Comm 819 Infectious Disease Epidemiolgy

COMM 819: (Infectious Disease Epidemiology)
Distance Learning Centre

AHMADU BELLO UNIVERSITY
ZARIA, NIGERIA
COURSE MATERIAL
FOR
Master’s in Public health
Course Code &Title: COMM 819 (Infectious Diseases

Epidemiology)
Distance Learning Centre A.B.U, Course Materials i

© 2021 Ahmadu Bello University (ABU) Zaria, Nigeria
All rights reserved. No part of this publication may be reproduced in any form or
by any means, electronic, mechanical, photocopying, recording or otherwise
without the prior permission of the Director, Distance Learning Centre,
Ahmadu Bello University, Zaria, Nigeria.
Published and Printed by

Ahmadu Bello University Press Limited,
Zaria, Kaduna State, Nigeria.
Tel: 0806594711.
E-mail: abupresslimited2005@yahoo.co.uk;
Abupresss2013@gmail.com; Website: www.abupress.com.ng
Distance Learning Centre A.B.U, Course Materials ii

Acknowledgement
We acknowledge the use of the Courseware of the “Training Guide for
Environmental and Occupational Health Students, Ethiopia Produced in
collaboration with the Ethiopia Public Health Training Initiative, The Carter
Center, the Ethiopia Ministry of Health, and the Ethiopia Ministry of
Education” as the primary resource. Internal reviewers in the Ahmadu Bello
University who extensively reviewed and enhanced the material have been duly
listed as members of the Courseware development team.
Revised By: Dr. Abdullateef Yusuf
Distance Learning Centre A.B.U, Course Materials iii

Course writers/
Development team
Editor
Prof. M.I Sule
Course Materials Development Overseer

Dr. Usman Abubakar Zaria
Subject Matter Expert

Dr Abdullateef Yusuf
Subject Matter Reviewer

Rahamatu Shamsiyyah Iliya
Language Reviewer
Enegoloinu Ojokojo
Instructional Designers/Graphics
Dr Abdullateef Yusuf
Course Coordinator
Rahamatu Shamsiyyah Iliya
ODL Expert
Prof. Adamu Z. Hassan
Distance Learning Centre A.B.U, Course Materials iv

Contents
Title Page - - - - - - - - - -i
Copyright Page - - - - - - - - - ii
Course Writers/Development Team - - - - - - - iii
Quote - - - - - - - - - - - iv
Contents - - - - - - - - - -v
Course Study Guide - - - - - - - - -vi
i. Course Information - - - - - - - vi
ii. Course Introduction and Description - - - - - vi
iii. Course Prerequisites - - - - - - - vii
iv. Course Learning Resources - - - - - - vii
v. Course Objectives and Outcomes - - - - - - viii
vi. Activities to Meet Course Objectives - - - - - viii
vii. Time (To complete Syllabus/Course) - - - - - ix
viii. Grading Criteria and Scale - - - - - - ix
ix. OER Resources - - - - - - -x
x. ABU DLC Academic Calendar - - - - - - xii
xi. Course Structure and Outline - - - - - - xiii
xii. STUDY MODULES - - - - - - -1
MODULE 1: Introduction to Basic Concept of Infectious Diseases Epidemiology -2
Study Session 1: Basic Concept, Definition and Methods in Epidemiology - - 2-18
Study Session 2: Transmission and Chain of Infection - - - - - 19-37
Study Session 3: Host Factor in Infectious Diseases - - - - - 38-45
Study Session 4: Surveillance and Outbreak Investigations of Infectious Diseases - - 46-84
MODULE 2: Infectious Diseases - - - - - - - 85

Study Session 1: Oral-Faecal Transmitted - - - - - - 85-109
Study Session 2: Arthropod or Intermediate Vector-Borne Transmitted - - - 112-152
Study Session 3: Sexually Transmitted - - - - - - - 153-168
Study Session 4: Food-Borne Transmitted - - - - - - 169-176
MODULE 3: Screening, Prevention and Management of Diseases - - - 177

Study Session 1: Screening for Diseases - - - - - - - 177-183
Study Session 2: Prevention and Control of Communicable Diseases - - - 184-194
Study Session 3: Management of Communicable Diseases - - - - 195-199
Study Session 4: Neglected Tropical Diseases - - - - - - 200-220
Study Session 5: History of Emerging and Re-Emerging Infectious
Diseases Outbreaks in Nigeria - - - - - - 221-236
XIII. Glossary - - - - - - - - - 237
Distance Learning Centre A.B.U, Course Materials v

Course Study Guide

i. COURSE INFORMATION
Course Code: MPH 813
Course Title: Infectious Disease epidemiology
Credit Units: 3
Year of Study: One
Semester: 1st Semester
ii. COURSE INTRODUCTION AND DESCRIPTION

Introduction:
This course COMM 819 is a 3 credit unit course which is compulsory for all
MPH Epidemiology students. The course encompasses basic concepts and
methods of infectious disease epidemiology. The courseware provides a good
guide to understand basic concept of epidemiology, infectious diseases
epidemiology, transmission, prevention control and management.
communicable diseases prevention and neglected tropical diseases transmission
and prevention strategies and emerging and re-emerging diseases in Nigeria. It
will be a reference book to medical students and students of allied courses as
well as other researchers in Medicine and Community Health.
On the other hand, a clinician whose primary role is to treat an individual
patient may be more concerned with the clinical symptoms or
pathophysiology of the disease. For example, an infectious agent that causes
secretory diarrhoea will be treated empirically with fluid replacement and
symptomatic management of the pathophysiology, irrespective of how the
infection was acquired or what the organism is.
The course will focus on the key concepts of infectious diseases as well as
methods used in infectious disease control as applied to public health. It will
introduce the basic methods for infectious disease epidemiology and case
studies of important disease syndromes and entities. Methods include
definitions and nomenclature, outbreak, investigations, disease surveillance,
case control studies, cohort studies, laboratory diagnosis, molecular
epidemiology, dynamics of transmission, and assessment of vaccine field
effectiveness. Case studies focus on acute respiratory infections, diarrhoeal
disease, hepatitis, HIV, tuberculosis, sexually transmitted diseases, ebola,
malaria, and other vector borne diseases.
Distance Learning Centre A.B.U, Course Materials vi

iii. COURSE PREREQUISITES

You should note that although this course has no subject pre-requisite, you
are expected to have:
1. Satisfactory level of English proficiency
2. Basic Computer Operations proficiency
3. Online interaction proficiency
4. Web 2.0 and Social media interactive skills
iv. COURSE LEARNING RESOURCES

i. Course Textbooks
Aintablian N, Walpita P, Sawyer MH (1998) Detection of Bordetella
pertussis and Respiratory syncytial virus in air samples from hospital
rooms. Infect Control Hosp Epidemiol 19:918–923
Alland D, Kalkut GE, Moss AR, McAdam RA, Hahn JA, Bosworth
W, Drucker E, Bloom BR (1994) Transmission of tuberculosis in
New York City. An analysis by DNA fingerprinting and conventional
epidemiologic methods. NEJM 330(24):1710–1716
American Academy of Pediatrics (AAP) (2006) In: Pickering LK (ed)

Red book: 2006 report of the committee on infectious diseases, 27th
edn. AAP, Elk Grove Village
American Public Health Association (2008) In: Heymann DL (ed)

Control of communicable diseases manual, 19th edn. United Book
Press Inc, Baltimore
Anderson RM, May RM (1991) Infectious diseases in humans:

transmission and control. Oxford University Press, Oxford
Balsamo G, Michaels S, Sokol T, Lees K, Mehta M, Straif-Bourgeois

S, Hall S, Krishna N, Talati G, Ratard R (2003) West Nile epidemic
in Louisiana in 2002. Ochsner Health J 5(3):13–15
Boelaert M, Arbyn M, Van der Stuyft P (1998) Geographical

Information System (GIS), gimmick or tool for health district
management? Trop Med Int Health 3(3):163–165
Distance Learning Centre A.B.U, Course Materials vii

Brachman PS (1998) Epidemiology of nosocomial infections,

Chapter 1:3. In: Bennett JV, Brachman PS (eds) Hospital infections,
4th edn. Lippincott-Raven Publishers, Philadelphia
Buehler JW, Hopkins RS, Overhage JM, Sosin DM, Tong V (2004)
Framework for evaluating public health surveillance systems for
early detection of outbreaks. Recommendations of a CDC Working
Group, MMWR 53 (RR05) May 7
CDC (1985) Update: International outbreak of restaurant-associated

botulism – Vancouver, British Columbia, Canada. MMWR
34(41):643
ii. Course Journals
The Lancet Journal of Infectious Diseases
https://www.thelancet.com/journals/laninf/home
International Journal of Infectious Diseases https://www.ijidonline.com/
The Journal of Infectious Diseases Oxford Academic

https://academic.oup.com/jid
v. COURSE OUTCOMES
After studying this course, you should be able to:
1. Describe infectious disease and mode of transmission
2. Manage communicable diseases
3.Describe disease prevention and control
4. Give account of emerging and re-emerging diseases in Nigeria
vi. ACTIVITIES TO MEET COURSE OBJECTIVES

Specifically, this course shall comprise of the following activities:
1. Studying courseware
2. Listening to course audios
3. Watching relevant course videos
4. Field activities, industrial attachment or internship, laboratory
or studio work (whichever is applicable)
5. Course assignments (individual and group)
6. Forum discussion participation
7. Tutorials (optional)
8. Semester examinations (CBT and essay based).
Distance Learning Centre A.B.U, Course Materials viii
vii. TIME (TO COMPLETE SYLABUS/COURSE)

To cope with this course, you would be expected to commit a minimum of X
hours daily for the Course.
viii. GRADING CRITERIA AND SCALE

Grading Criteria
A. Formative assessment
Grades will be based on the following:
Individual assignments/test (CA 1,2 etc) 20
Group assignments (GCA 1, 2 etc) 10
Discussions/Quizzes/Out of class engagements etc 10
B. Summative assessment (Semester examination)
CBT based 30
Essay based 30
TOTAL 100%
C. Grading Scale (as appropriate for the course):
A = 70-100
B = 60 – 69
C = 50 - 59
F = 0-49
D. Feedback
Courseware based:
1. In-text questions and answers (answers preceding references)
2. Self-assessment questions and answers (answers preceding references)
Tutor based:
1. Discussion Forum tutor input
2. Graded Continuous assessments
Student based:
1. Online programme assessment (administration, learning resource,
deployment, and assessment).
IX LINKS TO OPEN EDUCATION RESOURCES

OSS Watch provides tips for selecting open source, or for procuring free or
open software.
Distance Learning Centre A.B.U, Course Materials ix

SchoolForge and SourceForge are good places to find, create, and publish open
software. SourceForge, for one, has millions of downloads each day.
Open Source Education Foundation and Open Source Initiative, and other
organisation like these, help disseminate knowledge.
Creative Commons has a number of open projects from Khan
Academy to Curriki where teachers and parents can find educational materials
for children or learn about Creative Commons licenses. Also, they recently
launched the School of Open that offers courses on the meaning, application,
and impact of "openness."
Numerous open or open educational resource databases and search engines
exist. Some examples include:
 OEDb: over 10,000 free courses from universities as well as reviews of colleges
and rankings of college degree programmes
 Open Tapestry: over 100,000 open licensed online learning resources for an
academic and general audience
 OER Commons: over 40,000 open educational resources from elementary
school through to higher education; many of the elementary, middle, and high
school resources are aligned to the Common Core State Standards
 Open Content: a blog, definition, and game of open source as well as a friendly
search engine for open educational resources from MIT, Stanford, and other
universities with subject and description listings
 Academic Earth: over 1,500 video lectures from MIT, Stanford, Berkeley,
Harvard, Princeton, and Yale
 JISC: Joint Information Systems Committee works on behalf of UK higher
education and is involved in many open resources and open projects including
digitising British newspapers from 1620-1900!
Other sources for open education resources
Universities
 The University of Cambridge's guide on Open Educational Resources for
Teacher Education (ORBIT)
 OpenLearn from Open University in the UK
Global
 Unesco's searchable open database is a portal to worldwide courses and research
initiatives
Distance Learning Centre A.B.U, Course Materials x
 African Virtual University (http://oer.avu.org/) has numerous modules on

subjects in English, French, and Portuguese
 https://code.google.com/p/course-builder/ is Google's open source software that
is designed to let anyone create online education courses
 Global Voices (http://globalvoicesonline.org/) is an international community of
bloggers who report on blogs and citizen media from around the world,
including on open source and open educational resources
Individuals (which include OERs)
 Librarian Chick: everything from books to quizzes and videos here, includes
directories on open source and open educational resources
 K-12 Tech Tools: OERs, from art to special education
 Web 2.0: Cool Tools for Schools: audio and video tools
 Web 2.0 Guru: animation and various collections of free open source software
 Livebinders: search, create, or organise digital information binders by age,
grade, or subject (why re-invent the wheel?)
Distance Learning Centre A.B.U, Course Materials xi

X. ABU DLC ACADEMIC CALENDAR/PLANNER
N.B: - All Sessions commence in January

- 1 Week break between Semesters and 6 Weeks vocation at end of session.
- Semester 3 is OPTIONAL (Fast-tracking, making up carry-overs & deferments)
Distance Learning Centre A.B.U, Course Materials xii

XI. COURSE STRUCTURE AND OUTLINE

Course Structure
WEEK/DAYS MODULE STUDY SESSION ACTIVITY
1. Read Courseware for the Corresponding Study Session.

2. View the Video(s) on this Study Session
3. Listen to the Audio on this Study Session
Study Session 1: 4. View any other Video/YouTube
https://www.youtube.com/watch?v=jcmC9hzdqag
Day1 Title Basic https://www.youtube.com/watch?v=RwiQHTrS_RY
Concept, Definition https://www.youtube.com/watch?v=g3bnalKL7II
and Methods in 5. View referred OER(address/site??????)
Epidemiology 6. View referred Animation (Address/Site?????)
Pp 2-18 7. Read Chapter/page of Standard/relevant text.
8. Any additional study material
9. Any out of Class Activity
1. Read Courseware for the corresponding Study Session.
Day 2 Study Session 2 4. View any other Video/YouTube
https://www.youtube.com/watch?v=IBX3jj2uUjo
Title: Transmission https://www.youtube.com/watch?v=v9vRF160Jto
and Chain of https://www.youtube.com/watch?v=Y46BxHZa2gQ
STUDY Infection
5. View referred OER
MODULE Pp 19-37 6. View referred Animation
1 7. Read Chapter/page of Standard/relevant text.
Day3 Study Session 3 4. View any other Video/YouTube
https://www.youtube.com/watch?v=qnmfZuKHatg
Title: : Host Factor https://www.youtube.com/watch?v=zJcSv8iOugk
in Infectious https://www.youtube.com/watch?v=45xUMwEWfIM
Diseases 5. View referred OER
Pp 38-45 6. View referred Animation
7. Read Chapter/page of Standard/relevant text.
https://www.youtube.com/watch?v=MLqZum55Hx0
Title: Surveillance https://www.youtube.com/watch?v=LdJXHZaAUr8
and Outbreak 5. View referred OER
Investigations of
Distance Learning Centre A.B.U, Course Materials xiii
Infectious Diseases 6. View referred Animation

Study Session 1 3. Listen to the Audio on this Study Session
Day 5 Title: Oral-Faecal 4. View any other Video/YouTube
Transmitted https://www.youtube.com/watch?v=6uDH1LmVztI
Pp 85-109 5. View referred OER
6. View referred Animation
STUDY 1. Read Courseware for the corresponding Study Session.
MODULE Study Session 2 3. Listen to the Audio on this Study Session
Day 6 2 4. View any other Video/YouTube
Title: Arthropod or
Intermediate https://www.youtube.com/watch?v=DhbBjQSuLYk
Vector-Borne
Transmitted
Study Session 3 4. View any other Video/YouTube
https://www.youtube.com/watch?v=5eq6ytzjahk
Day7 Title: Sexually https://www.youtube.com/watch?v=ngMq-BUvVVA
Transmitted https://www.youtube.com/watch?v=LZ7ML3gwf0g
https://www.youtube.com/watch?v=3gi2IU520KA
Title: Food-Borne https://www.youtube.com/watch?v=iIaKWNZhz74
Transmitted https://www.youtube.com/watch?v=RV-IxADqsTY
Pp 169-176 5. View referred OER
Distance Learning Centre A.B.U, Course Materials xiv

Day 9 Title: Screening for 4. View any other Video/YouTube
Diseases https://www.youtube.com/watch?v=9r-4_hGlSfw
STUDY
MODULE 2. View the Video(s) on this Study Session
3 3. Listen to the Audio on this Study Session
Day 10 Study Session 2 4. View any other Video/YouTube
Title: Prevention https://www.youtube.com/watch?v=LBkXQ_mBO3Q
and Control of
Communicable
Diseases
Pp 184-194 8. Any additional study material
Day 11 Title: Management 4. View any other Video/YouTube
of Communicable https://www.youtube.com/watch?v=EQTnPzG8TYk
Diseases
Day 12 Title: Neglected 4. View any other Video/YouTube
Tropical Diseases https://www.youtube.com/watch?v=4-eXjKlCeCA
Distance Learning Centre A.B.U, Course Materials xv


Study Session 5 4. View any other Video/YouTube
https://www.youtube.com/watch?v=5pScf7xk3I8
Day 13
Title: History ofhttps://www.youtube.com/watch?v=8qPj3KO_KPo
Emerging and Re- https://www.youtube.com/watch?v=8swAWixSQPs
Emerging 5. View referred OER(address/site??????)
Infectious 6. View referred Animation (Address/Site?????)
Diseases 7. Read Chapter/page of Standard/relevant text.
Outbreaks in 8. Any additional study material
Nigeria 9. Any out of Class Activity
Pp 221-236
Week 13 REVISION/TUTORIALS (On Campus or Online) &

CONSOLIDATION WEEK
Week 14& 15 SEMESTER EXAMINATION
Distance Learning Centre A.B.U, Course Materials xvi

Course Outline
MODULE 1: Introduction to Basic Concept of Infectious Diseases
Epidemiology
Study Session 1: Basic Concept, Definition and Methods in Epidemiology
Study Session 2: Transmission and Chain of Infection
Study Session 3: Host Factor in Infectious Diseases
Study Session4: Surveillance and Outbreak Investigations of Infectious Diseases
MODULE 2: Infectious Diseases

Study Session 5: Oral-Faecal Transmitted
Study Session 6: Arthropod or Intermediate Vector-Borne Transmitted
Study Session 7: Sexually Transmitted
Study Session 8: Food-Borne Transmitted
MODULE 3: Screening, Prevention and Management of Diseases

Study Session 9: Screening for Diseases
Study Session 10: Prevention and Control of Communicable Diseases
Study Session 11: Management of Communicable Diseases
Study Session 12: Neglected Tropical Diseases
Study Session 13: History of Emerging and Re-Emerging Infectious Diseases
Outbreaks in Nigeria
Distance Learning Centre A.B.U, Course Materials 1

Study Modules
1.0 MODULE 1: Introduction to Basic Concept of Infectious Diseases
Epidemiology
Contents:
Study Session 1: Concept and Methods in Epidemiology
Study Session 2: Transmission and Chain of Infection
Study Session 3: Host Factor in Infectious Diseases
Study Session 4: Surveillance and Outbreak Investigations of Infectious
Diseases
Study Session 1
Concept and Methods in Epidemiology
Section and Subsection Headings:
Introduction
1.0 Learning Outcomes
2.0 Main Content
2.1 – Definition of epidemiological terms
2.2- Type of epidemiological studies
2.3- Natural history of infectious diseases
2.4- concepts from exposure to disease
3.0 Summary/Conclusion
4.0 Self-Assessment Questions
5.0 Additional Activities (Videos, Animations & Out of Class activities)
6.0 References/Further Readings
Introduction
I welcome you once again to this course MPH813 (Infectious Disease
Epidemiology) it is a three (3) credit unit, compulsory for all students
specialising in Epidemiology for Masters of Public Health (MPH) programme.
in this study session, we are going to discuss some basic concept of
epidemiology, definition of some epidemiological terms, methods used in
epidemiological studies, natural history of infectious diseases and basic
concepts used during exposure to a disease.

1.0 Study Session Learning Outcomes

After studying this session, I expect you to be able to
1. Define important terms used in infectious diseases epidemiology
2. Describe methods used in epidemiological studies.
3. explain terms used during exposure to disease
2.0 Main Content

2.1 Concepts ln Epidemiology
Epidemiology describes the distribution of health outcomes and determinants
for a purpose. It is important to question the goals and objectives of all
epidemiological activities and tailor these activities to meet these objectives.
The description of disease patterns includes analysis of demographic,
geographical, social, seasonal, and other risk factors.
Age groups to be used differ depending on the disease; for example, diseases
affecting young children should have numerous age groups among children;
sexually transmitted diseases require detailed age groups in late adolescence
and early adulthood. Younger age groups may be lumped together for diseases
affecting mainly the elderly. Gender categorization, while important for
sexually transmitted diseases and other diseases with a large gender gap (such
as tuberculosis), may not be important for numerous other diseases.
Geographical distribution is important to describe diseases linked to
environmental conditions but may not be so useful for other diseases.
Epidemiology is the study of the distribution and determinants of health-related
states, conditions, or events in specified populations and the application of the
results of this study to the control of health problems.
Image source: Google
It is a quantitative science concerned in infectious diseases with the

circumstances under which disease processes occur, the factors that affect their
incidence and the host response to the infectious agent, and the use of this
knowledge for control and prevention. It includes the pathogenesis of disease in
both the community and the individual. For infectious diseases, one must study
the circumstances under which both infection and disease occur, for these may
be different. Infection is the consequence of an encounter of a potentially
pathogenic microorganism with a susceptible human host through an
appropriate portal of entry and usually involves a demonstrable host response to
the agent. Exposure is the key factor, and the sources of infection lie mostly
outside the individual human host, within the environment, or in other infected
hosts. Disease represents one of the possible consequences of infection, and the
factors important in its development are mostly intrinsic to the host, although
the dosage and virulence of the infecting microbe play a role. These intrinsic
factors include the age at the time of infection, the portal of entry, the presence
or absence of immunity, the vigour of the primary defence system, the
efficiency and nature of humoral and cell-mediated immune responses, the
genetic makeup of the host, the state of nutrition, the presence of other diseases,
and psychosocial influences. These factors that result in the occurrence of
clinical illness among those infected have been called the “clinical illness-
promotion factors,” and many of them remain unknown. The host responses can
include death, the classic clinical features of the disease, mild or atypical forms,
subclinical and inapparent infections, and the carrier state, which may exist in
the absence of a detectable host response. While the clinician is primarily
concerned with disease, the epidemiologist is interested in both infection and
disease. Infection without disease is a common phenomenon, so that a study
limited to clinical illness alone would give an incomplete epidemiological
picture and would be a poor basis for control and prevention.
A full understanding involves the pathogenesis of the process leading to
clinical disease both in the community and in the individual. The concepts of
epidemiology in bacterial infections are very similar to those of viral infections
as expounded in the companion volume, Viral Infections of Humans, so there
will be overlap and repetition in this volume. Some of the differences between
viral and bacterial infection include the intracellular position of all viruses, their
smaller size, the requirement of living tissues for viral multiplication, the ease
with which many viruses are spread by respiratory routes or by insect vectors,
the relatively high order of immunity following viral infection, the usefulness of
serological tests for the diagnosis of most viral infections, and the failure of
viral infections to respond to antibiotic therapy. Highly sensitive and specific
molecular methods are being increasingly employed to define the agent and the
host response to it. Many concepts and methods of epidemiology apply to both
infectious and non-infectious diseases, and there should be no essential
dichotomy between the two. In general, epidemiology can be regarded as the
development, pathogenesis, and expression of infection and disease in a

community in much the same way as clinical medicine is concerned with the
development, pathogenesis, and expression in the individual. This book will
attempt to cover both these aspects. While the “epidemiology of infectious
diseases” has disappeared from the curriculum of many schools of medicine and
public health in developed countries, the current epidemic of the acquired
immunodeficiency syndrome (AIDS) has reawakened interest in the subject. In
addition, the emergence of new diseases such as Legionnaires’ disease, Lyme
disease, the toxic shock syndrome and the development of antibiotic-resistant
pneumococci and tubercle bacilli, the appearance of erythrogenic streptococci
(“flesh-eating” streptococci) and a new cholera strain termed 0139, foodborne
outbreaks of Escherichia coli O157:H7, and a large waterborne outbreak of
cryptosporidiosis are among the “emerging infections” that continue to pose
challenges to epidemiologists and for which the Centers for Disease Control and
Prevention (CDC) are developing preventive strategies. It is becoming apparent
that in developed countries, the continuing, and in some instances the
increasing, importance of infectious diseases is causing concern among public
health authorities. In developing countries, infectious diseases are still a major
cause of morbidity and mortality, and efforts are in progress to develop training
programs in epidemiology and in surveillance in such areas. The Field
Epidemiology Training Program of the CDC is a fine example of this effort.
Several recent texts address the problems of surveillance.
2.1 Definitions of epidemiological terms
Definitions; A working understanding of the terms commonly used in
epidemiology and infectious diseases may be helpful to the student,
microbiologist, and clinician unfamiliar with them. They are derived from those
in A Dictionary of Epidemiology, Viral Infections of Humans, and the
American Public Health Association handbook entitled Control of
Communicable Diseases Manual.
- Attack rate or case ratio:
This ratio expresses incidence rates in population groups during specified time
periods or under special circumstances such as in an epidemic. It is often
expressed as a percent (cases per 100). The secondary attack rate is the
proportion of persons who develop infection within an appropriate incubation
period after exposure to a primary case divided by the number exposed. The
groups so exposed are frequently family members or persons located in an
institution.
- Carrier: A carrier is a person, animal, or arthropod who harbors a specific
infectious agent in the absence of clinical illness with or without a detectable
immune response. The carrier state may reflect carriage of the organism in the
incubation period before clinical symptoms appear, during an apparent or
inapparent infection (healthy or asymptomatic carrier), or following recovery
from illness; it may be of short or long duration (chronic carrier), and it may be
intermittent or continuous. Carriers may spread the infectious agent to others.
Case-fatality rate: Number of deaths of a specific disease divided by the number
of cases × 100.
- Cell-mediated immunity: This term has been used previously to designate
immune mechanisms largely dependent on lymphocyte activity and in contrast
to “humoral immunity.” As T lymphocytes are now recognized as playing an
important role in both, the term T-cell immunity is being more widely used.
- Chemoprophylaxis: Administration of a chemical or antibiotic to prevent
infection or to prevent the development of disease in a person already infected.
- Colonisation: Multiplication of an organism on a body surface (e.g., skin,
epithelium, mucus membrane) without evoking a tissue or immune response.
Communicable period: Time during which a person (or animal) is infectious
for another person, animal, or arthropod. Endemic: This term denotes the
constant or usual presence of an infection or disease in a community. A high
degree of endemicity is termed hyperendemic, and one with a particularly high
level of infection beginning early in life and affecting most of the population is
called holoendemic.
Epidemic: An epidemic or outbreak is said to exist when an unusual number of
cases of a disease occur in a given time period and geographic area as compared
with the previous experience with that disease in that area. For diseases already
present in the community, it is necessary to know the number of existing cases
(prevalence) as well as new cases (incidence) to determine whether an increase
has occurred. The definition of increases or excess cases is arbitrary and will
vary from disease to disease. See Section 3 for further discussion.
Host: A person, animal (including birds), or arthropod in which infectious
agents subsist or infect under natural conditions. In this book the term will most
often refer to the “human host” unless otherwise stated. Immunity: The specific
resistance to an infectious agent resulting from humoral and local antibodies
and from cell mediated responses constitutes immunity. Immunity may be
acquired through natural infection, by active immunisation, by transfer of
immune factors via the placenta, or by passive immunisation with antibodies
from another person or animal. The immune state is relative and not absolute, is
governed largely through genetic control, and may be altered by disease- or
drug-induced immunosuppression.

Immunodeficiency: A state representing impairment of the immune system of

the host that affects its ability to respond to a foreign antigen. This may result
from an inherited defect, or an acquired one such as a result of the disease itself,
or of immunosuppressive drugs or an infectious agent that depresses the
immune system. The human immunodeficiency viruses (HIV-1 and HIV-2) are
the major examples of the latter.
Incidence rate: The number of new events (specific infection or disease)
occurring in a given time period in a given population as the numerator and the
number of susceptible persons in that population exposed to the agent as the
denominator. This is usually stated as cases (or infections) per 100, 1,000, or
100,000. This rate may be adjusted for an age- or sex-specific numerator and
denominator or any other characteristic of interest. Laboratory procedures may
be required for numerator data on new infections, as measured by isolation of
the agent or by antibody rises, or by both. They may also be required to identify
those actually at risk in the denominator, i.e., those lacking antibody; other
means of refining the denominator would be by eliminating adults in calculating
rates of childhood diseases or eliminating those with a valid history of having
had the disease.
Incubation period: The incubation period is the interval between exposure and
the appearance of the first detectable sign or symptom of the illness. Ill-defined
exposure to a source of infection or exposure to persons without apparent illness
may obscure the starting point of the incubation period, and vague, premonitory,
or prodromal signs of illness may obscure its termination point. The best
estimate is often derived from single exposures of short duration to a clinical
case or established source of infection (e.g., air, food, water, arthropod vector)
and the development of the first characteristic or classic features of the disease.
Experimental infections in volunteers give well-defined incubation periods, but
these may not always be the same as under natural conditions.
Index case: This is the index or primary case of an illness in a family, group,
institution, or community that may serve as a source of infection to others.
Infection: Infection represents the deposition, colonisation, and multiplication
of a microorganism in a host and is usually accompanied by an immune
response. Infection may occur with or without clinical illness. Isolation: This is
a term applied to the separation of infected persons in such places and/or under
such conditions as to prevent contact or airborne transmission of the infectious
agent to others during the period of communicability. Infection control practice
in hospitals as recommended by the CDC has divided isolation into two tiers of
isolation precautions. The first tier is known as standard precautions and the

second-tier transmission-based precautions. Hand washing remains a prime

preventive measure in regard to nosocomial infections.
Morbidity rate: An incidence rate in which the numerator includes all persons
clinically ill in a defined time and population and the denominator is the
population involved or a subunit thereof, usually expressed as the number of
cases per 100,000 persons at risk.
Mortality rate: The same as morbidity rate except the numerator consists of
deaths. This may be the total number of deaths in a population group (crude
mortality rate, usually expressed as deaths per 1,000) or deaths from a specific
disease (disease-specific mortality, usually expressed as deaths per 100,000).
Nosocomial infections: This term refers to infections that develop after entry
into a hospital or other health care institutions and that are not present or
incubating at the time of admission or the residual of an infection acquired
during a previous admission.
Pathogenicity: The ability of an infectious agent to produce disease in a
susceptible host. Some nonpathogenic agents can become pathogenic in an
immunocompromised host such as persons infected with HIV.
Prevalence rate: The ratio of the number of persons in a defined population
who are affected with the disease at any one time as the numerator and the
exposed population at that point as the denominator. If this is based on the
frequency of cases at a moment in time, then the term point prevalence is used.
If it reflects the proportion of persons affected over a longer period, then the
term period prevalence is employed. Most infectious diseases are acute and
short lived, so that prevalence rates are not commonly used. The use of
prevalence rates is more relevant to more protracted illnesses such as subacute
bacterial endocarditis, tuberculosis, and leprosy, or to reflect carrier states that
may persist for months or years. Prevalence rates reflect incidence times
duration of disease. In seroepidemiological usage, the term prevalence denotes
the presence of antigen, antibody, or another component in the blood.
Quarantine: The restriction of persons or animals exposed to an infected source
during the incubation period for that disease to observe if the disease develops
in order that other persons will not be exposed to the infectious agent during
that period. Reservoir: A person, animal, soil, or other environment in which an
infectious agent normally exists and multiplies and which can be a source of
infection to other hosts.
Surveillance: As concerns public health, surveillance is the systematic
collection of data pertaining to the occurrences of specific diseases or health-
related conditions, the analysis and interpretation of these data, and the
dissemination of consolidated and processed information to contributors to the

program and other interested persons for purposes of control and/or prevention.
Serological surveillance is the identification of current and past infection
through measurement of antibody or of antigen in serum from representative
samples of the population or other target groups.
Susceptibility: A state in which a person or animal is capable of being infected
with a microorganism. The lack of specific protective antibody usually indicates
susceptibility to that agent, although reactivation or reinfection to some agents
may occur in the presence of antibody.
Transmission: The mechanism by which an infectious agent is spread to
another host. Virulence: A measure of the degree of pathogenicity of an
infectious agent as reflected by the severity of the disease produced and its
ability to invade the tissues of the host.
Zoonosis: An infection or infectious disease transmissible under natural
conditions from animals to man. It may be endemic (enzootic) or epidemic
(epizootic).
2.2 Methods in epidemiology
Epidemiology can be divided into descriptive, analytical, experimental, and
serological epidemiology. The major analytic methods in use are the cohort
(prospective) and case–control (retrospective). This section will briefly present
these concepts. For more detailed descriptions, textbooks and recent articles of
epidemiology are recommended. A textbook on epidemiological methods that
includes discussion and examples in infectious disease, is recommended before
undertaking an epidemiological study. An excellent brief book on all aspects of
epidemiological studies has been published by the World Health Organisation
(WHO).
Types of Epidemiological Studies
Epidemiological studies may be descriptive or analytical. Descriptive studies
are based on available data sources and describe the patterns of disease in
population groups according to time, place, and person factors. Epidemic
investigations begin with a descriptive study. These data often suggest clues to
the aetiology of the condition or to the risk factors involved. Analytical studies
are then designed to test the hypotheses of causation developed from the
descriptive studies and usually require new data to do so. Three common
analytical methods are employed in pursuing epidemiological studies.
- Cohort Study

This is the most definitive and expensive type of study and is based on
identifying a group or groups of persons (cohorts) who are followed over time
for the development of disease (or infection) in the presence or absence of
suspected risk factors that are measured at the start of the study. These studies
are usually carried out by identifying a cohort or usually two or more cohorts at
the present time and then following them longitudinally over time. One cohort
will be the group exposed to a risk factor or there may be several cohorts, each
with a different degree of exposure. There usually is another cohort of
unexposed persons who are followed in the same way. The cohorts are followed
until the effect of the exposure occurs or the study is terminated for other
reasons. If the occurrence of disease is the expected outcome, persons immune
to the disease at the beginning of the study would not be included in a study
cohort. This has been called a prospective cohort study or simply a prospective
study. In infectious disease epidemiology, it may be possible to identify the
persons in the cohort who are susceptible or immune at the start of the study by
measuring the presence or absence of antibody in the initial serum specimens.
Serial serum samples are then taken in which the appearance of antibody
indicates the approximate time at which infection occurs. The occurrence of
clinical disease at the same time provides information of the clinical–
subclinical ratio. If the appropriate serum samples are taken and frozen, the
actual testing can be delayed to the end of the study. An alternative method of
conducting a cohort study is to identify a group of persons at some time in the
past who were presumably free of the disease under investigation at that time, as
indicated by examining existing records. The cohort is then followed to the
present, or even beyond, by measuring the occurrence of infection (by
serological tests) or disease in that defined population. This approach is called a
historical cohort study or a retrospective cohort study. Because the case–control
study is also retrospective in terms of the time when the observations are made,
it must be distinguished from the historical cohort study.
- Case–Control Study
This has been called a retrospective study because it studies persons already ill
with the disease and compares their characteristics with a control group without
the disease for the presence or absence of certain possible risk factors. When a
significant difference in the prevalence of a characteristic or risk factor is found,
then the possibility of a causal association is suspected. Further studies using
the cohort method are then often carried out to add strength to the association.
The case–control study is usually the first type made because it is based on
existing data, can be completed in a relatively short time, and is the least
expensive. However, it cannot define the true incidence of the disease in
relation to the various factors because the denominator at risk is not known. A

variation of the case–control study, and one encompassing the concept of a

cohort study, is termed the nested case–control study. In this a large cohort is
studied either prospectively or retrospectively for the occurrence of a specific
disease, then these cases are matched by age and sex with persons in the original
cohort who did not develop the disease. Various attributes of the two groups
defined at the start of the study can then be compared. This method is very
useful for diseases or conditions of low frequency in which analysis of the
entire cohort would be an overwhelming task. An example of this is a recent
study of Hodgkin’s disease in relation to elevated levels of antibody to Epstein–
Barr virus (EBV). In this analysis, 240,000 persons whose sera had been
collected and stored in four serum banks were followed for 5 years through
cancer registries or hospital records for the development of Hodgkin’s disease.
Forty-three cases were identified in this manner and the EBV and other
antibody levels were determined in sera from the group and compared with
results from matched controls bled at the same time. A significant increase in
certain EBV antibodies over those of controls was found 3–5 years preceding
the diagnosis of Hodgkin’s disease. Biases may occur in case–control studies in
the selection of cases, in the selection of controls, and in the elucidation of data
by interview or records concerning the characteristics in question in both cases
and controls. The selection of cases should ensure that they are representative of
all patients with that disease. Ideally, this would assume that all patients with
the disease seek medical attention, that the correct diagnosis is made and
substantiated, that all medical facilities are canvassed, and that all cases are
detected. In practice, these criteria are seldom met, and patients, for example,
from a single hospital may be the only ones studied. This introduces a bias,
since certain patients may be excluded from a given hospital because of such
factors as age (e.g., no pediatric wards), socioeconomic level, or military or
civilian status; the patient or physician may select a given hospital because of
nearness, religious affiliation, the physician’s privileges, nature of payment, or
other considerations. These patients are not representative of all patients with
the disease. The presence or absence of the characteristic under study may also
influence the selection process for either the case or the control group or both,
giving spurious associations. Biases also are common in the selection of
controls. Usually, controls should be selected from the same population group
from which the patients are drawn and should be closely comparable to the
cases in all known characteristics (age, sex, socioeconomic level, ethnic groups)
except the one under study. Random selection from a large group may equalize
those differences, but usually groups matched for certain variables or
individuals matched carefully for paired comparisons are selected. However, if
the two groups are matched too closely, the association between the cause and
its effect may be masked. In a hospital setting, ill patients with diseases other
than those under study are sometimes chosen. Bias may occur if some of these
patients have diseases that are influenced by the characteristic in question. To
limit this, patients with non-infectious diseases are often chosen in an infectious
disease study. In a community setting, healthy controls may be advantageous. In
matching, only those variables known to affect the disease should be selected.
Each matching factor included, while controlling the results, eliminates the
possibility of evaluating that factor itself. To avoid bias regarding the presence
or absence of a characteristic in the procurement of data by interview or from
records, those charged with data collection should not know which is case or
control, and the ascertainment should be uniform or standard. Once the data
have been obtained, the odds ratio associated with a given characteristic is
calculated. This estimate is based on the assumption that the frequency of the
disease in the population is relatively small and that cases and controls are
representative of their respective ill and nonill populations for that disease.
Examples of case–control studies for an infectious disease would include the
influence of some characteristic such as genetic makeup (HLA type), smoking,
pre-existing disease, or socioeconomic level as a factor in a given disease. It
should be emphasized that a particular risk factor might operate at different
levels or at several levels: It might affect exposure and infection, the severity of
illness after infection has occurred, the duration of disease, the development of
complications, or the case fatality rate.
Cross-Sectional or Prevalence Study
This third type of investigation examines the occurrence of disease and of
suspected risk factors in population groups at a point in time or over a relatively
short period of time. Prevalence rates among those with and without the
exposure are determined and compared. This approach is usually limited to
diseases of slow onset and long duration for which medical care is often not
sought until the disease has progressed to a relatively advanced stage. Thus, the
risk factors present at the start of the disease may be difficult to identify. This
method is used for certain chronic diseases, such as osteoarthritis, chronic
bronchitis, and some mental disorders, but it may also be useful in certain
infectious diseases such as those occurring in a hospital setting.
- Experimental Epidemiology
In infectious diseases, this represents planned experiments designed to control
the influence of extraneous factors, among those exposed or not exposed to an
etiologic factor, preventive measure, or environmental manipulation by the
investigator. One example is the planned introduction of an infectious agent in a
controlled fashion into a group of animals or volunteers and the analysis of the
spread of infection and disease within these groups as compared to a non-

exposed group. Such studies offer the most scientifically controlled method of
epidemiological study. Unfortunately, many bacterial species or agents may not
induce infection or disease in animal models. Certain susceptible animals
(marmosets, chimpanzees) may not be available for study or are too expensive.
Serological Epidemiology
The systematic testing of blood samples from a defined sample of a target
population for the presence of antibodies, antigens, genetic markers, specific
cell-mediated immunity, and other biological characteristics is called a
serological or immunological survey. It constitutes an important
epidemiological tool. Serological techniques can (1) identify the past and
current prevalence of an infectious agent in a community; (2) identify the
incidence of infection by seroconversion or a rise in titer in samples obtained at
two different times; (3) reveal the ratio of subclinical to clinical infections,
when combined with clinical data; and (4) determine the need for immunisation
programs and evaluate their effectiveness as to the presence, level, and quality
of antibody produced, its duration, and the degree of protection against disease.
Serological techniques are useful in defining the incidence, clinical importance,
and spectrum of illness of a new agent such as Legionella pneumophila. The
presence of antibody or antitoxin to diphtheria, pertussis, and tetanus, as
determined in a serological study, is a good reflection of the level of
immunisation and public health practice in a community. This is especially true
of tetanus, since antitoxin is acquired almost solely through immunisation and
rarely, if at all, through natural infection. The use of serological surveys in areas
where medical care, diagnostic facilities, and reporting practices are inadequate
may provide information essential for the control and evaluation of
immunisation programs.
3.3 Biology or Natural History of Infectious Diseases:
The natural history of an infectious disease is the way in which the disease
is transmitted, how it develops over time from the earliest stage of its
prepathogenesis phase to its termination as recovery, disability or death in
the human population, in the absence of treatment or prevention.
Epidemiologists dealing with an infectious disease issue are best served by
taking the time to study the natural history or biology of that specific
infectious disease. Facts to be studied are the nature of the infectious agent
(parasite, bacteria, fungus, virus, or prion), the natural hosts, mode of entry
into the host and exit from the host, distribution in the host tissues,
incubation period, signs and symptoms of illness, natural reservoir in
animals or environment, resistance to environmental factors, and
geographical distribution of the agent and of human illness (which may be

slightly different).
Infectious, Communicable, Contagious, Transmissible Diseases

An infectious disease is a disease due to a specific infectious agent or its
toxic products that arises through transmission of that agent or its
products from an infected person, animal, or reservoir to a susceptible
host, either directly or indirectly through an intermediate plant or animal
host, vector, or the inanimate environment (Porta et al. 2008). Infectious
diseases are caused by an infectious agent (helminth, protozoa, fungus,
bacteria, virus, or prion, sometimes referred to as microorganisms,
although helminths are really not microorganisms). This definition is
apparently simple but may get more complicated:
• The infectious agent does not need to be present all the time. The
infectious agent may trigger a pathological process that will continue
on its own, even after the agent is gone.
• Other factors may be necessary to trigger the disease; the infectious
agent alone cannot cause the disease. The infectious agent may be
necessary but not sufficient for the infectious disease. Most agents
causing opportunistic infections in AIDS patients cannot cause any
disease in normal individuals. They can only cause disease if the host
is severely immune-compromised.
The term communicable disease is specific to those diseases that can be
transmitted from an infected individual to another one directly or
indirectly. It is sometimes used interchangeably for infectious diseases
(Porta et al. 2008). Sometimes communicable diseases are defined as a
subset of infectious diseases that can spread from person to person.
The term transmissible or contagious disease is often synonymous to
communicable disease.
In-text Question
1. Give a concise definition of serological epidemiology.
Answer
Is the systematic testing of blood samples from a defined sample of a target population for
the presence of antibodies, antigens, genetic markers, specific cell-mediated immunity, and
other biological characteristics.
2.4 From Exposure to Disease

The infectious process may be broken down into the following steps. If the
infectious disease agent does not gain a foothold, the person was only
exposed and the infectious disease process ends. If the disease agent gains
a foothold but no reaction is occurring, the person will be colonised but
not infected. An infection occurs when the disease agent attaches itself to
the epithelium and begins to multiply. The infectious disease agent will
release cytotoxins which will damage the cells and injure the tissue which
leads to the dissemination through the human body. Even after
dissemination, humans might not show any signs and symptoms and are
therefore considered asymptomatic or show clinical signs and symptoms
and are then considered symptomatic.
Exposed means that a person is placed in a situation where effective
transmission of an infectious agent could occur. Being exposed does not
always mean that transmission did occur. For example, being in the same
room as an infectious tuberculous patient is being exposed since
tuberculosis is transmitted by droplet nuclei. However, being in the same
room with a person with HIV does not meet the criteria for exposure
because conditions are not met for transmission to occur.
Exposure definition relies on information that may not be all known:
• Being in the same room with a tuberculous patient means being
exposed if the patient is infectious (pulmonary tuberculosis with
positive sputum). If the patient is not infectious, then exposure does
not occur.
• Sharing a meal that resulted in a food poisoning outbreak is being
exposed. If we know that only the potato salad was contaminated,
then only those who ate the potato salad were exposed.
Infection: The entry and development or multiplication of an infectious
agent in the body of humans or animals. Infection is not synonymous
with disease. Disease implies some signs and symptoms or some
negative impact on the health status of the individual.
Colonisation: Porta et al. (2008) define in the Dictionary of
Epidemiology infection and colonisation as the same concept. However,
in hospital-acquired infection control programs (often abbreviated as
“infection control”), a distinction is made between colonisation and
infection: Colonisation is the presence of a microorganism in or on a host
with growth and multiplication but without any overt clinical expression
or immune reaction in the host at the time the microorganism is collected
(Brachman 1998). In contrast, infection entails some reaction from the
host, either only on an immunological level or on an immunological and
clinical level.
A carrier is an individual that harbors a specific microorganism in the
absence of discernible clinical disease and serves as a potential source of
infection. A carrier may be an individual who is colonised, incubating the

disease, infected and asymptomatic, or convalescent from acute disease.
The period of the carrier status may be short or lengthy. The portal of
exit may be urine, genital secretions, faeces, and respiratory, or the
carrier may not excrete the agent (agent is circulating in the
bloodstream).
Clinical infection: Clinical infection may result in signs and symptoms.
Some of these may be less obvious or very minor. At the end of the
spectrum is the individual with no sign, no symptoms who has an
asymptomatic infection or subclinical infection. Asymptomatic infection
does not mean that “all is quiet.” It may cover some very active
processes as in the asymptomatic phase of HIV infection, tuberculosis
infection, or Hepatitis B carrier state.
Case, Index Case, Primary Case, and Secondary Case
A case is an operational definition. It denotes usually a person with a
specific infectious disease.
A surveillance case definition is not a clinical diagnosis, both have very
different purposes. A surveillance case definition is usually very precise
and fairly restrictive so as to eliminate subjectivity, as much as possible.
It uses a fixed set of indicators to classify disease status regardless of
differences between individuals. In contrast to that, a clinical diagnosis’
purpose is to ensure best treatment options to the patient and the
diagnostic procedures may therefore vary between individuals.
A diagnosis is an expression of the clinical judgment of the physician
that leads to the therapeutic decisions to be taken.
An index case is the earliest documented case of a disease that is
included in an epidemiological study or the very first case of an
infectious disease that was identified in an outbreak.
A primary case is the first individual (case) who brought the infection in
the group of population studied. The primary case is not always the index
case. The index case may have triggered an investigation, and in the
course of the investigation, the primary (or original) case is identified.
A secondary case is a case that was infected from the primary case and
consequently occurred at a later date. There may be tertiary cases and so
on. Usually, one does not define cases further than secondary cases. If
cases are somewhat synchronized, one may speak of generations or
waves of cases.
Source, Reservoir, Vehicle, and Vector
A reservoir is any person, animal, plant, or environmental medium (soil,
water) in which the microorganism normally lives and multiplies, on
which it depends primarily for survival, and where it reproduces itself in

such a manner that it can be transmitted to the susceptible host. Consider
the following examples: Humans are the only reservoir for
Mycobacterium tuberculosis, measles, chickenpox and smallpox.
Numerous animal species are reservoirs for Salmonella; rodents are
reservoirs for plague. Surface water and water systems are reservoirs for
Legionella. Soils and the gut of some animals (horses) are reservoirs for
tetanus bacteria (Clostridium tetani).
In-text Question
Describe a carrier?
Answer
Is any person/ animal/ plant or environmental medium (soil, water) in which the
microorganism normally lives and multiplies, on which it depends primarily for survival, and
where it reproduces itself in such a manner that it can be transmitted to the susceptible host.
A source of infection is the actual person, animal, or object from which

the infection was acquired.
A source of contamination is the person, animal, or object from which
environmental media are contaminated. For example, the cook is the
source of contamination of the potato salad.
A vehicle is an inanimate object which serves to communicate disease,
for example, a glass of water containing microbes or a dirty rag.
A vector is a live organism that serves to communicate disease. Best
known examples are Anopheles mosquitoes and malaria as well as Ixodes
ticks and Lyme disease.
3.0 Conclusion/Summary
In this session, we discuss some epidemiological terms used in infectious
diseases epidemiology. Concepts in epidemiology of infectious diseases were
introduced. The Unit also covers methods used in epidemiological studies and
terms used during exposure to diseases.
we discuss some epidemiological terms used in infectious diseases
epidemiology. Concepts in epidemiology of infectious diseases were
introduced. The Unit also covers route of transmission of diseases. New
infectious diseases can be classified according to their epidemiologic,
clinical, or microbiologic features. Certainly, knowledge of all of these
characteristics is important. However, the epidemiologic features of a
disease are of paramount importance for a public health professional or an
epidemiologist who is concerned primarily with controlling or preventing
the epidemic spread of an infection.


