Abstract
Background
The resurgence of bed bugs is a major challenge to public health and housing authorities and is a social justice issue. Bed bugs are environmentally communicable, cause ill health, and decrease quality of life. Bed bug infestations are socially patterned, disproportionately affecting people facing vulnerability; they are more prevalent in high-density multi-unit housing environments. While bed bugs can cause cutaneous and allergic reactions along with other health reactions, the biggest health impacts of bed bugs appear to be psychological. To contribute to the limited number of studies documenting the prevalence of exposure to bed bugs and mental health impacts in general populations, this study reports on the prevalence of exposure to bed bugs in a large sample of tenants and measures the association between bed bug exposure and psychological symptoms.
Methods
This cross-sectional study set in Montreal, Canada, uses data on 5,000 tenants aged ≥ 18 years from the 2017 Montreal Housing Survey. Exposure to bed bugs in the year preceding the interview was self-reported by tenants. The 2-item Generalized Anxiety Disorder scale and the 2-item Patient Health Questionnaire-2 were used to measure anxiety and depression, respectively. Association between exposure to bed bugs and psychosocial symptoms was assessed using logistic regression adjusted for sociodemographic characteristics and housing conditions.
Results
Four percent of tenants reported being exposed to bed bugs in the year preceding the survey. In unweighted analysis, the odds of anxiety (OR: 1.72; 95%CI: 1.12, 2.64), depression (OR: 1.83; 95%CI: 1.20, 2.78), and anxiety and/or depression (OR: 1.69; 95%CI: 1.16, 2.44) were significantly higher for those exposed to bed bugs, independently of the sociodemographic characteristics and housing conditions of the survey respondents. In weighted analysis, the effect sizes were reduced. Exposure to bed bugs was marginally (p = 0.087) associated with higher odds of reporting anxiety and/or depression (OR: 1.53; 95%CI: 0.94, 2.50).
Conclusions
Findings reinforce the significant social inequalities in exposure to bed bugs and contribute to growing evidence that bed bug exposure is a risk factor for psychological symptoms. Coordinated, intersectoral actions that are attentive to social justice issues are needed to monitor and control bed bug infestations.
Supplementary Information
The online version contains supplementary material available at 10.1186/s12889-025-25936-7.
Keywords: Bed bugs, Housing, Mental health, Residence characteristics, Canada
Introduction
Once a ubiquitous pest, bed bugs became uncommon in many high-income countries soon after the Second World War as a result of the widespread use of synthetic insecticides [1, 2]. Since the late 1990 s, a world-wide resurgence of bed bugs has been observed [2, 3]. Resistance to insecticides, international travel, and poor pest management practices are thought to be responsible for their resurgence [4]. While bed bug infestations are reported in homes and apartments, hotel rooms, health care settings, nursing homes, and shelters [2, 5, 6], issues with bed bugs are also seen in prisons, public transportation, in office buildings, in the retail environment; “they can be found in any location where people sleep or sit” [4; p.164].
Adult bed bugs (with the two main species being the common bed bug, Cimex lectularius, and the tropical bed bug, Cimex hemipterus) are reddish-brown, flat, oval-shaped and measure approximately 5–7 mm in length when not engorged, and up to 10 mm when full of blood [4]. Generally, bed bugs avoid light; they hide close to hosts in box springs, seams in mattresses, headboards, spaces under baseboards, or loose wallpaper, feeding at night on human blood. Their life expectancy varies by ambient temperature; under temperatures of around 22 °C, bed bugs can live around 5 months whereas they may live longer (close to, or more than, 1 year) in cooler temperatures [4]. These insects are extremely resilient and difficult and costly to eradicate [1, 2, 5, 7, 8]. The financial burden of eradicating bed bugs can be severe; indeed, bed bugs are one of the most expensive home-invading pests to manage due to the difficulties in achieving control.
It is difficult to estimate the prevalence of exposure to bed bugs [2, 4]. Some people will show no reactions to bites [4, 5, 9, 10] or will have delayed cutaneous reactions [4, 9, 11]. The social stigma of living in an infested dwelling [12] or the fear of impact on business’s reputation (e.g., in the case of hotels, motels, resorts and other commercial accommodation) may lead to under-reporting. The general difficulty of recruiting marginalized populations in monitoring studies, i.e., those most likely to be exposed to bed bugs, is another reason. As a result, there is little information about the prevalence of bed bugs [3]; the extent of their resurgence has not been accurately (nor consistently) quantified [13]. The 2014 New York City Community Health Survey, estimated that 5% of residents were exposed to bed bugs, with this proportion reaching 12% in some neighborhoods [14]. In Philadelphia, 11% of respondents (n = 600) to a door-to-door survey in row houses reported a bed bug infestation. In France, a recent expert report based in part on data collected from a representative sample of 2000 adults, estimated that 11% of households likely experienced a bed bug infestation between 2017 and 2022 [15].
