IPM in a Medical IPM in a Medical Treatment FacilityTreatment Facility

John D. Nelson, BCEJohn D. Nelson, BCE

EntomologistEntomologist

Tripler Army Medical CenterTripler Army Medical Center

ReferencesReferences

AR 40-5, Preventive MedicineAR 40-5, Preventive Medicine TB MED 561, Occupational and Environmental TB MED 561, Occupational and Environmental

Health Pest SurveillanceHealth Pest Surveillance AR 200-5, Environmental Quality, Pest Mgmt.AR 200-5, Environmental Quality, Pest Mgmt. DODI 4150.7, Pest Mgmt. Program.DODI 4150.7, Pest Mgmt. Program. TIM No. 20 - Pest Mgmt. Operations in a

Medical Treatment Facility TIM No. 29 - IPM Mgmt. In and Around BuildingsTIM No. 29 - IPM Mgmt. In and Around Buildings

OutlineOutline

TAMC – Pest Mgmt. Program SummaryTAMC – Pest Mgmt. Program Summary ““Urban” IPM in a Hospital Environment Urban” IPM in a Hospital Environment

(MTF)(MTF)MTF PestsMTF PestsPest Mgmt. ProcessPest Mgmt. Process IPM Program Elements IPM Program Elements Case Study – Crazy AntsCase Study – Crazy AntsOpportunities / IniaitivesOpportunities / Iniaitives

Tripler Army Medical CenterTripler Army Medical CenterPest Mgmt. AdministrationPest Mgmt. Administration

Pest Mgmt. services non-standardized in MTFs across Pest Mgmt. services non-standardized in MTFs across DA, DoDDA, DoD

Tenant of USAG-HI (installation)Tenant of USAG-HI (installation) USAG-HI Entomologist maintains PMP for entire USAG-HI Entomologist maintains PMP for entire

installation; TAMC has autonomous programinstallation; TAMC has autonomous program Pest Mgmt. activities transferred from DPW to TAMC in 1998 Pest Mgmt. activities transferred from DPW to TAMC in 1998

TAMC Entomologist administers the PMP, serves as TAMC Entomologist administers the PMP, serves as COR for pest control service contractsCOR for pest control service contracts

Responsible for pest control activities in CAC 500 bldgs. Responsible for pest control activities in CAC 500 bldgs. Subcontractors carry out pest mgmt. actions within TAMC Subcontractors carry out pest mgmt. actions within TAMC

(funded by logistics division)(funded by logistics division) MOA between Logistics Div. and Dept. Prev. Med.MOA between Logistics Div. and Dept. Prev. Med.

Funding: 20K LOG, 5K Dept. PV, 20K EPR fundsFunding: 20K LOG, 5K Dept. PV, 20K EPR funds

TAMC Pest Mgmt. PersonnelTAMC Pest Mgmt. Personnel

EntomologistEntomologistDept. of Prev. Med., Env. Health Section.Dept. of Prev. Med., Env. Health Section.Pest Mgmt. CoordinatorPest Mgmt. CoordinatorMedical EntomologistMedical EntomologistCurrently “one-man-show”Currently “one-man-show”

91S91SGS-9 TechnicianGS-9 TechnicianContractorsContractors

FacilityFacility

2,159,509 sq. ft.2,159,509 sq. ft.

Installation Description

Hospital SettingHospital SettingImportant IssuesImportant Issues

Little to no threshold toleranceLittle to no threshold tolerance Nosocomial infectious agents (mechanical Nosocomial infectious agents (mechanical

transmission)transmission) Sensitive environments – pests may affect Sensitive environments – pests may affect

sterility of supplies and equipmentsterility of supplies and equipment Immunocompromised individualsImmunocompromised individuals Infants/childrenInfants/children Anxiety – pests may interfere with patient Anxiety – pests may interfere with patient

comfort or recoverycomfort or recovery High liability potential – if pests implicated in High liability potential – if pests implicated in

compromising quality of patient carecompromising quality of patient care

Hospital EnvironmentsHospital Environments Sensitive environmentsSensitive environments

Surgical suitesSurgical suites Sterile facilitiesSterile facilities ICUsICUs Patient wards/roomsPatient wards/rooms Waiting areasWaiting areas

Food handling / service establishmentsFood handling / service establishments Food areasFood areas Nonfood areasNonfood areas

Admin, Maintenance, & Utility areasAdmin, Maintenance, & Utility areas Lounges / Break-rooms Waiting roomsWaiting rooms Locker rooms Locker rooms OfficesOffices

