MRSA In Schools

The Newsletter for School Health Professionals

METHICILLIN-resistant Staphylococcus aureus (MRSA) is becoming more of a concern for school health professionals and educators. Once strong ly associated with hospital-acquired infection, health care providers and epi demiologists now find that MRSA may also occur as a result of exposures in the community, exposures not associated with hospital experience. The majori ty of community-acquired MRSA infections involve the skin or soft-tissue, and affect a younger and healthier population than associated with hospital-acquired MRSA infections.(1,2) MRSA infections have also been seen emerg ing in pet populations throughout the world, and recent evidence suggests MRSA infections may be transmitted between people and their pets (3).

MRSA is significant to school nurses. We work with students with needs for health care procedures at school, including those with wounds or stomas. Upon learning a student has been diagnosed with MRSA, multi-disciplinary school teams can become alarmed and raise many questions for the school nurse. What are the implications for the educational team and for students with whom the infected child may come into contact? Should MRSA be the basis for exclusion from school?

On another front, also alarming to educators and others may be the diag nosis of MRSA in an otherwise “well” setting, student athletics for example, when a wrestler or football player is diagnosed with MRSA.

Providing calm and knowledgeable leadership to the school community, the school nurse can be a vital asset in assuring: safe infection control prac tices at school; proper medical evaluation, treatment, and clearance of the infected student to return to school; medical privacy for affected individuals; case-finding; and education and reassurance for the school community.

The child who is ill and determined to have active infection needs to be treated and followed until medically cleared by the physician to return to school. Yet a person may also be colonized with MRSA. In this case, MRSA is present on the body, but there are no clinical symptoms of illness. The school nurse must be astute in gathering sufficient information to accurately discern between the two. Epidemiologists suspect an increasing number of persons in the general population are colonized with MRSA. (Remember Staphylococcus aureus is after all a part of the normal flora of the healthy person’s skin and nares.) It is not appropriate or necessary to exclude the clinically well individ ual who happens to be colonized with MRSA.

Once given medical clearance by their treating physicians, children who are colonized with MRSA should be allowed to attend school. Draining wounds or stomas should be covered. Consistent with developmental and cognitive abilities, the child should be instructed in good hand-washing and keeping the area covered while at school. Teachers should be instructed to observe that wounds remain covered and to assure good handwashing practices are a part of the daily classroom routine for all, as well as routine cleaning procedures. In early childhood settings, additional consideration may need to be given to avoid shared exposures to body fluids or secretions through toys or related to toileting/diapering activities. If treatments or procedures are provided to the child, personal protective equipment should be worn as appropriate, followed by good handwashing.

In student environments such as athletic venues, students should be instructed to wash skin thoroughly after exposures to shared common surfaces, especially where the skin has experienced friction rubbing, such as wrestling mats or tight-fitting shared head gear. All shared surfaces, such as mats and shower areas, should be cleaned thoroughly before use. Wounds should be kept covered and progress in healing monitored by school personnel.

In school health offices in otherwise undiagnosed persons, MRSA may potentially present in the form of boils, impetigo, or infected abrasions. The school nurse has an important educational role with both student and parents/guardians about adequate supervision and care of all wounds, and recommending medical attention when needed. Signs and symptoms of staph and other skin infections include: redness, swelling, warmth around the area; red streaks extending away from a wound; increased or throbbingp pain; and fever.

In summary, preventing spread of MRSA requires the basic infection control measures and precautions involving body fluids that should be practiced universally in all class rooms and other school environments at all times:

• Handwashing!
• Covering draining wounds and orifices, and contain ment of body fluids
• Identification and referral of non-healing or infected wounds
• Proper use of personal protective equipment to pre vent direct contact with potentially infectious body fluids
• Decontaminating surfaces that have been in contact with body fluids
• Proper disposal of contaminated materials
• Handwashing!

MRSA is an emerging health concern in child care and school settings, and the school nurse must stay alert to pre sentations of MRSA in the school population, and up-to date information as it develops about the epidemiology of MRSA in community settings, including schools.

RESOURCES TO LEARN MORE ABOUT MRSA:

The Maryland Dept. of Health and Hygiene has developed a set of guidelines for schools: http://www.cha.state.md.us/edcp/guidelines/guidelines.html
Guidelines for schools from the Indiana State Dept. of Health: http://www.in.gov/isdh/dataandstats/epidem/2004/sep/guidelines.pdf
Two excellent slide presentations on Community-Acquired MRSA on the Pennsylvania Dept. of Health Website:http://www.dsf.health.state.pa.us/health/cwp/view.asp?a=178&q=248839

REFERENCES

Fridkin SK et al, Methicillin-resistant Staphylococcus aureus disease in three communi ties. N Engl J Med. 2005 Apr 7; 352(14):1436-44.

Community-Associated MRSA Information for Clinicians. Centers for Disease Control and Prevention

Viatale CB et al, Methicillin-resistant Staphylococcus aureus in cat and owner. Emerging Infectious Diseases. 2006 Dec; 12(12);1998-2000. www.cdc.gov/eid .