PUBLIC HEALTH ISSUE

By John H. Klotz, William E. Evans Sr., Stephen A. Klotz and Jacob L. Pinnas Kissing Bugs &PUBLIC HEALTH Similar to stinging ant control in health-care facilities, Editor’s note: This

a thorough inspection and treatment are critical article is part two of a elements in a control program for kissing bugs. two-part series about

n Part I of this article in March PCT, we focused on allergic pest management reactions to stinging ants and the problems associated with Itheir management in sensitive accounts. Imported fire ants are professionals and by far the most important stinging ant pest in the Southeastern United States, but we also described cases of other exotic and public health. Part one native species that are a threat to public health in other parts of the country. For example, native fire ants and harvester ants appeared in the March thrive in urban areas of the desert Southwest and stings by these species are reported on a regular basis, sometimes with fatal 2006 issue of PCT.

Figure 1 (above). rubida (the smaller kissing bug on left) and Triatoma recurva, a larger species found in southern Arizona. (Photo: Jacob Pinnas)

Figure 2 (left). An extended proboscis on Triatoma protracta, also known as the western bloodsucking conenose bug, the most important species in California. (Photo: Gregory Ballmer) PUBLIC HEALTH ISSUE

consequences. In comparison to stinging bugs. Most members of this large family and lack wings. The last nymphal stage Hymenoptera, biting cause far fewer of hemipterans with 160 species in North has wing pads, which become functional anaphylactic reactions; however, in certain America are predators on other insects wings in the adult. regions of the country the incidence may (Triplehorn 2005), but kissing bugs in the The life cycle (Olson 1996) from egg be relatively high. In this article, we focus genus Triatoma are bloodsuckers on a wide to adult takes one to two years. Eggs are on kissing bugs, the most common cause of variety of mammals and birds. In Latin usually laid in summer and hatch three to anaphylactic reactions to biting insects. America, various species of triatomine bugs five weeks later, giving rise to the first of Other than kissing bugs, anaphylactic are vectors of American trypanosomiasis or five nymphal instars (growth stages). Each reactions to biting insects are rare. There Chagas’ disease, which affects more than 16 nymphal instar requires a blood meal be- are a few reports of anaphylactic reactions million people (Guerenstein et al. 1995). fore it can molt to the next growth stage. to bites of horse and deer flies (Freye and In the United States this disease is rare with Kissing bugs sometimes spend the winter Litwin 1996; Hemmer et al. 1998), black only a few reported cases in the Southeast as developing nymphs and molt into adults flies (Hoffman 1987), mosquitoes (McCor- and Southwest (Moffitt et al. 2003). in the spring.

