Principles of Infectious Diseases

Epidemiology
(1)
By
Prof. Amani Waheed
Topics:
• Principles of Infectious Diseases
Epidemiology
• Surveillance systems of communicable
diseases
• Preventive strategies of communicable
diseases
• Outbreak investigations
• Immunization
Objectives
• After completing these lectures, you should be able to:
• Define key concepts of infectious disease epidemiology
• Explain the relationship of an infectious agent to its host and
the environment
• Describe different modes of transmission
• Understand how common infectious agents are classified
• Identify Surveillance systems of communicable diseases
• Identify the Preventive strategies of communicable diseases
• Investigate Outbreak
• Describe Immunization types and programmes
• Describe the role of vaccination and other control measures in
preventing disease spread
• Infection occurs when an infectious agent enters a body and develops
or multiplies.
• Infectious agents are organisms capable of producing in-apparent
infection or clinically manifest disease and include bacteria, rickettsia,
chlamydiae, fungi, parasites, viruses, and prions.
• An infectious disease, or communicable disease, is an infection that
results in clinically manifest disease.

• Infectious disease may also be due to the toxic product of an infectious

agent, such as the toxin produced by Clostridium botulinum causing
classical botulism.
• Diseases considered are those that manifest in human hosts and are a
result of the interaction of people, animals, and their environment.

• Infectious diseases may be due to infectious agents exclusively found in

human hosts such as rubella virus, in the environment such
as Legionella pneumophila, or primarily in animals such as Brucella
abortus.
The epidemiology of infectious diseases include evaluation of
the factors
• leading to infection by an organism,
• affecting the transmission of an organism,
• associated with clinically recognizable disease among those
who are infected.

Both of incubation periods and reservoirs are essential in

epidemiology of communicable diseases.

Epidemiologic concepts such as the incubation period and

resistance were originally developed in studies of infectious
diseases and later applied to noninfectious diseases.
• Epidemiologic characterization is the first step in
defining a new disease although diseases can also be
classified according to their clinical or microbiologic
features.

• For the public health professional, it is the

epidemiologic features—for instance, the prevalence,
incidence, transmission route, and susceptible
populations—that are of paramount importance in
developing a control program.
In contrast, a clinician whose primary role is to treat a
disease may be more concerned with the clinical
symptoms or pathophysiology.

For example, an infectious agent that causes secretory

diarrhea will be treated empirically with fluid
replacement and symptomatic management of the
pathophysiology, irrespective of how the infection was
acquired or what the infectious organism is.

A microbiologist will be concerned primarily with the

characteristics of the organism and will focus on the
tasks of isolation, identification, and development of
targeted treatments.
• The control, treatment, and prevention of an epidemic
usually requires the cooperative efforts of all three
groups of specialists—
clinicians,
microbiologists, and
epidemiologists.

• However, each has a unique orientation and

contribution to make to this field. The perspectives
from each of these three areas of study can best be
appreciated by considering how infectious diseases
are classified by each specialist.
THE CLASSIFICATION OF INFECTIOUS
DISEASES

Clinical classification

Microbiological classification

Epidemiological classification
Infectious diseases Problem
• Infectious diseases remain a leading cause of morbidity,
disability, and mortality worldwide.
• Lower respiratory infections are the 3rd leading causes
of death worldwide (WHO).
• Their control is a constant challenge that faces health
workers and public health officials in both industrialized
and developing countries.
• Only one infectious disease, smallpox, was eradicated
and stands as a landmark in the history of the control of
infectious diseases. The international community is now
well down the path towards eradication of poliomyelitis
and dracunculiasis (Guinea worm infection).
• Other infectious diseases, like malaria and tuberculosis, foiled
eradication attempts or control efforts and are re-emerging as
increasing threats in many countries, including both
developing and developed countries.

• Multiple Drug Resistance problem increased with improper

use of antibiotics.

• Some infectious diseases, such as tetanus, will always be a

threat if control measures are not maintained.

