1

Research Proposal:

Isolation of Staphylococcus aureus and MRSA strains from mobile phone surfaces among

healthcare and non-healthcare students

Submitted by:

Asma Hussain Alkatheri (H00413842)

Fatoon Yaslam Saleh (H00413451)

Sara Mohammed Madhi (H00371629)

Tasneem Jawad Alameri (H00414139)

Tabarak Molammed Alhajeri (H00366848)

Research Proposal 2

Table of Contents

1 Introduction & Background: .......................................................................................... 3

2 Research Questions and Aim: ........................................................................................ 5

3 Methodology:................................................................................................................... 6

3.1 Research Paradigm: ............................................................................................................ 6

3.1.1 Ontology .......................................................................................................................................6

3.1.2 Epistemology ................................................................................................................................ 6

3.2 Research design: .................................................................................................................. 6

3.3 Research Sample: ................................................................................................................ 7

3.4 Data collection: .................................................................................................................... 8

3.5 Procedures and materials: .................................................................................................. 9

3.5.1 Survey: ..........................................................................................................................................9

3.5.2 Physiological Sample .................................................................................................................. 10

3.6 Ethical Considerations: ..................................................................................................... 13

3.7 Validation of results: ......................................................................................................... 13

3.8 Data Analysis: .................................................................................................................... 14

3.8.1 Survey: ........................................................................................................................................ 14

3.8.2 Physiological sample: ................................................................................................................. 14

4 Strengths and Limitations: ........................................................................................... 15

5 Conclusion: ................................................................................................................... 16

6 References: .................................................................................................................... 17
Research Proposal 3

1 Introduction & Background:

The microorganisms' rates have dramatically increased due to globalization. Competition

between technology industries, and the wide use of mobile phones have also contributed to the
increase in microorganism’s prevalence rate (Soto, 2009). The excessive usage of mobile phones
among all members of society regardless of their age or profession is relevant to bacterial
colonization, and increased risk of infection. Leading to high consumption of antibiotics. Which,
consequently, intensifies the antimicrobial drug resistance against a broad spectrum of antibiotics.

Mobile phones are the most handheld devices, which are utilized by people both in their
personal and professional lives. They act as a vehicle to spread bacterial infections that can be
pathogenic to humans (Akinyemi et al., 2009). The risk of exposure to certain bacterial infections
has been reported due to the widespread usage of smartphones in hospitals and healthcare
facilities. Staphylococcus aureus is one of the most common hospital-acquired infections that
appears due to frequent hospital visits (Cicciarella Modica et al., 2020).

The nature of healthcare workers' environments makes them far more vulnerable to
biohazards such as bacteria, viruses, fungi, and parasites, specifically the normal flora of the skin
"Microbiota" (Nwankwo et al., 2014). More than 80% of mobile phones used by healthcare
workers are contaminated with various microorganisms (Bodena et al., 2019). Further, bacterial
infections on mobile devices used by medical students are highly prevalent (Lubwama et al.,
2021).

International health organizations such as the World Health Organization (WHO) and the
Center of Disease Control & Prevention (CDC) set a guideline to restrict or minimize the use of
mobile phones during working hours due to increased risk of infection. In addition, practices
such as following proper hygienic measures and maintaining disinfection of mobile phone
surfaces are enforced (CDC 2019; WHO 2019). However, the percentage of medical students
and healthcare workers who do not adhere to the principles and practices of infection control is
increasing, which results in a one-third rise in microbial infections (Tajouri et al., 2021).
Research Proposal 4

Opportunistic bacteria are characterized by unique profiles, which can easily infect an
immunocompromised patient. One of these bacteria is Staphylococcus aureus, the most prevalent
on the smartphone surfaces of healthcare workers. The features of mobiles such as humidity and
heat provide the optimum environment for bacteria to grow and survive on mobile surfaces (Al-
Beeshi et al., 2021).

Staphylococcus aureus is transmitted through direct contact with infected humans (Davis et
al., 2012). Additionally, it can be transmitted indirectly through exposure to aerosols, dust settles,
and frequently touched surfaces (Chaibenjawong & Foster, 2011). In this regard, Staphylococcus
aureus can survive on dry surfaces for at least one week and up to 3 years, including methicillin-
resistant Staphylococcus aureus (Domon et al., 2016).

