In the year 2005, Methicillin-resistant Staphylococcus Aureus (MRSA) claimed the lives of nearly 19,000 people in hospital settings (Shilling, 2007). In hospitals, MRSA infections, though increasing in frequency, are not new issues among the ill and injured whose vulnerable immune systems are distressed or compromised. Yet the rise of potentially fatal outbreaks among the young and relatively healthy school population is a relatively new communicable-disease health threat. The emergence of MRSA in the public schools is what this literature review aims to look at.
A number of MRSA-related fatalities among the school population have raised new alarms about the new threat of what has been named Community-Acquired Methicillin-resistant Staphylococcus Aureus, or CA-MRSA. School leaders and public health officials have reacted to the CA-MRSA threat by identifying high-risk population, behavior, and conditions as well as what can be done to combat CA-MRSA outbreaks proactively. What follows is an examination of current literature into MRSA and CA-MRSA as it manifests itself as a health threat within our schools.
The key to preventing CA-MRSA outbreaks within schools appears to involve both educating both students and faculty on CA-MRSA prevention and proactively eliminating high-risk conditions and behavior that have been found to promote CA-MRSA outbreaks in schools. The consensus of literature on CA-MRSA prevention in schools recommends proactive and rigorous hygiene and sanitation as well as eliminating behavior known to increase the risk of CA-MRSA infection. Once key school staff, such as school coaches and nurses, have been educated on MRSA, they must in turn educate and “…. emphasize to students the importance of reporting suspicious skin lesions and complying with treatment and infection control recommendations” (Anlitta & Letizia, 2007).
The purpose of this paper is to conduct a review literature dealing with CA-MRSA outbreaks within schools. This paper will identify what the literature reviewed has to say about the CA-MRSA problem and other CA- MRSA issues such as the scope and severity of the CA-MRSA threat within our school as well as can be done to prevent the problem.
What is CA-MRSA and How Big is the Problem?
Though knowledge of the Staphylococcus Aureus bacterial infection caused by MRSA has been in existence since it’s identification in the 1880’s, recently the problem has migrated out of hospitals and into schools where it has infected a new group: the young and healthy (Anlitta & Letizia, 2007). Most people are aware that MRSA is a penicillin-resistant staph infection that has generated a significant amount of media coverage in the past few years. Authors Aniltta and Letizia more specifically define the bacterial culprit of MRSA as the microorganism staphylococcus aureus that thrives in dank, warm environments such as lockers, towels, sweaty skin, showers, and benches found in school locker rooms (Aniltta & Letizia, 2007). On humans, the CA-MRSA bacterium is most commonly found in the nasal passages, groin area, and armpits (Aniltta & Letizia, 2007).
Each of the studies that were reviewed addressed the question of how big of a problem CA-MRSA is in our schools and elsewhere. The study CDC Issues Guidelines for Schools on MRSA states that MRSA accounts for more deaths in the United States than HIV (Samuels, 2007). Breaking down further, one Center for Disease Control and Prevention stated that staph bacteria colonies exists peacefully in 25% to 30% of the general population, but only 1% of these have MRSA (Schilling, 2007).
A common theme found in half of the studies was that of the deadly seriousness of the CA-MRSA threat to our schools. To help make this point, recent cases of actual MRSA-related school fatalities were given in several of the studies reviewed. The cases of a 12-year old Brooklyn Middle School student and a 17-year old High School senior from Virginia, both who recently died from CA-MRSA infections, are given in both Deb Moore’s MRSA — Epidemic or Media Storm? and Samuels' CDC Issues Guidelines for Schools on MRSA. At the same time, as if to prevent a general panic, some authors seem to play down the CA-MRSA threat while at the same time sounding the alarm. In Schools Work to Prevent MRSA Infections, the author opens by stating that “…school children face the smallest risk in the general population of contracting MRSA…” (Lenckus, 2007). In MRSA — Epidemic or Media Storm?, author Debs Moore states that the frequency of MRSA in schools is hard to track because “… MRSA is not a reportable disease in most counties or states” (2007). Yet somewhat contradicting herself, Moore closed her article by stating that according to most health officials, there is no MRSA “… epidemic or unusual number of occurrences” (2007). Likewise, in her article The MRSA Threat, Schilling stated that “the vast majority of MRSA cases are mild” (2007), which contradicts the article’s title to some degree.
