mrsa epidemiology paper

Emelie Bahamonde and Marybel Zabel

July 18, 2011

PHC 6000: Managerial Epidemiology

Methicillin-Resistant Staphylococcus Aureus

We did not plagiarized on any aspect of this assignment.

Emelie BahamondeMarybel ZabelEpidemiology

PHC 6000Methicillin-Resistant Staphylococcus Aureus (MRSA)

Introduction

Methicillin-Resistant Staphylococcus Aureus, more commonly known as MRSA, is an

infectious disease that emerged due to the over and misuse of the antibiotic known as

“Methicillin”, MRSA is “commonly found on the skin of healthy individuals, but has the

potential to cause serious disease - About 20% of the population are long-term carriers; over

60% may carry S. aureus intermittently - Colonization is more common in people with greater

exposure to microbial agents and compromised immune systems - Colonized people are more

likely to develop infection” (Lesko, 2011).

MRSA Trends

MRSA developed after the introduction of the antibiotic known as “Methicillin”, in

England in 1959. In 1960, the first case of MRSA was detected in Great Britain, and then by

1967 it had spread to Western Europe and Australia through travelers (University of Chicago,

2011).

In 1968, the first outbreak of MRSA hit the United States, at the Boston City Hospital,

Massachusetts. From this point on MRSA spread gradually across the globe affecting hospitals,

prisons, schools, athletic faculties, and through communities, not only in the United State, but

through the globe. In 1982, the first MRSA case through intravenous drug users was reported in

Detroit, Michigan. After the introduction of policies in congress forcing hospitals to take control

of the epidemic, the Hospital-Acquired MRSA (HA-MRSA), began to stabilize; while the

number of Community-Acquired MRSA infections (CA-MRSA) began to increase at

astronomical rates. Data collected by the University of Chicago showed that by the Mid-1990’s

only “scattered reports of CA-MRSA infections in children in the United States” were present,

but after “comparing 2 periods—1993-1995 and 1995-1997—among children with no risk

factors for health care exposure, there was a 25-fold increase in the rate of hospitalizations due to

MRSA” (University of Chicago, 2010); including in 1999 when the first reports of “ healthy,

young children dying from severe MRSA infections” emerged (University of Chicago, 2010).

Surprisingly, until 2008, reporting of MRSA incidents had not been mandatory in most

the United States. Nevertheless, in 2008, many states, including the State of Florida, began

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PHC 6000requiring “labs participating in electronic reporting to submit all positive S. Aureus culture

results” (Lesko, 2011). Unfortunately, until this day reporting is only mandatory by commercial

labs, but not for hospitals or physicians (Lesko, 2011).

In 2009, CA-MRSA started causing “commonly cause infections in health care settings”

(University of Chicago, 2010). “CA-MRSA infections became more common in most U.S. cities,

while CA-MRSA infection and asymptomatic colonization remained less common outside the

U.S” (University of Chicago, 2010).

Since the Florida Department of Health (FLDOH) began requiring the reporting of

positive MRSA cases, the date collected revealed the number of hospitalization in Florida with

MRSA: “50,996 isolates in 2006, 53,131 in 2007, 61,083 in 2008, 63,427 in 2009, and 60,947 in

2010” (Lesko, 2011).

The data showed that the age groups most affected during the 2010 were from

individual’s age 25 to 64 years (44.0%). The age group with the highest proportion of S. aureus

isolates that were MRSA was the 1 to 4 year olds (62.9%). The age groups with the lowest

proportion of S. aureus isolates that were MRSA were the 5 to 14 year olds (45.7%) and the 15

to 24 year olds (47.9%). In all other age groups, the proportion of isolates that were MRSA was

close to 50%. “The proportion of S. Aureus isolates resistant to various antibiotics did not differ

substantially by age group, with a few exceptions” (Lesko, 2011).