On the other hand, methicillin-resistant Staphylococcus aureus strains are resistant to

several antibiotics, not only beta-lactam antibiotics. Methicillin-resistant Staphylococcus aureus
infection is a major cause of healthcare-associated infections, such as skin infections, sepsis,
pneumonia, and surgical infections (Domon et al., 2016). According to the CDC, anyone can get
a methicillin-resistant Staphylococcus aureus infection, where there are approximately 5% of
patients in U.S. hospitals carry methicillin-resistant Staphylococcus aureus in their skin and their
nose (CDC, 2019).

Enormous global statistics on the topic from different nations are available, including
Italy, Saudi Arabia, and Egypt. On the contrary, studies among the UAE population are limited or
nonexistent. It's crucial to determine whether the UAE experiences any similar issues. Therefore,
this research aims to study the prevalence of Staphylococcus aureus contamination on the surface
of mobile phones, detect their antimicrobial drug resistance, including methicillin-
resistant Staphylococcus aureus stains, and compare the level of contamination among healthcare
students and non-healthcare-students. Information obtained will support the UAE database with
unique data collected from healthcare students and non-healthcare students.
Research Proposal 5

2 Research Questions and Aim:

Research question 1: What is the prevalence rate and antimicrobial drug resistance of
Staphylococcus aureus that colonizes the mobile phone surfaces of Higher Colleges of
Technology healthcare students and non-healthcare students?

Research question 2: What are the factors that increase the colonization of
Staphylococcus aureus on the surface of the mobile phone?

Hypothesis: Colonization of Staphylococcus aureus and methicillin-resistant Staphylococcus

aureus is higher on the mobile phone surface of healthcare students than non-healthcare students

at the Higher Colleges of Technology.

Aim: The aim is to isolate Staphylococcus aureus from the surface of mobile phones, and
subsequently, to compare the prevalence of Staphylococcus aureus among healthcare students
with non-healthcare students. Additionally, to identify their antimicrobial resistance species
which is the Methicillin-resistant Staphylococcus aureus strain, and contribute unique data to the
UAE database. This research will also explore factors that may directly or indirectly influence
bacterial colonization.
Research Proposal 6

3 Methodology:

3.1 Research Paradigm:

3.1.1 Ontology
In this study, a quantitative post-positivist paradigm will be adopted that focuses on a
single reality position and will study the cause and effect between multiple factors that directly or
indirectly influence the prevalence of Staphylococcus aureus on the mobile phone surface, such
as the frequency of using a mobile phone, gender, hygienic measures followed, etc. In addition,
testing the antimicrobial drug resistance profile of the bacteria.

3.1.2 Epistemology
A correlational research design based on primary data collection will be used in this study
to obtain first-hand knowledge. Physiological samples will be collected by swabbing the
participant’s mobile phone surface to detect Staphylococcus aureus and their antimicrobial drug
resistance including methicillin-resistant Staphylococcus aureus. A survey will be used as
another type of data collection within a period of one month. The research sample will be 200
students, which includes healthcare students from the Medical Laboratory, and Emergency
Medical Service Students, and Non-healthcare students from Information Technology and
Engineering students. A descriptive statistic will be used to present an appealing result with
percentages like the standard deviation and mean.

3.2 Research design:

Correlational design is suitable for the study because it will help to investigate systematically
whether there is a relationship between healthcare and non-healthcare programs and
Staphylococcus aureus that colonize the mobile phones among healthcare students (Medical
laboratory and Emergency medical services) and non-healthcare students (Information
technology and Engineering science). The correlation design is chosen to examine the
relationship between two variables, the dependent and independent variables (Bloomfield &
Fisher, 2019). This design helps to explain the nature of the relationship between these variables,
and it does not examine causality. In addition, the correlation design has high external validity,
which allows the results and conclusions to be safely generalized to a large population (Seeram,
Research Proposal 7

2019). This study will be conducted at the Higher College of Technology, an institution for
higher education, in Abu Dhabi, United Arab Emirates among healthcare and non-healthcare
students.

3.3 Research Sample:

In this research, participants will be selected using a convenience sampling method in

which the inclusion and exclusion criteria are applicable. This sampling method is a
nonprobability sampling method in which participants are selected based on inclusion and
exclusion criteria, making it easier for researchers to reach the desired participants (Taherdoost,
2016). The inclusion and exclusion criteria of samples are shown in Table 1.

Table 1. Inclusion and exclusion criteria of the research sample.

Inclusion criteria Exclusion criteria

Participants from Abu Dhabi Participants from other emirates of the
UAE
Participants will be older than 18 years Participants less than 18 years old and
old and younger than 30 years old. more than 30 years

Health Medical Laboratory and Higher College of Technology students

Emergency Medical Services students from other Healthcare majors.

