Artificial turf sports fields connected to recent MRSA outbreaks and heat strokes on high school and college football teams raise sports safety concerns.
While players on artificial grass may know of an increased risk of turf toe and other muscle and ligament injuries, synthetic surfaces present additional health risks. MRSA infections and temperature-related injuries such as exertional heat illness and heat stroke are serious medical issues of primary interest.
Synthetic Field Turf Versus Natural Grass Infection Risks- MRSA Links
MRSA is a potentially fatal Staphylococcus infection that cannot be treated with conventional antibiotics due to evolved drug resistance. A number of highly publicized methicillin-resistant Staphylococcus aureus (MRSA) infections implicate artificial grass as a risk factor. Investigation of an outbreak of MRSA on a college football team found that there was a seven-fold increase in risk of infection for players who had received abrasions playing on artificial turf [Beiger 2004]. Cosmetic body shaving was an additional risk factor.
While a manufactured product such as synthetic turf may seem sterile compared to natural grass, MRSA is viable on polypropylene fibers for 20 to more than 90 days in a hospital setting [Neely and Maley 2000].
A more direct study by Andrew McNitt examined microbial populations in synthetic turf sand and rubber infill and found prolific bacterial populations living in the fill. Although the sample size was too small to detect the presence or absence of S. aureus, the research demonstrates microbes alive and well on turf. As a result, artificial field turf manufacturers frequently include disinfection in product bids and maintenance contracts.
Artificial Field Turf Versus Natural Grass Fields- Heat Stress Injuries
Artificial turf can reach high surface temperatures in sunny conditions [Williams and Pulley 2002]. During June 2002, the average air temperature was 81.5 degrees Fahrenheit, but the average surface temperature on Brigham Young University synthetic turf fields was more than 117 degrees. The average high on turf was 156-157 degrees Fahrenheit, but researchers measured a turf surface temperature of 200 degrees on a 98-degree day. By comparison, average concrete temperatures were only 94 degrees and natural grass averaged 78 degrees.
Higher turf temperatures not only impact playability, but cause heat stress injuries [Meyers and Barnhill 2004]. Cooling fields with water adds additional installation and maintenance costs. Unfortunately, Williams and Pulley found that a 174-degree field cooled to 85 degrees with sprinklers returned to 120 degrees after only five minutes.
Playing on Artificial Field Turf Sports Surfaces- Precautions Prevent MRSA Infection
While artificial grass sports fields may offer advantages in playability and maintenance, synthetic sports surfaces present a distinct set of injury and health concerns. Sports teams can avoid turf-related MRSA infections by:
Regularly disinfecting turf surfaces
Disinfecting even minor abrasions
Turf burn abrasions present opportunities for entry of infectious organisms like MRSA. Regular disinfection of artificial turf and extra care cleansing seemingly minor scrapes can reduce player risks for MRSA and other severe infections.
Playing on Synthetic Grass Sports Surfaces - Avoiding Heat Stress Injury with Proper Planning
High surface temperatures reduce playability, raise water costs, and increase the risks of potentially fatal heat stress injuries. According to a recent survey of heat injury prevention practices [Luke, et al. 2007], football teams can avoid heat stress injuries by:
Ensuring proper hydration
Allowing equipment modifications
Changing practice schedules
Monitoring turf temperatures
Cooling turf when necessary
Players on synthetic sporting surfaces need to pay particular attention to hydration issues and allow frequent water breaks. Football teams practicing on artificial turf may need to alter equipment requirements by removing pads or helmets on hot days. Changing practice schedules to early morning can ensure player safety in high temperatures. Field managers safeguard players by properly monitoring turf temperatures and cooling fields when necessary.
References:
Begier, EM et al. “A high-morbidity outbreak of methicillin-resistant Staphylococcus aureus among players on a college football team, facilitated by cosmetic body shaving and turf burns.” Clin infect Dis. Nov 15, 2004; 39(10):1446-53. Epub Oct 26 2004.
Luke AC, Bergeron MF, Roberts WO. “Heat injury prevention practices in high school football.” Clin J Sport Med, Nov 2007;17(6):488-93.