1. Define the basic terms used during exposure to disease
2. What is communicable and infectious diseases
3. Discuss the various type of epidemiological studies

Visit YouTube on https://www.youtube.com/watch?v=jcmC9hzdqag
. Watch the video & summarise in 1 paragraph

CDC (1987) Epidemiologic notes and reports restaurant associated botulism
from mushrooms bottled in-house – Vancouver, British Columbia, Canada.
MMWR 36(7):103
CDC (1996) Outbreaks of cyclospora cayetanensis infection – United States,
1996. MMWR 45(25):549–551
CDC (1997) Case definitions for infectious conditions under public health
surveillance. MMWR 46(10):1–55
CDC (1999) Framework for program evaluation in public health. MMWR
48(11):1–40
CDC (2001a) “Norwalk-like viruses”: public health consequences and
outbreak management. MMWR 50(9):1–17

Study Session 2
Transmission and Chain of Infection
Introduction
2.0 Main Content
2.1 – Source of infectious Material
2.2- Portal of entry into humans
2.3- Classification of Transmission
2.4- Environmental factors that influences diseases
Introduction
In the previous study session, we discuss the basic concepts in epidemiology
which is integral in understanding subsequent sessions. This present study
session entails the sources of infectious materials, portal of entry into
material, classification of transmission of diseases and environmental
factors that influences diseases.
1. Highlight sources of infectious materials
2. Classify infection base on transmission
3. Describe portal of entry into humans
2.0 Main Content

2.1 The Source of Infectious Material
When describing transmission, one should consider the source of the
infectious agent and the portal of entry in the human. There are very
different sources from where the potential infectious material is coming
from. It might be blood splashed on a medical employee during a
procedure or a person coming in contact with someone else’s blood after
a motor vehicle accident. It might be internal body fluids (such as
cerebrospinal, pericardial, pleural, peritoneal, synovial, and amniotic
fluids), and most of these exposures would occur in the medical setting.
For genital fluids (vaginal, prostatic secretions, semen), sexual contact is
the main mode of transmission through mucous membranes.
Furthermore, transmission of Hepatitis B virus (HBV) and herpes simplex

virus (HSV) to the newborn can occur during delivery as the newborns
are exposed to vaginal secretions. Both internal and genital fluids can
contain blood-borne pathogens (such as HIV, Hepatitis B virus, Hepatitis
C virus (HCV), and cytomegalovirus (CMV)). Both secretions (saliva,
nasal discharge, sweat, tears, breast milk) and excretions can be
infectious. Urine might be contaminated with schistosoma eggs or
leptospira bacteria, and faeces can contain numerous enteropathogens.
Persons can be infected via sexual contact of mucosal membranes (nasal,
oropharyngeal, rectal, genital). Contact with contaminated tissue can
occur in transfer of human or animal tissue: blood transfusion, blood
components (factor VIII), organ transplants, or tissue grafts. Some
hormones and proteins may be extracted from the tissue but still carry the
infectious microorganisms, for instance, prions of Creutzfeldt- Jakob
disease (CJD) in human growth hormone extract. The rabies virus is
normally transmitted through animal bites, but also human bites could
potentially (however never documented) infect the bite victim with
Hepatitis B or C virus. Last but not least, environmental materials such as
food, water, air, or even contaminated dust play a major role in the
transmission of infectious diseases.
2.2 The Portal of Entry into Humans

Infectious disease agents can enter the human body through very
different paths. They can be inhaled with the air (the respiratory system).
Eating contaminated food and drinking contaminated water
(gastrointestinal system) can infect persons and of course through sexual
activities. Transplacental or intrauterine transmission will pose a risk for
the fetuses. Persons also can be infected with viruses, bacteria, rickettsia,
and parasites through arthropod bites such as mosquito or tick bites.
Fig 1.2.1: Transmission route of diseases

2.3 Classification of Transmission

Droplet Transmission
There are many infectious diseases which are transmitted by droplets (see
Box 1.1). Droplets are generated in the upper respiratory tract during
talking, singing, spitting, sneezing, and coughing. They are also produced
during suctioning, sputum induction, bronchoscopy, and other respiratory
procedures. The droplets produced vary in size from 1 to 100 micron
(µm). Droplets will fall to the floor; the speed of fall is related to droplet
size (see Table 1.2.1).
Box 1.1. Infections transmitted by droplets
Haemophilus influenzae, Neisseria meningitidis, Streptococcus

pneumoniae, Corynebacterium diphtheriae, Yersinia pestis (pneumonic
plague), Bordetella pertussis, Mycoplasma pneumoniae, Streptococcus
group A (pharyngitis, pneumonia, scarlet fever), adenovirus, influenza,
mumps virus, parvovirus 19, and rubella virus
Table 1. 2.1 Droplet falling rates

A droplet of Will fall
(µm) in
100 10 Droplets above 5 µm are
seconds trapped in the nose and
40 1 minute upper respiratory tract and
usually do not make it to
20 4 min the bronchi
10 20 min
5–10 30–45 May reach the lower
min respiratory tract
≤5 Droplet May be inhaled into the
nuclei alveoli
Droplet transmission occurs by direct hit when these droplets are

propelled from the infected host to the recipient’s mouth, nasal mucosa, or
conjunctivae. As a rule of thumb, this method of transmission is common
within 3 feet of the infected patient. Inhalation of a droplet occurs also
while it floats; however, this occurs only during a short period of time

since the droplet is falling to the floor. Contact with surfaces

contaminated with droplets is the main mode of transmission for
rhinoviruses and respiratory syncytial viruses (RSV). Concentrations of
rhinoviruses are much higher on the hands than in aerosols. Droplets are
created by aerosolisation of infectious material: The success of such
aerosols reaching susceptible individuals depends on the environmental
conditions: humidity, temperature of the air, air currents, and distances of
the host. The use of suction devices, catheters in intensive care units
(ICU), and blood products in hemodialysis may produce some aerosols
containing infectious particles.
In nature, soil particles contaminated with rodent urine have been
aerosolised and thought to be responsible for the transmission of
Hantaviruses. Legionella are frequently present in waters (surface waters,
hot water systems, and condensation from air conditioning or ventilation
systems). When water is sprayed (cooling towers, showers, and cool mist
over produce), aerosols containing Legionella are generated.
The degree of infectivity depends on the microorganism concentration in
the droplets emitted. This varies from one virus to another, from one
strain to another. The infecting dose is variable. For some viruses, it may
be quite small: seven virions for adenoviruses. Experiments made with
influenza virus showed that for similar viral titer in lung tissue, some
strains will have very high titer in bronchial secretions while others will
not (Schulman 1970).
Airborne Transmission
Droplet nuclei or dust particles are responsible for this mode of
transmission. Droplet nuclei are small droplets less than 5 µm in
diameter. They result from evaporation of larger droplets or from direct
formation of smaller droplets (particularly during coughing or during
aerosol generating medical procedures). The transmission may occur
over a long distance from the source patient.
Tuberculosis (TB) is one of the most important diseases transmitted by
airborne means (see Box 1.2). Active pulmonary tuberculosis cases with
acid-fast bacilli (AFB) on sputum smear are the cases that are infectious.
Tuberculosis is almost exclusively transmitted by droplet nuclei (small
particle of 1–5 µm) that contain Mycobacterium tuberculosis. The
droplet nuclei must reach the pulmonary alveoli to start an infection.
Large droplets are swallowed or get stuck in the trachea and bronchus;
from there they are brushed back up and swallowed. The rare TB bacilli
reaching the stomach are inactivated there. The role of droplet nuclei in
the transmission of tuberculosis was demonstrated in several studies. In
1956, Riley and colleagues showed that air coming from rooms occupied
by TB patients could infect guinea pigs (Riley et al., 1956). Coughing is

the major producer of droplet nuclei. Speaking and singing also produce
droplet nuclei, but these do not last very long.
Pulmonary tuberculosis cases may have up to 10,000,000 TB
bacilli/milliliter (ml) of sputum. A typical
~
sputum smear is about a
~ of one ml (0.01 ml) and is covering about a 10,000 high power
hundredth
field (magnification 100 for the oil immersion lens and 10 for the eye
piece). The probability of finding an acid-fast bacillus depends on the
concentration of AFB in the sputum, and the number of microscopy fields
examined (Toman 2004). In a study carried out among
Box 1.2. Infections transmitted by droplet nuclei
• Tuberculosis (Mycobacterium tuberculosis)

• Measles (Morbilli virus)
• Chickenpox and shingles (Varicella zoster including disseminated zoster)
Box 1.3. Infections transmitted by contact
• Gastrointestinal, respiratory, skin, wound infections

• Colonisation with multidrug-resistant bacteria
• Enteric infections, enteroviral infections in infants
• Respiratory syncytial virus (RSV), parainfluenza
• Infectious skin infections: herpes simplex virus (HSV), impetigo, cellulitis,
scabies, staphylococcal furunculosis
• Viral hemorrhagic conjunctivitis, viral fevers
• Some respiratory infections, bronchiolitis in infants, children
• Abscess, draining wound
contacts of smear-positive pulmonary cases, Loudon and colleagues

showed that the more the index case coughs, the more infected individuals
are to be observed among the close contacts (Loudon et al. 1969).
Direct and Indirect Contact Transmission

Direct contact transmission results from a direct body surface to body
surface contact and physical transfer of microorganisms. Direct contact
occurs when shaking hands, taking pulse, turning a patient over, and
having sexual intercourse.

Fig 2.2.1:
Different viruses and bacteria can be transmitted by contact (see Box

1.3). Indirect contact transmission involves contact with the intermediate
of an object. Indirect contact occurs through a contaminated dressing,
instrument, or glove as well as door handles and keyboards.
Gastrointestinal Transmission: Faecal-Oral Route
Transmission by the faecal-oral route is the second most important mode
of transmission after the respiratory tract for several infectious disease
agents (see Box 1.4). The faecal-oral route refers to the mode of
transmission of microorganisms excreted.
Box 1.4. Infections transmitted by gastrointestinal transmission: faecal-oral

route
• Typhoid fever
• Shigella spp.
• Cholera (Vibrio cholerae)
• Polio
• Coxsackie virus, echovirus, reovirus
• Norovirus
• Rotavirus
• Hepatitis A, Hepatitis E
by the faeces and transmitted to the oral portal of entry through

contaminated food, water, milk, drinks, hands, and flies. The site of entry
may be the oropharynx for some microorganisms or the intestinal tract
for most viruses. Surviving through the upper GI tract is essential.
Viruses with envelopes do not survive exposure to hydrochloric acid in the
stomach, bile acids in the duodenum, salts and enzymes of the gut. Small
enteroviruses without envelope (norovirus, rotavirus, polio, and
coxsackie viruses) are able to resist. Hepatitis A and E are also
transmitted by the faecal-oral route. For adenoviruses and reoviruses, this

route is of minor importance.
Some of these pathogens are essentially found in humans (Shigella),

while others may survive or multiply in the environment for long periods
of time (Vibrio cholerae, poliomyelitis virus). This mode of transmission
is more amenable to control measures than the respiratory route. Good
personal hygiene (mostly proper hand washing), purification of drinking
water, pasteurisation of milk and dairy products, and sanitary preparation
of food are all highly effective prevention measurements for these types
of infectious diseases.
Gastrointestinal Transmission: Animal Host and Contaminated Food
Products
Salmonellas infect a wide variety of domestic animals, birds, and other
wildlife. Foods derived from salmonella-infected animal (eggs, dairy
products, meat) are the major source of infection if improperly prepared.
Salmonella is less often transmitted by water or direct contact. Other
microorganisms such as Campylobacter, Yersinia, and Listeria are also
transmitted through contaminated food products (see Box 1.5).
Food poisoning overlaps both classes of gastrointestinal transmission.
Food poisoning may result:
• From consumption of food from an infected animal or undercooked
eggs, for example, chicken and eggs with Salmonella or Listeria in
unpasteurised milk
Box 1.5. Infections transmitted by gastrointestinal (GI) transmission: animal

host and contaminated food products
• Salmonella
• Campylobacter
• Yersinia
• Listeria
• From consumption of food contaminated in the environment, for

example, Vibrio vulnificus or Vibrio cholerae in raw oysters or
undercooked seafood
• From food contaminated during preparation from an infected food
item, for example, potato salad contaminated with Salmonella from
raw chicken because the uncooked chicken and the salad ingredients
were cut on the same cutting board
• From food contaminated by a human source, for example, typhoid fever
carrier.
Skin or Mucous Membrane Transmission

Transmission through the skin is the third most common mode of
transmission of infection. Penetration through the intact skin is unlikely.
Break in the skin barrier may result from needle injection, cut during a
surgical procedure, accidental cut, crushing injury, and bite (rabies).
Transmission of blood-borne pathogens (Hepatitis B and C viruses (HBV,
HCV) and HIV) does not occur if the blood was splashed exclusively on
intact skin. Penetration through the skin is necessary. In the case of HIV,
it takes injury with a hollow bore needle or other sharp object (lancet,
glass, and scalpel) with blood to cause an infection. Solid needles do not
carry sufficient quantities of blood to cause an infection. The viral titer is
the best predictor of risk of infection. After percutaneous exposure to
blood from infected patients, the risk of infection in the recipient is 30%
for HBV (eAntigen positive), 3% for HCV, and 0.3% for HIV. This
follows the ranking of viral titers. Mucosal membranes allow penetration
by blood-borne pathogens. Data from 21 studies worldwide on mucosal
membrane exposure to HIV showed only one conversion in a total of
1,107 health-care workers (HCWs). The proportion of conversion was
0.09% (1/1,107). Some parasites are able to penetrate actively through
the intact skin: hookworm larvae and schistosoma cercariae.
Sexual Transmission (Mucous Membrane Transmission)
The genital tract is a special case for transmission through the mucosal
membranes. The bacteria and viruses listed are present in the genital
fluids and on the mucosal membranes (see Box 1.6). They may be
transmitted to the mucosal membranes of the partner during sexual acts:
Membranes involved may be the vagina, penile urethra, anus and rectum,
or oropharynx. Some of microorganisms such as Shigella spp. and
Campylobacter spp. are primarily considered to be transmitted to the
gastrointestinal (GI) tract. However, due to transmission when the rectum
is involved in sexual activities, they are also listed as sexually transmitted
disease (STD) agents. The presence of lesions on the recipient partner
seems to predispose to acquisition of infection, particularly for HIV.
Perinatal Transmission (Mucous Membrane Transmission)
These infections (see Box 1.7) occur when the newborn goes through the
birth canal, from the cervix or vagina to the newborn.

Box 1.6. Sexual transmissions (mucous membrane transmission)
• Neisseria gonorrhoeae, Chlamydia trachomatis

• Treponema pallidum (syphilis)
• Hemophilus ducreyi
• Mycoplasma hominis, Ureaplasma urealyticum
• Calymmatobacterium granulomatis
• Shigella spp., Campylobacter spp.
• Group B streptococci
• Bacterial vaginosis-associated bacteria
• Herpes simplex virus (HSV) 1 and 2
• Cytomegalovirus (CMV) or herpes virus 5
• Hepatitis B virus (HBV)
• Human papilloma virus
• Molluscum contagiosum virus
• HIV (human immunodeficiency virus) 1 and 2
• Trichomonas vaginalis
• Entamoeba histolytica, Giardia lamblia
• Phthirus pubis
• Sarcoptes scabiei
Box 1.7. Perinatal transmission (mucous membrane transmission)
• Neisseria gonorrhoeae
• Chlamydia trachomatis
• HBV
• HSV
Box 1.8. Transplacental transmission or vertical transmission
• Treponema pallidum (syphilis)

• Toxoplasma gondii
• CMV, HBV
• HIV
• HSV
• Rubella, varicella
Transplacental Transmission or Vertical Transmission

The microorganisms in this case are present in the blood of the mother and
are able to go through the placenta to infect the fetus (see Box 1.8). In

some cases, it is difficult to differentiate between perinatal or

transplacental transmission, since both modes of transmission are known
to occur.
Urinary Transmission
Although some bacteria (typhoid fever, leptospirosis) and viruses (CMV,
measles) may be excreted in the urine, the role of urine is a minor one in
the transmission of diseases. In urinary schistosomiasis, the adult worms
live in the venous plexus around the urinary bladder. They lay their eggs
in the lining of the bladder. The eggs are excreted in the urine. If they
reach water, they hatch into larvae which look for a suitable intermediate
host (freshwater mollusk).
Arthropod-Borne Transmission
Mosquitoes, flies, fleas, true bugs, ticks, and lice may transmit various
microorganisms by two mechanisms (see Table 2.2.1):
1. Passive transmission: the insect acts as a live syringe. It picks up
microorganisms from blood or superficial lesions and passes them on
to another human. There is no incubation time, no multiplication of
microorganisms while carried by the arthropod. This mode of
transmission is not specific; a wide variety of microorganisms may be
transmitted, but the transmission is not very efficient.
2. Active transmission involves multiplication of the microorganisms in
the arthropod. This applies only to some microorganisms with a
definite set of arthropods. This mode of transmission may be very
effective: The microorganisms may be multiplied a thousand to a
million times. This mode requires a period of multiplication in the
arthropod.
Table 2.2.1: Arthropod-borne diseases
Disease (infectious agent) Vector/intermediate host
Bacteria
Plague (Yersinia pestis) Fleas
Borrelia
Lyme disease (Borrelia Ixodes ticks
burgdorferi)
Relapsing fever (Borrelia Ornithodoros ticks
recurrentis)
Rickettsia

Epidemic typhus Lice, Pediculus humanus Murine typhus

(Rickettsia prowazekii) (Rickettsia typhi), Fleas
Scrub typhus (Rickettsia Larval mites
tsutsugamushi)
Rickettsialpox (Rickettsia Mouse mite
akari)
Rocky Mountain spotted Lice, Dermacentor, Amblyomma ticks
fever (Rickettsia rickettsii)
Trench fever (Rickettsia
quintana)
Virus
Dengue Aedes aegypti
Flaviviridae Mosquitoes
St. Louis encephalitis Culex mosquitoes
Japanese encephalitis Culex mosquitoes
Tick-borne encephalitis Ixodes ticks
Powassan Dermacentor ticks
Togaviridae: Alphavirus
Eastern equine Mosquitoes
encephalitis
Western equine Mosquitoes
encephalitis
Venezuelan equine Mosquitoes
encephalitis
Bunyaviridae
California encephalitis, La Mosquitoes
Crosse
Crimean-Congo Ticks
hemorrhagic fever
Kyasanur forest Ticks
hemorrhagic fever

Yellow fever Aedes mosquitoes

Protozoa
Malaria (Plasmodium sp.) Anopheles mosquitoes
Chagas disease Triatoma sp. (bugs)
(Trypanosoma cruzi)
Leishmaniasis Sand flies
(Leishmania sp.)
Sleeping sickness Glossina sp. (tsetse flies)
(Trypanosoma gambiense)
Bancroft’s filariasis Culex, Aedes, and Anopheles mosquitoes
(Wuchereria bancrofti) Malayan filariasis (Brugia malayi)
Mansonella ozzardi Culicoides, Simulium
Acanthocheilonema Gnats, Culicoides
perstans
Onchocerciasis Black flies, Simulium
(Onchocerca volvulus)
Loiasis (Loa loa) Mango flies, Chrysops
Common Vehicle Transmission

The microorganisms have contaminated the “common vehicle” and are
persisting over a long period of time in/on the common vehicle. The
common vehicle can be food, water (either drinking the water or
swimming in the water), soil (tetanus bacteria), medications, medical
devices, or equipment.
Different Roles in Transmission: Indicator, Maintenance, and Amplifier
For some infectious diseases, different segments of the population play
different roles. The best example for that is foot-and-mouth disease
(FMD), a viral disease which rarely affects humans. Cloven-hoofed
animals (such as cattle, goats, sheep, and pigs) are susceptible to FMD.
FMD viruses are transmitted by air from one infected animal to another.
Pigs are considered to be the amplifier host because they may exhale up
to 1 million viral particles/ml of air. Sheep are an important reservoir of
the virus and are considered maintenance hosts. They are usually
asymptomatic when infected with foot-and-mouth disease. When these
sheep mix with cattle, the cattle develop severe clinical signs and are
therefore easily detected (indicator host).
In-text Question
1. The vector of yellow fever is?
Answer
Aedes Mosquito
Incubation Period, Latent Period and Serial Interval

Incubation Period
The incubation period is the time interval between the invasion by a
microorganism and the first signs or symptoms of disease (onset of
disease). The concept of incubation period relies on the assumption that
the disease is not asymptomatic and that the onset is clearly identifiable.
For asymptomatic cases or carriers, incubation periods are irrelevant. For
some infections, a person may get exposed to the agent, become
colonised, and sometime in the future become a case. If this happens,
incubation is also irrelevant. Incubation periods are only useful if
infection is followed by disease within a certain period of time.
Incubation periods are useful tools when carrying out infectious disease
investigations. A person usually can tell when the first symptoms of a
specific disease appeared. From that date, subtracting the incubation
period, epidemiologists may estimate the date of infection (within a
certain interval). It is also important for follow-up on potential contacts
to the primary case that the primary case might have been already
infectious before exhibiting any clinical signs and symptoms (see Fig.
1.1). In many instances, a person may be infectious toward the end of the
incubation period but before the appearance of the first symptoms. The
incubation period varies according to numerous factors:
• Portal of entry: The closer the portal of entry to the site of disease, the
shorter the incubation period.
• Type of infection (local or systemic): Diseases caused by local
multiplication of a microorganism have short incubation periods.
Those that require systemic dissemination and secondary localization
have longer incubation periods.
• Pathogenesis: Diseases due to a preformed toxin have very short
incubation periods. Diseases due to direct involvement of epithelial
surfaces have short incubation periods, for example, streptococcal sore
throat, bacterial pneumonias, shigellosis, cholera, and gonorrhea.
Table 3.2.1 Incubation, latent period, and serial interval
Primary Infection Onset

Case
Incubation Disease
Latent Infectious
period period
Secondary Infection
Case
Incubation Disease
Onset of Serial interval Onset
primary of
secondary
In contrast, Mycoplasma pneumoniae, diphtheria, and pertussis as well as

diseases like syphilis, brucellosis, and typhoid fever have long incubation
periods (2–3 weeks).
• Immune status of the host: It is important that the notion of incubation is
relative. HIV provides a good example. Infection of an individual with
HIV is followed by a flu-like syndrome. It includes fever, headache,
miscellaneous aches (neck and back), malaise, lymphadenopathy, and rash.
The incubation period for this primary syndrome is 2 weeks to 2 months.
The patient then enters into a remission period with no clinical signs.
However, during this period, the HIV multiplies at variable rates,
destroying CD4+ lymphocytes which are generated as fast as they are
destroyed. The latent remission ends when the patient’s organism is no
longer able to produce CD4+ lymphocytes in sufficient quantities. Immune
defenses fail rapidly and opportunistic infections develop. This phase is
considered as the AIDS (acquired immune deficiency syndrome) disease.
The incubation period for AIDS diseases ranges from 2 to 10 years, with
less than 10% having an incubation period greater than 10 years.
In rabies, the incubation period depends on the length of time it takes the
virus to progress along the neurons to reach the brain. Once the brain is
reached, the disease becomes manifest. The incubation may be as short as
9 days if the bite was in the face or as long as 1 or 2 months if the bite
occurred in the leg. The longest incubation period known for rabies virus
is 9 years.
The incubation period is useful for tracing the source of infection and
contact, determine the period of surveillance, allow for prophylaxis to

become effective (diseases with a long incubation period may be
prevented by immunisation if administered early), identification of point
source or propagated epidemics.
In-text Question
1. In rabies, the incubation period depends on
Answer
The length of time it takes the virus to progress along the neurons to reach the brain
Incubation period in a vector

is the time interval between entry of the microorganism in the vector and
the time the vector becomes infective. This is also called the extrinsic
incubation in contrast to the intrinsic incubation period in humans.
Latent Period
The latent period of infection is the length of time between infection and
the beginning of the infectious period. It is also a period during which no
symptoms occur, an asymptomatic window in the disease (latent period of
syphilis, of HIV infection).
Serial Interval
A serial interval for diseases spread from person to person is the time
between successive generations of cases, that is, the time between
appearances of symptoms in successive generations. If a person is
infectious before onset of symptoms, the serial interval may be lower
than the incubation period.
Infectious (Infectivity) or Communicability Period
The infectious (infectivity) period is the length of time a person may transmit a
microorganism. There are several patterns for infectious periods:
• Short period at the end of the incubation period and at the beginning of
the disease (measles, chickenpox)
• Short period and a few individuals become chronic carriers (Hepatitis B)
• Throughout the disease (open cases of active pulmonary tuberculosis,
malaria).
Measuring infectivity is difficult. It is seldom the result of well-controlled
studies. It is often the interpretation of observational studies on the occurrence
of secondary cases. Factors such as number of infectious agents put out by the
source, closeness, length of contact, and susceptibility of the target contacts
have to be considered. In recent times, nucleic acid testing has been used to
find remnants of infectious disease agents in human or environmental materials,
but their significance to transmission is difficult to interpret.
 Distribution Pattern in the Population

For a better understanding of the distribution of infectious diseases in
populations, the below terms have to be defined: Epidemiologists define
sporadic cases as the occurrence of single illnesses in irregular or random
instances. Endemic defines the occurrence of cases of an illness with a
constant frequency. Depending on the intensity of the occurrence, the
terms holoendemic, hyperendemic, or hypoendemic are used.
Epidemic is defined as the occurrence in a community of cases of an

illness with a frequency clearly in excess of normal expectancy. If this
occurrence of an epidemic occurs worldwide or affects numerous
countries, epidemiologists consider it a pandemic. The most recent
pandemic was declared in June 2009, when the WHO declared a pandemic
of novel influenza A (H1N1). At the time, more than 70 countries had
reported cases of novel influenza A (H1N1) infection, and there were
ongoing community level outbreaks of novel H1N1 in multiple parts of
the world. An outbreak is defined as two or more related cases with the
identical infectious disease agent suggesting the possibility of a common
source or transmission between these cases. It also could be defined as a
very limited epidemic; however, the word “epidemic” is usually avoided
when the number of cases is relatively small so as not to scare the public.
Elimination of disease is the reduction to zero of the disease incidences in
a defined geographical area (e.g., neonatal tetanus) compared to the
elimination of infections which is defined as the reduction to zero of
incidence of infection in a defined geographical area (e.g., measles,
poliomyelitis).
If there is a permanent reduction to zero in the worldwide incidence, the
disease is considered eradicated, such as smallpox was in 1980.
Table 5.2.1 Infectious dose and attack rate

Dose (no. of organisms) Attack rate (%)
Experimental human salmonellosis
125,000 17
695,000 33
1,700,000 67
(McCullough and Eisele 1951)
Typhoid fever

1,000 0
100,000 28
10,000,000 50
100,000,000 89
1,000,000,000 95
(Hornick et al. 1970)
Infectious Dose
The dose of pathogens received by the exposed individual is an important
aspect of infectivity. There is also a close correlation between dose and
type of contact. A closer, more direct type of contact delivers a higher
dose.
It is rarely possible to have an exact measure of the infecting dose. In the
past, experiments have been carried out with human volunteers. In one
experiment, Salmonella bareilly was given to several groups of six
volunteers (McCullough and Eisele 1951). A case was defined as one
experiencing clinical diarrhoea with S. bareilly isolated from the stools.
Some of the cases excreted Salmonella for 1 day, some for 2 days. The
corresponding attack rates, that is, percentage of volunteers experiencing
a clinical diarrhoea, are displayed in Table 1.3. The attack rate depends
heavily on the working case definition.
From this type of data, one may calculate an infectious dose 50 (ID50) =
the dose of pathogenic microorganism that will cause disease in 50% of
the susceptible exposed. In some outbreaks, particularly foodborne
outbreaks where contaminated food is saved, it may be possible to
estimate the infectious dose. The dose may also be important in
determining the severity of disease. To give an example, 1,000 Vibrio
cholerae bacteria produce asymptomatic infections, 10,000 to 1 million
bacteria produce simple diarrhoea in 60%, and at least 1 million bacteria
produce severe diarrhoea with dehydration in 25–50% of volunteers.
2.4 Environmental Factors
There are several factors which influence the spread of microorganisms
in the environment. The spread of infectious diseases depends on:
1. The stability of the microorganism in the physical environment
required for its transmission including resistance to desiccation, high
or low temperature, and ultraviolet light
2. The number of microorganisms in the vehicle of transmission
3. The virulence and infectivity of the microorganisms
4. The availability of the proper vector or medium for the transmission
Environmental characteristics play a role on different levels:
1. Survival of the virus in the environment

2. Influence on the route of transmission
3. Influence on the behaviour of the host
Fig. 3.2.1
https://www.google.com/url?sa=i&url=https%3A%2F%2Fhealth2016.globalchange.gov%2Fvector
bornediseases&psig=AOvVaw3V8Mr9yS4CJFzvmrVIHNVq&ust=1625813512412000&source=image
s&cd=vfe&ved=2ahUKEwiFgaa48dLxAhU07-AKHcL_AQYQjRx6BAgAEA8
A warm environment enhances the transmission of microorganisms

transmitted by water. In tropical and temperate areas, summer increases
contacts between humans and surface water. Summer brings more people
outside, particularly in the evening, and increases contacts between
humans and mosquitoes and other arthropod vectors (see Fig. 3.2.1).
In the cooler seasons in temperate climates, in the rainy season in
tropical climates, people tend to stay and congregate indoors promoting
transmission by airborne or droplet mechanisms. Long stays in the hot
and dry environment indoors im- pair the protective mechanisms of
human mucous membranes and may facilitate the attachment of viruses
onto the upper respiratory mucous membranes. The incidence of upper
respiratory infections is as high in the middle of winter in the temperate
climates as in the middle of the monsoon or rainy season in the tropical
climates.

In this session, we discussed source of infectious material, the portal of entry
into humans, classification of transmission of disease. This study session also
covers environmental factors that influences diseases.

1. Highlight sources of infectious materials
2. Classify infection base on transmission
3. Describe portal of entry into humans

Visit YouTube on https://www.youtube.com/watch?v=IBX3jj2uUjo
Watch the video & summarise in 1 paragraph

MMWR 36(7):103
1996. MMWR 45(25):549–551
48(11):1–40

Study Session 3
HOST FACTORS IN INFECTIOUS DISEASE
Introduction
2.0 Main Content
2.1 – Extrinsic and intrinsic host factors
2.2- Occurrence of infectious Diseases
2.3- Contacts: pattern, Network and Structure of diseases spread
Introduction
In the previous study session, we discuss the basic concepts in epidemiology
which is integral in understanding subsequent sessions. This present study
session entails the sources of infectious materials, portal of entry into
material, classification of transmission of diseases and environmental
factors that influences diseases.
1. Highlight extrinsic and intrinsic host factor
2. Explain how seasonal and annual variation influences infectious disease
3. Discuss the contact pattern and structure of spread of infectious disease
2.0 Main Content
2.1 Extrinsic and Intrinsic Host Factors
Exposure to infectious disease agents depends on both intrinsic (internal)
and extrinsic (external) host factors. Extrinsic host factors are the method
of transmission of the microorganism as well as the host behavior.
Exposure to microorganisms which are transmitted by droplet or airborne
modes is very common. Anyone who is out in the public is likely to be
exposed to these microorganisms. Microorganisms which are transmitted
by vectors result usually from special occupations or special settings
(hobbies or leisure activities). For example, persons who love to be
outdoors (camping, hiking, or working on fields or in the forest) are more
likely to be bitten by ticks or mosquitoes and therefore more likely to
develop one of the zoonotic diseases which are transmitted by these
arthropods. Exposure to sexually transmitted microorganisms depends
entirely on the sexual activities, number of sex partners, and/or lifestyle of

the hosts and the carriers of these diseases.
Intrinsic Host Factors

The transmission of infectious diseases is also regulated by intrinsic
factors that influence the host response. It depends on how many
microorganisms are transmitted (dose), how virulent the strain is, and
how the microorganisms enter the human body. The person’s age at time
of infection is important, too. In general, the probability of clinical
disease increases with age (e.g., polio, Hepatitis). Preexisting level of
immunity to the disease, the nutritional status of the host, as well as any
preexisting disease will influence a successful transmission as well.
Individuals with impaired immune response (HIV, patients on
immunosuppressive therapy for cancer or transplant) have a higher risk
of developing severe disease. Also, personal habits or lifestyle factors
such as smoking, drinking alcohol, drug abuse, or exercise can influence
the host response. Smoking depresses the ciliary function of the
bronchial tree and increases susceptibility to infections (e.g.,
tuberculosis). Alcohol consumption increases the risk for chronic
Hepatitis infections. Also, psychological factors such as motivation and
attitude toward disease can contribute to the transmission of infectious
disease agents.
2.2 Occurrence of Infectious Diseases

Especially in outbreak situations, epidemiologists investigate the
occurrence of disease by asking the following questions:
• When did the disease occur (time)?
• Where do the cases come from (place)?
• Who got infected with the disease (person)?
 Time
- Epidemic Curve
An epidemic curve is the standard graphic representation of cases
occurring over time. It is a histogram with number of cases plotted along
the vertical axis and time along the horizontal axis. The time unit may be
in hours (rapid outbreak such as foodborne outbreaks due to a toxi-
infection), days, or weeks. It is important to have a good time unit
applied; if the time unit is too short or too long, one does not get a visual
picture of the outbreak dynamics.
An epidemic curve may provide some clues about the nature of the
outbreak. A point source outbreak is relatively contracted in time, while a
continuous source outbreak is more stretched out. In the beginning of an
outbreak which is due to person-to-person transmission, one may see the

successive generations.
Seasonal and Annual Variations
Seasonal variations are important for some infectious diseases, particularly
those which are heavily influenced by the environment such as water, food,
and arthropod vectors.
These are more prevalent during the warmer months of the year.
Respiratory infections on the other hand are more prevalent during the
winter in temperate areas or the rainy season in tropical areas.
Annual variations are thought to be mostly the result of accumulation of
immune people after epidemics of an infectious disease. Once the
proportion of the immune population has reached a certain threshold,
there are very few susceptible individuals. In the absence of large
epidemics, the pool of susceptible builds up back again, and herd
immunity is down again. Then the circumstances are right for another
epidemic. These cyclical patterns vary, every other year for measles
before the advent of the vaccine, every 3–4 years for pertussis.
In-text Question
What is an epidemic curve?
Answer
An epidemic curve is the standard graphic representation of cases occurring over time
 Place
- Mapping
Mapping cases is a very common tool used in infectious disease

epidemiology. The map may range from a facility to a city, county,
province, or country. Maps may be spot maps or rates in boundaries.
Mapping may also provide some clues as to the etiology and evolution of
an outbreak.
Cases are plotted according to their location and are numbered in
sequence as they were diagnosed. Cases among employees are underlined
compared to cases among patients which are not underlined.
Host Immunity
The immune status of individuals plays a major role in their susceptibility
to infectious agents.
Specific Immunity
After acquiring an infectious disease, the immune system reaction may (or
may not) lead to protection against another attack of the disease. This so-

called refractory period is the time period where no other infection of this
disease can occur. It may last from a few days up to lifetime depending
on the infectious agent. For some infections such as gonorrhea and
Chlamydia, there is hardly any protection. A person may become re-
infected soon after being cured of the previous infection. For some
diseases such as syphilis, a person may not be super-infected while being
already infected (immunity of premonition). Once treated, the immunity
disappears. For others, the immunity may last for years or even a lifetime
(measles, chickenpox). Lifetime immunity may be boosted by repeated
contacts with the infectious agents. Immunity may have been acquired
following an overt clinical bout of disease or following an unapparent
infection. Eighty percent of children in the USA are immune to
cytomegalovirus (CMV) infection, and the majority have had a
completely asymptomatic infection.
The herd immunity is the immunity of the group. It is related to the sum
of immune individuals over the total population. If a high proportion of a
population is immune to a disease, one speaks of herd immunity. Above
a certain threshold, the incidence of infections may decline. For example,
invasive pneumococcal disease decreased dramatically after the
pneumococcal conjugate vaccine (PCV7) for young children was
introduced in 2000 in the USA. The modeled incidence of pneumococcal
disease covered by this vaccine decreased by 76.6% in the unvaccinated
population if the three-dose vaccination was completed in children before
15 months of age based on an estimated vaccine coverage between
38.1% and 54% in this population (Haber et al. 2007).
Immunocompetence
Immunocompetence is the ability of the immune system to respond to
foreign substance and provide adequate protection. Humans with
normally functioning immune systems are protected against a wide
variety of infectious agents. Immunocompetence is not fully developed in
newborns and is weakened by age or by numerous chronic, acute
diseases or medical treatments. Deep depression of the immune system is
called immune deficiency. Infection by the HIV virus leads to a profound
acquired immune-deficiency syndrome (AIDS). The spread of an
infection may be very different depending on the prevalence and
distribution of immune-deficient individuals. For example, levels of
tuberculosis disease reach the highest incidence in countries with high
prevalence of HIV infection.
2.3 Contacts: Patterns, Networks, and Structures
Contacts (the persons who are the recipients of the infectious agent) and
contact patterns are important in infectious disease epidemiology.
Contact may be defined as the type of interaction (or situation) between a

person acting as a source of an infectious agent and a person
susceptible when the interaction may lead to transmission of the
infectious agent.
Contact and Interaction
The types of contact vary widely with the type of transmission. Direct
contact occurs when the infected host and the susceptible recipient have
their skin or mucous membranes touching, for example, by shaking
hands, kissing, or having sexual intercourse. Indirect contact occurs when
the transmission between both persons involves an inanimate object
(fomite) or a mechanical vector (e.g., fly).
When exposure occurs through the air, droplets or droplet nuclei are the
vehicles of the infectious agent. The circumstances of the “contact”
require a precise definition. For example, a contact of an infectious
pertussis case is a person who (1) had face-to-face interaction at less
than 3 ft for at least 10–15 min or (2) shared confined space for 1 hour or
(3) had a child in a crib located 3–6 ft away or (4) had direct contact with
oral, nasal, or respiratory secretions or (5) had shared food, drink, or
eating utensils or (6) kissed or (7) was in a medical setting during
examination of mouth, throat, intubation, or cardiopulmonary
resuscitation (CPR). This type of very detailed definitions is useful to
determine the persons at risk of infection and place them under
surveillance or prophylaxis.
Contact Patterns: Sociograms
Sociograms were developed to analyse choices or preferences within a
group. They can diagram the structure and patterns of group interactions.
A sociogram consists of nodes (people) and links (contact meeting the
definition of a possible transmission).
The nodes on a sociogram who have many choices are called stars. Those
with few or no choices are called isolates. Individuals who choose each
other are known to have made a mutual choice. One-way choice refers to
individuals who choose someone, but the choice is not reciprocated.
Cliques are groups of three or more people within a larger group who all
choose each other (mutual choice).
The following is an example of a sociogram for sexual contact patterns in
a hypothetical high school (Fig. 1.2). Squares represent males, circles
females, and links sexual relations.

Fig 3.2.1 Example of a sociogram depicting sexual relations in a hypothetical

high school. Square = males, circle=female.
There are celibate males and females, isolated pairs and a large network of
individuals having sexual relations, some with a single partner, and some
with multiple partners. Such sociograms may be useful to describe and
understand an outbreak, but it may also be useful to describe contact
patterns in the absence of any specific disease. It would then help
understand what would happen if an outbreak would occur in the
population.
Risk Measures
Incidence rate (cumulative incidence), incidence density, and prevalence
are commonly used. The numerator may be the number of cases or the
number of persons with serological evidence of past infections for
example. Depending on the circumstances, the denominator may be the
entire population or the number of persons exposed. All rates used in
epidemiology are also used in epidemiology of infectious diseases.
However, attack rate and case fatality rates are especially common to
infectious disease epidemiology.
Attack Rate
The attack rate is the proportion of those exposed to microorganisms that
develop the disease. Attack rates are frequently used in infectious disease
epidemiology. They are heavily influenced on the used definition of
exposure and disease. If a segment of the population is immune (previous
natural infection or immunisation), it will not be susceptible to the
disease, and therefore, the attack rate will be underestimated. Attack rate
is a misnomer. The attack rate is a cumulative incidence of cases that

occurred during an outbreak.
Case Fatality Rate
The case fatality rate is the proportion of people who will die of a certain
disease over those who have the disease. Since it is a rate, a time period
has to be specified. It is different from the mortality rate which is the
proportion of the entire population which dies from a certain disease
during a definite period of time (usually 1 year).
Reproductive Rate
The reproductive rate is the average number of cases that will result from
an index case. The reproductive rate depends on the:
• Probability of transmission in a contact between infected and susceptible
• Frequency of contacts in the population
• Duration of infection
• Proportion already immune in the population
• In-text Question
• What is attack rate?
• Answer
• attack rate is the proportion of those exposed to microorganisms that develop the disease
•
Study Designs
Although any design is used in infectious disease epidemiology studies,
the most common designs are descriptive and case-control studies (see
previous sections in this handbook).
Case reports are detailed descriptions of single cases with exposure,

clinical, treatment, and other relevant information. Description of single
cases exposed under unusual circumstances may have profound
consequences on the prevention of infectious diseases (case of HIV
transmitted by a dentist, cases of rabies transmitted by unspecified contact
with bats, case of West Nile virus infection transmitted by transfusion or
transplantation).
Case series are descriptions of a cluster of cases with detailed exposure,

clinical and outcome data without controls. Such case series description
has led to the identification of AIDS (cluster of Kaposi’s sarcoma and of
Pneumocystis carinii among homosexual men) and Lyme disease
(Borrelia burgdorferi) (cluster of arthritis in children in Lyme,
Connecticut).

In this session, we discussed extrinsic and intrinsic host factors in infectious
disease transmission, occurrence of infectious diseases and contact pattern. This
Unit also covers seasonal and annual variation as a factor that influences the
spread of diseases.

