Bed bugs and public health: new approaches for an old scourge.
Shum, Mona ; Comack, Elizabeth ; Stuart, D. Taz 等
Bed bugs (Cimex lectularuis) are small, elusive insects that feed
almost exclusively on human blood. Bed bug infestations have become
prominent worldwide, generating increased public concern. (1,2) Despite
the attention to bed bugs by the public, researchers, governments and
pest control companies, their control has been a challenge. (3,4)
Because bed bugs have not been proven to transmit disease between
humans, (3) there is resistance to framing their resurgence as a public
health threat. Nevertheless, bed bugs have been associated with negative
health effects, including allergic reactions, bacterial skin infections
and scarring as a result of the intense scratching they provoke.
improper insecticide use can result in acute health effects (3) and may
lead to chronic disease. (5,6) Perhaps of greatest concern to public
health is the psychological stress on persons living with bed bugs.
While bed bugs do not discriminate--anyone can be subject to a bed bug
infestation--health impacts differ depending upon people's social
and economic circumstances. One study conducted with Winnipeg's
inner-city residents found that bed bugs negatively impacted the
former's ability to lead healthy lives. Respondents reported that
bed bugs disrupted their sleep and led to stress, social isolation, loss
of self-worth, and social stigma. (4) Moreover, the financial costs (and
associated stress) incurred from an infestation can be overwhelming for
those with limited means. (4)
METHODS
A workshop at the 2010 Canadian Public Health Association (CPHA)
Conference* examined the re-emergence of bed bugs in Canada, discussed
the state of bed bug science (summarized elsewhere)7 and compared the
approaches to bed bug identification and control of municipal and public
health authorities in four large Canadian cities. Here we report on the
experiences of the four cities--Toronto, Winnipeg, Montreal and
Vancouver--with regard to their efforts to respond to the public health
threat posed by bed bugs.
By drawing on the experiences of the four cities (including updates
since 2010), we make the case that framing the bed bug problem as a
public health threat is key to the implementation of effective
strategies for its management--especially for vulnerable populations.
RESULTS
Toronto Public Health--Public health as lead
The number of requests for services related to bed bugs in Toronto
saw a seven-fold increase between 2005 and 2008. (8) While bed bugs were
not historically considered a public health issue, a combination of
political and public pressure and an increasing demand for service led
to the framing of the issue as a public health matter, and Toronto
Public Health (TPH) took the lead in bed bug management for the City,
becoming one of the first Canadian cities to do so. TPH encountered
complex cases involving the most vulnerable (the poor, the elderly, and
those with disabilities and mental health issues), which required
resource-heavy, long-term management.
The Toronto Board of Health directed TPH to hold a
multistake-holder bug forum, which led to the establishment of the
Toronto Bed Bug Project in 2008. (9) The Project includes working groups
of landlords, tenants, pest control firms, social housing and shelter
managers, community agencies and others. it supports education and
outreach, creation of legislative tools, and development of best control
practices.
TPH has relied extensively on partnerships, re-allocating funds and
donations in order to continue the project. Toronto and Ontario
governments provide limited amounts of funding for preparation of units
for treatment and replacement of furniture for those who need
assistance. TPH has not conducted a formal evaluation of the project but
has collected data on their response to infestations (Table 1).
In 2011, Ontario rolled out a $5 million plan to educate Ontarians
and fund public health agencies in the Province's fight against bed
bugs. (10) TPH hired a dedicated bed bug program manager and six public
health inspectors for a 12-month period. The program also enabled TPH to
contract with private agencies to undertake unit preparation and extreme
cleaning, both of which help ensure successful eradication of bed bugs.
** (11-15) Although Ontario's bed bug program funding ended March
31, 2012, both the City of Toronto and the Province of Ontario have
recognized the importance of the work undertaken in controlling bed bugs
and both are moving toward providing permanent, sustainable funding.
