Dr. Harley Rotbart’s GERMBlog™

The news headlines about MRSA “superbugs” (see 10/17/07 GERMBlog post) are spreading faster than the germs themselves. Yesterday an entire Kentucky school district closed (23 schools, more than 10,000 students) because of a single case of MRSA “superbug” infection. Other individual school closures are being reported around the country in response to single or multiple infections in a school.

Why are we seeing MRSA spreading in the schools? Schools are natural “amplifiers” of infection, “hot zones” if you will. Like day care centers, military barracks, and college dormitories, schools are an environment with lots of hand-to-hand, and hand-to-everywhere else, contact (see chapter 2 in Germ Proof Your Kids – The Complete Guide to Protecting (without Overprotecting) Your Family from Infections.

What can schools do to prevent the spread of MRSA among students and personnel? The approach is three-pronged:

1. Educate students (after all, isn’t that what schools do?) regarding healthy personal hygiene practices (see 10/17/07 GERMBlog post and Chapter 9 in Germ Proof Your Kids – The Complete Guide to Protecting (without Overprotecting) Your Family from Infections). This includes proper hand hygiene, careful wound management, daily showers (especially immediately after sports), and warnings that SHARING IS BAD!. For more on what kids shouldn’t share, see Chapter 9 in Germ Proof Your Kids – The Complete Guide to Protecting (without Overprotecting) Your Family from Infections. Schools must ensure that there’s plenty of soap in the bathrooms, that there are plenty of paper towels in the dispensers, and that kids have time between classes and before and after lunch to use the bathrooms and wash.

2. Environmental hygiene. Schools must identify areas in the building where students have frequent hand and body contact with environmental surfaces. For example, several school outbreaks appear to have originated in the locker room or other athletic facilities. One reason for this is that not only is there frequent and intimate contact between bodies and environmental surfaces, but kids in locker rooms and weight rooms often have scrapes and cuts that are ripe for becoming infected (see 10/17/07 GERMBlog post and Chapter 2 in Germ Proof Your Kids – The Complete Guide to Protecting (without Overprotecting) Your Family from Infections). Bathrooms, drinking fountains, and hand railings are other potential “hot spots”. These areas should be regularly and thoroughly cleaned. How “regularly” depends on whether there is a MRSA “problem” at the school. If there has been a case, or several cases, cleaning should occur at least daily if not twice a day. A disinfectant cleaner should be used (see Chapter 9 in Germ Proof Your Kids – The Complete Guide to Protecting (without Overprotecting) Your Family from Infections). EPA-approved disinfectants can be found at: http://epa.gov/oppad001/chemregindex.htm. Locker rooms must have plenty of clean towels so sharing is unnecessary; if possible, towels should also be used to cover equipment before body contact with it (e.g. on benches used for weight training). Gym and team uniforms, towels, and any other shared laundry should be washed in the hottest water setting with detergent (bleach is preferred if possible). Personnel in charge of laundry and/or cleaning should wear disposable gloves – and dispose the gloves between uses and before contact with clean surfaces. School nurses and other personnel caring for kids with wounds shoud observe careful infection-prevention precautions (see Chapters 2 and 9 in Germ Proof Your Kids – The Complete Guide to Protecting (without Overprotecting) Your Family from Infections).

3. Community notification. Not every case of MRSA needs to raise a red flag or be broadcast on local TV or even to the entire school community. Staph infections have been with us forever (hence the famous infectious diseases quip that “if you can’t get the staph off the staff, get the staff off the staff”, or something like that…). The difference with MRSA is that it is harder to treat, and can spread a little more efficiently, and can cause somewhat more severe disease (see 10/17/07 GERMBlog post and Chapter 3 in Germ Proof Your Kids – The Complete Guide to Protecting (without Overprotecting) Your Family from Infections). Rules regarding when to notify the school community, when to report the case to the health department, and when to close the school are usually determined by individual school districts and health departments. As a rule of thumb, though, a single case in a school usually requires only the first two steps above (education regarding personal hygiene and attention to environmental hygiene). If a second or third case occurs, most health departments require reporting the “outbreak”, and many schools choose at that time to notify parents and the community. School closures are rarely necessary except as to demonstrate to the community that “significant steps are being taken” to contain the outbreak. In fact, the significant steps that are most important to take are those listed in numbers 1 and 2 above. Kids with MRSA skin infections, unless otherwise directed by a doctor, do not need to be kept out of school – their wounds or sores must be covered, and they must be educated about personal hygiene practices as in #1 above.

There is much more about GERM PROOFing your schools to be found in Germ Proof Your Kids – The Complete Guide to Protecting (without Overprotecting) Your Family from Infections. For additional reading regarding MRSA precautions in schools, I recommend:

http://www.cdc.gov/Features/MRSAinSchools/

http://www.mass.gov/dph/cdc/antibiotic/mrsa_school_health.htm

Harley A. Rotbart, M.D.
www.germproofyourkids.com

This week, amidst the concern and near panic over resistant “Superbugs” (see 10/17 GERMBlog post), we are now reminded by a story in Newsweek about the “Hygiene Hypothesis”. Are your kids too clean?