1. Highlight extrinsic and intrinsic host factor
2. Explain how seasonal and annual variation influences infectious disease
3. Discuss the contact pattern and structure of spread of infectious diseases

a. Visit YouTube on https://www.youtube.com/watch?v=qnmfZuKHatg

MMWR 36(7):103
1996. MMWR 45(25):549–551
48(11):1–40

Study Session 4
SURVEILLANCE OF DISEASES
Introduction
2.0 Main Content
2.1 – Surveillance
2.2- Evaluation of a surveillance system
2.3- Investigation of cases, outbreaks, epidemics and survey
2.4- Rationale of selection diseases for surveillance purpose
Introduction
In the previous study session, we discuss the sources of infectious materials,
portal of entry into material, classification of transmission of diseases and
environmental factors that influences diseases. This present study session
covers the surveillance system, evaluation of a surveillance system,
investigation of cases and rationale of selecting diseases for surveillance
purposes.
1. Explain surveillance.
2. Explain the surveillance system.
3. Discuss the contact pattern and structure of spread of infectious disease.
2.0 Main Content
2.1 Surveillance
Surveillance is the continuous scrutiny of all aspects of occurrence
and spread of a disease that are pertinent to effective control (Porta
et al., 2008).
The basic activity in surveillance is to identify new cases.
Surveillance, both active and passive, is the systematic collection of
data pertaining to the occurrence of specific diseases, the analysis
and interpretation of these data, and the dissemination of
consolidated and processed information to contributors to the
program and other interested persons (CDC 2001b).
Surveillance has multiple purposes. It provides quantitative data on the
magnitude of an illness, documents the distribution throughout the

population and the geography leading to information on the natural
history of the disease, allows detecting outbreaks, monitors changes in
illness patterns, and evaluates the effects of control measures.
Fig. 4.2.1: Surveillance for early detection of disease

https://www.google.com/url?sa=i&url=https%3A%2F%2Fwww.semanticscholar.org%2Fpaper%2FI
nfectious-disease-related-laws%253A-prevention-and
- Passive Surveillance
In a passive surveillance system, the surveillance agency has devised
and put a system in place. After the placement, the recipient waits
for the provider of care to report. Passive case detection has been
used for mortality and morbidity data for decades throughout the
world. Many countries have an epidemiology section in the health
department that is charged with centralising the data in a national disease
surveillance system collecting mortality and morbidity data.
In theory, a passive surveillance system provides a thorough coverage
through space and time and gives a thorough representation of the
situation. Practically, compliance with reporting is often irregular and
incomplete. In fact, the main flaws in passive case detection are
incomplete reporting and inconsistencies in case definitions.
The main advantages are the low cost of such a program and the
sustained collection of data over decades. The purpose is to produce
routine descriptive data on communicable diseases, generate hypotheses,
and prompt more elaborate epidemiological studies designed to evaluate
prevention activities. Some conditions must be met to maximise
compliance with reporting:
1. Make reporting easy: provide easy to consult lists of reportable
diseases, provide pre-stamped cards for reporting, and provide
telephone or fax reporting facilities.
2. Do not require extensive information: name, age, sex, residence, and

diagnosis. Some diseases may include data on exposure, symptoms,
method of diagnosis, etc.
3. Maintain confidentiality and assure reporters that confidentiality will
be respected.
4. Convince reporters that reporting is essential: provide feedback; show
how the data are used for better prevention.
Case definitions are important to ensure that data are consistent over time
and multiple jurisdictions. On a global basis as well as for pandemics
(e.g., the novel H1N1 flu pandemic in 2009), this data consistency is
achieved by adhering to WHO case definitions for the respective
infectious disease. In the USA, case definitions are regularly updated and
published by the Centers for Disease Control and Prevention (CDC) in
the Morbidity and Mortality Weekly Report (MMWR) (CDC 1997).
Confidentiality of data is essential, particularly for those reporting health-
care providers who are subject to very strict confidentiality laws. Any
suspicion of failure of maintaining secure data would rapidly ruin a
passive surveillance program.
- Active Surveillance
In an active surveillance system, the recipient will actually take some
action to identify the cases. In an active surveillance program, the
public health agency organises a system by searching for cases or
maintaining a periodic contact with providers. Regular contacting
boosts the compliance of the providers. Providers are health agencies, but
also as in passive case detection, there may be day-care centers, schools,
long-term care facilities, summer camps, resorts, and even the public
involved in reporting diseases to the public health agency.
Active Surveillance Through Interaction with Providers
The agency takes the step to contact the health providers (all of them or a
carefully selected sample) and requests reports from them at regular
intervals. Thus, no reports are missing.
Active surveillance has several advantages:
• It allows the collection of more information. A provider sees that the
recipient agency is more committed to surveillance and is therefore
more willing to invest more time her/himself.
• It allows direct communication and opportunities to clarify definitions
or any other problems that may have arisen.
Active surveillance provides much better and more uniform data than
passive case detection. Active case detection is much more expensive;
however, for certain diseases such as Hepatitis A virus (HAV), the benefit
normally outweighs the cost.
 Active Surveillance Through Active Case Detection

Active surveillance systems are usually designed when a passive system is
deemed insufficient to accomplish the goals of disease monitoring. This
type of surveillance is reserved for special programs, usually when it is
important to identify every single case of a disease. Active surveillance is
implemented in the final phases of an eradication program. Best examples
are the smallpox and poliomyelitis eradication programs and African
guinea worm eradication program in some selected countries. Active
surveillance is also the best approach in epidemic or outbreak
investigations to elicit all cases. In the smallpox eradication program,
survey agents visited providers, asked about suspected cases, and actually
investigated each suspected case. In the global polio eradication program,
which was launched in 1988, all cases of acute flaccid paralysis were
investigated.
Thanks to the distribution of water filters, education about the
transmission of the parasite, as well as enhanced active surveillance for
guinea worm (Dracunculus medinensis) there are only five African
countries left where dracunculiasis is still endemic. The disease might be
eliminated by 2015 which would make guinea worm the first parasite to be
eradicated.
- Syndromic Surveillance
With increasing concerns about infectious disease outbreaks caused by
bioterrorism or emerging infectious agents, it became important to detect
health events (illnesses) before final diagnosis or laboratory confirmation.
The assumption is that early detection will lead to better prevention.
Timeliness and validity of the information are the two most important
factors in a successful syndromic surveillance system.
In a syndromic surveillance system, the data collected is not about
diagnoses but about indicators of the early stages of an outbreak.
Requests for laboratory tests may be part of a syndromic
surveillance system, while results of lab tests that may take hours or
days would be considered in a passive surveillance system. Other
examples of data that may be used are syndromes elaborated from the
chief complaints from emergency department records, clinical
impressions on ambulance worksheet, prescription filled, retail drug and
product purchases, and school or work absenteeism (Buehler et al. 2004).
Framework for evaluating public health surveillance systems for early
detection of electronic reporting of data is instrumental in obtaining a
rapid transfer of data which is essential for early detection. Statistical
tools for pattern recognition and aberration detection are necessary to
identify subtle outbreak patterns.

 Case Register
A case register is a complete list of all the cases of a particular
disease in a definite area over a certain time period. Registers are
used to collect data on infections over long periods of time. Registers
should be population based, detailed, and complete. A register will show
an unduplicated count of cases. They are especially useful for long-term
diseases, diseases that may relapse or recur, and diseases for which the
same cases will consult several providers and therefore would be
reported on more than one occasion.
Case registers contain identifiers, locating information, disease,
treatment, outcome, and follow-up information as well as contact
management information. They are an excellent source of information for
epidemiological studies. In disease control, case registers are
indispensable tools for follow-up of chronic infectious diseases such as
tuberculosis and leprosy.
The contents and quality of a case register determine its usefulness. It
should contain:
• Patient identifiers with names (all names), age, sex, place and date of
birth, and complete address with directions on how to reach the patient
• Name and address of a “stable” relative that knows the patient’s whereabouts
• Diagnosis information with disease classification and brief clinical
description (short categories are better than detailed descriptions)
• Degree of infectiousness (bacteriological, serological results)
• Circumstances of detection
• Initial treatment and response with specific dose, notes on compliance,

side effects, and clinical response
• Follow-up information with clinical response, treatment regimen,
compliance, and side effects
• Locating information (for some diseases, contact information is also useful)
Updating a register is a difficult task. It requires cooperation from

numerous persons. Care must be taken to maintain the quality of data. It
is important to only request pertinent information for program evaluation
or information that would remind users to collect data or to perform an
exam.
- Sentinel Disease Surveillance
For sentinel disease surveillance, only a sample of health providers is
used. The sample is selected according to the objectives of the
surveillance program. Providers most likely to serve the population
affected by the infection are selected; for example, child health clinics
and pediatricians should be selected for surveillance of childhood

diseases. A sentinel system allows cost reduction and is combined with
active surveillance. Program may include the collection of samples for
viral cultures or other diagnostic techniques. Such a level of surveillance
would be impossible to maintain on the national level.
2.2 Evaluation of a Surveillance System
Surveillance systems are evaluated on the following considerations (CDC
2001b):
• Usefulness: Some surveillance systems are routine programs that
collect data and publish results; however, it appears that they have no
useful purpose – no conclusions are reached, no recommendations are
made. A successful surveillance system would provide information
used for preventive purposes.
• Sensitivity or the ability to identify every single case of disease is
particularly important for outbreak investigations and eradication
programs.
• Predictive value positive (PVP) is the proportion of reported cases that
actually have the health-related event under surveillance. Low PVP
values mean that non-cases might be investigated, outbreaks may be
exaggerated, or pseudo- outbreaks may even be investigated.
Misclassification of cases may corrupt the etiological investigations
and lead to erroneous conclusions. Unnecessary interventions and
undue concern in the population under surveillance may result.
• Representativeness ensures that the occurrence and distribution of
cases accurately represent the real situation in the population.
• Simplicity is essential to gain acceptance, particularly when relying on
outside sources for reporting.
• Flexibility is necessary to adapt to changes in epidemiological patterns,
laboratory methodology, operating conditions, funding, or reporting
sources.
• Data quality is evaluated by the data completeness (blank or unknown
variable values) and validity of data recorded
• Acceptability is shown in the participation of providers in the system.
• Timeliness is more important in surveillance of epidemics.
• Stability refers to the reliability (i.e., the ability to collect, manage, and
provide data properly without failure) and availability (the ability to be
operational when it is needed) of the public health surveillance system.
 Elements of a Surveillance System
The major elements of a surveillance system as summarised by the WHO
are mortality registration, morbidity reporting, epidemic reporting,
laboratory investigations, individual case investigations, epidemic field
investigations, surveys, animal reservoir and vector distribution studies,

biologicals and drug utilisation, and knowledge of the population and
the environment. Traditional surveillance methods rely on counting
deaths and cases of diseases. However, these data represent only a small
part of the global picture of infectious disease problems.
- Mortality Registration
Mortality registration was one of the first elements of surveillance
implemented. The earliest quantitative data available on infectious
disease is about mortality. The evolution of tuberculosis in the USA, for
example, can only be traced through its mortality. Mortality data are
influenced by the occurrence of disease but also by the availability and
efficacy of treatment. Thus, mortality cannot always be used to evaluate
the trend of disease occurrence.
- Morbidity Reporting
Reporting of infectious diseases is one of the most common requirements
around the world. A list of notifiable diseases is established on a national
or regional level. The numbers of conditions vary; it ranges usually from
40 to 60 conditions. In general, a law requires that health facility staff,
particularly physicians and laboratories, report these conditions with
guaranteed confidentiality. It is also useful to have other non-health-
related entities report suspected communicable diseases such as day-care
centers, schools, restaurants, long-term care facilities, summer camps,
and resorts. Regulations on mandatory reporting are often difficult to
enforce. Voluntary compliance by the institution’s personnel is necessary.
Reporting may be done in writing, by phone, or electronically in the most
advanced system. Since most infectious diseases are confirmed by a
laboratory test, reporting by the laboratory may be more reliable. The
advantage of laboratory reporting is the ability to computerize the
reporting system. Computer programs may be set up to automatically
report a defined set of tests and results.
For some infectious diseases, only clinical diagnoses are made. These
syndromes may be the consequences of a large number of different
microorganisms for which laboratory confirmation is impractical.
When public or physician attention is directed at a specific disease,
reporting may be biased. When there is an epidemic or when the press
focuses on a particular disease, patients are more prone to look for
medical care and physicians are more likely to report. Reporting rates
were evaluated in several studies. In the USA, studies show report rates
of 10% for viral Hepatitis, 32% for Hemophilus influenzae, 50% for
meningococcal meningitis, and 62% for shigellosis.

- Morbidity Case Definition

It is important to have a standardised set of definitions available to
providers. With- out standardised definitions, a surveillance system may
be counting different entities from one provider to another. The
variability may be such that the epidemiological information obtained is
meaningless.
Most case definitions in infectious disease epidemiology are based on
laboratory tests; however, some clinical syndromes such as toxic shock
syndrome do not have confirmatory laboratory tests. Most case
definitions include a brief clinical description useful to differentiate
active disease from colonisation or asymptomatic infection. Some
diseases are diagnosed based on epidemiological data. As a result, many
case definitions for childhood vaccine preventable diseases and
foodborne
diseases include epidemiological criteria (e.g., exposure to probable or
confirmed cases of disease or to a point source of infection). In some
instances, the anatomic site of infection may be important; for example,
respiratory diphtheria is notifiable, whereas cutaneous diphtheria is not
(CDC 1997).
Cases are classified as a confirmed case, a probable, or a suspected case.
An epidemiologically linked case is a case in which (1) the patient has had
contact with one or more persons who either have/had the disease or have
been exposed to a point source of infection (including confirmed cases)
and (2) transmission of the agent by the usual modes is plausible. A case
may be considered epidemiologically linked to a laboratory-confirmed case
if at least one case in the chain of transmission is laboratory confirmed.
Probable cases have specified laboratory results that are consistent with
the diagnosis yet do not meet the criteria for laboratory confirmation.
Suspected cases are usually cases missing some important information in
order to be classified as a probable or confirmed case.
Case definitions are not diagnoses. The usefulness of public health
surveillance data depends on its uniformity, simplicity, and timeliness.
Case definitions establish uniform criteria for disease reporting and should
not be used as the sole criteria for establishing clinical diagnoses,
determining the standard of care necessary for a particular patient, setting
guidelines for quality assurance, or providing standards for
reimbursement. Use of additional clinical, epidemiological, and laboratory
data may enable a physician to diagnose a disease even though the formal
surveillance case definition may not be met.

Data for Which Stage of Disease Should Be Collected?

 The Morbidity Iceberg
Surveillance programs collect data on the overt cases diagnosed by the
health-care system. However, these cases may not be the most important
links in the chain of transmission. Cases reported are only the tip of the
iceberg. They may not at all be representative of the true endemicity of
an infectious disease. There is a continuous process leading to an
infectious disease: exposed, colonised, incubating, sick, clinical form,
convalescing, and cured. Even among those who have overt disease, there
are several disease stages that may not be included in a surveillance
system:
Cases reported
Cases diagnosed but not reported
Cases who seek medical attention but were not
diagnosed
Cases who were symptomatic but did not seek medical
attention
Cases who were not symptomatic
Fig. 5.2.1 The iceberg concept
– Some have symptoms but do not seek medical attention.
– Some do get medical attention but do not get diagnosed or get misdiagnosed.
– Some get diagnosed but do not get reported.
Infectious disease cases play different roles in the epidemiology of an
infectious disease; some individuals are the indicators (most
symptomatic), some are the reservoir of microorganisms (usually
asymptomatic, not very sick), some are amplifiers (responsible for most
of the transmission), and some are the victims (those who develop severe
long-term complications). Depending on the specific disease and the
purpose of the surveillance program, different disease stages should be
reported. For example:
 In a program to prevent rabies in humans exposed to a suspect rabid
animal (usually a bite) needs to be reported. At the stage where the
case is a suspect, prevention will no longer be effective.
 For bioterrorism events, reporting of suspects is of paramount
importance to minimise consequences. Waiting for confirmation causes
too long of a delay. In the time necessary to confirm cases,
opportunities to prevent coinfections may be lost, and secondary cases
may already be incubating, depending on the transmissibility of the

disease.
 Surveillance for West Nile viral infections best rests on the reporting of
neuroinvasive disease. Case reports of neuroinvasive diseases are a
better indicator than West Nile infection or West Nile fever cases that
are often benign, go undiagnosed, and are reported haphazardly.
 For gonorrhea, young males are the indicators because of the intensity
of symptoms. Young females are the main reservoir because of the high
proportion of asymptomatic infections. Females of reproductive age are
the victims because of pelvic invasive disease (PID) and sterility.
 A surveillance program for Hepatitis B that only would include
symptomatic cases of Hepatitis B could be misleading. A country with
high transmission of Hepatitis B from mother to children would have a
large proportion of infected newborns becoming asymptomatic carriers
and a major source of infection during their lifetime. Typically, in
countries with poor reporting of symptomatic Hepatitis, the reporting
of acute cases of Hepatitis B would be extremely low in spite of high
endemicity which would result in high rates of chronic Hepatitis and
hepatic carcinoma.
 Individual Cases or Aggregate Data?
Most morbidity reporting collects data about individual cases. Reporting
of individual cases includes demographic and risk factor data which are
analysed for descriptive epidemiology and for implementation of
preventive actions. For example, any investigation leading to contact
identification and prophylaxis requires a start from individual cases.
However, identification of individuals may be unnecessary and aggregate
data sufficient for some specific epidemiological purposes. Monitoring
an influenza epidemic, for example, can be done with aggregate data.
Obtaining individual case information would be impractical since it
would be too time consuming to collect detailed demographics on such a
large number of cases. Aggregate data from sentinel sites consists of a
number of influenza-like illnesses by age group and the total number of
consultants or the total number of “participants” to be used as
denominators. Such data is useful to identify trends and determine the
extent of the epidemic and geographical distribution.
Collection of aggregate data of the proportion of school children by age
group and sex is a useful predictive tool to identify urinary
schistosomiasis endemic areas (Lengeler et al. 2000) without having to
collect data on individual school children.
2.3 Investigations of Cases, Outbreaks, Epidemics, and Surveys

Epidemics of severe diseases are almost always reported. This is not the
case for epidemics of milder diseases such as rashes or diarrhoeal
diseases. Many countries do not want to report an outbreak of disease that
would cast a negative light on the countries. For example, many countries
that are tourism dependent do not report cholera or plague cases. Some
countries did not report AIDS cases for a long time.
Case investigations are usually not undertaken for individual cases unless
the disease is of major importance such as hemorrhagic fever, polio,
rabies, yellow fever, any disease that has been eradicated, and any disease
that is usually not endemic in the area.
Outbreaks or changes in the distribution pattern of infectious diseases
should be investigated, and these investigations should be compiled in a
comprehensive system to detect trends. While the total number of
infectious diseases may remain the same, changes may occur in the
distribution of cases from sporadic to focal outbreaks.
Surveys are a very commonly used tool in public health, particularly
in developing countries where routine surveillance is often inadequate
Survey data needs to be part of a comprehensive surveillance
database. One will acquire a better picture from one or a series of well-
constructed surveys than from poorly collected surveillance data. Surveys
are used in control programs designed to control major endemic diseases:
spleen and parasite surveys for malaria, parasite in urine and stools for
schistosomiasis, clinical surveys for leprosy or guinea worm disease, and
skin test surveys for tuberculosis.
Surveillance of Microbial Strains
Surveillance of microbial strains is designed to monitor, through active
laboratory- based surveillance, the bacterial and viral strains isolated.
Examples of these systems are:
In the USA, the PulseNet program is a network of public health
laboratories that performs DNA fingerprinting of bacteria causing
foodborne illnesses (Swaminathan et al. 2001). Molecular subtyping
methods must be standardised to allow comparisons of strains and the
building of a meaningful data bank.

West Nile virus, 2003-2004

Region1 Region5
N
Region2 Region6
Region3 Region7 W E
Region8
Region4 S
Region9
Major urban areas 0 20 40 80 120 160
Human cases Miles
Fig. 5.2.1 Human West Nile neuroinvasive disease cases in Louisiana, 2003–
2004
The method used in PulseNet is pulse field gel electrophoresis (PFGE).
The use of standardized subtyping methods has allowed isolates to be
compared from different parts of the country, enabling recognition of
nationwide outbreaks attributable to a common source of infection,
particularly those in which cases are geographically separated.
• The US National Antimicrobial Resistance Monitoring System
(NARMS) for enteric bacteria is a collaboration between CDC,
participating state and local health departments, and the US Food and
Drug Administration (FDA) to monitor antimicrobial resistance among
foodborne enteric bacteria isolated from humans. NARMS data are also
used to provide platforms for additional studies including field
investigations and molecular characterisation of resistance determinants
and to guide efforts to mitigate antimicrobial resistance (CDC 2006).
• Monitoring of antimicrobial resistance is routinely done by requiring
laboratories to either submit all or a sample of their bacterial isolates.
 Surveillance of Animal Diseases

Surveillance for zoonotic diseases should start at the animal level, thus
providing early warning for impending increases of diseases in the
animal population.
• Rabies surveillance aims at identifying the main species of animals
infected in an area, the incidence of disease in the wild animals, and the
prevalence of infection in the asymptomatic reservoir (bats). This
information will guide preventive decisions made when human
exposures do occur.
• Malaria control entomologic activities must be guided by surveillance of
Anopheles mosquito populations, their biting activities, and
Plasmodium infection rates in the Anopheles mosquitoes.
• Infection rates in wild birds, infection in sentinel chickens, and horse
encephalitis are all part of West Nile encephalitis surveillance. These
methods provide an early warning system for human infections.
• The worldwide surveillance for influenza is the best example of the
usefulness of monitoring animals prior to spread of infection in the
human population. Influenza surveillance programs aim to rapidly
obtain new circulating strains to make timely recommendations about
the composition of the next vaccine. The worldwide surveillance
priority is given to the establishment of regular surveillance and
investigation of outbreaks of influenza in the most densely populated
cities in key locations, particularly in tropical or other regions where
urban markets provide opportunities for contacts between humans and
live animals (Snacken et al. 1999).
2.4 Rationale of Selecting Diseases for Surveillance Purposes
The rationale for selecting infectious diseases and an appropriate
surveillance method is based on the goal of the preventive program.
- Outbreak Investigations
Outbreaks of acute infectious diseases are common, and investigations of
these outbreaks are an important task for public health professionals,
especially epidemiologists. In 2001, a total of 1,238 foodborne outbreaks
with 25,035 cases involved were reported in the USA (CDC 2004) with
norovirus being the most common confirmed etiological agent associated
with these outbreaks (see 5.2.1).
Table 5.2.1 Confirmed etiological agents of foodborne outbreaks in the USA in

2001
Etiology Number of
outbreaks
Bacillus cereus 5
Brucella spp. 1
Campylobacter spp. 16
Clostridium botulinum 3
Clostridium perfringens 30
Enterohemorrhagic Escherichia coli 4
Enterohemorrhagic Escherichia coli O157:H7 16
Enterotoxigenic Escherichia coli 2
Listeria monocytogenes 1
Salmonella spp. 112
Shigella spp. 15
Staphylococcus aureus 23
Vibrio spp. 4
Yersinia enterocolitica 3
Total bacteria 235
Ciguatera 23
Histamine 10
Other chemical 1
Scombroid 18
Total chemical 52
Cyclospora cayetanensis 2
Giardia lamblia 1
Trichinella spp. 2
Total parasitic 5
Hepatitis A 6

Norovirus 150
Total viral 156
Source: CDC Foodborne Outbreak Response and Surveillance Unit (2004)

Outbreaks or epidemics are defined as the number of disease cases above what
is normally expected in the area for a given time period. Depending on the
disease, it is not always known if the case numbers are really higher than
expected and some outbreak investigations can reveal that the reported case
numbers did not actually increase. The nature of a disease outbreak depends on
a variety of circumstances, most importantly the suspected etiological agent
involved, the disease severity or case fatality rate, population groups affected,
media pressure, political inference, and investigative progress. There are
certain common steps for outbreak investigations as shown in Table 6.2.1.
However, the chronology and priorities assigned to each phase of the
investigation have to be decided individually, based on the circumstances of the
suspected outbreak and information available at the time.
For example, in 2002, 21 outbreaks of acute gastroenteritis on cruise ships
with travel destinations outside the USA were reported to the CDC (CDC
2002).
Table 6.2.1 Fourteen steps in outbreak
investigations # Step
1 “Outbreak” detected based on initial report or analysis of
surveillance data
2 Collect basic numbers and biological specimens
3 Investigate or not?
4 Think prevention first
5 Get information on the disease or condition
6 Sometimes numbers do not count
7 Is the increase real or artificial?
8 Verify the diagnosis
9 Prepare a case definition

10 Put the information in a database
11 Find additional cases
12 Basic descriptive epidemiology (time, place, and person)
13 Hypothesis testing and measures of association
14 Final report and communications
In only 5 of these outbreaks, about 1,400 persons, with an average 280 cases
per cruise, had symptoms of viral acute gastroenteritis. Norovirus outbreaks
begin usually as a food- or waterborne disease but often continue because of
the easy person-to-person transmission in a closed environment and low
infectious dose (100 viral particles can be infectious) (CDC 2001a).
- Basic Steps in Outbreak Investigations
 The Initial Report
The original report can originate from very different sources. Examples are:
 A physician is calling the local or state health department about an increase
of number of patients seen and diagnosed with a specific disease.
 A high number of patients with similar signs and symptoms are showing up
in the emergency room.
 A school principal or day-care owner is reporting a high number of absent
students.
 A nursing home health-care professional is seeing a lot of residents with
gastrointestinal illnesses.
 A person is complaining to the health department that she/he got sick after
eating at a certain restaurant.
Another way to detect an increase of cases is if the surveillance system of
reportable infectious diseases reveals an unusually high number of people
with the same diagnosis over a certain time period at different health-care
facilities.
Outbreaks of benign diseases like self-limited diarrhoea are often not detected
because people are not seeking medical attention and therefore medical
services are not aware of them. Furthermore, early stages of a disease
outbreak are often undetected because single cases are diagnosed
sporadically. It is not until a certain threshold is passed that it becomes clear
that these cases are related to each other through a common exposure or
secondary transmission.
Depending on the infectious disease agent, there can be a sharp or a gradual
increase of number of cases. It is sometimes difficult to differentiate between
sporadic cases and the early phase of an outbreak. In the 2001 St. Louis
encephalitis (SLE) outbreak in Louisiana, the number of SLE cases increased
from 9 to 18 between weeks 1 and 2, and then the numbers gradually
decreased over the next 9 weeks to a total of 63 cases (Jones et al. 2002).
 Basic Information
After the initial report is received, it is important to collect and document
basic information: Contact information of persons affected, a good and
thorough event description, names and diagnosis of hospitalized persons (and
depending on the presumptive diagnosis their underlying conditions and
travel history), laboratory test results, and other useful information to get a
complete picture and to confirm the initial story of the suspected outbreak. It
also might be necessary to collect more biological specimens such as food
items and stool samples for further laboratory testing.
 Decision to Investigate
On the one hand, based on the collected information, the decision to
investigate must be made. It may not be worthwhile to start an investigation if
there are only a few people who fully recovered after a couple of episodes of
a self-limited, benign diarrhoea. Other reasons not to investigate might be that
this type of outbreak occurs regularly every summer or that it is only an
increase in number of reported cases which are not related to each other.
On the other hand, however, there should be no time delay in starting an
investigation if there is an opportunity to prevent more cases or the potential
to identify a system failure which can be caused, for example, by poor food
preparation in a restaurant or poor infection control practices in a hospital or
to prevent future outbreaks by acquiring more knowledge of the epidemiology
of the agent involved. Additional reasons to investigate include the interest of
the media, politicians, and the public in the disease cluster and the pressure to
provide media updates on a regular basis. Another fact to consider is that
outbreak investigations are good training opportunities for newly hired
epidemiologists. Sometimes lack of data and lack of sufficient background
information make it difficult to decide early on if there is an outbreak or not.
The best approach then is to assume that it is an outbreak until proven
otherwise.
 Prevention Comes First
Prevention of more cases is the most important goal in outbreak
investigations, and therefore a rapid evaluation of the situation is necessary. If
there are precautionary measures to be recommended to minimise the impact
of the outbreak and the spread to more persons, they should be implemented
before a thorough investigation is completed. Most likely control measures

implemented by public health professionals in foodborne outbreaks are:
• Recall or destruction of contaminated food items
• Restriction of infected food handlers from food preparation
• Correction of any deficiency in food preparation or conservation
 Natural History
After taking immediate control measures, the next step is to know more about
the epidemiology of the suspected agent. The most popular books for public
health professionals include the “Red Book” (American Academy of
Pediatrics 2006), the “Control of Communicable Diseases Manual” from the
American Public Health Association (APHA 2008), or other infectious
disease epidemiology books as well as the CDC website (www.cdc.gov). If
the disease of interest is a reportable disease or a disease where surveillance
data are available, baseline incidence rates can be calculated. Then a
comparison is made to determine if the reported numbers constitute a real
increase or not. Furthermore, the seasonal and geographical distribution of the
disease is important as well as the knowledge of risk factors. Many infectious
diseases show a seasonal pattern such as rotavirus or Neisseria meningitides.
For example, in suspected outbreaks where cases are associated with raw
oyster consumption, the investigator should know that in the US Gulf states,
Vibrio cases increase in the summer months because the water conditions are
optimal for the growth of the bacteria in water and in seafood. This kind of
information will help to determine if the case numbers show a true increase
and if it seems likely to be a real outbreak.
 Number of Cases
For certain diseases, numbers are not important. Depending on the severity of
the disease, its transmissibility, and its natural occurrence, certain diseases
should raise a red flag for every health professional, and even a single case
should warrant a thorough public health investigation. For example, a single
confirmed case of a rabid dog in a city (potential dog-to-dog transmission
within a highly populated area), a case of dengue hemorrhagic fever, or a
presumptive case of smallpox would immediately trigger an outbreak
investigation.
 Artifact
Sometimes an increase of case numbers is artificial and not due to a real
outbreak. In order to differentiate between an artificial and a natural increase
in numbers, the following changes have to be taken into consideration:
• Alterations in the surveillance system
• A new physician who is interested in the disease and therefore more likely
to diagnose or report the disease
• A new health officer strengthening the importance of reporting
• New procedures in reporting (from paper to web-based reporting)

• Enhanced awareness or publicity of a certain disease that might lead to
increased laboratory testing
• New diagnostic tests
• A new laboratory
• An increase in susceptible population such as a new summer camp
 Misclassification
It is important to be sure that reported cases of a disease actually have the
correct diagnosis and are not misdiagnosed. Is there assurance that all the
cases have the same diagnosis? Is the diagnosis verified and were other
differential diagnoses excluded? In order to be correct, epidemiologists have
to know the basis for the diagnosis. Are laboratory samples sufficient? If not,
what kind of specimens should be collected to ascertain the diagnosis? What
are the clinical signs and symptoms of the patient?
In an outbreak of restaurant-associated botulism in Canada, only the 26th case
was correctly diagnosed. The slow progression of symptoms and
misdiagnosis of the dispersed cases made it very difficult to link these cases
and identify the source of the outbreak (CDC 1985, 1987).
Case Definition
The purpose of a case definition is to standardize the identification and
counting of the number of cases. The case definition is a standard set of
criteria and is not a clinical diagnosis. In most outbreaks, the case definition
has components of person, place, and time, such as the following: persons
with symptoms of X and Y after eating at the restaurant Z between Date 1 and
Date 2. The case definition should be broad enough to get most of the true
cases but not too narrow so that true cases will not be misclassified as
controls. A good method is to analyse the data, identify the frequency of
symptoms, and include symptoms that are more reliable than others. For
example, diarrhoea and vomiting are more specific than nausea and headache
in the case definition of a food-related illness.
 Database
What kind of information is necessary to be collected? It is sufficient to have
a simple database with basic demographic information such as name, age,
sex, and information for contacting the patient. More often, date of reporting
and date of onset of symptoms are also important. Depending on the outbreak
and the potential exposure or transmission of the agent involved, further
variables such as school, grade of student, or occupation in adults might be
interesting and valuable.
 Case Finding
During an outbreak investigation, it is important to identify additional cases
that may not have been known or were not reported. There are several
approaches:
• Interview known cases and ask them if they know of any other friends or
family members with the same signs or symptoms.
• Obtain a mailing list of frequent customers in an event where a restaurant is
involved.
• Set up an active surveillance with physicians or emergency departments.
• Call laboratories and ask for reports of suspected and confirmed cases.
Another possibility is to review surveillance databases or to establish enhanced

surveillance for prospective cases. Occasionally, it might be worthwhile to
include the media for finding additional cases through press releases. However,
the utility of that technique depends on the outbreak and the etiological agent;
the investigator should always do a benefit risk analysis before involving the
media.
 Descriptive Epidemiology
After finding additional cases, entering them in the database, and organising
them, the investigator should try to get a better understanding of the situation
by performing some basic descriptive epidemiology techniques such as sorting
the data by time, place, and person. For a better visualisation of the data, an
epidemic or “epi” curve should be graphed. The curve shows the number of
cases by date or time of onset of symptoms. This helps to understand the
nature and dynamic of the outbreak as well as to get a better understanding of
the incubation period if the time of exposure is known. It also helps to
determine whether the outbreak had a single exposure and no secondary
transmission (single peak) or if there is a continuous source and ongoing
transmission.
Sometimes it is useful to plot the cases on a map to get a better idea of the
nature and the source of an outbreak. Mapping may be useful to track the
spread by water (see John Snow’s cholera map) or by air or even a person-to-
person transmission. If a contaminated food item was the culprit, food
distribution routes with new cases identified may be helpful. Maps, however,
should be taken with caution and carefully interpreted. For example, WNV
cases are normally mapped by residency but do not take into account that
people might have been exposed or bitten by an infective mosquito far away
from where they live. For outbreak investigations, spot maps are usually more
useful than rate maps or maps of aggregate data.
Depending on the outbreak, it might be useful to characterise the outbreak by
persons’ demographics such as age, sex, address, occupation, and health
status. Are the cases at increased susceptibility or at high risk of infection?
These kinds of variables might give the investigator a good idea if the
exposure is not yet known. For typical foodborne outbreaks, however,
demographic information is not very useful because the attack rates will be
independent of age and sex.
 Hypothesis Forming
Based on the results of basic descriptive epidemiology and the preliminary
investigation, some hypotheses should be formulated in order to identify the
cause of the outbreak. A hypothesis will be most likely formulated such as
“those who attended the luncheon and ate the chicken salad are at greater risk
than those who attended and did not eat the chicken salad.” It is always easier
to find something after knowing what to look for, and therefore a hypothesis
should be used as a tool. However, the epidemiologist should be flexible
enough to change the hypothesis if the data do not support it. If data clues are
leading in another direction, the hypothesis should be reformulated such as
“those who attended the luncheon and ate the baked chicken are at greater risk
than those who attended and did not eat the baked chicken.”
To verify or deny hypotheses, measures of risk association such as the relative
risk (RR) or the odds ratio (OR) have to be calculated.
The CDC has developed the software program “Epi Info” which is easy to use
in outbreak investigations and, even more importantly, free of charge. It can
be downloaded from the CDC website (http:// www.cdc.gov/epiinfo/).
Measures of association, however, should be carefully interpreted; even a
highly significant measure of association cannot give enough evidence of the
real culprit or the contaminated food item. The measure of association is only
as good and valid as the data. Most people have recall problems when asked
what they ate, when they ate, and when their symptoms started. Even more
biases or misclassifications of cases and controls can hide an association. A
more confident answer comes usually from the laboratory samples from both
human samples and food items served at time of exposure. Agents isolated
from both food and human samples that are identified as the same subtype, in
addition to data results supporting the laboratory findings, are the best
evidence beyond reasonable doubt.
 Final Report
As the last step in an outbreak investigation, the epidemiologist writes a final
report on the outbreak and communicates the results and recommendations to
the public health agency and facilities involved.
Types of Outbreaks
The “Traditional” Foodborne Outbreak
The “traditional” foodborne outbreak is usually a small local event such as
family picnic, wedding reception, or other social event and occurs often in a
local restaurant or school cafeteria. This type of outbreak is highly local with a
high attack rate in the group exposed to the source. Because it is immediately

apparent to those in the local group such as the group of friends who ate at the
restaurant or the students’ parents, public health authorities are normally
notified early in the outbreak, while most of the cases are still symptomatic.
Epidemiologists can start early on with their investigation and therefore have a
much better chance to collect food eaten and stool samples of cases with
gastroenteritis for testing and also to detect the etiological agent in both of
them.
- New Types of Outbreaks
A different type of outbreak is emerging as the world is getting smaller. In
other words, persons and food can travel more easily and faster from continent
to continent and so do infectious diseases with them. Foodborne outbreaks
related to imported contaminated food items are normally widespread,
involving many states and countries, and therefore are frequently identified. In
1996, a large outbreak of Cyclospora cayetanensis occurred in 10 US states
and Ontario, Canada, and was linked to contaminated raspberries imported
from South America. Several hundred laboratory-confirmed cases were
reported, most of them immunocompetent persons (CDC 1996).
A very useful molecular tool to identify same isolates from different
geographical areas is subtyping enteric bacteria with PFGE. In the USA, the
PulseNet database allows state health departments to compare their isolates
with other states and therefore increase the recognition of nationwide outbreaks
linked to the same food item (Swaminathan et al. 2001).
In a different scenario, a widely distributed food item with low-level
contamination might result in an increase of cases within a large geographical
area and therefore might be not get detected on a local level. This kind of
outbreak might only be detected by chance if the number of cases increased in
one location and the local health department alerts other states to be on the
lookout for a certain isolate.
Another type of outbreak is the introduction of a new pathogen into a new
geographical area as it happened in 1991 when Vibrio cholerae was
inadvertently introduced in the waters off the Gulf Coast of the United States.
Food can not only be contaminated by the end of the food handling process,
that is, by infected food handlers, but also can be contaminated by any event
earlier in the chain of food production. In 1996, an outbreak of Salmonella
enteritidis in a national brand of ice cream resulted in 250,000 illnesses. The
outbreak was detected by routine surveillance because of a dramatic increase of
Salmonella enteritidis in South Minnesota. The cause of the outbreak was a
basic failure on an industrial scale to separate raw products from cooked
products. The ice-cream premix was pasteurised and then transported to the ice-
cream factory in tanker trucks which had been used to haul raw eggs. This
resulted in the contamination of the ice cream and subsequent salmonella cases
(Hennessy et al. 1996).

- Surveys
Surveys are useful to provide information for which there is no data source or
no reliable data source. Surveys are time consuming and are often seen as a last
choice to obtain information. However, too often unreliable information is used
because it is easily available. For example, any assessment of the Legionella
problem using passive case detection will be unreliable due to underdiagnosis
and underreporting. Most cases of legionellosis are treated empirically as
community- acquired pneumonias and are never formally diagnosed.
In developing countries, surveys are often necessary to evaluate health
problems since data collected routinely (disease surveillance, hospital records,
case registers) are often incomplete and of poor quality. In industrialized
nations, although many sources of data are available, there are some
circumstances where surveys may be necessary.
Prior to carrying out surveys involving human subjects, special procedures
need to be followed. In industrialised countries, a human subject investigation
review board has to evaluate the project’s value and ethics. In developing
countries, however, such boards may not be formalised, but it is important to
obtain permission from medical, national, and local political authorities before
proceeding.
 Survey Methods
Surveys of human subjects are carried out by mail, telephone, personal
interviews, and behavioral observations. In infectious diseases, the collection
of biological specimens in humans (i.e., blood for serological surveys) or the
collection of environmental samples (food, water, environmental surfaces) is
very common. Personal interviews and specimen collection require face-to-
face interaction with the individual surveyed. These are carried out in offices
or by house-to-house surveys. Non-respondents are an important problem for
infectious disease surveys. Those with an infection may be absent from school,
may not answer the door, or may be unwilling to donate blood for a serological
survey, thus introducing a systematic bias into the survey results.
Since surveys are expensive, they cannot be easily repeated. All field
procedures, questionnaires, biological sample collection methods, and
laboratory tests should be tested prior to launching the survey itself. Feasibility,
acceptability, and reliability can be tested in a small-scale pilot study.
- Sampling
Since surveys are labor intensive, they are rarely carried out on an entire
population but rather on a sample. To do a correct sampling, it is necessary to
have a sampling base (data elements for the entire population) from which to
draw the sample. Examples of sampling bases are population census, telephone
directory (for the phone subscriber population), school roster, or a school list.
In developing countries, such lists are not often available and may have to be
prepared before sampling can start.
- Community Surveys (House-to-House Surveys)
Most community surveys are carried out in developing countries because
reliable data sources are rare. The sampling base often ends up to the physical
layout of the population. A trip and geographical reconnaissance of the area are
necessary. The most common types of surveys undertaken in developing
countries are done at the village level; they are based on maps and a census of
the village.
In small communities, it is important to obtain the participation of the
population. Villagers are often wary of government officials counting people
and going from door to door. To avoid misinterpretations and rumors,
influential people in the community should be told about the survey. Their
agreement is indispensable, and their help is needed to explain the objectives
of the survey and particularly its potential benefits. Increasing the knowledge
about disease, disease prevention and advancing science are abstract notions
that are usually poorly understood or valued by villagers who are, in general,
very practical people. If a more immediate benefit can be built into the survey,
there will be an increase in cooperation of the population. Incentives such as
offering to diagnose and treat an infection or drugs for the treatment of
common ailments such as headaches or malaria enhance the acceptance of the
survey.
In practically all societies, the household is a primary economic and social
unit. It can be defined as the smallest social unit of people who have the same
residency and maintain a collective organisation. The usual method for
collecting data is to visit each household and collect samples or administer a
questionnaire.
Medical staff may feel left out or even threatened whenever a medical
intervention (such as a survey) is done in their area. A common concern is that
people will go to their medical care provider and ask questions about the survey
or about specimen collection and results. It is therefore important to involve
and inform local medical providers as much as practical.
A rare example of a house-to-house survey in an industrialised nation was
carried out in Slidell, Louisiana, for the primary purpose of determining the
prevalence of West Nile infection in a southern US focus. Since the goal was to
obtain a random sample of serum from humans living in the focus, the only
method was a survey of this type. A cluster-sampling design was used to
obtain a representative number of households. The area was not stratified
because of its homogeneity. Census blocks were grouped so that each cluster
contained a minimum of 50 households. The probability of including an
individual cluster was determined by the proportion of houses selected in that
cluster and the number of persons participating given the number of adults in
the household. A quota sampling technique was used, with a goal of enlisting
ten participating households in each cluster.
Inclusion criteria included age (at least 12 years of age) and length of residence
(at least 2 years). The household would be included only if an adult household
resident was present. A standardised questionnaire was used to interview each
participant. Information was collected on demographics, any recent febrile
illness, knowledge, attitudes, and behaviors to prevent WNV infection and
potential exposures to mosquitoes. A serum sample for WNV antibody testing
was drawn.
In addition, a second questionnaire regarding selected household characteristics
and peridomestic mosquito reduction measures was completed. Informed
consent was obtained from each participant, and all participants were advised
that they could receive notification of their blood test results if they wished.
Institutional review board approvals were obtained.
Logistics for specimen collection, preservation, and transportation to the
laboratory were arranged. Interpretation of serological tests and necessary
follow-up were determined prior to the survey and incorporated in the methods
submitted to the ethics committee.
Sampling weights, consisting of components for block selection, household-
within-block selection, and individual-within-household participation, were
used to estimate population parameters and 95% confidence intervals (CI).
Statistical tests were performed incorporating these weights and the stratified
cluster sampling design.
In this survey, 578 households were surveyed (a 54% response rate),
including 1,226 participants. There were 23 Immunoglobulin M (IgM)
seropositive persons, for a weighted seroprevalence of 1.8% (with a 95%
confidence interval of 0.9–2.7%) (Michaels et al. 2005).
 Microbiological and Serological Issues

- Case Confirmation
Definitive confirmation of a case relies on the identification of the infectious
agent in the patient in some specific body sites. The site is important for
agents that may be pathogens or colonisers. For example, identification of
Neisseria meningitidis in an upper respiratory fluid could be due to
colonisation, while isolation from cerebrospinal fluid or blood would mean
definite invasive disease.
Identification of infectious agents is more frequently done by genotyping of
the agent nowadays. The reliability of these identifications depends on the
methods being used. Many of the tests are developed “in house.” The tests
that identify a single gene are less reliable than those that identify several
specific genes.
- Serological Issue and Seroepidemiology
Serological tests have long been used to diagnose the cause of an infectious
disease. In most instances, these methods are reliable, but this is not always
so. The old serological methods (agglutination, hemagglutination,
complement fixation, etc.) often resulted in a false-positive/false-negative
result. Dilutions were used to quantify the reactions. In general, positive
reactions at low titers were meaningless, while positivity at high dilutions was
indicative of a recent infection. A fourfold increase of positivity (e.g., from a
1:16 to 1:64 dilution) over a 2-week period was usually considered
confirmatory based on the dilution factor that meets the criteria for
positivity in the laboratory test. A good example for this is Brucella sp. (a
zoonotic disease where humans are accidental hosts) where a fourfold or
greater rise in the Brucella agglutination titer between acute (specimen taken
while patient is symptomatic) and convalescent (specimen taken while patient
is recovering from the disease) serum specimens obtained 2 or more weeks
apart is considered positive. Serological diagnosis is often discouraged
because of difficulties of collecting follow-up serum samples if the patient has
recovered and is not in medical care anymore.
Newer techniques such as enzyme immunoassays (EIA) do quantify the
amount of antibodies present, but do not allow for the “fourfold increase.”
The serological response to an infection consists of several types of
antibodies: IgM at first, Immunoglobulin G (IgG) antibodies later, and also
Immunoglobulin A (IgA) antibodies. The usual assumption is that IgM
antibodies are produced early (before IgG antibodies) and for a limited length
of time (usually 2–3 months). However, the postulate “IgM means recent
infection” is not always true. Onset and length of production of IgM
antibodies depend on the infectious agent. For West Nile infections, IgM
production starts a few days after infection but may last for several years; in
fact, 1 year after infection, 40% of the patients are still reported IgM positive
by most criteria established by laboratory definitions.
 Sensitivity, Specificity, and Predictive Value of a Positive Test

Issues of sensitivity, specificity, and predictive value are particularly relevant
to serological testing.
- Nosocomial Infection Epidemiology
Epidemiology plays a major part in prevention programs against nosocomial
(hospital-acquired) infections. Surveillance should provide systematic and
continuous observations on the occurrence and distribution of nosocomial
infections within the hospital population. Surveillance is the focal point for
infection control activities. The term surveillance implies that the observational
data are regularly analysed. Surveillance activities may provide valuable

epidemiological data such as the identification of outbreaks, priorities for
infection control activities, and the elucidation of important secular trends,
such as shifts in microbial pathogens, infection rates, or outcomes of hospital-
acquired infection. Surveillance activities provide the additional benefits of
increasing the visibility of the infection control team in the hospital during the
infection control practitioners’ ward rounds and of allowing an opportunity for
informal consultation and education for both nurses and physicians.
Ideally, the surveillance of hospital-acquired infection should be a continuous
process that consists of the following elements:
1. Definition of categories of infection
2. Systematic case finding and data collection
3. Tabulation of data
4. Analysis and interpretation of data
5. Reporting of relevant infection surveillance data to individuals and groups
for appropriate action
- Definitions
The use of consistent definitions of nosocomial infection is critical in
developing data on endemic infection rates. Definitions must be simple,
requiring only clinical information or readily available laboratory data.
- General Definitions
A nosocomial infection is either:
1. An infection which is acquired during hospitalisation and which was not
present or incubating at the time of admission or
2. An infection which is acquired in the hospital and becomes evident after
discharge from the hospital or
3. A newborn infection which is the result of passage through the birth canal.
An infection is defined as hospital acquired if the patient (1) has an infection,

not a simple colonisation, (2) was not infected at the time of admission, and
(3) had sufficient time to develop infection.
- True Infection and Not Colonisation or Contamination
Infections are accompanied by signs and symptoms of infection (fever,

malaise) and in localised infections: swelling due to inflammation, heat, pain,
and erythema (tumor, dolor, rubor, or calor). Immunocompromised patients
do not show signs of infection as easily as normal patients. Neutropenic
patients (500 neutrophils/cubic millimeter) show no pyuria, no purulent
sputum, little infiltrate, and no large consolidation on chest X-ray. An
antibiotic treatment by a physician is a presumption of infection.
– No Infection at Time of Admission Several criteria may be used to
establish prior negativity: history, symptoms and signs documented at
the time of admission, lab tests, and chest X-rays done in the early days
in the hospital. Normal physical examination, absence of signs and
symptoms, normal chest X-ray, negative culture, and lack of culture are
useful.
– Sufficient Time to Develop Infection For diseases which have a

specific incubation period, the hospital-acquired infection can only
develop if the patient has stayed in the hospital for a stay incubation
period. Numerous infections do not have well set incubation periods
(e.g., staphylococci and E. coli infections). However, these infections
rarely develop in less than 2 days.
To establish a nosocomial infection meeting the definition criteria, it is
sufficient that there is no need to have proof beyond the shadow of a doubt.
– Specific Definitions
To carry out surveillance, very specific definitions are necessary, not only
regarding the major nosocomial infections (surgical site infection,
bloodstream infections, pneumonia, and urinary tract infections) but regarding
all possible sites of nosocomial infections.
– Scope/Strategy of Surveillance
Active surveillance is much more effective than passive surveillance. Using
active surveillance increases the sensitivity of identifying infections.
– Case Finding
Case finding can be retrospective, prospective, or both. Prospective or
concurrent surveillance means monitoring the patient during hospitalisation.
Prospective surveillance may include the post-discharge period. In contrast,
retrospective surveillance involves review of the medical record after the
patient has been discharged. Prospective surveillance provides increased
visibility for infection control personnel and timely analysis of data and
feedback to clinical services, but this type of surveillance is more expensive.
Retrospective methodology is cheaper to implement but requires more
controls to verify how effective the infection control personnel are as follows:
• Patient-based case finding relies on evaluating medical records and doing
rounds in hospital wards. It allows assessing risk factors, procedures, and
practices related to patient care.
• Laboratory-based surveillance relies on identifying positive cultures for
pathogens. Then, further investigations are necessary to verify if this is a
health-care facility-associated infection, a community-associated infection,
a colonisation, or a contamination.
A major issue is determining the scope of surveillance. Choices can include
three major strategies: hospital-wide surveillance, surveillance by objective,
and limited or targeted surveillance.

