Prevention of Methicillin-Resistant Staphylococcus aureus (MRSA) Infections in the School Setting

Topics

1. Background

  • MRSA infections can occur in students and staff of schools, causing anxiety for parents and school staff.
  • Staphylococcus aureus, commonly referred to as "staph," are bacteria commonly carried on the skin or in the nose of healthy people.
    • Approximately 30% to 50% of the population carry staph bacteria on their skin and in their noses without causing infection and illness (also known as colonization).
    • Infections can start when staph bacteria get into a cut, scrape, or other break in the skin. Staph bacteria are one of the most common causes of skin infections in the U.S.
    • Most of these skin infections are minor (such as pimples and boils) and can be easily treated without antibiotics.
    • Staph bacteria can also cause more serious infections, such as blood stream infections and pneumonia, which require more aggressive treatment.
    • Some staph bacteria are resistant to antibiotics. MRSA is a type of staph that is resistant to a certain class of antibiotics. Fortunately, there are other antibiotics that can be used to treat MRSA infection when necessary.

2. Symptoms of MRSA

  • MRSA infections can cause a broad range of symptoms depending on the part of the body that is infected. Broken skin, such as scrapes or cuts or even surgical wounds, is often the site of a MRSA infection resulting in redness, swelling, and tenderness at the site of infection, sometimes accompanied by a fever.
  • Sometimes MRSA can cause pneumonia or bone, joint, heart, or bloodstream infections, including sepsis, but these more serious infections are rare in healthy people.
  • Many people carry MRSA on their skin or in their nose without ever having any symptoms.

3. Transmission Routes of MRSA

  • MRSA is spread most frequently by direct skin-to-skin contact with someone who has MRSA, even if that person does not have symptoms of infection.
  • MRSA can also be transmitted by:
    • Contact with drainage from infected scrapes, cuts, or other skin wounds.
    • Contact with personal items contaminated with drainage from infected scrapes, cuts, or other skin wounds. These items can include contaminated bandages, towels, washcloths, soap, razors, topical preparations (ointments, balms, lotions, deodorants, creams), athletic or gym equipment, and uniforms or other clothing.
  • The risk of transmission is low from environmental surfaces that are not contaminated by wound drainage or frequent direct skin contact.
    • Practical measures, such as cleaning surfaces when they become soiled, will reduce the levels of all bacteria on environmental surfaces. See section 7 for detailed guidance regarding environmental cleaning and disinfection.
    • Microfiber mops can reduce environmental bacteria better than conventional loop mops and can also substantially reduce the use of chemicals for routine cleaning.

4. Treatment of MRSA

  • Although MRSA is resistant to some commonly used antibiotics, MRSA infections can usually be treated effectively using other types of antibiotics and by draining any pus at the infected site.

