Infections Put Administrators to the Test
Resistant staph cases require swift response to secure public confidence, while avoiding panic.
Superintendents and school principals nationwide are working to find the right balance in easing public concerns about a drug-resistant bacterium that has sickened students in dozens of states so far this year and caused the reported deaths of at least four young people in the last month.
Even as they move aggressively to make sure that schools are safe and clean, officials say they must guard against setting off panic at schools where students have been diagnosed with methicillin-resistant Staphylococcus aureus, or MRSA, infections.
The key, school leaders say, is releasing accurate information to parents and students quickly, while collaborating closely with school-based and local health officials.
“Nothing I’m going to do here is going to cure MRSA,” said Richard J. Kelley, the principal of the 1,200-student Silver Lake Regional High School in Kingston, Mass., which had two students diagnosed with MRSA infections last month. “But if you don’t tell people everything you can share, they’ll make up their own answers, and they’ll fill in the blanks.”
Public-health officials stress that there’s nothing about schools that makes them more likely than other institutions to be the site of MRSA infections, and that the number of cases reported recently does not appear to be higher than usual.
Methicillin-resistant Staphylococcus aureus, or MRSA, cases have occurred among children in prekindergarten to 12th grade in at least 37 states since Jan. 1, 2007, media accounts indicate, while infections have been reported among school staff members in at least five states and the District of Columbia in the same period. The federal government does not require the reporting of MRSA cases to health authorities. Virginia late last month became the first state to require such reporting.
The current focus on MRSA was prompted by an Oct. 17 research study conducted by the federal Centers for Disease Control and Prevention that found that MRSA infections appeared to be more common than were once thought, and had been linked to the deaths of almost 19,000 people in the United States during the one-year period of the study. ("Resistant Staph Germ Poses School Health Concerns," Oct. 24, 2007.)
The release of the study came just after a 17-year-old boy in southwestern Virginia died Oct. 15 from what his family said was an MRSA infection. The strain of staph also has been blamed for the deaths of a 4-year-old girl in New Hampshire and an 11-year-old girl in Mississippi on Oct. 12, and of a 12-year-old boy in the Brooklyn borough of New York on Oct. 14.
The bacterium, which is carried harmlessly on the skin and in the noses of thousands of individuals, is most commonly spread in places where people fail to practice good hygiene, and where people have cuts or scrapes that don’t get cleaned immediately. Hospitals have been the site of most MRSA infections.
“Wherever those conditions are, that’s where we see it,” said Dr. Elizabeth A. Bancroft, a medical epidemiologist for the Los Angeles County Department of Public Health. “Schools themselves are not a vector for disease. There’s nothing particularly special about children, except that maybe they haven’t practiced good hygiene, and they may be engaging in activity where they come into close contact.”
Many school athletic officials, for example, say they have been attentive to the threat of MRSA for some time, given the contact involved in sports. (“School Athletics on the Front Line in MRSA Prevention” Nov. 7, 2007.)
But the virulence of the infection—and the troubling nature of the Atlanta-based CDC’s report last month—have raised anxiety in a number of communities with reported MRSA cases, complicating the task of local school and health officials.
At Silver Lake Regional High School, for example, the principal said rumors were rampant after two students were reported with the infection. Mr. Kelley said other students came to him asking if it was true that a student had had his thumbs amputated because of MRSA, or that the school would have to shut down for a week if another case was discovered.
Officials responded with school-based announcements, letters to parents, and information posted on the high school’s Web site that went a long way toward putting the rumors to rest, Mr. Kelley said. Silver Lake has also stepped up its cleaning procedures in the gym locker rooms, and has installed more than 100 hand-sanitizing foam dispensers in classrooms and in the cafeteria. The cost of the dispensers and overtime for school janitors has been about $6,500, Mr. Kelley said.
Health experts say people in schools should follow these measures recommended for institutional settings.