– Hospital-Wide Surveillance
Comprehensive or hospital-wide surveillance implies a continuous
surveillance of all patients for all types of nosocomial infections in all
hospital wards.
This strategy is time consuming. Efficiency is increased by using “clues” to
identify patients whose charts should be reviewed. A hospital-wide
surveillance provides a global view of the hospital, but the cost and the labor
involved may be prohibitive. Critics of whole-house surveillance argue that
collecting and analysing data may be overwhelming; time may not permit
developing objectives for surveillance, and many of the identified infections
may not be preventable. A modification of this strategy includes doing
hospital-wide surveillance for 1 year, or part of a year.
– Surveillance by Objectives
Surveillance by objectives focuses on specific outcome objectives defined
for surveillance purposes. Levels of surveillance effort are prioritised.
Prioritisation focuses on types of infections to be prevented, and levels of
effort may be adjusted to the relative seriousness of the problem.
Considerations in setting these priorities would include morbidity and
mortality data, costs of treating infections, length of stay, frequency of
occurrence of infection, and percentage of infections that are thought to be
preventable. If baseline rates (before objectives are met) are not established,
the identification of clusters and epidemics would be difficult. Areas that
were not included in the objectives could not be evaluated.
– Targeted Surveillance
• Targeted surveillance can be site specific, unit specific, rotating, or
limited to outbreak surveillance.
• Site-specific surveillance focuses on specific infection sites such as
surgical wounds or urinary tract infections. In contrast to surveillance by
objective, this strategy lacks a defined objective. It is flexible, because
this strategy can be used concurrently with alternating components such
as continuous and rotating surveillance as well as special projects.
• Unit-directed surveillance targets specific units or areas with highest
risk. Surveillance activities are limited to the areas of highest risks such
as intensive care units, burn units, and hematology and oncology units.
Targeting critical care and oncology units, for example, would capture
the majority of all bloodstream infections. The rate of infection in these
units is high, yet a relatively small number of patients are actually
treated. This approach may prevent infections in patients at greatest risk.
• Rotating surveillance is periodic and systematic surveillance in a given
unit for a specific time period. This technique is less time consuming and
more cost effective than other forms of surveillance because all areas of
the hospital are covered at sequential periodic intervals using careful
continuous surveillance. Ideally, rotating surveillance involves an
annual, detailed, and directed infection-control evaluation for each
hospital unit. One type of rotating surveillance, the prevalence survey,
can identify infection control risks; however, it can also miss clusters in
areas that are not currently under surveillance.
• Outbreak surveillance requires an alert hospital staff who report any
unusual cluster of events that, when based on surveillance data, extend
beyond threshold units.
Whichever surveillance strategies are selected, they should allow personnel to
recognise and workup clusters of infections or events.
– Epidemiological Aspects of Infectious Disease Prevention

• Antibiotic Resistance
There are an almost daily increasing number of publications on antibiotic
resistance creating the impression that the resistance is growing worldwide.
However, there is no comprehensive surveillance system for antibiotic
sensitivity and no comprehensive database documenting the spread of
resistance in the USA or worldwide. One of the best data sources for the USA
comes from the National Nosocomial Infection Surveillance (NNIS), now the
National Healthcare Safety Network surveillance which documents sensitivity
of nosocomial infections, an estimated 4% of bacterial infections occurring in
the USA.
On a very global aspect, antibiotics are still very effective. For many
hospitals, antibiotic sensitivity patterns are not very different nowadays than
what they were 10 years ago, except for very few pathogens. Reports obtained
from the medical literature are not representative of the whole hospitals, and
even of the whole “world” of bacteria. Many of the resistance reports from
the literature come from single institutions where antibiotic resistance was the
consequence of overuse of an antibiotic. Very few reports attempt to compare
several institutions. There is no randomised, non-selective, multicentered data
to evaluate the scope of resistance and its evolution. Most of the US data is
reported from large metropolitan hospitals affiliated with medical schools in
the northern USA. These hospitals treat the more severely ill patients who
often have been treated unsuccessfully at community hospitals and have
probably become resistant during previous attempts at treatment.
The impression is that the most severe cases of resistance are generated in the
tertiary care hospitals (these are specialty hospitals dedicated to specific
subspe- cialty care including ICUs). It may well be that resistance is
generated in primary (health care was provided by a general practitioner or

other health professional) and secondary care facilities (health care provided
by hospital clinicians) and those cases who did not respond to antibiotics were
referred to tertiary care hospitals.
– Active Surveillance
The goal of an antibiotic sensitivity active surveillance system is to estimate the
proportion of selected bacteria that are resistant to antibiotics by the reporting
of laboratory aggregate data. This surveillance system can only monitor a few
pathogens. In the USA, the most common pathogens monitored in such
programs are methicillin- resistant Staphylococcus aureus (MRSA), drug-
resistant Streptococcus pneumoniae (DRSP), and vancomycin-resistant
Enterococcus (VRE). Laboratories are asked to report:
1. The total number of drug-resistant or drug intermediate-resistant isolates
excluding duplicates (one isolate per patient per month if possible)
(numerator)
2. The total number of isolates of the bacterial species of concern
(denominator) from a given laboratory for each month
Antibiograms
Another approach to establish an antibiotic sensitivity surveillance system is
to use the hospital antibiograms. In 2001, the National Committee on Clinical
Laboratory Standards (NCCLS) now known as the Clinical and Laboratory
Standards Institute (CLSI) issued guidelines on how to analyse and present
cumulative antimicrobial sensitivity test data from antibiotic sensitivity
testing performed on health-care facility patients. The data show the percent
sensitivity for the first isolate from a patient within an analysis period
(generally 1 year), the specimen source, and the total number of isolates tested
(minimum ten for each organism to avoid describing sensitivity on a sample
of less than ten patients).
The compilation of individual hospital antibiograms over time is useful in
monitoring antibiotic sensitivity. The CDC conducted a study to compare data
from the resource-intensive active surveillance collection of antibiotic
resistance patterns to the data collected using hospital antibiograms. The
study found the proportions of drug-resistant isolates from antibiograms were
within ten percentage points of those from isolates obtained through active
surveillance, thereby providing a relatively simple and accurate way to
monitor antibiotic resistance (Van Beneden et al. 2003).
Limitations of hospital antibiograms are that they do not sort out community-
acquired infections from nosocomial infections and some laboratories may
not thoroughly unduplicate their data, thus giving a picture of a larger number
of resistant isolates than it is the case.

– Immunisation
Epidemiology plays a major role at several stages in immunisation programs.
At the Development Stage
Once a vaccine has been developed, it has to go through a rigorous process to
be recognised as safe and efficacious. Once information on the vaccine
composition, manufacturing, stability and sterility, and animal testing results
have been submitted for review, the vaccine has to go through preclinical and
clinical trials. In the preclinical studies, assays are carried out in animals to
determine the humoral and cellular responses, the optimal administration
route, the dose-response relationship, and the dosing schedule and the adverse
or toxic effects. This is followed by the clinical studies. Phase I studies are
intended to determine the efficacious dose and safety of the vaccine in a small
number of healthy adults. Phase II studies are more extensive “open-label”
prospective cohort studies or small randomised controlled trials on all
relevant age groups. Their goal is to establish safety and immunogenicity.
Phase III studies are randomised double-blind placebo-controlled vaccine
efficacy trials. A comparison is made for the incidence rate of a disease in the
standard versus a placebo group. The goal is to confirm the efficacy and
obtain a comprehensive list of side effects.
– At the Implementation Stage
Once in public use, the populations receiving the vaccine are much less
controlled than during the trials. The designs of epidemiological studies must
be adapted to these new conditions. Descriptive studies, surveys, case-control,
and cohort studies are then performed with a goal to evaluate efficacy, side
effects, and success of a vaccination campaign. The study of outbreaks
among unvaccinated populations becomes a very useful tool to evaluate
efficacy.
When Vaccine Led to Disappearing Illness: Eradication
Once a vaccine has been widely distributed among the population and the herd
immunity is very high, the incidence of disease will decrease until elimination.
Epidemiological studies are useful to determine if the widespread use of vaccine
has led to suppression of disease with continuation of circulation of the agent
or to the total disappearance of the infectious agent. With poliomyelitis, the
killed vaccine led to elimination of the disease, but the virus was still
circulating. The live oral vaccine on the other hand led to a complete
elimination of the circulating virus. Epidemiological methods are instrumental
in gathering this evidence.
During the final stages of a disappearing illness, active surveillance and
detailed case investigation are necessary to detect every suspect and confirm
the diagnosis with a definitive laboratory test (under these circumstances,
identification of the infectious agent is preferred to a
serological/immunological test). For poliomyelitis eradication, surveillance for

acute flaccid paralysis is implemented before declaring a country free of the
disease.
– Program Evaluation
Program evaluation is a systematic way to determine if prevention or
intervention programs for the infectious disease of interest are effective and to
see how they can be improved. It is beyond the scope of this chapter to
explain program evaluation in detail; however, there is abundant information
available, that is, the CDC’s Framework for Program Evaluation in Public
Health (CDC 1999) as well as many valuable text books on program
evaluation.
Most importantly, evaluators have to understand the program such as the
epidemiology of the disease of interest, the program’s target population and
their risk factors, program activities, and resources. They have to identify the
main objectives of the control actions and determine the most important steps.
Indicators define the program attributes and translate general concepts into
measurable variables. Data are then collected and analysed so that
conclusions and recommendations for the program are evidence based.
Evaluating an infectious disease control program requires a clear
understanding of the microorganism, its mode of transmission, the susceptible
population, and the risk factors. The following example of evaluation of
tuberculosis control shows the need to clearly understand the priorities.
Most of tuberculosis transmission comes from active pulmonary tuberculosis
cases that have positive sputum smears (confirmed as Mycobacterium
tuberculosis on culture). To a lesser extent, smear-negative, culture-positive
pulmonary cases are also transmitting the infection. Therefore, priority must
be given to find sputum- positive pulmonary cases. The incidence of smear-
positive tuberculosis cases is the most important incidence indicator.
Incidences of active pulmonary cases and of all active cases (pulmonary and
extrapulmonary) are also calculated but are of lesser interest. The proportion
of all cases of tuberculosis that are pulmonary versus extrapulmonary, smear-
positive culture-positive pulmonary versus culture-positive only pulmonary,
or culture-negative pulmonary is used to detect anomalies in case finding or
case ascertainment. A low proportion of smear-positive cases may result from
poor laboratory techniques or excessive diagnosis of tuberculosis with reliance
on chest X-rays and low interest in obtaining sputa for smears or cultures.
Once identified, tuberculosis cases are placed under treatment. Treatment of
infectious cases is an important preventive measure. Treatment efficacy is
evaluated by sputum conversion (both on smear and culture) of the active
pulmonary cases. After 2 months of an effective regimen, 85% of active
pulmonary cases should have converted their sputum from positive to
negative. Therefore, the rate of sputum conversion at 2 months becomes an

important indicator of program effectiveness. This indicator must be
calculated for those who are smear positive and with a lesser importance for
the other active pulmonary cases.
To ensure adequate treatment and prevent the development of acquired
resistance, tuberculosis cases are placed under directly observed therapy
(DOT). This measure is quite labor intensive. Priority must therefore be given
to those at highest risk of relapse. These are the smear-positive culture-proven
active pulmonary cases. DOT on extrapulmonary cases is much less
important from a public health standpoint because they are not infectious and
the major objectives of any public health program are to prevent transmission.
The same considerations apply to contact investigation and preventive
treatment in countries that can afford a tuberculosis contact program. A
recently infected contact is at the highest risk of developing tuberculosis the
first year after infection; hence, the best preventive return is to identify
contacts of infectious cases. Those contacts are likely to have been recently
infected. Systematic screening of large population groups would also identify
infected individuals, but most would be “old” infections at lower risk of
developing disease. Individuals infected with tuberculosis and HIV are at
extremely high risk of developing active tuberculosis. Therefore, the
tuberculosis control program should focus on the population at high risk of
HIV infection.
Often, program evaluation is performed by epidemiologists who have not taken
the time to understand the dynamics of a disease in the community. Rates or
proportions are calculated, no priorities are established, and precious resources
are wasted on activities with little preventive value. For example, attempting to
treat all tuberculosis cases, whether pulmonary or not with DOT, investigating
all contacts regardless of the bacteriological status of the index case would be
wasteful.
Today, the world is smaller than ever before, and international travel and a
worldwide food market make us all potentially vulnerable to infectious
diseases no matter where we live.
New pathogens are emerging such as the SARS, Ebola virus, Covid 19 virus
etc., spreading through new territories. Hospital-associated and community-
associated methicillin-resistant Staphylococcus aureus (MRSA) and resistant
tuberculosis cases and outbreaks are on the rise. Public health professionals are
concerned that a novel recombinant strain of influenza will cause a new
pandemic.
But not only the world and the etiological agents are changing; the world
population is changing as well. In industrialised countries, the life expectancy
is increasing, and the elderly are more likely to acquire a chronic disease,
cancer, or diabetes in their lifetime. Because of underlying conditions or the

treatment of these diseases, older populations also have an increased
susceptibility for infectious diseases and are more likely to develop life-
threatening complications.
Knowledge in the field of infectious disease epidemiology is expanding. While
basic epidemiological methods and principles still apply today, improved
laboratory diagnoses and techniques help to confirm cases faster, see how
cases are related to each other, and therefore can support the prevention of
spread of the specific disease. Better computers can improve the data analysis,
and the Internet allows access to in-depth disease-specific information.
Computer connectivity improves disease reporting for surveillance purposes,
and the epidemiologist can implement faster preventive measures if necessary
and is also able to identify disease clusters and outbreaks on a timelier basis.
The global threat of bioterrorism adds a new dimension. The intentional
release of anthrax spores and the infection and death of persons who contracted
the disease created a scare of contaminated letters in the US population.
With all these changes, there is renewed emphasis on infectious disease
epidemiology and makes it a challenging field to work in.
This study session covers disease surveillance, evaluation of a surveillance
system, investigation of cases outbreaks, epidemics and survey and rationale of
selecting disease for surveillance purposes.

1. List steps in disease outbreak investigations
2. Explain surveillance system of diseases
3. Give the rationale of selecting diseases for surveillance purpose

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Study Modules
MODULE 2: Infectious Diseases
Study Session 5: Oral-Faecal Transmitted
Study Session 6: Arthropod or Intermediate Vector-Borne Transmitted
Study Session 7: Sexually Transmitted
Study Session 8: Food-Borne Transmitted
Study Session 1
ORAL-FAECAL TRANSMITTED
Introduction
2.0 Main Content
2.1- Faeces in water
2.2- Faeces in soil
3.0 Summary/ Conclusion
Introduction
In this study session we are going to be discussing infectious diseases, those
transmitted through oral-faecal route via faecal contaminated water and soil.
What the diseases in this group have in common is that the causative organisms
are excreted in the stools of infected persons (or, rarely, animals). The portal of
entry for these diseases is the mouth. Therefore, the causative organisms have to
pass through the environment from the faeces of an infected person to the
gastro-intestinal tract of a susceptible person. This is known as the faecal-oral
transmission route. Oral-oral transmission occurs mostly through unapparent
faecal contamination of food, water and hands. As indicated in the schematic
diagram below, food takes a central position; it can be directly or indirectly
contaminated via polluted water, dirty hands, contaminated soil, or flies.

Image source: Google Images

1. give the infectious agent for oral-faecal transmitted diseases
2. Highlight ways of diagnosis, prevention, control and treatment of oral-faecal
transmitted diseases
3. Classify diseases base on their transmission route
4. give the incubation period, period of communicability and clinical
manifestation of oral-faecal transmitted diseases
2.0 Main Content

2.1 FAECES MAINLY IN WATER
The diseases in this group are mainly transmitted through faecally contaminated
water rather than food.

A. Typhoid fever
Definition: A systemic infectious disease characterized by high continuous
fever, malaise and involvement of lymphoid tissues.
Infectious agent:
Salmonella typhi
Salmonella enteritidis (rare cause)
Epidemiology:
Occurrence- It occurs worldwide, particularly in poor socioeconomic areas.
Annual incidence is estimated at about 17 million cases with approximately
600,000 deaths worldwide. In endemic areas the disease is most common in
preschool and school aged children (5-19 years of age).
Reservoir: Humans
Mode of transmission: By water and food contaminated by faeces and urine of
patients and carriers. Flies may infect foods in which the organisms then
multiply to achieve an infective dose.
Incubation period:1-3 weeks
Period of communicability: As long as the bacilli appear in excreta, usually
from the first week throughout convalescence. About 10% of untreated patients
will discharge bacilli for 3 months after onset of symptoms, and 2%-5% become
chronic carriers.
Susceptibility and resistance: Susceptibility is general and increased in
individuals with gastric achlorhydria or those who are HIV positive. Relative
specific immunity follows recovery from clinical disease, unapparent infection

and active immunisation but inadequate to protect against subsequent ingestion

of large numbers of organisms.
Clinical manifestation:
First week- Mild illness characterized by fever rising stepwise (ladder type),
anorexia, lethargy, malaise and general aches. Dull and continuous frontal
headache is prominent. Nose bleeding, vague abdominal pain and constipation
in 10% of patients.
Second week- Sustained temperature (fever). Severe illness with weakness,
mental dullness or delirium, abdominal discomfort and distension. Diarrhoea is
more common than first week and faeces may contain blood.
Third week- Patient continues to be febrile and increasingly exhausted. If no
complications occur, patient begins to improve and temperature decreases
gradually.
Clinical manifestations suggestive of typhoid fever:
Fever- Sustained fever (ladder fashion)
Rose spots- small pallor, blanching, slightly raised macules usually seen on
chest and abdomen in the first week in 25% of white people.
Relative bradycardia- Slower than would be expected from the level of
temperature.
Leucopoenia- White cell count is less than 4000/mm3 of blood.
Diagnosis:
i. Based on clinical grounds but this is confused with wide variety of
diseases.
ii. Widal reaction against somatic and flagellar antigens.
iii. Blood, faeces or urine culture.
Treatment:
1. Ampicillin or co-trimoxazole for carriers and mild cases.
2. Chloramphenicol or ciprofloxacin or ceftriaxone for seriously ill patients.
Nursing care:
 Maintain body temperature to normal.
 Apply comfort measures.
 Follow side effects of drugs.
 Monitor vital signs.
 Follow strictly enteric precautions:
 Wash hands
 Wear gloves
 Teach all persons about personal hygiene
 Observe the patient closely for sign and symptoms of
 Bowel perforation
 Erosion of intestinal ulcers
 Sudden pain in the lower right side of the abdomen
 Abdominal rigidity
 Sudden fall of temperature and blood pressure
 Accurately record intake and output.
 Provide proper skin and mouth care.
Prevention and control:

 Treatment of patients and carriers
 Education on handwashing, particularly food handlers, patients and
childcare givers
 Sanitary disposal of faeces and control of flies.
 Provision of safe and adequate water
 Safe handling of food.
 Exclusion of typhoid carriers and patients from handling of food and
patients
 Immunisation for people at special risk (e.g.Travelers to endemic areas)
 Regular check-up of food handlers in food and drinking establishments
 In-text Question
 What is the etiological agent of typhoid fever?
 Answer
 Salmonella typhi
B. Bacillary Dysentery (Shigellosis)

Definition: An acute bacterial disease involving the large and distal small
intestine, caused by the bacteria of the genus shigella.
Infectious agent:
Shigella is comprised of four species or serotypes.
Group A= Shigella dysentraie (most common cause) Group B= Shigella flexneri
Group C= Shigella boydii Group D= Shigella sonnei
Epidemiology:

Occurrence- It occurs worldwide, and is endemic in both tropical and

temperate climates. Outbreaks commonly occur under conditions of crowding
and where personal hygiene is poor, such as in jails, institutions for children,
day care centres, mental hospitals and refugee camps. It is estimated that the
disease causes 600,000 deaths per year in the world. Two-thirds of the cases,
and most of the deaths, are in children under 10 years of age.
Reservoir: Humans
Mode of transmission: Mainly by direct or indirect faecal-oral transmission
from a patient or carrier. Transmission through water and milk may occur as a
result of direct faecal contamination. Flies can transfer organisms from latrines
to a non-refrigerated food item in which organisms can survive and multiply.
Incubation period:12 hours-4 days (usually 1-3 days)
Period of communicability: During acute infection and until the infectious
agent is no longer present in faeces, usually within four weeks after illness.
Susceptibility and resistance: Susceptibility is general. The disease is more
severe in young children, the elderly and the malnourished. Breast-feeding is
protective for infants and young children.
Clinical Manifestation:
1. Fever, rapid pulse, vomiting and abdominal cramp are prominent.
2. Diarrhoea usually appears after 48 hours with dysentery supervening two
days later.
3. Generalised abdominal tenderness.
4. Tenesmus is present and faeces are bloody, mucoid and of small quantity.
5. Dehydration is common and dangerous - it may cause muscular cramp,
oliguria and shock.
Diagnosis:
1. Based on clinical grounds
2. Stool microscopy (presence of pus cells)
3. Stool culture confirms the diagnosis
Treatment:
 Fluid and electrolyte replacement
 Co-trimoxazole in severe cases or Nalidixic acid in the case of resistance.
1. Detection of carriers and treatment of the sick will interrupt an epidemic.
2. Handwashing after toilet and before handling or eating food.
3. Proper excreta disposal especially from patients, convalescent and
carriers.
4. Adequate and safe water supply.
5. Control of flies.
6. Cleanliness in food handling and preparation.
C. Amoebiasis (Amoebic Dysentery)
Definition: An infection due to a protozoan parasite that causes intestinal or
extra-intestinal disease.
Infectious agent:
Entamoeba histolytica
Epidemiology:
Occurrence- worldwide but most common in the tropics and sub-tropics.
Prevalent in areas with poor sanitation, in mental institutions and homosexuals.
Invasive amoebiasis is mostly a disease of young people (adults). Rare below 5
years of age, especially below 2 years.
Mode of transmission:
Faecal-oral transmission by ingestion of food or water contaminated by faeces
containing the cyst. Acute amoebic dysentery poses limited danger.
Incubation period: Variable from few days to several months or years;
commonly 2-4 weeks.
Period of communicability: During the period of passing cysts of E.
histolytica, which may continue for years.
Susceptibility and resistance: Susceptibility is general. Susceptibility to
reinfection has been demonstrated but is apparently rare.

Image source: Google Images

 Starts with a prodormal episode of diarrhoea, abdominal cramps, nausea,
vomiting and tenesmus.
 With dysentery, faeces are generally watery, containing mucus and blood.
Diagnosis:
Demonstration of etamoeba histolytica cyst or trophozoite in stool.
Treatment:
1. Metronidazole or Tinidazole
 Adequate treatment of cases
 Provision of safe drinking water
 Proper disposal of human excreta (faeces) and handwashing following
defecation.
 Cleaning and cooking of local foods (e.g.raw vegetables) to avoid eating
food contaminated with faeces.

In-text Question
1. What is the most common infectious agent of amoebiasis?
Answer
Entamoeba histolytica
D. Giardiasis
Definition: A protozoan infection principally of the upper small intestine
associated with symptoms of chronic diarrhoea, steatorrhea, abdominal cramps,
bloating, frequent loose and pale greasy stools, fatigue and weight loss.
Infectious agent:
Giardia lamblia
Epidemiology:
Occurrence- Worldwide distribution. Children are more affected than adults.
The disease is highly prevalent in areas of poor sanitation.
Reservoir: Humans
Mode of transmission: Person to person transmission occurs by hand to mouth
transfer of cysts from faeces of an infected individual especially in institutions
and day care centers.
Period of communicability: Entire period of infection, often months.
Susceptibility and resistance: Asymptomatic carrier rate is high. Infection is
frequently self-limited. Persons with AIDS may have more serious and
prolonged infection.
 Ranges from asymptomatic infection to severe failure to thrive and mal-
absorption.
 Young children usually have diarrhoea but abdominal distension and
bloating are frequent.
 Adults have abdominal cramps, diarrhoea, anorexia, nausea, malaise,
bloating, many patients complain of sulphur testing (belching).
Diagnosis:
Demonstration of Giardia lamblia cyst or trophozoite in faeces.
Treatment:
1. Metronidazole or Tinidazole
1. Good personal hygiene, and handwashing before food and following
toilet use
2. Sanitary disposal of faeces
3. Protection of public water supply from contamination of faeces
4. Case treatment
5. Safe water supply
E. Cholera
Definition An acute illness caused by an enterotoxin elaborated by vibrio
cholerae.

Infectious agent:
Vibrio cholerae
Epidemiology:
Occurrence- has made periodic outbreaks in different parts of the world and
given rise to pandemics. Endemic predominantly in children.
Reservoir: Humans
Mode of transmission: by ingestion of food or water directly or indirectly
contaminated with faeces or vomitus of infected person.
Incubation period: from a few hours to 5 days, usually 2-3 days.
Period of communicability: for the duration of the stool positive stage, usually
only a few days after recovery. Antibiotics shorten the period of
communicability.
Susceptibility and resistance: Variable. Gastric achlorhydria increases risk of
illness. Breast-fed infants are protected.
Abrupt painless watery diarrhoea; the diarrhoea looks like rice water.
In severe cases, several litres of liquid may be lost in few hours leading to
shock.
Severely ill patients are cyanotic, have sunken eyes and cheeks, scaphoid
abdomen, poor skin turgor, and thready or absent pulse.
Loss of fluid continues for 1-7 days.
Diagnosis:
Based on clinical grounds
Culture (stool) confirmation
Treatment:
1. Prompt replacement of fluids and electrolytes
2. Rapid IV infusions of large amounts
3. Isotonic saline solutions alternating with isotonic sodium bicarbonate or
sodium lactate.
4. Antibiotics like tetracycline dramatically reduce the duration and volume
of diarrhoea resulting in early eradication of vibrio cholerae.
Nursing care:

1. Wear gown and glove.

2. Wash your hands.
3. Monitor output including stool output.
4. Protect the patient family by administering Tetracycline.
5. Health education.
1. Case treatment
2. Safe disposal of human excreta and control of flies
3. Safe public water supply
4. Handwashing and sanitary handling of food
5. Control and management of contact cases
F. Infectious hepatitis
(Viral hepatitis A, Epidemic hepatitis, type A hepatitis)
Definition: An acute viral disease characterised by abrupt onset of fever,
malaise, anorexia, nausea and abdominal discomfort followed within a few days
by jaundice.
Infectious agent:
Hepatitis A virus
Epidemiology:
Occurrence- Worldwide distribution in sporadic and epidemic forms. In
developing countries, adults are usually immune and epidemics of HA are
uncommon. Infection is common where environmental sanitation is poor and
occurs at an early age.
Reservoir: Humans.
Mode of transmission: Person to person by faecal-oral route. Through
contaminated water and food contaminated by infected food handlers.
Incubation period:15-55 days, average 28-30 days.
Period of communicability: High during the later half of the incubation period
and continuing for few days following onset of jaundice. Most cases are non-
infectious following first week of jaundice.
Susceptibility and resistance: Susceptibility is general. Immunity following
infection probably lasts for life.
 Abrupt onset of fever, malaise, anorexia, nausea and abdominal
discomfort, followed in few days by jaundice.
 Complete recovery without sequel or recurrence as a rule.

Diagnosis:
 Based on clinical and epidemiological grounds
 Demonstration of IgM (IgM anti-HAV) in the serum of acutely or
recently ill patients.
Treatment:
Symptomatic: Rest, high carbohydrate diet with low fat and protein.
1. Public education about good sanitation and personal hygiene, with special
emphasis on careful handwashing and sanitary disposal of faeces.
2. Proper water treatment and distribution systems and sewage disposal.
3. Proper management of day care centres to minimise possibility of faecal-
oral transmission.
4. HA vaccine for all travellers to intermediate or highly endemic areas.
5. Protection of day care centres’ employees by vaccine.
2.2 FAECES MAINLY IN SOIL

The diseases in this category are mainly transmitted through faecal
contamination of soil. These infections are acquired through man’s exposure to
faecally contaminated soil.
A. ASCARIASIS
Definition: A helminthic infection of the small intestine generally associated
with few or no symptoms.
Infectious/ etiological agent:
Ascaris lumbricoides.
Epidemiology:
Occurrence- The most common parasite of humans where sanitation is poor.
School children (5-10 years of age) are most affected. Highly prevalent in moist
tropical countries.
Reservoir: Humans; ascarid eggs in soil.
Mode of transmission: Ingestion of infective eggs from soil contaminated with
human faeces or uncooked produce contaminated with soil containing infective
eggs but not directly from person to person or from fresh faeces.
Incubation period: 4-8 weeks.
Period of communicability: As long as mature fertilized female worms live in

the intestine. Usual life span of the adult worm is 12 months.
Susceptibility and resistance- Susceptibility is general.
1. Most infections go unnoticed until large worm is passed in faeces and
occasionally the mouth and nose.
2. Migrant larvae may cause itching, wheezing and dyspnea, fever, cough
productive of bloody sputum may occur.
3. Abdominal pain may arise from intestinal or duct (biliary, pancreatic)
obstruction.
4. Serious complications include bowel obstruction due to
knotted/intertwined worms.
Diagnosis:
1. Microscopic identification of eggs in a stool sample
2. Adult worms passed from anus, mouth or nose.
Treatment:
 Albendazole or
 Mebendazole or
 Piperazine or
 Levamisole

1. Treatment of cases
3. Prevent soil contamination in areas where children play

4. Promote good personal hygiene (handwashing).
B. Trichuriasis
Definition: A nematode infection of the large intestine, usually asymptomatic in
nature.
Infectious agent
Trichuris trichuria (whip worm)
Epidemiology
Occurrence- Worldwide, especially in warm moist regions. Common in
children 3-11 years of age.
Reservoir- Humans
Mode of transmission- Indirect, particularly through pica or ingestion of
contaminated vegetables. Not immediately transmissible from person to person.
Incubation period- Indefinite
Period of communicability- Several years in untreated carriers.
Susceptibility and resistance- Susceptibility is universal.
Clinical manifestation
1. Severity is directly related to the number of infecting worms.
2. Most infected people are asymptomatic.
3. Abdominal pain, tiredness, nausea and vomiting, diarrhoea or
constipation are complaints by patients.

4. Rectal prolapse may occur in heavily infected very young children.

Diagnosis
Demonstration of eggs in faeces.
Treatment
1. Albendazole or
2. Mebendazole
Prevention and control
2. Maintaining good personal hygiene (i.e. washing hands and vegetables
and other soil contaminated foods)
3. Cutting nails especially in children
4. Treatment of cases.
C. Entrobiasis
(Oxyuriasis, pinworm infection)
Definition: A common intestinal helminthic infection that is often
asymptomatic.
Infectious agent:
Entrobius vermicularis
Perianal itching, disturbed sleep, irritability and sometimes secondary infection
of the scratched skin.
Diagnosis:
Stool microscopy for eggs or female worms.

Treatment:
1. Mebendazole.
Educate the public about hygiene (i.e. handwashing before eating or preparing
food, keeping nails short and discourage nail biting).
Treatment of cases
 Reduce overcrowding in living accommodations.
 Provide adequate toilets.
D. Strongyloidiasis
Definition: often asymptomatic helminthic infection of the duodenum and
upper jejunum.
Infectious agent
Strongyloides stercolaris
Epidemiology
Occurrence- In tropical and temperate areas. More common in warm and wet
regions.
Reservoir- Human
Mode of transmission- Infective (filariform) larvae penetrate the skin and enter
the venous circulation.
Incubation period- 2-4 weeks (from skin penetration up to when rhabditi form
larvae appear in the faeces).
Period of communicability- As long as living worms remain in the intestine;
up to 35 years in cases of auto-infection.
Susceptibility and resistance- Susceptibility is universal. Patients with AIDS
or on immuno-suppressive medication are at risk of dissemination.

 Pneumonia occurs during heavy larval migration.
 Mild peptic ulcer like epigastric discomfort to severe watery diarrhoea.
 Heavy infection may result in malabsorption syndrome.
Diagnosis:
Identification of larvae in stool specimen.
Treatment:
Albendazole or
Thiabendazole
i. Proper disposal of human excreta (faeces)
ii. Personal hygiene including use of footwear.
iii. Case treatment.
E. Hookworm disease
(Ancylostomiasis, Necatoriasis)
Definition: A common chronic parasitic infection with a variety of symptoms
usually in proportion of the degree of anemia
Infectious agent: Ancylostoma duodenale and Necator americanus
Epidemiology:
Occurrence- Widely endemic in tropical and subtropical countries where

sanitary disposal of human faeces is not practiced and the soil moisture and
temperature conditions favour development of infective larvae.
Reservoir: Humans
Mode of transmission- Through skin penetration by the infective larvae.
Incubation period- Symptoms may develop after a few weeks to many months
depending on intensity of infection and iron intake of the host.
Period of communicability- Infected people can contaminate the soil for
several years in the absence of treatment.
Susceptibility and resistance- Susceptibility is universal. No evidence that
immunity develops with infection.
Clinical Manifestation
 The clinical manifestation is related to:
 Larval migration of the skin produces transient, localised maculopapular
rash associated with itching called ground itch.
 Migration of larva to the lungs.
 Produces cough, wheezing and transient pneumonitis.
 Blood sucking
 Light infection-no symptoms
 Heavy infection-result in symptoms of peptic ulcer disease like epigastric
pain and tenderness. Further loss of blood leads to anemia manifested by

exertional dyspenea, weakness and light-headedness.
Diagnosis
Demonstration of eggs in stool specimen.
Treatment
1. Mebendazole or
2. Albendazole or
3. Levamisole
1.Sanitary disposal of faeces
2.Wearing of shoes
3.Case treatment
4.Direct Contact with Faeces
5.These are diseases transmitted mainly through direct contact with faeces
of the infected person.
F. Poliomyelitis
Definition: A viral infection most often recognised by the acute onset of flaccid
paralysis.
Infectious agent
Polio viruses (type I, II and III)
Epidemiology
Occurrence – Worldwide prior to the advent of immunisation. Cases of polio
occur both sporadically and in epidemics. Primarily a disease of infants and
young children. 70-80% of cases are less than three years of age. More than
90% of infections are unapparent. Flaccid paralysis occurs in less than 1% of
infections.
Reservoir – humans, especially children
Mode of transmission- Primarily person-to-person, spread principally through
the faecal-oral route. In rare instances, milk, food stuffs and other materials
contaminated with faeces have been incriminated as vehicles.
Incubation period- commonly 7-14 days
Period of communicability – not precisely known, but transmission is possible
as long as the virus is excreted.
Susceptibility and resistance- Susceptibility is common in children but
paralysis rarely occurs. Infection confers permanent immunity.
1. Usually asymptomatic or non-specific fever is manifested in 90% of
cases.
2. If it progresses to major illness, severe muscle pain, stiff neck and back
with or without flaccid paralysis may occur.
3. Paralysis is asymptomatic and occurs within three to four days of illness.
4. The legs are more affected than other part of the body.
5. Paralysis of respiratory and swallowing muscles is life- threatening.
Diagnosis
Based on clinical and epidemiological grounds
Treatment
Symptomatic
 Educate public about the advantage of immunisation in early childhood.
 Trivalent live attenuated vaccine (OPV) at birth.
 Safe disposal of human excreta (faeces).
G. Hydatid Disease (Echinococcosis)
Definition: The tapeworm Echinococcus granulosus is the most common
species of Echinococcus and causes cystic hydatid disease.
Infectious agent
Echinococcus granulosus, a small tapeworm of dog
Epidemiology
Occurrence – occurs on all continents except Antarctica. Especially common in
grazing countries where dogs consume viscera containing cysts.
Reservoir- Domestic dogs and other canids are definitive hosts; they may
harbor thousands of adult tapeworms in their intestines without signs of
infection. Sheep act as intermediate hosts.
Mode of transmission – directly with hand to mouth transfer of eggs after
association with infected dogs or indirectly through contaminated food, water,
soil or fomites.
Incubation period – variable from 12 months to many years, depending on the
number and location of cysts and how rapidly they grow.

Period of communicability: Infected dogs begin to pass eggs approximately

7weeks after infection. Most canine infections resolve spontaneously by six
months.
Susceptibility and resistance: Children are more likely to be exposed to
infection because they are more likely to have close contact with infected dogs.
Clinical manifestations:
 The signs and symptoms vary according to location of the cyst and
number.
 Ruptured or leaking cysts can cause severe anaphylactic reactions.
 Cysts are typically spherical, thick walled and unilocular and are most
frequently found in the liver and lungs.
Diagnosis:
 History of residence in an endemic area along with association with
canines
 Sonography and CT scan
 Serologic test
Treatment
1. Surgical resection of isolated cysts is the most common treatment.
2. Albendazol (mebendazol)
3. If cysts rupture, praziquantel
1. Educate the public at risk to avoid exposure to dog faeces. Handwashing
should be emphasised.
2. Interrupt transmission from intermediate to definitive hosts by preventing
dogs’ access to uncooked viscera.
3. Safe disposal of infected viscera.
4. Periodical treatment of high-risk dogs.
This study session covers those diseases transmitted through oral-faecal route
via faecal contaminated water and soil. What the diseases in this group have
in common is that the causative organisms are excreted in the stools of infected
persons (or, rarely, animals). The portal of entry for these diseases is the mouth.

1. What does faecal-oral transmission mean?
2. Mention some of the diseases transmitted through unapparent faecal
contamination of food, water and hands.
3. State some of the common preventive and control measures of oral-

faecal transmitted diseases.

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Study Session 2
Arthropod or Intermediate Vector-Borne Diseases
Introduction
2.0 Main Content
2.1- Mosquito borne disease
2.2- Flea and louse borne diseases
2.3- Snail borne diseases
2.4- Zoonotic Diseases, Animal Bite Diseases and Animal reservoir
diseases
Introduction
In this study session we are going to be discussing infectious diseases, those
transmitted through arthropod or intermediate host transmitted diseases.
Generally speaking, a vector is any carrier of disease, but in the case of the
‘vector-borne diseases’ we restrict the word to those invertebrate hosts (insects
or snails), which are an essential part of the life cycle of the disease organism. A
housefly just carrying bacteria or amoebic cysts on its feet to food is not
regarded as a vector: this would be simple mechanical spread. Insect vectors
usually acquire the disease organism by sucking blood from infected persons,
and pass it on, later, by the same route. There are other routes, however;

infection may enter skin cracks or abrasions either from infected faeces
deposited when feeding, or from body fluid when an insect is crushed.
By definition the disease organism undergoes a period of development inside
the vector, and the time taken for this is called the extrinsic incubation period.
1. Describe what arthropod or intermediate vector-borne disease means.
2. Identify the common vectors which transmit disease to man.
3. List the common vector-borne diseases.
4. Participate in diagnosis and treatment of vector-borne diseases.
5. Implement the common preventive and control methods of vector-borne
diseases
2.0 Main Content
2.1 Mosquito-Borne Diseases
A. Malaria
Definition: An acute infection of the blood caused by protozoa of the genus
plasmodium.
Infectious agent.
Plasmodium falciparum/malignant tertian: Invades all ages of red blood cells.
Red blood cell cycle is 48 hours Plasmodium vivax/benign tertian: Invades
reticulocytes only. Red blood cell cycle is 48 hours. Plamodium ovale/tertian:
Invades reticulocytes only. Red blood cell cycle is 48 hours.
Plasmodium Malariae/Quartan malaria: Invades reticulocytes only. Red blood
cell cycle is 72 hours.
Epidemiology:

Occurrence- Endemic in tropical and sub-tropical countries of the world.

Affects 40% of the world population. Children less 5 years of age, pregnant
women and travelers to endemic areas are risk groups. Plasmodium falciparum
60% and vivax 40% are common in Ethiopia.
Predisposing factors are:
Environment- physical environment for the propagation
Patient source
Susceptible recipients
Anopheles capable to transmit the parasite
Socio-economic factors like immigration, war, poverty, ignorance, agricultural
irrigation farms, etc.
Reservoir- Humans
Mode of transmission- By the bite of an infective female anopheles mosquito,
which sucks blood for egg maturation. Blood transfusion, hypodermic needles,
organ transplantation and mother to fetus transmission is possible. Since there is
no pre-erythrocytic (tissue) cycle, the incubation period is short. Anopheles
gambae and funestus are common vectors in Ethiopia.
Incubation period- Varies with species
Plasmodium falciparum 7-14 days
Plasmodium virvax 8-14 days
Plasmodium ovale 8-14 days
Plasmodium malariae 7-30 days
Period of communicability- Mosquitoes are infective as long as infective
gametocytes are present in the blood of patients. Once infected, mosquito
remains infective for life.
Susceptibility and resistance- Susceptibility is universal except in some host-
resistance factors:
Nonspecific factors
Increased splenic clearance reaction
Hyperpyrexia- which is said to be schizontcidal
Sickle cell traits are resistant to plasmodium falciparum

Duffy blood group deficiency (Duffy antigen negative red blood cells) lack
receptor for plasmodium vivax.
Because of passive immunity infants are resistant in early life.
Specific factors
This is a humoral and cell mediated immunity that is species and strain specific,
and hard-won after repeated infection.
Chills, rigor, fever, head ache, diarrhoea, hallucinations, abdominal pain, aches,
renal or respiratory symptoms, jaundice, etc.
Diagnosis
 Clinical manifestation and epidemiological grounds
 Blood film for hemoparasite
 White blood cell count
 Blood culture to rule out sepsis
 Chest X-ray to rule out pneumonia.
Treatment
 Plasmodium vivax, ovale and sensitive plasmodium falciparum
 Chloroquine or

 Fansidar
 Chloroquine resistant falciparum and when sensitivity pattern is not
known.
 Quinine or
 Fansidar
Nursing care
 Advise patient to come back if the illness gets severe.
 Advise on personal protection (bed nets, etc).
 Reduce fever and maintain comfort.
1. Chemoprophylaxis- for those who go to endemic areas but not for those
who live in the endemic area (travellers and newcomers); for under-five
children and pregnant mothers who have not enough immunity.
2. Vector control
3. Avoiding mosquito breeding sites
4. Residual DDT spray or other chemicals
5. Personal protection against mosquito bite (use of bed nets, etc.)
6. Chemotherapy of cases
3. Bancroftian filariasis
Definition: A disease caused by the reaction of the body to the presence of
worms in the lymphatic system.
Infectious agent
Wucheriria bancrofti (vectors are culex, Anopheles and Aedes species)
Brugia malayi and (vector is mansonia species) Brugia timori (vector is
Anopheles)
Epidemiology
Occurrence- Widely prevalent in tropical and subtropical areas of Africa, Asia,
Pacific Region, Central and South America. Found in Gambella region (western
Ethiopia).
Reservoir- Humans are definitive hosts.
Mode of transmission- by bite of mosquito harbouring infective larvae
Incubation period- one month, while allergic inflammatory manifestations
may appear.
Period of communicability- Humans may infect mosquitoes when
microfilariae are present in the peripheral blood. Microfilaremia may persists

for 5-10 years or longer. The mosquito becomes infective about 12-14 days
after an infective blood meal.
Susceptibility and resistance- Universal. Susceptibility to infection is
probable.
The presence of worms in the lymph vessels gives rise to a foreign-body
reaction. After the death of the worm, more proteins are released; the reaction
then is even more severe. Three phases may be distinguished.
Acute phase:
Starts within a few months after infection
Lymphadenopathy
Fever
Eosinophilia
In this stage microfilariae are not demonstrable in the peripheral blood because
the worms are not yet mature. The acute phase is mainly due to a
hypersensitivity reaction.
Subacute phase:
This occurs after about one year following acute phases. In this phase worms
have matured and micro filariae are present in the peripheral blood.

