Honey Bee Stings Barnstable County Beekeepers Association April

Honey Bee Stings Barnstable County Beekeepers Association April 11, 2017 Bruce R. Gordon, MD, FACS, FAAOA Harvard Clinical Instructor President, American Academy of Otolaryngic Allergy, 2002 -2003

Objectives Learn to : • • • Understand sting reaction types Recognize responsible insects Understand risk factors Understand basic sting treatment Understand when and how to immunize

Types of Illness from Bee Contact 1. 2. 3. 4. Propolis skin contact allergy Nasal allergy to hive dust and bee bodies Asthma and anaphylaxis from royal jelly Sting reactions: 1. 2. 3. 4. Local & Large Local allergy reactions Multiple sting Toxic reactions Systemic Anaphylacic reactions Cardiac reactions Bousquet J, Menardo JL, Michel FB. Allergy in beekeepers. Allergol Immunopathol (Madr). 1982; 10(5): 395 -8.

U. S. A. General Population Insect Stings • 27% sensitized to bee, wasp, or ant • > 0. 5 - 5% severe venom allergy • > 40 deaths / year 1. Neugut AI, Ghatak AAT, Miller RRL. Anaphylaxis in the United States: an investigation into its epidemiology. Arch Intern Med. 2001; 161(1): 15 -21. 2. Schäfer TT, Przybilla BB. Ig. E antibodies to Hymenoptera venoms in the serum are common in the general population and are related to indications of atopy. Allergy. 1996; 51(6): 372 -7. 3. Valentine MD, Lichtenstein LM. Anaphylaxis and stinging insect hypersensitivity. JAMA 1987; 258: 2881 -2885

Stinging Insects Hymenoptera (membrane-winged insects) : • Apids (honeybees and bumblebees) • Vespids (yellow jackets, wasps, hornets, and paper wasps) • Formicids (ants, fire ants) Most stings: honeybees and yellow jackets

Apids (Bees) Risk of being Stung • Domestic honeybees do not sting unless provoked • Bumblebees rarely sting • Africanized honeybees are hostile, aggressive, and sting in swarms

Honeybee Stinger is Barbed • This distinguishes honeybee stings from all other stings: bumblebees, wasps, and ants have no barbs

Honeybee stings once this kills the bee

Alarm pheromones evaporate from stings, attracting other bees to the victim Lewis, FS, Smith, LJ. What’s eating you? Bees, part 1. Cutis 2007; 79: 439 -44

Africanized Bee Stings • Africanized bees and European bees have identical venoms • Africanized bees are more dangerous due to easy arousal, aggressive stinging, mass stings, and persistent pursuit of the victim Lewis, FS, Smith, LJ. What’s eating you? Bees, part 1. Cutis 2007; 79: 439 -44

2012

Will Africanized Bees Replace European Bees? • European (EHB) queens are not as good fighters • Africanized (AHB) hives grow quicker, swarm more, and invade and replace EHB hives • But…AHB hives do not thrive with over 55 inches of rain throughout the year, and AHB hives require more food, so won’t survive > 3 mo. without pollen & nectar supply (ie, Northern winter)

Africanized Bees Potential Range

Africanized Bee Advantages • AHB hives grow quickly and are disease resistant • AHB honey production is superior (Brazil went from 27 th to 4 th in global honey production after Africanization) • AHB are Hybrids, not as aggressive as pure African Bees, but still good foragers

Sting Risk Factors

Sensitization Risk • Frequent stings, especially less than 2 mo. apart, may sensitize • Very frequent stings, over 50 / yr, usually desensitize Pucci S, Antonicelli L, Bilo MB, Garritani MS, Bonifazi F. Shortness of interval between two stings as risk factor for developing Hymenoptera venom allergy. Allergy. 1994; 49: 894 -6

Beekeeper Stings • 90% are stung/year; 55% get >100 stings • Average of 58 stings/year (range: 0 -1000) • 4. 4% - 6. 5 % get serious reactions • Higher Risks: having any kind of allergies, current allergy symptoms, fewer years as beekeeper, stings in spring season Celikel S, Karakaya G, Yurtsever N et al. Bee and bee products allergy in Turkish beekeepers: determination of risk factors for systemic reactions. Allergol Immunopathol (Madr). 2006; 34(5): 180 -4. Münstedt K, Hellner M, Winter D, et al. Allergy to bee venom in beekeepers in Germany. J Investig Allergol Clin Immunol. 2008; 18(2): 100 -5

Developing Bee Allergy in New Beekeepers 35 new beekeepers tested yearly for 5 years: • 29% became venom sensitive • most within 12 months, all by 18 months Kalogeromitros D, Makris M, Gregoriou S et al. Pattern of sensitization to honeybee venom in beekeepers: a 5 -year prospective study. Allergy Asthma Proc. 2006; 27(5): 383 -7

Predicting Risk of Serious Reaction in Beekeepers • prior serious sting reaction • allergic symptoms during hive work • less than 8 years beekeeping • high blood allergic venom antibodies Annila IT, Annila PA, Mörsky P. Risk assessment in determining systemic reactivity to honeybee stings in beekeepers. Ann Allergy Asthma Immunol. 1997; 78(5): 473 -7.