• Newer infectious diseases, like AIDS, demonstrate the truth of

McNeill’s statement that infectious disease will remain ‘one of
the fundamental parameters and determinants of human
history’ McNeill (1976).
 Global burden of infectious diseases
• A WHO analysis of the global burden of disease estimates that
infectious diseases caused 12.3 million deaths, accounting for 21
per cent of total global mortality of 56.8 million deaths in 2008
(WHO 2008).
• Five diseases—lower respiratory infections, AIDS, diarrhoeal
diseases, tuberculosis, and malaria—account for some 81 per
cent of the total infectious disease burden.
• Most infectious disease (some 97 per cent) deaths occur in the
economically developing group of countries where approximately
a quarter of deaths are due to an infectious cause (WHO 2008).
• However, infectious diseases are also of importance in more
developed countries. In the United States, for example, influenza
still ranks as an important cause of death.
Relation between Infection and
Cancers
• For 2018, an estimated 2·2 million infection-attributable cancer
cases were diagnosed worldwide, corresponding to an infection-
attributable age-standardised incidence rates (ASIR) of 25·0 cases
per 100 000 person-years.
• Primary causes were Helicobacter pylori (810 000 cases, ASIR 8·7
cases per 100 000 person-years), human papillomavirus (690 000,
8·0), hepatitis B virus (360 000, 4·1) and hepatitis C virus (160 000,
1·7).
• Infection-attributable ASIR was highest in eastern Asia (37·9 cases
per 100 000 person-years) and sub-Saharan Africa (33·1), and lowest
in northern Europe (13·6) and western Asia (13·8). China accounted
for a third of worldwide cancer cases attributable to infection,
driven by high ASIR of H pylori (15·6) and hepatitis B virus (11·7)
infection.
• The cancer burden attributed to human papillomavirus showed the
clearest relationship with country income level (from ASIR of 6·9
cases per 100 000 person-years in high-income countries to 16·1 in
low-income countries).
Chain of infection: agent, transmission,
and host
• The chain of infection is the relationship between an
infectious agent, its routes of transmission, and a
susceptible host.

• The prevention and control of infectious diseases

depend upon the interaction of these three factors
that may result in the human host clinically
manifesting disease
 Chain of infection is the process that begins when an
agent leaves its reservoir or host through a portal of exit,
and is transported by some mode of transmission, then
enters through an appropriate portal of entry to infect a
susceptible host.
The epidemiological triad
 Agent
• The infectious agent is the first link in the chain of infection and
is any microorganism whose presence or excessive presence is
essential for the occurrence of an infectious disease. Examples of
infectious agents include the following:
• Bacteria
• Rickettsiae
• Chlamydiae
• Fungi
• Parasites
• Viruses
• Prions
• Agents can be described by their ability to infect
(infectivity), be transmitted (infectiousness), and
cause disease (pathogenicity) as well as their
ability to cause serious disease (virulence).

• The infectivity of an infectious agent is the extent

to which the agent can enter, survive, and
multiply in a host and is measured by the ratio of
the number of people who become infected to
the total number exposed to the agent.

• Rhinoviruses that can cause the common cold are

examples of infectious agents with high
infectivity.
• The infectiousness, or transmissibility, of an infectious
agent is the extent to which the agent can be
transmitted from one host to another.

• It is measured by the basic reproduction number

(known as R0) which is determined by the number of
secondary infections in a susceptible population that
result from a primary infection.

• Epidemic-prone diseases such as measles and

pertussis caused by measles virus and Bordatella
pertussis bacteria, respectively, are examples of
diseases due to highly infectious agents with an R0 of
10 or greater.
ReproductiveBasic
rate Epidemiology
of infection( Ro):
Basic Reproductive Number (Ro)
The expected number of secondary cases produced by a single
(typical) infection in a completely susceptible population.

It is affected by:

1-Virulence of the organisms

2-Immunity of susceptible
population
.

27
Basic reproductive rate decreasing, i.e.
<1. Un-sustained transmission: each
transmission gives rise to less than one new
case and the infection dies out
The pathogenicity of an infectious agent is the extent
to which clinically manifest disease is produced in an
infected population

It is measured by the ratio of the number of people

developing clinical illness to the total number infected.

Examples of highly pathogenic infectious agents are

the measles virus and the human (α) herpesvirus 3
(varicella-zoster) causing measles and chickenpox,
respectively, in which most infected susceptible people
will manifest disease.
The virulence of an infectious agent is the extent to
which severe disease is produced in a population with
clinically manifest disease.

It is the ratio of the number of people with severe and

fatal disease to the total number of people with
disease.