McNitt, AS. “A survey of microbial populations in infilled synthetic turf fields.” Epub available at http://cropsoil.psu.edu/mcnitt/microbial/index.cfm.
Meyers MC, Barnhill BS. “Incidence, causes, and severity of high school football injuries on FieldTurf versus natural grass: a 5 year prospective study.” Am J of Sports Medicine. Oct-Nov 2004; 32(7):1626-38.
Neely AN and Maley MP. “Survival of enterococci and staphylococci on hospital fabrics and plastic.” J Clinical Microbiol Feb 2000; 38(2): 724-726.
Williams CF and Pulley GE. “Synthetic Surface Heat Studies.” Brigham Young University, 2002. Epub available at http://cahe.nmsu.edu/programs/turf/documents/brigham-young-study.pdf.
The copyright of the article Artificial Field Turf vs. Natural Grass Safety in Sports Medicine is owned by Carla Marie Boulianne. Permission to republish Artificial Field Turf vs. Natural Grass Safety in print or online must be granted by the author in writing.
While all bio-related infectious disease are, in fact, able to survive in
the crumb rubber infill of synthetic turf fields, any study, or report with
results, would be incomplete if it were not to include the alternative
choices. There are but two methods that will prevent infections, treat the
field once every two weeks with an anti-microbial topical liquid, or use
Organite infill with the original installation. Organite is the only
virtually permanently coated anti-microbial infill. It prevents the
existence of infectious disease, such as MRSA and staph, but only on fields
where it is the only infill, no crumb rubber, no rubber and sand mix.
Details – www.targapro.com
Sep 29, 2008 8:05 AM
Carla Marie Boulianne
:
Although your comment includes a promo, I'll allow it because this opens an
excellent line of discussion. My professional background is actually in
the evolution of infectious diseases.
Microbes are skilled at
evolving resistance to antimicrobials. Why do we have drug-resistant
strains like MRSA? These strains evolve due to the overuse of antibiotics
and antimicrobials. The scary thing from a health safety standpoint is
that once these mechanisms of resistance evolve, they often transfer to
other microbes and combine with other resistance mechanisms, creating
"superbugs."
Unless you can provide peer-reviewed data
with excellent study design showing that none of the microbes commonly
found in fill can evolve resistance to the antimicrobial in Organite, then
there is no way I could recommend such a product. It only adds to the
problem of drug-resistant bacteria.
Is the antimicrobial in
Organite a Triclosan-like compound? If so, there is already research
showing evolution of resistance and transfer to other micro-organisms. In
general, anti-microbials and antibiotics should be used sparingly and for
as short a time as necessary. Anytime you put an antimicrobial in
long-term contact with microbes, you are creating optimal conditions for
resistance evolution. Humankind then loses one more weapon in our arsenal
against infectious disease.
From a purely scientific standpoint,
periodic treatment with a disinfectant is preferable. Short exposures hold
lower risk for evolution of resistance. Resistant bacteria often have a
reproducive fitness disadvantage. With short term exposure, resistant
bacteria still preferentially survive. With periodic application, these
resistant strains just don't reach predominence in the bacterial
population. Resistant strains lose their reproductive advantage when there
is no antimicrobial present and more benign strains dominate. Constant
contact with antimicrobials means that resistant strains will always have
the reproductive advantage.
The goal should not be a sterile
field, it should be a SAFE field.
Sep 29, 2008 3:27 PM
Guest
:
Hold on a minute!
This biased report fails to see the truth. In
fact, McNitt's report points out that natural grass has 259,500 CFU's while
the highest found in turf was 80,000.
McNitt also published a
report that stated "New Penn State Study Debunks Staph Bacteria Scare
In Synthetic Turf"
More details can be found here:
http://aginfo.psu.edu/News/2006/8/Staph.htm
To be blunt, there
HAS NEVER been a link between artificial turf and MRSA.
When it
comes to player injuries, the Barnhill report (which is cited) contains
facts about the REDUCTION of injuries on artificial turf!