MTF DemographicsMTF Demographics

Generals / senior officersGenerals / senior officersSurgeonsSurgeonsOther physiciansOther physiciansNursesNursesSenior / junior enlistedSenior / junior enlistedCiviliansCiviliansPatients (AD & Beneficiaries)Patients (AD & Beneficiaries)ContractorsContractors

Agricultural vs. Urban IPMAgricultural vs. Urban IPM

Field EnvironmentField Environment MonitoringMonitoring Multiple strategiesMultiple strategies Economic thresholdsEconomic thresholds Some insects tolerated Some insects tolerated Minimal human Minimal human

interaction interaction

Human EnvironmentHuman Environment MonitoringMonitoring Multiple strategiesMultiple strategies Aesthetic thresholdsAesthetic thresholds Very few insects Very few insects

toleratedtolerated Constant human Constant human

interactioninteraction

Urban environmentUrban environment

Manmade environmentManmade environmentConditions suitable/comfortable for Conditions suitable/comfortable for

humans & pestshumans & pestsConsistent world wideConsistent world wideSpecific assemblage of pestsSpecific assemblage of pests

Urban IPM ComponentsUrban IPM Components

InspectionInspection Education - clients and techniciansEducation - clients and technicians Analyzing pest problemAnalyzing pest problem Taking short term corrective actionsTaking short term corrective actions Implement long-term, preventive actionImplement long-term, preventive action

Sanitation / ExclusionSanitation / Exclusion

Monitoring, documenting, and evaluating resultsMonitoring, documenting, and evaluating results Follow-upFollow-up

Measurement of customer satisfaction criticalMeasurement of customer satisfaction critical

Essential Program ElementsEssential Program Elements(keys for success)(keys for success)

IPM treatment strategies - varietyIPM treatment strategies - variety Knowledgeable coordinatorKnowledgeable coordinator

Pest idPest id Treatment recommendationsTreatment recommendations ReevaluationReevaluation Long-term solutionsLong-term solutions

Comprehensive planComprehensive plan Decision modelsDecision models Paper trail/record keepingPaper trail/record keeping Public relationsPublic relations Contractor relationsContractor relations

PestsPests

AntsAnts RoachesRoaches RodentsRodents BirdsBirds TermitesTermites ArachnidsArachnids EctoparasitesEctoparasites FliesFlies Wasps / BeesWasps / Bees

Pest Management ProcessPest Management Process

Complaint

Inspection/Consultation

Sanitation/Education

Structural modification

Treatment

Monitoring

1) Complaint1) Complaint

AvenuesAvenues TelephoneTelephone EmailEmail Website – Sharepoint (internal)Website – Sharepoint (internal) Direct – “Hey you…”Direct – “Hey you…” PMC Inspection – routine and randomPMC Inspection – routine and random

Priority assignmentPriority assignmentFY 06’ Avg. response time FY 06’ Avg. response time ≤ 48 hrs.≤ 48 hrs.

Pest Complaint PercentagesPest Complaint Percentagesn=275 FY 06’n=275 FY 06’

ANTS

BEES/WASPS

FLIES

OTHER INVERTSOTHER VERTS

RODENTS

COCKROACHES

2) Inspection / Consultation2) Inspection / Consultation

Talk to POCTalk to POCHistory of problemHistory of problemPest speciesPest speciesSource of problemSource of problemFood / waterFood / waterOther concerns or issuesOther concerns or issuesDD Form 1532-1 (or equivalent) DD Form 1532-1 (or equivalent)

3) Education3) Education

Food / water sourcesFood / water sources Important speciesImportant speciesControl methods usedControl methods usedConcerns warranted?Concerns warranted?Attainable expectations?Attainable expectations?Listen & communicateListen & communicateTraining opportunity / EmpowermentTraining opportunity / Empowerment

Pests in Paradise PrimerPests in Paradise Primer

4) Structural Modification & 4) Structural Modification & SanitationSanitation

ElementsElements Door / windowsDoor / windows Cracks / crevicesCracks / crevices WaterWater

LandscapeLandscape PlantsPlants Water containersWater containers Garbage / recycle cansGarbage / recycle cans HarborageHarborage

Pest RequirementsPest Requirements

FOOD

WATER SHELTER

5) Treatment5) Treatment

Physical, biological, and or chemical controlPhysical, biological, and or chemical controlPesticides, baits (must be labeled for hospital Pesticides, baits (must be labeled for hospital

use)use)No preventive treatments allowed by regsNo preventive treatments allowed by regsCoordinator or Contractor as PCO?Coordinator or Contractor as PCO?