KISSING BUG REACTIONS REPORTED IN ARIZONA Figure 3. Monthly 30 30 incidence of people bitten by 25 25 kissing bugs in 20 20 Arizona (excluding Exposures Exposures Maricopa County) 15 15 for the years of 10 10 2002-03. Source: Arizona Poison & 5 5 Drug Information 0 0 Center Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec mack et al. 1995), and tsetse flies (Stevens et There are 16 species of Triatoma in the Due to low host specificity, kissing al. 1996). Other flies have been implicated United States distributed across the south- bugs will readily feed on other mammals such as punkies (Hoffman 1987), snipe ern two-thirds of the country (Vetter 2001). besides rodents. For instance humans often flies (Turner 1979), and the larval stage of However, most allergic reactions are to bites become accidental hosts when the bugs a stiletto fly (Smith 1979), but these reports of T. rubida (see Figure 1 on previous page) enter homes typically in spring and early lack definitive blood tests showing an im- in Arizona and T. protracta (see Figure 2 on summer when the adult bugs disperse from munologic response. There is one report 50 previous page) in California, the two species rodent nests on mating flights (see Figure 3 years ago of an anaphylactic-like reaction we will focus on in this article. above). They are strictly nocturnal and are to a bed bug bite (Parsons 1955). Although the geographic ranges of drawn toward lights in and around homes, In contrast, anaphylactic reactions to these two species overlap, T. rubida is more but in daylight they seek dark, shaded kissing bugs are frequently reported. More common in central and southern Arizona places often entering homes through any than 100 years ago their signature bites (Smith 1982). It is particularly a problem crack or gap in the structure. Once inside around the lips were reported in a rash of in the foothills of Tucson, where most of they hide in structural cracks and crevices, news stories around the country giving rise the allergic reactions are reported for this in bedding, mattresses and box springs, to their name and creating panic among species (Pinnas 1997). For example, of in and under furniture, in closets, and in many readers (Ryckman 1979). More the 110 Triatoma exposures reported to other dark locations. Often the bugs reside precisely, their bite is a pierce or stab since the National Data Collection System in in the home for months, not needing to they lack opposable jaws and instead have 1990, 73 were reported from Tucson, and go outdoors. At night they emerge to feed, modified piercing-sucking mouthparts 21 from California. The western blood- orienting to olfactory (CO2 and other host consisting of a short, three-segmented, sucking conenose, T. protracta is found odors) and thermal cues emanating from straight beak or proboscis that is folded throughout California in the foothill areas their potential victims (Guerenstein and back beneath the head; and, contrary to the that are inhabited by their primary hosts. Guerin 2001), which may be a sleeping common name, kissing bugs do not have In one community in southern California person or pet. They seek out flowing blood a predilection for lips but will bite any ex- 6.7 percent of the population were found beneath the surface of the skin, entering posed area. Other common names include to be sensitized to T. protracta (Marshall a blood vessel with their proboscis and Mexican or Texas bed bugs, conenose bugs et al. 1986). secreting a vasodilator (nitric oxide) and because of their elongated, conical-shaped anticoagulant. heads, and Wallapai tigers (referring to a BIOLOGY. The primary hosts are various For most people the bite is harmless, but Colorado River Yuman Tribe meaning “pine species of Neotoma, commonly called wood for those that are sensitized it can cause a tree folk,” and tiger due to the colorful rats or pack rats (Ebeling 1978). The adults life-threatening reaction such as described striping on some species). and nymphs of T. protracta and T. rubida in the following case that occurred in Their bite is painless unlike many other live in the nests of these rodents and feed southern Arizona: “A 45-year old lady has members of the family, which on them at night. The nymphs are similar had four severe reactions to an bite. are commonly known as assassin or ambush to adults in appearance, but are smaller She has found the insect in bed each time PUBLIC HEALTH ISSUE

more than $3,000 to repair. One insurance management professional. company paid while the other called it “an • Baiting typically takes less effort than act of God” and did not. They will also other techniques, however, proper place- burrow under patios, and gnaw through ment of the station to gain bait acceptance garage door seals. while limiting access to non-target Pack rats build their nests out of almost should be given serious consideration. any available material and sometimes in Cons: the most surprising places. For example, • Potential for secondary poisoning of one of the authors (EE) found a nest that non-target animals because poisoned rats was built entirely of 1-inch landscape can be fed upon by predators and scaven- rock, and another that was located in a gers. Consequently, every effort should be barbecue grill. In older neighborhoods made to recover and properly dispose of all Figure 