Survey of High School Athletic Programs in Iowa Regarding Infections and Infection Prevention Policies and Practices

Abstract

Objective

To assess high school athletic programs’ infection prevention policies and procedures and to estimate the frequency of skin and soft tissue infections (SSTIs) among Iowa’s high school athletes.

Methods

An on-line survey of high school athletic programs.

Results

Nearly 60% of programs responded. Schools in higher classifications were more likely to have a certified athletic trainer (AT; P < 0.0001) and to report that they had a policy preventing athletes with SSTIs from participating in athletic events than were schools in lower classifications (P = 0.0002). Programs that had an AT reported that athletic training equipment (P = 0.01) and tables (P = 0.02) were cleaned more frequently than did programs without ATs. Programs were significantly more likely to provide training equipment than to provide soap or towels. About 57% of programs reported that at least one athlete acquired an SSTI during the prior school year, including methicillin- resistant Staphylococcus aureus (N = 14; 10.8%). Programs that had an AT (P = 0.02) were in higher classifications (P < 0.0001), educated athletes about SSTIs (P < 0.0001), or had policies regarding athletes with SSTIs (P = 0.01) were more likely than other programs to report having at least one athlete with an SSTI. The estimated SSTI rate per 1000 athletes ranged from 22.0 in 1A to 5.9 in 4A programs.

Conclusions

SSTIs are common among Iowa’s high school athletes. Staff should review and update their infection prevention policies. Athletic programs need resources to support infection prevention efforts.

Introduction

Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) often causes skin and soft tissue infections (SSTIs) in young people, including athletes. This organism has caused numerous outbreaks on athletic teams and many of the investigations identified infection prevention deficits^1-8. Given that many of the reports in the literature affected high school athletes^3-5,8, we wanted to assess infection prevention policies and practices used by high school athletic programs in Iowa, to determine whether specific resources, such as certified athletic trainers (ATs), affected practices and rates of SSTIs reported by respondents, and to estimate the frequency of SSTIs, including those caused by CA-MRSA, among high school athletes in Iowa.

Methods

We developed a web-based survey and a cover letter that included a link to the survey and was signed by the Assistant Executive Director of the Iowa High School Athletic Association (AB; IHSAA) and the senior author (LAH). We distributed the letter by email to the athletic department at each high school in Iowa (N = 394). Each school was identified by a code number previously assigned by the IHSAA. The survey was available online between 09/05/2007 and 02/28/2008. We sent two emails reminding athletic programs to submit surveys.

We used the Pearson chi-square test to test the association between two categorical variables (e.g., does having policy on SSTI differ between schools with and without AT), and the Wilcoxon rank-sum test was used to test the association between a categorical variable and an ordinal variable (e.g., compare the frequency of cleaning in schools between those with and without AT). For the analysis that involved school classification by school size (1A, 2A, 3A, and 4A), we used the Cochran-Armitage trend test for the binary variables to test whether proportions increased (or decreased) with school classification, and the Jonkheere-Terpstra test to assess the rank-ordered responses. We performed logistic regression analysis, where the model was fitted using the method of generalized estimating equations (GEE), to test whether athletes participating in different sports had a significantly different likelihood of being educated about preventing SSTIs. The GEE method to account for the correlation of responses from a school (i.e., a school responded for each of the four sports). We did pairwise comparisons among the sports using Holm’s Bonferroni stepdown method. We used the negative binomial regression, with the model fitted using the GEE method to account for the correlation of a school’s responses for different sports, to determine whether the number of athletes with skin infections during the prior season varied among the four sports.

Results

Response Rate and Demographic Data

Three hundred ninety- two of 394 high schools had athletic departments; 320 surveys were submitted online but 85 school codes were entered into more than one survey. We assumed that surveys with the same internet protocol (IP) address and the same school code were from the same school. For each IP address, we analyzed the survey with the latest submission date and we excluded the 49 earlier submissions. Thirty-six surveys were submitted from separate IP addresses but had the same school code; we excluded these surveys because we could not determine whether they were duplicates or submissions from different schools. After excluding these 85 surveys, we had 235 surveys for a response rate of 59.9%.

Nearly 70% of the surveys were from 1A schools or 2A schools (Table 1) and athletic directors completed 221 (94.0%) surveys. The number of athletes increased significantly by school classification (P < 0.0001; Table 1). We estimated the total number of athletes in these schools to be 48,030. Of 227 responding schools, 111 (48.9%) did not have an AT, 107 (47.1%) schools had 1 AT, 1 (0.4%) school had 1.5 ATs, 7 (3.1%) schools had 2 ATs, and 1 (0.4%) school had 4 ATs. Schools in higher classifications were significantly more likely than schools in lower classifications to have at least one AT ((P < 0.0001); Table 1).