Reactions to the adult worms cause attacks of fever with lymphangitis,

funiculitis or Epididymitis. Recurrent attacks will sooner or later lead to
hydrocele.
Lesions caused by microfilariae are less common and are associated with
hypereosinophilia and lung symptoms (tropical pulmonary eosinophilia
syndrome).
Chronic phase:
After many years of repeated attacks, lymph glands and lymph vessels become
obstructed; as a result, lymph edema develops. Lymph edema most commonly
seen in the legs or scrotum (elephantiasis) but may also be present in vulva,
breasts, or arms.
Since the adult worms have usually died, microfilariae are not seen in the blood.
N:B Studies showed that elephantiasis of the lower legs is not encountered in
Ethiopia. But there is elephantiasis of the foot called the big foot disease
(elephantiasis of lower leg) as a result of accumulation of silica and other
minerals in the leg (lymphatics) mostly occurring in bare-footed individuals.
This big foot disease is named podoconiosis, which is common in the eastern
high lands of Ethiopia (Wolayita, Gojjam, Gondar, Gedeo, Sidamo, etc.).
Diagnosis
1. Clinical and epidemiological grounds
2. Obstructive signs with history and travel to and residence in endemic
areas.
3. Best established by identifying microfilariae in the peripheral blood
(blood film).
4. Before taking blood sample one should know the periodicity of
microfilariae. That is, microfilariae appear in the peripheral blood during
the night (nocturnal) in most parts of the world and during day (diurnal)
in the South Pacific region.
5. Single dose of Diethylcarbamazin Citrate (DEC) causes the sequestered
microfilariae to emerge to blood 45-60 minutes later. This test is said to
be the mazoti test, which is used in nocturnal periodicity.
Treatment
Diethyl carbamazin Citrate (DEC) results in rapid disappearance of most
microfilariae from blood but may not destroy the adult worm. Because of this,
we need to repeat DEC annually for some years.
Refer the patient for surgical treatment of hydrocele.


1. Reducing the vector population
2. Mass and selective treatment
3. Personal protection against mosquito bite.
B. Yellow fever
Definition: An acute infectious viral disease of short duration and varying
severity.
Infectious agent
Yellow fever virus
Epidemiology
Occurrence- The disease exists in two transmission cycles. Namely, the
sylvatic or Jungle cycle, which occurs between mosquitoes and non-human
primates, and an urban cycle, involving Aedes aegypti mosquitoes and humans.
Found in southwest Ethiopia (Gambella region).
Reservoir- Urban areas- humans and Aedes aegypti mosquitoes. Forest areas-
Vertebrates other than humans (mainly monkeys) and forest mosquitoes.
Mode of transmission- By the bite of infective Aedes aegypti mosquitoes
Incubation period- 3-6 days
Period of communicability- Blood of patients is infective for mosquitoes
shortly before onset of fever and for the first 3-5 days of illness. Not
communicable by contact or common vehicles. The disease is highly
communicable where many susceptible people and abundant vector mosquitoes
co-exist.
Susceptibility and resistance- Recovery from yellow fever is followed by
lasting immunity; second attacks are unknown. Transient passive immunity in
infants born to immune mothers may persist for up to 6 months. In natural
infections, antibodies appear in the blood within the first week.
 Typical attacks are characterized by sudden onset of fever, chills,
headache, backache, generalized pain, prostration, nausea and vomiting.
 Slow and weak pulse.
 Bleeding tendency is common resulting in epistaxis, bleeding of gums,
hematemesis, melaena.
 Jaundice occurs due to liver cell necrosis and this may result in liver
failure and death.
 Albumin uria occurs due to nephrosis and this may result in kidney
failure and anuria.
 Patients surviving the seventh day of the disease usually recover.
Diagnosis
History of residence and/or travel to endemic area
Treatment
1.
No specific treatment.
2.
Nursing care
3.
Monitor vital signs regularly.
4.
Maintain body temperature to normal.
5.
Monitor input and output balance.
6.
Keep patient in screened rooms or under mosquito nets to avoid further
infection.
 Active immunisation of all people greater than 9 months of age
necessarily exposed to infection because of residence, occupation or
travel.
 Eradication or control of Aedes aegypti mosquitoes in urban areas.
 Sylvatic /Jungle yellow fever- immunisation to all people in rural
communities whose occupation brings them into forests in yellow fever
areas and for people who visit those areas.
 Notification of the disease to the concerned health authorities.
2.2 Flea and Louse Borne Diseases
A. Plague
Definition: A highly infectious bacterial disease which can kill many people
within a short time.
Infectious agent
Yersinia pestis, the plague bacillus.
Epidemiology
Occurrence- Endemic in wild rodents living in forests in the highlands. Wild
rodent plague exists in western USA, large areas of South America, North,

Central, Eastern and Southern Africa, Central and Southeast Asia. However,
urban plague is controlled in most of the world.
Reservoir- Wild rodents (especially ground squirrels) are the natural vertebrate
reservoir of plague. Wild carnivores and domestic cats may also be a source of
infection to people.
Mode of transmission- Through the bite of infected fleas. Handling of tissues
of infected animals.
Incubation period- 1-7 days.
Period of communicability- Fleas may remain infective for months under
suitable conditions of temperature and humidity. Bubonic plague is not usually
transmitted directly from person to person unless there is contact with pus from
suppurating buboes. Pneumonic plague may be highly communicable under
appropriate climatic conditions. Overcrowding facilitates transmission.
Susceptibility and resistance- Susceptibility is general. Immunity after
recovery is relative; it may not protect against a large inoculum.
Bubonic plague- Characterised by swelling of lymph glands (bubos); mostly
the glands of the groins, sometimes arm pit or other places. Swelling may be the
size of an egg, tender or non-tender. Other symptoms are:
 Sudden high fever
 Shock
 Prostration
 Coma
 Death within 3-5 days
 Pneumonic plague
 Acute onset
 Severe prostration
 Watery sputum quickly followed by blood-stained sputum.
 Pleural effusion
 Death within 1-2 days
Diagnosis
Gram stain of sputum or pus-gram negative bacilli.
Treatment
1. Early treatment with antibiotics like streptomycin or tetracycline or sulfa
groups.
Prevention and Control

 Chemotherapy of patient
 Chemoprophylaxis of all contacts with Sulfa drugs
 The area where disease occurs must be quarantined (isolated from outer
world)
 Insecticides to kill fleas
 Encourage people to kill rats
 Notify the disease to the concerned health authority.
1. Endemic Typhus (Flea-borne typhus)
Definition: A rickettsial disease whose course resembles that of louse- borne
typhus, but is milder.
Infectious agent
Rickettsia typhi (Rickettsia mooseri)
Epidemiology
Occurrence- Worldwide, found in areas where people and rats occupy the same
buildings and where large numbers of mice live. Occurs sporadically.
Reservoir-Rats, mice and possibly other small animals. Infection is maintained
in nature by a rat-flea-rat cycle where rats are reservoirs (Commonly rattus and
rattus novergicus).
Mode of Transmission- Infective rat fleas defecate rickettsia while sucking
blood, contaminating the bite site and other fresh skin wounds. An occasional
case may follow inhalation of dried infective flea faeces.
Incubation period- from 1 to 2 weeks; commonly 12 days
Period of communicability- Not directly transmitted from person to person.
Once infected, fleas remain so for life.
Susceptibility and resistance- Susceptibility is general. One attack confers
immunity.
1. Prodromal symptoms of headache, myalgia, arthralgia, nausea, and
malaise developing 1 to 3 days before the abrupt onset of chills and fever.
Nearly all patients experience nausea and vomiting early in the illness.
2. The duration of untreated illness averages 12 days.
3. Rash is present in only 13% of patients
4. Pulmonary involvement: non-productive cough and pneumonia.
5. Diagnosis
6. Epidemiological ground
7. Weilfelix agglutination test (Serology)
Treatment
1. Doxycyclin or
2. Chloramphenicol
3. Prevention and control
4. Destroy rats from burrows and harborages.
5. Use insecticides to abolish flea from living quarters.
6. Treatment of patients.
Louse-Borne Diseases
C. Epidemic Typhus
Definition: An acute rickettsial disease often with sudden onset.
Infectious agent
Rickettsia Prowazeki
Epidemiology
Occurrence- In colder areas where people may live under unhygienic
conditions and are louse-infected. Occurs sporadically or in major epidemics,
for example during wars or famine, when personal hygiene deteriorates and
body lice flourish.
Reservoir- Humans. Infected lice die and don’t serve as a reservoir.
Mode of transmission- The body louse and head louse are infected by feeding
on the blood of a patient with acute typhus fever. Infected lice excrete
rickettsiae in their faeces and usually defecate at the time of feeding. People are
infected by rubbing faeces or crushed lice into the bite or into superficial
abrasions (scratch inoculation).
Incubation period- From 1 to 2 weeks, commonly 12 days
Period of communicability- Patients are infective for lice during febrile illness
and possibly for 2-3 days after the temperature returns to normal. Infected lice
pass rickettsiae in their faeces within 2-6 days after the blood meal; it is
infective earlier if crushed. The louse die within 2 weeks after infection.
Rickettsiae may remain viable in the dead louse for weeks.
Susceptibility and resistance- Susceptibility is general. One attack usually
confers long-lasting immunity.
 Early symptoms of fever, headache, mayalgia, macular eruption appear
on the body.
 Patient may have pneumonia, renal or CNS involvement, gastrointestinal
disease, skin rash singly or in combination.
 Disease usually terminates by rapid lysis after 2 weeks of fever.
Diagnosis
1. Based on clinical and epidemiologic grounds
2. Serologic test (weil-felix agglutination test)
Treatment
1. Chloramphenicol or Tetracycline
 Delousing of clothes by insecticides or dipping into boiling water
 Public education on personal hygiene
 Treatment of cases
 Chemoprophylaxis for contacts.
C. Relapsing Fever
Definition: An acute infectious bacterial disease characterized by alternating
febrile periods (recurrent pyrexial attacks).
Infectious agent
Borrelia recurrentis- cause of louse-borne relapsing fever Borrelia duttoni-
cause of tick-borne relapsing fever
Epidemiology
Occurrence- Occurs in Asia, eastern Africa (Ethiopia and Sudan), the highland
areas of central Africa and South America. It occurs in epidemic form when it is
spread by lice and in endemic form when spread by ticks.
Reservoir- Humans for Borrelia recurrentis; wild rodents and soft ticks through
transovarian transmission. for tick borne relapsing fever
Mode of transmission- vector-borne. Acquired by crushing an infected louse
so that it contaminates the bite wound or an abrasion of the skin.
Incubation period- 5-10 days usually 8 days.
Period of communicability- Louse becomes infective 4-5 days after ingestion
of blood from an infected person and remains so for life (20-40 days)
Susceptibility and resistance- Susceptibility is general. Duration and degree of
immunity after clinical attack are unknown; repeated infection may occur.
Sudden onset of illness with chills, fever and prostration, headache, mayalgia
and arthralgia
There may be nausea and vomiting, jaundice and liver swelling.
After 4-5 days the temperature comes down, the patient stays free for 8-12 days
and then a relapse follows with the same signs but less intense.
In untreated cases there may be up to ten relapses.
Diagnosis
Clinical and epidemiological grounds
Giemsa or Wright stain (blood film)
Dark field microscopy of fresh blood.
Treatment
Admit the patient.
Open vein (i.e. start iv-line) before administering penicillin.
Administer 400,000-600,000 IU procaine penicillin IM stat
Tetracycline during discharge for 3 days
Chloramphenicol in infants and children can be used in place of
tetracycline.
 Nursing care
 Maintain body temperature to normal.
 Close vital sign monitoring for 3 hours after medication.
 Check whether there is reaction or not and report.
 Comfort the patient by providing antipain.
 Shaving of hair, and delousing of clothes.
1. Control of vectors (louse)
2. Personal hygiene
3. Health education about hygiene and modes of disease transmission
4. Delousing of patient’s clothes and his/her family
5. Chemotherapy of cases and Chemoprophylaxis for contacts.
2.3 Snail-Borne Diseases
A. Schistosomiasis
Definition: It is a blood fluke (trematode) infection with adult worms living
within mesenteric or vesicle veins of the host over a life span of many years.
Infectious agent

The major schistoma species that cause schistosomiasis of humans are:

Schistosoma mansoni Schistosoma Japonicum Schistosoma hematobium
Others in limited areas are S. mekongi, S. intercalatum, S. malayesis, S.
mattheei.
Most prevalent species in Africa are S. mansoni and S. hematobium.
Snail vectors are:
Bulinus-S. hematobium
Biomphalaria-S. mansoni
Onchomelania-S. japonicum
Epidemiology
Occurrence- S. mansoni is found in South America, Caribbean Islands, Africa
and the Middle East. S. hematobium is found in Africa and the Middle East. S.
Japonicum is found in the Far East. The disease occurs worldwide and 2 million
people are expected to be infected; however, most infected individuals show
few or no signs and symptoms, and only a small minority develop significant
disease.
Reservoir-The principal reservoir for S. mansoni, S. hematobium and S.
intercalatum is man. Other animals, like dog, cat, pig, cattle, water buffalo,
horse and wild rodents, are hosts for S. japonicum.
Mode of transmission-Infection is acquired from water containing free-
swimming larval forms (cercariae) that have developed in snails.
Incubation period-Acute systemic manifestations (katayama fever) may occur
in primary infections 2-6 weeks after exposure, immediately before and during
initial egg deposition. The infection in humans can persist up to 10 years. Snails
release cercariae as long as they live (from several weeks to 3 months).
Susceptibility and resistance-Susceptibility is universal. Resistance is poorly
defined.

The stages of schistosomiasis are:
Invasion
Maturation
Established infection and late stage.
Invasion stage
Cercariae penetrate skin
Cercarial dermatitis with itching papules and local edema
Cercariae remain in skin for 5 days before they enter the lymphatic system and
reach the liver.
Maturation
Schistosoma mature in the liver.
Fever, eosinophilia, abdominal pain and transient generalized urticaria (known
as katayama syndrome)
Worms descend the portal vein. S. manson; migrates to mesenteric veins in the
intestinal wall and S. haematobium to bladder plexus.
This stage may be diagnosed as clinical malaria or may pass unnoticed.
Established infection
This is a stage of egg production and eggs reach to the lumen of bladder and
bowel.

Some eggs penetrate the tissue, reach the bladder and intestinal wall are
discharged with urine and faeces.
Eggs that could not penetrate the tissue are carried with blood to the liver and
lungs.
Other eggs that fail to reach the lumen of the bladder or bowel provoke an
inflammatory reaction.
The inflammatory reaction, resulting in fibrosis, causes signs and symptoms of
schistosomiasis.
Sign of colitis with bloody diarrhoea and cramps in S. mansoni infection.
Terminal haematuria and dysuria in S. haematobium infection.
Late stage
This is the stage of fibrosis, which occurs where there are eggs in the tissues.
Around the bladder this may result in:
Stricture of urethra leading to urine retention or fistula.
Dilatation of ureters (hydroureter) and kidney (hydronephrosis) possibly
leading to kidney failure
Calcification of bladder.
In the liver portal hypertension leads to hypersplenism and anemia, eosophageal
varices and bleeding.
In the lungs fibrosis results in pulmonary hypertension, which leads to
congestive cardiac failure.
Diagnosis
Demonstration of ova in urine or faeces,
Biopsy of urine and faeces are repeatedly negative (rectal snip, liver biopsy,
bladder biopsy).
Treatment
Praziquantel and oxamniquine are the drugs of choice but in Africa praziquantel
is best because of resistance strain of oxamniquine.
Treatment of cases
Intermittent irrigation
Drainage of water bodies

Clearing of vegetation in water bodies to deprive snails of food and resting

place
Flooding
Straightening and deepening margins of water bodies
Educating the public about the mode of transmission and ways of prevention
Proper disposal of human faeces and urine
Avoid swimming in water bodies known to have the infection
Use rubber boots to prevent exposure to contaminated water.
B. Guinea Worm Infection
Definition: An infection of the subcutaneous and deeper tissues by large
nematode.
Infectious agent
Dracunculus medinensis, a nematode
Epidemiology
Occurrence- In Africa (16 countries south of the Sahara) and in Asia (India and
Yemen) especially in regions with dry climates. Local prevalence varies greatly.
In some locales, nearly all inhabitants are infected, in others, few, mainly young
adults.
Reservoir- Humans
Mode of transmission- Larvae discharged by the female worm into stagnant
fresh water are ingested by minute crustacean copepods (Cyclops species). In
about 2 weeks, the larvae develop into the infective stage. People swallow the
infected copepods in drinking water from infested step- wells and ponds. The
larvae are liberated in the stomach, cross the duodenal wall, migrate through the
viscera and become adults. The female, after mating, grows and develops to full
maturity, then migrates to the subcutaneous tissues (most frequently of the legs).
Incubation period- About 12 months
Period of communicability- From rupture of vesicle until larvae have been
completely evacuated from the uterus of the gravid worm, usually 2-3 weeks. In
water, the larvae are infective for the copepods for about 5 days. After ingestion
by copepods, the larvae become infective for people after 12-14 days at
temperatures >25c0 and remain infective in the copepods for about 3 weeks.
Susceptibility and resistance- Susceptibility is universal. No acquired
immunity; multiple and repeated infections may occur in the same person.
Few or no clinical manifestations are evident until just before the blister forms.

Fever and generalized allergic symptoms, including periorbital edema,

wheezing, and urticaria.
The emergence of the worm is associated with local pain and swelling.
When the blister ruptures, the adult worm releases larva- rich fluid and this is
associated with a relief of symptoms.
The shallow ulcer surrounding the emerging adult worm heals over weeks to
months.
Diagnosis
Based on clinical and epidemiological grounds
Treatment
Gradual extraction of the worm by winding of a few centimeters on a stick each
day remains the common and effective practice. Worms may be excised
surgically.
Administration of thiabendazole or metronidazol may relive symptoms but has
no proven activity against the worm.
 Provide health education programs in endemic communities to covey
three messages:
 The guinea-worm infection comes from their drinking water
 Villagers with blisters or ulcers should not enter any source of drinking
water and
 That drinking water should be filtered through fine mesh cloth to remove
copepods
 Provision of safe drinking water
2.4 Zoonotic Diseases, Animal Bite Diseases and Animal reservoir diseases
Zoonotic Diseases
Infectious diseases transmitted under natural conditions between
vertebrate animals and man are called zoonosis. For most of these diseases,
man is a dead-end of the transmission cycle. This means under normal
conditions; man will not infect other human beings.
Food of Animals
a. Taeniasis
Definition: Taeniasis is an intestinal infection with the adult stage of large
tapeworms. Cysticercosis is a tissue infection with the larval stage.
Infectious agent
Taenia saginata (beef tapeworm) Taenia solium (pork tapeworm)
Epidemiology
Occurrence- Worldwide; frequent where beef or pork is eaten raw or
insufficiently cooked and where sanitary conditions permit pigs and cattle to
have access to human faeces. Prevalent in Latin America, Africa, South East
Asia and Eastern Europe.
Reservoir- Humans are definitive hosts of both species of Taenia; cattle are the
intermediate hosts for Taenia saginata and pigs for Taenia solium.
Mode of transmission- Eggs of Taenia saginata passed in the stool of an
infected person are infectious only to cattle in the flesh of which the parasites
develop into “cysticercus bovis”; the larva stage of Taenia saginata. In humans,
infection follows after ingestion of raw or under-cooked beef containing
cysticerci; the adult worm develops in the intestine. Taenia Solium eggs to
mouth of oneself or to another person or ingestion of food or water infected
with eggs-embryos escape from the shells-penetrate the intestinal wall
lymphatics or blood vessels and are carried to the various tissues where they
develop to produce the human disease of cysticercosis.
Incubation period- 8-14 weeks, eggs appear in stool in both species.
Period of communicability- T. saginata is not directly transmitted from person
to person but T. solium may be. Eggs of both species are disseminated into the
environment as long as the worm remains in the intestine, sometimes more than
30 years. Eggs may remain viable in the environment for months.
Susceptibility and resistance- Susceptibility is general. No apparent resistance
follows infection but more than one tapeworm in a person has rarely been
reported.

Cysticercosis: Infection with T. solium larvae can occur by ingesting eggs in

food or from hands contaminated with faeces. Eggs develop into cysticerci
causing cysticercosis and neurocysticercosis.
Clinical manifestation (for both species)
Symptoms of cysticercosis may appear after some days and stay for 10 years
after infection.
Passage of proglottidis (segmented adult worms) in the faeces and perianal
discomfort when proglottidis are discharged. Minimal or mild abdominal pain
or discomfort, nausea, change in appetite, weakness and weight loss.
Usually asymptomatic.
Epigastric discomfort, nausea, a sensation of hunger, weight loss, nervousness,
and anorexia.
Passage of proglottidis.
Diagnosis
 Identification of proglottidis (segments)
 Eggs in faeces or anal swab
 Cysticercus – palpable subcutaneous cysticercus and microscopic
examination of an excised cysticercus confirms the diagnosis.
 Intracerebral and other tissues- CT scan, MRI or by x-ray when the
cysticerci are calcified.
Treatment
 Single dose of praziqantel is highly effective or
 Niclosamide or
 Dechlorophil or
 Mebendazole or
 Albendazole
T. Solium
 Treatment is the same as to T. saginata but praziqantel can evoke an
inflammatory response in the CNS if cryptic cysticercosis is present.
 Cysticercosis management
 Chemotherapy
 Surgery and supportive medical treatment
For symptomatic patients with neurocysticercosis, admission is required.
Combination of Praziquantel and Albendazole can be used. Besides, high dose
of glucocorticoids can be used to decrease inflammation.
Educate the public to:
Prevent faecal contamination of soil, water, human & animal foods
Cook beef and pork thoroughly.
Use latrines.
Identification and immediate treatment of cases.
Freezing of pork/beef below –5co for more than 4 days kills the cystraci
effectively or cooking to a temperature of 56co for 5 minutes destroys cystcerci.
Deny swine access to latrines and human faeces.
b. Brucellosis
Definition: A systemic bacterial disease with acute or insidious onset
transmitted to humans from infected animals.
Infectious agent
Brucella melitensis (most common worldwide), acquired primarily from goats,
sheep and camels.
B. abortus from cattle
B. suis from pigs
B. canis from dogs

These are small aerobic gram-negative bacilli, intracellular parasites.
Epidemiology
Occurrence- Worldwide. Predominantly an occupational disease of those
working with infected animals or their tissues especially farm workers,
veterinarians and abattoir workers, which is more frequent among males.
Outbreaks can occur among consumers of raw milk and milk products,
especially unpasteurized soft cheese from cows, sheep and goats.
Reservoir- cattle, swine, goats and sheep, pet dogs.
Mode of transmission- by contact with tissues, blood, urine, vaginal
discharges, aborted foetuses and especially placentas (through breaks in the
skin). Most commonly through ingestion of raw milk and dairy products from
infected animals (raw meat or bone marrow). Airborne infection occurs in
humans in laboratories and abattoirs.
Incubation period- may last about 1-3 weeks but may be as long as several
months.
Period of communicability- no evidence of communicability from person to
person.
Susceptibility and resistance- Severity and duration of clinical illness are
subject to wide variation. Duration of acquired immunity is uncertain.
Abrupt onset of symptoms
Most common symptoms are: Fever, chills, diaphoresis, headache, myalgia,
fatigue, anorexia, joint and low back pain, weight loss, constipation, sore throat,
and dry cough.
Physical examination reveals
Often no abnormalities and patient look well
Some are acutely ill, with pallor, lymphadenopathy, hepatosplenomegally,
arthritis, spinal tenderness, epididymoorchitis, skin rash, meningitis, cardiac
murmurs, or pneumonia
Reactive asymmetric polyartaritis (knees, hips, shoulders, sacroiliac and
sternoclavicular joints)

Diagnosis
Exposure and consistent clinical features
Serology- raised levels of B. agglutinin
Blood or bone marrow culture
Treatments
Doxycyline + aminogrycoside for 2 weeks followed by Doxycycline +
Rifampcin for 4-8 weeks is the most effective regimen.
In pregnancy and in children less than 7 years, Bacterium and Rifapcin for 8-12
weeks
N:B 4-14 days after the initiation of therapy, patients become afebrile and
constitutional symptoms disappear but enlarged liver and spleen return to
normal size within 2-4 weeks.
1. Control depends on elimination of the disease among domestic animals.
2. Educate people not to drink untreated milk or eat products made from
untreated milk.
3. Educate farmers and slaughterhouse workers and those in meat
processing plants and butcher shops as to the nature of the disease and the
risk in the handling of carcasses and products of potentially infected
animals.
4. Educate hunters to use barrier precaution (gloves and clothing).
5. Eliminate infected animals.
6. Pasteurise milk; cook meat and bone well.
7. Proper disposal of placenta, discharges or fetus from an aborted animal.
Disinfect contaminated areas.
c. Trichinellosis or Trichinosis
Definition: A disease caused by an intestinal round worm whose larvae
(trichinae) migrate to and become encapsulated in the muscles.
Infectious agent
Trichinella spiralis, an intestinal nematode
Epidemiology
Occurrence - Worldwide, but variable incidence, depending in part on practices
of eating and preparing pork or wild animal meat.

Reservoir - swine, dogs, cats, horses, rats and many wild animals, including
fox, wolf, etc.
Mode of transmission - By eating raw or insufficiently cooked flesh of animals
containing viable encysted larvae, chiefly pork and pork products and "beef
products" such ashamburger adulterated either intentionally or inadvertently
with raw pork.
Incubation period - Systemic symptoms usually appear about 8 - 15 days after
ingestion of infected meat.
Susceptibility and resistance - Susceptibility is universal. Infection results in
partial immunity.
Symptoms result from invasion of the body by larvae produced by the adult
female worm in the intestine and from their encystment in striated muscles.
Infection ranges from symptomatic to mild febrile illness to a severe
progressive illness with multiple system involvement.
Fever (low - high grade)
Muscle pain mainly upon movement
Edema, and spasm (periorbital and facial)
Photophobia and conjunctivitis
Weakness or prostration
Pain on swallowing
Dyspnea, coughing and hoarseness
Subconjuctival, retinal and nail splinter hemorrhage and rashes
Diarrhoea
Abdominal cramps
Nausea and vomiting
Inflammatory reactions around larvae that reach tissues other than muscles may
result in:
Meningitis
Encephalitis
Myocarditis
Broncho-pneumonia
Nephritis
Peripheral and cranial nerve disorders
Diagnosis
History of ingestion of raw or inadequately cooked pork
Larvae in muscle biopsy
Positive serologic test
Eosinophilia
Treatment
Hospitalisation of the patient
Mebendazole or
Albendazole or
Thiabendazole
High doses of corticosteroids for 1-2 days followed by lower doses for several
days or weeks. But not for intestinal stage.
Educate the public on the need to cook all fresh pork and pork products and
meat from wild animals.
Freezing of pork and its products inactivates trichinae.
d. Toxoplasmosis
Definition: Toxoplasmosis is a systemic protozoal disease that can be either
acute or chronic type with intracellular parasite. Toxoplasma gondii in which
the parasite is responsible for the development of clinically evident disease,
including lymphadenopathy, myocarditis and encephalitis.
Infectious agent
Toxoplasma gondii
Epidemiology
Occurrence- Worldwide in mammals and birds. Infection in man is common.
In the United States and most European countries, the prevalence of sero-
conversion increases with age and exposure. In Central America, France,

Turkey and Brazil, sero-prevalence is much higher, approaching 90% by age of

40.
Reservoir- The definitive hosts are cats and other felines, which acquire the
infection mainly from eating infected mammals (especially rodents) or birds and
rarely from faeces of infected cats. Only felines harbour the parasite in the
intestinal tract where the sexual stages of its life cycle take place, which result
in the excretion of the oocyst in faeces for 10-20 days or rarely longer. The
intermediate hosts of T. gondii include sheep, goats, rodents, cattle, chicken and
birds. Intermediate hosts are man and other animals. The life cycle can be either
hetroxenous (requiring two hosts) or monoxenous (one host). Both sexual and
asexual reproduction occur in man. There are five main developmental forms in
the life cycle, but only trophozoites and cyst stages are found in human. All
stages occur in the felines (cats).
Toxoplasma has two forms
Tachyzoites- occur in the early acute stage of infection.
Bradyzoites-occur in the chronic stage of infection, develop slowly and multiply
in the tissue to form a true cyst.
Mode of Transmission
Ingestion of cysts in raw or under-cooked meat
Ingestion of oocysts in food, drink or from hands contaminated with faeces of
an infected cat.
Transplacental/congenital
Blood transfusion
Organ transplantation
Incubation period- from 10-23 days. One common source outbreak from
ingestion of under-cooked meat is possible.
Period of communicability- Not directly transmitted from person to person,
except in utero. Oocysts shed by cats sporulate and become infective 1-5 days
later and may remain infective in water or moist soil for about a year. Cysts in
the flesh of an infected animal remain infective as long as the meat is edible and
uncooked.
Susceptibility and resistance- Susceptibility to infection is general, but
immunity is readily acquired and most infections are asymptomatic. Duration
and degree of immunity are unknown, but are assumed to be long-lasting or
permanent. Antibodies persist for a year, and probably for life. Patient
undergoing cytotoxic or immuno-suppressive therapy or patients with AIDS are

at risk of developing the disease.
General symptoms: Although severe symptoms may be noted, Toxoplasmosis
gondii symptoms are mild and mimic those seen in cases of infectious
mononucleosis. The acute form of this disease is characterised by fatigue,
lymphodenitis, chills, fever, headache and myalgia. In addition to chronic
disease, the patient may develop maculopapular rash, encephalomyelitis and
hepatitis; retinochoriditis with subsequent blindness has been known to occur on
rare occasions.
Congenital Toxoplasmosis: The typical symptoms in an infected child include
hydrocephaly, microcephaly, choreoretinitis, convulsion and psychomotor
disturbance. Most of these infections ultimately result in mental retardation,
severe visual impairment or blindness.
Diagnosis
Clinical sign and symptom
Serological test
Demonstration of the agent in body fluid or tissue biopsy
cell culture
Treatment
Treatment is not routinely indicated for a healthy immunocompetent host,
except in an initial infection during pregnancy or the presence of active
choreoretinitis and myocarditis or other organ involvement.
The preferred treatment for those with severe symptomatic disease is:
Pyrimethamine combined with sufadiazine and folinic acid for four weeks. For
pregnant women, Spirmycin is commonly used to prevent placental infection. If
ultrasound or other studies indicate that fetal infection has occurred,
Pyrimethamine and sulfadiazine should be considered.
Treatment for infants
Pyrimethamine
Sufadiazine
Folinic acid

The cause of primary infection with Toxoplasma can be reduced by avoiding

eating under-cooked or raw meat and avoiding cyst-contaminated materials (i.e.
cat’s litter box).
Meat should be heated to 600c or frozen to kill cysts.
Hands should be washed thoroughly after work in the garden and all fruits and
vegetables should be washed.
Discourage cats from hunting.
Dispose cats’ faeces daily.
Control stray cats and prevent them from gaining access to sand boxes and sand
piles.
Educate pregnant women.
To avoid cleaning litter pans or contact with cats.
Dietary meat; to heat to 60oc or freeze it.
To wear gloves during gardening.
Blood intended for transfusion into Toxoplasma sero- negative immuno-
compromised individuals should be screened for antibody to toxoplasma gondii.
Patients with HIV/AIDS who have severe symptomatic toxoplasmosis should
receive prophylactic treatment (Prymethamine, sulfadizine, folinic acid)
throughout their life span.
Animal Bite Diseases
a. Rabies
Definition: It is almost invariably fatal: acute vial encephalomyelitis (attacking
brain and meninges).
Infectious agent
Rabies virus
Epidemiology
Occurrence- Worldwide in wildlife particularly in developing countries. It is
primarily a disease of animals (zoonotic). It is primarily an infection of
carnivores transmitted through bite.
Reservoir- Dog is common in urban areas; in the wild, wild carnivores and bats
are reservoirs.

Mode of transmission- Transmitted with saliva of rabid animal introduced by a

bite or scratch. Transmission from man to man is dead-ended.
Incubation period- Usually 3-8 weeks
Period of communicability -Usually 3-7 days before the onset of the disease
and throughout the course of the disease.
Susceptibility and resistance- All mammals are susceptible to varying degrees.
Humans are more resistant to infection than several animal species.
The clinical manifestation, which is the same in all species including humans,
has 3 phases:
Prodromal phase
Excitatory phase
Paralytic phase
Prodromal phase: Onset is heralded by a sense of apprehension, headache,
fever and nausea, abnormal sensations at the site of inoculation (bite) is most
significant, (i.e. paraesthesia, tingling sensations at the bite site).
Excitatory phase or Aerophobia: Slightest sound/wind excites the victim,
irritability, restless, nervousness, tendency to bite, are some of the symptoms.
Paralytic phase: Spasm of swallowing muscles leads to drooling of saliva and
fear of water (hydrophobia). Delirium and convulsions form and death is often
due to respiratory muscle paralysis.
Diagnosis
History of bite by known rabid animal and the bitten person show typical
symptoms leading to clinical diagnosis.
Treatment
Wound Care
Wash the wound with soap and water thoroughly to decrease the viral load.
If there is bleeding cover the wound.
Never suture the wound as this will spread the virus.
Start anti-rabies vaccine immediately if it is proved to be rabid animal bite.

Immunise all dogs and cats.

Detain and clinically observe for 10 days any healthy appearing dog or cat
known to have bitten a person.
Post exposure prophylaxis
Treatment of bite wounds
Specific immunologic protection
Keep dogs and cats at home.
Destroy stray animals where rabies is endemic.
Direct Contact Diseases
b. Anthrax
Definition: An acute bacterial disease usually affecting the skin, but which may
very rarely involve the oropharynx, lower respiratory tract, mediastinum or
intestinal tract.
Infectious agent
Bacillus anthracis, spore forming bacteria.
Epidemiology:
Occurrence- Worldwide. Primarily a disease of herbivores. Humans and
carnivores are incidental hosts. Primarily an occupational hazard of workers
who process hides, hair (especially from goats), bone and bone products and
wool: and of veterinarians and agriculture and wildlife workers who handle
infected animals. Human anthrax is common (endemic) in those agricultural
regions of the world where anthrax in animals is common, including countries
in South and Central America, southern and eastern Europe, Asia and Africa.
Reservoir- Animals, normally herbivores, both livestock and wildlife, shed the
bacilli in terminal hemorrhages or spilt blood at death. On exposure to air, the
vegetative forms sporulate, and the spores of B. anthracis, which are very
resistant to adverse environmental conditions and disinfections, may remain
viable in contaminated soil for many years after the source animal infection has
terminated. Dried or processed skins and hides of infected animals may harbor
the spores for years and are the fomites by which the disease is spread
worldwide.
Mode of transmission-
Cutaneous anthrax: Contact with tissues of animals (Cattle, sheep, goats, horses,
pigs and others) dying of the disease. Bite of flies that had partially fed on such
animals, contaminated hair, wool, hides, or products made from them such as
drums or brushes or contact with soil associated with infected animals.
Inhalation anthrax: inhalation of spores in risky industrial processes such as
tanning of hides, or wool or bone processing, where aerosols of B. antracis
spores may be produced.
Intestinal and oropharyngeal anthrax: ingestion of contaminated meat; but there
is no evidence that milk from infected animals transmits anthrax.
N:B. The disease is transmitted among grazing animals through:
contaminated soil and feed, and among omnivorous bone meal or other feeds
and among wildlife from feeding on anthrax carcasses.
Vultures have been reported to spread the organism from one area to another.
Incubation period- A few hours to seven days; most cases occur within 48
hours of exposure.
Period of communicability- transmission from person to person is very rare.
Articles and soil contaminated with spores may remain infective for decades.
Susceptibility and resistance- uncertain
Cutaneous Anthrax
Approximately 95% of human cases of anthrax are cutaneous form and about
5% are the inhalation form.
Found on exposed areas of skin (head, neck, face and hands).
Small red macules appear.
Lesion- progress to papule, vesicle or pustule during the next week and
formation of an ulcer with blackened necrotic eschar surrounded by a highly
characteristic, expanding zone of brawny edema.
The early lesion may be pruritic but painless.
Small satellite vesicle may surround the original lesion and painful non-specific
regional lymphadenitis is common.
Most patients are afebrile with mild or no constitutional symptoms; in severe
cases, however, edema may be extensive and associated with shock.
Spontaneous healing occurs in 80-90% of untreated cases but edema may
persist for weeks.

In 10-20% of cases, infection progresses, bacteria develop and is often

associated with high fever and rapid death.
Inhalation anthrax
Presentation of symptoms of severe viral respiratory diseases makes early
diagnosis difficult.
Acute phase supervenes after 1-3 days. With increasing fever, dyspnea, stridor,
hypoxia, and hypotension usually leading to death within 24 hours.
Gastrointestinal Anthrax- Symptoms are variable and include:
Fever, nausea and vomiting, abdominal pain, blood, diarrhoea, and sometimes
rapidly developing ascites.
Diarrhoea is occasional and massive in volume.
Oropharyngeal anthrax
Fever, sore throat, dysphagia, painful regional lymphadenopathy toxemia,
respiratory distress may be evident.
The primary lesion is most often on the tonsils.
Diagnosis
Clinical data
Gram stain of wound discharge
Culture from the wound discharge or blood
Treatment
For Cutaneous anthrax
Penicillin-G IV until edema subsides and with subsequent oral penicillin to
complete the course (adults). For Penicillin-sensitive adults, Ciprofloxacin,
erythromycin, Tetracycline, Chloramphenicol can be substituted.
Clean and cover the cutaneous lesions.
For Inhalation anthrax, Gastrointestinal and Anthrax meningitis
High dose of penicillin is recommended.

Decontaminate wool and goat’s hair and improvement of working condition for
handlers of animal products.
Vaccination of susceptible groups and domestic herbivores.
Carcasses of animals should be buried intact.
Butchering of infected animals should be avoided.
Education in mode of transmission and in care of skin abrasions for employees
handling potentially contaminated articles.
Dust control and proper ventilation in hazardous industries.
Treat all animals exposed to anthrax with Tetracycline or penicillin.
Animal Reservoir Diseases
a. Leishmaniasis
Definition: A polymorphic protozoan disease of the skin and mucous membrane
or a chronic systemic disease caused by a number of species of the genus
leishmania.
Infectious agents
For cutaneous and mucosal Leishmaniasis
Leishmania tropica Leishmania donovani *
Leishmania major and Leishmania infantum *
Leishmania aethiopica*
For visceral Leishmaniasis
Leishmania donovani. *
Leishmania infantum. *
Leishmania tropica. * and
Leishmania chagasi. *
*Common agents in Ethiopia.
Epidemiology
Occurrence- It occurs in Pakistan, India and recently China, the Middle East
including Iran and Afghanistan, southern regions of the former Soviet Union,
sub-Saharan Africa, Sudan, the highlands of Ethiopia, Kenya and Namibia.
Urban populations including children may be at risk. In the developed world,
the disease is restricted to occupational groups, such as those involved in work
in forest areas; to those whose homes are in or next to a forest and to visitors to
such areas from non-endemic countries. It is common where dog populations
are high, generally more common in rural than urban areas.
Reservoirs- locally variable; include human beings, wild carnivores and
domestic dogs.
Mode of transmission- Transmission is through the bite of the female
phlebotomine (sand flies). From person to person, by blood transfusion, and
sexual contact has been reported, but rare.
Incubation period- at least a week; up to many months.
Period of communicability- Infectious to sand flies as long as parasites remain
in lesion, in untreated cases, usually a few months to 2 years. Eventual
spontaneous healing occurs in most cases.
Susceptibility and resistance- Susceptibility is probably general. Life-long
immunity may be present after lesion due to L. tropica or L. major but may not
protect against other leishmanial species.
There are papules that further develop to ulcers. The disease is characterized by
fever, hepathosplenomegally, lymphadenopathy, anemia, leucopoenia,
thrombocy- topenea, and progressive emaciation and weakness.
Diagnosis
Demonstration of the parasite (blood or tissue)
By culture of the motile promastigote
Using serologic test

Treatment
Pentalvalent antimonial agents
Pentamidine or
Amphotercin or
Aminoglycoside aminosidine or
Cytokine immunotherapy

The avoidance of outdoor activities.
The use of mechanical barriers such as screens and bed nets.
Wearing of protective clothing.
Application of insect repellent.
Treatment of cases.
Vector control and elimination of reservoir host (e.g. domestic dogs).
b. African Trypanosomiasis
Definition: A systemic disease caused by protozoa characterized by fever
followed by general weakness and cerebral involvement leading to death.
Infectious agent
The commonest agents are:
T. Brucei rhodesiense
T. Brucei gambiense
Other species which are less important are;
T. Cruzi, which causes American Trypanosoniasis Vectors for all species are
tsetse flies of Genus Glossina.
Epidemiology
Occurrence-The trypanosomes that cause sleeping sickness are found only in
Africa. 20,000 new cases are reported each year. This number surely under-
estimates the true incidence.

T. brucei gambiense occurs and is widely distributed in the tropical rainforests

of Central and West Africa. Gambiense trypanosomes are primarily a problem
in rural population; tourists rarely become infected. The principal reservoir of
T.B rhodesiense in savanna and woodland areas of Central and East Africa are
Trypotolerant antelope species. Humans acquire T.B. rhodesiense infection only
incidentally while working in areas where infected vectors are present. T.
ganebie has no animal reservoir. However, T. rhodesiense causes the more
severe trypanosomiasis without sleeping sickness. In Ethiopia, the distribution
of Trypanosomiasis is mostly found in Jinca, Afar, Setitu Humera, Konso,
Moyale, Woito, and Dilla.
Reservoir- for T. brucie gambiense it is only humans. For T. brucie rhodesiense
the reservoir is dog, cattle, fox, wolf and human beings.
Mode of transmission- by the bite of infective Glossina Tsetse fly during blood
meal. Congenital transmission can occur in humans. Direct mechanical
transmission is possible by blood on the proboscis of Glossina and other man-
biting insects, such as houseflies or in laboratory accidents
Incubation period- T. brucei rhodensiense: 3 days to few weeks. T. brucei
gambiense: several months up to one year.
Period of communicability- The disease is transmitted as long as the parasite is
present in the blood of infected person or animal and infected Tsetse fly.
Susceptibility and resistance- All persons are equally susceptible for the
disease.
Stage I (Signs & symptoms)
Painful trypanosoma chancre
Hematogenous and lymphatic dissemination

High body temperature
Lymphadenopathy discrete
Winter bottom’s sign (classic), painless enlargement of lymph node
Malaise
Headache
Weight loss
Edema
Hepatomegally and
Tachycardia
Stage II
Abnormality in CSF
Day time somnolence
Tremors
Parkinson’s disease may appear
Hypertonia
Congestive heart failure
CNS disease develops
Coma and death
Diagnosis
Wet blood smear
Thick blood smear
Serological test
CSF analysis
Blood film
Bone marrow biopsy
Treatment
Pentamidine or
Etlornithine or
Helarsupron or
Trypansamide
These are drugs to be used for treatment of different stages.
For stage I (Normal CSF) – T.b. gambie treated with
Suramin or
Eflornithine or
Pentamidine
For stage II
Trypansamide
Public education on personal measures to protect against insect bite.
Eradication of vectors.
Drug treatment of infected humans.
Avoiding areas to be known by harboring infected insects.
By wearing protective cloth and by using insect repellents.
Reducing tsetse fly number by
Identifying and studying the breeding habits of local vector
Selectively clearing the bush and wooden areas especially around game
reservoirs, water holes, bridges and along rivers bank
Using and maintaining insecticide impregnated tsetse fly traps.
Spraying vehicles with insecticide as they enter and leave tsetse fly infested
areas
Prohibit blood donation from those who have visited or lived in endemic areas.
This study session covers infectious diseases, those transmitted through
arthropod or intermediate host transmitted diseases.
1. List the common zoonotic diseases and their main mode of
transmission.

