Infections and Infection Prevention &Control Practices in
Iowa’s High School Athletic Programs
Loreen A. Herwaldt Mark Pedersen
The University of Iowa Colleges of Medicine and Public Health
Disclosures• Loreen Herwaldt: 3M, Sage, CDC, AHRQ
research grants• Mark Pedersen: Nothing to disclose
Background• Community-associated methicillin-resistant
Staphylococcus aureus (CA-MRSA) often causes skin and soft tissue infections among young healthy persons.
• CA-MRSA has caused outbreaks among athletes, including:– Football (American) players– Football (Soccer) players– Fencers
Goals
Survey high school athletic departments in Iowa to:– Assess infection control measures and
hygiene practices– Assess the frequency of MRSA skin and soft
tissue infections– Assess the frequency of skin
infections caused by other pathogens
Methods
• Collaborated with staff from the Iowa High School Athletic Association
• Created and administered a web-based survey • Statistical Analyses
– Standard descriptive analyses– Cochran-Armitage trend test– Jonkheere-Terpstra test– Wilcoxon Rank-Sum– Pearson chi-square
Results• 229/393 (58.4%) of the high schools with
athletic programs responded• 219 (96%) were completed by athletic directors• Athletes per program: median = 125;
25th to 75th percentiles = 82-250
Results: Provided by SchoolsSupplies/Equipment Number of Schools Soap for showers 143 (62.7%) Towels for showers 86 (37.6%) Launder uniforms 81 (35.7%)Cardio equipment 181 (80.1%)Weights 228 (99.6%) Whirlpool 124 (55.5%)
Results: Turf, Floor, Mat Burns Managed by:
Person who Manages Lesions NumberAthlete 90 (39.3%)Athletic trainer 68 (29.7%)Manager 23 (10.0%)
Results: Risky ActivitiesActivity Number of SchoolsShave arms and legs (n = 224) 58 (25.9%)
Shave other areas (n = 225) 40 (17.8%)Share razors (n= 223) 1 (0.45%)Share protective equipment (n = 220)
19 (8.6%)
Share towels (n = 226) 23 (10.2%)Share bottles of water or sports drinks (n = 226)
70 (31.0%)
Results: Infections
Infection Number of Schools Reporting
Tinnea 56 (43.1%)S. aureus 36 (27.7%)Herpes simplex 26 (20.0%)Streptococci 17 (13.1%)
Results: Sport, Education, and SSTISport Educate
Athletes0 Athletes w/ SSTI
> 1 Athlete w/ SSTI
Wrestling 164 (71.6%) 113 (53.1%) 75 (35.2%)Football 145 (63.3%) 157 (73.7%) 30 (14.0%)Boys Basketball
106 (46.3%) 201 (94.4%) 1 (0.47%)
Girls Basketball
99 (43.2%) 204 (95.8%) 3 (1.4%)
ResultsClass Number
(%)No. of Athletes(Range)
Employ a CAT (%)*
1A 76 (33) 7-170 25 (33)
2A 81 (36) 50-384 36 (44)
3A 37 (16) 45-620 25 (68)
4A 33 (15) 270-1008 31 (94)
Overall 229 7-1008 117 (51)
CAT = Certified Athletic Trainer; *P < 0.0001
DailyWeeklyWhen SoiledAfter each useOtherNever
Frequency of Cleaning Locker Rooms
Increased by school classification; P = 0.02
Frequency of Cleaning Daily: School Classification
Class Lockerrooms
Showers Train-ingequip-ment
Prac-tice uni-forms
Train-ingtables
Pt care areas
1A 59% 44% 19% 29% 29% 26%
2A 79% 71% 24% 32% 34% 40%
3A 83% 54% 26% 41% 52% 48%
4A 81% 79% 35% 37% 62% 64%
P 0.02 0.012 0.0002 0.055 < 0.0001 0.0004
Frequency of Cleaning After Each Use
• Game uniforms: 69%-84%• Protective equipment: 8%-17%• Wrestling mats, practices: 19%-27%• Wrestling mats, tournaments: 37%-60%• The frequency of cleaning these items did not
vary by school classification.
