Thesis Submitted for the Degree of Master of Philosophy in Applied Epidemiology
Creators: name: Marmor, Alexandra Mary
Publisher: name: The Australian National University
Year: 2017
Subjects: Epidemiology
carbapenemase-producing Enterobacteriaceae
outbreak investigation
infection prevention and control
Aboriginal and Torres Strait Islander health
social and emotional wellbeing
invasive pneumococcal disease
infectious disease surveillance
program evaluation
Longitudinal Study of Indigenous Children

description: My field placement for Master of Philosophy in Applied Epidemiology (MAE) program was with the Indigenous Health Division of the Australian Government Department of Health, and it provided opportunities for epidemiological training in a broad range of contexts. I present four projects to fulfil the core requirements of the MAE. I participated in a retrospective investigation into cases of carbapenemase-producing Enterobacteriaceae (CPE) identified over a four year period in the Australian Capital Territory. In this investigation I collected epidemiological evidence and analysed existing environmental and whole-genome sequencing data to identify two small, but prolonged, outbreaks at a tertiary hospital. The investigation revealed that nosocomial transmission of CPE is more extensive than previously understood, and is characterised by lengthy asymptomatic carriage and persistence of CPE in the hospital environment. We used the outbreak data to assess the utility of an interstate CPE prevention and control guideline, and to develop infection control recommendations specifically for the hospital. I analysed data from the Longitudinal Study of Indigenous Children (LSIC) to identify early life exposures associated with social and emotional wellbeing (SEWB) in Aboriginal and Torres Strait Islander children at school commencement. Large household size and frequent exposure to major life events were weakly associated with poorer mental health and fewer prosocial behaviours; but conversely predicted a greater connection of the child to community, culture and country. Most importantly, I found that mainstream mental health assessment tools do not reflect the positive, holistic concept of SEWB, and I was unable to create a more appropriate index using LSIC data. This study highlighted the need to develop measures that privilege Indigenous ways of being and knowing. My evaluation of Australia’s Enhanced Invasive Pneumococcal Disease Surveillance Program found that this complex system is highly flexible and stable, and is acceptable to users and stakeholders. It has proved very useful for monitoring the national infant vaccination program—informing a change to the recommended vaccine in 2011. The program is less useful for evaluating targeted vaccination in other high-risk groups and for surveillance of antimicrobial resistance. My key recommendations focussed on collecting complete data for all cases, ensuring stakeholders can easily access useful surveillance data, and improving collection of antimicrobial resistance data. I conducted the first evaluation of the New Directions: Mothers and Babies Services (NDMBS) program, which aims to increase access to maternal and health child services for Aboriginal and Torres Strait Islander families. I assessed the effect of over $224 million of investment between 2007 and 2015 using data from the Australian Early Development Census. I found that there was little difference in indicators of early child development in the first year of school in areas that were serviced by NDMBS-funded organisations, compared to areas that did not. This may have been due to differences in geographical remoteness between the two exposure groups, but the equivocal findings were more likely due to the evaluation’s ecological design and classification error. The project highlighted the importance of developing a program logic model and evaluation plan during the program planning stage, to ensure that data is prospectively collected for use in evaluation.