A Collection of The Best Information From the Experts On Bed Bug Control

Part 1

A Collection of The Best Information From the Experts On Bed Bug Control Pt 1

After looking over tons of information on every web site on the web for the past year, I decided to put together the most reliable documents in hopes of saving some poor souls from the heartache of misinformation abut bed bugs. By heartache I mean 1. The waste of money, which could be hundreds or even thousands of dollars. I am very serious about this. As you will see, these creatures are like none you have ever dealt with so the tou need to have all of the REAL facts in order to make the best decision for your situation. 2. Waste of time. Very serious about this too. The wrong decision can spread them or drive them deeper into places that could make it nearly impossibe to reach. Please use this information to lead you to more. 3. Unnesessary conflict and hurt feelings with your loved ones and the people you live with. Everyone will be stressed but remember this is NO ONES FAULT, it is the bugs fault. Even if you know who brought them in, it is not their fault. No one brings them in on intentionally. Remember that the bed bug problem has exploded in the past few years all over the world. They have been in all government buildings, airplanes, schools and even the Hilton Hotel and Saks Fifth Avenue. It wil be okay if everyone works together nd gives each other emotional support. They reproduce very rapidly, but don't do anything till you read as much as you can to make the right decision. Above all, DO NOT SPRAY OR BOMB WITH OVER THE COUNTER INSECTICIDES, even if they say they kill bed bugs. They don't work and could make the situation much worse. Some of the things you can do now are 1. Vacuum very slowly and thoroughly, and empty the vacuum in a plastic bag nd throw it away each time after you are done. 2. Wash and dry on high heat all clothes and bag them in air tight plastic bags and pull out clothes as you need them. When you undress, put thse clothes in another plastic bag till you wash them. 3. Get bed incasements that say say they are for bed bugs, not the es that say they HELP keep bed bugs away. Put some kind of padding in the corner of bed frame so the encasement doesn't rip. Vacuum these every day. You might want to duct tape the zipper just in case. 4. They do have a tent on line you can put on your bed to keep from getting bit. 5. Wash and dry on high heat your sheets and blankets often. 6. Maybe I shouldn't say this, but rubbing alcohol does kill them on contact, but please be VERY CAREFUL, it is highly inflammable and I mean the fumes too. The documents here are from university and government studies and agencies who have no financial motives for their information so you know that what they print is the truth as far as they know. Beware of info from places that want you to buy their products. The document Code of Practice For the Control of Bed Bug Infestations I put in to show how complicated extermination of the bed bug is and for those that simply cannot afford an exterminater in these times when it's hard to even feed the family.

Others who are poor, but can afford a little monthly payment, weigh your options carefully because you may end up spending hundreds more when your motive was to save money. Also be advised, there are laws concerning bed bugs, which I have put a document in for all of the states. This may be your landlords resoncibility, so find out what your rights are. On line, two of the best sites are Bed Bug Central. Jeff White is one of the top experts in this country on bed bugs. He also has a lt of great videos on Youtube to help you. http://www.bedbugcentral.com/ And there is Bedbuggers.com with tons of info and a blog where you can ask questions and get truthful answers. http://bedbugger.com/

Bless you and Good Luck !!!!!!!

Bed Bugs Are Back Are we ready?

Bed Bugs Are Back Are we ready?

TABle of ConTenTs

1 7 20 27 29 46 47 59

ExEcutivE SummAry: BEd BugS ArE BAck rESEArch OvErviEw whAt tO dO tO rEvErSE thiS PAttErnBest Practices cOncluSiOn rESultS Of kEy infOrmAnt intErviEwS On BEd Bug infEStAtiOnS in tOrOntO cOncluSiOnS rEcOmmEndAtiOnS APPEndicES

59 Appendix A 60 Appendix B 64 Appendix C 67 Appendix D 70 Appendix E 76 Appendix F 80 Appendix G

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foreword Bed Bugs Are Back: Are we ready? is a research report that brings together our local Toronto experience and current worldwide knowledge and understanding of bed bugs. The ultimate goal of Bed Bugs Are Back: Are We Ready? is to inform and shape public policy, government responses, and community strategies aimed at implementing effective bed bug interventions that prevent uncontrolled outbreaks. We, at Habitat Services and WoodGreen Community Services, first started hearing about bed bugs four or five years ago. We initially believed that the increasing number of bed bug incidents being reported were isolated cases, which could be as easily eradicated as fleas, cockroaches, and other insects that are often a nuisance to us in the places where we live and work. Our experience, and the experience of other non-profit agencies in Toronto and members of our communities, indicated that bed bugs are complex insects. Bed bugs are not like other bugs; they are not easy to eradicate. They often cause much stress and anxiety, and to get rid of them requires adequate, and often ongoing, financial and physical resources. With funding from the City of Toronto and the Ministry of 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

located the most up-to-date and ground-breaking stories, trends, and strategies that describe the impact bed bugs are having at the local, national, and international level. We would like to thank the members of our Advisory Committee who helped us shape the scope and direction of this report: Reg AyreToronto Public Health Paula CassinABI Possibilities Joyce BrownOntario Coalition of Alternative Businesses Anne LongairCity of Toronto

Elaine MagilWoodGreen Community Services

Chris Persaud and Lorraine Van WagnerHabitat Services

Sean Meagher, Rebecca Price, and Alex GossPublic Interest We also would like to acknowledge and genuinely thank all of those who agreed to be interviewed as key informants and/or as experts (please see page 80 for a complete list of interviewees). These individuals have contributed toward the development of a more informed understanding of bed bug behaviour and to the public, government, and community responses needed to prevent and eradicate bed bug infestations. As the rate of bed bug infestations in our communities continues to increase, we hope that this report provides some useful insight and strategies for tackling this complex challenge. Leslie McDonald, Habitat Services Rima Zavys, WoodGreen Community Services

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All photographs used with permission from Dr. T. G. Myles, from the website: http://www.utoronto.ca/forest/termite/Bedbugs/photoindex.html design by yaddaYadda communication 2009 Woodgreen Community Services, Toronto printed in Canada

exeCuTive summAry: Bed Bugs Are BACk

Overwhelmingly, around the world, bed bugs are back. Between the 1970s and 2000, reports of bed bug infestations across the western world were few and far between. Today they are increasingly common. Cities around the world are facing significantly higher numbers of bed bug infestations. The number of bed bug calls to New York City staff rose from 537 in 2004 to 6,889 in 2007. A survey of 121 pest control companies in Australia showed a rise in bed bug treatments from 158 in 2000 to 2,464 in 20051. Toronto is no exception. Before 2003, there are no recorded numbers of bed bug infestations, but they have been characterized by Toronto Public Health as sporadic and mild. In 2003, a Toronto study showed that there were only 46 reports of bed bugs to Toronto Public Health but by 2008, preliminary numbers showed that Toronto Public Health received reports of almost 1,500 bed bug infestations between March and October. Concerns about growing bed bug problems are being heard from Ottawa, 2 Hamilton,3 Windsor,4 Kingston,5 London,6 Huntsville,7 North Bay,8 Wasaga Beach,9 and Owen Sound.10 Some of these cities have seen spectacular growth in the number of bed bug incidents over the last few years. The view of most experts is that the problem is growing rapidly and will likely become significantly worse unless there is rapid, focused, and multi-sector intervention. we Are noT reAdy for The ouTBreAk People have lived with bed bugs since prehistoric times, and, historically, the incidence of infestations was quite high. Records indicate that, in the 1880s, 75% of all homes in England were infested with bed bugs. Roughly half of all homes still had infestations in 1939. About 1 in 3 homes in Europe had infestations in the 1930s and 1940s11. A concerted effort to address the widespread presence of bed bugs succeeded in virtually eradicating them from most western cities by the 1970s.

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Though persistent toxic synthetic pesticides such as DDT receive much of the credit for the eradication of bed bugs, evidence indicates that government-led, integrated systematic approaches were critical. The U.K. Ministry of Health in 1934, for example, required local authorities to intervene actively, by: coordinating across government departments to ensure effective eradication strategies sending public health nurses to homes for proactive inspections creating clear protocols for inspection, cleaning, and spraying

developing public education tools and actively distributing them

providing cleaning materials and apparatus and, in some cases, staff to support effective action ensuring follow-up visits

making structural improvements to homes to prevent infestations and spreading issuing mandatory orders to landlords for interventions compensating tenants for costs.

There is every reason to believe that the effort would not have been successful without this multifaceted coordinated approach, not least because evidence shows that bed bug resistance to DDT was already becoming established by 1947only a few years after the product was introduced, and confirmed repeatedly over the next 10 years until, by 1956, the National Pest Control Association was recommending alternative pesticides for bed bugs. Unfortunately, much of the knowledge that helped to manage bed bugs has been forgotten during the 30 years that bed bugs were thought to be eradicated, yet that knowledge is badly needed to stem the tide of the current outbreak. lACk of AwAreness And eduCATion inTensifies The ProBlem Research indicates that most people have little if any knowledge about how to deal effectively with a bed bug infestation. Few people can even accurately identify the problem and they receive little support from professionals. Research shows that medical professionals routinely misdiagnose bed bug bites and pest control professionals need clearer protocols for effectively addressing an infestation. As a result, infestations often grow beyond easily manageable levels before effective interventions are applied. On detection, individuals and even some pest control professionals engage in practices that are at best ineffective and at times can spread infestations. Infested materials are taken, unprotected, through buildings for disposal, spreading bed bugs to hallways, elevators, and lobbies as they go. Infested items are disposed of unlabelled and often reclaimed by others, spreading the infestation to new sites. Partial treatments that disrupt but do not eradicate infestations are used, which fragment and spread colonies rather than destroying them. This weakness in bed bug awareness is contributing to the size and scope of the emerging bed bug problem.

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sCoPe of infesTATions is inCreAsingly BroAd Bed bugs can infest any home. However, bed bugs are mistakenly associated with low-income communities, because they spread most readily and rapidly in high-density settings with high turnover and find it easier to infest buildings with cracks and crevices to hide in. Not only low-cost rental housing fits this description, but also expensive hotels and the dormitories of universities; both face serious challenges managing bed bugs. Because they are most susceptible to infestations, these settings are the locations first affected by growing bed bug populations but they are by no means the only sites affected. These sites function as the proverbial canary in the coal mine, providing an early indication of a growing problem that will eventually affect a broad cross-section of the population. The scope of infestation continues to broaden because of the highly effective and adaptive nature of bed bug transmission. Bed bugs easily stow away on clothing or personal effects to travel to new locations, hide in the smallest of crevices in those new settings, and multiply with enough efficiency to establish colonies of thousands from a single bug in less than a year. As a result, key informants (bed bug experts and people who have experienced, or whose clients have experienced, bed bug infestations) and wide geographical distribution of bed bugs within cities consistently point to increasing incidents in even perceived lower-risk environments. More and more, bed bugs are affecting all residential settings. There Are growing numBers of severe infesTATions Bed bugs are able to spread with exceptional speed under a set of particularly advantageous circumstances that are increasingly common in the current outbreak. The presence of severe infestations, and the adaptability of bed bugs, increases the capacity of bed bugs to spread rapidly to a broader range of households in a shorter period of time. Experts around the world have noted the increasing tendency of highly vulnerable people to suffer severe infestations. The challenges vulnerable people face in addressing an initial infestation, due to infirmities; financial, health, and mental health disruptions in their lives; lack of resources; and limited supports can result in the growth of the infestation to hundreds or thousands of bugs. severe infesTATions inCreAse The risk of sPreAding According to leading bed bug experts, large-scale infestations make spreading inevitable. Bed bugs will travel from a severely infested site rapidly, even walking between buildings. Most significantly, bed bugs in severely infested sites will be sufficiently agitated to be mobile in the day and to travel in exceptional ways. People suffering from severe infestations have been documented travelling with bed bugs walking on their bodies and on their personal effects. Any sites they visit are subject to infestations. As a result, infestations are increasingly common in atypical sites such as offices, hospitals, buses, subways, and schools. Infestation of these sites exposes everyone to infestations, and these previously unusual infestations are being identified with increasing frequency in Toronto and around the world. Surveys of pest control companies in the United States and Australia show that offices, schools, theatres, and public transit make up one of every eight bed bug infestations. Bed bug incidents in New York schools reportedly rose from 40 in 2005 to 300 in 200712 and a public official in New York identified bed bug infestations in five New York subway stations.13
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These settings increase the risk of infestation to the broader population. An online survey conducted in Toronto in October of 2007 found that 62 of 139 non-profit agency respondents had staff who took bed bugs home from work. Pest control professionals, service providers, and experts all identify an increasing rate of infestation in middle-income single-family homes. The imPACT on PeoPle living wiTh infesTATions is ConsiderABle The consequences for people living with infestations are more severe than most people imagine. People who have suffered a bed bug infestation talk of feeling ashamed, fearful, and totally overwhelmed. They frequently describe extreme levels of isolation. Families have abandoned relatives with infestations. A Toronto transportation agency for people who are unable to use public transportation has refused to pick up people with bed bugs, effectively rendering them housebound. Meal delivery and other programs serving isolated people have refused service. People have been barred from work and banned from community service sites. Research into the impact of bed bug infestations shows debilitating impacts, including very high levels of stress, anxiety, depression, sleep deprivation, and intense preoccupation verging on delusional states. Sufferers have reported taking medication to cope with the experience, and some have reported ongoing mental health issues. Experts also identified significant psychological traumas, sometimes resulting in violent behaviour, cases of self-harm, and even suicide14. Despite these pressures, there are few social and psychological supports for people with bed bug infestations. There is A growing imPACT on workPlACes And PuBliC sPACes Confronted with clients facing a bed bug crisis with no meaningful systems of support, non-profit agencies, public health staff, and housing providers have attempted to fill the gap in service delivery. They are clearly not resourced to do so, and the consequences have been considerable. Staff at non-profit agencies reported increasing amounts of time spent implementing a range of precautions against getting and spreading bed bugs, including the use of protective clothing, laundering work clothes on site, and bagging shoes and materials during visits. Agency staff have to adopt awkward practices in spaces where services are provided such as never sitting, never placing materials on the floor, dressing and undressing for work in a garbage bag, and leaving possessions in sealable plastic bags during the day. Agency staff are increasingly involved in seeking funding to address bed bugrelated issues, including Ontario Works and Ontario Disability Support Program (financial assistance programs for people who are not working, or who are mentally or physically disabled) start-up funds to replace infested furniture and small sums to offset the cost of preparation and pesticide application. In cases of chronic unaddressed problems, agency staff have had to intervene directly, carrying out inspections, vacuuming, cleaning, arranging pest control for clients, and intervening with landlords. Some agencies have adopted complex protocols, including freezing the belongings of new residents in housing. Bed bug problems have progressively migrated from clients homes to agency offices. In agency infestations, the absence of hosts during the night has resulted in bed bugs moving about offices and biting staff in the daytime.

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Agencies report staff taking bed bugs home. One office worker got bed bugs despite never having entered a residential unit for work. The bugs were found in her chair at the office. Agencies are beginning to confront issues such as time off to manage infestations, compensation for bed bug related costs, work refusals, and resignations over exposure to bed bugs. CosTs AssoCiATed wiTh Bed Bugs will inCreAse unless effeCTive ACTion is TAken The cost of addressing bed bug infestations effectively can be significant. The most effective protocols employ a multi-faceted approach that includes inspection, preparation, cleaning, application of insecticides, and a follow-up inspection. Interventions of this kind can cost $800 for a single unit with a standard infestation. However, less intensive approaches tend to permit a resurgence of the infestation either by leaving eggs to hatch and repopulate the site, leaving untreated harbourages to repopulate the site, or dispersing bed bugs to other locations nearby and allowing reinfestation from the secondary site. Fear of stigma, concern about consequences, and reticence about costs often lead both residents and property managers to delay addressing bed bug infestations. Those who take action often lack clear and consistent protocols for addressing an infestation and may pursue less effective approaches. Repeated, ineffective interventions, or delayed action, can dramatically increase costs, requiring inspections over a broader area with a wider range of inaccessible hiding places, the cleaning of more materials, the spraying of more sites, and an increased number of eggs that can hatch to reestablish the infestation. Costs rise dramatically in these circumstances. A severe infestation in 73 units in a Winnipeg apartment building required $260,000 in pest control spending and resulted in only a 33unit reduction in infested apartments, an average cost of almost $8,000 per unit.15 The City of Hamiltons Housing Corporation has had to go over budget by $250,000 mainly due to bed bug pressures16 and Toronto Community Housing has had to increase its pest control budget from $1 million in total to $2.5 million for bed bugs alone.17 Bed bug expert Stephen Doggett estimates Australia has spent $100 million on bed bug treatments and the problem is on the rise.18 There Are effeCTive wAys To Address The ProBlem Fortunately, sound protocols exist for treating infestations, including the Code of Practice developed by Stephen Doggett at the Institute for Clinical Pathology and Research in Australia, the guidelines developed by Cornell University and the State of New York Integrated Pest Management Program, the recommendations produced by Michael Potter of the University of Kentucky Department of Entomology, the Bed Bug Handbook by Richard Cooper, Larry Pinto, and Sandy Kraft, Toronto Public Health Fact Sheets, Toronto Community Housing Pest Control Protocols, the Bed Bug Resource Manual by WoodGreen Community Services in Toronto, and the Bed Bug Handbook for Shelter Operators by the City of Toronto Shelter, Support, and Housing Administration. These protocols clearly lay out the most effective approaches to eradication of an infestation. They describe the critical elements of successful interventions, including:

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 detailed inspection

vacuuming and other forms of capture for live bugs

preparation and cleaning of infested materials including bedding, mattresses, and crevices that have been used as harbourages the application of insecticides or steam the sealing of cracks and openings that allow for the entrance of bed bugs the dusting of voids or inaccessible spaces that may harbour insects a follow-up inspection two weeks later to kill bed bugs that have emerged from eggs that survived the first eradication effort. Implementing effective protocols can manage the bed bug population, can successfully reduce the number and intensity of infestations, and have shown effectiveness in treating bed bug infestations and controlling the spread of bed bugs. However, these protocols also require time, energy, persistence, focused action, and investment, as well as the physical capacity to move furniture and the visual acuity to conduct close, detailed visual inspections, which are significant barriers for some. eduCATion is CriTiCAl There is universal agreement that the first and most important step in the eradication of bed bugs is proactive education. Bed bug infestations that are identified early are easier and cheaper to eradicate. Increased knowledge promotes compliance with effective protocols and prevents spreading and resurgence of bed bug infestations, while lack of information allows for the use of less effective methods and often exacerbates the problems. Fear, stigma, and misunderstanding frequently increase the problem by discouraging disclosure and early action. Broad awareness of the issue and its solutions, by the general public, before they experience infestations, is the most effective way to encourage early and effective response. leAdershiP is neCessAry To effeCTively Address The growing Bed Bug infesTATion The cost and complexity of the most successful protocols can deter their adoption, despite their efficacy and long-term cost effectiveness, as well as ensuring that the most vulnerable will have difficulty implementing them independently. Efforts to manage bed bugs require support and investment to overcome that barrier if severe infestations and their consequences are to be avoided. In the middle of the last century, government leadership, like that of the U.K. Ministry of Health, established clear protocols, strongly encouraged their adoption, and provided resources to support and compensate those who could not adopt them independently. This successful strategy curbed bed bug infestations many times the size of those now being experienced in communities across Ontario, and have proven effective again during more recent implementation in Australia. Ontarios efforts to address bed bugs should draw on these models to develop the most appropriate strategies.

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reseArCh overview

inTroduCTion

BEd BugS ArE BAck Overwhelmingly, across the world, bed bugs are back. Before the year 2000, reports of bed bug infestations across the western world were few and far between. Today they are increasingly common. Cities around the world are facing significantly higher numbers of bed bug infestations. Some major cities facing a resurgence of bed bugs include Vancouver, Montreal, Boston, Los Angeles, London, Paris, and Sydney. The number of bed bug calls to New York City staff rose from 537 calls in 2004 to 6,889 calls in 2007.19 One pest control company reported that the number of bed bug treatments it conducted across the United States rose tenfold from 1999 to 2002.20 A survey of 121 pest control companies in Australia showed a rise in bed bug treatments from 158 in 2000 to 2,464 in 2005.21 Bed bug incidents in New York City schools have risen from 40 in 2005 to 300 in 2007 (an increase of 750%).22 Toronto is no exception. Before 2003, Toronto Public Health characterized bed bug infestations as sporadic and mild. In 2003, a Toronto study showed that there were only 46 reports of bed bugs made to Toronto Public Health while Toronto pest control companies made over 1,300 treatments.23 The number of reports to Toronto Public Health tripled to about 150 by 2006.24 A small survey of pest control companies in 2007 indicated that bed bug infestations became much more widespread, with reports of as many as 4,800 treatments for a single company that year.25 Preliminary numbers show that Toronto Public Health received reports of almost 1,500 bed bug infestations between March and October in 2008 26 This is especially high considering the trend of underreporting bed bugs to Toronto Public Health. While there is the most data available for Toronto, bed bugs are not Torontos problem alone. Ottawa and Hamilton have produced educational documents to help residents address the bed bug populations,27, 28 the City of Kingston is looking for resources to manage an outbreak of bed bugs and is conducting housing staff trainings,29 and the Windsor Essex County Health Unit has said that several apartment buildings around the city are plagued by bed bugs.30 Incidents of bed bugs have also been reported in London, Huntsville, and North Bay.31 A pest control company that works in the Orillia, Barrie, and Wasaga Beach area said that it has seen a jump from about one call a week to about five calls a day.32 Bed bugs are also spreading in more rural areas; Owen Sound
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has also seen a dramatic rise from a few calls a month in 2007 to six calls a week in 2008.33 Across the globe, and here in Ontario, it is apparent that bed bug infestations are increasing exponentially. Research shows that the causes are complex but the strategies needed to address them are consistent. wErE nOt rEAdy Bed bugs are an age-old pest and archaeologists suggest that bed bugs have been with humans since prehistoric times. Despite the fact that bed bug fossils have been found dating back 3,500 years, their resurgence has caught most cities entirely off-guard.34 Bed bug infestations were virtually eliminated after the Second World War. Synthetic pesticides such as DDT are often credited with the victory, but evidence indicates a broad and coordinated combination of public investment, education, prevention, and extermination were critical to the success of the effort, and that bed bugs were developing resistance to DDT as early as 1947.35 In the first half of this century, governments in Europe pursued systematic strategies for bed bug control that combined the use of pesticides with effective education efforts and focused interventions to prevent infestation and reinfestation.36, 37 In some cases, vigorous and sometimes disturbing propaganda efforts were part of the effort, but the success of the process was built on better education around housekeeping procedures, methods of eradication, and building and housing improvements.38 In 1934, the U.K. Ministry of Health directed local authorities to take part in a sustained effort to manage infestations that was based heavily on education and a proactive bed bug response.39 The directive called for cleaning and preparation as important factors prior to chemical treatment in bed bug management and went even further by granting power to local authorities to demand the execution of repairs which will be a material factor in preventing re-infestation and acting to provide cleansing stations, apparatus and attendants.40 The policy also allowed for compensation to be paid to those who lost articles or had property damaged in the process of deinfestation.41 The integrated pest management (IPM) methods and proactive bed bug strategy used by the U.K. Ministry of Health are a key reason for the decline of bed bugs in the United Kingdom. As a result of the success of these types of methods, by the 1970s, bed bugs were thought to be a thing of the past. Unfortunately, apparent victory sowed the seeds for future failure. There has been little research in the field in the last 30 years and great deal of lost knowledge about bed bug treatment and prevention. Studies have found that older people are more likely to recognize and identify bed bugs than younger people.42 This lost knowledge led to later detections of bed bugs and their further spread.43 Persistent toxic sprays such as DDT are now banned in most western countries, and some evidence indicates that DDT may have had limited long-term efficacy due to the rise in pesticide resistance in bed bugs (see Pesticide Resistance on page 20). The preventative tools so effective in the last century have fallen into disuse, and inaccurate information about causes and solutions is now common. Bed bug education effectively ceased decades ago along with public investment in bed bug eradication. There is currently a lack of an effective coordinated information campaign to ensure that residents, landlords, pest control companies, non-profit agencies, and governments are knowledgeable about proper bed bug management.
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It is important to understand patterns of bed bug infestations, and best practices in terms of treatment, education, and investment, to determine how to bring the current bed bug problem under control. hisToriCAl sCoPe of infesTATions In the past, bed bugs were extremely widespread. There is mention of bed bugs in Ancient Greece and in medieval texts as the insects spread across Europe.44 Bed bugs travelled to North America with early European colonists.45 By the late 1600s bed bugs were sufficiently numerous to require specialized extermination firms. Among the better-known companies, Tiffin and Son cautioned clients to be vigilant, noting that bugs may start in the bed but if left alone they get numerous, climb about the corners of the ceiling, and colonize anywhere they can.46 In more recent history, cases of bed bugs are more precisely documented. Central heating apparently enhanced the success of bed bugs through the 1800s and in the 1880s it was estimated that over 75 per cent of Britains homes were infested with bed bugs.47 Over 4 million of Londons 8.6 million people had bed bug infestations in 1939,48 and about 1 in 3 homes in Europe had infestations in the 1930s and 1940s.49 In this same period, a survey of Swedish moving vans found 47% had bed bugs, and bed bug infestations were common in hospitals, movie theatres, and buses.50 The success of intensive post-war efforts at eradication have made the scale of infestation a distant memory, but the historical documentation suggests that large-scale infestations in modern times were common and could again become a genuine risk. According to etymologist Michael Potter, one of the worlds leading experts on bed bugs, If history repeats itself, bed bugs could again become the stuff of nightmares.51 PATTerns of infesTATion The widespread infestation of bed bugs in the mid-20th century is largely a function of the highly efficient way infestations become established and spread. hiding And trAvElling Only 5 mm long and almost completely flat when unfed, bed bugs can hide in almost any location without detection. Bed bug colonies have been found in seams, joints, and crevices; the slot of a screw; or the spine of a book. Their size and low profile make them very difficult to detect without concerted effort, and facilitate their ability to travel by stowing away in personal belongings. Bed bugs can hide easily in the hem of a garment, the seam of a briefcase, the crease in a shoe, secondhand furniture, or the vent of a laptop. Someone simply sitting in a location that has bed bugs can provide the bed bugs an excellent opportunity to hitch a ride. Many experts cite travel as being a major cause for the resurgence of bed bugs.52 Serious bed bug infestations have been occurring in major travel destinations and spreading to nearby locationsmuch as they did in the past when port cities were likely to show signs of the first infestations that then spread inland.53 EStABliShing And mAintAining cOlOniES The capacity of bed bugs to travel readily is coupled with a remarkable ability to establish and maintain colonies. Bed bugs can find mates exceptionally quickly due to the secretion of attraction pheromones.
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These chemicals draw bugs to each other to establish shared harbourages and to mate. Bed bugs mate rapidly and widely by traumatic insemination, which involves the males piercing the body of the female to impregnate her. Bed bugs mate readily with a broad range of partners, ensuring a diverse gene pool and high rates of reproduction. Females can lay 5 eggs each day and will generally lay 200 to 500 in less than 10 months. Each successive generation can reach breeding age in four to six weeks, meaning that a single female and her offspring could create a colony of thousands within six months. Bed bug expert Stephen Doggett confirms that a bed bug colony left unaddressed will grow to thousands within a year.54 Once established, bed bug colonies are very hard to locate and dislodge. Adult bed bugs feed only every 5 to 10 days, and will remain hidden and inactive at all other times, making them difficult to detect and treat. Bed bugs can live up to 18 months without feeding; in fact, not feeding increases the life span because the bed bug will remain inactive for long periods of time, enduring few biological stresses, almost like a state of hibernation.55 This long life span makes them difficult to destroy by passive methods, such as starvation and isolation. Eliminating bed bugs requires a direct intervention. Bed bugs also cope well with all but the most vigorous and decisive efforts to destroy a colony. Distressed bed bugs release alarm pheromones that cause other bed bugs to disperse immediately, so anything but a thorough eradication effectively carried out is likely to fragment the bed bug population and make it harder to trace and eliminate. Bed bug eggs are likely to survive efforts to destroy a colony. Bed bug eggs are only 1 mm in length and are often laid in crevices, making them difficult to locate. They are coated with a sticky substance to keep them in place so they are not dislodged by standard cleaning. There is no chemical currently available that kills eggs, which means that a colony can recover from even the most thorough pesticide treatment 12 days later when the eggs hatch and new bed bugs begin feeding. Bed bugs are also well protected against dehydration. Their natural rate of water loss is exceptionally low. Bed bugs can be killed using heat but lethal temperatures are above 44 degrees Celsius and must be sustained for 20 to 30 minutes.56 Lethal heat levels must also be achieved quickly, as gradually increasing heat will cause bed bugs to scatter. SPrEAding infEStAtiOnS Bed bugs can spread effectively throughout a room, apartment, or home. Varying reports show they are able to travel 20 to 100 feet for a blood meal and can wander to new parts of a home with little difficulty. Normally, bed bug infestations start in the mattress or bed frame, but infestations can start in any part of a home.57 Bed bugs tend to fragment the colony and move to new harbourages when the harbourage sites in the mattress and frame become heavily populated. In severe infestations, bed bugs can be found everywhere in the home including baseboards, drawers, tables, floor boards, cracks in the wall, electrical sockets, and inside belongings and appliances. There is no conclusive scientific explanation for bed bugs intermittent tendency to leave an established harbourage and start a new one. According to London bed bug expert David Cain, bed bugs may start new colonies based on the amounts of heat and carbon dioxide being
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produced.58 Studies conducted on traumatic insemination suggest that it causes females to become overwhelmed by repeated mating efforts and seek refuge in new harbourages.59, 60 According to Eric Hardebeck, president of Permakil in Ohio, some entomologists are currently exploring the theory that traumatic insemination in large colonies leads to the release of alarm pheromones.61 Stephen Kells, a bed bug researcher in Minnesota, suggests that fragmentation of harbourages occurs for a combination of reasons including sexual conflict, proportion of males to females, proportion of nymphs to adults, disturbing of the harbourage, and light. Kells suggests that there is likely a magic number of bed bugs in a harbourage that leads to spread, but insufficient research has been conducted to determine that magic number.62 It is clear that the more intense the infestation, the more likely it is to spread to new locations. According to Australian bed bug expert Stephen Doggett, in infestations of thousands of bed bugs (superinfestations), spreading is inevitable63. Regardless of the reason, colonization spreading from one area of an infested dwelling to another is well documented. These widespread infestations, understandably, become more challenging to eradicate as the number of sites for eradication grow. unit-tO-unit migrAtiOn In densely clustered housing such as in an apartment building, spread can occur quickly from one home to another.64 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.65 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.66 Doggetts 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.67 This could be a result of social networks and improper cleaning procedures.68 Doggetts study also shows that bugs bypass some units.69 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. 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.70 The efficiency of bed bugs in hiding, travelling, establishing colonies, spreading, and resisting eradication make them a challenging pest to manage and impose significant demands on any effort to eliminate them.

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CosTs of Bed Bug TreATmenT Bed bugs impose significant costs on those confronted with infestations. Treatment approaches currently in use vary widely, from the simple application of pesticides to complex interventions that include detailed inspections, thorough cleaning and preparation of the site, application of pesticides, and follow-up inspections and treatments. The greatest success is normally achieved through intensive, repeated multi-part treatments (see What to do to Reverse this PatternBest Practices on page 20), which involve a considerable amount of time and effort and often specialized equipment. Despite this broad range of approaches, all methods of treatment impose significant costs. AvErAgE cOStS fOr trEAtmEntS Costs of treating bed bugs vary greatly depending on the type of treatment used. Even pest control professionals have been known to pursue inexpensive but often ineffective strategies such as simple pesticide application. However, the most effective protocols require inspection, cleaning, pesticide application, and follow-up measures, which require considerably greater expense. Costs also depend on the size of the home, the size of the infestation, and the amount of preparatory deinfestation and furniture replacement required. A 2003 study in Toronto showed that homeless shelters were spending an average of $3,085 per infested shelter.71 The World Health Organization claims that the average cost of treatment in Canada and the United States is approximately $300 per room of treatment. This includes treatment of the bed and dressers and two baseboards.72 In 2007, Toronto Public Health found that treatments usually ranged from $200 to $450 depending on the size of the home being treatedwith an average of $325 per treatment.73 Costs of treatment range from $200 to $600 in Washington D.C., for an average of $400 per treatment. However, Washington Public Health also stated that usually it took three treatments to eliminate the bed bugs.74 Stephen Doggetts 2008 survey of pest control companies found that it took a median of two treatments to eliminate bed bug infestations.75 Doggett also found the average cost in a home to be about $617 (including multiple treatments), and in hotels to be about $1,526 per room, with an average cost of about $1,000 per infestation76. The costs typically included in a thorough bed bug eradication effort in North America are outlined in the Bed Bugs in New York City: A Citizens Guide to the Problem, and include caulking ($40), mattress cover ($120), plastic bags ($35), thorough laundering of bedding and infested materials ($225) and multiple pesticide applications at $150 each, for a cost of $720 and $1,020 for two to four applications of pesticides, with greater costs required if assistance is needed with physical tasks such as caulking or preparation of the site.77 The Citizens 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.78 For supportive housing, there are additional costs relating to staff time in supporting clients in the preparation and treatment of bed bugs. Based on the average cost per treatment, and the estimated number of infestations in Australia between the years 2000 and 2005, Doggett found that bed bugs cost at least $100 million in treatments79 over that time in Australia. 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
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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.80 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.81 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 $300.82 Cryonite is a type of deepfreezing 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.83 As this treatment is comparatively new, its effectiveness has not been firmly established. lEgAl ActiOn With the increase of bed bug infestations, there has been a rise in the number of lawsuits against landlords, offices, and hotels for exposure to bed bugs. Judgments range greatly from a few thousand dollars to the largest judgment of $382,000 against a hotel.84 The judgments are often lower than the claim amounts. There is currently no decision in the suit against a New York hotel for $20 Million in damages due to bed bugs85. A man who stayed at a luxury hotel in Phoenix, Arizona, is suing for $6 million for damages resulting from over 150 bed bug bites.86 In 2007, a university in New York was sued for damages caused by bed bugs suffered by dormitory residents.87 A couple in New Jersey successfully sued a furniture company for $49,000 after they bought a new dresser and bed frame that were infested with bed bugs. The money went to replace all of the furniture they lost as a result of the infestation.88 While it is in the power of landlords to evict tenants for not cooperating with bed bug treatments, there are no documented cases of this happening in Toronto. There have been cases of tenants being served eviction notices that have led to the tenants leaving of their own accord, and of tenants being served eviction notices for not paying rent because the tenant refuses to live inand pay rent foran apartment that is infested with bed bugs. One case in Toronto that began as an eviction notice for a lack of rent payment led to a judgment of a rent abatement of over $2,000 in favour of the tenant. The landlords inaction on bed bugs was cited as a factor in the decision.89 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.90 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.

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cOSt Of inEffEctivE ActiOn Generally, the do-it-yourself approach to bed bug treatment is ineffective. This can lead to higher costs for future treatments and can worsen the bed bug situation in the building by creating a repelling effect and spreading the infestation. Aerosol pesticide cans,91 diesel fuel,92 and rubbing alcohol93 have been used as home remedies to treat bed bugs. These treatments can be potentially dangerous because of flammability and the overexposure to chemicals. These remedies may create some temporary relief from the bed bug problem by repelling bed bugs, but since these treatments are rarely lethal to the entire colony, they almost certainly cause the bed bugs to spread to new harbourages nearby, and eventually to return when the repellant odours from the chemicals dissipate. U.K. bed bug expert David Cain maintains that the use of customer-applied bug sprays in aerosol cans will almost certainly repel bed bugs to a neighbouring unit, causing new infestations to start and then return to the original site at a later date.94 Besides these negative effects of home remedies, temporary relief adds to the delay of effectively dealing with the bed bug infestation. As previously stated, the more time the infestation is given, the more it will grow and spread. CorrelATion of PoverTy wiTh infesTATions One enduring myth about bed bugs is their correlation to poverty. All research sources agree that bed bugs do not discriminate among hosts and that absolutely anyone can get a bed bug infestation. In New York and Cincinnati there are well-publicized incidents of severe infestations in wealthy neighbourhoods and penthouse suites of expensive condo buildings.95, 96 In New York, bed bugs have infested an expensive condo building owned by the father of a prominent politician, a theatre on Broadway, a $25 million Central Park duplex, and the chambers of a federal judge.97 In Cincinnati, over 7% of homeowners have had bed bugs.98 Bed bugs have also been reported in student residences at New York University, Harvard, MIT, University of Vermont, University of Texas,99 Ryerson University,100 and an entire residence that was shut down at McGill University for treatment101. Research on bed bugs shows that certain risk factors increase exposure to bed bugs, allowing some settings to experience infestations earlier. These risk factors occur in not only inexpensive apartment buildings, exposing people living on low incomes to bed bugs, but also hotels and university residences, with their more affluent residents. cOnditiOnS Of BuildingS Typically, buildings that are high density and in need of repair are more prone to bed bug infestations. Buildings that are crowded bring together more people who can potentially have picked up bed bugs into a space where the bugs can spread. The proximity of new viable hosts makes it more likely that bed bugs will spread from one persons home to another. The presence of multiple homes in close proximity also makes bed bugs harder to treat because any lack of a coordinated pest control treatment allows the bed bugs to migrate back and forth between units.102 Units in need of repair with gaps between baseboards and in the walls and floors provide more places for bed bugs to hide or create harbourages. Larger gaps are also more difficult to seal or caulk shut, allowing bed bugs to travel easily. Gaps and cracks around pipes and electrical outlets provide opportunities for bed bugs to spread to neighbouring units. The more gaps and hiding places that exist in the home, the more difficult and more expensive it is to treat the infestation and prevent it from spreading.103

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turnOvEr High turnover in a building also makes it more likely that bed bugs will come in as new residents can bring bed bugs on their belongings, and moving equipment can become infested. tEnurE Tenants often lack control over their living environment and are not in a position to take action on the circumstances that contribute to infestations, such as repairing structural defects or ordering coordinated extermination efforts. Weak regulatory standards for rental properties can also contribute to people with lower incomes being exposed to more bed bug infestations.104 SEcOndhAnd gOOdS People living with low incomes are more likely to purchase items and furniture secondhand, increasing their risk of bringing infested items into their home.105 fEwEr rESOurcES tO mAnAgE BEd BugS The connection between available resources and the ability to eradicate bed bugs goes back to 16th-century England, where rich and poor alike were known to develop bed bug infestations, but affluent residents were able to replace their bedding and straw more often than those in the surrounding homes, rooting out the bed bugs and giving the appearance that bed bugs were more common in the less affluent households.106 That circumstance persists, with fewer lowincome households being able to dispose of infested furniture, employ costly pest control firms, and invest the time and energy necessary to systematically and comprehensively locate and eradicate harbourages. incOmE And BEd BugS People living on low incomes are exposed to a larger number of these risk factors than the general population. As a result, evidence indicates that people living on low incomes are more likely to be the first to get bed bugs, but over the course of a growing infestation, everyone is susceptible. The same conditions that lead to an increased risk of getting bed bugs apply in hotels and university dorms, which evidence shows, also experience frequent infestations. Reports consistently show that bed bugs reach all income levels eventually and that the scope of infestations, historically, is broad and encompasses all income groups. CorrelATion of vulnerABiliTy wiTh exTreme infesTATions Although the correlation between poverty and bed bugs is specious, there is a correlation between severe infestations and high levels of vulnerability. When they are left to grow unchecked, infestations grow to extreme levels, involving thousands of bed bugs. In most settings, the sufferers respond to the infestation before the infestation reaches the extreme level. However, for a variety of reasons, some households are unable to address the infestation, resulting in exceptionally intense infestations that, as Stephen Doggett notes, inevitably spread. High levels of poverty can be a barrier to addressing bed bugs. Some people do not have the resources or the financial assistance to manage bed bugs.107 Not having the financial means to address the bed bug infestation can be a serious barrier to eliminating bed bugs in the home, because often the high costs of preparation and treatment can affect a persons ability to afford other necessities, including food.108
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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.109 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.110 The increasing incidence of severe infestations in these populations has been noted by Australian researcher Stephen Doggett,111 as well as community service providers working with vulnerable populations in Toronto. rAnge of infesTATions Bed bug infestations have been found in such a wide range of locations that the risk of exposure to them extends to the entire population. hOtElS Hotels are one of the major hot spots for bed bug exposure. They are one of the first points of transfer for people who travel, and are believed to be a major cause of the Australian bed bug resurgence.112 Hotels face considerable risk with regard to bed bugs, with stigma and loss of reputation potentially damaging business. This makes it more difficult for the hotel industry to be seen to be active in addressing or preventing bed bug infestations, because the public might view it as an admission of having a bed bug infestation.113, 114 Michael Potters survey of 509 pest management professionals in the United States showed that 58% had seen infestations in hotels.115 Stephen Doggetts survey of pest control professionals in Australia found that 56% of all treatments carried out were in hotels, motels, hostels, and resorts.116 This includes 462 treatments in five-star hotels (5.6% of all treatments). Doggetts study also showed that the total number of bed bug infestations between 2000 and 2005 likely imposed millions of dollars in costs on the hotel industry for extermination alone. This excluded costs due to lost business, replacement of furniture, legal settlements, and overall harm to the tourism industry because of bed bug infestations. Hotels are best served by a proactive approach that encourages staff to identify early infestations of bed bugs and undertake a comprehensive approach to treatment117; however, the need for discretion can be daunting for hotel owners. hOSPitAlS There have been increasing numbers of documented incidents of bed bug infestations in hospitals in recent years. Six percent of pest management professionals in the United States had found bed bug infestations in hospitals in 2008.118 In 2007, a pediatric ward in Victoria, British Columbia, was reported to have been closed for fumigation after staff discovered bed bugs.119 A university hospital in Oregon was reported to be dealing with a bed bug infestation that had been growing for two weeks in a patients locker.120 infEStAtiOnS in rurAl ArEAS Infestations are not connected directly to urban living. Though city life is more conducive to bed bug spread through travel, hotels, high-density apartment buildings, and high rental and mobility rates, bed bug infestations are on the rise in rural areas. A survey through the
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University of Cincinnati Institute of Policy Research in 2008 showed that Hamilton County (the rural area surrounding Cincinnati) had an infestation rate of 3.6%.121 The number of bed bug complaints to the county health department had more than doubled every year since 2004.122 A pest control company that works in Wasaga Beach, Ontario, noted an increase from about one call a week to about five calls a day.123 Grey County and Bruce County in Ontario have also seen a dramatic rise in bed bug incidents, attracting the attention of the Medical Officer of Health for the Counties.124 infEStAtiOnS On clOthing And PErSOnAl EffEctS The presence of severe infestation has led to bed bugs infesting clothing and objects that are in daily use. People living in severely infested homes have been known to visit public places wearing clothing crawling with bed bugs and carrying personal items that are heavily infested125, 126 These situations can distribute bed bugs to non-residential sites quickly and contribute to the rapid increase in the range of places that bed bugs can be found. PuBlic SPAcES Places such as offices, schools, public transit, and theatres can be effective transfer points for bed bugs, and infestations are being found increasingly in these public and common spaces.127 Michael Potters survey of pest management professionals revealed that 2% had encountered bed bug infestations in offices, 5% in schools, 4% in public transportation, and 2% in movie theatres. The New York Times reported in 2008 claims that that bed bugs had infested a network newsroom, and that an employee had been bitten while at work.128 In New York City, the number of bed bug incidents in schools has increased to 300 a year, in 130 different schools in the city.129 University of Kentuckys department of Entomology states that bed bugs are increasingly being encountered in health care facilities, schools, ... theatres, laundries, furniture rental outlets and office buildings.130 Edward Brownbear of the New York Department of Housing identified five subway stations that had bed bugs.131 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.132, 133, 134 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.135 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 workoften after a client home visit.136 Other nonresidential 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
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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. PsyChologiCAl And soCiAl imPACTs Bed bugs have more than a monetary cost to their victims; they also wreak havoc on peoples personal lives. A recent study showed that the majority of people are more upset by finding bed bugs in their home than finding other pests such as rodents, termites, or roaches.137 There are many harmful impacts associated with an infestation, including those on emotional, psychological, and social levels. Constant worrying, lack of sleep, and feelings of shame are commonly associated with bed bugs. The physical health concerns associated with bed bugs are limited. They do not transmit diseases and the bites themselves do not necessarily require treatment. There are some minor health impacts of bed bugs such as secondary infections due to scratching, respiratory issues associated with an allergic reaction to bites, and, in severe cases, iron deficiency in infants.138 However, the impact of bed bugs on peoples mental health is more recognized and widespread.139 mEntAl hEAlth: AnxiEty, SlEEP dEPrivAtiOn, StrESS Leading health professionals and health organizations acknowledge that there are direct psychological and emotional implications that result from having bed bugs. An article in The National Review of Medicine stated that [b]ed bugs cause physical discomfort as well as a tremendous amount of anxiety, emotional distress and insomnia because they are persistent and reproduce rapidly.140 The World Health Organization (WHO) notes that people who constantly suffer from bed bug bites also suffer from a sensitivity syndrome that leaves them anxious and unable to sleep.141 The effects on a persons mental health are evident for both children and adults. There are also reports of children who become pale when living in homes with large infestations, and who are likely suffering a large number of bites per night.142 Concerns about prolonged anxiety and depression have been raised. These psychological impacts of bed bugs are compounded in people who already suffer from mental health or substance abuse issues. 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.143 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.144 There have
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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).145 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.146 In one case, an apartment building caught on fire in Cincinnati due to a tenant using alcohol to treat an infestation.147 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.148 soCiAl sTigmA And isolATion The WHO 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 infestation149. 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.150 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.

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whAT To do To reverse This PATTern Best Practices

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.151 Michael Potter has more recently found resistance to DDT in a particular strain of bed bugs in Ohio.152 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.153 The same study found significant resistance to pyrethroids in field strains of bed bugs. In fact, K.S. Yoons 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.154 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.155 A similar study by John Clark at the University of Massachusetts confirmed that some strains of bed bugs will thrive despite pyrethroid treatment.156 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.157 Resistance was also recently found in certain bed bugs in the
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United Kingdom and in Africa.158 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.159 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.160 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.161 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.162 Bed bug behaviour patterns and their emerging resistance to pesticides mean that pesticides alone are unlikely to solve a bed bug problem. The most prominent examples of best practices are Stephen Doggetts Code of Practice which has been a factor in reversing bed bug numbers in Australia163; Michael Potters recommendations through the University of Kentucky Entomology Department164; the Bed Bug Handbook by Richard Cooper, Larry Pinto, and Sandy Kraft165; an IPM partnership project between New York State and Cornell University166; Toronto Public Health Fact Sheets167; the Bed Bug Resource Manual by Torontos WoodGreen Community Services168; and the Bed Bug Handbook for Shelter Operators by the City of Toronto Shelter, Support, and Housing Administration.169 Review of these and other pest management studies has led to the following best practices for dealing with bed bugs. 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.170 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.171 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.
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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 Ontarios 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 freeby hiring a pest control company for treatmentwhile 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. 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. Light-coloured sheets can ease an inspection process as bed bugs, blood spots, and fecal spots will show more clearly than on dark sheets. Placing double-sided tape around the bed will not catch all bugs, but will likely catch some bed bugs if they are present, though this method isnt always effective. The tape can be checked regularly to see if the bed bugs are still present.
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PrEPArAtiOn A series of measures should be taken prior to treatment to ensure that all hard-to-treat areas are made accessible for the pest control company. This preparation includes bagging all clothing and bedding, and laundering them at high heat, removing clutter from floors and under the bed, vacuuming, and moving furniture away from the wall. Clutter should be removed from the floors to ensure that as many hiding places as possible are removed. The home should be thoroughly vacuumed to gather up bugs and signs of bugs. It is important to ensure that the vacuum itself does not transport bed bugs from one unit to another and that disposable vacuum bags are used and properly disposed of in closed plastic bags. Supports are needed for those who are unable to conduct effective preparation themselves due to economic, physical, or mental challenges. This may include having a social worker or other supportive partner help to coordinate preparation and treatment, financial compensation for the disposal of clothing and bedding, and temporary storage. This means that community workers may need to be trained specifically on how to support clients through bedbug infestations. All pets should be removed from the household prior to and during treatment. Disposing of furniture that is severely infested may be necessary as part of the preparation process. Because disposing on furniture improperly can lead to the further spread of bed bugs, it is best to consult with a non-profit agency or pest control company prior to disposal to make sure this action is warranted. Disposed furniture should be marked or damaged to prevent reuse, and sealed in plastic before removing from the home to prevent the bed bugs from falling off the items as they are being carried through the hallways. It should be noted that bed bugs will happily infest new furniture, so it is necessary to treat the bed bugs before bringing new items into the home. trEAtmEnt Prior to treatment, the pest control company should provide the resident with a management plan and information on the pesticides to be used. Treatment is only one part of a bed bug management plan, and cannot be successful without the other steps included in the What to do to Reverse this PatternBest Practices section. Proposed treatment timelines should also be outlined, detailing follow-up appointments. Pest control companies should be selected based on their development of a management plan, and their experience and knowledge of an IPM approach. A variety of eradication treatments have been shown to be effective to varying degrees, including spraying chemical pesticides, steam (attaining a surface temperature of 80 degrees Celsius), heat chambers, and extreme cold (below 20 degrees Celsius for two hours). Again, it is necessary that the pest control company is knowledgeable about applying the treatment appropriately, because too much can exacerbate health issues, too little can have a repelling effect, and pesticides inappropriate to the setting can be ineffective. While steam has been found to be effective in all of the protocols cited here, various types of sprays and pesticides can be applied to treat bed bugs depending on specific situations. Stephen Doggetts survey of pest control companies found that propoxur, bendiocarb, permethrin, and deltamethrin were the most effective pesticide ingredients for spraying in Australia.172 Of the
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most effective pesticides on the market, none has a residual effect longer than the hatching time of eggs (12 days). This means that the pesticide has to make direct contact with the bed bug to kill it. This can be especially difficult in a home with many hiding places (e.g., cracks, gaps, and clutter). Proper bed bug treatment requires selecting not only the right toxins for pest control but also the right formulations. Similar pesticides, formulated as powders, emulsions, aqueous solutions, or suspensions can deliver the toxic effects to the bed bugs more effectively when the formulation is well suited to the treated surface or setting. There is a need to establish protocols for pest control companies that go beyond basic pest control qualifications, encourage the application of pesticides using appropriate formulations and methods, and embed those efforts in an IPM approach. Other treatments, including dusting voids and other spaces with diatomaceous earth, can help lower populations or keep infestations at bay. Diatomaceous earth is a non-toxic dust made from crushed fossilized shells. At the microscopic level, the dust is sharp; as the bed bug walks over the dust, its outer shell is cut, causing the bed bug to lose water. The bed bugs will eventually die from dehydration. Caution should be taken when applying diatomaceous earth so that it is not directly inhaled due to potential health concerns with the dust entering the lungs. Further, a number of preventive measures can be taken to stop bed bugs from coming back, including ongoing inspection and monitoring for bed bugs; sealing all gaps along baseboards, windows, and doorways with caulking; enclosing mattresses and box springs with sealed plastic mattress covers; removing to eliminate harbourage sites; laundering clothes regularly (including drying at 45 degrees Celsius for 30 minutes); and avoiding bringing used furniture into the home without thorough inspection. Vacating a room is not a treatment option as bed bugs can survive for up to 18 months and the relocation of the host is more likely to spread bed bugs than to kill them. StEAm Research seems to indicate that steam is one of the most effective ways of eradicating bed bugs, but specific procedures and methods must be used in order to properly eliminate the bed bugs. Steam is more effective than most pesticides because it kills bed bugs in all stages of development, including eggs.173 As previously stated, no chemical pesticides can kill bed bug eggs. Some pest control companies use steam as their primary bed bug treatment as a less-toxic option. Both Stephen Doggett and the World Health Organization recommend steam as an effective and preferred treatment of bed bug infestations.174, 175 Steaming is appropriate for belongings that cannot be put in a dryer, and for locations such as mattresses, furniture, and baseboards. Steaming must be done slowly, no faster than 15 seconds per 30 centimetres, and at the right temperatures to prevent causing other detrimental health effects such as mould or promotion of other bugs. Certain steaming machines are better at producing dry steam, which can reduce the likelihood of mould developing. Surface temperatures of the areas steamed should be between 70 and 80 degrees Celsius immediately after steaming. The steamer nozzle must come in direct contact with the surface being treated (e.g., baseboards), and steam pressure should be low enough to avoid dispersing bed bugs. If the pressure is too high, or if a single jet nozzle is used, then the bed bugs can be literally blown to a different area of harbourage. Placing a cloth over the steamer head can help increase surface
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temperatures, and reduce the blowing effect. Steam is not a cure-all pest control method and should be done in conjunction with effective preparation, and the use of some type of residual pesticide. 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 effortas 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. BesT PrACTiCes: invesTmenT While an IPM approach is most likely to result in the elimination of bed bugs, it is also costly and time consuming for residents and property managers. This can potentially be a deterrent for people to follow the appropriate procedures, which can lead to the further spread of infestations. Experts recognize the need to address these barriers systematically and create financial incentives to support comprehensive IPM efforts. The Ontario Government has allowed Ontario Disability Support Program and Ontario Works recipients to apply for funds to prepare their units for treatment and to replace any lost furniture as a result of bed bug infestations. The funds may allow up to $799 per person once every 24 months (about $1,500 for families). In Toronto, Toronto Public Health has set aside $75,000 to support people in preparing their apartments for bed bug treatment. This money is specifically for people who live with low incomes and who do not qualify for Ontario Disability Support Program or Ontario Works funds. Toronto Public Health estimates that this money will likely support 100 people in preparing their units.176 Property owners in Boston have access to a fund that provides $200 per recipient through the State of Massachusetts and the Allston Brighton Community Development Corporation. Recipients are required to commit to an IPM strategy and a prevention strategy for each infested unit.177 Also in Toronto, WoodGreen Community Services administers a small fund of $8,000 to assist lowincome individuals and families who do not have the financial resources to get rid of bed bugs in their homes. The fund can be used for pest control spray, steaming, and other preparation activities. WoodGreen received the grant for this program from United Way of Toronto.
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In 2005, the City of Toronto made a one-time investment of $930,000 into the Toronto Shelter system. The funds were used to replace 45% of all mattresses and bed frames with bed bugresistant materials178. These initiatives show foresight but are not sufficient to fully address the demand for financial supports. BesT PrACTiCes: sysTemiC resPonse IPM protocols, education, and investment are effective only insofar as they are well informed, correctly applied, and widely adhered to. Lessons from our past, and lessons from Australia today, tell us that comprehensive adherence to protocols is best achieved through a government-led systemic response that outlines what needs to be done to eliminate bed bugs, actively promotes adherence to those guidelines, and provides an investment of resources to ensure that residents and property managers have the support they need to bring bed bugs under control. In the 1930s, people in Europe were more accustomed to bed bugs. Residents would fill all cracks in their homes, people (and even hospitals) replaced wooden bed frames with metal frames. New construction was done with bed bugs in mind, and people were advised to check their beds frequently for bed bugs.179 The impetus to do these things often came from governments. In the United Kingdom, the governments approach involved developing a coordinated effort to address bed bugs, including education for sanitation officers on how to identify and address infestations, and including natural colour drawings of what bed bugs look like for easy identification.180 Local Authorities were instructed on how to carry out the education and treatment work, and were granted the power to recover the reasonable costs and expenses.181 The work of the U.K. Ministry of Health not only highlights the importance of a coordinated approach backed by investment and resources, but also demonstrates that many of the recommendations around education, preparation, and prevention remain similar over 70 years later. In Australia, the government has increased funding to public housing to eliminate bed bugs using a Code of Practice developed by Stephen Doggett, similar to the best practices described above. The code was developed as a set of guidelines and practices to be followed for the control and treatment of bed bugs in Australia. Since implementing the code, Pest control companies in Australia have seen a decline in the number of bed bug infestations. While there are likely other contributing factors, including a global financial crisis, and a decline in tourism, the code is an important reason for the reversal of bed bug numbers in Australia.182 This is a promising result that has real applications for people trying to manage bed bugs in Ontario today.

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ConClusion

Bed bugs are a challenging pest to manage. They are clearly resurgent around the world, and their well-evolved strategies for establishing, maintaining and spreading colonies are difficult to overcome. The circumstances of urban living enhance their already robust opportunities to grow. While there is no correlation between poverty and bed bugs, low-income households are the most likely to face infestations first during the current resurgence. The complexities of addressing bed bug infestations also make vulnerable populations particularly susceptible to intensive infestations. Those intensive infestations make the spreading of bed bugs more rapid and more extensive, affecting a broader range of sites and a broader cross-section of the population. Failure to act and to support segments of the population in which the bed bug infestation is growing most rapidly has left cities such as New York and Sydney facing the exponential growth of bed bug populations. Toronto faces similar risks if we follow in their footsteps. However, that is not the only possible outcome. Historically, systematic dissemination of information and sound bed bug management protocols, supported by governmentled impetus to action and the economic and social supports necessary to enable compliance, have overcome the growth of bed bug populations. Current efforts in Australia appear to be re-creating that success. Communities facing this resurgence should draw on these lessons and perhaps avoid the adverse experiences of some world cities.

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resulTs of key informAnT inTerviews on Bed Bug infesTATions in ToronTo

To determine the extent of the bed bug problem in Toronto, 45 key informant interviews were carried out with selected experts, landlords, agency staff, and people who have experienced bed bug infestations. The interviews revealed growing concern among all participants and a realization that there is a significant challenge to be faced in the immediate future. Bed bugs are definitely back in Toronto as well as across Ontario. Along with them come not only the well-known itchy welts, but a host of other challenges. Bed bug sufferers face shame, isolation, insomnia, ill health, and often the loss of basic supports they rely on. Non-profit agencies experience disruptions in their operations, human resources challenges, and barriers to service for vulnerable people. Landlords, agencies and a range of public services, including hospitals, schools, daycares, and public transit, face new risks and considerable costs. But experts from around the world also point to opportunities that Toronto can seize to avoid the crises facing other world cities. Toronto Public Health and leading agencies in the city have already begun to take the critical steps required to address the growing bed bug issue. With clear policies, public education, and strategic investment, cities in Ontario could avoid the challenges now faced by New York, London, Sydney, and Washington D.C. Bed Bugs Are BACk
This is the most challenging pest Ive encountered in my career. Were in big trouble.
Professor michael Potter, Bed Bug Expert, university of kentucky

In interviews, all respondents indicated that the bed bug problem is widespread and growing in Toronto. All landlords and professionals interviewed have been encountering bed bugs in growing numbers over the last five years. All agencies interviewed have clients with bed bugs. Most agencies indicated that they had been encountering significant bed bug issues for roughly the last five years. Landlords indicate that 3% to 4% of their units have multiple incidences of bed bug infestations, and community service agencies indicate that anywhere from 4% to 70% of their clients have had bed bugs, with the median incidence being approximately 15% of all clients.
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PeoPle hAve liTTle knowledge of Bed Bugs And how To deAl wiTh Them

A lot also has to do with the lack of education [about bed bugs] and the fact that if you are uneducated then you will not know the signs of bed bugs.
richard grotsch, shelter staff

Interviews showed that most people who had experienced infestations were not well informed about bed bugs prior to their infestation and did not recognize the signs early on. Most were unaware that they had bed bugs until well into the infestation. Most sought advice from doctors around visible welts and itching but none received a correct diagnosis. Experts interviewed believed that doctors are generally poorly informed about bed bugs and that misdiagnosis with other types of pests such as fleas and scabies is common.
Some people think of bed bugs as a nursery rhyme.
Paula cassin, ABi Possibilities

Unfortunately, once bed bugs are correctly identified, many people adopted poor strategies to cope with them. Instead of systematic eradication, residents pursued haphazard strategies including improper use of chemicals, dangerous applications of homemade remedies, improper vacuuming, incorrect cleaning and laundering of clothing, and the improper disposal of infested furniture. The careless transportation of infested furniture and clothing has resulted in bed bugs being dropped in hallways, elevators, laundry rooms, and other common areas. In some cases, because of the apparent good condition of the discarded furniture, it was quickly taken in by other residents, contributing to the further spread of the infestation throughout the building. The sPreAding of infesTATions

They use that dust, youre supposed to sprinkle it sparingly but they just pour it everywhere, the bed bugs walk around it. Seniors use kerosene; oh, the fumes. Public education is not very effective.
Agency staff member

In some places bed bugs have spread because of people dragging their mattresses in the hallways and dropping the bugs.
Agency staff member

Infestations are spreading rapidly in Toronto, and respondents traced the origins of infestations to a daunting array of sources. Universities indicated that students bring bed bugs from home. Staff at community service agencies identified having picked up bed bugs from their workplaces and clients, as well as giving examples of clients who got bed bugs from secondhand furniture, used clothing, or even from a pre-existing condition in the apartment they moved into. Interview subjects identified that they had gotten bed bugs from new blankets and new mattresses. Most of the people interviewed could not identify an infested home they had visited at any time prior to suffering an infestation, which means they were either unaware of being in an infested home or were exposed
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to bed bugs in a non-residential setting. Agency staff had seen cases of bed bug infestations coming from daycares, stores, and doctors offices. Landlords noted that bed bugs have spread when people visit others homes, but also see infestations spread through exposure to bed bugs in common areas in apartment buildings. Professionals also tended to attribute increased risk of bed bugs with various aspects of travel, including hotel stays and even taxi rides.
Buildings that are poorly maintained can exacerbate the problem. Carpeting, panelling, cracks are a recipe for disaster.
reg Ayre, toronto Public health

Landlords, agency staff, and professionals found that spreading is more likely in high-density buildings, especially those that have structural problems such as cracks and voids between units. Bed bugs have used gaps in walls, electrical conduits, pipes and plumbing, and simply walking across hallways to access other units.
They will crawl or be carried; all it takes is one pregnant female to go undetected to give rise to the next generation.
lou Sorkin, bed bug expert

CorrelATion of Bed Bugs wiTh PoverTy

The difference is not that bed bugs are a product of ones income status but rather the ability to do treatment is impacted by ones income.
Sean rollo, bed bug expert

[Persistent infestations happen to low-income people] because they may lack resources to fund eradications; it is a capacity issue for people who are marginalized.
Paula fletcher, toronto city councillor

Among the common misconceptions about bed bugs is the widespread assumption that their presence is correlated with untidy conditions or poverty. All respondents agreed that bed bugs are a widespread issue facing people from all backgrounds, tenures, and incomes. Bed bugs can and will affect anyone with blood. Most respondents recognized that historical stigma distorts our understanding of bed bugs, and leads to assumptions that poverty or unsanitary conditions are associated with bed bugs. Most respondents also noted that people who live with low incomes are exposed to more risk factors for bed bugs and have fewer protective factors. People living on low incomes tend to live in denser settings, in buildings with more structural problems and higher turnover, and with more transient populations, all of which contribute to the spreading of bed bugs. People with low incomes are also more likely to obtain secondhand furniture and clothing, thereby increasing their risk of getting bed bugs. As a result, they tend to experience an upsurge of infestations earlier than the general population. Low-income households are the proverbial canary in the coal mine for the bed bug issue.

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severe infesTATions

The bug people said [the infestation] was the worst theyd seen. The infestation was covered; it looked like mildew with so many specks.
Sandy woodhouse, canadian mental health Association

When it comes to numbers of reported bed bug cases, it appears that Toronto is experiencing increasing and widespread incidence of severe infestations. Most respondents have had encounters with severe infestations, which have included as many as thousands of bed bugs active in the daytime, swarming on surfaces, and nesting in walls. Landlords are finding unit with have very serious infestations, and almost all agency staff interviewed could identify clients with severe infestations.
They are nocturnal but this does not mean that they cannot come out during the day.
dr. tomislav Svoboda, Seaton house

Most experts noted a proliferation in the number of severe infestations and intensity of those infestations as well. Some indicated that they were finding that the bugs were larger and more aggressive than in the past. Agency staff also noted an increase in the overall resilience of bed bugs and increasing incidents of behaviours such as feeding and travelling by day.
Some bugs were on one of our tables crawling in the day.
Agency staff member

Respondents found that vulnerable people were among the first to face the most serious problems. Agency staff found people facing mental health issues, especially hoarders, were at risk of severe infestations, but experts and agency staff also noted that seniors, people who are infirm, and people who have limited physical ability, time, or resources to address the problem were also among the people who developed serious infestations earliest. People lacking funds for an exterminator or the free time to conduct a thorough inspection, preparation, and cleaning as well as carry out an IPM effort have also faced significant infestations. Agency staff noted that public housing residents and other vulnerable populations seemed to be among the most frequently affected by severe infestations, either due to limited resources, infirmities, and other challenges, or proximity to others in those circumstances. While these factors have a distinct impact on who faces severe infestations earliest, most experts and agency staff experienced with bed bugs agree that everyone is at risk of infestations if the bed bug problem is allowed to escalate. imPACTs of severe infesTATions Severe infestations appear to be responsible for creating the more widespread distribution of bed bugs in Toronto, broadening the scope of infestations to a wider and wider range of potential populations. Experts interviewed agreed that bed bugs are normally nocturnal, but all respondents agreed that those habits will change if circumstances warrant. Agency staff and experts recognized that bed bugs will travel by day and feed by day, and many had encountered infestations severe enough that
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bugs were very active during the daytime, walking on people, and swarming on walls and objects, including objects in use. This daytime travel enables bed bugs to be more widely distributed as they hide on objects and individuals travelling about in their daily activities in public places, rather than emerging only in homes, when people are at rest. One expert noted that if bed bug infestations were severe enough, spreading is inevitable. As a result, experts and agency staff saw an increase in the number of bed bug incidences in middle-income homes in Toronto.
Bed bugs are nocturnal by nature. But it is the same thing with humans; if there is a niche that needs to be exploited, bed bugs will exploit that resource. If they 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.
Sean rollo, bed bug expert

Most respondents noted cases of infestations in offices and non-residential settings, including police stations, fire halls, laundries, hospitals, schools, daycares, public transit, and even movie theatres. Landlords are finding bed bugs in their common areas as well as in the residential portions of their buildings. Experts and agency staff agreed that non-residential sites function as places where bed bugs spread from the most exposed communities to those less at risk of early infestation. All experts interviewed anticipated that the situation would become significantly worse unless action was taken. One called the current experience with bed bugs the tip of the iceberg. imPACT on PeoPle in infesTed homes

I was afraid and scared and felt alone. I also felt the initial shame that people feel, and embarrassed. You go through this process of not wanting to talk about it or knowing who to talk to about itnot everyone will support you.
Bed bug sufferer

All interview subjects indicated that bed bug sufferers face a crushing array of negative impacts from infestations. Sufferers talk of feeling ashamed, fearful, and totally overwhelmed once they determined they had bed bugs, which was usually after extensive and fruitless efforts to determine the cause of their welts.
I was frantic; I could not sleep for two nights until the exterminator came to take care of it.
Bed bug sufferer

Virtually all respondents noted that people living with bed bugs face sometimes extreme levels of isolation. Families have abandoned relatives with infestations. A public transport service had refused to pick up people with bed bugs, effectively rendering them housebound. Landlords noted that families tend to panic when they find a relative has bed bugs and reactions are severe and often irrational. In many cases, people suffering from bed bugs self-impose isolation out of shame and fear of recrimination.
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Not surprisingly, most agencies had encountered people who had bed bugs but denied it to avoid the consequences.
There is a stigma attached to having bed bugs and it causes hardship for those with infestations. There is a false perception that individuals with a bed bug infestation must not be clean. There have been occasions when community agencies have refused to serve infested apartments, and in a few instances, an entire building, if even one of the units is known to be infested.
Steve floros, toronto community housing

Respondents also identified further debilitating economic impacts of bed bugs that extended also into the workplace. Many respondents cited cases in which people with bed bugs had missed work or even been barred from work, and lost income. Sufferers also reported having work-related problems and reported that their workplaces seemed unsympathetic and unprepared for the issue of bed bugs. In many cases, sufferers identified that their workplace environments became very hostile regarding their bed bug situation. One case documented that a bed bug sufferer was asked to repeatedly take showers at work and as a result quit from the associated humiliation and stigma. In another instance, a sufferer was humiliated at work for having bed bugs; as a result, agency staff were brought into her workplace to do a public education session about bed bugs for her colleagues. Experts, agency staff, and people who have suffered infestations described debilitating impacts from bed bugs, including very high levels of stress, anxiety, depression, sleep deprivation, and intense preoccupation verging on delusional states. Some sufferers reported taking medication to cope with the experience and some have reported ongoing mental health issues. Experts also identified significant psychological traumas, sometimes resulting in violent behaviour, cases of self-harm, and even two suicide attempts. Despite these intense challenges, few respondents could identify effective psychological or social supports for people suffering from bed bugs. Respondents insisted that psychological supports were badly needed.

Bed Bug sufferer Profile fEmAlE, middlE-incOmE hOuSEhOld

It took me a while before I found out that I had bed bugs. The reason for this is that my bites kept on getting misdiagnosed for months by doctors. I just kept on getting these welts on me like swollen hives, and I went to my doctor who told me that it was hives, then fleas. I could not understand how she could have thought that it was fleas; we dont even have pets. Then I went to a dermatologist and asked them what it was. They told me that they were not sure but they knew that it was an insect bite and prescribed some cortisone cream. This went on for a while until someone at work gave me a number to call. I called the number and the man came over to my house and told me that I had bed bugs. I was devastated. I mean me, I had bed bugs. People think that you are dirty or poor and I was not either of those. I was shocked and went into a downward spiral of fear, loss, and anger. Fear because I was afraid of having them and knew that they were so hard to get rid of, loss because it is difficult to have to throw things away, and anger because I wish that I had found out sooner so that the infestation did not have to get as bad as it did. I felt scared and ashamed. I mean who do I tell? How were people going to react? I remember taking my clothes

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to clean at the laundromat and seeing a friend of mine and she was asking me what I was doing there, so I told her that I had bed bugs and she flinched away from me in disgust, like eww. I mean this was a friend who was treating me like a leper. Bed bugs make you become social lepers. You have no one to really talk to, no one to really tell how you feel. I felt guilty for having bed bugs, I felt ashamed. I told my family not to come over to my house; we did not have anyone come over. After the laundromat incident I was very selective about who I told; I did not need another negative reaction like thatI could not handle it. I honestly think that I became mentally unhealthy. I lost focus in work, I could not think straight, and I became so emotional thinking and wondering why and how this could happen to me. For me this was very devastating; I could not sleep. I was afraid to sleep in my bed, my own bed. I felt vulnerable and alone and angry that I managed to bring them home. I did not know how to communicate with my husband about this, I was embarrassed. It totally disrupted my life. Just thinking back to this is starting to make me itch I cant talk about this anymore.

Bed Bug sufferer Profile mAlE, middlE-incOmE hOuSEhOld

I know that I got bed bugs from my former workplace. Despite their continuous efforts to prevent bed bugs, it was like they were playing in a losing battle with the little critters. I took what I thought were all the precautionary methods not to come in contact with them. Other people from work had brought them home and I was determined that I would not be another victim. Needless to say, one morning I woke up and found a bite that was itchy on my face. I immediately knew what it wasafter all, I had heard all the horror stories. I checked my mattress and sheets and found blood spots and some bed bugs. Even though I did have a familiarity with bed bugs from work, I must admit that I still became overwhelmed with the prospect of actually having them. I mean, I had to think about what having bed bugs meant to my life and what I would have to do to get rid of them. For me, this was very overwhelming and I became extremely distraught. Bed bugs really do change your life, how you live, and how others see you. Think about this; I had to spend over $4,000, throw out my furniture and other personal effects in many ways you start to lose yourself when you get bed bugs. This is something that is very hard for people to understand. Bed bugs for me also became very time consuming and totally interrupted my life. I had to take over three days off from work in order to prep my apartment just for the spraying. I had to do extra laundry, extra cleaning. Most importantly, I became so isolated. To be honest, until you go through it, you have no idea just how horrifying it really is. It is just natural for you to become paranoid; you lose sleep, you end up dreaming and thinking about bed bugsthey just consume every fibre of your being. I had to isolate myself from my family and friends; I did not want anyone coming over. I was too afraid that they would bring bed bugs home. This was very difficult for me because you need someone to talk to because it is awful very awful. There were many days that I did not see an end in sight. I became stressed, I lost focus, and I was constantly afraid that I was not being diligent enough about the bed bugs and that they were going to be in my life forever. To have this constantly preoccupying your thoughts can be very depressing. In the end, I just could no longer take it. After multiple sprayings and no real tangible results, I just decided to move. I could no longer live like a prisoner in my own home; it was just too hard for me. People need to really understand that, yes, there is the financial toll that bed bugs have on your lifeyou know, the money you spend and the time you lose from work. But it goes way beyond that; bed bugs also have a psychological and emotional toll. That, as well, you can always buy a new couch but you cant always buy peace of mind once you have bed bugs.

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imPACT on AgenCies And serviCes

One staff member decided to quit because she couldnt work with bed bugs.
Agency staff member

The sudden growth of the bed bug problem has had a significant impact on the agencies and housing providers that support vulnerable people. Agency and housing provider staff have formed the front line in the battle against bed bugs.
Work has increased. There is an increased amount of work and time being spent on bed bugs and the mad rush to get services and funding in place.
Agency staff member

Most agencies currently addressing bed bug issues are doing so from necessity. Confronted with clients facing a bed bug crisis and no meaningful systems of support, agencies have attempted to plug the service gap. Agencies also indicated that they are not only inadequately trained to deal with bed bugs, but also are clearly not resourced to do so, and the consequences have been severe. Staff at agencies report increased workloads from their efforts to address the issue. Staff indicated that they had to spend increasing amounts of time implementing a range of precautions against getting and spreading bed bugs, including the use of protective clothing, laundering work clothes on site, and bagging shoes and materials during visits. Agency staff find they need to adopt awkward practices such as never sitting, never placing materials on the floor, dressing and undressing for work in a garbage bag, and leaving possessions in sealable plastic bags during the day. Surprisingly, despite all these proactive measures, the majority of agencies interviewed had not developed protocols to deal with clients with severe infestations, including clients who arrive at the agency with live bed bugs on their body. Refusal of service is common in severe situations. Some housing organizations have had to pursue evictions to address chronic non-compliance with bed bug protocols.
With bed bugs, depending on infestation, it takes a full day [of staff time] for a housing support worker, half day for a case manager. Spread out over a couple weeks this is a lot of time. We do everything from bagging up belongings, admin-type items like filing reports, negotiating with landlords and ODSP; some need help doing the laundry.
Agency staff member

Staff spend more and more time learning about bed bugs, developing protocols, and providing information about bed bugs to colleagues and clients. Staff are increasingly involved in seeking funding to address bed bugrelated issues, including seeking Ontario Works and Ontario Disability Support Program funds to replace infested furniture and seeking small sums to offset the cost of pre-treatment preparation and pesticide application. Agencies also take on related matters for clients, including speaking to landlords and arranging referrals. In cases of chronic unaddressed problems, agency staff have had to directly intervene, carrying out inspections, vacuuming, preparing a site, and arranging pest control for clients. Some agencies have adopted complex protocols to reduce risks, including freezing the belongings of new residents in supportive housing settings. The impacts of bed bugs on agencies extend well past advocacy and awareness on behalf of their clients to their own staff as well. Many agency staff responded that they are not ready to handle
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the emotional and psychological toll that bed bugs cause for both their clients and themselves. Many cited not being trained as mental health professionals; others complained that they are trained mental health workers, but are not pest removal experts. Staff also noted that they were not reservoirs of information, and many of them lacked the formal knowledge and training needed to tackle bed bugs. For many of them, this was an ever evolving learning experience. Likewise, staff would sometimes turn to their managers for assistance and guidance, but noted that their managers were just as unprepared to effectively tackle bed bugs. Agency staff also noted that they had other jobs to do, but had become so immersed in bed bugs that their other work duties were being neglected. Agency staff also reported that both time and money were being diverted to bed bugs and that agencies are not properly funded to adequately deal with bed bugs; ultimately, there is just too little time and too little money to really make an impact.
There is on some levels a huge rift between employees and the organization. We hear things like I was trained as a social worker, I dont want to deal with bugs. I fear we have lost a number of long-standing employees because they are worried about taking [the bed bugs] home.
Agency staff member

Staff have bought scrubs to wear over their clothing. They leave them at work and wash them in the night. We are also advising staff not to sit on peoples furniture. We have to think about how to work with people differently. [Staff express]more anger than shame. There is an expectation that the employer can remove this. [The] office looks like a war zone with plastic bags everywhere for clothing and personal belongings.
Agency staff member

Bed bug problems have progressively migrated from clients homes to the agency offices. Agencies reported bed bug activity in their offices, including bed bugs travelling and biting by day and obvious bed bug activity in common areas. Agencies that have had bed bug occurrences in their offices have replaced considerable amounts of furniture.
For sure, bed bugs have added to the workload of what staff have to do. I have had dreams about bed bugs. There is a concern amongst staff about bringing them home.
Agency staff member

Landlords and agencies reported staff taking bed bugs home. Respondents cited cases of staff facing ongoing trouble with bed bugs, in one case throwing out 2 to 3 beds before getting the problem under control. One office worker got bed bugs despite never having entered a residential unit for work; the bugs were found in her chair at the office. She suffered lost work time and decontamination costs as well as considerable disruption in her work and personal life. Staff who have had bed bugs have tended to need a full day of time off to make the appropriate arrangements for deinfestation.
Staff have told me that they want to come back to work, but the bed bugs scare me. There has been work stoppage; in one case this led to a nervous breakdown. I must admit that I even wake up at night with skin tingling.
Agency staff member

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Some landlords and agencies are issuing staff protective clothing, often including full coveralls. Others arrange for staff to launder uniforms and other clothing at work. Despite these efforts, some housing providers are facing work refusals from staff, and agencies have had work refusals and resignations over exposure to bed bugs. Agencies reported growing challenges when addressing the increasing dissatisfaction staff feel over exposure to bed bugs and the pressure they get from their families to ensure minimal risk. Agencies demonstrated that there is a growing need to provide ongoing reassurance and support to staff. Agencies are also becoming increasingly concerned about staff retention issues as a result of bed bugs. One agency had an offer of employment refused by a candidate because of bed bugs and received a call in the middle of the night threatening resignation over bed bugs.
One staff found a bed bug on clothing, did a major office search, and now we are looking at better methods to protect the staff: bigger boots, etc. We are learning on the fly.
Agency staff member

Despite the growing pressure, most workplaces have no protocols for dealing with bed bugrelated human resource issues. Some have offered training and education, but few have a comprehensive strategy. Landlords and agency staff all anticipated the problem will grow worse with time. CosTs The cost of addressing a bed bug infestation varies with the intensity of the infestation and the approach used. The protocols that were generally identified as effective used detailed inspection vacuuming and other forms of capture for live bugs

preparation and cleaning of infested sites including bedding, mattresses, and crevices that have been used as harbourages the application of insecticides or steam the sealing of cracks and spaces that allow the entrance of bed bugs the dusting of voids or inaccessible spaces that may harbour insects follow-up inspection within two weeks to kill bed bugs that have emerged from eggs that survived the first eradication effort (see What to do to Reverse this PatternBest Practices on page 20 for a more specific review of effective eradiation protocols) These processes usually require an intensive effort on the part of sufferers and agency staff, and are time consuming and expensive. For the basic treatment of a single unit (including inspections, cleaning and preparation, and application of pesticides and/or steam), respondents tended to spend between $400 and $2,000. Ryerson University spends $1,000 on a single student residence, and agencies estimate $500 to $2,000 for most homes. Most experts felt a cost of $400 to $2,000 was typical. There was general agreement that more intense infestations cost significantly more to address.
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In addition to basic treatment, there are costs related to materials, including mattress covers, preparation-related supplies and, in some cases, furniture replacement. These costs, though considerable, are dramatically outweighed by the cost of inaction or of ineffective treatments. Some sufferers interviewed paid as much as $3,000 of their own money to address their bed bug issues due to repetitive, ineffective treatments, resulting in significant debt and a loss of their savings.
The cost of bed bug treatments has had a significant impact on our pest control budget. Four to five years ago, our budget for pest control was $1 million. This year, $2.5 million dollars is being spent - largely to address bed bug infestations. We recognize that treatment and elimination of bed bugs using only pesticides is often ineffective. Thats why we have implemented a holistic and environmentally-focused approach to pest management. This includes staff and tenant education, as well as effective, non-chemical treatment.
Steve floros, toronto community housing

Toronto Community Housing (TCH) has seen the extent to which bed bug costs can spiral out of control. TCHs pest control budget has skyrocketed in recent years, and it is attributed completely to the increased expenditure on bed bugs. There are additional costs for new furniture, new cupboards, and relocation costs if a unit has to be emptied. Toronto is discovering what most communities have found: the high cost of addressing bed bugs effectively is still cheaper than the stratospheric costs of waiting, when an infestation will often have grown out of control. BArriers To Addressing Bed Bugs

Education is a big barrier for landlords and for clients. Landlords play the blame game.
Agency staff member

Its hard to get all the stakeholders around an infestation on the same page.
Elaine magil, woodgreen community Services

Respondents anticipate significant growth of the bed bug problem in Toronto due to the many barriers to effective efforts to address the growing bed bug infestation. knOwlEdgE Most respondents acknowledged that there is relatively poor knowledge about the most effective ways to address bed bugs in Toronto. Some pest control professionals with experience working with infestations also noted that there appeared to be a lack of coordinated approaches to addressing bed bugs and that some strategies were consistently ineffective in terms of eradicating bed bugs. Some respondents had encountered the use of traditional but ineffective and dangerous do-it-yourself strategies such as the application of kerosene. In most cases, respondents had encountered practices that were more likely to contribute to spreading the bed bug infestations to other areas of the home and adjacent units. Others described the use
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of aerosols and other repellants, which simply dispersed bed bugs more widely. Pest control professionals, landlords, and agency staff agreed that understanding of the most effective practices was often poor even among their colleagues. They felt that education on this matter is critical to stemming the growth of the bed bug population. cOSt
People that dont have the funding available would give up; it is a battle they cant win. They cant afford to pay the money that is necessary.
Sandy costa, bed bug control expert

Most respondents also identified cost as a significant barrier to action. Low-income households and vulnerable people are most at risk of early infestation, and the cost in time and expenses of properly addressing a bed bug infestation often exceeds their physical and financial resources. lAndlOrd/tEnAnt iSSuES Lack of clarity around roles and lack of cooperation on the part of landlords and tenants was also seen by many respondents as a significant barrier. Tenants often avoided reporting bed bugs to landlords for fear of penalties such as being charged for exterminations, being evicted, having their furniture disposed of, or being exposed to stigma and recrimination by fellow tenants. These and other fears have resulted in tenants refusing access to units to prevent landlords from taking action on bed bugs. At the same time, landlords may choose to ignore or reject signs of bed bug infestations due to the cost of effective treatments and fear of damaging the reputation of the building. Experts and agency staff believe clearer protocols and expectations around roles would improve the control of bed bugs in multi-unit buildings in Toronto. cAPAcity
We are educating people on what to watch for and teaching them not to panic. Before that, people didnt even know, or they used Raid.
Agency staff member

There needs to be more skilled professionals who know the processand who are not out there just to make a quick buck. We need reputable companies that do the job right and not companies that dont follow up.
Steve koufis, bed bug prep expert

Agencies also pointed out a shortage of pest control services that have the capacity to carry out an effective bed bug management protocol. Many pest control firms simply apply pesticides, which fall well short of a fully effective protocol. Both agencies and pest control specialists identified that there needs to be greater emphasis and education focused on properly preparing units for treatments. They identified the importance of preparation as a critical component in achieving optimal results for bed bug treatments. Pest control respondents noted that there was a lack of companies who were able to do the needed preparation (bagging, wrapping, laundering, etc) and agencies reported that there was a lack of consistency on the pest control companys part when it came to understanding the importance of preparation and its direct implications
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on treatment failure. Effective eradication was hampered by the shortage of companies providing comprehensive preparation, which sets a ceiling on the number of infestations that could be addressed at any one time, causing long waitlists and a bottleneck effect, so that agencies had to wait weeks before they could get assistance for their clients.

sTrATegies for effeCTive ACTion EArly intErvEntiOn

The most important thing is getting the stigma out of the problem. Dont just call it a low-income/hygiene/hostel-related issue. This is a universal issue; this could happen in any building, anywhere in the city, at any income level, at any rent level. It could creep up in your building, and you need to be aware that there are supports and protocols that you need to follow. So when it happens, you can deal with it quickly. We need heightened awareness.
Brad Butt, greater toronto Apartment Association

Severe infestations are more difficult to eradicate and more likely to spread. As a result, experts indicated that early intervention is critical to managing bed bugs. Misdiagnosis, lack of awareness, lack of information on effective strategies, and lack of support for costs and other challenges tend to prevent effective early intervention, but respondents agree that efforts to address these critical gaps could dramatically improve Torontos ability to prevent infestations from growing and spreading. EducAtiOn Experts and agency staff agreed that lack of information and education is an important barrier to effectively dealing with bed bug infestations and, as a result, many infestations that could have been addressed early reached a level of severity that made them hard to eradicate. Not surprisingly, almost all respondents felt more education is a critical element of addressing the growing problem of infestations. Most respondents saw education as the most important tool in preventing bed bugs, effectively eradicating infestations and avoiding their recurrence in Toronto. There is already some evidence to support this expectation. Agency staff also indicated that agency-based education efforts in this city have had some positive effects on their clients abilities to manage bed bugs, and one local landlord found education efforts had helped tenants manage bed bugs better.
We need to develop strategies for entire buildings, mass education campaigns for the public at large, increase social assistance for vulnerable populations, have more public awareness to reduce stigma, get landlords on board teaching people integrated pest management, stop self-treating with over-the-counter products (as this builds resistance in bed bugs).
cathy loik, toronto Public health

Pest control professionals felt a need for increased education within their profession as well. Some respondents identified that there was a range of approaches to how a pest control company addresses an infestation. According to some respondents, this had direct implications
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on whether or not a treatment would be effective. For example, several pest control companies identified that not all their colleagues were aware of the crucial role that preparation played in the effectiveness of treatment. Pest control professionals also indicated that it was very important that there be follow-up after treatments. Many respondents identified that the lack of follow-up also had negative implications in terms of adequately treating bed bug infestations. Experts noted that proactive education on the prevention and treatment of bed bugs makes the greatest difference in keeping bed bugs at bay. Most respondents urged the creation of a range of informative written materials but many expressed concerns about the effectiveness of traditional flyers. Most respondents encouraged the use of simple fact sheets, preferably in multilingual formats with many pictures. Many experts, agency staff, landlords, and sufferers also encouraged more user-friendly formats including videos, workshops, community meetings, and even a hotline. All respondents agreed that sound protocols for bed bug prevention and eradication are the most important topics of education. Methods for inspection, cleaning and preparation work, and other aspects of effective eradication should be included. Experts also felt pest control companies needed to be educated about effective protocols.
Widespread education can help everyone with early recognition. This also keeps costs lower. We also need to work more on taking away the shame and stigma.
Agency staff member

Respondents indicated that education efforts should be broad-based and mainstream, appealing to people before they get bed bugs, not afterward, and supporting prevention as well as explaining eradication. Many respondents also felt that education efforts should help to demystify bed bugs, treating them as an increasingly common, manageable pest that can be controlled with the correct strategies. Materials should attempt to erase stigma and encourage people to seek support. Most respondents believed that local public health departments were the best organization to lead the eradication effort and promote better bed bug management. There was a sense that this would best be done in partnership with other city departments, and with support from senior levels of government. Agency staff also noted the success of community workers in reaching people facing infestations and providing direct support. They encouraged a public health approach that included agency-based interventions that made the best use of the strong connections agencies have, especially to vulnerable populations, to ensure the message gets to everyone. Some landlords also noted the benefits of engaging fellow tenants in the effort to educate people about bed bugs. PrOtOcOlS
Steam is a must. One of the best tools we currently have.
michael goldman, pest control

Experts and agency staff agreed that clear, consistent protocols for addressing bed bugs would be an effective tool in improving the success of eradication efforts and reducing the all-toocommon use of ineffective and sometimes harmful strategies. Experts recommend widely
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disseminated, government-endorsed protocols.