Over the past decades, there has been an increase in the diagnoses of allergic disorders (e.g. asthma), as well as autoimmune diseases (e.g. inflammatory bowel disease and lupus), both of which represent over-exuberant immune system reactions (see Chapter 4 in GERM PROOF YOUR KIDS - The Complete Guide to Protecting (without Overprotecting) Your Family from Infections). Conventional wisdom held for many years that the cause of these increases may be related to environmental pollution and toxins (i.e. the junk in the air is causing more wheezing type diseases, and the junk in our diet is causing more bowel inflammation, for example).

In the late 1990s, after reunification, a German investigator compared the occurrence rates of allergic diseases among East Germans living under impoverished and unhygienic conditions with those of West Germans living in more pristine and generally wealthier environments. Rather than seeing the expected higher allergy and asthma levels in the poor population, she saw the opposite – the “cleaner” Germans had more allergies and asthma. This led to the “hygiene hypothesis” that states the following: a certain critical mass of germs and “dirt” is required for the healthy maturation of the immune system. If we clean too much, and prevent too many infections, kids will develop aberrant immune system responses that result in more allergies and autoimmune diseases. That is, the immune system needs to be “taught” to respond normally to everyday challenges and to its own body; that “learning” requires a certain amount of germs and dirt, without which the immune system goes awry.

What are the scientific data to support this hypothesis? Right now, we have the potential for a classic “epiphenomenon”, the existence of two “truths” that may or may not be related to each other. Truth #1 is there are increasing diagnoses of allergies and autoimmune disorders; truth #2 is that those disorders tend to occur with higher frequency in wealthier socioeconomic environments. In Africa, where hygienic conditions are poor, the incidence of allergic and autoimmune disorders is lower than in the West. Is this genetic, or due to the beneficial effects of poor hygiene? Similarly low levels of allergic and autoimmune disorders are diagnosed in SE Asia, but that trend reverses itself when SE Asians immigrate to Western countries – their children have Western rates of allergic and autoimmune disorders; that seems to dispel a purely genetic explanation.

But maybe we are simply better at making the diagnoses of those disorders in the West. What factors other than “cleanliness” are associated with a higher socioeconomic class in the West and could explain the observation? Clearly there are many differences between Western societies and African and Asian societies that extend well beyond simple hygiene parameters. And how plausible is it that, with the extraordinary number of exposures kids get everyday at day care, school, and in the backyard (see Chapter 2 in GERM PROOF YOUR KIDS – The Complete Guide to Protecting (without Overprotecting) Your Family From Infections, there is still a deficit of critical germs and dirt resulting in allergic and autoimmune responses by the immune system?

Although the data are lacking for a true “nexus”, that is a proven connection between the two “truths” noted above, advocates of the “hygiene hypothesis” have asserted that overuse of antibiotics, including those in household cleaning products, contributes to the excessively clean environments that pose a risk for our kids (although the West Germans with lower rates of allergies and autoimmune disorders in the late 1990s did not have antibiotic-containing soaps yet). Addressing the antibiotic exposure factor, a paper published in March, 2006 assessed 8 previously published studies of kids who had received antibiotics in the first year of life and assessed whether that exposure predisposed them to asthma later in life. A small statistical association was found, when all 8 studies were combined, to suggest there may be a somewhat increased risk of asthma following early in life antibiotics – the authors caution that the quality of the original 8 studies was such that a meaningful conclusion cannot yet be drawn on this subject. A single study published in June, 2007 implicated antibiotics in the first year of life and the absence of a dog in the house during the first year of life as risk factors for asthma!

At this time, I recommend that you continue to have your kids wash their hands (simple soaps are fine; see Chapter 9 in GERM PROOF YOUR KIDS – The Complete Guide to Protecting (without Overprotecting) Your Family from Infections), take antibiotics when needed (but only when needed; see Chapter 5 in GERM PROOF YOUR KIDS – The Complete Guide to Protecting (without Overprotecting) Your Family from Infections), and receive all of their childhood immunizations (more on the concern that vaccines make kids too clean in Chapter 7 in GERM PROOF YOUR KIDS – The Complete Guide to Protecting (without Overprotecting) Your Family from Infections). Maintaining a clean home will reduce the number of infections passed around in your household – infections that keep your kids out of school and you out of work. Those infections can also be dangerous and even life-threatening (e.g. food borne infections). Community sanitation of water will prevent a retreat to the days of epidemics of cholera and cryptosporidiosis; maintaining air quality standards and removing household cigarette smoke exposure have been proven (proven!) to reduce asthma and other respiratory ailments.

