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Preventing MRSA in
Your School


Many U.S. schools already have dealt with outbreaks of Methicillin-resisitant Staphylococcus aureus (MRSA), a potentially-deadly skin infection that spreads rapidly. Good personal hygiene and cleanliness are the best defenses against this serious illness. Included: Strategies for preventing and handling MRSA outbreaks.

Super bugs -- infections that sneer at conventional drugs and run unchecked through the population -- used to only plague actors in science fiction movies. Over the past decade, though, drug-resistant infections have become a reality in the general population, and one of them has forced several school districts into the forefront of a battle against a major public health threat.

That infection, Methicillin-resisitant Staphylococcus aureus (MRSA, pronounced mersa), is feared because it spreads rapidly, does not succumb to common antibiotics, and if left untreated can cause serious complications. While that is the bad news about MRSA, the good news is that by instituting and enforcing strict personal hygiene and school cleanliness policies, the spread of MRSA in schools and elsewhere can be slowed and even prevented.


MRSA Education Campaign

To help prevent the spread of MRSA in schools, the U.S. Centers for Disease Control and Prevention has launched an education campaign aimed at clinicians, educators, and mothers. The campaign involves print and online resources and is stressing MRSA prevention, identification, and treatment.

Its something every school district will have to face, said Cissy Bowman, spokeswoman for the Mt. Lebanon (Pennsylvania) School District, which waged a very public campaign against a MRSA outbreak in 2007. We have to get parents involved, too. Its a public health issue.


MRSA is a Staphylococcus (Staph) infection. Staph is a type of bacteria that causes many common skin infections. MRSA passes from one person to another through skin contact, often entering the body through cuts and abrasions. Initially, MRSA will appear as a pimple or boil on the skin, filled with pus or fluid. Often the boil will be on a leg or an arm. Over time, the skin around the boil will become swollen, red, warm, and painful. An infected person may develop a fever and feel lethargic.

To determine if the sore is actually MRSA, the infected area has to be swabbed and the swab tested. While MRSA is resistant to a number of common antibiotics, certain drugs can cure it, so it is important to identify it quickly and begin appropriate treatment to prevent the infection from progressing. Once it spreads into the bloodstream, patients often need to be hospitalized. MRSA can damage internal organs and in some cases, cause death. School systems across the U.S. got a reality jolt about the seriousness of the disease in October 2007 when 17-year-old Ashton Bonds, a senior at Virginias Staunton River High School died of MRSA.


Where Did MRSA Come From?

Up until a decade or so ago, MRSA generally was confined to institutions such as hospitals, prisons, and nursing homes, according to the CDCs Jeffrey Hageman. Then in the late 1990s the infection began appearing in the general population, occurring in otherwise healthy people, often children. Health officials thought initially that the Staph infection was leaking out of hospitals, but that is not the case, Hageman said. The infection strain in the general population is different from the one in institutions.
One possible explanation for the spread of the infection into the public is the overuse of common antibiotics in the general population, causing certain infections to develop a resistance to the drugs, he said.

MRSA still is rarely fatal, said Hageman, adding that people react to Staph differently. It is not clear why some people get a simple infection and others get a more severe case.

We cant eradicate the bacteria, said Ryan L. Edwards, the public relations coordinator for the Bedford County School District, where Staunton River High School is located. But we can give children the knowledge of how to prevent its spread and what to do if they think they have it. Because if left untreated, its a killer.


Although it is a serious and frightening disease, the best defense against MRSA, experts stress, is at everyones fingertips: soap and water. Washing hands thoroughly and often, using hand sanitizers when soap and water is not available; not sharing personal items, and disinfecting common areas and equipment can kill the bacteria. A flu vaccine also can help prevent related infections.

Schools should encourage students to wash their hands before lunch and install alcohol-based hand sanitizer dispensers on athletic fields, in locker rooms, weight rooms, and common areas, said Jeffrey Hageman, an epidemiologist with the U.S. Centers for Disease Control and Prevention (CDC), who concentrates on MRSA education and prevention. Young children should be supervised when they use alcohol-based hand sanitizers, he added.

Coaches and athletic directors need to be particularly vigilant. Students who play contact sports can be more prone to MRSA, because of the physical contact among players and higher incidences of cuts and scrapes. Weve seen it in all types of athletes, but it is more common among wrestlers and football players, said Hageman. So kids need to know what to look for.

To avoid contracting or spreading MRSA, athletes should shower with hot water and soap immediately after practicing or competing, said Hagemen.

After Lynchburg (Virginia) City Public Schools officials learned in fall 2007 that a middle-school student had MRSA, school officials cleaned desks and common areas and alerted parents about the causes of the infection and ways to stop transmission, said Anne Bond-Gentry, the districts coordinator of student services. Several cases were reported in the high school as well that fall and school officials made it a point to clean common areas and athletic equipment more regularly. Benches, mats, and athletic equipment are wiped off between periods, she said. We are encouraging good personal hygiene -- such as not sharing towels or other personal items. Water fountains also were adjusted so that no ones mouth has to touch the fountains metal to get a drink, Bond-Gentry added.