Steam has its usages. For those sensitive to pesticides, its very useful; useful for wheelchairs and mattresses. Vacuuming and steaming done diligently could get rid of 90% of any infestation.
reg Ayre, toronto Public health

Leading experts and agency staff agreed that protocols would have to include an IPM approach that goes well beyond simple pesticide application, and includes thorough preparation and cleaning. Most agency staff also recommended some basic interventions such as enclosing and encasing mattresses in seamless mattress covers, replacing wooden furniture with metal wherever possible, sealing holes and cracks, and generally reducing the opportunities for harbourages.
Steam is great for killing the eggs. Steam needs to be a part of a broader plan.
Sean rollo, bed bug prep expert

Experts and leading agency staff agreed that the use of steam was a valuable tool in bed bug eradication. Most respondents agreed that pesticide application is a small part of the solution, in part due to the declining effectiveness of most legal pesticides, and they saw pesticides as a tool to be used in combination with other aspects of pest management. Landlords found pesticide application to be an ineffective solution and found that incomplete treatments led to repeated bed bug occurrences. Experts and most agency staff taking a leadership role on bed bugs agreed that a thorough inspection of an infested unit was critical and that adjacent units should also be inspected as a matter of course. Building managers should be notified of infestations so they can take appropriate precautions, but experts and agencies differed on the notification of other tenants due to the impact of stigma on the tenants in the infested units. Return visits were seen as absolutely necessary, and at least two and usually three visits were recommended. Though the history is brief on the application of these protocols in contemporary settings, one agency noted a decline in bed bug incidences once it had adopted clear and consistent protocols, and one expert noted declines in bed bug infestations where similar protocols were applied. Experts also recommended proactive inspections to prevent infestations, preferably twice a year. Landlords found that a building-wide management plan for bed bugs, based on the core strategies indicated by best practices, is the most appropriate approach. PSychOlOgicAl And SOciAl SuPPOrtS All respondents interviewed agreed that the psychological impacts of bed bugs were detrimental to the well-being of people suffering infestations. Many sufferers reported having felt anxiety and loss of sleep and a constant preoccupation with bed bugs. Bed bug sufferers noted that they were unable to concentrate on their work, lost focus, and withdrew from interacting with others. In some cases, after their homes had been eradicated of bed bugs, many sufferers felt uneasy and unsafe, and reported waking in the middle of the night because they felt something crawling on them. Others spoke of still living out of plastic containers a year after having a successful treatment to prevent bed bugs from re-entering their possessions. Agency staff and sufferers identified that the stigma that surrounds bed bugs made it very difficult to get support on a psychological level. Many bed bug sufferers identified that they faced the barrier of not having
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anyone to confide in about their emotions and trauma surrounding bed bugs. The inability to confide in someone meant they could not adequately address the trauma of having bed bugs, further compounding their social isolation and demonstrating the importance of the role of support in the coping process for addressing bed bugs. Bed bug sufferers agreed that psychological supports are needed to help people though these circumstances. Most agency staff and some landlords have also encountered the need for psychological supports during deinfestation. Experts also indicated that assistance to vulnerable people was a critical ingredient of a successful strategy for bed bug eradication. Sufferers recommended access to counselling for those who need it. One agency noted a San Francisco program that allows bed bug sufferers to share stories on a drop-in basis to relieve the sense of isolation. finAnciAl SuPPOrtS Experts, agency staff, landlords, and bed bug sufferers all agreed that the problem of bed bug infestations would require access to financial assistance and other supports for people who have few resources or who face significant challenges. Bed bug sufferers said they needed financial support to manage the intensive approach necessary for effectively addressing bed bugs, and believed that many people avoid addressing bed bugs in the early stages because of concern about costs. Bed bug sufferers also said that workplaces need to develop better HR protocols to support employees with bed bugs. Agencies currently link eligible clients to Ontario Works, Ontario Disability Supports Program, and other small support funds, but the funding available is inadequate to the task and the eligibility issues exclude many who need support. Agencies also expressed frustration in not being able to access alternative funds for those clients who did not have the financial means to tackle their bed bug infestation and did not qualify for social assistance supports. This was echoed by sufferers, who identified that in many cases they were unable to handle the financial costs associated with having bed bugs and had to resort to borrowing money from family and friends. This further reinforces what agencies and service providers have been saying for a whilethat the current level of funding in place does not adequately meet the demands of the financial implications of addressing bed bug infestations. A comprehensive strategy to fund bed bug interventions for those who cannot address them independently is required to avoid intensive infestation and the resulting rapid spread of bed bugs.
We are learning not to panic but to be aware.
Agency staff member

AgenCy inTervenTions All agencies interviewed would be interested in helping to create an infrastructure that supports people who have bed bugs. Agencies stated that, with the proper funding, they would be willing to play a role in education and outreach to clients and the broader population to encourage appropriate responses to bed bugs and to reduce stigma and anxiety. Agencies see a role for themselves in developing and promoting more coordinated and consistent education efforts for their clients and the broader public about bed bug
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issues. Agencies also indicated that with the proper supports they would be willing to follow up with clients to support their efforts to address bed bug problems, including playing a supportive role in advocating for and resolving landlord/tenant issues, which can be a barrier to successfully addressing bed bugs.
Unit prep is the key, and dealing with the client in a dignified and respectful manner. This is a real intrusion on their lives.
Agency staff member

Agencies articulated that various supports and resources need to be in place to assist them in helping their clients deal with bed bugs. They identified that this would have to be a multi-pronged approach in terms of communication, education, outreach, and materials. Many agencies responded that they would be willing to coordinate education and outreach efforts to addresses the stigma commonly associated with bed bugs. However, they also identified that the supports needed to coordinate these would require a communications budget. Having identified that some resources and supports are lacking for vulnerable populations to address bed bug issues, agencies would also be willing to be an access point for necessary practical supports such as steamers, vacuums, and laundry. Staff at agencies agreed that easier access to these supports would make the process of dealing with bed bugs less overwhelming their clients. Providing these supports, however, would require considerable storage space, as well as funding for staff time and materials such as vacuums, laundries, and steam machines.

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ConClusions

If people dont start reporting, and if companies dont provide better services, and if there is no money to help those in need, the problem is going to explode to [affect] everyone.
Steve koufis, bed bug prep expert

Bed bugs are on the rise in Toronto. Interviews in all sectors show evidence of rapidly increasing populations. The situation is worsened by the increasing numbers of severe infestations, for the most part occurring in the homes of highly vulnerable people with few of the resources needed to address the problem. Those severe infestations are increasing the rate at which bed bugs spread to public places. Most respondents noted that they are seeing a rise in bed bug infestations among higherincome populations, indicating that the rapid increase in bed bug populations is extending far beyond vulnerable people. However, a growing bed bug crisis can be prevented. Comprehensive protocols for managing bed bugs are showing success elsewhere, and Toronto has put in place some of the early stages of a potentially successful effort to curb the growth of this pest. Proactive education efforts, systematic responses, government-endorsed protocols, and social and financial supports to enable vulnerable people to comply with demanding protocols can, if established early, help Toronto avoid the fate of other world cities struggling to turn back a mushrooming bed bug crisis.
They will be the new cockroaches and mosquitoes and we will be living with them.
Agency staff member

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reCommendATions

reCommendATion 1: thAt thE PrOvincE Of OntAriO tAkE thE lEAd tO mAnAgE thE BEd Bug ErAdicAtiOn EffOrt in OntAriO.
1.1 Due to the rapid expansion of bed bug issues across Ontario, in urban and rural settings, and the need for public leadership to facilitate an effective, broad-based, comprehensive, and consistent response to the growing bed bug infestation, that the Ontario Government should take the lead and adopt, on a province-wide basis, the policies outlined below and support and facilitate the systematic adoption of those policies by municipalities across Ontario. 1.2 As local public health authorities have, in most jurisdictions, played the leading role in addressing bed bug infestations, that the Ontario Ministry of Health and Long-Term Care should take the lead for the provincial government and adopt, on a province-wide basis, the policies outlined below and support and facilitate the systematic adoption of those policies by jurisdictions across Ontario.

reCommendATion 2: thAt thE PrOvincE Of OntAriO, in cOnjunctiOn with lOcAl municiPAlitiES, crEAtE A PuBlic AwArEnESS cAmPAign tO AddrESS BEd BugS.
2.1 That the Ministry of Health and Long-Term Care initiate the public awareness campaign to support an effective effort to engage the public in addressing the bed bug issue in a proactive, well-informed, and pragmatic manner. 2.2 That the awareness campaign be implemented through municipal public health departments. 2.3 That municipal public health departments initiate the public awareness campaigns immediately, with Ministry of Health and Long-Term Care support augmenting the process as soon as possible. 2.4 That municipal public health departments engage community agencies, service organizations, tenant groups, and neighbourhood associations in the delivery of this awareness campaign to provide information sources that are familiar and comfortable to the intended audiences. 2.5 That the awareness campaign make every effort to reduce the stigma and alarm attached to bed bug infestations.

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2.6 That the awareness campaign be designed to inform residents, before they experience infestations, that bed bugs are a common pest and that they can be managed with appropriate interventions including early identification, early intervention, and consistent adherence to established bed bug management protocols. 2.7 That the awareness campaign provide residents with a basic understanding of best practices in bed bug management, connect residents to information and resources to assist them in the management of bed bugs, and provide residents with the tools to select appropriate supports including pest control professionals who apply effective protocols for bed bug eradication.

reCommendATion 3: thAt thE PrOvincE Of OntAriO AdOPt And PrOmOtE SOund PrOtOcOlS And wOrk with lOcAl municiPAlitiES tO SEE thEm imPlEmEntEd.
3.1 That the Ministry of Health and Long-Term Care adopt and promote bed bug management protocols based on best practices as exemplified in well-researched work in the field such as Stephen Doggetts Code of Practice; Michael Potters recommendations through the University of Kentucky Entomology Department; the Bed Bug Handbook by Richard Cooper, Larry Pinto, and Sandy Kraft; the Integrated Pest Management partnership project between New York State and Cornell University; the existing Toronto Public Health Fact Sheets; and the Bed Bug Resource Manual created by WoodGreen Community Services. 3.2 That these protocols include the approaches demonstrated to be effective in addressing infestations including proactive inspection, early identification, early intervention, detailed inspection, extensive cleaning and preparation, removal of live bugs, appropriate removal and disposal of severely infested materials, treatment through the application of steam or pesticides of the appropriate type and formulation, inspection and/or treatment of adjacent units including those vertically adjacent, and follow-up inspections. 3.3 That these protocols are promoted through municipal public health departments, municipal licensing, property standards, and by-law enforcement departments, either directly or through interdivisional structures, to make every effort to ensure that these protocols are as widely understood and adopted by property owners and managers as possible. 3.4 That the Ministry of Municipal Affairs and Housing actively promote the adoption of these protocols among municipalities and housing operators.

reCommendATion 4: thAt thE miniStry Of hEAlth And lOng-tErm cArE, in cOnjunctiOn with lOcAl municiPAlitiES, undErtAkE, thrOugh EducAtiOnAl And rEgulAtOry EffOrtS, tO EnSurE thAt criticAl PArtnErS in thE EffOrt tO ErAdicAtE BEd BugS, including PESt cOntrOl PrOfESSiOnAlS, lAndlOrdS, And mEdicAl PrOfESSiOnAlS, PlAy A cOnStructivE And ActivE rOlE in idEntifying And AddrESSing infEStAtiOnS.
4.1 That the Ministry of Health and Long-Term Care support education and/or undertake regulation to ensure that landlords: a. Pursue proactive inspection, early identification, and immediate action

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b. Understand and apply the protocols, best practices, and integrated pest management methods described in Recommendation 2 c. Understand and act on the responsibilities of landlords to address infestations under the relevant legislation d. Appreciate and be prepared to address the very high costs of decontamination if the infestations are not acted on quickly and are allowed to become severe and spread through a building. 4.2 That the Ministry of Health and Long-Term Care support education and/or undertake regulation to ensure that pest control professionals: a. Understand and apply the protocols, best practices, and integrated pest management methods described in Recommendation 2 b. Appreciate the insufficiency of simple pesticide application as a treatment for bed bugs and appreciate the range of options, including non-toxic options, for addressing bed bugs effectively c. Appreciate the insufficiency of one-time interventions and adopt protocols that ensure follow-up inspection and treatment. 4.3 That the Ministry of Health and Long-Term Care support public health departments in alerting medical professionals to the indicators of bed bug infestation to ensure they can accurately identify and diagnose bed bug bites and provide patients with timely and appropriate advice about actions to take to treat both the symptoms and the infestation itself. 4.4 That the Ministry of Health and Long-Term Care undertake efforts including information and if necessary public investment to develop an adequate supply of bed bug disinfestation preparation and cleaning services to adequately provide for the demand for this critical service. 4.5 That the Ministry of Health and Long-Term Care encourage the adoption of these protocols by municipalities and by housing providers, through education and regulation as appropriate. 4.6 That the Ministry of Municipal Affairs and Housing support the adoption of these protocols by municipalities and by housing providers, through education and regulation as appropriate. 4.7 That municipal departments of public health, licensing, property standards, and by-law enforcement take on the front-line delivery of these education and regulatory efforts, either directly or though interdivisional structures, and provide independent education and regulatory controls as required for an effective effort to ensure adoption of the protocols

reCommendATion 5: thAt thE PrOvincE Of OntAriO, in cOnjunctiOn with lOcAl municiPAlitiES, PrOvidE funding tO fAcilitAtE thE ErAdicAtiOn Of BEd BugS in rESidEntiAl SEttingS.
5.1 That the Ministry of Health and Long-Term Care provide resources required to ensure that every Ontario resident, regardless of income or circumstances, have access to effective bed bug eradication and the funding they need to complete a successful eradication effort. 5.2 Because the eradication of bed bugs requires the early identification of and effective intervention in all infestations, that municipal departments of public health act immediately to take the necessary steps to support and facilitate early identification and interventions, with Ministry of Health and Long-Term Care support augmenting those efforts as soon as possible.

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5.3 That efforts to support early intervention and effective eradication include: a. Providing for effective inspections b. Promoting and facilitating proactive inspection wherever possible c. Working with Local Health Integration Networks, Community Care Access Centres, and funding organizations to support community agencies as a vehicle for providing the assistance described in 4.1c and 4.1d d. Supporting community agencies by making tools, information, and staff available to enable vulnerable residents to independently address bed bug infestations. 5.4 That efforts to support early intervention and effective eradication ensure the populations most vulnerable to bed bug infestations, particularly those most vulnerable to severe infestations, receive the supports and funding necessary to enable them to address infestations when they occur, including, wherever necessary: a. Support in managing deinfestation processes b. Social and psychological supports during deinfestations c. Financial supports for households that cannot afford the costs of deinfestation including the clearing, preparation, and treatment of the home as well as the replacement of severely infested materials. 5.5 That the Ministry of Municipal Affairs and Housing facilitate the effort at early intervention and effective eradication by contributing resources and supporting action in the areas described in 5.3.

reCommendATion 6: thAt thE PrOvincE Of OntAriO, in cOnjunctiOn with lOcAl municiPAlitiES, dEvElOP EffEctivE tOOlS fOr idEntifying And AddrESSing BEd Bug infEStAtiOnS in PuBlic PlAcES And thE chAllEngES thOSE nOn-rESidEntiAl infEStAtiOnS crEAtE.
6.1 That municipal public health departments, either directly or though interdivisional structures, develop policies for proactive inspection and early intervention and treatment on City property as indicated by established patterns of infestation in public spaces in other jurisdictions. 6.2 That municipal public health departments, either directly or though interdivisional structures, support other public institutions and community organizations in developing policies for proactive inspection and early intervention and treatment on their property as indicated by established patterns of infestation in public spaces in other jurisdictions. 6.3 That municipal public health departments, either directly or through interdivisional structures, support the development of appropriate human resources protocols for staff affected by bed bug infestations in public institutions and community organizations, and staff exposed to bed bugs in private residences in the course of their duties. 6.4 That the Ministry of Health support municipalities in the development and implementation of these policies.

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end noTes
1

City of Hamilton, Bed Bugs, http://www.myhamilton.ca/NR/rdonlyres/741F5A03-D92D-452E-B855A5F5BD0B12D9/0/Bed bugs.pdf (accessed July 30, 2009).

City of Ottawa, Bed Bugs, http://www.ottawa.ca/residents/health/environments/bed_bug/index_en.html (accessed July 30, 2009).

S. Doggett and R. Russell. The Resurgence of Bed Bugs in Australia. Proceedings of the Sixth International Conference on Urban Pests, William H Robinson and Dniel Bajomi (editors), July 13 to 16, 2008.

6 7 8 9 10 11

City of Kingston, Affordable Housing Development Committee Meeting Notes. November 28, 2008, http://www. cityofkingston.ca/pdf/cityhall/committees/housing/minutes/2008/AHD_Minutes_Nov20.pdf (accessed July 30, 2009). Ibid. Bed Bug RegistryOntario, 2009, http://bedbugregistry.com/location/on,(accessed July 30, 2009).

D. Williamson, Balcony Bedroom, Windsor Star, September 19. 2007, http://www.canada.com/windsorstar/story. html?id=0c2eeb2f-0320-4ec4-bfeb-34f34d1cf9dd&k=59457 (accessed July 30, 2009).

Ibid.

N. Taylor, Bed Bugs! Instances of Irritating Insects Increasing, Orillia Packet and Times, January 23, 2009. Pg A1. M. Potter, Lessons from the Past, Pest Control Technology Online, August 21, 2008, http://www.pctonline.com/articles/article.asp?ID=3264 (accessed July 30, 2009). Conversation with Michael Siciliano, January 16, 2009. D. Langlois, Rise of Bed Bugs Troubles Health Unit, Owen Sound Sun Times, December 24, 2009. Pg A3.

12 13

14

Gallahue, P. et al., Subways Blood-Bug Invasion, New York Post, May 8, 2008, http://www.nypost.com/ seven/05082008/news/regionalnews/subways_blood_bug_invasion_109879.htm (accessed July 30, 2009).

15

16

Bed Bugger. Bed Bugs 40, Humans 33, Bed Bug Infestation: 185 Smith St. in Winnipeg, February 2, 2007, Bedbugger.com, http://bedbugger.com/2007/02/22/bed-bugs-40-humans-33-185-smith-street-in-winnipeg (accessed July 30, 2009).

H. Adami, Bed Bugs Turn Womans Life Upside Down, Ottawa Citizen, December 3, 2008, http://www. faceoff.com/hockey/columnists/bios/story.html?id=158426f1-5c42-4c03-ba9b-34a5926b529b&add_feed_ url=http%3A%2F%2Fwww.faceoff.com%2Fscripts%2Fcolumns.aspx%3Fpublication%3DOttawa%2BCitizen%26byli ne%3Dhugh%2Badami&p=1 (accessed July 30, 2009).

17 18

Conversation with Steve Floros, April 9, 2009.

Monthly Financial Report: City of Hamilton Housing, February 11, 2009, http://cityhousinghamilton.com/userfiles/ file/BOD_documents/BOD20090211/Report%2309009OctoberMonthlyFinancial.pdf (accessed July 30, 2009). S. Doggett and R. Russell. The Resurgence of Bed Bugs in Australia. Proceedings of the Sixth International Conference on Urban Pests, William H Robinson and Dniel Bajomi (editors), July 13 to 16, 2008.

19

20 21

D. Feiden. Bed Bug Epidemic Attacks New York, New York Daily News, December 30, 2007. http://www. nydailynews.com/news/2007/12/30/2007-12-30_bedbug_epidemic_attacks_new_york_city.html (accessed July 30, 2009). S. Doggett and R. Russell. The Resurgence of Bed Bugs in Australia. Proceedings of the Sixth International Conference on Urban Pests, William H Robinson and Dniel Bajomi (editors), July 13 to 16, 2008. S. Hwang et al., Bed Bugs in an Urban Environment, Emerging Infectious Diseases (April 2005), http://www.cdc.gov/ncidod/eid/vol11no04/04-1126.htm (accessed July 30, 2009). Conversation with Michael Siciliano, January 16, 2009.

M. Baumann, Bed Bugs Check into Properties Throughout the Country, Hotel and Hotel Management, vol. 270: 30.

22 23

24

25 26

Ibid.

Bed Bug Issues in Toronto: Board of Health Report (February 2008) http://www.toronto.ca/legdocs/mmis/2008/hl/bgrd/backgroundfile-11155.pdf (accessed July 30, 2009). Toronto Bed Bug Project Fund, Staff Report Action Required: Bed Bug Project Update, November 12, 2008, http://www.toronto.ca/legdocs/mmis/2008/hl/bgrd/backgroundfile-17412.pdf (accessed July 30, 2009).

27

28

29

City of Hamilton, Bed Bugs, http://www.myhamilton.ca/NR/rdonlyres/741F5A03-D92D-452E-B855A5F5BD0B12D9/0/Bed bugs.pdf (accessed July 30, 2009).

City of Ottawa, Bed Bugs, http://www.ottawa.ca/residents/health/environments/bed_bug/index_en.html (accessed July 30, 2009).

City of Kingston, Affordable Housing Development Committee Meeting Notes, November 28, 2008, http://www. cityofkingston.ca/pdf/cityhall/committees/housing/minutes/2008/AHD_Minutes_Nov20.pdf (accessed August 6, 2009).
B e d B u g Repor t

51

30

31 32 33 34

D. Williamson, Balcony Bedroom, Windsor Star, September 19, 2007. http://www.canada.com/windsorstar/story. html?id=0c2eeb2f-0320-4ec4-bfeb-34f34d1cf9dd&k=59457 (accessed July 30, 2009). N. Taylor, Bed Bugs! Instances of Irritating Insects Increasing, Orillia Packet and Times, January 23, 2009. Pg A1. Bed Bug RegistryOntario, http://bedbugregistry.com/location/on (accessed July 30, 2009).

D. Langlois, Rise of Bed Bugs Troubles Health Unit, Owen Sound Sun Times, December 24, 2009. Pg A3. M. Potter, Lessons from the Past, Pest Control Technology Online, August 21, 2008, http://www.pctonline.com/articles/article.asp?ID=3264 (accessed July 30, 2009).

35

36

W. Quarles, Bed Bugs Bounce Back, IPM Practitioner, Vol. 29, No. 3 (March/April 2007) http://www.birc.org/MarApril2007.pdf (accessed July 30, 2009). M. Potter, Lessons from the Past, Pest Control Technology Online, August 21, 2008, http://www.pctonline.com/articles/article.asp?ID=3264 (accessed July 30, 2009).

37

38

UK Ministry of Health, Report on the Bed Bug, 1934, http://lrs.afpmb.org/2TS11XKF9Y8PFBXYQSMZD25M/arc/al_06_tit_fetch/1/1021 (or search accession:1021 at lrs.afpmb.org) (accessed August 6, 2009).

39

40 41 42

UK Ministry of Health. Report on the Bed Bug, 1934, http://lrs.afpmb.org/2TS11XKF9Y8PFBXYQSMZD25M/arc/al_06_tit_fetch/1/1021 (or search accession:1021 at lrs.afpmb.org) (accessed August 6, 2009). Ibid. Ibid.

Mind the Bed Bugs Dont Bite as the Critter Numbers Boom, The Evening Standard, October 19, 2006. http://www.thisislondon.co.uk/news/article-23371319-details/Mind+the+bed+bugs+don%27t+bite+as+critter+number s+boom/article.do (accessed July 30, 2009).

43 44

K. Reinhardt, Who Knows the Bed Bug? Knowledge of Adult Bed Bug Appearance Increases with Peoples Age in Three Counties of Great Britain, Journal of Medical Entomology Vol. 45, No. 5 (2008): 95658. Ibid. M. Potter, Lessons from the Past, Pest Control Technology Online, August 21, 2008. http://www.pctonline.com/articles/article.asp?ID=3264 (accessed July 30, 2009). Ibid. Ibid.

45 46 47

48 49

50 51 52

2008. M. Potter. Lessons from the Past. Pest Control Technology Online, August 21, 2008, http://www.pctonline.com/articles/article.asp?ID=3264 (accessed July 30, 2009). Ibid. Ibid.

A. Mallis. Handbook of Pest Control, 8th Edition, 2007.

Mind the Bed Bugs Dont Bite as the Critter Numbers Boom, The Evening Standard, October 19, 2006, http://www.thisislondon.co.uk/news/article-23371319-details/Mind+the+bed+bugs+don%27t+bite+as+critter+number s+boom/article.do (accessed July 30, 2009).

53

S. Doggett, The Resurgence of Bed Bugs in Australia: With Notes on their Ecology and Control, Environmental Health Journal, Vol. 4, No. 2 (2004): 3038. http://medent.usyd.edu.au/bedbug/papers/jeh_bedbug_resurgence.pdf (accessed July 30, 2009). M. Potter, Lessons from the Past, Pest Control Technology Online, August 21, 2008, http://www.pctonline.com/articles/article.asp?ID=3264 (accessed July 30, 2009). Conversation with Stephen Doggett, January 8, 2009.

54 55

56

Blood Sucking Insects: Bed Bugs, NEWpestsolutions.com, http://www.newpestsolutions.com/bloodsuckinginsects. htm (accessed July 30, 2009). S. Doggett and R. Russell. The Resurgence of Bed Bugs in Australia. Proceedings of the Sixth International Conference on Urban Pests, William H Robinson and Dniel Bajomi (editors), July 13 to 16, 2008. Conversation with Stephen Kells, February 2, 2009. Conversation with David Cain, January 15, 2009.

57 58 59

60 61 62

M. Pfiester. Aggregation and Dispersal Behavior of the Common Bed Bug, Cimex lectularius L., and a Method of Detection Using Canines, Masters Thesis, University of Florida http://etd.fcla.edu/UF/UFE0022594/pfiester_m.pdf (accessed July 30, 2009). Conversation with Stephen Kells, February 2, 2009. Conversation with Eric Hardebeck, January 30 2009. Conversation with Stephen Kells, February 2, 2009.

52

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63 64

Conversation with Stephen Doggett, January 8, 2009.

65

66 67

C. Boase, Bed BugsReclaiming our City, The Biologist, Vol. 51, No. 1 (2004): 912. http://www.iob.org/userfiles/File/biologist_archive/Biol_51_1_Boase.pdf (accessed July 30, 2009). Conversation with Stephen Doggett, January 8, 2009. S. Doggett and R. Russell. The Resurgence of Bed Bugs in Australia. Proceedings of the Sixth International Conference on Urban Pests, William H Robinson and Dniel Bajomi (editors), July 13 to 16, 2008.

World Health Organization, Public Health Significance of Urban Pests, http://www.euro.who.int/document/e91435.pdf (accessed July 30, 2009).

68

69 70 71

S. Doggett, The Resurgence of Bed Bugs in Australia: With Notes on their Ecology and Control, Environmental Health Journal, Vol. 4, No. 2 (2004): 3038. http://medent.usyd.edu.au/bedbug/papers/jeh_bedbug_resurgence.pdf (accessed July 30, 2009). Conversation with Eric Hardebeck, January 30, 2009. Conversation with Stephen Doggett, January 8, 2009.

72

S. Hwang et al, Bed Bugs in an Urban Environment, Emerging Infectious Diseases, Vol. 11, No. 4 (April 2005): 53338. http://www.cdc.gov/ncidod/eid/vol11no04/04-1126.htm (accessed July 30, 2009).

73

World Health Organization. Public Health Significance of Urban Pests, 2008, http://www.euro.who.int/document/ e91435.pdf (accessed July 30, 2009). Bed Bug Issues in Toronto: Board of Health Report, 2008, http://www.toronto.ca/legdocs/mmis/2008/hl/bgrd/backgroundfile-11155.pdf (accessed July 30, 2009).

74 75

Conversation with Gerard Brown, D.C Public Health.

76 77

Ibid.

S. Doggett and R. Russell. The Resurgence of Bed Bugs in Australia. Proceedings of the Sixth International Conference on Urban Pests, William H Robinson and Dniel Bajomi (editors), July 13 to 16, 2008. New York vs. Bed Bugs, Bed Bugs in New York City: A Citizens Guide to the Problem, 2008 http://newyorkvsbedbugs. org/wp-content/uploads/2009/02/bed_bugs_in_new_york_city.pdf (accessed July 30, 2009).

78 79 80

Ibid. Ibid.

S. Munoz, New Tactics Take a Bite out of Bed Bugs, Wall Street Journal, March 20, 2008. http://online.wsj.com/article/SB120596873874750153.html (accessed July 30, 2009). Ibid. Packtite website, http://paktite.com (accessed August 6, 2009) World Health Organization, Public Health Significance of Urban Pests, 2008, http://www.euro.who.int/document/e91435.pdf (accessed July 30, 2009).

81 82 83 84

Ibid.

85

86

87

Wayodd.com, Guest Suing for $6 Million Over Bed Bug Bites at Hilton Hotel in Arizona, January 4, 2007, http://www.wayodd.com/guest-suing-for-6-million-over-bed-bug-bites-at-arizona-hilton-hotel/v/6120 (accessed July 30, 2009).

ABC News: Good Morning America, Couple Wants $20 Million after Bedbug Attack, March 9, 2006, http://abcnews.go.com/GMA/story?id=1704757 (accessed July 30, 2009).

88

J. Martinez, Fordham Coed Sues Over Bed Bugs, New York Daily News, September 21, 2007, http://www.nydailynews.com/news/2007/09/21/2007-09-21_fordham_coed_sues_over_bedbugs_in_hotel_.html (accessed July 30, 2009). J. Borg, Family Wins Verdict over Bed Bugs, ABC Action News, July 6, 2008, http://abclocal.go.com/wpvi/story?section=news/local&id=6255804 (accessed July 30, 2009).

89

90

91 92

Bed Bugger, Bed Bugs 40, Humans 33, Bed Bug Infestation: 185 Smith St. in Winnipeg, http://bedbugger.com/2007/02/22/bed-bugs-40-humans-33-185-smith-street-in-winnipeg (accessed July 30, 2009). Conversation with David Cain, January 15, 2009. A. Dutton, Good Night Sleep Tight, Washington City Paper, January 28, 2009. http://www.washingtoncitypaper.com/display.php?id=36746 (accessed July 30, 2009). Grandmas Home Remedies. Home Remedies for Bed Bugs, 2009, http://www.grandmashomeremedies.com/bed-bugs.html (accessed July 30, 2009).

Landlord and Tenant Board. Case of Havcare Investments Inc. and Tenant. Amended Order, Toronto, February 17, 2009.

93

94

Conversation with David Cain, January 15, 2009.

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53

95

96

97 98 99 100

D. Feiden, Bed Bug Epidemic Attacks New York, New York Daily News, December 30, 2007, http://www.nydailynews.com/news/2007/12/30/2007-12-30_bedbug_epidemic_attacks_new_york_city.html (accessed July 30, 2009). Ibid. Institute for Policy Research: University of Cincinnati, Greater Cincinnati Survey 2008.

Cincinnati NBC Video, Bed Bugs a Growing Problem in Tri-State, May 1, 2007, http://www.wlwt.com/video/13237549/ (accessed July 30, 2009).

101

K. Jarvis, Fumigating Pitman 831, The Eye Opener, November 14, 2006. http://www.theeyeopener.com/article/3032 (accessed July 30, 2009).

Bed Bugs in Dorms, Bedbugger.com, http://bedbugger.com/category/bed-bugs-in-dorms (accessed July 30, 2009).

102

103 104

World Health Organization, Public Health Significance of Urban Pests, 2008, http://www.euro.who.int/document/e91435.pdf (accessed July 30, 2009). Ibid.

K. Harris, Bed Bug Infestations Plagues More Residents, The McGill Tribune, October 24, 2006. http://media.www.mcgilltribune.com/media/storage/paper234/news/2006/10/24/News/Campus.Bed.Bug.Infestation. Plagues.More.Residents-2386353.shtml (accessed July 30, 2009).

105 106

Canadian Centre for Policy AlternativesManitoba, Scandalous Truth about Bed Bugs, November 6, 2008, http://www.policyalternatives.ca/documents/Manitoba_Pubs/2008/FF_Nov_6_2008_Bed_Bugs.pdf (accessed July 30, 2009). A. Mallis, Handbook of Pest Control, 8th Edition, 1997. M. Potter, Lessons from the Past, Pest Control Technology Online, August 21, 2008. http://www.pctonline.com/articles/article.asp?ID=3264 (accessed July 30, 2009).

107

108

109

T. Fletcher, Bug Off! A Bed Bug Infestation in the Lower Mainland is Wreaking Havoc on Peoples Lives, BC People with AIDS Society (November/December 2006) http://www.bcpwa.org/articles/issue_45_8_Bug_off.pdf (accessed July 30, 2009). Bed Bug Issues in Toronto: Board of Health Report, 2008, http://www.toronto.ca/legdocs/mmis/2008/hl/bgrd/backgroundfile-11155.pdf (accessed July 30, 2009).

Bed Bug Issues in Toronto: Board of Health Report, 2008, http://www.toronto.ca/legdocs/mmis/2008/hl/bgrd/backgroundfile-11155.pdf (accessed July 30, 2009).

110

111

N. Parness, Torontos Bed Bug Infestation Getting Worse, CTV News, November 14, 2008, http://toronto.ctv.ca/servlet/an/local/CTVNews/20081117/bed_bugs_081117/2001117/?hub=TorontoNewHome (accessed July 30, 2009). S. Doggett and R. Russell. The Resurgence of Bed Bugs in Australia. Proceedings of the Sixth International Conference on Urban Pests, William H Robinson and Dniel Bajomi (editors), July 13 to 16, 2008.

112 113

114

M. Baumann, Bed Bugs Check into Properties Throughout the Country, Hotel and Hotel Management, Vol. 270 (2003): 30.

Ibid.

115

116

M. Potter, The Business of Bed Bugs, Pest Management Professional, January 1, 2008. http://www.mypmp.net/ pestcontrol/Cover+Story/The-Business-of-Bed-Bugs/ArticleStandard/Article/detail/488172 (accessed July 30, 2009). S. Doggett and R. Russell. The Resurgence of Bed Bugs in Australia. Proceedings of the Sixth International Conference on Urban Pests, William H Robinson and Dniel Bajomi (editors), July 13 to 16, 2008.

E. Simon, Re-emergence of Bed Bugs Creates Pest-Control Issues, Hotel and Hotel Management, Vol. 42 (May 17, 2004) http://findarticles.com/p/articles/mi_m3072/is_9_219/ai_n6070427 (accessed July 30, 2009).

117

118

119

M. Potter, The Business of Bed Bugs, Pest Management Professional, January 1, 2008, http://www.mypmp.net/ pestcontrol/Cover+Story/The-Business-of-Bed-Bugs/ArticleStandard/Article/detail/488172 (accessed July 30, 2009).

E. Simon, Re-emergence of Bed Bugs Creates Pest-Control Issues, Hotel and Hotel Management, Vol. 442 (May 17, 2004), http://findarticles.com/p/articles/mi_m3072/is_9_219/ai_n6070427 (accessed July 30, 2009).

120

Bed Bug Infestation Closes Pediatric Rooms, Times Colonist, September 20, 2007, http://www2.canada.com/ victoriatimescolonist/news/story.html?id=6c6c2a1f-49ec-4b2a-8af4-2ff b300c5433&k=66348 (accessed July 30, 2009). J. Rojas-Burke, Visiting Hours are Over for Bed bugs Over at OHSU, September 24, 2008, http://www.oregonlive.com/news/index.ssf/2008/09/ohsu_working_to_rid_admiting.html (accessed July 30, 2009). Joint Bed Bug Task Force: Cincinnati-Hamilton County Health Department, Strategic Plan, 2008.

121 122 123

Institute for Policy Research: University of Cincinnati, Greater Cincinnati Survey, 2008.

N. Taylor, Bed Bugs! Instances of Irritating Insects Increasing, Orillia Packet and Times, February 2009, http://www.orilliapacket.com/ArticleDisplay.aspx?e=1400547 (accessed July 30, 2009).

54

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124

125 126 127

County of Grey: Social Services Committee Meeting Minutes, February 11, 2009. http://www.greycounty.ca/files/meetingdocuments/ssc-feb-11-2009.pdf (accessed July 30, 2009). Conversation with Rima Zavys, April 1, 2009.

The City of Portland, Bed Bugs, http://www.ci.portland.me.us/hhs/hhsbedbugsmanual.pdf (accessed July 30, 2009).

128

University of Kentucky Entomology, Bed Bugs, http://www.ca.uky.edu/entomology/entfacts/ef636.asp (accessed July 30, 2009).

129 130

J. Steinberg. Bedbugs at Fox News, The New York Times, March 18, 2008. http://www.nytimes.com/2008/03/18/arts/18arts-BEDBUGSATFOX_BRF.html (accessed July 30, 2009). Conversation with Michael Siciliano, January 16, 2009.

131

M. Potter, The Business of Bed Bugs, Pest Management Professional, January 1, 2008, http://www.mypmp.net/ pestcontrol/Cover+Story/The-Business-of-Bed-Bugs/ArticleStandard/Article/detail/488172 (accessed July 30, 2009). P. Gallahue et al., Subways Blood-Bug Invasion, New York Post, May 8, 2008 http://www.nypost.com/ seven/05082008/news/regionalnews/subways_blood_bug_invasion_109879.htm (accessed July 30, 2009).

132

133

134

Harvard University, Bed Bugs Biology and Management, 2008, http://www.hsph.harvard.edu/bedbugs (accessed August 6, 2009).

Cornell University, Bed Bugs, 2008, http://www.entomology.cornell.edu/public/IthacaCampus/ExtOutreach/ DiagnosticLab/Factsheets/Bed Bugs.html (accessed August 6, 2009).

135 136 137

Medical Entomology Purdue University, Bed Bugs. http://www.entm.purdue.edu/publichealth/insects/bedbug.html (accessed July 30, 2009). Key Informant Interview with Sean Rollo. March 18, 2009. Unpublished Research by WoodGreen Community Services, 2008.

138

139

S. Doggett, The Resurgence of Bed Bugs in Australia: With Notes on their Ecology and Control, Environmental Health Journal Vol. 4, No. 2 (2004): 3038. http://medent.usyd.edu.au/bedbug/papers/jeh_bedbug_resurgence.pdf (accessed July 30, 2009). T. Fletcher, Bug Off! A Bed Bug Infestation in the Lower Mainland is Wreaking Havoc on Peoples Lives, BC People with Aids Society (November/December 2006), http://www.bcpwa.org/articles/issue_45_8_Bug_off.pdf (accessed July 30, 2009).

J. Intini, Sleeping with the Enemy, Macleans, January 8, 2008, http://www.macleans.ca/science/health/article.jsp?content=20080103_112804_5792 (accessed July 30, 2009).

140

141

J. Wallace, Bed Bug Resurgence Crawls into Urban Centres, National Review of Medicine, Vol. 2, No. 19 (November 15, 2005), http://www.nationalreviewofmedicine.com/issue/2005/11_15/2_patients_practice01_19.html (accessed July 30, 2009). World Health Organization, Public Health Significance of Urban Pests, 2008 http://www.euro.who.int/document/ e91435.pdf (accessed July 30, 2009).

142

143

A. Anderson and K. Leffler, Bed Bug Infestations in the News: A Picture of an Emerging Public Health Problem in the United States, Journal of Environmental Health, May 2008, ppg 24-27.

144

145

T. Fletcher, Bug Off! A Bed Bug Infestation in the Lower Mainland is Wreaking Havoc on Peoples Lives, BC People with Aids Society (November/December 2006), http://www.bcpwa.org/articles/issue_45_8_Bug_off.pdf (accessed July 30, 2009). J. Intini, Sleeping with the Enemy, Macleans, January 8, 2008. http://www.macleans.ca/science/health/article.jsp?content=20080103_112804_5792 (accessed July 30, 2009).

H. Adami, Bed Bugs Turn Womans Life Upside Down, Ottawa Citizen, December 3, 2008, http://www.faceoff.com/hockey/columnists/bios/story.html?id=158426f1-5c42-4c03-ba9b-34a5926b529b&add_feed_ url=http%3A%2F%2Fwww.faceoff.com%2Fscripts%2Fcolumns.aspx%3Fpublication%3DOttawa%2BCitizen%26byli ne%3Dhugh%2Badami&p=1 (accessed July 30, 2009).

146

147

148

Self Treatment for Bed Bugs Probably Caused Cincinnati Fire. Bedbugger.com, January 26, 2009, http://bedbugger.com/2009/01/26/self-treatment-for-bed-bugs-probably-caused-cincinnati-fire (accessed July 30, 2009).

A. Dutton, Good Night, Sleep Tight, Washington City Paper, January 28, 2009, http://www.washingtoncitypaper.com/display.php?id=36746 (accessed July 30, 2009).

149

N. Hinkle, Delusory Parasitosis, American Entomologist (Spring 2000) http://www.ent.uga.edu/pubs/delusory.pdf (accessed July 30, 2009). World Health Organization, Public Health Significance of Urban Pests, 2008, http://www.euro.who.int/document/e91435.pdf (accessed July 30, 2009).

150

Canadian Centre for Policy AlternativesManitoba, Scandalous Truth about Bed Bugs, November 6, 2008, http:// www.policyalternatives.ca/documents/Manitoba_Pubs/2008/FF_Nov_6_2008_Bed_Bugs.pdf (accessed July 30, 2009).
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152

J. Busvine, Insecticide Resistance in Bed-Bugs, Bulletin of the World Health Organization, Vol. 19, No. 6 (1958): 104152, http://whqlibdoc.who.int/bulletin/1958/Vol19/Vol19-No6/bulletin_1958_19(6)_1041-1052.pdf (accessed July 30, 2009). M. Potter, Lessons from the Past, Pest Control Technology Online, August 21, 2008, http://www.pctonline.com/articles/article.asp?ID=3264 (accessed July 30, 2009).

153

154

155

Kyong Sup Yoon, Deok Ho Kwon, Joseph P. Strycharz, Craig S. Hollingsworth, Si Hyeock Lee, and J. Marshall Clark, Biochemical and Molecular Analysis of Deltamethrin Resistance in the Common Bed Bug, Journal of Medical Entomology, Vol. 45, No. 6 (2009): 1092101. M. Potter, et al., Insecticide-Resistant Bed Bugs: Implications for the Industry, PCT Online, July 2007, http://www.sterifab.com/new_web_page/MAGAZINE_REPRINTS/july%20bed%20bugs.pdf (accessed July 30, 2009). R. Lloyd, Bed Bugs Resist Pesticides, Live Science, January 12, 2009. http://www.livescience.com/animals/090112-bed-bug-resistance.html (accessed July 30, 2009).

David J. Moore and Dini M. Miller, Laboratory Evaluations of Insecticide Product Efficacy for Control of Cimex lectularius, Journal of Medical Entomology, Vol. 45 (2008): 95658.

156

157

158

159

A. Romero, M. Potter, and K. Haynes, Insectide-Resistant Bugs: Implications for the Industry, Pest Control Technology Online, July 26, 2007, http://pctonline.com/articles/article.asp?MagID=1&ID=2954&IssueID=232 (accessed July 30, 2009). Allen L. Szalanski, et al., Mitochondrial and Ribosomal Internal Transcribed Spacer 1 Diversity of Cimex lectularius (Hemiptera: Cimicidae), Journal of Medical Entomology, Vol. 45 (2008).

S. Doggett and R. Russell. The Resurgence of Bed Bugs in Australia. Proceedings of the Sixth International Conference on Urban Pests, William H Robinson and Dniel Bajomi (editors), July 13 to 16, 2008.

160

161

Toronto Public Health, Bed Bugs: For Professionals, 2009, http://www.toronto.ca/health/bedbugs/infoforprofessionals.htm (accessed July 30, 2009).

162 163

J. Gangloff and C. Pichler, Guidelines for Prevention and Management of Bed Bugs in Shelters and Group Living Facilities, Cornell University, 2008. http://nysipm.cornell.edu/publications/bb_guidelines/files/bb_guidelines_nyc1.pdf (accessed July 30, 2009). Ibid. S. Doggett, A Code of Practice: For the Control of Bed Bug Infestations in Australia, 2007,

164

http://medent.usyd.edu.au/bedbug/cop_ed2_completed.pdf (accessed July 30, 2009). M. Potter, Bed Bugs, University of Kentucky Entomology, 2008, L. Pinto, R. Cooper, and S. Kraft, The Bed Bug Handbook, 2007.

165

http://www.ca.uky.edu/entomology/entfacts/ef636.asp (accessed July 30, 2009). J. Gangloff and C. Pichler, Guidelines for Prevention and Management of Bed Bugs in Shelters and Group Living Facilities, Cornell University, 2008,

166

167

http://nysipm.cornell.edu/publications/bb_guidelines/files/bb_guidelines_nyc1.pdf (accessed July 30, 2009).

168

169

170

171

J. Goddard, R. DeShazo, Bed Bugs and Clinical Consequences of their Bites, Journal of American Medical Association, Vol. 301, No. 13 (April 1, 2009): 135866.

City of Toronto Shelter, Support, and Housing Administration, Bed Bugs: A Handbook for Shelter Operators, December 12, 2007, http://www.toronto.ca/housing/pdf/bedbug.pdf (accessed July 30, 2009).

WoodGreen Community Services and The Community Bed Bug Committee, The Bed Bug Resource Manual: A Guide to Preventing, Treating, and Coping with Bed Bugs, 2008, http://www.woodgreen.org/Temp/ BedBugResourceManualDec172008.pdf (accessed July 30, 2009).

Toronto Public Health, Fact Sheets for Public, Landlords and Property Managers, and Other Professionals, 2009, http://www.toronto.ca/health/bedbugs/factsheets.htm (accessed July 30, 2009).

172

WebMD, Dont Lose Sleep Over Bed Bugs, http://www.webmd.com/a-to-z-guides/features/dont-lose-sleep-overbed-bugs?page=2 (accessed July 30, 2009). S. Doggett and R. Russell. The Resurgence of Bed Bugs in Australia. Proceedings of the Sixth International Conference on Urban Pests, William H Robinson and Dniel Bajomi (editors), July 13 to 16, 2008.

173

174

175

S. Doggett et al., Encasing Mattresses in Black Plastic Will Not Provide Thermal Control of Bed Bugs, Journal of Economic Entomology, Vol. 99, No. 6 (2006), ppg 2132-2135.

S. Kells, Non-Chemical Control of Bed Bugs, American Entomologist, Vol. 52, No. 2 (2006): 10710, http://www.entsoc.org/pubs/periodicals/ae/ae-2006/Summer/Kells.pdf (accessed July 30, 2009).

World Health Organization, Public Health Significance of Urban Pests, 2008, http://www.euro.who.int/document/ e91435.pdf (accessed July 30, 2009).

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176

177

Toronto Bed Bug Project Fund, Staff Report Action Required: Bed Bug Project Update, 2008, http://www.toronto.ca/legdocs/mmis/2008/hl/bgrd/backgroundfile-17412.pdf (accessed July 30, 2009).

178

179

Staff Report: One Time Allocations of 2005 City of Toronto Homeless Initiatives Fund and Off the Streets and Into the Shelters Funds, 2005, http://www.toronto.ca/legdocs/2005/agendas/committees/cms/cms051011/it014.pdf (accessed July 30, 2009). M. Potter, Lessons from the Past, Pest Control Technology Online, August 21, 2008, http://www.pctonline.com/articles/article.asp?ID=3264 (accessed July 30, 2009).

Allston Brighton Community Development Corporation Website, Programs: Community Organizing, 2009, http://www.allstonbrightoncdc.org/bed bugs.htm (accessed July 30, 2009).

180

181 182

Ibid.

U.K. Ministry of Health. Report on the Bed Bug, 1934, http://lrs.afpmb.org/2TS11XKF9Y8PFBXYQSMZD25M/ arc/al_06_tit_fetch/1/1021 (or search accession:1021 at lrs.afpmb.org) (accessed August 6, 2009). Conversation with Stephen Doggett, January 8, 2009.

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58

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APPendiCes

APPendix A
key informAnT inTerview inTroduCTion

Hi, my name is ____________ and Im working with a team of people on behalf of WoodGreen Community Services to explore bed bug issues in Toronto. WoodGreen has suggested that it would be good to speak with you about your knowledge and experience with bed bugs, to get a better understanding of bed bugs in Toronto and globally. The interview will take about 45 minutes to an hour [depending on the type of interview]. Over the past couple months, we have been researching bed bugs through existing articles and news stories to gain an understanding of emerging trends and best practices. Were now trying to dig deeper and connect some of what weve found with your own knowledge and experience. We are interviewing a series of residents, agencies, landlords, and bed bug experts. Were hoping that the information we gather from these interviews will help improve bed bug education and management practices as well as point to areas where more support is needed. If you prefer not to have your name mentioned, please say so and we will honour that. If this is not a good time, could we arrange a date and time to go through the interview?

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APPendix B
key informant interview scriptAgenCies

gEnErAl Name: Organization: Position: Have any of your clients ever had bed bugs? Do you have a sense of how they came to be in their units? Accept standard answers (friends with infestations, used furniture/clothing) and prompt: Have you come across any unusual forms of spreading such as active walking, day travel, outdoor travel? Describe.

Have you encountered any bed bug spread that was unusual for other reasons (prompt: odd location)? Describe.

Are there any circumstances you have seen that make spreading more likely (prompt: persons behaviours, structure of building, etc.)? Describe. Can you describe the kinds of bed bug incidents your clients experience and any patterns you see in those incidents? Prompt for: What percentage of your clients would you say have had problems with bed bugs?

Do some clients seem to get bed bugs more than others? If so, what is the pattern? (check for income, travel, mental health, other challenges, clutter, age or condition of unit) Why do you think there would be a pattern here? Do your clients have recurring problems?

Generally, for those people, how often does an infestation recur? For how long? Have some clients had what you would consider a serious infestation? Can you describe the infestations (e.g., numbers of bugs or areas infested, visibility of infestation)?

Do some clients seem to get serious infestations more than others? If so, what is the pattern (prompt: who gets serious infestations)? Why do you think that pattern exists? How long have you been aware of bed bugs as a serious issue? Have you seen changes relating to bed bugs in the past few years? Prompt for: Have you seen a change in the frequency of incidents in the last several years?
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 Have you seen a change in the intensity of incidents in the last several years? Have you seen a change in who is getting bed bugs in the last several years? How would you describe the change?

What precautions do your clients take to avoid infestation and later recurrence? How do they know to take these precautions? How effective are they? What precautions do you and your staff take to avoid infestation and later recurrence in your clients residence? How effective are they? What kind of information or education might help clients be more proactive in preventing bed bugs or effective in addressing them? Prompt for: Form (workshops, flyers, posters) Content (general information, treatment, prevention tips) Source Distribution method What have been the consequences of infestations for your clients? Prompt for: Costs (extermination, thrown-away goods) Impacts on family and personal life Impact on sleep, health, wellbeing Psychological impacts

Do you have clients who have infestations but say they dont mind? If so, why are some clients more tolerant of bed bugs than others? How have bed bugs affected your work (and/or personal life)? What have been the consequences of infestations for you? Prompt for: Costs (extermination, thrown-away goods: try to identify an average cost and if the cost changes with severity of the infestation) Refusal of access and services to clients who have bed bugs Clients refusing services due to fear of bed bugs Increased complaints Challenges with staff Can you tell me how you and your clients deal with infestations? Prompt for: Tenant-led extermination efforts (prep/cleaning, steam, pesticides, disposal of goods,
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 Request to clients landlord to take action on the infestation

inspection of adjoining units, dusting, landlord notification)

Tracking effectiveness of extermination (repeat efforts, duration of process, outcome) Referrals to social supports, advice for clients (check on information, accessibility, effectiveness)

Are you aware of any resources or supports for people who have been psychologically impacted or had their health adversely impacted due to bed bugs? Do you think there should be some kind of support to assist people who have been impacted by bed bugs? What barriers have you encountered in dealing with bed bugs? Prompt for unit access, costs, shame/fear of bad reputation, lack of information, lack of supports Have you encountered incidents or infestations in non-residential areas (e.g., offices, meeting rooms, common spaces)? Was there anything about infestations you are aware of that was unusual or unexpected (such as unusual patterns of spreading or day feeding)? Have any of your staff ever had bed bugs? If so, can you tell me about that experience? Prompt for: Do you know if they got them from a unit or from a non-residential area? Do you know if they got them through their work?

How has that affected your staff? Prompt for: Do you know anything about how it felt (e.g., the impacts on family and personal life, the impact on sleep or any psychological impacts)

Precautions, effectiveness of precautions, changes in attitudes toward work, family and friend reactions, stress, costs for extermination and lost goods, shame, lack of information, support) Extermination process (cleaning, steam, pesticides) Effectiveness (repeat efforts, duration of process, outcome)

What precautions do your staff take to avoid getting bed bugs? What does that have on your operations? Do you think most people who are at risk in their jobs are aware of their risk? How has your work changed at all in light of what you now know about risk? Have you ever had issues with work refusal because of bed bugs?

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Does your agency/group currently provide any bed bugservices? If so, which ones? Prompt for: Inspections Education Access to financial assistance/resources Cleaning of units/prep work Booking pest control services

Communication with landlords Vacuuming

Liaise with OW/ODSP for Community Start-Up or other funds Referral to other resources If not, why not?

Other ______________________ If not, what do you currently do when clients/units have bed bug problems? (If provides bed bugrelated service): What led you to get involved in bed bug issues? If funding were available, would you want to be involved in more bed bug work or would you want to leave that to outside resources? If so, what type of bed bug work would you like to do? What would you be able/interested in doing? Prompt for: Inspections of clients homes Inspections of external community members homes Education sessions Mental health counselling/support around anxiety Prep/cleaning to prepare a home for pest control Other _____________________________ What resources would you need to do that? Would you be interested in promoting efforts to improve the work being done to address the bed bug problem? What do you know about bed bugs that you would want others to know? (For out of town only): Whats different or distinct about your experience because of where you live? (For out of town only): Are bed bugs just a Toronto issue? Do you expect, with things as they are, that bed bugs will get better or worse over time?
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APPendix C
key informant interview scriptlAndlords

gEnErAl Name: Organization: Position: Have any of your tenants/residents ever had bed bugs? Do you have a sense of how they came to be in their units? Accept standard answers (friends with infestations, used furniture/clothing) and prompt: Have you come across any unusual forms of spreading such as active walking, day travel, outdoor travel? Describe.

Have you encountered any bed bug spread that was unusual for other reasons (prompt: odd location)? Describe.

Are there any circumstances you have seen that make spreading more likely (prompt: persons behaviours, structure of building, density, clutter)? Describe. Can you describe the kinds of bed bug incidents your tenants/residents experience and any patterns you see in those incidents? Prompt for: What percentage of your tenants/residents would you say have had problems with bed bugs? Do some tenants/residents seem to get bed bugs more than others? What is the pattern? (check for income, travel, mental health, other challenges, clutter, age or condition of unit) If so, why do you think there is a pattern here? Do your tenants/residents have recurring problems?

Generally, for those people, how often does it recur? For how long?

Have some tenants/residents had what you would consider a serious infestation?

Can you describe the infestations (e.g., numbers of bugs or areas infested, visibility of infestation)?

Do some tenants/residents seem to get serious infestations more than others? If so, what is the pattern (prompt: who gets serious infestations)? Why do you think that pattern exists? Have you seen changes relating to bed bugs in the past few years? Prompt for: Have you seen a change in the frequency of incidents in the last several years? Have you seen a change in the intensity of incidents in the last several years? Have you seen a change in who is getting bed bugs in the last several years?
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 If so, how would you describe it? What precautions do your tenants/residents take to avoid infestation and later recurrence? How do they know to take these precautions? How effective are they? What precautions do you and your staff take to avoid infestation and later recurrence in your buildings? How effective are they? What kind of information or education might help tenants/residents be more proactive in preventing bed bugs or effective in addressing them? Prompt for: Form (workshops, flyers, posters) Content (general information, treatment, prevention tips) Source Distribution method What have been the consequences of infestations for your tenants/residents? Prompt for: Costs (extermination, thrown away goods, dollar amounts) Impacts on family and personal life Impact on sleep, health, wellbeing Psychological impacts

What have been the consequences of infestations for you? Prompt for: Costs (extermination, thrown-away goods: try to identify an average cost and if the cost changes with severity of the infestation, dollar amounts) Loss of business Increased complaints

Challenges with staff Can you tell me how you and your tenants/residents deal with infestations? Prompt for: Tenant-led extermination efforts (prep/cleaning, steam, pesticides, disposal of goods, inspection of adjoining units, dusting, landlord notification)

Landlord-led extermination efforts (prep/cleaning, steam, pesticides, disposal of goods, inspection of adjoining units, dusting, tenant education ) Tracking effectiveness of extermination (repeat efforts, duration of process, outcome) Referrals to social supports, advice for tenants/residents (check on information, accessibility, effectiveness)

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How do/did you choose a pest control company? From your experience, what makes an extermination effort particularly successful? Are you aware of any resources or supports for people who have been psychologically impacted or had their health adversely impacted due to bed bugs? Do you think that there should be some kind of support to assist people who have been impacted by bed bugs? Please describe. What barriers have you encountered in dealing with bed bugs? Prompt for unit access, costs, shame/fear of bad reputation, lack of information, lack of supports Have you encountered incidents or infestations in non-residential areas (e.g., offices, meeting rooms, common spaces)? Do you have any mandatory reporting procedures for staff who encounter bed bugs? Have any of your staff ever had bed bugs? If so, can you tell me about that experience? Prompt for: Do you know if they got them from a unit or from a non-residential area? Do you know if they got them through their work?

How has that affected your staff? Prompt for: Do you know anything about how it felt (e.g., the impacts on family and personal life, the impact on sleep or any psychological impacts)?

Extermination process (cleaning, steam, pesticides)

Precautions, effectiveness of precautions, changes in attitudes toward work, family and friend reactions, stress, costs for extermination and lost goods, shame, lack of information, support)

Effectiveness (repeat efforts, duration of process, outcome) What precautions do your staff take to avoid getting bed bugs? What impact does that have on your operations? Have you ever had issues with work refusal because of bed bugs? Was there anything about infestations you are aware of that was unusual or unexpected like unusual patterns of spreading or like day feeding? Do you expect, with things as they are, that this situation will get better or worse over time?

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APPendix d
key informant interview scriptsufferers

Id like you tell me about your [your clients] experience with bed bugs, including how you [they] got them, what it was like having them. Are you aware of how you got bed bugs? Prompt for: Where do you think you got them?

Were you aware that there was an infestation at the location from which you got them? Where in the home/setting that you know had bed bugs? Do you know if any units next to you had bed bugs? Were you in a home/setting that you think may have had bed bugs?

How did you figure out that you had bed bugs? Prompt for: Searching online, blogs, etc. Identified by family doctor Identified by family or coworker How did you feel when you found out that you had bed bugs? Prompt for: General feelings (scared, violated, ashamed, etc.) What was your initial reaction (anger, loneliness)?

After you discovered that you had bed bugs, what did you do? Prompt for: Call an exterminator; search place for other sites of infestation Throw away furniture Inform other people who had come in contact with place Did you disclose that you had bed bugs to family, friends, and coworkers? If so how was their reaction? How did that make you feel? Prompt for: Did they support you? Did they isolate themselves from you? Were they shocked and concerned for you? Did you feel that you needed to socially isolate yourself from family, friends, and coworkers? If so, why?
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What were the impacts of having bed bugs on your personal life? What were the impacts of having bed bugs on your work? What were the impacts of having bed bugs on your family? Where did you turn to get emotional support? Did having bed bugs affect your performance at work? What were some of the psychological effects of having bed bugs? Prompt for: Depression Anxiety Loss of sleep

Loss of focus How did these psychological effects affect you and your health? Did you notice any changes in other members of your household? If so, what kind of changes? Prompt for: Changes in childrens behaviour Changes in partners behaviour Changes in peoples behaviour at work Did you personally feel stigmatized, or discriminated against, for having bed bugs? If so, how? Why? Id like you to tell me about your [your clients] experience with bed bugs, how you dealt with them, and the costs of dealing with them. How far along was the infestation when you first noticed it? Are you aware of the number of infestations and the sizes of infestations that you had? Can you please describe the methods and measures that you took to address your bed bug infestation? Prompt for: Self-help methods (self-spraying, natural remedies, unsafe measures, etc.) Alternative methods such as IPM, sealing their house, steaming, buying a mattress cover, vacuuming, etc. What made you decide to use these methods? What was the financial cost of having bed bugs?
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Calling a pest control company

Prompt for: Costs of throwing away good, clothes, extermination Costs of cleaning and prepping Other identifiable cost How long was the duration of treatments, and do you feel that these treatments were effective? Did you have to undergo repeated treatments; if so, why? Were you able to handle the financial costs of dealing with your bed bug infestation? In your experience, what do you think works and does not work when it comes to dealing with bed bugs? What would make it easier for you to deal with a bed bug infestation? Id like you tell me what kind of advice you would give people working on the issue of bed bugs, including government. Is there anything that surprised you about your experience with bed bugs? What kinds of supports do you wish you had to help you to better address your bed bug problem? What kinds of information/educational tools would be helpful for people who are dealing with bed bugs? What kinds of supports do you think are needed to help people who are suffering from bed bugs? Prompt for: Financial Emotional Educational Who, or what institution, do you think is the most appropriate to administer bed bug education and why?

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APPendix e
key informant interview scriptexPerT/AgenCy ComBinATion

gEnErAl Name: Organization: Position: Who can get bed bugs? Why do you think that people associate bed bugs with low incomes or marginalized people? Are there things that contribute to the likelihood of getting bed bugs? Prompt for: Used materials Travel

Are there things that contribute to the likelihood of an infestation? Prompt for: Building condition Clutter Ability to address How do you define an infestation? Are there different levels of infestations? If so, how are they classified? Are there things that contribute to the severity of infestations? Prompt for: Clutter Building condition, etc.)

Does that affect some populations more than others? Have any of your clients ever had bed bugs? Do you have a sense of how they came to be in their units? Accept standard answers (friends with infestations, used furniture/clothing). Prompt for: Have you come across any unusual forms of spreading such as active walking, day travel, outdoor travel? Describe.
70

Have you encountered any bed bug spread that was unusual for other reasons (prompt: odd

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 Are there any circumstances you have seen that make spreading more likely (prompt for: persons behaviours, structure of building, etc.)? Describe. Are there things that contribute to the likelihood of spreading from an infested site? Does that affect some populations more than others? In what ways have you seen bed bugs spreading? Prompt for: Transfer from sites other than visits to homes Independent travel between units Independent travel between buildings Have you encountered cases of bed bugs travelling during the day? If so, can you describe the circumstances? What should be done to try to manage the spread of bed bugs? Can you describe the kinds of bed bug incidents your clients experience and any patterns you see in those incidents? Prompt for: What percentage of your clients would you say have had problems with bed bugs?

location)? Describe.

Do some clients seem to get bed bugs more than others? If so, what is the pattern? (check for income, travel, mental health, other challenges, clutter, age or condition of unit) Why do you think there would be a pattern here? Do your clients have recurring problems?

Generally, for those people how often does it recur? For how long?

Have some clients had what you would consider a serious infestation?

Can you describe the infestations (e.g., numbers of bugs or areas infested, visibility of infestation)?

Do some clients seem to get serious infestations more than others? If so, what is the pattern (prompt: who gets serious infestations)? Why do you think that pattern exists? Have you encountered cases of bed bugs feeding during the day? If so, can you describe the circumstances? How long have you been aware of bed bugs? Have you seen changes relating to bed bugs in the past few years? Prompt for: Have you seen a change in the frequency of incidents in the last several years? Have you seen a change in the intensity of incidents in the last several years? Have you seen a change in who is getting bed bugs in the last several years? How would you describe it?

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What precautions do your clients take to avoid infestation and later recurrence? How do they know to take these precautions? How effective are they? What precautions do you and your staff take to avoid infestation and later recurrence in your clients residence? How effective are they? What kind of information or education might help clients be more proactive in preventing bed bugs or effective in addressing them? Prompt for: Form (workshops, flyers, posters) Source Content (general information, treatment, prevention tips)

Distribution method Who, or what institution, do you think is the most appropriate to administer bed bug education and information, and why? How has your work changed at all in light of what you now know about risk? What have been the consequences of infestations for your clients? Prompt for: Costs (extermination, thrown away goods) Impacts on family and personal life Impact on sleep, health, wellbeing Psychological impacts

Do you have clients who have infestations but say they dont mind? If so, why are some clients more tolerant of bed bugs than others? How have bed bugs affected your work (and/or personal life)? What have been the consequences of infestations for you? Prompt for: Costs (extermination, thrown-away goods: try to identify an average cost and if the cost changes with severity of the infestation) Refusal of access and services to clients who have bed bugs Clients refusing services due to fear of bed bugs Increased complaints Challenges with staff Can you tell me how you and your clients deal with infestations? Prompt for: Tenant-led extermination efforts (prep/cleaning, steam, pesticides, disposal of goods,
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 Request to clients landlord to take action on the infestation

inspection of adjoining units, dusting, landlord notification)

Tracking effectiveness of extermination (repeat efforts, duration of process, outcome) Referrals to social supports, advice for clients (check on information, accessibility, effectiveness) How do/did you choose a pest control company? In your experience, what is required to eradicate a bed bug infestation? Prompt for: Inspection Cleaning Steaming

Pesticide application (including dust) Education Inspection and treatment of adjacent units Return visits

Notification of the managers and occupants of the infested building Process for return visits What is the typical cost required to eradicate infestations? Does that cost change with the severity of the infestations? What is the range? Are you aware of any resources or supports for people who have been psychologically impacted or had their health adversely impacted due to bed bugs? Do you think that there should be some kind of support to assist people who have been impacted by bed bugs? What barriers have you encountered in dealing with bed bugs? Prompt for: Unit access Costs Shame/fear of bad reputation Lack of information Lack of supports

What can help overcome those barriers? Have you encountered incidents or infestations in non-residential areas (e.g., offices, meeting rooms, common spaces)? Have any of your staff ever had bed bugs?
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Can you tell me about that experience? Prompt for: Do you know if they got them from a unit or from a non-residential area? Do you know if they got them through their work?

How has that affected your staff? Prompt for: How it felt, the impacts on family and personal life, the impact on sleep or any psychological impacts

Extermination process (cleaning, steam, pesticides)

Precautions, effectiveness of precautions, changes in attitudes toward work, family and friend reactions, stress, costs for extermination and lost goods, shame, lack of information, support)

Effectiveness (repeat efforts, duration of process, outcome) What precautions do your staff take to avoid getting bed bugs? What impact does that have on your operations? Do you think most people who are at risk in their jobs are aware of their risk? Have you ever had issues with work refusal because of bed bugs? Do you have any mandatory reporting procedures for staff who encounter bed bugs? Does your agency/group currently provide any bed bugrelated services? If so, which ones? Prompt for: Inspections Education Access to financial assistance/resources Cleaning of units/prep work Booking pest control services

Communication with landlords Vacuuming

Liaise with OW/ODSP for Community Start-Up or other funds Referral to other resources If not, why not?

Other ______________________ If not, what do you currently do when clients/units have bed bug problems? (If provides bed bugrelated service): What led you to get involved in bed bug issues? If funding were available, would you want to be involved in more bed bug work or would you want to leave that to outside resources?
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If so, what type of bed bug work would you like to do? What would you be able/interested in doing? Prompt for: Inspections of clients homes Inspections of external community members homes Education sessions Mental health counselling/support around anxiety Prep/cleaning to prepare a home for pest control Other _____________________________ What resources would you need to do that? Would you be interested in promoting efforts to improve the work being done to address the bed bug problem? Was there anything about infestations you are aware of that was unusual or unexpected like unusual patterns of spreading or like day feeding? What do you know about bed bugs that you would want others to know? (For out of town only): Whats different or distinct about your experience because of where you live? (For out of town only): Are bed bugs just a Toronto issue? Do you expect, with things as they are, that bed bugs will get better or worse over time? Starting a social enterprise to provide prep and/or spray services

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APPendix f
key informant interview scriptexPerTs

gEnErAl Name: Organization: Position: Have you ever encountered bed bugs through your work or in other ways? Please describe how you normally come in contact with bed bugs. incidEncE Who can get bed bugs? Why do you think that people associate bed bugs with low incomes or marginalized people? Are there things that contribute to the likelihood of getting bed bugs? Prompt for: Used materials Travel

Are there things that contribute to the likelihood of an infestation? Prompt for: Building condition Clutter Ability to address Does that affect some populations more than others? Are there things that contribute to the severity of infestations? Prompt for: Clutter Does that affect some populations more than others? SPrEAding Are there things that contribute to the likelihood of spreading from an infested site? Does that effect some populations more than others?
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Building condition, etc.

What ways have you seen bed bugs spreading? Prompt for: Transfer from sites other than visits to homes Independent travel between units Independent travel between buildings Have you encountered cases of bed bugs travelling during the day? If so, can you describe the circumstances? What should be done to try to manage the spread of bed bugs? nOn-rESidEntiAl infEStAtiOn And trAnSfEr How do you define an infestation? Are there different levels of infestations? If so, how are they classified? Weve heard of people finding bed bugs in non-residential settings such as schools, offices, movie theatres, public transit, and office buildings. Have you encountered any infestations in these locations? Have you encountered any cases of bed bugs being transferred to someone elses home through these transfer points? If so, did this result in an infestation? Have you encountered cases of bed bugs feeding during the day? If so, can you describe the circumstances? chAngE in SEvErity Have you seen any changes in the rate or types of bed bug incidents in the last five years? Have you seen changes in the severity of incidents? Have you seen changes in the locations of bed bug incidents? Prompt for: Types of people Types of businesses Types of settings

Given the current attitudes and awareness about bed bugs in Toronto, what do you expect will happen with the rate of infestation in the city of the next 5 to 10 years? imPActS Have you come across any instances where bed bugs have had an impact on someones life beyond
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the physical bites? What were those impacts?

Specifically, do you think are any psychological impacts associated with bed bug infestations? How do these impacts affect the overall health and well-being of someone affected by bed bugs? Have you come across any instances of people becoming stigmatized by bed infestations? Why is this? Are you aware of any social stigma associated with bed bugs? What have the social impacts of this been? How do you think people deal with this?

Are you aware of any resources or supports for people who have been psychologically or had their health adversely impacted due to bed bugs? Do you think that there should be some kind of support to assist people who have been impacted by bed bugs?

trEAtmEnt In your experience, what is required to eradicate a bed bug infestation? Prompt for: Inspection Cleaning Steaming

Pesticide application (including dust) Education Inspection and treatment of adjacent units Return visits

Notification of the managers and occupants of the infested building Process for return visits What is the typical cost required to eradicate infestations? Does that cost change with the severity of the infestations? What is the range? What are the barriers that people experience to addressing infestations? What would help them overcome those barriers? What should be done to prevent reinfestation?

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infOrmAtiOn What kinds of information would be helpful for people who deal with bed bugs? How would that information be best distributed? What kind of education would be the most effective for residents? For property managers? For pest control companies? Who, or what institution, do you think is the most appropriate to administer bed bug education and why? If there was one thing that you wanted to know about bed bugs, that would help eradicate bed bugs in North America, what would it be? Is there anyone we should be speaking with, or any reports we should be reading, to get a better understanding of these bed bug issues?

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APPendix g
key informAnT inTerview lisT
1. Reg Ayre, Toronto Public Health 2. Andalie Andamali, Toronto Community Housing 3. Heidi Billyard, Good Sheppard Centers 4. Gerard Brown, DC Public Health 5. Brad Butt, Greater Toronto Tenants Association 6. David Cain, Pest Control London, England 7. Paula Cassin, ABI Possibilities 8. Renee Coree, New York vs Bed Bugs 9. Sandy Costa, Pest Control 10. Stephen Doggett, University of Sydney and Westmead Hospital, Australia 11. Paula Fletcher, Toronto City Counsellor 12. Steve Floros, Toronto Community Housing 13. Dr. Abbass Ghavam-Rassoul, CAMH & St. Michaels Hospital 14. Michael Goldman, Pest Control 15. Richard Grotsch, BugnScrub 16. Dr. Camille Jones, Cincinnati Public Health 17. Dan Kass, New York City Health Department 18. Stephen Kells, University of MinnesotaEntomology 19. Steve Koufis, Pest Control 20. Cathy Loik, Toronto Public Health 21. Anne Longair, Toronto Shelter Services 22. Hazel Lynn, Grey Bruce 23. Elaine Magil, WoodGreen Community Services 24. Celine Mauboules, Vancouver Housing Planner 25. Rocky Merz, Cincinnati Health Department 26. Eric Hardback, Pest Control 27. Victoria Natola, Federation of Metro Tenants Association 28. Dr. Richard Pollack, Laboratory of Public Health Entomology, Harvard School of Public Health 29. Dr. Michael Potter, University of KentuckyEntomology 30. Sean Rollo, Bed Bug Expert 31. Michael Siciliano, New York Department of EducationPest Control 32. Jacqueline Schwan, Grey Bruce 33. Lou Sorkin, Museum of Natural History 34. Bed Bug Sufferer #1 35. Bed Bug Sufferer #2 36. Bed Bug Sufferer #3 37. Bed Bug Sufferer #4 38. Bed Bug Sufferer #5 39. Bed Bug Sufferer #6 40. Bed Bug Sufferer #7 39. Dr. Tomislav Svoboda, Seaton Hall & St. Michaels Hospital 40. Amele Teffera, Sherbourne Bus 41. Lynsdy Thomas, WoodGreen Community Services 43. Glenn Weppler, Ryerson University 44. Sandy Woodhouse, Peterborough CAMH 45. Rima Zavys, WoodGreen Community Services 80
Bed Bug Repor t

Bed Bug Biology and Behavior

Dini M. Miller, Ph.D., Department of Entomology, Virginia Tech Andrea Polanco, Department of Entomology, Virginia Tech

Introduction to the Bed bug Lifecycle

The bed bugs that are infesting homes today are the descendents of cave dwelling bugs that originally fed on the blood of bats. When humans began living in the caves, the bugs began feeding on humans. Later, when humans moved out of the caves and started their agricultural civilizations, the bugs moved with them. Since that time, humans have carried bed bugs all over the world. Bed bugs belong to a family of insects called Cimicidae. All members of this family feed exclusively on blood. The common bed bug (Cimex lectularius) has five developmental life stages. Each immature life stage (called nymphs or instars) must take a blood meal in order to develop into the next life stage. Because bed bugs, like all insects, have their skeleton on the outside of their body (exoskeleton) they have to shed their exoskeleton in order to grow larger. This shedding of the exoskeleton is called molting. A bed bug nymph must take a blood meal to molt successfully. After growing through five instar molts, the bed bug becomes an adult. Adult bed bugs, both male and female, must also take regular blood meals to reproduce. The diagram above illustrates the bed bug lifecycle including all instars, before and after feeding. The total development process from and egg to an adult can take place in about 37 days at optimal temperatures (>72 F). Adult bed bugs have a life span of nearly one year depending on regular access to blood meals and favorable temperatures.

Feeding Behavior
Bed bugs have a cryptic lifestyle, meaning they spend the majority of their time hiding together in cracks and crevices where they will not be seen or disturbed. However, they become active at night, between midnight and 5:00 am. It is during this time, when the human host is typically in their deepest sleep, that bed bugs like to feed. Bed bugs are known to travel many yards to reach their human host. Bed bugs are attracted to CO2 produced by the host exhalations, and they are also attracted to body heat. However, bed bugs are only able to detect these host cues over short distances (about 3 feet away for CO2 and even less for heat). It is not well understood how bed bugs hiding in a closet are able to

find a host located in a bed across the room. However, bed bugs are able to move very quickly, and it is thought that they do a lot of wandering around before they are able to locate their food. Ideally, most bed bugs would like to aggregate near the hosts bed, on the mattress or in the boxsprings, when they are not feeding. However, this is not always possible in heavy infestations where bed bugs are crowded and many bed bugs have to seek refuge at distances several yards from the host. Once a bed bug finds the host, they probe the skin with their mouthparts to find a capillary space that allows the blood to flow rapidly into their bodies. A bed bug may probe the skin several times before it starts to feed. This probing will result in the host receiving several bites from the same bug. Once the bed bug settles on a location, it will feed for 5-10 minutes. After the bed bug is full, it will leave the host and return to a crack or crevice, typically where other bed bugs are aggregating. The bed bug will then begin digesting and excreting their meal. Bed bugs usually feed every 3-7 days, which means that the majority of the population is in the digesting state, and not feeding most of the time.

Mating Behavior
After feeding, adult bed bugs, particularly the males, are very interested in mating. Cimicid bugs have unique method of mating called traumatic insemination. This mating behavior is considered traumatic because the male, instead of inserting his reproductive organ (paramere) into the female genitalia, he literally stabs it through her body wall into a specialized organ on her right side, called the Organ of Berlese. The male sperm is released into the females body cavity, where over the next several hours it will migrate to her ovaries and fertilize her eggs. The traumatic insemination stabbing creates a wound in the females body that leaves a scar. The females body must heal from this wound and consequently, females are known to leave aggregations after being mated several times to avoid any further abuse. Studies have shown that the process of healing from traumatic insemination has a significant impact on the females ability to produce eggs. In fact, females that mate only once, and are not subjected to repeated stabbings by the male will produce 25 percent more eggs than females that are mated repeatedly. In practical terms, this means that a single mated female brought into a home can cause an infestation without having a male present, as long as she has access to regular blood meals. The female will eventually run out of sperm, and will have to mate again to fertilize her eggs. However, she can easily mate with her own offspring after they become adults to continue the cycle.

Egg Production:
The number of egg batches a female will produce in her lifetime is dependent on her access to regular blood meals. The more meals the female can take the greater the number of eggs she will produce. For example, the average adult female will live about one year. If she is able to feed every week, she will produce many more eggs in that year than if she is able to feed only once a month.

On average:
A female bed bug will produce between 1- 7 eggs per day for about 10 days after a single blood meal. She will then have to feed again to produce more eggs. A female can produce between 5 and 20 eggs from a single blood meal. The number of male and female eggs produced is about the same (1:1 ratio). A single female can produce about 113 eggs in her whole life. Eggs can be laid singly or in groups. A wandering female can lay an egg anywhere in a room. Under optimal conditions, egg mortality is low and approximately 97% of the bed bug eggs hatch successfully. At room temperature (>70 F), 60 percent of the eggs will hatch when they are 6 days old; >90 percent will have hatched by the time they are 9 days old. Egg hatch time can be increased by several days by lowering ambient temperature (to 50 F). Due to the large numbers of eggs a female can produce under optimal conditions (temperatures >70 F but < 90 F, and in the presence of a host), a bed bug population can double every 16 days.

Nymph Development Time

The time it takes any particular bed bug nymph to develop depends on the ambient temperature and the presence of a host. Under favorable conditions, such as a typical indoor room temperature (>70 F), most nymphs will develop to the next instar within 5 days of taking a blood meal. If the newly molted instar is able to take a blood meal within the first 24 hours of molting, it will remain in that instar for 5-8 days before molting again. At lower temperatures (50 F 60 F), a particular instar may take two or three days longer to molt to the next life stage than a nymph living at room temperature. However, if a bed bug nymph does not have access to a host, it will stay in that current instar until it is able to find a blood meal, or it dies. The time for a bed bug to develop from an egg, through all five nymphal instars, and into a reproductive adult is approximately 37 days. Even under the best conditions some bed bug nymphs will die prior to becoming adults. The first instars are particularly vulnerable. Newly hatched nymphs are exceptionally tiny and cannot travel great distances to locate a host. If an egg is laid too far from a host, the first instar may die of dehydration before ever taking its first blood meal. However, laboratory studies have found that overall bed bug survivorship is good under favorable conditions, and that more than 80 percent of all eggs survive to become reproductive adults.

Adult Bed Bug Life Span

The most recent studies indicate that a well-fed adult bed bug held at room temperature (>70 F), will live between 99 and 300 days in the laboratory. Unfortunately, we do not know exactly how long a bed bug might live in someones home or apartment. No doubt it will be at least several months. However, conditions are usually more challenging for the bed bugs living in human dwellings than they are in the laboratory (finding food, fluctuations in temperature and humidity, the presence of insecticides, avoiding being crushed, etc.) and these conditions will have a negative impact on bed bug survival. A recent laboratory study has shown that starvation has a negative impact on bed bug survival. This modern study contradicts European studies conducted in the 1930s and 40s, when it was determined that bed bugs could survive periods of starvation lasting more than one year. While this may have been true for individual bed bugs in the UK living at very low temperatures (< 40 F; because of no central heating); modern bed bugs collected from homes in the United States do not live that long. On average starved bed bugs (at any life stage) held at room temperature will die within 70 days. Most likely these bed bugs are dying of dehydration, rather than starving to death. Because bed bugs have no source of hydration other than their blood meal, dehydration is the greatest natural threat to their survival while living in the indoor environment. In fact, one of the reasons that bed bugs pack themselves so tightly into small cracks and crevices is so that they can maintain a microhabitat of favorable temperature and humidity, thus increasing their ability to survive periods of starvation.

Bed Bugs that are Resistant to Insecticides

The lifecycle data presented in this publication is based on research conducted using bed bugs collected from apartments within the state of Virginia. These populations have documented resistance to pyrethroid insecticides. Laboratory studies have indicated that resistant bed bugs have a shorter developmental time (several days), shorter life spans and lower levels of egg production than bed bugs that are not resistant to insecticides. At the time of this writing, practically all natural bed bug populations collected in Virginia have been found to be a least somewhat resistant to pyrethroid insecticides.

Morbidity and Mortality Weekly Report

Weekly / Vol. 60 / No. 37 September 23, 2011

Acute Illnesses Associated With Insecticides Used to Control Bed Bugs Seven States, 20032010
The common bed bug, Cimex lectularius, is a wingless, reddish-brown insect that requires blood meals from humans, other mammals, or birds to survive (1). Bed bugs are not considered to be disease vectors (2,3), but they can reduce quality of life by causing anxiety, discomfort, and sleeplessness (4). Bed bug populations and infestations are increasing in the United States and internationally (3,5). Bed bug infestations often are treated with insecticides, but insecticide resistance is a problem, and excessive use of insecticides or use of insecticides contrary to label directions can raise the potential for human toxicity. To assess the frequency of illness from insecticides used to control bed bugs, relevant cases from 20032010 were sought from the Sentinel Event Notification System for Occupational Risks (SENSOR)-Pesticides program and the New York City Department of Health and Mental Hygiene (NYC DOHMH). Cases were identified in seven states: California, Florida, Michigan, North Carolina, New York, Texas, and Washington. A total of 111 illnesses associated with bed bugrelated insecticide use were identified; although 90 (81%) were low severity, one fatality occurred. Pyrethroids, pyrethrins, or both were implicated in 99 (89%) of the cases, including the fatality. The most common factors contributing to illness were excessive insecticide application, failure to wash or change pesticide-treated bedding, and inadequate notification of pesticide application. Although few cases of illnesses associated with insecticides used to control bed bugs have been reported, recommendations to prevent this problem from escalating include educating the public about effective bed bug management. To evaluate illnesses associated with insecticides used to control bed bugs, data from 20032010 were obtained from states participating in the SENSOR-Pesticides program* and from NYC DOHMH. Acute illnesses associated with an insecticide used to control bed bugs were defined as two or more acute adverse health effects resulting from exposure to an insecticide used for bed bug control. Cases were categorized as definite, probable, possible, and suspicious based on three criteria: certainty of exposure, reported health effects, and
* The SENSOR-Pesticides program consists of 12 states that conduct surveillance of pesticide-related illness. California, Florida, Michigan, North Carolina, New York, Texas, and Washington reported cases of acute illness associated with insecticides used for bed bug control. The other five states participating in the SENSOR-Pesticides program (Arizona, Iowa, Louisiana, New Mexico, and Oregon) did not identify any cases of acute illness associated with insecticides used for bed bug control during 20032010. The California Department of Public Health reported one case of acute illness associated with insecticides used for bed bug control. The other case in California was reported through the California Department of Pesticide Regulation. New York City Poison Control Center, a component of NYC DOHMH, contributed data from 20032010, in addition to data received from New York State Department of Health and Mental Hygiene. Because the New York City Poison Control Center does not report data to the New York State Department of Health, their data were reported separately.

INSIDE
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Morbidity and Mortality Weekly Report

consistency of health effects with known toxicology of the insecticide (causal relationship) (Table 1). Data were analyzed for demographics, health effects, report source, case definition category, illness severity, insecticide toxicity, insecticide chemical class, work-relatedness, and factors contributing to illness. A 2010 case report from Cincinnati Childrens Hospital Medical Center (CCHMC) in Ohio also was obtained.** For 20032010, a total of 111 cases were identified in seven states (Table 2). The majority of cases occurred during 20082010 (73%), were of low severity (81%), and were identified by poison control centers (81%). New York City had the largest percentage of cases (58%). Among cases with known age, the majority occurred among persons aged 25 years (67%). The majority of cases occurred at private residences (93%); 40% of cases occurred in multiunit housing. Among cases, 39% of pesticide applications were performed
Low severity cases usually resolve without treatment and cause minimal time lost from work (<3 days). Moderate severity cases are nonlife threatening but require medical treatment and result in <6 days lost from work. High severity cases are life threatening, require hospitalization, and result in >5 days lost from work. The toxicity category of an insecticide is determined by the Environmental Protection Agency (EPA) under guidance from CFR Title 40 Part 156. Insecticides in category I have the greatest toxicity, and insecticides in category IV have the least toxicity. ** This case was not included in the analysis because Ohio does not participate in the SENSOR-Pesticides program. However, this case received media coverage in Ohio and represents misuse and excessive application of pesticides. The case demonstrates the need for consumers to be diligent in choosing a certified or licensed pesticide applicator.

