The invisible enemy: alerting your staff about the dangers of MRSA, which could become your biggest opponent.

Ron Courson has treated every kind of sports-related injury as the Director of Sports Medicine at the University of Georgia. From sprains and bruises to broken bones and torn ligaments, he's seen it all. But for the past several years, something altogether different has reared its ugly head on the bustling, idyllic Athens, GA campus.

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The intruder doesn't wear an athletic uniform or have a rooting interest, other than finding a portal of entry into the skin and causing unsightly infections, that, if not treated correctly, can be life-threatening. The menace is community-acquired methicillin resistant Staphylococcus aureus or MRSA, a super strain of "staph," that has infiltrated the athletic world on its way to becoming a full-blown pandemic.

"I think you would be hard-pressed to find any school that hasn't had at least one or more cases," claims Courson, the Chairman of the College/University Athletic Trainers Committee for the National Athletic Trainers' Association. "We've been fortunate that we haven't had that many cases. We have had cases in more than one sport. We haven't had an outbreak or mass cases. But I am aware of scores of schools across the country that have."

According to published reports, Georgia has had eight cases of MRSA.

Two of the more high profile MRSA outbreaks occurred in the professional ranks. This summer, two members of the Toronto Blue Jays--right fielder Alex Rios (left leg) and pitcher Ty Taubenheim (left foot)--were both infected and spent time on the 15-day disabled list.

In November 2003, five members of the St. Louis Rams contracted MRSA, an incident that required the Centers for Disease Control and Prevention to do a full investigation, including field-testing.

Also in 2003, the University of Southern California football team reported seven cases. More recently, Indiana State's football team had 16 players afflicted. The San Francisco 49ers, Pittsburgh Steelers, Miami Dolphins, and Washington Redskins are just several of many professional football teams that have dealt with MRSA-related issues.

Scores of high school athletes, mainly football players and wrestlers, from coast to coast have also contracted MRSA. Boone Baker, a then- wide receiver for the Austin (TX) High Maroons junior varsity, nearly lost his life to MRSA after sustaining a turf abrasion on his shoulder following a tackle in an October 7, 2005 game vs Westlake High.

Ricky Lannetti wasn't as lucky. The former football player at Lycoming College in Pennsylvania died from MRSA in 2003. According to the CDC, Lannetti's tragic death, one of only two known football-related deaths, was more of a respiratory issue. It remains unclear whether it was contracted on the field or from someplace else.

The first documented "staph" outbreak in sports occurred in 1964 when 24 players on the Dartmouth football team came down with it. The football teams at North Carolina (1977) and Illinois (1979) also reported outbreaks.

Staph is carried on the skin or in the nose of 25 to 35 percent of healthy people. This is known as colonization. It occurs when the staph bacteria are present or in the body without causing illness. Infection occurs when the staph bacteria causes disease in the person.

"Humans are the main reservoirs for Staph aureus," says Jeff Hageman, staff epidemiologist for the CDC. "We carry Staph aureus in our nose--30% of the population. That means about 80-90 million people in the U.S. carry Staph aureu sin their noses. A lower proportion, carry MRSA, maybe 2.3 million."

MRSA infections usually develop in hospitalized patients, with some cases dating to the 1970s. However, MRSA rates have increased recently in persons outside of health care facilities, affecting athletes and the physically active. MRSA began infiltrating the community setting in the late 1990s, occurring in otherwise healthy people, particularly children.

The infections usually appear first as pimples, pustules, and boils. Some can be red, swollen, and painful and/or have pus or other drainage. The pustules may be confused with insect bites in early stages. The infected abscesses may also be associated with previous existing turf burns or abrasions. Without proper referral and care, more serious infections may cause pneumonia, bloodstream infections or surgical wound infections.

