FOLLOW-UP

Generally, eradication of a bed bug infestation will take two or more treatments. It is important that inspectors and pest control companies follow up with the client at least two weeks after the initial treatment to determine whether eradication was successful. This allows sufficient time for eggs that were present during the previous spraying to hatch and become vulnerable to the pesticides. Follow-up from a friend, landlord, or non-profit agency is particularly necessary to make sure they have the supports they need. Supports may be needed for people who are experiencing forms of trauma following a bed bug infestation. Ideally, the resident should be kept out of the home until the bed bug eradication has been confirmed by the follow-up visit, to prevent reinfestation by new bed bugs and feeding by any bed bugs that survived the initial eradication effort—as this can lead to the laying of more pesticide-resistant eggs. During the time leading up the follow-up visit, the floors should not be vacuumed as this can remove any residual pesticides.

Housing management should keep a record of infestation locations and dates within a building.

INSPECTION

Tenants and buildings owners should contact the local authorities (which is usually their Public Health Department) to have an inspection done to confirm a bed bug infestation. Inspectors should look for live bugs, bug shells, eggs, blood spots, and fecal stains. Inspectors should document locations of infestations and dates found.

The inspection should start in areas where the resident has noticed bed bugs, or noticed being bitten. As thorough an inspection as possible should be conducted, including looking at any potential harbourage within 20 feet of the bed including mattresses, bed frames, baseboards, dressers, bedside tables, electrical sockets, pictures, clocks, flooring, cracks in walls, peeling wallpaper, wheelchairs, and appliances and electronics. No items should be removed from the room prior to, or during, the inspection. Infestations often start in the mattress and move outward. Proper tools are needed to make the inspection effective. These include flashlights, magnifying glass, forceps, digital camera, screwdrivers, and plastic bags. Inspections should also be conducted in adjacent units, units across the hallway, and units above and below the infested unit. Similarly, residents should be asked about places they have spent significant amounts of time since they have had bed bugs. These places should also be inspected. The inspection can also be used as an opportunity to speak directly with the people affected by bed bugs and to provide them with education about bed bug identification, legal issues, preparation, sourcing appropriate pest control companies, effective methods of treatment, and prevention.

Inspectors need to take precautionary measures in order to ensure that they do not take bed bugs back to the workplace, or to their homes. This can include wearing a disposable suit over clothing, or taking a change of work clothes that are removed and bagged prior to returning home then promptly laundered.

EDUCATION

An IPM approach requires that residents, building staff, and pest control professionals be well informed and active participants in the eradication effort. Education should support a shared sense of the objectives and methods of IPM and an orientation toward bed bug prevention. Early identification of bed bug infestations is a major part of an education program. Eradication is easiest when bed bug infestations are identified early. Identification requires an ability to recognize bed bugs in their various life stages from egg to adult. Bites are often the first indication of infestation. The bites often occur in twos or threes as the bed bug looks for a capillary to feed on. However, many people will not react to bed bug bites. One study indicates that as many as 70% of people do not react to bites. Consequently, education about the signs of bed bug infestations is also important. Signs can include blood stains and fecal stains from bed bugs found on bedding or other surfaces, and the finding of cast bug skins on bedding and in cracks and gaps. Since not all people react to bites, these signs can be the first indication of an infestation. 

For those people who do react to bites, some doctors have misdiagnosed them as a variety of skin diseases, allowing the infestation to continue to grow. Bed bug experts see misdiagnosis as widespread, and when Richard Pollack, the lead entomologist at Harvard, tested a group of physicians on bed bug bite identification, not one picked out the bed bug bite correctly. Education around stigma, myths, and misinformation should be conducted to ensure that people are unashamed of the bed bugs in their home, are willing to report infestations when they are first suspected, and immediately pursue effective bed bug treatments.

Education should also focus on moving people away from home remedies including the use of over-the-counter insecticides in aerosol cans, rubbing alcohol, and kerosene, to systematic, professional eradication efforts. Home remedies often create a repelling effect that can fragment the colony and push the bed bugs towards adjacent units, only to return at a later time.