The Frequency of Cleaning: CAT vs. No CAT
• Training equipment (P = 0.012)– CAT: Daily or after each use = 41%– No CAT: Daily or after each use = 23%
• Protective equipment (P = 0.054)– CAT: Weekly, daily, or after each use = 63%– No CAT: Weekly, daily, or after each use = 42%
• Training table (P = 0.015)– CAT: Daily or after each use = 77%– No CAT: Daily or after each use = 60%
Education, Policies, SSTI, MRSA SSTI:School Classification
Class Educate re. SSTI
Policy re. SSTI
Athletes w/ SSTI
Athletesw/ MRSA
1A 67% 26% 34% 5%
2A 90% 35% 63% 4%
3A 92% 46% 73% 8%
4A 88% 61% 79% 24%
P 0.002 0.0004 < 0.0001 0.002
Education, SSTI, MRSA SSTI:CAT vs. No CAT
0
10
20
30
40
50
60
70
80
90
Educate SSTI MRSA SSTI
CATNo CAT
%
P 0.058 0.011 0.018
Association of Education & Policies with SSTI
0
10
20
30
40
50
60
70
80
90
100
Education Policy
SSTINo SSTI
%
P < 0.0001 0.016
Policies• Preventing participation in practices/games/meets
– Athletes w/ SSTI: 37%– Athletes w/ other infections: 22%
• Requiring hand hygiene– Before taping each athlete: 11%– After taping each athlete: 12%– Before caring for injured athletes: 23%– After caring for injured athletes: 26%
• Requiring gloves when caring for athletes who might be bleeding: 79%
Summary and Conclusions• Wrestling programs >> football programs >
basketball programs reported having > 1 athlete per season with SSTIs.
• CA-MRSA SSTIs still appear to be infrequent among Iowa’s high school athletes.
• Tinnea & S. aureus are the most common skin pathogens.
• School classification, the number of athletes, and having a CAT were highly correlated.
Summary and Conclusions
Ironically, schools;• In higher classifications• That educated athletes about SSTIs• That had certified athletic trainers• That had appropriate policies
were more likely to identify athletes with SSTIs, including MRSA SSTIs.
Summary and Conclusions
• We doubt these are risk factors for infection. But they may indicate that these programs have more resources for surveillance or that they are more aware of the issues.
• One alternative explanation could be that higher numbers of athletes means crowding and that crowding facilitates transmission of infectious agents.
Suggestions for ImprovementAll schools should develop policies:• Specifying when athletic staff and student
managers should do hand hygiene;• Specifying the frequency of cleaning shared
supplies & equipment;• Regarding athletes with SSTI participation in
practices, games, or meets;• Preventing athletes with SSTI from using the
whirlpool or other shared equipment.
Thank you!
Hand Hygiene: PresentLoreen Herwaldt, MD*Hospital Epidemiologist Professor
*I have no relevant conflicts of interest.
Thanks to:
Garrett Wilcox for his work on the survey.
Hsiu-yin Chiang, Sandra Cobb, Melissa Ward, and Laurie Leder for hand hygiene observations.
David Herwaldt for graphic design.
Survey Respondents
601 nurses 419 physicians 319 other HCWs
1,339 Healthcare Workers
Do you know hand hygiene indications?% answering “most” or “all”
physicians nurses other
Unrecognized hand hygiene indications
% physician respondents
beforecontact
beforedevice
moving aftercontact
afterenviron
beforegloves
aftergloves
How much effort does hand hygiene require?
% answering “none” or “a little”
physicians nurses other
How difficult is it to do hand hygiene when indicated?
physicians nurses other
% answering “not at all” or “a little”
Perceived Hand Hygiene Adherence
• % time you do hand hygiene:
median = 90%
• % time your colleagues do hand hygiene:
median = 80%
Why don’t physicians do hand hygiene?
% physician respondents
forgot little contact
no time patientneed
woregloves
How much could you improve your hand hygiene?
% answered "a little bit" or "somewhat"
physicians nurses other
How can hand hygiene be improved?
% physician respondents
knowinfectionrates
betteraccess
signs at doors
mentors,monitors,peers
betterproduct
adherencefeedback
Are your patients interested in your hand hygiene?
% answering “quite interested” or “extremely interested”
physicians nurses other
physicians nurses other
Is your mentor interested in your hand hygiene?
% answering “quite interested” or “extremely interested”
Are colleagues interested in your hand hygiene?
% answering “quite interested” or “extremely interested”
physicians nurses other
Does your hand hygiene affect behavior of colleagues?
% answering “likely” or “extremely likely”
physicians nurses other
• Need SICU graphs here
Perceived Hand Hygiene Efficacy
90.3% of physicians think that hand hygiene is a very
effective or extremely effective way to prevent
healthcare-associated infections
Take Home Question
Which healthcare tasks or procedures can safely
be done right 3 of 4 times or 9 of 10 times?•Placing a central venous catheter?
•Giving a blood transfusion?
•Doing a thoracentesis?
•Passing medications?
•Doing an ERCP?
Take Home Question
If you had a central venous catheter, would you
want someone to manipulate it who had been:•Touching your bedside table
•Handling your Foley catheter
•Typing on a computer key board
•Handling your roommate’s Foley catheter
IF that person had not done hand hygiene?
Want of care does us more damage than want of knowledge . . . . Sometimes a little neglect may breed great mischief.
from Poor Richard’s Almanac
Benjamin Franklin
For want of a nail the shoe was lost; for want of a shoe the horse was lost; and for want of a horse the rider was lost, being overtaken and slain by the enemy, all for want of care about a horse-shoe nail.
Benjamin Franklin