TABLE 1. Case classification matrix* for acute illness associated with insecticides used for bed bug control seven states, 20032010
Classification criteria Exposure Health effects Causal relationship Classification category Definite 1 1 1 1 2 1 Probable 2 1 1 Possible Suspicious 2 2 1 1 or 2 1 or 2 4

Source: CDC. Case definition for acute pesticide-related illness and injury cases reportable to the national public health surveillance system. Cincinnati, OH: US Department of Health and Human Services, CDC, National Institute for Occupational Safety and Health; 2005. Available at http://www.cdc.gov/niosh/ topics/pesticides/pdfs/casedef2003_revapr2005.pdf. * Cases are placed in a classification category based on scores received on available evidence for exposure, health effects, and causal relationship. Scores relating to exposure criteria are 1 = clinical, laboratory, or environmental finding supporting the exposure, 2 = evidence from written or verbal report; criteria for health effects are 1 = two or more abnormal signs after exposure and/or test or laboratory results that are reported by a licensed health-care professional, 2 = two or more symptoms postexposure are reported by the patient; and criteria for a casual relationship are 1 = health effects are consistent with known toxicity, 4 = insufficient toxicologic information to determine if a causal relationship exists between exposure and health effects. Based on either combination of scores for exposure, health effects, and causal relationship.

by occupants of the residence who were not certified to apply pesticides. The majority of insecticide exposures were to pyrethroids, pyrethrins, or both (89%) and were in toxicity category III (58%) (Table 2). The most frequently reported health outcomes were neurologic symptoms (40%), including headache and dizziness; respiratory symptoms (40%), including upper respiratory tract pain and irritation

The MMWR series of publications is published by the Office of Surveillance, Epidemiology, and Laboratory Services, Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services, Atlanta, GA 30333. Suggested citation: Centers for Disease Control and Prevention. [Article title]. MMWR 2011;60:[inclusive page numbers]. Thomas R. Frieden, MD, MPH, Director Harold W. Jaffe, MD, MA, Associate Director for Science James W. Stephens, PhD, Director, Office of Science Quality Stephen B. Thacker, MD, MSc, Deputy Director for Surveillance, Epidemiology, and Laboratory Services Stephanie Zaza, MD, MPH, Director, Epidemiology and Analysis Program Office Ronald L. Moolenaar, MD, MPH, Editor, MMWR Series Martha F. Boyd, Lead Visual Information Specialist John S. Moran, MD, MPH, Deputy Editor, MMWR Series Robert A. Gunn, MD, MPH, Associate Editor, MMWR Series Maureen A. Leahy, Julia C. Martinroe, Teresa F. Rutledge, Managing Editor, MMWR Series Stephen R. Spriggs, Terraye M. Starr Douglas W. Weatherwax, Lead Technical Writer-Editor Visual Information Specialists Donald G. Meadows, MA, Jude C. Rutledge, Writer-Editors Quang M. Doan, MBA, Phyllis H. King Information Technology Specialists William L. Roper, MD, MPH, Chapel Hill, NC, Chairman Virginia A. Caine, MD, Indianapolis, IN Patricia Quinlisk, MD, MPH, Des Moines, IA Jonathan E. Fielding, MD, MPH, MBA, Los Angeles, CA Patrick L. Remington, MD, MPH, Madison, WI David W. Fleming, MD, Seattle, WA Barbara K. Rimer, DrPH, Chapel Hill, NC William E. Halperin, MD, DrPH, MPH, Newark, NJ John V. Rullan, MD, MPH, San Juan, PR King K. Holmes, MD, PhD, Seattle, WA William Schaffner, MD, Nashville, TN Deborah Holtzman, PhD, Atlanta, GA Anne Schuchat, MD, Atlanta, GA John K. Iglehart, Bethesda, MD Dixie E. Snider, MD, MPH, Atlanta, GA Dennis G. Maki, MD, Madison, WI John W. Ward, MD, Atlanta, GA

Centers for Disease Control and Prevention

MMWR Editorial and Production Staff

MMWR Editorial Board

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TABLE 2. Characteristics of acute illnesses associated with insecticides used for bed bug control seven states, 20032010
Total Characteristic Total Year of exposure 2003 2004 2005 2006 2007 2008 2009 2010 Location California Florida Michigan North Carolina New York New York City Texas Washington Age group (yrs) 05 614 1524 2544 45 Unknown Sex Male Female Case definition category Definite Probable Possible Suspicious Illness severity Fatal High Moderate Low Body part/System affected Nervous system Respiratory Gastrointestinal Skin Eye Cardiovascular Other No. 111 3 4 9 6 8 23 19 39 2 3 8 4 18 64 3 9 6 9 11 26 27 32 51 60 3 14 91 3 1 20 90 45 45 37 35 11 8 15 (%)* (100) (3) (4) (8) (5) (7) (21) (17) (35) (2) (3) (7) (4) (16) (58) (3) (8) (5) (8) (10) (23) (24) (29) (46) (54) (3) (13) (82) (3) (1) (18) (81) (40) (40) (33) (32) (10) (7) (14)

TABLE 2. (Continued) Characteristics of acute illnesses associated with insecticides used for bed bug control seven states, 20032010
Total Characteristic Work related Yes Pesticide applicator certification Certified applicator Uncertified/Unsupervised applicator Home occupant not certified to apply pesticides Unknown certification of applicator Site where case was exposed Single family home Mobile home/Trailer Multiunit housing Private residence/Type not specified Residential institution Hotels Unknown Reporting source Physician report Poison control center State health department Other Toxicity category** I Danger II Warning III Caution Missing/Unknown Insecticide chemical class Pyrethroid Pyrethrin Carbamate Organophosphate Other Unknown No. 13 2 15 43 51 10 1 44 48 2 3 3 4 90 7 10 1 13 64 32 77 28 3 2 9 3 (%)* (12) (2) (14) (39) (46) (9) (1) (40) (43) (2) (3) (3) (4) (81) (6) (9) (1) (12) (58) (29) (69) (25) (3) (2) (8) (3)

* Percentages might not add to 100 because of rounding. The sums exceed the number of cases because some persons had more than one body part or system affected and some had exposure to more than one insecticide. Pyrethroids, pyrethrins, or both were implicated in 99 (89%) of cases. By occupation, the exposed workers included two pest control workers, two emergency medical technicians, two carpet cleaners, one health educator, one caregiver, one medical technician, one support staff member at a shelter, one hotel manager, one hotel maintenance worker, and one person whose occupation was unknown. One case occurred in an independent living facility, and the other case occurred at a shelter. ** Toxicity categories as classified by the Environmental Protection Agency, based on established criteria, with category I being the most toxic. Includes the following active ingredients: DEET (four), hydroprene (two), chlorfenapyr (one), coal tar (one), and acetamiprid (one). DEET and hydroprene are not insecticides, but were pesticides used to control bed bugs.

and dyspnea; and gastrointestinal symptoms (33%), including nausea and vomiting. Among cases, 13 (12%) were work-related. Of these, three illnesses involved workers who applied pesticides, including two pest control operators, of whom one was a certified applicator. Four cases involved workers who were unaware of pesticide applications (e.g., two carpet cleaners who cleaned

an apartment recently treated with pesticides). Two cases involved hotel workers (a maintenance worker and a manager) who were exposed when they entered a recently treated hotel room, and two cases involved emergency medical technicians who responded to a scene where they found white powder thought to be an organophosphate pesticide. Contributing factors were identified for 50% of cases. Factors that most

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TABLE 3. Contributing factors in acute illnesses associated with insecticides used for bed bug control seven states, 20032010
Total Contributing factor One or more contributing factors identified Excessive application Failure to wash or change pesticide-treated bedding Notification lacking/ineffective Failure to vacate premises Spill/Splash of liquid or dust Inadequate ventilation Early reentry Mixing incompatible chemicals Improper storage Label violation not otherwise specified No label violation but person still ill No. 56 10 9 6 5 4 3 2 2 1 16 2 (%)* (100) (18) (16) (11) (9) (7) (5) (4) (4) (2) (29) (4)

What is already known on this topic? Bed bug populations and infestations are increasing in the United States and internationally. Bed bugs have an increased prevalence of insecticide resistance, including resistance to commonly used agents such as pyrethroids. What is added by this report? During 20032010, seven states reported 111 acute illnesses associated with insecticides used to control bed bugs. The most frequently identified causes of illness were excessive application of insecticides, failure to wash or change pesticide-treated bedding, and inadequate notification of pesticide application. What are the implications for public health practice? Inappropriate use of insecticides to control bed bugs can cause harm. Media campaigns to educate the public on nonchemical methods to control bed bugs, methods to prevent bed bug infestation, and the prudent use of effective insecticides, can reduce insecticide-related illness. Making insecticide labels easy to read and understand also might prevent illnesses associated with bed bug control.

* The sum of proportions exceeds 100 because some cases had more than one contributing factor. For the remaining 55 (50%) cases, information was insufficient to identify contributing factors for acute illness. Inadequate ventilation of the treated area resulting from failure to follow label instructions. Among these 16 cases, five involved indoor use of an insecticide that was labeled for outdoor use only, eight involved use of an insecticide not labeled for use on a person or for use on bed bugs, one involved insecticide use in an enclosed space, one was in a child who licked the floor near a pesticide application, and in one case, a blind person inadvertently sprayed a piece of furniture, which he touched with his hand, and then put his hand in his mouth.

frequently contributed to insecticide-related illness were excessive insecticide application (18%), failure to wash or change pesticide-treated bedding (16%), and inadequate notification of pesticide application (11%) (Table 3). The one fatality, which occurred in North Carolina in 2010, involved a woman aged 65 years who had a history of renal failure, myocardial infarction and placement of two coronary stents, type II diabetes, hyperlipidemia, hypertension, and depression. She was taking at least 10 medications at the time of exposure. After she complained to her husband about bed bugs, he applied an insecticide to their home interior baseboards, walls, and the area surrounding the bed, and a different insecticide to the mattress and box springs. Neither of these products are registered for use on bed bugs. Nine cans of insecticide fogger were released in the home the same day. Approximately 2 days later, insecticides were reapplied to the mattress, box springs, and surrounding areas, and nine cans of another fogger*** were released in the home. On both days the insecticides were applied, the couple left their home for
Ortho Home Defense Max (Ortho Business Group), EPA registration number: 239-2663, with the active ingredient bifenthrin. Ortho Lawn and Garden Insect Killer (Ortho Business Group), EPA registration number: 239-2685, with the active ingredient bifenthrin. Hot Shot Fogger (Spectrum Group), EPA registration number: 9688-2548845, with active ingredients tetramethrin and cypermethrin. *** Hot Shot Bedbug and Flea Fogger (Spectrum Group), EPA registration number: 1021-1674-8845, with the active ingredient pyrethrins, piperonyl butoxide, MGK 264 (an insecticide synergist), and pyriproxyfen.

34 hours before reentering. Label instructions on the foggers to air out the treated area for 30 minutes with doors and windows open were not followed on either day. On the day of the second application, the woman applied a bedbug and flea insecticide to her arms, sores on her chest, and on her hair before covering it with a plastic cap. She also applied the insecticide to her hair the day before the second application. Two days following the second application, her husband found her nonresponsive. She was taken to the hospital and remained on a ventilator for 9 days until she died. Another example of insecticide misuse to control bed bugs occurred in Ohio in 2010. An uncertified pesticide applicator applied malathion to an apartment five times over the course of 3 days to treat a bed bug infestation. The malathion product was not registered for indoor use and was applied liberally such that beds and floor coverings were saturated. A family resided in the apartment that consisted of a father, mother, four children, and an adult roommate. One of the children, aged 6 years, attended kindergarten and arrived home around the time of the afternoon malathion applications. The father and roommate also were in the home during the applications. The child began experiencing diarrhea on the first application day, and headache and dizziness began on the second application day. The two adults present during the applications reported nausea, vomiting, headaches, and tremors. During the malathion applications, three younger children were in child care while their mother was at work, and they did not exhibit symptoms of insecticide poisoning. Each night following application of

Hot Shot Bed Bug and Flea Killer (Chemisco), EPA registration number: 9688-150-8845, with active ingredients pyrethrins and piperonyl butoxide.

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malathion, the children slept on sheets placed on the floor to avoid sleeping on saturated beds. Because symptoms in the child aged 6 years persisted on the third application day, he was taken to a community hospital emergency department (ED) and decontaminated. Because the hospital did not have pediatrics specialty care, he was transferred to CCHMC by ambulance for evaluation and treatment. His pseudocholinesterase level was within normal limits. He received 1 dose of pralidoxime and was observed in the CCHMC ED before release. The two adults were seen in a community hospital ED, treated, and released. The family did not return to the contaminated residence following the ED visits. The incident was investigated by the Cincinnati fire department and the Ohio Department of Agriculture. The applicator pled guilty to criminal charges, resulting in a fine and probation.
Reported by

James B. Jacobson, MPH, Katherine Wheeler, MPH, Robert Hoffman, MD, New York City Dept of Health and Mental Hygiene, New York; Yvette Mitchell, New York State Dept of Health. John Beckman, California Dept of Public Health; Louise Mehler, MD, PhD, California Dept of Pesticide Regulation. Prakash Mulay, Florida Dept of Health. Abby Schwartz, MPH, Michigan Dept of Community Health. Rick Langley, MD, Div of Public Health, North Carolina Dept of Health and Human Svcs. Brienne Diebolt-Brown, MA, Texas Dept of State Health Svcs. Joanne Bonnar Prado, MPH, Washington Dept of Health. Nicholas Newman, DO, Cincinnati Childrens Hospital/Univ of Cincinnati, Ohio. Geoffrey M. Calvert, MD, Div of Surveillance, Hazard Evaluations, and Field Studies, National Institute for Occupational Safety and Health; Naomi L. Hudson, DrPH, EIS Officer, CDC. Corresponding contributor: Naomi L. Hudson, nhudson1@cdc.gov, 513-841-4424.
Editorial Note

Bed bug populations and infestations are increasing in the United States and internationally (3,5). Contributing factors are thought to include increased bed bug resistance to insecticides, increased domestic and international travel, rooms with more clutter, and greater prevalence of bed bug friendly furnishings (e.g., wooden bed frames) (5). Insecticides containing pyrethroids are used widely to control bed bugs; however, pyrethroid-resistant bed bug populations have been found in five states (California, Florida, Kentucky, Ohio, and Virginia) (5). Given the increasing resistance of bed bugs to insecticides approved for bed bug control, at least one state has requested an emergency exemption from the Environmental Protection Agency (EPA) to use propoxur, a carbamate, to control bed bugs indoors.

CDC and EPA promote integrated pest management (IPM) for bed bug control (3,6). IPM is an effective pest control method that uses information on the life cycle of the pest and incorporates nonchemical and chemical methods (6). Nonchemical methods to effectively control bed bugs include heating infested rooms to 118F (48C) for 1 hour or cooling rooms to 3F (-16C) for 1 hour by professional applicators (7); encasing mattresses and box springs with bed bugexcluding covers; and vacuuming, steaming, laundering, and disposing of infested items (6). Any effective control measure for bed bugs requires support from all residents in affected buildings and ongoing monitoring for infestation from other housing units (3). Often, multiple inspections and treatments are needed to eradicate bed bugs (4). The findings in this report are subject to at least four limitations. First, acute illness associated with insecticide use might be underreported in the regions covered by the surveillance systems. Case identification in SENSOR-Pesticides relies on a passive surveillance system, so persons experiencing minor symptoms who do not seek medical treatment or advice from poison control centers are not reported to the system. Second, cases might have been excluded if insufficient information was provided to meet the case definition or to determine that the insecticide was used for bed bug control (e.g., surveillance systems do not systematically capture whether insecticides are used for bed bug control). Cases were identified only if available narrative information contained the term bed bug. Third, false positives might be included as cases. Symptoms for acute illnesses associated with insecticides are nonspecific; illnesses might be coincidental and not caused by insecticide exposure. Among the 111 cases described in this report, only 16% were categorized as either definite or probable. Finally, contributing factors were identified for only 50% of the cases; complete knowledge of contributing factors might alter the interpretation presented in this report. Although the number of acute illnesses from insecticides used to control bed bugs does not suggest a large public health burden, increases in bed bug populations that are resistant to commonly available insecticides might result in increased misuse of pesticides. Public health recommendations to prevent illnesses associated with insecticides used to control bed bugs include media campaigns to educate the public about bed bug related issues, including nonchemical methods to control bed bugs, methods to prevent bed bug infestation (e.g., avoiding the purchase of used mattresses and box springs), and prudent use of effective insecticides (3). Persons who have a bed bug

Among New York City cases, 33 were excluded because the affected persons each had only one reported symptom.

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infestation should be encouraged to seek the services of a certified applicator who uses an IPM approach to avoid pesticide misuse. Persons applying insecticides should follow product instructions for safe and appropriate use. Insecticide labels that are easy to read and understand also can help prevent illnesses associated with bed bug control.

References
1. Thomas I, Kihiczak GG, Schwartz RA. Bedbug bites: a review. Int J Dermatol 2004;43:4303. 2. Goddard J, deShazo R. Bed bugs (Cimex lectularius) and clinical consequences of their bites. JAMA 2009;301:135866. 3. CDC, Environmental Protection Agency. Joint statement on bed bug control in the United States from the U.S. Centers for Disease Control and Prevention (CDC) and the U.S. Environmental Protection Agency (EPA). Atlanta, GA: US Department of Health and Human Services; 2010. 4. Wang C, Gibb T, Bennett GW. Evaluation of two least toxic integrated pest management programs for managing bed bugs (Heteroptera: Cimicidae) with discussion of a bed bug intercepting device. J Med Entomol 2009;46:56671. 5. Romero A, Potter MF, Potter DA, Haynes KF. Insecticide resistance in the bed bug: a factor in the pests sudden resurgence? J Med Entomol 2007;44:1758. 6. Environmental Protection Agency. Bed bug information. Washington, DC: Environmental Protection Agency; 2011. Available at http://www. epa.gov/bedbugs/#treat. Accessed September 16, 2011. 7. Benoit JB, Lopez-Martinez G, Teets NM, Phillips SA, Denlinger DL. Responses of the bed bug, Cimex lectularius, to temperature extremes and dehydration: levels of tolerance, rapid cold hardening and expression of heat shock proteins. Med Vet Entomol 2009;23:41825.

Restricted-use pesticides may only be applied by licensed or certified applicators. States are responsible for the training, certification, and licensing of pesticide applicators. A certified applicator is a pesticide applicator who has been determined to have the knowledge and ability to use pesticides safely and effectively. Some states also require that certified pesticide applicators be licensed. In such states, a license is required to purchase, use and/or supervise the application of restricted-use pesticides. Information on certification of pesticide applicators is available at http://www.epa.gov/ oppfead1/safety/applicators/applicators.htm. EPA guidance for consumers on choosing a pest control company and on pesticide safety and nonchemical means of control is available at http://www.epa.gov/oppfead1/Publications/ Cit_Guide/citguide.pdf. Consumers who have questions about the licensing or certification of a pesticide applicator should contact their states agriculture department or agricultural extension service for information.

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Morbidity and Mortality Weekly Report

Dental Caries in Rural Alaska Native Children Alaska, 2008

In April 2008, the Arctic Investigations Program (AIP) of CDC was informed by the Alaska Department of Health and Social Services (DHSS) of a large number of Alaska Native (AN) children living in a remote region of Alaska who required full mouth dental rehabilitations (FMDRs), including extractions and/or restorations of multiple carious teeth performed under general anesthesia. In this remote region, approximately 400 FMDRs were performed in AN children aged <6 years in 2007; the region has approximately 600 births per year. Dental caries can cause pain, which can affect childrens normal growth and development (1). AIP and Alaska DHSS conducted an investigation of dental caries and associated risk factors among children in the remote region. A convenience sample of children aged 415 years in five villages (two with fluoridated water and three without) was examined to estimate dental caries prevalence and severity. Risk factor information was obtained by interviewing parents. Among children aged 45 years and 1215 years who were evaluated, 87% and 91%, respectively, had dental caries, compared with 35% and 51% of U.S. children in those age groups. Among children from the Alaska villages, those aged 45 years had a mean of 7.3 dental caries, and those aged 1215 years had a mean of 5.0, compared with 1.6 and 1.8 dental caries in same-aged U.S. children (2). Of the multiple factors assessed, lack of water fluoridation and soda pop consumption were significantly associated with dental caries severity. Collaborations between tribal, state, and federal agencies to provide effective preventive interventions, such as water fluoridation of villages with suitable water systems and provision of fluoride varnishes, should be encouraged. This Alaska region is comprised of 52 villages and has a population of approximately 25,000; 85% are Yupik Eskimo. The villages are small and remote, are commercially accessible only by air or boat, and have limited medical and dental resources; at the time of the investigation, four full-time dentists were working in the region. Sixteen villages (30%) have no in-home water and sanitation services, and only four (8%) have fluoridated water systems. During October and November 2008, oral examinations were conducted on a convenience sample of children living in five of the 52 villages. Villages were chosen based on size, water fluoridation status, and willingness of village residents and village schools to participate. Two villages with fluoridated water and three villages without fluoridated water were selected. Village populations ranged from approximately 350 to 6,000 residents. All village children were invited to participate. Families were notified by school officials, and signed parental consents were obtained. Children were examined for the presence of decayed teeth (untreated carious lesions) and filled and missing teeth (sequelae of decayed teeth) in their primary and permanent teeth by one experienced dentist using a visual and tactile protocol modified from the World Health Organizations oral health survey basic methods (3). The protocol was modified to match the diagnostic criteria used in surveys in the United States (2). Parents were interviewed, using questionnaires, to obtain risk factor information. All participants families completed the questionnaire, and more than one child per family was allowed to participate. The number of decayed primary teeth (dt), decayed and filled primary teeth (dft), decayed permanent teeth (DT), and decayed, missing, and filled permanent teeth (DMFT) were determined for each participant. Prevalence (having one or more tooth affected) and severity (mean dt, dft, DT, and DMFT) were determined by age group (45, 68, 911, and 1215 years), sex, and village fluoridation status. An ageadjusted bivariate analysis was performed to assess risk factors for dental caries (dft >0 and DMFT >0). Risk factors included sociodemographic factors (e.g., sex), childrens behaviors (e.g., tooth brushing, dental floss use, and soda pop consumption), parents behaviors (e.g., tooth brushing), access to care, and water fluoridation status. Backward selection of risk factors that reached a significance level of p0.25, on age-adjusted bivariate analysis, were used to conduct multivariate logistic regression. Multivariate models were age- and sex-adjusted. In addition, dental caries severity for the region was compared with estimates for same-aged U.S. children from the National Health and Nutrition Examination Survey from 19992004 (2). In total, 348 AN children aged 415 years were examined (39%63% of the total age cohort in four participating villages; only 3% were examined in the other village, primarily for examiner calibration). The median age of the children was 9 years, and 52% of the children were male. Among children aged 45, 68, and 911 years who lived in nonfluoridated villages, 71%100% had one or more decayed or filled primary tooth (dft >0), and 40%65% had one or more decayed primary tooth (dt >0). The mean dft ranged from 2.7 to 9.8. Among children aged 411 years from fluoridated villages, 67%73% had one or more decayed or filled primary tooth (dft >0), and 44%48% had one or more decayed primary tooth (dt >0). The mean dft among children aged 411 years from fluoridated villages ranged from 2.2 to 3.7 (Table 1, Figure). Among children aged 68, 911, and 1215 years from nonfluoridated villages, 57%91% had one or more decayed, missing, or filled permanent tooth (DMFT >0), and 45%68%
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TABLE 1. Dental caries prevalence and prevalence of decayed teeth* among children from five villages in rural Alaska, 2008
Children from nonfluoridated villages Age group (yrs) 45 68 911 1215 Primary teeth No. 26 65 65 76 % dft >0 100 97 71 % dt >0 65 54 40 Permanent teeth % DMFT >0 57 86 91 % DT >0 45 66 68 No. 18 45 31 22 Children from fluoridated villages Primary teeth % dft >0 67 73 68 % dt >0 44 47 48 Permanent teeth % DMFT >0 31 65 91 % DT >0 18 52 68

Abbreviations: dft = decayed and/or filled primary teeth; dt = decayed primary teeth; DMFT = decayed, missing because of caries, and/or filled permanent teeth; DT = decayed permanent teeth. * % dft >0 is the proportion of children with one or more decayed or filled primary tooth; % dt >0 is the proportion of children with one or more decayed primary tooth; % DMFT >0 is the proportion of children with one or more decayed, missing or filled permanent tooth; and % DT >0 is the proportion of children with one or more decayed permanent tooth.

FIGURE. Mean number of decayed, filled, and missing primary and permanent teeth among children, by age group and village water fluoridation status, in five rural Alaska villages and the United States, 2008
Missing and lled 10 9 8 7 Filled Decayed

*
Primary teeth Permanent teeth

* *

Mean number

6 5 4 3 2 1 0 ANF AF U.S. 45 ANF AF U.S. 68 ANF AF U.S. 911 ANF AF U.S. 68 ANF AF U.S. 911

ANF AF U.S. 1215

Age group (yrs)

Abbreviations: ANF = Alaska nonfluoridated water system, AF = Alaska fluoridated water system, U.S. = total for the United States, based on National Health and Nutrition Examination Survey 19992004 results. * p<0.05 for comparison between Alaska region fluoridated and nonfluoridated water systems; no statistical comparison could be made between the Alaska region and the total United States because of differences in survey methodology.

had one or more decayed permanent tooth (DT >0). The mean DMFT ranged from 1.6 to 5.6. Among children aged 615 years from fluoridated villages, 31%91% had one or more decayed, missing, or filled permanent tooth (DMFT >0), and 18%68% had one or more decayed permanent tooth (DT >0). The mean DMFT among children aged 615 years from fluoridated villages ranged from 0.5 to 2.7 (Table 1, Figure).

Dental caries severity was greater in nonfluoridated villages. Children from nonfluoridated villages had 1.22.9 times higher mean dft or DMFT than children from fluoridated villages and 1.23.1 times the mean number of decayed teeth (Figure). Children from the Alaska region had 1.54.5 times the number of dft or DMFT than same-aged U.S. children

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and 1.69.0 times the number of decayed teeth (Figure). On age-adjusted bivariate analysis, only lack of water fluoridation, increased soda pop consumption, and infrequent brushing of teeth were significantly associated with dental caries severity in primary and permanent teeth (all p-values <0.05). On multivariate analysis, only lack of water fluoridation and soda pop consumption were associated with dental caries severity. The adjusted odds ratio (AOR) for lack of water fluoridation was 3.5 and 1.7 for primary teeth and permanent teeth, respectively. Odds of dental caries increased with increased soda pop consumption; AORs were 1.1 and 1.3 in children drinking one soda pop per day in primary and permanent teeth, respectively, and 1.5 and 2.0 in children drinking three or more soda pops per day for primary and permanent teeth, respectively (p0.02 for trend). No other risk factor, including infrequent brushing or lack of dental floss use, was associated with dental caries severity (Table 2).
Reported by

TABLE 2. Multivariate analysis* of risk factors associated with dental caries severity in primary (dft) and permanent teeth (DMFT) among children from five villages in rural Alaska, 2008
Primary teeth (dft) Risk factor Water fluoridation Fluoridated Not fluoridated Soda pop/day 0 1 2 3 Brushed teeth (days/wk) 1 2 3 4 5 6 7 AOR (95% CI) Referent 3.5 (2.84.3) Referent 1.14 (1.031.31) 1.30 (1.061.66) 1.49 (1.102.13) p-value Permanent teeth (DMFT) AOR (95% CI) Referent 1.7 (1.4 2.1) p-value

<0.001

<0.001

0.02

Referent 1.27 (1.181.37) 1.61 (1.391.87) 2.04 (1.632.56) <0.001

1.33 (0.991.79) 1.27 (0.991.62) 1.21 (0.991.47) 1.15 (0.991.34) 1.10 (0.991.21) 1.05 (0.991.10) Referent

0.06

Joseph Klejka, MD, Yukon-Kuskokwim Health Corp; Meghan Swanzy, DDS, Southcentral Foundation; Bradley Whistler, DMD, Alaska Dept of Health and Social Svcs. Caroline Jones, MD, Emory Univ School of Medicine, Atlanta, Georgia. Michael G. Bruce, MD, Thomas W. Hennessy, MD, Dana Bruden, MS, Stephanie Rolin, MPH, Arctic Investigations Program, National Center for Emerging and Zoonotic Infectious Diseases; Eugenio Beltrn-Aguilar, DMD, DrPH, Div of Oral Health, National Center for Chronic Disease Prevention and Health Promotion; Kathy K. Byrd, MD, Farah Husain, DMD, EIS officers, CDC. Corresponding contributor: Kathy K. Byrd, kbyrd@cdc.gov, 404-718-8541.
Editorial Note

Abbreviations: AOR = adjusted odds ratio; CI = confidence interval; dft = decayed and/or filled primary teeth; DMFT = decayed, missing because of caries, and/or filled permanent teeth. * The regression model was performed using backward selection of risk factors; no ORs are listed for tooth brushing in permanent teeth because this variable was not included in the final model after backward selection. p-value for trend.

Based on archeologic evidence, approximately 1% of the AN population had dental caries in the mid-1920s (4). Starting in the 1940s, air transportation into Alaskan villages became more frequent, as did the transport of processed foods. This led to gradual dietary changes among the AN population, from a diet of fish and game, to a diet high in carbohydrates. By 1999, an Indian Health Service dental survey found that 64% of American Indian (AI) and AN children aged 614 years, throughout the United States, had dental caries in their permanent teeth (5). In 2005, the Alaska DHSS determined that 75% of AN kindergarteners, statewide, had dental caries (6). In contrast, since the beginning of the 20th century, the prevalence and severity of dental caries in the United States has decreased among most age groups (1) as a result of water fluoridation, use of fluoride toothpaste and other topical fluorides, and other factors. Approximately 72% of the U.S. population receives fluoridated water from public

water systems (7). Water fluoridation is one of the most cost-effective methods of preventing and controlling dental caries (7). Optimally fluoridated water can decrease dental caries by 30%50% (7), potentially resulting in substantial cost savings from averted treatment costs. The average cost of an FMDR is approximately $6,000 per case, whereas the yearly operational cost of fluoridating AN villages that have piped water distribution is approximately $4 per person (7). However, 40% of the villages in the Alaska region lack piped water systems suitable for fluoridation, and additional piped water systems need to be built. Increased use of fluoride varnishes might provide additional preventive benefits (8). Fluoride varnishes are easily applied to teeth by health-care professionals in dental and nondental settings after minimal training. In Alaska, dental health aide therapists, community health aides, and community health practitioners are providing fluoride varnishes in remote villages that have limited access to dentists. Even with an optimally fluoridated water supply, fluoride varnish applied at least four times from ages 9 to 30 months reduced caries prevalence by approximately 35% among AI children in one small, observational study (9). Soda pop consumption, an important risk factor for dental caries in the region, has been linked to other prevalent medical conditions among the AN population, including obesity and type II diabetes (10). Multiple health

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What is already known about this subject? Childhood dental caries can cause pain, which might affect growth and social interactions with others. What is added by this report? Alaska Native (AN) children in a remote region of the state had a high prevalence and severity of dental caries. Those living in communities with fluoridated water had fewer and less severe dental caries than those in communities without fluoridation. Reported soda pop consumption was associated with an approximately 30% increased risk for caries in permanent teeth for each soda pop consumed per day. What are the implications for public health practice? Water fluoridation is an effective and relatively inexpensive method of reducing dental caries; however, many rural AN villages have no in-home water or sanitation services, which prevents these villages from fluoridating. Because of this, additional preventive services, such as providing fluoride varnishes, are necessary to improve the dental health of rural AN children. In addition, decreasing soda pop consumption might result in fewer dental caries in primary and permanent teeth.

villages and state and federal agencies to implement preventive interventions should be encouraged.
Acknowledgments Matthew West, DMD, Sarah Shoffstall, DDS, Patty Smith, Suzy Eberling, DDS, Kim Boyd-Hummel, Troy Ritter, MPH, Jennifer Dobson, Jim Singleton, DDS, Ron Nagel, DDS, Joe McLaughlin, MD, and participating village school teachers and administrators. References
1. US Department of Health and Human Services. Oral health in America: a report of the Surgeon General. Washington, DC: US Department of Health and Human Services, National Institute of Health; 2000. 2. Dye BA, Tan S, Smith V, et al. Trends in oral health status: United States, 19941998 and 19992004. Vital Health Stat 2007;11(248):192. 3. World Health Organization. Oral health surveysbasic methods. 4th ed. Geneva, Switzerland: World Health Organization; 1997. 4. Zitzow RE. The relationship of diet and dental caries in the Alaska Eskimo population. Alaska Med 1979;21:103. 5. Indian Health Service. The 1999 oral health survey of American Indian and Alaska Native dental patients. Rockville, MD: Indian Health Service, Division of Dental Services; 2002. 6. Hardison JD. Results of the 2005 oral health survey of Alaskan kindergarteners: Alaska oral health basic screening survey. Contractors report for the Oral Health Program, Alaska Department of Health and Social Services; 2006. Available at http://www.hss.state.ak.us/dph/wcfh/ oralhealth/docs/2005_oralhealth_k.pdf. Accessed September 16, 2011. 7. Griffin SO, Jones K, Tomar SL. An economic evaluation of community water fluoridation. J Public Health Dentistry 2001;61:7886. 8. Wetterhall S, Burrus B, Shugars D, Bader J. Cultural context in the effort to improve oral health among Alaska Native people: the dental health aide therapist model. Am J Public Health 2011;101:183640. 9. Holve S. An observational study of the association of fluoride varnish applied during well child visits and the prevention of early childhood caries in American Indian children. Matern Child Health J 2008;12 (Suppl 1):647. 10. Malik VS, Schulze MB, Hu FB. Intake of sugar-sweetened beverages and weight gain: a systematic review. Am J Clin Nutr 2006;84:27488.

benefits in AN populations might result from decreasing soda pop consumption. The findings in this report are subject to at least one limitation. This investigation used a small convenience sample, which limits the statistical power and the generalizability of the results. The small sample size might explain why some known protective factors, such as brushing with fluoridated toothpaste, were only marginally significant in the multivariate model. In this investigation, AN children, including children from fluoridated communities, had much higher dental caries prevalence and severity than same-aged U.S. children. Thus, additional risk factors (e.g., diet), some of which might not have been captured in this investigation, contributed to higher levels of disease. The investigation suggests that fluoridating village water systems likely would decrease the prevalence and severity of dental caries among AN children in the region who live in villages without fluoridated water. Collaborations between the

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Morbidity and Mortality Weekly Report

FDA Approval of Expanded Age Indication for a Tetanus Toxoid, Reduced Diphtheria Toxoid and Acellular Pertussis Vaccine
On July 8, 2011, the Food and Drug Administration (FDA) approved an expanded age indication for the tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine (Tdap) Boostrix (GlaxoSmithKline Biologicals, Rixensart, Belgium). Originally, Boostrix was licensed in 2005 for persons aged 10 through 18 years, but in 2008, FDA approved an expanded age indication for Boostrix to include persons aged 19 through 64 years (1). FDA has now expanded the age indication to include persons aged 65 years and older. Boostrix is now licensed for use in persons aged 10 years and older as a single-dose booster vaccination (2). This notice summarizes the indications for use of Boostrix. Recommendations of the Advisory Committee on Immunization Practices (ACIP) for Tdap vaccines have been published previously (36). Publication of revised Tdap recommendations within the next year is anticipated. On October 27, 2010, ACIP was presented data on the safety and immunogenicity of Boostrix in adults aged 65 years and older (6). Data were reviewed by ACIP from two clinical trials on the safety and immunogenicity of Boostrix in adults in this age group. The safety and reactogenicity profiles of Boostrix generally were similar to currently available tetanus and diphtheria toxoids (Td) vaccine. Immunogenicity of pertussis vaccine components was inferred using a serologic bridge to infants vaccinated with pediatric diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP), as defined by the Vaccines and Related Biological Products Advisory Committee (7). For diphtheria and tetanus, immune responses to Boostrix were noninferior to the immune responses elicited by a comparator Td vaccine licensed in the United States (2). Immune responses to pertussis antigens (pertussis toxin [PT], filamentous haemagglutinin [FHA], and pertactin [PRN]) were noninferior to those observed following a 3-dose primary DTaP series with Infanrix (GlaxoSmithKline Biologicals) in a clinical trial in which clinical efficacy of DTaP also was demonstrated (2,8,9). Boostrix contains the same three pertussis antigens as Infanrix but in reduced quantities. The geometric mean concentrations for pertussis antibodies (PT, FHA, and PRN) after Boostrix administration increased 7.4 to 13.7-fold.* There are no contraindications to the co-administration of Tdap
* Additional information available at http://clinicaltrials.gov/ct2/show/results/ nct00835237.

and influenza vaccine (2). No data on the administration of Tdap with other vaccines recommended for persons aged 65 years and older (e.g., zoster and pneumococcal polysaccharide vaccines) are available. However, Tdap can be administered with other indicated vaccines during the same visit.

Indications and Guidance for Use

For prevention of tetanus, diphtheria, and pertussis, ACIP recommends that adolescents and adults receive a one-time booster dose of Tdap. Adolescents aged 11 through 18 years who have completed the recommended childhood diphtheria and tetanus toxoids and pertussis vaccine (DTP/DTaP) vaccination series should receive a single dose of Tdap instead of tetanus and diphtheria toxoids (Td) vaccine, preferably at a preventive-care visit at age 11 or 12 years (4). For adults aged 19 through 64 years who previously have not received a dose of Tdap, a single dose of Tdap should replace a single decennial Td booster dose (3). Persons aged 65 years and older (e.g., grandparents, child-care providers, and healthcare practitioners) who have or who anticipate having close contact with an infant aged less than 12 months and who previously have not received Tdap should receive a single dose of Tdap to protect against pertussis and reduce the likelihood of transmission (6). For other adults aged 65 years and older, a single dose of Tdap vaccine may be administered instead of Td vaccine in persons who previously have not received Tdap (6). Tdap can be administered regardless of interval since the last tetanus or diphtheria toxoidcontaining vaccine (6). After receipt of Tdap, persons should continue to receive Td for routine booster vaccination against tetanus and diphtheria, in accordance with previously published guidelines (3,4,6). Currently, two Tdap products are licensed for use in the United States, Boostrix and Adacel (Sanofi Pasteur, Toronto, Canada). Adacel has been approved by FDA as a single dose in persons aged 11 through 64 years (10). With the recent FDA expanded licensure for use of Boostrix, ACIP will be reviewing the current recommendations on use of Tdap in persons aged 65 years and older. At this time, either Tdap product may be used in persons aged 65 years and older (6).

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References
1. CDC. FDA approval of expanded age indication for a tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine. MMWR 2009;58:3745. 2. Food and Drug Administration. Product approval information licensing action, package insert: tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine, adsorbed (Boostrix, GlaxoSmithKline Biologicals). Rockville, MD: US Department of Health and Human Services, Food and Drug Administration; 2011. Available at http://www.fda.gov/downloads/biologicsbloodvaccines/ ucm152842.pdf. Accessed September 9, 2011. 3. CDC. Preventing tetanus, diphtheria, and pertussis among adults: use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine. Recommendations of the Advisory Committee on Immunization Practices (ACIP) and recommendation of ACIP, supported by the Healthcare Infection Control Practices Advisory Committee (HICPAC), for use of Tdap among health-care personnel. MMWR 2006;55(No. RR-17). 4. CDC. Preventing tetanus, diphtheria, and pertussis among adolescents: use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccines. Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2006;55(No. RR-3). 5. CDC. Prevention of pertussis, tetanus, and diphtheria among pregnant and postpartum women and their infants: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2008;57(No. RR-4).

6. CDC. Updated recommendations for use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis (Tdap) vaccine from the Advisory Committee on Immunization Practices, 2010. MMWR 2011; 60:135. 7. Food and Drug Administration. Proceedings from the Vaccines and Related Biological Products Advisory Committee meeting, convened June 5, 1997, in Bethesda, Maryland. Day one. Rockville, MD: US Department of Health and Human Services, Food and Drug Administration; 1997. Available at http://www.fda.gov/ohrms/dockets/ ac/97/transcpt/3300t1.pdf. Accessed September 9, 2011. 8. Food and Drug Administration. Summary basis for regulatory action. Rockville, MD: US Department of Health and Human Services, Food and Drug Administration; 2011. Available at http://www.fda.gov/ downloads/biologicsbloodvaccines/vaccines/approvedproducts/ ucm262892.pdf. Accessed September 9, 2011. 9. Schmitt HJ, von Konig CH, Neiss A, et al. Efficacy of acellular pertussis vaccine in early childhood after household exposure. JAMA 1996;275:3741. 10. Food and Drug Administration. Product approval information licensing action, package insert: tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine adsorbed (Adacel, Sanofi Pasteur). Rockville, MD: US Department of Health and Human Services, Food and Drug Administration; 2005. Available at http://www.fda.gov/ downloads/biologicsbloodvaccines/vaccines/approvedproducts/ ucm142764.pdf. Accessed September 9, 2011.

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Notes from the Field

Measles Among U.S.-Bound Refugees from Malaysia California, Maryland, North Carolina, and Wisconsin, AugustSeptember 2011
On August 26, 2011, California public health officials notified CDC of a suspected measles case in an unvaccinated male refugee aged 15 years from Burma (the index patient), who had lived in an urban area of Kuala Lumpur, Malaysia, which is experiencing ongoing measles outbreaks. Currently, approximately 92,000 such refugees are living in urban communities in Malaysia (1). Resettlement programs in the United States and other countries are ongoing. The health and vaccination status of urban refugees are largely unknown. The index patient developed a fever on August 21 and a rash on August 22. He and his family (his mother and two siblings, aged 13 and 16 years) departed Malaysia on August 24 and arrived the same day in Los Angeles, California, where they stayed overnight. He was hospitalized for suspected measles on August 25. Serologic testing for immunoglobulin M confirmed the diagnosis of measles on August 30 (2). The sibling aged 16 years was unvaccinated and had onset of a febrile rash illness in Malaysia on August 18. Serologic testing performed on August 30 in Los Angeles indicated evidence of recent measles infection. However, the sibling was not infectious during the flight. On September 1, Maryland public health officials notified CDC of laboratory-confirmed cases of measles in two unvaccinated refugee children (aged 7 months and 2 years) who were on the same flight as the index patient. A suspected case of measles in an unvaccinated refugee aged 14 years, who had traveled on the same flight, was reported by North Carolina public health officials on September 4 and confirmed on September 9. Whether these three patients were exposed to measles in Malaysia or during travel to the United States is unclear. On September 7, CDC was notified of another laboratory-confirmed case in an unvaccinated refugee child aged 23 months from Burma who traveled from Malaysia to Wisconsin through Los Angeles on August 24, but on a different flight than the index patient. Thirty-one refugees who traveled from Malaysia on the same flight with the index patient on August 24 arrived in the following seven states: Maryland, North Carolina, New Hampshire, Oklahoma, Texas, Washington, and Wisconsin. State and local health departments and CDC were contacted and initiated contact investigations and response activities. As of September 12, contact investigations and heightened surveillance had revealed three additional laboratory-confirmed measles cases that were epidemiologically linked to the index patient: one case in a U.S. Customs and Border Protection Officer with unknown vaccination status who processed the index patient in the Los Angeles airport (reported by California public health officials on September 8), and two cases in nonrefugee, unvaccinated children (aged 12 months and 19 months) who were seated nine rows from the index patient during the flight (reported by California public health officials on September 9). Rapid control efforts by state and local public health agencies have been a key factor in limiting the size of this outbreak and preventing the spread of measles in communities with increased numbers of unvaccinated persons. To prevent measles transmission and importation in this refugee population, refugee travel from Malaysia to the United States was temporarily suspended. CDC recommended that 1) U.S.-bound refugees in Malaysia without evidence of measles immunity (3) be vaccinated with measles, mumps, and rubella (MMR) vaccine and their travel be postponed for 21 days after vaccination; 2) refugees arriving in the United States receive their post-arrival health examinations as soon as feasible; 3) clinicians consider measles as a diagnosis in a refugee with a febrile rash illness and clinically compatible symptoms (i.e., cough, coryza, and/or conjunctivitis); 4) patients with suspected measles be isolated and appropriate specimens be obtained for measles confirmation and virus genotyping; and 5) cases be reported promptly to local health departments. To prevent measles in U.S. residents at home and abroad, CDC recommends that eligible persons without evidence of measles immunity (3) be vaccinated as recommended. Before international travel, infants aged 611 months should receive 1 MMR vaccine dose, and persons aged 12 months should receive 2 doses unless they have other evidence of measles immunity (3).
Reported by

Jennifer Zipprich, PhD, Kathleen Harriman, PhD, John Talarico, DO, California Dept of Public Health. Cindy Edwards, MHCA, Montgomery County Dept of Health and Human Svcs; David Blythe, MD, Dipti Shah, MPH, Maryland Dept of Health and Mental Hygiene. Jennifer Morillo, Sheree Smith, North Carolina Div of Public Health. Daniel Hopfensperger, Savitri Tsering, MSSW, Wisconsin Dept of Health Svcs. Greg Wallace, MD, Albert Barskey, MPH, Preeta Kutty, MD, Gregory Armstrong, MD, Div of Viral Diseases, National Center for Immunization and Respiratory Diseases; Karen Marienau, MD, Juliana Berliet,

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MPH, Keysha Ross, Christopher Schembri, MPH, Heather Burke, MA, MPH, Deborah Lee, MPH, Sharmila Shetty, MD, Michelle Weinberg, MD, Weigong Zhou, MD, PhD, Div of Global Migration and Quarantine, National Center for Emerging and Zoonotic Infectious Diseases; Maria Said, MD, Eboni Taylor, PhD, EIS officers, CDC. Corresponding contributor: Eboni Taylor, etaylor1@cdc.gov, 404-639-4511.
Acknowledgments International Organization for Migration. Assoc of Refugee Health Coordinators. Long Beach Dept of Health and Human Svcs; Immunization Program, Los Angeles County Dept of Public Health, California. Mark Hodge, MS, Montgomery County Dept of Health and Human Svcs, Maryland. Bur of Population, Refugees, and Migration, US Dept of State. Kim Crocker, Los Angeles Quarantine Station, Miguel Ocaa, MD, Washington, DC Quarantine Station, Clive Brown, MD, Div of Global Migration and Quarantine, National Center for Emerging and Zoonotic Infectious Diseases, CDC.

References
1. International Catholic Migration Commission. Combating gender-based violence (GBV) among urban refugees in Malaysia. Geneva, Switzerland: International Catholic Migration Commission; 2011. Available at http:// www.icmc.net/activities/combating-gender-based-violence-gbv-amongurban-refugees-malaysia. Accessed September 16, 2011. 2. CDC. Case definitions for infectious conditions under public health surveillance (measles). Atlanta, GA: US Department of Health and Human Services, CDC; 2011. Available at http://www.cdc.gov/osels/ph_surveillance/ nndss/casedef/measles_2010.htm. Accessed September 16, 2011. 3. CDC. Measles, mumps, and rubellavaccine use and strategies for elimination of measles, rubella, and congenital rubella syndrome and control of mumps: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 1998;47(No. RR-8).

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Announcements
Final State-Level 201011 Influenza Vaccination Coverage Estimates Available Online
Final state-specific influenza vaccination coverage estimates for the 201011 season are now available online at FluVaxView (http://www.cdc.gov/flu/professionals/vaccination/ vaccinecoverage.htm). The online information includes estimates of the cumulative percentage of persons vaccinated by the end of each month, from August 2010 through May 2011, for each state, for each U.S. Department of Health and Human Services region, and for the United States overall. Analyses were conducted using Behavioral Risk Factor Surveillance System data for adults aged 18 years and National Immunization Survey data for children aged 6 months17 years. Estimates are provided by age group and race/ethnicity. These estimates are presented using an interactive feature, complemented by an online summary report. This posting updates the estimates presented in the MMWR report, Interim Results: StateSpecific Influenza Vaccination Coverage United States, August 2010February 2011 (1).
Reference
1. CDC. Interim results: state-specific seasonal influenza vaccination coverageUnited States, August 2010February 2011. MMWR 2011;60:73743.

National Gay Mens HIV/AIDS Awareness Day: Focus on HIV Testing September 27, 2011
National Gay Mens HIV/AIDS Awareness Day is observed each year on September 27 to focus on the continuing serious and disproportionate effects of the human immunodeficiency virus infection (HIV) on gay, bisexual, and other men who have sex with men (MSM) in the United States. In 2008, an estimated 580,000 MSM were living with HIV infection (1). Although HIV testing has been recommended at least annually for persons with ongoing risk for exposure to HIV infection (2), recent data suggest that MSM might benefit from being tested more frequently than once per year. MSM represent approximately 2% of the U.S. population (3), but in 2009 they accounted for 64% of all new HIV infections (including MSM who were also injection drug users [3% of new infections]) (4). Based on CDCs 2008 National Behavioral Surveillance (NHBS) data, 19% of sexually active

MSM were infected with HIV, but 44% of infected MSM were unaware of their infection (5). Of MSM with undiagnosed HIV infection, 45% had been tested within the previous 12 months, and 29% within the previous 6 months (6). CDCs 2010 sexually transmitted disease treatment guidelines already recommend more frequent HIV retesting for MSM who have multiple or anonymous partners, who have sex in conjunction with illicit drug use (particularly methamphetamine use), or whose partners participate in these activities (7). However, among MSM in NHBS who had been tested for HIV within the past 12 months, the prevalence of undiagnosed HIV among MSM who reported these high-risk behaviors (7%) was similar to that among those who did not (8%) (6). Based on these findings, sexually active MSM might benefit from more frequent HIV testing (e.g., every 3 to 6 months) (6). CDC is using the 2011 National Gay Mens HIV/AIDS Awareness Day as an opportunity to highlight this information for gay men and their health-care providers. Additional information is available at http:/www.cdc.gov/msmhealth. CDC supports a range of efforts to reduce HIV infection among MSM. These include HIV prevention services that reduce the risk for acquiring and transmitting HIV, increase diagnosis of HIV infection, and support the linkage of MSM with HIV infection to treatment. Additional information about these efforts is available at http://www.cdc.gov/msmhealth. Additional information about National Gay Mens HIV/AIDS Awareness Day is available at http://www.cdc.gov/features/ngmhaad.
References
1. CDC. HIV surveillanceUnited States, 19812008. MMWR 2011; 60:68993. 2. CDC. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR 2006;55(No. RR-14). 3. Purcell DW, Johnson C, Lansky A, et al. Calculating HIV and syphilis rates for risk groups: estimating the national population size of MSM. Presented at the 2010 National STD Prevention Conference; Atlanta, GA, March 10, 2010. 4. Prejean J, Song R, Hernandez A, et al. Estimated HIV incidence in the United States, 20062009. PLoS One 2011;6:e17502. 5. CDC. Prevalence and awareness of HIV infection among men who have sex with men21 cities, United States, 2008. MMWR 2010;59:12017. 6. CDC. HIV testing among men who have sex with men21 cities, United States, 2008. MMWR 2011;60:6949. 7. CDC. Sexually transmitted disease treatment guidelines, 2010. MMWR 2010;59(No. RR-12).

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Errata
Vol. 60, No. 28
On page 974, in Table III, Deaths in 122 U.S. cities, data for week 28, ending July 16, 2011, data were incorrectly reported for Des Moines, IA. The correct data for All Ages, 65, 4564, 2544, 124, <1 and P&I Total, respectively, are as follows: 122, 83, 28, 5, 4, 2, and 10. The incorrect city data resulted in incorrect entries for two totals. The correct data for All Ages, 65, 4564, 2544, 124, <1, and P&I Total, respectively, are as follows: W.N. Central (504, 322, 126, 35, 16, 5, and 37) and Total (11, 102, 7,277, 2,636, 717, 273, 193, and 685). The corrected table for week 28 is available at http://wonder. cdc.gov/mmwr/mmwrmort.asp.

Vol. 60, No. 34

In the report, Human Rabies Wisconsin, 2010, an error appeared in the second to last sentence of the first full paragraph on p. 1165. The sentence should read as follows: An echocardiogram revealed a normal ejection fraction with diastolic dysfunction but no regional wall motion abnormalities.

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QuickStats
FROM THE NATIONAL CENTER FOR HEALTH STATISTICS

Location of Death for Decedents Aged 85 Years United States, 19892007

100 90 80 70 Hospital (inpatient) Nursing home Residence Other*

Percentage

60 50 40 30 20 10 0 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007

Year
* Includes hospital outpatient or emergency department, including dead on arrival, inpatient hospice facilities, and all other places and unknown. Beginning in 2003, the term long-term care facility was added to the nursing home check box on the death certificate.

Approximately 700,000 deaths occurred among persons aged 85 years in 2007, accounting for nearly 30% of all deaths in the United States. Forty percent of these deaths occurred in nursing homes or other long-term care facilities. The percentage of decedents aged 85 years who died while a hospital inpatient decreased from 40% in 1989 to 29% in 2007. The percentage of decedents aged 85 years who died at home increased from 12% in 1989 to 19% in 2007.
Source: National Vital Statistics System. Mortality public use data files, 19892007. Available at http://www.cdc.gov/nchs/nvss.htm.

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Notifiable Diseases and Mortality Tables

TABLE I. Provisional cases of infrequently reported notifiable diseases (<1,000 cases reported during the preceding year) United States, week ending September 17, 2011 (37th week)*
Disease Anthrax Arboviral diseases , : California serogroup virus disease Eastern equine encephalitis virus disease Powassan virus disease St. Louis encephalitis virus disease Western equine encephalitis virus disease Babesiosis Botulism, total foodborne infant other (wound and unspecified) Brucellosis Chancroid Cholera Cyclosporiasis Diphtheria Haemophilus influenzae,** invasive disease (age <5 yrs): serotype b nonserotype b unknown serotype Hansen disease Hantavirus pulmonary syndrome Hemolytic uremic syndrome, postdiarrheal , Influenza-associated pediatric mortality Listeriosis Measles Meningococcal disease, invasive: A, C, Y, and W-135 serogroup B other serogroup unknown serogroup Novel influenza A virus infections*** Plague Poliomyelitis, paralytic Polio virus Infection, nonparalytic Psittacosis Q fever, total acute chronic Rabies, human Rubella Rubella, congenital syndrome SARS-CoV Smallpox Streptococcal toxic-shock syndrome Syphilis, congenital (age <1 yr) Tetanus Toxic-shock syndrome (staphylococcal) Trichinellosis Tularemia Typhoid fever Vancomycin-intermediate Staphylococcus aureus Vancomycin-resistant Staphylococcus aureus Vibriosis (noncholera Vibrio species infections) Viral hemorrhagic fever Yellow fever

Current week 7 2 3 18 2 3 1 3 1 17

Cum 2011 56 2 12 1 399 65 8 50 7 49 12 27 128 5 81 158 29 18 107 112 402 165 131 67 10 204 6 3 2 68 49 19 3 84 133 6 52 8 91 227 46 445

5-year weekly average 0 3 0 0 0 1 3 0 2 0 2 0 0 2 1 2 2 2 0 8 2 22 1 4 2 0 7 0 0 0 3 2 0 0 1 8 1 2 0 2 13 1 19

Total cases reported for previous years 2010 75 10 8 10 NN 112 7 80 25 115 24 13 179 23 200 223 98 20 266 61 821 63 280 135 12 406 4 2 4 131 106 25 2 5 142 377 26 82 7 124 467 91 2 846 1 2009 1 55 4 6 12 NN 118 10 83 25 115 28 10 141 35 236 178 103 20 242 358 851 71 301 174 23 482 43,774 8 1 9 113 93 20 4 3 2 161 423 18 74 13 93 397 78 1 789 NN 2008 62 4 2 13 NN 145 17 109 19 80 25 5 139 30 244 163 80 18 330 90 759 140 330 188 38 616 2 3 8 120 106 14 2 16 157 431 19 71 39 123 449 63 588 NN 2007 1 55 4 7 9 NN 144 32 85 27 131 23 7 93 22 199 180 101 32 292 77 808 43 325 167 35 550 4 7 12 171 1 12 132 430 28 92 5 137 434 37 2 549 NN 2006 1 67 8 1 10 NN 165 20 97 48 121 33 9 137 29 175 179 66 40 288 43 884 55 318 193 32 651 NN 17 NN 21 169 3 11 1 125 349 41 101 15 95 353 6 1 NN NN

States reporting cases during current week (No.)

NY (7)

NYC (1), CO (1)

FL (1), CA (2) PA (1), OH (1), NE (2), FL (1), OK (4), CO (6), NM (1), CA (2)

MD (1), TX (1) FL (2), ID (1)

PA (1)

NY (1), MD (1), GA (1) NY (1) PA (1), MD (1), GA (1), FL (3), CO (1), WA (8), CA (2)

See Table 1 footnotes on next page.

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TABLE I. (Continued) Provisional cases of infrequently reported notifiable diseases (<1,000 cases reported during the preceding year) United States, week ending September 17, 2011 (37th week)*
: No reported cases. N: Not reportable. NN: Not Nationally Notifiable. Cum: Cumulative year-to-date counts. * Case counts for reporting years 2010 and 2011 are provisional and subject to change. For further information on interpretation of these data, see http://www.cdc.gov/osels/ph_surveillance/ nndss/phs/files/ProvisionalNationa%20NotifiableDiseasesSurveillanceData20100927.pdf. Calculated by summing the incidence counts for the current week, the 2 weeks preceding the current week, and the 2 weeks following the current week, for a total of 5 preceding years. Additional information is available at http://www.cdc.gov/osels/ph_surveillance/nndss/phs/files/5yearweeklyaverage.pdf. Not reportable in all states. Data from states where the condition is not reportable are excluded from this table except starting in 2007 for the arboviral diseases, STD data, TB data, and influenza-associated pediatric mortality, and in 2003 for SARS-CoV. Reporting exceptions are available at http://www.cdc.gov/osels/ph_surveillance/nndss/phs/infdis.htm. Includes both neuroinvasive and nonneuroinvasive. Updated weekly from reports to the Division of Vector-Borne Infectious Diseases, National Center for Zoonotic, Vector-Borne, and Enteric Diseases (ArboNET Surveillance). Data for West Nile virus are available in Table II. ** Data for H. influenzae (all ages, all serotypes) are available in Table II. Updated weekly from reports to the Influenza Division, National Center for Immunization and Respiratory Diseases. Since October 3, 2010, 116 influenza-associated pediatric deaths occurring during the 2010-11 influenza season have been reported. No measles cases were reported for the current week. Data for meningococcal disease (all serogroups) are available in Table II. *** CDC discontinued reporting of individual confirmed and probable cases of 2009 pandemic influenza A (H1N1) virus infections on July 24, 2009. During 2009, four cases of human infection with novel influenza A viruses, different from the 2009 pandemic influenza A (H1N1) strain, were reported to CDC. The four cases of novel influenza A virus infection reported to CDC during 2010, and the six cases reported during 2011, were identified as swine influenza A (H3N2) virus and are unrelated to the 2009 pandemic influenza A (H1N1) virus. Total case counts are provided by the Influenza Division, National Center for Immunization and Respiratory Diseases (NCIRD). No rubella cases were reported for the current week. Updated weekly from reports to the Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. There was one case of viral hemorrhagic fever reported during week 12 of 2010. The one case report was confirmed as lassa fever. See Table II for dengue hemorrhagic fever.

FIGURE I. Selected notifiable disease reports, United States, comparison of provisional 4-week totals September 17, 2011, with historical data
DISEASE Giardiasis Hepatitis A, acute Hepatitis B, acute Hepatitis C, acute Legionellosis Measles Meningococcal disease Mumps Pertussis 0.25 0.5 1 Ratio (Log scale)* Beyond historical limits 2 4 DECREASE INCREASE CASES CURRENT 4 WEEKS 845 61 111 49 234 4 8 12 512

* Ratio of current 4-week total to mean of 15 4-week totals (from previous, comparable, and subsequent 4-week periods for the past 5 years). The point where the hatched area begins is based on the mean and two standard deviations of these 4-week totals.

Notifiable Disease Data Team and 122 Cities Mortality Data Team Jennifer Ward Deborah A. Adams Rosaline Dhara Willie J. Anderson Pearl C. Sharp Lenee Blanton Michael S. Wodajo

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TABLE II. Provisional cases of selected notifiable diseases, United States, weeks ending September 17, 2011, and September 18, 2010 (37th week)*
Chlamydia trachomatis infection Reporting area United States New England Connecticut Maine Massachusetts New Hampshire Rhode Island Vermont Mid. Atlantic New Jersey New York (Upstate) New York City Pennsylvania E.N. Central Illinois Indiana Michigan Ohio Wisconsin W.N. Central Iowa Kansas Minnesota Missouri Nebraska North Dakota South Dakota S. Atlantic Delaware District of Columbia Florida Georgia Maryland North Carolina South Carolina Virginia West Virginia E.S. Central Alabama Kentucky Mississippi Tennessee W.S. Central Arkansas Louisiana Oklahoma Texas Mountain Arizona Colorado Idaho Montana Nevada New Mexico Utah Wyoming Pacific Alaska California Hawaii Oregon Washington Territories American Samoa C.N.M.I. Guam Puerto Rico U.S. Virgin Islands Current week 13,239 756 172 465 4 80 35 1,690 730 208 752 524 23 189 180 132 448 11 1 373 46 17 4,546 92 165 948 675 285 1,228 571 515 67 1,018 269 478 271 2,254 291 359 152 1,452 737 128 255 40 58 175 75 6 1,266 987 279 115 Previous 52 weeks Med 26,039 862 219 59 419 53 76 26 3,405 519 712 1,157 957 3,974 1,081 476 921 1,005 458 1,458 211 195 279 538 109 43 63 5,237 85 108 1,494 981 455 827 516 653 78 1,840 528 267 398 595 3,366 320 499 224 2,404 1,649 512 411 80 61 201 193 129 38 3,909 109 2,981 108 267 423 0 6 102 16 Max 31,142 2,043 1,557 100 860 81 154 84 5,069 931 2,099 2,612 1,240 7,039 1,320 3,376 1,408 1,134 559 1,668 255 288 368 759 218 90 93 6,685 220 180 1,698 2,384 1,125 1,477 946 965 121 3,314 1,566 2,352 696 795 4,338 440 1,052 850 3,107 2,155 698 848 235 89 380 1,183 175 90 6,559 157 5,763 138 524 522 0 81 349 27 Cum 2011 924,050 31,143 7,106 2,213 15,938 1,927 2,929 1,030 119,802 18,805 25,292 39,487 36,218 137,453 34,873 18,805 32,515 35,398 15,862 50,900 7,439 6,897 8,610 19,863 4,341 1,407 2,343 194,689 3,041 3,911 54,180 36,543 16,274 34,341 19,994 23,486 2,919 67,123 19,732 11,086 14,862 21,443 124,530 11,658 16,110 7,557 89,205 60,145 17,659 16,370 2,895 2,350 7,695 7,170 4,662 1,344 138,265 3,916 107,286 3,467 9,737 13,859 189 3,819 539 Cum 2010 914,746 28,830 7,487 1,812 14,526 1,676 2,444 885 119,600 18,599 23,766 43,919 33,316 145,225 42,824 14,156 35,241 36,474 16,530 51,288 7,500 6,938 11,035 18,359 3,555 1,666 2,235 184,421 3,126 3,839 54,046 31,471 16,932 31,599 18,639 22,106 2,663 65,566 18,898 11,054 15,621 19,993 125,574 11,043 18,690 10,143 85,698 59,178 19,360 13,822 2,757 2,162 7,227 7,682 4,688 1,480 135,064 4,401 103,278 4,388 7,965 15,032 691 4,353 412 Current week 53 50 50 3 3 Coccidioidomycosis Previous 52 weeks Med 291 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 267 265 0 0 0 1 0 0 0 13 0 12 0 0 0 0 0 0 0 Max 502 1 0 0 0 1 0 0 1 0 0 0 1 5 0 0 3 3 0 2 0 0 0 0 2 0 0 2 0 0 0 0 2 0 0 0 0 0 0 0 0 0 1 0 1 0 0 455 453 0 0 2 5 4 2 2 77 0 77 0 1 0 0 0 0 0 Cum 2011 10,793 1 1 3 3 37 22 15 6 6 3 3 1 1 9,864 9,745 3 67 36 10 3 878 873 5 Cum 2010 NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN Current week 129 1 1 12 7 5 51 51 23 21 2 20 12 4 1 2 1 2 1 1 10 1 9 6 3 1 1 1 4 2 2 N N Cryptosporidiosis Previous 52 weeks Med 133 5 0 1 2 1 0 1 17 0 4 2 9 32 3 5 5 9 8 19 6 0 0 4 4 0 2 21 0 0 8 5 1 0 3 2 0 7 3 1 0 1 7 0 0 2 4 12 1 3 2 1 0 3 1 0 8 0 4 0 2 1 0 0 0 0 Max 314 55 49 4 7 5 1 4 36 4 15 6 26 127 23 14 13 95 53 88 18 7 12 63 26 9 13 37 1 1 17 11 6 13 8 8 5 17 13 4 4 6 62 3 9 34 34 30 4 12 9 6 7 7 5 5 29 3 19 0 11 9 0 0 0 0 Cum 2011 5,706 256 49 37 89 47 1 33 662 20 158 53 431 1,710 127 180 213 767 423 988 278 23 401 154 16 116 845 7 5 327 206 49 36 105 94 16 225 100 28 28 69 329 13 35 63 218 441 28 124 85 55 3 93 33 20 250 7 102 87 54 N N Cum 2010 6,709 406 77 83 127 48 15 56 636 35 158 67 376 1,903 267 217 255 341 823 1,479 309 88 331 448 199 16 88 779 6 4 286 203 31 66 87 80 16 239 120 58 15 46 329 25 54 65 185 459 29 101 76 38 35 104 56 20 479 3 250 1 159 66 N N

C.N.M.I.: Commonwealth of Northern Mariana Islands. U: Unavailable. : No reported cases. N: Not reportable. NN: Not Nationally Notifiable. Cum: Cumulative year-to-date counts. Med: Median. Max: Maximum. * Case counts for reporting year 2010 and 2011 are provisional and subject to change. For further information on interpretation of these data, see http://www.cdc.gov/osels/ph_surveillance/ nndss/phs/files/ProvisionalNationa%20NotifiableDiseasesSurveillanceData20100927.pdf. Data for TB are displayed in Table IV, which appears quarterly. Contains data reported through the National Electronic Disease Surveillance System (NEDSS).

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TABLE II. (Continued) Provisional cases of selected notifiable diseases, United States, weeks ending September 17, 2011, and September 18, 2010 (37th week)*
Dengue Virus Infection Dengue Fever Reporting area United States New England Connecticut Maine** Massachusetts New Hampshire Rhode Island** Vermont** Mid. Atlantic New Jersey New York (Upstate) New York City Pennsylvania E.N. Central Illinois Indiana Michigan Ohio Wisconsin W.N. Central Iowa Kansas Minnesota Missouri Nebraska** North Dakota South Dakota S. Atlantic Delaware District of Columbia Florida Georgia Maryland** North Carolina South Carolina** Virginia** West Virginia E.S. Central Alabama** Kentucky Mississippi Tennessee** W.S. Central Arkansas** Louisiana Oklahoma Texas** Mountain Arizona Colorado Idaho** Montana** Nevada** New Mexico** Utah Wyoming** Pacific Alaska California Hawaii Oregon Washington Territories American Samoa C.N.M.I. Guam Puerto Rico U.S. Virgin Islands Current week Previous 52 weeks Med 3 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 29 0 Max 22 3 0 2 0 0 1 1 5 3 1 5 2 4 2 1 1 1 2 6 1 1 1 1 6 0 0 10 0 0 8 2 0 1 0 1 0 1 1 0 0 0 2 0 1 1 1 2 2 0 1 1 0 0 1 0 4 0 2 4 0 1 0 0 391 0 Cum 2011 92 1 1 22 10 12 7 1 1 2 1 2 4 3 1 35 27 3 1 4 5 2 3 3 2 1 15 5 5 5 662 Cum 2010 561 5 3 2 194 25 28 123 18 53 15 11 8 14 5 22 1 3 13 4 1 196 152 9 6 13 14 2 5 2 2 1 25 4 4 17 17 7 2 3 4 1 44 1 30 13 8,563 Current week Dengue Hemorrhagic Fever Previous 52 weeks Med 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Max 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 10 0 Cum 2011 9 Cum 2010 9 5 2 3 1 1 2 2 1 1 197

C.N.M.I.: Commonwealth of Northern Mariana Islands. U: Unavailable. : No reported cases. N: Not reportable. NN: Not Nationally Notifiable. Cum: Cumulative year-to-date counts. Med: Median. Max: Maximum. * Case counts for reporting year 2010 and 2011 are provisional and subject to change. For further information on interpretation of these data, see http://www.cdc.gov/osels/ph_surveillance/ nndss/phs/files/ProvisionalNationa%20NotifiableDiseasesSurveillanceData20100927.pdf. Data for TB are displayed in Table IV, which appears quarterly. Updated weekly from reports to the Division of Vector-Borne Infectious Diseases, National Center for Zoonotic, Vector-Borne, and Enteric Diseases (ArboNET Surveillance). Dengue Fever includes cases that meet criteria for Dengue Fever with hemorrhage, other clinical and unknown case classifications. DHF includes cases that meet criteria for dengue shock syndrome (DSS), a more severe form of DHF. ** Contains data reported through the National Electronic Disease Surveillance System (NEDSS).

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TABLE II. (Continued) Provisional cases of selected notifiable diseases, United States, weeks ending September 17, 2011, and September 18, 2010 (37th week)*
Ehrlichiosis/Anaplasmosis Ehrlichia chaffeensis Reporting area United States New England Connecticut Maine Massachusetts New Hampshire Rhode Island Vermont Mid. Atlantic New Jersey New York (Upstate) New York City Pennsylvania E.N. Central Illinois Indiana Michigan Ohio Wisconsin W.N. Central Iowa Kansas Minnesota Missouri Nebraska North Dakota South Dakota S. Atlantic Delaware District of Columbia Florida Georgia Maryland North Carolina South Carolina Virginia West Virginia E.S. Central Alabama Kentucky Mississippi Tennessee W.S. Central Arkansas Louisiana Oklahoma Texas Mountain Arizona Colorado Idaho Montana Nevada New Mexico Utah Wyoming Pacific Alaska California Hawaii Oregon Washington Territories American Samoa C.N.M.I. Guam Puerto Rico U.S. Virgin Islands Current Previous 52 weeks week Med Max 9 5 5 2 N 2 N 2 N 2 N N N N N N N N N N 6 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 0 3 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 109 2 0 1 0 1 1 0 7 1 7 1 1 3 2 0 2 1 1 18 0 1 12 18 1 0 1 33 2 0 3 3 3 17 1 14 1 8 2 3 1 5 87 12 0 82 1 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 Cum 2011 552 4 1 2 1 49 44 5 21 11 4 6 138 N 2 135 N 1 197 14 N 13 16 22 55 1 76 61 3 10 3 45 82 36 45 1 N N N N N N N N N N Cum 2010 546 3 2 1 75 47 22 5 1 40 14 2 6 18 114 N 6 107 1 N 209 16 N 8 19 18 76 4 66 2 82 10 14 3 55 22 4 1 14 3 N N N N N 1 N 1 N N N N Current week 15 12 12 N N 3 N 1 1 1 N N N N N N N N N N Anaplasma phagocytophilum Previous 52 weeks Med 16 2 0 0 0 0 0 0 4 0 3 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Max 42 15 5 2 10 4 10 1 27 3 25 5 1 9 2 0 1 1 9 20 0 1 20 7 0 0 1 8 1 0 3 2 2 6 1 2 0 2 1 0 0 1 9 2 0 7 1 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 0 0 0 Cum 2011 414 106 12 49 12 30 3 210 182 26 2 11 4 4 3 30 N 2 1 25 N 2 44 1 N 8 7 4 17 7 10 3 7 2 2 N N N N N 1 N N 1 N N N Cum 2010 1,416 75 31 13 13 17 1 203 57 136 10 438 6 3 2 427 627 N 1 616 10 N 53 4 N 3 1 12 21 1 11 18 7 2 9 2 2 N N N N N N N N N N Current week 2 1 1 N N 1 N 1 N N N N N N N N N N N Undetermined Previous 52 weeks Med 1 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Max 13 1 0 0 0 1 0 0 2 0 2 0 1 4 1 3 2 1 1 11 0 0 11 7 1 0 0 1 0 0 0 1 0 0 0 1 1 3 0 0 0 3 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Cum 2011 80 1 1 10 10 35 2 28 3 1 1 15 N 14 1 N 7 N 1 5 1 9 N 9 3 3 N N N N N N N N N N Cum 2010 75 2 2 9 1 6 2 40 3 14 23 9 N 9 N 4 N 1 2 1 8 N 1 1 6 1 1 N N N N N 2 N 2 N N N N

C.N.M.I.: Commonwealth of Northern Mariana Islands. U: Unavailable. : No reported cases. N: Not reportable. NN: Not Nationally Notifiable. Cum: Cumulative year-to-date counts. Med: Median. Max: Maximum. * Case counts for reporting year 2010 and 2011 are provisional and subject to change. For further information on interpretation of these data, see http://www.cdc.gov/osels/ph_surveillance/ nndss/phs/files/ProvisionalNationa%20NotifiableDiseasesSurveillanceData20100927.pdf. Data for TB are displayed in Table IV, which appears quarterly. Cumulative total E. ewingii cases reported for year 2010 = 10, and 11 cases reported for 2011. Contains data reported through the National Electronic Disease Surveillance System (NEDSS).

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MMWR / September 23, 2011 / Vol. 60 / No. 37

Morbidity and Mortality Weekly Report

TABLE II. (Continued) Provisional cases of selected notifiable diseases, United States, weeks ending September 17, 2011, and September 18, 2010 (37th week)*
Giardiasis Reporting area United States New England Connecticut Maine Massachusetts New Hampshire Rhode Island Vermont Mid. Atlantic New Jersey New York (Upstate) New York City Pennsylvania E.N. Central Illinois Indiana Michigan Ohio Wisconsin W.N. Central Iowa Kansas Minnesota Missouri Nebraska North Dakota South Dakota S. Atlantic Delaware District of Columbia Florida Georgia Maryland North Carolina South Carolina Virginia West Virginia E.S. Central Alabama Kentucky Mississippi Tennessee W.S. Central Arkansas Louisiana Oklahoma Texas Mountain Arizona Colorado Idaho Montana Nevada New Mexico Utah Wyoming Pacific Alaska California Hawaii Oregon Washington Territories American Samoa C.N.M.I. Guam Puerto Rico U.S. Virgin Islands Current Previous 52 weeks Cum week Med Max 2011 228 10 5 5 65 50 6 9 23 22 1 11 4 7 64 2 39 7 9 N 7 3 3 N N N 1 1 N 12 7 2 3 39 25 2 12 282 23 4 3 11 2 1 2 58 5 22 17 16 47 9 6 10 16 8 25 5 2 0 8 4 0 1 55 0 1 24 13 4 0 2 7 0 4 4 0 0 0 5 3 3 0 0 27 3 12 3 2 1 2 3 0 41 2 25 0 7 8 0 0 1 0 545 42 11 10 21 6 10 9 103 20 72 29 27 93 14 14 25 29 28 73 15 7 30 26 11 12 6 127 2 3 75 51 13 0 7 32 8 11 11 0 0 0 17 9 12 0 0 51 8 24 9 5 6 6 10 5 128 7 67 4 20 57 0 0 7 0 9,693 820 131 120 343 73 40 113 1,995 132 741 598 524 1,587 261 188 312 570 256 776 197 65 296 139 22 57 1,921 22 28 859 538 190 N 79 183 22 125 125 N N N 175 85 90 N 893 89 430 106 54 35 60 101 18 1,401 60 847 23 224 247 29 Cum 2010 14,003 1,204 218 148 518 129 50 141 2,331 343 791 655 542 2,415 546 296 504 590 479 1,538 214 167 604 297 165 17 74 2,795 25 43 1,507 549 202 N 110 332 27 145 145 N N N 283 83 138 62 N 1,279 114 509 150 79 77 76 236 38 2,013 70 1,228 45 364 306 3 63 Gonorrhea Current Previous 52 weeks week Med Max 3,366 109 45 47 5 11 1 436 148 64 224 122 2 47 46 27 147 5 1 129 12 1,295 19 56 294 206 76 371 180 82 11 284 79 126 79 591 97 116 35 343 120 56 20 2 4 34 3 1 262 256 6 1 5,876 101 43 3 48 2 7 0 762 128 114 246 261 1,012 263 117 232 316 95 299 37 40 37 150 24 4 11 1,457 17 40 379 313 118 278 145 110 16 504 161 68 116 143 913 95 140 60 598 191 69 44 2 1 35 28 4 0 615 20 501 13 24 51 0 0 6 2 7,484 206 150 17 80 7 16 8 1,121 215 271 497 364 2,091 369 1,018 490 392 127 363 53 57 53 182 49 8 20 1,862 48 69 465 874 246 468 257 185 29 1,007 410 712 197 217 1,319 138 372 254 867 253 110 87 14 4 103 98 10 3 791 34 695 26 40 86 0 10 14 7 Cum 2011 208,888 3,760 1,592 166 1,630 96 239 37 27,092 4,883 4,048 8,737 9,424 35,918 8,730 4,547 8,334 11,142 3,165 10,640 1,334 1,389 1,184 5,373 858 128 374 52,179 586 1,422 13,939 11,045 3,904 11,070 5,662 3,969 582 18,267 5,979 3,037 4,054 5,197 32,077 3,484 4,566 2,169 21,858 7,108 2,641 1,533 90 57 1,472 1,115 174 26 21,847 689 18,082 450 924 1,702 6 232 83 Cum 2010 215,576 3,929 1,793 125 1,667 107 190 47 24,821 3,974 3,874 8,438 8,535 39,822 10,950 4,001 9,742 11,664 3,465 10,337 1,257 1,473 1,550 4,816 812 143 286 54,864 713 1,485 14,586 10,892 4,951 10,609 5,739 5,525 364 17,770 5,489 2,876 4,383 5,022 34,515 3,342 5,680 3,017 22,476 6,805 2,286 1,947 77 82 1,310 829 249 25 22,713 955 18,546 527 723 1,962 72 212 103 Haemophilus influenzae, invasive All ages, all serotypes Current week 25 1 1 7 2 1 4 2 2 6 2 1 2 1 5 1 4 2 1 1 2 1 1 Previous 52 weeks Med 63 4 1 0 2 0 0 0 13 2 3 3 4 11 3 2 1 2 1 4 0 0 0 1 1 0 0 15 0 0 5 3 2 1 1 2 0 3 1 0 0 2 3 0 1 1 0 5 2 1 0 0 0 1 0 0 3 0 0 0 2 0 0 0 0 0 Max 141 12 6 2 6 2 2 3 32 7 18 6 11 22 10 7 4 7 5 10 0 2 5 5 3 6 1 31 2 1 12 7 5 8 5 8 9 11 4 4 3 5 26 3 4 19 4 12 6 5 2 1 2 4 3 1 10 3 6 3 6 2 0 0 0 0 Cum 2011 2,248 139 37 15 62 11 9 5 514 77 137 116 184 396 117 72 45 112 50 113 16 60 25 11 1 547 3 178 103 64 55 56 74 14 145 43 20 12 70 101 25 36 39 1 196 74 47 15 2 12 31 14 1 97 19 17 58 3 Cum 2010 2,166 127 25 10 67 8 11 6 406 73 107 68 158 353 122 70 25 87 49 159 1 16 56 63 14 9 561 5 3 130 126 49 99 67 65 17 129 21 25 10 73 100 15 20 58 7 233 86 67 12 2 6 29 26 5 98 18 16 17 42 5 1

C.N.M.I.: Commonwealth of Northern Mariana Islands. U: Unavailable. : No reported cases. N: Not reportable. NN: Not Nationally Notifiable. Cum: Cumulative year-to-date counts. Med: Median. Max: Maximum. * Case counts for reporting year 2010 and 2011 are provisional and subject to change. For further information on interpretation of these data, see http://www.cdc.gov/osels/ph_surveillance/ nndss/phs/files/ProvisionalNationa%20NotifiableDiseasesSurveillanceData20100927.pdf. Data for TB are displayed in Table IV, which appears quarterly. Data for H. influenzae (age <5 yrs for serotype b, nonserotype b, and unknown serotype) are available in Table I. Contains data reported through the National Electronic Disease Surveillance System (NEDSS).

MMWR / September 23, 2011 / Vol. 60 / No. 37

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TABLE II. (Continued) Provisional cases of selected notifiable diseases, United States, weeks ending September 17, 2011, and September 18, 2010 (37th week)*
Hepatitis (viral, acute), by type A Reporting area United States New England Connecticut Maine Massachusetts New Hampshire Rhode Island Vermont Mid. Atlantic New Jersey New York (Upstate) New York City Pennsylvania E.N. Central Illinois Indiana Michigan Ohio Wisconsin W.N. Central Iowa Kansas Minnesota Missouri Nebraska North Dakota South Dakota S. Atlantic Delaware District of Columbia Florida Georgia Maryland North Carolina South Carolina Virginia West Virginia E.S. Central Alabama Kentucky Mississippi Tennessee W.S. Central Arkansas Louisiana Oklahoma Texas Mountain Arizona Colorado Idaho Montana Nevada New Mexico Utah Wyoming Pacific Alaska California Hawaii Oregon Washington Territories American Samoa C.N.M.I. Guam Puerto Rico U.S. Virgin Islands Current Previous 52 weeks week Med Max 15 3 2 1 9 6 1 1 1 3 3 1 21 1 0 0 0 0 0 0 4 1 1 1 1 4 1 0 1 1 0 1 0 0 0 0 0 0 0 5 0 0 1 1 0 0 0 0 0 0 0 0 0 0 2 0 0 0 2 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 74 4 3 2 2 1 1 2 12 4 4 6 3 9 3 3 6 5 2 25 1 2 22 1 3 3 2 13 1 0 6 4 4 3 2 4 5 6 2 6 1 5 15 1 1 4 11 5 2 2 1 1 3 1 2 1 15 1 15 2 2 4 0 5 2 0 Cum 2011 703 38 9 5 16 3 5 143 18 35 49 41 131 32 12 53 29 5 32 4 3 9 10 4 2 164 2 55 32 21 19 9 18 8 35 4 7 6 18 81 2 3 76 50 13 17 6 2 5 4 1 2 29 2 7 5 15 8 5 Cum 2010 1,144 81 22 7 43 9 189 56 41 53 39 144 40 11 49 30 14 60 9 10 13 16 11 1 250 6 1 99 29 17 40 22 34 2 32 5 13 2 12 93 1 7 1 84 118 50 32 6 4 12 3 8 3 177 1 140 6 15 15 4 11 Current week 30 U 3 3 2 2 3 3 11 6 1 1 3 5 2 3 5 1 4 1 1 1 Med 48 1 0 0 0 0 0 0 5 1 1 1 2 5 1 1 1 1 0 2 0 0 0 2 0 0 0 12 0 0 4 2 1 2 1 1 0 9 2 2 1 3 7 1 1 1 3 2 0 0 0 0 0 0 0 0 2 0 0 0 0 0 0 0 0 0 B Previous 52 weeks Max 167 8 4 2 6 1 0 0 12 4 9 5 4 38 6 3 6 30 3 16 1 2 15 5 3 0 1 33 1 0 11 8 4 12 4 7 18 14 4 6 3 7 67 4 4 16 45 5 3 3 1 0 3 2 1 1 25 1 22 1 4 4 0 8 3 0 Cum 2011 1,606 46 10 6 29 1 U 189 32 34 58 65 240 51 34 61 74 20 97 7 9 9 60 11 1 421 145 64 41 82 23 47 19 301 75 76 31 119 205 35 23 48 99 55 12 15 2 16 5 5 52 4 1 5 25 17 28 7 Cum 2010 2,339 42 16 11 8 5 U 2 216 58 35 68 55 371 95 56 99 82 39 82 12 6 6 48 9 1 642 21 3 215 128 46 73 44 65 47 256 49 90 23 94 414 45 43 72 254 104 18 34 6 34 4 7 1 212 2 142 5 33 30 64 17 Current week 9 N U 2 2 2 U 2 U 1 1 U 4 U U 4 N Med 17 1 0 0 0 0 0 0 1 0 0 0 0 3 0 0 2 0 0 0 0 0 0 0 0 0 0 4 0 0 1 1 0 1 0 0 0 3 0 1 0 1 2 0 0 1 0 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 C Previous 52 weeks Max 39 4 3 2 2 0 0 1 6 4 4 0 4 12 1 5 7 1 1 6 0 1 6 1 1 0 0 11 0 0 5 3 2 7 1 2 6 7 1 6 0 5 11 0 2 10 3 4 0 3 2 1 1 1 1 1 12 0 4 0 3 5 0 4 0 0 Cum 2011 648 40 25 6 5 N U 4 58 1 33 24 128 5 46 72 4 1 6 2 2 2 161 U 41 26 28 39 1 10 16 114 9 44 U 61 66 5 34 27 41 U 14 7 3 5 9 1 2 34 U U 10 24 10 N Cum 2010 591 40 26 2 12 N U 78 17 38 3 20 69 24 30 8 7 11 6 3 2 134 U 2 41 17 18 32 1 9 14 112 5 76 U 31 51 1 2 18 30 47 U 10 8 2 4 13 10 49 U 20 U 11 18 52 N

C.N.M.I.: Commonwealth of Northern Mariana Islands. U: Unavailable. : No reported cases. N: Not reportable. NN: Not Nationally Notifiable. Cum: Cumulative year-to-date counts. Med: Median. Max: Maximum. * Case counts for reporting year 2010 and 2011 are provisional and subject to change. For further information on interpretation of these data, see http://www.cdc.gov/osels/ph_surveillance/ nndss/phs/files/ProvisionalNationa%20NotifiableDiseasesSurveillanceData20100927.pdf. Data for TB are displayed in Table IV, which appears quarterly. Contains data reported through the National Electronic Disease Surveillance System (NEDSS).

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MMWR / September 23, 2011 / Vol. 60 / No. 37

Morbidity and Mortality Weekly Report

TABLE II. (Continued) Provisional cases of selected notifiable diseases, United States, weeks ending September 17, 2011, and September 18, 2010 (37th week)*
Legionellosis Reporting area United States New England Connecticut Maine Massachusetts New Hampshire Rhode Island Vermont Mid. Atlantic New Jersey New York (Upstate) New York City Pennsylvania E.N. Central Illinois Indiana Michigan Ohio Wisconsin W.N. Central Iowa Kansas Minnesota Missouri Nebraska North Dakota South Dakota S. Atlantic Delaware District of Columbia Florida Georgia Maryland North Carolina South Carolina Virginia West Virginia E.S. Central Alabama Kentucky Mississippi Tennessee W.S. Central Arkansas Louisiana Oklahoma Texas Mountain Arizona Colorado Idaho Montana Nevada New Mexico Utah Wyoming Pacific Alaska California Hawaii Oregon Washington Territories American Samoa C.N.M.I. Guam Puerto Rico U.S. Virgin Islands Current Previous 52 weeks week Med Max 62 34 23 11 8 8 3 2 1 8 2 3 2 1 1 1 8 4 4 N 53 4 0 0 1 0 0 0 15 2 5 3 5 10 1 1 2 4 0 2 0 0 0 1 0 0 0 9 0 0 3 1 1 1 0 1 0 2 0 0 0 1 2 0 0 0 2 2 1 0 0 0 0 0 0 0 5 0 4 0 0 0 0 0 0 0 128 15 6 2 9 3 4 2 53 18 23 17 25 49 6 5 13 34 4 9 2 2 8 5 1 1 2 22 2 3 9 4 6 7 3 9 2 10 2 3 3 8 13 2 3 3 11 5 3 2 1 1 2 1 2 1 21 0 15 1 3 6 0 1 1 0 Cum 2011 2,017 120 25 8 58 11 9 9 628 73 223 98 234 465 60 65 94 245 1 60 7 5 41 4 1 2 315 9 9 109 27 52 49 12 42 6 113 17 23 10 63 80 8 13 7 52 62 21 4 4 1 11 6 13 2 174 146 1 11 16 N Cum 2010 2,292 186 31 10 94 16 27 8 597 93 180 110 214 507 125 44 129 158 51 84 14 8 23 23 8 3 5 386 13 14 121 42 87 43 10 46 10 101 13 21 12 55 118 14 8 11 85 131 45 23 5 4 18 7 22 7 182 2 154 1 10 15 N 1 Current week 372 8 1 7 248 143 105 1 1 115 2 4 102 7 N N N Lyme disease Previous 52 weeks Med 334 72 31 9 16 11 1 5 150 51 35 1 61 21 1 0 0 1 16 3 0 0 0 0 0 0 0 52 10 0 1 0 17 0 0 18 0 1 0 0 0 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 2 0 1 0 0 0 0 0 0 0 Max 1,588 293 173 47 62 60 35 62 1,142 541 214 18 482 90 19 15 10 9 63 32 11 2 31 0 2 10 1 163 43 2 8 3 103 8 6 76 14 5 2 1 1 3 29 0 1 0 29 4 2 1 2 2 1 2 1 1 11 2 9 0 2 4 0 0 0 0 Cum 2011 19,986 3,349 1,438 329 494 539 109 440 12,990 5,078 2,590 43 5,279 968 117 76 65 41 669 90 65 10 8 4 3 2,425 604 11 86 15 871 51 22 717 48 42 13 1 1 27 31 1 30 31 8 1 3 8 3 6 1 1 60 6 34 N 14 6 N N Cum 2010 24,409 7,400 2,524 509 2,884 1,082 117 284 8,654 3,030 1,954 563 3,107 3,346 120 75 83 22 3,046 1,886 79 10 1,772 4 8 12 1 2,840 528 32 64 9 1,171 63 27 858 88 39 2 5 32 85 3 82 23 2 2 8 3 5 3 136 6 85 N 38 7 N N Current week 18 6 2 4 6 2 2 1 1 1 1 5 4 1 Med 26 1 0 0 1 0 0 0 7 0 1 3 1 3 1 0 0 1 0 1 0 0 0 0 0 0 0 8 0 0 2 1 2 0 0 1 0 1 0 0 0 0 1 0 0 0 0 1 0 0 0 0 0 0 0 0 3 0 2 0 0 0 0 0 0 0 Malaria Previous 52 weeks Max 114 20 20 1 5 2 4 1 18 6 6 12 4 7 4 2 4 4 2 45 3 2 45 1 1 1 1 22 3 1 7 5 12 6 1 8 1 3 2 1 1 3 18 1 1 1 17 4 4 3 1 1 2 1 1 0 10 2 8 1 4 3 1 0 0 0 Cum 2011 886 52 6 3 33 2 2 6 192 8 31 108 45 103 41 7 19 30 6 24 15 6 2 1 316 6 5 78 57 80 34 3 53 25 5 6 1 13 25 3 1 4 17 50 20 18 2 1 6 2 1 99 4 62 5 12 16 1 Cum 2010 1,213 81 2 5 63 2 7 2 368 80 59 187 42 126 51 10 25 31 9 54 10 9 3 16 14 2 321 2 11 93 56 70 34 3 50 2 24 6 6 2 10 70 4 2 5 59 46 20 15 1 2 4 1 3 123 3 81 2 9 28 5

C.N.M.I.: Commonwealth of Northern Mariana Islands. U: Unavailable. : No reported cases. N: Not reportable. NN: Not Nationally Notifiable. Cum: Cumulative year-to-date counts. Med: Median. Max: Maximum. * Case counts for reporting year 2010 and 2011 are provisional and subject to change. For further information on interpretation of these data, see http://www.cdc.gov/osels/ph_surveillance/ nndss/phs/files/ProvisionalNationa%20NotifiableDiseasesSurveillanceData20100927.pdf. Data for TB are displayed in Table IV, which appears quarterly. Contains data reported through the National Electronic Disease Surveillance System (NEDSS).