Consecutive Stings increase Anaphylaxis Risk 59% of serious reactions occur when there was a prior sting within 2 months (p=0. 0001 – statistically highly significant) Pucci S, Antonicelli L, Bilò MB et al. Shortness of interval between two stings as risk factor for developing Hymenoptera venom allergy. Allergy. 1994; 49(10): 894 -6.

Sting Treatment

Immediate Action for all Bee Stings • Rapidly remove venom sacs - envenomation is complete in one minute ! • Use your HIVE TOOL to scrape it off ! Schumacher MJ, Tveten MS, Egen NB. Rate and quantity of delivery of venom from honeybee stings. J Allergy Clin Immunol. 1994; 93(5): 831 -5.

Types of Sting Reactions 1. Immediate Allergic – varies in severity 2. Rare, Delayed Toxic (Non-Allergic) – multiple stings required, always serious 3. Rare, Immediate Cardiac Sting Reaction – always serious Graft DF. Stinging insect hypersensitivity in children. Curr Opin Ped. 1996; 8: 597 -600

Toxic Sting Reactions • Organ toxicity: brain & nerves, blood clots, kidney or heart injury, multi-organ failure, and death • Without treatment, > 20 -200 wasp stings or > 150 -1000 bee stings can be fatal • Symptoms may not appear for hours to several days • Go to the hospital immediately for any mass sting (call 911 !!!) Vetter RS, Visscher PK, Camazine S. Mass envenomations by honey bees and wasps. West J Med. 1999; 170(4): 223 -7.

Cardiac Sting Reaction • Immediate Allergic Angina, which may progress to a Heart Attack • Requires treatment of both the sting allergy, and the poor blood flow to the heart • Must go to hospital for treatment 1. Kounis NG, Soufras GD, Lianas D, Patsouras N. After Administration of Intravenous Epinephrine for bee Sting-induced Anaphylaxis: Kounis Syndrome or Epinephrine Effect? Chin Med J (Engl). 2016 Feb 20; 129(4): 500– 501 2. Scherbak D, Lazkani M, Sparacino N, Loli A. Kounis syndrome: a stinging case of ST elevation myocardial infarction. Heart Lung Circ. 2015 Apr; 24(4): e 48 -50

Severity of Allergic Reactions to Bee Stings 1. Local: pain, redness at site 2. Large Local: swelling of extremity 3. Systemic: generalized, involves any symptoms at a remote site from the sting. These may quickly be life threatening

Immediate Therapy Local Reactions ice, antihistamine Schumacher MJ, Tveten MS, Egen NB. Rate and quantity of delivery of venom from honeybee stings. J Allergy Clin Immunol. 1994; 93(5): 831 -5.

Immediate Therapy Large Local Reactions ice, antihistamine, prescription prednisone Schumacher MJ, Tveten MS, Egen NB. Rate and quantity of delivery of venom from honeybee stings. J Allergy Clin Immunol. 1994; 93(5): 831 -5.

Immediate Therapy Systemic Anaphylaxis Inject epinephrine & treat for anaphylaxis. ALWAYS Call 911 !!! Schumacher MJ, Tveten MS, Egen NB. Rate and quantity of delivery of venom from honeybee stings. J Allergy Clin Immunol. 1994; 93(5): 831 -5.

Deciding to Observe a Sting • Remove stingers • Calmly call for help. It’s wise to have a friend or relative with you, while you wait to see how you will do • Take any oral antihistamine

Deciding to use Epinephrine • Do you have any symptoms distant from the sting site? YES • Do you have any breathing, swallowing, or voice difficulty? YES • Do you feel like you could die? YES • Use Epinephrine AND call 911

Systemic Anaphylaxis • Treat immediately – time matters ! • USE epinephrine self-injector - easy, safe, quick • Inject into muscle. Count 15 sec. to allow spring to inject the medicine • Be ready to Re-Treat. Epinephrine may only last 5 -10 minutes

• Epinephrine is required more than once in 35% of anaphylaxis cases • Most insurance companies cover dual packs of epinephrine injectors. Buy them ! Korenblat P, Lundie MJ, Dankner RE, Day JH. A retrospective study of epinephrine administration for anaphylaxis: how many doses are needed? Allergy Asthma Proc. 1999; 20(6): 383 -6.