Sep 29, 2008 5:06 PM
Carla Marie Boulianne
:
The press release for McNitt's work did state that his research debunked
the MRSA scare. Numerous sources have criticized the referenced report. It
does not reflect his data or that his study design was grossly insufficient
to detect the presence (or absence) of S. aureus. The reality is that
McNitt's work still hasn't passed the muster of a peer-reviewed journal.
You are accurate in stating that natural turf harbors a greater
CFU and diversity of microbes than turf. This article only states that
McNitt's work found microbial populations thriving on synthetic surfaces
and in no way implies that microbes are not also found in natural turf.
One problem with turf is that abrasive characteristics increase
the likelihood that any microbes present will contaminate an injury. The
Meyers and Barnhill study did detect a significantly higher rate of turf
burn injuries. Using antimicrobials to clean turf also raises the specter
that microbes contaminating a wound would have a greater likelihood of
being resistant strains. While the antimicrobials used for disinfection are
generally not medically important, unfortunately many types of resistance
are borne on bacterial plasmids. Selecting for resistance to one
antimicrobial can unintentionally increase the prevalence of resistance to
medically important drugs.
Contrary to your assertion, turf has
been clearly linked to MRSA infections in Beiger's peer-reviewed
research.
As for Meyers and Barnhill's work, it is not as simple
as you state. The rate of injuries was found to be higher on synthetic
turf, but certain severe injuries occurred with less frequency than on
grass. Read my article on artificial turf vs natural grass injuries for
more detail.
I apologize for any appearance of bias. Unlike the
guest selling Organite, I have no vested interest in promoting natural
grass over turf or vice versa. There is genuine interest in the links
between artificial turf, infections, and heat stress injuries. I'm just
reporting the research with as little spin as possible.
My
unbiased research of these topics was recently commissioned by a school
board. Their decision is irrelevant, as turf is the best choice in certain
circumstances while grass is best in others. Rest assured, the board was
sufficiently confident that my final report was unbiased.
Discussing issues of concern and solutions (disinfect turf and wounds;
stay hydrated and cool fields) needn't be construed as an anti-turf
stance.
Sep 29, 2008 5:50 PM
Carla Marie Boulianne
:
Quoted from the abstract for the Meyers and Barnhill research:
"Higher incidences of 0-day time loss injuries, noncontact injuries,
surface/epidermal injuries, muscle-related trauma, and injuries during
higher temperatures were reported on FieldTurf. Higher incidences of 1- to
2-day time loss injuries, 22+ days time loss injuries, head and neural
trauma, and ligament injuries were reported on natural grass."
A close reading of the results shows that in all broad injury
categories except the most severe, injury incidences were higher on
FieldTurf than on natural grass. Multivariate analysis uncovered the
statistically significant differences in specific injury types and time
loss that are quoted above.
The only injury rates pertinent to
this article are surface/epidermal injuries and those related to high
temperatures. In both cases, FieldTurf had higher incidences of injury.
Only the heat-related injury rates are referenced.
The
superior safety of artificial turf as related to head and neural trauma is
outside the scope of the stated topics- turf safety as related to MRSA and
heat stress. The article does not attempt to address turf safety as
related to traumatic sports injuries. Readers will find that information
in a separate article.
For those interested, the Meyers and
Barnhill abstract can be reviewed at
http://ajs.sagepub.com/cgi/content/abstract/32/7/1626.
No MRSA found
in tests at Mt. Lebanon High stadium
Friday, October 19, 2007 By Mary Niederberger, Pittsburgh Post-Gazette
Tests conducted
by the Allegheny County Health Department have shown that there is no staph
bacteria in the turf or the field house facilities at Mt. Lebanon High
School stadium.
Health Department Spokesman Guillermo Cole said
today that all 13 samples taken yesterday came back negative for any type
of staph germs, including those that cause the drug resistant MRSA
infections that have been confirmed in 10 students at Mt. Lebanon High
School, including nine football players.
Mr. Cole said 13
samples were taken in all, with eight coming from the field and five from
the indoor facilities, including the locker rooms, weight room and training
room.
"The fact that all of the results came back as
rapidly as they did is a testament to how clean things are," Mr. Cole
said. "They support what we believed all along -- that the field is an
unlikely source of staph."
