LECTURE 2: EPIDEMIOLOGY

After studying this chapter, you should be able to:

• Define epidemiology and understand common tools used in its study
• Classify diseases according to transmissibility and occurrence.
• Understand the concepts of chain of infection and identify reservoirs of infection

Epidemiology is the study of factors that determine the frequency, distribution, and determinants of
diseases in human populations, and ways to prevent, control, or eradicate diseases in populations.
Epidemiologist – are scientists who specialize in the study of disease and injury patterns (incidence and
distribution patterns) in populations, and ways to prevent or control diseases and injuries.
EPIDEMIOLOGY TOOLS

 Incidence – is defined as the number of new cases of that disease in a defined population during
a specific time period. Example: the number of new cases of Dengue in the Philippines in 2019.
 Morbidity rate – is the number of new cases of a particular disease that occurred during a
specified time period per a specifically defined population (usually per 1,000, 10,000, or 100,000
population), for example, the number of new cases of a particular disease in 2009 per 100,000
U.S. population.
 Period prevalence – is the number of cases of the disease existing in a given population during a
specific time period. Example: the total number of cases of malaria that existed in the U.S.
population during 2009.
 Point prevalence – is the number of cases of the disease existing in a given population at a
particular moment in time. Example: the number of cases of malaria in the U.S. population at
this moment.
 Mortality refers to death.
 Mortality rate – is the ratio of the number of people who died of a particular disease during a
specified time period per a specified population (usually per 1,000, 10,000, or 100,000
population). Example: the number of people who died of a particular disease in 2009 per
100,000 U.S. population.
 Case fatality rate – is the proportion of deaths from a certain disease compared to the total
number of people diagnosed with the disease for a certain period of time.
TYPES OF DISEASES ACCORDING TO TRANSMISSIBILITY
 Infectious diseases (infections) – are diseases caused by pathogens.
 Communicable disease – is an infectious disease that is transmissible from one human to
another. Example: HIV
 Contagious disease – is a communicable disease that is easily transmitted from one person to
another. Example: influenza
 Zoonotic diseases or zoonoses – are infectious diseases that humans acquire from animal
sources. Example: hantavirus
TYPES OF DISEASES ACCORDING TO OCCURRENCE
 Sporadic disease – is a disease that occurs only occasionally (sporadically) within the population
of a particular geographic area. In the United States, sporadic diseases include botulism, cholera,
gas gangrene, plague, tetanus, and typhoid fever. Some diseases occur only sporadically
because they are kept under control as a result of immunization programs and sanitary
conditions.
 Endemic diseases – are diseases that are always present within the population of a particular
geographic area. The number of cases of the disease may fluctuate over time, but the disease
never dies out completely. Example: tuberculosis (TB), staphylococcal and streptococcal
infections, sexually transmitted diseases (STDs) like gonorrhea and syphilis, and viral diseases
such as the common cold, influenza, chickenpox, and mumps.
 Epidemic (or outbreak) – is defined as a greater than usual number of cases of a disease in a
particular region, usually occurring within a relatively short period of time. Epidemics may occur
in communities that have not been previously exposed to a particular pathogen.
 Legionnaires’ disease or legionellosis occurred in 1976 in Philadelphia, Pennsylvania.
Approximately 220 were hospitalized and 34 died due to a Gram-negative bacillus
named Legionella pneumophila which was present in the water being circulated through
the air-conditioning system of the hotel where the affected Legionnaires were staying.
 Hamburger poisoning in 1992–1993 which involved Escherichia coli O157:H7-
contaminated hamburger meat in the Pacific Northwest. Approximately 500 had
diarrhea, 45 had kidney failure as a result of hemolytic uremic syndrome (HUS), and
several young children died.
 An epidemic of hantavirus pulmonary syndrome (HPS) occurred on Native American
reservations in the Four Corners region in 1993. It resulted in approximately 50 to 60
cases, including 28 deaths. The particular hantavirus strain (now called Sin Nombre
