Abstract
The resurgence of bed bugs poses an urgent situation since infestations are rampant globally, nationally, and locally. In Ohio, bed bugs have become a virtual epidemic in many towns and cities, especially in central and southwestern regions of the state. These blood-feeding insects cause an array of adverse health effects in humans. Furthermore, bed bugs disproportionately occur in urban areas, and housing and the built environment are now recognized as dominant influences on health. Bed bugs’ potential role in disease transmission remains unqualified to date, and research on this issue is urgently needed. The escalating global bed bug resurgence leaves the divided public health community in a precarious social justice position if the lack of response to bed bug infestations disproportionately impacts underserved populations. Bed bugs are an urgent public health and environmental justice concern, and the authors recommend that public health agencies respond with authority of agency.
Introduction
Bed bugs (Cimex spp.) are ubiquitous in the global environment (Hwang, Svoboda, De Jong, Kabasele, & Gogosis, 2005). Bed bug infestations have increased exponentially in North America, Canada, Europe, and Australia since the late 1990s (Harlan, Faulde, & Baumann, 2008). Bed bugs (Cimex lectularius) are presently plaguing the hospitality industry, schools, and residential populations, and they are threatening all aspects of American life (U.S. Environmental Protection Agency [U.S. EPA], 2009a). Many large cities and small communities in Ohio already have been negatively impacted by rampant bed bug infestations (Central Ohio Bed Bug Task Force, 2010; Joint Bed Bug Task Force, 2008). Bed bugs are poised to become one of the major pests in households throughout the U.S., necessitating the attention of many local jurisdictions in the near future.
The resurgence of bed bugs is theorized to be caused by a plethora of contemporary social and physical factors, including increased international travel and immigration; changes in pesticide availability, formulations, and application methodology; pesticide resistance; and the public’s lack of awareness of bed bugs and the ease with which they are spread (Hwang et al., 2005; Jones, 2004; Romero, Potter, Potter, Haynes, 2007; Zhu et al., 2010). All bed bug stages (eggs, young [nymphs], and adults) act as stowaways that are passively transported in luggage, clothing, bedding, and furniture. Urbanization plays an important role since bed bugs are frequently found in dwellings with a high rate of occupant turnover, such as hotels, motels, hostels, dormitories, shelters, apartment complexes, and so on (Jones, 2004).
Despite the negative health implications associated with bed bugs, many public health agencies are reluctant to take responsibility for these parasitic insects. While the resurgence of bed bugs and their impact upon global populations are easily demonstrated, the efficiency of the bed bug as a vector of disease is not (Goddard & deShazo, 2009). This latter point has been emphasized by many local jurisdictions hesitant to respond to bed bug complaints, while simultaneously considering their manpower shortages and lack of regulatory authority (Richland Health Department, 2009; Rossi & Jennings, 2010).
This is the era of health determinant differentiation, however, with housing and the built environment recognized as dominant influences on health and associated mental health considerations (Friedli, 2009). The escalating global bed bug resurgence leaves the divided public health community in a precarious social justice position if the lack of response to bed bug infestations disproportionately impacts underserved populations. Based traditionally upon local regulatory authority, local public health jurisdictions in the U.S. may be ignoring, or choosing to avoid, the inescapable responsibility of protecting people at both the individual level and at growing community levels from the infestation of an “insect of public health significance (Harlan et al., 2008).” It is noteworthy that a recent opinion survey revealed that 90% of all respondents considered bed bugs to be a public health concern, and 73% indicated that bed bugs pose an environmental justice concern (Eddy & Jones, 2011). Our article provides an evaluation of the literature pertaining to bed bugs’ effects on human health and their potential as disease vectors; public health agency and response to human habitation concerns; and social and environmental justice issues as they relate to underserved and vulnerable populations. We strive to draw recommendations for future discussion and potential revisions in policy relevant to the present global bed bug crisis.
