4.

Modeling to inform Disease and

Elimination
– Magister FK USU
Dr. Dra. Esther Sorta Mauli Nababan, M.Sc.
Outline :
• Mathematical Model
• Modeling the Spread of Disease with Mathematics
• Disease and Elimination
What is Model?
Why do we model ?
Why do we model ?
A Fundamental Principle of Modeling
The Modeling Process
Simplify VS Complexity
The Roadmap

v Why do we need mathematical models in infectious

diseases epidemiology?
v Impact of vaccination direct and indirect effects
v Potential for spread and disease elimination
v A model for Hepatitis A
v Mathematical models in infectious diseases
epidemiology and semi-algebraic methods
The Roadmap
vA population-based model integrates knowledge and
data about an infectious disease
vnatural history of the disease,
vtransmission of the pathogen between individuals,
epidemiology, in order to
vbetter understand the disease and its
population-level dynamics
vevaluate the population-level impact of
interventions vaccination, antibiotic or
antiviral treatment, quarantine, bednet (ex
malaria), mask (ex SARS, influenza),
vWe can describe mechanistic models, i.e models that try to
capture the underlying mechanisms (natural history,
transmission, )
vin order to better understand/predict th evolution of thee
disease in the population.
vThese models are dynamic ? they can account for both
direct and indirect herd protection effects induced by
vaccination.
Modeling can help to ...

vModify vaccination programs if needs change

vExplore protecting target sub-populations by vaccinating others
vDesign optimal vaccination programs for new vaccines
vRespond to, if not anticipate changes in epidemiology that may
accompany vaccination
vEnsure that goals are appropriate, or assist in revising them
vDesign composite strategies,
vWalter Orenstein, former Director of the National Immunization
Program in the Center for Diseases Control (CDC)
Types of Epidemiological Models
Simplest Epidemiological Models
Deterministic versus Stochastic
Why is Modeling Difficult?
Limitations of Models
Sucesses and Failures of Models
Sucesses and Failures of Models
Summary
B. Modelling the spread of diseases with mathematics

• Mathematicians try to find ways to model how diseases spread.

• The Standing Disease (an activity in the presentation
Epidemics: Introduction) is a simple way to do thisdrop.

Deaths
800
600
400
200

Weeks
5 10 15 20 25 30
Modelling the spread of diseases with mathematics
• Mathematicians try to find ways to model how diseases
spread.
• The Standing Disease (an activity in the presentation
Epidemics: Introduction) is a simple way to do this …
• … but it doesn’t explain why after a rapid rise in infections
there is a peak, and then the rate of infection starts to drop.

Deaths
800
600
400
200

5 10 15 20 25 30Weeks
 R0 Reproductive Ratio R0

Definition: Average number of people an infected

person infects at the start of an epidemic.

What is R0 for the

Standing Disease?
 R0 Reproductive Ratio R0

Definition: Average number of people an

infected person infects at the start of an
epidemic.

R0 = 2
 R0 Reproductive Ratio R0

Definition: Average number of people an

infected person infects at the start of an
epidemic.
Deaths
R0 = 2 800
600
400
200 R0 = ??
Weeks
5 10 15 20 25 30
 R0 Reproductive Ratio R0

R0 is a measure of how quickly an epidemic

will take off…
 R0 Reproductive Ratio R0
R0 is a measure of how quickly an epidemic
will take off…
 R0 Reproductive Ratio R0
R0 is a measure of how quickly an epidemic
will take off…
 R0 Reproductive Ratio R0
R0 is a measure of how quickly an epidemic
will take off…

R0 > 1
Cases increase
each step
 R0 Reproductive Ratio R0
R0 is a measure of how quickly an epidemic
will take off…

R0 > 1
Cases increase
each step
 Discussion

So we can understand the

start of an outbreak
(wabah), but what
happens next?
• Why does the number of
cases peak and then
decrease?
• Is there no one left to
infect?
• Has the disease changed
its nature?
Discussion
So we can understand the
start of an outbreak, but
what happens next?
• Why does the number of
cases peak and then
decrease?
• Is there no one left to
infect?
• Has the disease changed
its nature?