People with unsupportive landlords may need education about the legal implications of bed bugs. Tenants should know their rights under local housing legislation such as Ontario’s Residential Tenancies Act including who is responsible for what portion of the bed bug management strategy. Typically, the landlord is responsible for ensuring the apartment is bed bug free—by hiring a pest control company for treatment—while the tenant is responsible for making sure that the appropriate preparation work is done to allow for effective treatment. Legal advice and supports may be necessary prior to approaching the landlord for treatment; a lack of education and support might isolate people and discourage them from reporting bed bugs out of a fear of eviction or other repercussions from the landlord.

BEST PRACTICES: INTEGRATED PEST MANAGEMENT (IPM)

According to the evidence to date, an IPM approach is the best way to deal with bed bug infestations. IPM can be defined as the “use of all possible methods in a logical combination that minimizes risk of pesticide exposure, safeguards the environment, and maximizes effectiveness.” This involves coordinated education, identification, inspection, preparation, treatment, prevention, and follow-up measures to ensure that all bed bugs are eradicated and a resurgence of the infestation is prevented. Bed bug behaviour patterns and their emerging resistance to pesticides mean that pesticides alone are unlikely to solve a bed bug problem.

PESTICIDE RESISTANCE

As mentioned above, although DDT is widely credited with eliminating bed bugs in the last century, bed bugs are very efficient in developing pesticide resistance. Growing resistance to DDT was recognized in bed bugs as early as 1947 and had been widely recognized by 1958 in many countries around the world. Michael Potter has more recently found resistance to DDT in a particular strain of bed bugs in Ohio.Since the ban on DDT, other pesticides, most commonly pyrethroids, deltamethrin, and chlorfenapyr, have been used. These pesticides are not persistent toxic chemicals, and are ineffective if simply applied to surfaces; they must come into direct contact with the bed bugs during application. When used correctly, these pesticides have been shown to be effective against laboratory-raised bed bugs. Unfortunately, resistance to these products is being seen in strains of bed bugs found in the field. In a study at Virginia Tech, chlorfenapyr was not lethal to bed bugs during the test period and did not prevent bed bug activity including mating, laying eggs, nor the hatching of those eggs. The same study found significant resistance to pyrethroids in field strains of bed bugs. In fact, K.S. Yoon’s study on field strains of bed bugs in New York found them to be 264 times as resistant to deltamethrin as susceptible populations in Florida.

Entomologist Michael Potter and his colleagues published an article suggesting that bed bugs are evolving in a manner that has facilitated their resistance to pesticides. Potter argues that the evolution of insecticide resistance could be a primary factor for the resurgence of bed bugs. He and his colleagues conducted two different tests in two different locations of infested sites in Kentucky and Ohio. They found extremely high levels of resistance to two insecticides in both locations. A similar study by John Clark at the University of Massachusetts confirmed that some strains of bed bugs will thrive despite pyrethroid treatment. Clark found mutations in the nervous systems that prevented the effectiveness of pyrethroids. A survey of Australian pest control professionals conducted by Stephen Doggett found that 94.1% of respondents reported that pyrethroids were ineffective for bed bug control. Resistance was also recently found in certain bed bugs in the United Kingdom and in Africa

DNA analysis of bed bugs indicates that bed bugs have a high rate of gene flow due to high rates of reproduction and mating, indicating that pesticide resistance will continue to spread quickly.

SOCIAL STIGMA AND ISOLATION

The WHO (The World Health Organization) acknowledges that there is a social stigma associated with having a bedbug infestation which results in negative social impacts. Most people feel ashamed and embarrassed when they discover that they have bed bugs and, as result, socially isolate themselves from others. In addition, because of the negative connation of bed bugs, people do not want to openly disclose the fact that they have an infestation. Bed bugs are mistakenly associated with people who live in unclean conditions, resulting in particularly negative implications for marginalized people who already face barriers to social and economic inclusion. In many instances, people with bed bug infestations become pariahs, cut off from their friends, family, and work associates because no one wants to take the risk of getting bed bugs.