Bed Bugs and Human Health
Bed bugs are small parasitic insects that feed solely on blood, preferably human blood. Bed bugs typically feed when their host is asleep, biting the host’s exposed areas such as the face, neck, arms, and legs (Ter Poorten & Prose, 2005). After piercing the host’s exposed skin, the bug injects a salivary fluid containing an anticoagulant that helps it obtain blood. The bite itself is relatively painless, but the injected salivary fluid is responsible for considerable localized and, occasionally, systemic reactions, although individuals differ in their sensitivity. The majority of humans (70%) have allergic reactions to bed bug bites and experience inflamed swollen welts and itching, sometimes very intense, that last for hours to days (Potter et al., 2010). Scratching can cause the welts to become infected due to secondary bacterial agents (Feingold, Benjamini, & Michaeli, 1968), which may result in eczematoid dermatitis, cellulitis, impetigo, and pyoderma (Goddard & deShazo, 2009). Severe bed bug infestations can initiate iron-deficiency anemia due to significant blood loss (Pritchard & Hwang, 2009). Systemic reactions from bed bug bites occasionally are reported. These include asthma, generalized urticaria, and anaphylaxis (Goddard & deShazo, 2009). For example, bed bug infestations are associated with airborne allergens that may produce bronchial asthma.
Furthermore, a variety of physiological and psychological responses often is experienced by those dealing with bed bug infestations. Anxiety, stress, insomnia, and depression are common responses to bed bug infestations, and such medically important symptoms can lead to other health conditions (Hwang et al., 2005; Potter et al., 2010). In fact, routine exposure to bed bug bites may make a person more susceptible to common diseases (Usinger, 1966). Frequent bed bug bites have resulted in “sensitivity syndrome,” which is characterized by nervousness, jumpiness, and sleeplessness (Harlan et al., 2008). Feelings of social stigmatization, anger, frustration, paranoia, embarrassment, and devastation also are reported by those living with bed bugs (Potter et al., 2010). With such an array of health effects caused by bed bugs, how can any local public health jurisdiction justify an indifference to the plight of bed bug victims?
Bed bugs were officially designated as a public health pest in Pesticide Registration Notice 2002, which was jointly issued by the U.S. Environmental Protection Agency (U.S. EPA) and the Centers for Disease Control and Prevention (CDC) (U.S. EPA, 2002). In August 2010, these federal agencies issued a joint statement declaring bed bugs to be “a pest of significant public health importance (CDC & U.S. EPA, 2010).” The reemergence of bed bugs throughout the world poses a new challenge in modern public health since these small blood-feeding insects closely interact with humans and now are recognized at the federal level as an important environmental and public health issue.
Bed Bugs and Transmission of Human Disease
Bed bugs have been long been suspected in the transmission of human diseases given their blood-sucking behavior and close association with humans (Burton, 1963; Usinger, 1966). Burton’s (1963) review of the literature covered the early to mid-1900s, and he concluded that bed bugs could not be positively incriminated in disease transmission despite contrary evidence from some laboratory studies. Although C. lectularius have been found infected (in nature or experimentally) with at least 24 disease organisms (e.g., Trypanosoma cruzi, Brucella melitensis, Wuchereria bancrofti, and Staphylococcus aureus), many located in the bed bug gut and feces, no proof of transmission of the associated diseases exists (Burton, 1963; Usinger, 1966).