Make a mathematical model

to explore what is happening …
 26-Card Epidemic
1. Put the 26 black cards down in a pile face up.
2. Put the 26 red cards in a pile face down – this is your population.
3. Pick one card from this population and put it facing up on the table – this is the first infection (step 0).
4. It will be red, so replace it with a black card – this represents that person, now recovered and back in
the general population.
5. Shuffle the population cards, and put two cards face up on the table. These are the new infections
(step 1).
6. Put any black cards back into the population pack – these people are now immune, so won’t get the
infection again. Replenish the population pack with black cards to replace the red ones you’ve put
down.
7. Repeat items 5 and 6 until you pick only black cards. This is the end of the epidemic, when there are
no new infections.
8. Plot a graph to show how many new infections there are at each step.
9. Look at the shape of your graph. Does it look at all similar to the one on the right below?
Infections

Step 0 1 2 3 4 Time
 26-Card Epidemic
• What is the significance of keeping the population at 26?
• Any patterns?
• initial steps
• overall shape of graph
• duration
• variability
• What is the probability that no one new is infected at step 2?
• How might things change if:
• more than one person is infected at the start
• you have more cards
• each infected person infects 3 or 4 people rather than 2
• Is this a realistic model?
• How could you improve it?
Infections

Time
Step 0 1 2 3 4
 Model
Everyone starts here:
Susceptible
not yet infected
 Model
Everyone starts here:
Susceptible
not yet infected
Transmission

These people are unwell

and can infect others
Infected
 Model
Everyone starts here:
Susceptible
not yet infected
Transmission

These people are unwell

and can infect others
Infected

Recovery

People recover & become

immune to infection
Recovered
 Model
Everyone starts here:
Susceptible
not yet infected
Transmission

These people are unwell

and can infect others
Infected

Recovery

People recover & become

immune to infection
Recovered

Need to make assumptions about how people mix together.

The Network Disease
The Network Disease

• Like the Standing Disease but:

- before starting, everyone writes down the names of two other
people in the room.
• The first case picks the two they’ve written down to infect.
• The next generation stands up and each pick their two… and so on.

•How is this different from the standing

disease?
•How many steps to infect everyone?
 Challenge the models

•Are they realistic enough?

•What else might be
important?

4000
3500
R0
3000
2500
2000
1500
1000
500
0
0 5 10 15
C. Disease and Elimination
Berlin (Dahlem) Conference 1997, Atlanta Conference 1998
Ø Extinction: The specific infectious agent no longer exists in nature or the laboratory.
Ø Eradication: Permanent reduction to zero of the worldwide incidence of infection
caused by a specific agent as a result of deliberate efforts; intervention measures are
no longer needed.
Ø Elimination of Infection: Reduction to zero of the incidence of infection caused by a
specific agent in a defined geographic area as a result of deliberate efforts; continued
measures to prevent reestablishment of transmission are required.
Ø Elimination of Disease: Reduction to zero of the incidence of a specified disease in a
defined geographic area as a result of deliberate efforts; continued intervention
measures are required.
Ø Control: Reduction of disease incidence, prevalence, morbidity, or mortality to a locally
acceptable level as a result of deliberate efforts; continued intervention measures are
required to maintain the reduction.
Some Diseases that are Eliminated :
Strategis Include :
mass drug administration

control of illness levels Depending on

the disease
vector control

social mobilization and

education
Some Disease that can be eliminated
In summary:
Elimination and eradication programs are laudable goals, but they carry with
them an awesome responsibility. There is no room for failure. Careful and
deliberate evaluation is a prerequisite before embarking on any program.
Elimination and eradication are the ultimate goals of public health. The only
question is whether these goals are to be achieved in the present or some future
generation.