"Most of the information that we know about MRSA and Staphylococcus aureus comes from the healthcare settings where we have a lot of MRSA and the most experience in dealing with staph and MRSA disease," said Hageman. "In that setting, as well as the community--especially all of these community outbreaks from the prisons, the sports, religious communities, and certain indigenous populations--the role of the environment has really been unclear. It hasn't seemed to play a significant role in transmissions of these infections."

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In hospitals, transmission has primarily been transferred from patient to patient and through contact from healthcare workers' hands that have been contaminated. In the community settings, most of the transmission is thought to occur through the direct skin-to-skin contact. Especially in sports, where there is so much significant skin to skin contact and failure to cover infected wounds, as well as having a number of uncovered skin wounds on the body surfaces that allow for a portal of entry for staph to invade.

Hageman reveals that before the emergence of MRSA, staph and strep were believed to be the most common causes of skin infections. But recent studies now seem to show that staph is really the predominant cause of skin infections, whether it's susceptible or resistant.

"Several factors lead to transmissions in these settings and one of the first is an overall lack of awareness," Hageman says. "Maybe not among the healthcare professionals, like the Certified Athletic Trainers, but more among the players. What is MRSA? What does it look like? What should I bring to the attention of the trainer or physician? When should I go see a doctor? By not knowing what to look for and what to report, players that did get an infection, carry that infection uncovered, exposing other people.

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"Whether or not it's actual exposure from skin-to-skin contact on the field or whether it's the skin-to-skin contact or other contact that occurs in the locker rooms. The other thing that is complex is that these are not closed environments. A team has contact with the general community, with roommates, with family members. And MRSA now is the most prevalent cause of skin infections in the United States."

The twist is that MRSA is resistant to an entire class of antibiotics. The traditional antibiotics used to treat skin infections are called beta-lactams, a penicillin-like antibiotic. Before MRSA came on the scene, you never had to know what the skin infection was. Physicians didn't routinely take a sample of the infection and test it. Pretty much all staph infections were susceptible to these antibiotics.

That's not the case anymore. MRSA is more difficult to treat, requiring stronger antibiotics that are costlier and, in some cases, have to be administered intravenously.

To help combat MRSA, the CDC has formed a collaboration with the National Athletic Trainers Association, and Georgia's Courson, to learn how much of the disease is out there.

Said Hageman: "There is no source to find out how much is actually occurring. We'll be surveying ATC's to get a sense of how much disease is occurring among athletes and which athletes and what educational initiatives need to be taken. Most of the cases are reported from contact sports like rugby, football, and wrestling. But we're hearing more and more among volleyball players, soccer players, and basketball players."

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Courson reports that the most common sports from a national standpoint are wrestling and football. That makes sense since they have the highest amount of skin-on-skin contact and a large amount of athletes congregating in common locker rooms.

Since staph can survive in water, transmission can occur in a common water source such as whirlpools. So if a team is conducting a therapy session, players who do have wounds can get MRSA without necessarily having direct skin-to-skin contact. Commonly shared towels are another source. It's commonplace to see players coming to the sidelines and wiping off their faces, arms, and legs where they have may have these wounds, and potentially where they have infections, and transferring the infection as the towels are passed around.

That said, Courson and his staff have been highly proactive in providing athletes with a detailed brochure outlining MRSA and speak with them about recognizing it and seeking treatment.

"If a player has a knee or ankle sprain, typically, they are going to tell somebody about it," Courson said. "But athletes are a little bit more careful with skin lesions. A lot of times they will try and care of it themselves and wait a couple of days to see if it gets better on its own. Then, if it gets significantly worse, they may come in on their own. The other thing is, many times these lesions may be in a place that the players may be a little bit modest in showing, such as the groin area or buttocks. We tell them what to look for and show them color pictures and tell them, 'If you see this or suspect this, let us know as soon as possible.'"

