Bed Bug Prevention & Treatment in Hospitals & Long-Term Care
PULLING BACK THE SHEETS ON THE BED BUG CONTROVERSY:
Research, Prevention and Management in Hospitals & Long-Term Care
Bill Lawrence, Ph.D., B.C.E.
Entomologist, Orkin, Inc.
Ron Harrison, Ph.D., B.C.E.
Director of Technical Services, Orkin, Inc.
THE PEST MANAGEMENT PERSPECTIVE
The Environmental Protection Agency, in conjunction with the National Pest
Management Association, hosted a National Bed Bug Summit in April 2009 in
At the conference, professionals discussed the ongoing issues surrounding
bed bugs, one of which was Goddard’s and deShazo’s conclusions published
in the JAMA article two weeks prior to the Summit.
The consensus of the Summit was that evidence regarding the serious health
risks of bed bugs is inconclusive. If existing research indicated that bed
bugs facilitate pathogen transmission, it would likely gain the attention
of the Centers for Disease Control and Prevention and make the pests a
priority research topic. As it stands, bed bugs have only recently been
to study for the first time since the middle of the last century, and the
observed health implications are mild to moderate.
Some researchers believe that bed bugs have potential allergen and
respiratory effects, much like cockroaches. Others point to the sleep
disturbance caused by the night-feeding pests, resulting in fatigue and
mental health complications. For some, as noted, the bites cause mild to
serious skin reactions that result in soreness or itching. Those who
experience bites may also feel paranoia about the pests during the day and
especially at night. Delusionary parasitosis, in which the person believes
he or she is being actively bitten by the insects throughout the day, may
be incited by concern about bed bug activity, according to some
Beyond the potential health implications, bed bugs should be a business
concern for health care and long-term care facilities.
As an unwanted pest, the very presence of bed bugs is a disturbance to
patients and residents. Infestations are common and becoming more so in
these health care settings, and when they occur, they evoke – right or
wrong – the impression that infested facilities are unsanitary and of low
quality. With peace of mind and reputations at stake, pest management
professionals believe that attention should be given to developing
prevention and treatment strategies.
IN THE FIELD: ORKIN BRANCHES SEEING A MAJOR UPTICK IN BED BUG CALLS
Orkin, Inc. recently surveyed its branch locations and found that in 2008
bed bug activity remained consistent or increased over previous years,
according to respondents. For those that reported an increase, prevalence
of the pests grew by an average of 50 to 75 percent from the previous
year, with some branches reporting a 100 percent to 200 percent
year-over-year increase in the number of calls to service bed bug
infestations. One Orkin location reported two calls regarding bed bugs in
2007 and projects more than 120 service calls this year based on 2009 call
volume to date. Another respondent documented a 500 percent increase in
cases from 2008 to 2009. Taken together, Orkin branch locations reported
more than 500 treatments in hospitals and health care facilities and more
than 130 treatments in long-term care facilities related to bed bug
infestations. As one respondent noted, “Bed bugs are making a major
NO BITES DOESN’T NECESSARILY MEAN NO BUGS
In recent research conducted at Orkin’s Training
we introduced each of 900 volunteers to one to three bed bugs from a lab
colony for a feeding. Volunteers were monitored closely for reactions to
the initial bite. Almost immediately, 3.7 percent of participants reacted
with mild to serious skin irritation. Within 18 days, an additional 0.8
percent exhibited some level of reaction. In total, fewer than 5 percent
of the participants had a reaction to beg bug bites. In the affected
group, there were no discernible correlations between the subjects’ race,
age or gender and their reaction to bed bug bites.
Because so few people seem to react visibly to initial bed bug bites, the
presence of visible bite reactions – or the lack thereof –may not be a
reliable early indicator of bed bug presence. Instead, it would seem that
many hosts will have no reaction when first bitten, leaving bed bugs
undetected for a longer period.
Orkin recently witnessed this disconnect first-hand at an independent
living facility when we were called to consult on a severe bed bug
infestation. The source infestation was a colony of 500-1,000 bed bugs –
in one room – in various growth phases. Most of these bugs were found in
the resident’s bed. Upon further inspection, our Commercial Pest
Specialists identified 10 other separate cases of bed bugs in the same
facility. It was a severe infestation, but zero bite reactions were
reported by the facility’s residents in the other affected areas. This
finding was correlated by research at the University of
that found that the elderly have a
diminished response to skin irritants and are less likely than other age
demographics to exhibit a reaction.
In light of the resurgence of bed bugs, Orkin is participating in studies
to help identify effective ways to prevent and treat them. In a study at
Orkin works with researchers to gather samples of different bed bug
species and study effectiveness of different treatment methods. Orkin is
currently partnering with the University of
to formally survey victims of bed bug bites in order to identify any
trends among the respondents.
THE BED BUG EVOLUTION: FROM CAVES TO COUCHES
The history of the bed bug offers clues to why bed bugs bite people, but
don’t typically cause us severe health problems.