Engineering Tech & Science and Higher College of Technology students

Computer & Information science from other non-healthcare majors.
students

A swab from a mobile phone surface. Other physical sample collection.

Participants with both physical swab Participants with missing either a swab or
samples and survey a survey

A swab sample will be taken from 200 students’ phones at the Higher College of
Technology, Abu Dhabi campus. Researchers will divide the participants into two main groups,
the first group will be Healthcare students including Health Medical Laboratory and Emergency
 Research Proposal 8

Medical Services students, while the second group will be non-healthcare students including
Engineering Tech & science and Computer and information science students, as their field of
work is heavily dependent on the use of mobile phones, but they are not related to healthcare
system. Also, these groups will sub-divide into pre-internship students and post-internship
students. The sample size is shown in Table 2.

Table 2. Categories and size of the research sample.

No. of students
Sample categories Fields Pre-internship Post-internship

HML students 30 30
Health care students EMS students 30 30

Engineering students 20 20
non-Health care students
IT students 20 20
100 100
Total Students 200

3.4 Data collection:

Two types of primary data collection methods are conducted in the research, including a
collection of physiological swab samples and an online survey. The main method is an
experimental bacterial identification, which involves testing the colonization of Staphylococcus
aureus from the surfaces of mobile phones and investigating their antimicrobial drug resistance
strains, especially Methicillin-resistant Staphylococcus aureus. Testing to identify the bacteria
will be conducted by researchers at the laboratory of Higher Colleges of Technology, Abu Dhabi
campus under the supervision of a licensed medical laboratory scientist. The second method of
data collection is an online survey designed to identify factors that increase colonization, based
on participants' lifestyle and daily habits. The research data collection is expected to begin in
September and end at the beginning of October 2023 over a period of one month. Researchers
Research Proposal 9

will reach their target sample in two different groups shown in Figure1. For the first group of
pre-internship participants, who are first- and second-year students, researchers will approach
participants after completing their practical sessions, which are conducted on the college campus.
The second category of post-internship participants are the third- and fourth-year students. They
are reached by the researchers the day after they visit the internship site. All data will be
collected in the Higher College of Technology. Researchers will collect a physical swab sample
from participants' mobile phones, combined with an online survey to be completed. Written
consent will be obtained before handing out an online survey and collecting swab samples from
the mobile phones of participants. Participation is voluntary, and the identity of participants will
be anonymized.

Figure 1. Data collection flowchart.

3.5 Procedures and materials:

3.5.1 Survey:

A self-administered survey will be completed by potential participants before collecting

swabs. The survey will contain a series of questions including demographic questions such as
gender, age, and major. Also, there will be questions related to participants' habits of using
Research Proposal 10

mobile phones, the frequency of usage such as daily use of mobile phones during medical
practice, and usage at home as stated by Al-Beeshi et al., and 2021; Qadi et al., 2021. A survey
will be developed in both Arabic and English languages. In addition to questions about the usage
of mobile phones, there will also be questions regarding the frequency of hand washing, the
frequency of decontaminating mobile phone surfaces, and washing hands before or after using
mobile phones. In addition, participants will be asked about the presence of a damaged screen
protector and the presence of covers on their mobile phone similar to the survey of (Bodena et
al., 2019).

3.5.2 Physiological sample

3.5.2.1 Swab collection:

Samples will be collected by using a sterile cotton swab with gel preservative because it
is suitable for assessing the bacterial contamination of the surface. Cotton swab gives the optimal
detection, and identification of the pathogenic microorganisms collected from a dirty surface
(Jansson et al., 2020). While collecting swabs from participant’s mobile phones, the researchers
will follow the below procedure.
Researchers will wear pre-sterilized gloves before swabbing the samples. Then, a cotton
swab will be rotated on the surface of the mobile phones using an “S” pattern from both vertical
and horizontal directions as shown in Figure 2 (Bulut & Zor, 2021).

Figure 2. “S” pattern technique of collection swab samples from mobile phone surface.
Research Proposal 11

Extreme caution will be applied to ensure that all areas used by fingers and hands will be
swabbed, including the screen, the side of the phone, the ear jack, and the audio input. For
mobile phones with covers, the swabs will be taken from the outer surfaces of the cover and in
addition to the screen as recommended by the Center of Medical Laboratory Technology et al.,
(2020). There are instructions that researchers will follow while collecting samples from the
surfaces of mobile phones as shown in Table 2.