The training staff also emphasizes the importance of good and proper hygiene: Wash hands thoroughly; take hot showers immediately after athletic activity; use pump soap instead of bar soap, which can breed MRSA. It also educates them on not sharing items: towels, clothing, or equipment. Instead, Georgia is using more single-use towels. If an athlete has a wound, he is evaluated, has it cleaned daily, and the bandages changed frequently.

"One of the things about athletes, and it's the same thing in high school, a lot of them may not like to use the group showers and would rather wait till they get home," Courson said. "They may have the best intentions, but they may get sidetracked and before you know it, four or five hours have passed. And they've had all of that dirt, oil, and bacteria on their body all of that time. That's an opportunity for the infection to breed. MRSA is what they call an opportunistic infection. It seeks out an entry point to enter the body."

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Last, but not least, Courson educates Georgia's custodial staff,

"They really are our first line of defense," he said, before adding:

"Personally, I think the biggest thing we need to do to be proactive about MRSA is emphasize prevention and education. It goes back to Ben Franklin. He said an ounce of prevention is worth a pound of cure. We can prevent through proper hygiene and teaching people through basic tips. Hopefully we can keep this from happening. It is a problem nationally. Not just in athletics, but in the regular population."

Iowa State is taking a similar approach. According to Mark Coberley, Director of Athletic Training at ISU, the university has a several-tiered approach to prevention, beginning with hygiene: wound care and the monitoring of the facilities to keep them as clean and as ventilated as possible.

"In terms of MRSA management," Coberley declares, "there are so many areas within and around an athletic department that require management. That's it not just focused on one area. You can do cultures on different areas in and around an athletic department and find colonies of MRSA. Our prevention standpoint is great hygiene on the kids' part, paying attention to the wounds that they have--getting them cleaned and managed quickly and correctly."

The CDC has initiated a joint effort with the NCAA to develop guidelines for the prevention and control of community-associated MRSA among college football players.

The NCAA, in turn, has been educating its institutions and constituents about MRSA since 2003, when the CDC first introduced its information in the wake of the Rams' investigation. In fact, the NCAA has a health and safety section on its Web site dedicated to skin infections (www.ncaa.org/health-safety).

"We've been focusing on hygiene for student-athletes: taking care of wounds, cleaning your clothes, trying to prevent that staph from spreading," said David Klossner, the NCAA's Associate Director of Education Services. "That's the message. We also have an educational Power Point presentation that our medical staff can use to educate coaches and athletes about the impact of MRSA or the impact of other skin infections on campus.

"In our wrestling rulebook, we have a section on skin infections called Return to Play, for people looking for such guidelines. Wrestling is where most of our skin infections happen, but since MRSA came along, it impacts other sports more often."

Klossner said that the NCAA has been working in conjunction with the CDC to release a sports-specific educational piece on MRSA.

"It's in the works," he said. "I've been told it's almost finished."

Likewise, the National Federation of State High School Associations (NFHS) is doing its part regarding education and prevention.

Bob Colgate, Assistant Director, reports that the organization, in conjunction with its Sports Medicine Advisory Council, was finalizing its position on MRSA and staph at a meeting Oct. 7-9. The results were not available in time for publication of this story.

However, Colgate stressed that the NFHS is well aware of the concerns.

"The bottom line is that we have to do everything we can," he said. "We've got to make sure kids shower. We have to clean equipment. We have to clean facilities. We can take all of these precautionary measures and we still may not be able to stay on top of it. But the thing is you can't battle it if you're not doing all of those prerequisite things. You have to be proactive, start from the beginning, and stay on top of it.

"A lot of it goes back to what the CDC and all the experts are going to tell you, No. 1 is cleanliness. Kids aren't showering. They're not washing equipment. Just very general things. And we're trying to drive that home. When they're not showering and washing equipment, when facilities are not getting cleaned, it's only going to help spread this."

According to Colgate, the NFHS and the NCAA's intersurveillance study both indicate the highest cases of MRSA occur in wrestling.