Table 1.

Characteristics of Athletic Programs by School Classification

School classification*	Number of schools (%)	Employ AT‡	Number of Athletes in the Program
			N†	Median	25th-75th percentile	Range (min-max)
1A	78 (33.2%)	24 (30.8%)	73	70	47-90	7-170
2A	80 (34.0%)	37 (46.3%)	77	125	110-175	50-384
3A	39 (16.6%)	25 (64.1%)	35	250	210-325	45-620
4A	32 (13.6%)	30 (93.8%)	32	650	440-800	270-1008
Overall	235*	116 (49.4%)	218	125	82-250	7-1008

^*Data on the school classification was missing for six programs.

^†N is the number of respondents providing the number of athletes in their program.

^‡Schools in higher classifications were significantly more likely than schools in lower classifications to have at least one AT (P < 0.0001). Abbreviations: AT = certified athletic trainer; min = minimum; max = maximum.

Reported Education Practices

Overall, 189 (83.6%) respondents reported that they educated athletes about SSTIs.This practice varied significantly: 69.7% among respondents from 1A programs, 87.5% in 4A programs, 91.3% in 2A programs, and 92.1% in 3A programs (P = 0.004; Cochran-Armitage trend test). In addition, programs were most likely to educate wrestlers (N = 162, 68.9%; 95% confidence interval [CI], 63.0-74.8) about SSTIs compared with football players (N = 146, 62.3%; 95% CI, 55.9-68.3; P = 0.035), (N = 110, 46.8%; 95% CI, 40.4-53.2; P < 0.0001), and female basketball players (N = 103, 43.8%; 95% CI, 37.5-50.2; p < 0.0001) (logistic regression with p-values adjusted using Holm’s Bonferroni stepdown method). Schools that had an AT were somewhat more likely to report that they educated athletes about preventing SSTIs (87.9%) than schools that did not have ATs (79.5%; P = 0.8; Pearson chi-square test). We should state that there was a trend, but that it did not reach statistical significance

Reported Policies and Practices

Eighty-one (35.8%) of 226 respondents reported that they had a policy preventing athletes who had SSTIs from participating in athletic events. Programs in higher classifications were significantly more likely than programs in lower classifications to report that they had such a policy (range from 23.4% in 1A to 59.4% in 4A; P = 0.0002; Cochran-Armitage trend test). Less than 40% of the respondents reported having policies regarding hand hygiene before or after taping a player or caring for injured athletes; responses did not vary significantly by classification. At least 75% (75.0% in 3A to 86.1% in 1A) of respondents reported that they required staff to use gloves when an athlete might be bleeding. The presence or absence of an AT was not associated statistically (Pearson chi-square test) with policies about hand hygiene, glove use, or athletic participation by persons with SSTIs.

Of 223 respondents, 121 (54.3%) reported having a whirlpool and responses varied significantly by classification (range 49.3% in 1A to 71.9% in 4A; P = 0.04; Cochran-Armitage trend test). Thirty-three of 118 (27.7%) programs with whirlpools reported that they required athletes to shower before using it. Around 40% of the respondents indicated that athletes with broken skin (48/128 [40.7%]) and athletes with SSTIs (52/117 [44.4%]) were not allowed to use a whirlpool. Having policies about whirlpool use was significantly associated with school classification (P = 0.04 Cochran-Armitage trend test); 66.7% of respondents from 3A schools and 57.1% from 4A schools reported that they had policies compared with 37.8% of respondents from 1A schools and 34.2% from 2A schools. After controlling for school classification, having an AT was not associated statistically with having policies on whirlpool use (P = 0.276 Cochran-Mantel_Haenszel test of association).

