Honeybees and Your Health Inverness Beekeepers March 2011

1. Honeybees and Your Health Inverness BeekeepersMarch 2011

2. Honeybees and Your Health Topics • Stings • Allergy • Anaphylaxis • Moving and handling • Health benefits from beekeeping and honey

3. Honeybees and Your Health Health benefits from beekeeping and honey • Community • Interaction with nature and science • Financial • Honey as a treatment

4. Honeybees and Your HealthBee Stings Treatment The first step in treatment following a bee sting is removal of the stinger itself. The stinger should be removed as fast as possible without regard to method: studies have shown the amount of venom delivered does not differ if the sting is pinched or scraped off and even a delay of a few seconds leads to more venom being injected.

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6. Honey bees and your health Bee venom (apitoxin) • Unlike many other insect venoms, bee venom is water soluble, not fat soluble, and so must be injected into moist tissue to be effective. It is haemorrhagic, unlike snake venom, which is a coagulant • Bee venom is a mixture of histamine, pheromones, enzymes, peptides, amino acids and other acids, with 63 components in total. The main enzymes present are phospholipase A, hyaluronidase, and lecithinase; while the main peptides are mellitin, apamin and peptide 401. Bee venom is cytotoxic (ie. cell-destroying)

7. Honeybees and your health LOCAL REACTIONS •  Local reactions consist of symptoms that are confined to the tissues directly surrounding the sting site. They are usually mild and transient, although some patients develop large local reactions or secondary bacterial infections. • Uncomplicated local reactions — A typical local reaction to a bee sting is redness and an area of painful swelling (1 to 5 cm) at the site of the sting that develops within minutes and resolves within a few hours Occasionally, swelling may last 1 to 2 days. Uncomplicated local reactions may be treated with cold compresses.

8. Honeybees and Your Health • Large local reactions — Approximately 10 percent of individuals develop exaggerated redness and swelling at the site of the sting that gradually enlarges over one to two days. This response is called a large local reaction (LLR). LLRs peak at approximately 48 hours and then gradually resolve over 5 to 10 days. The area of swelling typically measures about 10 cm in diameter. Treatment of LLRs is based upon symptoms. : • Cold compresses are soothing acutely. The limb should be elevated if the sting is on an extremity. • Non-steroidal anti-inflammatory drugs (NSAIDs) can reduce pain. • Itch can be treated with oral antihistamines and topical corticoid steroids.

9. Honeybees and Your Health Initial treatment of bee stings • Many traditional remedies have been suggested for bee stings including damp pastes of tobacco, salt, baking soda, meat tenderizer, toothpaste, clay, garlic, urine, onions, aspirin and even application of copper coins. • As bee venom is acidic it is logical to try and neutralize the pH. • This is unlikely to be effective however as the venom is injected under the skin and deep into the tissues, where a topically applied alkali is unable to reach, so neutralization is unlikely to occur. • In any case, the amount of venom injected is typically very small (between 5 and 50 micrograms of fluid) and placing large amounts of alkali near the sting site is unlikely to produce a perfectly neutral pH to stop the pain. • A randomized trial of aspirin paste and topical ice packs showed that aspirin was not effective in reducing the duration of swelling or pain in bee and wasp stings, and significantly increased the duration of redness The study concluded that ice alone is better treatment for bee and wasp stings than aspirin. • The sting may be painful for a few hours. Swelling and itching may persist for a week. The area should not be scratched as it will only increase the itching and swelling. If a reaction persists for over a week or covers an area greater than 7-10 cm (3 or 4 inches), medical attention should be sought.