Common Sense RuleCommon Sense Rule Work order generationWork order generation On-call priority designationsOn-call priority designations

Control OptionsControl Options

SanitationSanitationEducation Education MonitoringMonitoringExclusionExclusionTrappingTrappingBaitingBaitingPesticide applicationPesticide application

Problem AreasProblem Areas

LockersLockersBreak roomsBreak roomsPlumbingPlumbingRestaurantsRestaurantsOffice goodiesOffice goodiesPatient waiting roomsPatient waiting rooms

6) Monitoring6) Monitoring Pesticides should only be applied with Pesticides should only be applied with

supportive monitoring datasupportive monitoring data Population estimationPopulation estimation Decision levelsDecision levels Baseline informationBaseline information Conducted regularly (fixed traps, customer Conducted regularly (fixed traps, customer

survey, or pest log) survey, or pest log)

Pest Control Contract ProblemsPest Control Contract Problems

No direct controlNo direct controlControl optionsControl optionsQuality of workQuality of work

Liability of environmental regulationsLiability of environmental regulationsNo vested interest in organizationNo vested interest in organizationDifficult to terminateDifficult to terminateMore difficult to rehire new companyMore difficult to rehire new company

Contract RelationsContract Relations

Recruiting quality companiesRecruiting quality companiesCommunicationCommunicationQuality ControlQuality Control

ProfessionalismProfessionalism Client satisfactionClient satisfaction EfficacyEfficacy TimelinessTimeliness SafetySafety Compliance with laws / regsCompliance with laws / regs

Pest Ants of HIPest Ants of HI

big-headedbig-headedcrazycrazyglaberglaberpharaohpharaoh long-leggedlong-leggedcarpentercarpenterghostghostargentineargentine

Ant RequirementsAnt Requirements

Food Food proteinprotein fatfat sugarsugar

WaterWater

Shelter (harborage) - Shelter (harborage) - sometimessometimes carpenter antscarpenter ants glaber antsglaber ants

Ant Food Preferences Ant Food Preferences & Colony Structure& Colony Structure

Species Sweet Protein Oil Insect Queen

Crazy X X X MGlaber X SPharaoh X X X X MLong-legged X X SCarpenter X X M

Big-headed X X X M

Ant IPM - BaitingAnt IPM - Baiting

Low toxicityLow toxicityFeeding preferenceFeeding preferencePre-baitingPre-baitingClosest to sourceClosest to sourceNONO insecticide use insecticide useBait acceptanceBait acceptanceRe-inspection / refresh baitsRe-inspection / refresh baits

Ant IPM - Bait TypesAnt IPM - Bait Types

Stations - various Stations - various

Gels – variousGels – various

Liquids - sugar/boric acid Liquids - sugar/boric acid

Custom mixturesCustom mixtures

Start

Pest Complaint

Inspection / identification

Education/Sanitation/ Environmental modification

Interior/exteriorBaiting

Ant Aesthetic Threshold:

A/D = Ants per day

(+) A/D > 10 (Complaint) (-) A/D < or = 10 (Satisfaction)

(+)

(+)

(+)

1-month follow-up inspection

(+)

(-)

(-)

(-)

Seek and destroy colonies (outside)

Group A Group B

Ant IPMAnt IPM

Ant IPMAnt IPM

Group A SpeciesGroup A Species Glaber AntsGlaber Ants Long-leggedLong-legged ArgentineArgentine Carpenter Carpenter Big-headedBig-headed

Group B SpeciesGroup B Species Crazy Crazy PharaohPharaoh GhostGhost

Pathogens Associated with Pathogens Associated with Pharaoh Ants in HospitalsPharaoh Ants in Hospitals

Pseudomonas aeroginosaPseudomonas aeroginosaStaphlococcus spp.Staphlococcus spp.Steptococcus pyogenesSteptococcus pyogenesSalmonella spp.Salmonella spp.Clostridium spp.Clostridium spp.Many others...Many others...

Paratrechina longicornis (Latr.)

