Natural history and Infectious Dis-

eases process

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1. Introduction
• Communicable diseases continue to account for
a major proportion of disease burden

• Occur in epidemic forms

• The problem is exacerbated by:

• Poor socio-economic status
• Poor personal and environmental hygiene
• Inadequate health service coverage, etc.

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2. Natural History of Diseases

• Refers to the progress of a disease process, in the

absence of intervention.
Usual time
of diagnosis
Pathologic Onset of
Exposure Changes Symptoms

Time
Stage of Stage of Stage of Stage of Recovery,
Susceptibility Subclinical Clinical Disability or Death
Disease Disease

Natural history time lines for infection and disease

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Cont…
• Begins with exposure with the causative agent
capable of causing disease.

• Without intervention, the process ends with

recovery, disability or death.

• The course can be halted at any time in the

progression by intervention, host factors, other
influences.
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 Cont…
The natural history of infectiousness
includes:
Prepatent period: the time interval from infec-
tion to becoming infectious (shedding of the agent).

Infectious period: the time during which an in-

fected host could infect another host or vector.

Incubation period: the time from infection to

symptomatic disease.

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• Latent Period: The interval between recovery
and the occurrence of relapse or recrudes-
cence in clinical disease.
-Examples of diseases in which a latent period
can occur include malaria and epidemic ty-
phus.
-The term “latent period” is some times used
instead to refer to the incubation period.

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 Timeline for Infection
.

•Infection
• .
Dynamics of
infectiousness
Latent Infectious Non-infectious
period period
Susceptible
Time
•Infection

Dynamics of Incubation Symptomatic Non-diseased

disease period period

Susceptible
Time

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 Cont….
• Eventually the host becomes non-infectious by,
– clearing the infection, possibly by developing immu-
nity

– therapeutic intervention, or

– death.

• The host may become non-infectious while still

harboring the microbe (carrier).
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3. Components of Infectious
Disease Process
• Infectious diseases result from the interaction
between the infectious agent, host/reservoir and
environment.
Host

Agent Environment

Fig 2. Components of infectious diseases

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 Cont…
• Agent: An infectious micro-organism depends
on:
– Pathogenicity, -- infectivity,
– infective dose, -- immunogenicity,
– Virulence

• Host: Related to human factors.

– Influences individual’s exposure, susceptibility or re-
sponse to a causative agent, and it depends on:
• Age, - gender,
• race, - habits,
• sexual activities, - immunization,
• contraception, - diet,
• nutrition, -etc.
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 Cont….

• Environment: encompasses all extrinsic of the hu-

man host
– Physical: describes the geography and climate,
tropical/temperate, urban/rural;

– Biological: made up of plants, animals, and other life

forms;

– Socioeconomic: includes factors like housing, sanita-

tion, population density, crowding, education, occupation,
public health resources.

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Infectivity
Infectivity –
(1) is the characteristics of the disease agent that embodies
capabilities to enter, survive, and multiply (produce infec-
tion) in the host.
(2) The proportion of exposures, in defined circumstance, that
results in infection
Some of the techniques for evaluating infectivity are:
- studies of the proportion of close contacts (such as
household contacts) who become infected .
-serosurveys after epidemics to determine the proportion
of persons recently infected.

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Pathogenecity
Pathogenicity – is the ability to produce clini-
cally apparent illness
• Is proportion of infections resulting in clinical
illness
• many host and environmental factors as well as
the dose, route of entrance of the infection, and
source of the infection may alter the patho-
genecity of a particular infectious disease
agent.

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Virulence
Virulence – the proportion of clinical cases resulting
in severe clinical manifestations.
• The CFR is one way of measuring virulence
CFR = Number of deaths from a disease
Number of clinical cases of that disease
• Virulence may depend on dose, route of infection,
and host factors such as age or race.
e.g. cholera outbreaks responsible for the virulence of epi-
demic 3.3%

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Immunogenecity
Immunogenecity – is the infection’s ability to pro-
duce specific immunity
• Depending on the type of pathogen, this may be
primarily humoral immunity, cellular immunity, or
mixture of both
• Immunogenecity can be affected by host factors
such as age, nutrition, dose, and virulence of infec-
tion
• Agents also differ in their instrinsic ability to in-
duce an effective, lasting immune response. For
example, the agent of measles produces life long
immunity 15
Causal Concepts of Disease
• Not all associations between exposure and disease are
causal.

• A cause: A factor that preceded the disease and with-

out which the disease would not occur.

• If disease does not develop without the factor, then the

causative factor is “necessary”.

• No specific factor is sufficient to produce a disease.

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Cont….
• A “sufficient cause” : defined as a set
of conditions and events that inevitably pro-
duce disease;

• The occurrence of all of the conditions or

events is necessary.

• For example,
Tobacco smoking is a cause of lung cancer, but by
itself it is not a sufficient cause.

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 Cont…
• If a single factor alone become sufficient to de-
velop the disease, then we term the causative
factor as both “Necessary” and “sufficient”.

• Example:
– Tubercle bacilli is a necessary factor for TB

– Rabies virus is sufficient for developing

clinical rabies

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1. Epidemiologic triangle and triad
(balance beam)

•Traditional model of infectious disease causation

Agent Agent Host

Host Environment Environment

Epidemiologic triangle Balance beam

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 2 .Wheel model of infectious diseases
Social
Agent environment

Host Agent

Genetic
Agent
core
Physical
(Humans) environment
Biologic
environment
Agent

•The interaction of humans with infectious agents and their environment, a

person’s state of health represents a dynamic equilibrium – a balance of forces.
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3. Chain of Infection
• Infection: implies that the agent has achieved en-
try and begun to multiply in the host and leads to
disease.