Bed bugs are thought to have evolved from insects that dwelled in caves,
feeding on bats and swallows. When humans in certain parts of the world,
especially in colder climates, moved off of the plains and into the same
caves, bed bugs seemed to change preferred hosts and began feeding on
humans as well. Early cave drawings seem to illustrate man’s interaction
with the nocturnal pest, depicting people being awoken by tiny, crawling
Humans are nearly ideal prey for bed bugs. We have less hair than other
mammals, which bed bugs prefer. Direct access to skin makes their feeding
much easier. Based on historical research, scientists believe the parasite
thrives at a temperature between 60 and 70 degrees, so rather than reside
on its host, it feeds and returns to the cool, dark hiding places that it
More recent research at Virginia Tech indicates that consistently cooler
temperatures may expand the lifespan of bed bugs. Human dwellings give bed
bugs a perfect combination of a reliable food source and convenient,
nearby harborage in cooler spots in mattresses, box
springs, behind wooden headboards, in couch cushions and other furniture.
Though not rapid breeders compared to many other pests, a bed bug
population left untreated can become a critical problem in a matter of
Today, beg bugs are one of the few parasites that feed almost exclusively
on human blood. This exclusive relationship may be one reason they don’t
seem to cause disease in human hosts. They may bite the hand that feeds
them, but they seem to do so without jeopardizing their food source.
AN OUNCE OF PREVENTION: HOW TO STOP BED BUGS AT THE DOOR
In the fiercely competitive health care and long-term care industries,
patient or resident satisfaction is crucial. Bed bug infestations, aside
from potential health concerns, can spark complaints about sanitary
conditions and lead to long-term reputation damage. Despite the fact that
the presence of bed bugs is not an indicator of poor sanitation, pests of
any kind are accompanied by a perception of being “dirty.” Because
prevention is key to avoiding bed bug problems, it is prudent to develop a
proactive plan to keep them from entering the facility and train staff to
monitor for bed bugs as part of their daily routine.
Prevention has patient rights and provider responsibility implications
that should be weighed carefully. When does a prevention measure become a
violation of patients’ rights? What message does it send to patients?
Aggressive policies to control incoming materials or conducting searches
of incoming personal items may raise privacy concerns and anxieties.
Particularly for long-term care providers, this approach could create a
discomforting atmosphere for incoming residents who may already be
stressed by a transition from independence to facility living. From the
provider’s perspective, the question is: what responsibility do you have
for keeping bed bugs out through inspections, quarantines and other
methods of prevention?
Some methods, though effective, can be untenable in the real world.
In a long-term care facility, preventing bed bugs from entering on
residents’ personal effects is the best way to lower the potential for an
infestation. The methods suggested below are effective without taxing
staff or alarming residents.
– Conduct a visual inspection of
bedding as it is brought in for evidence of bed bugs.
Require mattress and box springs to be encased
– An inexpensive synthetic covering on mattresses and especially box
springs prevents bed bugs from reaching the fibrous interior or hiding
along edges or under tags. For pests that have already found harborage,
the encasement prevents their escape and access to food sources.
Perform an inspection of incoming furniture
– Much like bedding, couches, plush chairs and other furniture can easily
harbor bed bugs.
Utilize monitoring technology
– Equipment that uses CO2,
heat and a kairomone can attract bed bugs out of hiding within two hours.
This technology is cost-prohibitive for private use at this point, but is
available through some pest management professionals. But smaller, less
expensive monitors are in the development stages and may come to the
consumer market within two years.
Bed bug-sniffing dogs
– Trained dogs are among
the most effective detectors of the presence of beg bugs. Many pest
management companies are now utilizing these trained canines to help
Hospitals and other health care facilities are typically less conducive
environments for bed bugs. Unlike nursing home residents, who stay in one
place for extended periods, health care patients enter, undergo treatment
and are released. In addition, most clinical beds have metal frames and
plastic-covered mattresses, which prevent bed bugs from reaching the
porous harborage they seek. As patients come and go, the stringent
cleaning practices that prevent cross-contamination also supports a
hostile environment for pests and can keep bed bugs in one room from
making their way to another.
Although hospitals are less conducive to bed bug infestations, there are
areas where patients stay for long periods of time that have the potential
for attracting bed bugs. Overnight guests in maternity, long-term care and
hospice are more likely to bring luggage and other personal effects. These
areas should be more closely monitored during routine cleaning to ensure
that bed bugs did not make their way into the facility in someone’s
luggage. Psychiatric wards where patients are admitted as temporary
residents are another hot spot for bed bug activity. A quarterly thorough
inspection in these areas will help to identify pests that have found
harborage in the furniture or elsewhere in the room.
