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Ascip risk alert

November 14, 2007
Attention: ASCIP Members

Methicillin-Resistant Staphylococcus Aureus (MRSA)
ASCIP has received numerous inquiries in regard to MRSA in schools. In mid-October theJournal of the American Medical Association (JAMA) published findings based on a studyconducted by the Center for Disease Control (CDC) which indicated that Methicillin-ResistantStaphylococcus Aureus (MRSA), commonly referred to as staph, infections had resulted inmore deaths than AIDS in 2005. With the release of these reports, MRSA received a great dealof media attention and many cases were being reported around the United States.
To prevent staph and other skin infections, students and staff should practice good personal-hygiene, which include: avoid sharing personal items such as towels and clothing; avoidtouching other people’s wounds or bandages; cover any wounds, cuts, scrapes, boils or otherskin infections with clean bandages; and wash hands thoroughly and often with soap andwater.
In addition to personal-hygiene, school staff should ensure that areas where staph and otherskin infections are most likely to occur receive regular and thorough cleanings. These areasinclude: weight-lifting rooms; wrestling areas; locker rooms; and other areas where sharedequipment may come in direct contact with a person’s skin. The manufacturer’s cleaninginstructions should be consulted when cleaning equipment such as wrestling mats to ensurethat the cleaners will not damage the equipment and/or void any warranties.
In the event that an MRSA infection is reported by staff or students at district or school sites,the district should contact the local public health department per California Code ofRegulations Title 17, Section 2508 - “It shall be the duty of anyone in charge of a public orprivate school, kindergarten, boarding school, or day nursery to report at once to the localhealth officer the presence or suspected presence of any of the communicable diseases.” Thelocal health officer may request the district to isolate affected individuals, isolate rooms, notifyaffected parties and/or take other necessary actions to control the communicable disease.
ASCIP staff verified with the California Department of Public Health that MRSA is areportable communicable disease and is required to be reported to the local health department.
Schools may elect to ensure that parents are aware of the concerns related to MRSA and wheresuspect exposures are observed, develop a mechanism by which those parents might be alertedto such exposures.
Please review the attached bulletin from the California Department of Public Health ASCIP staff isavailable to assist in addressing potential MRSA exposure concerns as they may arise.
State of California—Health and Human Services Agency MARK B HORTON, MD, MSPH
Skin Infections and MRSA Information for California Schools

Students, faculty and staff at schools should be sensitive to the possibility of disease
transmission; including respiratory diseases (influenza, colds, tuberculosis) and
diseases that are spread primarily through direct contact or contact with contaminated
objects (such as lice and scabies). The media has recently focused on the spread of
skin infections caused by methicillin-resistant Staphylococcus aureus (MRSA),
especially among school children. Most skin infections, regardless of cause, can be
easily treated if identified in a timely manner. This document is written to address the
concerns of the educational community in California about MRSA but the prevention
principles outlined are applicable to most skin infections.
What is Staphylococcus aureus
Staphylococcus aureus, often referred to simply as "staph," are bacteria that are most
commonly carried in the noses of healthy people. Approximately 25-30% of the
population are colonized (when bacteria are present, but not causing an infection) in the
nose with staph bacteria. Staph can also be carried in the armpit, groin, rectum, or
genital area. Staph bacteria are one of the most common causes of skin infections in
humans. Most of these skin infections are minor (such as boils and abscesses) and
smaller infections can be often be treated with incision and drainage without antibiotics.
However, staph also can cause serious infections such as pneumonia, bloodstream
infections, and joint infections. In the past, these staph infections typically have been
easy to treat with inexpensive antibiotics. Now in most communities in the U.S., over
half of the staph causing skin infections are resistant to commonly used antibiotics.

