CommunityAssociated MRSA: Community Interventions

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Community-Associated MRSA Community Interventions

• Elizabeth A Bancroft, MD, SM
• Acute Communicable Disease Control
• Los Angeles County Department of Health Services

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THREE CORE FUNCTIONS OF PUBLIC HEALTH

• Assessment
• Policy Development
• Assurance

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Reduce Morbidity and Mortality due to CAMRSA

• Surveillance
• Determine scope of problem
• Allocate resources
• Empiric diagnosis and treatment
• Determine risk factors
• Education/Guidelines
• Healthcare professionals
• Community
• Facilities
• Outbreak control

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Pediatric MRSA in Los Angeles County

• Reportable disease
• Hospitalized between May 5-November 7, 2003
• Medical, demographic information collected
• Standardized questionnaire for parents/caregivers
• Risk factors

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Age Range of Pediatric MRSA Cases
N140
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Clinical Findings

• Diagnoses
• 129 (92) SSTI
• 10 (9) Invasive
• 1 (1) Other
• Treatment 75 received ß-lactam antibiotics
• 23 misdiagnosed as spider bites

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Risk Factors

• The parents or guardians of 80 cases were
  interviewed
• 11 of the cases had exposure in the past month
  to someone who had been incarcerated
• 22 of the cases had nosocomial/traditional risk
  factors for MRSA
• 24 had a household contact with an SSTI within a
  month of diagnosis

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Laboratory Results

• Of 83 isolates
• 79 (96) were USA 300 PFGE
• This was true even for the 22 of children that
  had nosocomial risk factors.

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Public Health Impact of CAMRSA

• Relative to the most common reportable diseases,
  CAMRSA has a high rate of hospitalization for
  those lt18 years old (10.3 per 100,000 PY)

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Education

• Healthcare professionals
• Improve diagnosis
• Improve treatment
• Recognize risk factors
• Improve prevention
• General Public
• Prevent acquisition of disease
• Prevent sequelae
• Prevent spread of disease

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Education for Physicians
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Education for Patients
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Handouts for Physicians and Patients
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Guidelines

• Treatment
• Healthcare professionals
• Wisconsin, Washington State, CDC
• Prevention
• Athletic teams (CDC)
• Environmental Control

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Clinical Management/Prevention Guidelines
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CDC/MMWR Guidelines for Athletic Teams (2003/52
33 793-795)

• Cover all wounds. If a wound cannot be covered
  adequately, consider excluding players with
  potentially infectious skin lesions from practice
  or competitions until the lesions are healed or
  can be covered adequately.
• Encourage good hygiene, including showering and
  washing with soap after all practices and
  competitions.
• Ensure availability of adequate soap and hot
  water.
• Discourage sharing of towels and personal items
  (for example, clothing or equipment).
• Establish routine cleaning schedules for shared
  equipment.
• Train athletes and coaches in first aid for
  wounds and recognition of wounds that are
  potentially infected.
• Encourage athletes to report skin lesions to
  coaches and encourage coaches to assess athletes
  regularly for skin lesions.

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Environmental/Community Guidelines
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Los Angeles County Department of Health Services
MRSA Web Page
http//lapublichealth.org/acd/MRSA.htm
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Outbreak Control

• Athletic teams
• Correctional facilities
• Military
• Day care/developmentally disabled

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Athletic Teams

• 5 football teams (1 high school, 3 college, 1
  professional)
• 1 rugby team
• 2 wrestling teams
• Scattered other case reports

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Athletic Teams

• 5 football teams (1 high school, 3 college, 1
  professional)
• 1 rugby team
• 2 wrestling teams
• Scattered other case reports
• More review articles on athletic team outbreaks
  than actual original articles.

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Recurrent MRSA Outbreak in a College Football Team

• In August 2002, two members of the same football
  team were hospitalized with MRSA skin infections
  within 1 week of each other
• August/September of 2003, a recurrent outbreak of
  MRSA skin/soft-tissue infections was reported
  from the same team
• 15 cases (6 hospitalized)
• 8 players with MRSA nasal carriage (only 2
  infected)
• Both years USA 300

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Characteristics of Case-Players

• 11 case-players out of 107 team members for an
  attack rate of 10.
• Cases diagnosed during or 2 weeks end of training
  camp
• Boil on elbow most common

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Case-Control and Carrier-Control Study Results

• Case-players 15 times more likely to share bars
  of soap with teammates and to have had
  preexisting cuts or abrasions.
• Carrier-players 60 times more likely have locker
  adjacent to or across from teammate with an SSTI
  and 47 times more likely to have shared towels
  with teammates.
• Carrier-players more likely to live on campus in
  a dormitory or fraternity house, higher mean
  number of roommates than those who lived in
  off-campus apartments (2.3 vs. 1.5).

