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Infections and Infection Prevention &Control Practices in Iowa’s High School Athletic Programs Loreen A. Herwaldt Mark Pedersen The University of Iowa.

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Presentation on theme: "Infections and Infection Prevention &Control Practices in Iowa’s High School Athletic Programs Loreen A. Herwaldt Mark Pedersen The University of Iowa."— Presentation transcript:

1 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

2 Disclosures Loreen Herwaldt: 3M, Sage, CDC, AHRQ research grants Mark Pedersen: Nothing to disclose

3 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

4 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

5 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

6 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; 25 th to 75 th percentiles = 82-250

7 Results: Provided by Schools Supplies/EquipmentNumber of Schools Soap for showers143 (62.7%) Towels for showers 86 (37.6%) Launder uniforms81 (35.7%) Cardio equipment181 (80.1%) Weights228 (99.6%) Whirlpool124 (55.5%)

8 Results: Turf, Floor, Mat Burns Managed by: Person who Manages LesionsNumber Athlete90 (39.3%) Athletic trainer68 (29.7%) Manager23 (10.0%)

9 Results: Risky Activities ActivityNumber of Schools Shave 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%)

10 Results: Infections InfectionNumber of Schools Reporting Tinnea56 (43.1%) S. aureus36 (27.7%) Herpes simplex26 (20.0%) Streptococci17 (13.1%)

11 Results: Sport, Education, and SSTI SportEducate Athletes 0 Athletes w/ SSTI > 1 Athlete w/ SSTI Wrestling164 (71.6%)113 (53.1%)75 (35.2%) Football145 (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%)

12 Results Class Number (%) No. of Athletes (Range) Employ a CAT (%) * 1A76 (33)7-17025 (33) 2A81 (36)50-38436 (44) 3A37 (16)45-62025 (68) 4A33 (15)270-100831 (94) Overall2297-1008117 (51) CAT = Certified Athletic Trainer; *P < 0.0001

13 Frequency of Cleaning Locker Rooms Increased by school classification; P = 0.02

14 Frequency of Cleaning Showers Increased with school classification; P = 0.012

15 Frequency of Cleaning Daily: School Classification ClassLocker rooms ShowersTrain- ing equip- ment Prac- tice uni- forms Train- ing tables Pt care areas 1A59%44%19%29% 26% 2A79%71%24%32%34%40% 3A83%54%26%41%52%48% 4A81%79%35%37%62%64% P 0.02 0.012 0.0002 0.055 < 0.0001 0.0004

16 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.

17 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%

18 Education, Policies, SSTI, MRSA SSTI: School Classification ClassEducate re. SSTI Policy re. SSTI Athletes w/ SSTI Athletes w/ MRSA 1A67%26%34%5% 2A90%35%63%4% 3A92%46%73%8% 4A88%61%79%24% P 0.002 0.0004 < 0.0001 0.002

19 Education, SSTI, MRSA SSTI: CAT vs. No CAT % P 0.058 0.011 0.018

20 Association of Education & Policies with SSTI % P < 0.0001 0.016

21 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%

22 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.

23 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.

24 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.

25 Suggestions for Improvement All 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.

26 Thank you!

27 Hand Hygiene: Present Loreen Herwaldt, MD* Hospital Epidemiologist Professor *I have no relevant conflicts of interest.

28 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.

29 Survey Respondents 601 nurses 419 physicians 319 other HCWs 1,339 Healthcare Workers

30 Do you know hand hygiene indications? % answering “ most ” or “ all ” physiciansnursesother

31 Unrecognized hand hygiene indications % physician respondents before contact before device moving after contact after environ before gloves after gloves

32 How much effort does hand hygiene require? % answering “none” or “a little” physiciansnursesother

33 How difficult is it to do hand hygiene when indicated? physiciansnursesother % answering “not at all” or “a little”

34 Perceived Hand Hygiene Adherence % time you do hand hygiene: median = 90% % time your colleagues do hand hygiene: median = 80%

35 Why don ’ t physicians do hand hygiene? % physician respondents forgot little contact no time patient need wore gloves

36 How much could you improve your hand hygiene? % answered "a little bit" or "somewhat" physiciansnursesother

37 How can hand hygiene be improved? % physician respondents know infection rates better access signs at doors mentors, monitors, peers better product adherence feedback

38 Are your patients interested in your hand hygiene? % answering “quite interested” or “extremely interested” physiciansnursesother

39 physiciansnursesother Is your mentor interested in your hand hygiene? % answering “quite interested” or “extremely interested”

40 Are colleagues interested in your hand hygiene? % answering “quite interested” or “extremely interested” physiciansnursesother

41 Does your hand hygiene affect behavior of colleagues? % answering “likely” or “extremely likely” physiciansnursesother

42 Need SICU graphs here



45 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

46 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?

47 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?

48 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

49 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


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