2. What do you understand by vector-borne disease transmission?

3. Which of the vector-borne diseases pose major health problems?
4. What are the preventive and control methods for malaria and
schistosomiasis?

a.Visit YouTube on https://www.youtube.com/watch?v=DhbBjQSuLYk

in: Nature 2002, 415(6875):1056
London, p 1
cream. NEJM 334(20):1281–1286

Study Session 3
SEXUALLY TRANSMITTED DISEASES
Introduction
2.0 Main Content
2.1- Sexually Transmitted diseases
Introduction
In this study session we are going to be discussing infectious diseases,
identify sexually transmitted diseases that are transmitted through vertical route.
Apply the management of sexually transmitted diseases. State the preventive
and control measures for sexually transmitted diseases.
1. Participate in diagnosis and treatment of STDs.
2. Implement the common preventive and control methods of STDs
2.0 Main Content
2.1 Sexually transmitted diseases
The diseases belonging to this group are usually transmitted during sexual
intercourse; hence the name sexually transmitted diseases or STDs. During
sexual intercourse there is close body contact, which is an ideal situation for
transmission. The causative organisms of the STDs are very easily killed by
drying or by cooling to below body temperature. Therefore, transmission of
these agents from one person to another can only occur under very special
circumstances, mostly during sexual intercourse. STDs are very common in
adults, but they are often hidden for fear of the opinion of others. Single young
men are a high–risk group for STDs, as they satisfy their sexual needs with
women who have many sexual partners (promiscuity). They may be
professional prostitutes, barmaids, or persons who in other ways gain from
casual sexual relationships. This group is called the promiscuous women pool
(PWP). They are the reservoir of STDs.
Risk factors are:

Age: 15 years and older
Marital status: unmarried people who often change their sexual partners are
more frequently exposed. Most of the women in the PWP are unmarried or
divorced.
Occupation: soldiers, policemen, students, seasonal laborers, and other people
who are temporarily away from home tend to expose themselves more easily.
Residence: Due to industrialisation and consequent urbanisation there is usually
a large group of single young men in towns. Women in towns may have more
difficulty in earning their daily living than women in rural areas and may take
up prostitution for money.
Promiscuity
A. Syphilis (Hard chancre)
Definition: A disease characterized by a primary lesion, a later secondary

eruption on the skin and mucus membranes, then a long period of latency, and
finally late lesions of skin, bones, viscera, CNS and cardiovascular systems.
Infectious agent
Treponema pallidum, a spirochete.
Epidemiology
Occurrence: Worldwide spread. Primarily involving sexually active young
people between 20 and 29 years. More common in urban than rural areas.
Reservoir- Humans
Mode of transmission: - by direct contact with lesion mainly during sexual
intercourse. Accidentally by touching infective tissues. Or via blood transfusion.
Or congenitally, which may occur before birth, in the case of an infected
mother.
Incubation period– 10 days to 3 months, usually 3 weeks.
Period of communicability – variable and indefinite, during primary and
secondary stages and also in mucocutaneous recurrences that may occur during
the first 4 years of latency. Extent of communicability through sexual activity
during this latent period is not established. Adequate penicillin treatment
usually ends infectivity within 24 – 48 hours.
Susceptibility and resistance – Susceptibility is universal, although only
approximately 30% of exposures result in infection. Infection leads to
developing immunity against T. pallidum gradually and to some extent, but
immunity usually fails to develop because of early treatment in the primary and
secondary stages.
The clinical presentation is divided into three groups:
Primary syphilis – consists of hard chancre, the primary lesion of syphilis,
together with regional lymphadenitis. The hard chancre is a single, painless
ulcer on the genitalia or elsewhere (lips, tongue, breasts) and heals
spontaneously in a few weeks without treatment.
The lymph glands are bilaterally enlarged and not painful. There will not be
suppuration.

Secondary syphilis - After 4 – 6 weeks of the primary infection, a generalized

secondary eruption appears, often accompanied by mild constitutional
symptoms. These early rashes tend to be symmetrical, quickly passing, and do
not itch. These early skin lesions are highly infective and many spirochetes are
demonstrated in them.
Tertiary syphilis -This stage is characterized by destructive, non-infectious
lesions of the skin, bones, viscera, and mucosal surfaces. Other disabling
manifestations occur in the cardiovascular system (aortic incompetence,
aneurysms) or central nervous system (dementia paralytica, tabes dorsalis).
Syphilis in pregnancy- According to the severity, congenital syphilis can result
in congenital abnormalities, still birth, or repeated spontaneous abortions.
Diagnosis
Serological test – will be positive 6 to 8 weeks after infection
Dark field microscopy of smears from primary lesion (hard chancre) or from
skin lesions in the early secondary stage will show the spirochaetes.
Treatment
Primary and secondary syphilis
Benzathin penicillin 2.4 M IU Im stat or
Tetracycline or Erythromycin 500mg PO Qid for 2 weeks for penicillin
sensitive people
Tertiary syphilis
Benzathin penicillin 2.4 M IU Im single dose every week for 3 consecutive
weeks or
Tetracycline or Erythromycin for one month for penicillin sensitive individuals.
Early congenital syphilis
Crystalline penicillin 50,000 IU/ Kg per dose IV or Im bid in the first 7 days of
life and Tid then after for 10- 14 days.
Treatment of cases
Treatment of contacts and source of infection
Health education on safe sex
Controlling STDs among commercial sex workers
Monthly check up and treatment of cases

Provision of condom
Screening of pregnant women and early treatment to prevent congenital syphilis
Screening of blood before transfusion.
B. Chancroid (soft chancre)
Definition: An acute bacteria infection localised in the genital area and
characterised clinically by single or multiple painful narcotising ulcers at the
site of infection.
Infectious agent.
Haemophilus ducreyi, the Ducrey bacillus
Epidemiology
Occurrence – endemic in many developing countries. The commonest cause of
genital ulcer in many developing counties. Most frequently diagnosed in men,
especially those who frequently prostitutes.
Reservoir – Humans
Mode of transmission – by direct sexual contact with discharges from open
lesion and pus from buboes. Infected males don’t pass the infection farther
because of the painful ulcer.
Incubation period – from 3 to 5 days, up to 14 days after sexual contact.
Period of communicability – until healed and as long as the infectious agent
persists in the original lesion or discharging regional lymph nodes, which lasts
for several weeks or months without antibiotic treatment. Antibiotic therapy
eradicates H. ducreyi, and lesions heal in 1 – 2 weeks.
Susceptibility and resistance – Susceptibility is general. The uncircumcised
are at higher risk than the circumcised. No evidence of natural resistance.
Classic Chancroid ulcer begins as a tender papule that ulcerates within 24 hours.
The ulcer is painful, irregular and sharply demarcated from the nearby skin.
About 50% of men will have single ulcer.
Diagnosis
Clinical, but always rule out syphilis

Gram stain of smear from ulcer shows typical rods in chain

Culture.
Treatment
Co- trimorazele or
Erythromycin or
Tetracycline can be used
N.B. Do not incise lymph nodes even with fluctuation because they will
completely heal with treatment.
Case treatment
Investigation of contacts, source of infection and treatment
Thorough washing of genitalia with soap and water promptly after intercourse is
very effective.
Controlling STDs among commercial sex workers
Sex education for high risk groups
C. Lymphogranuloma venereum.
Definition: A venereal disease caused by chlamydia microorganisms, most
commonly manifested by acute inguinal lymph adenitis.
Infectious agent
Chlamydia trachomatis (Ll L2 and L3)
Epidemiology
Occurrence – Common in most parts of the world but very common in tropical
and subtropical regions of Africa and Asia. Its incidence is more common in
males than females, and is lower than Gonorrhea and Chancroid.
Reservoir- Humans often asymptomatic (particularly in females)
Mode of transmission- Direct contact with open lesions of infected people,
usually during sexual intercourse.
Incubation period – variable, with a range of 3 – 30 days for a primary lesion.
Period of communicability – variable, from weeks to years, during presence of
active lesions.

Susceptibility and resistance – Susceptibility is general. Status of natural or

acquired resistance is unclear.
Lymph adenopathy with non-specific symptoms of fever, chills, head ache,
malaise, anorexia and weight loss.
Regional lymph nodes undergo suppuration followed by extension of
inflammatory process to the adjacent tissues.
In the female, inguinal nodes are less frequently affected and involvement is
mainly of the pelvic nodes with extension to the rectum and recto vaginal
septum, resulting in proctitis, stricture of the rectum and fistula.
Elepthantiasis of genitalia, scrotum and vulva occur in either sex.
Diagnosis
Clinical presentation (i.e. presence of bubo.)
Culture of bubo aspirate.
Treatment
Tetracycline or
Erythromycin or
Co -trimoxazole can be used
Aspiration of fluctuating bubo and wound care
Early diagnosis and treatment of cases
Investigation of contacts, source of infectionand treatment
Controll STDs among commercial sex workers
Sex education for high-risk groups
D. Herpes Genitalia
Definition: A viral infection characterized by a localized primary lesion, latency
and a tendency to localized recurrence.
Infectious agent
Herpes simplex virus (HSv) type 2
Epidemiology

Occurrence – worldwide. HSV 2 infection usually begins with sexual activity

and is rare before adolescence, except in sexually abused children. Prevalence is
greater (up to 60%) in lower socio-economic groups and persons with multiple
sexual partners.
Reservoir – Humans.
Mode of transmission - Usually by sexual contact. Transmission to the neonate
usually occurs via the infected birth canal, but less commonly occurs
intrauterine or postpartum
Incubation period – 2 – 12 Days
Period of communicability – Patients with primary genital lesions are infective
for about 7 –12 days, with recurrent disease for 4 days to a week. Reactivation
of genital herpes may occur repeatedly in > 50% of women.
Susceptibility and resistance – Humans are universally susceptible.
First – episode primary genital herpes is characterized by fever, head ache,
malaise and myalgias
Pain, itching, dysuria, vaginal and urethral discharge, and tender inguinal lymph
adenopthy are the predominant local symptoms.
Widely-spaced bilateral lesions of the external genitalia are characteristic:
lesions may be vesicles, pustules, or painful erythematous ulcers.
Cervix and urethra are involved in more than 80% of women with first episode
infection.
A clear mucoid discharge and dysuria are characteristics/ symptoms of
urethritis.
Occasionally, HSV genital tract disease is manifested by endometritis and
salpingitis in women and by prostatitis in men.
Treatment
1. Oral acyclovir is effective
1. Consistent use of condom is an effective means of reducing the risk of genital
HSv – 2 transmissions.
E. Candidiasis

Definition: A mycosis usually confined to the superficial layers of skin or

mucus membranes, presenting clinically as oral thrush or vulvovaginitis.
Infectious agent
Candida albicans (most common cause) Candida tropicalis (rare cause)
Epidemiology
Occurrence – Worldwide. Candida albicans is often part of the normal human
flora.
Reservoirs – Humans
Mode of transmission – contact with secretions or excretions of mouth, skin,
vagina and faeces, from patients or carriers. Passage from mother to neonate
during childbirth.
Incubation period – variable.
Period of communicability - presumably while lesions are present.
Susceptibility and resistance – Susceptibility is very low except in low host
defense. It is common in diabetes, HIV- infected; women are prone to
vulvovaginitis in the third trimester of pregnancy. Oral contraceptive users,
individuals with prolonged steroid therapy are susceptible.
Severe vulvar pruritis (prominent feature)
vaginal discharge (scanty, whitish, yellow, thick to form curds, non-offensive)
sore vulva due to itching
speculum examination – thick whitish plugs attached to vaginal wall
vaginal epithlium bleeds when the plug is removed but the cervix is normal
Diagnosis
Based on clinical grounds
Microscopic demonstration of pseudohyphae or yeast cells in infected tissue or
body fluids (vaginal discharge)
Culture (vaginal discharge)
Treatment
Nystatine vaginal pessary or

Miconazole or clotrmazele creams or

Keto conazole or
Fluconazele in recurrent cases
Case treatment
Treatment of underlying medical conditions or predisposing factors
F. Gonorrhea
Definition: An acute or chronic purulent infection of the urogenital tract.
Infectious agent
Neisseria gonorrhea, the gonococcus
Epidemiology
Occurrence – worldwide, affecting both genders, especially sexually active
adolescents and young adults. Common in rural areas. Prevalent in communities
of lower socio-economic status. In most industrialized countries, the incidence
has decreased during the past two decades.
Reservoir - Strictly a human disease
Mode of transmission - almost always as a result of sexual activity
Incubation period - usually 2-7 days
Period of communicability - may extend for months in untreated individuals.
Effective therapy ends communicability within hours.
Susceptibility and resistance - Susceptibility is general. No immunity
following infection and reinfection is common.
Clinical manifestations
Males- Usually involves the urethra resulting in purulent discharge, dysurea and
frequency.
Females - Females are usually asymptomatic. Vaginal discharge is common.
Most common site of infection is cervix, followed by urethra, anal canal and
pharynx. Bartholinitis occurs unilaterally. Salpingitis as a complication
occurs in 20% of women. Neonates borne to infected mothers develop a
purulent discharge which exudes from between eyelids which are edematous
and erythematous 2 -3 days postpartum.

Diagnosis
Gram stain of discharge (urethral, cervical, conjuctival discharge)
Culture on selective media
Treatment
Co - trimoxazole or
Erythromycin or
Ceftriaxone can be used
The same as syphilis
Application of 1% tetracycline in both eyes of new borne as soon as delivered.
In-text Question
What is the etiological agent of gonorrhea
Answer
Neisseria gonorrhea
G. Trichomoniasis
Definition: A common and persistent protozoal disease of the genito- urinary
tract.

Infectious agent
Trichomonas vaginalis, a flagellate protozoan
Epidemiology
Occurrence - worldwide spread, a frequent disease of all continents and all
races, primarily of adults, with the highest incidence among females 16 - 35
years. Overall, about 20% of females may become infected during their
reproductive years.
Reservoir - Humans.
Mode of transmission- by contact with vaginal and urethral discharges of
infected people during sexual intercourse. Indirectly through contact with
contaminated articles and clothes.
Incubation period - 4 - 20 days, average 7days. Many are symptom-free
carriers for years.
Period of communicability - the duration of the persistent infection, which
may last for years.
Susceptibility and resistance -Infection is general, but clinical disease is seen
mainly in females.
Most men remain asymptomatic although some develop arthritis, and a few
have epididymitis or prostatitis.
Infection in women is usually symptomatic and manifests with malodorous
vaginal discharge often yellow, vulvar erythema and itching dysuria or urinary
frequency (in 30 - 50% of cases) and dyspareunia. These manifestations don't
clearly distinguish trichomoniasis from other types of infections/vaginitis.
Diagnosis
Detection of motile trichomonads by microscopy of wet mounts of vaginal or
prostatic secretions remains the conventional means of diagnosis.
Culture (most effective) takes 3 - 7 days.
Treatment.
Metronidazole or
Clotrimazole vaginal suppository for pregnant women cures up to 50%.

case detection and treatment

condom use
Educate public to seek medical help whenever there is an abnormal discharge
from the genitalia and to refrain from sexual intercourse until investigation and
treatment of self and partners are completed.
H. HIV/AIDS
Definition: A severe, life - threatening clinical condition, first recognised as a
distinct syndrome in 1981. This syndrome represents the late clinical stage of
infection with the human immunodeficiency virus (HIV), which most often
results in progressive damage to the immune and other organ systems, including
the CNS.
Infectious agent
Human immuno-deficiency virus (HIV) (HIV-1 and HIV-2 )
Epidemiology
Occurrence - worldwide spread pandemic. HIV -1 infections are now
distributed worldwide, but are most prevalent in Sub- Saharan Africa, the
Americas, western Europe and southern and Southeast Asia. HIV -2 has been
found primarily in West Africa, with some cases in the western hemisphere and
other African countries that are linked epidemiological to West Africa.
The MOH 2002 report depicts the following about the HIV/AIDS situation in
Ethiopia:
The HIV prevalence rate for the country as a whole is estimated at 6.66 percent.
The estimated HIV prevalence rate for urban areas is 13.7 percent
Prevalence rates for some urban centres other than Addis Ababa are much
higher than the rate for Addis Ababa.
The estimated rural prevalence rate is 3.7 percent, which is 25 percent of Addis
Ababa’s rate.
HIV seems to be driving the TB epidemic in Ethiopia.
The highest prevalence of HIV is seen in the age group 15 to 24.
The figure is worrying as it represents “recent” infections. Among the top ten
leading causes of deaths, AIDS ranked 9th with 0.8% in 1993 E.C.
Reservoir - Humans

Mode of transmission – Mainly through sexual exposure and exposure to

blood or tissues. Moreover, transplacental transmission from an infected mother
to the foetus.
Incubation period- variable. Although the time from infection to the
development of detectable antibodies is generally 1-3 months, the time from
HIV infection to diagnosis of AIDS has an observed range of less than 1year to
10years or longer. About half of infected adults will have developed AIDS
within 10 years after infection.
Period of communicability - unknown. Presumed to begin early after onset of
HIV infection and extend throughout life.
Susceptibility and resistance - unknown, but susceptibility presumed to be
general. Susceptibility is increased in the presence of other STDs, especially
those with ulcerations.
Clinical manifestations
Acute HIV syndrome. Occurs 3 - 6 weeks after primary infection. Clinical
findings in the acute syndrome are: fever, pharyngitis, lymphadenopathy, head
ache, retro-orbital pain, arthralgias, myalgias, lethargy or malaise, anorexia,
weight loss, nausea or vomiting or diarrhoea. Meningitis, Encephalitis,
peripheral neuropathy, myopathy, erythematous maculopupular rash,
mucocutaneous ulceration.
Late complications of HIV infection
These result from opportunistic infections like pneumocystis carinii pneumonia,
Tuberculosis, cryptococcal meningitis, etc.
Diagnosis
Based on clinical ground in the late stage
Based on serologic test in the early and late stage
Treatment
No specific treatment.
Treatment of opportunistic infections.
Use of anti-HIV drug to reduce transmission of the virus to the foetus of
pregnant mothers reduces foetal infection.

1. Prevention and control methods for other STDs
3.0 Summary /Conclusion

In this session, we discuss sexually transmitted diseases, their mode of
transmission, communicability, prevention, diagnosis, treatment and control. It
is important to note various way of preventing and controlling disease. Also,
understanding the epidemiology is key in disease management.

1. What are the common sexually transmitted infections?
2. What is the basic difference in the clinical manifestation of syphilis,
Chancroid and Herpes genitalia?
3. What are the common preventive and control methods applicable to all
STIs?

a.Visit YouTube on https://www.youtube.com/watch?v=LZ7ML3gwf0g
Abraham S. Benenson, 1995, Control of Communicable Diseases Manual, 16 th

edition, An Official Report of the American Public Health Association, The
United Book Press, Inc, Baltimore.
Davidson, S., 1999, Principles and Practice of Medicine, 18th edition, Harcourt,
Edinburgh, London.
Donowitz, 1996, Infection Control in the Child Care Center and Preschool, 3 rd
edition, Williams Wilkins, USA.
Eshuis Manschot, 1978, Communicable Diseases: A Manual for Rural Health
Workers, African Medical and Research Association, Nairobi.
Harrison, S., 1998, Principles of Internal Medicine, 14th edition, McGraw-Hill,
U.S.A
Hegazi M. 1994, Applied Human Parasitology, 1st edition, The Scientific Book
Centers, Cairo.
Kozier, et al, 1995, Fundamentals of Nursing, 5th edition, Addison - Wesley,
U.S.A
Madeleine Fletcher, 1992, Principles and Practice of Epidemiology, Addis
Ababa University, Ethiopia.
Meseret Shiferaw, Haile Tena, 1990, A Manual for Students and Health
Workers, Ministry of Health, Ethiopia.
Ministry of Health, 1997, Manual of National Tuberculosis and Leprosy
Control Program, 1st edition,
Health Learning Materials Development and Production Division, Addis Ababa,
Ethiopia.
Ministry of Health, 2001, Health and Health-related Indicators, Planning and
Programming Department, Addis Ababa, Ethiopia.
Ministry of Health, 2002, AIDS in Ethiopia, 4th edition, Disease Prevention
and Control Department, Addis Ababa, Ethiopia.
Monica Cheesbrough, 1998, District Laboratory Practice in Tropical
Countries, Part One; Cambridge University Press, London.

Study Session 4
FOOD-BORNE DISEASES (FOOD POISONING, FOOD-BORNE
INTOXICATIONS, FOOD-BORNE INFECTION)
Introduction
2.0 Main Content
2.1- Food borne diseases
Introduction
In this study session we are going to be discussing food-borne diseases,
including food-borne intoxications and food-borne infections, are terms applied
to illnesses acquired by consumption of contaminated food. They are frequently
and inaccurately referred to as food poisoning.
1. Explain the mode of transmission of food borne pathogens
2. Highlight preventive measures of food borne diseases
2.0 Main Content

2.1- Food borne diseases
Food-borne diseases, including food-borne intoxications and food-borne
infections, are terms applied to illnesses acquired by consumption of
contaminated food. They are frequently and inaccurately referred to as food
poisoning. While these terms would include illnesses caused by chemical
contaminants (heavy metals and organic compounds), this chapter will cover
illnesses caused by toxins elaborated by bacterial growth in the food before
consumption (staphylococcus aureus and botulism) and a food-borne infection
(salmonellosis).

A. Staphylococcal Food Poisoning (intoxication)

Definition: An intoxication (not infection) of abrupt and sometimes violent
onset.
Infectious agent (Toxic agent)
Several enterotoxins of staphylococcus aureus, stable at boiling temperature.
Staphylococci multiply in food and produce the toxins.
Epidemiology
Occurrence- Widespread and relatively frequent
Reservoir- Humans in most instances; occasionally cows with infected udders.
Mode of transmission-
By ingestion of a food product containing staphylococcal enterotoxin. Foods
involved are particularly those that come in contact with food handlers’ hands,
either without subsequent cooking or with inadequate heating or refrigeration,
(e.g. salad, sandwiches, sliced meat and meat products, pastries, etc.). When
these foods remain at room temperature for several hours before being eaten,
toxin-producing staphylococci multiply and elaborate the heat- stable toxin. The
organisms may be of human origin, from purulent discharges of an infected
finger or eye, abscesses, nasopharynyeal secretions.
Incubation period- 30 minutes to 8 hours, usually 2-4 hours.
Period of communicability- not applicable
Susceptibility and resistance- Most people are susceptible.
Sudden onset of vomiting and watery diarrhoea
Fever and abdominal cramp
The intensity of illness may require hospitalisation.
Diagnosis
Group of cases with characteristic acute predominantly upper gastrointestinal
symptoms and the short interval between eating a common food item and the
onset of symptoms.
Culture –staphylococcal recovery (≥105organisms per gram of food) or
detection of enterotoxin from an epidemiologically implicated food item
confirms the diagnosis.
Treatment
1. Fluid and electrolyte replacement if fluid loss is significant particularly in
severe cases.
Educate food handlers in strict food hygiene, sanitation and cleanliness of
kitchens, proper temperature control, handwashing, cleaning of finger nails,
need to cover wounds on the skin, etc.
Reduce food-handling time (initial preparation to service) to an absolute
minimum, with no more than 4 hours at ambient temperature. Keep perishable
food hot (>60c0) or cold (below 10c0).
Temporarily exclude people with boils, abscesses and other purulent lesions of
hands, face or nose from food handling.
B. Botulism
Definition: A paralytic disease that begins with cranial nerve involvement and
progresses caudally to involve the extremities.
Infectious agent (Toxic agent)
Toxin produced by Clostridium botulinum (Neurotoxin)
Epidemiology
Occurrence- Worldwide occurrence. Home-canned foods, particularly
vegetables, fruits and less commonly with meat and fish. Outbreaks have
occurred from contamination through cans damaged after processing.
Commercial products occasionally cause outbreaks but some of these outbreaks
have resulted from improper handling after purchase. Food-borne botulism can
occur when a food to be preserved is contaminated with spores.
Reservoir- The bacteria is found in the soil and in the intestine of animals.
Mode of transmission- Food ingestion in which preformed toxin is found.
Incubation period- Neurological symptoms of food-borne botulism usually
appear within 12-36 hours, sometimes several days, after eating contaminated
food.
Period of communicability- not communicable
Susceptibility and resistance- Susceptibility is general.
In-text Question
What is Botulism
Answer
A paralytic disease that begins with cranial nerve involvement and progresses caudally to
involve the extremities
Clinical Manifestations
Illness varies from a mild condition to very severe disease that can result in
death within 24 hours.
Symmetric descending paralysis is characteristic and can lead to respiratory
failure and death.
Cranial nerve involvement marks the onset of symptoms; usually produces
diplopia, dysphagia. Weakness progresses, often rapidly, from the head to
involve the neck, arms, thorax and legs; the weakness is occasionally
asymmetric.
Nausea, vomiting, abdominal pain may proceed or follow the onset of paralysis.
Dizziness, blurred vision, dry mouth, and occasionally sore throat are common.
No fever
Ptosis is frequent.
Papillary reflexes may be depressed: fixed or dilated pupils are noted in half of
patients.
The gag reflex may be suppressed; deep tendon reflexes may be normal or
decreased.
Paralytic illus, severe constipation and urinary retention are common.

Diagnosis
Clinical- afebrile, mentally intact patients who have symmetric descending
paralysis without sensory findings.
Appropriate History.
Demonstration of organisms or its toxin in vomitus, gastric fluid or stool is
strongly suggestive of the diagnosis
Wound culture
Treatment
Hospitalise the patient and monitor closely.
Intubation and mechanical ventilation may be needed.
Antitoxin administration after hypersensitivity test to horse serum.
Emesis and lavage if short time after ingestion of food to decrease the toxin.
Ensure effective control of processing and preparation of commercially canned
and preserved foods.
Education about home canning and other food preservation techniques
regarding the proper time,
pressure and temperature required to destroy spores, the need for adequate
refrigeration, storage, boiling with stirring home-canned vegetables for at least
10 minutes to destroy botulinal toxin.
Canned foods in bulging containers should not be used, eaten or tasted.
C. Salmonellosis
Definition: A bacterial disease commonly manifested by an acute enterocolitis.
Infectious agent
Salmonella typhimurium and Salmonella enteritidis are the two most commonly
reported.
Epidemiology:
Occurrence- Worldwide

Reservoir- Domestic and wild animals including poultry, swine, cattle, rodents
and pets (tortoises, dogs, cats and humans) and patients or convalescents are
carriers, especially of mild and unrecognised cases.
Mode of transmission: - ingestion of organisms in food derived from infected
food animals or contaminated by faeces of an infected animal or person. Raw
and under-cooked eggs and egg products, raw milk and its products,
contaminated water, meat and its products, poultry and its products.
Consumption of raw fruits and vegetables contaminated during slicing.
Incubation period –from 6 –72 hours, usually about 12-36 hours
Period of communicability- extremely variable through the course of
infection; usually several days to several weeks.
Susceptibility and resistance- Susceptibility is general and increased by
achlorhydria, antacid therapy, gastrointestinal surgery, prior or current broad
spectrum antibiotic treatment, neoplastic disease, immunosuppressive treatment
and malnutrition.
Self-limited fever and diarrhoea (bloody or dysenteric when colon is involved)
Nausea, vomiting and abdominal cramp
Microscopic leukocytosis.
Diagnosis
Blood culture initially
Stool, culture
Treatment
Symptomatic
If there is an underlying immunosuppressive disease (conditions like AIDS,
lymphoma, immunosuppressive treatment), treat the underlying cause.
Improved animal rearing and animal marketing
Quality testing of the known and commonly contaminated foods
Avoid consuming raw or partially cooked eggs
Wear gowns and gloves when handling stool and urine and handwashing after
patient contact.
3.0 Summary /Conclusion

In this session, we discuss food borne diseases, their mode of transmission,
communicability, prevention, diagnosis, treatment and control. It is important to
note various way of preventing and controlling disease.

1. Explain the mode of transmission of food borne pathogens
2. Highlight preventive measures of food borne diseases

Visit YouTube on https://www.youtube.com/watch?v=3gi2IU520KA
Abraham S. Benenson, 1995, Control of Communicable Diseases Manual, 16 th

edition, An Official Report of the American Public Health Association, The
United Book Press, Inc, Baltimore.
Davidson, S., 1999, Principles and Practice of Medicine, 18th edition, Harcourt,
Edinburgh, London.
Eshuis Manschot, 1978, Communicable Diseases: A Manual for Rural Health
Workers, African Medical and Research Association, Nairobi.
Harrison, S., 1998, Principles of Internal Medicine, 14th edition, McGraw-Hill,
U.S.A
Hegazi M. 1994, Applied Human Parasitology, 1st edition, The Scientific Book
Centres, Cairo.
U.S.A


Health Learning Materials Development and Production Division, Addis Ababa,
Ethiopia.

Study Modules
MODULE 3: Screening, Prevention and Management of Diseases
Study Session 9: Screening for Diseases
Study Session 10: Prevention and Control of Communicable Diseases
Study Session 11: Management of Communicable Diseases
Study Session 12: Neglected Tropical Diseases
Study Session 13: History of Emerging and Re-Emerging Infectious Diseases
Outbreaks in Nigeria
Study Session 1
SCREENING DISEASES
Introduction
2.0 Main Content
2.1- Screening for Diseases
2.2- Type of screening
2.3- Evaluation of Screening Test
Introduction
In this study session we are going to be discussing screening of infectious
diseases.
1. Explain how screening Test is evaluated
2. Explain the types of screening
2.0 Main content
2.1 Screening for Diseases
Process of Screening
Screening for disease is an important function of Public Health practice.

Screening can be defined as the search for unrecognised disease or defect
by means of rapidly applied tests, examinations or other procedures in
apparently healthy individuals. The process of screening sorts out apparently
well persons who probably have a disease from those who probably do not.
Aims of Screening
The general aim of screening is to sort out from a large group of apparently
health persons those that are likely to have the disease, or are at an increased
risk of having the disease under study. The persons that are “apparently
abnormal” should then be brought under medical supervision and treatment.
Detection of disease before symptoms develop alters the natural history of the
disease in a favorable manner and therefore improves the chances of preventing
death and disability.
Uses of Screening
Screening is used for the following purposes:
Case Detection
Screening is used for the presumptive identification of unrecognized disease,
which does not arise from a patient’s request, e.g. compulsory antenatal
screening of mothers for HIV in some health facilities. These persons are
screened primarily for their health benefit. Other diseases that can be screened
for are breast cancer, cervical cancer, diabetes mellitus, pulmonary tuberculosis,
haemolytic disease of the newborn, etc.
Control of Disease
This is also called “prospective screening”. In this type of screening, people are
examined for the benefit of others. Examples are screening of immigrants for
the detection of diseases like tuberculosis, syphilis and HIV, in order to protect
the home population. The screening programme leads to early diagnosis of these
problems and prompt treatment, thereby limiting the spread of infection to
others and/or resultant death from the disease.
Research

Screening may be used for research purposes because it aids in obtaining the
basic knowledge of the natural history of certain diseases such as cancer and
hypertension. The initial screening gives the prevalence estimate, while
subsequent ones give the incident rate.
2.2 Types of Screening

There are 3 types screening
Mass Screening
Mass screening is the screening of the whole population or a population
subgroup. An example is the screening of all adults in a community for
pulmonary tuberculosis. This type of screening is offered to all persons in the
population under study, irrespective of the particular risks individual may have
for the disease under study. There may be little justification for mass screening
in many instances.
Difference Between Screening and Diagnostic Tests

A screening is test not intended to be diagnostic. Persons with positive or
suspicious findings must be referred to physicians for diagnosis and necessary
treatment. A screening test is not a basis for treatment. Screening differs from
diagnostic medical examination in that it is done on apparently healthy people.
The initiative for screening comes from an investigator interested in a particular
disease entity or the agency that provides care or funds for a particular research.
Diagnostic tests are usually carried out on individuals with indications or those
that are sick and have presented themselves for medical advice test and
management. Screening is capable of wide application and usually one or a few
diseases are considered. This is contrary to what obtains in diagnostic tests,
where single patients are considered and all diseases are tested for.
Screening test are based on one criterion and have only one cut-off point, e.g. an
individual is considered to suffer from hypertension if his systolic blood
pressure is 140 mmHg and above or diastolic blood pressure 90 mmHg and
above. This is unlike what obtains in diagnostic tests, where evaluation is based
on a number of symptoms, signs and laboratory findings. A screening test is
therefore less accurate and less expensive than a diagnostic test. It is also less
time wasting for the physician, who is not often required to administer the test
but only to interpret the results.
High-Risk or Selective Screening

This type of screening is applied selectively to the high-risk groups for the
particular disease under study. The screening is more effective and economical.
Family members can be selectively screened for diseases that are familial in
origin e.g. hypertension, diabetes mellitus, breast cancer, etc. Risk factors can
also be screened for because they antedate the actual disease in question, e.g.
elevated serum cholesterol can lead to coronary heart disease. Preventive
measures can then be applied on time before the disease develops.
In-text Question
What is mass screening
Answer
Mass screening is the screening of the whole population or a population subgroup
Multiphasic Screening
Multiphasic screening means the application of two or more screening tests to a
large number of people at one time, rather than carrying out separate screening
tests for single diseases. The procedure may include administration of
questionnaire, clinical examinations and a variety of measurements and
investigations. All these can be performed rapidly with the appropriate staff and
equipment. However, most multiphasic screening has been wasteful of
resources, thereby casting doubts on their overall usefulness.
2.3 Evaluation of Screening Test

The following measures, calculated as percentages are used in evaluating a
screening test:
(Please refer to the 2x2 contingency cross-classification Table 1 below)
Contingency Cross-classification of Screening Test Results in Relation to
Diagnosis
Table 1: Screening Test Results in Relation to Diagnosis
Sensitivity = a/(a+c) x 100

Specificity = d/(b+d) x 100
Predictive value of a positive test = a/(a+b) x 100
Predictive value of a negative test = d/(c+d) x 100

Percentage of false negatives = c/(a+c) x 100
Percentage of false positives = b/(b+d) x 100
The following definitions apply:
Sensitivity
Sensitivity is the ability of attest to identify correctly all those who have the
disease, i.e the “true positives”. An 80% sensitivity means that 80% of the
diseased persons that have been screened by the test will give a “true positive”
result, while the remaining 20% will give a “false negative” result.
Specificity
Specificity is the ability of attest to identify correctly those who do not have the
disease, i.e. the “true negative”. An 80% specificity means that 80% of the non-
diseased people will give true negative results, while the reaming 20% of the
non-diseased people will be wrongly classified as diseased. An ideal screening
test should be 100% sensitive and 100% specific. In practice, this does not
occur; sensitivity and specificity are inversely related. As one increases the
other decreases and vice versa.
Predictive value of a Test

The predictive value of a screening test reflects its diagnostic power. The
predictive value of a positive test indicates the probability that a patient with
appositive test result has the disease in question. The more prevalence a disease
is in a community, the more accurate will be the predictive value of a positive
screening test.
False Negatives
False negatives concern the physician more than the epidemiologist, who is
more concerned with the sensitivity and the specificity of a screening test. False
negatives are patients who actually have the disease but are told that they do not
have it. This may lead to a false sense of well-being and postponement of
necessary treatment. A sensitive screening test has few false negatives.
False Positives
False positives are persons who do not have the disease in question but are told
they have it. These normal and healthy people are therefore subjected to further,
often inconvenient, uncomfortable and expensive diagnostic test until their
freedom from disease is established. A screening test with a high specificity will
have few false positives.

Yield
Yield is the amount of previously unrecognised disease that is diagnosed as a
result of the screening programme. It depends on the sensitivity and specificity
of the test, prevalence of the disease, and participation of individuals in the
screening exercise.
a) Sensitivity of the test. If a test has low sensitivity, it can identify only a
fraction of the diseased individuals, thereby leading to a poor yield.
b) Incidence and prevalence of unrecognised disease. The incidence of a disease
influences yield. The higher the incidence of a disease, the higher is the yield of
a screening test. Prevalence of a disease also affect yield. The higher the
prevalence, the higher is the yield of a screening test. Therefore, screening
should be aimed at a population with high prevalence of a disease. High-risk
individuals are usually selected for screening, thereby increasing the yield.
In this session, we discussed screening as the presumptive identification of
unrecognised disease or defects by the application of tests, examinations, or
other procedures that can be applied rapidly. Differs from diagnosis, which is
the process of confirming an actual case of a disease. The purpose is to classify
individuals as to whether they are likely to have disease or be disease free.

1. Explain the various type of screening for diseases detection

a. Visit YouTube on https://bit.ly/2Zlq5vX. Watch the video & summarise in
1 paragraph
b. View the animation on https://bit.ly/2L0vjbn and critique it in the
discussion forum
Abraham S. Benenson, 1995, Control of Communicable Diseases Manual,

16th edition, An Official Report of the American Public Health Association,
The United Book Press, Inc, Baltimore.
Davidson, S., 1999, Principles and Practice of Medicine, 18th edition,
Harcourt, Edinburgh, London.
Donowitz, 1996, Infection Control in the Child Care Center and Preschool, 3rd
Eshuis Manschot, 1978, Communicable Diseases: A Manual for Rural

Health Workers, African Medical and Research Association, Nairobi.
Harrison, S., 1998, Principles of Internal Medicine, 14th edition, McGraw-
Hill, U.S.A
Hegazi M. 1994, Applied Human Parasitology, 1st edition, The Scientific
Book Centers, Cairo.
U.S.A
Health Learning Materials Development and Production Division, Addis
Ababa, Ethiopia.

Study Session 2
PREVENTION AND CONTROL OF COMMUNICABLE DISEASES
Introduction
2.0 Main Content
2.1- Classification of Communicable Diseases
2.2-Measures targeting their mode of transmission
2.3 Measures targeting the susceptible host
2.4- Levels of Prevention of communicable diseases
2.5-Communicable Disease Control
Introduction
In this study session we are going to be discussing screening of infectious
diseases, type of screening, Prevention and control of communicable disease
based on the way they are transmitted; those transmitted through oral-faecal
route, arthropod or intermediate vector-borne transmission, sexually
transmitted ones and food-borne transmitted diseases.
In the previous study session, you learned about the basic concepts in the
transmission of communicable diseases. The knowledge you gained will help
you to understand this study session because they are interlinked. In the first
section, you will learn about the different ways of classifying communicable
diseases. Following classification, you will learn the approaches in prevention
and control of communicable disease. This will help you in identifying
appropriate measures for the prevention and control of communicable diseases
that you, as a Health Extension Practitioner, and other health workers will put
into place in your community.
1. Discuss the levels of prevention of communicable diseases
2. Explain measures of targeting the susceptible host
3. Explain measures targeting their mode of transmission

2.0 Main content

2.1 Classification of communicable diseases
Communicable diseases can be classified in different ways into groups with
similar characteristics. Classification will help you to select and apply
appropriate prevention and control measures that are common to a class of
communicable diseases. In this section you will learn the basis for each way of
classifying communicable diseases and its relevance to your practice. This will
be clarified using examples of communicable diseases that you may already be
familiar with.
In Study Session 1 you have learned the types of infectious agents which can be
used for classification of communicable diseases. Apart from this, there are two
main ways of classifying communicable diseases, which are important for you
to know. Two ways of classifying communicable diseases:
Clinical classification is based on the main clinical manifestations (symptoms
and signs) of the disease.
Epidemiologic classification is based on the main mode of transmission of the
disease.
Clinical classification of communicable diseases
This classification is based on the main clinical manifestations of the disease.
This way of classification is important in helping you to treat the symptoms and
signs that are common to (shared by) individuals who suffer from different
diseases. Clinical classification is illustrated by the example given below.
Some diseases are classified as diarrhoeal diseases. The main clinical
symptom is diarrhoea, which means passage of loose stool (liquid faeces) three
or more times per day. Two examples of diarrhoeal diseases are shigellosis and
cholera. (Further details about these diseases are in Study previous Module).
People with watery diarrhoeal disease suffer from loss of fluid from their
bodies. Therefore, even though the infectious agent might be different, as in the
examples of shigellosis and cholera, the common management of patients with
diarrhoeal disease includes fluid replacement. Another clinical classification
refers to diseases characterised as febrile illnesses, because they all have the
main symptom of fever for example, malaria. Respiratory diseases are another
clinical classification; their main symptoms include cough and shortness of
breath, as in pneumonia. Diseases have many symptoms and signs. As a Health
Extension Practitioner, you will need to decide which symptom is the main one
for classification. Using the method of clinical classification will help you
decide to treat the main symptom. You will be able to identify the main
symptoms more easily when you learn about specific diseases in previous
session. Bear in mind that for most diseases, treatment of the main symptom is

only supportive (that is it will not cure the disease). Therefore, you have to give
treatment specific to the infectious agent.
In-text Question
Give the two types of classification of communicable diseases
Answer
Clinical and epidemiological
Epidemiologic classification of communicable diseases

This classification is based on the main mode of transmission of the infectious
agent. The importance of this classification for you is that it enables you to
select prevention and control measures which are common to (shared by)
communicable diseases in the same class, so as to interrupt the mode of
transmission. To clarify the importance of epidemiologic classification, consider
the following examples Cholera and typhoid fever are two different diseases
which can be transmitted by drinking contaminated water. Therefore, they are
classified as waterborne diseases, using the epidemiologic classification. The
common prevention measures for the two diseases, despite having different
infectious agents, include protecting water sources from contamination and
treatment of unsafe water before drinking for example by boiling or adding
chlorine. Based on the mode of transmission of the infectious agent,
communicable diseases can be classified as:
Waterborne diseases: transmitted by ingestion of contaminated water.
Foodborne diseases: transmitted by the ingestion of contaminated food.
Airborne diseases: transmitted through the air.
Vector-borne diseases: transmitted by vectors, such as mosquitoes and flies.
Suppose while you are working in your health facility, a 20-year-old man comes
to you complaining of high fever accompanied by violent shivering (rigors),
vomiting and headache. A blood examination for malaria found evidence of
Plasmodium falciparum. Assume that he acquired the parasite after being bitten
by infected mosquitoes. How would you classify this man’s health problem
using two different classifications?
General approaches in the prevention and control of communicable diseases
You now have a working knowledge of factors involved in the chain of disease
transmission (described in Study Session 2), and how to classify communicable
diseases. This knowledge will help you to identify prevention and control
measures that can be applied at each link in the chain. When we say
prevention, it refers to measures that are applied to prevent the occurrence of a
disease. When we say control, it refers to measures that are applied to prevent
transmission after the disease has occurred. Most of the measures for prevention
and control of communicable diseases are relatively easy and can be applied
using the community’s own resources. You have an important role in educating
the public to apply these measures effectively.
We can simplify the discussion of prevention and control measures acting on
the chain of transmission by merging these six factors into three groups:
Infectious agents in the reservoir of infection and the route of exit from the
reservoir are discussed under the heading ‘reservoir’.
Diagnosis and treatment
First, you should be able to diagnose and treat cases of the disease, or refer the
patient for treatment at a higher health facility. There are two ways to identify
an infected individual: when a patient comes to you
Identifying and treating cases as early as possible, reduces the severity of the
disease for the patient, avoiding progression to complications, disability and
death; and it also reduces the risk of transmission to others.
Approaches to the diagnosis of a case
The first step is to ask about the main complaints of the patient.
Then ask about the presence of other related symptoms and risk factors.
Examine the patient physically to detect signs of any diseases you suspect.
Finally, refer the patient for laboratory examinations if available (e.g blood
examination for malaria).
Screening
Issues related to HIV/AIDS will be further discussed in in this Module.
Isolation
Following detection of a communicable or infectious disease, you may need to
separate patients from others to prevent transmission to healthy people. This is
called isolation. It is not indicated for every infection, but it is important to
isolate people with highly severe and easily transmitted diseases. For example,
an adult case of active pulmonary tuberculosis (‘pulmonary’ means in the lungs)
should be kept in isolation in the first two weeks of the intensive phase of
treatment. The isolation period lasts until the risk of transmission from the
infected person has reduced or stopped. The period and degree of isolation
differs between different diseases.
Reporting
Animal reservoirs
When infected animals are the reservoir involved in the transmission of
communicable diseases, different measures can be undertaken against them. The
type of action depends on the animal reservoir, and ranges from treatment to
destroying the infected animal, depending on the usefulness of the animal and
the availability of treatment. For example, to prevent and control a rabies
outbreak, the measures to be taken are usually to destroy all stray dogs in the

area, and vaccinate pet dogs if the owner can afford this protection and the
vaccine is available.
2.2 Measures Targeting the Mode of Transmission
The measures that can be applied to interrupt transmission of infectious agents
in water, food, other vehicles and by vectors, are described below.
Water
Measures to prevent transmission of infection due to contaminated water
include boiling the water, or adding chemicals like chlorine. Disinfection is the
procedure of killing most, but not all, infectious agents outside the body by
direct exposure to chemicals. Adding chlorine is one method of disinfecting
water. Physical agents can also be used, for example filtering water through a
box of sand, or pouring it through several layers of fine cloth. Faecal
contamination of water should also be prevented by protecting water sources
and through proper use of latrines.
Food
Measures to prevent transmission in contaminated food include washing raw
vegetables and fruits, boiling milk, and cooking meat and other food items
thoroughly before eating. Contamination with faeces can be prevented by hand
washing and proper use of latrines.
Measures to tackle transmission in or on vehicles other than water and food
include:
Contaminated objects like household utensils for cooking, eating and drinking
should be washed with soap and water.
Contaminated medical instruments and clothing can be sterilised, disinfected or
properly disposed of.
Sterilisation involves destruction of all forms of micro-organisms by physical
heat, irradiation, gas or chemical treatment. The difference between disinfection
and sterilisation is that disinfection kills most, but not all, micro-organisms.
Disinfection can be done using alcohol, chlorine, iodine or heating at the
domestic level; whereas sterilisation has to use extreme heating, irradiation or
strong chemicals like a high concentration of chlorine.
Vectors
Measures against vectors include preventing breeding of vectors, through proper
disposal of faeces and other wastes, eradication of breeding sites, and
disinfestation. Disinfestation is the procedure of destroying or removing small
animal pests, particularly arthropods and rodents, present upon the person, the
clothing, or in the environment of an individual, or on domestic animals.
Disinfestation is usually achieved by using chemical or physical agents, e.g.
spraying insecticides to destroy mosquitoes, and removing lice from the body
and clothing.
2.3 Measures targeting the susceptible host