In 2007, the county’s most affected by MRSA cases were located in the West and Central

part of Florida, with some high numbers in the counties such as Palm Beach County, Monroe

County, Martin County, and among others; however, Orange county had among the lowest cases

(see Figure 1). By 2010, the data showed that MRSA incidents where highest among Central

Florida counties all the way to West Florida counties; Orange county numbers were among the

highest - 50-60% (Lesko, 2011). (see Figure 2)

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PHC 6000In 2010, the Northern part of the state had the highest proportion of S. aureus isolates that

were MRSA (61.1% in the North Central Region, followed by 56.8% in the North West Region

and 56.0% in the North East Region), while the lowest proportion of isolates that were MRSA

was seen in the South East Region (44.9%). Additionally, the data showed that between West

and East Central Florida the total number of MRSA infections in 2010 was equal to 21,922.

Orange County represented 12.93 percent (2,835) of those infected in East/West Central Florida

(Lesko, 2011).

MRSA Risk FactorsOne out ten individuals carries MRSA, but the bacterium poses no harm unless it gets

inside the body of an individual (Sheen, 2010). MRSA is highly contagious and can be

transmitted quickly when individuals who have open wounds come in direct contact with

contaminated surfaces or skin-to-skin contact with individuals who are colonized or infected

with MRSA. An individual that is exposed to MRSA, but presents no signs or symptoms of

infection, is categorized as colonized; while an infected individual has all the clinical signs and

symptoms such as: fever, wound drainage, and lesions, such as carbuncles (Petersen, 2009).

There are two types of MRSA infections, with their own set of risk factors: CA-MRSA and HA-

MRSA.

HA-MRSA was first identified in persons in the 1960s and it is acquired in healthcare

settings including long-term care (LTC) facilities. Patients, LTC residents, and healthcare

workers who are at greater risk for acquiring HA-MRSA are show in Table 1 with their specific

risk factors. (see Table 1)

The

most

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PHC 6000common risk factor in patients and LTC residents is having an open wound that is exposed to

MRSA. The patients and LTC residents listed in Table 1 have weaker immune systems, which

therefore increase their likelihood of acquiring a MRSA infection if exposed. Environmental

conditions within healthcare facilities also play great role in the transmission of MRSA.

Healthcare workers who are colonized by MRSA can contribute to the problem if they do not

take precautionary measures.

In a case study by Albrich and Harbarth, MRSA endemic healthcare facilities had high

incidences of being understaffed and overworked, which resulted in low compliance rates for

hand washing protocols and contact precautions guidelines (Albrich & Harbarth, 2008). In a

guideline published by the Society for Healthcare Epidemiology of America (SHEA), it was

shown that equipment, which was touched only by clinicians, was found to be contaminated with

MRSA; consequently, further studies showed that the hands of clinicians were contaminating

hard and soft surfaces within the hospital (Muto et al., 2003). The SHEA guideline also

discussed how the clothes of healthcare workers had been contaminated with MRSA 65% of the

time after “performing routine ‘morning care’ for patients with MRSA in a wound or urine”

(Muto et al., 2003, pp. 366-367).

In LTC facilities, residents live close to each other and share communal spaces such as

the living room, bedrooms, and dining room. A MRSA carrier can contaminate objects that may

harbor MRSA for up to thirty-eight weeks (Sheen, 2010). The equipment that is used for medical

care is also shared within the LTC facilities. This equipment “may serve as a vehicle for

transferring infectious organisms” (Petersen, 2009).

Unlike HA-MRSA, CA-MRSA affects healthy individuals and it is a lot more virulent.

CA-MRSA infections occur outside of healthcare facilities and have different genetic strains.

Individuals who are at greater risk of getting a CA-MRSA infection are individuals who live in

close quarters where such as military personnel, prisoners, residents of college dormitories,

children attending day-care, and residents of homeless shelters (Sheen, 2010). Athletes also have

a greater risk factor for acquiring a CA-MRSA infection due to (a) close contact activities that

have a higher percentage of obtaining an open wound, such wrestling; (b) sharing of

contaminated items, such as towels, razors, gym equipment; and (c) unsanitary conditions or low

personal hygiene (CDC, 2011). These are the known as the 5 C’s: “Crowding, Contact (frequent

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PHC 6000skin-to-skin), Compromised skin (cuts/scrapes), Contaminated items and surfaces, and Lack of

Cleanliness” (CDC, 2011).