Reported Hygiene Practices

In general, the persons responsible for cleaning various items did not vary by school classification. Janitors were primarily responsible for cleaning locker rooms (94.9% 3A to 100% 4A) and showers (87.5% 2A to 100% 4A), whereas, athletes (44.4% 3A to 63.9% 1A) were primarily responsible for laundering their uniforms. Athletes (39.5% 3A to 57.4% 1A) and managers/coaches (30.9% 1A to 47.4% 3A) were responsible for cleaning protective equipment. Janitors (31.9% 1A to 59.4% 4A), managers/coaches (27.6% 2A to 46.1% 3A), and athletes (30.8% 3A to 41.7% 1A) were responsible for cleaning training equipment. The persons responsible for cleaning training tables and patient care areas varied significantly by school classification. About three quarters of the respondents from 4A schools reported that training tables (75.0%; P < 0.0001) and patient care areas (71.8%; P < 0.0001) were cleaned by ATs; whereas, in 1A to 3A schools, training tables were cleaned primarily by janitors (34.6% 1A to 41.3% 2A) or managers/coaches (23.7% 3A to 42.3% 1A) as were patient care areas (janitors 52.7%1A to 61.8% 3A; coaches/managers 17.6% 3A to 32.7% 1A; (Cochran-Armitage trend test).

Programs in higher classifications were significantly more likely than programs in lower classifications to report that the showers, locker rooms, patient care areas, and athletic training equipment were cleaned frequently (Table 2; Jonckheere-Terpstra test). In contrast, the frequency of cleaning game uniforms (8.0%-13.6% daily; 69.1%-84.0% after each use), protective equipment (14.0%- 23.8% daily; 4.5%-16.7% after each use), and wrestling mats before practice (67.7%-78.8% daily; 15.3%-23.8% after each use) or during tournaments (28.0%-57.7% daily; 38.5%-57.6% after each use) did not vary with school classification. Programs that had at least one AT were more likely to report that athletic training equipment (P = 0.01; Wilcoxon rank-sum test) and athletic training tables (P = 0.02; Wilcoxon rank-sum test) were cleaned more frequently than did programs without an AT. The frequency of cleaning other items did not vary significantly with the presence of an AT.

Table 2.

Frequency of Cleaning Items Daily by School Classification

School classification	Locker rooms	Showers	Training equipment	Practice uniforms	Training tables	Patient care areas
1A	35/58 (60.3%)	26/58 (84.6%)	8/49 (16.3%)	12/38 (31.6%)	6/55 (19.4%)	9/38 (25.7%)
2A	46/61 (75.4%)	39/56 (69.6%)	14/55 (25.5%)	14/39 (35.9%)	15/62 (33.3%)	19/47 (45.2%)
3A	25/30 (83.3%)	15/28 (55.6%)	8/27 (29.6%)	8/17 (47.1%)	13/25 (52.0%)	11/22 (45.8%)
4A	22/26 (84.6%)	18/23 (78.3%)	9/21 (42.9%)	6/17 (35.3%)	15/22 (62.5%)	17/21 (70.8%)
P-value*	0.04	0.03	0.0002	0.04	< 0.0001	0.0007

^*The P-values were calculated by the Jonckheere-Terpstra test for the distribution across the different frequencies for cleaning (other, never, when soiled, weekly, daily, after each use) and the different school classifications.

Programs were significantly more likely to report that they provide weights than to provide cardio equipment, and they were more likely to provide training equipment than to provide soap, towels, and laundry services (Table 3, logistic regression with p-values adjusted using Holm’s Bonferroni stepdown method). Programs in class 3A and 4A schools were significantly more likely to provide soap for showering, practice uniforms, and laundry services than were programs in 1A or 2A schools (Cochran- Armitage trend test).

Table 3.

Supplies, equipment, and Services Provided by high School Athletic Programs

Items/Service	Number of schools providing the item or service/Number of school responding	95% confidence intervals	Pairwise comparisons (P-value)*
Weights	226/227 (99.6%)	97.6-100.0	(< 0.0007) a
Cardio equipment	181/226 (80.1%)	74.9-85.3	(< 0.0007) b
Towels for practices and games	140/226 (62.0%)	55.6-68.3	(< 0.0009) c
Soap for showering	140/227 (61.7%)	55.4-68.0	(< 0.0006) c d
Uniforms for practices and games	135/226 (59.7%)	53.3-66.1	(< 0.0001) c d
Whirlpool	121/223 (54.3%)	47.7-60.8	(< 0.0053) c d
Laundry services for towels	113/225 (50.2%)	43.7-56.8	(< 0.0009) d
Towels for showering	87/228 (38.2%)	31.8-44.8	(< 0.0053) e
Laundry services for uniforms	78/226 (34.5%)	28.3-40.7	(< 0.0008) e

^*We used logistic regression to assess whether the percentage of schools providing specific equipment, supplies, and services varied significantly by item or service. Items with different letters are significantly different, with P-values as specified (e.g., c is significantly different from a, b, d, and e but not from c, d).