The measures described below help to protect the susceptible host either from
becoming infected, or from developing the stage of infectious disease if they are
exposed to the infectious agents.
Vaccination
vaccination refers to administration of vaccines to increase the resistance of the
susceptible host against specific vaccine-preventable infections. For example,
measles vaccination helps to protect the child from measles infection, and BCG
vaccination gives some protection from tuberculosis
Community diagnosis
In order to select and apply effective prevention and control measures, you first
have to determine which type of diseases are common in the community you are
working with. How do you do that? The method is called community diagnosis
and it involves the following four steps:
Data collection
Data analysis
Prioritising problems
Developing an action plan.
Data collection
Data collection refers to gathering data about the health problems present in the
community. This is important as it will help you to have good ideas about the
type of problems present in the area where you work. Where do you get useful
data concerning the health problems in your community? The following sources
of data can be used:
Discussion with community members about their main health problems
Reviewing records of the health services utilised by the community
Undertaking a community survey or a small-scale project
Observing the risks to health present in the community.
After collecting data, it should be analysed to make meaning out of it.
Data analysis
Data analysis refers to categorising the whole of the data you collected into
groups so as to make meaning out of it. For instance, you can assess the
magnitude of a disease by calculating its prevalence and its incidence from the
numbers of cases you recorded and the number of people in the population in
your community. Prevalence rates and incidence rates can also be expressed as
‘per 10,000’ or ‘per 100,000’ in much larger populations, e.g. of a region or a
whole country.
Prevalence refers to the total number of cases existing in the population at a
point in time, or during a given period (e.g. a particular month or year). The
number of cases can be more usefully analysed by calculating the prevalence
rate in the community: to do this you divide the total number of cases you
recorded in a given period into the total number of people in the population. The
result is expressed ‘per 1,000 population’ in a community as small as a kebele.
For example, suppose that in one year you record 100 cases of malaria in a
kebele of 5,000 people: for every 1,000 people in the kebele, there were 20
malaria cases in that year. So, the prevalence rate of malaria in that kebele is
expressed as 20 cases per 1,000 people in that year.
Calculating the prevalence rate is more useful than just counting the number of
cases, because the population size in your kebele can change over time. The
prevalence rate takes account of changes in the number of people, so you can
compare the prevalence rates from different years, or compare the rate in your
kebele with the rate in another one.
2.4 Levels of Prevention of communicable diseases
The different points in the progression of a disease at which one can

intervene can be classified according to three levels of prevention:
primary, secondary, and tertiary.
a. Primary prevention: The objectives here are to promote health,
prevent exposure, and prevent disease.
Health promotion: This consists of general non-specific
interventions that enhance health and the body’s ability to resist
disease, such as measures aimed at the improvement of socio-
economic status through the provision of adequately- paid jobs,
education and vocational training, affordable and adequate housing,
clothing, and food, old-age pension benefits; emotional and social
support, relief of stress, etc. In short it is any intervention that
promotes a healthier and happier life.
Prevention of exposure: - This includes actions such as the provision
of safe and adequate water, proper excreta disposal, vector control,
safe environment at home (e.g., proper storage of insecticides and
medicines, out of children’s reach), at school and at work (e.g., proper
ventilation, monitoring of harmful substances in factories), and on the
streets (e.g., driver licensing laws).
Prevention of Communicable disease: -This occurs during the
latency period between exposure and the biological onset of disease.
An example for this is immunisation.
Immunisation against an infectious organism does not prevent it from
invading the immunized host, but prevents it from establishing an
infection. Active immunisation means exposing the host to a specific
antigen against which it will manufacture its own protective
antibodies after an interval of about three weeks (during which the

immunised person remains susceptible to the disease). Passive
immunisation means providing the host with the antibodies necessary
to fight against disease. Both forms of immunisation act after
exposure. However, for active immunisation to be protective, the
timing of its administration must be at least three weeks prior to
exposure. Passive immunisation, on the other hand, is commonly
given after exposure has occurred (as in the case of exposure to rabies
or tetanus), or shortly before an exposure is expected, as in the
administration of immune globulin to prevent viral hepatitis A).
Breastfeeding is an example of an intervention that acts at all three
levels of primary prevention:
 Health promotion: by providing optimal nutrition for a young child,
either as the sole diet up to four months of age, or as a supplement in
later months.
 Prevention of exposure: by reducing exposure of the child to
contaminated milk.
 Prevention of disease after exposure: by the provision of anti-
infective factors, including antibodies, white blood cells, and others.
Secondary prevention: After the biological onset of disease, but
before permanent damage sets in, we speak of secondary prevention.
The objective here is to stop or slow the progression of disease so as
to prevent or limit permanent damage, through the early detection and
treatment of disease. (e.g. breast cancer (prevention of the invasive
stage of the disease), trachoma (prevention of blindness), and syphilis
(prevention of tertiary or congenital syphilis))
Tertiary prevention: After permanent damage has set in, the
objective of tertiary prevention is to limit the impact of that damage.
The impact can be physical, psychological, social (social stigma or
avoidance by others), and financial. Rehabilitation refers to the
retraining of remaining functions for maximum effectiveness, and
should be seen in a very broad sense, not simply limited to the
physical aspect. Thus the provision of special disability pensions
would be a form of tertiary prevention.
2.5 Communicable Disease Control
This refers to the reduction of the incidence and prevalence of
communicable disease to a level where it cannot be a major public
health problem.
Methods of Communicable Disease Control
There are three main methods of controlling communicable diseases:
Elimination of the Reservoir

Man as reservoir: When man is the reservoir, eradication of an
infected host is not a viable option. Instead, the following options are
considered:
 Detection and adequate treatment of cases: arrests the
communicability of the disease (e.g. Treatment of active pulmonary
tuberculosis).
 Isolation: separation of infected persons for a period of
communicability of the disease. Isolation is indicated for infectious
disease with the following features:
- High morbidity and mortality
- High infectivity
 Quarantine: limitation of the movement of apparently well person or
animal who has been exposed to the infectious disease for a duration
of the maximum incubation period of the disease.
Animals as reservoir: Action will be determined by the usefulness of
the animals, how intimately they are associated to man and the
feasibility of protecting susceptible animals. For example:
 Plague: The rat is regarded as a pest and the objective would be to
destroy the rat and exclude it from human habitation.
 Rabies: Pet dogs can be protected by vaccination but stray dogs are
destroyed.
 Infected animals used for food are examined and destroyed.
Reservoir in non-living things: Possible to limit man’s exposure to
the affected area (e.g. Soil, water, forest, etc.).
Interruption of transmission
This involves the control of the modes of transmission from the
reservoir to the potential new host through:
 Improvement of environmental sanitation and personal hygiene
 Control of vectors
 Disinfections and sterilization
Protection of susceptible host: This can be achieved through:

 Immunisation: Active or Passive
 Chemo-prophylaxis- (e.g. Malaria, meningococcal meningitis, etc.)
 Better nutrition
 Personal protection. (e.g. wearing of shoes, use of mosquito bed net,
insect repellents, etc.)

In this session, we discussed screening and type of screening of diseases, ways
of preventing, control and managing of communicable diseases and neglected
tropical diseases of world.

1. Explain the levels of prevention of communicable diseases
2. Discuss Measures targeting suspectable host in tackling outbreak.
3. Discuss Measures targeting their mode of transmission in tackling
outbreak.
a. Visit YouTube on https://bit.ly/2Zlq5vX. Watch the video & summarise in
1 paragraph
b. View the animation on https://bit.ly/2L0vjbn and critique it in the
discussion forum

Hill, U.S.A
U.S.A
Ababa, Ethiopia.

Study Session 3
THE MANAGEMENT OF COMMUNICABLE DISEASES
Introduction
2.0 Main Content
2.1- Oral-faecal transmitted communicable diseases
2.2- Air-borne communicable diseases
2.3- Sexually transmitted communicable diseases
2.4- Zoonotic communicable diseases
2.5- Food-borne diseases
Introduction
In this study session we are going to be discussing the proper nursing
management of communicable diseases involves both trying to stop people
getting diseases (prevention) and looking after those who have them (treatment
and care). The two are frequently close related and doing one without the other
is only half the job. The measures based on each disease category are described
as follows:
1. give the proper public health management measures for food-borne diseases
2. list the proper public health management measures for oral-faecal borne
diseases
3. Enumerates the various ways of managing sexual communicable diseases
2.0 Main content
2.1 Oral-faecal transmitted diseases:
1. Control of diarrhoeal diseases including dysentery is only possible when
the problem of stool disposal is solved (deep pit latrines in rural areas).
2. Providing handwashing facilities at toilets: wash hands after going to
toilet, wash hands before cooking or eating.
3. Fly control by proper refuse disposal and proper disposal of faeces.
4. Screen toilets, cover latrines
5. Screen kitchens and food stores

6. Store left-over food where flies cannot reach it
7. Spray with residual insecticides
8. Food should always be properly cooked.
9. Raw vegetables and fresh fruits without intact skins should be avoided.
10.Milk should be boiled or pasteurized.
11.Protection, purification and chlorination of public water.
12.Health education based on dangers of bottle–feeding; encourage
cup/spoon feeding methods and encourage prolonged breastfeeding.
13.Demonstrate prevention of dehydration by homemade soup or salt
solution.
14.Appropriate treatment of cases
2.2 Air-borne Diseases

1. Ventilation removes used air and replaces it with clean air.
2. Having too many people in the same room should be avoided. This is
especially important in prisons, dormitories, boarding schools, and in
urban housing where many people may be forced to live in a single room.
3. Health education about personal hygiene
4. To cover the mouth when coughing and sneezing
5. To use a hand kerchief or tissue paper for disposal of nasal secretions and
sputum
6. Not to spit on the ground in or outside the house
7. For vector-borne diseases
8. Draining water or ditches, and any accumulation of water around the
village or filling in holes and ditches so that water will not accumulate.
9. Clearing of bushes and grasses along water banks and in the village.
10.All containers likely to hold water are to be collected and disposed.
11.No water container should have water in it longer than one week.
12.Snails can be controlled by disturbing their habitant through changes in
water level, filling or damming habitant, and clearing habitat.
13.Mosquito net should be used at night.
14.Appropriate treatment of cases and provision of chemoprophylaxis.
In-text Question
Control of diarrhoeal diseases including dysentery is only possible when
Answer
the problem of stool disposal is solved (deep pit latrines in rural areas)

2.3 Sexually Transmitted Diseases

1. Early diagnosis and treatment: - This is the most important measure and
not difficult to achieve.
2. Patients should be encouraged to bring their contacts (including their
husband or wives) for treatment. Failure to do this will result in high
numbers of infection.
3. Elimination of reservoirs: The reservoir is exclusively human; it includes
untreated patients and especially unsuspected infectious persons in the
promiscuous women pool (PWP).
4. Regular examination and treatment of known prostitutes and other
promiscuous women will reduce the reservoir, but will not completely
eliminate the risk of infection (contact must be treated).
5. Sex education
6. This is a form of health education and should be directed at the groups at
risk, especially: students, soldiers, laborers, etc. Here it is important to
stress:
7. Dangers of sexual promiscuity
8. The early signs and symptoms of STD
9. The possibilities for individual prophylaxis.
10.Normal sexual behaviour
11.The dangers of antibiotic chemoprophylaxis
12.Suggest periodical checkups for STDs for bar ladies and other women at
risk.
2.4 Zoonotic diseases
1. Appropriate treatment of cases
2. Educate the public to:
3. Prevent faecal contamination of soil, water, human and animal foods
4. Cook beef and pork
5. Use latrines
6. Avoid drinking untreated milk or eating products made from untreated
milk
7. Eliminate infected animals
8. Use barrier precaution (gloves and clothing in the handling of carcasses
and products of potentially infected animals)
9. Keep dogs and cats at home and immunise them
10.Destroy stray animals where rabies is endemic
11.Bury carcasses of animals intact
12.Vector control and elimination of reservoir host
13.Education of workers to control dust by ventilating rooms of hazardous
industries where wool and goat’s hair is processed

2.5 Food-borne diseases

1. Appropriate treatment of cases
2. Educate food handlers in strict food hygiene, sanitation and cleanliness of
kitchens, proper temperature control, handwashing, cleaning of finger
nails, need to cover wounds on the skin, etc.
3. Temporary exclusion of people with boils, abscesses and other purulent
lesions of hands, face or nose for food handling
4. Education about home canning and other food preservation techniques.
5. Educate public to avoid eating canned foods in bulging or damaged
containers
6. Avoid consuming raw eggs or partially cooked ones
7. Wearing gowns and gloves when handling stool and urine and
handwashing after patient contact
In this session, we discussed ways of managing of communicable diseases.
1. give the proper public health management measures for food-borne diseases
2. list the proper public health management measures for oral-faecal borne
diseases
3. enumerates the various ways of managing sexual communicable diseases

e.g. Visit YouTube on https://www.youtube.com/watch?v=X0OxrsgAP2w

Hill, U.S.A
U.S.A
Ababa, Ethiopia.
Study Session 4
NEGLECTED TROPICAL DISEASES (NTD)

Introduction
2.0 Main Content
2.1- Neglected Tropical Disease of the World
2.2- Epidemiology and Risk Factor of NTD
2.3- Recommendations for Managing Neglected Tropical Diseases
Introduction
In this study session we are going to be discussing about NTD, their
management, epidemiology and risk factors and recommended policies and
approaches to controlling NTD

1. list the neglected tropical diseases in the world
2. Explain management of neglected tropical diseases
2.0 Main content

2.1 Neglected tropical diseases of the world

Neglected tropical diseases (NTDs) are a group of bacterial, parasitic, viral, and
fungal infections that are prevalent in many of the tropical and sub-tropical
developing countries where poverty is rampant. According to a World Bank
study, 51% of the population of sub-Saharan Africa, a major focus for NTDs,
lives on less than US$1.25 per day, and 73% of the population lives on less
than US$2 per day. In the 2010 Global Burden of Disease Study, NTDs
accounted for 26.06 million disability-adjusted life years (DALYs) (95%
confidence interval: 20.30, 35.12). In addition to their impact on health, NTDs
contribute to an immense social and economic burden resulting from social
stigma, physical disabilities, disfigurement, blindness, discrimination, loss of
social status, malnutrition, growth failure, and impaired cognitive development.
All of these interrelated outcomes perpetuate the cycle of poverty by preventing
individuals from leading productive lives, and by adversely affecting families,
communities, and countries as a whole. However, many of these diseases are
preventable, and could be eliminated with improved sanitation, vector control,
available treatments, and mass drug administration (MDA) campaigns.
For the programmatic point of view, the World Health Organisation (WHO)
classified NTDs into two groups: preventive chemotherapy and transmission
control (PCT) NTDs, and innovative and intensified disease management
(IDM) NTDs. The most prominent examples of NTDs that have been
allocated to the PCT group are lymphatic filariasis, onchocerciasis,
schistosomiasis, and soil-transmitted helminthiasis; the main tool for their
control is the periodic administration of efficacious, safe, and inexpensive
(usually donated) drugs to entire at-risk populations. IDM, on the other hand,
focuses on those NTDs that currently lack appropriate tools for large-scale
use. These diseases include Buruli ulcer, Chagas disease, human African
trypanosomiasis, and leishmaniasis. On 30 January 2012, a number of

organisations including the WHO, Bill & Belinda Gates Foundation, United
States Agency for International Development (USAID), World Bank, United
Kingdom Department for International Development (DFID),
pharmaceutical companies, and government officials from donor and
endemic countries met together at a meeting entitled “Uniting to Combat
NTDs: Ending the Neglect and Reaching the 2020 Goals”, and set targeted
goals for NTDs
Climate change and global warming are increasing the likelihood and spread of
many vector-borne diseases, including malaria, dengue fever, Chagas disease,
leishmaniasis, filariasis, onchocerciasis, schistosomiasis, and trypanosomiasis.
At the 70th World Health Assembly (WHA) held in Geneva, Switzerland in
May 2017, a resolution was adopted on a Global Vector Control Response for
2017–2030 that aims to prevent, detect, report and respond to outbreaks of
vector-borne diseases worldwide through an integrated, comprehensive
approach.
On 23 May 2017, the World Intellectual Property Organisation (WIPO)
Research launched a new five-year roadmap to guide public–private
consortium activities, including research, capacity-building, and outreach
efforts in the fight against NTDs, malaria and tuberculosis, which together
cause devastation and disproportionately affect the poorest and most
disadvantaged people. The Carter Center is also taking initiatives to eradicate
or eliminate several NTDs, including guinea worm disease in South Sudan,
Mali, Chad, and Ethiopia, and lymphatic filariasis in Nigeria, Ethiopia and
Hispaniola.
In-text Question
Define neglected tropical diseases
Answer
Neglected tropical diseases (NTDs) are a group of bacterial, parasitic, viral, and fungal
infections that are prevalent in many of the tropical and sub-tropical developing countries
where poverty is rampant.
2.2 Epidemiology and Risk Factors

The 2020 roadmap of WHO, joined by others, focuses on 20 NTDs. These
diseases include Buruli ulcer, Chagas disease, cysticercosis/taeniasis, dengue
fever, dracunculiasis (guinea worm disease), echinococcosis, food-borne
trematodiasis, human African trypanosomiasis (HAT) (sleeping sickness),
leishmaniasis, leprosy, lymphatic filariasis, onchocerciasis (river blindness),
rabies, schistosomiasis, soil-transmitted helminthiasis (ascariasis, hookworm,
trichuriasis), trachoma, and yaws (Table1).

Table 1. List of Neglected Tropical Diseases by Centers for Disease

Control and Prevention (CDC) and World Health Organisation (WHO).
Disease CDC WHO
Buruli ulcer (Mycobacterium ulcerans + +
infection)
Chikungunya a – +
Chagas disease + +
Cysticercosis + +
Dengue fever + +
Dracunculiosis (or guinea worm disease) b + +
Echinococcosis + +
Fascioliasis + +
Foodborne trematodiasis a – +
Human African trypanosomiasis (or sleeping + +
sickness)
Leishmaniasis (or kala-azar) + +
Leprosy + +
Lymphatic filariasis b + +
Mycetoma + +
Onchocerciasis (or river blindness) b + +
Rabies + +
Schistosomiasis b + +
Soil-transmitted helminthiasis b + +
Trachoma b + +
Yaws + +
Data source: CDC, 2017; WHO, 2017; a Not mentioned under CDC list of neglected
tropical diseases (NTDs); b Diseases that can be controlled or eliminated through mass
drug administration (MDA), or other interventions.
These diseases are also included in CDC action plans. In 2017, at the 10th
meeting of the Strategic and Technical Advisory Group for NTDs, the WHO
added mycetoma, scabies and snakebite to the NTD list. The London
Declaration on NTDs, launched in 2012, proposed to sustain, expand, and
extend programs to help eradicate guinea worm disease; eliminate lymphatic
filariasis, leprosy, sleeping sickness, and trachoma; and control
schistosomiasis, soil-transmitted helminthiasis, Chagas disease, visceral
leishmaniasis, and river blindness by the year 2020. A brief description of the
epidemiology and the risk factors of the common NTDs follows.
Buruli Ulcer
Buruli ulcer (BU) is a necrotising skin disease caused by Mycobacterium
ulcerans, which is a slow-growing mycobacterium that infects the skin and
subcutaneous tissues, giving rise to indolent ulcers. The disease has been
reported from more than 30 countries, but especially in West Africa, with 80%
of cases from the Ivory Coast, Ghana, Benin and Cameroon. In a household
survey between February and May 2013 along the Offin River in Ghana, 477
cases with healed BU and eight active cases were detected among 20,390
inhabitants, with an overall prevalence of 2.3%. Approximately 48,373 cases
were reported from 20 countries, mostly in West and Central Africa. The risk
is highest in children aged 4–14 years, and in people aged over 50 years.
Transmission of the disease has been linked with contaminated water. Aquatic
insects, adult mosquitoes and biting arthropods have been considered possible
reservoir species and/or vectors. Regular contact with open surface water (i.e.,
river, pond, creek, and dam) was associated with higher odds of contracting
BU (OR = 9.3, 95% CI: 4.3, 20.0). The riskiest daily activities directly or
indirectly related to water contact were farming (rice and vegetables) and
fishing (OR = 5.6, 95% CI: 2.6, 12.3), contacting water for household supply
at surface water points (OR = 3.3, 95% CI: 1.6, 6.6), and washing and/or
bathing at surface water points (OR = 2.5, 95% CI: 1.1, 5.6).
WHO recommends daily administration of streptomycin and rifampicin for
eight weeks as the treatment of choice. For pregnant women, the combination
of rifampicin and clarithromycin is considered the safer option because of
contraindication to streptomycin. The only effective control tool is early case
detection and treatment to reduce morbidity and associated disabilities that
occur as a result of late treatment. In a case study in the Obom sub-district in
Ghana, community involvement and social interventions were found to
enhance early diagnosis and treatment.
Chikungunya
The chikungunya virus (CHIKV), spread by Aedes (Ae.) aegypti mosquitoes to
humans, is now classified as a category C priority pathogen by the US National
Institute of Allergy and Infectious Diseases, as it has spread to over 40
countries worldwide. Another vector, the Ae. albopictus mosquito, thrives in a
wider range of water-filled breeding sites than the aegypti mosquito, which can
include coconut husks, cocoa pods, bamboo stumps, tree holes and rock pools
in addition to artificial containers and vehicle tires. In recent decades, Ae.
albopictus has spread from Asia and become established in areas of Africa,
Europe and the Americas. The continued transmission of chikungunya in
Colombia and other Latin American countries raises a public health concern.
Vertical transmission between mother and fetus, however, has been observed in
some cases. Confirmed cases have been reported from 24 countries in Africa,
20 in Asia, 44 in America, and 10 countries in Oceania/Pacific Attack rates
ranged from 0.4% to 50.76% in the different villages.
There is a positive linear relationship between the incidence of CHIKV and
mean temperature ranging from 10–25 ◦C. In face-to-face interviews with
more than 500 individuals with 314 (62%) seropositive cases in southern
Thailand, the risk factors associated with CHIKV infection were outdoor
activities daily for at least eight hours, and having a nearby garbage pile. The
protective factors for symptomatic infection were age ≥58 years, and having a
high level of formal education.
Treatment usually is for the symptoms, and includes taking sufficient rest, and
taking more fluid and food, and medicines to relieve pain (paracetamol for
example). Aspirin should be avoided. Prevention of chikungunya virus
infection is by avoiding mosquito bites: air conditioning or window/door
screens to keep mosquitoes outside; sleeping inside a mosquito net, wearing
long-sleeved shirts and long pants when weather permits, and using repellents
containing DEET, picaridin, IR3535, and oil of lemon eucalyptus or para-
menthane-diol (or menthoglycol).
Chagas Disease
The causative agent of Chagas disease is a parasite, Trypanosoma cruzi,
transmitted by Triatoma infestans (or kissing bug), the primary vector of the
disease. The disease is found in North America, Central America, and South
America. The most important consequence of T. cruzi infection is
cardiomyopathy, which occurs in 20–30% of infected persons. The vectors live
in the cracks in mud walls and thatched roofs of rustic rural houses, causing
repeated infections. The estimated global prevalence of T. cruzi infection
declined from 18 million in 1991, when the first regional control initiative
began, to 5.7 million in 2010. Most cases in the United States are imported from
Latin America, with an estimated 300,000 infected residents living in the U.S.
Outbreaks of orally transmitted T. cruzi infection through food or drink
contaminated with vector faeces appear to be associated with a higher
incidence of myocarditis and a higher case-fatality rate than vector-borne
infections.
Three studies that tested anti-T. cruzi seropositivity found strong and
statistically significant associations between socioeconomic status with
infection, with two to three times higher odds of infection among people of
lower than higher socioeconomic strata. A study of pregnant women in
Colombia showed about a 20-fold increase in the odds of contracting the

infection among women without completed primary education, compared with
university-educated women (OR = 19.6; 95% CI, 2.5–152.2).
All patients with acute Chagas disease, including infants with congenital
infection and persons with reactivation of chronic infections due to
immunosuppression, should be treated with either benznidazole or nifurtimox.
However, efficacy of medicines decreases as the duration of the infection
lengthens. More research is needed for prophylactic treatment of chronic
infection in immunosuppressed persons.
Dengue Fever
Dengue fever (DF) is caused by four serotypes of a virus (DENV), which is
transmitted by mosquitoes, primarily Aedes aegypti and Ae. albopictus.
Approximately 390 million people are exposed to DENV each year, resulting
in 96 million annual cases of viral-associated disease globally, while
approximately 3.6 billion people living in the tropical and sub-tropical regions
are at risk of infection. According to the WHO, approximately 500,000 people
develop severe disease each year, and among them, about 1250 (2.5%) die.
The first identified epidemic of DF and dengue hemorrhagic fever (DHF) in
Bangladesh took place during the monsoon season of 2000, and resulted in 5521
officially reported cases, with 93 fatalities. Risk of the positive seroprevalence
of DENV was significantly associated with increasing age (OR = 4.1 for the age
group 12–44 years; OR = 5.9 for age group 45 years and older compared with
younger age group <12 years, p <0.001). There was a protective effect on
seroprevalence among those who did not have indoor potted plants compared
with those who did (OR = 0.53, p = 0.004). Holding water in containers of
potted plants is a good source of breeding of A. aegypti mosquitoes. In another
study in Machala, Ecuador, older age, a female head of the household, and
poor household conditions were significantly associated with the presence of
dengue fever. People living in an unhygienic house, or in a house discharging
sewage directly to the ponds were 3·4 times and 4·3 times, respectively, more
likely to be associated with DF/DHF.
There is no effective treatment for dengue fever. Supportive care with analgesics,
fluid replacement, and bed rest is usually sufficient. Acetaminophen may be used
to treat fever and relieve other symptoms. Aspirin, nonsteroidal anti-inflammatory
drugs (NSAIDs), and corticosteroids should be avoided. Management of severe
dengue fever requires careful attention to fluid management and proactive
treatment of hemorrhage, such as platelet transfusion or whole blood
transfusion.

Dracunculiosis (or Guinea Worm Disease)

Dracunculiasis, commonly known as guinea worm disease, is caused by a two-
to three-foot long worm, Dracunculus medinensis. People contract the disease
by drinking contaminated water from open sources, such as stagnant ponds that
contain immature parasites in tiny copepods (water fleas). During the 1970s,
the disease was prevalent in the rural areas of India, the Islamic Republic of
Iran, Pakistan, Saudi Arabia, Yemen, and East and West Africa. The Global
Guinea Worm Eradication (Dracunculiasis) Program has made spectacular
progress since it began in the 1980s. From an estimated 3.5 million cases in
1986, it has dropped to only 25 cases in 2016. As of 2013, 197 countries have
been certified free from dracunculiasis. At the end of 2016, 17 of the 21
previously endemic countries had stopped transmission of the disease, out of
which 15 have been certified free of transmission by the WHO. Currently, four
endemic countries remain: Chad, Ethiopia, Mali, and South Sudan, which
reported a total of 25 human cases in 2016. Mali did not report any human
infection in 2016. Kenya and Sudan, which were previously endemic, have not
reported a case for at least three years. The use of open stagnant water sources
such as man-made ponds and sometimes shallow or step wells are the main
sources of transmission. In the Sahelian zone, transmission generally occurs in
the rainy season (May to August). In the humid savanna and forest zone, the
peak occurs in the dry season (September to January).
No specific drug is used to treat dracunculiasis. The mainstay of treatment is
the extraction of the adult worm from the patient using a stick at the skin
surface and wrapping or winding the worm a few centimeters per day. The
wound is cleaned, and gentle traction is applied to the worm to slowly pull it
out. Because the worm is long, full extraction can take several days to weeks.
Metronidazole or thiabendazole (in adults) is usually adjunctive to stick
therapy. The prevention of the disease can be achieved by promoting health
education and behavioral change of the people, such as drinking safe water
and avoiding wading into water.
In 1981, WHO’s decision-making body, the World Health Assembly, adopted
a resolution (WHA 34.25) recognising that the International Drinking Water
Supply and Sanitation Decade presented an opportunity to eliminate
dracunculiasis. In 1986, the Carter Center joined the battle against the disease,
in partnership with WHO and UNICEF. For the guinea worm eradication
program, the Carter Center received a $40 million grant from the Gates
Foundation. The UK Department for International Development (DFID)
pledged a £10 million (approximately US$15 million) to the Carter Center to
support the guinea worm eradication campaign, and its support will be
matched by the Gates Foundation.
Human African Trypanosomiasis (or Sleeping Sickness)
Human African trypanosomiasis (HAT), also known as sleeping sickness, is a

vector-borne parasitic disease caused by infection with one of two parasites:
Trypanosoma brucei gambiense and T. b. rhodesiense, and transmitted by
insect vectors, tsetse flies. An estimated 60 million people are at risk of both
forms of parasites in sub-Saharan Africa. According to Malvy and Chappuis, in
2010, Trypanosoma brucei gambiense was focally endemic in 24 countries of
Western and Central Africa, mainly Angola, the Democratic Republic of Congo
(DRC), the Central African Republic, Chad, Ivory Coast, Guinea, southern
Sudan, and northwest Uganda. In 2013, out of a total of 6228 reported new
gambiense HAT cases, 5647 (more than 90%) were clustered in the DRC.
Pentamidine is the recommended drug for first stage T. b. gambiense infection.

The other drugs used to treat African trypanosomiasis include suramin,
melarsoprol, eflornithine, and nifurtimox. There is no vaccine or drug for
prophylaxis against HAT. Preventive measures are aimed at minimizing contact
with tsetse flies. Control of HAT rests on two strategies: reducing the disease
reservoir, and controlling the tsetse fly vector. Reducing the reservoir of
infection is more difficult for T. b. rhodesiense, since there are a variety of
animal hosts. Vector control is the primary strategy in use. This is usually
done with traps or screens, in combination with insecticides and odors that
attract the flies.
Coordinated efforts have been made by the National Sleeping Sickness Control
Program and WHO in data collection, reporting, management, and mapping of
HAT distribution and risk in the DRC. Less than one third of the land area in
the DRC (i.e., 715 thousand km2) and approximately half of the population
(i.e., 36.6 million) are currently estimated to be at various levels of HAT risk.
Rapid detection and effective treatment of newly detected HAT patients is one
of the cornerstones of HAT control.
Leishmaniasis
Visceral leishmaniasis (VL) or kala-azar is a vector-borne parasitic disease
caused by Leishmania donovani, which is transmitted from man to man by the
sand fly Phlebotomus argentipes. Of the 200,000 to 400,000 new cases of VL
worldwide, more than 90% occur in six countries: India, Bangladesh, Sudan,
South Sudan, Ethiopia and Brazil. The risk of seroconversion and disease was
significantly increased in individuals aged 14–24 years old. Higher
socioeconomic status was associated with a decreased risk of seroconversion.
In the American region, the estimated annual incidence of VL is 4500 to 6800
cases; of these, 4200 to 6500 cases (>95%) occurred in Brazil alone. Treatment
of leishmaniasis depends on the type of the disease. The skin sores of
cutaneous leishmaniasis usually heal on their own, even without treatment.

The best way to prevent mucosal leishmaniasis is to ensure adequate treatment
of the cutaneous infection. Severe (advanced) cases of visceral leishmaniasis
typically are fatal. Possible treatments for cases include oral ketoconazole
(Nizoral, Extina, Xolegel, Kuric), intravenous pentamidine, or liposomal
amphotericin B.
Three neighboring countries in Southeast Asia—Bangladesh, India, and Nepal—

joined the WHO’s kala-azar elimination program in 2005. All three countries
have made significant progress towards the targets. The number of cases has
decreased by 59%, mortality by 85% and case fatality by 61%. Nepal has
eliminated the disease at district level, and maintained the situation for the past
two years. Bangladesh has achieved the elimination target in 90% of endemic
sub-districts. India has achieved the target in more than two-thirds of endemic
areas.
Leprosy
Leprosy is known as a disease of poverty. Only in the poorest areas of the
world is leprosy, an infectious disease caused by Mycobacterium leprae, still
endemic. Brazil, India, Nepal, Myanmar, Madagascar, and Mozambique are
responsible for almost 90% of the leprosy cases registered worldwide. The
worldwide use of multidrugs started in the 1980s, and their free access since
1995 contributed to the drastic decline in the number of new cases. In the
poverty-stricken northwestern part of Bangladesh, where The Leprosy Mission
Bangladesh operates a leprosy control program, the incidence was still 1.25 per
10,000 inhabitants in 2008. In a case-control study a recent period of food
shortage and not poverty per se was identified as the only socioeconomic factor
significantly associated with clinical manifestations of leprosy disease (OR =
1.79, 95% CI: 1.06, 3.02; p = 0.030). The overall prevalence of clinical leprosy
in a study area in Egypt was 24.9/10,000 (95% CI: 16.3, 37.6). Individuals
over age 40 were four-fold more likely to develop leprosy (OR = 4, p = 0.01).
The risk for leprosy was associated with HLA-DR2 and HLA-DQ1 markers,
and these markers appear to increase personal susceptibility to leprosy in this
area.
Eighty percent of all leprosy cases in the Americas occur in Brazil. In a case-
control study in northeast Brazil, a low education level, having ever
experienced food shortages, bathing weekly in open bodies of water (creeks,
rivers and/or lakes), and a low frequency of changing bed linen or hammock
were all significantly associated with leprosy. Having a BCG vaccination scar
was found to be a highly significant protective factor.
Several drugs are used in combination in multidrug therapy (MDT). Rifampicin

is now combined with dapsone to treat paucibacillary leprosy. Rifampicin and

clofazimine are now combined with dapsone to treat multibacillary leprosy. A
single dose of combination therapy has been used to cure single lesion
paucibacillary leprosy: rifampicin (600 mg), ofloxacin (400 mg), and
minocycline (100 mg). The child with a single lesion takes half the adult dose
of the three medications.
Lymphatic Filariasis
Lymphatic filariasis (LF) is a chronic, disabling and often disfiguring condition
due to lymphatic obstruction, which results in marked swelling of the lower
extremities (elephantiasis) and genitals (hydrocele, causing scrotal swelling in
men). The disease is caused by parasitic infection from filarial worms. Most of
the infections worldwide are caused by Wuchereria bancrofti. In Asia, the
disease can also be caused by Brugia malayi and Brugia timori. A wide range
of mosquitoes can transmit the parasite, depending on the geographic area. In
Africa, the most common vector is Anopheles and, in the Americas, it is Culex
quinquefasciatus. In the Pacific and in Asia, Aedes and Mansonia can transmit
the infection. Global estimates suggest that 120 million people are affected in
80 countries throughout the tropics and sub-tropics, with people at risk
exceeding 1.3 billion. In sub-Saharan countries alone, 46–51 million people
suffer from LF.
A case study in Congo demonstrated an increased risk for males (OR = 2.0,
95% CI: 1.3, 3.0) and for people who hunt or fish (OR = 1.5, 95% CI: 1.0, 2.4)
and a protective effect of latrines (OR = 0.5, 95% CI: 0.4, 0.8). Among males,
those hunting or fishing at night had an increased risk for antigenemia (OR =
1.9, 95% CI: 1.1–3.5), while the use of latrines was protective (OR = 0.5, 95%
CI: 0.3–0.9). For females, bed nets were protective (OR = 0.4, 95% CI: 0.1–
0.9).
Diethylcarbamazine (DEC) is the drug of choice. However, DEC should not be
administered to patients who may also have onchocerciasis, as DEC can
worsen onchocercal eye disease. Ivermectin kills only the microfilariae, but
not the adult worm. Some studies have shown adult worms can be killed with
doxycycline treatment (200 mg/day for four to six weeks).
Onchocerciasis (or River Blindness)

Onchocerciasis (river blindness) is a parasitic disease caused by the nematode
Onchocerca volvulus, transmitted by blackflies. The disease causes severe
itching, skin lesions, and vision impairment, including blindness.
Onchocerciasis is endemic in parts of Africa, Latin America, and Yemen, but

over 99% of all current cases are found in sub-Saharan Africa. Onchocerciasis
(river blindness) is one of the NTDs targeted for elimination. Studies in Mali
and Senegal proved the feasibility of elimination with ivermectin (Stromectol)
administration. However, elimination of the diseases remains a challenge in
some “hot spots” where the treatment with ivermectin increases the risk of
serious adverse events in individuals with high parasitemia. Non-compliance
with MDA, limited access to annual preventive chemotherapy, and inability of
health care providers to adequately diagnose the disease are among the
challenges of containing and eradicating the disease in the Republic of
Cameroon.
Rabies
Rabies is fatal, and one of the most important reemerging zoonotic diseases
throughout the world. Transmission of the virus usually occurs by the bite of
rabid animals. South Asian countries contribute to more than half of the global
burden of rabies. India is a major contributor to the global rabies burden, being
responsible for 17,000–20,000 of the 55,000–70,000 deaths that occur globally
each year. In Nepal, reported human deaths due to rabies are about 10–100 per
year. Pre-exposure prophylaxis is recommended for individuals who are at
increased risk of exposure to the rabies virus, such as animal handlers,
laboratory technicians, and veterinarians in endemic countries. The WHO-
recommended post-exposure prophylaxis consists of immediate and proper
wound management and a course of antirabies vaccine, and for high-risk
exposures, administration of rabies immunoglobulins.
Scabies
Scabies is a common parasitic infection caused by the mite Sarcoptes scabiei.
The worldwide prevalence has been estimated at about 300 million cases
yearly. Unhygienic living conditions and poor personal hygiene are favorable
for scabies. Mass treatment with an antiparasitic cream and personal hygiene
can effectively reduce the prevalence. In a controlled study among young
students in madrasahs (religious schools) in Dhaka, Bangladesh, the prevalence
of scabies was over 60%. After intervention with mass treatment of all students,
teachers and staff of the study areas with topical application of 5% permethrin
cream, weekly health education classes, and daily monitoring of students for five
key personal hygiene practices, the prevalence rate of scabies in the intervention
areas dropped to 5%, compared to 50% in the control areas, over a four-month
period.
MDA programs have been attempted to use ivermectin to control scabies in
endemic communities around the world. However, the superiority of such
programs over alternative topical treatment is questionable because (1)

pregnant women must be screened out; (2) giving ivermectin on an empty
stomach (for better absorption) is a challenge in community-based programs,
(3) the drug is recommended for people who have crusted scabies, or for
people who do not respond to the prescription lotions and creams, and (4) its
use is not recommended in those under five years of age, yet this is the most
vulnerable group.
Schistosomiasis
Schistosomiasis, or bilharzia, is a parasitic infection caused by any of several
trematode worms (flukes) of the genus Schistosoma. Snails are the intermediate
hosts. There are five species that are known to infect humans: S. mansoni, S.
intercalatum, S. haematobium, S. japonicum, and S. mekongi. In Africa, S.
mansoni and S. haematobium are predominant throughout the continent, while S.
intercalatum is found in certain areas of central and western Africa. S. mansoni
is also found in Latin America and the Caribbean. S. japonicum and S. mekongi
are mostly confined to Asia and the Pacific. Globally, at least 230 million people
are estimated to have schistosomiasis, the majority of which are from sub-
Saharan Africa. Factors responsible for persistent transmission of the disease in
sub-Saharan countries include climate changes and global warming, proximity
to water bodies, irrigation and dam construction, occupational activities such as
fishing and farming, and poverty.
The recommended strategy for schistosomiasis is mass treatment with
praziquantel, which effectively clears the body of worms, but reinfection is
common due to the nature of the parasites’ transmission and human behavior.
Despite considerable efforts made to control schistosomiasis using integrated
approaches, including repeated mass chemotherapy using praziquantel, public
health education focusing on behavior changes towards risk factors, improved
sanitation/hygiene, and treatment of snail habitats, the disease remains a
serious public health problem in sub-Saharan Africa.
Soil-Transmitted Helminthiasis
Soil-transmitted helminth (STH) infection is caused by intestinal nematodes, of
which the three major parasite types are Ascaris lumbricoides (roundworm),
Trichuris trichiura (whipworm), and two species of hookworm (Necator
americanus and Ancylostoma duodenale). STH is transmitted to humans
through faecally-contaminated soil. According to the Global Atlas of
Helminth Infection (GAHI), at least 120 countries across the tropics and
subtropics are endemic, and at least 1.3 billion people were estimated to be
infected with at least one STH species in 2010. South Asia, Southeast Asia,
and sub-Saharan Africa are the regions with the highest prevalence. In a study

using a field method of detecting STH eggs in soil in 2015, the prevalence of
any STH (Ascaris, Trichuris or hookworm) egg in soil was 78% in Bangladesh,
and 37% in Kenya. Morbidity control through preventive chemotherapy (PC)
has been embraced by endemic countries, the WHO, and by partners as a clear
and achievable goal. The WHO-recommended medicines—albendazole (400
mg) and mebendazole (500 mg)—are effective, inexpensive and easy to
administer by non-medical personnel. Globally, PC has reduced the number of
individuals with morbid STH infections by 85%. Data suggests that after 10
years of annual PC interventions, STH-associated morbidity can be virtually
eliminated.
Trachoma
Trachoma is a bacterial eye infection caused by the bacterium Chlamydia
trachomatis. It is spread from person to person through contact with infected
eye and nose secretions, often through hands and clothing, and is also spread
by eye-seeking flies. Repeated infection can develop into a condition known as
trichiasis, in which scarring and inward turning of the eyelid causes the
eyelashes to scrape against the cornea of the eye. In a typical endemic setting,
repeated chlamydial infection of the conjunctiva starts early in life. This can
initiate recurrent episodes of chronic conjunctival inflammation, characterized
by the formation of lymphoid follicles. These are most easily seen in the upper
tarsal conjunctival surface, known as pannus formation. If left untreated, this
painful condition can result in permanent blindness.
Globally, 1.2 billion people live in endemic areas, 40.6 million people are
suffering from active trachoma, and 48.5% of the global burden of active
trachoma is concentrated in five countries: Ethiopia, India, Nigeria, Sudan and
Guinea. Overall, Africa is the most affected continent, with 27.8 million
(68.5% of the 40.6 million) cases of active trachoma.
Trachoma is commonly found in areas with limited access to adequate water,
sanitation, and basic hygiene (WASH). In a study in southern Sudan, risk
factors such as an unclean face, less frequent face washing, cattle ownership,
and increasing fly density were found to be independently associated with
severity of active trachoma, after adjusting for age and sex. With the help of an
MDA program with azithromycin, the target of trachoma elimination set in
1998 appears to be a realistic and achievable goal.
 GLOBAL BURDEN
Disease burden is expressed in terms of disability-adjusted life years
(DALYs), which was calculated using the following formula: DALY = years
of life lost (YLL) + years of life lived with disability (YLD). The global
distribution of NTDs is shown in Figure1, in which the vast majority of cases
(seven or more NTDs) are located in Brazil and in some countries in Central
and East Africa, and in Yemen, followed by cases (five or more) in India,
Bangladesh, and China. Based on the data collected by WHO in 14 of the
targeted 20 NTDs, the total worldwide burden is 25,135.59 thousand years
lost, as estimated by DALYs in 2015 (Table 2). This enormous burden of the
NTDs is mostly shared by soil-transmitted helminthiasis (STH) (4443.47
thousand years), schistosomiasis (3513.85 thousand years), dengue fever
(2610.08 thousand years), lymphatic filariasis (2070.85 thousand years),
cysticercosis (a larval tapeworm infection) (1135.57 thousand years), human
rabies (1672.17 thousand years), leishmaniasis (1356.46 thousand years),
onchocerciasis (1135.57 thousand years), and foodborne trematodiasis (1066.3
4 thousand years). These data should be interpreted with caution because data
for years of life lost (YLL) were not available for trichuriasis, hookworm
infection, lymphatic filariasis, onchocerciasis, and trachoma for 2015.
Figure 1. Prevalence of neglected tropical diseases (NTDs) by country.

The burden of NTDs in different countries is expressed as number of
NTDs prevalent (ranging from one to seven or more). Modified from:
United to Combat. Burden map—Neglected Tropical Diseases.
Table 2. Global Burden of Major Neglected Tropical Diseases as Estimates

of Disability-Adjusted Life Years (DALYs), Years of Life Lost (YLL), and
Years Lost Due to Disability (YLD) in WHO Member States.
2015 Data a 2010 Data b
Disease YLL YLD DALY = DALY

YLL +
YDL
(thousand) (thousand) (thousand) (thousand)
b
Soil-transmitted 449.50 3993.97 4443.47 5043
helminthiasis
Ascariasis 225.30 869.37 1094.67 1254
Trichuriasis c - 542.80 542.80 630
Hookworm c - 1739.58 1739.58 3159
Schistosomiasis 1042.20 2471.65 3513.85 3971
Dengue fever 1848.79 761.29 2610.08 1243
Lymphatic - 2070.85 2070.85 2740
filariasis c
Cysticercosis 1258.27 598.09 1856.36 503
Rabies 1672.03 0.14 1672.17 2297
Leishmaniasis 1310.74 45.72 1356.46 3754
Onchocerciasis - 1135.57 1135.57 564
c
Foodborne 224.12 842.22 1066.34 665
trematodiasis
Echinococcosis 568.20 73.23 641.43 600
Leprosy 457.67 30.97 488.64 215
Human African 368.68 2.97 371.65 1346
trypanosomiasis
Trachoma c - 278.97 278.97 308
Chagas disease 189.65 63.05 252.70 499
a Data source: WHO Health Statistics and Information Systems, 2015.
Data on DALY are not available for Buruli ulcer disease; b Bhutta et
al. (2014)c No data available for YLL.
Bhutta et al. (2014) reported a global burden of NTDs using the WHO DALY
estimates for 2010 (Table 2). Obviously, the burden of the diseases in
numerical terms have changed over time. However, the major diseases
contributing to the overall burden remained similar. In another report from the
Global Burden of Disease Study 2010, the estimated DALYs of the NTDs was
26.06 million years, with the highest burden for soil-transmitted
helminthiasis, followed by leishmaniasis, schistosomiasis, lymphatic
filariasis, and food-borne trematodiasis. However, in an earlier report of NTD
burden by Mathers et al. (2007), there were some noticeable differences:
lymphatic filariasis accounted for the highest burden of 5777 thousand
DALYs, followed by soil-transmitted diseases (3796 thousand years),
trachoma (2329 thousand years), leishmaniasis (2090 thousand years),
schistosomiasis (1702 thousand years), and trypanosomiasis (1525 thousand
years), globally in 2002.
In addition to the above diseases, chikungunya has posed a public health
threat in recent years. Recent studies have shown that the DALYs lost during
the 2006 epidemic of chikungunya in India totaled 25,588 with an overall
burden of 45.26 DALYs per million people. For the 2014 epidemic of
Colombia, an estimated total DALYs lost was 40.44 to 45.14 per 100,000
population.
2.3 Recommendations for Managing Neglected Tropical Diseases

In order to achieve the 2020 roadmap against NTD, further research is needed
for their effective control. This includes the need for newer and safer drugs,
vector control, personal hygiene, and the development of vaccines. Based on
this review, we suggest the following:
1. Community awareness and early diagnosis of Buruli ulcer were found to
be effective tools in reducing complications of the disease in rural areas
of West and Central Africa, but more studies are needed to elucidate the
mechanism by which M. ulcerans is transmitted from the environment to
humans.
2. Integrated vector management through the elimination of breeding sites,
use of anti-adult and anti-larval measures and personal protection will
help to prevent outbreaks of several vector-borne diseases including
chikungunya, dengue fever, and HAT.
3. Because the efficacy of medicines in Chagas disease decreases with
increased chronicity of the disease, early intervention and treatment of the
acute phase of infection would be efficacious than treatment of the
chronic stage of the disease. There is a need for more effective, safer, and
easier-to-use medicines for both phases of Chagas disease.
4. Over 200 countries so far have been certified free of dracunculiasis, or
guinea worm disease. Health education and behavioural change are
effective tools in disease prevention.
5. Early detection and treatment of new cases and vector control are
essential to the control of HAT.

