Editorials

Advice for Protection Against Mosquitoes and Ticks

 


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Am Fam Physician. 2015 Jun 1;91(11):754-755.

Emerging vector-borne diseases have become a concern for travelers and nontravelers alike. Although Ebola has dominated recent headlines, tropical arboviruses such as dengue and chikungunya have more quietly reached the United States. Local transmission of chikungunya virus was first documented in the United States in July 2014, and local spread of dengue has occurred in Florida, Texas, and Hawaii.1,2 West Nile virus was initially detected in the United States in 1999 and has since been found in every state in the continental United States.3  Furthermore, tick-borne diseases such as Lyme disease, southern tick-associated rash illness, and Rocky Mountain spotted fever are endemic to many parts of the country. The changing epidemiology of vector-borne diseases highlights the importance of personal protective measures, including the use of insect repellents. There are many myths and misperceptions about repellents, and there is increasing consumer interest in “natural” alternatives to conventional products. Therefore, family physicians should be knowledgeable about which products are effective and safe. Table 1 lists effective insect repellents registered by the Environmental Protection Agency (EPA).4

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Table 1.

Effective Insect Repellents Registered by the Environmental Protection Agency

DEET (N,N-diethyl-m-toluamide)

IR3535 (3-[N-butyl-N-acetyl]-aminopropionic acid, ethyl ester)

Oil of lemon eucalyptus (para-menthane-3,8-diol)

Picaridin (KBR 3023)


Information from reference 4.

Table 1.

Effective Insect Repellents Registered by the Environmental Protection Agency

DEET (N,N-diethyl-m-toluamide)

IR3535 (3-[N-butyl-N-acetyl]-aminopropionic acid, ethyl ester)

Oil of lemon eucalyptus (para-menthane-3,8-diol)

Picaridin (KBR 3023)


Information from reference 4.

N,N-diethyl-m-toluamide (DEET) is the first-line mosquito repellent, and numerous studies have demonstrated its effectiveness and safety.4,5 Repellents with 20% to 50% DEET provide up to several hours of protection (there is no significant increase in effectiveness with concentrations greater than 50%.) DEET-impregnated wristbands repel mosquitoes only from areas covered by the band, so their usefulness is limited. DEET is considered safe in the second and third trimesters of pregnancy and in children older than two months.4,5 It should be noted that it can damage plastics and synthetic materials; therefore, care should be taken when it is used around plastic watches, eyeglasses, and synthetic fabrics.

Effective alternatives to DEET include Picaridin (KBR 3023) and IR3535 (3-[N-butyl-N-acetyl]-aminopropionic acid, ethyl ester).4 Picaridin does not affect plastic or synthetic materials and is essentially odorless. IR3535 is available in the United States as Avon Skin-So-Soft Bug Guard Plus IR3535 lotion. Picaridin and IR3535 are generally considered safe in children and pregnant women.

There is growing interest in natural insect repellents, but most are not recommended because of lack of effectiveness.6 An exception is oil of lemon eucalyptus (p-menthane-3,8-diol), a plant-based repellent that has been shown to have effectiveness and duration of action comparable to DEET. It is the only plant-based repellent recommended by the Centers for Disease Control and Prevention,4 but should not be used by pregnant women or children younger than three years. Studies have also shown that a repellent combining 2% soybean oil with other oils and emollients protects against mosquitoes for 1.5 to 7.2 hours.5 This type of repellent is available in the United States as Bite Blocker but is not registered by the EPA as a repellent.

Citronella is a common ingredient in many natural repellents. However, citronella-based products at lower concentrations have a limited duration of action, and higher concentrations can cause skin irritation. Therefore, citronella may be acceptable for brief exposure to nuisance mosquitoes, but it is not advised for protection against disease-carrying mosquitoes. Essential oils have no effectiveness and are not recommended.

There is no evidence to support the use of novel devices such as electronic mosquito repellents.7 Likewise, there is no validity to the notion that ingesting garlic or B vitamins protects against mosquitoes.