virus) was present in the urine and feces of deer mice, some of which had gained
entrance to the homes of villagers. Aerosols of the virus were produced when residents
swept up house dust containing the rodent droppings. The pathogen was then inhaled
by individuals in those homes.
 An epidemic of cryptosporidiosis (a diarrheal disease) occurred in Milwaukee, Wisconsin
in 1993. It resulted from drinking water that was contaminated with the oocysts of
Cryptosporidium parvum.
 West Nile virus. In 2002, (WNV) infections occurred throughout the United States with
more than 4,100 human cases, resulting in 284 deaths. In addition, more than 16,000
birds died as a result of WNV infections, and more than 14,500 horses were infected
with WNV during 2002. And in 2003, WNV epidemic in U.S. had a total of 9,862 cases
and 264 deaths.
 Foodborne disease outbreaks. Over 200 known diseases can be transmitted through
food, caused by microbes (viruses, bacteria, parasites, prions) or toxins and metals.
Foodborne diseases are estimated to cause approximately 76 million illnesses, 325,000
hospitalizations, and 5,000 deaths per year in the United States. More than 75% of
 illnesses caused by identified pathogens are caused by two bacteria (Salmonella and
Listeria spp.) and one parasite (Toxoplasma). The bacteria Campylobacter jejuni and E.
coli O157:H7, the protozoan parasite Cyclospora cayetanensis, and norwalk virus are
other important microbial causes of foodborne illness.
 Influenza (“flu”) epidemics occur in many areas during certain times of the year and
involve most of the population because the immunity developed in prior years is usually
temporary. Thus, the disease recurs each year among those who are not revaccinated or
naturally resistant to the infection. Epidemics of influenza cause approximately 20,000
deaths per year in the United States.
 Ebola virus has caused several epidemics of hemorrhagic fever in Africa (Sudan and the
Republic of the Congo in 1976; Sudan in 1979; the Republic of the Congo in 1995; Gabon
in 1994 and 1996; Uganda in 2000; several outbreaks in Gabon and the Republic of the
Congo between 2001 and 2003). The 2000 outbreak in Uganda (425 cases, 224 deaths)
was the largest Ebola epidemic ever recorded. Between 25% and 90% of infected
patients have died in these epidemics. The source of the virus is not yet known.
 Philippines, on August 6, 2019, declared National Dengue Epidemic after having 146,
062 cases from January to July 20, 2019. This epidemic worsened to 414,532 cases with
1,546 related deaths in November 30, 2019. In the same year, from January 1 to May
11, there were 34,950 reported cases of measles with 477 deaths.
 Pandemic disease – is a disease that is occurring in epidemic proportions in many countries
simultaneously, sometimes worldwide.
 The 1918 Spanish flu pandemic was the most devastating pandemic of the 20th century.
It infected 500 million and killed more than 50 million people worldwide.
 Human immunodeficiency virus (HIV) targets cells of immune system, called CD4 cells,
which help the body respond to infection. Without effective treatment, the immune
system will become weakened to the point that it can no longer fight infection and
diseases. Acquired immunodeficiency syndrome (AIDS) is used to refer to the most
advanced stages of HIV infection. There were approximately 37.9 million people living
with HIV at the end of 2018
 Tuberculosis. In 2018, approximately 10 million people fell ill and a total of 1.5 million
died with TB worldwide. It is caused by Mycobacterium tuberculosis bacteria that most
often affect the lungs. The symptoms of this disease are: cough, fever, night sweats, and
weight loss.
 Malaria. It is a life-threatening disease caused by parasites that are transmitted to
people through the bites of infected female Anopheles mosquitoes. In 2018, there were
an estimated 228 million cases and 405, 000 deaths of malaria worldwide.
 Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), commonly known as
COVID-19 has affected 213 countries and territories around the world (as of June 7,
2020). It is caused by a virus with an incubation period of 14 days and can be
transmitted through respiratory droplets or airborne transmission on circumstances
where aerosols are formed.
For the updated number of cases globally, you can visit
https://www.worldometers.info/coronavirus/?utm_campaign=homeAdvegas1?
INTERACTIONS AMONG PATHOGENS, HOSTS, AND ENVIRONMENTS
Factors pertaining to the pathogen:
 Virulence – the measure or degree of pathogenicity
 Way of entry
 Number of organisms that enter the body
Factors pertaining to the host:

