title: Evidence for Community Transmission of Community-Associated but Not Health-Care-Associated Methicillin-Resistant Staphylococcus Aureus Strains Linked to Social and Material Deprivation: Spatial Analysis of Cross-sectional Data.
abstract: BACKGROUND
  Identifying and tackling the social determinants of infectious diseases has become a public health priority following the recognition that individuals with lower socioeconomic status are disproportionately affected by infectious diseases. In many parts of the world, epidemiologically and genotypically defined community-associated (CA) methicillin-resistant Staphylococcus aureus (MRSA) strains have emerged to become frequent causes of hospital infection. The aim of this study was to use spatial models with adjustment for area-level hospital attendance to determine the transmission niche of genotypically defined CA- and health-care-associated (HA)-MRSA strains across a diverse region of South East London and to explore a potential link between MRSA carriage and markers of social and material deprivation.
  
  
  RESULTS
  This study involved spatial analysis of cross-sectional data linked with all MRSA isolates identified by three National Health Service (NHS) microbiology laboratories between 1 November 2011 and 29 February 2012. The cohort of hospital-based NHS microbiology diagnostic services serves 867,254 usual residents in the Lambeth, Southwark, and Lewisham boroughs in South East London, United Kingdom (UK). Isolates were classified as HA- or CA-MRSA based on whole genome sequencing. All MRSA cases identified over 4 mo within the three-borough catchment area (n = 471) were mapped to small geographies and linked to area-level aggregated socioeconomic and demographic data. Disease mapping and ecological regression models were used to infer the most likely transmission niches for each MRSA genetic classification and to describe the spatial epidemiology of MRSA in relation to social determinants. Specifically, we aimed to identify demographic and socioeconomic population traits that explain cross-area extra variation in HA- and CA-MRSA relative risks following adjustment for hospital attendance data. We explored the potential for associations with the English Indices of Deprivation 2010 (including the Index of Multiple Deprivation and several deprivation domains and subdomains) and the 2011 England and Wales census demographic and socioeconomic indicators (including numbers of households by deprivation dimension) and indicators of population health. Both CA-and HA-MRSA were associated with household deprivation (CA-MRSA relative risk [RR]: 1.72 [1.03-2.94]; HA-MRSA RR: 1.57 [1.06-2.33]), which was correlated with hospital attendance (Pearson correlation coefficient [PCC] = 0.76). HA-MRSA was also associated with poor health (RR: 1.10 [1.01-1.19]) and residence in communal care homes (RR: 1.24 [1.12-1.37]), whereas CA-MRSA was linked with household overcrowding (RR: 1.58 [1.04-2.41]) and wider barriers, which represent a combined score for household overcrowding, low income, and homelessness (RR: 1.76 [1.16-2.70]). CA-MRSA was also associated with recent immigration to the UK (RR: 1.77 [1.19-2.66]). For the area-level variation in RR for CA-MRSA, 28.67% was attributable to the spatial arrangement of target geographies, compared with only 0.09% for HA-MRSA. An advantage to our study is that it provided a representative sample of usual residents receiving care in the catchment areas. A limitation is that relationships apparent in aggregated data analyses cannot be assumed to operate at the individual level.
  
  
  CONCLUSIONS
  There was no evidence of community transmission of HA-MRSA strains, implying that HA-MRSA cases identified in the community originate from the hospital reservoir and are maintained by frequent attendance at health care facilities. In contrast, there was a high risk of CA-MRSA in deprived areas linked with overcrowding, homelessness, low income, and recent immigration to the UK, which was not explainable by health care exposure. Furthermore, areas adjacent to these deprived areas were themselves at greater risk of CA-MRSA, indicating community transmission of CA-MRSA. This ongoing community transmission could lead to CA-MRSA becoming the dominant strain types carried by patients admitted to hospital, particularly if successful hospital-based MRSA infection control programmes are maintained. These results suggest that community infection control programmes targeting transmission of CA-MRSA will be required to control MRSA in both the community and hospital. These epidemiological changes will also have implications for effectiveness of risk-factor-based hospital admission MRSA screening programmes.