Synthetic mosquito repellents also have some effectiveness against ticks; however, IR3535 provides the best protection against the Lyme vector Ixodes scapularis.8,9 Permethrin, a product originally derived from chrysanthemum flowers, has insecticidal and repellent properties and is highly effective against ticks, mosquitoes, and other arthropods. It is applied to clothing and other fabrics (e.g., nets, tents) and not on skin. Combining the use of permethrin on clothes with other repellents on exposed skin provides the best protection against biting arthropods.

Increased international travel and climate change will continue to influence the distribution of arthropods and the viruses they carry. Aedes aegypti, the vector for yellow fever and dengue, was found in Los Angeles County, Calif., for the first time in 2014.10 Consequently, the importance of using insect repellents has grown. The EPA recently introduced a repellency awareness graphic (Figure 1) to help consumers understand which insects the product protects against, as well as the duration of action of the product. It is anticipated that additional alternatives to traditional repellents will be developed, providing consumers with more options.

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Figure 1.

Sample Environmental Protection Agency repellency awareness graphic. The graphic is aimed at helping consumers understand which insects the product protects against, and the duration of action of the product.

Reprinted from U.S. Environmental Protection Agency. Repellency awareness graphic. http://www2.epa.gov/insect-repellents/repellency-awareness-graphic. Accessed March 25, 2015.


Figure 1.

Sample Environmental Protection Agency repellency awareness graphic. The graphic is aimed at helping consumers understand which insects the product protects against, and the duration of action of the product.

Reprinted from U.S. Environmental Protection Agency. Repellency awareness graphic. http://www2.epa.gov/insect-repellents/repellency-awareness-graphic. Accessed March 25, 2015.

Address correspondence to Johnnie Yates, MD, DTM&H, FAAFP, at johnnie.a.yates@kp.org. Reprints are not available from the author.

Author disclosure: No relevant financial affiliations.

REFERENCES

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1. Centers for Disease Control and Prevention. First chikungunya case acquired in the United States reported in Florida [news release]. July 17, 2014. http://www.cdc.gov/media/releases/2014/p0717-chikungunya.html. Accessed December 16, 2014....

2. Centers for Disease Control and Prevention. Locally acquired Dengue–Key West, Florida, 2009–2010. MMWR Morb Mortal Wkly Rep. 2010;59(19):577–581.

3. Centers for Disease Control and Prevention. West Nile virus. http://www.cdc.gov/westnile/faq/genQuestions.html. Accessed February 5, 2015.

4. Nasci RS, Zielinski-Gutierrez E, Wirtz RA, Brogdon WG. Protection against mosquitoes, ticks, & other insects & arthropods. In: Centers for Disease Control and Prevention. Health Information for International Travel 2014. New York, NY: Oxford University Press; 2014. http://wwwnc.cdc.gov/travel/yellowbook/2014/chapter-2-the-pre-travel-consultation/protection-against-mosquitoes-ticks-and-other-insects-and-arthropods. Accessed December 16, 2014.

5. Goodyer LI, Croft AM, Frances SP, et al. Expert review of the evidence base for arthropod bite avoidance. J Travel Med. 2010;17(3):182–192.

6. Maia MF, Moore SJ. Plant-based insect repellents: a review of their efficacy, development and testing. Malar J. 2011;10(suppl 1):S11.

7. Enayati AA, Hemingway J, Garner P. Electronic mosquito repellents for preventing mosquito bites and malaria infection. Cochrane Database Syst Rev. 2007;(2):CD005434.

8. Lupi E, Hatz C, Schlagenhauf P. The efficacy of repellents against Aedes, Anopheles, Culex and Ixodes spp. – A literature review. Travel Med Infect Dis. 2013;11(6):374–411.

9. Carroll SP. Prolonged efficacy of IR3535 repellents against mosquitoes and blacklegged ticks in North America. J Med Entomol. 2008;45(4):706–714.

10. ProMED Digest. Invasive mosquito – USA (03): (California). October 16, 2014. http://www.promedmail.org. Accessed December 16, 2014.



 

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