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