"We've seen in it happen in a lot of sports but it's more so in wrestling," he says. "That's not to say that that thing is not harboring and sitting in the football venue, because we know it is. It's a time bomb waiting to go off. From what the medical experts tell us, it's something that has developed here that they thought they would have a handle on, but now they found out they don't have a handle on it. We're trying to find ways to be able to keep it under control and deal with it."

TROUBLE UNDERFOOT?

In a 2005 study published in the New England Journal of Medicine, new research concluded that the MRSA infections among the St. Louis Rams in 2003 were likely spread among players on as well as off the field through rough play, shared towels, whirlpools, and weights.

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Researchers blamed "turf burns" or areas of skin rendered raw by a hard fall on artificial turf as both the source and means of spreading the bacteria. (The Rams previously played on an older-model AstroTurf field, which did not have a rubber / sand infill system.)

"These abrasions were usually left uncovered, and when combined with frequent skin-to-skin contact throughout the football season, probably constituted both the source and the vehicle for transmission," wrote researcher Sophia V. Kazakova, MD, MPH, PhD, of the CDC, and colleagues in the Feb. 3 issue.

The report went on to say that "all of the infections occurred at the site of a turf burn and rapidly progressed to large abscesses 5 to 7 centimeters in diameter that required surgery to drain."

"That component with the compromised skin--the breaks in the skin--were really acting as portals of entry," said the CDC's Hageman. "Not that people were acquiring it from the field itself. There were some studies that were done a little while ago where they did human experiments with staph disease in which they took pure staph and deposited it on the unaffected skin and then did the same with skin that had been abraded. The people who became infected were those who had the abrasions, and not those who had intact skin."

Since the CDC's study was released, there has been a movement trying to directly link synthetic turf fields as being a source or breeding ground for MRSA. In the case involving Boone Baker, a story entitled, "Field of Nightmares," (in the May 2006 issue of Texas Monthly), reported that the Boone family doctors believe MRSA entered Boone's body via the turf burn on his shoulder.

MRSA and its relationship, if any, to turf has become a hot-button issue within the synthetic turf industry, specifically in regard to infill systems. With nearly 800 fields, many multipurpose, installed annually, the concerns are many.

Dr. Andy McNitt, Associate Professor of Soil Science at Penn State University, on Aug. 29, debunked the staph bacteria scare in synthetic turf. The study, entitled "A Survey of Microbial Populations in Infilled Synthetic Turf Systems," is considered to be the first sports-specific controlled study which has some relevance into a possible cause for MRSA.

Conducted by the University's Center for Turfgrass Science, the study found no trace of Staphylococcus aureus bacterium in any of the 20 infilled synthetic turf fields and two natural grass fields tested in various locations in Pennsylvania.

In his findings, McNitt concluded: "These infilled systems are not a hospitable environment for microbial activity. They tend to be dry and exposed to outdoor temperatures, which fluctuate rapidly. Plus, the infill media itself (ground-up tires) contains zinc and sulfur, both of which are known to inhibit microbial growth. Considering the temperature range for growth of S. aureus is 7-48 degrees Celsius, we didn't expect to find this bacterium in fields exposed to sunlight, since the temperatures on these fields far exceed 48 degrees frequently."

McNitt observed that the study didn't differentiate between MRSA and the nonresistant strain because, "they are the same bacterium. It's just that some of the bacteria have developed resistance to antibiotics. We didn't differentiate, as we didn't find any staph--resistant or otherwise--in the synthetic turf."

The Penn State study also found low overall microbial populations in the synthetic turf systems. In fact, the microbe population of natural turf-grass far exceeded anything McNitt's team found in the infill systems.

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Staph was found, however, on blocking pads, weight equipment, stretching tables, and used towels, in addition to the hands of five randomly tested passersby.

"We expected to find higher bacterial incidence indoors and we actually found the opposite," McNitt told Scholastic Coach and Athletic Director. "Generally, the outdoor fields had higher overall bacteria."