Mr. Cole said the test results
should allay the fears that any parents may have had about the turf and
support the department's contention that it is safe for the Mt. Lebanon
varsity football team to host the Bethel Park team tonight on the turf.
"We had given it a clean bill of health even before
this," Mr. Cole said. "We believed all along that the field is an
unlikely source of staph."
The infections diagnosed among
the football players and another student athlete are methicillin-resistant
staphylococcus aureus, or MRSA, infections. They don't respond to the
antibiotics that are prescribed for most other types of infections.
Mt. Lebanon is among 17 school districts in the county reporting
MRSA infections among students this year.
Bethel Park High
School Principal Zeb Jansante this week sent a letter home to football
players, cheerleaders and marching band members explaining that Mt.
Lebanon's field has been cleared for use and recommending that all players
cover any exposed skin since the infections are spread by skin-to-skin
contact.
Dr. Jansante's letter said plans call for the Bethel
Park team to dress for the game in the Bethel Park facilities and to shower
there after the game as well. In addition, he said the Bethel Park district
plans to wipe down and sanitize the buses after the game.
Sep 30, 2008 4:59 AM
Guest
:
Here is the abtract to the Begier report:
BACKGROUND:
Athletics-associated methicillin-resistant Staphylococcus aureus (MRSA)
infections have become a high-profile national problem with substantial
morbidity. METHODS: To investigate an MRSA outbreak involving a college
football team, we conducted a retrospective cohort study of all 100
players. A case was defined as MRSA cellulitis or skin abscess diagnosed
during the period of 6 August (the start of football camp) through 1
October 2003. RESULTS: We identified 10 case patients (2 of whom were
hospitalized). The 6 available wound isolates had indistinguishable
pulsed-field gel electrophoresis patterns (MRSA strain USA300) and carried
the Panton-Valentine leukocidin toxin gene, as determined by polymerase
chain reaction. On univariate analysis, infection was associated (P<.05)
with player position (relative risk [RR], 17.5 and 11.7 for cornerbacks and
wide receivers, respectively), abrasions from artificial grass (i.e.,
"turf burns"; RR, 7.2), and body shaving (RR, 6.1). Cornerbacks
and wide receivers were a subpopulation with frequent direct
person-to-person contact with each other during scrimmage play and drills.
Three of 4 players with infection at a covered site (hip or thigh) had
shaved the affected area, and these infections were also associated with
sharing the whirlpool > or =2 times per week (RR, 12.2; 95% confidence
interval, 1.4-109.2). Whirlpool water was disinfected with dilute
povidone-iodine only and remained unchanged between uses. CONCLUSIONS: MRSA
was likely spread predominantly during practice play, with skin breaks
facilitating infection. Measures to minimize skin breaks among athletes
should be considered, including prevention of turf burns and education
regarding the risks of cosmetic body shaving. MRSA-contaminated pool water
may have contributed to infections at covered sites, but small numbers
limit the strength of this conclusion. Nevertheless, appropriate whirlpool
disinfection methods should be promoted among athletic trainers.
What is it really saying? Limit turf burns. They report does not say that
turf is a breeding ground for staph. OPEN WOUNDS are the problem and they
can happen in any sport, on any playing surface!
Sep 30, 2008 5:12 AM
Guest
:
Another great link to review when discussing turf safety: http://www.bhsfieldofdreams.org/pdf/TurfFieldResearch.pdf
In
this report, Jay H. Williams, Ph.D. of the Department of Human Nutrition,
Foods and Exercise at Virginia Tech compares natural grass to artificial
turf.
The conclusion?
Based on the available
evidence, it appears that the potential and risk for injury is not
increased for athletes playing on 3rd generation artificial turf
fields compared to grass fields. The potential for head or lower limb injury is low and similar between turf and grass fields. Research
indicates that the newer surfaces do not increase injury risk for
football or soccer players. In fact, some studies raise the possibility
that the risk of some types of injury might actually be reduced by
using the new FieldTurf type surfaces. Clearly the new surfaces are
softer, provide more “give” than the older AstroTurf fields and may reduce
the stress placed on the knee and ankle.