Reported Injuries and Infections

Among the 235 respondents, 90 (38.3%) reported that athletes managed their own turf, floor, or mat burns, 65 (27.7%) reported that ATs managed them, and 21 (8.9%) reported that managers did. Respondents reported that most athletes with SSTIs went to their own physicians or to clinics/hospitals for diagnosis (213; 90.6%) and treatment (221; 94.0%). Athletes also saw a team physician, student health, or an AT for diagnosis (103; 43.8%) and for treatment (120; 51.1%) of SSTIs.

Of the 130 (56.8%) programs that reported at least one athlete with SSTIs, 119 programs provided information on the number of athletes that acquired SSTIs by sport (Tables 4 and 5). As expected, wrestling programs reported more infections than did other programs. For the sports reported, we estimated at least 493 SSTIs occurred during the prior season, for an SSTI rate of at least 12.2/1000 (95% CI, 9.8-15.2 per 1000 athletes; N = 203, which includes respondents that reported SSTIs and those that did not report SSTIs). Respondents reported a total of 56 (43.1%) tinea infections, 31 (23.9%) S. aureus infections, 14 (10.8% or 7.9% of all schools) MRSA, 27 (20.8%) Herpes simplex infections, and 16 (12.3%) streptococcal infections. The percent of respondents that reported SSTIs or MRSA infections among athletes increased with the presence of an AT (Table 5) and as the classification increased from 1A to 4A (Table 6). The estimated SSTI rate per 1000 athletes was 22.0 (95% CI, 13.2-36.3) in 1A, 18.7 (95% CI, 14.3-24.5) in 2A, 10.7 (95% CI, 6.7-17.0) in 3A, and 5.9 (95% CI, 3.7-9.5) in 4A. The percent of respondents that reported knowing whether or not athletes acquired MRSA SSTIs did not vary with school classification or with the presence of an AT. A significantly higher proportion of programs that educated athletes about SSTIs reported having at least one athlete that acquired an SSTI (122/191; 63.9%) than programs that did not (7/37, 18.9%; OR, 7.58 [95% CI, 3.16-18.16]; P < 0.0001). Similarly, programs that had policies regarding athletes with SSTIs participating in practices or in athletic events were more likely to report having identified athletes with SSTIs (55/81; 67.9%) than were programs without such policies (74/147, 50.3%; OR, 2.09 [ 95% CI, 1.18-3.68]; P = 0.01; Pearson Chi-square test). Programs that enforced the policy by requiring a note from a doctor were more likely than other programs to report having athletes with SSTIs (48/67, 71.6% vs. 82/162, 50.6%; OR, 2.46 [95% CI, 1.33-4.55]; P = 0.003; Pearson Chi-square test). Programs that had hand hygiene policies and gloving policies were as likely to report SSTIs as programs that did not have such policies (Pearson Chi-square test).

Table 4.

Infections Identified among High School Athletes by Sport

Program	Number of Infections Identified	Number of Programs Reporting (N = 203)
Wrestling†	0	101 (49.8%)
	1	25 (12.3%)
	2	36 (17.7%)
	3	16 (7.9%)
	4-10	24 (11.8%)
	= 10	1 (0.5%)
	Total Athletes with Infections: 294 Mean Infections/School (95% CI) 1.45 (1.19-1.77)
Footbal†	0	146 (71.9%)
	1	24 (11.8%)
	2	18 (8.9%)
	3	4 (2.0%)
	4-10	9 (4.4%)
	= 10	2 (1.0%)
	Total Athletes with Infections: 160 Mean Infections/School (95% CI) 0.79 (0.52-1.19)
Boys’ basketball†	0	190 (93.6%)
	1	12 (5.9%)
	2	1 (0.5%)
	Total Athletes with Infections: 14 Mean Infections/School (95% CI) 0.07 (0.04-0.12)
Girls’ basketball	0	193 (95.1%)
	1	7 (3.4%)
	2	1 (0.5%)
	3	2 (1.0%)
	Total Athletes with Infections: 15 Mean Infections/School (95% CI) 0.07 (0.04-0.15)
Other sports	Total Athletes with Infections: 10

Note: To determine whether the number of athletes with skin infec-tions during the prior season varied among the four sports, we used negative binomial regression, with the model fitted using the GEE method, to account for the correlation of a school’s responses for different sports.