4. A nest in an oleander bush. they often build their nests in the leaf lit- rodent carcasses. (Photo: Ed Evans) ter of under-managed vegetation such as • Poisoning of non-target animals enter- oleander, whose thick foliage makes it a ing and feeding on the baits is possible. and from the description it fits the picture popular bush to plant along property lines • The most expensive technique from of Wallapai tiger or kissing bug. She never in order to provide privacy for homeowners a material cost standpoint. feels the bite, but she notices her heart (see Figure 4 at left). Trapping. Both live traps and snap traps rate increasing, then she feels hot. In two Being opportunistic, pack rats are able can be used to manage pack rat popula- instances she lost consciousness and she had to find abundant food and water around tions. One of the most effective is the one episode where she had a seizure.” homes. They will eat leftovers in pet food professional (expanded trigger) snap trap, As described, victims are typically bitten bowls, climb trees for fruit, and chew while sleeping and often find the engorged through plastic irrigation lines to obtain bug in their beds. Usually there are multiple water. bites that are clustered on areas of the body not covered such as the arms, shoulders, THE PCO. An experienced pest manage- neck, and face. There are two types of al- ment professional can usually find a dozen lergic reactions: one that is localized at the conditions that a homeowner should ad- site of the bite with a substantial welt that dress in order to help solve their pack itches intensely; and the other systemic with rat problem. However, one rarely finds anaphylaxis (Pinnas et al. 1986). Severe homeowners that are willing to adjust their reactions require immediate treatment with habits or make the needed environmental Figure 5. A rodent bait station secured on a epinephrine and antihistamines, so persons modifications to correct the problems. In- concrete block. (Photo: Ed Evans) at risk should keep a kit containing these stead, “How much to get rid of these rats?” medications close at hand in their bedroom is usually about as much cooperation as the but these should never be placed outside (Lynch and Pinnas 1978). pest management professional gets. where non-target species can encounter Despite this attitude, the pest manage- them. One of the authors (EE) designed a MANAGEMENT. Because of the serious ment professional should give the home- low-cost reusable protective device contain- health risks associated with kissing bug owner a fact sheet that provides basic ing two snap traps side-by-side. It consists bites, their control in and around the home information on pack rat biology and how of a large irrigation valve box (available at should be treated as a sensitive account by to eliminate them from their property. Home Depot or most hardware stores) that pest management professionals. Similar to It also should address the problems that is secured to a plywood base (see Figure 6a stinging ant control in health-care facili- can arise with pack rat ectoparasites such on next page). The large holes in the valve ties, a thorough inspection and treatment as ticks, fleas, and kissing bugs, and the box are sealed and two smaller holes are cut are critical elements in a control program importance of controlling these potential in opposite sides of the box using a 1- to for kissing bugs; however, in the case of public health pests. 2-inch hole saw (depending on the size of kissing bugs control must also include An integrated pest management ap- the target species). The traps are mounted their host. proach to pack rat control includes baiting, on the plywood base with screws (see Figure trapping, and habitat modification. The 6b on next page). PACK RAT CONTROL. The building pros and cons of each of these techniques Pros: of custom homes in natural habitats is a follow. • Inexpensive and reusable. popular trend in the Southwest. This en- Baiting. A rodenticide should only be • Poisoning of non-target animals is not croachment into wildlife areas, however, is used when it is enclosed in a tamper-re- an issue. not without its consequences for the human sistant bait station that has been secured • Baiting is optional (expanded trig- as well as residents. The bites and in place. One way to secure the station ger). stings of venomous animals are probably is to glue it to a concrete block using an • Humane (kills quickly). the most notorious and feared, but for industrial adhesive such as liquid nails (see Cons: shear destructive mischief pack rats are Figure 5 at right). This places the station off • Poses a threat to non-target animals (un- hard to beat. One of their favorite targets the ground keeping it dry and preventing less properly housed when used outside). is electrical wire and stories abound of their non-target animals such as coyotes from • Requires daily monitoring to remove damage to homes, vehicles, hot tubs, and dragging it away. and dispose rats and to reset the traps. pool pumps. One of the authors (JP) has Pros: • Live traps have the additional respon- two friends whose cars were damaged by • Rodent baits and tamper-resistant sibility of releasing the rat at a distant packrats gnawing electrical wiring costing stations are readily available to the pest location. PUBLIC HEALTH ISSUE

