Teah Bayless, DO: The Bed Bug Among Us

February 11, 2019

“Good night, sleep tight. Don’t let the bed bugs bite.”

Literally. For many community members this is all too real a hope as they close their eyes. A simple phrase of seemingly well-intentioned nighttime wishes takes on a whole new meaning when you have been a victim of a bed bug infestation. Bed bugs do not know the difference between a poor man and a rich one. They know no barriers.

Over the last decade or so, bed bugs have seen resurgence. It is all too often that our patients have to battle these little pests. Though they are not known to carry disease, the CDC and the EPA have referred to bed bugs as a “public health pest. “ Interestingly, no literature exists on the untold costs associated with bed bug infestations — inability to receive care due to inability to get transportation, declines in health status due to inability to get needed services in the home to retard deterioration of a patient’s condition, emotional turmoil, and social isolation associated with bed bugs — to name a few items. And as this continues to be an issue across the United States and in our local community, being aware of the risk and especially to the risk of vulnerable populations is a must. Instead of cringing and just adding “bed bug infestation” to the problem list, we (as medical teams) must ask ourselves how we can help without creating health care disparities.

The Story of Ms. S

Ms. S is an 82-year-old female who lives alone. She owns her own home and relies on her aide to assist with her activities of daily living: light housekeeping, preparation of breakfast, and assistance with bathing. She is not married and has no children. Her sister, also of similar age, checks on her as do some church members by phone. She was recently seen by home health who identified bed bugs in the home. Unfortunately, the home health worker took one home and the patient was not allowed to get any further services in her home until the issue was remediated. Neither her aide, nor the home health agency requested by her PCP for physical therapy and occupational therapy, is willing to go into her home. Ms. S can barely ambulate with a walker. How is she going to move boxes in preparation for the remediation? She is on a fixed income. How will she pay for the services? Just to have someone come out to ensure home is free of bed bugs is costly.

The Story of Mr. H

Mr. H came in for an acute visit one day. One of the nursing staff noted a small bug on his clothes. This caused a bit of gossip — bed bug! When he returned for his follow-up appointment, there was a note on the outside of the door indicating the patient had a bug problem (with exclamation points!!!!).

I see Mr. H in his home. I asked him did he know that a bed bug was seen on him last visit. Slightly embarrassed and surprised, he indicated that he had not. He is always careful and tries to pay attention at home, as these pests are frequently found in his apartment building.

The Story of Mr. B

Mr. B has bedbugs … again. He is fearful of telling the management of his housing building for fear he will be evicted. Currently, he is battling his infestation with a can of Raid.

The Story of Mrs. H

“Don’t set your stuff down in here Dr. Bayless. I have bed bugs.” A bed-bound, homebound client in a middle class neighborhood in a private home finds herself with an infestation likely due to a hitchhiker on either the bag of one of the home health workers, DME equipment suppliers (she was in the process of getting a motorized wheelchair to get out of her bed for the first time in 10 years!), or her aide. She and her husband tried to take care of them on their own, but soon found it a losing battle and had to have the pest control service come out. They had to move to a hotel for 24 hours.

What is old is new again

Bed bugs have made resurgence over the last two decades. They are equal opportunists, hiding out in dark crevices and mattresses everywhere in both the richest and poorest of homes. While they are not disease carrying pests, they most certainly evoke an emotional response in those who are (or have been) afflicted or those who fear an infestation. That’s right, infestation. A single female can produce 500 eggs. These flat, small parasitic bugs typically hide during the day and come out at night to feed. They like to hang out in carpets, baseboards, bedroom clutter, mattresses, and bed frames.

Bedbugs are parasites. They feed off blood, but don’t need to feed often. In fact, a bedbug can go upwards of 3-4 days without eating.

