:

– Red, round itchy bumps, clustered together and itching

• Will a client give me bed bugs?– Not likely if you follow the recommended

guidelines & standard precautions

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Adult bed bug by a penny

Prevention and Control of Bed BugsPrevention and Control of Bed BugsRECOMMENDED GUIDELINESRECOMMENDED GUIDELINES

REMEMBERREMEMBER

• Bed bugs can be in any kind of crease or crevice in a room

• Inspect bed frames, pillows, mattresses, mats regularly

• Report any signs of bed bugs to your supervisor right away.

• Extermination should be done by a licensed pest control operator

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Spotting on Mattress

Bed Bug Size

http://health.state.ga.us/epi/zvbd/infest/index.asp

All About LiceAll About Lice

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Head Lice

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Lice Can’t Fly or Jump……

Head Lice (Pediculosis)• Infestation of the hair on the scalp by Pediculus humanus capitus, or

the human head louse• Live by biting and sucking blood from the scalp• Problem common in schools and institutions• 6-12 million people worldwide are infested each year• Three forms of lice: nit, nymph, and adult

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www.headlice.org

Epidemiology of Head Lice• Worldwide distribution• Females are infested more often than males• More common in Caucasian and Asian hair; less

common in African-American hair• Transmitted by direct contact with an infested

person or with any object used in their hair (hairbrush, hat, pillow).

• Rarely found on the body, eyebrows, or eyelashes.

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Epidemiology of Head Lice

Diagnosis• Inspection of the hair for all nits and lice• If nits are found more than ¼ inch from the

scalp, it is likely an old infestation and does not need to be treated

• Found on the scalp behind the ears and near the neckline at the back of the neck

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Head Lice Nits

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Nits, empty and full

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Body Lice – lice on clothing

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Pubic Lice …

Epidemiology of LicePeriod of Communicability

• As long as lice or eggs remain alive on the infested host or on fomites.

• Head and pubic lice nits can live on clothing for 1 month

• Nymphs can survive 24 hours without a food source

• Adult lice live ~1 month, but can only survive a few days without a food source

• A female louse can lay up to 150 nits/month

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Symptoms of Lice• Lice present with itching.• The diagnosis is usually

straightforward because lice are visible to the naked eye.

• Pubic lice may be detected by the presence of black powder in under-garments.

• There is often severe skin irritation present.

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Control Measures: Head & Pubic Lice

• Isolation is generally not required, but it is desirable.

• Routine laundering practices can be performed for clothing and bedding.

• Standard cleaning procedures are all that is required for the environment.

• Standard infection control precautions are adequate (as for routine patients).

• Staff should ensure that their own loose hair is tied back to protect themselves from infection.

• The patient does not routinely need to wear any hair covering as they are only an infectious risk if they are in direct head to head contact with another person.

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Control Measures: Body Lice

• Body lice are now relatively uncommon and are a potentially serious threat to human health.

• Clothing and bed linen should be treated as infected.

• Patients with body lice should be isolated in a single room and a full gown and gloves should be used for direct patient contact.

• Separate medical equipment should be dedicated to the patient.

• This should be adequately decontaminated or disposed of after use.

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Head, Body, and Pubic LiceHead, Body, and Pubic Lice

• How do I get lice? – Very close contact, sharing of clothing and

bed linens– Sharing head gear, ear phones, combs,

brushes, etc. • Signs: Rash and itching• Will a client give me lice?

– No, not as long as you do not share belongings and follow standard precautions

http://health.state.ga.us/epi/zvbd/infest/index.asp 54

All About ScabiesAll About Scabies

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skin burrow

Scabies

• Highly contagious• Intensely pruritic (itchy) allergic reaction• Skin infestation by the mite:

– Sarcoptes scabiei hominis

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Background

• Main presenting features include rash and intense itching.

• In young infants, pruritus may be difficult to detect. Irritability, especially during sleep, may be the only symptom.

• History of involvement of other family members and contacts is often present and helps in establishing the diagnosis.

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Incidence

• Frequency In the US: In developed countries, scabies epidemics seem to occur in 15-year cycles; however, the most recent epidemic began in the late 1960s and for some unknown reason continues today.

• Internationally: In undeveloped countries, scabies infestation is endemic with millions affected worldwide.