PARANOIA AND EXTREME MENTAL HEALTH IMPLICATIONS

The increased sense of anxiety that is commonly associated with bed bugs has also caused people to resort to unsafe and unhealthy measures to deal or cope with the bed bugs. The Ottawa Citizen documented a story of woman who had been suffering from anxiety and insomnia as a direct result of infestation of bed bugs. Her case of sensitivity to bed bugs was so severe that she had overdosed on sleeping pills as a means to commit suicide to alleviate the stress and psychosis associated with bed

bugs. The anxiety associated with bed bugs also has led people to sleep in their cars, offices, or other locations because they are afraid of the constant bites when they go to sleep at night. There have also been reports of people getting rid of, and not replacing, their furniture, of sleeping in tents in their homes after the bed bugs were eradicated, and of a nurse that slept in an intensive care unit to get away from bed bugs at home (her home took five treatments before the bed bugs were eliminated).

Newspaper stories document cases of paranoia following the discovery of bed bugs, and extreme and reckless reactions including a mother pouring diesel fuel on mattresses in order to kill the bugs, risking exposure to fumes and fire in the desperate effort to eliminate bed bugs. In one case, an apartment building caught on fire in Cincinnati due to a tenant using alcohol to treat an infestation.

Bed bugs are identified in connection with “delusory parasitosis” a psychological condition first described in the medical literature more than a century ago, in which the patient has an unwarranted belief that bed bugs are present on or in his body.

PUBLIC SPACES

Public locations are increasingly identified as the sites of infestations because bed bugs, though naturally nocturnal, will adapt and feed on people during the day in some settings, especially when they become agitated or are very hungry making adjustment to non-residential locations increasingly likely. Canadian bed bug expert Sean Rollo says that bed bugs are extremely opportunistic: “If [bed bugs] are hungry for food during the day then they will go and look for food during the day and this is not a problem for them … bed bugs will exploit their food source; if something happens they will change their habits to adapt to this change as well as to their environment.”

Bed bugs can not only infest non-residential sites, but also transfer to a new host there. An Internet survey conducted in Toronto found that 62 of 139 non-profit agencies interviewed had staff who took bed bugs home from their work—often after a client home visit. Other non- residential infestations in schools, daycares, offices, and theatres, and on transit make it possible For individuals to develop a bed bug infestation without any direct contact with an infested home. This accelerates the pace at which bed bugs move from high-risk settings to normally low-risk settings, and broadens the infestation more quickly.

Despite the concrete evidence that bed bugs are infesting non-residential sites including offices and public facilities, virtually no policies exist to address non-residential infestations on anything but a reactive basis. Research located no proactive inspection of public facilities, no significant body of human resource policies addressing the impact of workplace infestations, no consistent policies for compensating staff for infestations at home obtained through work, and no consistent policies for addressing the impact clients with severe bed bug problems have on fellow service users, staff, or facilities.

The well-established incidence of non-residential infestation, its significant impact on the rate of spreading for bed bugs, and the lack of proactive public policy on the matter exposes

communities to accelerating rates of infestation and a dramatic broadening of the types of homes and facilities that will confront infestations. 

THE DISABLED / ELDERLY

People with physical or mental disabilities or frail or elderly people are more vulnerable to extreme bed bug infestations because of their limited capacity to take the necessary steps to deal with the problem. Eliminating bed bugs from the home involves not only resources, but also physical work including moving furniture, detailed and extensive visual inspection of the rooms, bagging clothes and belongings, high volumes of laundry, and the disposal of severely infested items. People who face mental challenges or severe addictions, or lack the ability to carry out heavy physical work or the visual acuity to carry out detailed inspections have the hardest time completing these extensive

procedures.