Bed bug infestations are more prevalent in high-density, multi-unit housing environments [2]. In these environments, pest management and eradication efforts are challenging because of the required cooperation between landlords and all tenants, which can be difficult to achieve generally and especially in high-density buildings [1]. Bed bugs have been found to disproportionately affect people facing vulnerability and with less control over their living environments, e.g., tenants, those with lower incomes, younger and older adults, racialized individuals, those with impaired mobility, and those experiencing homelessness [15–20]. Because of limited resources and alternative housing options, these groups may be more likely to have difficulty in reporting and eliminating a bed bug infestation [21–23], or be more hesitant to disclose the problem for fear of being evicted [24] or for being responsible for the cost of eradication. Providing social and health care to people whose living environments are infested with bed bugs can also be met with reluctance [23, 25].
Bed bugs are environmentally communicable, cause ill health, and can decrease one’s quality of life [21]; their public health burden is substantial [26]. Bed bugs can cause cutaneous and allergic reactions, along with other health reactions; there is no evidence for disease transmission by bed bugs [5, 27, 28]. Exposure to insecticides and poisoning have also been reported [29]. The biggest health impacts of bed bugs appear to be psychological. Indeed, studies have noted that people exposed to bed bug infestation may deal with social isolation, increased stress (including financial stress related to the treatment of the infestation), have nightmares and insomnia, be in a state of hypervigilance, show symptoms of psychological distress, anxiety and even posttraumatic stress disorder [12, 23, 30–35].
Ashcroft and colleagues’ 2015 scoping review of the literature identified 51 publications discussing bed bug infestations and potential mental health impacts [30]. Of the included publications, only five reported results from original research; the other publications were commentaries, case reports, literature reviews, or technical guidelines. Among the five original studies included in the review, only two collected data with people exposed to bed bugs in high-income countries and examined association with psychological symptoms [28, 36]. In a survey conducted in seven American cities with 474 residents in dwellings known to be infested with bed bugs (as confirmed by pest control companies), respondents reported sleep disturbance, emotional distress, anxiety, and stress as symptoms they attributed to the presence of bed bugs [28]. In a case-control study in Montreal, Canada, tenants exposed to bed bugs (n = 39) presented with significantly higher odds of anxiety symptoms and sleep disturbance, and with marginally higher odds of depression symptoms, in comparison to unexposed tenants (n = 52) [36].
More recent studies on the association between bed bug exposure, well-being and mental health symptoms reported increased risk of sleep problems and poorer self-rated health [16] and elevated stress levels [35]. In France, a recent study estimated the incidence of general practice (GP) consultations related to bed bugs over a one-year period (2019–2020) [37]. A total of 217 general practitioners participated to the study, with more than half reporting at least one consultation related to bed bugs. This led to an estimated annual incidence of consultation related to beg bug exposure of 109 per 100,000 inhabitants. GPs were asked to report on symptoms and clinical signs for each patient. GPs observed moderate-to-severe repercussions on everyday life in 39% of their patients, insomnia in 39%, and psychological distress (assessed using the Mental Health Inventory test) in 27% [37].
Results from qualitative studies further demonstrate the breadth of psychological impacts experienced by those exposed to bed bugs. In a study conducted with 16 inner-city residents in Winnipeg, Canada, increased stress and sleep deprivation resulting from bed bug infestations were reported during in-depth interviews [12]. Participants also reported social isolation, loss of self-worth, and social stigma due to bed bug infestations, and found it difficult to complete daily tasks, such as work, school, and raising families, further impacting their health and well-being [12]. Results from in-depth interviews with lower-income older adults residing in social housing and with service providers in Toronto, Canada [38] showed that pest control, and especially bed bug infestation, were a pervasive issue that had a negative impact on the quality of life. Among impacts, respondents noted that bed bug infestation created high levels of stress, the fear of having to manage another infestation, facing multiple obstacles navigating the pest management process, and facing stigma from service providers refusing to provide services in infested units [23].
The resurgence of bed bugs is a major challenge for public health and housing authorities. Bed bugs impose an important economic burden for those affected, with estimated billions of dollars in costs for the world economy [3, 39]. In France, for example, yearly costs of bed bug eradication have been estimated at €1.4 billion for the period of 2017 to 2022; this represents an average annual financial burden on French households of €230 million [15]. To date, however, very few studies have documented the prevalence of exposure to bed bugs in general populations, with most studies reporting on bed bug exposure in specific settings such as in hotels, hospitals, or other care settings. Using data from a public health and housing survey, this study reports on the prevalence of exposure to bed bugs and associated risk factors, and examines the association between exposure to bed bugs and psychological symptoms in a sample of 5000 tenants on the Island of Montreal, Canada. We hypothesize that exposure to bed bugs is higher among tenants of lower socioeconomic status and for those living in multi-unit buildings and that it will be associated with higher risk of self-reported psychological symptoms.
Methods
Study design
This cross-sectional study uses data from the 2017 Montreal Housing Survey, conducted by Montreal Public Health. Using the population of the Island of Montreal as a sampling frame, participants aged ≥ 18 years stratified by housing tenure (homeowners vs. tenants) were randomly recruited from a sample of 90,000 landlines. Three quarters of phone numbers were validated from a phonebook, and the rest were generated randomly. A sample size of 5000 tenants and 500 homeowners was determined to be representative of the diverse neighborhoods of Montreal and was achieved by calling 31,228 numbers. In total, 12,448 numbers were included, for a 44% response rate. Household and individual weights were created to account for the number of dwellings, mode of occupation (renters vs. homeowners), and housing type (household weight), as well as for the gender, age, and the number of adults per dwellings (individual weight) in the various boroughs on the Island of Montreal. The residential location of participants was validated using postal code during the interview. The survey was carried out in the context of the Montreal Regional Public Health surveillance plan, which was approved by the Quebec Public Health Surveillance Ethics Board. All respondents provided informed consent to participate in the survey. For the secondary data analysis reported in this paper, further ethical approval was granted by McGill University Research Ethics Board (REB #20-08-052).