We’ll wait and watch together to see if the “hygiene hypothesis” stands the tests of time, careful study, and reproducibility (see Chapter 12 in GERM PROOF YOUR KIDS – The Complete Guide to Protecting (without Overprotecting) Your Family from Infections). In the meantime, and until proven otherwise, clean is still better than dirty.

Harley A. Rotbart, M.D.
www.germproofyourkids.com

Today, a group of outside experts advised the FDA (Food and Drug Administration) to do what many pediatricians and family medicine doctors have been urging the FDA to do for some months now: study over-the-counter (OTC) cough, cold, and flu medicines more thoroughly before continuing to approve their use in kids. Right now, with little study but years of use, these medicines are permitted by the FDA for use in kids. However, when the expert advisors reviewed the sparse data for safety and effectiveness of the medicines in kids, they found no evidence that the medicines worked, and they also found evidence that the medicines caused side effects. Although most side effects are mild (irritability, drowsiness, upset stomach, etc.), overdoses of the medicines do occur and can be severe. The advisors to the FDA said that with no evidence for effectiveness, there is no reason to risk the side effects.

The advice of the outside experts was that the medicines not be used by kids younger than 6 years. Although some urged that even kids older than 6 not be given the mediciines, the experts could not agree on that recommendation.

The FDA does not have to take the advice of these experts – the votes were all “non-binding”. For the immediately forseeable future, the medicines will remain on the shelves – but there is no reason to use them for young kids. They don’t work.

For more on the pros (few) and cons (many) of OTC cough, cold, and flu medicines for kids, see Chapter 8 (Over-the-Counter or Over-the-Top) in Germ Proof Your Kids – The Complete Guide to Protecting (without Overprotecting) your Family from Infections.

Harley A. Rotbart, M.D.
www.germproofyourkids.com

As antibiotic use has increased exponentially over the past several decades, bacteria germs have increasingly become resistant to formerly powerful germ-fighting drugs. The mechanisms of this resistance are sophisticated. The more we use new antibiotics with great potency to treat simple infections that either don’t require antibiotics at all or would respond to antibiotics of lesser potency, the more stories we’ll see in the headlines about resistant bacteria.

The news of this week is the increased occurrence of resistant staphylococcal bacteria (called MRSA, for Methicillin-Resistant Staphylococcus Aureus) in schools and communities across the country. A teenager in Virginia tragically died, and schools have been closed to contain the spread of the germ. Although most infections with MRSA are benign and usually limited to the skin, when more serious infections do occur (as they can with any bacteria, resistant or not), they are more difficult to treat because the antibiotic options are limited.

What can be done to slow or halt the spread of these germs? It’s back to basics. Careful and compulsive handwashing, and limiting the unnecessary use of antibiotics. Here are some specific suggestions (from: GERM PROOF YOUR KIDS – The Complete Guide to Protecting (without Overprotecting) your Family from Infections):

1. Teach kids how to wash. They should spend at least 20 seconds at the sink scrubbing between fingers and under their fingernails. Simple soap and water is more than adequate. Antibacterial soap, while probably not harmful (to your child or to the environment, as far as anyone has been able to prove so far), is also not necessary. Use alcohol hand wipes when washing is needed but your kids aren’t near the sink.

2. Teach kids when to wash (see: “The Top Ten Handwashing Moments” listed below)

3. Employ a “mini-quarantine” if someone in your home is sick (see GERM PROOF YOUR KIDS for details)

4. Teach kids that sharing is bad. This undoes much of what you’ve spent their entire childhoods teaching them, but inanimate objects like towels, toothbrushes, toiletries, tissues, teacups, and many things that don’t start with “t” can harbor bacteria for days.

5. Promptly clean and bandage all cuts and scrapes. Keep wounds covered until they are healed.

6. Help your doctor by not requesting antibiotics for infections that don’t require them – e.g. the common cold, the flu, most sore throats, some ear infections.

7. When antibiotics are necessary, ask your doctor for the least expensive antibiotic available that will still treat your child’s infection – generally, the least expensive antibiotics are those that have the least risk of spreading resistance among germs (there’s an important reason why this is true – see GERM PROOF YOUR KIDS for more details).

Top 10 most important hand washing moments

1. After playing with a sick friend or sibling (or after handling things that a sick child might have handled – like in the doctor’s waiting room; see below)
2. After using the bathroom (use the hand towel to turn off the sink and open the bathroom door – see “hand drying” below).
3. Before eating
4. After high-fiving the opposing team at the end of a sports competition (or any other mass-handshaking event like the receiving line at a Bar Mitzvah or graduation).
5. After recess
6. After school or day care
7. After playing with animals or in areas where animals hang out
8. After playing outside
9. After blowing their nose, or coughing into their hands. Although your kids cannot “give themselves an infection” by contact with their own secretions, this is a very considerate gesture that protects other kids from the germs on your kids’ hands.
10. Before bedtime

Harley A. Rotbart, M.D.
www.germproofyourkids.com