Environmental conditions that aid in the transmission of the bacterium is a “common”

risk factors of both types of MRSA. With this knowledge, healthcare organizations (HCO) and

the community can identify preventative strategies that will reduce the transmission and

infections rates of MRSA.

Preventive Strategies or Efforts

The study of the effectiveness of preventive strategies worldwide and in the United States

has been limited due to the lack of consistent data. Many studies on MRSA have had conflicting

results, such as effectiveness and efficiency of implementing a complete screening process

during admissions, some experts believe that it should only be implemented in high risk areas,

others believe that it should be implemented when cases occur in the environment (a reactive

approach), others believe the expense is to large in comparison to the benefits (cost-benefit

analysis), while a great majority believe it should be implemented everywhere, because it saves

lives and unnecessary expense in the long-run. However, many studies and journals have

published that “a program of universal surveillance, contact precautions, hand hygiene, and

institutional culture change was associated with a decrease in health care–associated

transmissions of and infections with MRSA” (Barclay, April 2011). MRSA preventive strategies

have evolved since its first appearance across the globe. Many believed that it was an Emergency

Care issue, but since data began emerging, it became clear that preventive measures had to be

taken across the entire healthcare organization, and now within our communities.

Globally, the World Health Organization has been a great influence on the preventive

strategies that many countries worldwide have been implementing in the control of MRSA.

Some of these strategies are: 1) improving antibiotic use in hospitals, by decreasing diagnostic

uncertainty; 2) heightening awareness of the vital role of hospitals in the control of MRSA, by

“Centralization of available laboratory resources in a few selected centers;” (source) 3)

monitoring and reporting of AB susceptibility data (WHOnet); 4) adapting empiric treatment

regimens; 5) reducing hospital stays to the minimum, but without sacrificing quality of care; 6)

improving peri-operative antibiotic prophylaxis (ABP); 7) “Improve antimicrobial prescribing,

through: a) education (pre- and postgraduate), b) practice guidelines, administrative means

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PHC 6000(antibiotic order forms), and c) Feedback to prescribers” (Harbarth, 2010); 8) improving Out-

Patient Use of antibiotic use; 9) promote local guidelines; and 10) improve marketing strategies

to educate public and change consumer expectations (Harbarth, 2010). By 1999, Chile began to

improve on WHO guidelines by “educate physicians & the public, regulating the consumption of

antibiotics, and restrict over-the-counter antibiotic sales” (Harbarth, 2010). In addition, by 2000,

the Korean government implemented a new policy that “prohibited doctors from dispensing and

pharmacists from prescribing drugs by law” (Harbarth, 2010). Figure 4 below provides further

detail of the global compliance of WHO preventive strategies. (see Figure 4)

In the United States, three organizations have led the development of guidelines for

quality control of MRSA outbreaks in the United States. These are a) CDC’s Healthcare

Infection Control Practices Advisory Committee (HICPAC), b) the Society of Healthcare

Epidemiology of America (SHEA), and c) the Association for Professionals in Infection Control

and Epidemiology (APIC). HICPAC and SHEA have many similar guidelines, but differ in that

HICPAC guidelines utilize a two-tier approach. The first tier “includes general recommendations

for all healthcare settings, regardless of the prevalence of MultiDrug-Resistance Organisms

(MDRO) while the second tier includes recommendations for intensified interventions to prevent

MDRO transmission when prevalence is not decreasing despite routine control measures or when

the first case or outbreak of an MDRO is identified in a facility” (Eisenstein & Sanderson, 2008).

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PHC 6000“APIC’s guide builds upon these documents and provides more detail on how to implement the

strategies outlined in the HICPAC and SHEA guidelines” (Eisenstein & Sanderson, 2008).