The survey questionnaire was developed collaboratively by Montreal Public Health and the City of Montreal’s Housing Department, and was administered by B.I.P. Recherche, a private survey firm. Phone interviews were conducted from Monday to Saturday between 10AM and 9PM, and on Sunday between 3PM and 9PM. 15% of interviews were monitored for quality control. The questionnaire was administered in French or English. Topics covered in the questionnaire included exposure to pests, such as bed bugs; housing and sociodemographic conditions; and mental health symptoms. In Montreal, tenants generally move to a new dwelling around July 1st. Therefore, participants were asked to answer questions based on the occupied dwelling up until June 30th of the same year. On average, interviews with homeowners lasted seven minutes, and those with tenants lasted 14 min. This study is restricted to the 5000 tenants, since questions on mental health were only included in the questionnaire for tenants (not for homeowners). The English version of the questionnaire is available in the supplementary file.
Measures
Exposure to bed bugs
Bed bug sightings in the dwelling in the previous year were self-reported by participants (rather than being independently confirmed) using the question: In the past 12 months, have you noticed bed bugs in your dwelling? Those responding affirmatively were further asked if they saw bed bugs in the past month, at which frequency, and whom they contacted to report the problem. Participants who reported seeing bed bugs in the past year were further asked about the frequency of avoiding having people over because of bed bugs (an indicator of social isolation) and of having sleep problems. These variables were examined for descriptive purposes.
Psychological symptoms
The 2-item Generalized Anxiety Disorder scale (GAD-2) and the 2-item Patient Health Questionnaire-2 (PHQ-2) were used to assess mental health symptoms. The GAD-2 has been shown to have high sensitivity and specificity for detecting generalized anxiety, panic disorder, social anxiety disorder, and post-traumatic stress disorder [40, 41]. The PHQ-2 is used to detect depression. It is a sensitive and specific tool to screen for major depressive disorder and, to a lesser extent, for all other depressive disorders [42]. Both instruments have shown excellent or acceptable discriminative validity [43, 44]. Each scale uses two questions scored from 0 to 3, for an overall score of 6. For each scale, a score of ≥ 3 denotes the possible presence of a mental disorder [40, 42]. We also combined the number of respondents who scored ≥ 3 to both scales, in a variable denoting ‘anxiety or depression’.
Sociodemographic characteristics and housing conditions
Selected variables were considered as covariates (age, gender) and as potential confounders (annual household income; housing characteristics) of the association between exposure to bed bugs and psychological symptoms. Missing data for income (29% missing data among tenant respondents) were imputed. For housing characteristics, building type (detached, duplex, triplex; dwellings in apartment building with < 4 stories; dwellings in apartment building with ≥ 4 stories) and problems related to water infiltration, humidity or mold (defined as reporting at least one problem, in the past 12 months, with water infiltration; water spots, peeling paint or flaking plaster on walls and/or ceiling; musty or earthy smells; or mold spots larger than a letter size paper) were considered. Because of the small numbers of respondents living in social housing (less than 5%), we did not distinguish tenants by their rental status (private vs. social housing).
Statistical analysis
Weighted proportions (with 95% confidence intervals) were computed for exposure to bed bugs, psychological symptoms, sociodemographic characteristics, and housing conditions. Association between exposure to bed bugs and psychological symptoms was examined using logistic regression adjusted for selected confounding variables. We elected to conduct, and report on, both unweighted and weighted logistic regression modelling. In the results, we comment on the discrepancies observed for both types of models [45, 46]. Three models were run to test the association between exposure to bed bugs and each of the three psychological symptoms. The bivariate association between exposure to bed bugs and the selected outcome is reported in Model 1. Model 2 is adjusted for sex, age and annual household income. Building type and number of problems related to water infiltration, humidity or mold were added in Model 3. Regression analyses were conducted on a sample of ≥ 4500 tenants with non-missing data on all variables, weighted to represent over 825,000 tenants. Analyses were performed using Stata version 14.2.
Results
Sociodemographic characteristics and housing conditions of tenants are presented in Table 1. Over half of tenants are women and most are aged between 18 and 64 years. Half reported an annual household income below 40,000 CAD and 15% reported an annual income of 80,000 CAD or more (in the Montreal CMA, about 40% of tenant households have an annual household income below 40,000 CAD, and about 20% have an annual household income above 80,000 CAD; authors’ computations based on the Public Use Microdata File of the 2016 Canadian Census). Close to one in four lived in an apartment building with four or more stories and over 30% of tenants reported at least one problem with water infiltration, humidity or mold. About 9% of respondents screened positive for anxiety (8.6%) or for depression (8.5%) when asked about their moods in the two weeks preceding the survey; 13% screened positive for either anxiety and/or depression.
Table 1.