 The person’s health status

 The person’s nutritional status
 The susceptibility of the host (e.g., age, lifestyle [behavior], socioeconomic level, occupation,
travel, hygiene, substance abuse, immune status [immunizations or previous experience with
the pathogen])
Factors pertaining to the environment:
 Physical factors such as geographic location, climate, heat, cold, humidity, and season of the
year.
 Availability of appropriate reservoirs, intermediate hosts, and vectors (discussed later in this
chapter)
 Sanitary and housing conditions; adequate waste disposal; adequate healthcare
 Availability of potable (drinkable) water

CHAIN OF INFECTION
The six components in the chain of infection are
1. a pathogen [example: a cold virus]
2. a reservoir of infection [Example: Andy has a cold virus.]
3. a portal of exit [Example: When Andy blows his nose, cold
viruses get onto his hands.]
4. a mode of transmission [Example: Andy shook hands with
Bob and transferred the virus to Bob’s hand]
5. a portal of entry [Example: Bob rubs his nose, the cold
virus is transferred from his hand to the mucous
membranes of his nose.]
6. a susceptible host [Example: Since Bob had previously
been infected by that particular cold virus and had
Figure 1. The six components of the chain of infection
developed immunity to it, he is not susceptible and will Source: Burton’s Microbiology FTHS 9th ed.page 178
not develop a cold.]
STRATEGIES FOR BREAKING THE CHAIN OF INFECTION
 Practice effective hand hygiene procedures.
 Maintain good nutrition and adequate rest and reduce stress.
 Obtain immunizations against common pathogens.
 Practice insect and rodent control measures.
 Practice proper patient isolation procedures.
 Ensure proper decontamination of surfaces and medical instruments.
 Dispose of infectious waste properly.
 Use gloves, gowns, masks, respirators, and other personal protective equipment, whenever
appropriate to do so.

RESERVOIRS OF INFECTION
A reservoir is any site where the pathogen can multiply or merely survive until it is transferred to
a host. Reservoirs may be living hosts or inanimate objects or materials. Respiratory secretions or
feces are usually the vehicles by which the pathogen is transferred, either directly from the carrier
to a susceptible individual or indirectly through food or water.
A carrier is a person who is colonized with a particular pathogen, but the pathogen is not
currently causing disease in that person.
 Passive carriers carry the pathogen without ever having had the disease.
 Incubatory carrier is a person who is capable of transmitting a pathogen during the
incubation period of a particular infectious disease.
 Convalescent carriers harbor and can transmit a particular pathogen while recovering from
an infectious disease (i.e., during the convalescence period).
 Active carriers have completely recovered from the disease, but continue to harbor the
pathogen indefinitely.
Zoonoses are acquired by direct contact with the animal, by inhalation or ingestion of the
pathogen, or by injection of the pathogen by an arthropod vector.

 Dogs, cats, bats, skunks, and other animals are known reservoirs of rabies. The rabies
virus is usually transmitted to a human through the saliva that is injected when one of
these rabid animals bites the human.
 Cats litter can cause toxoplasmosis. Toxoplasmosis is a protozoan disease caused by
Toxoplasma gondii which can be contracted by ingesting oocysts from cat feces as well
by ingesting cysts that are present in infected raw or undercooked meats.
Toxoplasmosis may cause severe brain damage to, or death of, the fetus when
contracted by a woman during her first trimester first 3 months) of pregnancy.
 The diarrheal disease, salmonellosis, is frequently acquired by ingesting Salmonella
bacteria from the feces of turtles, other reptiles, and poultry.
  Variant C-J disease, a variant form of Creutzfeldt-Jakob (CJ) disease in humans, may be
acquired by ingestion of prion-infected beef from cows with bovine spongiform
encephalopathy (BSE or “mad cow disease”).
 Persons skinning rabbits can become infected with the bacterium Francisella tularensis
and develop tularemia.
 Contact with dead animals or animal hides could result in the inhalation of the spores of
Bacillus anthracis, leading to inhalation anthrax, or the spores could enter a cut, leading
to cutaneous anthrax. Ingestion of the spores could lead to gastrointestinal anthrax.
 Psittacosis or “parrot fever” is a respiratory infection that may be acquired from
infected birds (usually parakeets and parrots).
 Arthropods (insects and arachnids) are referred to as vectors. The arthropod vector may
first take a blood meal from an infected person or animal and then transfer the
pathogen to a healthy individual. Many different types of arthropods serve as reservoirs
of infection, including insects (e.g., mosquitoes, biting flies, lice, fleas), and arachnids
(e.g., mites, ticks).
Nonliving or inanimate reservoirs of infection include air, soil, dust, food, milk, water, and
fomites.

