Introduction

Bed bug infestations have resurged globally, nationally, and locally, yet the public health community in the U.S. has yet to mount a coordinated response to the escalating bed bug problem. We were included in recorded comments from public health officials and academicians that resulted in a key, unanimous recommendation from the 2009 U.S. Environmental Protection Agency (U.S. EPA) National Bed Bug Summit: determine bed bugs to be a public health pest (U.S. EPA, 2009a). Although such a determination would enable public health jurisdictions to develop policy and procedure to act upon the burgeoning bed bug complaints registered by their constituency, other serious programmatic and political considerations remain in some locales: manpower and budget issues, nuisance and housing complaint jurisdiction, and the competing authority of nonhealth government entities.

As we discussed in part 1 of this article (Eddy & Jones, 2011), bed bug infestations are exacerbated by residential health determinants, yet local health jurisdictions are increasingly unresponsive to housing program demands. This results in social justice, health equity, environmental justice, and health disparity considerations. Because local health jurisdictions are not unified in their positions on bed bugs as a disease vector, no consistency of response exists to complaints of bed bug infestations. Hence, we performed an opinion survey of selected community stakeholders to gauge perspectives on bed bugs as a public health concern or social justice issue.

Methods

Convenience surveys were performed during presentations delivered by Christopher Eddy at the below-listed educational programs:

* the 2009 Association of Ohio Health Commissioners (AOHC) Annual Education Conference, September 30, 2009, Columbus, Ohio;

* the 2009 National Environmental Health Association (NEHA) Annual Educational Conference & Exhibition, June 22, 2009, Atlanta, Georgia;

* the 2009 Central Ohio Bed Bug Summit sponsored by the Central Ohio Bed Bug Task Force (COBBTF), November 10, 2009, Reynoldsburg, Ohio; and

* the 2010 Council on Aging (CoA) of Southern Ohio Annual Education Conference, March 3, 2010, Sharonville, Ohio.

All four test populations were informed that the surveys were performed casually, and two questions were administered: (1) Are bed bugs a public health concern? and (2) Are bed bugs an environmental justice issue? Turning Point(TM), a real-time "voting" software platform, was used to record responses from individual electronic "voting cards" that were distributed to audience members. The voting cards were limited to 50 per session, but because the COBBTF audience was about 200 individuals, a student assistant also hand counted "votes" by attendees who did not receive a voting card. For all surveyed groups, audience members were neither asked to identify themselves nor was any information about their personal identity recorded.

Although the surveys were performed casually and audience members decided whether or not to participate after voting cards were distributed, such an observational study can produce only nonprobability samples. Given that the test populations were surveyed at Eddy's convenience and he introduced inherent bias due to the presentation format, confidence intervals cannot be computed.

A luxury of convenience sampling processes is the large test population, but a downside is self-selection error since the chosen groups shared common and uncommon characteristics. The "summit" group was expected to show some bias due to their demonstrated interest in the subject of bed bugs. The social worker group (Council on Aging) attended an educational session specifically on the subject of bed bugs. Two of the groups, health commissioners and environmental health professionals, are public health practitioners with an interest in bed bugs as a public health concern.

Results and Discussion

Survey results, which are shown in Table 1, revealed that 90% of all respondents considered bed bugs to be a public health concern, and 73% of the respondents indicated that bed bugs pose an environmental justice concern. It is important to emphasize that the vast majority of people surveyed believe that bed bugs are a public health concern, yet public health jurisdictions are divided in their response to bed bug complaints from the public.

Compared to the other surveyed groups, the health commissioner population (AOHC) was less inclined to agree (53%) that bed bugs are an environmental justice issue, perhaps signaling political concerns that could arise in their jurisdictions if they adopt policy and procedures that disregard bed bug complaints from their constituency. The findings that 85% of the health commissioner group and 84% of the environmental professional group (NEHA) agree that bed bugs are a public health issue supports a notion to exclude the health commissioner environmental justice data from consideration due to potential, and understandable, political sensitivity to the subject matter. Some health commissioners who do not support an aggressive response to bed bug complaints or bed bug regulation, while maintaining that bed bugs are a public health issue, may be hesitant to report that they consider bed bugs to be an environmental justice issue. Although the health commissioner audience may be more politically sensitive than the three other survey populations, more than 50% of the commissioners agreed that bed bugs present environmental justice issues.