These guidelines focus on preventive strategies or efforts through: a) surveillance; b)

hand-hygiene; c) personal protective equipment (PPE) for healthcare personnel; d) gloves; e)

isolation Gowns; f) face protection: masks, goggles, face shields; g) respiratory protection; h)

safe work practices to prevent HCW exposure to bloodborne pathogens; i) prevention of

needlesticks and other sharps-related injuries; j) prevention of mucous membrane contact; k)

precautions during aerosol-generating procedures; l) patient placement; m) chemoprophylaxis; n)

patient-care equipment and instruments/devices; o) care of the environment, and p) among others

(Siegel, Rhinehart, Jackson, Chiarello, 2006).

In the State of Florida, many hospitals have developed and implemented policies and

procedure, in addition to these guidelines in order to reduce the transmission of MRSA, such as

educating staff; however, there is “no systematic information available on what types of

initiatives have been implemented in Florida” (Eisenstein and Sanderson, October 2008). A

survey was conducted between 2007 and 2008, by the Florida Hospital Association, which

concluded that from all the data collected from the responding facilities, 50.8% were in

compliance with HICPAC tier two recommendations and about 53% for SHEA

recommendations, and 63.4% for HICPAC tier one recommendations” (Eisenstein and

Sanderson, October 2008).The recommendation with the most compliance for the State of

Florida was staff education, at 100%. The survey also revealed that the facilities with the most

compliance were those of mid-size (200-299 beds), and those with the least were the “smallest

facilities (<100 beds), and the largest facilities (400+), which were only slightly more compliant

than the smallest facilities” (Eisenstein and Sanderson, October 2008). The survey also revealed

that preventive measures are not being implemented effectively in the smaller facilities, perhaps

due to budget constraints, and in the larger facilities, perhaps due to lack of coordination and

consistency between the systems.

From a CA-MRSA perspective, there is a lack of preventative strategies, especially from

facilities that are at high-risk. There are no mandatory reporting that would allow health agency

or the public to be informed of MRSA incidents in their community. This could be a contributing

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PHC 6000factor to why in 2007 out of the 48,043 cases of hospitalization with positive MRSA in Florida,

34,674 (72%) where diagnosed positive at the emergency room (AHCA, July 2009).

In Central Florida and including Orange County, the preventive guidelines for HA-

MRSA has improved the reduction of MRSA –incidents within the hospital setting, through the

use of HICPAC, SHEA and APIC guidelines; however, the number of CA-Incidents remain on

the rise due to lack of preventive strategies being implemented at a State, Region and County

level. Ms. Catherine Lesko stated in her report that in order to reduce the number of CA-MRSA

incidents three main preventive strategies should be executed: “Primary Prevention Strategy:

Self-enhanced surveillance, Self education on the importance of frequent hand washing and good

hygiene, Prohibit sharing of any personal hygiene items reporting of skin lesions). Secondary

Prevention Strategy: Education of cases on how to contain their infection, Interview cases on

potential sources of infection, including recent hospitalizations, sharing of personal hygiene

items, injection drug use, unauthorized tattooing, participation in contact sports, and exposure to

other people with draining wounds or skin infections. Physician Preventive Contribution

Strategy: Treatment decisions should be made by physicians, and should be customized to

patients needs, taking into consideration all empirical data. We also recommend FDOH requiring

physicians to report any cases of MRSA incidents” (Lesko, 2011).

Additional to this, Florida HCOs are now participating in ongoing survey of MRSA

preventive strategies in collaboration with Florida Hospital Association. The survey analyzes

active surveillance cultures, contact precautions, education, antibiotic utilization, incidence

surveillance, adherence to hygiene protocols, plans, and potential barriers (Eisenstein &

Sanderson, 2006).