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Biology

• The mite spreads disease through direct and prolonged contact between hosts.

• The mite remains viable for 2-5 days on inanimate objects; so transmission of mites through infected bedding or clothing is possible.

• Once on a host, mites mate on the surface of the skin.

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Biology

• After mating, the male mite dies. • The female mite burrows into the epidermis of the

host using her jaws and front legs, where she lays up to 3 eggs per day for the duration of her 30-60 day lifetime.

• An affected host harbors approximately 11 adult female mites during a typical infestation. The eggs hatch in 3-4 days.

• The larvae leave the burrow to mature on the skin. Fewer than 10% of the eggs laid result in mature mites.

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INCUBATION

• In people without previous exposure the incubation period is 2-6 weeks before the onset of itching.

• People who have been previously infested develop symptoms 1-4 days after exposure.

People are infectious until the mites and eggs are destroyed by treatment (usually 1 treatment, occasionally 2 treatments).

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Symptoms

• Pruritus (itch)– Caused by a hypersensitivity of the skin– Reacting to the eggs and feces

• Lesions appear 3 to 10 days after exposure• Fingers, wrists, arms, underarms, trunk• Intense itch occurs after lesion eruption• Especially intense itching at night• Itching continues even after the mites are gone

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Presents typically on the hands and

finger webs64

Norwegian (crusted) Scabies

• In 1848, the Norwegians Danielssen and Boeck described a highly contagious variant of scabies that occurs in immunocompromised patients.

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• Crusted or hyperkeratotic scabies, as it has come to be known, is an overwhelming scabies infestation.

Norwegian (crusted) Scabies

• This rare form of scabies occurs in elderly or immunocomprimised patients. Because of an impaired antibody response, these individuals can be infested with thousands to a couple million mites.

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Norwegian (crusted) scabies

• Norwegian scabies is characterized by crusted lesions and scaly plaques located mainly on the hands, feet, scalp, and other pressure-bearing areas.

• These may sometimes generalize. Hyperkeratosis may occur in these lesions.

• Patients with Norwegian scabies can be infected with hundreds to millions of adult female mites.

• As a result, this type of scabies is highly contagious and may spread rapidly through patients in an institutionalized setting.

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Diagnosis – Skin ScrapingsDiagnosis – Skin Scrapings

• Equipment (alcohol preparation, mineral oil, fountain pen, number 15 blade, glass slide and coverslip, microscope).

• Look for a papule with a fine white to gray line across the top, and place two or three drops of ink over the papule.

– Leave the ink on for 5 to 10 seconds, then wipe the area clean with an alcohol prep. – The ink will seep into the burrow, and a fine stained line will be evident.

• Place a drop of mineral oil on the skin, and either scrape the area with a number 15 blade or pinch the area between the thumb and index finger and superficially shave the top layer of skin.

– Anesthesia is not necessary.

• Place the specimen on a glass slide, apply the coverslip, and examine it under the microscope at 10x magnification to identify the female adult mite (0.4 mm long), the male (0.2 mm long), the eggs, or feces.

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• Acute urticaria: eruption of itching papules, usually systemic • Allergies: hypersensitive reaction induced by allergen

exposure • Atopic dermatitis: inflammation of skin resulting from a

genetically determined state of hypersensitivity• Contact dermatitis: inflammation of skin resulting from direct

allergen or irritant contact• Dermatitis herpetiformis: reoccurring and chronic itching of

vesicles and/or papule eruptions caused by Duhring’s disease• Eczema: generic term for inflammatory conditions of the skin • Folliculitis: inflammation of hair follicles • Fungal infections: unusual multiplication of molds and/or

yeast organisms in or on the body

Differential Diagnoses

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• Impetigo: bacterial infection of the skin resulting in tiny blisters • Insect bites: itchy bumps resulting from the bite of an insect • Lupus “rash”: red or purple lesions of the skin • Mycosis fungoides: cutaneous T-cell lymphoma affecting the

skin • Neurodermatitis: chronic form of scaly and/or itchy skin • Pityriasis: large, scaly, pink skin patches of rash-like

appearance • Psoriasis: itchy, dry, cracked, and/or blistering of skin caused by

a chronic autoimmune disease • Pyoderma: infection of the skin • Syphilis: rough, red, or reddish-brown spots or rash resulting

from the secondary stage of syphilis infection • Tinea: inflamed, scaly skin caused by a fungal infection;

“ringworm” • Vasculitis: red or purple lumps and/or rash caused by

inflammation of blood vessels

Differential Diagnoses (cont)

Infection Control

• Classical scabies has low infectivity, therefore isolation is not required but may be desirable.