McNitt said his PSU team conducted the study in June because they wanted a relatively high period of humidity. They felt if they were going to find staph, it would be on fields that were being used indoors and in high humidity. In retrospect, that turned out to be a false premise.

Despite his findings, Dr. McNitt's study has been left open to interpretation based on sample size, time of year it was conducted, location, etc. Several industry insiders and a renowned microbiologist disagree and contradict what McNitt has stated. Some believe the verbiage and conclusion in the press release (http://www.aginfo.psu.edu/news/06August/Staph.htm) differs from the actual study (http://cropsoil.psu.edu/mcnitt/microbial/results.cfm).

"The study, the methodology, and the conclusions that were drawn, based upon his information, are really not accurate," said Art McWood, President of SportCoatings, manufacturer of a sports antimicrobial system. "I think he makes a very broad conclusion off of a very narrow focused study. This is not a personal attack on Andy McNitt. He's a soil science guy. He's not a microbiologist. He's not an infectious disease specialist. His press release is different from his study.

"This whole issue of microbial growth in general, and in the athletic environment, is a big problem. You have mold issues, mildew issues, which can actually be very dangerous. There are some molds out there that are very toxic and very prevalent."

William C. H. White, an accredited microbiologist, found fault with McNitt's report due to his belief that it didn't discuss anything about antimicrobials, or the durability, or usefulness, or utility of them. White went so far as to challenge McNitt to basically offer a mea culpa and profess it was a baseline study and he didn't mean to conclude to the industry that there is no MRSA on the field.

"Let me offer a perspective that I gleaned from all of this," states White. "I think he unquestionably wants to contribute the right things to this issue. But you have to look at it two ways: Is the field a propagation site, a primary source, an amplification site? The odds of that are nil. I mean really low. Whether it's synthetic turf or a soil field, whatever. Now, the other question is, when we do hospitals and other buildings, one of the things we look for are transfer routes. When you are looking for routes of transmission--whether it's in sweat, in pus, in blood, or other body fluids during a contest--is it plausible that someone could slobber on the field and sweat on the field and then somebody would roll on top of it and there would be transfer? Yes!"

McNitt said the sample size was 2-3 grams, which he admitted is not big. Each field was tested twice.

McNitt tried to quiet his critics by asking what if his team had sampled 1,000 one-gram samples? Would that have been enough? That's only four pounds of material and they would have had to run through that 1,000 times. Or what if they sampled 10,000 fields and they found one incidence of staph on one spot on one of them? Does that mean they would have to spray an anti-microbial on all 10,000?

"To say that 8,000 pounds is one percent of the field and somehow that would be your reasonable sample size is ridiculous," McNitt said. "Because a microbiologist knows the process that it takes to measure the amount of colonies growing in 8,000 pounds is gigantic. I'd like to do a thousand fields a thousand times but it's just not feasible at this time."

It's nearly impossible to sample a whole field. A football field (including the two end zones) is 360 feet long and 160 feet wide for a total of 57,600 square feet. Even the CDC's Jeff Hageman admits that environmental testing is "often looking for a needle in a haystack."

"I don't think that my study is an ending or is definitive about this subject at all," said McNitt. "I believe that if we looked hard enough we might be able to find some staph on synthetic turf. But just because you found it there, we know that it's not going to live autonomously for a long period of time on a synthetic surface."

Hageman said there are studies in the laboratory under controlled environments where staph has been shown to survive from hours to weeks to months.

"Bacteria doesn't care if it has high enough concentrations," he said. "It will tend to stay on a surface. It doesn't matter whether if it's artificial or natural."

McNitt added: "The bottom line is we need a lot more research on not only whether it exists, but if it does exist, how do we control it? It's easy to criticize research. It's a lot harder to go do some yourself."

