MRSA

MRSA CONTROL CONTROLLING OUTBREAKS OF COMMUNITY ASSOCIATED STAPHYLOCOCCUS AUREUS (CAMRSA) IN SCHOOL SETTINGS Roy E. Costa, R.S., M.S/MBA., CFSP Environmental health practitioners can control CAMRSA outbreaks in schools by identifying hazardous conditions that lead to the spread of infections and by implementing science-based disease control and sanitation programs. A. Environmental Health Interventions and CAMRSA CAMRSA infected persons in schools create hazardous environmental conditions leading to outbreaks of potentially serious infection. Infected persons are the vehicles for spreading CAMRSA, which may remain viable in contaminated schools for extended periods. Investigators must apply effective environmental health interventions at critical control points, and reduce both direct (person-to-person) and indirect (environmental) CAMRSA transmission to limit the extent of outbreaks in schools. Preventive measures such as education, surveillance, diagnosis, exclusion, isolation, wound care, case-management, effective cleaning, disinfection, and personal hygiene will reduce the likelihood of CAMRSA transmission in schools and stem outbreaks. Investigators may regard some or all of these interventions as critical and require schools with CAMRSA outbreaks to document, verify and validate proof of their implementation. School administrators may also implement these same interventions to prevent outbreaks from occurring. B. CAMRSA Hazard Analysis 1. Infected/colonized persons and contaminated environments as reservoirs of infection Infected and colonized students, teachers, and other employees are CAMRSA reservoirs. Infected skin abscesses are the primary foci of infection, while colonization or infection of the nares, and respiratory, urinary and digestive tracts is possible. Contaminated inanimate objects, such as towels, clothing and sports equipment also constitute a reservoir of CAMRSA infection. 2. Broken skin and nares as the portals of exit Infected wounds, cuts, and abrasions emit infectious body fluids directly to others or to environmental surfaces and inanimate objects. Infected nasal secretions contaminate hands and spread infection to wounds, environmental surfaces, and inanimate of objects. 3. Modes of transmission Transmission between people occurs through direct contact with infective lesions. Persons infect their own wounds and the wounds of others through contact with contaminated hands. Infective inanimate objects such as towels, clothing, sports equipment, shaving razors and environmental surfaces (fomites) act as modes of transmission. 4. The mucosa and skin as portal of entry Breaks in the skin and other tissue allow the agent to permeate the skin or mucous membranes. Students and others participating in physical activities, such as sports, are at high risk for infection if the skin is broken. 5. Susceptible host The ability of the agent to gain entry into and infect a host depends on age, underlying health status and the competence of the skin and mucous membranes. C. Preventive Measures during MRSA Outbreaks at Schools 1. Inform and educate Inform and educate all attendees to the school about mandatory reporting requirements for any broken skin and especially any skin abscess. Require reporting of any broken skin, especially infected abscesses. Stress the need for good personal hygiene. 2. Active surveillance and treatment Conduct active surveillance for CAMRSA cases, especially in students in high-risk situations, athletes, immune compromised students, those with skin abnormalities, and students in special education. Conduct active surveillance for high-risk staff including gym teachers, maintenance personnel, and food service workers. Conduct medical screening for students and staff with broken skin, cuts, sores, and other wounds, who are at increased risk for CAMRSA infection. 3. Isolation, diagnosis, exclusions and case management Isolate or cohort suspect cases and confirm differential diagnosis quickly (rapid tests for CAMRSA are available). Exclude individuals with CAMRSA infections from the school and ensure effective medical treatment. Only remove exclusions when the case is no longer infective or after a medical exam. Restrict or exclude suspect cases and manage confirmed cases. 4. Wound care Identify persons with wounds, skin abrasions, or cuts in the mouth and ensure they are properly treated and bandaged. Practice Universal Precautions when treating any wound. Treat any used dressing as infective biomedical waste. 5. Monitor and disinfect the environment, and enforce strict hygienic standards Identify environments potentially contaminated by infective persons. Close exposed areas. Mitigate contamination through detailed cleaning of surfaces likely exposed. Reopen closed areas after verifying cleaning. Environments likely exposed to infective persons include, buses, school playgrounds, schoolrooms, common areas, gymnasiums/showers, cafeterias, and bathrooms. Use rapid microbiological test platforms to establish the most likely points of transmission within these areas such as water fountains, athletic equipment, bathroom surfaces, vending machines, tables and desks, chairs and other high touch points. Establish baselines for microbial contamination and establish effective decontamination procedures to achieve a 5-log reduction in indicator organisms or equivalent reductions in ATP-bioluminescent criteria. Clean and disinfect microenvironments likely to harbor the agent, and retest. Train all attendees on proper hygiene. Ensure there is an adequate supply of soap, paper towels, and hand antimicrobials, and that lavatories are always accessible. Monitor the use of lavatories ensuring effective washing at key times of the day, upon arrival at school, before and after recess, sports or common group activities, and before going home. Encourage personal hygiene at home. 6. Maintain records for validation and verification Keep and share data on cases (some medical information may be confidential), CAMRSA incidence, and the details of the personal hygiene and cleaning programs with investigators. 7. Verification, validation and corrective actions Conduct internal and external audits. Validate the effectiveness of programs and adjust controls as needed. Review records daily. Track and compare CAMRSA incidence to baseline incidence and react to negative trends. Find problem areas in compliance; develop and document corrective actions. D. Chain of Infection