Health Advisory
COMMUNITY-ASSOCIATED METHICILLIN RESISTANT STAPHYLOCOCCUS AREUS (CA-MRSA)

Increased MRSA cases have been reported across the country, with 3 pediatric deaths recently hitting the media from Virgina, Mississippi and New Hampshire.

More than 90,000 life-threatening illnesses and nearly 19,000 deaths associated with a MRSA infection are estimated to occur annually in the United States, according to a report released this week by the Centers for Disease Control and Prevention (CDC). The study, published in the Journal of the American Medical Association, also found that nearly 85% of MRSA cases were connected to healthcare settings. (JAMA, 2007; 298(15):1763-1771)

However, mild cases of MRSA are diagnosed every day in Delaware, and nationwide. Generally, these cases are easily treated by a healthcare provider and resolve without complications.

Delaware Division of Public Health (DPH) added MRSA to its list of notifiable diseases in February 2006 under the Regulations for the Control of Communicable Diseases. The following cases have been confirmed as of 10/18/2007:

This data includes both hospital and community associated infections. Incidence data for the current year should be viewed as a ‘snapshot in time’ as the data is continually changing.

Schools

MRSA is now a frequent topic for the media, especially when children and schools are involved. DPH has worked closely with the Department of Education (DOE) to distribute resource materials to public schools to assist with the education and recommendations for management of rash illnesses and skin lesions. DPH’sprimary focus is to provide recommendations to help schools, hospitals, etc. implement control measures to limit transmission. Recommendations have also been developed specifically for sports teams and athletes where frequent person-to-person contact occurs, thus increasing the possibility of contact transmission.

Prevention

• The single best way to prevent the spread of CA-MRSA infections is frequent hand-washing. Alcohol based sanitizers should be utilized when soap and water are not available.
• Cleaning and disinfecting common surfaces that have the potential to come in contact with the MRSA bacteria is necessary to keep the environment healthy. Germs (bacteria and viruses) are killed during routine cleaning and disinfecting activities. Allergen (mold, pollen, dust mites and other irritants) are removed during cleaning activities like vacuuming, sweeping and mopping. Surfaces and equipment such as floors, light switches, door handles, desks, keyboards, handrails and shared items should be cleaned routinely. Athletic equipment and areas such as wrestling mats, wall padding, locker/weight rooms, protective gear and shower facilities should be disinfected routinely and after each use. Commercial disinfectants containing phenol or a fresh mixed solution of one part bleach to 100 parts water are suitable for cleaning.
• Treat any draining wound as a potential MRSA infection. This may include culture, incision and drainage, proper antibiotic usage and proper exclusion and return policies.
• Treat uncultured wounds as MRSA.
• Avoid sharing personal items such as towels, razors, clothing, protective athletic gear, bar soap, etc.
• Keep cuts, scrapes and wounds clean and covered with a bandage until healed. If a wound cannot be covered adequately, exclusion from school and/or sporting activities may be indicated.
• Avoid contact with other people’s skin wounds or bandages.
• Encourage good hygiene, including showering and washing with soap after all practices, competitions and physical education classes. Always dry off with a clean, dry towel.
• Athletes should wash towels, uniforms, scrimmage shirts, and any other laundry in hot water with ordinary detergent. Soiled laundry from school to home should be contained in an impervious container or plastic bag for transporting home.
• Educate teaching and coaching staff regarding prevention measures. Educate custodial staff regarding environmental sanitation and disinfection of common surfaces.

Identification

• Infections with MRSA can look like ‘spider bites’, turf burns, abscesses, boils, etc.
• The only way to determine if a wound is infected with MRSA is by performing a culture.
• Treat any draining wound as a potential MRSA infection.
• Treat uncultured wounds as MRSA.

Treatment

• Healthcare providers should culture suspect skin lesions. When the culture is completed the laboratory generates sensitivity patterns which determine appropriate antibiotic usage.
• Healthcare providers may choose to drain the lesion and treat with topical antibiotics which help to reduce the amount of bacteria on the skin.

Exclusion: Sports

• Any athlete/sports team member presenting with a suspect Staph infection should be excluded from further athletic activity. This applies to any activity involving person-to-person contact and use of any shared athletic equipment (i.e., weight room equipment, wrestling mats, and protective gear).
• If the participant is evaluated by a healthcare provider who chooses to treat with topical medications and wound care, the participant should continue to be excluded until they are clear of any moist, exudative or draining lesions.
• If MRSA is culture-confirmed, at a minimum, the athlete/sports team member should be excluded for 48 hours after antimicrobial therapy was begun. However, the participant should be reevaluated as detailed below prior to return to play. As a general rule, participant’s who have culture-confirmed MRSA should be excluded until they are clear of any moist, exudative or draining lesions.
• Dermatologic conditions that are not suspect Staph infections (or other communicable condition) can be covered by a bandage made of non-permeable material that will withstand the rigors of competition. These participants need not be excluded.
• Under no circumstances shall a participant with a suspect or confirmed Staph infection be allowed to participate until they are clear of any moist, exudative or draining lesions.

Exclusion: General Student Population

• Any student presenting with a suspect Staph infection that is draining and unable to be thoroughly covered to prevent contamination of other individuals or common surfaces, should be excluded and referred for medical evaluation.

Reporting to DPH

• MRSA is a reportable disease in Delaware. Healthcare providers have the responsibility of reporting culture-confirmed cases to DPH. DPH welcomes reports from school nurses and high school wellness centers.
• DPH list of notifiable diseases and reporting requirements can be found at: http://www.dhss.delaware.gov/dhss/dph/dpc/rptdisease.html   Reporting forms can be printed from this site and faxed to the Bureau of Epidemiology to: 302-739-3171

Further Information

• Please contact the Division of Public Health at 1-888-295-5156
• New CDC resource - Questions & Answers about MRSA in schools:   http://www.cdc.gov/Features/MRSAinSchools/
• CDC - Community-Associated MRSA: http://www.cdc.gov/ncidod/dhqp/ar_mrsa_ca.html
• Division of Public Health Fact Sheets:
  • MRSA  http://www.dhss.delaware.gov/dhss/dph/files/mrsafaq.pdf
  • MRSA Spanish translation  http://www.dhss.delaware.gov/dhss/dph/files/mrsafaqsp.pdf
  • MRSA Sports Teams / Athletes  http://www.dhss.delaware.gov/dhss/dph/files/mrsaathlfaq.pdf

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