Characteristics of study participants and variation by self-reported bed bug sightings in their dwelling in the year preceding the survey
| Weighted % (95% CI) | Exposure to bed bugs Weighted % (95% CI) |
p-valueb | ||
|---|---|---|---|---|
| No | Yes | |||
| Self-reported exposure to bed bugs | 4.0 (3.2, 4.8) | |||
| Psychological symptoms a | ||||
| Anxiety | 8.6 (7.5, 9.8) | 8.4 (7.3, 9.6) | 15.1 (8.9, 21.4) | 0.011 |
| Depression | 8.5 (7.3, 9.6) | 8.1 (7.0, 9.2) | 16.3 (9.3, 23.2) | 0.004 |
| Anxiety and/or depression | 13.0 (11.6, 14.3) | 12.6 (11.2, 13.9) | 23.0 (15.3, 30.8) | 0.002 |
| Sociodemographic characteristics | ||||
| Gender a | ||||
| Men | 48.1 (46.1, 50.1) | 47.4 (45.4, 49.5) | 63.0 (54.0, 71.9) | Ref. |
| Women | 51.9 (49.9, 53.9) | 52.6 (50.5, 54.6) | 37.0 (28.1, 46.0) | 0.002 |
| Age group a | ||||
| 18–44 years | 31.1 (29.3, 33.0) | 31.1 (29.3, 33.0) | 31.1 (22.0, 40.3) | Ref. |
| 45–64 years | 53.0 (51.0, 54.9) | 52.9 (50.9, 54.9) | 54.2 (44.4, 64.0) | 0.918 |
| 65–74 years | 9.8 (8.8, 10.8) | 9.9 (8.9, 10.9) | 8.6 (3.5, 13.6) | 0.693 |
| ≥ 75 years | 6.1 (5.2, 7.0) | 6.1 (5.2, 7.0) | 6.1 (1.9, 12.1) | 0.989 |
| Annual household income (CAD) c | ||||
| < $40,000 | 49.8 (47.5, 52.1) | 48.7 (46.3, 51.1) | 76.5 (66.9, 86.1) | < 0.001 |
| $40,000 to <$80,000 | 35.0 (32.7, 37.2) | 35.6 (33.3, 37.8) | 20.3 (10.8, 29.8) | 0.064 |
| ≥ $80,000 | 15.2 (13.6, 16.8) | 15.7 (14.1, 17.4) | 3.2 (0.2, 6.3) | Ref. |
| Housing characteristics | ||||
| Building type | ||||
| Detached, Semi-detached, Duplex, Triplex | 43.0 (41.1, 45.0) | 44.1 (42.1, 46.1) | 17.3 (11.5, 23.0) | Ref. |
| Building with < 4 stories | 33.6 (31.7, 35.4) | 33.1 (31.3, 35.0) | 43.6 (33.5, 53.7) | < 0.001 |
| Building with ≥4 stories | 23.4 (21.8, 25.1) | 22.8 (21.1, 24.4) | 39.1 (29.1, 49.1) | < 0.001 |
| Problems in the dwelling | ||||
| Water infiltration | 18.4 (16.9, 19.9) | 18.2 (16.7, 19.6) | 24.5 (16.7, 32.2) | 0.087 |
| Water spots, peeling paint, flaking plaster | 17.7 (16.3, 19.2) | 17.2 (15.8, 18.7) | 29.3 (21.0, 37.7) | 0.001 |
| Musty or earthy smells | 8.4 (7.3, 9.5) | 8.2 (7.1, 9.3) | 13.7 (8.1, 19.3) | 0.023 |
| Mold spots larger than letter size paper | 9.0 (8.0, 10.1) | 8.6 (7.5, 9.7) | 18.9 (11.8, 26.1) | < 0.001 |
| At least one problem with water infiltration, humidity or mold | 31.4 (29.6, 33.1) | 30.6 (28.8, 32.4) | 49.4 (39.5, 59.2) | < 0.001 |
aVariables with individual weights applied. Household weights are applied to the other variables
b Ref. = reference category
cAs a reference, in June 15, 2025, 1 CAD =0.74 USD
In the year prior to the survey, 4% of tenant respondents reported seeing bed bugs in their dwelling (Table 1). The prevalence of anxiety (15% vs. 8%), depression (16% vs. 8%), or anxiety and/or depression (23% vs. 13%) was significantly higher for those reporting exposure to bed bugs compared to those who were not. Men were significantly more likely to report exposure to bed bugs compared to women; there was no difference between age groups. Reported exposure was significantly higher for tenants with an annual income below $40,000, for those living in a multi-story building, and for tenants living in dwellings with water infiltration, humidity or mold problems.
Among tenants reporting having seen bed bugs in their dwelling in the past year (Table 2), 37% reported bed bug sightings in the past month. Among these tenants, 27% reported seeing bed bugs every day. Most tenants reported the infestation to their property owner or building manager, whereas 13% did not report the infestation or dealt with it themselves. Over 75% of tenants who reported seeing bed bugs in their dwelling in the past year also reported having their dwelling unit treated for bed bugs by an exterminator. Tenants who reported seeing bed bugs stated sometimes (19%) or often (31%) avoiding inviting friends or family members over because of issues with bed bugs. Over half reported that they, or someone in the household, had problems sleeping either sometimes (27%) or often (27%) because of bed bug infestation.
Table 2.