Winnipeg--Public education campaigns
Like other Canadian cities, Winnipeg has experienced an increase in
bed bug reports. One local extermination company reported 2,800 bed bug
calls in 2010, compared with only a handful of calls in the previous six
years. (16) City by-law enforcement officers (CBEOs), not necessarily
trained in public health, have replaced public health inspectors (PHIs)
as responders to bed bug complaints. If landlords do not comply within a
given time period, CBEOs can issue a written order and timelines to
complete extermination. Landlord non-compliance can lead to charges
under the Neighbourhood Liveability By-Law. Nevertheless, when
interviewed in 2009, CBEOs indicated that no charges had been issued
under the new by-law and, because bed bugs are considered more a
"nuisance" than a public health threat, no health hazard
orders had been issued for bed bugs. (4)
In March 2011, the Manitoba government implemented a more
comprehensive program for responding to bed bugs, setting aside $770,000
to finance the first year of a two-year bed bug response plan, with
funding expected to continue for at least two more years. A key plank of
the program is a public education campaign that stresses both prevention
and eradication. Educational materials include brochures, posters, fact
sheets, a website, and a phone line that offers information and tracks
infestations. (17) Grants are also provided for community-based
organizations and individuals to support education and prevention
efforts, and include provision of bed bug prevention materials (mattress
covers, insect monitors, and laundry bags) and assistance with treatment
(furniture removal, vacuuming, heat treatments).18 Manitoba has also
assembled a coalition of municipalities, health authorities, business
groups, property managers and other key stakeholders to advance its
province-wide approach.
Since the program began in 2011, bed bug complaints and treatments
have decreased. While the number of overall complaints has decreased by
60% to levels similar to 2008, the number of provincially owned housing
complexes with bed bug issues has decreased only fractionally.
Nevertheless, in developing and maintaining partnerships between
tenants, pest management professionals, and landlords to assist
residents in living pest-free, the Manitoba program has served as an
example for other jurisdictions, including Minneapolis/St Paul, Seattle,
Sacramento, Tampa Bay and Ottawa. (19)
Montreal Public Health--Surveillance and support for city action
A 2011 survey of 1,000 Montreal Island residents by la Direction de
sante publique de Montreal (DSP Montreal) found that 24,293 city
households (2.8%) dealt with a bed bug infestation in 2010-2011.20 In
managing bed bug infestations in Montreal, multiple partners are
integral; DSP Montreal partners with the Centre de sante et des services
sociaux (CSSS), the City, its boroughs, non-profit organizations,
owners, tenants, Montreal's housing corporation, and the health
service sector in its fight against bed bugs. DSP Montreal is
responsible for the education of partners and the public, second-line
support for agencies dealing with bed bugs, communication strategies,
and field epidemiology. DSP Montreal produces educational materials and
conducts training for municipal inspectors, nurses, social workers,
physicians, and non-profit organizations. Non-profit organizations and
the CSSS collaborate with municipal inspectors by reporting infested
housing units, and advocate for affordable, healthy housing. They
support vulnerable populations, educate clients and help identify
sources of funding for bed bug management.
Municipal inspectors, although not specifically trained in bed bug
control, are responsible for responding to bed bug complaints. In
Montreal, inspection responsibilities are decentralized to boroughs,
each of which has local teams of housing inspectors. A small central
team supports the boroughs.
Several limitations hinder early detection and appropriate response
to bed bug infestations. Most Montreal boroughs ask that tenants send a
registered letter to the owner of the building and provide 10 days for
the landlord to address their concerns; if the issue is not addressed in
that time frame, the tenant can call the municipal inspector. This
formal process discourages many tenants through fear of retribution,
while others are unaware of its existence. Municipal inspectors from
most boroughs provide only the landlord (and not the tenant) with the
inspection report. A notice of infraction, which is not a legally
binding document, may be negotiated by the owner without penalty. The
inspector may also issue a statement of offence, which does have
associated penalties; however, there is little consistency among
boroughs as to how and when these statements are issued. Since
inspectors are not trained to deal with bed bugs, they usually cease to
intervene once a pest control operator is hired by the owner. Although
pest control operators in Canada are required to take courses, no
quality assurance system (such as certification by a professional
organization) exists to ensure that they apply pesticides safely and
effectively. For example, some operators use ineffective pesticides like
boric acid or do not use proper spraying techniques. However, in order
to partially offset these shortcomings, the City has recently
implemented a by-law that requires pest control operators to submit a
bed bug control plan. (21)
In March 2011, the City of Montreal, in collaboration with
Montreal's housing corporation and the DSP Montreal, developed an
action plan to decrease bed bug infestations. The plan is based on
surveillance, research, prevention, stakeholder communication and
intervention. The communication platform will be based on a survey of
public awareness of bed bugs to be completed by the end of 2012. DSP
Montreal, in collaboration with the housing corporations and the CSSS,
started a randomized controlled trial aimed at demonstrating the
effectiveness of providing assistance in the preparation of dwellings of
vulnerable households, as inadequate preparation is often cited as a
reason for ineffective bed bug eradication. (12-14,22) Funding is
provided in part by the Quebec Health Ministry; given additional
funding, DSP Montreal plans to evaluate issues in implementation and
intervention.
