PLAYING ON BOUNCY castles has been linked to the largest ever recorded outbreak of a common superbug in Ireland last year.

A new medical report has revealed that four children were hospitalised after an outbreak of a rare and aggressive strain of methicillin-resistant Staphylococcus aureus – better known as MRSA – swept through a large group who had been playing on bouncy castles.

The study detailed how 48 children and adolescents developed skin and soft tissue infections after a gathering in the east of Ireland, including 15 who sought treatment in hospital.

Doctors claim it is the first time that such a large outbreak of the antibiotic-resistant bacteria has been linked to playing on bouncy castles as the mechanism had “not been described before in the scientific literature.”

While outbreaks of community-acquired MRSA are associated with close physical contact and crowded settings, most previous large outbreaks have been found in sporting activities, prisons and childcare facilities.

The report concluded that the outbreak occurred due to close physical contact among children and adolescents playing on three bouncy castles on a green area in a suburb in the HSE Dublin and Midlands region last autumn.

Conditions on the day were humid, warm and showery, with parents recalling that the children were noticeably wet and engaging in “rough-and-tumble” play on crowded bouncy castles.

All but one of the 48 patients had attended the event, with many spending a substantial amount of time on the bouncy castles, including 19 who estimated they had spent at least four hours on the equipment.

The outbreak was declared over 40 days after the event when two maximum incubation periods had passed without any new case.

The first case was a 12-year-old boy who was diagnosed with MRSA folliculitis – an infection of hair follicles that causes small red pimples filled with pus – and required hospitalisation.

He provided a history of having attended a social gathering nine days earlier.

The report, which is published in Eurosurveillance – a medical journal on infectious diseases – noted an outbreak control team was urgently convened when doctors subsequently became aware of the outbreak after a cluster of 25 other children who had attended the same event sought treatment with unusual skin infections.

The control team involved doctors from various areas of the HSE as well as the National MRSA Reference Laboratory and Children’s Health Ireland at Crumlin.

The event organiser helped doctors to identify families who had attended the gathering, with each family being contacted and provided with a risk assessment to determine if they had developed symptoms of skin infection.

None of the four children who were admitted to hospital experienced severe outcomes or required intensive care, although they had an average stay of 4 days.

Patients were treated with antibiotics, body wash and a nasal ointment, while they were also advised to stay away from crèches and schools until their acute symptoms were fully resolved.

The operator of the bouncy castles was advised that the equipment should not be re-used until it was adequately cleaned and disinfected.

A local primary school where most of the cases attended was also issued with advice on infection prevention and control measures.

The outbreaks comprised 22 confirmed and 26 possible cases involving children aged 5-16 with an average of 12 years.

Almost three-quarters of the affected children were male.

The infections most commonly appeared as spots, redness and blisters.

The most common location for the infection was the legs, particularly the thighs, followed by the abdomen and hips/buttocks.

Twelve patients also reported suffering either fever, nausea or vomiting.

The majority of cases developed symptoms two days after the party, although one only developed them 17 days later.

One of the report’s main authors, Domhnall McGlacken-Byrne, said it was “an unusual and complex community outbreak” with bouncy castle play being “a novel mechanism for an outbreak of this size.”

Dr McGlacken-Byrne, who is with the HSE’s Department of Public Health, said the strain of MRSA in the outbreak had not previously been linked to an outbreak in either a healthcare setting or in the community in Ireland.

He said it was also notable for a high attack rate and relatively short period of incubation.

Dr McGlacken-Byrne said no other exposure appeared as plausible to explain the outbreak as the close contact play on the bouncy castles.

Although it was not possible to determine the exact source of the infection or how it was transmitted, he said it was likely that one or more children had a symptomatic infection which had resulted in onward transmission.

The report advised public health practitioners to be aware of the risk of community-acquired MRSA outbreaks where there might be prolonged, close physical contact such as play activities and contact sport.

It also recommended that the suppliers of inflatable play equipment should be made aware of the risk and the need to ensure items like bouncy castles were decontaminated between use.

It noted that “multidisciplinary governance and collaboration” were essential to investigating and responding to the outbreak.

Dr McGlacken-Byrne said the limited evidence of secondary transmission suggested that prompt recognition of the linked cases, early medical treatment, effective communication and strict infection control measures had successfully controlled the outbreak.