5. Prevention of MRSA in Schools

  • Schools should provide ready access to sinks, soaps, and clean paper towels.
  • Staph and MRSA infections in schools can be prevented if staff and students follow basic hygiene measures:
    • Keep hands clean by washing thoroughly with liquid soap (preferably not bar soap) and water or by using an alcohol-based hand sanitizer if hands are not visibly soiled. Consultation with the school district health services director and proper supervision are needed when children use alcohol-based hand sanitizers.
    • Practice good skin care. Since staph infections start when staph enters the body through a break in the skin, keeping skin healthy and intact is an important preventive measure.
    • Wash any cut or break in the skin with soap and water and apply a clean bandage until healed.
    • Avoid contact with other people's wounds or bandages. If it is necessary for a staff member to assist with a student's bandage, that staff member should do so under the direction/advisement of the school health personnel. They should wear gloves, place the used bandage in the trash, and wash their hands and forearms immediately after removing gloves.
    • Avoid sharing personal items such as cloth towels.
  • The risk of transmitting MRSA in the classroom is low when proper infection control measures are in place.
  • Students or staff with symptoms of MRSA should contact a health care provider and do the following:
    • Keep wounds clean and covered with a bandage until healed. Change bandages as recommended by the health care provider or when soiled. Discard used bandages or tape promptly in the regular trash.
    • Wash hands and forearms before and after caring for wounds and throughout the day. Wash for at least 20 seconds using liquid soap (preferably not bar soap) and warm water and dry your hands with a clean paper towel.
    • Do not share personal items such as towels, washcloths, soap, razors, topical preparations, uniforms, or clothing that may have had contact with an infected wound or bandage.
    • Wash soiled towels, washcloths, and uniforms or clothes with hot water and laundry detergent. Drying clothes in a hot dryer, rather than air-drying, also helps kill bacteria in clothes.
    • Take all antibiotics as prescribed and for the full length of time prescribed.
    • Report new skin sores or boils to a health care provider.
  • School attendance:
    • Unless directed by a physician, students with MRSA infections should not be excluded from attending school. According to NYSED Commissioner's Regulations [8 NYCRR 136.3(h)], schools may only exclude those students with communicable diseases which are reportable under Public Health Law. A list of such diseases may be found at 10 NYCRR2.1. However, not all disease cases require exclusion. Individual cases of MRSA infection are not reportable in New York State.
    • Students with any open or draining wounds, such as MRSA infections, should be excluded from swimming pools, whirlpools, hot tubs, etc. until the wound has healed.
  • Parent/staff notification:
    • Typically, it is not necessary to inform the entire school community about a single MRSA infection. Schools should take care to maintain the student's right to privacy with this or any health issue.
    • When an outbreak or an increase in MRSA infections occurs within the school population, or if transmission within a school is identified, the school should contact the local health department (LHD).
    • Parent and staff notification should be based on consultation between the LHD and the appropriate school administrators, according to the established school board policy.
  • Considerations for students with immune suppression:
    • Students with weakened immune systems may be at risk for more severe illness if they get infected with MRSA.
    • These students should follow the same prevention measures as all others to prevent staph infections and should contact their health care provider with any specific concerns. Schools should take care to maintain the students' right to privacy and confidentiality with this or any health information.
  • Reporting requirements for MRSA infection:
    • Clusters of MRSA infection are reportable to the LHD.
  • Environmental cleaning:
    • See section 7 for detailed guidance regarding environmental cleaning and disinfection.