OUT OF SIGHT, NOT OUT OF MIND: MONITORING & EARLY DETECTION
On an ongoing basis, monitoring and early detection are crucial to
preventing bed bugs from taking hold and causing an infestation. A pest
management professional can educate your staff on the importance of being
aware of the problem and train them to recognize the signs of a bed bugs
As nocturnal pests, bed bugs typically hide during the day, but evidence
of their nightly wandering can be found on mattress edges and tags. Small
dark brown-colored stains in these areas may be the leave-behinds of bed
In a long-term care facility or long-term care units in a hospital,
integrating bed bug monitoring into regular cleaning routines can help
identify problems before they spread throughout the facility:
– Monitor for evidence when changing the sheets. Check the mattress
cover and the edges of the mattress.
– Inspect the box springs for similar signs.
– Conduct thorough inspections of potential harborage locations –
behind pictures and headboards and in
furniture, sofas or plush chairs.
SEND BED BUGS PACKING: TREATMENT
If routine monitoring uncovers a bed bug problem, contact your pest
management professional immediately. Remediation tactics will be less
invasive if initiated in the early stages of an infestation. Non-chemical
and environmentally conscious methods:
– If furniture or other items harboring bed bugs can be disposed
of, it increases the chances of a successful eradication.
– For items that can be laundered, wash in hot water with detergent
and dry in a dryer. The combination of heat and soap will kill bed bugs
and remove any eggs.
– Pest management professionals can use special equipment to heat
the room or the room’s belongings to the necessary temperature for a
sustained period of time that will eradicate any bed bugs in the room. Use
dry steam on carpet, mattress
edges and cushioned furniture.
– Due to bed bugs’ need for moderate temperatures, cold seems to be
as effective as heat.
management professionals also have the equipment to cool bed bug harborage
areas, which should kill any bed bugs in the space.
A wide-spread infestation possibly affecting multiple locations within the
facility will require a more aggressive approach involving chemical
treatments. Chemical treatments should only be applied by a licensed,
trained pest management professional who can advise you of the best course
– A chemical material will kill all pests and leaves no residual.
It does require the facility to be completely cleared,
which can be a challenge.
Non-residual Chemical Treatments
– Alcohol will create a
chemical solution that kills bed bugs.
Residual Chemical Treatments
– Chemically treat carpet
edges, baseboards, furniture, headboards, etc. Treating for bed bugs does
present some challenges. In some cases, the pest can be resistant to
chemicals. They may also be repelled by chemicals and be driven to seek
harborage elsewhere in the facility after treatment. Sensitivity to the
chemicals in a health care facility is also a concern and should be
discussed with your pest management professional. Insect Growth
Regulators, or IGRs, which have been effective in the treatment of other
types of pests, appear to be less consistently successful with bed bugs.
IGRs use synthetic pest hormones to prevent pests from reaching maturity –
thereby preventing subsequent pest activity. IGRs are sometimes part of
the bed bug treatment, since they may have some effect on slowing the
expansion of a bed bug population in some cases.
Bed bugs exhibit a number of unique characteristics that make them
problematic pests: parasites that are almost exclusive to humans; bites
that frequently produce no reaction; nocturnal feeders that stay out of
sight during the day, making them difficult to detect. The severity of the
risk presented to humans is inconclusive. Clearly, further research is
needed to define the degree of the threat that bed bugs pose. Until then,
prevention and early detection are the best practices.
Health care providers will need to rely on their staff for an effective
monitoring and prevention strategy. Working hand in hand with your pest
management professional, staff education and cooperation is essential to
identifying and reporting potential bed bug infestations. Your pest
management professional can educate employees about the pests, harborage
points and signs of their presence. They can also train staff on
sanitation practices and monitoring activities that will reduce the risk
of a bed bug infestation and ensure that if bed bugs do enter your
facility, they don’t take up residence.
As the debate around bed bug continues to evolve and further research
brings to light new information about these pests, the prevention and
management practices will also evolve. In the meantime, rest easy with a
proactive approach and the advice of a trained pest management
MEDICAL PROFESSIONALS MAKE A BED BUG DIAGNOSIS
April 1, 2009,
issue of the Journal of American Medicine, an article authored by
Jerome Goddard, Ph.D., of Mississippi
University, and Richad deShazo, M.D., of the University of Mississippi
Medical Center, reviewed 53 previously published articles on the topic of
In their analysis of the existing research, Drs. Goddard and deShazo
conclude that bed bugs
do not transmit communicable diseases, translating into little to no
serious health risks to humans. Similar parasites, like ticks, carry
pathogens that can be transferred to hosts.
According to Goddard and deShazo, previous research strongly suggested
bed bugs do not exhibit the same characteristic.
Though they may not carry pathogens, bed bugs’ bites can be a source of
serious irritation for some. For those who experience a reaction, the
researchers noted the lack of an effective treatment for the bites, which
typically cause minor to complex skin reactions and, in rare cases,
Treatments ranging from antibiotics and topical corticosteroids and
have had varying degrees of impact on the reaction.
The authors also conclude that the management and treatment of bed bugs is
extremely difficult. The paper cites a lack of evidenced-based
interventions that prevented an infestation or eradicated a population.
Drs. Goddard and deShazo essentially positioned bed bugs to be less of a
concern to the medical field and squarely in the jurisdiction of pest