At several other schools that had MRSA outbreaks in 2007, school and health officials learned about some conditions in locker rooms and personal habits among student athletes that surpassed unsanitary, and which allowed the Staph to spread among players. This realization launched major overhauls in district policies about cleaning school facilities and equipment as well as education programs about personal hygiene.

“It’s something every school district will have to face. We have to get parents involved, too. It’s a public health issue.”



But not all the outbreaks only involve athletes. Bonds, the Virginia student who died, was not a member of a sports team, Edwards told Education World. Determining the origin of Bonds infection is nearly impossible, he added, because the bacteria is so prevalent in society.

The district recorded between 15 and 20 cases of MRSA in fall 2007, Edwards said. A large share of cases involved high school students and athletes who played contact sports, but infections were reported at the elementary- and middle- school-levels as well. When administers were notified about cases, students were removed from school for a period of time, and the schools they attended thoroughly and professionally cleaned, he said.

While information about MRSA is more available now, district officials had to become Staph infection experts on short notice last year. It was a very unique experience, said Edwards, about dealing with the outbreak and the death of a teenager. We were thrown into the national spotlight -- and wound up educating ourselves, the community, and the nation as well. Now we think we have a prevention program that rivals any in the U.S.

Parents were understandably terrified after the teens death, and many said their children would not return to school until the buildings were cleaned. Administrators opted to close all 22 school buildings for a day and professionally clean them.


Five C Factors that Facilitate MRSA Transmission

  • Crowding
  • Frequent skin-to-skin Contact
  • Compromised skin (such as cuts or abrasions)
  • Contaminated items and surfaces
  • lack of Cleanliness

Once school officials gained a better understanding of the disease, officials launched a vigorous school and community education effort, stressing personal hygiene. Students are instructed to frequently wash their hands, especially after being in high-student-contact areas such as the gym, cafeteria, library, and after recess. Athletic trainers and coaches were educated about what to look for and student athletes told to promptly report any cuts or scrapes so they can be treated.

It seems to be working. Bedford County schools had no MRSA cases as of late September, but officials know they remain vulnerable -- several surrounding districts reported students infected with MRSA.


Mt. Lebanon is another school district that revamped its approach to cleaning and hygiene. District officials are taking no chances after a MRSA outbreak in fall 2007 thrust the disease and the districts response into the national media.

Last year was intense for us, Bowman, the districts spokeswoman, told Education World. Now the county health department is using us as a model [for preventing and dealing with the infection.] We know we are doing all we can to prevent and educate -- its a partnership between the school and home. And we are always looking to improve.

The district put together online resources and brochures that were sent to all parents before school started this year and some literature targeted at athletes. Parents need to be aware what the infection looks like and how to contain it, said Bowman.

Mt. Lebanons effective response and follow-up measures to the outbreak to prevent further cases of the disease were featured on the news show 60 Minutes.


Initially, students at the high school didnt understand why prevention was so important. We stressed hand hygiene -- they didnt realize how easy it [MRSA] was to transmit.

Over a period of time in October 2007, Mt. Lebanon logged 15 MRSA cases, 14 of which involved high-school football players. Several students had to be hospitalized for a two-three day course of antibiotics, but there were no fatalities.

Part of the problem was an information gap in the community. Initially, some local physicians prescribed a common antibiotic, such as amoxicillin, to infected students without culturing their wounds. Since MRSA is resistant to the usual antibiotics, the infection intensified to the point where more aggressive treatment was necessary. Early treatment is critical to reduce hospital stays, said Bowman, who now sounds as knowledgeable as an infectious disease specialist. That type of treatment [hospitalization] does take a toll -- the hospital stay and high doses of antibiotics cause students to miss school, miss sports, and feel wiped out. It has a physical and emotional impact.


District officials opted to be as open as possible with the community and called in representatives from the Allegheny County Health Department to participate in information meetings for parents. Still, many parents were worried. Mt. Lebanon scheduled a parents meeting the same day news broke of Bonds death from MRSA in Virginia, and that districts decision to shut down all its schools. That news further escalated the Mt. Lebanon communitys anxiety level.

Searching for reassurance, parents asked the school district to test the turf on the football field for any signs of MRSA, because some students scraped their skin on the turf. (County health officials noted that it was unlikely that the MRSA bacteria would appear on the turf.) When those tests turned up negative, parents asked that the district test the field again, this time after a football game. Those tests also did not show any MRSA on the field. There is no way to determine the origin, Bowman noted. There are so many different ways to acquire it.

People began to worry Mt. Lebanon would be known as the MRSA district, Bowman said. While some districts choose to close some or all its schools if MRSA is reported, based on information from its local health department, Mt. Lebanon did not to close any schools.