• This is sometimes called the chain of infection,

or transmission cycle.

• For infection to occur a chain of events must

take place.
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The infectious process of a specific disease can be
described by six diseases transmission.
1. The Agent
2. Its reservoirs
3. Its portal of exits
4. Its mode of transmission
5. Its portals of entry
6. The human host

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Chain model of infectious diseases

Causative
agent
Reservoir
Susceptible
host
Portal of
exit
Portal of
entry Mode of
transmission

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•Chain of Infection

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1. Agent: An infectious micro-organism
- bacteria
- viruses
- fungus
- protozoas

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Cont….
2. Reservoir: The habitat of an infectious
agent where it normally lives, grows and multi-
plies.
– Eg dog for rabies, - Cattle for anthrax

• Carrier: A person without apparent disease

who is capable of transmitting the agent to oth-
ers.
– Asymptomatic carrier: transmitting infection without
ever showing signs of the disease.
e.g polio, ameobiasis
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 Cont…
• Incubatory carrier: transmitting infection by
shedding the agent before the onset of clinical
manifestations.
e.g measls
• Convalescent carrier: Transmitting infection af-
ter the time of recovery from the disease
e.g typhoid fever
• Chronic carrier: Shed the agent for a long pe-
riod of time, or even indefinitely.
e.g viral hepatitus, typhoid fever

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3. Portal of exit

• is the way the infectious agent leaves the

reservoir.
• Possible portals of exit include all body se-
cretions and discharges: Mucus, saliva,
tears, breast milk, vaginal and cervical dis-
charges, excretions (feces and urine), blood,
and tissues (including the placenta).

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4. Modes of Transmission

• The transfer of an infectious agent from an infected

host (reservoir) to a susceptible host.

• Direct transmission: Immediate transfer of

the agent from a reservoir to a susceptible host.

• Indirect transmission: Transmission of an in-

fectious agent to a susceptible host through the aid
of a vehicle, a vector or suspended air particles.

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 Cont…
• Direct transmission • Indirect transmission
 Touching  Airborne

 Kissing  Vehicle-borne

 Biting
 Vector-borne

 Direct projection
 Non-vector
 Blood transfusion intermediate host

 Parenteral injections
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Direct transmission
1.1 Direct contact: The contact of skin, mucosa, or con-
junctiva with infectious agents directly from person
or vertebrate animal, via touching, kissing, biting,
passage through the birth canal, or during sexual in-
tercourse.
Example: HIV, rabies, gonorrhea
1.2 Direct projection: projection of saliva droplets by
coughing, sneezing, singing, spitting or talking.
Example: common cold
1.3Transplacental: Transmission from mother to fetus.
Example: syphilis
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 MoT cont…
2. Indirect transmission
2.1 Vehicle-borne:
 A vehicle is any non-living substance or object
by which an infectious agent can be transported
and introduced in to a host through a suitable
portal of entry.
 Transmission occurs through indirect contact
with inanimate objects (fomites): bedding, toys,
or surgical instruments; as well as through con-
taminated food, water, IV fluids etc.
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 MoT cont…
2.2 Vector-borne:
A vector is an organism (usually an arthropod)
which transports an infectious agent to a susceptible
host or to a suitable vehicle.
Biological vector:
• A period of multiplication and/or development of
the agent in the vector is required before transmis-
sion to the host can occur (extrinsic incubation pe-
riod).
• Transmission occurs while the vector is feeding on
its host.

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 MoT cont…
Mechanical vector:
– agent is directly infective to the host, without having to go
through a period of multiplication or development.
– agent is transported (carried) on the leg or mouth parts of the
vector, or passes through its gastrointestinal tract and is ex-
creted or regurgitated onto the host or vehicle.

– Introduction of the agent into the host is either:

 by bite (e.g by blood sucking flies),
 by vector-host contact (e.g- Trachoma by flies),
 through contamination of a vehicle

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 Mo T cont…
Airborne: which may occur by dust or droplet nuclei
(dried residue of aerosols)
Example: Tuberculosis

Non vector intermediate host: hosts not playing an ac-

tive role in transporting the agent to humans.
Example: Aquatic snails in the transmission of
schistosomiasis.

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5. Portal of entry
Is the site where an infectious agent enters a sus-
ceptible host.
The Mucosa:
• Nasal
• Conjunctiva
• Respiratory
• Vaginal -
• Urethral
Injury site: Tetanus
Skin: Hook worm infection (Ancylostomiasis)
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6. Susceptible Host
• The susceptible human host is the final link in the infectious
process.
•  Host susceptibility can be seen at the individual level and at the
community level.
• At the individual level: The state of the host at any given time is
the interaction of genetic endowment with the environment over
the entire life span.
Examples:
• Genetic factors: sex, blood type, ethnicity etc.
• Environmental factors: immunity acquired as a result of past in-
fection
• At the community level: Host resistance at the community
(population) level is called herd immunity.

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Summary
Define each of the following terms?
1. Agent
2. reservoirs
3. portal of exits
4. mode of transmission
5. portals of entry
6. human host

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Thank you!!

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