Routine testing of MRSA?
About 20 % of otherwise healthy individuals are long-term carriers of Staphylococcus aureus in the nose. The bacteria can cause infections if they get the chance to penetrate skin or mucosa (11,12). Serious infections occur in persons who have another main disease, a weakened defense against infections or both (1,13). Patients in health institutions are especially vulnerable. The results in this study indicate that children adopted from abroad have an increased risk of being MRSA carriers, but that general testing at arrival will only give a few positive results annually. According to data from MSIS no serious infections have been detected in those adopted from abroad. On the other hand there are rare examples of complications after MRSA infections in this group of children. (14). One argument to start general MRSA testing of adopted children upon arrival to the country is that it enables treatment of infections and carrier states. This may spare the child for later MRSA infections and prevent spread of infection to close contacts and to vulnerable patients within the health services. One important argument against routine testing of MRSA upon arrival to the country is the danger of stigmatisation. To be a carrier of MRSA is not dangerous for otherwise healthy children or for close contacts who are healthy. MRSA may in some cases be difficult to eradicate. To be found MRSA positive upon arrival may render the parents unnecessarily anxious, especially if there is not an indication for eradication of the carrier state or in cases where the eradication is not successful. It is mainly upon admission to health institutions that one should take precautions against transmission of MRSA. Children and adults with MRSA who live at home should live their lives in a normal way, without restriction regarding their participation in day-care centres, school, working life (outside the health services) and leisure activities. Children who come from other countries, look different, speak another language and have unfamiliar habits meet many challenges in relation to integration in the Norwegian society. Fear of infection may prevent the integration process and lead to stigmatisation of children adopted from abroad.
Even if no serious MRSA infections have been reported in children adopted from abroad, and MRSA carriers do not pose a threat to otherwise healthy children, the risk for spreading the bacteria to those especially prone to infection is a challenge that should be taken seriously. The Norwegian Institute of Public Health do give advice about MRSA testing of groups who require hospitalisation and are suspected to be MRSA positive (7). Children adopted from abroad have not yet been regarded as a group at special risk of acquiring MRSA.
The results from our study indicate that children who have recently been adopted from abroad should be regarded in the same way as others with an increased risk of MRSA carriership for whom MRSA is currently tested upon admission to a health institution. The study does not provide evidence on whether the incidence of MRSA in the group studied is high enough to justify the economical aspects of routine testing.
If the incidence rate remains on the 2005 level or increases, this will strengthen the argument for testing upon admission to hospital. This presumes that the incidence rate reflects a real prevalence in this group.
Even if the hospitals should start to test children adopted from abroad, these only make up 20 % of those in our material who are below three years of age and have MRSA. 80 % of those below three years, reported to have MRSA to MSIS in the period 1995 - 2005, would therefore not be discovered through a routine test of all adopted children. The Scandinavian Society for Antimicrobial Chemotherapy (SSAC), Nordic Working Party on MRSA, issued a report in 2004 where they strongly recommended coordination of the Nordic countries’ measures against MRSA (15). Adoption of routines in Norway similar to those in Denmark and the Netherlands (all children adopted from abroad are tested for MRSA upon admission to hospital) would contribute to a more similar screening practice in the low endemic countries.
Many carriers will get rid of MRSA after a certain time without undergoing eradication. If testing of adopted children before admission to institution(s) becomes a routine, this should only be required during a certain time after arrival to the country, for example for children who have been adopted from abroad during the last 12 months.