Georgia epidemiology report [Vol. 25, no. 4 (Apr. 2009)]

April 2009

volume 25 number 04

Sleep Tight, and Don't Let the Bed Bugs Bite

Bed bugs were once a common public health pest worldwide,

but declined in incidence through the mid-20th Century.

adult

Recently, bed bugs have undergone a dramatic resurgence

worldwide and there are reports of increasing numbers of infestations.

actual size

Bed bugs are becoming a problem within residences of all kinds, including homes, apartments, hotels, cruise ships, dormitories and shelters. While we often associate bed bugs with unsanitary conditions, they may be found in the cleanest of homes, hotels or other buildings.

Bed bugs are small, wingless insects that feed solely upon the blood of warm-blooded animals. They are sometimes mistaken for ticks or cockroaches. A mature bed bug is oval-bodied, brown to red-brown in color, wingless and flattened top to bottom. Unfed bugs are 1/4 to 3/8 inch long and the upper surface of the body has a crinkled appearance. A bed bug that has recently fed is engorged with blood, dull red in color, and the body is elongated and swollen.
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).
Female bed bugs deposit 3 to 8 eggs at a time; a total of 200500 eggs can be produced by one female over her 10-month life-span. The eggs are 1/25 inch long and are slightly curved. They are usually deposited in clusters and fastened to cracks and crevices or rough surfaces near adult harborages with a sticky cement-type substance.

eggs

nymph

can survive months without feeding and adult bed bugs can survive for 6-7 months without a blood meal. They have been known to live in abandoned houses for at least a year. Under favorable conditions (70-90 F), the bugs can complete development in as little as a month, producing three or more generations per year. Cool temperatures or limited access to a blood meal extends the development time.
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.

The eggs hatch in 4-12 days. The newly hatched nymph is nearly colorless or straw-colored before feeding, and then turns red or purple in color after taking a blood meal. Bed bugs go through 5 nymphal stages before reaching maturity. This usually takes 35-48 days.
Nymphs look like small adults with the exception that adults have minute wing pads; females are larger than males. Nymphs

Bed 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.

The Georgia Epidemiology Report via e-mail , see last page for details. Please visit, http://health.state.ga.us/epi/manuals/ger.asp for all current and past pdf issues of the GER.

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. Individual bed bugs usually do not feed every night but at intervals of a few days to a week. Once a bed bug is finished feeding, it quickly retreats back to its hiding place. They do not remain on the host between feedings. Bed bugs may also feed on small animals, such as pets.
Some of the most common ways new bed bug infestations may be introduced include: Spending a night (or longer) in an environment that 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.

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.
Bed bugs have been found to harbor at least 28 human pathogens and have been considered in the transmission of a wide variety of infectious agents. However, bed bugs have never been proven to biologically transmit any human pathogen, including HIV and hepatitis B. Although bed bugs are considered more of a nuisance than a health concern, public health officials maintain a level of interest due to the possibility of secondary infections.

Medical Importance

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. Unlike flea bites, which occur mainly around the ankles, 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. However, 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.

Common allergic reactions include the development of large welts, often >1cm, which 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. In India, iron deficiency in infants has been associated with severe infestations. It has been suggested that allergens from bed bugs may be associated with asthmatic reactions. Reactions to the bites may be delayed up to 9 days before lesions appear. Reactions may be accompanied by severe itching that lasts for several hours to days. Scratching may cause the welts to become infected.
Depending 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

Other "Bugs"
When bed bug-like insects are found, it is important to consider whether bats, swallows, chimney swifts, pigeons or other wild reservoirs are involved. Although similar in appearance, bed bug species that normally feed on bats and birds can be differentiated from those that prefer humans by using a hand lens to examine the shape of the bug's head. Other species of bed bugs have appearances similar to the common bed bug. The bat bug is virtually identical but feeds upon bats and has longer hairs on its body than the bed bug. The barn swallow bug is similar in size and coloration but is

Division of Public Health http://health.state.ga.us Rhonda M. Medows, M.D., F.A.A.F.P. Acting Director, State Health Officer
Please send comments to: gaepinfo@dhr.state.ga.us

John M. Horan, M.D., M.P.H. State Epidemiologist
Director, Epidemiology Section http://health.state.ga.us/epi
Cherie Drenzek, D.V.M., M.S. Director, Acute Disease Epi Section

Georgia Epidemiology Report Editorial Board
Carol A. Hoban, M.P.H., Ph.D. Editor Kathryn E. Arnold, M.D.
Cherie Drenzek, D.V.M., M.S. John M. Horan, M.D., M.P.H. Angela Alexander - Mailing List Jimmy Clanton, Jr. - Graphic Designer

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Two Peachtree St., N.W., Atlanta, GA 30303-3186 Phone: (404) 657-2588 | Fax: (404) 657-7517

clothed with long silky hairs. The poultry bug or Mexican chicken bug is more active than the common bed bug, has longer legs, and a longer beak.
Flea

Table. Comparison of Bed Bug Bites and Scabies Similarities
Signs & Symptoms Flea-bitten rash pattern/sign Papulosquamous rash Pruritic/itching rash Rash
Clinical Presentation & Variations Presentation/ Papular Rash Face Upper Arms
From http://en.diagnosispro.com/disease_comparison-for/scabiesversus-bedbug-bites-cimex-lectularius/19394-21772.html
When it comes to bed bugs remember the old saying, "good night, sleep tight and don't let the bed bugs bite."
Author: Rosmarie Kelly, Ph.D., M.P.H., Medical Entomologist, Acute Disease Epidemiology Section

REFERENCES

Cockroach
Earwig
There are other insects and arthropods that can invade buildings and that might be confused with bed bugs. These include roaches, other hemipterans (stink bugs, wheel bugs, etc), fleas, ants, beetles, and earwigs. The masked hunter, an assassin bug, is known to feed upon bed bugs. Presence of this insect in the home may be indicative of bed bug infestations, although this is not always the case.