An example of a highly virulent infectious agent is HIV

whereby nearly all untreated people with AIDS will die.
Characteristics of infectious agents that affect
pathogenicity
include their ability to
• invade tissues (invasiveness),
• produce toxins (intoxication),
• cause damaging hypersensitivity (allergic) reactions,
• undergo antigenic variation,
• and develop antibiotic resistance.
• An example of an infectious agent with
high invasiveness is the Shigella organism which can
invade the submucosal tissue of the intestine and
cause clinically manifest shigellosis (bacillary
dysentery).
An example of an infectious agent that has a high degree of ability
to produce toxins is the Clostridium botulinum organism which can
elaborate toxins in inadequately prepared food and cause classical
botulism.

An example of an infectious agent that is highly allergenic is

the Mycobacterium tuberculosis organism which can cause
tuberculosis.

An example of an infectious agent that has a high degree

of antigenic variation is the type A influenza virus which frequently
experiences minor antigenic changes—antigenic ‘drift’.

Influenza A viruses, on an irregular basis, may also undergo a major

antigenic change creating an entirely new subtype—antigenic
‘shift’. Antigenic shifts that have the characteristic of high
transmissibility between people may result in an influenza
pandemic.
An example of an infectious agent that can
develop antibiotic resistance that challenges control
efforts is Neisseria gonorrhoeae that has both
chromosomally mediated and resistance transfer plasmid-
mediated genetic factors for antibiotic resistance.
 The infective dose
• The infective dose of an infectious agent is the number of
organisms needed to cause an infection.

• The infective dose may vary depending upon the route of

transmission and host susceptibility.

• An example of an infectious agent that needs only a very

low infective dose (as few as ten organisms) is Escherichia
coli O157:H7 which causes entero-haemorrhagic diarrhoea.

• An example of an infectious agent that needs a relatively

higher infective dose is Vibrio cholerae which requires
around 100 million bacteria to be ingested to cause cholera
disease in a healthy adult.
Examples of Control measures for infectious
diseases
• Control measures for infectious diseases directed at
inactivating the agent are designed according to the
type of agent and its reservoirs and sources.
• For example, an agent like Vibrio cholerae can be
inactivated through adequate chlorination of the
water supply. This is a chemical method for provision
of safe water to control cholera.
• An agent like hepatitis B virus can be inactivated
through adequate autoclaving of injection and surgical
equipment. This is a sterilization method to control
hepatitis B.
 Control measures for infectious diseases
is through breaking the chain of infection
• Infectious agents are spread from reservoirs or sources
to human hosts.

• A reservoir of an infectious agent is any person, other

living organism, or inanimate material in which the
infectious agent normally lives and grows.

• The source of infection for a host is the person, other

living organism or inanimate material from which the
infectious agent came.
Route of transmission

• Horizontal transmission refers to

transmission between individuals

• Vertical transmission refers to the specific

situation of transmission between parent to
offspring (e.g. transplacentally in utero,
during passage through the birth canal, or
through breast milk).
Route of transmission
1- Direct

2- Indirect
a. vehicle- born
b. vector- born

3- Air-born
 1- Direct transmission
• Direct and essentially immediate transfer of infectious
agents to a receptive portal of entry through which human
or animal infection may take place.
• This may be by direct contact such as touching, biting,
kissing or sexual intercourse, or through direct projections
(droplet spread) of droplet spray onto the conjunctiva or
onto the mucous membranes of the eye, nose or mouth
during sneezing, coughing, spitting, singing or talking
(risk of transmission in this manner is usually limited to a
distance of about 1 meter or less from the source of
infection).
Direct transmission may also occur through direct exposure
of susceptible tissue to an agent in soil, through the bite of a
rabid animal, or trans-placentally.
 2- Indirect transmission
a. Vehicle born
Contaminated inanimate materials or objects (fomites)
such as toys, handkerchiefs, soiled clothes, bedding, cooking
or eating utensils, surgical instruments or dressings; water,
food, milk, and biological products including blood, serum,
plasma, tissues or organs; or any substance serving as an
intermediate means by which an infectious agent is
transported and introduced into a susceptible host though a
suitable portal of entry.

The agent may or may not have multiplied or developed in

or on the vehicle before being transmitted
b. Vector-borne which are Mechanical & Biological
Mechanical: includes simple mechanical carriage by a
crawling or flying insect through soiling of its feet or
proboscis, or by passage of organisms through its
gastrointestinal tract. This does not require multiplication
or development of the organism.