HIGH COST OF INACTION

The costs of managing an infestation become higher if the problem is left alone, or is treated improperly. The longer there is inaction, the more the infestation will spread. The larger the infestation, the harder it is to treat, the longer it takes to treat, and more rooms need treatment. Also, the more widespread the infestation becomes, the less likely it is that one will be able to find all of the areas of infestation to treat properly. This can lead to multiple treatments before all harbourages are eradicated. The reported case of an apartment building in Winnipeg illustrates how costs can rise as the problem worsens. In 2004, the building had infestations that, untreated, had spread throughout the building to 73 of its 373 units.

Between 2004 and 2008, the building manager spent $260,000 to get rid of the bed bugs.

Because of the large number of units infested, the bed bugs were able to spread effectively from unit to unit during isolated treatments, and have therefore become more difficult to eradicate. After four years of expensive treatments, bed bugs continued to infest 40 units. 

COSTS OF ALTERNATIVE TREATMENTS

Other methods of inspection and treatment are being used, and they vary in cost. Using specially trained dogs to detect bed bugs in a home can enable a resident to more accurately identify where in the home bed bug treatment is needed (dogs are 90% accurate at detecting bed bugs, while a human inspector is only 35% to 40% effective), but at $200 per hour can cost more than a human inspector. Some companies can super-heat a room using portable heaters to bring the temperature over 120 degrees Fahrenheit (approximately 49 degrees Celsius), and kill the bed bugs. This treatment can cost between $500 and $1,000 per room.

Another company sells a device that allows you to super-heat smaller belongings such as luggage in a sealed container. This device sells for about $300. Cryonite is a type of deep- freezing carbon dioxide that can be applied to belongings, and to baseboards and cracks. The treatment dry freezes and thaws, so no moisture is left in the walls. This treatment can cost $600 to $700 per room. As this treatment is comparatively new, its effectiveness has not been firmly established.

The Citizen’s Guide also notes the potential need for replacement costs for new bed frame ($140); couch ($220); coffee table ($120); bookshelf ($120); cabinets ($200); chairs ($150); armoire ($350); clothes, shoes, and coats ($800); and blankets, sheets, and comforters ($400) that add up to well over $2,000 in additional costs. For supportive housing, there are additional costs relating to staff time in supporting clients in the preparation and treatment 

of bed bugs. 

Walking Bed Bugs

While bed bugs are known to travel unit to unit, they are also known to walk from building to building in severe and exceptional cases. Eric Hardebeck of Permakil, an American pest control company, reported bed bugs crawling through an alley in broad daylight, climbing up the sides of a building and crawling along telephone wires to enter into an apartment building adjacent to the alley. Bed bugs were found running out into the street, and some had been run over by cars. 

The bed bugs had survived in mattresses discarded in the alley and by feeding on homeless people who were using the mattresses. The infestation had reached such high levels that the 

bugs were mobile outside during the day.

Unit to Unit Migration -

BY:  Health and Long-Term Care, Habitat Services and WoodGreen Community Services worked with Public Interest, which conducted over 30 key informant interviews in Toronto spoke with bed bug experts in Canada, and all over the world 

In densely clustered housing such as in an apartment building, spread can occur quickly from one home to another. Within a year, bed bug infestations can grow from a few bugs to thousands.  According to U.K. bed bug expert Clive Boase, a bed bug infestation that is left untreated will spread at the rate of about one room every seven weeks through the walls, electrical wiring, and plumbing. This spread is often to adjacent units, across the hall, and above and below the infested unit. Stephen Doggett has found that the most severe infestations, with several thousand bugs, will invariably lead to infestations in adjacent units. Doggett’s study of a nursing staff dormitory in 2004 showed that bed bugs spread not only from one unit to the next, but also to units all around the building. This could be a result of social networks and improper cleaning procedures. Doggett’s study also shows that bugs bypass some units.

This is likely due to limited access to the units or factors affecting access to the unit such as proper sealing around pipes and plumbing, and the filling of cracks.