• Practice good hygiene—wash your hands with soap and water or use an alcohol-based hand sanitizer; shower immediately after exercising.
• Avoid sharing items such as towels, sheets, clothing, razors, and athletic equipment. Staph, including the antibiotic-resistant MRSA strain, spreads on contaminated objects as well as through direct contact.
• Wash athletic gear and towels properly after each use. For clothing, use a washer and laundry detergent, and a dryer to dry clothes completely. Use detergent-based cleaners or U.S. Environmental Protection Agencyregistered disinfectants to remove MRSA from surfaces. Avoid whirlpools or common tubs if you have an open wound, scrape, or scratch.
• Cover scrapes or cuts with clean, dry bandages until healed.
• Clean frequently touched surfaces, such as athletic equipment, that come into direct contact with peoples’ skin.
“There’s a lot of things you don’t have to do, but you do them anyway,” he said.
In Nashua, N.H., administrators moved quickly to relieve fears among parents and students after two cases of MRSA were reported in recent weeks in the district’s two high schools.
Within about a week, the 12,500-student district had notified all parents about the infections, which were diagnosed in a football player in one high school in the last week of September, and a few days later in a non-athlete who used the weight room in another high school.
School district staff members were directed to take special care cleaning locker rooms and other athletic facilities. Athletes were told to take their belongings home for laundering. The high school students also were gathered in small assemblies to tell them about MRSA and the simple hygiene tips that can prevent the spread of infection.
“I don’t think that was overreaction,” said Edward L. Hendry, the associate superintendent of the district. Before the district took the measures, he said, “there were some parents who were saying, ‘Why don’t you shut schools down?’ So we acted in a way that was very constructive.”
As at Silver Lake, both of the Nashua students have recovered from their infections, and no further cases have been reported, Mr. Hendry said last week.
In the vast majority of cases, MRSA infections can be easily treated with antibiotics other than penicillin or amoxicillin. Federal health officials do not require that the cases be reported to health authorities, and they say that most cases among school-age children need not be reported to the school community at large.
But in the wake of the CDC report and the student death in southwestern Virginia’s Bedford County, Gov. Tim Kaine of Virginia, a Democrat, signed an emergency regulation requiring that MRSA infections be reported to state health authorities by medical laboratories. U.S. Sen. Charles E. Schumer, D-N.Y., has said that he believes the CDC should set up a national reporting system.
In September, Texas started a two-year pilot program that would require tracking of MRSA cases in one county. The county health authority then would report on whether the tracking program helped reduce cases.
When infections do become public, school administrators—faced with community pressure—sometimes respond in ways that may exceed what health officials say is strictly necessary.
Dr. William Schaffner, an infectious-disease specialist at the Vanderbilt University School of Medicine in Nashville, Tenn., said that disinfecting schools, a frequent step taken in recent weeks, is more a public relations move than a way to stop the spread of MRSA infections.
■ Staphylococcus aureus, or “staph,” is a common bacterium, that lives harmlessly on the bodies of 25 percent to 30 percent of the U.S. population. People who carry staph without being sick are said to be “colonized” with the bacterium.
■ Methicillin-resistant staph, or MRSA, is a strain resistant to the broad-spectrum antibiotics used to fight regular staph infection, such as penicillin and amoxicillin. About 1 percent of the population carries the drug-resistant strain of staph without being harmed by it.
■ Both strains can cause infection if they enter the body, most commonly through a break in the skin. The infection can become more serious if the bacteria enter the bloodstream.
■ Staph infections typically look like pimples or boils, or may be misdiagnosed as insect or spider bites. They are often at the site of a cut or scrape, or in parts of the body that are covered by hair, such as the back of the neck, the groin, or an armpit.
■ Doctors first noticed drugresistant staph in the 1960s. Then, as now, the strain was most commonly found among people in hospitals or who had recently been hospitalized. It is believed to be spread by doctors and nurses who fail to practice proper hygiene. In other settings, infection can also be spread through skinto- skin contact—in athletics, for example.