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Football Team Interventions

• Interventions in 2002 and 2003
• Hygiene education
• Environmental cleaning
• Hexachlorophene soap in showers for all players
  (x 1 month)
• Active surveillance for skin lesions
• Decolonized carriers with mupirocin
• New cases in 2003 after discontinuation of
  hexachlorophene showers
• With improved infection control- no more cases

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Control in Other Athletic Teams

• Risk Factors
• Skin abrasions, shaving
• Linemen
• Sharing personal items
• ? Environmental contamination (whirlpools)
• Control measures (interventions)
• Education
• Mupirocin, chlorhexidine for all
• Active Surveillance
• Wound coverage
• Increased environmental/equipment disinfection
• Active surveillance
• All but one successful in controlling the outbreak

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Number of Adults in Correctional System 1980-2004

• In 2004, nearly 7 million people were on
  probation, in jail or prison, or on parole at
  year end 2004 -- 3.2 of all U.S. adult residents
  or 1 in every 31 adults.
• gt2 million were in detention facilities
• ¼ on drug charges (1/3 of the women on drug
  charges)

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MRSA Outbreaks in Correctional Facilities

• Mississippi, Georgia, Texas, California, Missouri
  
• Jail, prison, detention centers, juvenile halls
• Anecdotal and press reports from around the
  country
• Lawsuits
• USA 300
• FemalegtMale

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Outbreak in Georgia Facility (2001)

• 200 bed detention facility
• 11 cases
• Interventions
• Active surveillance for skin infections
• All treated with chlorhexidine
• Infected inmates decolonized
• Standardized and intensive wound care
• Education
• Successful short term eradication

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MRSA in Los Angeles County Jail

• June 2002, the Los Angeles County Department of
  Health Services was notified by the Los Angeles
  County Jail of an increase in MRSA positive
  cultures in inmates in the jail
• First noticed in February
• Attributed to spider bites
• Non-biting spiders captured
• Pesticides applied

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Percentage of Wounds and S. aureus with MRSA
2002
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Recommendations

• Standardize diagnosis and treatment
• Culture wounds
• Use incision and drainage
• If antibiotics, use Bactrim Rifampin or
  Clindamycin Rifampin
• Recommended increased access to soap, change of
  garments
• Screen inmates on admission
• Increased environmental cleaning
• Education of inmates and staff

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Recommendations, cont.

• Specialized educational materials developed
• For inmates
• Identification
• Prevention
• Environmental cleaning
• For staff
• Dedicated treatment wards/personnel
• Doubled the laundry distribution

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MRSA Cases in Inmates By Month of CultureLA
County, 2002 2006

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MRSA Cases in Inmates By Month of CultureLA
County, 2002 2006

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Time to First MRSA Culture in Inmates By Month
of CultureLA County, 2002 2005
Time from booking date to first positive MRSA
culture.

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Time to First MRSA Culture in MenBy Month of
CultureLA County, 2002 2005
Time from booking date to first positive MRSA
culture.
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Time to First MRSA Culture in WomenBy Month of
CultureLA County, 2002 2005
Time from booking date to first positive MRSA
culture.

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Antibiotic Susceptibility Trends
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Challenges to Control in Correctional Facilities

• Close crowded living conditions
• Low literacy
• Limited supplies
• Security more important
• To inmates
• To guards
• Turnover
• Outside risk factors
• Homeless
• Drug users

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Other Populations

• Military Daycare/developmentally disabled
• Share similar problems
• Close crowded living conditions
• Increased skin to skin contact
• Sub-optimal hygiene
• Controlled by
• Hygiene education
• Screening
• Chlorhexidine/mupirocin
• Increased environmental cleaning

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Outbreak Control What We Dont Know

• What is the most effective part of control?
• Usefulness of surveillance for colonization
• Significance of MRSA colonization
• Role of decolonization
• Significance of MRSA in the environment as a
  source of disease
• Who/When should be excluded from work, sports,
  other activities?

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Other Challenges

• Difficulty in surveillance
• Antibiograms not specific
• Lack of resources for intensive surveillance
• Changing case definitions
• Conservation of USA 300
• How to change medical practice
• Need to know local prevalence
• Decrease use of antibiotics
• How to change consumer behavior
• Improve personal hygiene
• Improve environmental disinfection