Health Disparities in Staphylococcus aureus Transmission and Carriage in a Border Region of the United States Based on Cultural Differences in Social Relationships: Protocol for a Survey Study
Authors: Pearson Talima , Barger Steven D , Lininger Monica , Wayment Heidi , Hepp Crystal , Villa Francisco , Tucker-Morgan Kara , Kyman Shari , Cabrera Melissa , Hurtado Kevin , Menard Ashley , Fulbright Kelly , Wood Colin , Mbegbu Mimi , Zambrano Yesenia , Fletcher Annette , Medina-Rodriguez Sarah , Manone Mark , Aguirre Amanda , Milner Trudie , Trotter II Robert T 
Published: July 2019

Background
Health care–associated Staphylococcus aureus infections are declining but remain common. Conversely, rates of community-associated infections have not decreased because of the inadequacy of public health mechanisms to control transmission in a community setting. Our long-term goal is to use risk-based information from empirical socio-cultural-biological evidence of carriage and transmission to inform intervention strategies that reduce S aureus transmission in the community. Broad differences in social interactions because of cultural affiliation, travel, and residency patterns may impact S aureus carriage and transmission, either as risk or as protective factors.

Objective
This study aims to (1) characterize S aureus carriage rates and compare circulating pathogen genotypes with those associated with disease isolated from local clinical specimens across resident groups and across Hispanic and non-Hispanic white ethnic groups and (2) evaluate social network relationships and social determinants of health-based risk factors for their impact on carriage and transmission of S aureus.

Methods
We combine sociocultural survey approaches to population health sampling with S aureus carriage and pathogen genomic analysis to infer transmission patterns. Whole genome sequences of S aureus from community and clinical sampling will be phylogenetically compared to determine if strains that cause disease (clinical samples) are representative of community genotypes. Phylogenetic comparisons of strains collected from participants within social groups can indicate possible transmission within the group. We can therefore combine transmission data with social determinants of health variables (socioeconomic status, health history, etc) and social network variables (both egocentric and relational) to determine the extent to which social relationships are associated with S aureus transmission.

Results
We conducted a first year pilot test and feasibility test of survey and biological data collection and analytic procedures based on the original funded design for this project (#NIH U54MD012388). That design resulted in survey data collection from 336 groups and 1337 individuals. The protocol, described below, is a revision based on data assessment, new findings for statistical power analyses, and refined data monitoring procedures.

Conclusions
This study is designed to evaluate ethnic-specific prevalence of S aureus carriage in a US border community. The study will also examine the extent to which kin and nonkin social relationships are concordant with carriage prevalence in social groups. Genetic analysis of S aureus strains will further distinguish putative transmission pathways across social relationship contexts and inform our understanding of the correspondence of S aureus reservoirs across clinical and community settings. Basic community-engaged nonprobabilistic sampling procedures provide a rigorous framework for completion of this 5-year study of the social and cultural parameters of S aureus carriage and transmission.