Description of exposure to bed bugs, and its consequences, among tenants self-reporting bed bug sightings in their dwelling in the year preceding the survey
| Weighted % (95% CI) | ||
|---|---|---|
| Saw bed bugs in month preceding the survey | Yes | 36.5 (26.5, 46.6) |
| Frequency seeing bed bugs (from 1.5% of tenants who saw bed bugs in the month preceding the survey) | Everyday | 26.6 (13.5, 39.7) |
| Once a week | 24.1 (6.3, 42.0) | |
| Less than once a week | 42.0 (23.7, 60.4) | |
| Don’t know/No response a | 7.3 (0.0, 14.5) | |
| To whom the infestation was reported (more than one answer possible) | Landlord/building owner | 63.8 (48.0, 79.7) |
| Exterminator | 30.7 (16.3, 45.2) | |
| Building Manager | 28.6 (10.9, 46.3) | |
| City of Montreal’s 311 phone service | 14.9 (−3.1, 32.9) | |
| Nobody/took care of it personally | 12.9 (3.9, 22.0) | |
| Exterminator treated dwelling unit for bed bugs in the past 12 months | 77.1 (68.4, 85.9) | |
| Avoided inviting friends or family members because of bed bugs? b | No | 50.7 (40.8, 60.5) |
| Sometimes | 18.8 (11.2, 26.3) | |
| Often | 30.6 (21.8, 39.3) | |
| Respondents, or other members of the household, had trouble sleeping because of bed bugs | No | 45.4 (35.6, 55.3) |
| Sometimes | 27.2 (17.2, 37.1) | |
| Often | 27.4 (19.2, 35.6) |
aNon-response proportions are only reported if >5%
b Variables with individual weights applied. Household weights are applied to the other variables
Results of unweighted and weighted regression models reporting on the association between exposure to bed bugs and anxiety, depression, and anxiety or depression are presented in Tables 3, 4 and 5, respectively. In bivariate analyses (model 1), exposure to bed bugs was significantly associated with elevated odds of anxiety, depression and depression or anxiety in both unweighted and weighted analysis, with stronger effect size and narrower confidence intervals in unweighted models compared to weighted models.
Table 3.
Association between self-reported exposure to bed bugs and anxiety among tenants
| Unweighted logistic regression | Weighted logistic regression | |||||
|---|---|---|---|---|---|---|
| Model 1 | Model 2 | Model 3 | Model 1 | Model 2 | Model 3 | |
| OR (95%CI) | OR (95%CI) | OR (95%CI) | OR (95%CI) | OR (95%CI) | OR (95%CI) | |
| Self-reported exposure to bed bugs | ||||||
| No | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
| Yes | 2.35 (1.55, 3.55)*** | 2.01 (1.32, 3.08)** | 1.72 (1.12, 2.64)* | 2.05 (1.23, 3.42)** | 1.70 (1.01, 2.85)* | 1.48 (0.87, 2.52) |
| Gender | ||||||
| Men | 1.00 | 1.00 | 1.00 | 1.00 | ||
| Women | 1.36 (1.08, 1.72)* | 1.36 (1.08, 1.73)* | 1.24 (0.91, 1.70) | 1.25 (0.92, 1.70) | ||
| Age | ||||||
| 18–64 years | 1.00 | 1.00 | 1.00 | 1.00 | ||
| ≥ 65 years | 0.68 (0.54, 0.85)** | 0.76 (0.59, 0.96)* | 0.47 (0.33, 0.68) *** | 0.51 (0.34, 0.76)** | ||
| Household income | ||||||
| ≥ $80,000 | 1.00 | 1.00 | 1.00 | 1.00 | ||
| $40,000 to < $80,000 | 1.41 (0.90, 2.20) | 1.43 (0.91, 2.24) | 1.56 (0.91, 2.68) | 1.56 (0.90, 2.70) | ||
| < $40,000 | 2.39 (1.56, 3.65)*** | 2.37 (1.53, 3.65)*** | 2.66 (1.56, 4.52)*** | 2.64 (1.52, 4.59)** | ||
| Water infiltration, humidity or mold problem | ||||||
| No problem | 1.00 | 1.00 | ||||
| ≥ 1 problem | 2.15 (1.73, 2.66)*** | 1.60 (1.18, 2.17)** | ||||
| Type of building a | ||||||
| Semi-detached | 1.00 | 1.00 | ||||
| Apart. < 4 storeys | 1.16 (0.91, 1.48) | 1.05 (0.75, 1.47) | ||||
| Apart. ≥ 4 storeys | 1.10 (0.83, 1.45) | 0.92 (0.60, 1.41) | ||||
a Semi-detached, corresponds to detached, semi-detached, duplex or triplex; Apartments in buildings with fewer than 4 storeys or with 4 storeys or more
* p < 0.05; ** p < 0.01; *** p < 0.001; †p < 0.10
Table 4.