6. Prevention Measures for MRSA in the School Athletics Setting

  • Hygiene and infection control practices
    • Personal hygiene is the single most important factor in preventing the spread of MRSA.
    • Coaches and trainers should practice appropriate hand hygiene (wash with soap and water or use alcohol-based hand sanitizer if soap and water are not available) after contact with players, especially when changing bandages and providing care for wounds. Consult with the school health services director regarding the use of alcohol-based hand sanitizer and provide appropriate student supervision.
    • If necessary, people other than school health personnel may assist a student with the application of clean dressings following initial approval and assessment by appropriate authorized school health staff. These individuals should wear disposable gloves and wash their hands and forearms immediately after removing gloves using barrier precautions at all times.
    • In situations where access to sinks is limited (e.g., on playing fields), carry individual containers of alcohol-based hand sanitizer. (See note above regarding the use of alcohol-based sanitizer and appropriate supervision.)
    • Provide enough clean towels so players do not need to share them.
    • Educate players on appropriate management of wounds.
    • Exclude players with draining lesions or open wounds (whether or not they are covered) from swimming pools, whirlpools, ice tubs, saunas, and hot tubs. All excluded students should comply with their district's standard clearance process for returning to sports and physical education class.
    • All wounds (i.e., cuts, scrapes, abrasions) should be covered with a bandage until healed, especially when contact with multi-use items (e.g., weight equipment, electric stimulation cuffs) may occur.
    • Wounds (i.e., cuts, scrapes, abrasions) should be completely and securely covered during competition (e.g., bandaged and use of protective sleeve).
    • Students with active skin and soft tissue infection (e.g., draining wounds, boils, abscesses) should not participate in activities where skin-to-skin contact is likely to occur until their infections are completely healed.
    • Specific guidance for players to prevent MRSA:
      • Do not share towels (even on the sidelines of games), washcloths, soap, razors, topical preparations, or other personal hygiene items with other players.
      • Shower with liquid soap (preferably not bar soap) before using the whirlpool, steam room, or sauna. Do not share bar soap.
      • Shower as soon as possible after EVERY practice, game, or tournament. Do not share bar soap.
      • Shower before and after sports with extensive skin-to-skin contact (e.g., wrestling, football). Do not share bar soap.
      • Avoid contact with draining lesions and contaminated items (e.g., bandages) from other people.
      • Wash hands with soap and water (or use alcohol-based hand sanitizer if soap and water are not available) after using multi-use equipment (e.g., weight equipment) and after contact with potentially contaminated items (e.g., another person's wounds, infected skin, or soiled bandages).
      • Follow good hygienic practices—hand hygiene, showering, and regularly laundering clothes.
      • Wear protective clothing or gear to prevent skin injuries.
  • Environmental Surfaces and Equipment
    • See section 7 for detailed guidance regarding environmental cleaning and disinfection.
  • Disease Surveillance
    • MRSA infections can spread quickly on athletic teams and can be difficult to control.
    • It is important for coaches and trainers to be aware of every skin infection as soon as it occurs to prevent a single case from becoming an outbreak. School employees should consult with the school's health professional(s) as needed for information and assessment as appropriate.
    • If MRSA infections occur among team members, associated students and staff should be encouraged to report skin changes such as redness, warmth, swelling, tenderness, or drainage, especially when associated with cuts, boils, or sites of skin irritation and abrasions. Coaches and staff observing open or undressed skin lesions on team members should direct the student to a health care provider to have the lesion evaluated.
    • If MRSA infections occur among players on children's sports teams, appropriate school officials based on school board policy should consider notifying parents of all team members to enlist their support with reinforcing hygiene measures and reporting skin lesions to team officials.
      • Care must be taken to maintain confidentiality of players with infected wounds to avoid stigmatization and anxiety.
  • Diagnosis and Treatment
    • Players with skin lesions should be referred to a health care provider.
    • See Section 4 for additional guidance with respect to treatment of MRSA infections.
  • Player Exclusion from Participation
    • Individuals with open wounds (i.e., cuts, scrapes, abrasions) need not be excluded if the wounds can be completely and securely covered with clean, dry bandages. A health care provider might exclude an athlete if the activity poses a risk to their health even if the wound is covered.
    • Athletes with active skin and soft tissue infection (e.g., draining wounds, boils, abscesses) should not participate in activities where skin-to-skin contact is likely to occur or from using water facilities until their infections are completely healed. Follow the district process of clearance for students to return to sports and physical education classes.