10. Honeybees and Your Health Allergic reactions to bee stings Cells involved in allergic disease • Mast cells and basophils • Monocytes, macrophages, and lymphocytes

11. Honeybees and Your Health The mediators of allergic disease • Histamine • Eicosanoids • Platelet-activating factor • Kinins

12. Honeybees and Your Health Allergic reactions Stages of an allergic reaction 1: Sensitization. The initial meeting of an allergen and the immune system yields no symptoms; it may prepare the body to react promptly to future encounters with the substance. The sensitization process begins when macrophages degrade the allergen and display the resulting fragments to T lymphocytes (bottom left). Following this, in a process involving secretion of interleukin 4 by T cells, B lymphocytes mature into plasma cells able to secrete allergen-specific molecules known as immunoglobulin E (IgE) antibodies. These antibodies attach to receptors on mast cells in tissue and on basophils circulating in blood.

13. Honeybees and Your HealthAllergic reactions Stages of an allergic reaction 2: Activation of mast cells. On further exposure between the allergen and the immune system, allergen molecules bind to IgE antibodies on mast cells (top left). When one such molecule connects with two IgE molecules on the cell surface, it draws together the attached IgE receptors, thereby directly or indirectly activating various enzymes in the cell membrane. Cascades of chemicals and enzymes are released from intracellular granules These cascades also appear to promote the synthesis and release of chemicals known as cytokines The various chemicals released by mast cells are responsible for many allergic symptoms.

14. Honeybees and Your Health Allergic reactions Stages of an allergic reaction 3: Prolonged immune activity. Chemicals emitted by activated mast cells and their neighbours in tissue may induce basophils, eosinophils, and other cells flowing through blood vessels (right) to migrate into that tissue. The chemicals facilitate migration by promoting the expression and activity of adhesion molecules on the circulating cells and on vascular endothelial cells. The circulating cells then attach to the endothelial cells, roll along them, and eventually, cross between them into the surrounding matrix. These recruited cells secrete chemicals of their own , which can sustain immune activity and damage tissue.

15. Honeybees and your health Beyond the basic sting reaction • Systemic allergic reactions • Urticaria • Angioedema

16. Honeybees and Your Health Urticaria

17. Honeybees and Your Health Urticaria • Urticaria is characterized by well-defined areas of transient pruritic dermal oedema, demarcated by a red border, which usually resolve spontaneously within a few hours, although episodes may continue for days. If the oedema spreads through the underlying epidermis, then it is called angio-oedema. The latter occurs mostly in the periorbital regions, the lips, the tongue, and the oropharynx and does not itch. In these instances, the possibility of pharyngeal obstruction may develop rapidly. Urticaria is probably due to mast cell degranulation, whether this is immunologically or non-immunologically mediated. Basophils may play a role in the longer episodes. • Acute urticaria usually resolves within hours or days. If attacks of urticaria are recurrent and without obvious precipitating factors, patients should keep a diary to document food, beverage, and drug intake. In this way, triggers may be identified. It should also be remembered that urticaria sometimes is associated with systemic diseases such as lymphoma or systemic lupus erythematosis. • Treatment at first is with antihistamines, and since they may have to be used quite vigorously, the non-sedating antihistamines are probably preferable. Systemic corticosteroids may be required in very severe cases that do not respond to other treatments.

18. Honeybees and Your Health Angioedema • Similar to urticaria, but involving mucosal surfaces, often around face, ie the mouth and eyes, larynx, can sometimes involve bowel. • Caused by fluid leaking from vessels.

19. Honeybees and Your Health Anaphylaxis Anaphylaxis is a severe, life-threatening, generalised or systemic hypersensitivity reaction. Anaphylaxis is likely when all of the following 3 criteria are met: • Sudden onset and rapid progression of symptoms • Life-threatening Airway and/or Breathing and/or Circulation problems • Skin and/or mucosal changes (flushing, urticaria, angioedema) Exposure to a known allergen for the patient supports the diagnosis: Remember: • Skin or mucosal changes alone are not a sign of an anaphylactic reaction • Skin and mucosal changes can be subtle or absent in up to 20% of reactions (some patients can have only a decrease in blood pressure,i.e., a Circulation problem)

