Protecting your athletic department from a MRSA outbreak is not difficult, but you need to know what steps should be taken at what times, and how to communicate the plan.
By Greg Scholand
Greg Scholand is an Assistant Editor at Athletic Management. He can be reached at: gs@MomentumMedia.com.
For anyone who has seen recent headlines from around the country related to methicillin-resistant Staphylococcus aureus (MRSA), a sense of alarm seems perfectly natural. In Wellington, Ohio: "Staph Takes Down Wrestlers." In Fayetteville, N.C.: "MRSA Infects Teenager's Life." In Austin, Texas: "Texas Football Succumbs to Virulent Staph Infection." In Battle Creek, Mich.: "The Next Epidemic?" In Gillette, Wyo.: "Keeping a Killer at Bay."
From coast to coast, this tiny bacterium is creating anxiety, if not panic. Athletic administrators, coaches, parents, student-athletes, school officials, sports medicine professionals, and everyone else in the athletic world can feel like there are more questions than answers. Is our school at risk? Are we doing enough to prevent an outbreak? What should we do if one occurs? Why is MRSA so dangerous, anyway?
In this article, we'll answer some important questions about MRSA and the challenges it poses in an athletic setting. Infectious disease experts and athletics professionals will explain what MRSA is and how it spreads, outline ways to keep athletes safe, and debunk a few common myths about the nature of the risk. Some of what follows is information you'll hopefully never need--but the better educated and prepared you are, the more you can be an effective leader in confronting this serious subject.
What are staph and MRSA, and how do they cause infections?
Staphylococcus aureus, or staph for short, is a very common species of bacteria. The Centers for Disease Control and Prevention (CDC) estimates that 25 to 30 percent of people in the U.S. have it living in their nasal passages or on their skin. These individuals are said to be "colonized" with staph, but that doesn't mean they're infected, and they exhibit no symptoms.
Infection occurs when the bacteria find an entry point into the body. "Staph needs a break in the skin to cause a skin infection--typically a cut, scrape, or other abrasion," explains Jeff Hageman, an epidemiologist at the CDC who specializes in staph infections. "The bacteria don't need a large opening. Even an ingrown hair or the small, imperceptible tears caused by shaving with a razor can be enough."
Because colonized people have the bacteria present on their bodies, they can spread it just by touching another person or something in their environment. If the bacteria then find their way to compromised skin--on a colonized or non-colonized person--they can take up residence and form an infection.
Methicillin-resistant Staphylococcus aureus is like other types of staph, but with one important difference: MRSA strains are immune to many common antibiotics, including penicillin and amoxicillin. (Methicillin itself, a form of penicillin, is no longer used to treat infections, though its name is still used to identify drug-resistant staph strains.) MRSA is more dangerous than ordinary staph because if an infected person is prescribed an antibiotic that can't kill the bacteria, the infection grows worse and can lead to more serious and potentially fatal complications, such as pneumonia and bloodstream infections. Untreated MRSA also releases a dangerous toxin called Panton-Valentine leukocidin (PVL) into the blood.
With the right antibiotics and prompt infection-site treatment, a MRSA infection can be cured fairly easily in almost all cases. Most serious health problems and MRSA-related deaths are caused by late and/or incorrect diagnosis and treatment of the infection, which is why awareness is such an important step in preventing serious outbreaks.
How common are MRSA infections?
MRSA used to be found only around hospitals, prisons, nursing homes, and other similar facilities, but in the past decade, it has become much more prevalent in the community at large. The CDC estimates that around one percent of the current U.S. population is colonized with MRSA bacteria.
"In several large studies performed across the country, we've seen that among skin infections that have pus associated with them, around 60 percent are now caused by MRSA bacteria," Hageman says. "The percentage is higher in some regions than in others, but it's clear that MRSA is a predominant cause of skin infections in the general population today.
"In Atlanta, where the CDC is located, it has become so prevalent that when a skin infection is brought to the emergency room at some local hospitals, they automatically assume it's MRSA," continues Hageman. "That's partially because it's better to err on the safe side when treating a potential MRSA infection. But it's also because MRSA has become such a common source of infection in our city."