7. Environmental Cleaning and Disinfection in the School and School Athletics Settings

  • Control measures as part of routine building and vehicle maintenance:
    • Follow routine procedures for cleaning school environments, (e.g., classrooms, lunchrooms, time out rooms) and school buses.
    • Follow New York State Office of General Services (OGS) green cleaning guidance for school environments and school bus cleaning using OGS-approved green-cleaning products.
  • Follow regular cleaning and maintenance procedures for equipment and materials that may be shared in the classroom such as protective eyewear or clothing.
    • Particular attention should be given to cleaning high touch surfaces.
    • Use of disinfectants (see description below) on shared environmental surfaces and equipment as part of regular facility maintenance may also be considered.
      • In order for environmental surface disinfection to be effective, surfaces must first be cleaned of soil, visible dirt and debris.
    • Clean and disinfect health room cots regularly (at least daily) and use pillow protectors. Launder pillow covers and washable pillows between use, following the manufacturer's directions.
    • Any surfaces or objects contaminated with body fluids or secretions should be cleaned and disinfected immediately, following the school's Exposure Control Plan and SED infection control guidance for blood-borne pathogens. Keep students away from the area and cover with paper towels until the area is cleaned and disinfected. Call appropriate personnel for clean-up (e.g., designated custodial staff).
    • If soiled linens and clothing are washed on school premises, wash with laundry detergent. If hot water laundry cycle is used, the water should be at minimum 160°F. When laundering with water at low temperatures, consider adding one cup of household bleach or use oxygen-activated bleach to help reduce microbial contamination. Dry in a hot dryer. Consider wearing gloves when handling dirty laundry.
  • If an outbreak of MRSA is confirmed in the school population:
    • Disinfect surfaces that are likely to be in contact with an individual known to have an uncovered or poorly covered skin lesion that is infected with MRSA, especially if the lesion has uncontained drainage. Use an U.S. Environmental Protection Agency (EPA) registered product effective against MRSA for surface disinfection of:
      • Environmental surfaces, high touch surfaces and shared equipment in the classroom(s) where direct-skin contact by multiple users is likely (e.g., desks, counter-tops).
      • Environmental surfaces, including walls, carpets, and floors in time out rooms after use by an individual with MRSA infection.
      • Seats in the school bus of the individual with MRSA infection if surface contamination from wound drainage is suspected.
    • Widespread disinfection of entire buildings or vehicle fleets based on the occurrence of a single MRSA infection is not recommended.
  • Considerations for use of registered disinfectants or sanitizer products:
    • The EPA has a list of disinfectant products effective against MRSA. More information about these products can be found on the EPA website. When using a disinfectant, always read and carefully follow the directions on the product label.
    • Routine use of disinfectants is not without risk.
      • Many of the active ingredients in disinfectant products can burn or irritate the skin and eyes, and, in some cases, can cause respiratory irritation.
      • Take precautions, such as ensuring adequate ventilation, use of gloves, eye, and face protection to reduce exposure to applied disinfectants to the extent practical and follow all label directions and precautions.
    • The school green cleaning guidelines pertain to cleaning products.
    • In some cases, school athletic facilities may require special cleaning and disinfection practices.
      • If disinfectant use is deemed desirable in a setting such as for shared athletic equipment or locker room facilities, that use is not precluded by the school green-cleaning guidelines.
      • Train personnel in proper disinfectant use and to follow label directions.
  • Cleaning and disinfection of environmental surfaces and equipment in the school athletics setting:
    • Establish a regular cleaning schedule for shared environmental surfaces such as wrestling mats or strength-training equipment.
      • Disinfect all skin-contact points of weight equipment at least once per day.
      • Disinfect mats and other high-use equipment before each practice and several times a day throughout a tournament.
    • Use a clean towel as a barrier between bare skin and shared surfaces (e.g., exercise equipment, sauna bench, leg supports during therapy) to reduce the need for frequent disinfecting.
      • Encourage athletes to disinfect all shared surfaces that come in contact with bare skin (e.g., mats, massage tables, training tables, and therapy machines) between each use.
    • Cover treatment tables. Discard or launder coverings after each use.
    • Repair or discard equipment with damaged surfaces that cannot be adequately cleaned (e.g., equipment with exposed foam).
    • Consider regularly disinfecting shared surfaces and equipment that come into contact with bare skin.
      • Follow the directions listed on the labels of all cleaning/disinfecting products with particular attention to the contact times for any disinfectant solution.
      • Sanitize using soap and water or use a disinfectant registered for use against MRSA on surfaces or use a freshly-mixed solution of one part bleach to 100 parts water (1 tablespoon bleach to 1 quart of water).
    • Disinfection of artificial playing surfaces (e.g., artificial turf) is not recommended.
      • Artificial turf has been reported to be associated with an increased risk for MRSA infection, not because it is a reservoir for MRSA, but because skin abrasions are more common from falling and sliding on artificial turf ("turf burns") than from similar falls on natural turf. Turf burns provide a portal of entry for the bacterium.
      • Sunlight and weather reduce survival of bacteria on outdoor artificial turf.

8. Additional Information

Additional information about MRSA can be found on the web on the following sites: