Kissing Bugs and Chagas Disease. Center for Integrated Pest Management epa.gov/managing-pests-schools

Size: px

Start display at page:

Download "Kissing Bugs and Chagas Disease. Center for Integrated Pest Management epa.gov/managing-pests-schools"

Jeffrey Sullivan
5 years ago
Views:

1 Kissing Bugs and Chagas Disease Center for Integrated Pest Management epa.gov/managing-pests-schools

2 Tips for Participants

3 Kissing Bugs and Chagas Disease Center for Integrated Pest Management epa.gov/managing-pests-schools

4 Integrated Pest Management A smart, less costly option for effective pest control in the community. IPM employs common sense strategies to reduce sources of food, water and shelter for pests in your home, community buildings, and grounds. IPM takes advantage of all pest management strategies, including the judicious use of pesticides. Center for Integrated Pest Management epa.gov/managing-pests-schools school.ipm@epa.gov

Presenters Patricia Dorn, Ph.D. William and Audrey Hutchinson Distinguished Professor of Biological Sciences - Loyola University Ph.

vector-borne disease with work in Central America and the southern U.S.

Kansas, Kansas City VA Medical Center, LSU School of Medicine, Overton Brooks VA Medical Center, Mescalero Apache Indian

5 Presenters Patricia Dorn, Ph.D. William and Audrey Hutchinson Distinguished Professor of Biological Sciences - Loyola University Ph.D. - University of Maryland Post-Doctoral Fellowship - Stanford Medical School Research focuses on interrupting transmission of vector-borne disease with work in Central America and the southern U.S. Stephen Klotz, MD Professor of Medicine, University of Arizona M.D. - University of Kansas School of Medicine Formerly with the Univ. Kansas, Kansas City VA Medical Center, LSU School of Medicine, Overton Brooks VA Medical Center, Mescalero Apache Indian Reservation Research interests include kissing bugs and the adherence of Candida to human tissue. Center for Integrated Pest Management epa.gov/managing-pests-schools school.ipm@epa.gov

6 Kissing Bugs and Chagas Transmission February 13, 2018 EPA Webinar Patricia L. Dorn, Ph.D., Stephen A. Klotz, M.D. Loyola University New Orleans University of Arizona Health Sciences Center

Locally-acquired Human Chagas, Louisiana, USA June 2006 74 year old female resident, numerous bites Pest control operator

7 Locally-acquired Human Chagas, Louisiana, USA June year old female resident, numerous bites Pest control operator identified Kissing bugs Serum drawn from both residents InBios Immunochromatic Rapid Test Dorn et al., 2007 Emerging Infect. Dis.

8 New Orleans Kissing Bugs: Triatoma sanguisuga Fecal streaks

9 Chagas Disease Background 6-7 million people infected 40 million people at risk 12,000 deaths annually 0.55M DALYs Human Chagas Disease Hotez, et al., 2014; WHO, 2015

10 Chagas Lifecycle

11 Bad mannered bugs!

12 How Efficient is the Transmission? 1,000-2,500 bites per infection Rabinovich, et al., 1990 Nouvellet, et al., 2013

13 Kissing Bug Bites: What do they look like? Typically occur at night Are painless Bugs frequently found in bed

14 Central punctum with hemorrhage; surrounding urticaria with itching; bug found in bed

15 Acute 1-2 mo. Chagas Disease ~30% Chronic Decades Digestive Disease Heart Disease

16 How do people get infected with the Chagas parasite? 80 % Transmission by kissing bug feces

17 What are some less common ways people get infected with the Chagas parasite? Congenital U.S. estimates /year Food and drink Laboratory work Blood and Organ recipients U.S. 19 reported

18 Who is most at risk?

19 How Many Documented Locally Acquired Cases, US? mo. female Texas Woody & Woody, infant Texas Greer, yr. female California Schiffler, et al., mo. male Texas Ochs, et al., mo. male Tennessee Herwalt, et al yr. female Louisiana Dorn, et al., small child Texas Kjos, et al., individuals found by blood screening Mississippi & Elsewhere Cantey, et al., , individuals found by blood screening Texas Garcia, et al., 2015 Gunter, et al., yr. old female Texas soldiers Arizona, Texas Curtis-Robles, et al Harris, et al., 2017, Webber et al., 2017

20 Vectors? Parasite? Reservoirs? Photo: H. Baquet Photo: P. Dorn Is Chagas a Risk in the US? Human-Vector Contact? Photo: P. Dorn Infection in Humans? Photo: C.B. Beard Infection in Animals? Photo: P. Dorn

21 How are Kissing Bugs and Assassin Bugs Related? Photo: C.B. Beard By Evolution!

22 Triatoma recurva Photo: M. Schumacher Are kissing bugs in the U.S.? Yes - 11 Species Bern et al. 2011

23 U.S. Kissing Bug Distribution Klotz, et al., 2014

24 Are there other consequences of kissing bug bites besides Chagas?

25 Commonly Asked Questions: True or Arizona kissing bugs do not defecate on humans after feeding. We are missing a lot of Chagas disease in patients from Tucson. Bites are common and frequently result in anaphylaxis. False?

26 Bite Leading to Infection with T. cruzi Romana s sign (weeks before resolution) Accompanying chagoma In the US seen frequently but due to allergies (days before resolution)

27 Kissing Bug Reactions Reported in Arizona Exposures Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Exposures Jul Aug Sept Oct Nov Dec Dispersal Flights Dispersal Flights Database of Arizona Poison & Drug Information Center

28 What are the allergies that occur to bites Repeated exposure leads to some sensitivity (local pruritus) Some individuals may develop anaphylaxis or an accelerated allergic reaction such as extensive urticaria (hives)

29 Klotz SA et al., Environ Health Insights 8: 2016

30 What is the Problem? A 68 year-old man from Sahuarita, AZ awakened suddenly at 2:00 AM with SOB and diffuse urticaria in August, He vomited, felt palpitations and fainted getting out of bed. He was brought to the ER with hypotension and tachycardia. He took amoxicillin the previous morning for a UTI, ate strawberries at lunch, shrimp at dinner and had peanuts with a cocktail the evening before. (His wife found a bug in the bed.)

31 Anaphylaxis The patient presented with anaphylaxis Given epinephrine with reversal of symptoms The bite history is overlooked and the cause is often attributed to food or drug allergies

32 Symptoms of Anaphylaxis from chemical mediators, especially histamine Hives Breathing difficulties Dizziness Shock

Anaphylaxis from bites of Triatoma Urban sprawl into Triatoma habitat has resulted in accidental entry of bugs into homes and feeding on humans.

33 Anaphylaxis from bites of Triatoma Urban sprawl into Triatoma habitat has resulted in accidental entry of bugs into homes and feeding on humans. A potentially risk factor in sensitized individual. Not a reportable disease and will require a registry to establish data. Current treatment is epinephrine No immunotherapy approved No commercially available testing kits

34 Is the Chagas Parasite Present in the U.S.?

35 Chagas Parasite: Trypanosoma cruzi present in the U.S. Photo: P. Dorn T. cruzi isolates from vectors, humans, commensal and wild animals High amount of genetic diversity T. cruzi has been a part of native fauna of the United States for a very long time Barnabé, et al Subset of seven strains reported in the U.S. Most common TcI, TcIV Rare TcII Roellig, et al., 2008, Herrera, et al., 2015, Hodo, et al., 2016, Curtis-Robles, et al., 2016, 2017, Garcia et al., 2017

& J. Berquest Others Non-human Primates Dogs

36 Is T. cruzi in animals in the U.S.? Found in at least 26 mammal species Rodents: Woodrat = packrat (Western States) Raccoon, opossum, armadillo (Eastern States) Photo: P. & J. Berquest Others Non-human Primates Dogs Photo P. Dorn Nieto, et al., 2009, Dorn et al., 2012, Hodo and Hamer, 2017

37 Are humans in contact with kissing bugs?

38 Home entry by Triatomines Following summer dispersal flights Attracted to lights Not mating flights Enter homes through doorway thresholds, windows Potential for domiciliation of bugs

39 Common home invaders in Tucson, Arizona From Pinnas et al J. Allergy Clin. Immunol. 77: Blood-sucking insects

40 Seasonality of Kissing Bug Bites

41 Arizona-Sonora Desert Museum, elevation 2,389 feet

42 Majority of kissing bugs in the Museum were Triatoma rubida and lesser numbers of T. protracta

43 Do kissing bugs feed on humans in the U.S.?

44 Human / Vector Contact? Kissing Bug Blood Sources - Arizona, California Blood Sources 57% 33% 23% N = 34, T. rubida, T. recurva, T. protracta 10% - rat, mouse, opossum, sheep/goat, deer, skunk, cat Stevens, et al., 2012, Klotz, et al., 2014, Dorn, et al (unpublished)

45 Human / Vector Contact? T. sanguisuga Blood Sources - Louisiana Blood Sources 54% 49% 30% T. cruzi + 61% 38% 58% Photo T Pierson 2011 Photo Animalvoices.org N = 49 T. sanguisuga <15% - cow, dog, squirrel, cat, woodrat Waleckx et al., 2014

46 Are U.S. bugs bad mannered?

47 Are U.S. bugs bad mannered? Bugs leave the host before defecating Klotz et al Our bugs are better mannered!

48 Are U.S. Vectors Becoming Domesticated? T. protracta, CA Photo: Justin Schmidt T. recurva, AZ Stevens, et al. 2011, Klotz, et al., 2014, 2016

What kind of housing predisposes to kissing bug domiciliation? In Vera Cruz, Mexico: unplastered walls and wood walls with T. dimidiata: Sandoval-Ruiz, C.A. Salud Publica de Mexico;56, 2014.

49 What kind of housing predisposes to kissing bug domiciliation? In Vera Cruz, Mexico: unplastered walls and wood walls with T. dimidiata: Sandoval-Ruiz, C.A. Salud Publica de Mexico;56, In Costa Rica: dirt floors and firewood in the house with T. dimidiata: Zeledon, R. Am.J.Trop.Med.Hyg 33, 1984 Northeastern Brazil: peridomiciliary ecotopes around the house; roofing of goat and pig pens with T. brasiliensis: Sarquis, O. Mem Inst Oswaldo Cruz 10: 2006.

50 Geographic transitional zone-bisbee Zacatecas Canyon, Bisbee, Arizona, elevation 5,538 feet. It is a Sky Island Likely domiciliated T. recurva Associated with anaphylaxis and allergies Is Chagas present in this community?

51 T. Recurva is the largest kissing bug in the US Associated with Chagas in Mexico Found commonly in the historical city of Bisbee within homes We have found it walking on roadsides next to houses Found on the walls of city homes in summer at evening

52 Landscape of Bisbee

53 Zacatecas Canyon Residents retrieve nymphs in their homes throughout the year. Residents sleep under mosquito netting.

54 Are people becoming infected with/without domiciliation? Louisiana Arizona Domiciliation NO YES No. homes surveyed No. homesteads with bugs 13.6% 100%* No. people tested No. people testing positive 0 0 Moudy, et al., 2014 Klotz, et al., unpublished *Resident supplied bug from inside home to request testing

55 How do I protect myself and my family from kissing bugs?

56 Can The Kissing Bugs be Prevented from Biting? DEET 5% Control (Acetone) 8 cm 40 cm 6 cm 50 cm

59 Conclusions: Kissing bugs feed on humans in the U.S. Human contact: ~50-60% vectors (CA, AZ, LA) fed on human Different blood sources in different localities Human cases: Locally-acquired cases rare Need attention to cases coming from endemic countries and their children Photo: C.B. Beard