MMWR / September 23, 2011 / Vol. 60 / No. 37

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TABLE II. (Continued) Provisional cases of selected notifiable diseases, United States, weeks ending September 17, 2011, and September 18, 2010 (37th week)*
Meningococcal disease, invasive All serogroups Reporting area United States New England Connecticut Maine Massachusetts New Hampshire Rhode Island Vermont Mid. Atlantic New Jersey New York (Upstate) New York City Pennsylvania E.N. Central Illinois Indiana Michigan Ohio Wisconsin W.N. Central Iowa Kansas Minnesota Missouri Nebraska North Dakota South Dakota S. Atlantic Delaware District of Columbia Florida Georgia Maryland North Carolina South Carolina Virginia West Virginia E.S. Central Alabama Kentucky Mississippi Tennessee W.S. Central Arkansas Louisiana Oklahoma Texas Mountain Arizona Colorado Idaho Montana Nevada New Mexico Utah Wyoming Pacific Alaska California Hawaii Oregon Washington Territories American Samoa C.N.M.I. Guam Puerto Rico U.S. Virgin Islands Current Previous 52 weeks week Med Max 5 3 2 1 1 1 1 1 13 0 0 0 0 0 0 0 1 0 0 0 0 2 0 0 0 1 0 1 0 0 0 0 0 0 0 2 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 53 3 1 1 2 1 1 3 6 1 4 3 2 7 3 2 4 2 2 4 1 1 2 2 2 1 1 8 1 1 5 1 1 3 1 2 3 3 2 2 1 2 12 1 2 2 10 4 1 1 1 2 1 1 2 1 26 1 17 1 3 8 0 0 1 0 Cum 2011 412 24 3 4 11 1 5 58 5 18 22 13 67 20 11 7 20 9 33 8 2 12 8 1 2 101 1 1 40 11 11 13 9 10 5 20 9 2 2 7 41 8 8 7 18 35 10 8 5 3 1 1 7 33 2 4 15 12 Cum 2010 570 14 2 3 4 5 58 18 9 15 16 97 19 22 15 23 18 40 8 6 3 16 5 2 106 1 49 8 7 12 10 17 2 28 5 12 3 8 63 5 12 14 32 45 11 16 5 1 8 3 1 119 1 76 1 24 17 1 Current week 2 1 1 1 1 Med 7 0 0 0 0 0 0 0 1 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 0 0 Mumps Previous 52 weeks Max 47 1 0 1 1 0 1 1 23 2 3 22 16 7 3 1 1 5 1 4 1 1 4 3 1 3 0 3 0 0 2 2 1 2 0 2 0 1 1 0 1 1 15 1 2 1 14 4 0 1 1 0 1 2 1 1 3 1 3 1 1 1 0 9 1 0 Cum 2011 194 5 3 1 1 24 8 6 9 1 52 31 7 11 3 29 5 4 1 11 4 4 19 5 4 1 7 2 3 1 2 49 1 1 47 6 3 1 2 7 1 2 4 12 1 Cum 2010 2,374 24 11 1 9 3 2,051 339 658 1,032 22 47 17 3 17 9 1 79 37 4 4 9 23 2 46 3 8 2 9 8 4 10 2 9 6 1 2 66 5 5 56 18 5 7 1 1 3 1 34 1 22 3 2 6 441 1 Current week 147 5 4 1 42 34 8 9 9 22 20 2 10 4 2 4 4 4 23 1 4 18 10 1 6 3 22 22 Med 241 8 1 2 3 1 0 0 34 2 13 0 14 58 15 4 20 17 10 24 5 2 0 7 1 0 0 31 0 0 6 3 2 3 3 7 0 9 3 1 0 2 23 1 0 0 19 43 14 9 2 2 0 3 5 0 20 0 0 1 5 9 0 0 0 0 Pertussis Previous 52 weeks Max 2,925 22 8 8 10 7 3 3 125 7 81 19 70 198 50 26 57 80 26 501 36 10 469 43 11 10 6 106 5 2 17 13 6 35 25 41 41 28 11 16 10 10 297 16 3 92 187 100 29 63 15 16 5 10 16 2 1,710 6 1,569 9 11 131 0 14 1 0 Cum 2011 7,965 305 30 99 99 48 17 12 1,072 77 482 38 475 1,935 492 135 484 545 279 850 137 71 326 210 45 37 24 966 21 3 242 120 58 127 102 241 52 258 104 52 22 80 658 42 15 29 572 1,285 529 292 99 70 18 87 182 8 636 21 8 69 188 350 31 2 Cum 2010 15,035 374 83 37 199 13 31 11 974 121 330 62 461 3,426 595 487 970 1,067 307 1,440 386 135 433 285 136 38 27 1,228 9 6 229 182 94 231 280 152 45 562 153 190 56 163 2,140 166 32 42 1,900 1,037 313 156 142 53 23 91 248 11 3,854 28 3,302 58 223 243 2 2

C.N.M.I.: Commonwealth of Northern Mariana Islands. U: Unavailable. : No reported cases. N: Not reportable. NN: Not Nationally Notifiable. Cum: Cumulative year-to-date counts. Med: Median. Max: Maximum. * Case counts for reporting year 2010 and 2011 are provisional and subject to change. For further information on interpretation of these data, see http://www.cdc.gov/osels/ph_surveillance/ nndss/phs/files/ProvisionalNationa%20NotifiableDiseasesSurveillanceData20100927.pdf. Data for TB are displayed in Table IV, which appears quarterly. Data for meningococcal disease, invasive caused by serogroups A, C, Y, and W-135; serogroup B; other serogroup; and unknown serogroup are available in Table I. Contains data reported through the National Electronic Disease Surveillance System (NEDSS).

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MMWR / September 23, 2011 / Vol. 60 / No. 37

Morbidity and Mortality Weekly Report

TABLE II. (Continued) Provisional cases of selected notifiable diseases, United States, weeks ending September 17, 2011, and September 18, 2010 (37th week)*
Rabies, animal Reporting area United States New England Connecticut Maine Massachusetts New Hampshire Rhode Island Vermont Mid. Atlantic New Jersey New York (Upstate) New York City Pennsylvania E.N. Central Illinois Indiana Michigan Ohio Wisconsin W.N. Central Iowa Kansas Minnesota Missouri Nebraska North Dakota South Dakota S. Atlantic Delaware District of Columbia Florida Georgia Maryland North Carolina South Carolina Virginia West Virginia E.S. Central Alabama Kentucky Mississippi Tennessee W.S. Central Arkansas Louisiana Oklahoma Texas Mountain Arizona Colorado Idaho Montana Nevada New Mexico Utah Wyoming Pacific Alaska California Hawaii Oregon Washington Territories American Samoa C.N.M.I. Guam Puerto Rico U.S. Virgin Islands Current Previous 52 weeks week Med Max 57 6 4 1 1 16 16 2 2 N 26 N 26 4 4 1 N N 1 2 2 N 53 3 0 1 0 0 0 0 13 0 7 0 6 2 1 0 1 0 0 2 0 1 0 0 0 0 0 18 0 0 0 0 6 0 0 11 0 2 1 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 3 0 3 0 0 0 0 0 0 0 119 13 9 6 0 3 4 2 29 0 20 4 17 16 6 6 6 6 0 40 1 4 34 2 3 6 0 87 0 0 78 0 14 0 0 27 30 7 7 2 1 4 31 10 0 20 30 5 0 0 2 0 2 2 2 1 15 2 8 0 2 14 0 0 6 0 Cum 2011 1,852 130 28 52 17 15 18 449 271 9 169 140 46 18 41 35 N 64 24 29 11 798 78 204 N 453 63 91 65 12 1 13 53 41 12 24 N 3 N 4 10 7 103 9 84 10 N 24 Cum 2010 3,313 236 107 47 15 25 42 819 389 138 292 210 108 59 43 N 209 23 51 25 57 43 10 868 121 275 N 416 56 140 58 16 66 629 23 40 566 56 N 10 N 5 9 9 23 146 12 121 13 N 34 Current week 853 2 2 96 66 1 29 44 1 43 57 1 10 36 10 328 2 5 193 55 24 10 14 25 49 17 8 6 18 158 35 29 94 21 3 11 3 3 1 98 55 7 36 Salmonellosis Previous 52 weeks Med 874 26 0 2 17 3 0 1 93 12 25 21 32 87 28 11 13 21 9 47 9 7 0 16 4 0 3 279 3 1 107 42 18 35 30 21 0 60 18 9 20 17 131 14 14 11 85 48 14 10 3 2 3 6 6 1 75 1 55 6 6 12 0 0 6 0 Max 1,627 351 330 8 38 8 62 5 182 35 66 45 111 147 57 23 29 47 44 97 20 20 17 45 13 15 17 713 9 4 226 121 38 251 99 68 14 185 70 32 59 50 515 47 52 95 381 91 34 24 8 10 8 21 15 9 288 6 232 14 14 42 0 3 25 0 Cum 2011 29,844 1,279 330 97 554 125 128 45 3,506 322 998 805 1,381 3,104 1,026 348 520 895 315 1,685 330 297 722 177 30 129 9,269 115 43 3,691 1,652 662 1,320 975 769 42 2,579 765 308 826 680 4,052 556 537 458 2,501 1,720 517 414 111 96 98 214 224 46 2,650 44 1,807 247 171 381 6 134 Cum 2010 36,686 1,903 491 91 990 139 140 52 4,363 894 1,042 991 1,436 4,508 1,525 581 727 992 683 2,203 402 326 573 586 176 28 112 9,824 128 78 3,994 1,976 788 905 1,040 772 143 2,653 698 401 826 728 4,528 506 937 443 2,642 2,117 707 428 123 76 239 231 267 46 4,587 65 3,352 247 412 511 2 8 414 Shiga toxin-producing E. coli (STEC) Current week 60 6 5 1 6 6 7 6 1 9 6 1 1 1 2 1 1 4 1 3 5 1 1 3 21 7 14 Previous 52 weeks Med 92 2 0 0 0 0 0 0 10 2 4 1 3 12 2 2 2 2 2 13 2 1 0 4 2 0 1 14 0 0 3 2 1 2 0 3 0 4 1 1 0 2 6 0 0 1 5 11 2 3 2 1 0 1 1 0 11 0 7 0 1 2 0 0 0 0 Max 264 36 36 3 10 3 2 3 28 6 12 6 17 38 10 8 15 10 13 39 15 8 8 14 7 10 4 29 2 1 15 8 8 11 4 9 4 22 15 5 12 11 151 3 2 55 95 30 14 11 6 5 7 6 7 3 46 1 36 1 11 16 0 0 0 0 Cum 2011 3,213 138 36 22 44 20 4 12 412 58 153 60 141 561 114 85 109 132 121 519 135 70 188 78 10 38 460 11 3 100 85 31 84 15 128 3 196 67 30 17 82 218 29 6 41 142 391 65 86 75 34 26 29 62 14 318 1 166 6 53 92 Cum 2010 3,685 173 60 15 65 18 2 13 419 96 138 54 131 649 124 101 129 112 183 678 135 52 228 178 56 5 24 488 4 8 152 75 68 45 17 103 16 185 37 49 13 86 215 43 14 16 142 457 46 169 60 31 28 33 71 19 421 2 180 27 71 141

C.N.M.I.: Commonwealth of Northern Mariana Islands. U: Unavailable. : No reported cases. N: Not reportable. NN: Not Nationally Notifiable. Cum: Cumulative year-to-date counts. Med: Median. Max: Maximum. * Case counts for reporting year 2010 and 2011 are provisional and subject to change. For further information on interpretation of these data, see http://www.cdc.gov/osels/ph_surveillance/ nndss/phs/files/ProvisionalNationa%20NotifiableDiseasesSurveillanceData20100927.pdf. Data for TB are displayed in Table IV, which appears quarterly. Includes E. coli O157:H7; Shiga toxin-positive, serogroup non-O157; and Shiga toxin-positive, not serogrouped. Contains data reported through the National Electronic Disease Surveillance System (NEDSS).

MMWR / September 23, 2011 / Vol. 60 / No. 37

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TABLE II. (Continued) Provisional cases of selected notifiable diseases, United States, weeks ending September 17, 2011, and September 18, 2010 (37th week)*
Spotted Fever Rickettsiosis (including RMSF) Shigellosis Reporting area United States New England Connecticut Maine Massachusetts New Hampshire Rhode Island Vermont Mid. Atlantic New Jersey New York (Upstate) New York City Pennsylvania E.N. Central Illinois Indiana Michigan Ohio Wisconsin W.N. Central Iowa Kansas Minnesota Missouri Nebraska North Dakota South Dakota S. Atlantic Delaware District of Columbia Florida Georgia Maryland North Carolina South Carolina Virginia West Virginia E.S. Central Alabama Kentucky Mississippi Tennessee W.S. Central Arkansas Louisiana Oklahoma Texas Mountain Arizona Colorado Idaho Montana Nevada New Mexico Utah Wyoming Pacific Alaska California Hawaii Oregon Washington Territories American Samoa C.N.M.I. Guam Puerto Rico U.S. Virgin Islands Current week 142 8 6 1 1 4 4 3 1 2 60 2 41 10 2 3 2 5 5 30 1 4 25 6 6 26 19 7 Previous 52 weeks Med 214 2 0 0 2 0 0 0 14 2 3 4 3 16 4 1 3 5 0 8 0 2 0 5 0 0 0 68 0 0 42 11 2 4 1 2 0 13 4 1 2 4 60 2 5 2 49 16 6 2 0 1 0 3 1 0 16 0 12 1 1 1 1 0 0 0 Max 742 29 28 4 6 2 4 1 74 8 18 12 56 40 10 4 10 27 4 38 4 12 4 18 10 0 2 133 1 2 98 26 7 36 4 8 66 29 15 6 9 14 503 7 20 161 338 32 19 8 3 15 6 9 4 1 63 2 59 3 4 7 1 1 1 0 Cum 2011 7,190 133 28 19 76 1 6 3 485 51 171 177 86 510 115 43 116 236 223 13 39 156 11 4 2,631 3 12 1,890 390 71 154 36 71 4 408 144 36 107 121 1,752 49 166 71 1,466 525 187 71 15 116 19 78 37 2 523 5 388 41 30 59 1 1 Cum 2010 9,963 284 69 5 188 10 11 1 1,320 306 165 238 611 1,268 731 46 193 239 59 1,736 41 204 43 1,414 27 7 1,699 36 27 722 545 97 111 51 101 9 518 117 190 38 173 1,804 41 196 210 1,357 553 297 69 20 7 28 99 33 781 1 620 38 42 80 2 5 4 Current week 1 1 1 N N N N N Med 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Confirmed Previous 52 weeks Max 16 0 0 0 0 0 0 0 2 0 1 0 2 2 1 0 1 2 0 7 0 0 0 4 3 1 0 8 1 1 1 5 1 4 2 1 0 3 1 1 0 2 8 2 0 5 1 5 4 1 0 0 0 0 0 0 2 0 2 0 0 1 0 0 0 0 Cum 2011 128 11 3 8 4 1 3 24 17 5 2 66 1 1 3 36 2 12 9 2 6 2 1 3 4 3 1 13 12 1 N N N N N Cum 2010 111 2 1 1 3 2 1 11 8 3 68 1 2 49 12 1 3 17 4 6 1 6 4 3 1 2 2 4 N 4 N N N N Current week 11 1 1 1 1 7 2 2 3 2 1 1 N N N N N Med 23 0 0 0 0 0 0 0 1 0 0 0 0 1 0 0 0 0 0 4 0 0 0 4 0 0 0 6 0 0 0 0 0 1 0 2 0 5 1 0 0 4 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Probable Previous 52 weeks Max 245 1 0 1 1 1 1 0 5 3 2 2 3 6 2 4 1 2 1 30 2 0 2 30 1 0 1 55 4 1 2 0 3 49 2 9 1 26 8 0 4 20 235 38 2 202 5 6 6 1 1 1 0 1 1 2 0 0 0 0 0 0 0 0 0 0 Cum 2011 1,272 3 1 1 1 31 6 13 12 71 24 36 11 272 5 264 2 1 363 16 1 8 21 201 16 97 3 286 54 9 223 218 190 4 21 3 28 15 2 1 1 1 1 7 N N N N N Cum 2010 1,193 3 2 1 81 47 11 11 12 70 32 19 1 12 6 224 5 216 2 1 368 17 7 35 192 12 105 334 66 17 251 101 61 2 21 17 11 1 1 4 1 1 3 1 N N 1 N N N

C.N.M.I.: Commonwealth of Northern Mariana Islands. U: Unavailable. : No reported cases. N: Not reportable. NN: Not Nationally Notifiable. Cum: Cumulative year-to-date counts. Med: Median. Max: Maximum. * Case counts for reporting year 2010 and 2011 are provisional and subject to change. For further information on interpretation of these data, see http://www.cdc.gov/osels/ph_surveillance/ nndss/phs/files/ProvisionalNationa%20NotifiableDiseasesSurveillanceData20100927.pdf. Data for TB are displayed in Table IV, which appears quarterly. Illnesses with similar clinical presentation that result from Spotted fever group rickettsia infections are reported as Spotted fever rickettsioses. Rocky Mountain spotted fever (RMSF) caused by Rickettsia rickettsii, is the most common and well-known spotted fever. Contains data reported through the National Electronic Disease Surveillance System (NEDSS).

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TABLE II. (Continued) Provisional cases of selected notifiable diseases, United States, weeks ending September 17, 2011, and September 18, 2010 (37th week)*
Streptococcus pneumoniae, invasive disease All ages Reporting area United States New England Connecticut Maine Massachusetts New Hampshire Rhode Island Vermont Mid. Atlantic New Jersey New York (Upstate) New York City Pennsylvania E.N. Central Illinois Indiana Michigan Ohio Wisconsin W.N. Central Iowa Kansas Minnesota Missouri Nebraska North Dakota South Dakota S. Atlantic Delaware District of Columbia Florida Georgia Maryland North Carolina South Carolina Virginia West Virginia E.S. Central Alabama Kentucky Mississippi Tennessee W.S. Central Arkansas Louisiana Oklahoma Texas Mountain Arizona Colorado Idaho Montana Nevada New Mexico Utah Wyoming Pacific Alaska California Hawaii Oregon Washington Territories American Samoa C.N.M.I. Guam Puerto Rico U.S. Virgin Islands Current Previous 52 weeks week Med Max 71 3 1 2 N 12 N 12 2 N N N 2 N 31 15 10 4 N 2 N 6 N N N 6 13 1 N 12 4 4 N N N N N N N 298 17 6 2 0 2 2 1 33 13 2 14 0 66 0 15 15 26 9 4 0 0 0 0 2 0 0 72 1 1 23 22 10 0 8 0 0 19 0 0 0 19 31 3 3 0 25 32 12 11 0 0 0 3 2 0 3 2 0 0 0 0 0 0 0 0 937 79 49 13 3 8 8 6 81 35 10 42 0 112 0 32 29 45 24 35 0 0 24 0 9 25 0 170 6 3 68 54 32 0 25 0 48 36 0 0 0 36 368 26 11 0 333 72 45 23 0 0 0 13 8 15 11 11 0 3 0 0 0 0 0 0 Cum 2011 9,918 549 235 96 21 73 73 51 990 463 60 467 N 2,151 N 477 474 885 315 127 N N N 84 43 N 2,760 36 28 995 742 396 N 334 N 229 654 N N N 654 1,318 162 119 N 1,037 1,254 596 391 N N N 174 74 19 115 112 N 3 N N N Cum 2010 10,941 600 246 86 53 82 73 60 1,125 500 111 514 N 2,205 N 506 503 844 352 579 N N 437 N 96 46 N 2,990 27 53 1,102 961 379 N 378 N 90 747 N N N 747 1,344 125 77 N 1,142 1,270 611 380 N N N 118 150 11 81 81 N N N N Current week 8 1 1 N 2 N 2 N N N N 2 1 1 N N N N N 2 1 N 1 1 1 N N N N N N N Med 23 1 0 0 0 0 0 0 3 1 1 0 0 4 0 0 1 2 0 0 0 0 0 0 0 0 0 7 0 0 3 2 1 0 0 0 0 1 0 0 0 1 4 0 0 0 3 3 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Age <5 Previous 52 weeks Max 101 5 3 1 3 1 1 2 27 4 9 14 0 10 0 4 4 7 3 5 0 0 5 0 2 1 0 22 1 1 13 7 4 0 3 0 6 4 0 0 0 4 30 3 2 0 27 8 5 4 0 0 0 2 3 1 1 1 0 1 0 0 0 0 0 0 Cum 2011 717 29 6 3 8 5 2 5 84 28 34 22 N 119 N 21 25 61 12 9 N N N 8 1 N 204 4 90 51 26 N 20 N 13 41 N N N 41 126 13 10 N 103 96 45 28 N N N 11 12 9 8 N 1 N N N Cum 2010 1,340 77 22 6 37 4 4 4 167 41 82 44 N 199 N 41 62 68 28 81 N N 65 N 14 2 N 373 7 148 116 43 N 43 N 16 71 N N N 71 182 12 20 N 150 174 78 53 N N N 15 25 3 16 16 N N N N Syphilis, primary and secondary Current week 86 1 1 8 4 4 2 2 1 1 46 3 1 11 10 11 4 6 3 3 20 2 1 2 15 5 5 9 Previous 52 weeks Med 258 8 1 0 5 0 0 0 31 5 3 15 7 31 13 3 5 9 1 7 0 0 3 2 0 0 0 64 0 3 23 12 9 8 4 4 0 15 4 2 3 5 35 4 8 1 23 12 4 2 0 0 2 1 0 0 51 0 42 0 2 5 0 0 4 0 Max 363 18 8 3 11 3 7 2 49 13 20 30 13 48 22 8 11 21 5 17 2 3 10 6 2 1 1 178 4 8 37 130 19 19 10 16 2 34 11 16 16 11 59 10 27 6 33 23 8 8 4 1 9 4 4 0 66 1 57 5 10 13 0 0 13 0 Cum 2011 8,726 254 39 11 153 14 32 5 1,048 138 129 536 245 1,060 424 113 173 310 40 210 12 17 87 88 5 1 2,254 15 119 790 437 322 269 151 149 2 515 138 79 127 171 1,226 143 262 42 779 387 150 77 11 4 92 45 8 1,772 1 1,456 10 111 194 158 Cum 2010 9,645 344 70 19 214 14 25 2 1,209 170 97 684 258 1,409 672 134 184 385 34 239 16 14 88 111 6 4 2,189 4 101 799 475 209 298 101 198 4 628 180 92 156 200 1,501 156 391 67 887 413 159 90 2 3 74 35 50 1,713 3 1,454 28 49 179 167

C.N.M.I.: Commonwealth of Northern Mariana Islands. U: Unavailable. : No reported cases. N: Not reportable. NN: Not Nationally Notifiable. Cum: Cumulative year-to-date counts. Med: Median. Max: Maximum. * Case counts for reporting year 2010 and 2011 are provisional and subject to change. For further information on interpretation of these data, see http://www.cdc.gov/osels/ph_surveillance/ nndss/phs/files/ProvisionalNationa%20NotifiableDiseasesSurveillanceData20100927.pdf. Data for TB are displayed in Table IV, which appears quarterly. Includes drug resistant and susceptible cases of invasive Streptococcus pneumoniae disease among children <5 years and among all ages. Case definition: Isolation of S. pneumoniae from a normally sterile body site (e.g., blood or cerebrospinal fluid). Contains data reported through the National Electronic Disease Surveillance System (NEDSS).

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TABLE II. (Continued) Provisional cases of selected notifiable diseases, United States, weeks ending September 17, 2011, and September 18, 2010 (37th week)*
West Nile virus disease Varicella (chickenpox) Reporting area United States New England Connecticut Maine Massachusetts New Hampshire Rhode Island Vermont Mid. Atlantic New Jersey New York (Upstate) New York City Pennsylvania E.N. Central Illinois Indiana Michigan Ohio Wisconsin W.N. Central Iowa Kansas Minnesota Missouri Nebraska North Dakota South Dakota S. Atlantic Delaware District of Columbia Florida Georgia Maryland North Carolina South Carolina Virginia West Virginia E.S. Central Alabama Kentucky Mississippi Tennessee W.S. Central Arkansas Louisiana Oklahoma Texas Mountain Arizona Colorado Idaho Montana Nevada New Mexico Utah Wyoming Pacific Alaska California Hawaii Oregon Washington Territories American Samoa C.N.M.I. Guam Puerto Rico U.S. Virgin Islands Current week 75 21 N 21 27 1 3 23 N N N N 3 3 N N 18 N 18 5 2 N N 3 1 1 N N N Previous 52 weeks Med 273 21 4 5 6 0 0 2 36 12 0 0 19 68 16 4 20 20 0 8 0 3 0 4 0 0 1 36 0 0 15 0 0 0 0 8 7 5 4 0 0 0 43 3 1 0 38 19 3 4 0 2 0 1 4 0 2 1 0 1 0 0 0 0 4 0 Max 367 46 16 16 18 9 6 10 71 60 0 0 41 118 31 18 38 58 22 42 0 15 0 24 5 10 7 64 3 2 38 0 0 0 9 25 32 15 14 0 3 0 258 17 6 0 247 65 50 31 0 28 0 2 26 3 5 4 3 4 0 0 0 4 21 0 Cum 2011 8,412 679 169 147 260 9 29 65 1,524 875 N 649 1,955 504 171 620 659 1 245 N 77 111 3 31 23 1,240 6 12 626 N N N 12 305 279 189 178 N 11 N 1,679 150 54 N 1,475 827 383 160 N 111 N 28 137 8 74 40 34 N N N 16 112 Cum 2010 10,927 790 250 143 202 94 29 72 1,214 427 N 787 3,518 918 270 1,035 921 374 639 N 264 305 11 33 26 1,594 25 17 768 N N N 75 387 322 222 215 N 7 N 2,085 150 57 N 1,878 781 288 N 158 N 86 236 13 84 32 26 26 N N N 23 458 Current week Neuroinvasive Previous 52 weeks Med 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Max 71 3 2 0 1 0 1 1 14 2 5 5 2 13 9 2 5 2 0 3 1 1 1 1 2 1 1 4 1 1 4 1 2 1 1 2 1 6 1 1 4 2 12 0 2 1 11 18 13 2 1 0 2 2 1 1 8 0 8 0 0 1 0 0 0 0 Cum 2011 183 8 5 1 1 1 11 1 1 6 3 29 5 4 15 5 12 2 2 6 1 1 26 1 12 2 4 1 5 1 25 1 20 4 9 3 6 31 21 1 7 2 32 32 Cum 2010 520 12 7 4 1 116 14 53 33 16 62 34 3 23 2 28 3 3 3 3 10 2 4 29 2 7 4 13 3 6 1 2 2 1 85 6 15 64 126 81 25 18 1 1 56 56 Current week Nonneuroinvasive Previous 52 weeks Med 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Max 30 1 1 0 0 0 0 0 5 3 1 0 1 4 2 1 1 3 0 6 1 2 0 1 4 1 0 3 0 1 1 1 2 0 0 0 0 3 0 0 3 1 1 1 1 0 1 10 5 5 0 0 1 0 1 1 5 0 5 0 0 0 0 0 0 0 Cum 2011 85 6 3 2 1 7 1 6 12 3 6 3 10 1 2 7 14 13 1 6 3 3 14 9 2 2 1 16 16 Cum 2010 362 5 4 1 60 13 30 9 8 26 13 7 3 1 2 72 4 12 4 29 7 16 19 2 2 8 6 1 8 2 1 3 2 17 1 6 10 117 54 52 1 2 4 4 38 37 1

C.N.M.I.: Commonwealth of Northern Mariana Islands. U: Unavailable. : No reported cases. N: Not reportable. NN: Not Nationally Notifiable. Cum: Cumulative year-to-date counts. Med: Median. Max: Maximum. * Case counts for reporting year 2010 and 2011 are provisional and subject to change. For further information on interpretation of these data, see http://www.cdc.gov/osels/ph_surveillance/ nndss/phs/files/ProvisionalNationa%20NotifiableDiseasesSurveillanceData20100927.pdf. Data for TB are displayed in Table IV, which appears quarterly. Updated weekly from reports to the Division of Vector-Borne Infectious Diseases, National Center for Zoonotic, Vector-Borne, and Enteric Diseases (ArboNET Surveillance). Data for California serogroup, eastern equine, Powassan, St. Louis, and western equine diseases are available in Table I. Not reportable in all states. Data from states where the condition is not reportable are excluded from this table, except starting in 2007 for the domestic arboviral diseases and influenzaassociated pediatric mortality, and in 2003 for SARS-CoV. Reporting exceptions are available at http://www.cdc.gov/osels/ph_surveillance/nndss/phs/infdis.htm. Contains data reported through the National Electronic Disease Surveillance System (NEDSS).

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TABLE III. Deaths in 122 U.S. cities,* week ending September 17, 2011 (37th week)
All causes, by age (years) Reporting area New England Boston, MA Bridgeport, CT Cambridge, MA Fall River, MA Hartford, CT Lowell, MA Lynn, MA New Bedford, MA New Haven, CT Providence, RI Somerville, MA Springfield, MA Waterbury, CT Worcester, MA Mid. Atlantic Albany, NY Allentown, PA Buffalo, NY Camden, NJ Elizabeth, NJ Erie, PA Jersey City, NJ New York City, NY Newark, NJ Paterson, NJ Philadelphia, PA Pittsburgh, PA Reading, PA Rochester, NY Schenectady, NY Scranton, PA Syracuse, NY Trenton, NJ Utica, NY Yonkers, NY E.N. Central Akron, OH Canton, OH Chicago, IL Cincinnati, OH Cleveland, OH Columbus, OH Dayton, OH Detroit, MI Evansville, IN Fort Wayne, IN Gary, IN Grand Rapids, MI Indianapolis, IN Lansing, MI Milwaukee, WI Peoria, IL Rockford, IL South Bend, IN Toledo, OH Youngstown, OH W.N. Central Des Moines, IA Duluth, MN Kansas City, KS Kansas City, MO Lincoln, NE Minneapolis, MN Omaha, NE St. Louis, MO St. Paul, MN Wichita, KS All Ages 536 135 32 17 25 60 22 8 15 41 58 3 32 37 51 1,828 35 27 69 19 13 46 14 1,050 19 23 163 47 33 82 25 38 72 17 17 19 2,048 59 47 227 94 247 237 121 160 49 72 17 63 204 44 88 57 55 60 101 46 638 73 39 44 106 55 56 94 22 60 89 65 373 84 28 14 18 40 18 4 12 29 42 3 21 27 33 1,256 24 22 50 10 9 35 8 712 9 15 96 33 25 62 19 29 60 12 14 12 1,340 36 39 146 45 184 153 88 82 35 55 8 41 122 30 58 34 39 42 63 40 418 57 31 28 62 40 31 53 9 43 64 4564 120 41 3 1 5 15 4 4 2 12 10 7 5 11 424 10 5 15 5 4 11 4 246 8 3 43 12 7 14 3 8 12 5 3 6 471 16 7 51 33 43 58 26 53 12 11 6 15 47 10 25 11 11 11 21 4 154 12 6 13 28 13 19 24 7 11 21 2544 23 5 1 1 2 2 1 3 2 5 1 91 1 1 2 2 61 2 4 11 1 4 1 1 133 1 22 5 13 18 4 11 5 2 2 21 3 1 8 3 2 10 2 45 2 2 12 2 3 15 4 4 1 124 8 2 1 1 2 2 33 1 20 7 1 1 2 1 57 3 1 5 3 4 3 1 10 2 1 4 8 2 2 2 2 4 9 1 1 1 2 1 1 2 <1 12 3 2 1 6 24 2 2 11 1 6 2 47 3 3 8 3 5 2 4 1 1 6 1 2 2 3 3 11 1 1 2 3 1 2 1 Total 34 13 3 1 2 1 5 1 4 4 78 1 2 5 1 1 2 2 35 1 5 1 2 5 3 3 6 1 2 127 1 4 11 5 15 19 6 10 4 3 4 15 2 3 8 5 4 6 2 37 3 3 2 3 2 6 5 1 6 6 P&I Reporting area (Continued) S. Atlantic Atlanta, GA Baltimore, MD Charlotte, NC Jacksonville, FL Miami, FL Norfolk, VA Richmond, VA Savannah, GA St. Petersburg, FL Tampa, FL Washington, D.C. Wilmington, DE E.S. Central Birmingham, AL Chattanooga, TN Knoxville, TN Lexington, KY Memphis, TN Mobile, AL Montgomery, AL Nashville, TN W.S. Central Austin, TX Baton Rouge, LA Corpus Christi, TX Dallas, TX El Paso, TX Fort Worth, TX Houston, TX Little Rock, AR New Orleans, LA San Antonio, TX Shreveport, LA Tulsa, OK Mountain Albuquerque, NM Boise, ID Colorado Springs, CO Denver, CO Las Vegas, NV Ogden, UT Phoenix, AZ Pueblo, CO Salt Lake City, UT Tucson, AZ Pacific Berkeley, CA Fresno, CA Glendale, CA Honolulu, HI Long Beach, CA Los Angeles, CA Pasadena, CA Portland, OR Sacramento, CA San Diego, CA San Francisco, CA San Jose, CA Santa Cruz, CA Seattle, WA Spokane, WA Tacoma, WA Total All Ages 1,169 147 132 136 128 85 38 72 57 61 215 89 9 823 157 92 106 58 169 74 23 144 1,216 81 64 59 220 95 U 161 90 U 258 86 102 1,165 141 43 74 85 284 40 163 29 128 178 1,713 13 129 39 72 55 245 19 93 222 185 108 183 34 132 56 128 11,136 All causes, by age (years) 65 716 81 71 87 82 56 23 37 32 40 142 57 8 507 101 57 69 34 101 37 18 90 788 50 50 36 134 61 U 101 53 U 178 53 72 738 83 34 43 47 171 29 100 24 84 123 1,205 11 84 32 59 43 166 14 63 158 138 72 130 22 78 46 89 7,341 4564 326 49 43 31 40 22 10 26 16 12 55 21 1 224 38 26 31 14 53 20 3 39 303 22 9 18 59 25 U 43 32 U 56 18 21 295 39 5 22 28 74 7 43 2 30 45 359 1 34 4 6 9 48 3 18 49 35 29 44 6 40 7 26 2,676 2544 70 13 10 10 3 2 3 5 6 5 11 2 59 12 7 5 5 7 14 9 61 2 4 3 13 4 U 9 1 U 11 6 8 81 9 1 5 7 28 2 14 2 8 5 86 4 1 4 3 17 1 9 10 8 5 4 3 6 3 8 649 124 37 3 4 5 2 4 1 3 2 3 6 4 15 3 2 1 3 2 1 3 37 5 1 1 8 2 U 3 2 U 10 4 1 24 6 1 2 1 7 1 1 1 1 3 32 5 3 6 1 3 2 1 3 1 2 5 252 <1 20 1 4 3 1 1 1 1 1 1 1 5 18 3 5 5 1 1 3 27 2 1 6 3 U 5 2 U 3 5 25 4 2 2 2 4 1 3 5 2 31 1 2 2 8 1 2 2 2 1 2 2 6 215 P&I Total 86 4 14 13 8 2 1 4 7 8 15 10 72 19 5 11 4 19 3 4 7 60 6 7 11 4 U 4 1 U 16 8 3 55 7 2 2 3 13 1 11 8 8 123 2 7 4 8 8 26 1 5 24 4 8 9 1 6 3 7 672

U: Unavailable. : No reported cases. * Mortality data in this table are voluntarily reported from 122 cities in the United States, most of which have populations of >100,000. A death is reported by the place of its occurrence and by the week that the death certificate was filed. Fetal deaths are not included. Pneumonia and influenza. Because of changes in reporting methods in this Pennsylvania city, these numbers are partial counts for the current week. Complete counts will be available in 4 to 6 weeks. Total includes unknown ages.

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The Morbidity and Mortality Weekly Report (MMWR) Series is prepared by the Centers for Disease Control and Prevention (CDC) and is available free of charge in electronic format. To receive an electronic copy each week, visit MMWRs free subscription page at http://www.cdc.gov/mmwr/mmwrsubscribe. html. Paper copy subscriptions are available through the Superintendent of Documents, U.S. Government Printing Office, Washington, DC 20402; telephone 202-512-1800. Data presented by the Notifiable Disease Data Team and 122 Cities Mortality Data Team in the weekly MMWR are provisional, based on weekly reports to CDC by state health departments. Address all inquiries about the MMWR Series, including material to be considered for publication, to Editor, MMWR Series, Mailstop E-90, CDC, 1600 Clifton Rd., N.E., Atlanta, GA 30333 or to mmwrq@cdc.gov. All material in the MMWR Series is in the public domain and may be used and reprinted without permission; citation as to source, however, is appreciated. Use of trade names and commercial sources is for identification only and does not imply endorsement by the U.S. Department of Health and Human Services. References to non-CDC sites on the Internet are provided as a service to MMWR readers and do not constitute or imply endorsement of these organizations or their programs by CDC or the U.S. Department of Health and Human Services. CDC is not responsible for the content of these sites. URL addresses listed in MMWR were current as of the date of publication.

U.S. Government Printing Office: 2011-723-011/21073 Region IV

ISSN: 0149-2195

Taken from the Toronto Public Health Bed Bug Fact Sheet :
Cornell University/New York State Integrated Pest Management Program 2010 http://www.nysipm.cornell.edu/whats_bugging_you/bed_bugs/bedbugs_faqs.asp#di diget

What Bed Bugs Are And What They Do

1.

What are bed bugs? What does a bed bug look like? Can I see bed bugs? Do bed bugs fly, jump or burrow into skin? What other names do bed bugs have?

If you ever heard that nursery rhyme Good night, sleep tight, dont let the bed bugs bite, you know these critters bite in the night. But most of us never heard of them in real life until now. What do bed bugs look like? Briefly: 1/4 long, oval, flat, 6 legs, and reddish-brown.

Some fast facts Life Stages: Eggs hatch into nymphs. Newly hatched nymphs are tinyabout 1/16th of an inch. Nymphswhich look like small adultsbecome adults in 5 weeks. They go through 5 molts to reach adult sizemeaning they shed their old, smaller skin 5 times. They must feed before each molt. Females can produce 5-7 eggs per week, laying up to 500 in a lifetime. Bed bugs grow fastest and lay most eggs at about 80F. They feed only on blood. They feed when people are sleeping or sitting quietly, often when its dark. They seek shelter in cracks and crevices when not feeding.

They poop out blood spots. Spots look like dots made by a fine felt-tipped marker. Youd see them near where they fed and near their hideouts.

Adults can live over a year without a meal. Adults, nymphs and eggs can survive sustained heat and cold if given time to adjust.

Can be found in the cleanest of clean places. But clutter makes them harder to get rid of.

They have no grooming behaviormeaning that insecticides meant to be swallowed by roaches and flies wont work on bed bugs.

A little more Anatomy: A bed bug has 6 legs. Its antennae point forward and are about half as long as the bodynot longer. Its head is broadly attached to its body and it has no wings. Eight legs indicate a tick or mite. Six legs and long antennae with two spikes coming off the back (cerci) might be a roach nymph. Carpet beetle larvae have hairs all over their bodies. Carpet beetle adults have two hard wings. Color: A drop of blood with legs is probably a recently fed bed bug. It will be red, plump, and oval. After it digests its meal, itll be mahogany-colored, round, and flat. Unfed nymphs are tan. Eggs are oval, white, and stick to whatever theyre laid on. Size: You can see the adultstheyre about 1/4 long. The trick is finding their hiding spots. They can wedge themselves into any crack or crevice. If the edge of a credit card can fit, so can a bed bug. Eggs and just-hatched nymphs are tiny: 1/16 (1mm) longthe size of the R in LIBERTY on a penny. Theyll plump up after feedingjust like a mosquito. Behavior: Bed bugs crawlscurrying into dark, tight spaces to hidethey move as fast as an ant. They cant jump or fly and youll never find them burrowing into your skin. If the insect you have came out on its own accord at night when the lights were out near the bed or a couch, it was probably a bed bug looking for a meal. Bed bugs arent social insects like ants, so they dont need a colony. But while they group together in good hiding spots, loners could be hiding elsewhere. More on bed bug biology (and yes, it matters): they have an odd way of making babies. Its called traumatic insemination. Males simply stab females in the side with

their reproductive organ and inject their sperm, which makes its way to her eggs. Females recover from one mating, but several matings increase the chance of infection and death. Females may try to get away from groups of males and go off and hide alone to avoid being stabbed to death. If you dont find those females, theyll keep laying eggs and could restart an infestation: a good reason to get a pest management professional (PMP) involved. Good PMPs know how to find them and how to target every hiding place without harming people. If the bugs you think are bed bugs come in the spring but go away during the summer they might be bat bugs. Bats in attics hibernate elsewhere during the winter. Bat bugs that are left behind and chill out for the winter, literally, but if warm weather comes before the bats return, they may seek another host to tide them over. In this scenario, inspect the attic and external wall voids for bat guano and bugs in cracks and crevices. Have a professional treat these roosts as well as the rooms bed bugs were found in. To prevent bat re-entry, repair all holes 1/4 or larger that lead to the outside. Bed bugs are also known as: Cimex lectularius, chinches de camas, chintzes or chinches, mahogany flats, red coats, crimson ramblers, wall lice, the bug that nobody knows, lentils on legs, animated blood drops. 2. What can bed bugs do to me? Are bed bug bites worse for children or the elderly, compared to healthy adults? Can I get a disease from bed bugs?

The serious negative effects of bed bugs are more mental than physical, but the itchy bites cant be ignored either. The mental effects are stress and lack of sleep. (And then theres delusory parasitosismeaning the bugs really are gone, but you cant shake the feeling that theyre still there.) Even if the thought of sleeping with bed bugs doesnt keep you up at night, the time and money it takes to get rid of them can stress you out. Bed bugs can be a public relations nightmare. Youd hope customers would respect a proactive hotel, motel, or landlord who tried to educate them before a problem came in, but thats rarely the case. Simply the mention of bed bugs can deter customers. And householders worry what friends, family, and neighbors will say if their problem becomes known. Bed bugs arent associated with filth or social status, but many people think they are. Bed bugs arent known to transmit disease. And some people dont even get marks when bit. But scratching bites can lead to a secondary infection. Resist the urge to scratch. People with health problems and children are more at risk for infection because their immune systems are compromised or they cant stop scratching.

3. What does a bed bug bite look like? How do bed bugs feed? How do I tell if my bites are caused by bed bugs? Why do I get bites, but my significant other doesnt?

You cant describe the bites as looking only one way. Some look and feel like mosquito or flea bites. Some people dont react at all. On the opposite extreme, others get big itchy welts that take two or more weeks to heal. Theres a myth that bed bug bites occur in threes (breakfast, lunch, and dinner), but its not true. Bites can occur singly, in clumps, or in a line. Bites can show up within hoursor two weeks later. Confirming an infestation on bites alone is impossible. You need evidence: a bed bug. Bed bugs usually feed while people sleep, about an hour before dawn. But if theyre hungry and given the opportunity, they feed anytime. Feeding itself is painlessthe bed bugs saliva numbs the skin and makes the blood easier to drink. But later, many people react to the saliva, getting itchy bumps or rashes. After feeding for about five minutes, drawing only a drop or two of blood, bugs return to their hiding places. Although bed bugs can live for over a year without feeding, they typically seek blood every five to ten days. The only way to know for sure what bit you is to find a bug and get it identified. Bed bugs live off only bloodlike mosquitoes do. They probably prefer to feed on people. But if people move out, bed bugs can survive by feeding on rats or miceso control these pests, too. Theyre attracted by warmth and the presence of carbon dioxidewhat we animals breathe out. They usually feed about an hour before dawn, but given the opportunity, they may feed at other times of day or night. Remembernot everyone reacts to bed bug bites. (Not everyone reacts to poison ivy, either.) You could get an itchy rash while your home companion getsnothing. If you think bed bugs bit you, have a PMP do a thorough inspection to determine whether an arthropod is in your living space, or send samples to a diagnostic lab. 4. Where did bed bugs come from? Bed bugs may have evolved when a close relative, the bat bug, switched to feeding off cave-dwelling humans. The ancient Egyptians, Greeks, and Romans wrote about them. They were part of many peoples lives in the U.S. and around the world before World War II. Then DDT came along. DDT seemed wonderful at the time. Unlike most of the insecticides sold in stores today, DDT had a lasting effecta long residual effect. Insects died when they crawled where DDT was used, even if it had been there for weeks. Though most homeowners used DDT for large pests like cockroaches, it did the bed bugs in too. When the bed bugs came out to feed, there was something there to kill them.

Modern furnishings and appliances helped too. Bed bugs dont care if a home is clean or messy. They just like good hiding spotsand food. When modern furniture came into style they had fewer hiding spots. Home appliances such as washing machines and vacuums helped keep them at bay. Bed bugs were a rarity in the US from the early 1950s through the late 1990s. A whole generation of people grew up whod never seen one. By the mid 1970s insecticides like DDT, which were blamed for environmental problems, were on the outs. The pest control industry began to use the environmentally friendly approaches common today. Using noninsecticide traps and monitors, blocking entry into homes, and using pest-specific, least-toxic insecticides became the staples of an integrated pest management approach. Bed bugs had been off the radar for so long they were almost forgotten. By the time anyone noticed, they were back in a big way. Right now there are no traps or monitors proven to detect a population when its still small. And since bed bugs travel on things such as luggage, souvenirs, and furniture we bring into our homes, its hard to block their entry. Fortunately, some modern insecticides work well. Because these insecticides break down quicklymaking them safer for humansthey may not be around to kill the bed bugs that hatch from eggs laid before the insecticide was applied. Two or more carefully targeted applications are the best way to eliminate bed bugs. Leave insecticides to the professionalseven the right ones, used incorrectly, can scatter bed bugs to other rooms. It would take an extremely capable and dedicated person to learn and do everything necessary to get rid of bed bugs on their own. How to Find Bed Bugs 5. Where do bed bugs live? Are bed bugs a sign of poor sanitation or hygiene? Where do bed bugs hide?

Any place with a high turnover of people spending the nighthostels, hotels near airports, and resortsare most at risk. But the list continues apartments, barracks, buses, cabins, churches, community centers, cruise ships, dormitories, dressing rooms, health clubs, homes, hospitals, jets, laundromats, motels, motor homes, moving vans, nursing homes, office buildings, resorts, restaurants, schools, subways, theaters, trains, used furniture outlets. Bed bugs dont prefer locations based on sanitation or peoples hygiene. If theres blood, theyre happy. Bed bugs and their relatives occur nearly worldwide. They became relatively scarce during the latter part of the 20th century, but their populations have resurged in recent years, particularly throughout parts of North America, Europe, and Australia. What about in your home? Most stay near where people sleep, hiding near the bed, a couch or armchair (if thats where you snooze)even cribs and playpens. Their flat bodies allow them to hide in cracks and crevices around the room and in furniture joints. Hiding sites include mattress seams, bed frames, nearby furniture, or

baseboards. Clutter offers more places to hide and makes it harder to get rid of them. Bed bugs can be found alone but more often congregate in groups. Theyre not social insects, though, and dont build nests. How infestations spread through a home or within an apartment building differs from case to case. Inspect all adjacent rooms. Bed bugs travel easily along pipes and wires and the insides of walls can harbor them. Before treating, you need to confirm that you have bed bugs. The only way to do that is to find a bug and get it identified. Look in the most likely places first. We tell you how. If you find one, freeze it for identification or put it in a sealed jar with a 1 tsp. of rubbing alcohol. Then stop lookingyou dont want to disrupt the bugsand call a professional. 6. How do I find out if I have bed bugs? Do bed bug-sniffing dogs work? How to I check a room for bed bugs?

Have these on hand during the inspection: flashlight magnifier or hand lens a vial, pill bottle, or ziplock bag to hold specimens for identification tweezers or sticky tape to help grab the bugs gloves (vinyl, latex, etc.or even a plastic bag over your hand) knife, index card, or credit card for swiping bed bugs out of cracks trash bags and tape for bagging infested items vacuum cleaner (just in case you find a large group): keep a few for identification and suck up the rest. Since the vacuum bag will have live bugs in it, take out the bag right away. Seal it in a plastic bag and throw it away. Look for bed bugs in all their life stages: eggs, nymphs and adults. Also look for cast skins and blood spots. But note: blood spots, hatched eggs, and cast skins may be from an infestation thats been dealt with already. Live bed bugs are the only confirming evidence. Use a flashlighteven if the area is well litand work systematically. A magnifying glass will help you zoom in on hard to see spots. Start with one corner of the mattress and work around the piping, down the sides, and underneath. Do the same with the box spring. If you own the bed, slowly remove the dust cover (ticking) on the bottom of the box spring and seal in a trash bag. Next, inspect the bed frame. If you can take it apart, do so. Bed bugs could be hiding in the joints. No bed bugs yet? Work out from the bed in a systematic way (clockwise or counterclockwise) to the walls of the room. Look in the pleats of curtains, beneath loose

pieces of wallpaper near the bed, the corners and drawers of desks and dressers, within spaces of wicker furniture, behind door, window, and baseboard trim, and in laundry or other items on the floor or around the room such as cardboard boxes. Inspect everything. Any crack, crevice, or joint a credit card edge could fit in could hide adult bed bugs. This routine gives you a systematic approach and increases the chance youll find evidence early on. One last way to inspectabout an hour before dawn, lift the sheets and turn on a flashlight. It might lead to a discovery, but this method can also be unsettling. If you dont find bed bugs but bites continue or you find blood spots on bedding, contact a professional with bed bug experience and have them inspect. Professional inspection may be done by a person or by a bed bug-sniffing dog and its handler. Dogs have a powerful sense of smell and can be trained to find bed bugs (which do give off an odor). Theyre best used to find infestations. If used to tell whether bed bugs are gone, they may find old evidence rather than fresh. If you hire a handler and dog, be sure theyre accredited. If you find bed bugs at home, its best to keep sleeping in the bedor try to find someone who will sleep there. Packing up to spend time elsewhere could bring bugs to an uninfested area. And the bugs could move to neighboring rooms in search of a meal. 7. How do I have specimens identified? Put specimens in small, break-resistant containers such as a plastic pill bottle or a zipper-lock bag with 1 tsp of rubbing alcohol in it. Or tape them to a sheet of white paper with clear tape. First, look at pictures on university websites. If you think its a bed bug, package it carefully to prevent damage and send to an expert for positive identification. Bed bugs have close relatives: poultry bugs, barn swallow bugs, bat bugs, and tropical bed bugs to name a few. They too can feed on humans and act like bed bugs do. For accurate identification, send a samplepreferably several adultsto a Cooperative Extension diagnostic lab. If the critter is, for example, a bat bug, call a professional wildlife control operator to find and remove bats, then prevent their re-entry.

8. How did I get bed bugs in the first place? Bed bugs come in as stowaways in luggage, furniture, clothing, pillows, boxes, and more when these are moved between dwellings. Moving out wont solve the problem, since bed bugs will just come with you. In fact, while dealing with bed bugs its best not to sleep away from home. Used furniture, particularly bed frames and mattresses, are most likely to harbor bed bugs. Watch out for items found on the

curb! Because they survive for many months without food, bed bugs could already be present in clean, vacant apartments. In a few cases, bats or birds could introduce and maintain bed bugs and their close relativesusually bat bugs and bird bugs. The source of the infestation determines where your inspection should start. Look through these scenarios and see which fits: Only one bedroom: inspect that room first. People watch TV or snooze on a couch: check it after inspecting the bedroom. A traveler returned home: insects can hide in luggage and then crawl out when its dark and peacefulbegin where luggage was placed upon returning home. A used bed or piece of furniture (bought or from the curb) was brought into the house: inspect it first. The problem began after a visitor stayed overnight: inspect the beds that they slept in and where their luggage was placed. Next, inspect the nearest place where people sleep. An infestation persists after several treatments by a professional: bed bugs may come through the wall from a neighboring apartment. Inspect rooms that share a wall with a neighbor. (This scenario happens in large apartment complexes and hotels where management didnt get adjacent rooms treated.) If the building has a laundry room, inspect it too. Home health aides come in frequently: bed bugs may have hitched a ride on their bags. Backpacks go to and from school: could have bed bugs. Inspect the bed or couch nearest the spot where backpacks are kept.

How to Prevent Bed Bugs 9. Can I prevent bed bugs with insecticides? Insecticidal dusts will remain effective if not covered by other dust. As part of the IPM approach, routine spraying of insecticides is strongly discouraged. Bed bugs do not spread disease, but insecticides do pose risks. Only use them when the pest insect is confirmed and the least-toxic steps have been tried. As a preventative measure alternative to insecticides, inspect and clean regularly, keeping bed bughiding spots in mind.

10. How can I avoid bed bugs when traveling? Every traveler should learn about bed bugs. Always inspect before settling into any room. Pack a flashlight (even the keychain LED variety) and gloves to aid in your inspection. The inspection should focus around the bed. Start with the headboard, which is usually held on the wall with bracketslift up 1 2 inches, then lean the top away from the wall to gain access to the back. If youre traveling alone, someone on staff should help. After checking the headboard, check sheets and pillows for blood spots. Next, pull back the sheets. Check the piping of the mattress and box spring. Finally, look in and under the drawer of the bedside table. If all these places are clear, enjoy the night. The next morning, look for blood spots on the sheetsbed bugs poop soon after they feed. If you find evidence, but no live bed bugs, the evidence may be old and doesnt mean that the hotel is dirty. Tell the front desk discreetly what you found and ask for another roomone that doesnt share a wall with the room you just vacated. Bed bugs are a PR nightmare for the hospitality industry. If you run to a competitor (whos just as likely to have bed bugs) it makes it less likely that the industry will become more open about this issue. Communication is key. Ideally hotels and motels would pride themselves on their bed bug programs and show customers how to inspect to keep all parties bed bug free. If you can avoid it, dont unpack into drawers and keep luggage closed on a luggage rack pulled away from the wall. Never set luggage on the bed. 11. What can I do if I just got back from a place where there might have been bed bugs? Launder your clothes before or as soon as these items are brought back into the home. If you found bed bugs after moving into a hotel room, you could ask the hotel to pay for launderingand for steam-cleaning your luggage. The hotel may refuse, but its worth asking. Regardless, once home you should unpack on a floor that will allow you to see bed bugsstay off carpets! Unpack directly into plastic bags for taking clothes to the laundry. Suitcases should be carefully inspected and vacuumedfreeze if possible. 12. Will bed bugs actually travel on me? Its unlikely that a bed bug would travel on you or the clothes you are wearing. You move too much to be a good hiding place. Bed bugs are more likely to be spread via luggage, backpacks, briefcases, mattresses, and used furniture. 13. What should everyone know about bed bugs? YOU CAN STOP THEIR SPREAD Adults are , reddish-brown and flat. You can see them without magnification. They like to hide in cracks and crevices.

Inspect sleeping areasif you find a bed bug, STOP looking and contact a professional. Do-it-yourself pest control could make bed bugs to spread. Launder and freeze when possible. Live bugs or eggs may drop off while moving things from one place to another items with bed bugs should be sealed in a bag before moving them. Avoid used furniture and items left on the curbthey might have bed bugs! Tell your friends! Not warning others robs them of the chance to avoid bringing bed bugs into their homes and businesses. How to Deal With Bed Bugs 14. I have bed bugs. What do I do? Step back a minute. Because several different kinds of insects resemble bed bugs, specimens should be carefully compared with good reference images and sent to a professional entomologist. Next: make a plan. Well tell you how. You want to get rid of bed bugs, limit your exposure to insecticides, and minimize costs. Dont get rid of stuff and dont treat unless you have a plan. A big part of your plan: hire an experienced professional. Trust us, itll save you time and money in the long run. Youll still have a lot to do just leave the insecticides to the pros. Working as a team with a professional is the quickest way to get bed bugs out of your life. Integrated Pest Management (IPM) is the way to go for pest control. Its costeffective, it works, and it lessens reliance on insecticides. Note: IPM doesnt mean no insecticides. You should call a professional dedicated to IPM so the least amount of insecticides can be used and still work. Here are the basics of bed bug IPM: Inspection: ALWAYS inspect. Proper identification helps you know what to do and where to target your efforts. Along with looking, you should write down what you do and see. Use this reporting form to track what youve done. Having a history will help if more people become involved. Educate yourself: find out about bed bug biology and behavior to become even more effective. Cultural and Mechanical Control: This makes your home unwelcoming to bed bugs, blocks them from feeding, or at least makes finding them easier. Dont skip these steps and go straight to insecticides. Examples: Choose furniture of plain design. A metal chair offers fewer places for a bed bug to hide than a wicker one.

Dont buy or pick up used furniture. Choose light-colored beddingeasier to see insects and blood spots. Dont store things under beds. In fact, get rid of clutter anywhere near the bed.

Use tightly fitting, zippered, bed-bug proof mattress and box spring encasements. Putting them in place ahead of time (proactively) makes bed bugs easier to see since encasements have no piping or tags and theyre light-colored. Putting them on during an infestation means no need to throw away the mattress and box spring. But check periodically to be sure they havent torn.

Vacuum regularly. Use an attachment to get in cracks and crevices. Maintain a gap between the walls and your bedroom and living room furniture.

Seal cracks in wooden floors. Repair peeling wallpaper. Keep bedding and dust ruffles from touching the floor. Better yet, remove the ruffles.

When returning from a trip, unpack on a light-colored, bare-wood or vinyl floor keeping an eye out for bed bugs. Put everything that traveled in a warm dryer for an hour or a hot dryer for 60 minutes. Put things that cant be heated in a freezer for two weeks. Everything else inspect carefully!

When you travel, inspect rooms, keep luggage closed and use luggage racks away from the walldont leave things on the bed! Take along a travelers card to guide your inspection.

See non-insecticidal control for more ideas.

Biological Control: No known biological control agents target bed bugs well enough to keep them at bay. Chemical Control: Insecticides supplement but dont replace your work. Get a pest management professional (PMP) involved. Licensed PMPs know what products, in what formulations, should be usedand where. PMPs know how to be selective and effectivefewer insecticides used and best results. Any insecticide used should be labeled for the pest and location where it is being used. Many products are not labeled for mattresses. Hire only professional pest control companies with licensed PMPs who are affiliated with a state or national association. This helps ensure that the company stays up-todate on the current practices and only uses legal insecticides. PMPs are trained for sensitive situations: people who are ill, children, pregnant women, pets, and more.

They know how to properly apply insecticides. They also know best how to find bed bugs. PMPs will not use illegal insecticides. If you use insecticides but they dont work and then you still have to call in a professional, overall insecticide use will be higher. Plus, what you used could drive bed bugs into new areasmaking removal a longer and pricier process. Monitoring: This involves inspecting regularly to be sure: Control is working. Bed bugs havent been brought back in. Encasements havent torn. There isnt any way you could improve your cultural or mechanical control.

15. What shouldnt I do when trying to eliminate bed bugs? Do I have to throw out my mattress and furniture?

Dont panic. Although bed bugs can be annoying, you can get rid of them if you adopt a well-considered strategy. Dont put the legs of the bed frame in kerosene or coat them with petroleum jelly. Bed bugs have been known to climb on the ceiling and drop down onto the bed. Plus kerosene is a fire hazard. Dont depend on thyme oil. Thyme oil may discourage bed bugs, but it wont kill them. Chances are itll spread, not fix, the problem. Dont leave the home unoccupied through a winter as a control measure. Bed bugs have adapted to the unpredictable habits of humans. If given time to go dormant for example, in a vacation cabin that slowly gets cooler, then cold over fall and winterbed bugs can survive, living without a meal for many months while waiting for humans to return. The quick penetration of killing cold (or heat) is the key to any temperature treatment. Dont turn up the heat. Exposing bed bugs to 120 F or more an hour will kill all life stagesand whole-structure or container heat treatments do work. But the caution is similar to using cold. High heat must be maintained at every point in the building: the outer walls, deep in the sofa, etc. for the full hour. Professionals enclose the structure, using tools to guarantee that it reaches the right temperature. If you go with a full-structure heat treatment, consider if the heat could damage furniture, appliances, and belongings. Dont sleep with a light on. Bed bugs feed when hosts are inactive. Usually thats when its darkbut theyll feed under lights if theyre hungry. Dont sleep in a different room. Bed bugs will move to a neighboring room if they cant find food. And they can live months between meals. Sleeping in a different room, staying at a hotel, or moving in with friends wont solve the problem. And the

chances of carrying the bugs to a new place are good. Keep sleeping in your bed. If you have awful reactions to the bites, try to get someone to sleep in the bed. Dont throw a bed bug-infested mattress away and buy a new mattress. Buying a new mattress wont solve the problem. Bed bugs hide in more than just mattresses. New mattresses might be transported in the same trucks that pick up used and possibly contaminated ones. If you need a new mattress, wait until the infestation is eliminated before buying a new one. (Remember: A bed bug-proof mattress and box-spring encasement kept in place for 1 years will starve them to death. Inspect often for torn spots in the encasement (and evidence of bed bugs). Dont dispose of good furniture. Infested furniture can be cleaned and treated. Placing infested furniture (particularly mattresses) into common areas or on the street could spread bed bugs to other peoples homes. If youre getting rid of infested furniture, deface it: make it less attractive to other people. Paint a picture of a bug on it and write bed bugs or chinches. Building managers should make sure disposed furniture is in a dumpster or taken to a landfill or waste facility right away. Dont wrap items in black plastic and leave them in the sun: it needs to get hotter than that to kill bed bugs, and heat needs to evenly penetrate the entire item. Dont move infested items out of the room without wrapping them in plastic. Bed bugs or eggs could be knocked off into an uninfested area. Dont apply insecticides unless you fully understand what you are applying and the risks involved. You are legally liable if you misapply an insecticide or apply it without a license to the property of othersincluding common spaces in apartment buildings. In most cases, landlords, owners and building managers cannot legally apply insecticides unless they are licensed to do so. 16. What do I do with my pets if I have bed bugs? Pest management professionals (PMPs) have seen bed bugs feeding on pets, but no one knows if they prefer pets. The bugs might get caught in a pets hair, but they wont live on pets the way fleas do. Still, a pet could carry a bed bug from one room to another. Since bed bugs rarely feed for more than 10 minutes and their feet dont grip onto hair, Twenty minutes of grooming outside lets you rest at ease. All bedding and cage items should be inspected and washed and dried (60 minutes on hot) or frozen (for 2 weeks). Inspect furniture, floors, and walls near the pets areas.

17. How long does it take to get rid of bed bugs? It will take at least three weeks to be rid of bed bugs. Heres why: Preparation usually takes about a week

Two weeks in a freezer kills the crawling bed bugs Insecticides dont kill the eggs, which take about two weeks to hatchthe pest management professional (PMP) should reinspect and apply more insecticides if needed two full weeks after the first treatment. The fastest IPM fix relies on the team effort of a PMP and the owner. The owner must do the necessary preparation and do the cultural and mechanical control work while the PMP handles the insecticides. Fumigation and full-structure heat treatments work after one treatment, but are very costly. Fumigation is not the same thing as fogging. 18. What should a pest control company do for meand vice versa? Customer Preparation Pest Management Professionals (PMPs) should be knowledgeable about bed bugs, educating you so you understand why time-consuming and thorough preparation is so important. If the company doesnt require you to do prep work, call the next company on your list. PMPs may ask you to launder all clothing, bedding, and draperies; buy resealable bags for all possessions in drawers, closets, etc.; clean rooms thoroughly; and vacate rooms on all treatment days. One thing that differs by pest control company is whether callers should do anything to the bed ahead of time. Theres no right way. Still, the company should be able to explain the why behind their methods. The time and money it takes to battle bed bugs will be easier to grasp if you understand: Clutter makes it harder for PMPs to find and treat all likely hiding spots of loner females that could restart an infestation. Bed bugs arent found just in beds. Any space a credit card edge could slide in is a possible hiding spot. PMPs need to treat baseboards, picture frames, bed frames, dressers, drawers, and tables. Because preparation will disturb the bugs, you should choose a pest control company and learn their operating procedure before doing much to the room. Remember: Insecticides dont penetrate the eggs, which take up to two weeks to hatch. The follow-up treatment is usually scheduled two or three weeks after the first treatment to get those newly hatched nymphs. You want to get them before they become adults and lay more eggs. Prepare the same as for the first treatment. You can save time and money by unpacking only a few essentials until the follow-up is done. Cost Bed bug jobs take time and expertise. The service is justifiably costly. Prices vary by region and the type of contract. Call around to get an idea of prices in your region.

$500 or more for the first visit and treatment and $250 for the follow-up arent unreasonable. It might even be cheap for an area. If you shop around and find a company that offers service at a much lower price, chances are theyre less thorough. Treatment Technicians who inspect and treat should be able to answer questions about bed bug biology and behavior as well as explain their plans. Even if someone has already come to inspect and quote the job (some companies will quote over the phone, others inspect first and quote at that visit), technicians should always inspect before treating. At the very least, they should use a flashlight when inspecting. Proper inspection takes time and shouldnt be rushed. And whats their plan for treatment? If its to treat least-infested areas first, working toward most-infested areas, the plan is good. PMPs should use a range of formulations and methods, both liquids and dusts. The PMP should target cracks, crevices, and behind electrical sockets. Not every company uses a vacuum or steamerthat might be your job. Vacuuming just before the PMP arrives will get dirt out of cracks so the insecticide can get in. The PMP must take care not to spread the problem. Anything that needs to be removed from the treatment area should be covered with plastic. Once an area has been treated, only treated items should be moved back in. If people or pets are present, they should be in a different room. Dont enter a room that has been treated with an insecticide for at least 4 hoursor whatever the insecticide label states, whichever is longer. Childrens and sick peoples mattresses shouldnt be treated. Follow-Up Treatments Count on at least one follow up treatment. Bed bugs should be gone after 2 3 visits. Unless the structure is fumigated (this is different from bombing!), one visit wont get rid of bed bugs. Follow up treatments should still include a full inspection, followed by insecticide if bed bugs are found. Because complete elimination is hard to achieve for any pest, most bed bug contracts dont guarantee it. Bed bugs can be reintroduced. Companies with a good business sense cant guarantee bed bug work for a long period of time. This doesnt mean the company wont go to great lengths to help you. And yes, it is possible to eliminate bed bugs from a home. 19. How do I kill bed bugs without insecticides? Can cold kill bed bugs? Can heat kill bed bugs? Can steam kill bed bugs?

Cleaning: Thoroughly clean infested rooms as well as others in the residence. Scrub infested surfaces with a stiff brush to dislodge eggs and use a powerful vacuum to

remove bed bugs from cracks and crevices. This wont ensure that youve got all the eggs since they can be cemented deep in cracks. But it will help. Dismantle bed frames to expose additional hiding sites. Remove drawers from desks and dressers and turn furniture over, if possible, to inspect and clean all hiding spots. Vacuuming: A vacuum is not a stand-alone solution. But it will suck up some bed bugs and, used frequently, help keep their numbers down. The narrowest attachment should be used along seams, cracks, and crevices. Theres no guarantee itll suck all bed bugs out of hiding. Immediately after, the bag or canister should be removed. Bed bugs in that bag will still be alive! Put the bag or canister contents into a plastic bag, freeze for two weeks, then dispose of properly. Wash the canisterbe sure its unplugged! Inspect the vacuum to be sure no bugs remain inside. Steam: Research is underway on how well steamers work. A good steamer will kill eggs, nymphs, and adults on contact. But were not sure how deeply killing heat penetrates wood and fabrics. And it offers no defense against reintroducing bed bugs. When using a steamer, move extremely slowly (1 foot in 15 seconds) and methodically. Dont use a small nozzle that blows bed bugs away from the treatment areathey will survive. The heat needed to kill bed bugs will burn skin. Manufacturers instructions take priority over anything that anyone tells you. Afterward, let things dry completely. This prevents moisture or mold damage. Steam can carry electricity. Stay away from switch plates, electrical outlets, and plugged in appliances. Heat: Extreme heat will kill bed bugs. 60 minutes on the hottest setting in a dryer kills eggs and insects. If taking belongings to a laundromat sort at home and put loads in a bagdispose of the bag once empty. Dont use the same bag to bring clothes back. Dry cleaning kills bed bugs, but tell them that the item might be contaminated. If the clothes wont be damaged by heat and stains wont set, put them in a dryer before going to the dry cleaner. Blankets, pillows, some shoes, childrens plush toys, curtains, rugs, seat cushions, and fabric bagsif the item can survive heat and tumbling and it wont damage the dryer, it can go in a dryer. Check the lint filter for bed bugs afterwards. Its another way to confirm their presence. Freezing: More research is needed on how well freezing works. Quickly expose items to 32 F or below and leave them there for at least two weeks. All crawling life stages will die. To kill the eggs, 30 days is needed. Mattress Encasements: Mattresses and box springs can be permanently encased within bed bug proof zippered mattress encasements. They must stay on for a full year and a half. Inspect them often to be sure they dont have rips. If you find holes or tears, seal these completely with permanent tape or buy a new bag. Any bugs trapped within these sealed bags will eventually die. 20. How do I kill bed bugs with insecticides? What are the dangers of using insecticides to fight bed bugs?

Unless you have a pesticide applicators license, you shouldnt apply insecticides to treat bed bugs. Why? If you try to get rid of the bed bugs on your own and it doesnt work, then you call a pest control company and

Even more insecticides get used. The bed bugs will be in new hiding spots, making it harder for pest management professionals (PMPs) to target them. If, despite our warning, you try over-the-counter products, READ THE LABEL of any product you use. If it isnt labeled for indoor use, dont use it. If it isnt labeled for use on a mattress, dont use it on a mattress. Keep records of everything you do the date, location, and insecticide or tool used. You have the right to know whats being applied in your home and at what concentration. The EPA registration number (EPA Reg. No.) is on the label. Material Safety Data Sheets (MSDS) are available online for the active ingredient for all products. (Your pest control company might have them too). If youre worried about children, the elderly, pregnancy, ill people, or pets, a doctor or veterinarian can use the EPA Reg. No. and MSDS to tell them what precautions to take. If the label doesnt have an EPA Reg. No., dont buy it! For more info on pesticides, call the National Pesticide Information Center (NPIC) at 800-858-7378, or go online at npic.orst.edu. Ask your pest control company about their standard operating procedures for sensitive cases. Generally, it is best to leave your things in your home or apartment when its treated. All food, plates, silverware, etc. should be protected from insecticides. Insecticides used to treat bed bug infestations consist mainly of: Insecticidal dusts, such as finely ground silica powder, which abrade an insects waxy coat and cause it to dry out and die quickly. Some dusts are mixed with other dry insecticides. These dusts are applied in or behind permanent fixtureswalls, light switches, and the like. Piles of dust wont work. If you can see the dust, its not being used right. Read the label! Contact insecticides kill the bugs shortly after they come into direct contact with the product or its residue. These products tend to knock down bugs that wander over or otherwise contact the insecticide. BUT some repel bed bugs. Use the wrong product, and bed bugs could survive the pesticide and spread to other rooms. Insect Growth Regulators (IGRs) affect the development and reproduction of insects. Although they can work well, they dont kill bugs quickly. PMPs often use these products to supplement other insecticides. 21. How do I kill bed bug eggs? Eggs keep unborn bed bugs safe from insecticides. Sixty minutes in a hot dryer heat will kill bed bug eggs, and freezing (below 32F) for 30 days will too. Fumigation (not the same as foggers or bombs) also kills eggs. Steam is another option as long as the nozzle is moved slowly and the steamed item is given time to dry. Bed bug eggs

hatch in about two weeks. A follow up inspection after two weeks is necessary to confirm that theyre gone. Taken Directly from: Cornell University/New York State Integrated Pest Management Program 2010 http://www.nysipm.cornell.edu/whats_bugging_you/bed_bugs/bedbugs_f aqs.asp#didiget

Morbidity and Mortality Weekly Report

Weekly / Vol. 60 / No. 37 September 23, 2011

Acute Illnesses Associated With Insecticides Used to Control Bed Bugs Seven States, 20032010
The common bed bug, Cimex lectularius, is a wingless, reddish-brown insect that requires blood meals from humans, other mammals, or birds to survive (1). Bed bugs are not considered to be disease vectors (2,3), but they can reduce quality of life by causing anxiety, discomfort, and sleeplessness (4). Bed bug populations and infestations are increasing in the United States and internationally (3,5). Bed bug infestations often are treated with insecticides, but insecticide resistance is a problem, and excessive use of insecticides or use of insecticides contrary to label directions can raise the potential for human toxicity. To assess the frequency of illness from insecticides used to control bed bugs, relevant cases from 20032010 were sought from the Sentinel Event Notification System for Occupational Risks (SENSOR)-Pesticides program and the New York City Department of Health and Mental Hygiene (NYC DOHMH). Cases were identified in seven states: California, Florida, Michigan, North Carolina, New York, Texas, and Washington. A total of 111 illnesses associated with bed bugrelated insecticide use were identified; although 90 (81%) were low severity, one fatality occurred. Pyrethroids, pyrethrins, or both were implicated in 99 (89%) of the cases, including the fatality. The most common factors contributing to illness were excessive insecticide application, failure to wash or change pesticide-treated bedding, and inadequate notification of pesticide application. Although few cases of illnesses associated with insecticides used to control bed bugs have been reported, recommendations to prevent this problem from escalating include educating the public about effective bed bug management. To evaluate illnesses associated with insecticides used to control bed bugs, data from 20032010 were obtained from states participating in the SENSOR-Pesticides program* and from NYC DOHMH. Acute illnesses associated with an insecticide used to control bed bugs were defined as two or more acute adverse health effects resulting from exposure to an insecticide used for bed bug control. Cases were categorized as definite, probable, possible, and suspicious based on three criteria: certainty of exposure, reported health effects, and
* The SENSOR-Pesticides program consists of 12 states that conduct surveillance of pesticide-related illness. California, Florida, Michigan, North Carolina, New York, Texas, and Washington reported cases of acute illness associated with insecticides used for bed bug control. The other five states participating in the SENSOR-Pesticides program (Arizona, Iowa, Louisiana, New Mexico, and Oregon) did not identify any cases of acute illness associated with insecticides used for bed bug control during 20032010. The California Department of Public Health reported one case of acute illness associated with insecticides used for bed bug control. The other case in California was reported through the California Department of Pesticide Regulation. New York City Poison Control Center, a component of NYC DOHMH, contributed data from 20032010, in addition to data received from New York State Department of Health and Mental Hygiene. Because the New York City Poison Control Center does not report data to the New York State Department of Health, their data were reported separately.

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consistency of health effects with known toxicology of the insecticide (causal relationship) (Table 1). Data were analyzed for demographics, health effects, report source, case definition category, illness severity, insecticide toxicity, insecticide chemical class, work-relatedness, and factors contributing to illness. A 2010 case report from Cincinnati Childrens Hospital Medical Center (CCHMC) in Ohio also was obtained.** For 20032010, a total of 111 cases were identified in seven states (Table 2). The majority of cases occurred during 20082010 (73%), were of low severity (81%), and were identified by poison control centers (81%). New York City had the largest percentage of cases (58%). Among cases with known age, the majority occurred among persons aged 25 years (67%). The majority of cases occurred at private residences (93%); 40% of cases occurred in multiunit housing. Among cases, 39% of pesticide applications were performed
Low severity cases usually resolve without treatment and cause minimal time lost from work (<3 days). Moderate severity cases are nonlife threatening but require medical treatment and result in <6 days lost from work. High severity cases are life threatening, require hospitalization, and result in >5 days lost from work. The toxicity category of an insecticide is determined by the Environmental Protection Agency (EPA) under guidance from CFR Title 40 Part 156. Insecticides in category I have the greatest toxicity, and insecticides in category IV have the least toxicity. ** This case was not included in the analysis because Ohio does not participate in the SENSOR-Pesticides program. However, this case received media coverage in Ohio and represents misuse and excessive application of pesticides. The case demonstrates the need for consumers to be diligent in choosing a certified or licensed pesticide applicator.

TABLE 1. Case classification matrix* for acute illness associated with insecticides used for bed bug control seven states, 20032010
Classification criteria Exposure Health effects Causal relationship Classification category Definite 1 1 1 1 2 1 Probable 2 1 1 Possible Suspicious 2 2 1 1 or 2 1 or 2 4

Source: CDC. Case definition for acute pesticide-related illness and injury cases reportable to the national public health surveillance system. Cincinnati, OH: US Department of Health and Human Services, CDC, National Institute for Occupational Safety and Health; 2005. Available at http://www.cdc.gov/niosh/ topics/pesticides/pdfs/casedef2003_revapr2005.pdf. * Cases are placed in a classification category based on scores received on available evidence for exposure, health effects, and causal relationship. Scores relating to exposure criteria are 1 = clinical, laboratory, or environmental finding supporting the exposure, 2 = evidence from written or verbal report; criteria for health effects are 1 = two or more abnormal signs after exposure and/or test or laboratory results that are reported by a licensed health-care professional, 2 = two or more symptoms postexposure are reported by the patient; and criteria for a casual relationship are 1 = health effects are consistent with known toxicity, 4 = insufficient toxicologic information to determine if a causal relationship exists between exposure and health effects. Based on either combination of scores for exposure, health effects, and causal relationship.

by occupants of the residence who were not certified to apply pesticides. The majority of insecticide exposures were to pyrethroids, pyrethrins, or both (89%) and were in toxicity category III (58%) (Table 2). The most frequently reported health outcomes were neurologic symptoms (40%), including headache and dizziness; respiratory symptoms (40%), including upper respiratory tract pain and irritation

The MMWR series of publications is published by the Office of Surveillance, Epidemiology, and Laboratory Services, Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services, Atlanta, GA 30333. Suggested citation: Centers for Disease Control and Prevention. [Article title]. MMWR 2011;60:[inclusive page numbers]. Thomas R. Frieden, MD, MPH, Director Harold W. Jaffe, MD, MA, Associate Director for Science James W. Stephens, PhD, Director, Office of Science Quality Stephen B. Thacker, MD, MSc, Deputy Director for Surveillance, Epidemiology, and Laboratory Services Stephanie Zaza, MD, MPH, Director, Epidemiology and Analysis Program Office Ronald L. Moolenaar, MD, MPH, Editor, MMWR Series Martha F. Boyd, Lead Visual Information Specialist John S. Moran, MD, MPH, Deputy Editor, MMWR Series Robert A. Gunn, MD, MPH, Associate Editor, MMWR Series Maureen A. Leahy, Julia C. Martinroe, Teresa F. Rutledge, Managing Editor, MMWR Series Stephen R. Spriggs, Terraye M. Starr Douglas W. Weatherwax, Lead Technical Writer-Editor Visual Information Specialists Donald G. Meadows, MA, Jude C. Rutledge, Writer-Editors Quang M. Doan, MBA, Phyllis H. King Information Technology Specialists William L. Roper, MD, MPH, Chapel Hill, NC, Chairman Virginia A. Caine, MD, Indianapolis, IN Patricia Quinlisk, MD, MPH, Des Moines, IA Jonathan E. Fielding, MD, MPH, MBA, Los Angeles, CA Patrick L. Remington, MD, MPH, Madison, WI David W. Fleming, MD, Seattle, WA Barbara K. Rimer, DrPH, Chapel Hill, NC William E. Halperin, MD, DrPH, MPH, Newark, NJ John V. Rullan, MD, MPH, San Juan, PR King K. Holmes, MD, PhD, Seattle, WA William Schaffner, MD, Nashville, TN Deborah Holtzman, PhD, Atlanta, GA Anne Schuchat, MD, Atlanta, GA John K. Iglehart, Bethesda, MD Dixie E. Snider, MD, MPH, Atlanta, GA Dennis G. Maki, MD, Madison, WI John W. Ward, MD, Atlanta, GA

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TABLE 2. Characteristics of acute illnesses associated with insecticides used for bed bug control seven states, 20032010
Total Characteristic Total Year of exposure 2003 2004 2005 2006 2007 2008 2009 2010 Location California Florida Michigan North Carolina New York New York City Texas Washington Age group (yrs) 05 614 1524 2544 45 Unknown Sex Male Female Case definition category Definite Probable Possible Suspicious Illness severity Fatal High Moderate Low Body part/System affected Nervous system Respiratory Gastrointestinal Skin Eye Cardiovascular Other No. 111 3 4 9 6 8 23 19 39 2 3 8 4 18 64 3 9 6 9 11 26 27 32 51 60 3 14 91 3 1 20 90 45 45 37 35 11 8 15 (%)* (100) (3) (4) (8) (5) (7) (21) (17) (35) (2) (3) (7) (4) (16) (58) (3) (8) (5) (8) (10) (23) (24) (29) (46) (54) (3) (13) (82) (3) (1) (18) (81) (40) (40) (33) (32) (10) (7) (14)

TABLE 2. (Continued) Characteristics of acute illnesses associated with insecticides used for bed bug control seven states, 20032010
Total Characteristic Work related Yes Pesticide applicator certification Certified applicator Uncertified/Unsupervised applicator Home occupant not certified to apply pesticides Unknown certification of applicator Site where case was exposed Single family home Mobile home/Trailer Multiunit housing Private residence/Type not specified Residential institution Hotels Unknown Reporting source Physician report Poison control center State health department Other Toxicity category** I Danger II Warning III Caution Missing/Unknown Insecticide chemical class Pyrethroid Pyrethrin Carbamate Organophosphate Other Unknown No. 13 2 15 43 51 10 1 44 48 2 3 3 4 90 7 10 1 13 64 32 77 28 3 2 9 3 (%)* (12) (2) (14) (39) (46) (9) (1) (40) (43) (2) (3) (3) (4) (81) (6) (9) (1) (12) (58) (29) (69) (25) (3) (2) (8) (3)

* Percentages might not add to 100 because of rounding. The sums exceed the number of cases because some persons had more than one body part or system affected and some had exposure to more than one insecticide. Pyrethroids, pyrethrins, or both were implicated in 99 (89%) of cases. By occupation, the exposed workers included two pest control workers, two emergency medical technicians, two carpet cleaners, one health educator, one caregiver, one medical technician, one support staff member at a shelter, one hotel manager, one hotel maintenance worker, and one person whose occupation was unknown. One case occurred in an independent living facility, and the other case occurred at a shelter. ** Toxicity categories as classified by the Environmental Protection Agency, based on established criteria, with category I being the most toxic. Includes the following active ingredients: DEET (four), hydroprene (two), chlorfenapyr (one), coal tar (one), and acetamiprid (one). DEET and hydroprene are not insecticides, but were pesticides used to control bed bugs.

and dyspnea; and gastrointestinal symptoms (33%), including nausea and vomiting. Among cases, 13 (12%) were work-related. Of these, three illnesses involved workers who applied pesticides, including two pest control operators, of whom one was a certified applicator. Four cases involved workers who were unaware of pesticide applications (e.g., two carpet cleaners who cleaned

an apartment recently treated with pesticides). Two cases involved hotel workers (a maintenance worker and a manager) who were exposed when they entered a recently treated hotel room, and two cases involved emergency medical technicians who responded to a scene where they found white powder thought to be an organophosphate pesticide. Contributing factors were identified for 50% of cases. Factors that most

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TABLE 3. Contributing factors in acute illnesses associated with insecticides used for bed bug control seven states, 20032010
Total Contributing factor One or more contributing factors identified Excessive application Failure to wash or change pesticide-treated bedding Notification lacking/ineffective Failure to vacate premises Spill/Splash of liquid or dust Inadequate ventilation Early reentry Mixing incompatible chemicals Improper storage Label violation not otherwise specified No label violation but person still ill No. 56 10 9 6 5 4 3 2 2 1 16 2 (%)* (100) (18) (16) (11) (9) (7) (5) (4) (4) (2) (29) (4)

What is already known on this topic? Bed bug populations and infestations are increasing in the United States and internationally. Bed bugs have an increased prevalence of insecticide resistance, including resistance to commonly used agents such as pyrethroids. What is added by this report? During 20032010, seven states reported 111 acute illnesses associated with insecticides used to control bed bugs. The most frequently identified causes of illness were excessive application of insecticides, failure to wash or change pesticide-treated bedding, and inadequate notification of pesticide application. What are the implications for public health practice? Inappropriate use of insecticides to control bed bugs can cause harm. Media campaigns to educate the public on nonchemical methods to control bed bugs, methods to prevent bed bug infestation, and the prudent use of effective insecticides, can reduce insecticide-related illness. Making insecticide labels easy to read and understand also might prevent illnesses associated with bed bug control.