Hageman and the CDC team did significant environmental sampling of the Rams' home field, the team's training facility which had both natural grass and synthetic turf, as well as other environmental surfaces: saunas, whirlpools, steam rooms, athletic training tables, and benches.

When it comes to the field, Hageman said there are several methods for testing, one being the use of a sterile wipe. However, the process is limited as you can only actually sample a one square foot area, or about the size of a sheet of paper. From that perspective, when you're looking at 57,000 square feet, you're obviously not sampling a large proportion of the field.

Both the CDC and the NCAA concur that MRSA has yet to be found in synthetic turf and that McNitt's study is conclusive in its findings.

"I'm not aware of any studies, even from companies that produce these [microbial] products, finding MRSA in turf," says Hageman. "In the Penn State study, one of the manufacturers of one of these products sent out a message where they said that the [artificial] turf had the highest bacterial counts. Actually, that's not true. When you look at the Penn State data, the natural grass had the highest levels. The company stated that the highest bacterial count was in sand/rubber infill fields--80,000 colony forming units. Actually, in [McNitt's] study, if you look at his results, the non-artificial turf, the natural grass, had the highest material counts, of almost 300,000 colony forming units. So more than three times the amount found on artificial turf was found in natural grass. And they didn't find any staph in the turf or the natural grass. He stated that no colonies isolated from any crumb rubber or fiber sample tested positive for Staph aureus. So some of the statements that were sent to athletic trainers were a little misleading and didn't show all of the data."

"We have an injury reporting tracking system and it's limited by sample size, but we haven't had any linkage to turf," said the NCAA's David Klossner. "I know there have been some reports in the media. The CDC continues to tell us that the turf is not a harbor for this MRSA/staph infection. And if things are handled appropriately as far as hygiene practices, common sense, and wound cleaning and coverage, then a lot of these things can be prevented. We just allow the medical experts to guide us in that direction. Now the Penn State study kind of reinforces what the CDC has been telling us all along. A lot of people were anxious to jump to conclusions."

But to say that it's undeniably plausible that a synthetic or natural grass surface cannot spread MRSA is like the National Cotton Council of America refuting that a towel can transmit MRSA or Proctor & Gamble denying a bar of Ivory soap is a possible cause.

"There is no data to suggest that turf will never spread MRSA," said Hageman. "We sampled the turf for the Rams' investigation and didn't find it. We actually observed the game. We mapped where the contact on the turf occurred. We sampled those areas where the players were tackled. And then we sampled areas where there wasn't any direct contact to the turf. We didn't find any MRSA.

"I wouldn't say that just because we didn't find any MRSA that you would never find it."

Needless to say, McNitt's study sent a collective "Whew" throughout the entire synthetic turf industry, even though many insiders were already confident.

"There was never a doubt in our minds that this was an issue that needed to be debunked," said John Gilman, CEO of FieldTurf. "Simply put, there were some who made an attempt at striking fear into the minds of some of our customers, but there was never any backing to their claims. We had done our homework and looked at the existing research. In addition, speaking to groups such as the NATA allowed us to get a better understanding of the so-called staph scare.

"It was nice to see Andy McNitt address the issue and we commend him for his thorough investigation."

Said Jim Dobmeier, President of Surface America/A-Turf: "We had no concerns. On one hand I'm not relieved at all because I believed that the accusations were false. Because we have had no experience and I have heard no word, zero, of any legitimacy to any staph infections ever being associated with this infill-type of product, whether our's or our competitors' fields. I am relieved that Andy McNitt's study supported what we all thought. On the other hand, there are a lot of things in this world that are believed that are not true. So it's nice to see that there is science behind the fact."

Hageman said it doesn't matter whether you get a turf abrasion on synthetic or natural grass. The idea is to prevent any abrasions in the first place. (He suggests players wear neoprene sleeves or use disposable single-use stickys to guard against abrasions.)

Football players are pretty well covered by most of the equipment except for their extremities, where most of the infections occur. The elbow is a common site, as players tend to get a lot of abrasions when they are tackling or falling on the field.