C.R. Lazzari. 1995. Baker’s yeast, an attractant for The effort involved in kissing bug management may seem baiting traps for Chagas’ disease vectors. Experientia unduly extreme but for the individual at risk for an allergic 51: 834-837. Guerenstein, P.G. and P.M Guerin. 2001. Olfac- reaction it is certainly well worth it. tory and behavioral responses of the blood-sucking bug to odours of vertebrate hosts. Habitat Modification. Removal of condi- or on pets; 3) when new eggs hatch; 4) J. Exper. Biol. 204: 585-597. tions conducive to pack rat infestation such another season arrives; and 5) levels of Hemmer, W., M. Focke, D. Vieluf, B. Berg- as readily available food and water as well pesticides fall. Drewniok, M. Götz, R. Jarisch. 1998. Anaphylaxis as unoccupied nests will prevent additional During the active season of kissing induced by horsefly bites: identification of a 69 kd rats from moving in. If the homeowner bugs, homeowners should inspect their IgE-binding salivary gland protein from Chrysops agrees, it is advisable that only the near- homes thoroughly for bugs both outside spp. (Diptera Tabanidae) by western blot analysis. J est pack rat nests and pack rats should be and inside. During the day the bugs hide in Allergy Clin Immunol. 101:134-136. removed in the hope that the kissing bugs dark, sheltered places such as beneath flower Hoffman, D.F. 1987. Allergy to biting insects. will move to more peripheral nests rather pots, and emerge at night often resting on Clin Rev Allergy. 5:177-190. than into the home. the house by the windows (Olson 1996). Lynch, P.J. and J.L. Pinnas. 1978. “Kissing bug” Kissing Bug Control. After the pack rats Inside, homeowners should thoroughly bites Triatoma species as an important cause of insect have been removed, a broad spectrum in- vacuum the bedroom, and before going to bites in the Southwest. Cutis 22: 585-589. secticidal dust or spray should be applied bed inspect it and shake out the bedding. Marshall, N., M. Liebhaber, Z. Dyer, and A. at the old nesting sites to eliminate any Sticky trap monitors placed under and Saxon. 1986. The prevalence of allergic sensitization remaining ectoparasites. This is a critical around beds will often catch wandering to Triatoma protracta (Heteroptera: Reduviidae) in step because in the absence of their natural bugs. Other protective measures on beds a southern California, USA, community. J. Med. host kissing bugs will search for another include double-sided sticky tape placed on Entomol. 23: 117-124. source of blood, which generally ends up the legs, and mosquito netting that is tucked McCormack, D.R., K.F. Salata, J.N. Hershey, G.B. being the homeowner (Olson 1996). in all around the mattress (Greenberg and Carpenter, R.J. Engler. 1995. Mosquito bite anaphy- All cracks and openings into the home Klotz 2002). laxis: immunotherapy with whole body extracts. Ann should be sealed as completely as possible The effort involved in kissing bug man- Allergy Asthma Immunol. 74:39-44. (Lynch and Pinnas 1978), using weather agement may seem unduly extreme but for Moffitt, J.E., D. Venarske, J. Goddard, A.B. stripping, caulk or silicone seal. All win- the individual at risk for an allergic reaction Yates, and R.D. deShazo. 2003. Allergic reactions dows and vent openings should be properly it is certainly well worth it. to Triatoma bites. Ann. Allergy Asthma Immunol. screened, dog and cat entrances insect 91: 122-128. proofed, and unused fireplace flues kept John Klotz is a cooperative extension specialist Olson, C. 1996. Kissing bugs. Access at: http:// shut (Greenberg and Klotz 2002). Lights in the Department of Entomology, UC River- www.arose.net/triatoma/olson.htm. should be moved away from door or win- side; William E. Evans Sr. is owner/operator Parsons, D.J. 1955. Bedbug bite anaphylaxis dows where they may attract insects. of Ed Evans Pest Control; Jacob Pinnas and misinterpreted as coronary occlusion. Ohio State An outside perimeter treatment using a Stephen Klotz are MDs at the University of Med J. 51:669. broad spectrum insecticide should be ap- Arizona School of Medicine, Tucson. Pinnas, J.L., R.E. Lindberg, T.M.W. Chen, and plied, paying close attention to thoroughly G.C. Meinke. Studies of kissing bug-sensitive patients: treat entryways such as doors and windows. References: evidence for the lack of cross-reactivity between Tri- In addition, an interior crack and crevice Ebeling Walter. 1978. Urban Entomology. Division atoma protracta and Triatoma rubida salivary gland application of insecticide should be made of Agricultural Sciences, University of California. extracts. J. Allergy Clin. Immunol. 77: 364-370. in bedrooms and bathrooms. Spraying the Berkeley. Pinnas, J.L. 1997. Bites and stings, p. 57-58, In: home will kill bugs but does not prevent Freye, H.B. and C. Litwin. 1996. Coexistent Allergy and the Environment an Arizona Handbook by others from suddenly or eventually ap- anaphylaxis to Diptera and Hymenoptera. Ann. Al- the Arizona Allergy and Asthma Society. pearing: 1) via openings in the home such lergy Asthma Immunol. 76: 270-272. Ryckman, R.E. 1979. Host reactions to bug bites as doors or eaves; 2) possibly attracted to Guerenstein, P.G., M.G. Lorenzo, J.A. Nunez, and (, Homoptera): a literature review and an- notated bibliography. Calif. Vector News 26: 1-24. Smith, K.G.V. 1979. Allergic reaction to bite of fly larva of family Therevidae. Lancet. 1(8112):391-392. Smith, R.L. 1982. Venomous Animals of Arizona. Cooperative Extension Service, College of Agriculture, University of Arizona, Tucson. Stevens, W.J., J.V. den Abbeele, C.H. Bridts. 1996. Anaphylactic reaction after bites by Glossina morsitans (tsetse fly) in a laboratory worker. J Allergy Clin Immunol. 98:700-701. Triplehorn, C.A. 2005. Study of Insects. 7th ed. Belmont, CA: Thomson Brooks/Cole. Turner, W.J. 1979. A case of severe human al- lergic reaction to bites of Symphoromyia (Diptera: Rhagionidae). J Med Entomol. 15:138-139. Figure 6. Outside view of pack rat trapping device constructed from irrigation valve box (a); Vetter, R. 2001. Kissing bugs (Triatoma) and the inside view of device showing two expanded trigger traps (b). (Photos: Ed Evans) skin. Dermatol. Online J. Vol. 7, No. 1.

Reprinted with the permission of PCT Magazine, April 2006.