Table 2. Instructions that researchers will follow while collecting samples from the
surfaces of mobile phones.

Do Don’t
Hold the swab at the top. Don’t touch the swab bud.
Ensure collecting samples on all sides of swab Don’t collect the sample only on one side of
tips. the swab tip.

Apply pressure while rotating the swab. Don’t keep the swab straight.
Collect the sample by using an “S” pattern. Don’t lightly swab the mobile surfaces.

All swabs will be placed into gel preservative after swabbing the surface of mobile
phones and all swabs will be labeled with participants’ college ID numbers. Then swabs will be
placed inside a sterile biohazard plastic bag with a label indicating the time of collection of
swabs and the category of participants. After labeling, researchers will transport swabs at room
temperature via a transport box to the Microbiology laboratory at the Higher College of
Technology campus within 20-30 minutes, where they will be processed for microbiological
investigations. Once the samples arrive at the microbiology lab, each swab sample will have a
specific serial abbreviation including category, gender, academic year, and several participants.
Then, all swabs will be cultured in blood agar using the four quadrants streaking technique
(Nwankwo et al., 2014). The inoculated culture media will be incubated at 37°C for 24 hours.
Figure 3 shows the flow chart depicting the methods used to identify the bacteria.
Research Proposal 12

Figure 3. Bacterial identification methods.

3.5.2.2 Identification of microorganisms:

After an incubation period, all the culture plates will be observed to check for growth

(Qadi et al., 2021). The primary identification of Staphylococcus aureus growth on Blood agar is

based on morphological identifications, colonies should appear spherical, small, and golden in

color. Gram staining will be done to rule out the gram-negative bacteria and further testing on

gram-positive bacteria because it is a characteristic of Staphylococcus aureus due to the large

peptidoglycan membrane it has. For further differentiation of Staphylococcus aureus species,

researchers will perform a coagulase test to identify and differentiate pathogenic Staphylococcus

species (Staphylococcus aureus) and non-pathogenic Staphylococcus species (Staphylococcus

epidermidis).
Research Proposal 13

3.5.2.3 Antibiotic susceptibility testing:

Antibiotic susceptibility testing will be performed using the disc diffusion method. This
test will be performed to investigate Methicillin-resistant Staphylococcus aureus. A suspension
of each positive staphylococcus aureus sample will be prepared with a specific concentration
equivalent to the McFarland value of 0.5. Then, each suspension will be cultured onto the surface
of the Mueller-Hinton agar, the antibiotic discs will be placed on top and incubated at 37 °C for
24 hours (Nwankwo et al., 2014). The sensitivity of the isolated Staphylococcus aureus to
different antibiotics which are Amikacin, Vancomycin, Clindamycin, Cefoxitin, Gentamicin,
Ampicillin, Ampicillin with sulbactam, and Ciprofloxacin will be measured based on Clinical
and Laboratory Standards Institute (CLSI) guidelines.

After overnight incubation, the result of sensitive, intermediate, or resistance of

Staphylococcus aureus isolates for all antibiotic discs will be evaluated and decided based on
measuring the zone of inhibition with a calibrated ruler according to the Clinical and Laboratory
Standards Institute (CLSI) criteria.

3.6 Ethical Considerations:

The participant's information will be kept confidential and anonymous. In addition,

ethical approval will be sought from relevant institutions such as the Higher College of
Technology (HCT) prior to collecting data. The informed consent will contain a description of
the purpose of the study and procedures for collecting the samples. Also, potential risks and
benefits of participation in the study will be provided to potential participants.

3.7 Validation of results:

To ensure validity and reliability, researchers will undergo training the lab technicians
working at the Higher Colleges of Technology on regard to swab collection, sample
transportation to the microbiology laboratory, how to culture it on an agar, and how to test it.
Then the results will be checked by an expert working in the lab. To ensure internal validity, One
Research Proposal 14

agar plate among each new batch will be incubated at 37°C for 24 hours and will be used as a
control to ensure that the agars are not contaminated. A large sample size of 200 is used to help
with external validity. To ensure the validity and reliability of the survey, it will be tested first by
an expert from the Higher College of Technology and checked to see if it is simple and readable.
The same participants will be surveyed to ensure internal and external validity.