20. Honeybees and Your Health Time course for fatal anaphylactic reactions • When anaphylaxis is fatal, death usually occurs very soon after contact with the trigger. From a case-series, fatal food reactions cause respiratory arrest typically after 30–35 minutes; insect stings cause collapse from shock after 10–15 minutes;and deaths caused by intravenous medication occur most commonly within five minutes. • Death never occurred more than six hours after contact with the trigger

21. Honeybees and Your Health Time to cardiac arrest following exposure to triggering agent From Resuscitation Council UK website

22. Honeybees and Your Health Table 1. Suspected triggers for fatal anaphylactic reactions in the UK between 1992-2001 (from Resuscitation Council UK website)

23. Honeybees and Your Health • Hospital admission rates for anaphylaxis, 1990 to 2004, England ICD – International Classification of Diseases (www.who.int/classifications/icd/en) from Resuscitation Council UK website

24. Honeybees and Your Health Anaphylaxis Confusion arises because some patients have systemic allergic reactions that are less severe, crucially it is the combination of these 3 criteria. 1 Sudden onset and rapid progression of symptoms • The individual will feel and look unwell. • Most reactions occur over several minutes. Rarely, reactions may be slower in onset. • The time of onset of an anaphylactic reaction depends on the type of trigger. An intravenous trigger will cause a more rapid onset of reaction than stings which, in turn, tend to cause a more rapid onset than orally ingested triggers • The patient is usually anxious and can experience a “sense of impending Doom” • Sudden onset and rapid progression of symptoms • Life-threatening Airway and/or Breathing and/or Circulation problems • Skin and/or mucosal changes (flushing, urticaria, angioedema)

25. Honeybees and Your Health Anaphylaxis 1 Sudden onset and rapid progression of symptoms 2Life-threatening Airway and/or Breathing and/or Circulation problems 3 Skin and/or mucosal changes (flushing, urticaria, angioedema) Life-threatening Airway and/or Breathing and/or Circulation problems Airway problems: • Airway swelling, e.g., throat and tongue swelling (pharyngeal/laryngeal oedema). The patient has difficulty in breathing and swallowing and feels that the throat is closing up. • Hoarse voice. • Stridor – this is a high-pitched inspiratory noise caused by upper airway obstruction. Breathing problems: • Shortness of breath – increased respiratory rate. • Wheeze. • Patient becoming tired. • Confusion caused by hypoxia. • Cyanosis (appears blue) – this is usually a late sign.

26. Honeybees and Your Health Anaphylaxis 1 Sudden onset and rapid progression of symptoms 2Life-threatening Airway and/or Breathing and/or Circulation problems 3 Skin and/or mucosal changes (flushing, urticaria, angioedema) 2 - Circulation problems: • Signs of shock – pale, clammy. • Increased pulse rate (tachycardia). • Low blood pressure (hypotension) – feeling faint (dizziness), collapse. • Decreased conscious level or loss of consciousness. • Cardiac arrest. Circulation problems (often referred to as anaphylactic shock) can be caused by direct myocardial depression, vasodilation and capillary leak, and loss of fluid from the circulation. Patients with anaphylaxis can deteriorate if made to sit up or stand up. The above Airway, Breathing and Circulation problems can all alter the patient’s neurological status because of decreased brain perfusion. This can present as confusion, agitation and loss of consciousness. Patients can also have gastro-intestinal symptoms

27. Honeybees and Your Health Anaphylaxis 1 Sudden onset and rapid progression of symptoms 2 Life-threatening Airway and/or Breathing and/or Circulation problems 3Skin and/or mucosal changes (flushing, urticaria, angioedema) 3 Skin and/or mucosal changes • They are often the first feature and present in over 80% of anaphylactic reactions. • They can be subtle or dramatic. • There may be just skin, just mucosal, or both skin and mucosal changes. • There may be erythema – a patchy, or generalised, red rash. • There may be urticaria (also called hives, nettle rash, weals or welts), which can appear anywhere on the body. They are usually itchy. • Angioedema may occur Although skin changes can be worrying or distressing for patients and those treating them, skin changes without life-threatening airway, breathing or circulation problems do not signify an anaphylactic reaction. Reassuringly, most patients who have skin changes caused by allergy do not go on to develop an anaphylactic reaction.