Lastly, locally, the Seminole County MRSA Project is working with local HCOs,

Seminole county schools, patients, and the community to address issues relating to MRSA. They

educate on the importance of preventative measures and education geared towards health clubs,

schools, clinics, nursing homes, and local hospitals. This ongoing project will eventually lead to

the reduction of MRSA cases in local hospitals and the community as well as research

opportunities UCF graduate students (The Seminole County Patient Safety Council, 2007).

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PHC 6000Implications for Public Health Interventions

There are various levels of public health interventions that are being implemented in

order to reduce the transmission of MRSA. The patterns, trends, risk factors, and preventive

strategies at the various levels are able to have an impact on the implications of public health

interventions. Globally many countries conduct their own studies on MRSA since the pathogens

are genetically different where they are resistant to different types of antibiotics. The preventive

strategies in other countries also vary. The Netherlands, for example has taken aggressive

screening and infection control measures, which have resulted in MRSA infection rate of 1-3%.

Other European countries, such as Belgium and Denmark, are trying to implement the same

screening and infection control guidelines (Siegel, Rhinehart, Jackson, & Chiarello, 2006).

In the United States, HICPAC lists multiple studies in which seven types of public health

interventions for MRSA prevention are categorized: 1) administrative support, 2) education, 3)

judicious use of antimicrobials, 4) MDRO surveillance, 5) infection control precautions, 6)

environmental measures, and 7) decolonization.

1) Administrative support increases a) implementation, adherence, and feedback of

surveillance programs and infection control programs; b) communication; and c)

collaboration between other parties at the local, state, and national levels (Siegel,

Rhinehart, Jackson, & Chiarello, 2006).

2) Educational public health interventions were noted to have increased the awareness of

infection control issues that in turn decreased transmission rates (Siegel, Rhinehart,

Jackson, & Chiarello, 2006).

3) Public health interventions involving the use of antimicrobials include updating practice

guidelines that limits the use of a) broad spectrum antibiotics, b) limiting the influence of

pharmaceutical companies on the patterns of prescribing medicine, and c) using social

marketing to increase consumer information about antibiotic use Siegel, Rhinehart,

Jackson, & Chiarello, 2006).

4) MDRO surveillance programs have the potential to identify emerging trends and patterns

of MRSA. States are adopting new laws that require the reporting of MDRO infections.

HCOs use various ways to screen their patients such as using risk factors, using lab tests,

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PHC 6000and isolation precautions. These interventions were shown to decrease MRSA infection

rates (Siegel, Rhinehart, Jackson, & Chiarello, 2006).

5) Infection control interventions for MRSA patients include standard precautions, contact

precautions, and grouping patients into the same area of a healthcare facility. Implications

for these interventions had mixed results in various research studies and it was shown that

patients who were in isolation for longer periods had higher rates of depression and patient

satisfaction (Siegel, Rhinehart, Jackson, & Chiarello, 2006).

6) Environmental conditions greatly affect the transmission of MDROs. A couple of research

studies were documented to decrease the transmission rate of MRSA and included using

educational tools geared towards the housekeeping staff, increased disinfection of objects

with high rates of contamination, and assigning cleaning teams to high endemic areas.

7) Decolonization of patients before they were admitted to a hospital has proven to eradicate

MRSA colonization, which in turn decreases the infection rate of patients after medical

procedures. HCOs screen patients via risk factors and lab tests, if the test results are

positive, patients are treated with nasal muciprocin, oral antibiotics, and three days of

antimicrobial baths (Siegel, Rhinehart, Jackson, & Chiarello, 2006).

Preventive measures not only have the potential to eliminate MRSA, but also to save lives.

The implications of these measures mean that the additional costs of treating patients with

MRSA would be eliminated. The average cost of non-MRSA hospitalizations in the U.S. is

$33,687, while the average for MRSA hospitalization is $70,644 (110% more); and the ones

picking up the majority of the tab are taxpayers, as 71% ($2.591.292.8886) of MRSA

hospitalization charges where paid by Medicare, Medicaid and other government agencies in

2007 (AHCA, July 2009).

