Neighborhood-level Income and the Risk for community-acquired MRSA Infection: Systematic Review and Meta-analysis Restricted; Files Only

Abstract

Background: CA-MRSA emerged as a global public health threat in the 1990s causing life-threatening infections of the respiratory system and skin and soft tissue (SSTI), with heightened pathogenicity and ease of transmission. Sixty percent of SSTIs in the U.S. are CA-MRSA and over 15,000 invasive CA-MRSA infections occur annually in the U.S. Predisposing risk factors for CA-MRSA have been linked to socioeconomic factors, disproportionately affecting disadvantaged groups. The impact of neighborhood-level income on CA-MRSA risk remains poorly understood, despite its potential influence on exposure pathways. There are conflicting findings in the existing literature and no known systematic reviews based in the U.S. investigating neighborhood-level income as a risk factor for CA-MRSA.

Methods: Databases were systematically reviewed for observational studies of neighborhood-level income and CA-MRSA infections. A random-effects model meta-analysis was used to measure the pooled effect measure. Three study design-specific risk of bias assessments were created using the modified Newcastle-Ottawa Quality Assessment Scale (NOS).

Results: Of the six publications that met eligibility criteria, all but one study concluded that neighborhood-level income was associated with a higher risk of CA-MRSA. Two studies were not eligible for inclusion in the meta-analysis because the neighborhood-income exposure variable was continuous and not dichotomous. Among the other four studies, the pooled odds ratio for CA-MRSA infection among low vs high-income neighborhoods (reference group) was 1.28 (95% CI 1.13, 1.46), with statistical heterogeneity (I2 73%). When analyses were limited to low risk of bias studies, there was no significant relationship between low income and CA- MRSA (1.13 95% CI 0.96, 1.33) with heterogeneity of 0%.

Conclusion: Available evidence supports an association between lower neighborhood income and a higher risk of CA-MRSA infections, but there was considerable heterogeneity in the meta-analysis. Future researchers exploring this relationship should carefully consider the method of measuring income, the intersectionality of race/ethnicity and income, and the collinearity of income and other SES factors like education, area deprivation, and access to healthcare. 

Table of Contents

I. Literature Review.................................................................................................1

Introduction.......................................................................................................................1

Epidemiology of CA-MRSA in the U.S. .................................................................................1

Risk Factors for CA-MRSA ..................................................................................................3

Income as a Risk Factor for CA-MRSA .................................................................................4

Published Studies Investigating CA-MRSA and Income .......................................................5

Systematic Reviews Investigating CA-MRSA and Income ....................................................8

II.Introduction....................................................................................................... 10

III. Methods ............................................................................................................ 11

Search strategy................................................................................................................ 11

Eligibility Criteria ............................................................................................................. 12

Screening, Data Extraction, and Synthesis ....................................................................... 12

Risk of Bias (ROB) Assessment ......................................................................................... 13

Data analysis ................................................................................................................... 14

IV. Results .............................................................................................................. 15

Study Characteristics ...................................................................................................... 15

Risk of Bias Outcomes ..................................................................................................... 19

Meta-Analysis Results ..................................................................................................... 19

V. Discussion and Conclusion ............................................................................... 21

VI. Public Health Implications and Recommendations............................................ 27

VII. SupplementaryMaterials...................................................................................28

VIII. References ........................................................................................................ 35 

About this Master's Thesis

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School	Rollins School of Public Health
Department	Epidemiology
Degree	M.P.H.
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Epidemiology Health Sciences, Public Health
Stichwort	CA-MRSA SES Socioeconomic status Staphylococcus aureus Neighborhood-level Income Antimicrobial resistance
Committee Chair / Thesis Advisor	Dr. Maya Nadimpalli , Emory University

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