^†Wrestlers had significantly more infections than football players (P = 0.030). Wrestlers and football players had significantly more infec-tions than female basketball players (both comparisons P < 0.0001) and male basketball players (both comparisons P < 0.0001).

Table 5.

High School Athletic Programs Reporting that Athletes Acquired Skin Infections during the prior School Year by whether or not the School had a Certified Athletic Trainer

Event	All schools	With AT	Without AT	Pearson chi-square P-value	Odds Ratio (95% CI)
Any athletes acquired skin infection*	130 (56.8%)	75 (64.7%)	55 (48.7%)	0.02	1.93 (1.14, 3.28
Any athletes acquired MRSA skin infections*	14 (6.1%)	12 (10.3%)	2 (1.8%)	0.007	6.40 (1.40, 29.30)
Know of presence/ absence of MRSA	174† (73.6%)	90‡ (77.6%)	83§ (69.7%)	0.17	--

^*Unknowns were grouped with “no” for the analysis and N = 229 for all schools, 116 for “with AT,” and 113 for “without AT.”

^†N = 235.

^‡N = 116.

^§N = 119.

Abbreviation: MRSA = methicillin-resistant S. aureus.

Table 6.

High School Athletic Programs Reporting Athletes that Acquired Skin Infections during the prior School Year by School Classification

Event	1A	2A	3A	4A	Cochran-Armitage trend test P-value
Any athletes acquired skin infections*	25 (32.9%)	51 (63.8%)	27 (71.0%)	26 (81.3%)	< 0.0001
Any athletes acquired MRSA skin infections*	2 (2.6%)	3 (3.8%)	2 (5.3%)	7 (21.9%)	0.0009
Know whether or not athletes acquired MRSA skin infections	62† (79.5%)	55 (68.8%)	28‡ (71.8%)	25 (78.1%)	0.71

^*Unknowns were grouped with “no” for the analysis and N = 76 for 1A, N = 80 for 2A, N = 38 for 3A, and N = 32 for 4A.

^† N = 78.

^‡ N = 39.

Abbreviation: MRSA = methicillin-resistant S. aureus.

Eighteen programs (7.9%) reported that more than one athlete had diarrheal illness and 48 (21.1%) reported that more than one athlete had infections such as mononucleosis, influenza, or athlete’s foot. Two of 202 (0.99%) programs reported requiring wrestlers with a history of Herpes simplex to take antiviral medication and 1 of 199 (0.5%) reported requiring all wrestlers to take antiviral medication if one wrestler had Herpes simplex. Two of 226 (0.88%) programs reported requiring athletes in contact sports to have nares cultures for MRSA.

Discussion

This study is one of the first to assess infection prevention policies and procedures among a state’s high school athletic programs and to estimate the frequency of SSTIs among the athletes. Nearly 60% of the responding athletic programs reported that they identified athletes with SSTIs during the 2006-2007 seasons but less than 10% reported identifying MRSA SSTIs. Buss et al. surveyed high schools in Nebraska and found that the percent of schools reporting one or more athletes with MRSA infections increased from 4.4% during 2006-2007 to 14.4% during 2007-2008⁹. These investigators estimated that the incidence of MRSA infections increased from 19.6/10,000 to 60/10,000 among wrestlers and from 5.0/10,000 to 25.1/10,000 among football players. In contrast, about 32% of licensed ATs working in 4A and 5A high school athletic programs in Texas reported MRSA infections among their athletes and about 17% reported that they identified two or more MRSA infections during the 2003 fall athletic season⁵. One program reported an outbreak affecting 23 football players⁵. Barr et al. queried ATs at schools in the highest classifications and in our study these programs were the ones most likely to report that they had identified athletes with MSRA SSTIs. In addition, we previously found that the most common CA-MRSA strains ( USA300 and USA400) began causing invasive infections in Iowa later than in more populated areas¹⁰. Thus, a lower percentage of programs in Iowa than in Texas may have had athletes with MRSA SSTIs.

However, we suspect that our results may underestimate the percentage of programs that had athletes with MRSA SSTIs, in part, because most student-athletes with SSTIs were seen by their own physicians and many physicians do not obtain cultures before treating SSTIs. Also students might not report culture results to their athletic programs and athletic directors (the primary respondents to our survey) are less likely than ATs to know whether athletes have had infections. Furthermore, MRSA has been the most common cause of SSTIs among patients seen in emergency departments, with MRSA causing 15% to 74% of these infections^11,12.

