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Running head: PREVENING TOXIC SHOCK SYNDROM Preventing Toxic Shock Syndrome in School Age and Adolescent Girls Devyn Gravley Lamar University 1 PREVENING TOXIC SHOCK SYNDROM 2 Preventing Toxic Shock Syndrome in School Age and Adolescent Girls Puberty is a time of numerous changes in a child’s body. For females, this includes beginning menstruation and, as a result, the use of feminine hygiene products. Often, a brief presentation is given to fifth or sixth grade students by teachers to explain puberty (M. Guidry, personal communication, March 7, 2016). Many parents rely solely on the school system to educate their children on the eminent changes which will occur in their bodies during puberty. Because the teachers educating the students about puberty are not sex education teachers, children may not receive important information, which can potentially be detrimental to their health. A school nurse, M. Guidry, identifies the need for education on toxic shock syndrome resulting from the use of tampons (personal communication, March 7, 2016). Lack of knowledge about toxic shock syndrome and tampon use contribute to preteen girls risk of developing the condition. Pathophysiology Toxic Shock Syndrome is a systemic infection, primarily caused by Staphylococcus aureus and group A streptococcus bacteria (Mayo Clinic, 2016, p. 1). The bacteria “can induce massive activation of T cells” causing an inflammatory cascade within the body, “which mediate shock” (Li, Pian, Hao, Zheng, Zang, H. Jiang and Y.Q. Jiang, 2016, p. 527). The systemic symptoms include pain, hypotension, vomiting, diarrhea, red rash, desquamation on the palms of hands and soles of the feet, confusion, muscle aches, headaches, and seizures (Mayo Clinic, 2016, p. 2). Localized symptoms include redness and edema at the primary site of infection. Toxic shock syndrome requires urgent medical treatment as systemic “shock is apparent at the time of hospitalization or within 4-8 hours for all patients” (Venataraman, Sharma, 2015, p. 5). Hypotension occurs as a result of systemic shock and is often not responsive to intravenous PREVENING TOXIC SHOCK SYNDROM 3 fluids. Over half of patients experiencing toxic shock syndrome must be mechanically ventilated to combat respiratory distress (Venataraman, Sharma, 2015, p. 5). Females are at the greatest risk for developing toxic shock syndrome. The use of “highly absorbent tampons, using tampons for more days of their cycle, and keeping a single tampon in place for a longer period of time” drastically increases females’ risk (Venataraman, Sharma, 2015, p. 1). Those diagnosed with chronic diseases, particularly HIV, diabetes mellitus, and cancer, use nonsteroidal antiinflammatory medications, and “a recent history of varicella infection” are also at increased risk for developing toxic shock syndrome (Venataraman, Sharma, 2015, p. 5). As toxic shock syndrome is a life-threatening condition, complex interventions must be implemented to treat the patient. Antibiotics to treat the underlying infection and hypotensive medications and fluids are given as well as medications to combat individual symptoms. “The toxins produced by the staph or strep bacteria and accompanying hypotension may result in kidney failure” (Mayo Clinic, 2016, p. 8). If kidney failure occurs, dialysis is necessary. Patients may undergo surgery to remove necrotic tissue and drain the infection. By knowing how toxic shock syndrome occurs, who is at risk and what the signs and symptoms are, prevention and early detection can decrease the incidences of fatal toxic shock syndrome. What Is Being Done Healthy People 2020 set the goal to “increase the proportion of schools that require newly hired staff who teach required health instruction to be certified, licensed, or endorsed by the State in health education” (2014, p. 2). This goal can be extended to encompass the “puberty talk” students receive in school, not included in a health education class. By requiring teachers to be educated by the State, a more in depth explanation of puberty can be explained, as well as risks that accompany puberty such as toxic shock syndrome related to tampon usage. PREVENING TOXIC SHOCK SYNDROM 4 The U.S. Food and Drug Administration (FDA) has had a significant role in decreasing the risk of menstruating women developing toxic shock syndrome by regulating tampon products and setting guidelines for safe usage. “Manufacturers pulled certain types of tampons off the market,” including super absorbent tampons and tampons made out of particular materials as a result of pressure from the FDA (Mayo Clinic, 2016, p. 1). In addition, information pamphlets or sections on the box are required to be included with tampon packages warning of toxic shock syndrome associated with tampon usage. The FDA also developed guidelines to reduce menstruating females’ risk for developing toxic shock syndrome. These guidelines include using the lowest absorbance possible to control flow, change tampons at least every eight hours, do not use tampons overnight, read the pamphlet included in tampon packages, store tampons in a sanitary and dry environment, wash hands before and after inserting or removing a tampon, and be knowledgeable of symptoms of toxic shock syndrome (Brown, 2013, para 21). Because approximately half of those diagnosed with toxic shock syndrome are associated with tampon use, easily accessible information included with a purchase of the product is a convenient resource in preventing toxic shock syndrome. As technology progresses, children and adolescents utilize the internet as an informational