Bed bugs may transmit disease mechanically, a process that sanitarians and disease pathologists can appreciate. According to Jupp and co-authors (1983), “The results as a whole indicate that no biological multiplication of virus occurs in C. lectularius but that mechanical transmission from insects to man could occur by (i) contamination of a person when crushing infective bugs; (ii) contamination from infected feces; and (iii) infection by bite due to regurgitation or interrupted feeding.” Therefore, mechanical transmission of disease organisms through infected feces remains the most plausible scenario since bed bugs have been observed to defecate on their host following a meal (Pinto, Cooper, & Kraft, 2007). Hepatitis B virus appears to be the most likely pathogen to be transmitted by bed bugs; DNA of this virus was detected in bed bugs and their feces up to six weeks after the bugs fed on infected blood (Blow, Turell, Silverman, & Walker, 2001; Silverman et al., 2001). In the most recent review of the literature pertaining to health and medical effects due to bed bugs, Goddard & deShazo (2009) concluded that “evidence for disease transmission by bed bugs is lacking.” This is not equivalent to the often said, yet incorrect, statement that “bed bugs do not transmit disease.” Goddard & deShazo (2009) also noted that “evidence for disease transmission by bed bugs is equivocal.” Contemporary research is urgently needed on this issue.
Cockroaches, long considered as mechanical disease vectors by health officials and field inspectors, walk readily from filth to food, carrying potential disease pathogens to food, environmental surfaces, and other items. The comparatively slower moving bed bug is a direct human parasite, which conveniently seeks harborages close to its food source, i.e., humans in slumber. Future research will reveal if bed bugs should be classified in some, or perhaps all, of the vector types listed below.
The health hazard of a pest infestation may arise through it being a direct parasite (e.g., bed bugs feeding on human blood), a disease vector (e.g., the large number of diseases transmitted by rats), a hygiene hazard (e.g., cockroaches and houseflies that carry harmful microorganisms on their bodies and transmit these to food items), or the source of an allergen (e.g., house dust mite fecal droppings) (Thomson & Petticrew, 2005).
The 2009 U.S. EPA National Bed Bug Summit in Washington, DC, resulted in a call for more research regarding bed bugs as vectors of disease and as causes of mental health issues (U.S. EPA, 2009b).
Urbanization, Human Habitation, and Bed Bugs
“Combined public health and medical initiatives to fight infectious disease in the United States were considered so successful that the U.S. secretary of state in 1948 and the U.S. surgeon general in 1967 announced that infectious disease had been, or would soon become, extinct (Eddy, Sase, & Schuster, 2010).” Improvements in the built environment (specifically housing quality), modern sanitary practices, and economic prosperity signaled the beginning of the age of chronic disease, as infectious disease was thought to be subsiding (Wilkinson & Marmot, 2009). Many of the same public health reform programs that ushered in the new era of community health, however, also relinquished administrative primacy to nonhealth agency, code enforcement authorities in the mid-20th century (Fairchild, Riosner, Colgrove, Bayer, & Fried, 2010; U.S. Department of Health and Human Services [HHS], 2009). Thus, as the unstudied (and soon-to-reawaken) bed bug scourge was considered essentially extinct in the urban environment in the U.S., many in public health were in the process of abandoning housing programs.
Bed bugs disproportionately affect people in densely occupied, dilapidated urban structures (Harlan et al., 2008), and some underlying reasons why such areas are very prone to bed bug infestations include the following. Cities typically have diverse housing stock and a high percentage of residential rental units that allow for mobility of the city’s population. Compared to rural areas, cities have a larger number and higher density of hotels, motels, shelters, and other lodging establishments to accommodate transient populations. Bed bugs also are mobile and quickly spread to occupy numerous residences in multi-unit buildings as they move through wall voids and along utility lines and heating ducts as well as elevator shafts and laundry and mail chutes. Furthermore, bed bugs are easily transported to previously uninfested habitations when infested items are moved onto the premises. If the premises remain untreated or improperly treated, bed bug populations rapidly increase. Bed bug infestations, particularly in low-income and senior housing, cause significant hardship for those who are least able to pay for proper treatment. Those in senior housing, however, need to be particularly vigilant since the elderly show less reactivity to bed bug bites than other age groups (Potter et al., 2010). Research has shown that bed bug infestations are particularly difficult to eradicate in low-income communities (Wang, Saltzmann, Chin, Bennett, & Gibb, 2010).