Unlike the "fuzzy cement" artificial fields of yesteryear, today's synthetic fields employ Polyethylene, which has two outstanding qualities. It's soft, meaning it's friendly to the skin, and it's durable.

"This generation of materials that is used extensively by A-Turf and several of our competitors, there isn't a big incidence of turf burns anymore," Dobmeier said. "Can there be minor abrasions just like there is on natural grass? Yes, but because of the nature of the sport, not because of the nature of the surface."

Said FieldTurf's Gilman: "Bacteria needs an entry point to the athletes' body, and an untreated abrasion due to turf burns. Turf burns have been commonly associated with AstroTurf or carpet-like systems, not infill systems. The scientific data available are clear: skin abrasions are the major problem. Therefore, reducing the skin abrasion rate as well as improving the hygiene of the players is the recommended standard until a valid, well-designed study comparing infection rates on a "protected" vs. an "unprotected surface" has been published."

Elliot Levine, President, Sprinturf: "We look at the situation more broadly, with the prevention of turf burns only a part of the overall issue. First, our fiber was designed to help prevent turf burns and abrasions by being soft and pliable. The challenge was achieving that softness while maintaining toughness and durability. Our exclusive Ultrablade fiber achieves this as it is remarkably soft to the touch yet can withstand being drilled by a wire brush."

FieldTurf says its abrasion testing shows that it is very close to natural grass. Furthermore, its new monofilament fiber, FieldTurf DUO, combines four spined monofilament fibers with four softer rectangular monofilament fibers. Sprinturf has introduced FlexSand, a special sand that is coated with a thin layer of rubber and also eliminates abrasiveness.

MICROBE MANAGEMENT

While synthetic turf companies appear to be tackling the abrasion issue, several manufacturers have developed anti-microbial products.

McWood's company, SportsCoatings, offers a trio of products: TurfAide (for synthetic turf systems), SportsAide (for use in locker rooms, training rooms, whirlpools, sports equipment, etc.), and SportsAide Fabric Conditioner (for use in laundering uniforms and towels). Cleveland-based Pioneer Manufacturing has an artificial-turf disinfectant called Titan Turf Gard. AstroTurf sells a synthetic turf product it calls AstroShield.

It must be noted that SportCoatings, like the rest of the manufacturers of anti-microbial products, has a huge stake in the MRSA turf scare.

"Our company is not against the synthetic turf industry," McWood states. "In fact, it's the direct opposite. The reality of it is that these issues exist and in the environment in general. They can exist on grass fields. They can exist on synthetic fields. What we have in place now is an ability to control microbial growth so now you have the best surfaces in the world that you're able to have peace of mind because there's an opportunity to put some microbial control on these surfaces, which you cannot do cost effectively on grass."

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William C.H. White, who also happens to be the CEO of AEGIS Environments, which produces the microbe material in TurfAide: "The idea that we are controlling disease organisms, we don't make any claims about that. And we won't. The microbe problems on synthetic fields have to do with biofilms causing sliming and plugging of drainage. They have to do with staining. What we're concerned about are the odors that can be generated both by aerobic and anaerobic organisms within the matrix. These are things that can be avoided to increase the life and functionality of the field."

But is applying anti-microbial products on a field a viable solution?

Hageman isn't so sure.

"When it comes to turf, we do not know if that will prevent infection," he said. "There's just no data to support that it prevents infection."

Michael Andresen, Manager of Athletic Grounds at Iowa State and President-Elect for the Sports Turf Managers Association (STMA), said the general consensus among his constituents is that since pretty much all of them have medical people at their facilities, they would prefer to follow the lead of the experts.

"We're interested in the health of the grass and the health of the surface," he said. "Obviously, safety with microbials or bacterias is a concern for us. And it's right there in our headlights. It's such a touchy subject that we're not going to put anything down until they tell us. When our trainer feels that disinfecting the turf will be part of the solution, then we will buy into it.