 Air can become contaminated by dust or respiratory secretions of humans expelled into
the air by breathing, talking, sneezing, and coughing. Air currents and air vents can
transport respiratory pathogens throughout healthcare facilities and other buildings.
Bacteria cannot multiply in the air, but can easily be transported by airborne particles to
a warm, moist, nutrient-rich site, where they can multiply.
 Dust particles can carry spores of certain bacteria and dried bits of human and animal
excretions containing pathogens. Some fungal respiratory diseases (e.g., histoplasmosis)
are frequently transferred by dust containing yeasts or spores.
 Soil contains the spores of the Clostridium species that cause tetanus, botulism, and gas
gangrene. Any of these diseases can follow the introduction of spores into an open
wound.
 Food and milk may be contaminated by careless handling, which allows pathogens to
enter from soil, dust particles, dirty hands, hair, and respiratory secretions. If these
pathogens are not destroyed by proper processing and cooking, food poisoning can
develop.
 Human and animal fecal matter from outhouses, cesspools, and feed lots is often
carried into water supplies. Improper disposal of sewage and inadequate treatment of
drinking water contribute to the spread of fecal and soil pathogens.
 Fomites are inanimate objects capable of transmitting pathogens. Fomites include
clothes, bedding, towels, eating and drinking utensils, etc., which become contaminated
by pathogens from the respiratory tract, intestinal tract, or the skin of patients. Even
telephones, doorknobs, and computer keyboards can serve as fomites.
 MODES OF TRANSMISSION
The five principal modes by which transmission of
pathogens occur are contact (either direct or indirect
contact), droplet, airborne, vehicular, and vector
transmission.
 Direct skin-to-skin contact. For example, the
common cold virus is frequently transmitted from
the hand of someone who just blew his or her
nose to another person by hand shaking.
 Direct mucous membrane-to-mucous membrane
contact by kissing or sexual intercourse. Most
STDs are transmitted in this manner. STDs include
syphilis, gonorrhea, and infections caused by
Figure 2. Modes of disease transmission
chlamydia, herpes, and HIV. Source: Burton’s Microbiology FTHS 9th ed.page 184
 Indirect contact via airborne droplets of
respiratory secretions, usually produced as a result of sneezing or coughing. Most contagious
airborne diseases are caused by respiratory pathogens carried to susceptible people in droplets
of respiratory secretions. Some respiratory pathogens may settle on dust particles and be
carried long distances through the air and into a building’s ventilation or air-conditioning
system.
 Indirect contact via food and water contaminated with fecal material.
 Indirect contact via arthropod vectors.
 Indirect contact via fomites that become contaminated by respiratory secretions, blood, urine,
feces, vomitus, or exudates from hospitalized patients.
 Indirect contact via transfusion of contaminated blood or blood products from an ill person or
by parenteral injection (injection directly into the bloodstream) using nonsterile syringes and
needles.

The World’s Worst Influenza Pandemic

The 1918–1919 Spanish flu pandemic (also known as the swine flu pandemic) killed an estimated
20 to 100 million people, worldwide—between 2.5% and 5% of the world population. The pandemic
killed between 2% and 20% of those infected compared with a mortality rate of about 0.1% for modern-
day flu epidemics. Although most victims of modern-day flu epidemics are very young, very old, and
immunosuppressed people, the 1918–1919 pandemic killed primarily healthy young adults. Scientists
have recovered the virus (designated A/H1N1) that caused the pandemic from frozen tissue samples,
and are currently studying it. They have discovered that the virus kills by causing an overreaction of the
body’s immune system. This could explain why healthy young adults with strong immune systems were
affected to a greater extent than those with weaker immune systems—very young, very old, and
Activity
immunosuppressed individuals.
Direction: Complete the table below by supplying the required information.

Scenario 1: Disease: Measles in 2025; Place: Dolphin Island; Population: 101,000; Positive cases: 567;
deaths connected to this disease: 35; total number of cases of the same disease on the previous years:
20.

Scenario 2: Disease: Polio in 2030; Place: Utopia; Population: 200,000; positive cases: 5 (in different
cities); deaths connected to this disease: 2; number of cases on the previous year:2; total number of
cases of the same disease on the previous years: 525.

Scenario 3: Place: Disease: Bacterial food poisoning in 2022; MV Princess Marinella Cruise ship;
Population: 1000; Patients who had diarrhoea: 257; number of deaths due to dehydration (effect of
prolonged diarrhoea): 29; total number of cases of the same disease before this event: 0.

*Disclaimer: The cases above are pure fiction.

Required Parameters Scenario 1 Scenario 2 Scenario 3

Classification of the disease
according to
transmissibility
Classification of the disease
according to occurrence
Incidence
Morbidity Rate (per 1000)
Period Prevalence
Mortality
Mortality rate (per 1000)
Case Fatality rate

References:
Burton’s Microbiology for the Health Sciences, 9th Edition
https://www.cdc.gov/flu/pandemic-resources/1918-commemoration/1918-pandemic-history.htm
https://www.who.int/news-room/fact-sheets/detail/tuberculosis
https://www.who.int/news-room/fact-sheets/detail/malaria
https://www.who.int/news-room/q-a-detail/hiv-aids
https://www.google.com/amp/outbreaknewstoday.com/philippines-dengue-outbreak-414k-cases-
through-november-2019/amp/
https://reliefweb.int/report/philippines/unicef-who-philippines-measels-outbreak-situation-report-11-
27-may-2019
https://www.who.int/news-room/commentaries/detail/modes-of-transmission-of-virus-causing-covid-
19-implications-for-ipc-precaution-recommendations