How does someone typically get a MRSA infection?
Anyone is susceptible to a MRSA infection when they have a skin opening. All they have to do is come into direct contact with someone or something harboring the bacteria.
"In athletic settings, MRSA is usually spread through physical contact," Hageman says. "In football, wrestling, rugby, and any other sport with skin-to-skin contact, there are countless opportunities for the transmission of bacteria. And because athletes in those sports frequently experience skin abrasions, the risk is increased."
In addition, many objects and surfaces in athletic settings can be "transiently colonized," meaning the bacteria are deposited on them for a short period of time and can thus be passed to a new person. For instance, whenever an athlete comes into contact with a towel, razor, bar of soap, locker room bench, or athletic field, he or she may leave live bacteria behind, and another athlete in the same environment may pick them up.
Colonized athletes with perfectly healthy skin can spread staph and MRSA bacteria, but the risk is heightened once someone is actually infected. MRSA skin infections typically produce pus and other organic matter that's rich in bacteria and can easily be left behind when the infection site comes into contact with an object or surface.
"Covering all infected skin with clean bandages is one of the most effective ways to prevent isolated MRSA infections from turning into outbreaks," says Eddie Hedrick, Emerging Infections Coordinator for the Missouri Department of Health and Senior Services. "The key is to prevent the sharing of bacteria as much as possible, especially if someone has an infection."
How can I prevent my athletes from spreading staph and MRSA bacteria among themselves?
"The famous physician Sir William Osler once said, 'Soap and water and common sense are the best disinfectants.' Anyone looking to avoid MRSA should always remember that," says Hedrick, who also coaches the men's club lacrosse team at the University of Missouri. "When confronting a serious danger, it's tempting to think your prevention measures have to be elaborate. But basic personal cleanliness is as important as anything."
One of the most common ways athletes put themselves and others at heightened risk is by eschewing the shower room. "Athletic departments could do themselves a huge favor by requiring athletes to shower immediately after all practices and games," says Jim Thornton, Head Athletic Trainer at Clarion University and a member of the National Athletic Trainers' Association (NATA) Board of Directors. "That's critical for several reasons. First, it washes away bacteria the athletes have picked up on their bodies during activity. If they have a cut or scrape, they can remove the bacteria before it has a chance to create an infection. And just as important, they're reducing the odds that they'll spread bacteria around when they touch things.
"Many athletes today, in high school and college, put off showering until they get home or back to their dorm," Thornton continues. "They don't realize that by doing so, they're seriously increasing staph and MRSA risk."
Hand washing is another key prevention measure. "Anytime you touch a surface--a doorknob, a table, a piece of athletic equipment--you can pick up harmful bacteria. But if you remove it from your skin quickly, it won't cause infection," explains Hageman. "Since our hands are constantly touching things, they're both picking up and spreading bacteria. Cleaning them frequently needs to be a top priority."
Several studies have shown that effective hand washing can be performed with plain or antibacterial soap. "When you form a lather, you're lifting the dirt and germs from your skin, so it's not particularly important whether the soap is antibacterial or not," Hageman says. "In group settings, liquid soap is preferable because it eliminates the potential for a shared bar of soap to transmit bacteria."
Virtually any shared item can be a conduit for bacteria, so sharing should be actively discouraged in all locker rooms and playing areas. "Some MRSA outbreaks among athletes have been linked to shared razors, locker room towels, and towels used on the field," says Hageman. "It's hard to keep track of who has used a towel on the sideline--it can be transiently colonized by one person and then picked up by another person, who can infect himself by using it on skin that has been compromised."
What does a MRSA infection look like, and how is it identified?
At first, many MRSA skin infections are mistaken for spider bites, ingrown hairs, or pimples. The common symptoms include redness (and sometimes the presence of red streaks or other discoloration), swelling, the formation of a pustule or pus and other drainage, and the sensation of heat. "Anytime we see something suspicious on an athlete's skin, we either have the team physician look at them or we send them straight to the emergency room--we don't waste any time," says Thornton. "A physician needs to be brought into the picture immediately to begin treatment and decide whether the wound should be cultured."
Identifying a MRSA infection through a standard wound culture used to take several days, but in January, the Food and Drug Administration (FDA) approved a new test called the BD GeneOhm StaphSR assay, which can identify MRSA in just two hours. As this new test gains acceptance at hospitals and doctors' offices, it should make diagnosis more efficient, leading to faster recovery and better outcomes for MRSA-infected people.
What should I be doing as an administrator to prevent MRSA from endangering my athletes?
Luckily, information about MRSA can spread more easily than the bacterium itself. A well-educated athletic department, with coaches, athletes, and parents understanding the risks and prevention strategies, can go a long way in keeping your program safe.
"Communication is everything when it comes to facing MRSA," says Michael Stutzke, Athletic Director at Sebastian (Fla.) River High School. "When we first heard about MRSA in our area, I sat down with our athletic trainer to discuss how we would approach it at our school. We decided the most important thing was to make sure everyone was in the loop."
The athletic trainer took the lead, talking to coaches about the importance of making sure athletes report every suspicious skin mark or wound, and asking them to discuss proper hygiene with their teams. "Within 24 hours, she had distributed fliers and put up posters in all our locker rooms and bathrooms, telling student-athletes what to look for on their skin and explaining how simple things like washing their hands and showering after practice could help them stay healthy.
"Some posters also had pictures of what MRSA infections look like, which was both educational and got athletes' attention," Stutzke continues. "The old adage that a picture is worth a thousand words definitely applies with MRSA. When athletes saw the various stages of what at first looked like a pimple becoming a serious infection, it helped them realize they need to take this seriously."
Sebastian River's athletic trainer and coaches also spread the message in the weightroom, at practices, and in the hallways. "Young athletes need constant reminders about something like this," Stutzke says. "Around our facilities, you'll frequently hear a coach say, 'Why isn't that cut covered?' or 'Hey, I see your band aid fell off--take a break and go get a new one.'"
Well-educated coaches can also take the lead in informing parents. "Many parents have heard only a little about MRSA, but they know it's dangerous and could affect their kids," says Stutzke. "It's natural that they'll stand up at a meeting and express concerns about the topic. If the coach is prepared to offer a brief explanation of what MRSA is, how athletes can protect themselves, and what steps the school is taking to protect them, that means a lot."
What should parents be told about MRSA?
Parents need the same information about prevention as their children do--the importance of hygiene, being proactive about wound protection, keeping an eye on even minor skin problems, and contacting a healthcare professional about any suspicious wound. They also need to be told to communicate with the school if their child contracts an infection.
"If a high school student thinks they have a skin infection, their parents will usually take them to the family physician, and the school may never be notified," says Hageman. "That's a real problem, because if multiple athletes on the same team react that way, it can prevent anyone from noticing an outbreak is underway. Other teammates might be experiencing early symptoms, but not yet realize what it is.
"Schools should set up some sort of policy for reporting," Hageman continues. "Parents should be told to inform a designated person so the athletic trainer or school nurse can be made aware of the situation, and someone can put all the pieces together to see if there's a trend."
With any infectious disease, parents and athletes may be tempted to keep things quiet to avoid embarrassment, so it's important to set procedures carefully. "You should assure everyone that the athlete's privacy will be respected," says Stutzke. "You don't want things to get worse just because an athlete was afraid to tell anyone about their infection."
If an athlete has a MRSA infection, should they be segregated from their teammates?
Parents of healthy athletes may wish to see anyone with a MRSA infection kept as far away from their children as possible. But as long as common sense is used, there's no need to make anyone feel like a plague carrier.
"The last thing you want to do is make an athlete with MRSA feel like an outcast, because that will lead others who may have an infection to avoid speaking up," advises Thornton, who has seen all manner of reactions to skin infections as the NATA's liaison to the NCAA Wrestling Rules Committee. "The truth is, once they're under the care of a physician and receiving treatment, they will not put teammates at risk as long as they follow good hygiene practices and take care of the infection site."