Local Public Health Policy Regarding Bed Bugs
Local public health jurisdictions are the frontline guard against disease in the community, and they are traditionally mandated to assess risk, develop policy, and assure health in the community. Some local public health jurisdictions have ceded authority, however, to other agencies for residential housing inspection and hotel regulation. A recent report by the U.S. surgeon general states,
In the mid-20th century, however, housing and health agencies became organizationally separated, resulting in a diminished focus on the prevention of housing-related disease and illness (HHS, 2009).
Local policy or interpretation of constitutional prohibition has caused some local health jurisdictions to choose to have no housing program and no hotel program; some health agencies dictate policy restricting sanitarians and other environmental and housing code officials from entering residential structures. Many local health jurisdictions do not have housing or hotel regulations and therefore hold no jurisdiction over those structures. The fact that some local health jurisdictions have relinquished housing authority (or emphasis upon housing inspection) may help to explain the impact of other variables that result in an uneven approach to bed bug complaints. Some of the underlying reasons for local jurisdictions’ failure to respond to bed bug complaints include cost and manpower limitations, reluctance to accept additional responsibility, lack of policy and procedure (legal mandates), and the uncharacterized zoonotic potential of bed bugs as efficient vectors of disease. For example, in 2009, the Cincinnati Health Department suspended their bed bug inspection program, which had been implemented since 2007, due to the city council’s economic decision to slash funding for the program (City of Cincinnati, 2009) (see sidebar).
Determinants of Health and Environmental Justice
Poor housing is a determinant of health according to the World Health Organization (Thomson & Petticrew, 2005). Many sources show housing to be a social justice issue, necessitating discussion upon health equity, environmental justice, and health disparity grounds. The Alliance for Healthy Homes (2009) Web site presents the following regarding housing-related environmental justice:
Health hazards in homes tend to be highly concentrated in lower-income communities and communities of color, and they disproportionately harm poor and minority families.
U.S. EPA (2010) defines “environmental justice” as
Fair treatment and meaningful involvement of all people regardless of race, color, national origin or income with respect to the development, implementation, and enforcement of environmental laws, regulations, and policies.
“Poverty fosters infectious disease,” according to the Blueprint for A Healthier America (Levi, Kaiman, Juliano, & Segal, 2008). Furthermore, Thomson & Petticrew (2005) state that “... the reports from cross-sectional studies are consistent, and the link between poor housing and poor health is generally accepted.” Bed bugs, lice, cockroaches, fleas, mites, and rodents all present a health hazard (Thomson & Petticrew, 2005).
Driven both by affluence and poverty, housing tenure (own vs. rent) influences health (Thomson & Petticrew, 2005). Homeowners tend to have larger incomes than residential renters and “Blacks and Hispanics are less likely to be homeowners on any socioeconomic level (Rossi & Weber, 1996).” Furthermore, renters live in higher densities than homeowners and hence wield less control over their living environments, worsening the “communal” aspect of pest control complexities and effectiveness (Alliance for Healthy Homes, 2009). Tenants in underserved communities may be exposed needlessly to excessive volumes of pesticides, misapplied by residents in efforts to control difficult insect infestations where cleaning may be impossible due to dilapidated structures (Srinivasan, O’Fallon, & Dearry, 2003). Pesticides cannot be applied effectively to areas that cannot be cleaned. Effective integrated pest management plans, which require cooperation among all tenants in a multi-unit dwelling, may be difficult to achieve (Harlan et al., 2008). Communication and cooperation among residents, staff, and the pest control service provider are keys to successful bed bug control in multi-family housing (Taisey & Neltner, 2010). A need clearly exists for education of residents as to the complexities of bed bug management. Although public officials and other interested stakeholders are quick to state that bed bugs (unlike cockroaches and rodents) are not caused by poor residential hygiene, bed bug infestations are perpetuated by poor residential hygiene, particularly accumulated clutter that offers many hiding places for the bugs.