* The sum of proportions exceeds 100 because some cases had more than one contributing factor. For the remaining 55 (50%) cases, information was insufficient to identify contributing factors for acute illness. Inadequate ventilation of the treated area resulting from failure to follow label instructions. Among these 16 cases, five involved indoor use of an insecticide that was labeled for outdoor use only, eight involved use of an insecticide not labeled for use on a person or for use on bed bugs, one involved insecticide use in an enclosed space, one was in a child who licked the floor near a pesticide application, and in one case, a blind person inadvertently sprayed a piece of furniture, which he touched with his hand, and then put his hand in his mouth.

frequently contributed to insecticide-related illness were excessive insecticide application (18%), failure to wash or change pesticide-treated bedding (16%), and inadequate notification of pesticide application (11%) (Table 3). The one fatality, which occurred in North Carolina in 2010, involved a woman aged 65 years who had a history of renal failure, myocardial infarction and placement of two coronary stents, type II diabetes, hyperlipidemia, hypertension, and depression. She was taking at least 10 medications at the time of exposure. After she complained to her husband about bed bugs, he applied an insecticide to their home interior baseboards, walls, and the area surrounding the bed, and a different insecticide to the mattress and box springs. Neither of these products are registered for use on bed bugs. Nine cans of insecticide fogger were released in the home the same day. Approximately 2 days later, insecticides were reapplied to the mattress, box springs, and surrounding areas, and nine cans of another fogger*** were released in the home. On both days the insecticides were applied, the couple left their home for
Ortho Home Defense Max (Ortho Business Group), EPA registration number: 239-2663, with the active ingredient bifenthrin. Ortho Lawn and Garden Insect Killer (Ortho Business Group), EPA registration number: 239-2685, with the active ingredient bifenthrin. Hot Shot Fogger (Spectrum Group), EPA registration number: 9688-2548845, with active ingredients tetramethrin and cypermethrin. *** Hot Shot Bedbug and Flea Fogger (Spectrum Group), EPA registration number: 1021-1674-8845, with the active ingredient pyrethrins, piperonyl butoxide, MGK 264 (an insecticide synergist), and pyriproxyfen.

34 hours before reentering. Label instructions on the foggers to air out the treated area for 30 minutes with doors and windows open were not followed on either day. On the day of the second application, the woman applied a bedbug and flea insecticide to her arms, sores on her chest, and on her hair before covering it with a plastic cap. She also applied the insecticide to her hair the day before the second application. Two days following the second application, her husband found her nonresponsive. She was taken to the hospital and remained on a ventilator for 9 days until she died. Another example of insecticide misuse to control bed bugs occurred in Ohio in 2010. An uncertified pesticide applicator applied malathion to an apartment five times over the course of 3 days to treat a bed bug infestation. The malathion product was not registered for indoor use and was applied liberally such that beds and floor coverings were saturated. A family resided in the apartment that consisted of a father, mother, four children, and an adult roommate. One of the children, aged 6 years, attended kindergarten and arrived home around the time of the afternoon malathion applications. The father and roommate also were in the home during the applications. The child began experiencing diarrhea on the first application day, and headache and dizziness began on the second application day. The two adults present during the applications reported nausea, vomiting, headaches, and tremors. During the malathion applications, three younger children were in child care while their mother was at work, and they did not exhibit symptoms of insecticide poisoning. Each night following application of

Hot Shot Bed Bug and Flea Killer (Chemisco), EPA registration number: 9688-150-8845, with active ingredients pyrethrins and piperonyl butoxide.

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malathion, the children slept on sheets placed on the floor to avoid sleeping on saturated beds. Because symptoms in the child aged 6 years persisted on the third application day, he was taken to a community hospital emergency department (ED) and decontaminated. Because the hospital did not have pediatrics specialty care, he was transferred to CCHMC by ambulance for evaluation and treatment. His pseudocholinesterase level was within normal limits. He received 1 dose of pralidoxime and was observed in the CCHMC ED before release. The two adults were seen in a community hospital ED, treated, and released. The family did not return to the contaminated residence following the ED visits. The incident was investigated by the Cincinnati fire department and the Ohio Department of Agriculture. The applicator pled guilty to criminal charges, resulting in a fine and probation.
Reported by

James B. Jacobson, MPH, Katherine Wheeler, MPH, Robert Hoffman, MD, New York City Dept of Health and Mental Hygiene, New York; Yvette Mitchell, New York State Dept of Health. John Beckman, California Dept of Public Health; Louise Mehler, MD, PhD, California Dept of Pesticide Regulation. Prakash Mulay, Florida Dept of Health. Abby Schwartz, MPH, Michigan Dept of Community Health. Rick Langley, MD, Div of Public Health, North Carolina Dept of Health and Human Svcs. Brienne Diebolt-Brown, MA, Texas Dept of State Health Svcs. Joanne Bonnar Prado, MPH, Washington Dept of Health. Nicholas Newman, DO, Cincinnati Childrens Hospital/Univ of Cincinnati, Ohio. Geoffrey M. Calvert, MD, Div of Surveillance, Hazard Evaluations, and Field Studies, National Institute for Occupational Safety and Health; Naomi L. Hudson, DrPH, EIS Officer, CDC. Corresponding contributor: Naomi L. Hudson, nhudson1@cdc.gov, 513-841-4424.
Editorial Note

Bed bug populations and infestations are increasing in the United States and internationally (3,5). Contributing factors are thought to include increased bed bug resistance to insecticides, increased domestic and international travel, rooms with more clutter, and greater prevalence of bed bug friendly furnishings (e.g., wooden bed frames) (5). Insecticides containing pyrethroids are used widely to control bed bugs; however, pyrethroid-resistant bed bug populations have been found in five states (California, Florida, Kentucky, Ohio, and Virginia) (5). Given the increasing resistance of bed bugs to insecticides approved for bed bug control, at least one state has requested an emergency exemption from the Environmental Protection Agency (EPA) to use propoxur, a carbamate, to control bed bugs indoors.

CDC and EPA promote integrated pest management (IPM) for bed bug control (3,6). IPM is an effective pest control method that uses information on the life cycle of the pest and incorporates nonchemical and chemical methods (6). Nonchemical methods to effectively control bed bugs include heating infested rooms to 118F (48C) for 1 hour or cooling rooms to 3F (-16C) for 1 hour by professional applicators (7); encasing mattresses and box springs with bed bugexcluding covers; and vacuuming, steaming, laundering, and disposing of infested items (6). Any effective control measure for bed bugs requires support from all residents in affected buildings and ongoing monitoring for infestation from other housing units (3). Often, multiple inspections and treatments are needed to eradicate bed bugs (4). The findings in this report are subject to at least four limitations. First, acute illness associated with insecticide use might be underreported in the regions covered by the surveillance systems. Case identification in SENSOR-Pesticides relies on a passive surveillance system, so persons experiencing minor symptoms who do not seek medical treatment or advice from poison control centers are not reported to the system. Second, cases might have been excluded if insufficient information was provided to meet the case definition or to determine that the insecticide was used for bed bug control (e.g., surveillance systems do not systematically capture whether insecticides are used for bed bug control). Cases were identified only if available narrative information contained the term bed bug. Third, false positives might be included as cases. Symptoms for acute illnesses associated with insecticides are nonspecific; illnesses might be coincidental and not caused by insecticide exposure. Among the 111 cases described in this report, only 16% were categorized as either definite or probable. Finally, contributing factors were identified for only 50% of the cases; complete knowledge of contributing factors might alter the interpretation presented in this report. Although the number of acute illnesses from insecticides used to control bed bugs does not suggest a large public health burden, increases in bed bug populations that are resistant to commonly available insecticides might result in increased misuse of pesticides. Public health recommendations to prevent illnesses associated with insecticides used to control bed bugs include media campaigns to educate the public about bed bug related issues, including nonchemical methods to control bed bugs, methods to prevent bed bug infestation (e.g., avoiding the purchase of used mattresses and box springs), and prudent use of effective insecticides (3). Persons who have a bed bug

Among New York City cases, 33 were excluded because the affected persons each had only one reported symptom.

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infestation should be encouraged to seek the services of a certified applicator who uses an IPM approach to avoid pesticide misuse. Persons applying insecticides should follow product instructions for safe and appropriate use. Insecticide labels that are easy to read and understand also can help prevent illnesses associated with bed bug control.

References
1. Thomas I, Kihiczak GG, Schwartz RA. Bedbug bites: a review. Int J Dermatol 2004;43:4303. 2. Goddard J, deShazo R. Bed bugs (Cimex lectularius) and clinical consequences of their bites. JAMA 2009;301:135866. 3. CDC, Environmental Protection Agency. Joint statement on bed bug control in the United States from the U.S. Centers for Disease Control and Prevention (CDC) and the U.S. Environmental Protection Agency (EPA). Atlanta, GA: US Department of Health and Human Services; 2010. 4. Wang C, Gibb T, Bennett GW. Evaluation of two least toxic integrated pest management programs for managing bed bugs (Heteroptera: Cimicidae) with discussion of a bed bug intercepting device. J Med Entomol 2009;46:56671. 5. Romero A, Potter MF, Potter DA, Haynes KF. Insecticide resistance in the bed bug: a factor in the pests sudden resurgence? J Med Entomol 2007;44:1758. 6. Environmental Protection Agency. Bed bug information. Washington, DC: Environmental Protection Agency; 2011. Available at http://www. epa.gov/bedbugs/#treat. Accessed September 16, 2011. 7. Benoit JB, Lopez-Martinez G, Teets NM, Phillips SA, Denlinger DL. Responses of the bed bug, Cimex lectularius, to temperature extremes and dehydration: levels of tolerance, rapid cold hardening and expression of heat shock proteins. Med Vet Entomol 2009;23:41825.

Restricted-use pesticides may only be applied by licensed or certified applicators. States are responsible for the training, certification, and licensing of pesticide applicators. A certified applicator is a pesticide applicator who has been determined to have the knowledge and ability to use pesticides safely and effectively. Some states also require that certified pesticide applicators be licensed. In such states, a license is required to purchase, use and/or supervise the application of restricted-use pesticides. Information on certification of pesticide applicators is available at http://www.epa.gov/ oppfead1/safety/applicators/applicators.htm. EPA guidance for consumers on choosing a pest control company and on pesticide safety and nonchemical means of control is available at http://www.epa.gov/oppfead1/Publications/ Cit_Guide/citguide.pdf. Consumers who have questions about the licensing or certification of a pesticide applicator should contact their states agriculture department or agricultural extension service for information.

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Dental Caries in Rural Alaska Native Children Alaska, 2008

In April 2008, the Arctic Investigations Program (AIP) of CDC was informed by the Alaska Department of Health and Social Services (DHSS) of a large number of Alaska Native (AN) children living in a remote region of Alaska who required full mouth dental rehabilitations (FMDRs), including extractions and/or restorations of multiple carious teeth performed under general anesthesia. In this remote region, approximately 400 FMDRs were performed in AN children aged <6 years in 2007; the region has approximately 600 births per year. Dental caries can cause pain, which can affect childrens normal growth and development (1). AIP and Alaska DHSS conducted an investigation of dental caries and associated risk factors among children in the remote region. A convenience sample of children aged 415 years in five villages (two with fluoridated water and three without) was examined to estimate dental caries prevalence and severity. Risk factor information was obtained by interviewing parents. Among children aged 45 years and 1215 years who were evaluated, 87% and 91%, respectively, had dental caries, compared with 35% and 51% of U.S. children in those age groups. Among children from the Alaska villages, those aged 45 years had a mean of 7.3 dental caries, and those aged 1215 years had a mean of 5.0, compared with 1.6 and 1.8 dental caries in same-aged U.S. children (2). Of the multiple factors assessed, lack of water fluoridation and soda pop consumption were significantly associated with dental caries severity. Collaborations between tribal, state, and federal agencies to provide effective preventive interventions, such as water fluoridation of villages with suitable water systems and provision of fluoride varnishes, should be encouraged. This Alaska region is comprised of 52 villages and has a population of approximately 25,000; 85% are Yupik Eskimo. The villages are small and remote, are commercially accessible only by air or boat, and have limited medical and dental resources; at the time of the investigation, four full-time dentists were working in the region. Sixteen villages (30%) have no in-home water and sanitation services, and only four (8%) have fluoridated water systems. During October and November 2008, oral examinations were conducted on a convenience sample of children living in five of the 52 villages. Villages were chosen based on size, water fluoridation status, and willingness of village residents and village schools to participate. Two villages with fluoridated water and three villages without fluoridated water were selected. Village populations ranged from approximately 350 to 6,000 residents. All village children were invited to participate. Families were notified by school officials, and signed parental consents were obtained. Children were examined for the presence of decayed teeth (untreated carious lesions) and filled and missing teeth (sequelae of decayed teeth) in their primary and permanent teeth by one experienced dentist using a visual and tactile protocol modified from the World Health Organizations oral health survey basic methods (3). The protocol was modified to match the diagnostic criteria used in surveys in the United States (2). Parents were interviewed, using questionnaires, to obtain risk factor information. All participants families completed the questionnaire, and more than one child per family was allowed to participate. The number of decayed primary teeth (dt), decayed and filled primary teeth (dft), decayed permanent teeth (DT), and decayed, missing, and filled permanent teeth (DMFT) were determined for each participant. Prevalence (having one or more tooth affected) and severity (mean dt, dft, DT, and DMFT) were determined by age group (45, 68, 911, and 1215 years), sex, and village fluoridation status. An ageadjusted bivariate analysis was performed to assess risk factors for dental caries (dft >0 and DMFT >0). Risk factors included sociodemographic factors (e.g., sex), childrens behaviors (e.g., tooth brushing, dental floss use, and soda pop consumption), parents behaviors (e.g., tooth brushing), access to care, and water fluoridation status. Backward selection of risk factors that reached a significance level of p0.25, on age-adjusted bivariate analysis, were used to conduct multivariate logistic regression. Multivariate models were age- and sex-adjusted. In addition, dental caries severity for the region was compared with estimates for same-aged U.S. children from the National Health and Nutrition Examination Survey from 19992004 (2). In total, 348 AN children aged 415 years were examined (39%63% of the total age cohort in four participating villages; only 3% were examined in the other village, primarily for examiner calibration). The median age of the children was 9 years, and 52% of the children were male. Among children aged 45, 68, and 911 years who lived in nonfluoridated villages, 71%100% had one or more decayed or filled primary tooth (dft >0), and 40%65% had one or more decayed primary tooth (dt >0). The mean dft ranged from 2.7 to 9.8. Among children aged 411 years from fluoridated villages, 67%73% had one or more decayed or filled primary tooth (dft >0), and 44%48% had one or more decayed primary tooth (dt >0). The mean dft among children aged 411 years from fluoridated villages ranged from 2.2 to 3.7 (Table 1, Figure). Among children aged 68, 911, and 1215 years from nonfluoridated villages, 57%91% had one or more decayed, missing, or filled permanent tooth (DMFT >0), and 45%68%
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TABLE 1. Dental caries prevalence and prevalence of decayed teeth* among children from five villages in rural Alaska, 2008
Children from nonfluoridated villages Age group (yrs) 45 68 911 1215 Primary teeth No. 26 65 65 76 % dft >0 100 97 71 % dt >0 65 54 40 Permanent teeth % DMFT >0 57 86 91 % DT >0 45 66 68 No. 18 45 31 22 Children from fluoridated villages Primary teeth % dft >0 67 73 68 % dt >0 44 47 48 Permanent teeth % DMFT >0 31 65 91 % DT >0 18 52 68

Abbreviations: dft = decayed and/or filled primary teeth; dt = decayed primary teeth; DMFT = decayed, missing because of caries, and/or filled permanent teeth; DT = decayed permanent teeth. * % dft >0 is the proportion of children with one or more decayed or filled primary tooth; % dt >0 is the proportion of children with one or more decayed primary tooth; % DMFT >0 is the proportion of children with one or more decayed, missing or filled permanent tooth; and % DT >0 is the proportion of children with one or more decayed permanent tooth.

FIGURE. Mean number of decayed, filled, and missing primary and permanent teeth among children, by age group and village water fluoridation status, in five rural Alaska villages and the United States, 2008
Missing and lled 10 9 8 7 Filled Decayed

*
Primary teeth Permanent teeth

* *

Mean number

6 5 4 3 2 1 0 ANF AF U.S. 45 ANF AF U.S. 68 ANF AF U.S. 911 ANF AF U.S. 68 ANF AF U.S. 911

ANF AF U.S. 1215

Age group (yrs)

Abbreviations: ANF = Alaska nonfluoridated water system, AF = Alaska fluoridated water system, U.S. = total for the United States, based on National Health and Nutrition Examination Survey 19992004 results. * p<0.05 for comparison between Alaska region fluoridated and nonfluoridated water systems; no statistical comparison could be made between the Alaska region and the total United States because of differences in survey methodology.

had one or more decayed permanent tooth (DT >0). The mean DMFT ranged from 1.6 to 5.6. Among children aged 615 years from fluoridated villages, 31%91% had one or more decayed, missing, or filled permanent tooth (DMFT >0), and 18%68% had one or more decayed permanent tooth (DT >0). The mean DMFT among children aged 615 years from fluoridated villages ranged from 0.5 to 2.7 (Table 1, Figure).

Dental caries severity was greater in nonfluoridated villages. Children from nonfluoridated villages had 1.22.9 times higher mean dft or DMFT than children from fluoridated villages and 1.23.1 times the mean number of decayed teeth (Figure). Children from the Alaska region had 1.54.5 times the number of dft or DMFT than same-aged U.S. children

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and 1.69.0 times the number of decayed teeth (Figure). On age-adjusted bivariate analysis, only lack of water fluoridation, increased soda pop consumption, and infrequent brushing of teeth were significantly associated with dental caries severity in primary and permanent teeth (all p-values <0.05). On multivariate analysis, only lack of water fluoridation and soda pop consumption were associated with dental caries severity. The adjusted odds ratio (AOR) for lack of water fluoridation was 3.5 and 1.7 for primary teeth and permanent teeth, respectively. Odds of dental caries increased with increased soda pop consumption; AORs were 1.1 and 1.3 in children drinking one soda pop per day in primary and permanent teeth, respectively, and 1.5 and 2.0 in children drinking three or more soda pops per day for primary and permanent teeth, respectively (p0.02 for trend). No other risk factor, including infrequent brushing or lack of dental floss use, was associated with dental caries severity (Table 2).
Reported by

TABLE 2. Multivariate analysis* of risk factors associated with dental caries severity in primary (dft) and permanent teeth (DMFT) among children from five villages in rural Alaska, 2008
Primary teeth (dft) Risk factor Water fluoridation Fluoridated Not fluoridated Soda pop/day 0 1 2 3 Brushed teeth (days/wk) 1 2 3 4 5 6 7 AOR (95% CI) Referent 3.5 (2.84.3) Referent 1.14 (1.031.31) 1.30 (1.061.66) 1.49 (1.102.13) p-value Permanent teeth (DMFT) AOR (95% CI) Referent 1.7 (1.4 2.1) p-value

<0.001

<0.001

0.02

Referent 1.27 (1.181.37) 1.61 (1.391.87) 2.04 (1.632.56) <0.001

1.33 (0.991.79) 1.27 (0.991.62) 1.21 (0.991.47) 1.15 (0.991.34) 1.10 (0.991.21) 1.05 (0.991.10) Referent

0.06

Joseph Klejka, MD, Yukon-Kuskokwim Health Corp; Meghan Swanzy, DDS, Southcentral Foundation; Bradley Whistler, DMD, Alaska Dept of Health and Social Svcs. Caroline Jones, MD, Emory Univ School of Medicine, Atlanta, Georgia. Michael G. Bruce, MD, Thomas W. Hennessy, MD, Dana Bruden, MS, Stephanie Rolin, MPH, Arctic Investigations Program, National Center for Emerging and Zoonotic Infectious Diseases; Eugenio Beltrn-Aguilar, DMD, DrPH, Div of Oral Health, National Center for Chronic Disease Prevention and Health Promotion; Kathy K. Byrd, MD, Farah Husain, DMD, EIS officers, CDC. Corresponding contributor: Kathy K. Byrd, kbyrd@cdc.gov, 404-718-8541.
Editorial Note

Abbreviations: AOR = adjusted odds ratio; CI = confidence interval; dft = decayed and/or filled primary teeth; DMFT = decayed, missing because of caries, and/or filled permanent teeth. * The regression model was performed using backward selection of risk factors; no ORs are listed for tooth brushing in permanent teeth because this variable was not included in the final model after backward selection. p-value for trend.

Based on archeologic evidence, approximately 1% of the AN population had dental caries in the mid-1920s (4). Starting in the 1940s, air transportation into Alaskan villages became more frequent, as did the transport of processed foods. This led to gradual dietary changes among the AN population, from a diet of fish and game, to a diet high in carbohydrates. By 1999, an Indian Health Service dental survey found that 64% of American Indian (AI) and AN children aged 614 years, throughout the United States, had dental caries in their permanent teeth (5). In 2005, the Alaska DHSS determined that 75% of AN kindergarteners, statewide, had dental caries (6). In contrast, since the beginning of the 20th century, the prevalence and severity of dental caries in the United States has decreased among most age groups (1) as a result of water fluoridation, use of fluoride toothpaste and other topical fluorides, and other factors. Approximately 72% of the U.S. population receives fluoridated water from public

water systems (7). Water fluoridation is one of the most cost-effective methods of preventing and controlling dental caries (7). Optimally fluoridated water can decrease dental caries by 30%50% (7), potentially resulting in substantial cost savings from averted treatment costs. The average cost of an FMDR is approximately $6,000 per case, whereas the yearly operational cost of fluoridating AN villages that have piped water distribution is approximately $4 per person (7). However, 40% of the villages in the Alaska region lack piped water systems suitable for fluoridation, and additional piped water systems need to be built. Increased use of fluoride varnishes might provide additional preventive benefits (8). Fluoride varnishes are easily applied to teeth by health-care professionals in dental and nondental settings after minimal training. In Alaska, dental health aide therapists, community health aides, and community health practitioners are providing fluoride varnishes in remote villages that have limited access to dentists. Even with an optimally fluoridated water supply, fluoride varnish applied at least four times from ages 9 to 30 months reduced caries prevalence by approximately 35% among AI children in one small, observational study (9). Soda pop consumption, an important risk factor for dental caries in the region, has been linked to other prevalent medical conditions among the AN population, including obesity and type II diabetes (10). Multiple health

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What is already known about this subject? Childhood dental caries can cause pain, which might affect growth and social interactions with others. What is added by this report? Alaska Native (AN) children in a remote region of the state had a high prevalence and severity of dental caries. Those living in communities with fluoridated water had fewer and less severe dental caries than those in communities without fluoridation. Reported soda pop consumption was associated with an approximately 30% increased risk for caries in permanent teeth for each soda pop consumed per day. What are the implications for public health practice? Water fluoridation is an effective and relatively inexpensive method of reducing dental caries; however, many rural AN villages have no in-home water or sanitation services, which prevents these villages from fluoridating. Because of this, additional preventive services, such as providing fluoride varnishes, are necessary to improve the dental health of rural AN children. In addition, decreasing soda pop consumption might result in fewer dental caries in primary and permanent teeth.

villages and state and federal agencies to implement preventive interventions should be encouraged.
Acknowledgments Matthew West, DMD, Sarah Shoffstall, DDS, Patty Smith, Suzy Eberling, DDS, Kim Boyd-Hummel, Troy Ritter, MPH, Jennifer Dobson, Jim Singleton, DDS, Ron Nagel, DDS, Joe McLaughlin, MD, and participating village school teachers and administrators. References
1. US Department of Health and Human Services. Oral health in America: a report of the Surgeon General. Washington, DC: US Department of Health and Human Services, National Institute of Health; 2000. 2. Dye BA, Tan S, Smith V, et al. Trends in oral health status: United States, 19941998 and 19992004. Vital Health Stat 2007;11(248):192. 3. World Health Organization. Oral health surveysbasic methods. 4th ed. Geneva, Switzerland: World Health Organization; 1997. 4. Zitzow RE. The relationship of diet and dental caries in the Alaska Eskimo population. Alaska Med 1979;21:103. 5. Indian Health Service. The 1999 oral health survey of American Indian and Alaska Native dental patients. Rockville, MD: Indian Health Service, Division of Dental Services; 2002. 6. Hardison JD. Results of the 2005 oral health survey of Alaskan kindergarteners: Alaska oral health basic screening survey. Contractors report for the Oral Health Program, Alaska Department of Health and Social Services; 2006. Available at http://www.hss.state.ak.us/dph/wcfh/ oralhealth/docs/2005_oralhealth_k.pdf. Accessed September 16, 2011. 7. Griffin SO, Jones K, Tomar SL. An economic evaluation of community water fluoridation. J Public Health Dentistry 2001;61:7886. 8. Wetterhall S, Burrus B, Shugars D, Bader J. Cultural context in the effort to improve oral health among Alaska Native people: the dental health aide therapist model. Am J Public Health 2011;101:183640. 9. Holve S. An observational study of the association of fluoride varnish applied during well child visits and the prevention of early childhood caries in American Indian children. Matern Child Health J 2008;12 (Suppl 1):647. 10. Malik VS, Schulze MB, Hu FB. Intake of sugar-sweetened beverages and weight gain: a systematic review. Am J Clin Nutr 2006;84:27488.

benefits in AN populations might result from decreasing soda pop consumption. The findings in this report are subject to at least one limitation. This investigation used a small convenience sample, which limits the statistical power and the generalizability of the results. The small sample size might explain why some known protective factors, such as brushing with fluoridated toothpaste, were only marginally significant in the multivariate model. In this investigation, AN children, including children from fluoridated communities, had much higher dental caries prevalence and severity than same-aged U.S. children. Thus, additional risk factors (e.g., diet), some of which might not have been captured in this investigation, contributed to higher levels of disease. The investigation suggests that fluoridating village water systems likely would decrease the prevalence and severity of dental caries among AN children in the region who live in villages without fluoridated water. Collaborations between the

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FDA Approval of Expanded Age Indication for a Tetanus Toxoid, Reduced Diphtheria Toxoid and Acellular Pertussis Vaccine
On July 8, 2011, the Food and Drug Administration (FDA) approved an expanded age indication for the tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine (Tdap) Boostrix (GlaxoSmithKline Biologicals, Rixensart, Belgium). Originally, Boostrix was licensed in 2005 for persons aged 10 through 18 years, but in 2008, FDA approved an expanded age indication for Boostrix to include persons aged 19 through 64 years (1). FDA has now expanded the age indication to include persons aged 65 years and older. Boostrix is now licensed for use in persons aged 10 years and older as a single-dose booster vaccination (2). This notice summarizes the indications for use of Boostrix. Recommendations of the Advisory Committee on Immunization Practices (ACIP) for Tdap vaccines have been published previously (36). Publication of revised Tdap recommendations within the next year is anticipated. On October 27, 2010, ACIP was presented data on the safety and immunogenicity of Boostrix in adults aged 65 years and older (6). Data were reviewed by ACIP from two clinical trials on the safety and immunogenicity of Boostrix in adults in this age group. The safety and reactogenicity profiles of Boostrix generally were similar to currently available tetanus and diphtheria toxoids (Td) vaccine. Immunogenicity of pertussis vaccine components was inferred using a serologic bridge to infants vaccinated with pediatric diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP), as defined by the Vaccines and Related Biological Products Advisory Committee (7). For diphtheria and tetanus, immune responses to Boostrix were noninferior to the immune responses elicited by a comparator Td vaccine licensed in the United States (2). Immune responses to pertussis antigens (pertussis toxin [PT], filamentous haemagglutinin [FHA], and pertactin [PRN]) were noninferior to those observed following a 3-dose primary DTaP series with Infanrix (GlaxoSmithKline Biologicals) in a clinical trial in which clinical efficacy of DTaP also was demonstrated (2,8,9). Boostrix contains the same three pertussis antigens as Infanrix but in reduced quantities. The geometric mean concentrations for pertussis antibodies (PT, FHA, and PRN) after Boostrix administration increased 7.4 to 13.7-fold.* There are no contraindications to the co-administration of Tdap
* Additional information available at http://clinicaltrials.gov/ct2/show/results/ nct00835237.

and influenza vaccine (2). No data on the administration of Tdap with other vaccines recommended for persons aged 65 years and older (e.g., zoster and pneumococcal polysaccharide vaccines) are available. However, Tdap can be administered with other indicated vaccines during the same visit.

Indications and Guidance for Use

For prevention of tetanus, diphtheria, and pertussis, ACIP recommends that adolescents and adults receive a one-time booster dose of Tdap. Adolescents aged 11 through 18 years who have completed the recommended childhood diphtheria and tetanus toxoids and pertussis vaccine (DTP/DTaP) vaccination series should receive a single dose of Tdap instead of tetanus and diphtheria toxoids (Td) vaccine, preferably at a preventive-care visit at age 11 or 12 years (4). For adults aged 19 through 64 years who previously have not received a dose of Tdap, a single dose of Tdap should replace a single decennial Td booster dose (3). Persons aged 65 years and older (e.g., grandparents, child-care providers, and healthcare practitioners) who have or who anticipate having close contact with an infant aged less than 12 months and who previously have not received Tdap should receive a single dose of Tdap to protect against pertussis and reduce the likelihood of transmission (6). For other adults aged 65 years and older, a single dose of Tdap vaccine may be administered instead of Td vaccine in persons who previously have not received Tdap (6). Tdap can be administered regardless of interval since the last tetanus or diphtheria toxoidcontaining vaccine (6). After receipt of Tdap, persons should continue to receive Td for routine booster vaccination against tetanus and diphtheria, in accordance with previously published guidelines (3,4,6). Currently, two Tdap products are licensed for use in the United States, Boostrix and Adacel (Sanofi Pasteur, Toronto, Canada). Adacel has been approved by FDA as a single dose in persons aged 11 through 64 years (10). With the recent FDA expanded licensure for use of Boostrix, ACIP will be reviewing the current recommendations on use of Tdap in persons aged 65 years and older. At this time, either Tdap product may be used in persons aged 65 years and older (6).

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References
1. CDC. FDA approval of expanded age indication for a tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine. MMWR 2009;58:3745. 2. Food and Drug Administration. Product approval information licensing action, package insert: tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine, adsorbed (Boostrix, GlaxoSmithKline Biologicals). Rockville, MD: US Department of Health and Human Services, Food and Drug Administration; 2011. Available at http://www.fda.gov/downloads/biologicsbloodvaccines/ ucm152842.pdf. Accessed September 9, 2011. 3. CDC. Preventing tetanus, diphtheria, and pertussis among adults: use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine. Recommendations of the Advisory Committee on Immunization Practices (ACIP) and recommendation of ACIP, supported by the Healthcare Infection Control Practices Advisory Committee (HICPAC), for use of Tdap among health-care personnel. MMWR 2006;55(No. RR-17). 4. CDC. Preventing tetanus, diphtheria, and pertussis among adolescents: use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccines. Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2006;55(No. RR-3). 5. CDC. Prevention of pertussis, tetanus, and diphtheria among pregnant and postpartum women and their infants: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2008;57(No. RR-4).

6. CDC. Updated recommendations for use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis (Tdap) vaccine from the Advisory Committee on Immunization Practices, 2010. MMWR 2011; 60:135. 7. Food and Drug Administration. Proceedings from the Vaccines and Related Biological Products Advisory Committee meeting, convened June 5, 1997, in Bethesda, Maryland. Day one. Rockville, MD: US Department of Health and Human Services, Food and Drug Administration; 1997. Available at http://www.fda.gov/ohrms/dockets/ ac/97/transcpt/3300t1.pdf. Accessed September 9, 2011. 8. Food and Drug Administration. Summary basis for regulatory action. Rockville, MD: US Department of Health and Human Services, Food and Drug Administration; 2011. Available at http://www.fda.gov/ downloads/biologicsbloodvaccines/vaccines/approvedproducts/ ucm262892.pdf. Accessed September 9, 2011. 9. Schmitt HJ, von Konig CH, Neiss A, et al. Efficacy of acellular pertussis vaccine in early childhood after household exposure. JAMA 1996;275:3741. 10. Food and Drug Administration. Product approval information licensing action, package insert: tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine adsorbed (Adacel, Sanofi Pasteur). Rockville, MD: US Department of Health and Human Services, Food and Drug Administration; 2005. Available at http://www.fda.gov/ downloads/biologicsbloodvaccines/vaccines/approvedproducts/ ucm142764.pdf. Accessed September 9, 2011.

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Notes from the Field

Measles Among U.S.-Bound Refugees from Malaysia California, Maryland, North Carolina, and Wisconsin, AugustSeptember 2011
On August 26, 2011, California public health officials notified CDC of a suspected measles case in an unvaccinated male refugee aged 15 years from Burma (the index patient), who had lived in an urban area of Kuala Lumpur, Malaysia, which is experiencing ongoing measles outbreaks. Currently, approximately 92,000 such refugees are living in urban communities in Malaysia (1). Resettlement programs in the United States and other countries are ongoing. The health and vaccination status of urban refugees are largely unknown. The index patient developed a fever on August 21 and a rash on August 22. He and his family (his mother and two siblings, aged 13 and 16 years) departed Malaysia on August 24 and arrived the same day in Los Angeles, California, where they stayed overnight. He was hospitalized for suspected measles on August 25. Serologic testing for immunoglobulin M confirmed the diagnosis of measles on August 30 (2). The sibling aged 16 years was unvaccinated and had onset of a febrile rash illness in Malaysia on August 18. Serologic testing performed on August 30 in Los Angeles indicated evidence of recent measles infection. However, the sibling was not infectious during the flight. On September 1, Maryland public health officials notified CDC of laboratory-confirmed cases of measles in two unvaccinated refugee children (aged 7 months and 2 years) who were on the same flight as the index patient. A suspected case of measles in an unvaccinated refugee aged 14 years, who had traveled on the same flight, was reported by North Carolina public health officials on September 4 and confirmed on September 9. Whether these three patients were exposed to measles in Malaysia or during travel to the United States is unclear. On September 7, CDC was notified of another laboratory-confirmed case in an unvaccinated refugee child aged 23 months from Burma who traveled from Malaysia to Wisconsin through Los Angeles on August 24, but on a different flight than the index patient. Thirty-one refugees who traveled from Malaysia on the same flight with the index patient on August 24 arrived in the following seven states: Maryland, North Carolina, New Hampshire, Oklahoma, Texas, Washington, and Wisconsin. State and local health departments and CDC were contacted and initiated contact investigations and response activities. As of September 12, contact investigations and heightened surveillance had revealed three additional laboratory-confirmed measles cases that were epidemiologically linked to the index patient: one case in a U.S. Customs and Border Protection Officer with unknown vaccination status who processed the index patient in the Los Angeles airport (reported by California public health officials on September 8), and two cases in nonrefugee, unvaccinated children (aged 12 months and 19 months) who were seated nine rows from the index patient during the flight (reported by California public health officials on September 9). Rapid control efforts by state and local public health agencies have been a key factor in limiting the size of this outbreak and preventing the spread of measles in communities with increased numbers of unvaccinated persons. To prevent measles transmission and importation in this refugee population, refugee travel from Malaysia to the United States was temporarily suspended. CDC recommended that 1) U.S.-bound refugees in Malaysia without evidence of measles immunity (3) be vaccinated with measles, mumps, and rubella (MMR) vaccine and their travel be postponed for 21 days after vaccination; 2) refugees arriving in the United States receive their post-arrival health examinations as soon as feasible; 3) clinicians consider measles as a diagnosis in a refugee with a febrile rash illness and clinically compatible symptoms (i.e., cough, coryza, and/or conjunctivitis); 4) patients with suspected measles be isolated and appropriate specimens be obtained for measles confirmation and virus genotyping; and 5) cases be reported promptly to local health departments. To prevent measles in U.S. residents at home and abroad, CDC recommends that eligible persons without evidence of measles immunity (3) be vaccinated as recommended. Before international travel, infants aged 611 months should receive 1 MMR vaccine dose, and persons aged 12 months should receive 2 doses unless they have other evidence of measles immunity (3).
Reported by

Jennifer Zipprich, PhD, Kathleen Harriman, PhD, John Talarico, DO, California Dept of Public Health. Cindy Edwards, MHCA, Montgomery County Dept of Health and Human Svcs; David Blythe, MD, Dipti Shah, MPH, Maryland Dept of Health and Mental Hygiene. Jennifer Morillo, Sheree Smith, North Carolina Div of Public Health. Daniel Hopfensperger, Savitri Tsering, MSSW, Wisconsin Dept of Health Svcs. Greg Wallace, MD, Albert Barskey, MPH, Preeta Kutty, MD, Gregory Armstrong, MD, Div of Viral Diseases, National Center for Immunization and Respiratory Diseases; Karen Marienau, MD, Juliana Berliet,

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MPH, Keysha Ross, Christopher Schembri, MPH, Heather Burke, MA, MPH, Deborah Lee, MPH, Sharmila Shetty, MD, Michelle Weinberg, MD, Weigong Zhou, MD, PhD, Div of Global Migration and Quarantine, National Center for Emerging and Zoonotic Infectious Diseases; Maria Said, MD, Eboni Taylor, PhD, EIS officers, CDC. Corresponding contributor: Eboni Taylor, etaylor1@cdc.gov, 404-639-4511.
Acknowledgments International Organization for Migration. Assoc of Refugee Health Coordinators. Long Beach Dept of Health and Human Svcs; Immunization Program, Los Angeles County Dept of Public Health, California. Mark Hodge, MS, Montgomery County Dept of Health and Human Svcs, Maryland. Bur of Population, Refugees, and Migration, US Dept of State. Kim Crocker, Los Angeles Quarantine Station, Miguel Ocaa, MD, Washington, DC Quarantine Station, Clive Brown, MD, Div of Global Migration and Quarantine, National Center for Emerging and Zoonotic Infectious Diseases, CDC.

References
1. International Catholic Migration Commission. Combating gender-based violence (GBV) among urban refugees in Malaysia. Geneva, Switzerland: International Catholic Migration Commission; 2011. Available at http:// www.icmc.net/activities/combating-gender-based-violence-gbv-amongurban-refugees-malaysia. Accessed September 16, 2011. 2. CDC. Case definitions for infectious conditions under public health surveillance (measles). Atlanta, GA: US Department of Health and Human Services, CDC; 2011. Available at http://www.cdc.gov/osels/ph_surveillance/ nndss/casedef/measles_2010.htm. Accessed September 16, 2011. 3. CDC. Measles, mumps, and rubellavaccine use and strategies for elimination of measles, rubella, and congenital rubella syndrome and control of mumps: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 1998;47(No. RR-8).

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Announcements
Final State-Level 201011 Influenza Vaccination Coverage Estimates Available Online
Final state-specific influenza vaccination coverage estimates for the 201011 season are now available online at FluVaxView (http://www.cdc.gov/flu/professionals/vaccination/ vaccinecoverage.htm). The online information includes estimates of the cumulative percentage of persons vaccinated by the end of each month, from August 2010 through May 2011, for each state, for each U.S. Department of Health and Human Services region, and for the United States overall. Analyses were conducted using Behavioral Risk Factor Surveillance System data for adults aged 18 years and National Immunization Survey data for children aged 6 months17 years. Estimates are provided by age group and race/ethnicity. These estimates are presented using an interactive feature, complemented by an online summary report. This posting updates the estimates presented in the MMWR report, Interim Results: StateSpecific Influenza Vaccination Coverage United States, August 2010February 2011 (1).
Reference
1. CDC. Interim results: state-specific seasonal influenza vaccination coverageUnited States, August 2010February 2011. MMWR 2011;60:73743.

National Gay Mens HIV/AIDS Awareness Day: Focus on HIV Testing September 27, 2011
National Gay Mens HIV/AIDS Awareness Day is observed each year on September 27 to focus on the continuing serious and disproportionate effects of the human immunodeficiency virus infection (HIV) on gay, bisexual, and other men who have sex with men (MSM) in the United States. In 2008, an estimated 580,000 MSM were living with HIV infection (1). Although HIV testing has been recommended at least annually for persons with ongoing risk for exposure to HIV infection (2), recent data suggest that MSM might benefit from being tested more frequently than once per year. MSM represent approximately 2% of the U.S. population (3), but in 2009 they accounted for 64% of all new HIV infections (including MSM who were also injection drug users [3% of new infections]) (4). Based on CDCs 2008 National Behavioral Surveillance (NHBS) data, 19% of sexually active

MSM were infected with HIV, but 44% of infected MSM were unaware of their infection (5). Of MSM with undiagnosed HIV infection, 45% had been tested within the previous 12 months, and 29% within the previous 6 months (6). CDCs 2010 sexually transmitted disease treatment guidelines already recommend more frequent HIV retesting for MSM who have multiple or anonymous partners, who have sex in conjunction with illicit drug use (particularly methamphetamine use), or whose partners participate in these activities (7). However, among MSM in NHBS who had been tested for HIV within the past 12 months, the prevalence of undiagnosed HIV among MSM who reported these high-risk behaviors (7%) was similar to that among those who did not (8%) (6). Based on these findings, sexually active MSM might benefit from more frequent HIV testing (e.g., every 3 to 6 months) (6). CDC is using the 2011 National Gay Mens HIV/AIDS Awareness Day as an opportunity to highlight this information for gay men and their health-care providers. Additional information is available at http:/www.cdc.gov/msmhealth. CDC supports a range of efforts to reduce HIV infection among MSM. These include HIV prevention services that reduce the risk for acquiring and transmitting HIV, increase diagnosis of HIV infection, and support the linkage of MSM with HIV infection to treatment. Additional information about these efforts is available at http://www.cdc.gov/msmhealth. Additional information about National Gay Mens HIV/AIDS Awareness Day is available at http://www.cdc.gov/features/ngmhaad.
References
1. CDC. HIV surveillanceUnited States, 19812008. MMWR 2011; 60:68993. 2. CDC. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR 2006;55(No. RR-14). 3. Purcell DW, Johnson C, Lansky A, et al. Calculating HIV and syphilis rates for risk groups: estimating the national population size of MSM. Presented at the 2010 National STD Prevention Conference; Atlanta, GA, March 10, 2010. 4. Prejean J, Song R, Hernandez A, et al. Estimated HIV incidence in the United States, 20062009. PLoS One 2011;6:e17502. 5. CDC. Prevalence and awareness of HIV infection among men who have sex with men21 cities, United States, 2008. MMWR 2010;59:12017. 6. CDC. HIV testing among men who have sex with men21 cities, United States, 2008. MMWR 2011;60:6949. 7. CDC. Sexually transmitted disease treatment guidelines, 2010. MMWR 2010;59(No. RR-12).

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Errata
Vol. 60, No. 28
On page 974, in Table III, Deaths in 122 U.S. cities, data for week 28, ending July 16, 2011, data were incorrectly reported for Des Moines, IA. The correct data for All Ages, 65, 4564, 2544, 124, <1 and P&I Total, respectively, are as follows: 122, 83, 28, 5, 4, 2, and 10. The incorrect city data resulted in incorrect entries for two totals. The correct data for All Ages, 65, 4564, 2544, 124, <1, and P&I Total, respectively, are as follows: W.N. Central (504, 322, 126, 35, 16, 5, and 37) and Total (11, 102, 7,277, 2,636, 717, 273, 193, and 685). The corrected table for week 28 is available at http://wonder. cdc.gov/mmwr/mmwrmort.asp.

Vol. 60, No. 34

In the report, Human Rabies Wisconsin, 2010, an error appeared in the second to last sentence of the first full paragraph on p. 1165. The sentence should read as follows: An echocardiogram revealed a normal ejection fraction with diastolic dysfunction but no regional wall motion abnormalities.

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QuickStats
FROM THE NATIONAL CENTER FOR HEALTH STATISTICS

Location of Death for Decedents Aged 85 Years United States, 19892007

100 90 80 70 Hospital (inpatient) Nursing home Residence Other*

Percentage

60 50 40 30 20 10 0 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007

Year
* Includes hospital outpatient or emergency department, including dead on arrival, inpatient hospice facilities, and all other places and unknown. Beginning in 2003, the term long-term care facility was added to the nursing home check box on the death certificate.

Approximately 700,000 deaths occurred among persons aged 85 years in 2007, accounting for nearly 30% of all deaths in the United States. Forty percent of these deaths occurred in nursing homes or other long-term care facilities. The percentage of decedents aged 85 years who died while a hospital inpatient decreased from 40% in 1989 to 29% in 2007. The percentage of decedents aged 85 years who died at home increased from 12% in 1989 to 19% in 2007.
Source: National Vital Statistics System. Mortality public use data files, 19892007. Available at http://www.cdc.gov/nchs/nvss.htm.

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Notifiable Diseases and Mortality Tables

TABLE I. Provisional cases of infrequently reported notifiable diseases (<1,000 cases reported during the preceding year) United States, week ending September 17, 2011 (37th week)*
Disease Anthrax Arboviral diseases , : California serogroup virus disease Eastern equine encephalitis virus disease Powassan virus disease St. Louis encephalitis virus disease Western equine encephalitis virus disease Babesiosis Botulism, total foodborne infant other (wound and unspecified) Brucellosis Chancroid Cholera Cyclosporiasis Diphtheria Haemophilus influenzae,** invasive disease (age <5 yrs): serotype b nonserotype b unknown serotype Hansen disease Hantavirus pulmonary syndrome Hemolytic uremic syndrome, postdiarrheal , Influenza-associated pediatric mortality Listeriosis Measles Meningococcal disease, invasive: A, C, Y, and W-135 serogroup B other serogroup unknown serogroup Novel influenza A virus infections*** Plague Poliomyelitis, paralytic Polio virus Infection, nonparalytic Psittacosis Q fever, total acute chronic Rabies, human Rubella Rubella, congenital syndrome SARS-CoV Smallpox Streptococcal toxic-shock syndrome Syphilis, congenital (age <1 yr) Tetanus Toxic-shock syndrome (staphylococcal) Trichinellosis Tularemia Typhoid fever Vancomycin-intermediate Staphylococcus aureus Vancomycin-resistant Staphylococcus aureus Vibriosis (noncholera Vibrio species infections) Viral hemorrhagic fever Yellow fever

Current week 7 2 3 18 2 3 1 3 1 17

Cum 2011 56 2 12 1 399 65 8 50 7 49 12 27 128 5 81 158 29 18 107 112 402 165 131 67 10 204 6 3 2 68 49 19 3 84 133 6 52 8 91 227 46 445

5-year weekly average 0 3 0 0 0 1 3 0 2 0 2 0 0 2 1 2 2 2 0 8 2 22 1 4 2 0 7 0 0 0 3 2 0 0 1 8 1 2 0 2 13 1 19

Total cases reported for previous years 2010 75 10 8 10 NN 112 7 80 25 115 24 13 179 23 200 223 98 20 266 61 821 63 280 135 12 406 4 2 4 131 106 25 2 5 142 377 26 82 7 124 467 91 2 846 1 2009 1 55 4 6 12 NN 118 10 83 25 115 28 10 141 35 236 178 103 20 242 358 851 71 301 174 23 482 43,774 8 1 9 113 93 20 4 3 2 161 423 18 74 13 93 397 78 1 789 NN 2008 62 4 2 13 NN 145 17 109 19 80 25 5 139 30 244 163 80 18 330 90 759 140 330 188 38 616 2 3 8 120 106 14 2 16 157 431 19 71 39 123 449 63 588 NN 2007 1 55 4 7 9 NN 144 32 85 27 131 23 7 93 22 199 180 101 32 292 77 808 43 325 167 35 550 4 7 12 171 1 12 132 430 28 92 5 137 434 37 2 549 NN 2006 1 67 8 1 10 NN 165 20 97 48 121 33 9 137 29 175 179 66 40 288 43 884 55 318 193 32 651 NN 17 NN 21 169 3 11 1 125 349 41 101 15 95 353 6 1 NN NN

States reporting cases during current week (No.)

NY (7)

NYC (1), CO (1)

FL (1), CA (2) PA (1), OH (1), NE (2), FL (1), OK (4), CO (6), NM (1), CA (2)

MD (1), TX (1) FL (2), ID (1)

PA (1)

NY (1), MD (1), GA (1) NY (1) PA (1), MD (1), GA (1), FL (3), CO (1), WA (8), CA (2)

See Table 1 footnotes on next page.

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Morbidity and Mortality Weekly Report

TABLE I. (Continued) Provisional cases of infrequently reported notifiable diseases (<1,000 cases reported during the preceding year) United States, week ending September 17, 2011 (37th week)*
: No reported cases. N: Not reportable. NN: Not Nationally Notifiable. Cum: Cumulative year-to-date counts. * Case counts for reporting years 2010 and 2011 are provisional and subject to change. For further information on interpretation of these data, see http://www.cdc.gov/osels/ph_surveillance/ nndss/phs/files/ProvisionalNationa%20NotifiableDiseasesSurveillanceData20100927.pdf. Calculated by summing the incidence counts for the current week, the 2 weeks preceding the current week, and the 2 weeks following the current week, for a total of 5 preceding years. Additional information is available at http://www.cdc.gov/osels/ph_surveillance/nndss/phs/files/5yearweeklyaverage.pdf. Not reportable in all states. Data from states where the condition is not reportable are excluded from this table except starting in 2007 for the arboviral diseases, STD data, TB data, and influenza-associated pediatric mortality, and in 2003 for SARS-CoV. Reporting exceptions are available at http://www.cdc.gov/osels/ph_surveillance/nndss/phs/infdis.htm. Includes both neuroinvasive and nonneuroinvasive. Updated weekly from reports to the Division of Vector-Borne Infectious Diseases, National Center for Zoonotic, Vector-Borne, and Enteric Diseases (ArboNET Surveillance). Data for West Nile virus are available in Table II. ** Data for H. influenzae (all ages, all serotypes) are available in Table II. Updated weekly from reports to the Influenza Division, National Center for Immunization and Respiratory Diseases. Since October 3, 2010, 116 influenza-associated pediatric deaths occurring during the 2010-11 influenza season have been reported. No measles cases were reported for the current week. Data for meningococcal disease (all serogroups) are available in Table II. *** CDC discontinued reporting of individual confirmed and probable cases of 2009 pandemic influenza A (H1N1) virus infections on July 24, 2009. During 2009, four cases of human infection with novel influenza A viruses, different from the 2009 pandemic influenza A (H1N1) strain, were reported to CDC. The four cases of novel influenza A virus infection reported to CDC during 2010, and the six cases reported during 2011, were identified as swine influenza A (H3N2) virus and are unrelated to the 2009 pandemic influenza A (H1N1) virus. Total case counts are provided by the Influenza Division, National Center for Immunization and Respiratory Diseases (NCIRD). No rubella cases were reported for the current week. Updated weekly from reports to the Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. There was one case of viral hemorrhagic fever reported during week 12 of 2010. The one case report was confirmed as lassa fever. See Table II for dengue hemorrhagic fever.

FIGURE I. Selected notifiable disease reports, United States, comparison of provisional 4-week totals September 17, 2011, with historical data
DISEASE Giardiasis Hepatitis A, acute Hepatitis B, acute Hepatitis C, acute Legionellosis Measles Meningococcal disease Mumps Pertussis 0.25 0.5 1 Ratio (Log scale)* Beyond historical limits 2 4 DECREASE INCREASE CASES CURRENT 4 WEEKS 845 61 111 49 234 4 8 12 512

* Ratio of current 4-week total to mean of 15 4-week totals (from previous, comparable, and subsequent 4-week periods for the past 5 years). The point where the hatched area begins is based on the mean and two standard deviations of these 4-week totals.

Notifiable Disease Data Team and 122 Cities Mortality Data Team Jennifer Ward Deborah A. Adams Rosaline Dhara Willie J. Anderson Pearl C. Sharp Lenee Blanton Michael S. Wodajo

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TABLE II. Provisional cases of selected notifiable diseases, United States, weeks ending September 17, 2011, and September 18, 2010 (37th week)*
Chlamydia trachomatis infection Reporting area United States New England Connecticut Maine Massachusetts New Hampshire Rhode Island Vermont Mid. Atlantic New Jersey New York (Upstate) New York City Pennsylvania E.N. Central Illinois Indiana Michigan Ohio Wisconsin W.N. Central Iowa Kansas Minnesota Missouri Nebraska North Dakota South Dakota S. Atlantic Delaware District of Columbia Florida Georgia Maryland North Carolina South Carolina Virginia West Virginia E.S. Central Alabama Kentucky Mississippi Tennessee W.S. Central Arkansas Louisiana Oklahoma Texas Mountain Arizona Colorado Idaho Montana Nevada New Mexico Utah Wyoming Pacific Alaska California Hawaii Oregon Washington Territories American Samoa C.N.M.I. Guam Puerto Rico U.S. Virgin Islands Current week 13,239 756 172 465 4 80 35 1,690 730 208 752 524 23 189 180 132 448 11 1 373 46 17 4,546 92 165 948 675 285 1,228 571 515 67 1,018 269 478 271 2,254 291 359 152 1,452 737 128 255 40 58 175 75 6 1,266 987 279 115 Previous 52 weeks Med 26,039 862 219 59 419 53 76 26 3,405 519 712 1,157 957 3,974 1,081 476 921 1,005 458 1,458 211 195 279 538 109 43 63 5,237 85 108 1,494 981 455 827 516 653 78 1,840 528 267 398 595 3,366 320 499 224 2,404 1,649 512 411 80 61 201 193 129 38 3,909 109 2,981 108 267 423 0 6 102 16 Max 31,142 2,043 1,557 100 860 81 154 84 5,069 931 2,099 2,612 1,240 7,039 1,320 3,376 1,408 1,134 559 1,668 255 288 368 759 218 90 93 6,685 220 180 1,698 2,384 1,125 1,477 946 965 121 3,314 1,566 2,352 696 795 4,338 440 1,052 850 3,107 2,155 698 848 235 89 380 1,183 175 90 6,559 157 5,763 138 524 522 0 81 349 27 Cum 2011 924,050 31,143 7,106 2,213 15,938 1,927 2,929 1,030 119,802 18,805 25,292 39,487 36,218 137,453 34,873 18,805 32,515 35,398 15,862 50,900 7,439 6,897 8,610 19,863 4,341 1,407 2,343 194,689 3,041 3,911 54,180 36,543 16,274 34,341 19,994 23,486 2,919 67,123 19,732 11,086 14,862 21,443 124,530 11,658 16,110 7,557 89,205 60,145 17,659 16,370 2,895 2,350 7,695 7,170 4,662 1,344 138,265 3,916 107,286 3,467 9,737 13,859 189 3,819 539 Cum 2010 914,746 28,830 7,487 1,812 14,526 1,676 2,444 885 119,600 18,599 23,766 43,919 33,316 145,225 42,824 14,156 35,241 36,474 16,530 51,288 7,500 6,938 11,035 18,359 3,555 1,666 2,235 184,421 3,126 3,839 54,046 31,471 16,932 31,599 18,639 22,106 2,663 65,566 18,898 11,054 15,621 19,993 125,574 11,043 18,690 10,143 85,698 59,178 19,360 13,822 2,757 2,162 7,227 7,682 4,688 1,480 135,064 4,401 103,278 4,388 7,965 15,032 691 4,353 412 Current week 53 50 50 3 3 Coccidioidomycosis Previous 52 weeks Med 291 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 267 265 0 0 0 1 0 0 0 13 0 12 0 0 0 0 0 0 0 Max 502 1 0 0 0 1 0 0 1 0 0 0 1 5 0 0 3 3 0 2 0 0 0 0 2 0 0 2 0 0 0 0 2 0 0 0 0 0 0 0 0 0 1 0 1 0 0 455 453 0 0 2 5 4 2 2 77 0 77 0 1 0 0 0 0 0 Cum 2011 10,793 1 1 3 3 37 22 15 6 6 3 3 1 1 9,864 9,745 3 67 36 10 3 878 873 5 Cum 2010 NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN Current week 129 1 1 12 7 5 51 51 23 21 2 20 12 4 1 2 1 2 1 1 10 1 9 6 3 1 1 1 4 2 2 N N Cryptosporidiosis Previous 52 weeks Med 133 5 0 1 2 1 0 1 17 0 4 2 9 32 3 5 5 9 8 19 6 0 0 4 4 0 2 21 0 0 8 5 1 0 3 2 0 7 3 1 0 1 7 0 0 2 4 12 1 3 2 1 0 3 1 0 8 0 4 0 2 1 0 0 0 0 Max 314 55 49 4 7 5 1 4 36 4 15 6 26 127 23 14 13 95 53 88 18 7 12 63 26 9 13 37 1 1 17 11 6 13 8 8 5 17 13 4 4 6 62 3 9 34 34 30 4 12 9 6 7 7 5 5 29 3 19 0 11 9 0 0 0 0 Cum 2011 5,706 256 49 37 89 47 1 33 662 20 158 53 431 1,710 127 180 213 767 423 988 278 23 401 154 16 116 845 7 5 327 206 49 36 105 94 16 225 100 28 28 69 329 13 35 63 218 441 28 124 85 55 3 93 33 20 250 7 102 87 54 N N Cum 2010 6,709 406 77 83 127 48 15 56 636 35 158 67 376 1,903 267 217 255 341 823 1,479 309 88 331 448 199 16 88 779 6 4 286 203 31 66 87 80 16 239 120 58 15 46 329 25 54 65 185 459 29 101 76 38 35 104 56 20 479 3 250 1 159 66 N N

C.N.M.I.: Commonwealth of Northern Mariana Islands. U: Unavailable. : No reported cases. N: Not reportable. NN: Not Nationally Notifiable. Cum: Cumulative year-to-date counts. Med: Median. Max: Maximum. * Case counts for reporting year 2010 and 2011 are provisional and subject to change. For further information on interpretation of these data, see http://www.cdc.gov/osels/ph_surveillance/ nndss/phs/files/ProvisionalNationa%20NotifiableDiseasesSurveillanceData20100927.pdf. Data for TB are displayed in Table IV, which appears quarterly. Contains data reported through the National Electronic Disease Surveillance System (NEDSS).

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TABLE II. (Continued) Provisional cases of selected notifiable diseases, United States, weeks ending September 17, 2011, and September 18, 2010 (37th week)*
Dengue Virus Infection Dengue Fever Reporting area United States New England Connecticut Maine** Massachusetts New Hampshire Rhode Island** Vermont** Mid. Atlantic New Jersey New York (Upstate) New York City Pennsylvania E.N. Central Illinois Indiana Michigan Ohio Wisconsin W.N. Central Iowa Kansas Minnesota Missouri Nebraska** North Dakota South Dakota S. Atlantic Delaware District of Columbia Florida Georgia Maryland** North Carolina South Carolina** Virginia** West Virginia E.S. Central Alabama** Kentucky Mississippi Tennessee** W.S. Central Arkansas** Louisiana Oklahoma Texas** Mountain Arizona Colorado Idaho** Montana** Nevada** New Mexico** Utah Wyoming** Pacific Alaska California Hawaii Oregon Washington Territories American Samoa C.N.M.I. Guam Puerto Rico U.S. Virgin Islands Current week Previous 52 weeks Med 3 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 29 0 Max 22 3 0 2 0 0 1 1 5 3 1 5 2 4 2 1 1 1 2 6 1 1 1 1 6 0 0 10 0 0 8 2 0 1 0 1 0 1 1 0 0 0 2 0 1 1 1 2 2 0 1 1 0 0 1 0 4 0 2 4 0 1 0 0 391 0 Cum 2011 92 1 1 22 10 12 7 1 1 2 1 2 4 3 1 35 27 3 1 4 5 2 3 3 2 1 15 5 5 5 662 Cum 2010 561 5 3 2 194 25 28 123 18 53 15 11 8 14 5 22 1 3 13 4 1 196 152 9 6 13 14 2 5 2 2 1 25 4 4 17 17 7 2 3 4 1 44 1 30 13 8,563 Current week Dengue Hemorrhagic Fever Previous 52 weeks Med 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Max 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 10 0 Cum 2011 9 Cum 2010 9 5 2 3 1 1 2 2 1 1 197

C.N.M.I.: Commonwealth of Northern Mariana Islands. U: Unavailable. : No reported cases. N: Not reportable. NN: Not Nationally Notifiable. Cum: Cumulative year-to-date counts. Med: Median. Max: Maximum. * Case counts for reporting year 2010 and 2011 are provisional and subject to change. For further information on interpretation of these data, see http://www.cdc.gov/osels/ph_surveillance/ nndss/phs/files/ProvisionalNationa%20NotifiableDiseasesSurveillanceData20100927.pdf. Data for TB are displayed in Table IV, which appears quarterly. Updated weekly from reports to the Division of Vector-Borne Infectious Diseases, National Center for Zoonotic, Vector-Borne, and Enteric Diseases (ArboNET Surveillance). Dengue Fever includes cases that meet criteria for Dengue Fever with hemorrhage, other clinical and unknown case classifications. DHF includes cases that meet criteria for dengue shock syndrome (DSS), a more severe form of DHF. ** Contains data reported through the National Electronic Disease Surveillance System (NEDSS).

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TABLE II. (Continued) Provisional cases of selected notifiable diseases, United States, weeks ending September 17, 2011, and September 18, 2010 (37th week)*
Ehrlichiosis/Anaplasmosis Ehrlichia chaffeensis Reporting area United States New England Connecticut Maine Massachusetts New Hampshire Rhode Island Vermont Mid. Atlantic New Jersey New York (Upstate) New York City Pennsylvania E.N. Central Illinois Indiana Michigan Ohio Wisconsin W.N. Central Iowa Kansas Minnesota Missouri Nebraska North Dakota South Dakota S. Atlantic Delaware District of Columbia Florida Georgia Maryland North Carolina South Carolina Virginia West Virginia E.S. Central Alabama Kentucky Mississippi Tennessee W.S. Central Arkansas Louisiana Oklahoma Texas Mountain Arizona Colorado Idaho Montana Nevada New Mexico Utah Wyoming Pacific Alaska California Hawaii Oregon Washington Territories American Samoa C.N.M.I. Guam Puerto Rico U.S. Virgin Islands Current Previous 52 weeks week Med Max 9 5 5 2 N 2 N 2 N 2 N N N N N N N N N N 6 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 0 3 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 109 2 0 1 0 1 1 0 7 1 7 1 1 3 2 0 2 1 1 18 0 1 12 18 1 0 1 33 2 0 3 3 3 17 1 14 1 8 2 3 1 5 87 12 0 82 1 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 Cum 2011 552 4 1 2 1 49 44 5 21 11 4 6 138 N 2 135 N 1 197 14 N 13 16 22 55 1 76 61 3 10 3 45 82 36 45 1 N N N N N N N N N N Cum 2010 546 3 2 1 75 47 22 5 1 40 14 2 6 18 114 N 6 107 1 N 209 16 N 8 19 18 76 4 66 2 82 10 14 3 55 22 4 1 14 3 N N N N N 1 N 1 N N N N Current week 15 12 12 N N 3 N 1 1 1 N N N N N N N N N N Anaplasma phagocytophilum Previous 52 weeks Med 16 2 0 0 0 0 0 0 4 0 3 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Max 42 15 5 2 10 4 10 1 27 3 25 5 1 9 2 0 1 1 9 20 0 1 20 7 0 0 1 8 1 0 3 2 2 6 1 2 0 2 1 0 0 1 9 2 0 7 1 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 0 0 0 Cum 2011 414 106 12 49 12 30 3 210 182 26 2 11 4 4 3 30 N 2 1 25 N 2 44 1 N 8 7 4 17 7 10 3 7 2 2 N N N N N 1 N N 1 N N N Cum 2010 1,416 75 31 13 13 17 1 203 57 136 10 438 6 3 2 427 627 N 1 616 10 N 53 4 N 3 1 12 21 1 11 18 7 2 9 2 2 N N N N N N N N N N Current week 2 1 1 N N 1 N 1 N N N N N N N N N N N Undetermined Previous 52 weeks Med 1 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Max 13 1 0 0 0 1 0 0 2 0 2 0 1 4 1 3 2 1 1 11 0 0 11 7 1 0 0 1 0 0 0 1 0 0 0 1 1 3 0 0 0 3 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Cum 2011 80 1 1 10 10 35 2 28 3 1 1 15 N 14 1 N 7 N 1 5 1 9 N 9 3 3 N N N N N N N N N N Cum 2010 75 2 2 9 1 6 2 40 3 14 23 9 N 9 N 4 N 1 2 1 8 N 1 1 6 1 1 N N N N N 2 N 2 N N N N

C.N.M.I.: Commonwealth of Northern Mariana Islands. U: Unavailable. : No reported cases. N: Not reportable. NN: Not Nationally Notifiable. Cum: Cumulative year-to-date counts. Med: Median. Max: Maximum. * Case counts for reporting year 2010 and 2011 are provisional and subject to change. For further information on interpretation of these data, see http://www.cdc.gov/osels/ph_surveillance/ nndss/phs/files/ProvisionalNationa%20NotifiableDiseasesSurveillanceData20100927.pdf. Data for TB are displayed in Table IV, which appears quarterly. Cumulative total E. ewingii cases reported for year 2010 = 10, and 11 cases reported for 2011. Contains data reported through the National Electronic Disease Surveillance System (NEDSS).

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TABLE II. (Continued) Provisional cases of selected notifiable diseases, United States, weeks ending September 17, 2011, and September 18, 2010 (37th week)*
Giardiasis Reporting area United States New England Connecticut Maine Massachusetts New Hampshire Rhode Island Vermont Mid. Atlantic New Jersey New York (Upstate) New York City Pennsylvania E.N. Central Illinois Indiana Michigan Ohio Wisconsin W.N. Central Iowa Kansas Minnesota Missouri Nebraska North Dakota South Dakota S. Atlantic Delaware District of Columbia Florida Georgia Maryland North Carolina South Carolina Virginia West Virginia E.S. Central Alabama Kentucky Mississippi Tennessee W.S. Central Arkansas Louisiana Oklahoma Texas Mountain Arizona Colorado Idaho Montana Nevada New Mexico Utah Wyoming Pacific Alaska California Hawaii Oregon Washington Territories American Samoa C.N.M.I. Guam Puerto Rico U.S. Virgin Islands Current Previous 52 weeks Cum week Med Max 2011 228 10 5 5 65 50 6 9 23 22 1 11 4 7 64 2 39 7 9 N 7 3 3 N N N 1 1 N 12 7 2 3 39 25 2 12 282 23 4 3 11 2 1 2 58 5 22 17 16 47 9 6 10 16 8 25 5 2 0 8 4 0 1 55 0 1 24 13 4 0 2 7 0 4 4 0 0 0 5 3 3 0 0 27 3 12 3 2 1 2 3 0 41 2 25 0 7 8 0 0 1 0 545 42 11 10 21 6 10 9 103 20 72 29 27 93 14 14 25 29 28 73 15 7 30 26 11 12 6 127 2 3 75 51 13 0 7 32 8 11 11 0 0 0 17 9 12 0 0 51 8 24 9 5 6 6 10 5 128 7 67 4 20 57 0 0 7 0 9,693 820 131 120 343 73 40 113 1,995 132 741 598 524 1,587 261 188 312 570 256 776 197 65 296 139 22 57 1,921 22 28 859 538 190 N 79 183 22 125 125 N N N 175 85 90 N 893 89 430 106 54 35 60 101 18 1,401 60 847 23 224 247 29 Cum 2010 14,003 1,204 218 148 518 129 50 141 2,331 343 791 655 542 2,415 546 296 504 590 479 1,538 214 167 604 297 165 17 74 2,795 25 43 1,507 549 202 N 110 332 27 145 145 N N N 283 83 138 62 N 1,279 114 509 150 79 77 76 236 38 2,013 70 1,228 45 364 306 3 63 Gonorrhea Current Previous 52 weeks week Med Max 3,366 109 45 47 5 11 1 436 148 64 224 122 2 47 46 27 147 5 1 129 12 1,295 19 56 294 206 76 371 180 82 11 284 79 126 79 591 97 116 35 343 120 56 20 2 4 34 3 1 262 256 6 1 5,876 101 43 3 48 2 7 0 762 128 114 246 261 1,012 263 117 232 316 95 299 37 40 37 150 24 4 11 1,457 17 40 379 313 118 278 145 110 16 504 161 68 116 143 913 95 140 60 598 191 69 44 2 1 35 28 4 0 615 20 501 13 24 51 0 0 6 2 7,484 206 150 17 80 7 16 8 1,121 215 271 497 364 2,091 369 1,018 490 392 127 363 53 57 53 182 49 8 20 1,862 48 69 465 874 246 468 257 185 29 1,007 410 712 197 217 1,319 138 372 254 867 253 110 87 14 4 103 98 10 3 791 34 695 26 40 86 0 10 14 7 Cum 2011 208,888 3,760 1,592 166 1,630 96 239 37 27,092 4,883 4,048 8,737 9,424 35,918 8,730 4,547 8,334 11,142 3,165 10,640 1,334 1,389 1,184 5,373 858 128 374 52,179 586 1,422 13,939 11,045 3,904 11,070 5,662 3,969 582 18,267 5,979 3,037 4,054 5,197 32,077 3,484 4,566 2,169 21,858 7,108 2,641 1,533 90 57 1,472 1,115 174 26 21,847 689 18,082 450 924 1,702 6 232 83 Cum 2010 215,576 3,929 1,793 125 1,667 107 190 47 24,821 3,974 3,874 8,438 8,535 39,822 10,950 4,001 9,742 11,664 3,465 10,337 1,257 1,473 1,550 4,816 812 143 286 54,864 713 1,485 14,586 10,892 4,951 10,609 5,739 5,525 364 17,770 5,489 2,876 4,383 5,022 34,515 3,342 5,680 3,017 22,476 6,805 2,286 1,947 77 82 1,310 829 249 25 22,713 955 18,546 527 723 1,962 72 212 103 Haemophilus influenzae, invasive All ages, all serotypes Current week 25 1 1 7 2 1 4 2 2 6 2 1 2 1 5 1 4 2 1 1 2 1 1 Previous 52 weeks Med 63 4 1 0 2 0 0 0 13 2 3 3 4 11 3 2 1 2 1 4 0 0 0 1 1 0 0 15 0 0 5 3 2 1 1 2 0 3 1 0 0 2 3 0 1 1 0 5 2 1 0 0 0 1 0 0 3 0 0 0 2 0 0 0 0 0 Max 141 12 6 2 6 2 2 3 32 7 18 6 11 22 10 7 4 7 5 10 0 2 5 5 3 6 1 31 2 1 12 7 5 8 5 8 9 11 4 4 3 5 26 3 4 19 4 12 6 5 2 1 2 4 3 1 10 3 6 3 6 2 0 0 0 0 Cum 2011 2,248 139 37 15 62 11 9 5 514 77 137 116 184 396 117 72 45 112 50 113 16 60 25 11 1 547 3 178 103 64 55 56 74 14 145 43 20 12 70 101 25 36 39 1 196 74 47 15 2 12 31 14 1 97 19 17 58 3 Cum 2010 2,166 127 25 10 67 8 11 6 406 73 107 68 158 353 122 70 25 87 49 159 1 16 56 63 14 9 561 5 3 130 126 49 99 67 65 17 129 21 25 10 73 100 15 20 58 7 233 86 67 12 2 6 29 26 5 98 18 16 17 42 5 1

C.N.M.I.: Commonwealth of Northern Mariana Islands. U: Unavailable. : No reported cases. N: Not reportable. NN: Not Nationally Notifiable. Cum: Cumulative year-to-date counts. Med: Median. Max: Maximum. * Case counts for reporting year 2010 and 2011 are provisional and subject to change. For further information on interpretation of these data, see http://www.cdc.gov/osels/ph_surveillance/ nndss/phs/files/ProvisionalNationa%20NotifiableDiseasesSurveillanceData20100927.pdf. Data for TB are displayed in Table IV, which appears quarterly. Data for H. influenzae (age <5 yrs for serotype b, nonserotype b, and unknown serotype) are available in Table I. Contains data reported through the National Electronic Disease Surveillance System (NEDSS).

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TABLE II. (Continued) Provisional cases of selected notifiable diseases, United States, weeks ending September 17, 2011, and September 18, 2010 (37th week)*
Hepatitis (viral, acute), by type A Reporting area United States New England Connecticut Maine Massachusetts New Hampshire Rhode Island Vermont Mid. Atlantic New Jersey New York (Upstate) New York City Pennsylvania E.N. Central Illinois Indiana Michigan Ohio Wisconsin W.N. Central Iowa Kansas Minnesota Missouri Nebraska North Dakota South Dakota S. Atlantic Delaware District of Columbia Florida Georgia Maryland North Carolina South Carolina Virginia West Virginia E.S. Central Alabama Kentucky Mississippi Tennessee W.S. Central Arkansas Louisiana Oklahoma Texas Mountain Arizona Colorado Idaho Montana Nevada New Mexico Utah Wyoming Pacific Alaska California Hawaii Oregon Washington Territories American Samoa C.N.M.I. Guam Puerto Rico U.S. Virgin Islands Current Previous 52 weeks week Med Max 15 3 2 1 9 6 1 1 1 3 3 1 21 1 0 0 0 0 0 0 4 1 1 1 1 4 1 0 1 1 0 1 0 0 0 0 0 0 0 5 0 0 1 1 0 0 0 0 0 0 0 0 0 0 2 0 0 0 2 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 74 4 3 2 2 1 1 2 12 4 4 6 3 9 3 3 6 5 2 25 1 2 22 1 3 3 2 13 1 0 6 4 4 3 2 4 5 6 2 6 1 5 15 1 1 4 11 5 2 2 1 1 3 1 2 1 15 1 15 2 2 4 0 5 2 0 Cum 2011 703 38 9 5 16 3 5 143 18 35 49 41 131 32 12 53 29 5 32 4 3 9 10 4 2 164 2 55 32 21 19 9 18 8 35 4 7 6 18 81 2 3 76 50 13 17 6 2 5 4 1 2 29 2 7 5 15 8 5 Cum 2010 1,144 81 22 7 43 9 189 56 41 53 39 144 40 11 49 30 14 60 9 10 13 16 11 1 250 6 1 99 29 17 40 22 34 2 32 5 13 2 12 93 1 7 1 84 118 50 32 6 4 12 3 8 3 177 1 140 6 15 15 4 11 Current week 30 U 3 3 2 2 3 3 11 6 1 1 3 5 2 3 5 1 4 1 1 1 Med 48 1 0 0 0 0 0 0 5 1 1 1 2 5 1 1 1 1 0 2 0 0 0 2 0 0 0 12 0 0 4 2 1 2 1 1 0 9 2 2 1 3 7 1 1 1 3 2 0 0 0 0 0 0 0 0 2 0 0 0 0 0 0 0 0 0 B Previous 52 weeks Max 167 8 4 2 6 1 0 0 12 4 9 5 4 38 6 3 6 30 3 16 1 2 15 5 3 0 1 33 1 0 11 8 4 12 4 7 18 14 4 6 3 7 67 4 4 16 45 5 3 3 1 0 3 2 1 1 25 1 22 1 4 4 0 8 3 0 Cum 2011 1,606 46 10 6 29 1 U 189 32 34 58 65 240 51 34 61 74 20 97 7 9 9 60 11 1 421 145 64 41 82 23 47 19 301 75 76 31 119 205 35 23 48 99 55 12 15 2 16 5 5 52 4 1 5 25 17 28 7 Cum 2010 2,339 42 16 11 8 5 U 2 216 58 35 68 55 371 95 56 99 82 39 82 12 6 6 48 9 1 642 21 3 215 128 46 73 44 65 47 256 49 90 23 94 414 45 43 72 254 104 18 34 6 34 4 7 1 212 2 142 5 33 30 64 17 Current week 9 N U 2 2 2 U 2 U 1 1 U 4 U U 4 N Med 17 1 0 0 0 0 0 0 1 0 0 0 0 3 0 0 2 0 0 0 0 0 0 0 0 0 0 4 0 0 1 1 0 1 0 0 0 3 0 1 0 1 2 0 0 1 0 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 C Previous 52 weeks Max 39 4 3 2 2 0 0 1 6 4 4 0 4 12 1 5 7 1 1 6 0 1 6 1 1 0 0 11 0 0 5 3 2 7 1 2 6 7 1 6 0 5 11 0 2 10 3 4 0 3 2 1 1 1 1 1 12 0 4 0 3 5 0 4 0 0 Cum 2011 648 40 25 6 5 N U 4 58 1 33 24 128 5 46 72 4 1 6 2 2 2 161 U 41 26 28 39 1 10 16 114 9 44 U 61 66 5 34 27 41 U 14 7 3 5 9 1 2 34 U U 10 24 10 N Cum 2010 591 40 26 2 12 N U 78 17 38 3 20 69 24 30 8 7 11 6 3 2 134 U 2 41 17 18 32 1 9 14 112 5 76 U 31 51 1 2 18 30 47 U 10 8 2 4 13 10 49 U 20 U 11 18 52 N

C.N.M.I.: Commonwealth of Northern Mariana Islands. U: Unavailable. : No reported cases. N: Not reportable. NN: Not Nationally Notifiable. Cum: Cumulative year-to-date counts. Med: Median. Max: Maximum. * Case counts for reporting year 2010 and 2011 are provisional and subject to change. For further information on interpretation of these data, see http://www.cdc.gov/osels/ph_surveillance/ nndss/phs/files/ProvisionalNationa%20NotifiableDiseasesSurveillanceData20100927.pdf. Data for TB are displayed in Table IV, which appears quarterly. Contains data reported through the National Electronic Disease Surveillance System (NEDSS).

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Morbidity and Mortality Weekly Report

TABLE II. (Continued) Provisional cases of selected notifiable diseases, United States, weeks ending September 17, 2011, and September 18, 2010 (37th week)*
Legionellosis Reporting area United States New England Connecticut Maine Massachusetts New Hampshire Rhode Island Vermont Mid. Atlantic New Jersey New York (Upstate) New York City Pennsylvania E.N. Central Illinois Indiana Michigan Ohio Wisconsin W.N. Central Iowa Kansas Minnesota Missouri Nebraska North Dakota South Dakota S. Atlantic Delaware District of Columbia Florida Georgia Maryland North Carolina South Carolina Virginia West Virginia E.S. Central Alabama Kentucky Mississippi Tennessee W.S. Central Arkansas Louisiana Oklahoma Texas Mountain Arizona Colorado Idaho Montana Nevada New Mexico Utah Wyoming Pacific Alaska California Hawaii Oregon Washington Territories American Samoa C.N.M.I. Guam Puerto Rico U.S. Virgin Islands Current Previous 52 weeks week Med Max 62 34 23 11 8 8 3 2 1 8 2 3 2 1 1 1 8 4 4 N 53 4 0 0 1 0 0 0 15 2 5 3 5 10 1 1 2 4 0 2 0 0 0 1 0 0 0 9 0 0 3 1 1 1 0 1 0 2 0 0 0 1 2 0 0 0 2 2 1 0 0 0 0 0 0 0 5 0 4 0 0 0 0 0 0 0 128 15 6 2 9 3 4 2 53 18 23 17 25 49 6 5 13 34 4 9 2 2 8 5 1 1 2 22 2 3 9 4 6 7 3 9 2 10 2 3 3 8 13 2 3 3 11 5 3 2 1 1 2 1 2 1 21 0 15 1 3 6 0 1 1 0 Cum 2011 2,017 120 25 8 58 11 9 9 628 73 223 98 234 465 60 65 94 245 1 60 7 5 41 4 1 2 315 9 9 109 27 52 49 12 42 6 113 17 23 10 63 80 8 13 7 52 62 21 4 4 1 11 6 13 2 174 146 1 11 16 N Cum 2010 2,292 186 31 10 94 16 27 8 597 93 180 110 214 507 125 44 129 158 51 84 14 8 23 23 8 3 5 386 13 14 121 42 87 43 10 46 10 101 13 21 12 55 118 14 8 11 85 131 45 23 5 4 18 7 22 7 182 2 154 1 10 15 N 1 Current week 372 8 1 7 248 143 105 1 1 115 2 4 102 7 N N N Lyme disease Previous 52 weeks Med 334 72 31 9 16 11 1 5 150 51 35 1 61 21 1 0 0 1 16 3 0 0 0 0 0 0 0 52 10 0 1 0 17 0 0 18 0 1 0 0 0 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 2 0 1 0 0 0 0 0 0 0 Max 1,588 293 173 47 62 60 35 62 1,142 541 214 18 482 90 19 15 10 9 63 32 11 2 31 0 2 10 1 163 43 2 8 3 103 8 6 76 14 5 2 1 1 3 29 0 1 0 29 4 2 1 2 2 1 2 1 1 11 2 9 0 2 4 0 0 0 0 Cum 2011 19,986 3,349 1,438 329 494 539 109 440 12,990 5,078 2,590 43 5,279 968 117 76 65 41 669 90 65 10 8 4 3 2,425 604 11 86 15 871 51 22 717 48 42 13 1 1 27 31 1 30 31 8 1 3 8 3 6 1 1 60 6 34 N 14 6 N N Cum 2010 24,409 7,400 2,524 509 2,884 1,082 117 284 8,654 3,030 1,954 563 3,107 3,346 120 75 83 22 3,046 1,886 79 10 1,772 4 8 12 1 2,840 528 32 64 9 1,171 63 27 858 88 39 2 5 32 85 3 82 23 2 2 8 3 5 3 136 6 85 N 38 7 N N Current week 18 6 2 4 6 2 2 1 1 1 1 5 4 1 Med 26 1 0 0 1 0 0 0 7 0 1 3 1 3 1 0 0 1 0 1 0 0 0 0 0 0 0 8 0 0 2 1 2 0 0 1 0 1 0 0 0 0 1 0 0 0 0 1 0 0 0 0 0 0 0 0 3 0 2 0 0 0 0 0 0 0 Malaria Previous 52 weeks Max 114 20 20 1 5 2 4 1 18 6 6 12 4 7 4 2 4 4 2 45 3 2 45 1 1 1 1 22 3 1 7 5 12 6 1 8 1 3 2 1 1 3 18 1 1 1 17 4 4 3 1 1 2 1 1 0 10 2 8 1 4 3 1 0 0 0 Cum 2011 886 52 6 3 33 2 2 6 192 8 31 108 45 103 41 7 19 30 6 24 15 6 2 1 316 6 5 78 57 80 34 3 53 25 5 6 1 13 25 3 1 4 17 50 20 18 2 1 6 2 1 99 4 62 5 12 16 1 Cum 2010 1,213 81 2 5 63 2 7 2 368 80 59 187 42 126 51 10 25 31 9 54 10 9 3 16 14 2 321 2 11 93 56 70 34 3 50 2 24 6 6 2 10 70 4 2 5 59 46 20 15 1 2 4 1 3 123 3 81 2 9 28 5

C.N.M.I.: Commonwealth of Northern Mariana Islands. U: Unavailable. : No reported cases. N: Not reportable. NN: Not Nationally Notifiable. Cum: Cumulative year-to-date counts. Med: Median. Max: Maximum. * Case counts for reporting year 2010 and 2011 are provisional and subject to change. For further information on interpretation of these data, see http://www.cdc.gov/osels/ph_surveillance/ nndss/phs/files/ProvisionalNationa%20NotifiableDiseasesSurveillanceData20100927.pdf. Data for TB are displayed in Table IV, which appears quarterly. Contains data reported through the National Electronic Disease Surveillance System (NEDSS).

MMWR / September 23, 2011 / Vol. 60 / No. 37

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Morbidity and Mortality Weekly Report

TABLE II. (Continued) Provisional cases of selected notifiable diseases, United States, weeks ending September 17, 2011, and September 18, 2010 (37th week)*
Meningococcal disease, invasive All serogroups Reporting area United States New England Connecticut Maine Massachusetts New Hampshire Rhode Island Vermont Mid. Atlantic New Jersey New York (Upstate) New York City Pennsylvania E.N. Central Illinois Indiana Michigan Ohio Wisconsin W.N. Central Iowa Kansas Minnesota Missouri Nebraska North Dakota South Dakota S. Atlantic Delaware District of Columbia Florida Georgia Maryland North Carolina South Carolina Virginia West Virginia E.S. Central Alabama Kentucky Mississippi Tennessee W.S. Central Arkansas Louisiana Oklahoma Texas Mountain Arizona Colorado Idaho Montana Nevada New Mexico Utah Wyoming Pacific Alaska California Hawaii Oregon Washington Territories American Samoa C.N.M.I. Guam Puerto Rico U.S. Virgin Islands Current Previous 52 weeks week Med Max 5 3 2 1 1 1 1 1 13 0 0 0 0 0 0 0 1 0 0 0 0 2 0 0 0 1 0 1 0 0 0 0 0 0 0 2 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 53 3 1 1 2 1 1 3 6 1 4 3 2 7 3 2 4 2 2 4 1 1 2 2 2 1 1 8 1 1 5 1 1 3 1 2 3 3 2 2 1 2 12 1 2 2 10 4 1 1 1 2 1 1 2 1 26 1 17 1 3 8 0 0 1 0 Cum 2011 412 24 3 4 11 1 5 58 5 18 22 13 67 20 11 7 20 9 33 8 2 12 8 1 2 101 1 1 40 11 11 13 9 10 5 20 9 2 2 7 41 8 8 7 18 35 10 8 5 3 1 1 7 33 2 4 15 12 Cum 2010 570 14 2 3 4 5 58 18 9 15 16 97 19 22 15 23 18 40 8 6 3 16 5 2 106 1 49 8 7 12 10 17 2 28 5 12 3 8 63 5 12 14 32 45 11 16 5 1 8 3 1 119 1 76 1 24 17 1 Current week 2 1 1 1 1 Med 7 0 0 0 0 0 0 0 1 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 0 0 Mumps Previous 52 weeks Max 47 1 0 1 1 0 1 1 23 2 3 22 16 7 3 1 1 5 1 4 1 1 4 3 1 3 0 3 0 0 2 2 1 2 0 2 0 1 1 0 1 1 15 1 2 1 14 4 0 1 1 0 1 2 1 1 3 1 3 1 1 1 0 9 1 0 Cum 2011 194 5 3 1 1 24 8 6 9 1 52 31 7 11 3 29 5 4 1 11 4 4 19 5 4 1 7 2 3 1 2 49 1 1 47 6 3 1 2 7 1 2 4 12 1 Cum 2010 2,374 24 11 1 9 3 2,051 339 658 1,032 22 47 17 3 17 9 1 79 37 4 4 9 23 2 46 3 8 2 9 8 4 10 2 9 6 1 2 66 5 5 56 18 5 7 1 1 3 1 34 1 22 3 2 6 441 1 Current week 147 5 4 1 42 34 8 9 9 22 20 2 10 4 2 4 4 4 23 1 4 18 10 1 6 3 22 22 Med 241 8 1 2 3 1 0 0 34 2 13 0 14 58 15 4 20 17 10 24 5 2 0 7 1 0 0 31 0 0 6 3 2 3 3 7 0 9 3 1 0 2 23 1 0 0 19 43 14 9 2 2 0 3 5 0 20 0 0 1 5 9 0 0 0 0 Pertussis Previous 52 weeks Max 2,925 22 8 8 10 7 3 3 125 7 81 19 70 198 50 26 57 80 26 501 36 10 469 43 11 10 6 106 5 2 17 13 6 35 25 41 41 28 11 16 10 10 297 16 3 92 187 100 29 63 15 16 5 10 16 2 1,710 6 1,569 9 11 131 0 14 1 0 Cum 2011 7,965 305 30 99 99 48 17 12 1,072 77 482 38 475 1,935 492 135 484 545 279 850 137 71 326 210 45 37 24 966 21 3 242 120 58 127 102 241 52 258 104 52 22 80 658 42 15 29 572 1,285 529 292 99 70 18 87 182 8 636 21 8 69 188 350 31 2 Cum 2010 15,035 374 83 37 199 13 31 11 974 121 330 62 461 3,426 595 487 970 1,067 307 1,440 386 135 433 285 136 38 27 1,228 9 6 229 182 94 231 280 152 45 562 153 190 56 163 2,140 166 32 42 1,900 1,037 313 156 142 53 23 91 248 11 3,854 28 3,302 58 223 243 2 2

C.N.M.I.: Commonwealth of Northern Mariana Islands. U: Unavailable. : No reported cases. N: Not reportable. NN: Not Nationally Notifiable. Cum: Cumulative year-to-date counts. Med: Median. Max: Maximum. * Case counts for reporting year 2010 and 2011 are provisional and subject to change. For further information on interpretation of these data, see http://www.cdc.gov/osels/ph_surveillance/ nndss/phs/files/ProvisionalNationa%20NotifiableDiseasesSurveillanceData20100927.pdf. Data for TB are displayed in Table IV, which appears quarterly. Data for meningococcal disease, invasive caused by serogroups A, C, Y, and W-135; serogroup B; other serogroup; and unknown serogroup are available in Table I. Contains data reported through the National Electronic Disease Surveillance System (NEDSS).