The percentage of programs reporting that athletes had SSTIs in the prior season increased with school classification. Moreover, programs in higher classifications were also more likely to have ATs, to educate athletes about SSTIs, and to have policies excluding athletes with SSTIs from participating in practices or games/meets and these three variables were positively associated with programs that reported SSTIs among their athletes. Programs in higher classifications most likely had more resources (e.g., ATs) for education, prevention, and surveillance than programs in lower classifications and their staff members may have had more educational opportunities. However, the estimated rate of SSTIs was higher in 1A and 2A programs than in 3A and 4A programs. Anderson recently reported that 299 (4.2%) wrestlers participating in Minnesota’s high school wrestling state tournament had SSTIs. In contrast to our results, larger schools (i.e., higher classification) had significantly more wrestlers with SSTIs than did smaller schools¹³.

A high percentage of athletic programs reported that they educated athletes about preventing SSTIs. As expected, education was most common for wrestlers and football players, whose risk of infection was higher than that of other athletes. However, less than 25% of the programs reported having policies on hand hygiene and only one third reported having policies about other practices to limit spread of infectious agents such as restricting athletes with SSTIs from participating in practices or games/meets or from using whirlpools. Data from outbreaks suggest that such policies may be important preventive measures^1,3,14. Moreover, Sosin et al. found that skin injuries and contact with other athletes who had furuncles increased the risk for furuncles among male high school athletes³. Begier et al. noted that the risk of infections at covered sites increased significantly as use of the cold whirlpool increased¹.

Hall et al. determined that use of therapeutic hydrocollator packs and use of miscellaneous training equipment were risk factors for MRSA infections among college football players¹⁴. Other investigators found MRSA contamination on 29% to 89% of surfaces in athletic facilities^15-17, suggesting that athletic training environments could be a reservoir for this organism. Oller et al. demonstrated that MRSA could be eliminated from a football locker room by implementing infection control interventions and educating athletes and custodial staff¹⁷. Thus, ATs and other athletic department staff should develop procedures for cleaning and disinfecting their areas, to prevent infections in athletes.

The frequency of cleaning the environment increased with the school classification, suggesting that larger schools had more resources for cleaning. Thus, while the wrestling mats and locker rooms were cleaned frequently, other areas were cleaned less frequently and could serve as reservoirs for pathogenic organisms.

Athletic programs were significantly more likely to provide weights and cardio equipment than they were to provide soap for showers and other supplies or services that would improve infection prevention. Among collegiate football players, one outbreak of MRSA SSTIs occurred in a setting where soap was not provided in the showers¹ and another was associated with sharing bars of soap⁷. Given the economic situation, high schools in rural Iowa might not be able to hire ATs or to provide soap, towels, and laundry services. Program staff, athletes, athletes’ parents, and local communities may need to identify creative ways to provide these supplies and services so that the risk of SSTIs can be minimized.

Although this survey was conducted before the current economic crisis, less than half of the high schools in our survey reported having an AT, which may help explain why ATs were not significantly associated with either having policies and procedures that would help prevent SSTIs or with educating athletes about preventing SSTIs. ATs are trained to prevent, diagnose, and treat conditions that can impair athletes’ performance, including MRSA SSTIs. Thus, ATs could help athletic programs implement policies and practices that would prevent SSTIs among athletes¹⁸.

Our study had several limitations. We did not validate the answers the respondents submitted, culture the environment, or observe the efficacy of cleaning. We also did not ask the programs how many MRSA infections their staff identified. Thus, we could not estimate the incidence of these infections. Moreover, athletic directors were the most frequent respondents but ATs, coaches, or school nurses might know more about athletes’ practices and infections than do athletic directors.

SSTI were identified commonly among high school athletes in Iowa but athletic directors believe that MRSA SSTIs are not common. Staff members of most athletic programs are aware of MRSA SSTIs and are using some measures to reduce the risk of SSTIs but many programs have not implemented policies on hand hygiene and glove use or on excluding athletes with SSTIs from participating in sports. Such policies could improve athletes’ and caregivers’ (e.g., ATs) safety. CDC, the National Athletic Trainers’ Association (NATA), and the National Collegiate Athletic Association (NCAA) have developed guidelines that can help prevent SSTIs, including those caused by MRSA^18-21. ATs, physicians, athletic directors, school nurses, and coaches should work together to develop and implement policies to address infection control practices that could prevent SSTIs. Many high school athletic programs need additional resources so that they can implement current guidelines and improve their infection prevention practices.