Stigma

In a world where these little pests are prevalent, please avoid shaming patients. This will not help. Try not to label — we want to communicate with each other to avoid negative outcomes, but certainly don’t want to ostracize our patients by making them feel uncomfortable. In the examples above, more than likely, one of health care workers or Meals on Wheels volunteers brought a hitch hiker in to Ms. S’s home (she doesn’t go out!). She is left with the burden of #1 paying for the remediation, #2 trying to figure out how to complete all the necessary steps in remediation (Just imagine your 80-year-old grandmother with a walker trying to roll up carpets and de-clutter!), #3 coordinating most of this when she is hard of hearing on the telephone, #4 finding the extra money on a fixed income to do this, and #5 trying to find someone to come out and certify that all the bugs are gone so your services can resume. All of this when you don’t trust strangers coming into your home to start with.

Bedbugs can happen to anyone. For sure, they are more prone to occur in close quarters such as apartment buildings, hotels, college dorms, and similar properties. We can share an elevator with someone who is carrying bed bug eggs on their shoes or ride the bus with someone who has one on their bag. The reality is that bed bugs can travel on bags, people, and whatever else they take a fancy, too. They can travel by walking or crawling via hallways or by squeezing through tiny cracks in common walls, ceiling and utility ports.

Instead of reacting with hysteria, we need to be proactive. Education is key.

Inability To Get Access To Needed Services

While it is true, we don’t want to make matters worse by having an individual who has a current bed bug infestation possibly share their bugs with others in another setting , it is important to remember that if you have a patient, especially a vulnerable senior, who is in need of care, we must not abandon them. Encouraging practices (and companies that service seniors) to think through strategies to prevent transmission to health care workers and other patients, is important and a conversation worth having.

Take Action

Creating plans for this is important. As a community, putting together a list of resources might be of some help. There are resources on line that do just this. Collaboration is key. But on the ground level, in clinic, discussing ways to remediate is important — not everyone knows what to do and believe it or not, there are seniors in our community who do not have smartphones nor access to a computer to figure it out on their own.

Should we, as health care professional do a bit more than wrinkle our nose? I say, yes. Here are a few tips we can share with our patients, our friends, and yes, all you antique and flea market lovers out there.

Encourage your patient to check second-hand furniture, such as beds, mattresses, and couches, before bringing it into their home.
Use protective covers that encase mattresses and box springs. The heavier duty variety will resist tears.
Reduce clutter. Always good advice to reduce falls, especially among seniors, but also it gives less hiding spots for bugs.
Vacuum frequently and dispose of the bags. If it is a canister vacuum, encourage.

If you identify bed bugs, a professional extermination service is likely best. Getting rid of bedbugs begins with cleaning up the places where bedbugs live. This should include the following:

Clean bedding, linens, curtains, and clothing in hot water and dry them on the highest dryer setting. Place stuffed animals, shoes, and other items that can't be washed in the dryer and run on high for 30 minutes.
Use a stiff brush to scrub mattress seams to remove bedbugs and their eggs before vacuuming.
Vacuum your bed and surrounding area frequently. After vacuuming, immediately place the vacuum cleaner bag in a plastic bag and place in garbage can outdoors.
Encase mattress and box springs with a tightly woven, zippered cover to keep bedbugs from entering or escaping. Bedbugs may live up to a year without feeding, so keep the cover on your mattress for at least a year to make sure all bugs in the mattress are dead.
Repair cracks in plaster and glue down peeling wallpaper to get rid of places bedbugs can hide.
Get rid of clutter around the bed.
If your mattress is infested, you may want to get rid of it and get a new one, but take care to rid the rest of your home of bedbugs or they will infest your new mattress.

Arming ourselves with the correct knowledge in primary care settings is important as often we are on the front lines. Not only do we want to avoid being unwitting transporters of these tiny pests, but we need to figure out how to reduce the impact on all the patients that come through our lobbies on a daily basis. Additionally, we need to have mechanisms in place to help educate our patients about bed bugs to include how to avoid getting them and of course, how to get rid of them once they have been identified as a problem.

Dispelling myths, arming individuals with facts, and above all, assisting our vulnerable populations navigate the process of remediation is key.

More Resources

Teah Bayless is core faculty with the Duke Family Medicine Residency Program and a health care provider in the Duke Family Medicine Center. Email teah.bayless@duke.edu with questions.

Editor’s note: A member of the Duke Family Medicine faculty guest blogs every month. Blogs represent the opinion of the author, not the Department of Community and Family Medicine or Duke University.