Biological: propagation (multiplication), cyclic

development, or a combination of these
(cyclopropagative) is required before the arthropod can
transmit the infective form of the agent to humans.
 3- Airborne transmission
• The dissemination of microbial aerosols to a suitable portal of entry, usually
the respiratory tract.
• Microbial aerosols are suspensions of particles in the air consisting partially or
wholly of microorganisms.
• They may remain suspended in the air for long periods of time, some retaining
and others losing infectivity or virulence.
• Particles in the 1- to 5-micrometer range are easily drawn into the alveoli of
the lungs and may be retained there.
• Droplet nuclei: usually the small residues that result from evaporation of fluid
from droplets emitted by an infected host. They also may be created purposely
by a variety of atomizing devices, or accidentally as in microbiology
laboratories, abattoirs, rendering plants or autopsy rooms. They usually remain
suspended in the air for long periods.
• Dust: the small particles of widely varying size that may arise from soil (e.g.,
fungus spores), clothes, bedding, or contaminated floors
Route of entry
Some Infectious Diseases Spread by
Contact
• 1. Sexually transmitted diseases − Syphilis,
gonorrhea, chlamydia, AIDS
• 2. Staphylococcal infections
• 3. Streptococcal infections
• 4. Many nosocomial infections
• 5. Rhinovirus colds
• 6. Brucellosis (slaughter house contact)
• 7. Hepatitis B virus infection
Some Important Food- and Waterborne
Infections
1. Salmonellosis
2. Campylobacter
3. Shigellosis
4. Clostridium perfringens food poisoning
5. Staphylococcal enterotoxin food poisoning
6. Cholera
7. Giardiasis
Some Important Airborne Infections
1. Tuberculosis
2. Influenza
3. Childhood Infections − Measles, mumps,
rubella, pertussis
4. Parainfluenza
5. Legionella
Some Important Vector-borne Infections

1. Malaria
2. Viral encephalitis
3. Schistosomiasis
4. Tularemia
5. Dengue
6. Yellow fever
7. Rocky Mountain spotted fever
8. Leishmaniasis
9. Trypanosomiasis
Reservoirs of Infectious Diseases
1. Human

2. Animal (zoonoses)

3. Soil

4. Water
Some Infectious Diseases with a
Human Reservoir
1. AIDS (HIV infection)
2. Syphilis
3. Gonorrhea
4. Shigellosis
5. Typhoid fever
6. Hepatitis-B virus
7. Herpes simplex virus
Some Diseases with an Animal
Reservoir (Zoonoses)
1. Nontyphoidal salmonellosis
2. Brucellosis
3. Anthrax
4. Listeriosis
5. Viral encephalitis
6. Rabies
7. Plague
Some Important Diseases with a Soil
Reservoir
1. Histoplasmosis
2. Coccidioidomycosis
3. Blastomycosis
4. Tetanus
5. Botulism
Some Infectious Diseases with a
Water Reservoir
1. Pseudomonas infections − Sepsis, UTI, “hot
tub” folliculitis
2. Legionnaires’ disease
3. Melioidosis
Temporal Trend of Infectious Diseases

• Seasonal variation

• Annual variation

• Variation over decades

• Recent trends
Susceptible hosts and risk factors
• After an infectious agent gets inside the body it has to
multiply in order to cause the disease. In some hosts,
infection leads to the disease developing, but in others it
does not. Individuals who are likely to develop a
communicable disease after exposure to the infectious
agents are called susceptible hosts. Different individuals are
not equally susceptible to infection, for a variety of reasons.
• Factors that increase the susceptibility
Risk factors arise from outside the individual – for example,
poor personal hygiene, or poor control of reservoirs of infection
in the environment.
Factors such as these increase the exposure of susceptible
hosts to infectious agents, which makes the disease more likely
to develop eg injured skin, immune supression
• Additionally, some people in a community are more
likely to develop the disease than others, even though
they all have the same exposure to infectious agents.
This is due to a low level of immunity within the more
susceptible individuals. Immunity refers to the resistance
of an individual to communicable diseases, because
their white blood cells and antibodies (defensive
proteins) are able to fight the infectious agents
successfully.
Low levels of immunity could be due to:
• diseases like HIV/AIDS which suppress immunity
• poorly developed or immature immunity, as in very
young children
• not being vaccinated
• poor nutritional status (e.g. malnourished children)
• pregnancy.
Natural history of a communicable
disease
Period of Communicability is t he time during which an
infectious agent my be transmitted directly or indirectly
from an infected person to a susceptible person or
animal. Its length varies from one disease to another
Incubation Period is the period from exposure
to infection to the onset of symptoms or signs
of infectious disease.
The length of incubation period depends on:
• The portal of entry.
• The rate of growth of the organism in the
host.
• The dosage of the infectious agent.
• The host resistance.
States of infectious diseases
• Clinical State ( Symptoms &Signs)
• Cases are classified as Primary case, Index case,
Secondary cases. According to spectrum of disease
Clinical cases: (mild/severe-typical/atypical)
• Non- clinical State:
1* Preclinical ( will progress to clinical state)
2*Subclinical ( +ve serology only)
3* Persistent chronic disease (e.g., post polio
syndrome in adults)
4*latent disease( genetic messages of the agents
only persist in the host.
 Susceptible & Carrier Status
• Susceptible: A person or animal not possessing
sufficient resistance against a particular pathogenic
agent to prevent contracting infection or disease
when exposed to the agent.