1294

MMWR / September 23, 2011 / Vol. 60 / No. 37

Morbidity and Mortality Weekly Report

TABLE II. (Continued) Provisional cases of selected notifiable diseases, United States, weeks ending September 17, 2011, and September 18, 2010 (37th week)*
Rabies, animal Reporting area United States New England Connecticut Maine Massachusetts New Hampshire Rhode Island Vermont Mid. Atlantic New Jersey New York (Upstate) New York City Pennsylvania E.N. Central Illinois Indiana Michigan Ohio Wisconsin W.N. Central Iowa Kansas Minnesota Missouri Nebraska North Dakota South Dakota S. Atlantic Delaware District of Columbia Florida Georgia Maryland North Carolina South Carolina Virginia West Virginia E.S. Central Alabama Kentucky Mississippi Tennessee W.S. Central Arkansas Louisiana Oklahoma Texas Mountain Arizona Colorado Idaho Montana Nevada New Mexico Utah Wyoming Pacific Alaska California Hawaii Oregon Washington Territories American Samoa C.N.M.I. Guam Puerto Rico U.S. Virgin Islands Current Previous 52 weeks week Med Max 57 6 4 1 1 16 16 2 2 N 26 N 26 4 4 1 N N 1 2 2 N 53 3 0 1 0 0 0 0 13 0 7 0 6 2 1 0 1 0 0 2 0 1 0 0 0 0 0 18 0 0 0 0 6 0 0 11 0 2 1 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 3 0 3 0 0 0 0 0 0 0 119 13 9 6 0 3 4 2 29 0 20 4 17 16 6 6 6 6 0 40 1 4 34 2 3 6 0 87 0 0 78 0 14 0 0 27 30 7 7 2 1 4 31 10 0 20 30 5 0 0 2 0 2 2 2 1 15 2 8 0 2 14 0 0 6 0 Cum 2011 1,852 130 28 52 17 15 18 449 271 9 169 140 46 18 41 35 N 64 24 29 11 798 78 204 N 453 63 91 65 12 1 13 53 41 12 24 N 3 N 4 10 7 103 9 84 10 N 24 Cum 2010 3,313 236 107 47 15 25 42 819 389 138 292 210 108 59 43 N 209 23 51 25 57 43 10 868 121 275 N 416 56 140 58 16 66 629 23 40 566 56 N 10 N 5 9 9 23 146 12 121 13 N 34 Current week 853 2 2 96 66 1 29 44 1 43 57 1 10 36 10 328 2 5 193 55 24 10 14 25 49 17 8 6 18 158 35 29 94 21 3 11 3 3 1 98 55 7 36 Salmonellosis Previous 52 weeks Med 874 26 0 2 17 3 0 1 93 12 25 21 32 87 28 11 13 21 9 47 9 7 0 16 4 0 3 279 3 1 107 42 18 35 30 21 0 60 18 9 20 17 131 14 14 11 85 48 14 10 3 2 3 6 6 1 75 1 55 6 6 12 0 0 6 0 Max 1,627 351 330 8 38 8 62 5 182 35 66 45 111 147 57 23 29 47 44 97 20 20 17 45 13 15 17 713 9 4 226 121 38 251 99 68 14 185 70 32 59 50 515 47 52 95 381 91 34 24 8 10 8 21 15 9 288 6 232 14 14 42 0 3 25 0 Cum 2011 29,844 1,279 330 97 554 125 128 45 3,506 322 998 805 1,381 3,104 1,026 348 520 895 315 1,685 330 297 722 177 30 129 9,269 115 43 3,691 1,652 662 1,320 975 769 42 2,579 765 308 826 680 4,052 556 537 458 2,501 1,720 517 414 111 96 98 214 224 46 2,650 44 1,807 247 171 381 6 134 Cum 2010 36,686 1,903 491 91 990 139 140 52 4,363 894 1,042 991 1,436 4,508 1,525 581 727 992 683 2,203 402 326 573 586 176 28 112 9,824 128 78 3,994 1,976 788 905 1,040 772 143 2,653 698 401 826 728 4,528 506 937 443 2,642 2,117 707 428 123 76 239 231 267 46 4,587 65 3,352 247 412 511 2 8 414 Shiga toxin-producing E. coli (STEC) Current week 60 6 5 1 6 6 7 6 1 9 6 1 1 1 2 1 1 4 1 3 5 1 1 3 21 7 14 Previous 52 weeks Med 92 2 0 0 0 0 0 0 10 2 4 1 3 12 2 2 2 2 2 13 2 1 0 4 2 0 1 14 0 0 3 2 1 2 0 3 0 4 1 1 0 2 6 0 0 1 5 11 2 3 2 1 0 1 1 0 11 0 7 0 1 2 0 0 0 0 Max 264 36 36 3 10 3 2 3 28 6 12 6 17 38 10 8 15 10 13 39 15 8 8 14 7 10 4 29 2 1 15 8 8 11 4 9 4 22 15 5 12 11 151 3 2 55 95 30 14 11 6 5 7 6 7 3 46 1 36 1 11 16 0 0 0 0 Cum 2011 3,213 138 36 22 44 20 4 12 412 58 153 60 141 561 114 85 109 132 121 519 135 70 188 78 10 38 460 11 3 100 85 31 84 15 128 3 196 67 30 17 82 218 29 6 41 142 391 65 86 75 34 26 29 62 14 318 1 166 6 53 92 Cum 2010 3,685 173 60 15 65 18 2 13 419 96 138 54 131 649 124 101 129 112 183 678 135 52 228 178 56 5 24 488 4 8 152 75 68 45 17 103 16 185 37 49 13 86 215 43 14 16 142 457 46 169 60 31 28 33 71 19 421 2 180 27 71 141

C.N.M.I.: Commonwealth of Northern Mariana Islands. U: Unavailable. : No reported cases. N: Not reportable. NN: Not Nationally Notifiable. Cum: Cumulative year-to-date counts. Med: Median. Max: Maximum. * Case counts for reporting year 2010 and 2011 are provisional and subject to change. For further information on interpretation of these data, see http://www.cdc.gov/osels/ph_surveillance/ nndss/phs/files/ProvisionalNationa%20NotifiableDiseasesSurveillanceData20100927.pdf. Data for TB are displayed in Table IV, which appears quarterly. Includes E. coli O157:H7; Shiga toxin-positive, serogroup non-O157; and Shiga toxin-positive, not serogrouped. Contains data reported through the National Electronic Disease Surveillance System (NEDSS).

MMWR / September 23, 2011 / Vol. 60 / No. 37

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Morbidity and Mortality Weekly Report

TABLE II. (Continued) Provisional cases of selected notifiable diseases, United States, weeks ending September 17, 2011, and September 18, 2010 (37th week)*
Spotted Fever Rickettsiosis (including RMSF) Shigellosis Reporting area United States New England Connecticut Maine Massachusetts New Hampshire Rhode Island Vermont Mid. Atlantic New Jersey New York (Upstate) New York City Pennsylvania E.N. Central Illinois Indiana Michigan Ohio Wisconsin W.N. Central Iowa Kansas Minnesota Missouri Nebraska North Dakota South Dakota S. Atlantic Delaware District of Columbia Florida Georgia Maryland North Carolina South Carolina Virginia West Virginia E.S. Central Alabama Kentucky Mississippi Tennessee W.S. Central Arkansas Louisiana Oklahoma Texas Mountain Arizona Colorado Idaho Montana Nevada New Mexico Utah Wyoming Pacific Alaska California Hawaii Oregon Washington Territories American Samoa C.N.M.I. Guam Puerto Rico U.S. Virgin Islands Current week 142 8 6 1 1 4 4 3 1 2 60 2 41 10 2 3 2 5 5 30 1 4 25 6 6 26 19 7 Previous 52 weeks Med 214 2 0 0 2 0 0 0 14 2 3 4 3 16 4 1 3 5 0 8 0 2 0 5 0 0 0 68 0 0 42 11 2 4 1 2 0 13 4 1 2 4 60 2 5 2 49 16 6 2 0 1 0 3 1 0 16 0 12 1 1 1 1 0 0 0 Max 742 29 28 4 6 2 4 1 74 8 18 12 56 40 10 4 10 27 4 38 4 12 4 18 10 0 2 133 1 2 98 26 7 36 4 8 66 29 15 6 9 14 503 7 20 161 338 32 19 8 3 15 6 9 4 1 63 2 59 3 4 7 1 1 1 0 Cum 2011 7,190 133 28 19 76 1 6 3 485 51 171 177 86 510 115 43 116 236 223 13 39 156 11 4 2,631 3 12 1,890 390 71 154 36 71 4 408 144 36 107 121 1,752 49 166 71 1,466 525 187 71 15 116 19 78 37 2 523 5 388 41 30 59 1 1 Cum 2010 9,963 284 69 5 188 10 11 1 1,320 306 165 238 611 1,268 731 46 193 239 59 1,736 41 204 43 1,414 27 7 1,699 36 27 722 545 97 111 51 101 9 518 117 190 38 173 1,804 41 196 210 1,357 553 297 69 20 7 28 99 33 781 1 620 38 42 80 2 5 4 Current week 1 1 1 N N N N N Med 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Confirmed Previous 52 weeks Max 16 0 0 0 0 0 0 0 2 0 1 0 2 2 1 0 1 2 0 7 0 0 0 4 3 1 0 8 1 1 1 5 1 4 2 1 0 3 1 1 0 2 8 2 0 5 1 5 4 1 0 0 0 0 0 0 2 0 2 0 0 1 0 0 0 0 Cum 2011 128 11 3 8 4 1 3 24 17 5 2 66 1 1 3 36 2 12 9 2 6 2 1 3 4 3 1 13 12 1 N N N N N Cum 2010 111 2 1 1 3 2 1 11 8 3 68 1 2 49 12 1 3 17 4 6 1 6 4 3 1 2 2 4 N 4 N N N N Current week 11 1 1 1 1 7 2 2 3 2 1 1 N N N N N Med 23 0 0 0 0 0 0 0 1 0 0 0 0 1 0 0 0 0 0 4 0 0 0 4 0 0 0 6 0 0 0 0 0 1 0 2 0 5 1 0 0 4 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Probable Previous 52 weeks Max 245 1 0 1 1 1 1 0 5 3 2 2 3 6 2 4 1 2 1 30 2 0 2 30 1 0 1 55 4 1 2 0 3 49 2 9 1 26 8 0 4 20 235 38 2 202 5 6 6 1 1 1 0 1 1 2 0 0 0 0 0 0 0 0 0 0 Cum 2011 1,272 3 1 1 1 31 6 13 12 71 24 36 11 272 5 264 2 1 363 16 1 8 21 201 16 97 3 286 54 9 223 218 190 4 21 3 28 15 2 1 1 1 1 7 N N N N N Cum 2010 1,193 3 2 1 81 47 11 11 12 70 32 19 1 12 6 224 5 216 2 1 368 17 7 35 192 12 105 334 66 17 251 101 61 2 21 17 11 1 1 4 1 1 3 1 N N 1 N N N

C.N.M.I.: Commonwealth of Northern Mariana Islands. U: Unavailable. : No reported cases. N: Not reportable. NN: Not Nationally Notifiable. Cum: Cumulative year-to-date counts. Med: Median. Max: Maximum. * Case counts for reporting year 2010 and 2011 are provisional and subject to change. For further information on interpretation of these data, see http://www.cdc.gov/osels/ph_surveillance/ nndss/phs/files/ProvisionalNationa%20NotifiableDiseasesSurveillanceData20100927.pdf. Data for TB are displayed in Table IV, which appears quarterly. Illnesses with similar clinical presentation that result from Spotted fever group rickettsia infections are reported as Spotted fever rickettsioses. Rocky Mountain spotted fever (RMSF) caused by Rickettsia rickettsii, is the most common and well-known spotted fever. Contains data reported through the National Electronic Disease Surveillance System (NEDSS).

1296

MMWR / September 23, 2011 / Vol. 60 / No. 37

Morbidity and Mortality Weekly Report

TABLE II. (Continued) Provisional cases of selected notifiable diseases, United States, weeks ending September 17, 2011, and September 18, 2010 (37th week)*
Streptococcus pneumoniae, invasive disease All ages Reporting area United States New England Connecticut Maine Massachusetts New Hampshire Rhode Island Vermont Mid. Atlantic New Jersey New York (Upstate) New York City Pennsylvania E.N. Central Illinois Indiana Michigan Ohio Wisconsin W.N. Central Iowa Kansas Minnesota Missouri Nebraska North Dakota South Dakota S. Atlantic Delaware District of Columbia Florida Georgia Maryland North Carolina South Carolina Virginia West Virginia E.S. Central Alabama Kentucky Mississippi Tennessee W.S. Central Arkansas Louisiana Oklahoma Texas Mountain Arizona Colorado Idaho Montana Nevada New Mexico Utah Wyoming Pacific Alaska California Hawaii Oregon Washington Territories American Samoa C.N.M.I. Guam Puerto Rico U.S. Virgin Islands Current Previous 52 weeks week Med Max 71 3 1 2 N 12 N 12 2 N N N 2 N 31 15 10 4 N 2 N 6 N N N 6 13 1 N 12 4 4 N N N N N N N 298 17 6 2 0 2 2 1 33 13 2 14 0 66 0 15 15 26 9 4 0 0 0 0 2 0 0 72 1 1 23 22 10 0 8 0 0 19 0 0 0 19 31 3 3 0 25 32 12 11 0 0 0 3 2 0 3 2 0 0 0 0 0 0 0 0 937 79 49 13 3 8 8 6 81 35 10 42 0 112 0 32 29 45 24 35 0 0 24 0 9 25 0 170 6 3 68 54 32 0 25 0 48 36 0 0 0 36 368 26 11 0 333 72 45 23 0 0 0 13 8 15 11 11 0 3 0 0 0 0 0 0 Cum 2011 9,918 549 235 96 21 73 73 51 990 463 60 467 N 2,151 N 477 474 885 315 127 N N N 84 43 N 2,760 36 28 995 742 396 N 334 N 229 654 N N N 654 1,318 162 119 N 1,037 1,254 596 391 N N N 174 74 19 115 112 N 3 N N N Cum 2010 10,941 600 246 86 53 82 73 60 1,125 500 111 514 N 2,205 N 506 503 844 352 579 N N 437 N 96 46 N 2,990 27 53 1,102 961 379 N 378 N 90 747 N N N 747 1,344 125 77 N 1,142 1,270 611 380 N N N 118 150 11 81 81 N N N N Current week 8 1 1 N 2 N 2 N N N N 2 1 1 N N N N N 2 1 N 1 1 1 N N N N N N N Med 23 1 0 0 0 0 0 0 3 1 1 0 0 4 0 0 1 2 0 0 0 0 0 0 0 0 0 7 0 0 3 2 1 0 0 0 0 1 0 0 0 1 4 0 0 0 3 3 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Age <5 Previous 52 weeks Max 101 5 3 1 3 1 1 2 27 4 9 14 0 10 0 4 4 7 3 5 0 0 5 0 2 1 0 22 1 1 13 7 4 0 3 0 6 4 0 0 0 4 30 3 2 0 27 8 5 4 0 0 0 2 3 1 1 1 0 1 0 0 0 0 0 0 Cum 2011 717 29 6 3 8 5 2 5 84 28 34 22 N 119 N 21 25 61 12 9 N N N 8 1 N 204 4 90 51 26 N 20 N 13 41 N N N 41 126 13 10 N 103 96 45 28 N N N 11 12 9 8 N 1 N N N Cum 2010 1,340 77 22 6 37 4 4 4 167 41 82 44 N 199 N 41 62 68 28 81 N N 65 N 14 2 N 373 7 148 116 43 N 43 N 16 71 N N N 71 182 12 20 N 150 174 78 53 N N N 15 25 3 16 16 N N N N Syphilis, primary and secondary Current week 86 1 1 8 4 4 2 2 1 1 46 3 1 11 10 11 4 6 3 3 20 2 1 2 15 5 5 9 Previous 52 weeks Med 258 8 1 0 5 0 0 0 31 5 3 15 7 31 13 3 5 9 1 7 0 0 3 2 0 0 0 64 0 3 23 12 9 8 4 4 0 15 4 2 3 5 35 4 8 1 23 12 4 2 0 0 2 1 0 0 51 0 42 0 2 5 0 0 4 0 Max 363 18 8 3 11 3 7 2 49 13 20 30 13 48 22 8 11 21 5 17 2 3 10 6 2 1 1 178 4 8 37 130 19 19 10 16 2 34 11 16 16 11 59 10 27 6 33 23 8 8 4 1 9 4 4 0 66 1 57 5 10 13 0 0 13 0 Cum 2011 8,726 254 39 11 153 14 32 5 1,048 138 129 536 245 1,060 424 113 173 310 40 210 12 17 87 88 5 1 2,254 15 119 790 437 322 269 151 149 2 515 138 79 127 171 1,226 143 262 42 779 387 150 77 11 4 92 45 8 1,772 1 1,456 10 111 194 158 Cum 2010 9,645 344 70 19 214 14 25 2 1,209 170 97 684 258 1,409 672 134 184 385 34 239 16 14 88 111 6 4 2,189 4 101 799 475 209 298 101 198 4 628 180 92 156 200 1,501 156 391 67 887 413 159 90 2 3 74 35 50 1,713 3 1,454 28 49 179 167

C.N.M.I.: Commonwealth of Northern Mariana Islands. U: Unavailable. : No reported cases. N: Not reportable. NN: Not Nationally Notifiable. Cum: Cumulative year-to-date counts. Med: Median. Max: Maximum. * Case counts for reporting year 2010 and 2011 are provisional and subject to change. For further information on interpretation of these data, see http://www.cdc.gov/osels/ph_surveillance/ nndss/phs/files/ProvisionalNationa%20NotifiableDiseasesSurveillanceData20100927.pdf. Data for TB are displayed in Table IV, which appears quarterly. Includes drug resistant and susceptible cases of invasive Streptococcus pneumoniae disease among children <5 years and among all ages. Case definition: Isolation of S. pneumoniae from a normally sterile body site (e.g., blood or cerebrospinal fluid). Contains data reported through the National Electronic Disease Surveillance System (NEDSS).

MMWR / September 23, 2011 / Vol. 60 / No. 37

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Morbidity and Mortality Weekly Report

TABLE II. (Continued) Provisional cases of selected notifiable diseases, United States, weeks ending September 17, 2011, and September 18, 2010 (37th week)*
West Nile virus disease Varicella (chickenpox) Reporting area United States New England Connecticut Maine Massachusetts New Hampshire Rhode Island Vermont Mid. Atlantic New Jersey New York (Upstate) New York City Pennsylvania E.N. Central Illinois Indiana Michigan Ohio Wisconsin W.N. Central Iowa Kansas Minnesota Missouri Nebraska North Dakota South Dakota S. Atlantic Delaware District of Columbia Florida Georgia Maryland North Carolina South Carolina Virginia West Virginia E.S. Central Alabama Kentucky Mississippi Tennessee W.S. Central Arkansas Louisiana Oklahoma Texas Mountain Arizona Colorado Idaho Montana Nevada New Mexico Utah Wyoming Pacific Alaska California Hawaii Oregon Washington Territories American Samoa C.N.M.I. Guam Puerto Rico U.S. Virgin Islands Current week 75 21 N 21 27 1 3 23 N N N N 3 3 N N 18 N 18 5 2 N N 3 1 1 N N N Previous 52 weeks Med 273 21 4 5 6 0 0 2 36 12 0 0 19 68 16 4 20 20 0 8 0 3 0 4 0 0 1 36 0 0 15 0 0 0 0 8 7 5 4 0 0 0 43 3 1 0 38 19 3 4 0 2 0 1 4 0 2 1 0 1 0 0 0 0 4 0 Max 367 46 16 16 18 9 6 10 71 60 0 0 41 118 31 18 38 58 22 42 0 15 0 24 5 10 7 64 3 2 38 0 0 0 9 25 32 15 14 0 3 0 258 17 6 0 247 65 50 31 0 28 0 2 26 3 5 4 3 4 0 0 0 4 21 0 Cum 2011 8,412 679 169 147 260 9 29 65 1,524 875 N 649 1,955 504 171 620 659 1 245 N 77 111 3 31 23 1,240 6 12 626 N N N 12 305 279 189 178 N 11 N 1,679 150 54 N 1,475 827 383 160 N 111 N 28 137 8 74 40 34 N N N 16 112 Cum 2010 10,927 790 250 143 202 94 29 72 1,214 427 N 787 3,518 918 270 1,035 921 374 639 N 264 305 11 33 26 1,594 25 17 768 N N N 75 387 322 222 215 N 7 N 2,085 150 57 N 1,878 781 288 N 158 N 86 236 13 84 32 26 26 N N N 23 458 Current week Neuroinvasive Previous 52 weeks Med 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Max 71 3 2 0 1 0 1 1 14 2 5 5 2 13 9 2 5 2 0 3 1 1 1 1 2 1 1 4 1 1 4 1 2 1 1 2 1 6 1 1 4 2 12 0 2 1 11 18 13 2 1 0 2 2 1 1 8 0 8 0 0 1 0 0 0 0 Cum 2011 183 8 5 1 1 1 11 1 1 6 3 29 5 4 15 5 12 2 2 6 1 1 26 1 12 2 4 1 5 1 25 1 20 4 9 3 6 31 21 1 7 2 32 32 Cum 2010 520 12 7 4 1 116 14 53 33 16 62 34 3 23 2 28 3 3 3 3 10 2 4 29 2 7 4 13 3 6 1 2 2 1 85 6 15 64 126 81 25 18 1 1 56 56 Current week Nonneuroinvasive Previous 52 weeks Med 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Max 30 1 1 0 0 0 0 0 5 3 1 0 1 4 2 1 1 3 0 6 1 2 0 1 4 1 0 3 0 1 1 1 2 0 0 0 0 3 0 0 3 1 1 1 1 0 1 10 5 5 0 0 1 0 1 1 5 0 5 0 0 0 0 0 0 0 Cum 2011 85 6 3 2 1 7 1 6 12 3 6 3 10 1 2 7 14 13 1 6 3 3 14 9 2 2 1 16 16 Cum 2010 362 5 4 1 60 13 30 9 8 26 13 7 3 1 2 72 4 12 4 29 7 16 19 2 2 8 6 1 8 2 1 3 2 17 1 6 10 117 54 52 1 2 4 4 38 37 1

C.N.M.I.: Commonwealth of Northern Mariana Islands. U: Unavailable. : No reported cases. N: Not reportable. NN: Not Nationally Notifiable. Cum: Cumulative year-to-date counts. Med: Median. Max: Maximum. * Case counts for reporting year 2010 and 2011 are provisional and subject to change. For further information on interpretation of these data, see http://www.cdc.gov/osels/ph_surveillance/ nndss/phs/files/ProvisionalNationa%20NotifiableDiseasesSurveillanceData20100927.pdf. Data for TB are displayed in Table IV, which appears quarterly. Updated weekly from reports to the Division of Vector-Borne Infectious Diseases, National Center for Zoonotic, Vector-Borne, and Enteric Diseases (ArboNET Surveillance). Data for California serogroup, eastern equine, Powassan, St. Louis, and western equine diseases are available in Table I. Not reportable in all states. Data from states where the condition is not reportable are excluded from this table, except starting in 2007 for the domestic arboviral diseases and influenzaassociated pediatric mortality, and in 2003 for SARS-CoV. Reporting exceptions are available at http://www.cdc.gov/osels/ph_surveillance/nndss/phs/infdis.htm. Contains data reported through the National Electronic Disease Surveillance System (NEDSS).

1298

MMWR / September 23, 2011 / Vol. 60 / No. 37

Morbidity and Mortality Weekly Report

TABLE III. Deaths in 122 U.S. cities,* week ending September 17, 2011 (37th week)
All causes, by age (years) Reporting area New England Boston, MA Bridgeport, CT Cambridge, MA Fall River, MA Hartford, CT Lowell, MA Lynn, MA New Bedford, MA New Haven, CT Providence, RI Somerville, MA Springfield, MA Waterbury, CT Worcester, MA Mid. Atlantic Albany, NY Allentown, PA Buffalo, NY Camden, NJ Elizabeth, NJ Erie, PA Jersey City, NJ New York City, NY Newark, NJ Paterson, NJ Philadelphia, PA Pittsburgh, PA Reading, PA Rochester, NY Schenectady, NY Scranton, PA Syracuse, NY Trenton, NJ Utica, NY Yonkers, NY E.N. Central Akron, OH Canton, OH Chicago, IL Cincinnati, OH Cleveland, OH Columbus, OH Dayton, OH Detroit, MI Evansville, IN Fort Wayne, IN Gary, IN Grand Rapids, MI Indianapolis, IN Lansing, MI Milwaukee, WI Peoria, IL Rockford, IL South Bend, IN Toledo, OH Youngstown, OH W.N. Central Des Moines, IA Duluth, MN Kansas City, KS Kansas City, MO Lincoln, NE Minneapolis, MN Omaha, NE St. Louis, MO St. Paul, MN Wichita, KS All Ages 536 135 32 17 25 60 22 8 15 41 58 3 32 37 51 1,828 35 27 69 19 13 46 14 1,050 19 23 163 47 33 82 25 38 72 17 17 19 2,048 59 47 227 94 247 237 121 160 49 72 17 63 204 44 88 57 55 60 101 46 638 73 39 44 106 55 56 94 22 60 89 65 373 84 28 14 18 40 18 4 12 29 42 3 21 27 33 1,256 24 22 50 10 9 35 8 712 9 15 96 33 25 62 19 29 60 12 14 12 1,340 36 39 146 45 184 153 88 82 35 55 8 41 122 30 58 34 39 42 63 40 418 57 31 28 62 40 31 53 9 43 64 4564 120 41 3 1 5 15 4 4 2 12 10 7 5 11 424 10 5 15 5 4 11 4 246 8 3 43 12 7 14 3 8 12 5 3 6 471 16 7 51 33 43 58 26 53 12 11 6 15 47 10 25 11 11 11 21 4 154 12 6 13 28 13 19 24 7 11 21 2544 23 5 1 1 2 2 1 3 2 5 1 91 1 1 2 2 61 2 4 11 1 4 1 1 133 1 22 5 13 18 4 11 5 2 2 21 3 1 8 3 2 10 2 45 2 2 12 2 3 15 4 4 1 124 8 2 1 1 2 2 33 1 20 7 1 1 2 1 57 3 1 5 3 4 3 1 10 2 1 4 8 2 2 2 2 4 9 1 1 1 2 1 1 2 <1 12 3 2 1 6 24 2 2 11 1 6 2 47 3 3 8 3 5 2 4 1 1 6 1 2 2 3 3 11 1 1 2 3 1 2 1 Total 34 13 3 1 2 1 5 1 4 4 78 1 2 5 1 1 2 2 35 1 5 1 2 5 3 3 6 1 2 127 1 4 11 5 15 19 6 10 4 3 4 15 2 3 8 5 4 6 2 37 3 3 2 3 2 6 5 1 6 6 P&I Reporting area (Continued) S. Atlantic Atlanta, GA Baltimore, MD Charlotte, NC Jacksonville, FL Miami, FL Norfolk, VA Richmond, VA Savannah, GA St. Petersburg, FL Tampa, FL Washington, D.C. Wilmington, DE E.S. Central Birmingham, AL Chattanooga, TN Knoxville, TN Lexington, KY Memphis, TN Mobile, AL Montgomery, AL Nashville, TN W.S. Central Austin, TX Baton Rouge, LA Corpus Christi, TX Dallas, TX El Paso, TX Fort Worth, TX Houston, TX Little Rock, AR New Orleans, LA San Antonio, TX Shreveport, LA Tulsa, OK Mountain Albuquerque, NM Boise, ID Colorado Springs, CO Denver, CO Las Vegas, NV Ogden, UT Phoenix, AZ Pueblo, CO Salt Lake City, UT Tucson, AZ Pacific Berkeley, CA Fresno, CA Glendale, CA Honolulu, HI Long Beach, CA Los Angeles, CA Pasadena, CA Portland, OR Sacramento, CA San Diego, CA San Francisco, CA San Jose, CA Santa Cruz, CA Seattle, WA Spokane, WA Tacoma, WA Total All Ages 1,169 147 132 136 128 85 38 72 57 61 215 89 9 823 157 92 106 58 169 74 23 144 1,216 81 64 59 220 95 U 161 90 U 258 86 102 1,165 141 43 74 85 284 40 163 29 128 178 1,713 13 129 39 72 55 245 19 93 222 185 108 183 34 132 56 128 11,136 All causes, by age (years) 65 716 81 71 87 82 56 23 37 32 40 142 57 8 507 101 57 69 34 101 37 18 90 788 50 50 36 134 61 U 101 53 U 178 53 72 738 83 34 43 47 171 29 100 24 84 123 1,205 11 84 32 59 43 166 14 63 158 138 72 130 22 78 46 89 7,341 4564 326 49 43 31 40 22 10 26 16 12 55 21 1 224 38 26 31 14 53 20 3 39 303 22 9 18 59 25 U 43 32 U 56 18 21 295 39 5 22 28 74 7 43 2 30 45 359 1 34 4 6 9 48 3 18 49 35 29 44 6 40 7 26 2,676 2544 70 13 10 10 3 2 3 5 6 5 11 2 59 12 7 5 5 7 14 9 61 2 4 3 13 4 U 9 1 U 11 6 8 81 9 1 5 7 28 2 14 2 8 5 86 4 1 4 3 17 1 9 10 8 5 4 3 6 3 8 649 124 37 3 4 5 2 4 1 3 2 3 6 4 15 3 2 1 3 2 1 3 37 5 1 1 8 2 U 3 2 U 10 4 1 24 6 1 2 1 7 1 1 1 1 3 32 5 3 6 1 3 2 1 3 1 2 5 252 <1 20 1 4 3 1 1 1 1 1 1 1 5 18 3 5 5 1 1 3 27 2 1 6 3 U 5 2 U 3 5 25 4 2 2 2 4 1 3 5 2 31 1 2 2 8 1 2 2 2 1 2 2 6 215 P&I Total 86 4 14 13 8 2 1 4 7 8 15 10 72 19 5 11 4 19 3 4 7 60 6 7 11 4 U 4 1 U 16 8 3 55 7 2 2 3 13 1 11 8 8 123 2 7 4 8 8 26 1 5 24 4 8 9 1 6 3 7 672

U: Unavailable. : No reported cases. * Mortality data in this table are voluntarily reported from 122 cities in the United States, most of which have populations of >100,000. A death is reported by the place of its occurrence and by the week that the death certificate was filed. Fetal deaths are not included. Pneumonia and influenza. Because of changes in reporting methods in this Pennsylvania city, these numbers are partial counts for the current week. Complete counts will be available in 4 to 6 weeks. Total includes unknown ages.

MMWR / September 23, 2011 / Vol. 60 / No. 37

1299

Morbidity and Mortality Weekly Report

The Morbidity and Mortality Weekly Report (MMWR) Series is prepared by the Centers for Disease Control and Prevention (CDC) and is available free of charge in electronic format. To receive an electronic copy each week, visit MMWRs free subscription page at http://www.cdc.gov/mmwr/mmwrsubscribe. html. Paper copy subscriptions are available through the Superintendent of Documents, U.S. Government Printing Office, Washington, DC 20402; telephone 202-512-1800. Data presented by the Notifiable Disease Data Team and 122 Cities Mortality Data Team in the weekly MMWR are provisional, based on weekly reports to CDC by state health departments. Address all inquiries about the MMWR Series, including material to be considered for publication, to Editor, MMWR Series, Mailstop E-90, CDC, 1600 Clifton Rd., N.E., Atlanta, GA 30333 or to mmwrq@cdc.gov. All material in the MMWR Series is in the public domain and may be used and reprinted without permission; citation as to source, however, is appreciated. Use of trade names and commercial sources is for identification only and does not imply endorsement by the U.S. Department of Health and Human Services. References to non-CDC sites on the Internet are provided as a service to MMWR readers and do not constitute or imply endorsement of these organizations or their programs by CDC or the U.S. Department of Health and Human Services. CDC is not responsible for the content of these sites. URL addresses listed in MMWR were current as of the date of publication.

U.S. Government Printing Office: 2011-723-011/21073 Region IV

ISSN: 0149-2195

National Pest Management Association State Bed Bug Specific Laws & Rules as of August 26, 2011 Alabama Administrative Code/ALABAMA STATE BOARD OF HEALTH/DEPARTMENT OF PUBLIC HEALTH BUREAU OF ENVIRONMENTAL AND HEALTH SERVICE STANDARDS CHAPTER 420-3-11 CONSTRUCTION, MAINTENANCE, AND OPERATION OF HOTELS http://www.alabamaadministrativecode.state.al.us/docs/hlth/420-311.pdf 420-3-11-.12 Insect And Rodent Control. (1) General - Effective measures intended to minimize the presence of rodents, flies, cockroaches and other insects on the premises shall be utilized. The premises shall be kept in such condition as to prevent the harborage or feeding of insects or rodents. Openings to the outside shall be protected from rodents and insects by tight-fitting, self-closing doors, closed windows, screening, controlled air-currents or other means. Screening material shall be not less than sixteen mesh to the inch, tight-fitting and free of breaks. (2) Infestations - Guest rooms and other areas of the hotel found to be infested with rodents and/or insects, including but not limited to cockroaches, bed bugs, fleas, lice or mites, shall be subject to immediate closure until treatment of the room or area has been deemed effective in elimination of the vermin. The Health officer shall declare the problem abated before the room or area is reopened to guests. (3) Premises - Immediate surroundings and premises shall be kept clean and free from rank growth of vegetation, discarded materials and insanitary nuisances. (4) Garbage and Refuge - Each guest room and vanity area shall be provided with garbage containers. All containers used in guest rooms, vanities, bathrooms, lobbies, hallways, and public assembly rooms shall be constructed of durable materials that do not leak or absorb liquids. These containers shall be kept clean and in good repair. Garbage containers and singleservice
National Pest Management AssociationAugust 26, 2011

liners shall be provided in kitchenette areas. Author: Ronald Dawsey, Tim Hatch Statutory Authority: Code of Ala. 1975, 22-2-2, 34-15-3. History: Filed September 1, 1982. Repealed and Replaced: Effective March 26, 1993. Amended: December 20, 2006; effective January 24, 2007.

Arizona Revised Code http://www.azleg.gov/ars/36/00601.htm

A. The following conditions are specifically declared public nuisances dangerous to the public health: 7. The presence of ectoparasites such as bedbugs, lice, mites and others in any place where sleeping accommodations are offered to the public. B. If the director has reasonable cause to believe from information furnished to the director or from investigation made by the director that any person is maintaining a nuisance or engaging in any practice contrary to the health laws of this state, the director shall promptly serve on that person by certified mail a cease and desist order requiring the person, on receipt of the order, promptly to cease and desist from that act. Within fifteen days after receipt of the order, the person to whom it is directed may request the director to hold a hearing. The director, as soon as practicable, shall hold a hearing, and if the director determines the order is reasonable and just and that the practice engaged in is contrary to the health laws of this state, the director shall order the person to comply with the cease and desist order. C. If a person fails or refuses to comply with the order of the director, or if a person to whom the order is directed does not request a hearing and fails or refuses to comply with the cease and desist order served by mail under subsection B, the director may file an action in the superior court in the county in which a violation occurred, restraining and enjoining the person from engaging in further acts. The court shall proceed as in other actions
National Pest Management AssociationAugust 26, 2011

for injunctions. 33-1319. Bedbug control; landlord and tenant obligations; definitions http://www.azleg.gov/ars/33/01319.htm A. A landlord has the following obligations with respect to a bedbug infestation: 1. The landlord shall provide bedbug educational materials to existing and new tenants. Educational materials may include: (a) A description of measures that may be taken to prevent and control bedbugs. (b) Information about bedbugs, including a description of their appearance. (c) A description of behaviors that are risk factors for attracting bedbugs such as purchasing renovated mattresses, using discarded mattresses and furniture, using used or leased furniture, purchasing pre-owned clothing and traveling without proper precautions. (d) Information provided by the United States centers for disease control and prevention and other federal, state or local health agencies. (e) Information provided by federal, state or local housing agencies. (f) Information provided by nonprofit housing organizations. (g) Information developed by the landlord. 2. The landlord shall not enter into any lease agreement with a tenant for a dwelling unit that the landlord knows to have a current bedbug infestation. B. A tenant has the following obligations with respect to a bedbug infestation: 1. The tenant shall not knowingly move materials into a dwelling unit that are infested with bedbugs. 2. A tenant who knows of the presence of bedbugs shall provide the
National Pest Management AssociationAugust 26, 2011

landlord written or electronic notification of the presence of bedbugs. C. This section does not limit any other rights, remedies and obligations under this chapter. D. The landlord and tenant of a single family residence are excluded from the provisions of this section. E. Except as specifically provided in this section, this section does not create a cause of action against: 1. A landlord or a landlord's employees, officers, agents and directors by a tenant or a tenant's guests for any damages caused by bedbugs. 2. A tenant by a landlord for any damages caused by bedbugs. F. For the purposes of this section: 1. "Bedbugs" means any insect in the genus cimex and its eggs. 2. "Infestation" or "infested" means that the presence of bedbugs is sufficient to materially affect the health and safety of tenants and their guests. 11-269.11. Prohibition on adopting landlord tenant bedbug control requirements http://www.azleg.gov/ars/11/00269-11.htm A. Except as provided in subsection B of this section the board of supervisors and any other person under the authority of the board of supervisors shall not adopt requirements by ordinance or otherwise for landlords or tenants that relate to the control of bedbugs as defined in section 33-1319, other than the requirements prescribed by section 331319. B. The board of supervisors or a person under the authority of the board of supervisors may adopt requirements relating to the proper disposal of items that are infested with bedbugs. 9-500.31. Prohibition on adopting landlord tenant bedbug control
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requirements http://www.azleg.gov/ars/9/00500-31.htm A. Except as provided in subsection B of this section, a city or town shall not adopt requirements by ordinance or otherwise for landlords or tenants that relate to the control of bedbugs as defined in section 33-1319, other than the requirements prescribed by section 33-1319. B. A city or town may adopt requirements relating to the proper disposal of items that are infested with bedbugs. Senate Bill 1306 Enacted April 2011/Implemented July 2011 http://www.azleg.gov/legtext/50leg/1r/bills/sb1306h.pdf

Florida Revised Code/Title VI/Civil Practice and Procedure/Chapter 83Landlord and Tenant http://www.leg.state.fl.us/statutes/index.cfm?mode=View%20Statutes&Sub Menu=1&App_mode=Display_Statute&Search_String=bedbugs&URL=000 0-0099/0083/Sections/0083.51.html 83.51 (1) Landlords obligation to maintain premises.

The landlord at all times during the tenancy shall:

(a) Comply with the requirements of applicable building, housing, and health codes; or (b) Where there are no applicable building, housing, or health codes, maintain the roofs, windows, screens, doors, floors, steps, porches, exterior walls, foundations, and all other structural components in good repair and capable of resisting normal forces and loads and the plumbing in reasonable working condition. However, the landlord shall not be required to maintain a mobile home or other structure owned by the tenant. The landlords obligations under this subsection may be altered or modified
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in writing with respect to a single-family home or duplex. (2)(a) Unless otherwise agreed in writing, in addition to the requirements of subsection (1), the landlord of a dwelling unit other than a single-family home or duplex shall, at all times during the tenancy, make reasonable provisions for: 1. The extermination of rats, mice, roaches, ants, wood-destroying organisms, and bedbugs. When vacation of the premises is required for such extermination, the landlord shall not be liable for damages but shall abate the rent. The tenant shall be required to temporarily vacate the premises for a period of time not to exceed 4 days, on 7 days written notice, if necessary, for extermination pursuant to this subparagraph. 2. 3. 4. Locks and keys. The clean and safe condition of common areas. Garbage removal and outside receptacles therefor.

5. Functioning facilities for heat during winter, running water, and hot water. (b) Unless otherwise agreed in writing, at the commencement of the tenancy of a single-family home or duplex, the landlord shall install working smoke detection devices. As used in this paragraph, the term smoke detection device means an electrical or battery-operated device which detects visible or invisible particles of combustion and which is listed by Underwriters Laboratories, Inc., Factory Mutual Laboratories, Inc., or any other nationally recognized testing laboratory using nationally accepted testing standards. (c) Nothing in this part authorizes the tenant to raise a noncompliance by the landlord with this subsection as a defense to an action for possession under s. 83.59. (d) (e)

This subsection shall not apply to a mobile home owned by a tenant. Nothing contained in this subsection prohibits the landlord from
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providing in the rental agreement that the tenant is obligated to pay costs or charges for garbage removal, water, fuel, or utilities. (3) If the duty imposed by subsection (1) is the same or greater than any duty imposed by subsection (2), the landlords duty is determined by subsection (1). (4) The landlord is not responsible to the tenant under this section for conditions created or caused by the negligent or wrongful act or omission of the tenant, a member of the tenants family, or other person on the premises with the tenants consent. History.s. 2, ch. 73-330; s. 22, ch. 82-66; s. 4, ch. 87-195; s. 1, ch. 90133; s. 3, ch. 93-255; s. 444, ch. 95-147; s. 8, ch. 97-95. Hawaii 2006 Resolution http://www.capitol.hawaii.gov/session2006/Bills/HCR36_SD1_.htm

H.C.R. NO.

36 TWENTY-THIRD LEGISLATURE, 2006 STATE OF HAWAII H.D. 1 S.D. 1

HOUSE CONCURRENT RESOLUTION

REQUESTING THE DEPARTMENT OF HEALTH TO WORK IN COOPERATION WITH THE STATE TOURISM LIAISON AND THE HAWAII HOTEL & LODGING ASSOCIATION IN RAISING AWARENESS, EDUCATION, AND PREVENTION OF THE INCREASING
National Pest Management AssociationAugust 26, 2011

INCIDENCE OF BEDBUGS.

WHEREAS, after nearly being eradicated six decades ago, bedbugs are appearing in growing numbers throughout the United States; and WHEREAS, the National Pest Management Association indicates they have received reports of bedbugs in forty-three states; and WHEREAS, changing pest control practices that favor non-toxic alternatives is believed to have contributed to the current bedbug problem; and WHEREAS, increased world travel has also been a factor in the re-emergence of bedbugs, which are easily transported in a suitcase and can survive for long periods without food; and WHEREAS, nationally, a number of hotels with bedbug problems have had to deal with frustrated visitors and negative publicity; and WHEREAS, Hawaii's visitor industry and residents alike are susceptible to the increasing incidence of bedbugs and the costs related to their control and extermination; now, therefore, BE IT RESOLVED by the Senate of the Twenty-third Legislature of the State of Hawaii, Regular Session of 2006, the House of Representatives concurring, that the Department of Health is requested to work in cooperation with the State Tourism Liaison and the Hawaii Hotel & Lodging Association in raising awareness, education, and prevention of the increasing incidence of bedbugs; and BE IT FURTHER RESOLVED that the Director of Health is requested to submit findings and recommendations to the Legislature not later than twenty days prior to the convening of the Regular Session of 2007; and BE IT FURTHER RESOLVED that a certified copy of this Concurrent Resolution be transmitted to the Director of Health, the State Tourism Liaison, and the Hawaii Hotel & Lodging Association.
National Pest Management AssociationAugust 26, 2011

Report Title: Bedbugs; Department of Health

Illinois Compiled Laws Chapter 610-Railroads http://www.ilga.gov/legislation/ilcs/documents/061000850K1.htm (610 ILCS 85/1) (from Ch. 114, par. 100a) Sec. 1. No owner or operator of a railroad shall permit any railroad car to be dispatched for the transportation of or occupation by passengers unless such cars is in a clean and sanitary condition and is free from cockroaches, body lice, bedbugs and other vermin. (Source: Laws 1949, p. 1243.) (610 ILCS 85/2) (from Ch. 114, par. 100b) http://www.ilga.gov/legislation/ilcs/documents/061000850K2.htm Sec. 2. Owners and operators of railroads shall require railroad cars used for the transportation of or occupation by passengers to be regularly cleaned and inspected and to be fumigated or otherwise treated to free them from cockroaches, body lice, bedbugs and other vermin. (Source: Laws 1949, p. 1243.) (610 ILCS 85/3) (from Ch. 114, par. 100c) Sec. 3. Whoever violates this Act shall be guilty of a petty offense. The use of any car for the transportation of or occupation by passengers when the car is not in a clean and sanitary condition or is not free from cockroaches, body lice, bedbugs and other vermin is a separate offense for each day such car is so used. (Source: P. A. 77-2199.) http://www.ilga.gov/legislation/ilcs/documents/061000850K3.htm

National Pest Management AssociationAugust 26, 2011

PROFESSIONS AND OCCUPATIONS (225 ILCS 235/) Structural Pest Control Act. http://www.ilga.gov/legislation/ilcs/documents/022502350K10.15.htm (225 ILCS 235/10.15) (Section scheduled to be repealed on January 1, 2012) Sec. 10.15. Findings and Council report. The General Assembly makes the following findings: (1) The quality of life for a growing number of Illinois families has been impacted by a significant increase in bed bug (Cimex lectularius) infestations. (2) A joint EPA/CDC statement recognizes bed bugs as a pest of public health importance. (3) Bed bug infestations are increasing, are difficult to abate, and pose a challenge to those affected by those infestations. (4) There is a lack of public awareness about bed bug prevention, management, and control, necessitating the need for education of consumers, tenants, landlords, property owners, and managers. (5) In April of 2009, the United States Environmental Protection Agency held its first National Bed Bug Summit to solicit recommendations on dealing with the growing public nuisance of bed bugs; among the major recommendations emanating from the summit was the importance of legislative support and better education about bed bugs for governments and elected officials. (6) It is in the public interest to study the increase in bed bug infestations and make specific recommendations for addressing this growing public nuisance. The Structural Pest Control Advisory Council shall

National Pest Management AssociationAugust 26, 2011

convene a subcommittee to develop a report to the General Assembly with recommendations on the prevention, management, and control of bed bug infestations. The report shall include, but not be limited to, recommendations related to the availability of education materials on bed bug prevention, management, and control; proper transport, storage, and disposal of bed bug infested materials; promote the development of effective treatment methods or options to eradicate bed bug infestation; and increasing knowledge and awareness among tenants, landlords, and property managers and owners about preventing bed bug infestations. In addition to the members of the Structural Pest Control Advisory Council, the subcommittee may include: a representative of a nonprofit organization, particularly one involved with tenant advocacy issues; a representative of apartment associations; and staff from the Illinois Housing Development Authority and the Office of the Illinois Attorney General. The members of the subcommittee shall serve without compensation for their duties or expenses incurred with the work of the subcommittee. The Structural Pest Control Advisory Council shall issue its report to the General Assembly on or before December 31, 2011. This Section is repealed on January 1, 2012. (Source: P.A. 96-1330, eff. 7-27-10.) Iowa Administrative Rule TITLE IV PUBLIC HEALTH/SUBTITLE 2 HEALTH-RELATED ACTIVITIES/CHAPTER 138 MIGRANT LABOR CAMPS/138.13 Conditions for permit. 138.13 Conditions for permit. To be eligible for a permit, a migrant labor camp, or portion thereof, shall meet each and all of the following requirements: 10. Insect and rodent control. a. Effective measures shall be taken to control rats, mice, flies, mosquitoes; bedbugs , and all other insects, rodents, and parasites within the camp premises. b. Pesticides and pest control equipment shall be stored and used in a safe manner.
National Pest Management AssociationAugust 26, 2011

[C71, 73, 75, 77, 79, 81, 138.13]

Kansas Administrative Rules/Article 36.FOOD SERVICE ESTABLISHMENTS, FOOD VENDING MACHINE COMPANIES AND LODGING ESTABLISHMENTS/28-36-77. Guest rooms. http://www.kssos.org/pubs/KAR/2009/2A004_28Department%20of%20Health%20and%20Environment%20Articles% 2036%20through%2040,%202009%20KAR%20Vol%202A.pdf (p) Each guest room shall be free of any evidence of insects, rodents, and other pests. (1) If a guest room has been vacant for at least 30 days, the licensee shall visually inspect that room for any evidence of insects, rodents, and other pests within 24 hours of occupancy by the next guest. (2) No guest room that is infested by insects, rodents, or other pests shall be rented until the infestation is eliminated. (3) The presence of bed bugs, which is indicated by observation of a living or dead bed bug, bed bug carapace, eggs or egg casings, or the typical brownish or blood spotting on linens, mattresses , or furniture, shall be considered an infestation. (4) The presence of bed bugs shall be reported to the regulatory authority within one business day upon discovery or upon receipt of a guest complaint. (5) All infestations shall be treated by a licensed pest control operator (PCO). (6) All pest control measures, both mechanical and chemical, shall be used in accordance with the manufacturers recommendations. (7) No rodenticides, pesticides, or insecticides shall be stored in a guest room or in any area that could contaminate guest supplies, food, condiments, dishware, or utensils.

Maine Revised Statutes-Title 14: COURT PROCEDURE CIVIL/ Part 7: PARTICULAR PROCEEDINGS/Chapter 710: RENTAL PROPERTY http://www.mainelegislature.org/legis/statutes/14/title14sec6021A.html
National Pest Management AssociationAugust 26, 2011

http://www.mainelegislature.org/legis/statutes/14/title14sec6021-A.pdf

6021-A. Treatment of bedbug infestation 1. Definition. As used in this section, unless the context otherwise indicates, "pest control agent" means a commercial applicator of pesticides certified pursuant to Title 22, section 1471-D. [ 2009, c. 566, 8 (NEW) .] 2. Landlord duties. A landlord has the following duties. A. Upon written or oral notice from a tenant that a dwelling unit may have a bedbug infestation, the landlord shall within 5 days conduct an inspection of the unit for bedbugs. [2009, c. 566, 8 (NEW).] B. Upon a determination that an infestation of bedbugs does exist in a dwelling unit, the landlord shall within 10 days contact a pest control agent pursuant to paragraph C. [2009, c. 566, 8 (NEW).] C. A landlord shall take reasonable measures to effectively identify and treat the bedbug infestation as determined by a pest control agent. The landlord shall employ a pest control agent that carries current liability insurance to promptly treat the bedbug infestation. [2009, c. 566, 8 (NEW).] D. Before renting a dwelling unit, a landlord shall disclose to a prospective tenant if an adjacent unit or units are currently infested with or are being treated for bedbugs. Upon request from a tenant or prospective tenant, a landlord shall disclose the last date that the dwelling unit the landlord seeks to rent or an adjacent unit or units were inspected for a bedbug infestation and found to be free of a bedbug infestation. [2009, c. 566, 8 (NEW).] E. A landlord may not offer for rent a dwelling unit that the landlord knows or suspects is infested with bedbugs. [2009, c. 566, 8 (NEW).] F. A landlord shall offer to make reasonable assistance, including financial assistance, available to a tenant who is not able to comply with requested bedbug inspection or control measures under subsection 3, paragraph C. After first disclosing what the cost of the tenant's compliance
National Pest Management AssociationAugust 26, 2011

with requested bedbug inspection or control measures may be, a landlord may charge the tenant a reasonable amount for any such assistance, subject to a reasonable repayment schedule, not to exceed 6 months, unless an extension is otherwise agreed to by the landlord and the tenant. [2009, c. 566, 8 (NEW).] [ 2009, c. 566, 8 (NEW) .] 3. Tenant duties. A tenant has the following duties. A. A tenant shall promptly notify a landlord when the tenant knows of or suspects an infestation of bedbugs in the tenant's dwelling unit. [2009, c. 566, 8 (NEW).] B. Upon receiving reasonable notice as set forth in section 6025, including reasons for and scope of the request for access to the premises, a tenant shall grant the landlord of the dwelling unit, the landlord's agent or the landlord's pest control agent and its employees access to the unit for purposes of an inspection for or control of the infestation of bedbugs. The initial inspection may include only a visual inspection and manual inspection of the tenant's bedding and upholstered furniture. Employees of the pest control agent may inspect items other than bedding and upholstered furniture when such an inspection is considered reasonable by the pest control agent. If the pest control agent finds bedbugs in the dwelling unit or in an adjoining unit, the pest control agent may have additional access to the tenant's personal belongings as determined reasonable by the pest control agent. [2009, c. 566, 8 (NEW).] C. Upon receiving reasonable notice as set forth in section 6025, a tenant shall comply with reasonable measures to eliminate and control a bedbug infestation as set forth by the landlord and the pest control agent. The tenant's unreasonable failure to completely comply with the pest control measures results in the tenant's being financially responsible for all pest control treatments of the dwelling unit arising from the tenant's failure to comply. [2009, c. 566, 8 (NEW).] [ 2009, c. 566, 8 (NEW) .] 4. Remedies. The following remedies are available. A. The failure of a landlord to comply with the provisions of this section constitutes a finding that the landlord has unreasonably failed under the
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circumstances to take prompt, effective steps to repair or remedy a condition that endangers or materially impairs the health or safety of a tenant pursuant to section 6021, subsection 3. [2009, c. 566, 8 (NEW).] B. A landlord who fails to comply with the provisions of this section is liable for a penalty of $250 or actual damages, whichever is greater, plus reasonable attorney's fees. [2009, c. 566, 8 (NEW).] C. A landlord may commence an action in accordance with section 6030-A and obtain relief against a tenant who fails to provide reasonable access or comply with reasonable requests for inspection or treatment or otherwise unreasonably fails to comply with reasonable bedbug control measures as set forth in this section. For the purposes of section 6030-A and this section, if a court finds that a tenant has unreasonably failed to comply with this section, the court may issue a temporary order or interim relief pursuant to Title 5, section 4654 to carry out the provisions of this section, including but not limited to: (1) Granting the landlord access to the premises for the purposes set forth in this section; (2) Granting the landlord the right to engage in bedbug control measures; and (3) Requiring the tenant to comply with specified bedbug control measures or assessing the tenant with costs and damages related to the tenant's noncompliance. Any order granting the landlord access to the premises must be served upon the tenant at least 24 hours before the landlord enters the premises. [2009, c. 566, 8 (NEW).] D. In any action of forcible entry and detainer under section 6001, there is a rebuttable presumption that the action was commenced in retaliation against the tenant if, within 6 months before the commencement of the action, the tenant has asserted the tenant's rights pursuant to this section. [2009, c. 566, 8 (NEW).] [ 2009, c. 566, 8 (NEW) .] SECTION HISTORY 2009, c. 566, 8 (NEW).
National Pest Management AssociationAugust 26, 2011

LD 1198 Signed June 22, 2011-Amended 2010 Bed Bug Law http://www.mainelegislature.org/legis/bills/bills_125th/chappdfs/PUBL IC405.pdf Sec. 9. 14 MRSA 6021-A, sub-2, F, as enacted by PL 2009, c. 566, 8, is amended to read: F. A landlord shall offer to make reasonable assistance, including financial assistance, available to a tenant who is not able to comply with requested bedbug inspection or control measures under subsection 3, paragraph C. The landlord shall disclose to the tenant what the cost may be for the tenant's compliance with the requested bedbug inspection or control measure. After first disclosing what the cost of the tenant's compliance with requested bedbug inspection or control measures may be, amaking this disclosure, the landlord may provide financial assistance to the tenant to prepare the unit for bedbug treatment. A landlord may charge the tenant a reasonable amount for any such assistance, subject to a reasonable repayment schedule, not to exceed 6 months, unless an extension is otherwise agreed to by the landlord and the tenant. This paragraph may not be construed to require the landlord to provide the tenant with alternate lodging or to pay to replace the tenant's personal property. Sec. 10. 14 MRSA 6021-A, sub-4, D, as enacted by PL 2009, c. 566, 8, is amended to read: D. In any action of forcible entry and detainer under section 6001, there is a rebuttable presumption that the action was commenced in retaliation against the tenant if, within 6 months before the commencement of the action, the tenant has asserted the tenant's rights pursuant to this section. The rebuttable presumption of retaliation does not apply unless the tenant asserted that tenant's rights pursuant to this section prior to being served with the eviction notice. There is no presumption of retaliation if the action for forcible entry and detainer is
National Pest Management AssociationAugust 26, 2011

brought for failure to pay rent or for causing substantial damage to the premises.

Minnesota Administrative Code

CHAPTER 4625, LODGING ESTABLISHMENTS https://www.revisor.mn.gov/rules/?id=4625.1700&keyword_type=al l&keyword=bedbugs 4625.1700 INSECT AND RODENT CONTROL. Every hotel, motel, lodging house, and resort shall be so constructed and equipped as to prevent the entrance, harborage, or breeding of flies, roaches, bedbugs, rats, mice, and all other insects and vermin, and specific means necessary, for the elimination of such pests such as cleaning, renovation, or fumigation shall be used. The commissioner may order the facility to hire an exterminator licensed by the state to exterminate pests when: A. the infestation is so extensive that it is unlikely that a nonprofessional can eradicate the pests effectively; or B. the extermination method of choice can only be carried out by a licensed exterminator; or C. upon reinspection, it is found that an establishment has not been brought into compliance with a prior order to rid the establishment of pests. Statutory Authority: MS s 144.08; 144.12; 157.01 to 157.14; 327.10 to 327.67 Posted: January 21, 2000

https://www.revisor.mn.gov/rules/?id=4625.1700&keyword_type=all&keywo rd=bedbugs
National Pest Management AssociationAugust 26, 2011

CHAPTER 4665, SUPERVISED LIVING FACILITIES

4665.2300 INSECT AND RODENT CONTROL. Every facility shall be so constructed or equipped as to prevent the entrance, harborage, or breeding of flies, roaches, bedbugs, rats, mice, and all other insects and vermin. Cleaning, renovation, or fumigation by licensed pest control operators for the elimination of such pests shall be used when necessary. Statutory Authority: MS s 144.56 Posted: October 11, 2007

https://www.revisor.mn.gov/rules/?id=4665.2300&keyword_type=all&keywo rd=bedbugs

Nevada Revised Code-CHAPTER 447 - PUBLIC ACCOMMODATIONS http://www.leg.state.nv.us/Division/Legal/LawLibrary/NRS/NRS-447.html

NRS 447.030 Extermination of vermin. Any room in any hotel in this state which is or shall be infested with vermin or bedbugs or similar things shall be thoroughly fumigated, disinfected and renovated until such vermin or bedbugs or other similar things are entirely exterminated. [3:136:1915; 1919 RL p. 2811; NCL 3339]

New York Laws http://public.leginfo.state.ny.us/LAWSSEAF.cgi?QUERYTYPE=LAWS+&Q UERYDATA=$$ADC27-2018.1$$@TXADC027 National Pest Management AssociationAugust 26, 2011

2018.1+&LIST=LAW+&BROWSER=BROWSER+&TOKEN=08327425+&T ARGET=VIEW (Note: While a state law, this statute revised New York City Administrative Code) 27-2018.1 Notice of bedbug infestation history. a. For housing accommodations subject to this code, an owner shall furnish to each tenant signing a vacancy lease, a notice in a form promulgated or approved by the state division of housing and community renewal that sets forth the property's bedbug infestation history for the previous year regarding the premises rented by the tenant and the building in which the premises are located. b. Upon written complaint, in a form promulgated or approved by the division of housing and community renewal, by the tenant that he or she was not furnished with a copy of the notice required pursuant to subdivision a of this section, the division of housing and community renewal shall order the owner to furnish the notice. New York Education Code/Article 19 - MEDICAL AND HEALTH SERVICE http://public.leginfo.state.ny.us/LAWSSEAF.cgi?QUERYTYPE=LAWS+&Q UERYDATA=$$EDN920$$@TXEDN0920+&LIST=SEA2+&BROWSER=B ROWSER+&TOKEN=08327425+&TARGET=VIEW 920. Public schools; infestation of bedbugs (Cimex lectularius). 1. In a city school district having a population of one million or more inhabitants, the principal of each public school shall provide immediate notification to parents, persons in parental relation or guardians of potentially affected students attending the school, disclosing a finding relating to the infestation of bedbugs (Cimex lectularius) in such school; provided, however, that if pursuant to regulations of the commissioner it is determined that any infestation is contained within a discrete area, the principal may limit such notification to parents, persons in parental relationship or guardians of all potentially affected students within such area, and shall advise the parents' association of the scope of such notification. 2. Along with the notification required pursuant to subdivision one of this section, the principal of such public school shall also include information regarding proper procedures to prevent further infestations at the school and to prevent the transfer of bedbugs from the school to
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the residences of students. Such information shall be developed by the board of education in consultation with other city agencies and shall be available in various languages as deemed necessary. 3. The principal shall ensure that the bedbug infestation at the school is properly addressed in the most effective and safe manner. Ohio Revised Code http://codes.ohio.gov/orc/3731.13 Title [37] XXXVII HEALTH - SAFETY - MORALS Chapter 3731: HOTELS 3731.13 Bedding, floors, and carpets must be kept sanitary. All bedding used in any hotel must be thoroughly aired, disinfected, and kept clean. No bedding which is infested with vermin or bedbugs shall be used on any bed in any hotel. All floors, carpets, and equipment in hotels, and all walls and ceilings shall be kept in sanitary condition.

South Dakota Administrative Code/44:02:08-Vacation homes. http://legis.state.sd.us/rules/DisplayRule.aspx?Rule=44:02:08:05 44:02:08:05. Vermin control. A vacation home establishment must be constructed, equipped, and maintained to prevent the entrance, harborage, or breeding of flies, roaches, rats, mice, bed bugs, and all other insects and vermin. Specific means necessary for the elimination of such pests, such as cleaning, renovation, or fumigation, must be used. The department may require the facility to hire a professional exterminator to exterminate pests under the following conditions: (1) The infestation is so extensive that it is unlikely a nonprofessional can eradicate the pests effectively; (2) The chosen method of extermination can only be carried out by a
National Pest Management AssociationAugust 26, 2011

licensed professional exterminator; or (3) The department finds that an establishment has not been brought into compliance with a prior order to rid the establishment of pests. Regularly scheduled professional extermination services shall be required following the determination of an excessive pest infestation by the department. Source: 34 SDR 321, effective June 30, 2008. General Authority: SDCL 34-1-17, 34-18-22. Law Implemented: SDCL 34-18-22, 34-18-24.

Texas Revised Code/Health and Safety Code-Chapter 341-Minimum Standards of Sanitation and Health Protection Standards

http://www.statutes.legis.state.tx.us/DocViewer.aspx?K2DocKey=odbc%3a %2f%2fTCAS%2fASUPUBLIC.dbo.vwTCAS%2fHS%2fS%2fHS.341%40T CAS2&QueryText=bedbugs&HighlightType=1 SUBCHAPTER B. NUISANCES AND GENERAL SANITATION Sec. 341.011. NUISANCE. Each of the following is a public health nuisance: (10) the presence of ectoparasites, including bedbugs , lice, and mites, suspected to be disease carriers in a place in which sleeping accommodations are offered to the public; Sec. 341.012. ABATEMENT OF NUISANCE. (a) A person shall abate a public health nuisance existing in or on a place the person possesses as soon as the person knows that the nuisance exists. (b) A local health authority who receives information and proof that a public health nuisance exists in the local health authority's jurisdiction
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shall issue a written notice ordering the abatement of the nuisance to any person responsible for the nuisance. The local health authority shall at the same time send a copy of the notice to the local municipal, county, or district attorney. (c) The notice must specify the nature of the public health nuisance and designate a reasonable time within which the nuisance must be abated. (d) If the public health nuisance is not abated within the time specified by the notice, the local health authority shall notify the prosecuting attorney who received the copy of the original notice. The prosecuting attorney: (1) shall immediately institute proceedings to abate the public health nuisance; or (2) request the attorney general to institute the proceedings or provide assistance in the prosecution of the proceedings, including participation as an assistant prosecutor when appointed by the prosecuting attorney. Acts 1989, 71st Leg., ch. 678, Sec. 1, eff. Sept. 1, 1989. Amended by Acts 1993, 73rd Leg., ch. 648, Sec. 1, eff. Sept. 1, 1993. West Virginia Revised Code CHAPTER 16. PUBLIC HEALTH. ARTICLE 6. HOTELS AND RESTAURANTS. http://www.legis.state.wv.us/WVCODE/16/code/WVC%2016%20%20%20%206%20%20-%20%2016%20%20.htm 16-6-16. Bedbugs. In every hotel, any room infected with vermin or bedbugs shall be fumigated, disinfected and renovated until said vermin or bedbugs are extirpated.

National Pest Management AssociationAugust 26, 2011

Over 201 Things To Know About Bed Bugs

By: Paul J. Bello PJB Pest Management Consulting, LLC paul.bello@att.net

From the author of:

The Bed Bug Combat Manual

(now available online)

Updated: October 15, 2011 The original Over 101 . . . article was published many months ago. It was originally presented as written and in no specific order during the writing process. The original list was compiled in response to the numerous questions that had been received in conversations, at meetings, via telephone and e-mail queries. As you will see the list has grown to over two hundred things and will likely continue to grow as more is learned. In an effort to further assist the reader questions have been underlined and the list has been categorized for your convenience to include the following headings with initial category list number in parenthesis: Bed Bug Behavior, Biology & General Information (1) Bed Bug Information of Interest to Hospitality & Housing Professionals (89) Bed Bug Litigations (104) Bed Bug Inspection & Detection (114) Bed Bug Dogs (135) Bed Bug Control (147) Bed Bug Tips for Travelers, Homeowners & Apartment Residents (179) Closing Comments (216) This list of practical and useful things to know about bed bugs was written specifically with the many bed bug victims, hospitality professionals, property management professionals and pest management professionals in mind. Please note that these bits of information were gleaned from years of first hand field experience in dealing with bed bugs and working with industry colleagues across the country. They are presented to you the reader in an effort to assist you with your current bed bug concerns.
Behavior, Biology & General Information: 1. Do not underestimate them; bed bugs take a lot of knowledge, experience time & effort to deal with successfully. 2. 3. You need to keep a heightened level of vigilance to assure you are properly prepared to detect and deal with bed bugs. Bed bugs can last a long time without feeding. Some references indicate bed bugs can survive about one year without feeding under ideal conditions. Of course we are dealing with live entities and longevity is based upon local conditions. As such, your mileage may vary. In a recent conversation one of the industrys leading technical directors commented that because bed bugs have avoided the industrys attention since the 1960s that much of the basic biological information we have on bed bugs is limited and old information that needs to be updated. The good news is that there are several researchers working at modern labs and universities conducting bed bug research and that new information is being on bed bugs is being published nearly every day about bed bugs. Generally speaking, bed bugs can not climb smooth surfaces such as glass, some plastics and other such surfaces. In a bed bug video session conducted recently we witnessed an adult bed bug successfully scale a one cup Pyrex glass bowl not once, but twice. Subsequent inspection of the bowl under magnification revealed that the bowl may have been slightly dirty or dusty and there were small ridges in the glass invisible to the unaided eye. As such, be

4.

5. 6. 7.

sure your pitfall type traps are clean and suitably smooth. Additionally, place a small amount of a suitable dust/powder such as talc as this will help to prevent bed bug escape. 8. We found that adult bed bug ground speed on smooth poster board is from about three to four feet per minute. This means that a determined bed bug, if a bed bug can be characterized as determined, can cover a significant distance, up to twenty feet in just five minutes, if need be to seek out a host while were sleeping. At about four feet per minute, bed bugs travel at about 0.045 mph or about 22 hours per mile.

9.

10. Except for the egg, all stages of bed bugs from nymphs to adults feed on blood. 11. Some experts point out that, if necessary, bed bugs can get a blood meal from other bed bugs. While this may be a rare occurrence, it is possible and it underscores the tenacity of this troublesome pest. 12. Generally speaking, bed bugs can survive cold temperatures very well but succumb to heat rather easily. Recent industry literature sights temperatures of as low as about 113 degrees Fahrenheit can be lethal to bed bugs. 13. Temperatures of about 120 degrees Fahrenheit kill all stages of bed bugs in about one minute. Industry references and publications indicate a variety of temperatures and duration times to achieve mortality. It is likely best to be conservative to assure you achieve the desired results. 14. Bed bug eggs are tiny. Eggs and first instar nymphs are only about one millimeter long, that's only about 1/32nd of an inch. 15. Bed bug eggs are coated with a sticky substance. Once deposited by the female the eggs become glued in place to hidden areas which can make them difficult to find. 16. Once dried in place bed bug eggs are difficult to remove without a scraping action. 17. While accessible bed bug eggs may be removed by careful vacuuming, it is unlikely that a significant amount of hidden bed bug eggs, if any, will be removed using a vacuum alone. 18. Bed bug eggs are shaped cylindrical and oval like, rounded at one end with a round flat hatch shape at the opposite end. The round flat end opens like a "round hatch top" when the immature bed bug immature emerges. 19. Bed bug eggs are a shiny, translucent and a milky white color as are the newly hatched bed bug nymphs. 20. Prior to taking their initial blood meal immature bed bugs are translucent and may appear slightly yellowish in color. 21. Once engorged after a blood meal nymphal bed bugs may take on a bright red color. However, just like your mileage, individual bed bug color may vary. 22. Immature bed bugs maintain their reddish color for as long as they have remnants of their blood meal within their gut. As the blood meal is digested over time they become more and more translucent again. 23. It may take several weeks for an immature bed bug to fully digest a blood meal such that no or very little blood matter appears within the abdomen. 24. Hatched bed bug eggs appear hollow and may have their hatch top opened and attached like a pop top or missing. 25. As are the eggs, newly emerged/hatched immature bed bugs are equally small and difficult to see. 26. Newly hatched bed bugs are translucent, may appear shiny and milky white to slightly yellowish in color making them difficult to see on light color mattress, bedding materials and other such surfaces. 27. Bed bug eggs can be about the same size as one stitch of sewn mattress fabric. 28. Much like mosquitoes, bed bugs suck blood from their host victims. These blood meals are sucked in through the piercing sucking mouthparts at the "north end" and once digested are expelled out the south end as a dark inklike appearing fecal liquid.

29. Reportedly alcohol, such as rubbing alcohol, kills bed bugs on contact. 30. At the time of this writing there are no independent university research trial proven bed bug repellent products currently available. 31. There are no effective university research proven "sonic electronic" type repelling devices to rid your dwelling of bed bugs currently available at the time of this writing. However, this doesnt prevent the consuming public from buying a surprising number of these sonic pest repelling devices each year. 32. Bed bug eggs hatch in about three to five days depending upon a number of factors, including temperature and resource availability. Again, your mileage may vary. 33. Generally speaking, bed bugs spend most of their time hiding. 34. Not all people react to bed bug bites in an equivalent manner and its possible that while some family members react that others may not. 35. Bed bugs prefer to hide in undisturbed areas. 36. When viewed from the side, bed bugs are built rather flat and adult bed bugs can be thinner than the thickness of a normal business card. 37. It's a "wives tale" that bed bugs "bite in a line" or "along a vein". Bed bug bites may appear to be in a line because of where the bed bugs were located at when they bit the victim such as along the area where the victim's body was laying on the bed. Bed bugs resting on the mattress, sheet or other surface where the hosts body contacts that surface may then appear to have bitten in a line. 38. Generally speaking, bed bugs avoid crawling on their host when seeking a blood meal. This kinda-sorta makes sense because in doing so the bed bug may inadvertently awaken the host which would very likely result in its demise. 39. It seems that bed bugs do not bite where the body is covered by clothing or pajamas however, it is possible for bed bugs to crawl underneath loose fitting garments. 40. Adult bed bugs are about 1/4 of an inch long by about 3/16 inch wide, your mileage may vary. 41. As a snake does, bed bugs must molt or shed their skin to grow to the next stage of development ( entomologists call these stages an instar ) until they become adults. 42. Shed skins may be found in bed bug harborages or other areas and can be a tell tale sign of the presence of bed bugs. 43. Bed bugs must have a blood meal to molt or grow to the next instar or stage of development. If you find multi stages of bed bug development at your location along with the typical fecal staining present, guess what; thats probably your blood ! 44. Bed bugs go through five instars to become adults. This means adult bed bugs in your house may have fed upon you, your guests or your family members at least five times if they started off there as first instar immatures. 45. There are no "albino bed bugs" (nor are their albino cockroaches either). Immature bed bugs may appear light in color after molting and get their dark rusty red color after feeding or taking a blood meal. 46. A bed bug's abdomen (the hind end area) grows many times its original size as it takes in your blood. Just check out one of the popular bed bug feeding videos now widely available online. 47. Based on their size, bed bugs are capable of hiding nearly anywhere within a hotel room, apartment, dorm room, home or any such place. 48. Where do bed bugs come from? The short answer is mommy & daddy bed bugs. However, people get bed bugs from being at places where bed bugs are.

49. Bed bugs reproduce via a process entomologists call traumatic insemination. This term is used because the male actually pierces the abdomen of the female to inseminate her. The University of Florida, Department of Entomology has published excellent photos of this. 50. During traumatic insemination the male climbs atop the female and wraps the tip of his abdomen around and toward the underside of the female where he inserts his reproductive appendage known as a paramere. The female bed bug is pierced where an inverted v-shaped invagination is present in the margin of one of her abdominal sclerites. Spongy tissues within her abdomen at the insemination site serve to prevent the female from suffering lethal fluid loss. The male bed bug must then mow the lawn, clean the garage or basement as he promised prior to this event taking place. 51. Researchers have found that females may migrate away from bed bug harborages as a reaction to or as an avoidance behavior associated with traumatic insemination. 52. Depending upon your perspective, generally speaking bed bugs are a "people problem". They are not a building problem. However, if youre the neighbor of someone who brought bed bugs into your building, your perspective is likely different. 53. What do bed bug bites look like? People may react to bed bugs bites differently and the bites may appear differently on different people. Generally speaking, bed bug bites appear as raised reddened bumps on the skin that are usually itchy. There are photos of bed bug bites available for view online. 54. Can I feel the bed bugs bite me? It's doubtful that you will. Bed bugs make their living by being "stealthy". That is, they need to sneak in, find a suitable place to bite, stick in their piercing mouthparts, suck your blood and sneak away. If you could feel them do this, you'd wake up and simply squish the bed bug. Like mosquitoes, bed bugs inject an anti-coagulant and an anesthetic so you wont feel the bite and the blood flows. 55. It is possible to feel a bed bug crawl on you if it inadvertently contacts hair, such as those hairs on the back of your hand or arm as it crawls. 56. While bed bugs are commonly active at night, they will feed in the daytime if their host happens to be a night shift type worker or a person who maintains such hours. At the end of the day, these are tiny animals and their behavior can vary as individuals or local circumstances dictate. 57. Some people may be bitten over extended periods of time without knowing that they are being bitten. In extreme cases weve seen people experiencing bed bug bites for over a year without them or their medical doctors being able to identify that they in fact have bed bugs. 58. My husband isn't being bitten and thinks that "it's all in my head" and that there are no bed bugs. Is this so, am I crazy? From time to time the lady of the house asks this question and at one home the husband was particularly tough on his wife regarding her suspicion of bed bugs in their home. After inspecting his recliner I advised her to ask him why we were able to find six well fed bed bugs in his Lazy Boy and whos blood was in them. Your husband may be being bitten but may be one of those people who just doesn't react noticeably nor suffers any itchiness from bed bug bites. Again, your mileage may vary. 59. Won't my doctor be able to tell if I have bed bug bites? Your medical doctors or dermatologist may not know about bed bugs. Medical doctors may not have training in medical entomology and, even at best, insect bites can be difficult to detect or diagnose accurately. We once had a woman who was an intensive care nurse who had experienced bed bugs for nearly two years before she discovered that she, in fact, had a bed bug problem. This woman had been to her general practitioner and was later referred to a dermatologist. She had received prescriptions and treatments for dry skin, psoriasis, seborrhea dermatitis, scabies and other skin related maladies over the course of those many months when her actual problem was bed bugs. 60. How bad can bed bugs get in a hotel, home or apartment? The worst Ive seen is an apartment with a sole occupant who was a retired man in his seventies. The apartment was sparsely furnished with just a bed, table with four chairs, and an upholstered chair in front of a television set on a plastic milk crate. There had to be over ten thousand bed bugs in this apartment. I visited this apartment the day after one of my clients performed a bed bug treatment there for the follow up inspection. Dead bed bugs were mounded like drifted snow in the tracks of the sliding glass door leading to the terrace. Mounds of dead bed bugs were in every corner of every room, along all the floor wall junctions and the walls were covered with fecal stains. The last few surviving bed bugs were found along the crown moldings. While the application work was very successful, there were still live bed bugs present and follow up treatments were scheduled. Within about 48 hours this person was moved out, the apartment was

rendered bed bug free and totally renovated. Interestingly enough, when I asked this man if he had been bitten by bed bugs he replied that he wasnt and that he had never been bitten in the six months that he had lived in this apartment. It was clear that this person was suffering from mental health related conditions as well as severe bed bug problems. In a hotel Ive been to locations where up to about 75% of the rooms were infested. 61. Bed bugs are tough adversaries. Just like a very good team exposes the weaknesses of their opponents, bed bugs will expose the weaknesses in a poorly designed or poorly implemented bed bug program. 62. Where can I find reliable information about bed bugs? There is a lot of good information available online. Generally, I recommend that folks review the information found on unbiased web sites including university based web sites, medical school websites and others. You can do a search on bed bugs and find many references to learn more about bed bugs. The more you know, the better able you are to make good decisions. 63. Bed bugs crawl at about the same speed as argentine ants or odorous house ants ( about 1/8th inch ants commonly found trailing into homes & buildings in many areas of the US ) . As mentioned previously, we found an adult bed bug is capable of traveling at from three to four feet per minute when crawling across common poster board. 64. After feeding, when fully engorged bed bug nymphs can grow as much as about six times their body weight. 65. Bed bug adults may grow about two to two and a half times their size after feeding. 66. Bed bugs excrete digested blood as a fecal liquid that produces stains on various surfaces where the excretion takes place. 67. Just as its useful to know how many fecal pellets rodents produce, it would be good to know how many fecal stains bed bugs produce on average when assessing a bed bug situation. 68. Recently we found that an isolated and fully engorged second instar bed bug nymph produced just twenty fecal stains over a sixty day time period. 69. Recently we found that an isolated and fully engorged third instar bed bug nymph produced just twenty six fecal stains over a sixty day time period. 70. Recently we found that an isolated and fully engorged adult bed bug produced just six fecal stains over a two week time period. 71. While the information presented in items #64, 65 & 66 are interesting, we understand that a larger population sample size and more work is needed to arrive at a more accurate average number of fecal stains produced over time by bed bugs. 72. Based on current results on average it appears that well bed bugs are producing about one fecal stain per day. 73. Bed bug fecal stains on walls and other such surfaces will run when sprayed with water or spray cleaners. 74. There are many bed bug videos that can be seen online if you do a proper search. 75. There are many excellent bed bug photos available online if you do a proper search. 76. In August 2011 Bayer Crop Science Environmental Science Division updated their excellent bed bug training video on DVD featuring Dr. Austin M. Frishman, BES Technical Representative Joe Barile, BCE and others. Check with your local distributor or Bayer representative to get a copy of this video. 77. There are many folks working behind the scenes in the pest management industry on new bed bug products and techniques, always stay tuned for new tools, techniques and solutions that become available. 78. Bed bug eggs are coated with a sticky substance which glues them in place where they are laid. These eggs can hold on surprisingly well opposite a vacuum. 79. Based on field experience it is doubtful that a significant amount of eggs, if any at all, would be successfully removed via vacuuming when these eggs are laid in cracks and crevices where they can not be scraped along while also vacuuming.

80. It is beneficial to use a vacuum to remove as many crawling bed bugs as possible as part of your bed bug management program. 81. Its possible, and it has been happening, for service personnel to take bed bugs home with them from work. 82. Its possible for bed bug cross contamination to occur where bed bugs are brought to non-infested locations by service technicians who service bed bug infested accounts. 83. Companies dealing with bed bugs on a regular basis should have policies and procedures in place that address the prevention of cross contamination. 84. Cross contamination may be avoided if the proper precautions are implemented. 85. Having a complete change of clothes and sealing suspected work clothing within a plastic bag or other suitable container may be useful in preventing cross contamination. 86. Cross contamination may occur from a variety of sources including housekeeping, maintenance, deliveries and other service providers. 87. Its possible for bed bugs to crawl up a wall, across the ceiling and drop on unsuspecting victims as they sleep. 88. Can I bring bed bugs home from work with me? Yes, you can and people have done so. However, lets not panic about it. Bringing bed bugs home from work is dependent upon many factors including but not limited to: if there are actually bed bugs present at your work, what type of place you work at, the type of operation and practices utilized at your place of employment and what prevention methodologies, if any, are being utilized. If this is a concern refer to some of the prevention tips listed elsewhere in this list. Bed Bug Information Of Interest to Hospitality & Housing Professionals: 89. We dont have or have never had a bed bug problem at our location. Isn't the bed bug problem just a lot of hype being promoted by the media and the pest management industry? Not at all, the incidence of bed bugs is certainly on the rise across the country and, even as an independent pest management consultant that does not advertise, I find that bed bugs take up as much as 85% of my time with an increased frequency of calls coming in. 90. It is wise to train your entire housekeeping and maintenance service staff about bed bugs such that signs of infestation can be discovered early on before a bed bug infestation can grow to a significant and broad scale problem at your hotel. 91. Hospitality locations should adopt an adequately scheduled inspection process to assist in early detection and prevention of significant bed bug infestations. 92. Bed bugs are an equal opportunity infester. They do not discriminate between properties based upon location, type or quality as might the discerning vacation or business traveler. Due simply to their nature, logistics and other factors, every lodging location and multi-family property is subject to bed bug infestation. 93. That a guest picks up bed bugs from a hotel room may be largely dependent upon who may have stayed in that room or adjoining room prior to that guest. And, it is likely that your location getting bed bugs is largely due to a guest or resident bringing them in. 94. Bed bugs are "hitch-hikers and dependent upon man to travel from place to place, it's possible for you to transport bed bugs to other rooms, floors or locations during your regular servicing of your hotel by maid staff, maintenance staff, bell staff or other services. 95. Do not rely on a guest reporting bed bug problems as your sole first alert system of a bed bug problem. It is possible, and considered common by some, for people to get bitten without knowing it. As such, a bed bug problem may continue for many weeks or months before it is brought to your attention by a guest or discovered in another manner at your property. Additionally, consider that some guests may be hesitant to complain at all. A pro-active, well planned monitoring program to detect bed bug activity prior to a broad scale infestation develops is better than a non-existent program that relies on haphazard discovery of bed bugs.

96. Consider adopting the use of BDS ( Bed Bug Detection System ) monitor traps or other such bed bug traps to serve as a proactive bed bug monitoring so you may find bed bugs early on before a large scale and significant infestation occurs. 97. Hotel managers; keeping a bed bug suspected room out of inventory or service for a number of days, weeks or months will not starve out the bed bugs and solve your bed bug problem. It is not necessary for bed bugs to feed every day or every week. They can "lay in wait" for the next host for surprisingly long periods of time. In fact, under certain conditions research data indicates that bed bugs can survive up to periods of about one year without feeding. 98. Apartment managers; a reliable bed bug program that delivers acceptable results can NOT be had for just $75 per door. Again, if it sounds too good to be true, it probably is ! 99. Bed bug work is labor intensive and costly work to do correctly and result in a bed bug free apartment. Anyone who is doing this work and taking it seriously will attest to that. 100. As a hotel manager, how can I tell guest about bed bugs without raising a red flag or making my property seem as if it is infested? This is certainly a tricky question and one that the hospitality industry must wrestle with. Recently, I attended a presentation where a resort manager gave a presentation on how they handle bed bugs at his location. It was encouraging to hear that they had implemented a well prepared bed bug management program at his location and that they were rather candid in their communications with concerned guests opposite the bed bug problem. While we realize that this is a very touchy subject with a perceivably significant down side risk for the hospitality industry however, at the end of the day the truth is the truth. 101. It may not be necessary to simply discard mattresses and box springs indiscriminately just because of the presence of bed bugs. Mattresses and box springs in otherwise good condition may be suitably vacuumed, steam cleaned or treated for bed bugs and further protected by suitable encasements produced for this purpose. Use high quality mattress encasements or covers such as those by produced by Mattress Safe to seal bed bugs in and take away the multiple hiding places on your mattress and box spring. 102. What sort of places have you seen bed bug problems occur? The list of places that the pest management industry has been called in to handle bed bug problems is long and disconcerting. Bed bugs can be anywhere that man is and they have been so, lets leave it at that as we dont wish to cause unnecessarily alarm to anyone. 103. In hotels, why is the head board area a prime spot to find bed bugs? Bed bugs prefer to hide in undisturbed areas. In a hotel, the maid changes the sheets daily or at least regularly. As such, the mattress becomes less of a desirable hiding place for bed bugs. The head board is close by and seldom moved or disturbed. However, with bed bugs, we are dealing with live animals and once again, youre mileage may vary. Bed Bug Litigations and Lawsuits: 104. What about bed bug lawsuits? Currently we are seeing bed bug litigations increasing along with the bed bug problem. The Mathias case is a published and well documented case that occurred years ago, you can Google it. In this case a hotel was ordered to pay a significant sum in punitive damages by the court. This huge sum was partly due to the fact that there was an ongoing bed bug problem, the property management knew it, the property management took inadequate actions to address the bed bug problem and management had the front desk staff tell guests that the bed bugs were ticks. If a property is not going to take suitable actions to adequately address a bed bug problem or attempt to hide or misrepresent their bed bug problem to the consuming public they are making poor choices and it will be more difficult to successfully defend such a situation. 105. At the time of this writing I am aware of with several bed bug litigations with additional cases on the horizon. 106. Bed bug litigations are clearly on the rise. There is one firm that is reportedly dealing with about forty five cases. 107. Anyone following or interested in the bed bug situation is aware that bed bug related litigations have been in the news. Recently a case involving a celebrity and former SNL cast member was in the news. Celebrity involvement generally brings added media attention and this case was no exception. You can Google it. 108. As bed bug victims, plaintiffs are making claims against landlords, hotels, property management companies, employers, summer camps, furniture rental companies, mattress stores, other entities and pest management firms. 109. It is now possible that a pest management firm that provides pest management service at a hotel may be sued by a guest who stayed at that hotel and was bitten by bed bugs.

