Study Design

The institutional review board reviewed the protocol and designated the investigation a quality improvement study prior to study initiation. There were 2 suburban high schools and 2 suburban colleges selected for inclusion in the investigation. These schools were representative of the surrounding community and agreed to participate after discussion and approval from athletic trainers and athletic directors.

Bacterial swabs of high-touch surfaces were obtained at 4 separate time points during the academic year. Baseline samples were taken at the start of the school year in September 2017 (time 0). Subsequent samples were obtained in November 2017 (time 1), February 2018 (time 2), and May 2018 (time 3) to correspond with infection control interventions. Sampled surfaces included water bottle lids, water cooler nozzles, training room benches, front door handles, and drawer/cabinet handles. The number of surfaces was proportional to the size of the athletic training room, ranging from 24 to 28 samples at each facility, and varied in total quantity from visit to visit because of availability (eg, if no water bottles were clean and ready to use by athletes, no samples were obtained).

An infection control program was formulated based on CDC and DICON guidelines.^2,3,12,20,21 Key components included utilization of disinfectant products with rapid, broad-spectrum antimicrobial efficacy for skin and surfaces, teaching athletic trainers principles of infection control and proper use, and educating student-athletes on hygiene measures. An alcohol-based hand sanitizer (PURELL Foam Handwash; GOJO Industries Inc) was selected along with an antimicrobial spray for hard surfaces (PURELL Surface Spray; GOJO Industries Inc). Educational components involved distribution of electronic and paper educational tools, presented to the athletic trainers, coaches, athletes, and parents at each of the 4 schools. Informative posters were placed around the training rooms and locker rooms to reinforce concepts of proper hand hygiene and infection awareness. Each athletic training room was equipped with written guidelines, and daily checklists were provided to athletic trainers to ensure compliance.

The infection control program was implemented in 3 phases throughout the year to track changes in bacterial and viral load. Phase 1 (between time 0 and time 1) involved installation of products at the point of care in athletic training rooms. Phase 2 (between time 1 and time 2) involved the initiation of educational interventions with the placement of posters and checklists. Posters featuring athletes following CDC protocols were designed by the research team and placed throughout the training room and locker room (see Appendix 1, available in the online version of this article). Checklists were provided in each training room for reference by the athletic trainer, reminding him or her to use surface and hand disinfectants daily. Phase 3 (between time 2 and time 3) involved targeted educational materials distribution. Athletic trainers distributed informational slides to each coach, which were then shared with the athletes. Additional educational emails/handouts were given to parents and athletes. Figure 1 outlines the study design. Athletic trainers were required to record and report any incidence of infection noted during the study period.

Overview of study design. The above sampling periods are noted in the boxes, with each intervention phase initiated between samples.