AND FIREFIGHTERS (040908, v8)
Eric L. Nelson, M.S., M.A. ©2008
enelson.0000@gmail.com
Methicillin-resistant Staphylococcus aureus (MRSA) is a staph infection which only responds to the most powerful drugs, and it can be fatal even in children (Mayo Clinic, 2007; CDC, 2001). In 2005 MRSA killed 18,650 people in the U.S. -- more than were killed by AIDS. Another 94,000 Americans sustained life-threatening MRSA infections, and MRSA has become the leading cause of soft tissue infections presented in hospital Emergency Rooms (Klevens, Morrison & Nadle, 2007). Additionally, MRSA can contribute to the worsening of other disease processes such as toxic shock syndrome, bacteremia, pneumonia, endocarditis, and osteomyelitis (Christianson et. al., 2007).
MRSA appears as a red, swollen, warm, painful sore which may drain pus or other fluids. More serious cases can include chills, rash, shortness of breath, chest pain, headaches and fever (National Institute of Health, 2007). Initially MRSA is sometimes incorrectly believed to be a spider bite (Moellering, 2006). Because a MRSA infection can spread rapidly and in some cases be fatal, it is important for peace officers and fire fighters who develop a red, warm, swollen, painful sore to see a physician right away, because laboratory testing is required in order to determine if the lesion is MRSA infected.
There are two strains of MRSA: Hospital-associated (HA-MRSA) and Community-associated (CA-MRSA). Community-acquired MRSA is not just escaped HA-MRSA; rather, they are genetically different (Moellering, 2006). As suggested by the name, CA-MRSA is usually acquired outside of hospitals, (Klevens et al., 2007).
The Centers for Disease Control and Prevention (2006) explains how Community-acquired MRSA infects someone: "CA-MRSA skin infections are usually transmitted from person to person by direct contact with a draining lesion or by contact with an asymptomatic carrier of S. aureus. Transmission also can occur indirectly through contact with contaminated items or environmental surfaces." Persons with draining MRSA lesions will typically have MRSA bacteria on their hands secondary to touching the lesion (Nicolle, 2006). A recent study showed that MRSA bacteria can then get onto shared surfaces. For example, when surfaces such as computer keyboards and bed rails were sampled and cultured in a hospital Emergency Room, 19% of the samples were positive for MRSA (Bascom, 2005). When three Fresno California firehouses were tested for MRSA, it was found in two of them (Sexton, 2007).
Additional risk factors for MRSA infection include sharing of contaminated items, crowded living conditions, poor hygiene, high rates of skin disease, and high rates of immunosuppression diseases; in short, the conditions found in jails and prisons (Baillargeon et al., 2004). As noted by Hartley, et al., (2006) Institutions such as prisons are “... focal points for transmission of emerging infections”, calling them “epidemiological engines that drive the unfolding MRSA epidemic”, and noting “Prisons can be sources of MRSA-colonized individuals at rates comparable to those of hospitals.” The CDC (2001) adds, in reference to MRSA, “Disease transmission can occur easily among inmates at correctional facilities.”
Prisoners are a high risk group for having a MRSA infection (CDC, 2003; CDC 2006; Klevens, Morrison & Nadle, 2007; Hota et al.,2007). The Federal Bureau of Prisons estimates that 10-30% of their population are colonized with Staphylococcus aureus in their noses or breaks in their skin, and some of those prisoners are further colonized with Methicillin-Resistant Staphylococcus aureus (FBP, 2005).
1. In 2002 Los Angeles County jail had 921 MRSA infections among prisoners. In the first six months of 2003 there were 776 cases, representing a growth rate of 1.69.
2. The number of MRSA cases in Texas state prisons from January 1996 to July 2002 was 10,942, with three inmate deaths due to MRSA.
3. Three incarceration centers were studied in Georgia:
A. 200 bed minimum security prison: 14 cases of MRSA.
B. 1500 bed maximum security prison: 73 cases of MRSA.
C. 2800 bed jail: 75 cases of MRSA.
The Centers for Disease Prevention and Control report concludes: "The emergence of MRSA as a cause of inmate skin and soft tissue infections presents a challenge to correctional facilities, health-care providers, and public health agencies. The potential public health impact of MRSA disease transmission in correctional facilities is substantial..."
In addition to jails and prisons, homeless shelters are also sources of MRSA exposure and outbreaks (Hawkes et al., 2007, Klevens et al., 2007). Additionally, there is a high rate of MRSA among drug users. Even drug paraphernalia such as crack pipes can potentially have MRSA bacteria on it (Gilbert et al., 2006). Additionally, injections sites of drug users may contain MRSA (Lettington, 2002).
Peace officers and firefighters are exposed to MRSA because their jobs bring them into frequent physical contact with all of the high risk groups which have been identified as carriers of MRSA. Police and fire can touch contaminated body parts during provision of medical care, during searches, arresting of suspects, and taking samples. Fire and police are regularly exposed to saliva, vomit, feces, urine, and blood (Mayhew, 2001). Because police officers and firefighters frequently encounter the populations who are spreading MRSA, staff screening is recommended (Lettington, 2002).