Conclusion

MRSA is a highly infectious disease that is dangerous and prevalent both globally and

locally. Although studies are being conducted and new preventative strategies implemented,

understanding MRSA and how it is evolving will take more resources and commitment from all

health and public organizations. Leaders must put forward preventive measures in an aggressive

proactive approach. Consequently, it will save lives, improve the quality of care and taxpayers

money.

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PHC 6000References

AHCA. (July 2009). MRSA in 2007 Florida hospitalizations. Statistical Brief. Florida Center for

Health Information and Policy Analysis. Florida Agency for Health Care Administration

(AHCA). Retrieved July 5, 2011 from URL:

https://floridahealthfinderstore.blob.core.windows.net/documents/researchers/

documents/MRSAbrieffinal.pdf

Albrich, W. C., & Harbarth, S. (2008). Health-care workers: Source, vector, or victim of

MRSA? The Lancet Infectious Diseases, 8(5), 289-301. doi: 10.1016/S0140-

6736(08)61345-8

Barclay, L. (April 2011). MRSA prevention effective in large healthcare system.

MedscapeToday News. Medscape Medical News. Retrieved July 7, 2011 from URL:

http://www.medscape.com/viewarticle/740863

CDC. (2011). MRSA and the workplace. Workplace Safety & Health Topics. NIOSH. Centers

for Disease Control and Prevention (CDC). Retrieved July 1, 2011 from URL:

http://www.cdc.gov/niosh/topics/mrsa/

Eisenstein, L., & Sanderson, R. (October 2008). MRSA Infection Control Practices in Florida

Hospitals in Comparison to Published Guidelines (Tech.) EpiUpdate. Bureau of

Epidemiology. Florida Department of Health. Retrieved July 10, 2011, from Florida

Professionals in Infection Control website:

http://www.flpic.com/MRSA_Infection_Control_Practices_in_Florida_Hospitals_in_Co

mparison_to_Published_Guidelines.pdf

Harbarth, S. (2010). Strategies to control antibiotic resistance (low-and middle-income

countries). Hopitaux Universitaires de Geneva. World Health Organization (WHO).

Retrieved July 12, 2011 from URL:

http://www.who.int/gpsc/5may/news/webinars/ps_webinar_slides_23sept2010.pdf

Lesko, C. (2011, April). A Community Antibiogram for Community-Associated Staphylococcus

Aureus in Florida, 2006-2010 (United States, Florida Department of Health, Bureau of

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PHC 6000Epidemiology). Retrieved July 5, 2011, from

http://www.doh.state.fl.us/disease_ctrl/epi/htopics/anti_res/MRSA_StatewideSummary_

CHDs.pdf

Lesko, C. (2011, April). A community antibiogram for Community-Associated Staphylococcus

Aureus in Florida, 2006-2010. Staphylococcus Aureus. Retrieved July 05, 2011, from

http://www.doh.state.fl.us/Disease_ctrl/epi/htopics/anti_res/Antibiogram_CA-

Saureus_FL06-10.pdf

Muto, C. A., Jernigan, J. A., Ostrowsky, B. E., Richet, H. M., Jarvis, W. R., Boyce, J. M., &

Farr, B. M. (2003). SHEA guidelines for preventing nosocomial transmission of

multidrug-resistant strains of Staphylococcus aureus and Enterococcus. Infection Control

and Hospital Epidemiology, 24(5), 362-378. Retrieved July 6, 2011, from

http://www.shea-online.org/Assets/files/position_papers/SHEA_MRSA_VRE.PDF

Petersen, E. (2009). Ftag 441, infection control. In Infection control for nursing homes: a guide

to government standards. Retrieved July 6, 2011, from

http://www.hcmarketplace.com/supplemental/8274_browse.pdf

The Seminole County Patient Safety Council. (2007, September 28). MRSA committee

report (Rep.). Retrieved July 16, 2011, from

http://scmsociety.typepad.com/patient_safety/files/mrsa_committee_report_092807.pdf

Sheen, B. (2010). MRSA. Detroit, MI: Lucent Books.