3.8 Data Analysis:

3.8.1 Survey:

The data collected through a survey from each participant before collecting the swab
samples, including age, gender, major, habits of using mobile phones, frequency of using mobile
phones, and frequency of hand washing, will be analyzed using Microsoft Excel software. Also,
statistical values such as mean, median, mode, standard deviation, and percentage will be
calculated. Through these statistical measurements, researchers will be able to determine the
ratio of males to females, the average age of participants, the percentage of participants who
wash their hands before/after using mobile phones, the percentage of participants who use the
phone while at work, and the most frequent number of hours they use their mobile phones. Once
the analysis of the survey data is complete, analytical charts and tables will be used to present the
results. For example, a bar chart will be used to show demographic data and a pie chart will be
used to show the frequency of hand washing and frequency of cleaning mobile phones.

3.8.2 Physiological sample:

After collecting the samples with sterile cotton swabs from the mobile phones of the
participants following the “S” pattern, all swab samples will be labeled with the student’s college
ID. After labeling, the swabs will be stored at room temperature in a stable container and
transported to the microbiology laboratory at the Higher College of Technology within 20-30
minutes, and will be De-identified, the old label will be removed and replaced with a specific
serial abbreviation to ensure the anonymity to the participant, and to categorize the sample based
on research groups, and record the laboratory tests results, for example:
HCS-FA-1: Healthcare student- Female after training - No. 1.
Research Proposal 15

HCS-FB-1: Healthcare student- Female before training - No. 1.

HCS-MB-1: Healthcare student- Male before training - No. 1.
NHCS-FA-1: non-Healthcare student- Female after training - No. 1.
NHCS-FB-1: non-Healthcare student- Female before training - No. 1.

In the microbiology laboratory, all swabs will be subjected to several microbiological tests,
including culturing on Blood agar, gram staining, biochemical identification test which is a
coagulase test, and antibiotic susceptibility test based on CLSI guidelines.

4. Strength and Limitations:

One of the major strengths of this study is that it is the first to be conducted in the
United Arab Emirates on the isolation of pathogenic Staphylococcus aureus bacteria from
mobile phone surfaces and their antimicrobial resistance profiles. In addition, this study will
provide an overview of the colonization of Staphylococcus aureus on mobile phone surfaces
and its antimicrobial drug resistance profiles.

Our study has four main limitations. The first limitation of this study is the research
design. This study is correlational design, it helps explore the association between variables,
but it cannot provide a conclusive and descriptive explanation of each participant (He & Li,
2022). The second limitation concerns the sampling method. This study is based on a
nonrandomized sampling strategy, which gives an unfair advantage to certain members of a
community (Ferrandez et al., 2022). The third limitation is the small size of the sample. This
study planned a sample size of 200 individuals. When the sample size is small the results
cannot be generalized to a larger population. In addition, the sample size may prevent the
findings from being extrapolated. The last limitation of the study sample is that Medical Lab
students and Emergency Medical Service students cannot represent all healthcare workers or
the medical student population; this also applies to samples from non-healthcare students.
Research Proposal 16

5 Conclusion:

To conclude, the objective of this study is to identify the isolated pathogenic

Staphylococcus aureus bacteria from mobile phone surfaces and their antimicrobial drug
resistance profiles. The results of this research will benefit the UAE in many ways. The outcome
of the study will also contribute to some recommendations related to hospital-acquired
infections. Such studies are necessary because the data can be used to develop acceptable rules
and procedures for isolating microorganisms from the mobile phones of medical students and
healthcare workers. Improve awareness and guidance of medical students and health care
workers regarding the risk of colonization with Staphylococcus aureus from mobile phone
surfaces and with Methicillin-resistant Staphylococcus aureus, which is resistant to many
antimicrobial drugs, and spread awareness of hygiene in hospitals.

The findings of this research will help fill the gap in the literature that will enable future
recommendations and national health care policies. In addition, the present sampling of the total
Medical Laboratory Science and Emergency Medical will provide an idea for future research
where a larger sample will include all healthcare workers and the medical student population in
the UAE to generate better results and drive greater data. Moreover, future research will use a
randomized sample to ensure a fair selection of the studied sample.
Research Proposal 17

6 References:

Al-Beeshi, N. Z., Alohali, R. M., Torchyan, A. A., & Somily, A. M. (2021). The bacterial colonization of

healthcare workers’ mobile phones in a large tertiary care teaching hospital in Saudi Arabia. The

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MARA, Selangor, Malaysia, Hikmah, N. ‘Ain, Anuar, T. S., Centre of Medical

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