60 Conclusions: Vectors & Manners 11 Species of vectors present across southern 2/3 of U.S. Vectors do colonize houses Vectors moderately (T. protracta, T. rubida) and highly infected (T. sanguisuga) Our bugs are better mannered! Photo: H. Baquet

61 Vectors Parasite Reservoirs Photo: H. Baquet Photo: P. Dorn Is Chagas a Risk in the US? Human-Vector Contact Infection in Animals Photo: P. Dorn Infection in Humans Photo: C. B. Beard

62 What Have We Established? Local species of kissing bugs do not defecate on the host. Anaphylaxis and other allergic reactions are common in Tucson. Humans appear to be common victims of feeding by kissing bugs. One community in Southeast Arizona may have year-round domiciliation of houses by kissing bugs which live out their life in the home. Citronella may be a deterrent to feeding of kissing bugs.

63 Non-chemical measures to reduce risk of household infestation Reduce clutter inside houses (Monroy et al., 2009) Eliminate junk, wood or rock piles, trash, and other objects in peridomestic environments (Ferral et al., 2010) Manage surrounding vegetation and conserve local fauna (Teixeira et al., 2009) Replace outside white lights with yellow lights (Gouge et al., 2010) Seal structural cracks and crevices (Gouge et al., 2010) Klotz, SA et al., Advances Parasitol 75: 2011

64 Important Collaborators Arizona Justin Schmidt PhD John Klotz PhD Lori Stevens PhD Shannon Smith MBA Norman Beatty MD Residents Louisiana Lori Stevens PhD Nick de la Rúa Kristina Cesa Prixia Nieto PhD Etienne Waleckx PhD Jonathan Kurtz PhD Dawn Wesson PhD Katherine Phillippi- Falkenstein PhD Residents

66 IPM to Avoid Kissing Bugs Educate - Especially in areas around where the pest has been reported. Sanitation - Remove potential harborage sites indoors and out. Clean up clutter indoors. Remove all items from being stacked around house. Locate trash, away from the building. Maintenance - Exclusion Seal them out. Install door sweeps, screens are fully intact and repaired. Seal all holes to exterior. Remove vegetation from immediate area surrounding the home. Replace white night time lighting with yellow bulbs. Use pesticides judiciously. Pesticides Physical & Mechanical Controls Cultural & Sanitation Practices Education & Communication Center for Integrated Pest Management epa.gov/managing-pests-schools school.ipm@epa.gov

67 Submit Your Questions Center for Integrated Pest Management epa.gov/managing-pests-schools

68 Upcoming Webinars Managing Mosquitoes Around the Home March 6, 2018 Integrated Mosquito Management in Urban Environments March 20, 2018 Pesticide Resistance Testing to Improve Mosquito Management April 10, 2018 Using GIS to Improve Integrated Mosquito Management April 24, 2018 Dealing with Canada Geese and Pigeons May 15,2018 Center for Integrated Pest Management epa.gov/managing-pests-schools

69 View Recorded Webinars Ants Bed Bugs Birds Cockroaches Contracting IPM Services Head Lice IPM - basics, policy, tools Kitchens and Cafeterias Mosquitos and Vector Management Pest Prevention by Design Rodents Stinging Insects Ticks Turf Pests Termites Center for Integrated Pest Management epa.gov/managing-pests-schools school.ipm@epa.gov

70 Center for Integrated Pest Management epa.gov/managing-pests-schools

71 Questions? Center for Integrated Pest Management epa.gov/managing-pests-schools

Fig. 3. Second, third, and fourth stage nymphs (immatures) of Triatoma gerstaeckeri from Texas (LSAM).

Fig. 3. Second, third, and fourth stage nymphs (immatures) of Triatoma gerstaeckeri from Texas (LSAM). The causative agent of Chagas disease, Trypanosoma cruzi, is a protozoan parasite that infects an estimated 24 million people in Central and South America. During 2006, the first indigenous case in Louisiana