Siegel, J. D., Rhinehart, E., Jackson, M., & Chiarello, L. (2006). (Unites States, Centers for

Disease Control and Prevention, Healthcare Infection Control Practices Advisory

Committee). Retrieved July 10, 2011, from

http://www.cdc.gov/ncidod/dhqp/pdf/ar/MDROGuideline2006.pdf

University of Chicago. (2010). MRSA history timeline: The first half century, 1959-2009.

MRSA Research Center. The University of Chicago Medical Center. Retrieved June 27,

2011 from URL: http://mrsa-research-center.bsd.uchicago.edu/timeline.html

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PHC 6000Appendix

Benefits

As future healthcare administrators, it is extremely important to learn how to work with

colleagues to reach goals and objectives. Our goal and objective in this case was to a) research

MRSA, b) communicate to each other findings, c) write about MRSA, and d) review each other’s

work to turn in the best MRSA epidemiology paper. Working together we were able to retrieve

more sources of information, especially when either one of us was busy. We were also able to

communicate to each other research findings that we felt were extremely important. When

writing our paper, we were able to correct each other’s errors or make suggestions that would

improve the paper. Working as a team allowed us to have creative ideas on how to increase the

quality on the paper, such as deciding to add CA-MRSA to the paper and adding financial

information on the implications section.

In a world where time is limited, splitting up the sections evenly allowed us to focus our

research on the various sections. Many times, we were both working on paper in the middle of

the night due to our parental, work, and school responsibilities. Because we both understood

each other’s personal life, we were both able to work together well.

Synergy

During the first class meeting, we decided that we wanted to do our epidemiology paper

on MRSA. We had previously worked together on a previous project about hospital-acquired

infections and felt that MRSA was a topic we were familiar with. We quickly turned in our

choice of working together and our topic. We were very excited that we were chosen to write

about the topic as a team. We were familiar with each other’s work and knew each other

strengths and weaknesses.

After receiving notice that we would work together on the topic of MRSA, we talked

about how we would communicate with each other. We decided that we would mainly

communicate by cell phone, text messages, and wiki-spaces. We also agreed that we would take

turns posting the updates on the discussion boards. Working on wiki-spaces was new for the two

of us but we managed to add a page for every section where we inserted our references and any

information. In our early discussions of MRSA, we also agreed to concentrate on HA-MRSA

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PHC 6000since at the time we were not that familiar with the topic. We felt it was important to include CA-

MRSA due to the high transmission rates within the community therefore decided to add it to the

paper.

Early in the semester, Emelie was able to contact Catherine Lesko from the Florida

Department of Health. Catherine was able to provide us with information that she worked on

relating to MRSA and the information greatly enhanced our paper. We were also able to find a

local source who wants to work with UCF graduate students on the topic of MRSA.

Contributions

The epidemiology paper was divided evenly between both team members. We both

reviewed each other’s work and made suggestions for improvements.

Section 1: Emelie was responsible for researching and writing about the patterns and

trends of MRSA. She was also able to contact Catherine Lesko from FLDOH.

Various figures were added to the paper to add graphical representation of the

information presented.

Section 2: The research and writing of risk factors was completed by Marybel. Table

1 was created from a variety of references. Wiki-spaces was updated regularly to

show the references that were being used in the writing process. Summaries of the

references were also shown with the appropriate links.

Section 3: Emelie worked on the MRSA preventive strategies and efforts. Wiki-

spaces were updated with the links that were used on this section.

Section 4: Marybel was responsible for the research and writing of the implications

for public health interventions. Many of the references that were used were the same

ones that Emelie used in section 3.

Discussion Board: We both took turns every week posting the progress reports on the

discussion board.

Miscellaneous: During the review process some of the paragraphs that were written

in Section 1, were shifted into Section 2. Additionally, some paragraphs from Section

4 were shifted into Section 3. We both decided that the paragraphs flowed better in

the sections in which they were ultimately placed.

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mrsa epidemiology paper

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