• Patients presenting with dry, flaking skin should be isolated until a positive diagnosis is established.

• Universal infection control precautions, including gloves and aprons, must be worn for close contact with the patient, and for handling of clothing and bed linen.

• Routine cleaning of the patients room/bed space is sufficient.

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Infection control precautions for Crusted/ Norwegian Scabies• Immediate isolation and early identification of cases with urgent referral to dermatology

is essential to control spread and ensure prompt, effective treatment of the affected patient and their contacts.

• A contact list of both patients and staff must be completed. – This will include all those who have been in contact with the affected patient e.g. patients in

the same bay and staff who have been nursing the patient

• Isolation precautions are recommended until treatment has been completed. – This includes the use of personal protective clothing including the use of long sleeved gowns

and gloves in severely affected patient. – Linen must be handled very carefully and treated as infectious linen

• Daily cleaning of the isolation room is required. – After treatment of the patient, the floor and upholstery must be vacuumed and all bedding and

clothes changed.

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ScabiesScabies• How do I get scabies:

– Extended person to person contact• Signs of scabies

– Identification of burrows or rash– Intense itching especially at night

• Will a client give me scabies? – Not likely if you follow standard & contact

precautions

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http://health.state.ga.us/epi/zvbd/infest/index.asp

STANDARD PRECAUTIONSSTANDARD PRECAUTIONS• Treat things that might be contaminated as

if they are contaminated• Use personal protective equipment (PPE)

when handling something that may be contaminated

• Never put your hands where you can’t see them

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CONTACT PRECAUTIONS

PATIENT PLACEMENT

• SINGLE ROOM

• Patient suspected or confirmed to have lice or scabies should be placed in a single room until 24 hours after commencement of treatment.

• The door to the patient room must be closed at all times except for entering and exiting.

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• GOWNS AND GLOVES

o Must be worn at all times while in the room until 24 hours after commencement of treatment.

o Must be changed after contact with infective or contaminated material or objects.

o Must be removed before leaving the room.

o Hands must be washed or disinfected immediately after leaving the room.

CONTACT PRECAUTIONS

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VISITORS /Patient Movement

• All visitors must wear gloves and gowns at all time while in the room until 24 hours after commencement of treatment.

CONTACT PRECAUTIONS

• Limit patient movement outside the room to medically necessary/essential procedures.

• Before the patient is transferred, the ward/unit in which the patient is isolated should notify the accepting area that the patient has lice or scabies and requires additional CONTACT PRECAUTIONS.

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Daily and terminal cleaning of the room should be performed by appropriately trained cleaning staff.

Cleaning and disinfection of bedside equipment and environmental surfaces should include:

o Bedrails o Bedside table o Trolleys o Commodes o Doorknobs o Tap handles

• Patient care equipment such as IV pumps, ventilators must be cleaned at least daily or more often when visible soiling or contamination occurs.

• Consider a checklist to promote accountability for cleaning responsibilities.

Cleaning the Patient’s Room

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~Protect Yourself~~Protect Yourself~

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BOTTOM LINE– How do you avoid taking pests home with you?

– Use gloves and gowns when handling patient belongings, dirty sheets, blankets, etc

• FOR BED BUGS– Airtight bag your personal belongings while at work – Don’t bring personal items onto the main floors of the facility– Inspect yourself and your belongings before leaving work– Change clothes and shower at home– If bed bugs have been found where you work, leave your shoes outside your front

door when you go home

Any Questions?

81http://health.state.ga.us/epi/zvbd/infest/index.asp

Public Health EntomologistContact Info

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Rosmarie Kelly, PhD MPH2 Peachtree St NWAtlanta

Office: 404-657-2912Cell: 404-408-1207

rmkelly@dhr.state.ga.us

http://health.state.ga.us/epi/zvbd/infest/index.asp