Crazy Ant Case Study

Crazy Ant ComplaintsCrazy Ant Complaints

Several urgent complaints from A-wing, 2Several urgent complaints from A-wing, 2ndnd floorfloor

Party Friday - Department of SurgeryParty Friday - Department of SurgeryRefreshments left out over the weekend – Refreshments left out over the weekend –

covered with antscovered with antsAnts now in exam rooms and doc officesAnts now in exam rooms and doc officesOrigin – perimeter of hospitalOrigin – perimeter of hospital

Crazy Ants Crazy Ants Contract PCO ManagedContract PCO Managed

Boric acid sugar-based gel baitBoric acid sugar-based gel bait Perimeter treatment Perimeter treatment

Cyfluthrin (Tempo WP)Cyfluthrin (Tempo WP) Cypermethrin (Demon WP)Cypermethrin (Demon WP)

Re-infestation- one monthRe-infestation- one month Re-treatment with same strategy Re-treatment with same strategy Infestation continuing and spreading to other Infestation continuing and spreading to other

areasareas

Crazy Ant BiologyCrazy Ant Biology

Large coloniesLarge coloniesMultiple queens – colonies split readilyMultiple queens – colonies split readilyShifting food preferences – difficult to baitShifting food preferences – difficult to baitVery mobile – invades quicklyVery mobile – invades quicklyAssociated with nectar producing plantsAssociated with nectar producing plantsTends aphids/scale insectsTends aphids/scale insects

Crazy Ants Crazy Ants Coordinator ManagedCoordinator Managed

Reevaluation of infestation Reevaluation of infestation Boric acid & Hydromethylnon baits insideBoric acid & Hydromethylnon baits inside

Rapid control - no re-infestationsRapid control - no re-infestationsContinual sporadic infestationsContinual sporadic infestationsPerimeter treatmentsPerimeter treatmentsExclusionExclusionEducate staffEducate staff

Crazy Ants Crazy Ants Perimeter ProgramPerimeter Program

Vegetation managementVegetation management Monthly monitoringMonthly monitoring ExclusionExclusion Perimeter treatmentsPerimeter treatments

Borate baits (Terro II)Borate baits (Terro II) Hydromethylnon baits (Amdro, Maxforce granules)Hydromethylnon baits (Amdro, Maxforce granules) Bifenthrin (Talstar granules)Bifenthrin (Talstar granules)

Follow-up treatments as necessaryFollow-up treatments as necessary

Crazy Ant ComplaintsCrazy Ant Complaints

0

2

4

6

8

10

12

A-wing

B-wing

C-wing

D-wing

PCO Coordinator

Perimeter Program

Crazy Ant ControlCrazy Ant ControlKeys to Successful ManagementKeys to Successful Management

Manage exterior populationsManage exterior populations ExclusionExclusion Vegetation ManagementVegetation Management

Eliminate nectar producersEliminate nectar producers Control aphids/scale insectsControl aphids/scale insects

Bait aggressively – be flexibleBait aggressively – be flexible Granular pesticideGranular pesticide Client EducationClient Education

Underlying Issues - PeopleUnderlying Issues - People

Perimeter vegetationPerimeter vegetation

Personal sanitation – food / shelter / waterPersonal sanitation – food / shelter / water

Trash management Trash management

Underlying Issues - Contractors Underlying Issues - Contractors

Do:Do:Apply treatmentsApply treatmentsTreat a single point (in time)Treat a single point (in time)

Don’t DoDon’t DoPreventionPreventionSanitationSanitationEducationEducationSolve long-term problemsSolve long-term problems

Crazy Ants Crazy Ants Coordinator ManagedCoordinator Managed

Rapid feedback and reevaluation/re-treatmentRapid feedback and reevaluation/re-treatment

Rapid control inside - no re-infestationsRapid control inside - no re-infestations

Continual sporadic infestationsContinual sporadic infestations

Definitive ID of pest and sourceDefinitive ID of pest and source

Precise application of appropriate treatmentPrecise application of appropriate treatment

Historical perspectiveHistorical perspective

Centralized solution – for entire facility not just a given pointCentralized solution – for entire facility not just a given point

Long-term solutionsLong-term solutions

Initiatives / OpportunitiesInitiatives / Opportunities

GPS geo-referencing & Bar-codingGPS geo-referencing & Bar-coding Research projectsResearch projects

Pesticide resistance studiesPesticide resistance studies Bait preference studiesBait preference studies

Establish self-help pest management programEstablish self-help pest management program Waste water / Sewer line treatmentsWaste water / Sewer line treatments Enforce designated staff eating areasEnforce designated staff eating areas Steam-clean or cold store carts, tray racks, and Steam-clean or cold store carts, tray racks, and

other portable itemsother portable items

Aloha!