110. Plaintiff attorneys are seeking compensation for damages and injury including but not limited to: mental anguish, mental duress, legal fees, medical expenses, plastic surgery, psychological counseling, bed bug remediation fees, cost of replacement contents, moving expenses and many other such damages including lack of consortium. 111. Bed bug plaintiff attorneys are analogizing bed bug cases to needle stick type cases where victims are concerned over blood borne diseases such as HIV and others. 112. It is wise to exclude bed bugs from your normal pest control service agreements or contracts and have a separate service agreement or contract that covers bed bug services. 113. While some attorneys may advise that having well written bed bug service agreements or contracts is the best protection from lawsuits, practically speaking, doing good work and taking care of the customers will likely serve you much better in the long run if bed bug litigations are a concern. Bed Bug Inspection & Detection: 114. How can I tell I have bed bugs? Bed bugs are difficult to detect in the early stages. In my observation and experience, it's rare that a person who unknowingly brings bed bugs home from a trip will discover that she/he did so until they begin to notice that they are bitten and the problem is already established in their own home. And, this is equally so for hospitality and multi-family locations as well. 115. Based on experience, folks are more likely to notice the tell tale signs of bed bugs rather than see the actual live bed bugs themselves and this is especially so in the early stages of an infestation. 116. What are the tell tale signs of bed bugs? While live bed bugs may be difficult to find, the leave behind tell tale signs of bed bugs are much easier to see. These tell tale signs include fecal stains, shed skins, eggs and carcasses of dead bed bugs. 117. Generally speaking, more bed bugs are found toward the head of the bed than toward the foot of the bed. 118. Until you have not seen a bed bug or have not experienced bites for several weeks, some practitioners say as many as eight weeks, it may be wise to assume you still have bed bugs and act accordingly. 119. There are various methodologies that may be used to assist in determining the presence or absence of bed bugs including the use of effective bed bug monitors, traps and canine scent detection. 120. How can I confirm that a room, apartment or home no longer has bed bugs? Research conducted at the University of Florida indicates that bed bug detecting canines are about 98% to 99% accurate and some clients rely on canine scent detection inspections to help determine if rooms are bed bug free. There are high tech electronic bed bug traps that may be utilized as well. However, you can also build an effective bed bug trap that utilizes carbon dioxide (dry ice ) for under ten bucks too. Search the article How to Build Bed Bug Trap For Under Ten Bucks and other such articles. Such traps use dry ice/carbon dioxide to attract bed bugs. Heat based traps have also demonstrated an ability to draw bed bugs. However, we must also consider that these traps may only be attracting those bed bugs that are seeking a meal. 121. An effective bed bug trap can be built for less ten bucks using a two gallon drink cooler, a large plastic dog dish, masking tape and dry ice. 122. Bed bugs can not climb smooth surfaces such as clean glass or smooth plastic. Use this to your advantage and at least isolate your bed and furniture from bed bugs by using products such as the Insect Interceptor Climbup or glass jars that prevent bed bugs from being able to climb up your bed or furniture to bite you as you sleep. There are also other bed bug blocking type devices that are now commercially available. These devices place a nonclimbable surface between the bed bug and the bed or furniture. The may not capture the bed bugs as the Climbup does however. 123. While live immature and adult bed bugs may be difficult to find, look for the "signs of bed bugs" including: fecal stains, eggs, shed skins and bed bug carcasses. 124. Do bed bug traps work? There are new bed bug traps being introduced to the pest management professional market and my suspicion is that such traps will soon be marketed to the general public. Those traps that emit certain bed bug attractants including heat, carbon dioxide, octanol and other materials have demonstrated high

attractiveness to bed bugs. Simple trap designs, such as the Climb Up Interceptor unit by McNight, that rely on the bed bugs inability to climb smooth surfaces have also demonstrated effectiveness and are economical. Researchers have recently published data indicating that both heat and carbon dioxide may attract bed bugs in a relatively equivalent manner. And, there have been a few articles published on how to build your own bed bug traps that you can find online. 125. While a bed bug will consume many times its body weight when taking a blood meal, the much of this added weight is expelled as liquid fecal matter. 126. Excreted fecal liquid creates the stains that may be found in areas where bed bugs travel and hide. And, because much of the liquid consumed is excreted, these fecal stains may be the most prevalent sign of bed bug activity observed. 127. A simple $1.99 magnifying glass found at an office supply, K-Mart, Target or Wal-Mart will make you a better bed bug finder. Of course, the better the lens quality the better you will be able to see so, if you can afford it, go for a higher quality glass lens unit. 128. You need a very good flashlight fitted with well charged batteries to optimize your hunt for bed bugs. 129. An LED type flashlight will serve you better than the older normal bulb type flashlight. LED flashlights are now widely available at reasonable prices. 130. In a home or apartment, the top hiding places for bed bugs seems to be the mattress, box spring and bed frame. 131. In a hotel room, the top hiding place seems to be the head board area. This is likely so because housekeeping changes bedding either daily or very often in hospitality locations versus at a private home. As bed bugs prefer to hide in undisturbed places this makes the head board area an ideal hiding location at hospitality locations. 132. Bed bugs may also be found on or near any place that their human hosts rest or sleep. It is common to find bed bugs hiding on couches and upholstered chairs. 133. Bed bugs may be flushed or drawn from hiding places by release carbon dioxide. 134. A Gallo Gun or a CO2 bicycle pump may be used to disperse carbon dioxide to draw or flush bed bugs during inspections. Gallo guns are available at professional plumbing supply locations. CO2 cartridge bicycle pumps are available at many retail that sell bicycles. Bed Bug Dogs: 135. Are bed bug dogs any good? Yes. Research conducted by the University Of Florida Department Of Entomology indicated that well trained bed bug scent detection canines are up to 98% accurate. Many experienced bed bug professionals support the use of well trained and maintained bed bug dogs. 136. How come dogs can detect bed bugs by their sense of smell but humans cant? References indicate that the average dog has about 250 million receptors and that blood hounds have about 350 million. Humans have about 35 million. Thats pretty much why ! 137. Are bed bug detecting dogs reliable? Bed bug sniffing dogs are capable and effective at finding bed bugs and viable bed bug eggs. After learning about such dogs, my opinion is that those dogs that are trained bed bug specific, or only used for bed bug work, are superior to multi-pest type detection dogs. 138. What about the dog handlers? Just because you taught your dog to get the paper, sit, stay and roll over it doesnt make you a scent detection dog handler. Scent detection dog handlers are trained professionals. These handlers receive extensive training by the canine training center that they acquire their dog from. 139. Is there a scent detection dog certification program or professional association? Yes there is. Recently the University of Florida worked in cooperation with scent detection dog trainers to establish scent detection dog training certification training and an association known as NESDCA. If continuing education is good enough for medical doctors and other professionals it seems that it is reasonable for scent detection dogs and their handlers as well. Check out nesdca.com for more information.

140. Im a pest professional that does a lot of bed bug work. Should I purchase my own dog ? While that decision is totally up to you, understand that such a dog is a significant commitment. These dogs are not pets! They are additional trained employees of your company. The dogs training must be maintained and an effective dog requires a dedicated and well trained handler. Speak with a bed bug dog trainer, learn as much as you can and then make your decision. The initial cost for a bed bug trained dog can be from $8,000 to $15,000 however, the cost to maintain the dog, the handler and keep up with the long term training must also be considered. 141. Bed bug detection dog services may be hired to help you with certain bed bug situations and youll likely find this more cost effective for you than investing in your own bed bug dog. 142. What breed of dog is best for bed bug scent detection? While it may be argued that the blood hound has superior ability, there are many breeds that make suitable scent detection canines. Beagles and other small to medium breed dogs seem to be of the most popular breeds being trained for these purposes. 143. For bed bug detection why dont they use German shepherds like the police, DEA, military and other security forces do? While these large breed dogs may have the capability, there are sound reasons that smaller dogs such as beagles are preferred. Some people are scared of dogs and German shepherds can be intimidating to people. If need be a small dog may be easily lifted to check a large chest of drawers, wall hanging or other such item. Try doing that with a 100 pound German shepherd. A beagle that jumps up on a couch or bed while hot on the trail of bed bugs is not as alarming or likely to cause damage as might a large breed dog. Smaller dogs are easier to transport, take up much less space and are easier overall to board. 144. Whats better, dual purpose dogs or single purpose dogs? This topic has been argued by those closely involved with dog training and use. However, my preference is the use of single use dogs and this opinion is based upon practicality. If a dog alerts, we cant very well ask him if its bed bugs or termites. 145. Recently while traveling through airports I had the opportunity to converse with several canine security dog handlers. These folks confirmed that their dogs are trained purpose specific. As such, if single purpose dogs are good enough for the DEA, the military and other such folks, theyre good enough for me. 146. Which training centers dogs are best? I am often asked this question. Generally speaking I have not yet met a canine scent detection person who is not well versed and dedicated to their dogs and their work. I refer people to JK Canines in High Springs, FL. However, I do not know every canine scent detection training center in the country and Im sure there are many well qualified training centers that are also doing a great job of providing well trained canines for bed bug scent detection purposes. Check out www.jkk9.com and other websites for further information. Bed Bug Control: 147. As a well coached team will expose the opposing teams weaknesses, bed bugs will expose the weaknesses of a poorly designed or implemented control program. Make sure your control program is well planned and well implemented by your team. 148. When dealing with bed bugs it is wise to adopt the mind set that bed bugs are like invisible microscopic germs capable of spreading infection to everyone and everywhere, like in the Andromeda Strain. Handling these accounts and the contents in a manner to prevent further infection will serve you well. 149. Whats the secret to getting rid of bed bugs? There is no secret or shortcut to getting rid of bed bugs. While if caught early on a bed bug problem can be much easier to take care of, the normal experience is that once a person notices that she/he has bed bugs, the problem can be advanced such that a lot of inspection and control work is necessary to rid the property of bed bugs. The real secret is that the control work needs to be very thorough to assure that no bed bugs escape the control program and the property can be rendered bed bug free. 150. An ongoing bed bug monitoring program is an important part of any bed bug management program. 151. Are there any natural ways to kill bed bugs? Well, at least to me, its natural for man to kill bed bugs or any other pest any way possible but thats not really what you asked. Suppose you find bed bugs in your shoes or suspect that they are in your luggage. You can places these items in a large black plastic bag and place the bag out in the hot sun for a few hours. If the sun heats the contents of the bag sufficiently hot enough and long enough, youve killed the bed bugs in a natural way. Note that I said if. The bed bugs must be heated to a high enough temperature for a long enough period of time to be killed ! This means that all the surfaces of the contents must be

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equally heated throughout and it takes time to get the middle of the teddy bear or other possibly infested item up to the 113 degrees youre looking for so, take your time and be sure. 152. It's not necessary to completely launder all your clothing, drapes, sheets, blankets and other garments to rid them of suspected bed bugs. If these items are already clean, simply run them through the hot clothes dryer to kill your bed bugs. 153. Once clothing and other garments have been rendered bed bug free, it is wise to seal them in bed bug proof plastic bags or other containers to assure bed bugs do not harbor within them. 154. Can I get rid of bed bugs myself? It's possible but it takes a lot of work, knowledge and experience expended over an extended period of time. Most folks are much better off leaving bed bug control to a competent pest professional. 155. If you simply can not afford professional bed bug elimination services it is possible to get rid of bed bugs yourself but youre going to have to be committed to doing the work and will likely need to either read up on it or get advice from a suitable person. 156. Are bed bugs resistant to today's chemicals? Current research indicates that various degrees of resistance exists in bed bugs to a variety of chemicals. 157. Back in the 1960s DDT was one of the best products used to kill bed bugs. In a study published by University of Arkansas bed bugs collected from poultry farms were found to be resistant to DDT and dosages of 100,000 parts per million were required to produce an LC50 (i.e. the lethal concentration necessary to kill 50% of the test population). 158. For the most part, bed bugs can be successfully killed by those products that are currently labeled for bed bugs if used and applied in a suitable fashion. 159. For the most part, where and how insecticides are applied to control bed bugs is of primary importance to your success in the bed bug battle. 160. Within reason the efficacy of bed bug treatments is more significantly affected by the quality and thoroughness of the bed bug control work performed rather than the products used to kill the bed bugs. In the good ole days we used to say you have to get the bug juice to where the bugs are and with bed bugs it is important that the harborage sites are properly treated. 161. Plastic bags and suitable containers can be your best friends in bed bug control and avoidance. Store your clothing and other items that you are 100% sure are bed bug free within a plastic bag and tie it shut to prevent bed bugs from entering. The more things and areas you can make off limits to bed bugs, the better for you. 162. Bed bugs can hide in just about anything. In addition to the normal places you'd expect such as beds, mattresses, box springs, bed frames, head boards, etc.; we've also found them in places including night stands, clock radios, lamps, shoes, wall hangings, speakers, stereo components, computers, desks, artificial floral arrangements, curtains, wall outlets, moldings, door frames, crutches, artificial limbs, pet bedding, toys, plush toys/stuffed animals, clocks, potted plants, furniture, under carpets, fire alarms, telephones, just about everywhere. 163. Just because bed bugs are capable of hiding "just about anywhere" that doesn't mean that they will be "everywhere" within your location. Up until the point that the problem grows to become a "bed bug ground zero" type location it is likely that the bed bugs will be found in areas "close to the food" in your home or location which, in reality, is you or the guests ! 164. Bed bugs will likely harbor (hide) in areas near where people or their victims sleep. Remember, the victim doesnt have to be a person 100% of the time. 165. Remember, a sound bed bug program needs to be thorough ! If the program sounds too simple or too good to be true, it probably is! 166. Heat can be used successfully to kill bed bugs in items that can not be laundered or treated with conventional pesticides.

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167. Always use care when heat treating sensitive items that may be damaged by extreme temperatures including electronics, certain garments and other sensitive items. 168. Pest strips containing DDVP are now labeled for bed bugs. With sufficient exposure DDVP is one of the few active ingredients that provides 100% control of bed bugs, including the eggs, in the published trial data. 169. Nearly all products currently labeled for bed bugs will kill bed bugs on contact at labeled rates. Residual efficacy of such products against bed bugs varies and is dependent upon a variety of conditions. 170. Used properly, steam will kill 100% of the bed bugs and bed bug eggs contacted. A suitably built and equipped steam cleaner machine is an excellent tool that may be used for normal cleaning purposes as well as for bed bug control. 171. Continuous fill professional steamers will allow you to work longer and more efficiently than non-reservoir continuous fill type steam units. A steam unit that delivers at least 50 psi and generates steam of at least 270 degrees Fahrenheit is a good choice. 172. At the time of this writing suitable steamers for professional work are priced from about six hundred and fifty dollars and up. 173. Homeowner type steamers normally used for wall paper removal are poor choices for bed bug control. 174. Vacuums may be used to immediately remove many bed bugs from an infested location. 175. If you choose to use a vacuum to remove bed bugs, be sure to use a vacuum that is fitted with a HEPA filter which will prevent the escape and distribution of bed bug particulate matter that may be harmful allergens for some people. 176. Professional vacuums manufactured by Atrix are fitted with removable and sealable cartridges that are also HEPA filters into which the pests are deposited during vacuum removal. 177. Homeowners without access to commercial professional equipment may find retail vacuum units suitable but must check to assure that they are equipped with HEPA filtration. 178. Just because a vacuum has a HEPA filter does not mean that the entire vacuum system conforms to HEPA parameters.

Travelers, Homeowners and Apartment Resident Bed Bug Tips 179. People who travel regularly are more susceptible and likely to bring home bed bugs than people who dont. As an example, when conducting German cockroach field trials in section eight type housing recently we had hundreds of apartments that were virtually loaded with German cockroaches and not one with bed bugs. Within five miles of this location we worked at an apartment complex of nearly four hundred apartments whose residents were of international origin and nearly every cockroach infested apartment also had bed bugs. 180. If necessary, bed bugs can feed on your pets so dont forget to inspect your pets bedding if you need to do bed bug work in your home. 181. Generally, folks who unknowingly bring bed bugs home do not discover that they have a problem for anywhere from weeks to months. By this time the population may have grown and spread to additional areas within the home. 182. Based upon my experience, most homeowner folks who have a bed bug problem have one thing in common, they have traveled and brought bed bugs home with them from a business or vacation trip. 183. I travel for my job, what can I do to prevent picking up bed bugs ? Wow, this is a tough question but you can do what I do. When I check in at a hotel, I enter my room just far enough to be able to close the door behind me. Using my LED flashlight, I then inspect the area around and behind the head board, the mattress and box spring for signs of bed bugs. 184. There are a number of small decent LED flashlights available for about $10 at many retail locations.

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185. Even though I check my hotel rooms regularly, luckily thus far, I have yet to encounter bed bugs in any hotel room where I have stayed. 186. Any other bed bug prevention tips? Yes, bring large plastic bags with you. I prefer the large white, draw string type plastic trash bags. These bags may be used in two ways; you can put your luggage and other stuff into these bags to prevent bed bugs from entering and, if you think you encountered bed bugs, you can seal your bed bug suspected clothing and other items within the bag keeping them trapped within the plastic bags until you have the time to kill them within the bags and keep them from getting into your home. 187. Well designed luggage wraps are now commercially available. 188. Some bed bug professionals place pest strips in their tool boxes and use plastic bags to prevent bed bug entry. 189. Recently Ive seen bed bug detection devices available that I can take with me when traveling to detect bed bugs in my room. Are these devices reliable and can they detect bed bugs? It is difficult to answer this question fully without knowing exactly which device you are asking about. My colleagues and I are familiar with these electronic devices. Units I am aware of are designed to detect carbon dioxide emissions from bed bugs and, consequently, detect the presence of bed bugs. We need to realize the small amounts of carbon dioxide, or any off gas for that matter, emitted by bed bugs will, in fact, be emitted in small amounts simply due to the diminutive size of these insects. This said, even if we were able to successfully develop an electronic sensing device that could adequately and accurately detect bed bug emissions, detection results of the device would also be dependent upon air currents and suitable inspection/detection work conducted by the user. As you may imagine, it is a complex process with may factors that must be considered. In trial work personally conducted with such devices my observation is that they are not accurate or reliable devices and that both false positive and failed detections were observed. Additionally, in many instances a large number of bed bugs needed to be present to produce consistent detections. 190. There are commercially available bed bug proof luggage encasements that may be used to seal out bed bugs from entering your luggage. Mattress Safe makes a product called Luggage Safe that come in various sizes to protect luggage from bed bugs and there are others that manufacture and market luggage encasements. 191. If you as a pest professional are going to visit and work at bed bug ground zero locations regularly, have you ever brought bed bugs home with you? Well, so far Ive been lucky but I do take many necessary steps to make sure I dont bring bed bugs home. These steps include; I generally dress in all white and look like an ice cream man when visiting bed bug locations so that I increase the chance that I will see bed bugs if they are on me, Im very careful to not touch or lean on anything in a bed bug location, I keep a Nuvan Pro Strip pest strip within my tool cases just in case, I place my luggage in plastic bags with a pest strip just in case, I keep a change of clothes on hand so that I can change clothes completely immediately after working at bed bug locations and, I place all clothing items in a suitably sealed plastic bag. 192. While it may seem difficult to do. Find a discrete location to change clothes prior to entering your vehicle after working at a bed bug location. 193. Recently I began using a portable bed bug oven that I constructed using a plastic storage bin, two inch PVC pipe and a hair dryer. I place all y suspect clothing and other articles within this oven and heat treat them to assure that no bed bugs are inadvertently brought home. 194. If you have doubts or suspect bed bugs while traveling, it may be possible to use a suitably heavy bag or container and hairdryer to heat treat your luggage while staying at a hotel. 195. Some hotels have guest laundry facilities available where you can run your things through the hot dryer. Be careful to only place those items that will not be ruined by a dryer within the dryer. 196. What if I only stay at the better brand name hotels, will I avoid bed bugs? As stated previously, bed bugs are a people problem and not a building problem and are an equal opportunity infester. Ive worked at numerous locations and have encountered bed bugs in five star locations as well as lower end locations. 197. How can I avoid moving into an apartment location that has bed bugs? There are web sites that list bed bug problem locations however, after checking on these web sites, I have found that they do not verify the information presented, may not update the information on a timely basis and, as such, the information presented may not be reliable. As stated previously, bed bugs are a people problem and not a building problem. If you have concerns ask

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the lease/rental agent or apartment manager about bed bugs, what they know about them and what their experience has been regarding bed bugs. 198. A reputable apartment company will be truthful with you and have a sound bed bug management program and policies in place to protect you, your neighbors and their investment in the property location. 199. How will I know if Im staying in a bed bug free hotel? The short answer is you wont. You can ask but my experience at the time of this writing is that the experience of the hospitality and property management industries opposite the bed bug problem is varied. Generally, my experience has been that they will tell you an answer that indicates that theyve never had a bed bug situation at their location. Over the past few years Ive asked such questions at locations upon check in and have rarely had a front desk person tell me that they have experienced bed bugs at their location. If you do have a concern or suspicion it may be wise to go ahead and ask your question and be mindful of how your question is answered. 200. Cant I find out if a hotel or other property has bed bugs or not by looking on one of those online bed bug websites? No, not necessarily. Check out the various parameters for submission, parameters and rules of these websites. The content of such websites is authored by the general public and not subject to verification. As such, the information posted may or may not be entirely true. 201. Can I get bed bugs from my neighbor? Yes, you can. Hungry bed bugs seek out their hosts. They are attracted to heat, carbon dioxide and other factors given off by their victims. Its possible that bed bugs can find their way from room to room and apartment to apartment through many available pathways. 202. Is bed bug work expensive? Expensive is a relative and subjective term. Bed bug work must be thorough and comprehensive. Currently, there are pest management professional companies doing state of the art efficacious bed bug work at fees as high as about $500 per room. At the end of the day, if you have a bed bug problem, you want to hire a professional company that does professional work and stands behind their work. 203. How do I know if I am hiring the right pest management company to get rid of my bed bugs? There are about twenty thousand pest management companies in the United States but few who actually specialize in bed bug control. The bed bug problem is growing in the Unites States and, as a result, the pest management industry is becoming increasingly effective at handling bed bug problems with more and more companies increasing their knowledge and experience in dealing with bed bugs successfully. A good bed bug company will have a sound bed bug management program. Their program will be thorough and make sense to you. Their program will integrate a number of methodologies and techniques. Their program will include adequate follow up. They will stand behind their work. They will send at least two technicians to do the work. They will provide you with information on how to prepare for the bed bug management work. They will provide you with sound bed bug information and provide you with viable recommendations on what you can do to enhance the over all results of your bed bug management program. They will answer your questions truthfully and, if necessary, find the answers to your questions. They will tell you what they are going to do and they will actually do what they said they would do. When you call them you will have no trouble contacting a supervisor or manager to discuss your questions or concerns. Their service contract will be equivalent to and include the services that the sales inspector described to you during the sales process. 204. Dont all advertisements have to contain true information? So, if a pest management company advertises that they are bed bug experts doesnt it mean that they are? Truthful statements and marketing claims found in advertisements can be two different things and worlds apart. Dont allow yourself to be misled simply by marketing claims. Educate yourself about bed bugs and check the references of prospective pest management providers before you contract with a selected provider. Its likely that youll be glad you did. 205. Should I spray my home myself to prevent bed bugs at my home or property location? The decision to apply pesticide products in your own home is solely up to you. Generally speaking, homeowners are free from the regulations that pest management professionals must comply with when applying pesticides. However, in some states there may be regulations governing the application of pesticides by property managers of apartments or hospitality properties. It may be necessary for property staff, such as maintenance staff, to take a test to become certified to apply pesticides in such properties. There are liabilities associated with the application of pesticides to consider as well. For the most part, while we all wish to maintain a pest free environment, we also wish to limit or avoid any unnecessary exposure to pesticides and related liabilities within our homes, properties and the environment if possible. Lets be very careful when considering pesticide use and application and take care to implement some of the non-chemical dependent preventative measures to avoid pest problems in the first place.

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206. Being careful and using the preventative techniques mentioned elsewhere in this article is likely a wiser way to go than spraying pesticides either unnecessarily or by inexperienced individuals. 207. My house has been treated for bed bugs, what should I do now? Be careful to utilize all the preventative techniques and follow the directions provided to you by your pest management professional. 208. I had bed bugs on my bed, do I need to throw out my mattress and box spring? Im often asked this question. The truth is that it is not entirely necessary to throw away your mattress simply because you had bed bugs and there are other factors that need to be considered. If your mattress is in good condition, has years of useful life remaining and has been successfully rendered bed bug free by your bed bug service provider than there is no need to discard an otherwise useful mattress. However, if you have doubts about your mattress and/or box spring still harboring bed bugs than purchase a good quality bed bug proof mattress encasement like those manufactured by Mattress Safe. High quality mattress encasements have been tested to be bed bug proof. That is bed bugs can not enter, escape or bite through these encasements. As such, even if your bed bug service provider missed a bed bug or any bed bug eggs, any such bed bugs left behind 209. I have seen a variety of mattress covers where the label information indicates bed bug protection. Are these good for bed bugs? Without seeing exactly which product and label you are asking about it is difficult to fully answer this question. However, we need to understand the difference between marketing claims and actual product capabilities and performance. My recommendation is to only purchase products that specifically state that they are bed bug proof and have been bed bug tested. Remember, it may be possible to state that a product is bed bug resistant but that is not bed bug proof. Additionally, the best bed bug proof mattress encasement products will specifically state that they have been bed bug tested. 210. I have seen some spray products that have labels that indicate that they are natural and kill bed bugs. Are these good bed bug spray products? Once again, without seeing exactly which product and label you are asking about it is difficult to fully answer this question. However, we need to understand the difference between marketing claims and actual product capabilities and performance. There seems to be a number of products being launched or introduced to the market as manufacturers seek to access the bed bug related market opportunity. My recommendation is to only purchase products that have proven performance and independent laboratory testing against bed bugs. In conducting such tests, my observation is that many of the natural type products may provide contact kill but do not provide any residual or long term results against bed bugs. 211. My apartment company has a pest control provider, should I hire my own to take care of my apartment? Generally speaking, you are able to hire a pest professional to take care of pest situations within your own apartment at your own expense. When you hire them yourself, they work directly for you and may provide you with superior service. However, contact your landlord company and ask questions about the bed bug services being provided by their pest professional before you make a decision on whats best for you. Recently, some municipalities have been enacting new laws related to bed bugs and the responsibilities of landlords regarding bed bugs. Check out the bed bug regulations in your location. 212. The neighboring apartment has a bed bug problem, what should I do? If you suspect that the neighboring apartment has a bed bug problem this does not necessarily mean that your apartment will get bed bugs. However, it is possible that bed bugs can travel from apartment to apartment by various means so you are wise to be concerned. Contact the apartment company/landlord to express your concerns. Find out what they are doing about the bed bug situation. Find out what they are doing to assure that they prevent a problem from getting into your apartment and maintain a level of increased vigilance opposite bed bugs. If after doing this you have continued questions and concerns, be persistent and make decisions in your best interest to avoid bed bugs. 213. Cant I simply wrap my mattress and box spring in plastic rather than by an expensive mattress encasement? Yes you can but if you have ever slept on plastic you probably found it very uncomfortable. In the field I have seen folks take desperate measures opposite their bed bug problems. Ive seen them wrap their beds in plastic and shower curtains but these plastic covers usually rip and we need to make sure that we have 100% coverage. The Mattress Safe and other commercially available covers are well built, tested bed bug proof, dependable, comfortable to sleep on and widely available. 214. Be sure that whatever mattress encasement you select has been tested bed bug proof and that it clearly states bed bug proof on the label. 215. What does bed bug proof mean? While its easy to say bed bug proof, its best to explain exactly what we mean by bed bug proof. By bed bug proof we mean the following: bed bugs can not enter the encasement, bed bugs can not

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escape from the encasement, bed bugs can not enter or escape through the encasement zipper apparatus and that bed bugs can not bite through the encasement fabric. Closing Comments: 216. The current bed bug resurgence has given birth to a boon of new products targeting the bed bug opportunity. Scores of products are available online and at retail shops. Of concern is the efficacy of some products being marketed as the ultimate answer to your bed bug problems. Just because a product or formulation is considered exempt does not also mean that the product is exempt from working or being efficacious against bed bugs. Remember, we exist in a free market business environment where buyer beware continues to be an important consideration. 217. Hey, thats a lot of bed bug information. It seems like you know all there is to know about bed bugs? Whoa, hold on there. Field experience has well taught me that none of us know all there is to know about most things, especially bed bugs. Each day presents additional opportunities for all of us to learn more about bed bugs, new stuff is being discovered and developed every day. 218. Be on the constant search for increasing your knowledge and experience opposite bed bugs and the successful management of bed bugs. The pest management industry provides an important service to the public. No one deserves to suffer the inconvenience, agony and deleterious affects of life with bed bugs ! Yours in pest management, Paul J. Bello PJB Pest Management Consulting, LLC 770-500-0460

This information was provided to you courtesy of your friends at: Bedbugger.com

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A Code of Practice
For the Control of Bed Bug Infestations in Australia
4th Edition (Draft) September 2011

Stephen L. Doggett

Draft 4th Edition

Page 1

A Code of Practice for the Control of Bed Bug Infestations in Australia

Draft Fourth Edition (www.bedbug.org.au)
Stephen L. Doggett* Principal Editor
Department of Medical Entomology, Institute for Clinical Pathology & Medical Research, Westmead Hospital, WESTMEAD NSW 2145, Australia. *On behalf of the Bed Bug Code of Practice Working Party, Australian Environmental Pest Managers Association, GPO Box 4886, SYDNEY NSW 2001, Australia.
First Edition: July 2006. Draft Fourth Edition: September 2011 2006-2011. This publication is joint copyright of the Department of Medical Entomology, Institute for Clinical Pathology & Medical Research, Westmead Hospital and the Australian Environmental Pest Managers Association. All images are copyright to the Department of Medical Entomology. No part of this publication may be reproduced in any form or by any means, electronically, mechanically, by photocopying, recording or otherwise, without the prior permission of the copyright owners. However, permission is granted for the reproduction of this document or parts of it, for the purpose of assisting the management of bed bug infestations, on the following conditions: (i) the document is reproduced in its original appearance, (ii) the reproduction is not for the purpose of financial gain, (iii) this Copyright Notice is included in the reproduction. Permission is granted for organisations or individuals to include a link within their own web site to the official web site for this Code of Practice (www.bedbug.org.au). Warning and Disclaimer Every effort has been made to make this Code of Practice to be as complete and accurate as possible, but no warranty or fitness is implied. The information provided is on an as is basis. The author or any persons on the Working Party that developed this Code of Practice shall have neither liability nor responsibility to any person, organisation or entity with respect to any loss or damages arising from the information contained in this Code. ISBN: 1 74080 135 0 This Code can be freely downloaded from www.bedbug.org.au

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TABLE OF CONTENTS
1. 2. 3. 4. 5. 6. PREFACE TO THE DRAFT FOURTH EDITION AIMS DOCUMENT ADMINISTRATION & REVIEW LIMITATIONS OF THE CoP SCOPE OF THIS CoP REQUIRED PHILOSOPHIES 6.1. Pest Manager 6.2. The Client 6.3. Accommodation Industry TRAINING 7.1. Pest Managers 7.2. Accommodation/Housekeeping Staff 7.3. Publications CUSTOMER RELATIONS & EDUCATION 8.1. Pest Managers 8.1.1. Client Confidentiality 8.1.2. Client Education 8.1.3. Professionalism 8.1.4. Warranties 8.1.5. Insecticide Usage 8.2. Accommodation Industry 8.2.1. Guest Complaint 5 6 7 8 8 9 9 10 10 11 11 12 13 13 13
13 14 14 14 14

7.

8.

15
15

9. OCCUPATIONAL HEALTH AND SAFETY 9.1. Pest Managers 9.2. Accommodation Industry 10. 11. CHOOSING A PEST MANAGER BED BUG CONTROL - AN OVERVIEW

15 15 16 17 18 18 18 20 20 AND 23 23
23

12. IDENTIFICATION 12.1. Bed Bug Identification 12.2. Bed Bug Indications 12.3. Diagnostic Confounders 13. PLANNING AND PREPARING FOR INSPECTIONS TREATMENTS 13.1. Pest Manager Preparation 13.1.1. Pest Manager Equipment 13.2. Client Preparation & Preparation of Infested Sites

24 25 25

14. INSPECTION PROCEDURES 14.1. Introduction

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14.2. The Inspection 14.2.1. Hotels 14.2.2. Residential 14.2.3. The Inspection Process 14.2.4. Bed Bug Detection Dogs 15. HIGH RISK FACTORS 16. BED BUG MANAGEMENT PLANS 16.1. Proactive Management Plan 16.2. Eradication Management Plan 17. TREATMENT PROCEDURES 17.1. Non-Chemical Control 17.1.1. Introduction 17.1.2. Disposal of Infested Items 17.1.3. Physical Removal 17.1.4. Heat 17.1.5. Steam 17.1.6. Cold 17.1.7. Mattress Encasements 17.1.8. Vacating a Room 17.1.9. Bed Bug Traps/Barriers 17.2. Chemical Control 17.2.1. Insecticide Application & Situational Choices 17.2.2. Currently Registered Products 17.2.3. Insecticide Efficacy 17.2.4. Insecticide Reapplication 17.2.5. Insecticide Resistance Strategies 18. POST-TREATMENT PROCEDURES 18.1. Client 19. POST ERADICATION PROCEDURES 19.1. Pest Manager 19.1.1. Measurement of Success 19.2. Eradication Declaration 20. PREVENTION MEASURES 20.1. Bed Bug Population Dynamics 20.2. Bed Bug Management Policy 20.2.1. Bed Bug Detection 20.3. The Traveller 20.3.1. Luggage 20.3.2. Inspecting Luggage for Bed Bugs 20.4. Second Hand Furniture 20.5. Guest Linen & Bedding 20.6. Room Furnishings & Room Construction 20.7. Ongoing Maintenance 20.8. Bed Design

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25 25 26 27

25

28 33 33 33 34 34
34 34 35 36 37 39 40 41 41

44 45 45 48 49

44

49 49 50 50
50

50 51 51 52
52 54 54

53

54 55 55 55 56

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57 57 57
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20.9. Mattress Design, Encasement and Treatment 20.10. Hygiene 20.11. Risk Assessment and Management 20.11.1. Tracking Infestations 20.12. Notification by Tenants 20.13. Linen Handling 20.14. Pest Inspections 20.14.1. Preventative Insecticide Applications 20.15. Destruction of Infested Items 21. SITUATIONAL CONTROL 21.1. Multiple Occupancy Residential Complexes 21.2. Rental Accommodation 21.3. Transport Industry 21.3.1. Bed Bugs on Aircraft 21.4. Extreme Bed Bug Infestations 22. 23. 24. 25. DEFINITIONS REFERENCES AND FURTHER READING ACKNOWLEDGMENTS APPENDIX A The CoP Working Party

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58 58 58

59 59 59 60 60
60

61 65 67 69 70 71 71 71 71 72 73

26. APPENDIX B Suppliers & Contacts 26.1. Mattress Encasements 26.2. Alginate Bags 26.3. Medical Entomological Expertise 27. 28. 29. APPENDIX C Bed Bug Service Checklist for the Client APPENDIX D Bed Bug Service Checklist

APPENDIX E Pesticides registered by the APVMA for bed bug control as of 15/Sep/2011 79

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1. PREFACE TO THE DRAFT FOURTH EDITION

Bed bugs continue to be a major problem in the developed world including Australia, and management technology has evolved at a rapid pace , hence the need for an updated edition of the Code of Practice for the Control of Bed Bug Infestation in Australia (CoP). Up until recently in the modern bed bug resurgence, encounters with the insect were mainly in areas where people slept. However, bed bugs have had a broader societal impact with infestations occurring in shops, offices, hospitals, physician waiting rooms, public transport systems such as planes, trains and buses, and cinemas. You no longer need to stay in an infested bed to pick up bed bugs. One of the major factors for the degree of the bed bug resurgence has been poor pest control and the failure of industry associations around the world to provide guidance to their members on best practice in the management of modern insecticide resistant strains of bed bugs (Doggett et al. 2011). Thus it is encouraging to see the release to two major industry standards this year. The European Code of Practice Bed Bug Management was initially developed from the third edition of the Australian CoP and has been adapted for the European market (Madge 2011). This has become a quality document such that the current edition of the CoP has cherry-picked the best from the European CoP. The organisation behind the European CoP, the Bed Bug Foundation (BBF), has joined forces with the Working Party for the Australian CoP, in an information co-sharing arrangement to better improve standards on bed bug management. The chair of the BBF, Oliver Madge, is especially acknowledged for his collaboration. From the US, the NPMA BMP Bed Bugs Best Management Practices was released this year (NPMA 2011). While more limited in detail and scope then the European Code, it is a welcome edition to the fight against bed bugs and does contain useful information that was used to enhance the Australian CoP. As mentioned in the previous editions, bed bugs are an international problem and infestations can only be reduced in number worldwide if best practice management options are undertaken globally. The adoption and promotion of this CoP by other organizations and stakeholders, especially those in the pest management and accommodation industries, is welcomed. Many of the updates within this version represent knowledge refinements and there are few major amendments or additions. One of the big trends in the US is the use of thermal heating to control bed bugs which is now included in this CoP (Section 17.1.4). If done properly thermal heat can result in the very quick eradication of infestations, unfortunately however, there has been a recent

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series of fires resulting in the complete destruction of buildings with the use of heating and so such technology should only be employed by the most experienced. To help assist those in the accommodation industry and to minimise the impacts of bed bugs, the development of Proactive Management Plans is encouraged (Section 16.1). These plans should be part of an overall Bed Bug Management Policy and Procedural Guide; such a guide has recently been developed in Australia and is freely available from www.bedbug.org.au (Doggett 2011). Pest Managers are encouraged to produce an Eradication Declaration report at the end of the treatment process and to list any impediments to a successful treatment (Section 19.1.2). There is also an update on new insecticides registered in Australia (Section 17.2.3); of these only amorphous silica (Diatomaceous Earth Dust) is likely to offer any real benefit to the Pest Manager. Despite the market being flooded with bed bug management devices and products since the last edition of the CoP, not one has been verified as efficacious by an independent scientific body. Accordingly such devices and products are not mentioned nor recommended within the CoP. The use of any management device not specifically mentioned in this CoP is at your own and your clients risk. As always, all drafts of any new edition are made available for public comment before finalisation and all submissions will be considered. Submissions can be emailed to: Stephen.Doggett@swahs.health.nsw.gov.au. The CoP is the culmination of the hard work of many and sincere thanks must be given to the CoP Working Party (listed in Appendix B), those who provide feedback, and to the individuals listed in the acknowledgements. Stephen Doggett September 2011

2. AIMS
The aims of the CoP are: i. To define best practice and outcomes through a CoP that encompasses an integrated pest management approach to the eradication of active bed bug infestations and the management of potential infestations, ii. To develop the CoP through broad industry consultation, iii. To provide education of stakeholders, iv. To protect stakeholders, v. To provide a reference document on which other more focused

Draft 4th Edition

documents can be based.

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The CoP endeavours to provide a reference document with broad acceptance by the pest management industry, which would be a guide to Pest Managers, the accommodation industry, service industries and professions and the general public on best practice in the control of active bed bug infestations, minimisation of the spread of existing infestations and the prevention of possible future infestations. The expected outcome from adherence to the CoP would be to minimise the impact of bed bug infestations wherever they occur. If improved control results from the CoP, then this should lead to a reduction in the rate of new infestations.

3. DOCUMENT ADMINISTRATION & REVIEW

This CoP was devised and is administered by a Working Party of the Australian Environmental Pest Managers Association (AEPMA), the national peak professional association for urban and commercial pest management in Australia. The appointment of the Working Party and ongoing administration and review of the CoP are conducted in accordance with guidelines agreed by the national board of AEPMA. Members of the Working Party, listed in Appendix A, include at least; one representative of AEPMA, one published scientist who is a recognised expert, one member of a University or Institute of Higher Education (which may or may not be the expert), one representative of an insecticide company and at least three licensed Pest Managers who are recognised as having experience in bed bug control. The CoP is reviewed periodically to ensure that it incorporates the most recent advances in research and management technology in the control of bed bugs. Draft versions of each edition are made available for public comment and feedback is sought from various groups. This includes Pest Managers, pesticide manufacturers and suppliers, the accommodation industry and tourism bodies, environmental health managers and other health workers, researchers in tertiary institutions, and many other affected stakeholders. The feedback is used to develop the final release of each edition of the CoP. Any version encompassing major changes is made available for public comment. Minor changes are undertaken at the discretion of the Working Party. All subsequent changes to the CoP are documented and made available on the bed

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bug CoP web site. The Department of Medical Entomology Bed Bug CoP web site (www.bedbug.org.au) should be checked for the latest version of the CoP. Each edition of the CoP is valid for a maximum of eighteen months from the date that appears on the front cover at which time it is reviewed to ensure currency. Only the current edition as displayed on the CoP bed bug web site is valid. Any suggestions that may improve the CoP can be sent to Stephen Doggett, Department of Medical Entomology, Westmead Hospital, Westmead NSW 2145, or email: Stephen.Doggett@swahs.health.nsw.gov.au.

4. LIMITATIONS OF THE CoP

Where possible the control and management strategies recommended herein are based on independent and peer reviewed scientific publications. However, due to the paucity of research in some areas since the recent bed bug resurgence, it has been necessary to initiate this CoP using the successful experiences of numerous Pest Managers and researchers. It should be noted that this CoP does not attempt to discuss every technology proposed for the control and management of bed bugs; only those where there is evidence of efficacy through common practice or via publications. If a product within the CoP is being promoted in a manner based on unsubstantiated claims, the company will be seen not to be promoting best practice in bed bug management and the product may be removed from subsequent editions of the CoP. As the bed bug situation is currently highly dynamic, it is envisaged that more insecticides and other management devices will become available, and scientific publications will be forthcoming. Thus it will be necessary to regularly review the CoP. The CoP does not attempt to provide detailed background information on the biology and ecology of bed bugs. It is recognised that this is essential information and such knowledge will aid in the control and management of bed bug infestations. The biology of the pest will be the guiding principle for management practices. See Section 23 for references to bed bug biology.

5. SCOPE OF THIS CoP

The CoP will include currently identified effective measures, which may be employed against bed bug infestations:

Draft 4th Edition

These To control active infestations, To minimise the spread of active infestations, and To prevent future infestations. measures will include: Inspection and surveillance practices, Monitoring techniques, Hygiene practices, Management techniques and technologies, Environmental manipulation.

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In describing measures that may be employed, the following details will be included: Risk assessment and management, How the measures should be employed for maximum effectiveness and safety, Circumstances under which the measures should be used, Possible integration of measures, Limitations of the measures, Contra-indications of measures, Documentation of measures, Required training of Pest Managers, Required client education. The CoP is targeted towards any Australian individual, organisation (both government and non-government), or industry involved with the control and management of bed bugs, those who may be directly impacted by bed bugs, government organisations in the position of enforcing compliancy, or those who are in a position where they could inadvertently spread bed bugs (e.g. second hand furniture sellers, linen contractors). This includes for example; Pest Managers, the hospitality industry including housekeeping staff, campervan hire industry, tourism operators, environmental health officers, charter boat operators, staff accommodation managers, housing organisations, landlords, property managers, transport operators, linen contractors, second hand furniture sellers and government.

6. REQUIRED PHILOSOPHIES
6.1. Pest Manager
For bed bug control the Pest Manager must realise that the normal practice of

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management is not an option and that the client desires elimination. The cryptic nature of bed bugs means that complete eradication with a single treatment is unlikely, especially in heavy infestations. The inspection process must be extremely thorough and may take considerable time, as all harbourages need to be identified and subsequently treated. Follow up inspections are always required and repeated treatments are usually necessary even in minor infestations. Ongoing surveillance during the control program is essential. Inadequate control often leads to a spreading of the infestation with inevitable escalating control costs to the client. By aiming to achieve complete eradication, the risk of insecticide resistance will be reduced. The Pest Manager should never undertake a bed bug treatment that does not conform to this CoP as a quick fix solution. For example, the mattress should not be treated on one day and the remainder of the room on the next, as this can lead to dispersal of the insect even to adjoining rooms and units. The Pest Manager must attempt to eradicate the infestation with the first treatment. There should be a minimum of one follow up visit (or more with heavy infestations) and the final inspection should determine the success of the treatment. The Pest Manager should integrate both non-chemical and chemical means of control and aim to minimise the risk of insecticide exposure to the public. Only those insecticides that are either currently registered or approved for use for bed bug control by the Australian Pesticides and Veterinary Medicines Authority (APVMA) must be used by the Pest Manager. The Pest Manager must provide quality work as per best practice defined in this CoP or warn the client that control will not be achieved. Where the client is unwilling to follow the recommendations of this CoP, the client must accept responsibility for this decision, and this fact must be documented and signed by the client. Bed bug control can only be achieved if the client fully cooperates with the Pest Manager. Cooperation may include preparing the room for treatment, to possible room closure. If the client is unwilling to cooperate with the Pest Manager, then a successful elimination may not be achieved. In this case the Pest Manager should consider not accepting the work.

6.2.

The Client

The client can not solely rely on the Pest Manager for the prevention and control of bed bug infestations. For the Hotelier there is a responsibility

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to undertake preventative measures including, risk management, education of staff in bed bug management, ensuring that appropriate hygiene measures are implemented and maintained, ensuring that rooms are not bed bug friendly, and that other strategies are implemented to reduce the risk of potential infestations (Section 20). The Pest Manager will require the client to undertake certain activities during a control program, without this cooperation, the treatment is likely to fail. The client should not attempt to control an infestation prior to a site assessment by the Pest Manager. Such attempts can spread the infestation, increase the downtime of the premises, present a health and safety risk and lead to an increase in control costs. The client must realise that the control of bed bugs is expensive, especially in heavy infestations when rooms may be closed for extended periods. It is not the intention of the CoP to compromise any control activity on the basis of financial impact, no matter how costly. Rather the intention of this CoP is to provide current best practice for the control of active infestations, the prevention of spreading active infestations and the management of future potential infestations. However, research is encouraged to find the fastest control methods in an effort to minimise disruption and possible cost to the client.

6.3.

Accommodation Industry

To reduce the risk of litigation and to minimise the potential for bed bugs, those in the sector of providing accommodation should attempt to demonstrate due diligence. Due diligence is the ability to prove beyond a reasonable doubt that everything possible was done to prevent a certain act from happening. For the accommodation industries, due diligence would involve risk minimisation strategies for potential bed bug infestations and ensuring that management strategies were promptly implemented once an infestation was detected. The development and implementation of a bed bug management policy and procedural based on best practice, which is subject to regular review, would assist in the demonstration of due diligence. A bed bug policy and procedural guide, which was developed from this CoP is freely available from www.bedbug.org.au.

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7. TRAINING
7.1. Pest Managers
Pest Managers who undertake bed bug control should be specifically trained in bed bug identification, biology and management. Likewise, the Pest Manager should be trained in how to reduce the risk of acquiring and transporting bed bugs on themselves or their equipment when attending a bed bug infested site. This includes procedures for how equipment is brought in and taken out of infested sites, how infested beds and furnishings should be physically handled, how infested items are properly disposed of, and how pest control equipment is stored in the vehicle after leaving an infestation. Due to the difficulty of bed bug control, under no circumstances should an untrained person undertake a bed bug treatment without the direct supervision of a licensed pest manager, experienced in bed bug control. This CoP should form the basis of any bed bug training program. Likewise, any bed bug training program being appraised for PestCert compliance must ensure that this CoP forms the basis of the program. All training should be through RTOs or a PestCert appraised activity. Companies and Pest Managers who undertake bed bug management should review industry developments on a regular basis. It is preferable that only sales staff who have practical experience in bed bug management provide quotes on bed bug jobs, to avoid inaccurate costings. The Working Party has developed an appraised one day course for the training of Pest Managers in bed bug management. The curriculum for this is based on the CoP. Pest Managers who successfully complete the course will be listed on the CoP web site, www.bedbug.org.au.

7.2.

Accommodation/Housekeeping Staff

Housekeeping staff are in the position where they may recognise the signs of a bed bug infestation before the guests become aware of the problem. While this may not always happen, vigilance can prevent the bed bugs from becoming well established. Housekeeping staff should be trained in recognising the signs of bed bugs, including blood spotting on the sheets, mattresses and walls, and the bed bugs themselves, and routinely inspect the beds for signs of activity. Samples of bed bugs should be kept for future reference and training. Management could record bed bug signs via digital imagery. As housekeeping staff in Australia may not have English as the first language, staff information should be multi-lingual

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where appropriate. For the Hotelier, it is important to maintain records of staff training. Training should be undertaken by an appropriately skilled person. For hotels who use outside cleaning contractors, the Hotelier may consider establishing an in-house executive housekeeping position who would take responsibility for training and documentation. It is often in the interest of the Pest Manager and their organisation to offer training to accommodation/housekeeping staff as a bed bug aware client can appreciate the difficulties involved in eradication and are more likely to cooperate. Other staff who may have to deal with affected guests or those responsible for ensuring that control of infestations are undertaken, should also receive specific training in bed bugs. This may include front of house, managerial and maintenance staff.

7.3.

Publications

All industry publications (be they in pest management, accommodation or housekeeping journals) making recommendations on bed bug control should be in compliance with this CoP. Industry publications should only be produced by recognised bed bug experts, and/or be externally refereed by a recognised bed bug expert. The referee/s should be included in the acknowledgement to show that the article has been reviewed by a recognised expert.

8. CUSTOMER RELATIONS & EDUCATION

8.1.
8.1.1.

Pest Managers
Client Confidentiality

In the past, bed bugs were largely associated with substandard housing. While this is no longer the case, for many the past association has developed into a stigma by which the client is embarrassed if an infestation occurs. For example, the Hotelier sees bed bugs as potentially impacting on their public image and they may lose clientele if in-house infestations became known. Thus the confidentiality of any bed bug infestation must be assured and must be written into the contract.

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Client Education

8.1.2.

To assist in the education of the client on bed bugs, the Pest Manager should consider providing the following; A copy of this CoP or details from where this can be downloaded (i.e. www.bedbug.org.au). Information on bed bugs and their biology (a fact sheet should be provided; one can be downloaded from www.bedbug.org.au), and clients should be informed that bed bugs are difficult to control due to their elusive nature. Information stating that there is no evidence that bed bugs transmit disease-causing organisms, although some people can develop allergic reactions. If the client has any medical issues, the Pest Manager must never provide medical advice and suggest that they should consult a Medical Practitioner (or see article by Doggett & Russell, 2009).

8.1.3.

Professionalism

As noted above, bed bugs can give a hotel a poor public image. Thus all dealings with clients must be conducted in a professional manner. The infestation should not be discussed in a location where guests may overhear the conversation, and preferably only the management or housekeeping staff should be consulted. Treatments in common areas should be undertaken during times that would least inconvenience guests.

8.1.4.

Warranties

A client accepting the recommended Bed Bug Management Plan (Section 16) typically expects that elimination will be achieved. Accordingly where practical, the Pest Manager should offer a written service warranty. However, any contractual obligation should contain reference to client and Pest Manager responsibilities and limitations within the Bed Bug Management Plan. These would include the cooperation of the client during treatment as described in this CoP, circumstances encountered during the implementation of the plan, the quality of ongoing housekeeping, the nature of the room itself (whether or not it is bed bug friendly; refer to Sections 20.6, 20.8 & 20.9), the level of ongoing maintenance (Section 20.7) and the potential risk of bed bug reintroduction (e.g. Section 20.11).

8.1.5.

Insecticide Usage

It is required by Australian law that all insecticides must be used strictly according to the product label. Consideration should be given to using low odour insecticides. All relevant product label warnings should be discussed with the client prior to any insecticide application. If further information is required then

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the MSDS or the product manufacturer should be consulted.

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8.2.
8.2.1.

Accommodation Industry
Guest Complaint

Procedural guidelines within the Bed Bug Management Policy (Section 20.2) must be followed if a guest lodges a complaint suggestive of bed bug involvement or if housekeeping staff find evidence of bed bugs; Any report of a possible bed bug infestation must be investigated and be recorded as an incident report. This is the responsibility of the Hotelier. Any guest complaining of bed bugs should be immediately moved to another room whenever possible; otherwise if the guest is bitten again, the hotel could increase the potential liability. Consideration should be given to assisting the guest in disinsecting their belongings (Section 17). Management should document within the incident report when the putative infestation was reported, the room number, if and where the bed bugs were observed, and the customer complaint (this may include such aspects as if bite marks were evident). If guests have a severe reaction to the bite, the Hotelier should encourage and assist the guest to seek medical assistance. The Hotelier must never provide any medical advice. The hotelier should demonstrate empathy with the guest by explaining that bed bugs are becoming increasingly common throughout the entire industry and that the hotel has strict guidelines in handling an infestation. The room should be inspected for bed bugs as soon as possible by appropriately trained staff or a Pest Manager. Inexperienced individuals may not readily detect an infestation if it is in a poorly accessible location such as behind a bed head. If the room can not be inspected on the same day, then it should be vacated until an inspection is undertaken. The inspection date and time must be documented, along with the date when the Pest Manager was contacted (ideally the same day), the dates the room was closed, when treatment was undertaken and when the Pest Manager declared the infestation eradicated.

9. OCCUPATIONAL HEALTH AND SAFETY

9.1. Pest Manager

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All Pest Managers must comply with the relevant State occupational health and safety laws when mixing and applying insecticides. This includes wearing of the appropriate personal protective equipment, and storage and disposal of insecticides. For any insecticide selected for use, the label should be consulted for application rates and application directions, safety instructions, and if there are any use restrictions or requirements (for example, some products can not be applied to mattresses). If power needs to be disconnected in a room (e.g. switch plates removed for inspection and insecticide application) then housekeeping staff should facilitate any electrically related procedures. It is likely that in the majority of bed bug jobs that the Pest Manager will need to move beds and other heavy furnishings to gain access to bed bug harbourages. For this reason, it is suggested that housekeeping always assist the Pest Manager in gaining access to harbourage areas in preparation for inspection and treatment. However, this should only be undertaken with the Pest Manager in attendance. Pest Managers should minimize the risk of exposure to bed bug allergens by only using vacuums fitted with HEPA filters (Section 17.1.3) and by wearing dust masks particularly in heavy infestations or dirty environments. Pest Managers should also undertake measures to minimise the risk of spreading bed bugs on their own belongings and clothing. It should be company policy that white clothing is worn, which enables bed bugs to be spotted more easily, and disposable overalls and shoes should be used which are placed into sealable plastic bags at the completion of treatment and labelled for disposal. Spare clothing should be carried and all worn clothing should be placed into sealable plastic bags, and subsequently laundered as described in Section 17.1.4. All equipment should be stored in sealable plastic containers.

9.2.

Accommodation Industry

Those in the accommodation industry should not attempt to undertake insecticide treatments; only licensed Pest Managers have been trained in the safe handling and proper use of insecticides. Access to infested rooms should be minimised only to essential staff and preferably only those who have received training in how to conduct themselves in an infestation. This is to minimise the further possible transfer of bed bugs within the facility and to prevent staff spreading the infestation to their own homes.

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10. CHOOSING A PEST MANAGER

Choosing a Pest Manager to undertake bed bug eradication can be a daunting prospect. Bed bugs are considered by many as the most difficult of all pests to control. Unfortunately some Pest Managers are not successful in treating these pests, which can cause the infestation to spread and dramatically increase overall eradication costs. The following suggestions can assist in selecting a reliable Pest Manager; Check that Pest Manager is licensed and that the licence is current. The Pest Manager must abide by this Code of Practice and to use this doctrine as their principal guide in controlling the insect. This should be stated in the Bed Bug Management Plan. Ask others whom they have found successful in controlling bed bugs. Following the initial assessment, the Pest Manager should provide a Bed Bug Management Plan (Section 16). If the Pest Manager suggests undertaking just one treatment and makes the comment see how you go after that, then shop elsewhere. Request past management plans for similar situations (the Pest Manager must ensure names are removed for confidentiality). Enquire as to what warranty the company is willing to offer. Request information on the companys response time. Check that the company has current insurance cover (both professional indemnity and public liability). The pricing of the job is usually a good indication of likely success. Bed bug control is very expensive and if the price is too good to be true, then it probably is. Request proof of specific training in bed bug management, such as attendance at bed bug courses where the course was conducted in accordance with the AEPMA approved curriculum developed by this CoP Working Party (see www.bedbug.org.au for trained Pest Managers). It is important that individuals rather than the company should have bed bug training. Ask the company for a list of current clients with contact details that have had a bed bug infestation successfully treated (although many in the accommodation industry will not allow their Pest Manager to pass this information on). Check the local consumer affairs association to see if there have been any complaints brought against the company. Ask the company if they belong to a professional association or are accredited. In Australia, the peak professional association is the Australian Environmental Pest Managers Association (www.aepma.com.au) and the accreditation body is PestCert Ltd (www.pestcert.com.au). Professional associations provide educational

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seminars to members through national conferences and regional meetings and members follow an acceptable code of conduct and often are better trained. PestCert accreditation requires that Pest Managers have appropriate training, stay up to date by attending regular professional development and subject themselves to periodic audit. Accreditation status can be checked at the PestCert web site. However it should be noted there are many competent Pest Managers in Australia who do not belong to an association and are not PestCert accredited.

11. BED BUG CONTROL - AN OVERVIEW

Achieving elimination of a bed bug infestation requires: Proper identification of the pest (Section 12), A site assessment and a thorough inspection (Sections 13.1 & 14), Client co-operation (Section 13.2), The development of Bed Bug Management Plans (Section 15), which should include consideration of any high risk factors that can make control challenging (Section 16), Non chemical and chemical means of pest elimination (Section 17), Follow up inspections/re-treatments (Sections 18 & 19). Risk minimisation procedures will then need to be implemented to reduce possible new infestations (Section 20).

12. IDENTIFICATION
12.1. Bed Bug Identification
Bed bugs (Cimex spp.) are insects that are wingless and dorsoventrally flattened. Adult bed bugs are a reddish brown, 5-6mm when unfed to almost 10mm when fully blood engorged. An unfed adult is not dissimilar in size and shape to that of an apple seed. There are five nymphal stages that have a similar body shape to the adults but start out translucent and cream in colour in the first instar (or stage), becoming darker in the later instars. The size of the juveniles varies between 1-4mm depending on growth stage (Figure 1). Currently in Australia there are only two species of Cimex, which are both introduced; Cimex hemipterus (the Tropical bed bug) and Cimex lectularius, (the Common bed bug). The Tropical species occurs mainly north of the NSW/Qld

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Figure 1. The various life stages of the Common bed bug, Cimex lectularius. The numbers represent the different instar stage. Bar = 5mm. 2009,
Stephen Doggett, Department of Medical Entomology, Westmead Hospital, Westmead.

Figure 2. Adult bed bugs. The Common species (C. lectularius) on the left has a lateral flange on the margin of the pronotum (arrow), making this structure wider than that of the Tropical species (C. hempiterus) on the right. 2009, Stephen Doggett, Department of Medical Entomology, Westmead Hospital, Westmead.

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d border and the Common species to the south, with some overlap between northern NSW and southern Qld. The two species are taxonomically differentiated on the basis of the shape of the pronotum of the thorax; the Common species having a pronounced lateral extension of the pronotum and thus is much wider than that of the Tropical species (Figure 2).

12.2. Bed Bug Indications

Indications of a bed bug infestation include (Figures 3-6); Live or dead bed bugs, and cast skins. Live bed bugs will confirm that the infestation is currently active. Faecal spotting. This is digested blood defaecated by the bed bugs. It may be initially observed on the sheets, but will be commonly noticed along the mattress seams and other places where bed bugs hide. On light coloured surfaces individual faecal marks appear as small dark round spots, however the spotting may be in colour from cream, through grey to almost black. Generally the spotting, will occur in groups and appear as splotches of dark marks (see Figures 3-5). Note that the faeces of nymphal cockroaches appear similar, however bed bug blood spotting tends to occur in groups as the insect by nature aggregates. Red blood coloured spots or smears on the sheets may occur which can be the result of bed bugs passing sera, or engorged bugs being squashed by movements of the sleeping host. Eggs (cream in colour with a slight bend, approx. 1mm, Figure 13), which tend to be laid in crevices in dark areas. A bed bug smell sometimes described as sickly sweet but is akin to that of stink bugs. This is usually only noticed in heavy infestations, if close to the bugs or during the treatment process.

12.3. Diagnostic Confounders

It is important to realise that if a client is bitten by an unknown pest it may not necessarily be from a bed bug. Other common biting arthropods include; ticks, mites (bird, rat, chigger & various stored product mites), biting flies (mosquitoes, midges, stable flies, march flies), lice (head, body & pubic), fleas, wasps, bees, ants, and urticating caterpillars, to name but a few. There can also be non-entomological causes of bite-like reactions, which may include; environmental factors (fibres, dust, low humidity producing cable bug, plant hairs), medical conditions (skin pathogens and other infectious diseases, hormonal conditions such as formication, adverse reactions to medications, side effects of medications and/or drugs of addiction), and power of suggestion (if one person starts itching in a workplace, then others often follow). There can

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Figure 3. Bed bug adults, nymphs and eggs, along with blood spotting, at a wall/floor junction. 2005 Department of Medical Entomology, Westmead Hospital.

Figure 4. Blood spotting on a mattress, which is typically grouped, indicating the gregarious nature of the insect. No bed bugs can be seen in this image. 2005 Department of Medical Entomology, Westmead Hospital, Westmead.

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Figure 5. A massive bed bug infestation in an ensemble base. It is always necessary to remove the material covering the base in order to treat the infestation. 2005 Department of Medical Entomology, Westmead Hospital, Westmead.

Figure 6. The 'straight edge' that holds the carpet in place. Numerous eggs and blood spotting are evident. 2005 Department of Medical Entomology, Westmead
Hospital, Westmead. For more bed bug related images see Doggett (2005).

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also be a delay in the appearance of a clinical reaction to a bed bug bite, even in the order of 9-14 days, and this can cause confusion as to the origin of the bites. For more information on the clinical consequences of bed bug bites, see Doggett and Russell (2009). If bed bugs are not found in a possible infestation, then these other entomological causes need to be considered by the Pest Manager. Under no circumstance should the Pest Manager consider or advise on possible medical conditions. With the recent focus on bed bugs in the media, many people find insects that are often mistakenly identified; nymphal cockroaches are often suspected of being bed bugs. In any putative infestation, it is important that the insect pest is properly identified by an appropriate Medical Entomology laboratory reference. A list of Medical Entomology laboratories with experience in bed bug identification is in Section 26.3.

13. PLANNING AND PREPARING FOR INSPECTIONS AND TREATMENTS

13.1. Pest Manager Preparation
It is extremely important that the Pest Manager explains the inspection processes in detail to the client and should provide; Instructions that it will be necessary to inspect the bedroom, including looking through cupboards and drawers. Instructions that it will be necessary to remove bed heads, lift carpets and dismantle other items to access all bed bug harbourages. Instructions on any activities the client will be required to undertake prior to the inspection (see below). Advice to the client that follow up inspections after the initial inspection and treatment will be necessary.

13.1.1. Pest Manager Equipment

The Pest Manager may find the following useful for a bed bug inspection; A powerful torch. A 10x magnifying lens (to inspect for live bed bugs and eggs). Collection bottles (for gathering bed bugs for later confirmation of identity, sticky tape can also be used for gathering bugs). Fine tipped forceps (for picking up bed bugs).

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Screwdrivers and spanners for dismantling items. An inspection mirror. Plastic bags (large and small) to hold bottles, tape, infested items, etc. Notepad, for recording details of the infestation. Digital camera (for recording infested sites, the digital images or printouts can also be given to the Hotelier in a report or provided as part of an educational package). Checklists for a bed bug service (Appendix C & D).

13.2. Client Preparation & Preparation of Infested Sites

The client should not attempt to remove any item from the room before an inspection is undertaken by the Pest Manager, for the following reasons: The Pest Manager needs to gauge the true extent of the infestation, Disturbing the infestation may cause the bed bugs to disperse and, Removal of items to another location may spread the infestation. In the process of, or immediately following the inspection and only upon the recommendation of the Pest Manager, all bed linen, curtains and clothing must be removed from the infested areas. It is essential to handle all such items as infectious; they must be bagged (and sealed) before removal from the room and labelled as being infested with bed bugs. They should then be washed in the hottest water possible (>55oC) and/or dried in a hot air clothes drier for at least 30 minutes. Alginate bags are preferable for infested linen, as the bags with the linen enclosed can be placed directly into the washing machine and the bags will dissolve. This reduces extra handling of infested linen and reduces potential cross contamination in laundry facilities. If alginate bags are used then it is imperative that these are stored dry and away from sources of moisture, otherwise the bag will breakdown before laundering. If alginate bags are not available then plastic bags should be used. Delicate items can be placed into a freezer after bagging (Section 17.1.6). If a linen contractor is used then all potentially infested linen must be kept isolated, labelled infested and have instructions to wash separately in hot water. Likewise, all wardrobes, drawers and cupboards must be emptied and the contents treated as above. After clothing and materials have received the heat treatment, these should not be returned to wardrobes but kept sealed in plastic bags away from the infestation until eliminated. Prior to treatment, the client must be advised to undertake the following: Cover up any fish tanks or preferably remove them from the room to be treated, after careful inspection by the Pest Manager for evidence of bed bugs.

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All occupants and pets must vacate the premises and/or area of treatment. For infested hotel rooms, the room must be kept unoccupied until the infestation is declared eradicated. If possible the client should provide the Pest Manager with a plan of the building so that the bed bug infestation/s can be recorded where detected. To sign and date any Bed Bug Management Plan (Section 16) and return a copy to the Pest Manager.

14. INSPECTION PROCEDURES

14.1. Introduction
Bed bug infestations may be found in buildings, vehicles, boats, trains, buses and aircraft, and attention to detail will always be required. The main aim of the initial assessment is to develop the Bed Bug Management Plan (Section 16) and the aim of the inspection process is to detect every possible bed bug harbourage. One of the most common reasons for control failures is that inspections often fail to reveal all hiding places. A proper inspection is also necessary to anticipate the time required to undertake control, which is a prerequisite for accurate job costing.

14.2. The Inspection

14.2.1. Hotels
If a treatment is being undertaken in a hotel, then it is important that the housekeeping staff are interviewed to seek information on where guests have complained of bites and where staff may have seen bed bugs. Housekeeping staff are at the coalface and are more likely to have detailed knowledge about an infestation than the management.

14.2.2.

Residential

For treatments in homes, similar questions should be asked to determine areas where residents are being attacked. The Pest Manager should attempt to determine how the bugs were brought into the home; for example if the bugs were brought in via the occupant, then luggage storage areas need to be inspected and treated. The movements of the person/s affected by bed bugs need to be established; if they have slept in various areas within the home or

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away from the home then all of these need to be inspected and probably treated. Areas where dirty clothes and used linen are stored should be examined and the occupant questioned about any previous control attempts.

14.2.3. The Inspection Process

To avoid the risk of transferring bed bugs in equipment a minimum of items should be brought into the infested room. These items should be placed either on a previously inspected chair (with the clients permission and then on a plastic bag to protect the chair) or positioned in an open area away from walls, preferably on a plastic sheet. Equipment should never be placed onto beds, on other furniture or next to walls. Likewise the Pest Manager should avoid prolonged contact with beds, curtains and other potentially infested materials. Bed bugs have a very flat body shape and can hide in virtually any crack and crevice, preferring dark, isolated and protected areas. Bed bugs prefer wood, paper and fabric surfaces and so these materials should be paid special attention in the inspection process. The mattress should be the first site inspected, and generally, bed bugs are more likely to be present in the darker areas near the wall. Close attention should be paid to: The seams, beading, under buttons, labels, and corner protectors if not previously removed. For an ensemble, the base is more likely to harbour the bugs than the top mattress. The edge of the material underneath the ensemble base is a favourite spot for bugs as well as any hollow plastic caster legs. It will be necessary to remove the material covering the base of the ensemble. For metal framed beds if wooden slats are present; these contain many cracks for bed bugs to hide in and lay their eggs. If the wooden slats are bolted to the bed frame, the bolts should be undone and the drilled holes inspected and treated. Bed bugs can also hide in coils of bed springs and inside hollow bed posts. The areas around the bed should be investigated next, these include: The bed frame, bed head and bedside furniture. Bedside furniture, tables, etc, should be turned over and examined. The drawers in tables and cupboards should be removed and examined. If bed heads are attached to the wall, they should be removed after consulting maintenance staff. Other furniture in the room should be inspected, especially locations where luggage is placed, such as luggage racks. For these, close attention should be paid to the seams and buttons (if upholstered) and any wooden join (especially if constructed of chipboard).

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Other inspection sites include appliances such as telephones and audio visual equipment, books, power points and behind switch plates, underneath carpet edges and the straight edge that holds the carpet in place along with rugs, skirting boards, joins in floor boards and under floor boards, loose wall paper and paint, architraves, old nail and screw holes, ornaments, window casings and wall voids. Bed bugs may be found higher on the wall in wall hangings, picture frames, wall mirrors, Venetian and vertical blinds, curtains and curtain rods, books, behind electrical conduit, cracks and joins in the ceiling, under ceiling mouldings, smoke detectors and light fittings.

A room site plan should be drawn showing the location of any activity. The room inspection should be as methodical as possible noting all sites of bed bug activity on the site plan. In any infestation, adjoining rooms and spaces, both either side and above and below, should be inspected. Bed bugs are often found in lounges in common rooms of hotels and these should be examined. Housekeeping trolleys and laundry areas should also be inspected.

14.2.4. Bed Bug Detection Dogs

Bed bug infestations may be detected by the use of pest detection dogs. These have been used successfully for a number of years for termite detection and in the case of bed bugs, pest detection dogs can check a room for bed bugs more quickly than any human Pest Manager. Pest detection dogs are especially useful for detecting small infestations that are not always obvious and they can be employed in a proactive system of bed bug detection. If an infestation is detected early, control is easier and thus treatment success is more likely to be achieved. For the accommodation industry this means there is less chance of guests being bitten by bed bugs (and reduced litigation risk) and room closure time will be reduced. Detection dogs can also be used to check the success of the treatment. It is important to note that dogs are not always accurate and that the Pest Manager must confirm a suspect infestation and examine those areas where the animal cannot access (e.g. high areas). Not just any dog can be used as a detection dog. Dogs must be trained by an accredited facility and undergo regular retraining. Members of the US based association, the National Entomology Scent Detection Canine Association (NESDCA), suggests that a quality control system must be used daily as part of the process of regular assessing the accuracy of detection by the dogs. The National Pest Management Association of America (NPMA) has recently defined

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standards for the certification of bed bug detection dogs and their handlers (NPMA 2011). At present in Australia there are very few dogs trained in bed bug detection.

15. HIGH RISK FACTORS

Certain risk factors at the site of the infestation can make the job extremely challenging and increase the likelihood of treatment failure. These risk factors should be considered in the development of the Bed Bug Management Plan, especially in terms of the control limitations, and in costing the job. These include:

Bed Design; certain types of beds will always make bed bug control more

challenging. Bed bugs will almost always get into ensemble bases, particularly underneath and between the staples of the base covering (Figure 7). Likewise plastic corner protectors provide an excellent harbourage. Even if the bed is made completely of metal, fittings such as metal springs provide ample bed bug habitat (Figure 8). Metal springs are especially difficult to treat; using an aerosol or steam can result in bugs being blown out without being killed. It is necessary to flood the springs with insecticide or treat them with dry heat. Wooden bed slats (Figure 9) and the underneath of the material strip that holds the slats in position both are favoured harbourage areas.

Room Integrity and Access; gaps, cracks and crevices around skirting boards (Figure 10), in the wall, along the cornice and other areas will provide harbourages for bed bugs and all of these sites will need to be assessed. In some cases, access for inspection can be very difficult, such as in hollow metal skirting fascia.
materials used can make bed bug control more challenging. In exposed brick work (Figure 11), bed bugs often harbour in and lay eggs along the mortar which necessitates time consuming treatment of all mortar work. In false walls, bed bugs often access behind the wall making treatment extremely problematic. In this case it may be necessary to remove the false wall.

Room Construction; a room may be of sound construction yet the type of

Clutter; bed bug control in cluttered rooms is impossible unless the clutter is
removed and either discarded or treated.

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Figure 7. Ensemble bases make great bed bug motels due to the large number of harbourages. Blood spotting can be seen in groups along the top, which is between the staples that hold the material that covers the underneath. 2010
Department of Medical Entomology, Westmead Hospital, Westmead.

Figure 8. Metal bed springs make an excellent bed bug harbourage and are a challenge to treat. Extensive bed bug faecal spotting is evident. 2010 Department of
Medical Entomology, Westmead Hospital, Westmead.

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Figure 9. Wooden bed slats provide numerous bed bug harbourages. 2010
ment of Medical Entomology, Westmead Hospital, Westmead.

Depart-

Figure 10. A large crack is present in the corner of the skirting and bed bug spotting is evident. Poor room integrity always makes bed bug control more challenging. 2010 Department of Medical Entomology, Westmead Hospital, Westmead.

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Figure 11. Exposed brick work is very challenging to treat for bed bugs and requires extensive spraying along all mortar lines. 2010 Department of Medical Entomology,
Westmead Hospital, Westmead.

Figure 12. Underneath a chest of drawers showing massive bed bug activity. Chipboard furniture is very bed bug friendly and can be very problematical when bed heads are constructed of this material. 2010 Department of Medical Entomology,
Westmead Hospital, Westmead.

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Bed Bug Friendly Furnishings; certain construction materials make

furnishings bed bug friendly. Both chipboard (Figure 12) and wicker cane provide numerous harbourages and if present within an infestation, will make control more challenging.

Extent of the infestation; not surprising, a heavy bed bug infestation will be
much harder to control than one where few bed bugs present. A heavy infestation will require multiple insecticide applications and frequent inspections and thus involves a lot of time.

Access to adjoining properties; in multi-apartment dwellings, the Pest

Manager should make every attempt to inspect all properties adjoining the infestation. However, in some cases residents refuse access. If privately owned then it may be impossible for any authority to force access, under these circumstances reinfestation is highly likely to occur.

Apartment complexes; control is often much more difficult in apartment

complexes and multiple occupancy dwellings as the infestation may have originated from adjoining premises. Naturally the client is not willing to pay for control in a neighbours property.

Residential properties; bed bug control is often made more difficult due to

the fact that there tends to be more furniture and items within residential properties than hotel accommodation. This means that more items will need to go through a disinsection process.

Client co-operation; if a client does not consider that bed bug control is a co-

operative venture between themselves and the Pest Manager then the possibility of failure increases. The Pest Manager must communicate with the client and inform them of their duties. This should be both verbally and via the Bed Bug Management Plan. contain synthetic pyrethroids which are largely ineffectual and due to the excitorepellent nature of the chemical, often disperse an infestation. If the client has attempted to control the infestation with such products (especially insecticide bombs), then usually the infestation will be far more diffused and spread throughout the property. Naturally control becomes more challenging.

Previous use of household insecticides; most household insecticides

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16. BED BUG MANAGEMENT PLANS

16.1. Proactive Management Plan
Ideally a Bed Bug Proactive Management Plan for accommodation providers should be developed in collaboration with the contracted Pest Management company prior to any bed bug infestation. This plan should then become a part of an overall bed bug management policy and procedural guide for the accommodation provider (see www.bedbug.org.au for such a policy and procedural guide). The Proactive Management Plan should include: History of past bed bug activity and treatments (including insecticides used). Findings of the initial room inspections by the Pest Manager, which would include various risk factors relating to construction elements and challenges to control (see Section 15). A review of current management practices that may influence potential bed bug risk, e.g. current housekeeping practices, documentation, training, etc. Responsibilities of the accommodation provider, including principal contacts. Floor plans, which can help determine which adjoining rooms will need inspection and monitoring in the advent of an infestation. The eradication processes by the Pest Manager, including response times, treatment regiments (including insecticides used), warranties and limitations of the treatment. Period of validity for the plan (which should be reviewed regularly). The Bed Bug Proactive Management Plan should also include a review of the financial impacts to the facility.

16.2. Eradication Management Plan

A Bed Bug Eradication Management Plan must be provided to the client for the treatment of all bed bug infestations by the Pest Manager, which can also serve as the service contract. This plan can be seen as a one off treatment regimen as opposed to a long-term proactive management plan. The plan sets out the pest control processes by detailing the work to be undertaken. It must be stated up front that the aim of the treatment is to achieve complete eradication of the infestation. Following an initial site assessment, the Bed Bug Eradication Management Plan should include: The findings of the initial assessment (e.g. where bed bugs were evident, the degree of the infestation, including photographs where possible). For commercial dwellings and/or managed facilities such as public

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housing, a review of past bed bug infestations in the building. It may be necessary to speak to staff and tenants in order to provide a complete history of bed bug activity. The treatment process. This would include; estimated treatment commencement date and a time frame for the treatment process, nonchemical means of control, insecticides to be used (and MSDSs as required), where the insecticides will be physically applied, times when the client needs to vacate the premise and can re-enter, any client duties prior to and post treatment (such as the placement of a mattress cover over insecticide treated mattresses). Realistic expectations of the treatment. The requirements for follow up inspections and treatments. That the Plan follows this CoP. Warranties, limitations and restrictions. Period of validity. The charge for the treatment.

In the plan, it must be stated that inspection of adjoining rooms (both vertically and horizontally) should be undertaken (even though this may not be possible in apartment complexes). The Bed Bug Eradication Management Plan should explain clearly the clients and organisation's responsibilities and include authorised signatures stating when each will carry out any recommendations made by the Pest Manager. For example, the Pest Manager should insist that Housekeeping help with the removal of carpets, bed heads, and any other item/ s, to protect the Pest Manager from liability claims of excessive damage. Where possible, a warranty on the service should be detailed on the Bed Bug Eradication Management Plan (Section 8.1.4).

17. TREATMENT PROCEDURES

17.1. Non-Chemical Control
17.1.1. Introduction
Non-chemical options should be considered as management tools only. Thus while they can be utilised to reduce the overall bed bug population, complete elimination of an infestation is unlikely unless insecticides are used.

17.1.2. Disposal of Infested Items

Reducing the overall biomass of a bed bug infestation can be achieved through discarding infested furnishing, although complete control will not be achieved. While the Pest Manager can recommend this option, it can be very expensive to

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the homeowner or Hotelier and not always necessary. The exceptions are mattresses that are torn; these are difficult to treat by insecticides and steam, and should be discarded. However they can be covered with an appropriate mattress encasement (Section 17.1.7), heat treated or fumigated. Any item to be removed must be sealed in plastic before removal, ensuring that all openings are securely taped shut. Such furnishings should be treated before discarding. To avoid others acquiring bed bugs from discarded infested items, the furniture should be destroyed or rendered unusable, for example mattresses and bases should be slashed. They should also be clearly labelled with obvious signs indicating that the items are infested with bed bugs and must be destroyed. Disposal of items should be co-ordinated with waste disposal collection. Around the world, heat is being employed to effectively treat infested mattresses and furniture, and such processes are now becoming available in Australia.

17.1.3. Physical Removal

Bed bugs should be physically removed via vacuuming or by sticky tape if numbers are small on mattresses. Always use a vacuum machine that has a disposable dust bag. A crevice nozzle can be used along carpet edges, bed frames, mattress seams and in ensemble bases, furniture, and other potential harbourages. Vacuuming cracks and crevices prior to insecticide treatment will not only remove the bugs but dirt as well, which will allow the chemicals to penetrate better and improve their residual effect. After vacuuming is complete, the contents must be sealed within a plastic bag. This should then be destroyed by incineration if possible, rather than just being placed into the general rubbish. If incineration is not possible, then apply insecticide dust to the contents and seal in a plastic bag prior to disposal. Under no circumstances should an insecticide aerosol or spray be applied to an operating vacuum machine as this may cause an explosion and/or fire. The allergens from bed bugs are known to trigger asthmatic reactions and dispersal of the allergens can occur through vacuuming. Repeated exposure to the allergens can lead to a sensitisation thereby increase the risk of adverse respiratory effects, thus it is important that a vacuum machine fitted with a HEPA filter is used to protect the health of the client and the Pest Manager. It is important that the vacuum machine does not become the source for further infestations so it must be properly disinsected following use and only be used for Figure 13. Bed bugs eggs are glued down when pest control. Vacuum units that have laid, which means that they resist removal via
vacuuming.

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the base and all hoses composed of solid plastic can be readily sterilised in hot water. This should be done as soon as possible after use. When not in use the vacuum unit itself should be stored in a sealed bag. The Pest Manager should be aware of the limitations of vacuuming. All previously vacuumed areas need to be treated with insecticides as bed bugs within crevices can hold on against the suction forces. The eggs themselves are glued in place when laid and resist removal via vacuum (Figure 13), meaning that other control measures must be subsequently applied. Stiff brushes are sometimes suggested for removing bed bug eggs, however they are not recommended as they can disperse the eggs and make control more difficult.

17.1.4. Heat
Bed bugs are very sensitive to heat and are rapidly killed when exposed to temperatures over 45oC. If heat is used for bed bug control it is important that the high temperatures are applied suddenly; a gradual rise in temperature may cause the bed bugs to disperse, thereby potentially spreading an infestation. water followed by a hot tumble drying to kill any bed bugs. Studies from the United Kingdom (Naylor & Boase, 2010) have shown if the water is at 60oC, then every bed bug stage will be killed in the wash. However, a temperature of 40oC will not be lethal to all the eggs. In Australia, there are State plumbing codes for the temperature of hot water at the outlet. For example, in NSW the requirement for personal hygiene fixtures (such as hand basins, showers and baths) is that the water must be delivered at no more than 43oC in childcare centres, schools or nursing homes, or 50oC for other classes of building. This means that if such water is used to treat infested linen, it may not be hot enough to ensure a complete kill of all stages. Laundries and kitchen sinks do not need to comply with this regulation and the water should be around 60oC (unless mixed with cold water or a long way from the water heater) and will kill all stages. Clearly if hot water is to be relied on for bed bug disinsection, the temperature must be confirmed at or above 60oC. For tumble drying, the Naylor and Boase investigations found that the dryer had to be operated on the hot setting for 30 minutes for dry clothes to achieve a complete kill of all stages. If clothes are wet, then they should be left in the machine until completely dry. employed for bed bug control around the world. The most efficient are bubble

Laundering: As noted in Section 13.2, infested linen can be laundered in hot

Thermal Heating: large electric of gas driven heating units are increasingly being

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treatments, where infested items are treated in a small contained area. Heat treating whole rooms is rarely successful without the use of insecticides as there are many harbourages that can protect the bed bugs, and control is especially difficult in heavily cluttered rooms. Ideally the airspace should be heated first before fans are switched on. Thermal control for bed bugs in large spaces requires a high level of skill; fans are required to distribute hot air evenly, multiple temperature monitoring devices are necessary to record heat changes and to ensure that the appropriate temperatures are reached. There have been a series of fires resulting in the complete destruction of dwellings caused by the inappropriate use of heating units; this method should only be undertaken by trained individuals.

Solar Heating: It is often claimed that bed bugs can be killed via heat by placing

infested materials into black plastic bags and then into the sun. However, a scientific investigation has shown that this can be ineffective with large items such as mattresses, which have a high thermal inertia (Doggett et al., 2006). Since this method can not be relied upon to disinfest items it is not recommended within the CoP.

17.1.5. Steam
One practical method of exploiting heat is through the use of steam. The great advantage is that it will kill all bed bug stages including the eggs (most insecticides are non-ovicidal). A study from the United States (Meek 2003) has shown that a program that employs steam followed by insecticides provides better long-term control than with the use of insecticides alone. As steam is composed only of heated water, some clients favour this treatment over chemicals, particularly for their mattress and bed. However, control can not reliably be achieved with steam alone. It is important to note that there are many different brands and types of steam machines on the market, however not all are appropriate; the unit must be able to produce steam of a low vapour flow and high temperature. It is best to use commercial units that employ dry steam, which allows for quicker drying times.

Note: dry steam is a misnomer; items treated will still be damp and a fan or ventilation should be used to dry the room afterwards, otherwise mould growth could occur. Steam machines that have a continual flow feature can be filled and
remain operational without the downtime of some of the cheaper units, which must go though a cooling and reheating phase.

As with all equipment, the steam machine must be properly maintained and the operating temperatures should be regularly checked with the aid of an infrared thermometer. Immediately after steam treatment the surface should be recording at least a temperature of 70-80oC.

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Steam flow rate must be kept to a minimum to avoid blowing bed bugs about (along with exuviae which may contain eggs and nymphs) and to reduce wetting. Likewise, single jet steam nozzles can blow bed bugs away. If such nozzles are used on mattresses then the nozzle should be always pointed towards the centre of the mattress where propelled bugs can be seen and re- Figure 14. Covering the steam head with cloth will steamed if still alive. Multiple ensure that bugs will not be blown about, yet the jet steam heads produce a temperature will be high enough to kill the insects. gentler flow rate, are thus less likely to blow bed bugs away and can treat larger areas over a shorter period. In comparison for example, with single jet nozzles it will be necessary to run the nozzle along both sides of edge beading, whereas a single pass with a multiple jet head placed over the beading will usually suffice. By placing a cloth over the steam head as in Figure 14, bed bugs will not be blown about by the jets and the treated surface becomes much hotter, which better guarantees the killing of all stages. However, heat penetration into the surface being treated will not be as great. Brush heads and brush fittings on steam machines should be avoided as the stiff bristles can fling off eggs and bugs. It is important that the steam be applied directly to the bugs as even a thin layer of cloth may shield the insects. To reduce the risk of blowing bed bugs about if a cloth is not used over the steam head, all areas destined for steam treatment should be vacuumed first. Like any tool, steam machines are only as effective as the operator. To achieve control, an intimate knowledge of the pest and its ecology are essential, inspections must be diligent and the treatment process must be meticulous. The instructions of the steam machine must be read thoroughly noting all safety instructions prior to use. As all steam machines take time to reach operating temperatures, this can be done while the inspection is in progress. As the steam machines are operated with a low vapour flow rate it is necessary to place the nozzle in direct contact with the surface being treated; the temperature drops away rapidly from the nozzle and a separation of only a few centimetres will not be lethal to the bugs. The nozzle should be moved along at a rate of only 30cm per every 10-15 seconds.

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The steam treatment should start with the mattress and be applied to the seams, under labels and handles, and both inside and out of an ensemble base. It will be necessary to remove the material base of the ensemble, which should be kept for the client to reattach after the infestation has been eradicated. Cushions of chairs and sofas should be treated next, paying particular attention to seams and buttons. Always check if the sofa is a sofa bed, and if so, treat the mattress as above. Carpet edges can also be treated with steam, along with the straight edge both above and below. After the completion of the steam treatment, any dead bugs should be removed via vacuuming, which will help facilitate the determination of treatment success. As with any technology, steam has its limitations. Being water based, electrocution is a potential issue and thus power points and other electrical fittings should not be steam treated. Steam may damage heat and water sensitive materials, thus the Pest Manager should always test the item to be treated in a non-conspicuous area. Steam will raise the humidity in a room, which can lead to mould growth leading to other potential health issues. Steam treatments are very time consuming. The greatest disadvantage is that steam is non-residual. Thus bugs that are not directly killed (and it is prudent to assume that a certain percentage will not be contacted) will not be exposed to any further control influence unless an insecticide is present. Thus it is always necessary to complete the control process by following up any steam treatment with a residual insecticide.

17.1.6. Cold
The alternative to extreme heat is extreme cold, i.e. freezing the bugs. This has the advantage that heat sensitive materials will not be damaged. While this method can often not be directly used by the Pest Manager, it can be recommended to the home owner and Hotelier for small items. Any item for freezing should be placed loosely into a bag, and as always, this must be done in the infested room prior to removal. The amount of time in the freezer would be dependent on the size of the item; the larger the item, the longer in the freezer. If the freezer is operating at or around -20oC, then two hours at this temperature will kill all stages. However, for the average household freezer, studies have indicated that 10 hours will be required (Naylor & Boase, 2010). Dense items may take several days for the centre to cool sufficiently to kill the bugs and the longer an item is kept frozen, the more likely the bugs will be destroyed. Naylor and Boase suggest around 8 hours of freezing is required per 2.5kg of dry weight of laundry. Many modern freezers are of the frost-free type and go through cycles of varying temperatures. As a result, bed bugs will require a much longer time in the freezer to be killed, even up to several days.

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17.1.7. Mattress Encasements

Seamless mattress covers provide fewer potential harbourage areas than mattresses, thus making them less susceptible to an infestation. The covers can also be readily removed for laundering thereby making control easier and being white makes bed bugs and their spotting easier to notice. The benefits provided by mattress covers have been further extended with the recent development of specialised anti bed bug mattress encasements, which are now available in Australia. These encasements have incorporated an in built membrane that is impervious to bed bugs; not only can bed bugs not penetrate these encasements, they are even unable to bite through the material. Encasements may be used in two modes; to completely contain and hence inactivate an existing infestation in a mattress and ensemble base, or to prevent the mattress and base becoming infested in the first place. In the containment mode, the infested mattress and ensemble base are encased for an extended period of time and in due course all the encased bugs will die of starvation. The obvious advantages of this system are that insecticide use is minimised and costs reduced as the infested mattress and base do not need to be discarded, even if damaged or heavily infested. As bed bugs can live for up to six months without feeding at 22oC, or even longer in cooler climates, the encasements must be left in place for much longer than this, as removal represents a reinfestation risk. Thus users need to be made aware that encasements should not be removed if being used for bed bug containment. In these circumstances, bed sanitation can be improved by covering the mattress encasement with a seamless mattress cover which can be regularly removed and hot washed and hot dried. In the prevention mode, the encasements are used as a risk management tool to minimise the possibility of an infestation becoming established in new or uninfested mattresses and ensemble bases. The encasements have few seams meaning that there are few places where bed bugs can hide on the outer surface. If an infestation ensues, then the encasement can be sanitised via hot wash and dry cycles without affecting the integrity of the membrane. The encasement should be immediately replaced after washing. It is important to note that mattress encasements cannot by themselves stop bed bugs and should be used as part of an overall bed bug management program. For suppliers of mattress encasements see Appendix C. The desirable features of mattress encasements include: small zipper teeth that stop juvenile bed bugs passing through, few seams and tightly stitched joins, an inbuilt bite-proof membrane, end zipper stops that prevent bed bug escape or

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entry, and anti-removal devices.