Sep 30, 2008 7:36 AM
Carla Marie Boulianne
:
Thank you for the great links. Here are a few observations:
http://www.postgazette.com/pg/07292/826788-100.stm This is not a
peer-reviewed study, but rather the results from 13 samples from a locker
room and field. It appears the health department did this to alleviate
parent fears. Eight samples were taken from the field. It says nothing
about the sample sizes.
Read
http://www.athleticturf.net/athleticturf/article/articleDetail.jsp?id=37240
5&ref=25 for a discussion of the importance of sample size when
trying to disprove the presence of an organism. This was a criticism of
McNitt's study.
"The study attempts to draw conclusions
about which type of bacteria do or do not exist based on a sample of
0.00000000058% of the infill on the field and 2 of 33 billion fibers.
This is hardly representative. In fact, a 1% infill sample would have
required the analysis of 3,628,720 grams (8,000 lbs) of crumb rubber per
field and 330,000,000 fibers per field, not 2.With a sample so
insignificant, to declare that MRSA cannot grow on these fields is an
improbable conclusion. This method would be the equivalent of determining
that no sharks live in the ocean because you looked underwater once and
saw fish… but no sharks."
The current research does show
that third generation turf reduces some of the most severe injuries. The
research also shows compression characteristics changing over time. It
will be interesting to see how these fields perform as they age. Spots on
3rd generation outdoor fields can become just as hard as older foam-based
fields. See my article on turf injuries for sources.
It is
accurate to say that the concern with MRSA is open wounds. Looking for S.
aureus on a field and finding none is a distraction from the true concern.
Beiger found a 7.2-fold increased risk of MRSA infections in players with
abrasions sustained on turf. Players with cosmetic body shaving had a
6.1-fold increase in risk. The point is that abrasions increase risk of
infection. Whether the MRSA inoculates the wound sustained on the field
while in the locker room, gym, or whirlpool does not change the fact that
playing on turf increases risk of infection. The solution is sterilizing
and covering wounds immediately and maintaining precautions until healed,
thus preventing wound contamination and infection.
Sep 30, 2008 7:42 AM
Carla Marie Boulianne
:
It is of interest that the Mt. Lebanon High School samples were taken after
a MRSA outbreak involving 9 football players. It would be very odd to not
find any S. aureus in a locker room, as it is a common microbe living in
most peoples' noses. The fact that no benign strains of S. aureus were
found suggests that these samples were taken post-sterilization following
the outbreak or that sample sizes were insufficient. S. aureus is easy to
find and benign strains should be expected in a public space.
Oct 1, 2008 12:22 PM
Guest
:
You go, girl! Thank you Carla, for the great information and research.
Oct 31, 2008 12:59 AM
Guest
:
I am not a microbiologist. However, I can read. When I review research
from the CDC and other related sites, it is very evident that MRSA and
staph in general can and DO survive for significant amounts of time on
surfaces from towels to polyester to polyurethane (56 days in one source
and over 90 days in another). I have not conducted specific studies of
turf, but I have been told that 3 of 8 samples taken from fields have shown
staph. This does not mean it is always found in turf fields, but it does
show that the situation does allow this to happen. We have to remember if
there is food, moisture, adequate temperature, etc., staph can grow and
survive. Hospitals and medical facilities all preach to society that
staph and MRSA can be prevented with proper hygiene, cleanliness of locker
rooms, no sharing of personal equipment or clothes, proper use of athletic
equipment, proper showering after activity, avoiding use of community
whirlpools with open wounds, etc. Do we really think that by washing hands
we can adequately prevent passing staph from person to person? In no
way am I saying that synthetic turf is causing the problem we are facing
today with staph and MRSA infections. Turf is another source of contact
where germs can be passed, and thus transferred to other persons. The
health care community has a responsibility to use products which are
effective and used properly to disinfect surfaces. Further, there are
products today which can be further utilized to treat surfaces and provide
a dynamic antimicrobial protection for months. This technology has been
expanded to synthetic turf products, and should assist in the minimization
of secondary transfer of microbes.
Sep 28, 2008