Vancouver--A city-based complaint-driven process
In 2008, the City's Property Use Division took over the
inspection and enforcement of bed bug management from the Vancouver
Coastal Health Authority (VCH). VCH currently plays a
supportive/consultative role to City inspectors and becomes involved in
bed bug management only in the presence of a health hazard as defined by
the BC Public Health Act.
In Vancouver, almost all bed bug inspections are complaint-driven,
but occasionally property use inspectors (PUIs), who have limited
training on bed bugs, discover infestations during the course of regular
building inspections. PUIs are responsible for case management, and they
conduct inspections with fire, police, and/or social services
representatives. PUIs are only able to inspect the unit of complaint as
they have no mandate to enter adjacent units and will not inspect if a
tenant objects. The landlord must make necessary arrangements with
adjoining tenants if he/she believes that additional units are infested.
As a result, often bed bugs are not completely eradicated after
treatment (T. Hamilton, City of Vancouver, 2011, personal
communication). If a landlord does not comply with a Standards of
Maintenance order, inspectors can refer the matter for prosecution.
Generally it takes over a year for cases to reach trial and if the
landlord is found guilty, the trial judge may levy a fine of between
$250 and $2000. Vancouver has had no instances where landlords were
prosecuted for bed bugs. If a landlord is continually non-compliant,
tenants tend to move. If tenants are non-compliant (in preparing their
unit), the landlord may rely on the rental agreement to resolve the
issue. PUIs are not involved in dispute settlement (T. Hamilton, City of
Vancouver, 2011, personal communication).
Currently, there are no ongoing programs that help disadvantaged
tenants prepare their units for treatment. The PUI is only responsible
for inspection and does not participate in outreach or educational
activities (T. Hamilton, City of Vancouver, 2011, personal
communication). Vancouver Coastal Health offers information to the
public, conducts occasional inspections and holds workshops for the
health care sector, municipal departments, landlord groups, hotel
operators and groups requesting information. (23) Prior to April 1,
2008, VCH was a lead agency (and is still quite involved) in bed bug
control, liaising with a wide variety of stakeholders with the goal of
developing educational materials, determining best practices and
controlling bed bugs. BC Housing also provides education to building
managers and tenants through information sheets supplemented by
one-on-one consultation. (24) The Vancouver Area Network of Drug Users
(VANDU) has partnered with VCH, Ministry of Employment and Investment,
City of Vancouver and three owners of single-room-occupancy buildings to
reduce bed bug infestations in pilot projects that were considered
successful. (25,26) The BC Residential Tenancy Branch can also have a
role in resolving bed bug complaints.
DISCUSSION
The four case cities highlighted here provide insight into evolving
and promising practices for bed bug management and for the role of
public health. Once bed bugs are declared a threat to public health,
they become a part of the public health mandate. Toronto is perceived as
a leader in bed bug management in Canada; that leadership may relate to
the fact that the City confronted bed bugs as a public health issue,
offering front-line support by inspectors working in the health
department who understand public health, who implement surveillance and
develop partnerships based on education and advocacy, and who are backed
up by legislative authority when necessary.
The experiences of the four cities provide examples of how public
health agencies can play an important role in bed bug management. While
legal enforcement of standards may prompt action by property managers
and tenants, prosecution can be a slow and uncertain process, such that
cases involving vulnerable clients are better addressed through
education, outreach and support. Nowhere is that clearer than in the
area of residential preparation for pest management. In that regard,
public health can work with and facilitate collaboration between social
services, housing, mental health, and municipal and other levels of
government. Also, public health can educate property managers, health
professionals, home care workers, school and nursing home staff and the
public, which will help reduce the spread of bed bugs, decrease stigma
and increase recognition of bed bug problems (both in terms of diagnoses
and infestations). At the 2010 CPHA bed bug session, participants agreed
that greater education of the public would serve to de-stigmatize bed
bug issues and make it more likely that affected persons report and
remediate problems early.