authors.affiliation: Centre for Clinical Infection and Diagnostics Research, Department of Infectious Diseases, King's College London and Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom.|Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom.
authors.forename: Olga
authors.initials: O
authors.lastname: Tosas Auguet
authors.affiliation: Illumina, Cambridge Limited, Chesterford Research Park, Little Chesterford, Essex, United Kingdom.
authors.forename: Jason R
authors.initials: JR
authors.lastname: Betley
authors.affiliation: Department of Pathogen Molecular Biology, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom.
authors.forename: Richard A
authors.initials: RA
authors.lastname: Stabler
authors.affiliation: Centre for Clinical Infection and Diagnostics Research, Department of Infectious Diseases, King's College London and Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom.
authors.forename: Amita
authors.initials: A
authors.lastname: Patel
authors.affiliation: Illumina, Cambridge Limited, Chesterford Research Park, Little Chesterford, Essex, United Kingdom.
authors.forename: Avgousta
authors.initials: A
authors.lastname: Ioannou
authors.affiliation: Centre for Clinical Infection and Diagnostics Research, Department of Infectious Diseases, King's College London and Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom.
authors.forename: Helene
authors.initials: H
authors.lastname: Marbach
authors.affiliation: Centre for Clinical Infection and Diagnostics Research, Department of Infectious Diseases, King's College London and Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom.
authors.forename: Pasco
authors.initials: P
authors.lastname: Hearn
authors.affiliation: Centre for Clinical Infection and Diagnostics Research, Department of Infectious Diseases, King's College London and Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom.
authors.forename: Anna
authors.initials: A
authors.lastname: Aryee
authors.affiliation: Centre for Clinical Infection and Diagnostics Research, Department of Infectious Diseases, King's College London and Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom.
authors.forename: Simon D
authors.initials: SD
authors.lastname: Goldenberg
authors.affiliation: Centre for Clinical Infection and Diagnostics Research, Department of Infectious Diseases, King's College London and Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom.
authors.forename: Jonathan A
authors.initials: JA
authors.lastname: Otter
authors.affiliation: Department of Medical Microbiology, King's Hospital NHS Foundation Trust, London, United Kingdom.
authors.forename: Nergish
authors.initials: N
authors.lastname: Desai
authors.affiliation: Department of Microbiology, University Hospital Lewisham, Lewisham and Greenwich NHS Trust, London, United Kingdom.
authors.forename: Tacim
authors.initials: T
authors.lastname: Karadag
authors.affiliation: Department of Social and Environmental Health Research, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom.
authors.forename: Chris
authors.initials: C
authors.lastname: Grundy
authors.affiliation: Department of Pathogen Molecular Biology, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom.
authors.forename: Michael W
authors.initials: MW
authors.lastname: Gaunt
authors.affiliation: Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom.|Mahidol Oxford Tropical Medicine Research Unit (MORU), Bangkok, Thailand.
authors.forename: Ben S
authors.initials: BS
authors.lastname: Cooper
authors.affiliation: Centre for Clinical Infection and Diagnostics Research, Department of Infectious Diseases, King's College London and Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom.
authors.forename: Jonathan D
authors.initials: JD
authors.lastname: Edgeworth
authors.affiliation: School of Mathematical Sciences, University Park, University of Nottingham, Nottingham, United Kingdom.
authors.forename: Theodore
authors.initials: T
authors.lastname: Kypraios
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D002648:Child; D002675:Child, Preschool; D017714:Community-Acquired Infections / Q000175:diagnosis / Q000453:epidemiology* / Q000523:psychology; D003428:Cross Infection; D003430:Cross-Sectional Studies; D003627:Data Interpretation, Statistical; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008131:London / Q000453:epidemiology; D008297:Male; D008426:Maternal Deprivation; D055624:Methicillin-Resistant Staphylococcus aureus / Q000302:isolation & purification; D008875:Middle Aged; D012934:Social Isolation / Q000523:psychology; D013203:Staphylococcal Infections / Q000175:diagnosis / Q000453:epidemiology* / Q000523:psychology; D055815:Young Adult
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