What is methicillin-resistant Staphylococcus aureus
Methicillin-resistant Staphylococcus aureus (MRSA) is Staphylococcus aureus that is
resistant to all penicillins (including dicloxacillin and other methicillin-related antibiotics)
and cephalosporins, such as Keflex®. Until recently, most MRSA infections occurred
among hospitalized patients. However, recently newer, more virulent strains of MRSA
have emerged in the community, causing community-associated MRSA infections. The
reasons for the emergence of these new strains are not entirely clear. What is clear is
that community-associated MRSA strains did not originate from the strains of MRSA
that have caused infections in hospitals and other healthcare facilities for decades.
Division of Communicable Disease Control/Infectious Diseases Branch 850 Marina Bay Parkway, Building P 2nd Floor, Richmond, CA 94804 What increases the risk for MRSA skin infections?
The following factors increase the risk of MRSA skin infections:
Compromised skin (such as cuts or abrasions)
Contact (frequent skin-to-skin)
with contaminated items and surfaces
Crowding, and
• Difficulty keeping skin clean or not cleaning skin after a cut or abrasion
The occurrence of an MRSA skin infection does not mean that the person is not clean
or has been in an unhygienic environment. Some persons with no apparent risk factors
for MRSA infection may come into contact with the bacteria at the same time that they
have a small break in the skin and this can result in an infection in what had appeared
to be normal skin.
How is MRSA spread?
MRSA spreads easily through direct contact with people or contact with MRSA
contaminated surfaces or items. MRSA is spread more frequently in crowded areas
such as locker rooms, dormitory rooms, or other crowded living conditions, particularly
when skin-to-skin contact is likely. In school settings, there are many opportunities for
skin-to-skin contact among students, especially those on athletic teams or in residential
facilities. Most infections occur when staph that is already on the skin enters through a
break in the skin (cut or scrape), or when broken skin is in contact with MRSA
contaminated objects (such as shared athletic equipment, clothing, towels, or razors).
Contaminated hands can also transfer MRSA to cuts or scrapes on the skin. Staph is
not usually passed through the air.
Why should school health professionals be concerned about MRSA?
School health professionals (i.e., school nurses and school physicians) can play an
important role in disseminating information about MRSA to staff, students, and parents
and may also provide care for infected students and refer infected students to
healthcare providers.
School health professionals should ensure that they have the most accurate and up-to-
date information on MRSA. One student with a severe MRSA infection or an outbreak of
skin infections can cause much anxiety for parents, students and staff. Although
concern about MRSA is greatest following the occurrence of a severe infection, the risk
to other students does not depend upon the severity of an infection but rather the
number of students infected with MRSA and the circumstances under which infections
are occurring. An outbreak among an athletic team may not pose a significant risk to
other students, as long as the infected athletes are receiving appropriate treatment and
follow recommended prevention measures.
Students with skin infections may need to be referred to a healthcare provider for
diagnosis and treatment. School health professionals should notify parents/guardians of
the affected students when possible skin infections are detected. Identifying an MRSA
infection can be difficult because the symptoms of MRSA infection are the same as
those of other skin infections. MRSA can only be diagnosed by culture and antibiotic
susceptibility testing. Unfortunately, misdiagnosis (e.g., many MRSA infections are
misdiagnosed as spider bites) or delayed diagnosis of MRSA infection can result in
delayed treatment and more serious complications.
School health professionals may provide care to students with skin infections. When
such care is provided, standard precautions should be used (e.g., hand hygiene before
and after contact, wearing gloves) when caring for nonintact skin or potential infections.
Should students with MRSA skin infections be excluded from school?
Unless directed by a physician, students with MRSA infections should not be excluded
from attending school. Students who have draining infections that cannot be covered
and contained should be excluded from school until the infection is healed or can be
covered and contained. If the student is involved in a physical activity or sport that
involves skin-to-skin contact with other students, they should be excluded from those
activities until the lesions are healed or can be covered and contained adequately;
return to those activities should be approved by a school official or doctor.
Do schools need to be closed and disinfected if a student is diagnosed with
No, it is not necessary to close the school if a student is suspected of or diagnosed with
an MRSA infection. MRSA skin infections are transmitted primarily by skin-to-skin
contact and contact with surfaces or items that have come into contact with MRSA
wound drainage. Ensuring that skin infections are covered will greatly reduce the
risk of contaminating surfaces or items with MRSA or other bacteria.
When MRSA skin infections occur, cleaning and disinfection should be performed on
surfaces or items that are likely to have had contact with uncovered or poorly covered