Goddard, J. 2003. Do Bed Bugs Carry Human Diseases? Pest Control Technology, 31: 38-40.
Search for "Do Bed Bugs Carry Human Diseases" at http://lrs.afpmb.org/rlgn_app/ar_login/guest/guest
Gordon's Key to Insect Orders http://www.earthlife. net/insects/orders-key.html
Meek, F. 2003. Bed Bugs Bite Back. Pest Control Technology, 31: 43-52.
Search for "Bed Bugs Bite Back" at http://lrs.afpmb. org/rlgn_app/ar_login/guest/guest
Instant Symposium: Not Letting the Bed Bugs Bite... Bed, Lab, and Beyond. American Entomologist. Summer 2006, 52 (2):98-122.

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The Georgia Epidemiology Report Epidemiology Section Two Peachtree St., NW Atlanta, GA 30303-3186
Providers can contact Public Health IMMEDIATELY 24 hours a day, 7 days a week, by calling: 1-866-PUB-HLTH (1-866-782-4584) to report immediately notifiable diseases and public health emergencies
April 2009

Due to the rising costs of printing and mailing the GER to over 30,000 subscribers, we are switching to an electronic version of the GER. The electronic version will be available as a portable document format (pdf ) file on the Division of Public Health web site, http://www.health.state.ga.us/epi/manuals/ger.asp. We will send an e-mail notification to all subscribers when the monthly GER has been posted to the web site. This will enable us to continue distributing the GER to all of our subscribers.
We have also created an electronic database where GER subscribers may log on to request an electronic subscription to the GER, enter their current e-mail address for the GER electronic notification, update their contact information, or cancel their electronic subscription. To access this database, please visit this website, https:// sendss.state.ga.us/ger, and follow the instructions when prompted.
We look forward to continuing to provide you with important public health information in Georgia.
Volume25Number04

Reported Cases of Selected Notifiable Diseases in Georgia, Profile* for January 2009

Selected Notifiable Diseases
Campylobacteriosis Chlamydia trachomatis Cryptosporidiosis E. coli O157:H7 Giardiasis Gonorrhea Haemophilus influenzae (invasive) Hepatitis A (acute) Hepatitis B (acute) Legionellosis Lyme Disease Meningococcal Disease (invasive) Mumps Pertussis Rubella Salmonellosis Shigellosis Syphilis - Primary Syphilis - Secondary Syphilis - Early Latent Syphilis - Other** Syphilis - Congenital Tuberculosis

Total Reported for January 2009
2009 51 3616 26 0 52 1229 11 2 11 7 1 2 0 3 0 109 52 17 63 63 81 0 25

Previous 3 Months Total Ending in January

2007 2008 2009

113

134

120

10033

9285

9109

52

48

73

3

7

3

132

166

165

4532

3861

3511

41

47

39

18

15

9

44

43

46

12

13

15

1

2

2

8

4

4

0

0

0

7

3

7

0

0

0

371

393

405

443

410

186

30

18

40

129

162

196

104

109

134

254

337

252

4

4

1

115

123

82

Previous 12 Months Total Ending in January

2007 2008 2009

588

689

703

40470

43012

42237

281

239

275

44

48

44

691

721

721

20213

17826

15899

123

136

138

65

65

52

201

161

181

39

44

47

7

11

36

22

22

19

4

0

3

31

14

27

0

0

0

1864

2007

2321

1420

1660

1049

122

99

160

491

605

780

395

445

579

1033

1244

1293

10

12

10

518

483

460

* The cumulative numbers in the above table reflect the date the disease was first diagnosed rather than the date the report was received at the state office, and therefore are subject to change over time due to late reporting. The 3 month delay in the disease profile for a given month is designed to minimize any changes that may occur. This method of summarizing data is expected to provide a better overall measure of disease trends and patterns in Georgia.
** Other syphilis includes latent (unknown duration), late latent, late with symptomatic manifestations, and neurosyphilis.
AIDS Profile Update

Report Period
Latest 12 Months

Disease

Total Cases Reported*

Classification <13yrs

>=13yrs Total

HIV, non-AIDS 12

2,910

2,922

Percent Female MSM

26

31

Risk Group Distribution %

IDU

MSM&IDU HS

Unknown Perinatal White

2

1

4

62

<1

22

Race Distribution %

Black

Hispanic Other

72

4

1

3/08-02/09 AIDS

0

1,846

1,846

24

31

3

1

6

60

<1

23

70

5

<1

Five Years Ago:**

HIV, non-AIDS 100

1,802

1,902

35

32

9

4

14

41

<1

21

75

3

1

03/04-02/05 AIDS

9

1,438

1,447

28

33

7

3

14

43

<1

18

77

5

<1

Cumulative: HIV, non-AIDS 224

13,314

13,538

31

29

6

2

10

53

<1

21

74

4

1

07/81-02/09 AIDS

240

33,898

34,138

20

43

14

5

14

23

<1

30

66

3

<1

Yrs - Age at diagnosis in years

MSM - Men having sex with men

IDU - Injection drug users

HS - Heterosexual

* Case totals are accumulated by date of report to the Epidemiology Section ** Due to a change in the surveillance system, case counts may be artificially low during this time period

***HIV, non-AIDS was not collected until 12/31/2003

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