28. Honeybees and Your Health • Signs and symptoms of anaphylaxis

29. Honeybees and Your Health Mortality from anaphylaxis • The overall prognosis of anaphylaxis is good, with a case fatality ratio of less than1% reported in most population-based studies. Risk of death is, however, increased in those with pre-existing asthma, particularly if the asthma is poorly controlled or in those asthmatics who fail to use, or delay treatment with adrenaline. There are approximately 20 anaphylaxis deaths reported each year in the UK, although this may be a substantial under-estimate. Risk of recurrence • The risk of an individual suffering recurrent anaphylactic reaction appears to be quite substantial, being estimated at approximately 1 in 12 per year. Trends over time • There are very limited data on trends in anaphylaxis internationally, but data indicate a dramatic increase in the rate of hospital admissions for anaphylaxis, this increasing from 0.5 to 3.6 admissions per 100,000 between 1990 and 2004: an increase of 700%

30. Honeybees and your health Treatment of anaphylaxis • Recognize • ABC • Lie flat • Call for help • Adrenaline

31. Honeybees and Your Health Non life-threatening conditions that may mimic anaphylaxis (these usually respond to simple measures): • Faint (vasovagal episode). • Panic attack. • Breath-holding episode in child. • Idiopathic (non-allergic) urticaria or angioedema.

32. Honeybees and your health Venom Immunotherapy (VIT) Clinical Immunology Part of national guidelines of treatment of anaphylaxis • From NHS UK website • “Following treatment for an insect sting, you may be referred to an allergy clinic, or immunologist (a specialist on the immune system). If you have had a severe or potentially life threatening allergic reaction, it is very likely that you will be referred. • Your GP may also suggest venom immunotherapy treatment, which is sometimes known as hyposensitisation. This involves having injections on a weekly basis with small doses of venom, and being observed for about an hour or so to check for an allergic reaction. • The regular injections will desensitise you to the venom (make you used to it), as well as encouraging your body to make antibodies to stop further reactions. The injections will carry on with increasing amounts of venom and will change to monthly appointments when a high enough dose has been reached. The injections could last a further two or three years. • The actual amount of venom injected and the length of time that the injections continue for will be decided by your immunologist. This will depend on your initial allergic reaction and your response to the treatment.”

33. Honeybees and Your Health VIT • The production of venom-specific IgG - Venom-specific IgG typically increases, peaking at two to four months after starting VIT and then remaining fairly constant over five to six years of treatment. These IgG antibodies are referred to as "blocking" antibodies, because they are capable of blocking mediator release from allergen stimulated mast cells and basophils. • IgE levels decline over the course of therapy, presumably as a consequence of above.

34. Honeybees and Your Health Multiple stings Mass envenomation: • Occasionally, a person is stung many times. Depending on the number of stings, the person may be in pain, feel sick, or very unwell. Humans can be killed if stung enough times in a single incident. With honey bees the toxic dose (LD50) of the venom is estimated to be 8.6 stings per pound of body weight 2.8mg/kg. Obviously, children are at a greater risk than are adults. Most deaths caused by multiple stings have occurred in men in their 70s or 80s who were known to have underlying health issues. Renal insufficiency: • can occur later as an effect of immune complexes damaging renal tissue

35. Honeybees and Your Health Infant botulism • Number of cases in UK ; 11 in last 33 years (Health Protection Agency figures 28 05 2010) • 9 England • 1 Wales had consumed honey • 1 Scotland had consumed honey and C botulism spores in honey jar, not sure if same strain • 2 in 2007 in England had consumed honey, but no C botulism spore in honey, one had C botulism in dust • 2 in 2009 were 8 weeks old • No fatalities. • Prevalence in California; Infantile botulism shows geographical variation. The U.S. has much higher rates 1.9 per 100,000 live births, 47.2% of which are in California. Although honey has been implicated as a risk factor for infection, it is household dust that is the major source of spores. Therefore the risk honey poses to infant health is small, and uncertain.