Moreover, public health agencies can train inspectors in: bed bug
recognition and safe and effective control; supporting challenged
residents (particularly with preparation of their homes); managing
complex social environments; community mobilization; and surveillance
activities. Public health agencies can work with cities or provinces to
pass regulations that require cooperation between tenants and owners and
can encourage funding of social programs aimed at assisting the most
vulnerable.
Surveillance and evaluation has been lacking in Canadian cities.
TPH and DSP Montreal have conducted surveys about infestations, Manitoba
has been recording complaint calls, and TPH has tracked website hits
(90,000 hits in 2010) about bed bugs. As surveillance is necessary to
promote the allocation of resources and to inform evaluation of
interventions, public health agencies can draw on their surveillance
experience to develop surveillance programs themselves or help cities
develop their own. Public health agencies are also well positioned to
play a key role in undertaking ongoing evaluations of bed bug control
programs, ensuring that effective protocols and remedies are in place.
Public health agencies can also play a significant role in
advocating that the federal government recognize bed bugs as a public
health matter, thereby encouraging effective provincial responses
(including dedicated funding).
Other promising actions for public health agencies could involve
requiring that pest management companies submit plans for control
strategies (as in Montreal) and/or obtain certification governed by a
professional organization to ensure that those who respond to
infestations implement best practices. (27) Also, public health agencies
could encourage municipalities to adopt pest control/pesticide bylaws,
which would give staff the necessary powers to deal with problem
building owners.
CONCLUSION
Although there have been no known cases of disease transmission,
bed bugs can cause severe reactions, secondary infections, and severe
stress that impact health--especially for vulnerable populations.
Canadian city public health agencies can consider bed bugs a public
health threat, support legislation around pest control and
responsibilities of tenants and owners, and conduct or encourage
surveillance and evaluation activities. By working with the public,
owners, tenants, the health sector and other stakeholders, public health
practitioners can begin to curb the resurgence of bed bugs and the
accompanying personal scars and social strains.
Acknowledgements: Production of this manuscript has been made
possible through a financial contribution from the Public Health Agency
of Canada. We thank Michele Wiens for providing library assistance.
Conflict of Interest: None to declare.
Received: June 8, 2012 Accepted: September 3, 2012
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* The workshop facilitator was Dr. John Carsley, Vancouver Coastal
Health. Speakers included: Dr. Stephane Perron, Montreal Public Health;
Taz Stuart, City of Winnipeg; Dr. Elizabeth Comack, University of
Manitoba; and Reg Ayre, Toronto Public Health.
** At the time of the 2010 CPHA conference, TPH had a "Bug and
Scrub" program, where homeless men were trained in preparing units
before treatment. The program provided low-cost, reliable,
non-judgemental assistance to the most vulnerable in dealing with an
infestation. However, the program has since been scaled back due to
employment standards issues.
Mona Shum, MSc, [1] Elizabeth Comack, PhD, [2] D. Taz Stuart, MSc,
[3] Reg Ayre, CPHI(c), [4] Stephane Perron, MD, [5] Shelley A. Beaudet,
BSc, [6] Tom Kosatsky, MD [7]
Author Affiliations
[1.] Manager, National Collaborating Centre for Environmental
Health, Vancouver, BC
[2.] Professor, Department of Sociology, University of Manitoba,
Winnipeg, MB
[3.] Entomologist, City of Winnipeg, Winnipeg, MB
[4.] Manager, Healthy Environments, Toronto Public Health, Toronto,
ON
[5.] Physician-Advisor, Direction de sante publique de Montreal,
Montreal, QC
[6.] Senior Environmental Health Officer, Vancouver Coastal Health,
Vancouver, BC
[7.] Medical Director, National Collaborating Centre for
Environmental Health, BC Centre for Disease Control, Vancouver, BC
Correspondence: Mona Shum, NCCEH, 555 W. 12th Avenue, Vancouver, BC
V5Z 3X7, Tel: 604-707-2460, Fax: 604-707-2444, E-mail:
mona.shum@bccdc.ca
Table 1. Comparison of Legislation, Owner and Tenant Obligations,
Assistance for Vulnerable Groups, and Evaluation Related to Bed Bugs
in Four Canadian Cities
Owner and Tenant
City/Inspector Legislation Obligations
Toronto/PHI Section 13 of the Ontario Under Ontario's
(TPH) Health Promotion and Residential Tenancies Act,
Protection Act (28) the landlord is
indicates that Medical responsible for ensuring
Officers of Health can his or her apartments are
order both landlords and free of bed bugs by hiring
tenants to manage bed a pest control company,
bugs. and the tenant is
responsible for preparing
the unit for
treatment. (28)
Winnipeg/City Before 2008, bed bug Manitoba's Residential
By-Law infestations in rental Tenancies Act holds the
Enforcement accommodations were landlord responsible for
Officers subject to Winnipeg's ensuring that premises are
Maintenance and Occupancy made free of bed bugs by
By-Law, which identified hiring a licensed
owners as responsible for exterminator; the tenant
managing infestations. is responsible for
preparing the unit for
In 2008, the Neighbourhood treatment and allowing
Liveability By-Law, (29) access.