■ About 85 percent of the MRSA infections tabulated in a recent study by the U.S. Centers for Disease Control and Prevention were found among people in the hospital or who had recently been hospitalized. Infections are most common among those age 65 or older, and least common among 1- to 17-year-olds. Drug-resistant infections are more common among men than women and among black people than those of other ethnic backgrounds.
■ Doctors sometimes treat staph infections without drugs, by draining the abscessed areas. Vancomycin is a commonly used antibiotic that can kill MRSA, but because doctors are starting to see Vancomycin-resistant strains, they may use nondrug treatments first if possible.
“I’d like parents not to think it’s in the school building and the stuff in it. I want them to think, ‘Oh, I have to pay attention to the personal hygiene of my child. And if my child has something that looks like an insect bite, it’s probably worth getting it checked out,’ ” he said.
Still, the 10,300-student Pike County district in eastern Kentucky shut all 23 of its schools Oct. 29 for cleaning. The closings came two weeks after students at Pike Central High School staged a lunchroom sit-in in support of having the school cleaned. A student was diagnosed with an MRSA infection in September.
“We’re not closing schools because there’s been a large number of breakouts, but as a preventative measure,” Superintendent Roger Wagner told the Associated Press.
In Virginia’s 11,000-student Bedford County system, where 17-year-old Ashton Bonds had attended school, officials closed the district’s 21 schools for cleaning by school staff members after his death last month. In addition, a cleaning service was hired to dispense disinfectant as a fog throughout Mr. Bonds’ high school, then wipe down frequently touched surfaces such as desktops and doorknobs with more disinfectant, said Earl Clarke, whose company handled the work.
The job at the high school took 30 people 10 to 11 hours to complete, said Mr. Clarke; his company and the school system are still working out the price.
“We’re trying to make it fair for everyone,” he said last week.
The Bedford County district previously had notified parents about MRSA infections in other students that had occurred this school year. There had been about six cases, said Ryan Edwards, the spokesman for the district. The district followed established protocols, which were to ask a child to stay home for a day, “while continuing to clean the school vigorously,” Mr. Edwards said.
But the furor that mounted after Mr. Bonds’ death was intense, Mr. Edwards said, and prompted officials to mount an information campaign.
“We could spend a day educating to the best of our ability the community,” he said. “We put a plethora of material out to our media. We posted a multitude of information on our Web site.”
Getting the Word Out
Other schools and districts appear to be releasing as much information as they can, in order to encourage parents to take the right hygiene steps. Sometimes, releasing that information prompts parents to come forward and say that their children had been infected with MRSA months earlier.
That happened in the 1,900-student Glen Ridge, N.J., district, said Superintendent Daniel Fishbein. Based on the report of cases in other schools, the district decided to send a letter home to parents letting them know what steps officials were taking to keep schools clean. That led a parent to mention that her son had been successfully treated for MRSA earlier in the year.
“She was really concerned about telling us late, but it’s not anything to be mad about,” Mr. Fishbein said. Unless it’s an illnesses such as tuberculosis, he said, “it’s not a reportable medical incident in New Jersey.”
Mr. Fishbein said that he felt he needed to reach out to parents as a way to cut through what might be seen as hype. “You want to inform parents that you’re doing what you can do,” he said.
The 38,000-student Buffalo, N.Y., district appears to be following a similar philosophy. Seven Buffalo students have been treated successfully for MRSA this year, officials said, and the district held a press conference last week to announce that it was installing hand-sanitizing fluid dispensers in all of its schools. The system also used a phone system to call parents and leave messages informing them of the personal-hygiene tips that stop the spread of infection.
“We have not received any questions; we’re the ones raising the issue,” said Superintendent James A. Williams. “We are the educators in the community. It’s our job to make sure the news gets out to our community.”
Vol. 27, Issue 11, Pages 1,16,18