All of the literature sources reviewed in this paper covered the topic of what makes individuals or groups more or less at risk of contracting a CA-MRSA infection than the general population. Deb Moore states that in the US, by far most MRSA cases occur in hospitals as the general population (2007). Other settings, groups, and lifestyles that are at a higher-risk for MRSA are “… sports team members, prison communities, men who have sex with men, military personnel, and drug users” (Huijsdens et al., 2006). These groups and group activities have a common denominator in that they all come into frequent physical contact or very close physical proximity with others who might just have an active and exposed MRSA infection.
Therefore, it does not come as any surprise that MRSA is “… usually transmitted by direct skin-to-skin contact, or contact with shared items or surfaces that have come into contact with someone else's infection (e.g., towels, used bandages)…” (Moore, 2007). These groups are at a higher CA-MRSA risk due to environments that their lifestyles create. In Deb Moore’s work, settings that promote a higher MRSA risk have been listed out in an easy to remember 5-C’s format: Crowding, frequent skin-to-skin Contact, Compromised skin (i.e., cuts or abrasions), Contaminated items and surfaces, and lack of Cleanliness. Many of these factors are common in schools and dormitories (2007).
Within a school setting, high-risk CA-MRSA factors are categorized as “sharing (sharing soap/towels and benches with teammates), skin injury (cuts, abrasions), and close contact…” in sports such as football and wrestling (Nguyen et al., 2007). Another individual factor that places a person in a higher-risk group for a CA-MRSA infection is simply one’s body mass. This was supported by Nguyen’s findings in that linemen on the football team studied had larger body mass and a greater incidence of MRSA (2007). It stands to reason that more body mass equals a larger target for a CA-MRSA invasion. Physical contact with a CA-MRSA-infected person or item is not the only means that CA-MRSA can spread. The CA-MRSA contagion can also be spread through droplet transmission from those with persistent MRSA basal colonization (Anlitta & Letizia, 2007).
The literature selected on CA-MRSA in Schools can be divided into two general categories: those that provide a general overview on the subject such as identification, isolation, and treatment; and those that are more specialized such as Nguyen et al’s Recurring Methicillin-resistant Staphylococcus aureus Infection in a Football Team and Huijsdens et al’s Methicillin-resistant Staphylococcus aureus in Dutch Soccer Team (2006). Of those that provide a general overview, the individual symptoms of a CA-MRSA infection have been simply described as “…pustules, ‘insect bites,’ boils, and abscesses” that do not respond to conventional treatment and contain the MRSA-causing contagion Staphylococcus Aureus (Nguyen et al., 2007). Furthermore, in Nguyen’s study, it was found that CA-MRSA symptoms generally manifested within two weeks of exposure to the CA-MRSA bacteria.
Contrasting the simplified information on CA-MRSA symptoms given in Nguyen et al’s study is that of Alex Aniltta and Marijo Letizia’s Community-Acquired Methicillin-Resistant Staphylococcus aureus: Considerations for School Nurses. In this study, CA-MRSA symptoms are described in greater detail and are progressive in severity:
MRSA causes mild to severe skin and soft tissue infections. The infection is manifested locally by redness, warmth, induration, and pain. Systemically, individuals can experience general malaise, fever, chills, and night sweats. If the infection is not diagnosed promptly or treated inappropriately, life-threatening illnesses can result, including osteomyelitis, endocarditis, septic arthritis/bursitis, necrotizing pneumonia, necrotizing fasciitis, bacteremia, septic shock, and death (2007).