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17.1.8. Vacating a Room

Leaving an infested room vacant for extended periods is not an option to control the bugs as they can live for many months without a blood meal. Infested rooms must be treated as per this CoP.

17.1.9. Bed Bug Traps/Barriers

Over the last year there have been a number of devices coming onto the marketplace claimed to capture or detect bed bugs (traps and monitors) or that aim to prevent the insects crawling onto beds (barriers). Neither will eliminate an infestation by themselves and must be used as part of an IPM program. Most traps are active devices that attempt to catch host seeking bed bugs via the use of various attractants such as heat, humidity, carbon dioxide, and/or various other attractants. Historically within the literature there has been considerable debate on what attracts bed bugs to the host and over what distance, and much of this research is over 50 years old and requires updating. More recent research in the area of pheromones has been shown that most bed bug stages respond positively to an aggregation pheromone, however mated females respond negatively and are thus repelled. This is a major problem for any traps that employs pheromones as they may help to disperse an infestation. Arguably, any trap that employs an olfactory stimulant may inadvertently help to disperse bed bugs. For example, if the bed bugs are at the far range of the ability to detect the olfactory stimuli this may elicit a non-directional wandering response. However, it can also be argued that this probably happens when humans are present anyway. Most active traps either have a short life (<24hrs) and are disposable, or use consumables that only last overnight. These types of devices require regular replacement or continuing maintenance to function. There are very traps few that use attractants that can operate continually. There are also passive traps becoming available that have no attractant and rely on bed bugs using the trap as a harbourage location. These types of traps aim to act as a longer term monitoring device. A number of traps have attributes that may limit their use either due to their physical size or perceived occupational health and safety issues. Regarding physical issues, some traps are over 10cm tall, while most beds with casters in motels have a clearance to the floor of around 6-8cm, which makes placement of the trap problematic. The trap can not be placed in an obvious location within a hotel room while in use, as the guest would not want to stay in a facility where there obviously is or has been bed bugs. The hotel also certainly does not want

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to risk their reputation by announcing that they have an infestation. For some hotels where the bed frame consists of sheets of timber nailed together, there is no space available at all underneath. In motels with ensembles or solid bed bases, bed bug traps could only be employed while the room is closed during the treatment process. Regarding occupational health and safety, a number of bed bug traps utilise mains power. Many in the accommodation industry may not want power cords under the bed for risk of fire or power cords around the room for risk of clients tripping. Additionally, some traps have a canister of compressed carbon dioxide and again it is probable that many hotels would not want a high pressure gas cylinder within their rooms. Such devices may have insurance implications. Currently the limitations of bed bug traps and how most effectively they can be employed are yet to be fully evaluated. Given this and the issues discussed above, the most likely scenarios of their use include: Non-commercial premises; in privately owned residences there are no reputation threats, although the occupational health and safety issues are still real. The traps could be used to monitor the success of treatment or to allay the fears of a homeowner that they have bed bugs. Traps could be used for monitoring while a room is closed during the treatment process to monitor the success of treatment. The passive traps could be used for long term monitoring in commercial premises. As of August 2011, none of the traps have been tested and found efficacious in an independent scientific study. Thus presently, they are not recommended within this CoP. Barriers, also referred to as intercepting devices, are simple passive units that aim to protect the sleeper by preventing bed bugs climbing beyond the bed legs. They are not dissimilar to the various techniques historically used to thwart bed bugs accessing the bed. Barriers are placed either underneath the bed legs/ casters or on top of the casters of ensemble bases. Added to the barrier may be additional security devices to reduce the risk of the bed bugs gaining access to the sleeper including the inclusion of various dusts (insecticidal or talc) and/or sticky substances that entrap the insects. For barriers to be effective the bed must be kept away from the wall and valances and sheets must not touch the ground, otherwise bed bugs can then access the bed. Many barrier devices are quite obvious and unlikely to be used in the commercial accommodation market for the same reasons relating to reputation threats as mentioned with traps. However, barriers can be a cost effective option in low

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income housing and homeless shelters. Despite barriers not having any attractant, they can trap bed bugs and could play a monitoring role. As these devices are based on old proven technology, they are likely to be effective. The use of sticky tapes for the monitoring of bed bugs have been found ineffective (Doggett et al. 2011). Bed bugs tend to react negatively to gels and other sticky surfaces, and avoid capture. The Climbup Interceptor (www.insect-interceptor.com, Figures 15 & 16) is a barrier that has been demonstrated efficacious in a scientific study as part of an IPM program (Wang et al. 2009). Like all barriers, this device aims to prevent bed bugs accessing the bed and thence the sleeping host. The success of this device does rely on the assumption that the bed has been cleared of any active infestation. The Climbup Interceptor is made of a smooth plastic that bed bugs find difficult to climb and it is further supplemented with the addition of a light dusting of talc, which does need refreshing from time to time, but this makes it even more difficult for the bed bugs to breach the device. The barrier is proving to be very useful in the US not only to prevent bed bugs crawling onto the bed, but also as a monitoring tool, as inspection is convenient and trapped bed bugs easily observed. Another advantage is that the device forces the bed to be kept away from the wall, which further isolates the bed ensuring that bed bugs can not access the host via the wall. There are a few disadvantages; beds with

Figure 15. The Climbup Interceptor barrier.

Figure 16. The 'Climbup Interceptor' installed underneath a bed leg.

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castors can no longer be easily rolled out for vacuuming once the device is installed, beds without bed heads can have issues as the pillows will fall down at the back, and valances and blankets can touch the ground and render them ineffective. These devices do require maintenance as a build up dirt and debris can render them less effective and the talc needs occasional replacing (see www.insect-interceptor.com/Precautionary_Statements.pdf for notes on maintenance). However, the advantages may outweigh the negatives and this device could prove to be a very effective tool particularly in low income housing. The BB Secure Ring is a very simple barrier that fits between the bed leg and the bed, and is constructed from an ultra smooth plastic which bed bugs can not climb over. In laboratory trials, the device was able to prevent access by bed bugs of all strains and stages (Doggett et al. 2011).

17.2. Chemical Control

17.2.1. Insecticide Application & Situational Choices
It is a requirement of Australian law that only those insecticides that are either currently registered or permitted for use by the APVMA for the control of bed bugs may be used. The label of the product must be consulted to ensure that it is currently registered. However, due to the problems of insecticide resistance, registration of a product by the APVMA is not proof of efficacy as the APVMA does not require that efficacy data is provided on modern insecticide resistant bed bug strains. The insecticide/s to be applied must be directed to all harbourage areas identified in the inspection process, in accordance with label instructions. In most infestations, the carpet and underlay should be peeled back for at least 30cm, and the straight edge treated underneath. Following the completion of treating the infested room, it may be advisable to treat the adjoining rooms even if no bed bugs were seen in the inspection. The type of formulation selected for the treatment will be dependent on its usage patterns. For example dusts if applied in obvious areas in a hotel will be quickly vacuumed up and rendered ineffective. Dusts can be used in electrical areas while liquid formulations can be utilised in more obvious locations. Dusts can be applied to wall voids if the bugs are suspected of penetrating such areas. They can also be directed to the underneath of carpet edges and under straight edges. Currently there are several brands of dust registered for the control of bed bugs in Australia, although only four different active ingredients occur in the products that are currently available. These include amorphous silica (also known as Diatomaceous Earth Dust, trade name: Bed Bug Killer), bendiocarb (Ficam), deltamethrin (Cislin) and permethrin (many brands).

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Aerosol insecticides have their use as quick killing agents. Products such as synergised synthetic pyrethroids act very effectively to knockdown and kill the bugs rapidly when applied directly to the insects in situ (although it is always best to vacuum first). With extension nozzles, the chemical can be very accurately applied to areas such as beading on mattresses, and cracks and crevices in furniture. For wall hangings and delicate or antique furniture, aerosols may be more appropriate than other formulations, after vacuuming. Aerosols should never be used as space sprays for bed bug elimination; the fine droplets simply will not penetrate into the locations where the insects hide. As most contain pyrethroids, there is an associated excitory flushing effect and by spraying into a space rather than harbourage areas, the bugs are likely to disperse and can spread an infestation. Like aerosols, the smoke generating insecticides (known as pyrotechnics) or total release insecticides (bombs) are also unlikely to penetrate into harbourage areas. For applying liquid formulations, fan sprays should be used along carpet edges and pin streams for cracks and crevices. Avoid using hollow cone sprays. It is important to note that not all surfaces can be treated by all insecticides and so the label needs to be carefully consulted. For example, some of the carbamates and organophosphates cannot be used on mattresses. If mattresses are to be treated, there are often specific instructions for this use and it is advisable to recommend to the client that a non-porous cover be placed between the mattress and sheets. Insecticides on a mattress should be kept to a minimum to reduce human exposure and it is best to use vacuuming and steam first to remove and eliminate bed bugs on beds. In the past, fumigants were widely used for bed bug control and there are fumigants registered for bed bug control. However this is a highly specialised area and an appropriate specialist should be consulted.

17.2.2. Currently Registered Products

A list of currently registered products is in Appendix E. The main chemicals available to the Pest Manager including their formulations are in Table 1.

17.2.3. Insecticide Efficacy

Efficacy studies have been undertaken in Australia with registered insecticide groups via topical (i.e. directly applied to the insect) and residual application, using both liquid formulations and dusts (Doggett & Russell 2008; Lilly et al., 2009a,b,c). The test animal used was an insecticide resistant modern strain of the Common bed bug (C. lectularius) sourced from Australian field infestations

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Table 1. The various insecticidal active ingredients currently registered for bed bug control in Australia.
Active Ingredient Amorphous Silica (Diatomaceous Earth Dust) Bendiocarb Betacyfluthrin Cyfluthrin Chlorfenapyr Deltamethrin (some synergised with PBO) Diazinon Dichlorvos Permethrin Pirimiphos-Methyl Propoxur Sulfuryl Fluoride Various aerosols containing synergised pyrethroids Formulation/s Dust DP, WP SC AC, WP SC SC, DP EC Impregnated pest strip DP, EC, WP EC Aerosol Fumigant Aerosol Insecticide Group Silicates Carb SP (4G) SP (4G) Arylpyrrole SP (4G) OP OP SP (3G) Organophosphate Carb Miscellaneous SP (2,3,4G) Mode of Action Group* Not listed 1A 3A 3A 13 3A 1B 1B 3A 1B 1A 8C Mostly 3A

AC= Aqueous Concentrate, DP=Dustable Powder, EC= Emulsifiable Concentrate, SC=Suspension Concentrate, WP=Wettable Powder. PBO=Piperonyl Butoxide (synergist). Carb=Carbamate, OP=Organophosphate, SP=Synthetic Pyrethroid, G=Generation of Synthetic Pyrethroid (4th being the most modern and insecticidal). No Dichlorvos product is specifically registered for bed bug control, but it could be used where the label lists for use with other insects. *see the Insecticide Resistance Action Committee web site www.irac-online.org for details on the various modes of action.

and thus the studies are relevant to present strains. For the registered liquid insecticide groups it was found in the topical investigations that the order of effectiveness from most to least was: OPs > synergised 4th generation SPs > non-synergised SPs and carbamates > 3rd generation SPs > natural pyrethrins. In the study, the natural pyrethrins provided no control and the 3rd generation SPs (permethrin) virtually no control. The carbamate (bendiocarb) produced an equivalent level to that of the non-synergised SPs with around 60% control at ten days, while the synergised 4th generation SPs produced 95% control over an equivalent time. Only the OPs (diazinon and pirimiphos-methyl) provided 100% mortality within six hours. The residual experiments produced somewhat similar trends to the topically

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applied insecticide trials in that 100% mortality was achieved within 24 hours with the OPs and even after 52 weeks of ageing the pirimiphos-methyl treated surface, 100% mortality was still being achieved. However, the remaining insecticide groups produced consistently poor results with no greater control than 50% mortality after ten days. These research findings suggest the following: Where possible, the first choice of insecticide would be the OPs, Non-OP products cannot be relied on as a residual treatment to achieve complete control, rather the aim should be to directly treat the bed bugs, A synergised SP is preferable to a non-synergised SP. However, the OPs and some carbamates (notably propoxur) have use limitations. They have an unpleasant odour which would be unacceptable to many clients, especially for accommodation providers. The OPs also contain various solvents that can cause staining on some surfaces, notably fabrics, which means that there are restricted use patterns. For example, the label for Actellic (primiphos-methyl) states Do not apply to carpets, mats or soft furnishings, which means this product can not be used in the eradication of many bed bug infestations. Despite this, there are circumstances when the OPs may be used, for example in premises which remain unoccupied for some time such that the odour can dissipate. The studies above did not measure repellency of the insecticides. It is known that the SPs have an excito-repellency effect with various insects and investigations have shown that bed bugs are indeed repelled from SP treated surfaces (Romero et al. 2009) at sublethal doses. Arguably, this makes the SPs less effective than the non-repellent insecticides in the field situation as if poorly applied, they can spread an infestation making control more difficult. The carbamates appear not to repel bed bugs and anecdotally appear more effective as a killing agent. Currently the only carbamate registered against bed bugs is bendiocarb. This is available as both dust and wettable powder formulations, and it should be noted that bendiocarb is not registered for use on mattresses. In September 2011, amorphous silica, more commonly known as Diatomaceous Earth Dust (DED), was registered for bed bug control. DED is a slow acting compound taking up to 1-2 weeks for a complete kill with adult bed bugs, although is much quicker on the nymphal stages. It does however offer a number of advantages over other products; it is highly residual with an extremely long shelf life, dusted bed bugs can transfer the insecticide to other bugs thereby killing others indirectly, there is a low probability of resistance developing due to its physical mode of action, dose rate is not as critical compared with other products (under-dosing results in a longer time to achieve

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a complete kill), it has very low mammalian toxicity and is often recommended by environmental groups, and DED could be used in a prophylactic sense to minimise the risk of bed bugs establishing in otherwise uninfested rooms (Doggett & Russell 2008). Other management means should be used to quickly reduce the biomass of infestations when DED is employed, however this product should prove highly beneficial in bed bug management. In 2010, Phantom Insecticide was registered in the Australia for the control of bed bugs. Published efficacy data have demonstrated variable results; while one laboratory investigation in the US found that it would slowly kill all bed bugs exposed to the product, another found the product so ineffective that the treated bed bugs mated and laid eggs, with many of the hatching nymphs surviving. A third laboratory trial, from Australia, found that the product was unable to kill any bed bug strain, even those resistant to the pyrethroids (Doggett et al. 2011). Two field investigations have also demonstrated poor efficacy; in one of the trials complete control was not achieved over five months despite repeated applications with the product. In light of the generally poor published efficacy results, the use of Phantom Insecticide against bed bugs is not recommended. At the time of writing this CoP, there are no insect growth regulators (IGRS) which are registered for bed bug control in Australia and thus their use can not be recommended.

17.2.4.

Insecticide Reapplication

Most of the insecticides registered for bed bug control in Australia have little proven ovicidal effect and thus do not kill the eggs. These products also provide poor residual control and thus to kill newly emerged nymphs, additional treatments must be undertaken after the initial application. This time will be dependent on the ambient temperature (Table 2) and at least one follow up visit must be made with an insecticidal application. If the infestation is heavy, further inspection and treatments will be needed. Table 2. The development time (in days) to hatching at various temperatures for the eggs of Cimex spp. (after Usinger, 1966).
Species Temperature (oC) 18 20.9 25 22 12.1 13.2 27 5.3 5.9 30 4.4 4.6 33 4.1 4

Cimex lectularius

(Common bed bug) (Tropical bed bug)

Cimex hemipterus

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17.2.5. Insecticide Resistance Strategies

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Overseas investigations have reported a high degree of insecticide resistance in bed bugs. One study in the USA found that field collected Common bed bugs were several thousand times more resistant to deltamethrin and lambdacyhalothrin (both synthetic pyrethroids) than susceptible strains (Romero et al. 2007). Resistance to both the synthetic pyrethroid alphacypermethrin and the carbamate bendiocarb has been recorded in the Common bed bug in the United Kingdom (Boase et al. 2006), while the Tropical bed bug was found resistant to synthetic pyrethroids in Africa (Myamba et al. 2002). Investigations have also found high levels of resistance to the SPs and the Carbamates in Australia as well (Lilly et al. 2009c). Currently, there are very few insecticides from different chemical groups registered for bed bug control in Australia and thus presently it is not possible to formulate an effective insecticide resistance strategy. The Pest Manager should however assist in reducing the further development of insecticide resistance by integrating non-chemical with chemical means of control and always following the application instructions on the product label when applying insecticides.

18. POST-TREATMENT PROCEDURES

18.1. Client
The client should be advised to undertake the following after each treatment: Occupants should be encouraged not to re-enter the treated area until after the chemical has completely dried. Refer to label instructions for re-entry period. The client should be requested not to vacuum floors and upholstered furniture for at least 12-14 days after final treatment. The room should be kept vacant until the Pest Manager declares the area free of bed bugs in a follow up visit. The time for eggs to hatch is dependent on temperature (Table 2), and this time should be a guide to the minimum period for any follow up, using the average daily temperature. However, in heavy infestations several follow up visits will be required before bed bug elimination is achieved. All past signs of the infestation should be removed, such as dead bugs and the blood spotting on walls and mattresses, to avoid future confusion. Preventative measures should be undertaken as outlined below.

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19. POST ERADICATION PROCEDURES

19.1. Pest Manager
19.1.1. Measurement of Success
A successful treatment has been achieved when the infestation identified at the initial inspection has been eliminated. All adjoining rooms must be inspected; an infestation in these rooms may indicate a control failure. Treatment success should also be based on assessing the level of client cooperation, along with follow up inspections and treatments. The Pest Manager should ensure that the client has followed all the recommendations prior, during and post treatment. The final inspection should be as detailed as the initial inspection, or even more so. All previously identified locations with bed bugs must be examined, cracks and crevices retreated with a knockdown agent and surrounding areas examined in case bugs have been flushed out by the insecticides. If live bed bugs are observed then a further treatment and subsequent inspection should be undertaken.

19.1.2. Eradication Declaration

At the completion of treatment the Pest Manager should add to the Bed Bug Eradication Plan: The date of eradication. Any variations in the Bed Bug Management Plan. Limitations or conditions experienced during the treatment, which could not be envisaged from the initial inspection (e.g. areas that could not be accessed). If these factors prevented successful eradication, then all actions to demonstrate that reasonable steps have been undertaken must be recorded. If heat was employed, include temperature readings and locations of sensors for whole rooms. Any client duties such as recommendations to minimise risks of further infestations (see next section).

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20. PREVENTION MEASURES

For practical reasons it is not always possible to prevent bed bugs from entering a premise. Thus the following section attempts to discuss methods that may minimise the risk of an infestation, and to minimise bed bug impacts if introduced. The ultimate key to reducing bed bug impacts is to detect early and act quickly.

20.1. Bed Bug Population Dynamics

The dynamics of a bed bug infestation can be classified into four broad phases: I. Introduction, II. Establishment, III. Growth, & IV. Spread. Thus bed bugs are first brought into a premise (Introduction) and the population becomes entrenched (Establishment). Next the population expands in number (Growth) and finally the infestation is passed onto new premises or to other areas or rooms within the same facility (Spread). It should be noted that this is a general path; bed bugs could spread soon after introduction even though the population has yet to substantially grow. To reduce the risk of bed bug infestations and their ultimate spread, an accommodation facility must attempt to undertake prevention strategies for each of these infestation phases. Various strategies for each of the phases include: Introduction; educating travellers on avoiding bed bugs (Section 20.3), the treatment of luggage suspected contaminated with bed bugs (Section 20.3.1 & 20.3.2), banning of second hand furniture (Section 20.4), and banning external bedding and linen (Section 20.5). Establishment; making the room less suitable for bed bugs through appropriate room construction (Section 20.6) and maintenance (Section 20.7), the use of bed bug unfriendly furniture (Section 20.6) and bed types (Section 20.8), the use of mattress encasements (Sections 17.1.7 & 20.9), employment of bed bug barriers (Section 17.1.9), appropriate hygiene measures (Section 20.10), and undertaking risk analysis of previous infestations (Section 20.11). Growth; training of housekeepers in bed bug recognition (Section 7.2), informing tenants to encourage reporting (Section 20.12), ensuring that linen

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handling procedures are appropriate (Section 20.13), and proactive pest inspections (Section 20.14). Spread; infested items should be quarantined, access to infested rooms should be limited, control measures should be implemented promptly, any items within an infested room should be bagged before removal (Section 17.1.2), any belongings of the tenant should be disinsected before relocated (Section 17), and items that are removed should be appropriately destroyed (Section 20.15) No one method of prevention should be relied on, rather a multi-disciplinary approach undertaken as part of an integrated pest management program should be employed. Within an accommodation facility, the approach to prevention and control must be consistent and based on a Bed Bug Management Policy (Section 20.2).

20.2. Bed Bug Management Policy

As part of the risk management process, those in the accommodation industry should have a Bed Bug Management Policy. This policy should cover aspects including; staff training (Section 7.2), the documentation of putative and actual infestations (Sections 8.2.1 & 20.2.1), occupational health and safety (Section 9), the eradication processes (Sections 17-19) and preventative measures (Section 20). Records of bed bug infestations should be kept to distinguish new infestations from potentially failed treatments. The policy should be reassessed regularly, updated and refined as for routine risk management reviews. Such a Bed Bug Management Policy now exists and can be downloaded from www.bedbug.org.au (Doggett, 2010).

20.2.1. Bed Bug Detection

The following procedures should be included within the Bed Bug Management Policy and implemented upon the detection of a bed bug infestation; If the guest has been moved to another room, then the second room should also be inspected and treated once the guest has vacated (again ensuring all above procedures are documented). In the event of a positive bed bug infestation, the Hotelier should provide information to the guest on how to prevent the establishment of bed bugs in their home. The Hotelier may wish to contact past guests that had stayed in the room over the previous month to inform of the bed bug infestation and the possibility that the infestation could have been transferred to their home, or other locations. The Hotelier should undertake those processes relevant under Section 13

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Planning and preparing for inspections and treatments.

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20.3. The Traveller

Bed bugs are often inadvertently brought home in conjunction with travelling, or transferred to other accommodation facilities. Reducing the risk of establishing bed bugs in the home involves; Minimising the possibility of bed bugs infesting luggage, A thorough inspection of the motel mattress and room for bed bugs, Decontamination of luggage and clothing upon returning home. Luggage is the prime means by which bed bugs are transferred from one location to the next and consideration should always be given to means of reducing the risk of bugs infesting the luggage. Prior to inspecting the mattress and bed for signs of bed bugs, luggage should be initially left outside, in the centre of the room where there are fewer harbourage areas, or on pre-inspected tables. Belongings should not be unpacked from luggage, and in turn, the luggage itself should be kept in plastic bags at all times as this may prevent bed bugs from entering the luggage (bed bugs prefer dark areas and so black bags should be avoided). After leaving the room, the external plastic bag should be discarded. An alternative to plastic bags are BugZip luggage encasements (www.bugzip.com), which can stop bed bugs entering the luggage. BugZip also produce draw liners that can prevent bugs infesting clothing. Solid luggage, such as those made of polypropylene or ABS plastic, without external pockets may be more resilient to bed bug invasion than soft bags. However, soft material bags (unless of a nylon composition) may be laundered in hot water thereby killing any unwanted hitchhiking bed bugs. The traveller must be aware of the possibility of their belongings becoming infested and consideration should be made to only including clothing that can be safely laundered or dried at high temperatures. Any items that can not be treated by extremes of high (or low) temperatures should be kept protected by being constantly sealed in zip lock disposable plastic bags. It is sometimes recommended that spraying luggage with synthetic pyrethroid insecticides (such as permethrin) may prevent bed bugs entering bags. However, this group of insecticides provides poor residual control against modern resistant bed bug strains and is thus unlikely to offer any real protection, and there is no evidence to suggest that this method is effective. Thus other methods of avoiding luggage becoming infested should be followed. To minimise the risk of taking bed bugs home or transferring the bugs elsewhere, it is important for the traveller to check their hotel room on arrival for evidence of bed bugs, as described in Section 12.2. The edges of the mattress should be exposed, and the seams and beading of the mattress checked for the tell tale signs of bed bugs particularly in the darker areas where the bed meets

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the wall. It is advisable also to check the areas where luggage is placed. If there is evidence of bed bugs then a new room should be requested. If there are signs of blood spotting, even if no live bed bugs are present, it would still be highly advisable to ask for a clean room as it is impossible to know how well the room has been treated and what stage of treatment it is in (such as between the initial treatment and subsequent inspections). An inspection of the mattress and room may uncover no evidence of bed bugs, yet the possibility of an infestation can not be totally excluded. In new infestations or when numbers are low, the bugs can hide in less obvious locations such as in ensemble bases, which are hard to access for inspection. If the traveller experiences any bite-like reaction or has suspicions of bed bugs being present (such as blood spotting on the sheets), then it would be best to assume that luggage and clothing is infested and requires decontamination. On returning home, luggage should be kept isolated from the bedroom (such as in a garage). All clothing should be hot washed and/or dried on the hot cycle of a clothes dryer (see Section 17.1.4). Luggage can be disinsected by heating and/ or freezing (Section 17.1.4 & 17.1.6). If there is any possibility an infestation may have been acquired, then a Pest Manager should be consulted. It can take up to nine days or more for the bed bug bite to appear. If the traveller has stayed in multiple locations during this period, then it may be impossible to determine where the exposure occurred.

20.3.1. Luggage
Isolating luggage such as backpacks and other belongings separately from bedrooms in accommodation facilities may help in preventing the transmission of bed bugs but this practice presents obvious logistical problems in terms of storage and security of belongings. If the bags are to be stored elsewhere, this would have to be in metal lockers, which provide fewer harbourages and could be readily treated, otherwise the storage area could aid in the spreading of the bugs. As there is no current information on the benefit of such procedures they are not recommended within this CoP.

20.3.2. Inspecting Luggage for Bed Bugs

Inspecting luggage for bed bugs is probably not practical; the eggs are too small to be easily seen, can be laid in any small crack and crevices, and thus may not be visible. Inspection of client luggage by hoteliers may also violate privacy laws.

20.4. Second Hand Furniture

There are numerous reports of bed bugs being transmitted via second hand furniture. It is inadvisable to purchase or use any second hand mattresses,

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furniture or furnishings, unless the items can be confirmed bed bug free. Accommodation facilities should also limit the practice of transferring mattresses and furniture from one location to another. If this becomes necessary, then the items need to be thoroughly inspected for bed bugs. For Second Hand Furniture Retailers, all mattresses and bed frames should be examined for signs of bed bugs by an appropriately trained inspector before being placed into the store for sale. Infested furniture should be treated as outlined in the CoP.

20.5. Guest Linen & Bedding

As the transmission of bed bugs is linked with bedding, guests should not be allowed to use their own sleeping bags and linen. Ideally, sleeping bags should not be allowed in the bedroom but sealed in a plastic bag and placed in a separate storage room. The Hotelier should explain to the client the need for this. All linen should be provided by and laundered by the accommodation facility or contractor. Laundering should be in hot water, preferably on a daily basis. For backpacking lodges, rooms should have multi-lingual signs requesting guests to use the linen provided.

20.6. Room Furnishings & Room Construction

For the other areas of the room, access for inspection and treatment, and reduction in harbourages should always be the overriding design philosophy for the bed bug unfriendly room. For example, fixed cupboards should be replaced with metal, removable shelves. While these are probably not as aesthetically pleasing, control would be easier as there are fewer places for bed bugs to hide. Many hotels use cane or wicker furniture, especially in seaside and tropical locations. Such furniture is very bed bug friendly, offering numerous harbourages. Likewise, so is open brickwork and sprayed concrete walls. Such walls should be rendered and heavily painted or covered with plasterboard ensuring all joins are well sealed. Carpeted floors provide more harbourages than solid tiles and carpet squares should be avoided. Solid tiles have the advantage of being easily cleaned via vacuuming or even washed with hot water (or steam). For situations of high risk, the solid plastic chairs would be preferable over cloth and wooden types.

20.7. Ongoing Maintenance

The main aim of ongoing maintenance for preventing bed bugs is the reduction

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of potential harbourages via sealing any cracks and crevices. Loose wallpaper should be reglued, while paint should not be allowed to deteriorate to the extent that it is flaking from the wall. Decorative plates are often placed over wiring that penetrates into the walls and it is important that a sealant such as silicon is placed around the wiring. This is also true for any plumbing pipes.

20.8. Bed Design

Metal framed beds can limit the impact of bed bugs as they provide fewer harbourages and the bed bugs are averse to climbing smooth hard surfaces (unless starved for some time). Thus metal frames can help to contain an infestation; if the bugs fall off the bed, they are unlikely to climb back up and eventually die without a blood meal. Wooden beds offer numerous cracks and crevices for harbourages, and provide many footholds for the insect. The inherent advantages of metal beds can be rendered ineffective if valances or bed linen are in constant contact with the floor or walls, or if curtains are touching the bed. Such contact will allow access for the bed bugs. Ideally, the metal bed frame should be constructed so that the feet of the legs splay out so that it is impossible to push the bed hard against the wall. To be most effective, the bed must be made like an island, isolated in the room. Other bed designs are not so effective at containing an infestation. Ensemble beds contain many places for bed bugs to hide and lay their eggs. The base of this bed type is especially notorious; the material base cover limits inspection and the areas between the staples are a favoured bed bug haunt. If the caster legs are plastic, they will be hollow and provide further harbourages. The other problem with ensemble bases is that they can be pushed hard against the wall, enabling the bugs to spread via the wall and utilise other locations in the room as harbourages. Keeping beds away from the wall (more than a few centimetres) will minimise the risk of bed bugs climbing up the wall and onto the bed. In motels the bed head is usually a separate component to the mattress and bed base and is often firmly fixed to the wall. This makes inspection and treatment impossible unless the bed head can be completely removed from the wall (often they are nailed or even glued in place). If power points are attached to the bed head, this can make the inspection more time consuming as power will have to be turned off and electrical fitting disconnected and treated. Where such electrical wires penetrate the wall, this can be an access point by which the infestation can spread to adjoining units. Often the bed heads are made of laminated chipboard, which provides numerous harbourages. Such materials should be avoided in a room to limit bed bug infestations. Ideally in a bed bug

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unfriendly room, bed heads would not be used.

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20.9. Mattress Design, Encasement and Treatment

As bed bugs often hide on the beading of mattress, those without beading, such as the solid rubber foam variety, may be less attractive to bed bugs as fewer harbourages are available. The alternative is to use a mattress encasement (Section 17.1.7) that can be easily removed for regular washing. If not prohibited to do so, all tags, labels and corner protectors should be removed from the mattress to limit harbourage areas. Presently there are mattresses available pre-treated with insecticides and claiming to resist bed bug infestations. Until the Working Party has sighted data supporting efficacy of treated mattresses against modern insecticide resistant Australian bed bug strains, such mattresses are not recommended within the CoP.

20.10. Hygiene
A regular regimen of vacuuming all areas of a room, especially around skirtings and under lounges and sofas, can reduce the severity of a bed bug infestation, and limit the potential for spreading an infestation. The contents of the vacuum should be sealed and discarded (Section 17.1.3), and the vacuum, when not in use, should ideally be confined to the one location. For larger establishments, vacuums and cleaning trolleys should be confined to one floor or to a certain section of a floor. Bed bugs can be transferred via cleaning trolleys and isolating the trolleys to an area should help contain this possibility. A minimum of items should be brought into the room, for example cleaning trolleys should be left outside. Any crevices on the cleaning trolleys should be sealed with a caulking agent. Clutter in a room should be kept to a minimum.

20.11. Risk Assessment and Management

Those in the accommodation industry, who are seriously affected by bed bugs, should undertake a risk analysis of past infestations. Rooms afflicted should be analysed to see where the past guests have come from, whether they be from a local region or from overseas. If clear patterns emerge, then the high risk groups should be kept separately from the low risk groups. This may help to contain infestations to certain rooms and to a certain area of a facility.

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Tracking Infestations

20.11.1.

Hotels belonging to a chain should advise their head office of any infestation and the possibility of new infestations via guests transferring between hotels.

20.12. Notification by Tenants

In high density housing if bed bugs are problematic, management should encourage tenants to promptly notify if they suspect an infestation. Information signage can be placed on noticeboards and educational leaflets distributed to tenants.

20.13. Linen Handling

All used sheets and bedding should be sealed in plastic bags within the room before taken outside and placed into linen hoppers. For a known or suspected bed bug infestation, the bedding should be placed into alginate bags. Clean and used linen should be kept separate at all times; they should not be transported to and from rooms via the same trolleys. It may be advisable to colour code linen hoppers to distinguish between clean and used linen. If linen is washed by outside contractors, the dirty and clean linen should not be transported in the same vehicle. It is not uncommon for used linen to be placed in the corridor outside a room; this is a high risk practice for spreading bed bugs and should be avoided.

20.14. Pest Inspections

Ongoing pest inspections are essential to reduce the severity of infestations. Ideally this should be undertaken on a routine basis by housekeeping staff when linen is changed and the inspection date recorded, even if no bugs are noticed. The frequency of inspections should be dictated by the number of past infestations and modified according to the rate of new infestations. Pest detection dogs may be used as a sensitive means of detecting early infestations (Section 14.2.4).

20.14.1.

Preventative Insecticide Applications

The majority of the presently registered insecticides provide a very poor level of control against bed bugs when applied as a residual treatment, therefore their use as a preventative treatment is not advised in this code. Also, such ineffective use of insecticides can increase the probability of insecticide resistance developing, which is already a problem in bed bug management.

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20.15. Destruction of Infested Items

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When items are disposed of for control, it must be ensured that they are not sent to a recycling facility, unless the facility has processes and procedures in place to disinsect the items. It is preferable that they are sent to land fill or are incinerated. All beds and furniture must be clearly labelled as bed bug infested and rendered unusable before discarding.

21. SITUATIONAL CONTROL

21.1. Multiple Occupancy Residential Complexes
Like hotels, if bed bugs are detected in one dwelling within a multiple occupancy residential complex (such as apartments, units, flats, townhouses or villas), then the adjoining dwellings should also be inspected. However, there are big differences in management responsibilities between hotels and multiple occupancy residential complexes, which can pose many challenges for bed bug control. For example, a hotelier has complete control of the building, including housekeeping, and can readily undertake inspections and treatments in any room whenever necessary. This is not the case for multiple occupancy residential complexes and ensuring that an adjoining room is inspected can be very difficult. It would be unprofessional and a breach of client confidentiality for the Pest Manager to contact the neighbouring premises without the consent (preferably written) of the client. The situation becomes difficult when the adjoining property is the source of the infestation as reinfestation in the treated premise is likely to occur. All the Pest Manager can do in this case is to encourage the occupant to inform the Body Corporate or the Body Strata Manager that bed bugs have been found in the complex and that anyone who experiences bite type reactions should have their premises inspected by a licensed Pest Manager. In some cases, an occupants premise within a complex may become infested when an adjoining tenant fails to undertake control of their own bed bug infestation. In these situations, the occupant should inform the Body Corporate or the Body Strata Manager. If the problem remains unresolved it may be necessary to contact an Environmental Health Officer (sometimes known as a Health and Building Surveyor) within the local Council, the Public Health Unit and/or State Health Department. In some states there are strict notification requirements for undertaking

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insecticidal treatments in common areas and the Pest Manager should check to see if such legislation applies in their respective state (for NSW, see: www.epa.nsw.gov.au/resources/pestmanagement.pdf). For example, under the NSW requirements, normally the residents must be informed five days prior to the treatment of common areas. However, as bed bugs are biting insects they are exempt from this notification process under the Emergency Situation provision. Despite this exemption, the Pest Manager must still put up notices on the site when the treatment is undertaken and must keep records to justify carrying out the treatment under the emergency conditions.

21.2. Rental Accommodation

A disturbing trend for people with bed bugs in rental accommodation is for the tenants to move to another property leaving an uncontrolled infestation behind. Subsequent tenants then often become involved in disputes with the landlord over who pays for the bed bug control. In such cases the following steps can be taken by the disputing parties: Ensure that the pest is properly identified as a bed bug. Have the premise inspected by a Pest Manager with experience in bed bug management. Ensure that the report lists the signs of bed bug activity and the extent of the infestation. For any disputes refer to the Tenancy Agreement.

21.3. Transport Industry

As bed bugs are transferred from one location to another mainly via luggage, there is a risk that the bugs could be passed from luggage to luggage in cargo holds, luggage trailers, car boots or other areas where luggage is placed, transported or stored. All such sites should be made bed bug unfriendly; cracks and crevices should be kept to a minimum, surfaces should be metal (or tiled for floors) and carpet should be avoided.

21.3.1. Bed Bugs on Aircraft

There have been a number of reports from overseas of bed bugs infesting aircraft. In this situation control is more challenging as there are a limited number of insecticidal products approved for use on aircraft. It must be noted that a product that is registered by the APVMA may not necessarily be used on aircraft. The only active ingredient and formulation approved as a residual treatment is permethrin as an EC. As noted under Section 17.2.3 (Insecticide Efficacy), permethrin provides very poor control in both direct and residual application. This means that there needs to be greater reliance on non-chemical means of control, including vacuuming and steam. In the US, heat treatment of

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whole planes has been undertaken.

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Australian Quarantine and Inspection Service, and the New Zealand Ministry of Agriculture Quarantine Service. 42pp. This can be freely downloaded from:
www.daff.gov.au/__data/assets/pdf_file/0005/111992/mqs-procedures.pdf

The products that are approved for use on international aircraft are listed in: MQS and AQIS. 2008. Schedule of aircraft disinsection procedures.

21.4. Extreme Bed Bug Infestations

A disturbing recent trend is the increasing number of bed bug infestations that are occurring amongst socially disadvantaged groups, particularly in public housing and homeless shelters. These infestations can be massive, involving thousands to even tens of thousands of bugs in a single dwelling. Usually the occupant does not have the economic capability to pay for control or sometimes even the cognitive awareness to know that bed bugs are present. In multistorey dwellings, these large infestations often only become evident after the adjoining units in turn become infested, which is almost inevitable. Units three stories above or below the prime source can become invaded, while the tenant in the main infestation can pass bed bugs to other units via their clothing, visitors, or shared items of furniture and appliances. Once bed bugs are introduced in high density housing they can quickly become established and spread throughout the building. This makes ultimate control more difficult and expensive. If only one room is left untreated, than this can act as a reservoir for the reinfestation of the whole of the building. Thus management should be proactive and aim to identify and treat every infestation. Tenants must be encouraged to notify management of the suspicion of bed bugs and not to attempt to treat the insect themselves. Management should place notices of bed bugs with pictures of the insect and signs of an infestation onto communal boards and include information in tenant meetings. Councillors and carers should be notified of any bed bugs and encourage clients in the management of the insect. Tenants should not be allowed to bring discarded furniture or other items off the street. In all cases the rooms adjoining those to the infested premise should be inspected for bed bugs; failure to do so may result in the perpetuation of the infestation. Carers and other visitors often can take bed bugs home and in the event of an infestation, the carers premise should also be inspected. Most importantly management must rapidly respond to any putative bed bug incident. Due to the high costs associated with these heavy infestations and the risk for uncontrolled spreading of the infestation throughout multi-storey dwellings, the authority managing the building should bear the financial costs for eradication.

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They should also ensure that eradication is conducted as per this CoP. The extreme infestation site often will have bed bugs virtually everywhere within the dwelling. Not only will the bed be heavily infested, but the bed bugs will be in books, CDs, pictures, wall hangings, clothing, cupboards and other furniture, lounges, whitegoods, appliances, telephone, under carpets, behind skirtings, in wall cavities, etc. Compounding the challenge of controlling such a large infestation in these homes is that they tend to be heavily cluttered, and bed bugs will be scattered throughout these belongings. Control thus becomes impossible unless the clutter is removed and discarded, or taken off site for fumigation or heat treatment. For the tenant this clutter may be their lifelong belongings and any suggestions of disposal of such property must be undertaken with due sensitivity and in conjunction with the manager of the facility, with the possible assistance of social workers. The decision to discard, fumigate or heat treat personal belongings must be undertaken on a case by case basis. Fumigating and heat treating belongings is a logistical challenge; items must be bagged on site, taken to the appropriate facility, the bags opened, the items treated, and post-treatment airing undertaken for fumigation. All belongings must be taken to a bed bug free storage area and only returned once the initial infestation is eradicated. Thus fumigation and heat treatment must be based on a logistical and financial assessment. In heavy infestations, the Pest Manager will require considerable cooperation from a number of parties to achieve control. This may include the owner or manager of the facility (such as public housing), contract cleaners, community health nurses, social and/or charitable workers to help relocate the tenant and provide assistance in removing and replacement of clothing and belongings, and maintenance workers to assist the Pest Manager in gaining access to areas for treatment and dismantling fixed items in the premise. It will be necessary that the tenant is relocated and that none of their belongings (including any clothing currently worn) should be permitted into the new premise. It is advisable that the Pest Manager has a detailed Bed Bug Management Plan, which is provided to all parties (Section 16). Not only does this appear highly professional but it also protects the Pest Manager in the event that recommended procedures are not undertaken. If an Environmental Health Officer is called in to investigate the infestations, which is not an uncommon occurrence, then a Bed Bug Management Plan may well be requested. In the Bed Bug Management Plan in extreme infestations the following aspects are especially important: The proper handling and disposal of infested items.

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The handling of infested items to be kept for treatment via fumigation. Advice on minimising the risk of the tenant passing bed bugs onto any other premise. The need to remove carpets, wall paper, floorings, and other fixtures to gain access to harbourage areas for treatment. The need to remove skirtings, architraves and other solid fixtures to gain access to harbourages for treatment and wall voids for dusting. The treatment process, including non-chemical methods and a list of the actual insecticides employed and how they are used. The need for follow up inspections and treatments. The necessity to keep the unit unoccupied during the treatment period. The need to inspect, and if necessary, treat all adjoining units. Recommendations on reducing harbourage locations post treatment, e.g. sealing cracks and crevices. Other post treatment processes, such as housekeeping recommendations or other needed refurbishments.

Most importantly, the Bed Bug Management Plan must stress that bed bug eradication is a cooperative venture between the client, the Pest Manager and the other parties. A behaviour common amongst these tenants is the tendency to collect items off the street that are intended for disposal, such as old furniture. These items may well have been discarded for the very reason of being infested with bed bugs. It thus becomes important for the manager of these facilities to attempt to change such behaviours and limit what can be brought into the dwelling, and this recommendation should be included in the Bed Bug Management Plan. If the tenant is under a carer or regularly visited by friends and family, then these people may have also inadvertently transported bed bugs to their own home. The Bed Bug Management Plan should recommend that the manager attempts to inform all of the tenants contacts about the bed bug infestation and the possible need of undertaking an inspection in their respective homes. The Pest Manager should be present when the contract cleaners arrive to discard belongings. The Pest Manager must then inform the cleaners on how the infested belongings are best handled, including any OH&S recommendations (such as the wearing of overalls and the use of gloves), to minimise the risk of spreading the bugs further. Regarding the control process itself, vacuuming should supplement the discarding of infested items as the preferred form of non-chemical control. As steam is extremely time consuming, in these infestations it becomes impractical to use. This means that insecticides will be the main control tool.

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Such large infestations represent a high risk to the Pest Manager as control equipment items brought into the dwelling can easily become infested. Likewise, the bugs can get onto clothing and so the Pest Manager should be wary of their procedures, such as inadvertently leaning against objects. The difficult task with these infestations is establishing when eradication is finally achieved. Only through repeated treatments and follow up inspections, including one at least some months after the initial course of treatments, can the Pest Manager be certain of success. Not surprisingly, such jobs are time consuming, involving numerous consultations, inspections, treatments and follow up visits. Thus the overall price must be commensurate with the labour input and may come to many thousands of dollars. For more information on bed bug control in public housing and homeless shelters, see: Gangloff-Kaufmann and Pichler, Guidelines for Prevention and Management of Bed Bugs in Shelters and Group Living Facilities: www.nysipm.cornell.edu/publications/bb_guidelines/ and The Bed Bug Resource Manual: A Guide to Preventing, Treating and Coping with Bed Bugs: www.woodgreen.org/Temp/BedBugManualOct242008.pdf

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22. DEFINITIONS
AEPMA Australian Environmental Pest Managers Association. Alginate Bags Dissolvable laundry bags used for handling infectious bedding. APVMA Australian Pesticides and Veterinary Medicines Authority. BBF The Bed Bug Foundation, the organisation who have developed the
European Code of Practice Bed Bug Management.

Bed bug/s Either the Common bed bug (Cimex lectularius) or the Tropical Bed bug (Cimex hemipterus). Bed Bug Elimination The inspection and treatment have been undertaken
according to the CoP and no living bed bugs were detected in the final inspection.

Bed Bug Friendly Any item, material (e.g. wood, chipboard, cane, unsealed
brick work, etc) or dwelling that contains numerous cracks and crevices, and provides a multitude of bed bug harbourages. procedures for the eradication of pests.

Best Practice Utilising the most current and safe technologies and Client An individual, business or organisation that employs a Pest Manager to
undertake a bed bug treatment.

Control In the context of this CoP, primarily implies the elimination of a bed
bug infestation. In some contexts, control also includes bed bug management and prevention.

CoP Code of Practice, i.e. this document. Disinsection The process of eliminating an insect infestation. Due Diligance Is the ability to prove beyond a reasonable doubt that
everything possible was done to prevent a certain act from happening. For those in the accommodation sector, this would be to minimise the risk of bed bugs and ensuring that management strategies were promptly implemented once an infestation was detected. Having a bed bug policy and procedural guide in place, and following it, would assist in the demonstration of Due Diligence. Due to the highly toxic nature of fumigants, they can only be used by pest managers with a fumigation licence. Fumigation is rarely undertaken for bed bug control at the site of the infestation. within any form of accommodation, excluding those privately owned (i.e. homes, units).

Fumigation The process of using a fumigant, which are gaseous insecticides.

Guest In the context of this CoP, the term is used for any individual staying

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Harbourages Places where bed bugs hide. Hotel In the context of this CoP, this is a generic term used for any level of
accommodation, excluding those privately owned (i.e. homes, units).

Hotelier In the context of this CoP, any manager, administrator or owner of

short-medium stay accommodation, for example, hotels, motels, guest houses, student lodgings, backpackers, caravans and cabins in caravan parks, B&Bs, landlords, etc., excluding those privately owned (i.e. homes, units).

Housekeepers Includes staff responsible for hotel maintenance and cleaning. ICPMR The Institute for Clinical Pathology and Medical Research at Westmead
Hospital, Westmead, NSW.

IPM Integrated Pest Management is a multidisciplinary approach to pest

management with the main aim being to maximise the control of insect infestations by the use of multiple methods. IPM is based on the proper identification of the pest, knowledge of the pests ecology, non-chemical means of control and the judicious use of insecticides.

MSDS Material Safety Data Sheet. NPMA The National Pest Management Association of America. OPs Organophosphate insecticides. PestCert The Australian accreditation body for Pest Managers (see
www.pestcert.com.au for more information on PestCert).

Pest Manager A person licensed to undertake pest management services

under relevant State Legislation, and who undertakes a bed bug treatment. Note that this name varies across the country with the different State Legislative Acts. have not been confirmed.

Putative Infestation A suspected infestation; i.e. the presence of bed bugs Residual Application The process of applying insecticide to a surface such
that an insect will contact the insecticide when it walks on the treated surface. Quality Training Framework (see www.dest.gov.au for more information). control their own circumstances.

RTO Registered Training Organisation under the definition of the Australian Socially Disadvantaged People who for whatever reason are unable to SPs Synthetic pyrethroid insecticides. Topical Application The process of applying insecticide directly at the insect
(as opposed to residual application).

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23. REFERENCES AND FURTHER READING

Those marked with an asterisk contain extensive information on bed bug biology.
Anon. 2008. The bed bug resource manual: A guide to preventing, treating and coping with bed bugs. www.woodgreen.org/Temp/BedBugManualOct242008.pdf Boase C, Small G and Naylor R. 2006. Interim report of insecticide susceptibility status of UK bedbugs. Professional Pest Controller, Summer: 12-13. *Cooper RA & Harlan H. 2005. Ectoparasites, part three: Bed Bugs & Kissing Bugs, Chapter 8. in Mallis A. Handbook of Pest Control. 9th Ed. GIE Media, Pa. *Doggett SL. 2005. Bed bug ecology and control. in Doggett SL (ed). 2005. Pests of Disease and Unease. Synopsis of Papers. Westmead Hospital, Westmead. 69pp. (see www.bedbug.org.au/moreinfo.htm). *Doggett SL. 2009. Bed bug workshop 2009. Course notes. Westmead Hospital, Westmead. 135pp. Doggett SL. 2011. A Bed Bug Management Policy and Procedural Guide for Accommodation Providers. Westmead Hospital, Westmead. 25pp. Available from: www.bedbug.org.au. Doggett SL, Geary MJ and Russell RC. 2006. Encasing mattresses in black plastic will not provide thermal control of bed bugs, Cimex spp. (Hemiptera: Cimicidae). Journal of Economic Entomology, 99(5): 2132-2135. Doggett SL, Orton CJ, Lilly DG and Russell RC. 2011. Bed bugs - a growing problem worldwide. Australian and international trends update and causes for concern.

Australian Environmental Pest Managers Association, NSW Conference 2011. Session 2A, 2nd June 2011, Bicentennial Park, Homebush Bay, Sydney. 24pp. Available from:
http://medent.usyd.edu.au/bedbug/papers/aepma_2011_doggett.pdf Doggett SL and Russell RC. 2007. Bed Bugs: Recent Trends and Developments.

Australian Environmental Pest Managers Association Annual Conference, Synopsis of Papers, Coffs Harbour. 20pp.
Doggett SL and Russell RC. 2008. The resurgence of bed bugs, Cimex spp. (Hemiptera: Cimicidae) in Australia: experiences from down under. Proceedings of

the 6th International Conference on Urban Pests. Budapest, Hungary, 13-16th July 2008, pg: 407-425.

Doggett SL and Russell RC. 2009. Bed bugs, what the GP needs to know. Australian Family Physician, 38(11): 880-884. Gangloff-Kaufmann JL and Pichler C. 2008. Guidelines for Prevention and Management of Bed Bugs in Shelters and Group Living Facilities. New York State IPM Program, Cornell University. 39pp. www.nysipm.cornell.edu/publications/bb_guidelines/

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Lilly D, Doggett SL, Orton CJ and Russell RC. 2009a. Bed Bug Product Efficacy under the Spotlight Part 1. Professional Pest Manager, 13(2): 14,19-20. Lilly D, Doggett SL, Orton CJ and Russell RC. 2009b. Bed Bug Product Efficacy under the Spotlight Part 2. Professional Pest Manager, 13(3): 14-15,18. Lilly GD, Doggett S.L., Zalucki MP, Orton CJ and Russell R.C. 2009c. Bed bugs that bite back, confirmation of insecticide resistance in the Common bed bug, Cimex lectularius. Professional Pest Manager, 13(5): 22-24. Madge O. 2011. European Code of Practice, Bed Bug Management. Bed Bug Foundation, London, UK. p.36. Available online: www.bedbugfoundation.org/downloads/45632_BedBug_ECoP_v9_forWeb.pdf Myamba J, Maxwell CA, Asidi A and Curtis CF. 2002. Pyrethroid resistance in tropical bedbugs, Cimex hemipterus, associated with use of treated bednets. Medical and Veterinary Entomology, 16: 448-51. Meek F. 2003. Bed bugs bite back. Pest Control Technology, 31: 43,44,46,47,50,52. Naylor RA and Boase CJ. 2010. Practical solutions for treating laundry infested with Cimex lectularius (Hemiptera: Cimicidae). Journal of Economic Entomology, 103(1): 136-139. NPMA. 2011. Bed bugs best management practices. The National Pest Management Association of American. Available online: www.npmapestworld.org/publicpolicy/documents/
NPMABedBugBMPAPPROVED20110124_prettified.pdf

*Pinto LJ, Cooper R and Kraft SK. 2007. Bed Bug Handbook. The complete guide to bed bugs and their control. Pinto & Associates, Inc. Potter MF, Haynes KF, Romero A, Hardebeck E and Wickemeyer W. 2008. Is there a new bed bug answer? Pest Control Technology, June: 116, 118-124. Romero A, Potter MF, Potter DA and Haynes KF. 2007. Insecticide resistance in the bed bug: a factor in the pests sudden resurgence? Journal of Medical Entomology, 44(2): 175-178. Romero A, Potter MF and Haynes KF. 2009. Behavioural responses of the bed bug to insecticide residues. Journal of Medical Entomology, 46(1): 51-57. *Usinger RL. 1966. Monograph of Cimicidae. The Thomas Say Foundation, Maryland. Wang C, Gibb T and Bennett G. 2009. Evaluation of two least toxic integrated pest management programs for managing bed bugs (Hemiptera: Cimicidae) with discussion of a bed bug intercepting device. Journal of Medical Entomology: 43(3): 566-71.

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24. ACKNOWLEDGMENTS
The ICPMR, AEPMA and members of the Working Party would like to acknowledge the following for their assistance in the production of the Bed Bug Code of Practice Draft Fourth Edition: Mr Frank Meek, Orkin Pest Control (USA), for providing the service checklist templates used in Appendix C & D. Mr Oliver Madge, The Bed Bug Foundation, for allowing the use of aspects of the European Code of Practice, Bed Bug Management. The Working Party also wishes to acknowledge all those who took time to provide comments on all previous editions.

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25. APPENDIX A The CoP Working Party

Name Stephen Doggett (National Cordinator) Dr Chris Orton (Chair) Position Medical Entomologist/ Senior Hospital Scientist Entomologist Urban and Commercial Pest Management, Senior Visiting Fellow UNSW Technical Services Manager Pest Manager/Director President Training Manager Technical Manager Operations Manager Field Biologist Pest Manager/Director Affiliation (State) Dept of Medical Entomology ICPMR, Westmead Hospital (NSW) School of Biological Earth and Environmental Sciences, Faculty of Science, University of New South Wales. (NSW) Amalgamated Pest Control (Qld) WR Gay Pest Control (Vic) Australian Environmental Pest Managers Association Rapid Training Australia (NSW) Bayer Environmental Science (Vic) Ecolab Pest Elimination (NSW) Rentokil Initial (NSW) Westate Pest Control (WA)

Gary Cochrane David Gay

Keith Farrow John Hall Garry Jones Peter Lamond Brian Langenberg David Lilly Frank Meek Greg Mills Stephen Ware

Technical Support Manager Ecolab Pest Elimination (NSW) International Technical and Orkin Pest Control (USA) Training Director Pest Manager/Director Allpest (WA)

National Executive Director Australian Environmental Pest Managers Association (NSW)

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26. APPENDIX B Suppliers & Contacts

Products are listed in alphabetical order within categories.

26.1. Mattress Encasements

The following have undergone comprehensive laboratory testing and if used according to manufacturers instructions, bed bugs are unable to escape from the encasements. They also incorporate a membrane which is impervious to the bite of a bed bug. Mattress Safe Encasements: Agserv Pty Ltd., 6/105 Derby St, Silverwater NSW 2128 Ph: 1800 55 44 45, Fax 02 9648 2262, www.agservaustralia.com, Email: safe@agservaustralia.com. Protect-A-Bed Encasements: Protect A Bed Snugfit Australia, 2 Simpson St, Moorabbin VIC 3189. Ph: 1300 857 123 or (03) 9551 7255, Fax: (03) 9551 7266. www.protectabed.com.au. Protect-A-Bed encasements are also available from Garrards, consult www.garrards.com.au for branch locations.

26.2. Miscellaneous
Alginate Bags: Confident Care, see www.confidentcare.com.au for state contacts. BugZip luggage and clothing encasements: The Bed Protector, PO Box 2019, St Kilda West VIC 3182. Ph: 1300 760 646, Mob: 0419 777 776, Fax: (03) 9534 1892, www.bedbugbarrier.com.au (BugZip luggage and clothing encasements are also available from this supplier).

26.3. Medical Entomological Expertise

The following laboratory is the de facto national reference Medical Entomology laboratory for the identification of arthropods of medical importance: The Department of Medical Entomology, ICPMR, Westmead Hospital, PO Box 533, Wentworthville, NSW, 2145. Ph: 02 9845 7265 www.medent.usyd.edu.au

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27. APPENDIX C Bed Bug Service Checklist for the Client*

These should only be undertaken following the inspection and upon the advice of the Pest Manager. Note that all rooms adjoining the infested room will need to be inspected and possibly treated.

Customer Responsibilities Loosen carpet around the perimeter of the room (s) to be treated. Do not remove carpet from room unless instructed to do so. Remove any items that are mounted to the walls i.e. pictures, mirrors, light fixtures, but do not remove from the room as these need treatment. Loosen outlet and switch plate covers. Remove linen from bed and ensemble base. These should be bagged and hot washed. Remove items from closets, treat appropriately for bed bugs and bag. Do not remove any items of furniture from the room. Provide a building layout plan of the rooms to be treated. For Commercial facilities Make housekeeping carts available for inspection and treatment. Make housekeeping rooms available for inspection and treatment. After Treatment Replace all items removed from walls. Replace carpet on straight edge or glue back down. Re-assemble room for use. Keep room unoccupied until infestation is declared eliminated.

Company/Motel Name/Room no:____________________________________ Signed:____________________________ Date:_____________________

*This checklist was kindly provided by Mr Frank Meek, Technical Manager, Orkin Pest Control, USA, and includes some modifications.

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28. APPENDIX D Bed Bug Service Checklist*

(Copy to be provided to client once completed) Motel Name:______________________ Contact Name:__________________ Contact Phone:_______________________Fax:________________________ Address:________________________________________________________ Date Pest Manager Contacted by Company:___________________________ Date First Inspection:_______________ Date First Treatment:____________ Date/s Follow up Treatments:_______________________________________ Date infestation eliminated:________________________________________ Period of Warranty:_______________________________________________

Pest Manager Refer to A Code of Practice for the Control of Bed Bug infestations in Australia Third Edition. Respond to calls for bed bug service within 24 hours by phone to schedule the service. Coordinate the service to coincide with preparations by the facility. The Pest Manager must be on site to direct the preparation. If necessary, preparation must be done on several rooms so it is possible to start service after the first room is prepared.

Information to client Bed bug service checklist provided. Recommended that rooms to be treated taken out of service until the infestation is eliminated. Bed bug fact sheets provided, along with details of insecticides. Contract and billing details provided, along with schedule of treatment. Client advised that adjoining rooms are to be inspected/treated.

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Customer responsibilities completed Carpet loosened at floor / wall junction around the perimeter of the rooms. All items attached to the walls removed (e.g. pictures, light fixtures, outlet covers, bed heads, etc.) Outlet and switch plate covers loosened. Linen removed from bed and ensemble base Items removed from closets. Housekeeping carts (if applicable) available for inspection and treatment. Housekeeping rooms (if applicable) available for inspection and treatment. Pest Manager:___________________________________________________ Sign:_______________________________ Date:___________________

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Pest Manager Service Procedures

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Room nos:________________________________________________________

Inspection Mattress/es (seams, beading, under buttons, labels and corner protectors if not previously removed). Ensemble base (material covering base removed, check hollow plastic caster legs). Bed frame (wooden slats, bed posts, etc). Bed head (if attached, remove from wall). Bedside furniture (including removing and checking drawers in tables and cupboards). Other furniture (e.g. luggage racks, especially along seams and buttons, wooden joins, especially if constructed of fibreboard. Electrical fittings and appliances. Underneath carpet edges and the straight edges (plus any other floor coverings, along with joins in floor boards). Wallpaper and paint (if loose). Architraves, wall hangings, picture frames, wall mirrors, Venetian and vertical blinds, curtains and curtain rods, books, behind electrical conduit, cracks and joins in the ceiling and ceiling mouldings. Lounges in common rooms of backpacker lodges. Housekeeping carts & rooms, linen & mattress storage rooms, laundry areas. Adjoining rooms, above & below.

Inspection Notes _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ ______________________________________________________________________

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Non-chemical control - Vacuuming Use a vacuum cleaner with a disposable bag. Vacuum floors using crack and crevice tool along the base of the wall. Remove cloth cover from the bottom of the ensemble base. Save for reattachment after service. Vacuum the seams and general surface area of the mattress and ensemble base. If sofa contains a fold out sofa bed, it must also be vacuumed and removed from the sofa for treatment. Vacuum the seams and general surface area of all cushions from sofa and chairs. Remove cushions from sofas and recliners. Turn sofas and chairs upside down and place in the middle of the room away from the walls. Remove vacuum cleaner bag, dust contents with insecticide, seal and dispose. Inspect folding luggage rack for evidence of insects, if found, treat the infestation. Non-chemical control - Steam Place nozzle directly onto the surface being treated. The nozzle should be moved along at a rate of only 30cm per every 10-15 seconds. Start treatment with the mattress applying steam to the seams, under labels and handles, and both inside and out of an ensemble base. Cushions of chairs and sofas should be treated, paying particular attention to seams and buttons. Check if the sofa is a sofa bed and if so treat the mattress as above. Treat carpet edges along with the straight edge both above and below and curtains. Do not apply steam to electrical fittings.

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Chemical control

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If steam is unavailable treat those areas described above with insecticide, ensuring that all products are used according the label directions. Apply insecticide to the floor wall junction and under the carpet and straight edge. Apply dust to the inside of all electrical junction boxes. (Light switches, outlets, television cable outlets.) Ensure that the cracks and crevices of the ensemble bases and framework of furniture are treated. Ensure items that will be re-attached to the wall are treated. Inspect guide tracks of closet doors for evidence of bed bugs. If insects are found in this area, have the maintenance staff pull the metal track up and treat. Have maintenance re-attach after treatment. Inspect and treat all rooms where housekeeping carts and extra mattresses or furniture are stored.

Rooms are to be treated in blocks in this general pattern.

X = infested room All rooms that make contact with the infested room, both above and below, must be treated on the same service.

Notify customer to undertake the following if necessary Repair any loose wallpaper and baseboard covering. Repair any sources of moisture, such as leaky taps and air conditioner condensation lines and pans. After treatment, seal cracks and crevices.

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Re-attach material covering to ensemble base. Re-attach carpet to straight edge. Place a mattress cover on the mattress according to labelling instructions if treated with insecticides.
*This checklist was based upon a list kindly provided by Mr Frank Meek, Technical Manager, Orkin Pest Control, USA.

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29. Appendix E Pesticides registered by the APVMA for bed bug control as of 15/Sep/2011

Note this is for information only; the APVMA (www.apvma.gov.au) should be consulted for accuracy of information and to obtain a current list of registered products. This list does not distinguish between products available for the home user and the Pest Manager. The Approved Use is as per instructions as described on the label, as appears on the Queensland Department of Primary Industries InfoPest web site. Access to this site was via the link direct from the APVMA site. The product label must be consulted prior to use to confirm the current approved use and for application rates and safety instructions. Note also that just because a product is registered does not necessarily mean that it is still available or that it is effective against modern insecticide resistant bed bug strains (i.e. registration by the APVMA is not proof of efficacy).
Active Ingredient/s Bendiocarb Bendiocarb Deltamethrin Permethrin Permethrin Permethrin Liquid WP Dust SC WP Dust Formulation Approved Use Insect hiding places such as electrical areas, ceilings, wall cavities. Bed frames, cracks & crevices, not bedding. Bed frames, walls, skirting boards, cracks & crevices. Directly at insects, carpets, floor areas, under furniture, wardrobes, and skirtings.

Product Code

Product

31986

FICAM D INSECTICIDE DUST

31988

FICAM W INSECTICIDE

32223

CISLIN RESIDUAL INSECTICIDE

32254

32843

DEFENDER HOME GARDEN READY FOR USE SPIDER COCKROACH & ANT INSECTICIDE COOPEX RESIDUAL INSECTICIDE

33210

COOPEX INSECTICIDAL DUSTING POWDER INDUSTRIAL STRENGTH

40102

ACTELLIC PUBLIC HEALTH INSECTICIDE Diazinon

Pirimiphos-Methyl

Liquid

41698

COUNTRY DIAZINON 800 INSECTICIDE

LC

Not stated. Bedsteads, bedsprings, mattresses, floor coverings, upholstered furniture, cracks in walls, behind torn wallpaper, joints in woodwork and other cracks and crevices that may provide harbourages. Skirting boards, floors and adjacent wall area. Machine wash linen at time of treatment to destroy bed bugs in sheets and blankets. Spray should be applied under beds, along skirting boards and anywhere bed bugs may be able to shelter, as well as lightly to bedding.

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Page 80 D-Allethrin, permethrin Aero Not stated. Pip but, deltamethrin, D-tetramethrin SC AC Liquid Dust Aero Aero Dust Dust EC Not stated. Not stated. Not stated. Apply to run-off point. Bedsteads, mattresses, springs, floor coverings, upholstered furniture, cracks, torn wallpaper, joints in woodwork. Cracks & crevices, bed frames. Mattresses, clothing (wash before reuse), walls, cracks & crevices, skirting & bed frames. Cyfluthrin Pirimiphos-methyl Permethrin

41760

CLEVELAND PEST GUARD SURFACE SPRAY AND CRAWLING INSECT KILLER

45907

CRACKDOWN RESIDUAL INSECTICIDE

46237

46465

SOLFAC 50 EW PROFESSIONAL INSECTICIDE ACTELLIC 900SF SOLVENT FREE LIQUID INSECTICIDE

46589

TARGET DUST TREATMENT FOR INSECT CONTROL

47105

48234 Permethrin Permethrin Diazinon

Permethrin, tetramethrin Allethrin, permethrin

48570

49084

PEA-BEU SURFACE SPRAY HOUSEHOLD INSECTICIDE INSECT KILLER COMMERCIAL INSECTICIDE ROACH TOX SURFACE SPRAY OZTEC PERMETHRIN 10 INSECTICIDAL DUSTING POWDER BARMAC PERMETHRIN D PROFESSIONAL INSECTICIDE DUST

50007

BARMAC DIAZINON INSECTICIDE

Bedroom furniture, mattresses, cracks & crevices, etc. Spray should be applied under beds, along skirting boards and anywhere bed bugs may be able to shelter, as well as lightly to bedding. SC Aero Aero SC Dust Cracks & crevices, bed frames, adjacent walls. Not stated. Not stated. Not stated. Bedsteads, mattresses, springs, floor coverings, upholstered furniture, cracks, torn wallpaper, joints in woodwork.

50682

BLITZ INSECTICIDE

51915 Permethrin, tetramethrin Deltamethrin Permethrin

PIF PAF POWER PLUS CRAWLING INSECT KILLER

Pip but, deltamethrin, Tetramethrin Imiprothrin, cypermethrin

51916

PIF PAF ODOURLESS SURFACE SPRAY

51943

INSECTIGONE INSECTICIDE

52336

DRAGNET DUST - INSECTICIDAL POWDER INDUSTRIAL STRENGTH

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Page 81 Deltamethrin Permethrin Dust Bedsteads, mattresses, springs, floor coverings, upholstered furniture, cracks, torn wallpaper, joints in woodwork. Apply up to run off point. SC Apply up to run off point.

52365

DELTASHIELD 10 RESIDUAL INSECTICIDE

52913

PERMEDUST INSECTICIDAL DUSTING POWDER INDUSTRIAL STRENGTH Deltamethrin SC

53210

CREEPY CRAWLEY PRODUCTS DELTA PRO 10 RESIDUAL INSECTICIDE N-Octyl Bicycloheptene Dicarboximide, Pip But, pyrethrins Aero EC EC EC Dust Dust Apply up to run off point. Deltamethrin Permethrin, hydrocarbon solvent Permethrin, hydrocarbon solvent Permethrin Permethrin Not stated.

53312

PRECLUDE INSECTICIDE

Mattresses, bed linen (wash linen and clothing before reuse), walls, cracks & crevices, skirting & bed frames.

53349

53534

COUNTRY DELTAMETHRIN 10 RESIDUAL INSECTICIDE DAVID GRAYS ANT AND TERMITE SPRAY

Spray in cracks and crevices and other insect harbourages. Spray in cracks and crevices and other insect harbourages.

53625

FARMOZ PERMEX EC RESIDUAL INSECTICIDE

53632

DRAGNET HOUSEHOLD READY-TOUSE DUSTING POWDER

53794

DAVID GRAYS PERMETHRIN ANT DUST

53819 Betacyfluthrin Permethrin, tetramethrin Permethrin

HEALTHGUARD EC MITICIDE

Benzalkonium Chloride/permethrin

EC SC Aero EC

54134

TEMPO RESIDUAL INSECTICIDE

Bedsteads, mattresses, springs, floor coverings, upholstered furniture, cracks, torn wallpaper, joints in woodwork. For use in industrial situations associated with the manufacture of polyurethane foam, fibre, textile and carpets products for the purpose of controlling bed bugs and dust mites on the treated articles. Bed frames, walls, cracks & crevices near beds. Not stated. Spray infested carpets, floor areas, in cupboards and wardrobes, and around furniture, bookshelves and skirting boards. Do not apply to clothing or bed linen. Aero Not stated.

54146

MORTEIN LOW IRRITANT SURFACE SPRAY KILLS COCKROACHES FAST

54181

CHEMSPRAY HOME PEST CONTROL ANT, SPIDER & COCKROACH KILLER

54192

MORTEIN HIGH PERFORMANCE SURFACE SPRAY KILLS COCKROACHES FAST

Imiprothrin, cypermethrin

Draft 4th Edition

Page 82 Permethrin Emulsion Spray insect directly, carpet, floor areas, under furniture, in and around cupboards, wardrobes, skirting boards, not clothing. Bed frames, walls, skirting boards, cracks & crevices near beds. Not stated. Cracks & crevices, bed frames, adjacent walls.

54224

GARD & GROW ANT, SPIDER & COCKROACH SPRAY READY TO USE Deltamethrin Aero SC Water Dispersible Granule

54456

CISLIN WG RESIDUAL INSECTICIDE

54626

MORTEIN ODOURLESS SURFACE SPRAY KILLS COCKROACHES FAST

54682

COUNTRY DELTRA RESIDUAL INSECTICIDE

Imiprothrin, permethrin Pip but, deltamethrin, D-tetramethrin Permethrin, hydrocarbon solvent EC Permethrin Dust

54934

BLITZEM! INSECT KILLER CONCENTRATE

55091

COUNTRY PERMETHRIN 25:75 INSECTICIDAL DUSTING POWDER INDUSTRIAL STRENGTH Permethrin Imiprothrin, cypermethrin Aero SC Deltamethrin Dust

55137

HOVEX PERMETHRIN ANT KILLER

Spray at insects, carpets, floor areas and furniture. Avoid treated area for several hours. Spray in and around book shelves, cupboards, wardrobes, skirting boards. Do not apply to clothing or bed linen. Bedsteads, mattresses, springs, floor coverings, upholstered furniture, cracks, torn wallpaper, joints in woodwork. Bedsteads, mattresses, springs, floor coverings, upholstered furniture, cracks, torn wallpaper, joints in woodwork. Not stated. Apply up to run off point.

55217

55221

MORTEIN EASY REACH SURFACE SPRAY KILLS COCKROACHES FAST SUPERWAY DELTA-M RESIDUAL INSECTICIDE Permethrin, hydrocarbon solvent Permethrin Permethrin, hydrocarbon solvent Permethrin EC

55329

TERMINANT ANT, TERMITE AND SPIDER SPRAY

Spray at insects, carpets, floor areas and furniture. Avoid treated area for several hours. Spray in and around book shelves, cupboards, wardrobes, skirting boards. Do not apply to clothing or bed linen. Powder EC Not stated. Cracks & crevices, bed frames, adjacent walls, mattresses. Emulsion Spray insect directly, carpet, floor areas, under furniture, in and around cupboards, wardrobes, skirting boards, not clothing.

55426

RICHGRO GARDEN PRODUCTS PERMETHRIN ANT KILLER FOR INDOOR AND OUTDOOR USE

55656

RENTOKIL CHEK-PEST RESIDUAL INSECTICIDE

55787

LOW ODOUR GET-IT FLY SPRAY WATER-BASED INSECTICIDE SPRAY READY TO USE

Draft 4th Edition

Page 83 Permethrin Emulsion Spray insect directly, carpet, floor areas, under furniture, in and around cupboards, wardrobes, skirting boards, not clothing. Bed frames and walls, cracks, crevices and skirting boards in the vicinity of the bed. Do not apply to bedding. Not stated. Not stated.

55790

LOW ODOUR GET-IT BUG SPRAY HOME AND GARDEN SURFACE AND INSECTICIDE SPRAY READY TO USE Deltamethrin Permethrin Permethrin, tetramethrin Aero Permethrin Emulsion EC Tablet

55992

K-O TAB WT RESIDUAL INSECTICIDE TABLET

56496

56576

56765

KONK-EM-D READY TO USE INSECTICIDE SPRAY BLACK & GOLD LOW IRRITANT SURFACE SPRAY CRAWLING INSECT KILLER ASTRO ECOTECH PEST EXTERMINATOR, READY TO USE, COCKROACH, SPIDER & ANT KILLER Permethrin EC

Spray insect directly, carpet, floor areas, under furniture, in and around cupboards, wardrobes, skirting boards, not clothing. Apply up to run off, except for mattresses and carpets. Spray in cracks, crevices and other insect harbourages. When applying to mattresses and carpets apply an even thorough coverage. Not stated. Bed frames, walls, cracks & crevices near beds. Not stated.

56840

FARMOZ PERMEX 100 RESIDUAL INSECTICIDE

57333 Deltamethrin Allethrin, permethrin Pip but, deltamethrin, D-tetramethrin Cyfluthrin Aero SC EC

SUMITOMO BORAFUME FUMIGATOR

Cyphenothrin

Vapour releasing

58044

BARMAC DELTA FORCE INSECTICIDE

58267

FRANKLINS NO FRILLS SURFACE SPRAY HOUSEHOLD INSECTICIDE FOR CRAWLING INSECTS

58423

TRADEWYNS DELTRA RESIDUAL INSECTICDE

Treat cracks and crevices in bed frames and the adjacent walls. WP Fumigate all mattresses or clothing. Wash sheets and clothing before re-use. Apply Prolong to walls, cracks and crevices, skirting boards and bed frames. SC Cracks and crevices in bed frames and adjacent walls. EC Spray should be applied under beds, along skirting boards and anywhere bed bugs may be able to shelter, as well as lightly to bedding.

58460

PROLONG FLY AND LITTER BEETLE INSECTICIDE

58499

DELTATHOR PLUS INSECTICIDE

Pip but, deltamethrin, tetramethrin-R Diazinon

58505

DAVID GRAYS DIAZINON 800 INSECTICIDE

Draft 4th Edition

Page 84 Imiprothrin, cypermethrin Aero Aero Aero SC Aero SC Not stated. Cracks and crevices in bed frames and adjacent walls. Not stated. Cracks and crevices in bed frames and adjacent walls. Imiprothrin, cypermethrin Cypermethrin, Imiprothrin Deltamethrin Lightly spray mattresses, bed frames and skirting boards. Lightly spray mattresses, skirting boards and bed frames

58600

BAYGON GERMKILL CRAWLING INSECT SPRAY ANTIBACTERIAL

58630

BAYGON FAST KILL CRAWLING INSECT SPRAY

58717

MORTEIN HIGH PERFORMANCE COCKROACH KILLER ODOURLESS

58723

DELTATHOR INSECTICIDE

58783

ATLAS CRAWLING INSECT SURFACE SPRAY FOR HOME USE

58904

BARMAC DELTA FORCE PLUS INSECTICIDE Permethrin Dust

Imiprothrin, permethrin Pip but, deltamethrin, D-tetramethrin

59005

PERMETHOR INSECTICIDAL DUST

Bedsteads, bedsprings, mattresses, floor coverings, upholstered furniture, cracks in walls, behind torn wallpaper, joints in woodwork and other harbourages.

59345

PREMISE FOAM INSECTICIDE

Imidacloprid

Foaming Aero

Insert applicator hose directly into crack or crevice infested with pest insects. Foam should be injected until flow-back our of the harbourage starts to occur. The foam should temporarily fill the harbourage and engulf insects present during application. Apply to the bed-frame and walls, cracks, crevices and skirting boards in the vicinity of the bed.

59424

SOLFAC PRO RESIDUAL INSECTICIDE

Betacyfluthrin

SC

59707

FARMOZ DIAZOL 800 INSECTICIDE

Diazinon

EC

Spray should be applied under beds, along skirting boards and anywhere bed bugs may be able to shelter, as well as lightly to bedding. Liquid Apply thoroughly to all areas to be treated to run off point. Do not apply to carpets, mats or soft furnishings.

59710

ACTELLIC 900 SOLVENT FREE LIQUID INSECTICIDE

Pirimiphos-Methyl

59750

KILLMASTER ZERO PEST STRIP

Dichlorvos

Impregnated Pest Strip

Note that this is not specifically registered for bed bug controlled, but could be used as it is registered for use on other insects. Items to be disinsected must be stored in plastic with the pest strip, and away from people.

Draft 4th Edition

Page 85

59945

GARDEN PRO ANT KILLER

Permethrin

Dust

Apply powder to bedsteads, bed springs, mattresses, floor coverings, upholstered furniture, cracks in walls, behind torn wallpaper, joints in woodwork and other harbourages.

59952

PROFUME GAS FUMIGANT

Sulfuryl Fluoride

Fumigant

For the control of insects in buildings (commercial & residential), timber, construction materials, furnishings, shipping containers & vehicles (excluding aircraft). Situational use includes Dwellings (including mobile homes), Buildings, Furnishings (household effects). For use only by licensed fumigators trained under appropriate industry program Not stated. Spray around bed, bed frame and other locations close to sleeping areas. Spray directly when seen. Spray infested carpets, floor areas and under furniture, in and around cupboards, wardrobes, and skirting boards. Do not apply to clothing. Not stated. Not stated. Lightly spray mattresses, bed frames and skirting boards.

60325 Permethrin, tetramethrin Aero Permethrin EC

MORTEIN DETTOL WITH GERM STOP COCKROACH KILLER Aero

Cypermethrin, imiprothrin

60414

WOOLWORTHS HOME BRAND HOUSEHOLD INSECTICIDE

60634

SEARLES ANT, SPIDER & COCKROACH KILLER Imiprothrin, cypermethrin Aero SC Aero Deltamethrin Allethrin, permethrin Permethrin

60644

RAID SURFACE SPRAY NATURALLY FRESH

61012

SCARID 10 RESIDUAL INSECTICIDE

61272

SURFACE SPRAY INSECT KILLER

61618

RICHGRO ANT, SPIDER & COCKROACH INSECTICIDE Cypermethrin, imiprothrin Permethrin

EC

Spray directly when seen. Spray infested carpets, floor areas and under furniture, in and around cupboards, wardrobes, and skirting boards. Do not apply to clothing. Aero EC Lightly spray mattresses, bed frames and skirting boards. Spray directly when seen. Spray infested carpets, floor areas and under furniture, in and around cupboards, wardrobes, and skirting boards. Do not apply to clothing.

61751

DAVID GRAYS HIGH PERFORMANCE ROACH SURFACE SPRAY

61917

RICHGRO PERMETHRIN ANT, SPIDER AND ROACH KILLER

Draft 4th Edition

Page 86

62147

CISLIN 25 PROFESSIONAL INSECTICIDE Deltamethrin SC

Apply to the bed-frame and walls, cracks, crevices and skirting boards in the vicinity of the bed. May also be applied to the edges and seams of the mattress but do not treat the flat surfaces which people sleep on. Apply powder to bedsteads, bed springs, mattresses, floor coverings, upholstered furniture, cracks in walls, behind torn wallpaper, joints in woodwork and other harbourages. Apply powder to bedsteads, bed springs, mattresses, floor coverings, upholstered furniture, cracks in walls, behind torn wallpaper, joints in woodwork and other harbourages. Not stated.

62303

CISLIN DUST INSECTICIDE

Deltamethrin

Dust

62664

CHAINDRITE PERMFORCE DUST INSECTICIDE Permethrin Dust

62988

MORTEIN DO-IT-YOURSELF HIGH PERFORMANCE SURFACE SPRAY COCKROACH KILLER Cypermethrin, imiprothrin Aero Cypermethrin, imiprothrin Aero Not stated.

62989

MORTEIN DO-IT-YOURSELF ODOURLESS HIGH PERFORMANCE COCKROACH KILLER Cypermethrin, imiprothrin Aero Not stated.

63064

COLES CRAWLING INSECT KILLER HIGH PERFORMANCE KILLS COCKROACHES FAST KILLS COCKROACHES FOR UP TO 6 MONTHS

63065

COLES CRAWLING INSECT KILLER WITH GERM KILL KILLS COCKROACHES FOR UP TO 6 MONTHS KILLS 99.9% OF THE GERMS COCKROACHES CARRY Deltamethrin S-bioallethrin Cypermethrin, imiprothrin Chlorfenapyr

Alkyl Dimethyl Benzyl Ammonium Saccharinate, cypermethrin, imiprothrin

Aero

Not stated.

63129

CISLIN ULTRA RESIDUAL INSECTICIDE

SC Aero SC

Not stated. Not stated. Treat affected room by applying Phantom directly to bed bug activity as a spot treatment.

63337

ATLAS HIGH PERFORMANCE SURFACE SPRAY

63575

PHANTOM INSECTICIDE

Draft 4th Edition

Page 87 Cypermethrin, imiprothrin Aero Aero SC Dust Aero Aero Aero SC Dust Not stated. Apply powder to bedsteads, bedsprings, mattresses, floor coverings, upholstered furniture, cracks in wall, behind torn wallpaper, joins in woodwork and other harbourages. Not stated. Lightly spray bed frames and skirting boards. Spray areas where bed bugs hide such as bed frames, floors and skirting boards. Not stated. Apply powder to bedsteads, bed springs, mattresses, floor coverings, upholstered furniture, cracks in walls, behind torn wallpaper, joints in woodwork and other harbourages. Not stated. Cypermethrin, imiprothrin Deltamethrin Permethrin Cypermethrin, imiprothrin Cypermethrin, imiprothrin Cypermethrin, imiprothrin Deltamethrin Permethrin Spray areas where bed bugs hide such as bed frames, floors and skirting boards.

63593

AEROTHOR EXTRA STRENGTH CRAWLING INSECT SPRAY

63610

63673

BAYGON ANT KILL SURFACE SPRAY 2 IN 1 ENVIROMAX DELTAMETHRIN 10SC RESIDUAL INSECTICIDE

63723

WOOLWORTHS HOMEBRAND ANT KILLER

63767

MORTEIN POWERGARD CRAWLING INSECT KILLER

63772

MORTEIN POWERGARD CRAWLING INSECT KILLER EASY REACH

63850

CHAINDRITE EXTRA STRENGTH CRAWLING INSECT SPRAY

63941

DELFORCE RESIDUAL INSECTICIDE

63984

BLACK & GOLD VALUE YOU CAN TRUST ANT KILLER

64048 Phenothrin-D

BEDLAM INSECTICIDE KILLS BED BUGS, LICE AND DUST MITES Aero

Apply as a spot treatment to cracks and crevices on and around baseboards, floorboards, bed frames, wall hangings, headboards, furniture, door and window frames, millwork and walls. Apply as a surface spray to carpet, mattresses, box springs, walls, furniture, bedding, floor and floor coverings, rugs, garments, luggage, closets, drapes and other window appointments. SC Aero EC Apply to the bed frame and walls, cracks, crevices and skirting boards in the vicinity of the bed. Spray directly at insects when they are visible. Spray infested carpets, floor areas, in cupboards and wardrobes and around furniture, bookshelves and skirting boards. Do not apply to clothing or bed linen.

64148 D-Allethrin, permethrin Permethrin

MAXUMPRO 125 SC INSECTICIDE

Betacyfluthrin

64517

TONIZONE AUSTRALIA'S OWN POW SURFACE SPRAY INSECTICIDE

64679

AMGROW PATROL ANT, SPIDER & COCKROACH KILLER

Draft 4th Edition

Page 88 Cypermethrin, imiprothrin Aero Not stated. Cypermethrin, imiprothrin Aero Not stated.

64937

RAID TESTED BY EXPERTS ANT KILLER FOR INDOOR AND OUTDOOR USE

65067

RAID TESTED BY EXPERTS COCKROACH AND SPIDER KILLER INDOOR SURFACE SPRAY Cypermethrin, imiprothrin Aero Not stated. Permethrin, tetramethrin Aero Aero Cypermethrin, imiprothrin

65084

KILLS UP TO 6 MONTHS WOOLWORTHS SELECT EXTRA STRENGTH HIGH PERFORMANCE SURFACE SPRAY

65131

IGA SIGNATURE SURFACE SPRAY LOW IRRITANT

Spray around bed, bed frame and other locations close to sleeping areas. Lightly spray around bed, bed frame and other locations close to sleeping areas.

65133

IGA SIGNATURE SURFACE SPRAY HIGH PERFORMANCE

65290

BED BUG BARRIER BED BUG KILLER

Amorphous silica

Dust

Apply powder using the powder puffer or a powder duster to cracks and crevices, underneath edges of carpet, power points, wall sockets, behind skirting boards, in wall voids and other areas known to harbour bed bugs and in bed bug barrier devices

65387 Deltamethrin SC

DELTAPRO 25 PROFESSIONAL INSECTICIDE

Apply to the bed-frame and walls, cracks, crevices and skirting boards in the vicinity of the bed. May also be applied to the edges and seams of the mattress but do not treat the flat surfaces which people sleep on. Dust EC Aero Aero Not stated. Not stated. Lightly spray mattresses, bed frames and skirting boards. Not stated.

65487 Permethrin Pip but, propoxur tetramethrin Imiprothrin, permethrin Permethrin

KDPC INSECTICIDAL DUST

Permethrin

65628

OZTEC PERMETHRIN 100 EC INSECTICIDE

65697

BATTLEAXEPRO PROFESSIONAL CRACK & CREVICE AEROSOL

65856

RAID MAX BAYGON ODOURLESS CRAWLING INSECT SURFACE SPRAY 2 IN 1

65979

ATLAS PERMETHRIN ANT KILLER

Dust

Not stated.

Draft 4th Edition

Page 89 Permethrin Cypermethrin, imiprothrin Aero Aero SC Not stated. Not stated. Cypermethrin, imiprothrin Betacyfluthrin Lightly spray around bed, bed frame and other locations close to sleeping areas. Dust Not stated.

65986

66006

COLES PERMETHRIN ANT KILLER KILLS UP TO 6 MONTHS WOOLWORTHS SELECT HIGH PERFORMANCE SURFACE SPRAY

66216

GALA SURFACE INSECT SPRAY

66448

BEETLEBETA 125 SC INSECTICIDE

Approved for use upon mattresses LC = Liquid Concentrate SC = Suspension concentrate WP = Wettable Powder

AC = Aqueous Concentrate

Aero = Aerosol

EC = Emulsifiable Concentrate

Not Stated = Approved use directions are not stated on the Infopest web site