infections. Cleaning surfaces with routinely used detergent-based cleaners or
Environmental Protection Agency (EPA)-registered disinfectants is effective at removing
MRSA. It is important to read the instruction labels on all products to make sure they are
used safely and appropriately. For example, many disinfectants require at least 30
seconds of contact time on a surface to ensure killing of bacteria. Environmental
cleaners and disinfectants should not be used to treat infections. The EPA provides a
list of EPA-registered products effective against MRSA:
It is important to note that since MRSA infections are now common in the community;
the location of acquisition/transmission may not be in the schools.
Should the entire school community be notified of every MRSA infection?
No, it is usually not necessary to inform the entire school community about a single
MRSA infection. When an MRSA infection occurs within the school population, the
school nurse and school officials should determine which students, parents, and staff
should be notified based on the athletic activities and close contacts of the infected
student. Consultation with local public health authorities should be used to guide this
decision. Remember that staph bacteria have been and remain a common cause of
skin infections and that most infections are not associated with severe disease.
Consideration may be given to notifying the school community of an outbreak of staph
or other infections when additional measures are being taken to control the outbreak.
What should teachers know about MRSA?
Teachers can recognize children with open draining wounds or other infections and
refer them to the school nurse. In addition, teachers can help prevent the spread of
MRSA and other infections by enforcing student hand hygiene with soap and water or
alcohol-based hand sanitizers before eating and after using the restroom and can help
protect themselves from becoming infected with MRSA and other infections by also
using good hand hygiene.
What do schools need to do to reduce the spread of skin infections?
Hand hygiene by washing hands with soap and water or using an alcohol-based hand
sanitizer is the single most important measure that can be taken to prevent the spread
of skin infections and should be emphasized to students and staff. Hands should be
clean before they touch the eyes, mouth, nose, or any cuts or scrapes on the skin.
School staff serve as role models and should wash hands or use an alcohol-based hand
sanitizer frequently. If hands are visibly soiled, they should be washed with soap and
Hand washing procedure:
1. Use warm water and wet hands and wrists; 2. Use a bar or liquid soap (antimicrobial soap is not necessary to remove MRSA); 3. Work soap into a lather and wash palms, back of hands up to wrists, between fingers, around thumbs, and under fingernails for at least 15 seconds (about the time it takes to sing “Happy Birthday” or “Row, Row, Row Your Boat”); 4. Rinse well under warm, running water, and 5. Dry hands, using a disposable paper towel or hand-dryer.
Hand sanitizer procedure: Apply a dime sized amount of hand sanitizer to the palm of
one hand; rub hands together covering all surfaces of hands and fingers until all hand
sanitizer is absorbed. To be effective, hand sanitizers must be at least 60% alcohol
(check label) and used on hands that are clear of visible dirt. If there is any visible dirt,
hand sanitizers are not fully effective and hands should be washed with soap and water.
When should hands be cleaned?
• Whenever there is bare skin contact with others or with shared surfaces or • After sneezing, coughing, blowing or touching nose, • Before and after touching wounds, the mucous membranes of your eyes, nose, or mouth, or non-intact skin like acne, boils and skin rashes, • After using the toilet or urinal, and, • Before preparing food, eating, or drinking.
How can infected students minimize spreading it to others?
Those infected with MRSA should following these steps to minimize spreading the
infection to others:
• Cover the wound. Keep wounds that are draining or have pus covered with clean, dry bandages. Follow the healthcare provider’s instructions on proper care of the wound. Drainage and pus from infected wounds can contain large amounts of bacteria, so keeping the infection covered will help prevent the spread of infections to others. Bandages or tape can be discarded with the regular trash. • Clean hands. The student, their family, and others in close contact with the infected student should clean their hands frequently with soap and warm water or an alcohol-based hand sanitizer, especially after changing bandages or touching an infected wound. • Do not share personal items. Avoid sharing personal items such as towels, washcloths, razors, clothing, or sports uniforms/equipment that may have had contact with the infected wound or bandage. Wash sheets, towels, and clothes, including sports uniforms that become soiled, with water and laundry detergent. Drying clothes in a hot dryer also helps kill bacteria. • Inform healthcare providers who treat them that they are or have been infected
Is MRSA a reportable disease in California?

MRSA is not a reportable disease in California. However, it is reportable in a few
counties including Santa Clara and San Mateo. Contact your local health department if
there is an outbreak of skin infections occurring at your school.
Are there any educational materials available on MRSA?
Yes, educational materials can be found at the following websites:
CDPH: including

Washington State Department of Health:


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