Fifteen custodial deputies acquired MRSA in Greenville South Carolina's jail (IUPA, undated; Greenville News, 2006). Thirteen firefighters in Fresno California acquired MRSA, as did 20 firefighters working in the “Skid Row” part of Los Angeles County, and dozens of guards at the Folsom, California prison (Colon, 2007).
The National Institute for Occupational Safety and Health (NIOSH, 2007) indicates that MRSA can be acquired at work, and provides the following precautions:
1. Uniforms can become contaminated with MRSA. After washing them, fully dry in a hot dryer to kill the MRSA bacteria.
2. Equipment can become MRSA contaminated. Use detergent or disinfectant to decontaminate.
3. Employers can reduce work-related MRSA infection by placing safety warnings in the workplace, encourage good hygeine by workers, provide hygeine facilities, and regularly clean the workplace.
Prevention includes hand washing, avoid sharing personal items and equipment, cover wounds, (Mayo Clinic, 2007); isolate linen used by prisoners known to be MRSA positive and decontaminate separately, use chlorine to decontaminate cells and patrol cars (Lettington, 2002); insure inmates practice good personal hygiene, including daily showers, and hand washing with soap (CDC, 2001); skin screening upon intake, and culturing suspected lesions, isolation of MRSA positive inmates (CDC, 2003).
Peace officers at busy agencies can detain or arrest a dozen or more individuals in a single shift, patting all of them down for weapons, and performing a detailed search on those who are arrested. Peace officers and firefighters go to vehicle accidents and handle injured people. Police lift intoxicated arrestees into their patrol car, for transport to a detoxification center or jail. Firefighters lift injured persons onto gurneys, and go “hands-on” in order to insert intravenous catheters, apply pressure to stop bleeding, or extract injured persons from mangled vehicles. Sometimes wanted suspects run away and are pursued on foot by police, and when caught they may put up a fight and have to be physically subdued. Some suspects will fight police every time they are arrested.
All of these activities put firefighters and peace officers into direct physical contact with individuals who are in one or more high risk groups with respect to MRSA. As a result, peace officers and firefighters are developing MRSA positive lesions, and filing workers compensation claims with their agencies. In some cases, the claims are automatically accepted as work related; e.g., city of Fresno, California. However, it appears in many cases the claims are denied on the basis that the peace officer or firefighter cannot specify the date, time, and incident of exposure, and therefore it cannot be determined with certainty that the MRSA exposure occurred at work. The natural conclusion of that line of reasoning must be that the firefighter or peace officer must have gotten the exposure from a spouse, child, or perhaps someone at their religious house of worship. Of course it is possible that fire and police could acquire MRSA away from their job; it is this tiny potential which is exploited by workers compensation examiners when they deny MRSA claims.
The scientific and medical literature, as well as statistical probabilities substantially favor the assertion that when peace officers and firefighters acquire a MRSA infection, it is likely related to their employment. On this matter the literature is quite one sided; that is, there isn't a single scholarly study which suggests otherwise. That is why some cities, such as Fresno California, have created statutory acceptance of MRSA infections in their peace officers and fire fighter as work related, and some states such as California are contemplating laws which will automatically establish MRSA infections in firefighters and peace officers as work related. In California Majority Speaker of the state assembly Karen Bass introduced AB 166, which provided that MRSA claims by peace officers and firefighters would be accepted as work related. It was killed in committee by lobbiests. Speaker Bass has reintroduced the bill as AB 2754. Advocacy is called for by firefighter and peace officers and their unions, because strong opposition is being mounted by organizations such as the County of Los Angeles (Janssen, 2007) and the League of California Cities and the Association of Counties (FASIS, 2007).
Bascom, E. (2006). Community-Acquired MRSA infections pose threat to health care workers, report suggests. Oncology Times, 28(20), 64-67.
Baillargeon, J., Kelley, M., Leach, C., Baillargeon, G., & Pollock, B. (2004). Methicillin-resistant Staphylococcus aureus infection in the Texas prison system. Clinical Infectious Diseases, 38(9), e92-e95.
Center for Disease Prevention and Control. (2001). Editorial note. Morbidity and Mortality Weekly Report 50(42), 920-921.
Center for Disease Prevention and Control. (2003). Methicillin-Resistant Staphylococcus aureus Infections in Correctional Facilities --- Georgia, California, and Texas, 2001--2003. Morbidity and Mortality Weekly Report, 52(41), 992-996.
Center for Disease Prevention and Control, (2006). Methicillin-resistant Staphylococcus aureus skin infections among tattoo recipients --- Ohio, Kentucky, and Vermont, 2004--2005. Morbidity and Mortality Weekly Report, 55(24) 677-679.
Christianson, S., Golding, G., & Campbell, J. (2007). Comparative genomics of Canadian epidemic lineages of Methicillin-Resistant Staphylococcus Aureus. Journal of Clinical Microbiology, 45(6), 1904-1911.