• Carrier: A person or animal that harbors a specific

infectious agent without apparent clinical disease
and serves as potential source of infection.
• It occurs either due to inadequate treatment or
immune response, or the disease agent is not
completely eliminated, leading to a carrier state.
 Types of Carriers
• Asymptomatic (In-apparent) carrier: The carrier state that may
occur in an individual with an infection that is in-apparent
throughout its course. Examples: Polio virus, meningococcus,
hepatitis A virus.
• Incubatory, Convalescent, Post-Convalescent carriers: The carrier
state may occur during the incubation period, convalescence, and
post convalescence of an individual with a clinically recognizable
disease.
• Examples of Incubatory carrier: Measles, chickenpox
• Examples of convalescent carriers: Salmonella typhi, Diphtheria,
hepatitis B virus
• Healthy (chronic) carriers: They continue to harbor an agent for an
extended time (months or years) following the initial infection. The
most famous one was Mary Mallon who carried S tayphi and died in
1938 in NY. Another Examples is Hepatitis B virus
 Classification of Infectious Diseases
according to the occurrence
• Endemic: constant presence of a disease in a given
population

• epidemic: outbreak or occurrence of one specific

disease from a single source, in a group population,
community, or geographical area, in excess of the
usual level of expectancy

• outbreak: The unusual occurrence of a disease(in

excess of the expected) in a localized small area.

• pandemic: epidemic that is widespread across a

country, or large population, possible worldwide
(world- wide)
• A disease can either be epidemic or endemic.

• Epidemic diseases can be common source or propagated, but

by measuring the minimum and maximum incubation period
from the first case, the time of infection can be determined.

• The size of the population will determine the frequency of

epidemics and the number that need to be vaccinated to
produce herd immunity.

• An endemic disease is described by its incidence and

prevalence, but foci of infection can also occur.

• Mathematical models can look at different parameters of a

disease and deter-mine the best strategy for control.
Point source epidemic
Propagated source epidemic
Exotic diseases are those which are imported into a
country in which they do not otherwise occur, as for
example, rabies in the UK.

Hyperendemic and holoendemic

The term “hyperendemic” expresses that the disease is
constantly present at high incidence and/or prevalence
rate and affects all age groups equally.

The term “holoendemic” expresses a high level of infection

beginning early in life and affecting most of the child
population, leading to a state of equilibrium such that the
adult population shows evidence of the disease much less
commonly than do the children (e.g. malaria)
Sporadic
The word sporadic means “scattered about”.
The cases occur irregularly, haphazardly from time to time, and
generally infrequently.
The cases are few and separated widely in time and place that they
show no or little connection with each other, nor a recognizable
common source of infection e.g. polio, meningococcal meningitis,
tetanus….
However, a sporadic disease could be the starting point of an
epidemic when the conditions are favorable for its spread.
Zoonosis, epizootic and enzootic
Zoonosis is an infection that is transmissible under natural
conditions from vertebrate animals to man, e.g. rabies, plague,
bovine tuberculosis…..An epizootic is an outbreak (epidemic) of
disease in an animal population, e.g. rift valley fever. An Enzootic is
an endemic occurring in animals, e.g. bovine TB.
Nosocomial infections
Nosocomial (hospital acquired) infection is an infection
originating in a patient while in a hospital or another
health care facility. It has to be a new disorder unrelated
to the patient’s primary condition. Examples include
infection of surgical wounds, hepatitis B and urinary tract
infections.
Opportunistic infection
This is infection by organisms that take the opportunity
provided by a defect in host defense (e.g. immunity) to
infect the host and thus cause disease. For example,
opportunistic infections are very common in AIDS.
Organisms include Herpes simplex, cytomegalovirus, M.
tuberculosis….