6. Treatment with ivermectin remains a challenge in individuals with
onchocerciasis, especially those with high rate of parasitemia, because of
the side effects and poor compliance of the drug in such cases. Similarly,
ivermectin is not recommended universally in the treatment of scabies.
Future studies should aim at finding newer and safer medicines.
In terms of DALY, the major burden of NTDs remains due to soil-transmitted
diseases, schistosomiasis, dengue fever, and lymphatic filariasis. In fact,
dengue fever epidemics have created havoc in many developing countries in
recent years. The need for a dengue fever vaccine is evident. Priorities in
public health action plans are needed for those diseases which are causing most
disabilities, and thereby, the most productive years lost among the other
NTDs.
crucial in the fight against NTDs and enabling access to treatment for millions
of people worldwide. Several partners have already announced new funding in
order to combine efforts to prevent and to find new treatments for NTDs.
Although progress is being made against NTDs, continued success depends on
a policy environment, considerable political support, and collaboration from
all participants.
In this session, we discussed the global fight against NTDs continues, more
cutting-edge public health policies and research are needed to find effective
drugs and vaccines. Partnerships involving major donor agencies, charitable
organisations, NGOs, government leaders, pharmaceutical companies, and other
key stakeholders.

1. list the neglected tropical diseases in the world
2. Explain management of neglected tropical diseases
a. Visit YouTube on Watch the video & summarise in 1 paragraph
https://www.youtube.com/watch?v=EhHuk3oV3Lk


Hotez, P.J.; Kamath, A. Neglected tropical diseases in sub-Saharan Africa:
Review of their prevalence, distribution, and disease burden. PLoS Negl.
Trop. Dis. 2009, 3, e412.
World Health Organisation. Neglected Tropical Diseases. Program. 2017.

Available online:http://www. who.int/neglected_diseases/en/(accessed on 18
July 2017).
Rosenberg, M.; Utzinger, J.; Addiss, D.G. Preventive chemotherapy versus

innovative and intensified disease management in neglected tropical diseases:
A distinction whose shelf life has expired. PLoS Negl. Trop. Dis. 2016, 10,
e0004521.
Molyneux, D.H. The ‘Neglected Tropical Diseases’: Now a brand identity,

responsibilities, context and promise. Parasites Vectors 2012, 5.
Githeko, A.K.; Lindsay, S.W.; Confalonieri, U.E.; Patz, J.A. Climate change
and vector-borne diseases: A regional analysis. Bull. World Health Organ.
2000, 78, 1136–1147.
The Carter Center. Health Programs. Available

online:https://www.cartercenter.org/health/index.html (accessed on 16 June
2017).
Centers for Disease Control and Prevention. Neglected Tropical Diseases.

2017. Available online:https:
//www.cdc.gov/globalhealth/ntd/diseases/index.html(accessed on 15 June
2017).
London Declaration on Neglected Tropical Diseases. 2012. Available

online:https://www.gov.uk/
government/uploads/system/uploads/attachment_data/file/67443/NTD_20Ev
ent_20-_20London_ 20Declaration_20on_20NTDs.pdf(accessed on 16 June
2017).
Ampah, K.A.; Asare, P.; Binnah, D.D.-G.; Maccaulley, S.; Opare, W.;
Röltgen, K.; Pluschke, G.; Yeboah-Manu, D. Burden and historical trend of
Buruli ulcer prevalence in selected communities along the Offin River of

Ghana. PloS Negl. Trop. Dis. 2016, 10, e0004603.
Sears, A.V.; Hay, R.J. Buruli ulcer—A rapidly changing scene. Acta Derm.
Venereol. 2015, 95, 387–388.
Ahorlu, C.K.; Koka, E.; Yeboah-Manu, D.; Lamptey, I.; Ampadu, W.
Enhancing Buruli ulcer control in Ghana through social interventions: A case
study from the Obom sub-district. BMC Public Health 2013, 13, 59.
Sanyaolu, A.; Okorie, C.; Badaru, O.; Wynveen, E.; White, S.; Wallace, W.
Chikungunya epidemiology: A global perspective. SM J. Public Health
Epidemiol. 2016, 2, 1028.
Cardona-Ospina, J.A.; Villamil-Gomez, W.E.; Jimenez-Canizales, C.E.;

Castaneda-Hernandez, D.M.; Rodrıguez-Morales, A.J. Estimating the burden
of disease and the economic cost attributable to chikungunya, Colombia, 2014.
Trans. R. Soc. Trop. Med. Hyg. 2015, 109, 793–802.

Study Session 5
HISTORY OF EMERGING AND RE-EMERGING INFECTIOUS
DISEASES OUTBREAKS IN NIGERIA
Introduction
2.0 Main Content
2.1- Emerging infectious diseases
2.2- Some of Nigeria’s outbreak preparedness, detection, and response
efforts so far
2.3- Limitation against effective infectious disease outbreak response
Introduction
In this study session we are going to be discussing preparedness of tackling
emerging and re-emerging infectious diseases in Nigeria.
1. Know emerging and re-emerging diseases in Nigeria
2. Explain limitation against effective infectious disease outbreak responses in
Nigeria
2.0 Main content

2.1 Emerging infectious diseases
Emerging infectious diseases are diseases that either have never occurred in
humans before, previously occurred but only affecting a limited number of
people in affected places, or have occurred throughout history but only
recently identified as distinctly due to an infectious agent while re-emerging

infectious diseases are those that were once major public health problems
globally for a significant portion of the population.
Lassa fever (LF)
LF is an acute viral hemorrhagic fever caused by the single-stranded RNA
virus from the family Arenaviridae. It has been said that 80% of infected
individuals remain asymptomatic with others displaying acute symptoms of
fever, weakness, chest pain, and gastrointestinal (GI) side effects such as
nausea, vomiting and diarrhoea.
About 1–15% of symptomatic cases present with severe symptomatology
ranging from: abnormal bleeding from the facial orifices, hearing loss,
tremors, encephalitis, coma and death. With an incubation period of 6 to 21
days, LF has been known to be associated closely with seasonal variations,
peaking in the dry season usually between the months of December and April,
a situation attributed to the migration of the rodent reservoirs into human
settlements in search for food. LF is one infectious disease that has caused
emerging and re-emerging outbreaks in Nigeria. Since its discovery in Lassa,
Borno State, in 1969, there have been outbreaks in Jos, Plateau (1969–1970);
Zonkwa, Kaduna (1974); Pankshin, Plateau and Onitsha, Anambra (1976);
Ekpoma (1989); Lafia (1993–1994); Ebonyi and Ogun (2005) after which
subsequent outbreaks involved multiple states across several geopolitical
zones. The epidemic of 2011–2012 is regarded as the worst outbreak so far,
affecting 41 local government areas (LGAs) in 23 states, resulting in 937 cases
and 95 deaths—a case: fatality rate (CFR) of 10.14%. This statistic worsened
in 2018 and now seems to have further worsened in 2020, with 3,735
suspected cases, of which 906 are laboratory-confirmed as of March 15, 2020.
Thus, LF remains one infectious disease that has re-emerged several times
over and continues to pose a significant challenge to the Nigerian health
system.
Ebola virus disease (EVD)

EVD is an acute viral hemorrhagic fever caused by the Ebola virus, which
belongs to the family Filoviridae. The first case of EVD in Nigeria was
confirmed on July 25, 2014, triggering an outbreak infecting 20 people and
killing 8 (CFR = 40%). The Nigerian outbreak was brought under control in
record time, with the World Health Organisation (WHO) declaring the nation
free from Ebola transmission on October 20, 2014.
Yellow fever disease (YFD)

YFD is an acute viral hemorrhagic fever caused by the yellow fever virus, a
member of the family Flaviviridae, and transmitted by an infected female
Aedes mosquito The first recorded yellow fever outbreak in Nigeria occurred
in Lagos in 1864. This was followed by other outbreaks in Lagos in 1894,
1905, 1906, 1925 and 1926. The next outbreak happened in Jos in 1969,
infecting over 100,000 people, and then in 1987 and 1996, infecting over
120,000 people in different parts of the country including: Jos, Azare in
Bauchi state, Ogoja in Cross River state, Oju in Benue state and Ogbomosho
in Oyo state. There were only sporadic cases after this period and for 21 years,
till September 2017, when a 7-year-old presented with the classic symptoms
of yellow fever in the Ifelodun LGA of Kwara state. This eventually resulted
in an outbreak of 4,189 suspected cases and 604 confirmed nationwide.
Following the 2017 outbreak, the nation has fought yearly outbreaks since
then, in 2018, 2019 and 2020.
Poliomyelitis
This is a highly infectious viral disease caused by the poliovirus, which
belongs to the family of Enteroviruses and results in muscle weakness or
paralysis of the limbs, with very few other symptoms except minor
headaches, neck stiffness, and stiffness of the arms and legs. The last major
outbreak to happen in Nigeria was in 2007, involving 69 children in Northern
Nigeria, and was a direct consequence of the refusal of locals to vaccinate
their children due to anti-vaccination religious propaganda. In 2015, the WHO
removed Nigeria from the list of polio-endemic nations due to the high
likelihood that wild poliovirus (WPV) circulation had been interrupted in
Nigeria. However, four new cases were discovered in August and September
2016 in Borno, and were attributed to the destabilisation of healthcare
infrastructure as a consequence of the protracted Boko Haram insurgency in
North-East Nigeria. Following this isolated occurrence, no new case has been
reported to date.
Monkeypox disease
The monkeypox virus was first identified in 1958 in captive monkeys imported
into Copenhagen, Denmark from Africa. However, the first human case of
monkeypox was identified in a 9-year-old in the village of Bukenda, Zaire
(now the Democratic Republic of Congo (DRC)). Between 1970 and 1978,
Nigeria reported a total of 3 cases of human monkeypox infection, one in 1970
and two in 1978, and none until 38 years later, in September 2017, when a re-
emergence of what would be the largest ever recorded outbreak of the West
African Clade of human monkeypox, with 228 suspected cases (and 60
confirmed) in 24 of 36 states in the country. The index case was an 11-year-old

boy referred to the Niger Delta University Teaching Hospital (NDUTH) with
symptoms suggestive of chickenpox. However, this was later ruled out due to
the nature of the associated skin lesions and persistence of symptoms, and
monkeypox was then considered as a possible diagnosis.
In-text Question
Ebola virus belongs to the family?
Answer
Filoviridae
is any person/ animal/ plant or environmental medium (soil, water) in which the
microorganism normally lives and multiplies, on which it depends primarily for survival,
and where it reproduces itself in such a manner that it can be transmitted to the susceptible
host
2.2 Some of Nigeria’s outbreak preparedness, detection, and response

efforts so far
In response to the elaborate history of infectious disease outbreaks in Nigeria,
the idea of a national public health institute charged with the responsibility of
preventing, detecting, and responding to infectious disease threats in the
country was first conceived in 2007; however, it was not until 2011 that the
Nigerian Centre for Disease Control (NCDC) was established by the
amalgamation of certain instruments of the Federal Ministry of Health
(FMoH)—Epidemiology Division, Avian Influenza Project and the Nigeria
Field Epidemiology and Laboratory Training Program (NFELTP).
Retrospectively speaking, this singular act represents one of the most
important efforts taken towards preparedness against infectious disease
outbreaks in the nation, as would be highlighted shortly. Since its
establishment, the NCDC has grown rapidly into its role and the achievement
of its mandate to lead the preparedness, detection and response to infectious
disease outbreaks and public health emergencies in the country. Through the
establishment of a nationwide network of reference laboratories, which has
matured into a consortium of five viral hemorrhagic fever (VHF) laboratories,
four yellow fever/measles/rubella laboratories, 17 cholera/cerebrospinal
meningitis laboratories and four sentinel sites each for influenza and hepatitis
E/Rotavirus, the NCDC has strengthened the diagnostic capabilities of the
Nigerian health system, in preparation for potential infectious diseases
outbreaks.
Furthermore, through the NFELTP, a 2-year in-service training in applied
epidemiology and laboratory techniques, implemented in partnership with the
African Field Epidemiology Network, the NCDC is building a critical mass of
highly-skilled indigenous public health specialists who can be deployed to

curtail an infectious disease outbreak should any arise. The program has
developed a pool of field epidemiologists who have been instrumental in
coordinating the response to several infectious disease outbreaks in recent
times, most notable was their role in the effective response to the 2014
outbreak of EVD, a feat that was rightly described by the WHO as “a piece of
world-class epidemiological detective work”. In order to further deepen its
ability to coordinate preparedness and response activities, the NCDC
established an Incident Coordination Centre (ICC), to review reports from
previous and current outbreaks and map out holistic plans towards
preparedness for future outbreaks and containment efforts for on-going ones.
The NCDC has also forged sustainable partnerships with foreign bilateral and
multilateral agencies such as the US Centers for Disease Control and
Prevention (CDC), the WHO, and the ECOWAS Regional Centre for Disease
Control, which support the work of the agency via several grants and technical
assistance to support infectious disease surveillance, establish a working
laboratory network for diagnosis and other outbreak and disaster response
activities. It remains a fact that the NCDC has taken giant strides towards the
achievement of its mandate, in this paper we dive into the specifics, examining
the practical steps the agency has taken to prepare for, detect and respond to
infectious disease outbreaks in the country in recent times.
Ebola virus disease (EVD): July 2014–October 2014

The spread of the EVD to Nigeria in 2014 was accompanied by a great deal of
concern locally and internationally, enough to instigate the Director-General
of the WHO to declare a Public Health Emergency of International Concern
(PHEIC). This is because the outbreak affected two of the largest complex
megacities in the country—Lagos and Port Harcourt, with a combined
population of over 30 million people, of which a significant proportion live in
crowded slums and shanties with limited public health-supportive
infrastructure. There were concerns about the possibility of effective contact
tracing under such circumstances and the situation was given numerous
elaborate appellations such as “powder keg situation”, “potential apocalyptic
urban outbreak” and “potentially the most explosive Ebola outbreak
imaginable”, but indeed the reality of what ensued was a stark contrast to all
projections that had been made. Barely three months from when the first case
was established, Nigeria had fulfilled the 42 days benchmark needed to be
declared free of Ebola virus transmission by the WHO, with 20 cases and 8
deaths.
But how did this happen? A robust detection and response mechanisms

deployed in 2016 by all involved stakeholders, which ensured that the

outbreak was effectively curtailed. The EVD outbreak response in Nigeria was
led by the NCDC, in collaboration with the Ministries of Health (MoH) of
Lagos and Rivers State, utilising existing integrated disease surveillance and
response (IDSR) systems to ensure effective contact tracing, rapid
identification of suspected cases, laboratory diagnoses to establish confirmed
cases and clinical management of all cases. The response also involved
strategies for safeguarding the points of entry (PoE), managing rumors and
alerts from the populace as well as creating awareness and mobilising support
and goodwill from the general public.
For effective response coordination, the NCDC established Ebola Emergency
Operations Centers (EOC) in both affected cities, and an Incident Management
System (IMS) was introduced at the forefront of outbreak response. The IMS
was overseen by an Incident Manager (IM) (Figure 1), who reported directly to
the NCDC, and the IMS was organised into six response teams including (i)
Epidemiology/Surveillance (comprising rumor/alert management, contact
tracing, data management), (ii) Case Management/Infection Control
(comprising clinical management of EBV cases, infection prevention and
control for health workers, psychosocial support, decontamination, and burial
sub-teams), (iii) Social Mobilisation, (iv) Laboratory Services, (v) Points of
Entry and (vi) Management/Coordination (comprising human resources,
administrations, finance, logistics and procurement. Each operational team had
a team leader and was semi-autonomous, being responsible for developing
their own lists of staff, material and resources, and operating procedures,
subject to the approval of a technical strategy group, chaired by the IM.

Ebola Emergency Operations Center (EOC) Organogram.
Contact tracing was conducted according to a national guideline adopted

from a WHO reference document, by residents of the NFELTP,
epidemiologists from the NCDC, Lagos and Rivers State MoH as well as
WHO surveillance officers. A total of 892 contacts of interest were
identified, comprising of 362 contacts in Lagos and 530 contacts in Port
Harcourt, and contact tracers made use of android mobile phone applications
with GIS capabilities to monitor daily temperature measurements of each
contact while mapping their locations against their registered residential
address. Contacts were reclassified as suspected cases once they met certain
pre-determined criteria, and they were counseled on social distancing for a
period of 21 days. The temperature data from the mobile phone applications
were monitored closely at the EOC, ensuring that all contacts were
effectively monitored and the possibility of false data reporting by the
contact tracers was eliminated. Through this innovative technique, the NCDC
was able to monitor 100% of all contacts in Lagos and 99.8% of contacts in
Port Harcourt, a feat that shocked the public health community, worldwide.
While there were a few contacts who proved challenging to follow-up and
even escaped follow-up, special intervention teams were in place to track
them down and bring them back into the system.
For case management, Ebola Treatment Centers (ETC) were established in both
affected cities. In Lagos, a 40-bed facility (with a surge capacity of 10 beds) was
set-up, while in Port Harcourt, a 26-bed facility (with a surge capacity of 8
beds) was established by the state MoH with support from the NCDC. Both
facilities were managed by a combined team of Nigerian health workers, with
support from the WHO and Médicins Sans Frontières (MSF) staff. The ETCs
were equipped with medicine, consumables, personal protective equipment
(PPEs), body bags and independent ambulances. Laboratory diagnosis of
confirmed cases was carried out at the Virology laboratory of the Lagos
University Teaching Hospital (LUTH) and through a mobile laboratory donated
by the CDC and equipped with reverse transcriptase-polymerase chain reaction
(RT-PCR) capabilities. An important note of preparedness to highlight at this
point is the fact that the necessary primers and buffers required to make a
laboratory diagnosis of EBV were available at the LUTH virology laboratory
prior to the arrival of the first case. This was very instrumental to the timely
diagnosis of this index case and thus the rapid deployment of detection and
response efforts. For alert/rumour management, Toll-free lines were opened and
widely circulated through print/electronic/social media to the public, and they
were encouraged to call in to report suspected cases or to clear up any
inquiries. Further, printed fliers containing important information about EVD

was distributed house-to-house by trained public health personnel.
Community engagement/sensitisation was achieved by meeting with
community gatekeepers such as traditional rulers, religious leaders, youth
organisations, market women associations and school administrators.
Through such a systematic, holistic and well-implemented approach, EVD
was curtailed in Nigeria in record time, a feat that will go down in history as
an unprecedented win for an apparently struggling public health system.
Challenges encountered by the NCDC in the containment of the EVD
outbreak of 2014 included a lack of infrastructure during the first few days of
the outbreak. In addition, there was an on-going industrial action by medical
doctors in Nigeria, making it difficult to recruit qualified personnel for
clinical case management during the early days of the outbreak. Other
challenges faced by the NCDC with the containment of the EVD 2014
outbreak were related to misconceptions and myths about the disease, and
self-protective behavior among health workers.
Lassa fever: endemic

Since its discovery in 1969, Lassa fever remains endemic in Nigeria, exhibiting
seasonal variation, with most cases occurring during the late rainy and early dry
seasons, often due to a reduction in rain output and subsequent shortage of food
for the disease vectors—multimammate rats belonging to the Mastomys species-
complex in their natural habitat. This results in their migration to human habitats,
where they come into contact with humans, ultimately leading to disease
transmission. One such outbreaks in Abakaliki, Ebonyi State between January to
March 2012, significant shortcomings in outbreak preparedness, detection, and
response, especially in resource-limited settings. Such shortcomings included: the
lack of an infectious disease isolation ward in the tertiary health facility where
the index patient was diagnosed; logistical limitations which prevented effective
and timely testing of suspected cases as the reference laboratory where tests were
carried out was located 300 km away from the hospital, a factor that contributed
to the delayed onset of treatment for the index patient, contributing to her
eventual death and forcing healthcare personnel to resort to the empirical
treatment of suspected cases with ribavirin; and a shortage of necessary PPE,
which was partly responsible for the nosocomial spread of the disease among
healthcare workers.
The outbreak response was coordinated by the Lassa fever technical
committee of the Federal Teaching Hospital, Abakaliki, with support from the
State and Federal MoH. Active disease surveillance was carried out in
partnership with community elements, by several public advocacy and

community mobilisation efforts using print and electronic media and

community gatekeepers. Contact tracing eventually identified 20 cases (10
suspected and 10 confirmed). The suspected cases could not be confirmed due
to logistical challenges associated with laboratory testing unique to resource-
limited settings. Ultimately, the outbreak was curtailed due to the early
detection of the index case, a factor attributed to the high index of suspicion of
the managing team; as well as the strong collaboration between different
sectors and stakeholders involved in the response.
A recent communication by Dan-Nwafor et al. (2019), described the measures
taken by the NCDC to control the 2019 outbreak that occurred in 21 states
between January and April 2019, a period during with 554 laboratory-confirmed
cases and 124 deaths were reported. In preparation for the outbreak, national
guidelines on the treatment of Lassa fever patients had been reviewed and
updated 2 months earlier, to include vital infection prevention and control (IPC)
measures, as well as care of complications such as septic shock and kidney
injury, after Lassa fever infection. This was in response to an observational
cohort study, which showed that such complications are an important risk factor
for fatality in Lassa fever patients. In addition, vital PPEs needed by frontline
healthcare workers had been distributed to the Lassa fever treatment centers in
anticipation of the outbreak.
Following the onset of the outbreak, the response involved the organisation of
national and zonal workshops on the clinical management of Lassa fever
patients, for healthcare workers as well as community sensitisation efforts for
the public through print, social and electronic media channels on the mode of
presentation of the disease, available treatment sites and toll-free lines for
alerts and inquiries. The establishment of the Lassa fever reference laboratory
network also greatly enhanced diagnostic capacity during the outbreak.
Monkey pox: September 2017–December 2017

Following this presumptive diagnosis two days after admission, hospital, state
and national authorities were notified for confirmation and further
investigation. The diagnosis was confirmed and a multiagency
interdisciplinary EOC was activated at the NCDC. A week later, a Rapid
Response Team (RRT) from the NCDC was deployed to Bayelsa state, to
partner with the state government to respond to the outbreak and the NDUTH
was subsequently designated as the treatment center for all monkeypox cases
during the outbreak. The NCDC prepared the Interim National Guidelines to
guide the outbreak response and ensure it is carried out in a coordinated
fashion. At the onset of the outbreak, the NDUTH did not have a dedicated
isolation ward for the monkeypox patients, compelling the hospital

administration to convert the 12-bed medical ward into an isolation ward for
adult cases.
An NDUTH monkeypox response committee was also constituted to include case
management teams, waste management, and laboratory technicians, to be
responsible for coordinating the hospital’s response to the outbreak, with support
from the NCDC and the State Ministry of Health [25]. The response committee
organised hospital-wide sensitisation training for all staff on IPC strategies,
monkeypox case management and use of PPEs. Laboratory confirmation of
suspected cases was done through real-time PCR, IgM serology and genome
sequencing, and was carried out at the Institute Pasteur, Dakar, Senegal; African
Centre of Excellence for Genomics of Infectious Diseases (ACEGID), Ede,
Nigeria and the CDC, Atlanta, GA, USA. Further tests were carried out at the
NCDC Reference Laboratory, Abuja. The lack of laboratory testing facilities at
NDUTH posed significant constraints on the rapid testing of suspected cases as
they presented to the facility.
In-text Question
1. Mention one infectious disease that is endemic to Nigeria?
Answer
Lassa Fever
Yellow fever: endemic since September 2017

In September 2017, a 7-year-old presented with the classic symptoms of
yellow fever in the Ifelodun LGA of Kwara state. Following the confirmation
of this first case, within a week, the NCDC deployed a multiagency RRT to
Kwara state, to respond to the outbreak. The functions of this RRT were to
support the state surveillance team in conducting yellow fever surveillance
activities such as verbal autopsy (getting enough information from a
deceased individual to determine the cause of death), entomological surveys,
reactive vaccination campaigns, and an assessment of immunisation profiles
of children aged 1–10 years in the affected communities. The RRT was also
responsible for developing the request for vaccines to be sent to the
International Coordinating Group (ICG), and also to support the risk
assessment and social mobilisation efforts of the state government. The onset
of the outbreak in Nigeria followed news of similar outbreaks in other
African countries such as Angola and the DRC. The response of the NCDC
to the outbreak may be conceptualised to be divided into the following
stages: active case search, rapid yellow fever vaccination coverage
assessment, verbal autopsy, sample collection and laboratory testing,
entomology surveillance, social mobilisation and reactive vaccination
campaigns.
Active case search involved house-to-house visits in affected communities,
where family members were quizzed on history of jaundice and fever within
the period between July 1 and October 6, 2017. A similar search was carried
out in all healthcare facilities in the affected communities by retrospective
analysis of hospital records for patients with symptoms meeting the standard
case definition. Individuals and patients who met these criteria were listed as
suspected cases and the process gave rise to a total of 55 suspected cases. A
rapid yellow fever vaccination coverage assessment was also conducted to
determine the yellow fever vaccination status of children aged 1–10 years old
in the affected communities. To achieve this, systematic sampling of alternate
houses was done, starting from the meeting point of the RRT with the
community and going in a clockwise direction. Members of the community
were asked questions regarding the yellow fever vaccination status of the
children and to provide evidence such as routine immunisation cards, if
possible. The assessment result showed that 46% of children in all affected
communities had been vaccinated for yellow fever, while only 27.5% could
provide their immunisation cards. In the hardest-hit Ifelodun LGA, only 25%
of children were vaccinated. The results of this assessment were used to draft
a vaccine request to the ICG on vaccine provision, to support a reactive
yellow fever vaccination campaign to follow.
A verbal autopsy was also carried out to determine the burden of morbidity
and mortality, and assess for a potential under-reporting of yellow fever cases
in the community. A case eligible for verbal autopsy was defined as: “any
death of a family member(s) who before death developed acute onset of fever
and jaundice with or without bleeding appearing within 14 days in a person
who resided in Ifelodun or any other part of Kwara State between 1 July to 6
October 2017”. The verbal autopsy revealed 26 deaths, 24 of which the RRT
were able to sight their graves. All deaths were epidemiologically linked to a
single case confirmed at the Institut Pasteur. Testing involved collection of
5mL of blood sample from suspected cases for IgM serology and real-time
polymerase chain reaction (RT-PCR) at the Central Public Health
Laboratory, Lagos and the Lagos University Teaching Hospital (LUTH)
virology laboratory. Confirmation tests were carried out at the Institute
Pasteur, Dakar, Senegal, which serves as the WHO reference laboratory for
the region. Of the 55 cases uncovered by active search, 32 tests were carried
out, yielding ten presumptive positive results and one inconclusive result, all
of which were sent to the WHO regional reference laboratory, where seven
were confirmed positive.
An entomological survey was conducted to confirm the presence of the
yellow fever vector in the affected communities. The methods used for larval
sampling include ovitraps and modified human landing catch (HLC), while
for adult flies include: CDC UV light trap, BG-Sentinel trap, and CDC Light
trap. The survey findings demonstrated the presence of Aedes mosquito at
various stages of development in six out of seven target communities. The
vectors collected include the Aedes africanus, Aedes aegypti and Aedes
luteocephalus species. In-country next-generation sequencing of confirmed
cases was also done at ACEGID, Ede, Osun state, to understand the genomic
diversity and origin of YFV in Edo state.
The outbreak response also involved the activation of an IMS to coordinate a
possible nationwide response. Through this IMS, other state MoH were
notified to intensify surveillance in all states in the country. This was
followed by the report of cases from other states such as Kogi and Zamfara.
Similar to Kwara, RRTs were deployed from the NCDC to these states, to
help in outbreak response. The initial request for vaccines was made to the
ICG on vaccine provision on September 26, 2017, and following the
approval of the request, the first wave of yellow fever reactive vaccination
campaign was carried out in the affected communities of Kwara state
between the 11th and 20th October 2017. A second wave was implemented
in two LGAs—Pategi and Edu between 7th and 8th December 2017.
2.3 Limitations Against Effective Infectious Disease Outbreak Response

Rapid population growth
A significant factor to be considered while planning infectious disease
preparedness and response strategies is the population for which these
strategies are meant to serve. In the presence of rapid population growth, it
would be expected that outbreak preparedness and response strategies also
ought to evolve in a manner commensurate with the population increase, a
lack of which would render outbreak preparedness and response strategies
largely inadequate. With a population growth rate ranging from 3.2% to 6.5%
across the country, effective planning is made a herculean task for the public
health agencies in the absence of much-needed resources and commitment
from the political leadership to encourage a reduction in population growth.
Personnel shortage
A critical element necessary to mount a worthwhile infectious disease
outbreak response is skilled human resources. The personnel working within
different departments such as clinicians and nurses for case management,
epidemiologists for contact tracing, and laboratory technicians for laboratory
diagnosis and case confirmation are indispensable components in outbreak
periods. It has been estimated that Nigeria has 27 doctors per 100,000 people,
a statistic only about a quarter of the WHO recommendation of 100 per

100,000 for developing countries. This shortage of physicians is representative
of the rapidly dwindling number of frontline healthcare workers across all
levels that pervades the Nigerian health system and has been blamed on the
massive emigration of these personnel to other countries due to immense
social and economic pressure and the search for greener pastures. Sadly, this is
also true of the health systems of 36 other African nations. Furthermore, losses
as a result of retrenchment and restrictions on employment due to structural
changes in the Nigerian health system have deprived the sector, but most
importantly, rural communities, leaving them at the mercy of recurrent
infectious diseases outbreaks and rendering outbreak preparedness and
response efforts largely more reactive than proactive.
Poor healthcare funding

Over successive years, the Nigerian health sector has been chronically
underfunded, resulting in its widespread infrastructural deterioration, and a
fall in the standards of health service delivery, invariably impacting
negatively on outbreak preparedness and response strategies. In April 2001,
African Heads of State under the umbrella of the African Union gathered in
Abuja and resolved that each nation would commit a minimum of 15% of its
annual budget to the development of its health sector [50]. It is however
paradoxical that Nigeria, playing host to this “Abuja Declaration” has been
unable to meet this target. while the most recent figure for 2020 is a meager
4.5%, falling far short of the requirement of such an essential sector.
Nigeria has very little isolation capacity for infectious disease outbreaks
prior to the onset of the ongoing COVID-19 pandemic. Apart from a few
locations such as the Infectious Diseases Hospital, Yaba (115-beds) and the
newly-opened Stella Obasanjo Hospital Isolation Centre, Benin (31-beds),
there were no stand-alone infectious disease isolation facilities in the country,
and the only ones that existed were all found in the southwestern region. The
alternative to stand-alone infectious diseases isolation centers are infectious
diseases wards of secondary and tertiary healthcare facilities, and a few other
private establishments. However, the onset of the COVID-19 pandemic in
Nigeria served as a catalyst for the creation of many stand-alone, albeit
temporary isolation facilities all over the country, through several funding
partnerships between the government and private sector players across
various sectors.
Inadequate diagnostic capacity

In the wake of the 2014 EVD outbreak in West Africa, a report by the African
Development Bank established the shortage in laboratory diagnostic capacity
of many African countries, Nigeria inclusive. As most infectious disease
outbreaks are either viral infection requiring at least PCR laboratory
capabilities or bacterial infections requiring cell culturing and susceptibility
testing, it is imperative that an improvement of diagnostic capability be
prioritised for effective outbreak preparedness and response strategies to be
implemented. Underscoring this assertion is the fact that the availability of a
virology laboratory at the LUTH, and genomic data made available by
ACEGID, was critical to the rapid diagnosis of the index EVD case in Nigeria
during the 2014 outbreak, allowing the early deployment of response efforts,
which contributed greatly to Nigeria’s success in curtailing the spread of the
disease.
Political instability
Political instability, which is typical of many developing nations with young
and fragile democratic systems such as Nigeria, creates a deplorable situation of
inconsistency on outbreak preparedness and response strategies, resulting in
long-term ineffectiveness of such efforts.
Insecurity
Almost half of the West African countries have been classified as fragile states
by the African Leadership Centre, battling one form of insurgency, political
strife, or natural disaster. This labile state weighs heavily on public health
response systems in these countries, contributing to a deterioration of existing
healthcare infrastructure and limiting access to often life-saving healthcare
services, making outbreak response in such settings challenging. In Nigeria’s
case, following a period of her removal from the list of nations endemic for
the wild poliovirus in 2015, the smooth transition to being fully declared
polio-free hit a temporary hurdle when three new cases were discovered in
Borno, a situation attributed to the infrastructural collapse that followed the
Boko Haram insurgency, ravaging the North-Eastern region at that time.
Absence of trans-border collaborations

The cross-border challenges experienced by Nigeria with her neighboring
countries are a result of long-standing cultural, political, and economic
relationships. The three recent outbreaks of Lassa fever in Nigeria, Benin and
Togo between 2017 and 2019 also revealed how critical information sharing
could be to disease outbreak preparedness and response. The absence of an
adequate trans-border surveillance system increases the risk of infectious
diseases being imported into the country through migrants.

Technological limitations
Information and Communications Technology (ICT) limitations such as gaps
in internet connectivity and the dearth of ICT literacy among the population
also limits the extent to which the internet is leveraged as a source of
outbreak-related information. On the other end, the internet has also been used
as an effective tool of misinformation during the outbreak period, significantly
hampering the efficacy of response efforts and causing heightened fear.
In this session, we discussed the history of emerging and re-emerging diseases
in Nigeria and responses in managing outbreaks of communicable diseases and
neglected tropical diseases of world.

1. Write a short note on an endemic disease in Nigeria
2. Discuss emerging and re-emerging diseases in Nigeria.
3. Give the limitation against effective infectious disease outbreak response in
Nigeria

a.Visit YouTube on https://www.youtube.com/watch?v=8swAWixSQPs Watch
the video & summarise in 1 paragraph

Hotez, P.J.; Kamath, A. Neglected tropical diseases in sub-Saharan Africa:
Review of their prevalence, distribution, and disease burden. PLoS Negl.
Trop. Dis. 2009, 3, e412.
World Health Organisation. Neglected Tropical Diseases. Program. 2017.

Available online:http://www. who.int/neglected_diseases/en/(accessed on 18
July 2017).
Rosenberg, M.; Utzinger, J.; Addiss, D.G. Preventive chemotherapy versus

innovative and intensified disease management in neglected tropical diseases:
A distinction whose shelf life has expired. PLoS Negl. Trop. Dis. 2016, 10,
e0004521.
Molyneux, D.H. The ‘Neglected Tropical Diseases’: Now a brand identity,

responsibilities, context and promise. Parasites Vectors 2012, 5.
Githeko, A.K.; Lindsay, S.W.; Confalonieri, U.E.; Patz, J.A. Climate change
and vector-borne diseases: A regional analysis. Bull. World Health Organ.
2000, 78, 1136–1147.
The Carter Center. Health Programs. Available
online:https://www.cartercenter.org/health/index.html (accessed on 16 June
2017).
Centers for Disease Control and Prevention. Neglected Tropical Diseases.
2017. Available online:https:
//www.cdc.gov/globalhealth/ntd/diseases/index.html(accessed on 15 June
2017).
London Declaration on Neglected Tropical Diseases. 2012. Available
online:https://www.gov.uk/
government/uploads/system/uploads/attachment_data/file/67443/NTD_20Ev
ent_20-_20London_ 20Declaration_20on_20NTDs.pdf(accessed on 16 June
2017).
Ampah, K.A.; Asare, P.; Binnah, D.D.-G.; Maccaulley, S.; Opare, W.;
Röltgen, K.; Pluschke, G.; Yeboah-Manu, D. Burden and historical trend of
Buruli ulcer prevalence in selected communities along the Offin River of
Ghana. PloS Negl. Trop. Dis. 2016, 10, e0004603.
Sears, A.V.; Hay, R.J. Buruli ulcer—A rapidly changing scene. Acta Derm.
Venereol. 2015, 95, 387–388.
Ahorlu, C.K.; Koka, E.; Yeboah-Manu, D.; Lamptey, I.; Ampadu, W.
Enhancing Buruli ulcer control in Ghana through social interventions: A case
study from the Obom sub-district. BMC Public Health 2013, 13, 59.
Sanyaolu, A.; Okorie, C.; Badaru, O.; Wynveen, E.; White, S.; Wallace, W.
Chikungunya epidemiology: A global perspective. SM J. Public Health
Epidemiol. 2016, 2, 1028.
Cardona-Ospina, J.A.; Villamil-Gomez, W.E.; Jimenez-Canizales, C.E.;

Castaneda-Hernandez, D.M.; Rodrıguez-Morales, A.J. Estimating the burden
of disease and the economic cost attributable to chikungunya, Colombia, 2014.
Trans. R. Soc. Trop. Med. Hyg. 2015, 109, 793–802.
Glossary
Albuminuria Urine containing protein

Anuria Cessation of the production of urine

Biopsy The removal and examination of tissue from somebody who is ill, in
order to find out more about his/her disease.
Bloating Full of liquid or gas and therefore abdomen is felt larger than normal
in a way that is unpleasant.
Case An infected or diseased person or animal having specific clinical,
laboratory and epidemiological characteristics.
Cercariae The stage of the fluke life cycle that develops from germ cells in a
daughter sporocyst. This is the final developmental stage in the snail host,
consisting of a body and a tail that aids in swimming.
Chemoprophylaxis The administration of a chemical, including
antibiotics, to prevent the development of an infection or the progression of an
infection to clinical disease.
Chemotherapy The treatment of diseases with the use of chemical substances.
Chronic diarrhoea Diarrhoea which persists for more than two weeks.
Contact A person or animal that has been in such association with an infected
person or animal, or a contaminated environment as to have an opportunity to
acquire the etiologic agent.
Cyst The immotile stage protected by a cyst wall. In this stage the protozoan is
readily transmitted to a new host.
Epididymoorchitis Inflammation of testis and epididymis.
Fomites A subclass of vehicles including inanimate objects such as articles of
clothing which can become contaminated and transmit agents.
Health A state of physical, mental and social wellbeing of an individual, not
merely the absence of disease or infirmity.
Health education the process by which individuals and groups of people learn
to behave in a manner conducive to the promotion, maintenance or restoration
of health.
Hematemesis Vomitus consisting blood.
Host A person or other living animal including birds that affords subsistence or
lodgment to an infectious agent under natural (as opposed to experimental)
conditions. Hosts in which the parasite attains maturity or passes its sexual stage

are primary or definitive hosts; those in which the parasite is in a larval or

asexual stage are secondary or intermediate hosts.
Hydrocele Accumulation of serous fluid in the scrotum
Immune individual A person or an animal that has specific
protective antibodies and/or cellular immunity as a result of previous infection
or immunisation, or is so conditioned by such previous specific experience as to
respond in such a way that prevents the development of infection and/or clinical
illness following re-exposure to the specific infectious agent.
Immunity That resistance usually associated with the presence of antibodies or
cells having a specific action on the microorganism concerned with a particular
infectious disease or its toxin.
Unapparent infection:The presence of infection in a host without recognizable
clinical signs or symptoms. Unapparent infections are identifiable only by
laboratory means such as blood test or by the development of positive reactivity
to specific skin tests. (Synonymous asymptomatic, subclinical, occult infection).
Incidence The number of instances of illness commencing or, of persons
falling ill during a given period in a specified population. More generally the
number of new events (e.g. New cases of a disease in a defined population
within a specified period.)
Infected individual A person or animal that harbours an infectious agent and
who has either manifest disease (patient or sick personal) or unapparent
infection (see carrier).
Intermediate host A host for only the larval or sexually immature stages of
parasite development.
Jaundice A syndrome characterized by an increased level of bile pigments in
the blood and tissue fluid.
Lymphadenopathy Enlargement of lymph glands in more than one centimetre
for a variety of disease conditions.
Lymphadenitis Inflammation of the lymphatic vessels.
Melaena Faeces containing blood.
Merozoite One of the trophozoite released from human red blood cells or liver
cells at maturation of the asexual cycle of malaria.
Microfilaria A term used for the embryo of a filaria, usually in the blood or
tissues of humans ingested by the arthropod intermediate host.

Miracidium Ciliated first swimming larva of a trematode, which emerges from

the egg and must penetrate the appropriate species of snail in order to continue
its life cycle development.
Oocyst The encysted form of the ookinet, which occurs on the stomach wall of
anopheles mosquito species infected with malaria.
Ookinete The motile zygote of plasmodium species formed microgamate
(male) fertilisation of a macrogamate (female).
Resistance The sum total of body mechanisms that interpose barriers to the
invasion or multiplication of infectious agents, or to damage by their toxic
products.
Source of infection the person, animal, object or substance from which an
infectious agent passes to a host.

Comm 819 Infectious Disease Epidemiolgy

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Comm 819 Infectious Disease Epidemiolgy

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COMM 819: (Infectious Disease Epidemiology)

Distance Learning Centre

Course Code &Title: COMM 819 (Infectious Diseases

Distance Learning Centre A.B.U, Course Materials i

© 2021 Ahmadu Bello University (ABU) Zaria, Nigeria

Published and Printed by

Distance Learning Centre A.B.U, Course Materials ii

Revised By: Dr. Abdullateef Yusuf

Distance Learning Centre A.B.U, Course Materials iii

Course Materials Development Overseer

Subject Matter Expert

Subject Matter Reviewer

Distance Learning Centre A.B.U, Course Materials iv

MODULE 2: Infectious Diseases - - - - - - - 85

MODULE 3: Screening, Prevention and Management of Diseases - - - 177

Distance Learning Centre A.B.U, Course Materials v

Course Study Guide

ii. COURSE INTRODUCTION AND DESCRIPTION

Distance Learning Centre A.B.U, Course Materials vi

iii. COURSE PREREQUISITES

iv. COURSE LEARNING RESOURCES

American Academy of Pediatrics (AAP) (2006) In: Pickering LK (ed)

American Public Health Association (2008) In: Heymann DL (ed)

Anderson RM, May RM (1991) Infectious diseases in humans:

Balsamo G, Michaels S, Sokol T, Lees K, Mehta M, Straif-Bourgeois

Boelaert M, Arbyn M, Van der Stuyft P (1998) Geographical

Distance Learning Centre A.B.U, Course Materials vii

Brachman PS (1998) Epidemiology of nosocomial infections,

CDC (1985) Update: International outbreak of restaurant-associated

International Journal of Infectious Diseases https://www.ijidonline.com/

The Journal of Infectious Diseases Oxford Academic

vi. ACTIVITIES TO MEET COURSE OBJECTIVES

vii. TIME (TO COMPLETE SYLABUS/COURSE)

viii. GRADING CRITERIA AND SCALE

IX LINKS TO OPEN EDUCATION RESOURCES

Distance Learning Centre A.B.U, Course Materials ix

 African Virtual University (http://oer.avu.org/) has numerous modules on

Distance Learning Centre A.B.U, Course Materials xi

X. ABU DLC ACADEMIC CALENDAR/PLANNER

N.B: - All Sessions commence in January

Distance Learning Centre A.B.U, Course Materials xii

XI. COURSE STRUCTURE AND OUTLINE

1. Read Courseware for the Corresponding Study Session.

Infectious Diseases 6. View referred Animation

9. Any out of Class Activity

1. Read Courseware for the corresponding Study Session.

Distance Learning Centre A.B.U, Course Materials xv

8. Any additional study material

Week 13 REVISION/TUTORIALS (On Campus or Online) &

Distance Learning Centre A.B.U, Course Materials xvi

MODULE 2: Infectious Diseases

MODULE 3: Screening, Prevention and Management of Diseases

Distance Learning Centre A.B.U, Course Materials 1

Distance Learning Centre A.B.U, Course Materials 2

1.0 Study Session Learning Outcomes

2.0 Main Content

Image source: Google

It is a quantitative science concerned in infectious diseases with the

development, pathogenesis, and expression of infection and disease in a

Distance Learning Centre A.B.U, Course Materials 6

Immunodeficiency: A state representing impairment of the immune system of

Distance Learning Centre A.B.U, Course Materials 7

second-tier transmission-based precautions. Hand washing remains a prime

dissemination of consolidated and processed information to contributors to the