Association between self-reported exposure to bed bugs and depression among tenants, 2017 Montreal housing survey
| Unweighted logistic regression | Weighted logistic regression | |||||
|---|---|---|---|---|---|---|
| Model 1 | Model 2 | Model 3 | Model 1 | Model 2 | Model 3 | |
| OR (95%CI) | OR (95%CI) | OR (95%CI) | OR (95%CI) | OR (95%CI) | OR (95%CI) | |
| Self-reported exposure to bed bugs | ||||||
| No | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
| Yes | 2.63 (1.75, 3.95)*** | 2.12 (1.40, 3.21)*** | 1.83 (1.20, 2.78)** | 2.35 (1.37, 4.02)** | 1.88 (1.06, 3.33)* | 1.55 (0.88, 2.73) |
| Gender | ||||||
| Men | 1.00 | 1.00 | 1.00 | 1.00 | ||
| Women | 1.03 (0.82, 1.30) | 1.04 (0.83, 1.30) | 1.21 (0.89, 1.63) | 1.22 (0.90, 1.64) | ||
| Age | ||||||
| 18–64 years | 1.00 | 1.00 | 1.00 | 1.00 | ||
| ≥ 65 years | 0.79 (0.63, 1.00)* | 0.86 (0.68, 1.09) | 0.74 (0.51, 1.07) | 0.83 (0.56, 1.24) | ||
| Household income | ||||||
| ≥ $80,000 | 1.00 | 1.00 | 1.00 | 1.00 | ||
| $40,000 to < $80,000 | 1.52 (0.95, 2.42)† | 1.49 (0.94, 2.37)† | 1.86 (1.06, 3.27)* | 1.79 (1.02, 3.16)* | ||
| < $40,000 | 2.88 (1.84, 4.49)*** | 2.68 (1.71, 4.19)*** | 3.35 (1.93, 5.83)*** | 3.06 (1.74, 5.39)*** | ||
| Water infiltration, humidity or mold problem | ||||||
| No problem | 1.00 | 1.00 | ||||
| ≥ 1 problem | 1.67 (1.34, 2.08)*** | 1.88 (1.39, 2.54)*** | ||||
| Type of building a | ||||||
| Semi-detached | 1.00 | 1.00 | ||||
| Apart. < 4 storeys | 1.48 (1.16, 1.90)** | 1.53 (1.09, 2.13)* | ||||
| Apart. ≥ 4 storeys | 1.36 (1.02, 1.79)* | 1.21 (0.79, 1.84) | ||||
a Semi-detached, corresponds to detached, semi-detached, duplex or triplex; Apartments in buildings with fewer than 4 storeys or with 4 storeys or more
* p < 0.05; ** p < 0.01; *** p < 0.001; †p < 0.10
Table 5.
Association between self-reported exposure to bed bugs and anxiety or depression among tenants, 2017 Montreal housing survey
| Unweighted logistic regression | Weighted logistic regression | |||||
|---|---|---|---|---|---|---|
| Model 1 | Model 2 | Model 3 | Model 1 | Model 2 | Model 3 | |
| OR (95%CI) | OR (95%CI) | OR (95%CI) | OR (95%CI) | OR (95%CI) | OR (95%CI) | |
| Self-reported exposure to bed bugs | ||||||
| No | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
| Yes | 2.37 (1.66, 3.38)*** | 1.97 (1.37, 2.84)*** | 1.69 (1.16, 2.44)** | 2.21 (1.40, 3.50)** | 1.82 (1.12, 2.95)* | 1.53 (0.94, 2.50)† |
| Gender | ||||||
| Men | 1.00 | 1.00 | 1.00 | 1.00 | ||
| Women | 1.18 (0.98, 1.43)† | 1.18 (0.98, 1.43)† | 1.22 (0.95, 1.57) | 1.23 (0.95, 1.57) | ||
| Age | ||||||
| 18–64 years | 1.00 | 1.00 | ||||
| ≥ 65 years | 0.70 (0.58, 0.84)*** | 0.78 (0.64, 0.94)* | 0.57 (0.42, 0.76)*** | 0.62 (0.45, 0.85)** | ||
| Household income | ||||||
| ≥ $80,000 | 1.00 | 1.00 | 1.00 | 1.00 | ||
| $40,000 to < $80,000 | 1.44 (1.00, 2.06)* | 1.45 (1.01, 2.07)* | 1.62 (1.04, 2.51)* | 1.59 (1.02, 2.49)* | ||
| < $40,000 | 2.55 (1.80, 3.60)*** | 2.48 (1.74, 3.53)*** | 2.76 (1.78, 4.28)*** | 2.66 (1.68, 4.19)*** | ||
| Water infiltration, humidity or mold problem | ||||||
| No problem | 1.00 | 1.00 | ||||
| ≥ 1 problem | 1.96 (1.64, 2.34)*** | 1.71 (1.34, 2.19)*** | ||||
| Type of building a | ||||||
| Semi-detached | 1.00 | 1.00 | ||||
| Apart. < 4 storeys | 1.26 (1.03, 1.54)* | 1.24 (0.94, 1.64) | ||||
| Apart. ≥ 4 storeys | 1.17 (0.93, 1.48) | 1.09 (0.76, 1.54) | ||||
a Semi-detached, corresponds to detached, semi-detached, duplex or triplex; Apartments in buildings with fewer than 4 storeys or with 4 storeys or more
* p < 0.05; ** p < 0.01; *** p < 0.001; †p < 0.10
When adjusting the model for age, sex and household income (model 2), we continue to observe an independent association between exposure to bed bugs and the three outcome variables, in both unweighted and weighted models. In unweighted models, exposure to bed bugs was significantly associated with elevated odds of reporting anxiety (OR: 2.01, 95%CI: 1.32, 3.08), depression (OR: 2.12; 95%CI: 1.40, 3.21), and anxiety or depression (OR: 1.97; 95%CI: 1.37, 2.84). The strength of the association was lower in weighted models but remained statistically significant at p < 0.05.