But cleanliness took on a new urgency and intensity in the district. Football players now take practice gear home every day and wash it. Some had lucky T-shirts they used to hang on to -- those days have come and gone, Bowman said. The school also invested in a towel service for the football team.

The training room and locker room were swabbed and tested for MRSA and the locker rooms and benches now are cleaned regularly. Disinfectant wipes are available for use on weights and benches and students are encouraged to regularly wash their hands.


We cant eradicate the bacteria. But we can give children the knowledge of how to prevent its spread and what to do if they think they have it. Because if left untreated, its a killer.

Coaches have participated in an orientation program, so they know what MRSA looks like what to do if they suspect a student has it. Athletes with open wounds can continue to play, as long as the wound is securely covered. If a wound is suspicious, coaches alert the athletic trainer, who contacts the nurse. If the nurse is concerned, the students parents are asked to have the wound tested. All MRSA cases are reported to the county health department, so any trends in infection rates can be monitored.

Mt. Lebanon chose to be very open and proactive, said Guillermo Cole, public information officer for the Allegheny County Health Department, in looking back at the districts response. It is one of the more open districts, which is probably a good thing, because then doctors seeing patients with skin infections are more likely to test for MRSA. This [openness] also helps dispel rumors before they get out of control.


Sometimes the effort to contain MRSA involves a whole community. In one Texas town, alert hospital staff members were able to halt a MRSA outbreak in the schools and trigger an investigation and a comprehensive public education campaign that has significantly slowed infection rates.

Emergency-room personnel at Harris Methodist Northwest Hospital in Azle, Texas, noted a 36 percent increase in the number of cases of MRSA among 8-to-18-year-olds in 2004. Hospital staff members decided in December 2004 to reach out to officials in the Azle Independent School District to try to identify the source of the infections.


To Close or Not to Close?

While even one case of MRSA in a school is frightening, usually it is not necessary to close and disinfect the school and/or prohibit infected students from attending class, according to CDC epidemiologist Jeffrey Hageman. Most students diagnosed with MRSA should be able to attend school as long as the sore is covered, he said. Student athletes might have to sit out some practices or games because of the possibility of contact with other students.

The hospital started by visiting the high school in January 2005, and got an education about some teens personal hygiene habits, said Marsha Ingle, who is in charge of community relations, education, and marketing for the hospital. Some football players had never taken towels home to be washed since twice-daily practices had begun -- in August. Students shared the dirty towels, as well as razors. Numerous students admitted they didnt wash their hands regularly, in some cases because soap had been stolen from bathrooms.

At the junior-high school, students also were passing around unwashed towels in the locker room and some boys were sliding naked through puddles of water on the locker room floor, Ingle said.

And almost no one washed their hands before eating lunch.

Initially, students at the high school didnt understand why prevention was so important, Ingle told Education World. We stressed hand hygiene -- they didnt realize how easy it [MRSA] was to transmit.

One of the most dramatic illustrations of how quickly MRSA and other infections can spread took place when hospital staff members at an education program sprayed their hands with a substance that represented bacteria. They started shaking hands with people in the room and encouraged audience members to do the same. After several minutes, hospital personnel shown a black light that identifies germs around the room -- and almost everyones hands glowed. All of a sudden, it made sense, said Ray Ivey, director of administration for the school system.


After the hospital staffs visit and presentation, school officials made numerous changes. Athletic trainers now are marking towels so students only use their own and they are washed regularly, Ivey said. Athletic equipment is regularly cleaned and disinfected. The junior and senior-high school locker rooms are fumigated once a week.

Were after this with a vengeance, said Ivey.


We were thrown into the national spotlight -- and wound up educating ourselves, the community, and the nation as well. Now we think we have a prevention program that rivals any in the U.S.


Students at all grade levels are required to bring a bottle of hand sanitizer to school and time has been built into the day to allow all K-12 students to wash their hands before eating lunch. Desks and other common areas are cleaned with disinfectant wipes. Efforts are made to keep the bathrooms stocked with soap.

If a student comes to school with an open sore, he or she must go to the nurses office to determine if it needs to be tested for MRSA. If it is MRSA, the student may return to school as long as the wound is covered, Ivey said.

One year after starting the new hygiene program, the hospitals emergency department recorded a 57 percent drop in the number of MRSA abscesses among children. Hospital officials continue to visit the high school each year and talk to science and health classes about MRSA prevention and personal hygiene.

The MRSA-prevention practices have moved community-wide, with reminders throughout town for residents to regularly wash their hands. Is it overkill? We dont think so, said Ivey.

The best defenses against MRSA continue to be cleanliness and education. Enlisting the community can make battling the infection easier, noted Bowman. My advice would be to share as much information as possible and make sure everyone works together, she told Education World. If you suspect you have cases, get them tested. And focus on prevention.



Article by Ellen R. Delisio
Education World®
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