A major and common theme of the literature studied is the prevention of CA-MRSA in schools. Of all seven sources reviewed, Anlitta and Letizia’s study was by far the most comprehensive in addressing CA-MRSA prevention. CA-MRSA preventative measures given in the other studies are covered in the Anlitta and Letizia article. To start with, according to Anlitta and Letizia the “… hands are the main source of transmission of infection; therefore, hand washing is the most important way to prevent the spread of infection” (2007). School nurses play a central role in CA-MRSA control and should therefore “… engage in careful surveillance of those students who have come into direct contact with CA-MRSA infected individuals…” (Anlitta & Letizia, 2007). The Anlitta and Letizia study goes on to list out thirteen hygiene and sanitation measures, many of which are not covered in the other literature reviewed in this study. Anlitta and Letizia treat the topic of CA-MRSA as deadly serious and do succeed in conveying a sense that this is a threat of top priority requiring vigorous action to halt its spread.
Description of Studies
MRSA — Epidemic or Media Storm?, by Deb Moore (2007), is a concise – yet informative article that answers many questions about MRSA: what it is, when it was identified, who is at risk, treatment and prognosis, and more. The author does not answer the question that the title poses – but presents facts and leaves it to the reader to decide. The article is strong in its concise overview presentation of MRSA facts. It is weak in that it does not answer the question the title poses and leaves the reader wondering if the author knows or has an opinion.
CDC Issues Guidelines for Schools on MRSA, by C Samuels, offers a brief overview of the 2007 CDC guidelines for schools on MRSA. The article, while playing down the overall threat of MRSA becoming anything like a pandemic disease, does list out recent school fatalities in which CA-MRSA was the culprit. A strength in this article is that it is concise and hits only on critical information. A weakness is that it provides little in-depth information and conveys nothing in regards to why the reader should be concerned with the subject.
Schools Work to Prevent MRSA Infections (2007), by D Lenckus, is an informational document that addresses school legal liability and insurance coverage in CA-MRSA-related incidents as well as CA-MRSA-related expenses such as costly extra sanitation measures and school closings. This study opens with the statement that school-age children are at least risk in the general population for contracting CA-MRSA but that, in light of recent school deaths, schools are at the forefront in taking precautionary actions against CA-MRSA. The study’s audience would be school superintendents, school boards, other major decision and school policy makers, and insurance agencies. The study provides no other factual information about CA-MRSA other than insurance liability scenarios.
Community-Acquired Methicillin-Resistant Staphylococcus Aureus: Considerations for School Nurses (2007), by Alex Aniltta and Marijo Letizia, is a comprehensive presentation of facts concerning CA-MRSA. The main theme of this study is recognition, treatment, and prevention, with an emphasis on special duties and responsibilities that school nurses have in fighting CA-MRSA. Of the seven CA-MRSA articles reviewed, Anillta and Letizia’s is the most serious in tone and imparts that this is a problem to be taken very seriously and given nothing less than top priority in schools today.
The MRSA Threat (2007), by Becky Schilling, offers general information on CA-MRSA with a main emphasis on what food service directors at schools should be doing to stop the spread of the CA-MRSA problem. The article is built around actual case coverage of what certain schools and food service individuals are doing to combat MRSA. In this regard, the article is strong in that it offers information on proactive measures that are already in use. The article is weak in that it does not prompt the reader to think of new ways to fight CA-MRSA. Also, nearly one entire page is taken up with photos of people washing their hands and this is a silly waste.
Recurring Methicillin-resistant Staphylococcus aureus Infections
in a Football Team (2005), by Dao M. Nguyen, Laurene Mascola, and Elizabeth Bancroft, presents a scientific case study of a football team beset with reoccurring MRSA infections in 2003. The researchers systematically cover the subject, posing questions relating to the case, such as infection patterns, and answering those questions with empirical evidence. The authors make good use of tables and charts to present their findings and have detailed sections for methods, results, and discussion. A possible weakness of this study is that it is limited in the scope of its subjects.