How to Use Epi-Pen • Caution after removing safety cap don’t inject hand • Swing hard • Inject through your clothes • Hold against leg & count slowly to 15

After Giving Epinephrine • Always CALL 911 • If patient has asthma, USE THEIR INHALERS • If available, give any oral antihistamine • Keep giving Epinephrine, as often as needed to control symptoms

Clinical History - helps with hospital treatment Important to Identify: • what kind of insect • type of reaction • severity of reaction • progression of this reaction over time • ? worse compared to last sting

After a Reaction is Over

Testing for Bee Venom Allergy 1. Blood testing 4 -6 weeks after sting 2. Evaluate results and consider reaction severity, progression in severity on serial stings, likelihood of another sting, and other medical conditions (like heart disease) 3. Consider skin testing

Management of Proven Sting Allergy Insect Avoidance – Extra care in Picnic/Garden areas • Orchards, flowers, pools & water sources – Wear shoes, long sleeves, pants, gloves – Avoid fragrances, bright colors – Use protective suit, veil, & gloves when working with bees – every time !

Management of Sting Allergy • Epinephrine kits – Kits must be with you to be useful • epinephrine stability is poor with oxygen, light, & heat. Do not keep in hot car ! ( check expiration and replace kits when needed ) – Practice injector use – Always call 911 after epinephrine

Management of Sting Allergy Venom Immunotherapy (Allergy Shots) - should be considered in all persons who: • have a positive history of one or more Systemic Reactions to stings • have a positive diagnostic test • are likely to be re-stung

Who Needs Immunotherapy ? Only 25 - 50% of patients repeat Systemic Reactions when re-stung • risk increases with repeat stings, especially if close together in time • higher risk for occupational exposure • higher risk for asthmatics • highest risk if Circulatory Shock occurs • clinical judgement required

Immunotherapy Results • Treatment effectiveness is 97% (Wasps) or >80% (Honeybees) • < 20% have mild reactions due to treatment • Rare patients (0. 7 %) require epinephrine during therapy 1. Mosbech H, Muller U. Side-effects of insect venom immunotherapy: results from an EAACI multicenter study. Allergy 2000; 55: 1005 -1010 2. Muller UR. Duration of venom immunotherapy. J Allergy Clin Immunol. 1997; 95: 271 -272

Immunotherapy Results 6. 5 years after beginning venom treatment: • 41% had been re-stung • >90% had improved quality of life: less fear, anxiety, depression, and fewer changes in lifestyle because of treatment 1. Findeis S, Craig T. The relationship between insect sting allergy treatment and patient anxiety and depression. Allergy Asthma Proc. 2014 May-Jun; 35(3): 260 -4 2. Roesch A, Boerzsoenyi J, Babilas P. et al. Outcome survey of insect venom allergic patients with venom immunotherapy in a rural population. J Dtsch Dermatol Ges. 2008; 6(4): 292 -7.

Immunotherapy Results immunotherapy patients, after at least 3 years of treatment. • 55% were re-stung, and 92% had only local reactions • 8% had milder systemic reactions than before treatment Hafner T, Du. Buske L, Kosnik M. Long-term efficacy of venom immunotherapy. Ann Allergy Asthma Immunol. 2008 100(2): 162 -5.

Benefits of Immunotherapy for Beekeepers vs non-beekeepers: no difference in immunotherapy results • beekeepers had fewer reactions during treatment • most beekeepers continued beekeeping with immunotherapy protection Eich-Wanger C, Müller UR. Bee sting allergy in beekeepers. Clin Exp Allergy. 1998; 28(10): 1292 -8.

Checking on Treatment Effectiveness

Blood Test of Immunity • If protective immunity is occurring : – Ig. E allergic antibodies decrease – Ig. G protective antibodies increase • Blood may be checked before stopping treatment (usually at 5 years) • Higher venom doses can be used if standard doses do not work 1. Valentine MD, Lichtenstein LM. Anaphylaxis and stinging insect hypersensitivity. JAMA 1987; 258: 2881 -2885 2. Bosquet J, Muller UR, Drebord S, et al. Immunotherapy with Hymenoptera venoms. Allergy 1987; 42: 401 -413

• In rare patients, it is impossible to increase the venom treatment dose high enough to produce good immunity, without triggering unacceptable reactions • Most people with this problem can be helped with Xolair anti-Ig. E treatment

Summary • Avoidance techniques should always be used (WEAR YOUR GEAR) • If allergic, epinephrine injector should always be with you • Accurate diagnosis is critical • Immunotherapy is highly effective, but treatment failures still can occur

Happy, Safe, Beekeeping !