source. A variety of web pages have been designed particularly for girls and female adolescents educate them on the use of tampons and toxic shock syndrome. Kidshealth.org has a section devoted to adolescence titled Teens Health, which compiles information related to safe tampon usage and toxic shock syndrome in an easy to navigate web page. The web page includes the FDA tips for preventing toxic shock syndrome in a manner that is geared towards adolescents, the cause of toxic shock syndrome, and its signs and symptoms. PREVENING TOXIC SHOCK SYNDROM 5 By marketing the information specifically to adolescences, the information provided is appropriate for their educational level and specific to the adolescent’s needs. What needs to be done There is a significant knowledge deficit in reference to toxic shock syndrome, particularly in school and adolescent girls. Even among those informed of the correlation between tampon use and toxic shock syndrome, most have not been educated on the signs and symptoms of the condition. Knowing the signs and symptoms is critical to the early diagnosis and treatment. The formal education provided in schools often does not educate girls on toxic shock syndrome. A revision of materials and specially certified teachers will promote a more in depth education in female health. Most information on toxic shock syndrome emphasizes the rarity of developing the condition. Although this is true, young females are at the highest risk for contracting toxic shock syndrome. The emphasis on rarity can give young females a false sense of security causing them to develop a not-me mentality. This decreases the likelihood of implementing simple, yet effective preventative interventions in developing toxic shock syndrome. Although informational resources are available, many young females are not aware of these resources. Simply typing in “toxic shock syndrome” into a search engine brings up countless web pages, however the majority of these resources are above a middle school education level. Valuable information aimed at decreasing the risk of the condition can easily be over looked because it is presented at a more advanced level than the young girls are able to comprehend. The school nurse can be a valuable resource to school age girls. School nurses posses the knowledge and resources to aid young females in preventing the development of toxic shock syndrome. PREVENING TOXIC SHOCK SYNDROM 6 Conclusion Toxic shock syndrome, a medical emergency, presents with characteristic signs and symptoms. Those most at risk, such as young females, should be educated on these issues. Although federal programs and independent organizations have released information on the signs and symptoms as well as intervention to prevent the development of toxic shock syndrome, a gap exists between producers and consumers of the information. The school nurse can aid in closing this gap by providing students with the information. PREVENING TOXIC SHOCK SYNDROM 7 References Healthy People 2020. (2014). Early and Middle Childhood. Retrieved from https://www.healthypeople.gov/2020/ topics-objectives/topic/early-and-middlechildhood/objectives L. Li, Y.Y. Pian, H.J. Hao, Y.L. Zheng, Y.T. Zang, H. Jiang and Y.Q. Jiang (2016). "Findings from Institute of Microbiology in Toxic Shock Syndrome Reported. Obesity, Fitness & Wellness Week 30 Apr. 2016, 527. Retrieved from http://go.galegroup.com.libproxy. lamar.edu Mayo Clinic. (2016). Toxic Shock Syndrom. Retrieved from http://www.mayoclinic.org/diseasesconditions/toxic-shock-syndrome/basics/definition/con-20021326 Nemorus. (2016). Toxic Shock Syndrome. Teen Health. Retrieved from http://kidshealth.org/en/teens/tss.html# Venkataraman, R., & Sharma, S., (2015) Toxic Shock Syndrome. Medscape. Retrieved from http://emedicine.medscape.com/article/169177-overview#a6 Winters, L., (2013). Female Health Topics. Sutter Health: Palo Alto Medical Foundation. Retrieved from http://www.pamf.org/teen/health/femalehealth/periods/tampons.html PREVENING TOXIC SHOCK SYNDROM 8 U.S. Food and Drug Administration (FDA) recommends the following to lower your risk of TSS: Use the tampon with the lowest absorbency you need, e.g. don't use a bigger or more absorbent tampon for a small blood flow. Change your tampon at least every four to eight hours. Avoid using tampons overnight when sleeping. Follow the manufacturer's instructions. Store tampons in a clean, dry place. Wash hands with soap and water before and after inserting or removing a tampon. Try a less absorbent variety if a tampon is irritating or difficult to remove. Stay informed of TSS by reading the package information included in the tampon box and asking about TSS when you have a medical checkup. Stay aware of TSS symptoms because early diagnosis and speedy treatment are crucial in avoiding the most serious effects of TSS. Brown, N., (2013). Female Health Topics. Sutter Health: Palo Alto Medical Foundation. Retrieved from http://www.pamf.org/teen/health/femalehealth/periods/tampons.html A few specific tampon designs and high absorbency tampon materials were also found to have some association with increased risk of TSS. These products and materials are no longer used in tampons sold in the U.S. Tampons made with rayon do not appear to have a higher risk of TSS than cotton tampons of similar absorbency. (Food and Drug Administration, 2015, para 11) Food and Drug Administration. (2015). Tampons and Asbestos, Dioxin, & Toxic Shock Syndrome. U.S. Food and Drug Administration. Retrieved from http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/PatientAlerts/ucm070003.h tm PREVENING TOXIC SHOCK SYNDROM 9