replaced this by-law and
categorizes bed bugs as a
"nuisance" and
"unsanitary", and assigns
responsibility to both
owners and occupants to
prevent infestations.
Montreal/City A Montreal municipal Most Montreal boroughs
or Borough by-law on sanitation and ask that tenants send a
Inspector maintenance of dwelling registered letter to the
units (21) is designed to owner of the building and
ensure that apartments provide 10 days for the
and residential buildings landlord to address their
are safe, sanitary and concerns; if the issue is
properly maintained. not addressed in that time
frame, the tenant can call
Recently, the city the municipal inspector.
implemented a by-law that
requires pest control Provincially, the Regie
operators to submit a bed du logement du Quebec
bug control plan. (21) intervenes in residential
lease matters, informs
citizens of their rights
and obligations related to
leases, promotes
conciliation between
landlords and tenants,
and provides legal
assistance regarding bed
bug infestations.
Vancouver/ Until April 2008, If a landlord does not
Property Use Vancouver Coastal Health comply with a Standards of
Inspector Authority (VCH) was Maintenance order,
(City) responsible for pest inspectors can refer the
control enforcement under matter for prosecution. If
the City of Vancouver's tenants are non-compliant
Health By-law No. 6580. (in preparing their unit),
the landlord may rely on
In 2008, Vancouver moved the rental agreement to
pest control under the resolve the issue.
Standard of Maintenance
By-law and the City's
Property Use Division took
over inspection and
enforcement.
Assistance for Vulnerable Evaluation (e.g.,
City/Inspector Groups Indicators)
Toronto/PHI Toronto and Ontario In 2010, Toronto 1)
(TPH) governments provide responded to more than
limited amounts of funding 2,000 requests for
for preparation of units service, 2) conducted over
for treatment and 3,500 apartment unit
replacement of furniture assessments, 3) assisted
for those who need 110 vulnerable residents
assistance. with unit preparation/
extreme cleaning, 4)
developed bed bug best
practice fact sheets in
13 different languages,
5) distributed over
$25,000 worth of donated
mattress encasements, 6)
sealed over 6,000 units,
7) replaced common area
carpeted floors with
cleanable solid surfaces
in 12 multi-residential
buildings, 8) started a
loaner vacuum program, and
9) with the Toronto
Community Housing
Corporation (TCHC),
developed an illustrated
brochure on preparing
apartments for cleaning.
Winnipeg/City Grants are provided for Since the program began in
By-Law community-based 2011, it has seen an
Enforcement organizations and overall decrease of 60% in
Officers individuals to support bed bug infestations to
their education and levels similar to 2008;
prevention efforts and however, the overall
include provision of bed number of provincially
bug prevention materials owned housing complexes
(mattress covers, insect with bed bug issues has
monitors, and laundry been reduced only
bags) and assistance with fractionally.
treatment (furniture
removal, vacuuming, heat
treatments).
Montreal/City Montreal's housing In 2012, DSP Montreal, in
or Borough corporation promotes collaboration with the
Inspector Integrated Pest Management housing corporations and
(IPM) and pays for the CSSS, initiated a
treatment of its randomized controlled
facilities (but usually trial aimed at
not for their demonstrating the
preparation). effectiveness of providing
assistance in the
Non-profit organizations preparation of dwellings
such as RCLALQ of vulnerable households.
(Regroupement des Comites
de Logement et
Associations des
Locataires du Quebec)
help defend the legal
rights of tenants. Several
CSSS in Montreal provide
funding for preparation of
units for treatment on an
ad hoc basis.
Vancouver/ None None
Property Use
Inspector
(City)