These findings, which indicate that bed bugs are an inescapable public health mandate with environmental justice undertones, should rally public health agencies at federal, state, and local levels, to establish unified and responsive policy, procedures, and housing code enforcement authority to prevent and eradicate bed bug infestations in the community.

Conclusion

The survey data demonstrate overwhelming consensus that bed bugs are a public health concern. Of even greater interest is that the surveyed populations strongly associated bed bugs and environmental justice. Housing or "place," the immediate environment as best described by the private residence, is a primary determinant of health. Our homes significantly affect our health.

Annotation

U.S. EPA National Bed Bug Summit

On April 14 and 15, 2009, we attended the National Bed Bug Summit, sponsored by U.S. EPA in Washington, DC. The objectives for the meeting, according to the Federal Register announcement (U.S. EPA, 2009b), were as follows:

To share information and knowledge on the topic of bed bugs and their newfound resurgence, provide a venue to identify ideas and opinions for their control, and develop recommendations as how affected stakeholders, communities, and local jurisdictions can begin to address the emerging nationwide bed bug problem.

Approximately 150 attendees, broadly representing human agency, academia, research and laboratory, the private sector, and concerned citizens, were grouped into 10 workgroups. Each workgroup was assigned to identify the reason for bed bug resurgence, options and solutions for a remedy, and make suggestions. Many testimonials (including those we gave) from research, academic, public health, and private interest groups included discussion that bed bugs were thought to be eradicated in the U.S. decades ago, hence research is not contemporary to the current problem (U.S. EPA, 2009a).

The following recommendations were among those made by the workgroups at the summit and are part of the public record (U.S. EPA, 2009a):

* Recognize bed bugs as a public health pest.

* Centers for Disease Control and Prevention (CDC) should recognize bed bugs as disease vectors.

* Educate government and elected officials.

* Form public/private relationships for extermination and assurance oversight.

* Fund more research on bed bugs as disease vectors.

* Perform research on bed bugs and asthma.

* Broaden definition of public health to include mental health problems such as those generated by bed bug infestations.

* Protect underserved communities with subsidies for bed bug control and extermination. Ü

Acknowledgements: The authors thank Ken Dahms, JD, MA, Master of Public Health Program, Wright State University; Joshua L. Bryant, MS, Entomology, Ohio State University; and Eriko Sase, PhD, Community and Global Community Health, Graduate School of Medicine, University of Tokyo, for their critical analyses, important input, and related contributions to this paper. This project was supported in part by state and federal funds appropriated to the Ohio Agricultural Research and Development Center.

References

Eddy, C, & Jones, S.C. (2011). Bed bugs, public health, and social justice: Part 1, A call to action. Journal of Environmental Health, 73(8), 8-14.

U.S. Environmental Protection Agency. (2009a). EPA's national bed bug summit: Participant recommendations. Retrieved November 9, 2010, from httpy/wvmepa.gov/pesticides/ppdc/bedbug-summit/ partic-recom.pdf

U.S. Environmental Protection Agency. (2009b). National bed bug summit; Notice of public meeting. Federal Register Notices, 7 4(51), 11550-11551. Retrieved December 12, 2009, from http://www. gpo.gov/fdsys/pkg/FR-2009-03-18/pdt7E9-5863.pdf

Author affiliation:

Christopher Eddy, MPH, REHS, RS

Susan C. Jones, PhD

Author affiliation:

Corresponding Author: Christopher R. Eddy, Assistant Program Director, Master of Public Health Program, Wright State University, 3123 Research Blvd., #200, Kettering, OH 454204006. E-mail: christopher.eddy@wright.edu.