"It's similar to anything else in our program, like soil fertility or fungicide for disease control on grass. We're not going to do those things unless we absolutely see the problem and know we can cure it with that application. If I am convinced of that, then I will apply it, without reservation."

According to White, there is no independent study done on the application of TurfAide on the field.

"We know that there are abrasive factors that can, in a sense, wear the surface away of the crumb and the face fibers," said White. "Those actions, because our material is like a coating on there, will have an adverse effect. As soon as the surface is sacrificed, so is our material. So we know we have to go back and monitor the fields. Luckily we have a good technique for doing that. Then we are able to recoat as needed."

As for cleaning environmental surfaces or other items, like uniforms or towels, the rule of thumb, according to Hageman, is to follow the manufacturer's instructions.

"Whether you are using a detergent-based product or you are using a disinfectant-based product, both are adequate," Hageman said. "In addition to following the instructions, check if it's an EPA registered disinfectant. If it is, it had to undergo testing to demonstrate that it does what it is saying. Read the label and you should be fine. The key is doing something."

When it comes to funding and prevention, NCAA's David Klossner suggests people need to make an educated decision.

"People are going to ask, 'Where do I put my resources,?'" he said. "Are you going to put your resources in buying expensive chemicals that are put on the field? Or are you going spend resources on proper hygiene practices for your student-athletes and care and coverage of wound care?"

Ron Courson, head trainer at Georgia, thinks the possibility exists that MRSA can live on playing fields. But, from every indication he's gotten, that's the least of the problems.

"In talking with Jeff Hageman at the CDC, the big picture is that's not our most immediate concern," said Courson. "Sure, one thing that's been corroborated is the high index of MRSA with athletes that have turf burns. But I don't think you can necessarily say that they got the infection from the turf. All we know is that they got a break in their skin from the turf. And now they have an entry point for those bacteria to get in. But honestly, I think they are much more likely to get it form the locker room, from their own environment, or from sharing towels and other equipment, to whirlpool baths. I think it's definitely an issue but I personally don't think it's as big an issue as it has been made out to be."

Iowa State's Andresen is of an equal mindset.

"Our athletic trainer, Mark Coberley, and I talk regularly. And MRSA is a big issue. I've had many conversations with fellow turf managers about it. We're all concerned. But I don't know anybody that has had an issue. That they pointed at the turf and said, 'That is the problem.' You do get a few more abrasions on the artificial turf. I wouldn't say that it is alarming but it is one thing we keep our attention on. From everything I've heard, I see that as more of a point of entry rather than the turf will contribute to it."

Coberley said in terms of handling things medically, he thinks there are a plethora of areas needed to be addressed, in addition to the field: locker rooms, weight rooms, training rooms, and medical facilities. Iowa State is concentrating its efforts on trying to cover its bases in all of those areas.

"We had MRSA problems here a couple of years ago," he said. "And in the limited number of outbreaks we had, there has been no correlation on whether a wound occurred on grass or turf that MRSA was involved.

"We'll continue to watch the turf. We'll continue to monitor things. But medically, I don't think there is enough information out there yet for us to make a decision. Can turf be a definitive cause? Sure it could. We just don't know."

Can anyone say for certain that natural and synthetic turf fields are not a cause or breeding ground for MRSA? At this point in time, no.

The bottom line is educating the end user. That is, the athletic directors, coaches, parents, and most importantly, the players.

Until more, broader studies are done to prove otherwise, we have to assume that the origin--the human body--remains the primary culprit.

"The idea that a hospital infection has crossed over and become a community infection is an extremely onerous thing to the public health community," said White. "When you talk about SARS and the fears of bird flu, ladies and gentleman, we have a pandemic. We have a bunch of them and MRSA is one. This is a global infectious problem and it's not just in hospitals, it's also in the public domain."