Dose-response associations of methicillin-resistant Staphylococcus aureus between school environmental contamination and nasal carriage by elementary students Jialing Lin,1 Jianping Liang,2 Ting Zhang,1 Chan Bai,1 Jiaping Ye,1 Zhenjiang Yao1 1Department of Epidemiology and Health Statistics, School of Public Health, Guangdong Pharmaceutical University, Guangzhou, China; 2Department of Health Education, Guangzhou Primary and Secondary School Health Promotion Center, Guangzhou, China Background: Methicillin-resistant Staphylococcus aureus (MRSA) can cause serious infections in elementary students. Therefore, we aimed to elucidate the quantitative associations of school environmental contamination with nasal carriage of MRSA by students in a dose-response manner. Phenotypic and molecular characterizations were performed to further assess the associations. Materials and methods: A cross-sectional study was conducted from March to August 2016 in eight elementary schools in Guangzhou, China. A multistage stratified cluster sampling design was used to include Chinese students and selected classes. Nasal swabs from students and environmental swabs from the schools were collected. The dose-response relationship was examined using multivariate logistic regression modeling with cluster-correlated robust variance estimates to account for correlations of isolates between the environment and the students. Results: The prevalence rates of MRSA among 1705 students and 1240 environment samples were 10.15% and 3.87%, respectively. There were positive prevalence associations of school (odds ratio 1.09, 95% confidence interval [CI] 1.05–1.13) and class (odds ratio 1.03, 95% CI 1.01–1.06) environmental contamination with nasal carriage of MRSA isolates by students.Conclusions: Comparisons of MRSA isolates between the environment and the students in terms of phenotypic and molecular characterization were mostly insignificant. School environmental contamination with MRSA was positively associated with MRSA nasal carriage by elementary students. Disinfection measures and education regarding hand hygiene should be considered to decrease the prevalence of MRSA nasal carriage among students. Keywords: methicillin-resistant Staphylococcus aureus, school environment, contamination, elementary students, nasal carriage