And, importantly, poverty is a driving force in bed bug infestation. Low-income minority communities face higher unemployment rates and contain immigrants who may have previous exposure to deleterious environmental parasites and who often lack effective communication skills (Alliance for Healthy Homes, 2009). Migrant housing often is plagued with persistent bed bug infestations— professional pest control is unaffordable yet self-help control measures are ineffective and simultaneously deplete financial resources, resulting in an endless problem for those living in poverty (Harlan et al., 2008). Furthermore, “difficulties [are] associated with low-income people in dealing with bed bugs and their control and housing or building quality... (Harlan, Faulde, & Baumann, 2008).” Therefore, we find considerable support in the literature that residential determinants of health all factor into the community bed bug problem. The following residential health determinants impact the presence and severity of bed bug infestations:
1) housing tenure (own vs. rent),
2) density of multi-unit apartment complex occupancy,
3) dilapidated, unfit housing structures,
4) education pertaining to bed bug management,
5) tenant cooperation to prepare for pesticide application processes,
6) poverty,
7) employment,
8) potentially excessive pesticide exposure,
9) immigrant status,
10) age of tenant,
11) local housing program status and viability, and
12) health agency response capacities.
Significant evidence indicates that not only are bed bug infestations exacerbated by social health determinants, but also that local health jurisdictions are increasingly unresponsive to housing program demands, causing social justice, health equity, environmental justice, and health disparity considerations. Furthermore, local health jurisdictions are divided in their opinions regarding bed bugs as an efficient vector of disease, resulting in their responsiveness or lack thereof to complaints of infestations (based upon local policy determination).
Recommendations
A heightened understanding of bed bug biology, behavior, disease transmission pathways, and the physiological and psychological effects of those suffering from infestations is necessary. Scant research showing that efficient disease transmission evidence is unavailable is not equivalent to the assumptions that bed bugs do not transmit disease or do not constitute a public health issue. Funding mechanisms are needed to overcome the dearth of research on bed bugs. Evidence-enlightened perspectives will enhance approaches to policy and procedure, thereby enabling local health jurisdictions presently choosing not to respond to bed bug complaints to make better-informed decisions. Furthermore, in order to better track the bed bug pandemic, local public health jurisdictions need to institute a reporting system for bed bug infestations. Monetary resources also need to be allocated to local and state government agencies responding to the bed bug resurgence.
Further public health systems research also should be conducted to evaluate the residential housing inspection service capacity for local public health jurisdictions. The residential housing inspection service traditionally determined and enforced residential hygiene standards, and in coordination with social workers, “allied health,” and emergency personnel, it provided protection for the elderly and the very young, as well as the mentally and physically challenged.
"The connection between the health and the dwelling of the population is one of the most important that exists." ~ Florence Nightingale
Our article serves as an urgent and emphatic call to service—public health must rise above complacency and agency apathy to meet expected and traditional public health mandates,counterbalance against health disparity, inequity, environmental and other social justice issues, and fulfill the obligation as protector of the health of the community. Bed bugs are a significant housing and residential hygiene concern and an influence upon the social determinants of health. Bed bugs are an urgent public health concern, and we recommend that public health agencies respond with authority of agency.
Acknowledgements: The authors thank Ken Dahms, JD, MA, Master of Public Health Program, Wright State University, Joshua L. Bryant, MS, Entomology, State University; and Eriko Sase, PhD, Community and Global Community Health, Graduate School of Medicine, University of Tokyo, for their critical analyses, important input, and related contributions to this paper. This project was supported in part by state and federal funds appropriated to the Ohio Agricultural Research and Development Center.
Corresponding Author: Christopher R. Eddy, Assistant Program Director, Master Ohio of Public Health Program, Wright State University, 3123 Research Blvd., #200, Kettering, OH 45420-4006. E-mail: christopher.eddy@wright.edu.
Reprinted with permission from the Journal of Environmental Health, April 2011, (Volume 73, Number 8, pp. 8-17), a publication of the National Environmental Health Association, www.neha.org.
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