Methicillin-resistant Staphylococcus aureus in Dutch Soccer Team (2006), by Xander W. Huijsdens et al, is nearly identical to Nguyen’s article in that it covers a specific case of reoccurring MRSA in a football team (AKA soccer in the US). However, this article covers the general facts around CA-MRSA to a much lesser degree than Nguyen’s article. A strength inherent to this article is its solitary focus on the findings of the subject studied. A weakness might be the relative lack of data tables and charts that were present in Nguyen’s article of a similar scope and purpose.
CA-MRSA is an emerging health threat to the population that may be a consequence of past and present overuse of penicillin. The bacterium behind the MRSA problem has been called a “superbug” (Moore, 2007). So-called superbugs get ‘super’ by genetically surviving the onslaught of available strains of penicillin. In this regard, it is somewhat surprising that only one of the seven articles reviewed made much mention of this man-made culprit behind the MRSA problem. Only Aniltta and Letizia acknowledge this by stating that “… by the 1960s, widespread use of penicillin led to antibiotic resistance, leading to the development and use of the antibiotic methicillin... Soon after that… [MRSA] became prevalent in hospital settings” (2007). Further tracing the pathology of CA-MRSA, Anlitta and Letizia state that in the 1990’s a “… genetically distinct strain of MRSA has emerged in community settings among healthy individuals who have not had contact with health care facilities…” and at this point in time CA-MRSA entered places such as our schools (2007). The old adage that to defeat an enemy; one must know the enemy holds true in the battle against CA-MRSA. In this regard, it would be wise for the other authors to cover the historical problem and present consequences of overusing antibiotics.
In specific regards to the topic of MRSA in the schools, all of the authors made the point that sanitation and hygiene are critical to stop the potentially deadly CA-MRSA superbug. In this regard, Anlitta and Letizia made the point best by listing out in sufficient detail the symptomatic real-world consequences of a CA-MRSA infection – starkly ending the list with death. After making that point and letting it sink in, the authors launch into a detailed set of instructions to follow in the fight against CA-MRSA in the schools. To drive the issue home, the authors take power statements, such as “school nurses must engage in careful surveillance of those students who have come into direct contact with CA-MRSA infected individuals”, and enlarge, embolden, and set apart in text boxes these statements to make sure that the reader gets the point. Contrasting Anlitta and Letizia’s work is Moore’s weaker MRSA — Epidemic or Media Storm? that leaves the reader unclear as to how big of a threat MRSA is to the schools. Moreover, Moore’s work leaves the reader feeling that the author does not know whether MRSA is a real epidemic or just another media storm and, subsequently, it leaves the reader thinking that if the author does not know, then why is it important that I (the reader) know?
In the battle against CA-MRS in the schools, people are taking the right path and turning towards knowledge and education as the main weapon of choice. Educating staff and students on the prevention of CA-MRSA through rigorous sanitation and hygiene is the best option. If people chose the usual weapons against CA-MRSA that have been used and overused in the past battles against bacterial infections, then the real risk of making an already superbug even stronger exists.
Aniltta, A. & Letizia, M. (August 2007). Community-Acquired Methicillin-Resistant
Staphylococcus aureus: Considerations for School Nurses. The Journal of School
Nursing, 4(23), 210-213.
Huijsdens, X. W., et al. (October 2006). Methicillin- resistant Staphylococcus aureus in
Dutch Soccer Team. Emerging Infectious Diseases, 10(12), 1584-1586.
Lenckus, D. (2007). Schools work to prevent MRSA infections. Business Insurance. 41 (44):45-45.
Moore, D. (2007) MRSA — epidemic or media storm? School Planning & Management.
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Nguyen, D. M., Mascola, L. & Bancroft, E. (2005, April). Recurring methicillin-resistant
staphylococcus aureus infections. Emerging Infectious Diseases, 3(11), 526-
Samuels, C. (2007). CDC issues guidelines for schools on MRSA. Education Week.
Schilling, B. (2007, December 15). The MRSA Threat: Media attention over the
"superbug" is causing foodservice directors—esp at schools and universities—to
step up sanitation measures. Food Service Director, pp. 20-21.