Colon, V. (2007, September 05). Staph infection plagues California firefighters. Fresno Bee, Retrieved April 02, 2008 from http://www.scrippsnews.com/node/26580.
Federal Bureau of Prisons. (2005). Management of Methicillin-Resistant Staphylococcus aureus (MRSA) Infections. Washington, DC: US Department of Justice.
Fire Agencies Self Insurance System (2007, October 15). Legislative updates. Available online: http://www.fasisjpa.org
Gilbert, M., MacDonald, J., Gregson, D., Siushansian, J., Zhang, K., Elsayed, K., Louie, T., Hope, K., Mulvey, M., Gillespie, J., Nielsen, D., Wheeler, V., Louie, M., Honish, A., Keays, G., & Conly, J. (2006). Outbreak in Alberta of community-acquired (USA300) methicillin-resistant Staphylococcus aureus in people with a history of drug use, homelessness or incarceration. Canadian Medical Association Journal, 175(2), 149-154.
Inmates, guards threaten lawsuit after staph outbreak at jail. (2006, June 07). Greenville News. Retrieved April 02, 2008 from http://www.wyff4.com/news/9334077/detail.html
Hawkes, M., Barton, M., Conly, J., Nicolle, L., Barry, C., & Ford-Jones, E. (2007). Community-associated MRSA: Superbug at our doorstep. Canadian Medical Association Journal, 176(1), 54-56.
Hartley, D., Furuno, J., Wright, M., Smith, D., & Perencevich, E. (2006). The role of institutional epidemiologic weight in guiding infection surveillance and control in community and hospital populations. Infection Control and Hospital Epidemiology, 27(2), 170-174.
Hota, B., Ellenbogen, C., Hayden, M., Aroutcheva, A., Rice, T., & Weinsein, R. (2007). Community-Associated Methicillin-Resistant Staphylococus aureus skin and soft tissue infections at a public hospital. Archives of Internal Medicine, 167(10), 1026-1033.
International Union of Police Associations (undated). Police union calls on county to clean up jail problems. Downloaded March 29, 2008. Retrieved March 27, 2008 from http://www.iupa.org/mrsa.html
Janssen, D. (2007). Unpublished correspondence from the Chief Administrative Officer to the Board of Supervisors (2007, March 21).
Klevens, R., Morrison, M., Nadle, J., Petit, S., Gershman, K., Ray, S., Harrison, L., Lynfield, R., Dumyati, G., Townes, J., Craig, A., Zell, E., Fosheim, G., McDougal, L., Carey, R., & Fridkin, S. (2007). Invasive methicillin-resistant Staphylococcus aureus infections in the United States. Journal of the American Medical Association, 298(15), 1763-1771.
Lettington, W. (2002). Methicillin resistant Staphylococcus aureus (MRSA) in injecting heroin user: Implications for hygiene in police station custody suites. Journal of Clinical Forensic Medicine, 9(4), 175-177.
Mayhew, C. (2001). Occupational health and safety risks faced by police officers. Trends and Issues in Crime and Criminal Justice. Australian Institute of Criminology, paper No.196. Retrieved March 28, 2008 from www.aic.gov.au/publications/tandi/tandi196.html
Mayo Clinic. (2007). MRSA infection. Retrieved April 01, 2008 from http://www.mayoclinic.com/health/mrsa/DS00735
Moellering, R. (2006). The growing menace of community-acquired methicillin-resistant Staphylococcus aureus. Annals of Internal Medicine, 144(5), 368-370.
Nicolle, L. (2006). Community-acquired MRSA: A practitioner's guide. Canadian Medical Association Journal, 175(2), 145-146.
National Institute of Health (2007). MRSA Infection. Retrieved March 28, 2008 from http://www.nlm.nih.gov/medlineplus/ency/article/007261.htm
National Institute of Health (2007). MRSA Infection. Retrieved March 28, 2008 from http://www.nlm.nih.gov/medlineplus/ency/article/007261.htm
Sexton, A. (Reporter). (2007, September 25). Infections among police, firefighters recognized as work-related illness [Internet streaming video]. Fresno, California: KSEE 24 Television. Retrieved March 25, 2008 from http://www.ksee24.com/news/local/10025506.html
The author solicits stories of MRSA positive firefighters and peace officers; please contact through the email supplied above. The author also welcomes inquiries from law enforcement officials, elected officials, media, and from attorneys who represent peace officers and firefighters.
Permission is granted to reproduce and distribute this informational flier to peace officers and firefighters only, under the following conditions: 1) The article must be presented in full, as seen here, and cannot be edited; 2) It will not be sold; 3) Authorship will be properly cited; 4) It cannot be listed with, associated with, linked to or linked from any website engaged in pornography, or engaged in or expressing views which can be regarded as seditious against the United States, 5) If requested by the author it will be removed immediately. Permission to use includes printed and electronic media directed towards an intended audience of peace officers and firefighters.