36. Honeybees and Your Health Toxic honey • Toxic honey may result when bees are proximate to tutu bushes (Coriaria arborea) and the vine hopper insect (Scolypopa australis). Both are found throughout New Zealand. Bees gather honeydew produced by the vine hopper insects feeding on the tutu plant. This introduces the poison tutin into honey. Fortunately only a few areas in New Zealand (Coromandel Peninsula, Eastern Bay of Plenty and the Marlborough Sound) frequently produce toxic honey. • Honey producing areas; Coromandel beekeepers took precautions to prevent a toxin linked with causing stupors and violent convulsions infecting their honey supply that summer. The tutin poison, produced by bees feeding on the native tutu bush, was blamed for poisoning 22 people who purchased comb honey from a Whangamata hobbyist beekeeper in 2008.

37. Honeybees and Your Health • The order of common sense

38. Honeybees and Your Health Moving and Handling There are general guidelines - or maximum weights - for men and women. If applying these, no man should attempt to lift anything heavier than 25kg and a woman’s maximum limit is 16kg. • But it is important to take into account other factors which can change the maximum safe weight –such as how high an object will need to be lifted. When You Should Take Extra Care: • Stacking items above shoulder height • Carrying items up or down stairs • Carrying items for long distances • Lifting in a small work space – this could mean you have to twist or stoop • Things to Check: • Is the weight of the item within your physical capability? • Is there adequate space to lift safely? • Can lifting be shared

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41. Honeybees and Your Health Therapeutic Uses for bee venom • Bee venom has recently found a use in a form of complementary therapy. In bee venom therapy, bees may be induced to sting the affected area, or the venom may be applied by intramuscular injection. The venom stimulates the release of cortisol, and so biologically it may be expected to bee effective in the treatment of rheumatic disorders such as Multiple Sclerosis, rheumatoid arthritis and gout. There is no clinical evidence for this however. Bee venom therapy is one aspect of apitherapy - use of bee products for curing disease. • Bee venom acupuncture. Used in Korea • Melittin also exhibits potent anti-microbial activity. For example, Melittin has been shown to exert "profound inhibitory effects" on Borrelia Burgdorfereii, the bacteria that causes lyme disease. Again not necessarily clinicallyrelevant yet. Do Not look to being stung if you find a tic attached to you !!! Melittin has also been shown to kill the yeast Candida albicans and to suppress Mycoplasma hominis and Chlamydia trachomatis infections • Mellitin is also being investigated as an anti-cancer agent. By modifying the mellitin molecule to prevent allergic reaction, and attaching a cancer-specific antibody (this combination of toxin and antibody is called an immunotoxin), researchers hope to produce a ‘magic bullet’ treatment - so called because it would only destroy cancer cells (unlike conventional chemotherapy agents, which destroy all types of cell, causing unpleasant side effects such as vomiting and hair loss).

42. Honeybees and Your Health The Quran 'And thy Lord taught the bee to build its cells in hills, on trees and in (men's) habitations..... there issues from within their bodies a drink of varying colours, wherein is healing for mankind. Verily in this is a Sign for those who give thought'.(Translation of Quran 16:68-69)

43. Honeybees and your health • Conclusion/Summary • Benefits from beekeeping • Safe moving and handling • First aid principles for stings, allergic reactions • First aid for severe allergic reactions

44. Honeybees and your health Conclusion/Summary • Benefits from beekeeping

45. Honeybees and your health Conclusion/Summary • Safe moving and handling Phone a fred

46. Honeybees and your health Conclusion/Summary • First aid principles for stings

47. Honeybees and your health Conclusion/Summary First aid for severe allergic reactions • Recognition • Lie down, elevate legs • Call for help

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49. Honeybees and Your Health www.resus.org.uk/pages/reaction.pdf www.hpa.org.uk/hpr/archives/2010