"A doctor can provide specific guidelines, which can vary based on the individual's situation. But in general, an infected person only has to be excluded from activities that may lead to transmission, such as those involving direct physical contact with others," says Hageman. "If they can keep the infection covered and they're washing their hands frequently, there's a low risk of transmission from an athlete to a teammate simply through everyday interaction.
"The one definite thing we recommend, though, is for MRSA-infected people to avoid using common water sources, like whirlpools or swimming pools, until the infection has healed completely," he adds. "A shared whirlpool can easily become a mode of transmission for bacteria. Even healthy athletes should be showering before using a whirlpool to prevent bacteria from spreading."
How should we clean our school's athletic facilities and locker rooms to help prevent the spread of MRSA?
Surfaces that should be singled out for most frequent cleaning are those that people touch most often, such as benches, treatment tables, and door handles. "Take the weightroom for example," says Hedrick. "In many facilities, it is now common practice to keep a spray bottle near the machines, and for each person to wipe down the equipment after using it. That's a great idea, because those surfaces are shared by multiple users in close succession. Athletic training tables should also be cleaned after each use.
"On the other hand, when a student in Virginia died recently after contracting MRSA, they closed all the area schools to clean and disinfect everything inside," he continues. "That was an overreaction. As soon as the students came back, they brought the bacteria right back with them. The focus for facilities should be on making it standard practice to clean areas that are most frequently touched--not making an all-out one-time effort."
What should our custodians and others who clean our athletic facilities know about MRSA?
There are many cleaning and disinfecting products on the market today specifically formulated to be effective against MRSA bacteria. But to have the desired effect, and for the safety of everyone who shares your facilities, these products have to be used properly.
"With any disinfecting product, it's important to closely follow the directions on the label," notes Hageman. "Some products may cause irritation if they come into contact with skin, so if they're being used on an athletic training table, for instance, the surface has to be rinsed afterward."
In addition, some products are made for use only on hard surfaces, and thus should not be used to clean porous objects. For instance, athletic padding is often made with materials that cannot be rinsed thoroughly enough to ensure that the chemicals from a cleaning agent are completely removed. The product label will usually indicate what types of surfaces a product can safely be used on.
"Contact time is also very important with disinfectants--they need to stay on a surface long enough to be effective against the bacteria they're targeting," Hageman adds. "Whoever is using the product should always carefully read the instructions first."
How about the care and maintenance of athletic equipment?
After practices, many athletes throw their sweaty gear in a gym bag, drop it in a locker or on the floor at home, and don't take it out again until the next time it's needed. This creates a moist, dark, warm environment, which is ideal for bacteria growth.
"A couple of years ago, our campus hosted a coaches' clinic at which I gave a short presentation on MRSA infections, and I brought up the subject of gym bags full of sweaty clothes," recalls Thornton. "When I explained how this produced a great environment for bacteria, the coaches couldn't believe they'd never thought of that. Washing workout clothing and letting pads dry out after each use seems like such a simple thing. But sometimes, it's the simple things that escape us."
As an administrator, how can I remain on top of MRSA?
Both on and off campus, there are resources you can use to make sure MRSA never catches your school by surprise. "I keep as many channels of communication open as possible--from regularly talking with our school nurse to sharing information with nearby athletic directors," says Stutzke.
Staying in touch with peers at other institutions is a particularly valuable step. "If I hear from our county's Director of Risk Management about an illness that's going around, I'll send an e-mail to all the athletic directors in my conference and ask what they know about it," Stutzke continues.
Hedrick adds that local public health professionals can be an asset as well. "A local health department can often point you toward an infectious disease expert at an area hospital, provide educational resources offered by the state, or even help investigate to find the underlying cause of an outbreak," he says. "We also bring individual outbreaks into a reporting structure so that patterns can be identified at the state or national level, which is what public health is all about.
"With MRSA, you always want to eliminate the 'uh-oh' factor," continues Hedrick. "You don't want to learn about an outbreak and say, 'Uh-oh, we weren't doing this or that, which could have prevented it.' If you're following the right procedures, making sure everyone is educated, and remaining aware of what's going on around you, you've created a culture where MRSA isn't something to be afraid of."