When adding housing conditions to the model (model 3), the association between bed bug exposure and psychological symptoms remained significant only in unweighted regression models. Specifically, elevated odds of anxiety (OR: 1.72; 95%CI: 1.12, 2.64), depression (OR: 1.83; 95%CI: 1.20, 2.78), and anxiety and/or depression (OR: 1.69; 95%CI: 1.16, 2.44) were observed among tenants exposed to bed bugs, independently of their sociodemographic characteristics and housing conditions.
In fully adjusted weighted regression models, exposure to bed bugs was not associated with anxiety or depression at p < 0.05. However, exposure to bed bugs was marginally (p = 0.087) associated with higher odds of reporting anxiety or depression (OR: 1.53; 95%CI: 0.94, 2.50).
Discussion
This study, based on a representative sample of 5,000 tenants on the Island of Montreal, Canada, explored the prevalence of self-reported exposure to bed bugs, associated risk factors and the association between self-reported bed bug exposure and psychological symptoms. Using data from the public health-led 2017 Montreal Housing Survey, we estimated that 4% of tenants reported seeing bed bugs in their dwelling in the past year. This amounts to about 16,800 households and 35,000 tenants (based on an average of two people per household) who are potentially affected on a yearly basis.
In our study, exposure to bed bugs was self-reported rather than being independently confirmed. While over-reporting seeing bed bugs is possible because of media coverage of bed bugs resurgence and the fear and stigma attached to bed bugs, underreporting is also likely. Results of Wang and colleagues’ study conducted in four lower-income communities in northern New Jersey, USA in 2014, showed that residents’ report of bed bug sightings was less reliable than visual inspection (or placing interceptors); in this study almost half of survey respondents were unaware of the presence of bed bugs in their units, even in the presence of an infestation [20]. In the sample of tenants participating to the Montreal Housing Survey, over three quarters who reported seeing bed bugs also reported their units being treated for bed bug infestation by an exterminator. Given the probable underestimation of the prevalence of bed bugs, especially because of the limited representation of tenants in social housing in our study, and bed bug infestations in privately owned homes, the 4% prevalence observed on the Island of Montreal is likely a conservative estimate.
As in other studies, self-reported exposure to bed bugs is socially patterned. In Montreal, the prevalence of self-reported bed bug sightings was higher for tenants living in a household with an annual income below the city median, speaking to the increased vulnerabilities of living in poorer housing conditions for lower-income households. Other studies, but not all [15], have reported on the elevated risk of bed bug exposure among lower-income populations [16, 18, 20]. As in other studies [2, 15, 17], self-reported exposure to bed bugs was higher among tenants living in multi-story buildings and in dwellings with water infiltration, humidity or mold problems. Dwellings in need of repairs (cracks around doors and windows caused by water infiltration, warped woodwork and floors, loose tiles or wallpaper, etc.), as well as cluttered dwellings, provide an ideal environment for bed bugs, while making it difficult to treat effectively [1]. Our results suggest that inequities in exposure to bed bugs may be partially conditioned by structural factors such building type. Contrary to other studies [15–18], there was no variation in self-reported exposure to bed bugs between age groups. The higher prevalence of self-reported bed bug sightings among men in our analysis has not been documented in other studies. Of the studies investigating the gendered exposure to bed bugs [16–18], one study conducted in the USA observed a higher proportion of bed bug infestation among households headed by women [18]. The reason for the gendered difference in exposure to bed bugs in our study is unclear and could result from confounding from variables not included in our analysis and/or from differences in the distribution of housing and socioeconomic characteristics between men and women. Given the small sample size, it was not possible to stratify the analysis by gender.
Among survey respondents, around 5% lived in social housing (data not shown in tables). Previous studies indicate that bed bug infestations are higher in residential buildings in poorer conditions and with higher density [2] – these features tend to characterize a large portion of the social housing stock on the Island of Montreal. The small sample size prevented analysis comparing tenants in the private rental market vs. those in social housing.
In unweighted fully adjusted analysis, self-reported exposure to bed bugs was significantly associated with 72% and 83% higher odds of anxiety and of depression, respectively, in the sample of tenants who took part in the survey. In weighted analysis, the strength of these associations was lower and no longer statistically significant. However, when considering anxiety or depression in combination, weighted results showed that tenants on the Island of Montreal had marginally higher odds of anxiety and/or depression when exposed to bed bugs in their dwelling (p = 0.087). Survey weights inflated the confidence interval of the model parameter estimates [45], which might explain the non-significance of results. While our study did not focus on sleep quality as an outcome, descriptive analyses showed that 54% of tenants self-reporting exposure to bed bugs also reported trouble sleeping, an association observed in other studies [16, 28]. Half of tenants who reported seeing bed bugs avoided inviting friends or family members over because of issues with bed bugs, potentially leading to social isolation as reported in other studies [35]. To our knowledge, this study is the first estimating the association between self-reported exposure to bed bugs and psychological symptoms in a large, representative, population-based sample.
Our results align with previous studies conducted in Montreal and in the United States, which also reported on poorer mental health in the presence of bed bugs [28, 36]. In unweighted analysis, results are robust to adjustments for the socioeconomic characteristics of tenants and their housing conditions. The relationship between bed bug exposure and psychological symptoms may be explained by pre-existing mental health conditions being aggravated by exposure to bed bugs or triggered by this exposure [34]. The relationship may also be explained (and mediated) by increased stress, poor sleep quality, hypervigilance, and social isolation [12, 23, 30–35]; these factors were not measured in the 2017 Montreal Housing Survey. It is possible that people with poorer mental health status drift into housing units in poorer conditions that are characterized, at least in our sample, by increasing risk of bed bug infestation. Because of the cross-sectional design of the study, reverse causality can therefore not be ruled out.
Results of our study need to be interpreted considering some limitations related to, e.g., cross-sectional study design, self-reported bed bug exposure and psychological symptoms, small sample size, and an underrepresentation of tenants in social housing – as described above. Another limitation has to do with the recruitment of participants using landlines; it is possible that the profile of the population using landlines differs from the population using cellphones. This difference might not be fully accounted for by the weighting procedure.
Conclusion
The resurgence of bed bugs in western societies is a major challenge for housing and public health authorities, which is disproportionately affecting people living in poorer housing conditions. Large-scale population surveys and monitoring are required to measure the prevalence of bed bug infestation and its health, social, and economic impacts and to provide information to support housing and public health surveillance and cross-sectoral actions. The social and environmental patterning of exposure to bed bugs compounds the complexity of the eradication process. For tenants, eradication sometimes means replacing furniture and mattresses, which bears important costs on sometimes already stretched budgets [4, 47, 48]. Treating bed bugs effectively requires reporting an infestation, proactive inspections of apartments, high-effectiveness of chosen pest management professionals and methods, cooperation on the part of the property manager and residents, and government funding to subsidize the costs of bed bug eradication [2]. In addition, to be effective, interventions to eradicate bed bugs may need to consider overall housing conditions as well as social inequalities in exposure. Interventions that focus solely on individual tenant responsibilities without taking into account such factors may be less effective. Without clear regulations and comprehensive approaches, eradicating bed bugs appears unattainable.
There is a continued need to increase active surveillance of bed bug infestations, while at the same time enacting regulations and comprehensive and coordinated action for disclosing infestations and for their eradication. As an example, in the 2010’s, New York City implemented an extensive approach to tackle bed bug infestations [24], with ordinances assigning landlords with the responsibility for treatment and for disclosure of infestations to tenants, and with substantial resources committed to responding to bed bug-related complaints [26]. A study by Hacker and colleagues showed that bed bug complaints significantly decreased in New York City between 2014 and 2020 [26]. These results lend support to a previous modelling study indicating the potential for disclosure ordinances to reduce the spread of bed bug infestations and the costs incurred by landlords and tenants [49]. Hacker and colleagues also observed that the decline in bed bug complaints was lower in lower-income neighborhoods and where bed bug infestations have historically been higher. This speaks to the difficulty of eradicating bed bugs as well as to the clustering and persistence of bed bug infestations is parts of the city where housing needs are more acute [26]. In another example in Oslo, Norway, a recent pest control intervention saw the incorporation of a procurement competence in a major public housing owner, in addition to a pest management framework on bed bug control and monitoring [8]. The intervention was deployed in more than 11,000 housing units over a six-year period; it demonstrated improved bed bug control [8].
Best practices for eliminating bed bugs [2, 15, 50–52] coupled with education [53], ongoing community engagement [54], a preoccupation for social justice [24], along with more research, could guide cities and other jurisdictions in implementing and monitoring their own strategies to control bed bug infestations.
Supplementary Information
Acknowledgements
The authors would like to thank Michel Fournier for his guidance in the data analysis process and Sophie Goudreau for her coordinating role. The authors also acknowledge previous contribution of undergraduate and graduate students at McGill University: Sophie Birks for her contribution to inventorying relevant literature, and Maaz Sahid for conducting preliminary data analysis.
Authors’ contributions
M.R. conceptualized and designed the study, contributed to the analysis and interpretation of data, wrote the main manuscript text, and integrated comments from all co-authors. D.K. was responsible for data acquisition; he contributed to the conceptualization and design of the study, to the interpretation of data, and revised and commented on the manuscript. P.D. conducted the data analysis, contributed to data interpretation, drafted sections of the manuscript, revised and commented on the manuscript. C.P. contributed to data analysis and interpretation, and commented on the manuscript. All authors approve the submitted version and agree both to be personally accountable for the author’s own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature.
Funding
Work reported in this paper was made possible thanks to funding from the Canada Research Chair in Housing, Community, and Health (CIHR 950-231678).
Data availability
The datasets analyzed for the current study are not publicly available due to confidentiality reasons.
Declarations
Ethics approval and consent to participate
The survey was carried out in the context of the Montreal Regional Public Health surveillance plan, which was approved by the Quebec Public Health Surveillance Ethics Board. All respondents provided informed consent to participate in the survey. For the secondary data analysis reported in this paper, further ethical approval was granted by McGill University’s Research Ethics Board (REB #20-08-052).
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The datasets analyzed for the current study are not publicly available due to confidentiality reasons.