Introductions to Epidemiology (2) (1)ggfddssdfgygssrtyyyytrdsertyyfdedfghj

Epidemiology
BY: Wakgari Mosisa (BSc , MPH in Epidemiology)

Contents
Basic Concepts in Community Health

Definitions
History of Epidemiology
Use/applications of Epidemiology
Scope of epidemiology
Basic assumptions of epidemiology
Theories of disease causation
Levels of disease prevention
2 BY Wakgari Mosisa . (BSc, MPHE) Jul 8, 2024

Basic Concepts of Health
HEALTH
Definition of health has negative and positive models:
Negative model- defines health as the absence of the constraints
of health.
 That is you are healthy if you are not ill.
 The renewal of health in a diseased individual is the removal of the
disease.
 This model equates health with the absence of disease
Positive model is by WHO- "a state of complete physical,
mental and social wellbeing and not merely the absence of
disease or infirmity".
 This definition is also simplified to “ The ability to lead a
socially and economically productive life”
Basic Concepts Cont…
 Disease- is a physiological/psychological dysfunction
 Illness- a subjective state of the person who feels aware of not
being well
 Sickness- is a state of social dysfunction that is a role that the
individual assumes when ill
 Risk factors - are factors positively associated with the risk of
developing disease but are not sufficient.
 Some risk factors are associated with many diseases while some
diseases are associated with many factors.
 Community- refers to a group of people who share something in
common.
 Examples of common denominators may be neighborhood, workplace,
race, religion, or social activity.
 Communities are characterized by people’s engagement in activities that
demand interrelationship of efforts, they give rise to shared culture, and
they are often sited in a particular geographic location.
 Community medicine- is a system of delivery of comprehensive health
care to the people by a health team to improve the health of a
community
community medicine, the community replaces the
individual patients as the primary focus of concern.
The problem here is to evaluate the health of a

defined community including those members who
would benefit from, but could not seek medical care.
These approach requires techniques and skills in

addition to those needed for clinical practice.

Clinical medicine- medical care of individuals. Typically
these are sick people who have presented for help.
In community medicine, the community replaces the

individual patients as the primary focus of concern.
Community diagnosis- is the process of identification and

detailed description of the most important problems of a
given community.
It may be broad or narrow in scope, and may deal with only
a single topic or a single sub group.

 The task of community diagnosis requires statistical knowledge in
addition to medical skills
 Ways that one could make community diagnosis are:
 Discussion with community leaders and health workers-community felt
health problems
 Attending community gatherings-community felt health problems
 Survey of available health records
 Field survey
 Analysis of data collected and compilation of report in order to reach at
community diagnosis
Basic Concepts Cont.…
Community diagnosis provides basis for decision on:
 The need for intervention
 Type of intervention needed
 Target group at whom intervention should be directed
 Provide baseline for later intervention

Public health- Is the science and art of preventing diseases,
prolonging life and promoting health through community efforts
and government action.
 Public health is:
 Preventing disease
 Prolonging life
 Improving quality of life
 Eliminating health inequalities
 Organizing community to promote active participation
Impact of Public Health
Great Vaccinations
Public Motor-vehicle safety
Health
Achieveme Safer workplaces
nts of the Control of infectious diseases
20th
Century Decline in deaths from coronary health disease and stroke
include: Safer and healthier foods
Healthier mothers and babies
Family planning
Fluoridation of drinking water
Recognition of tobacco use as a health hazard

cont….
Among the greatest global achievements:

 Plague ==> Quarantine
 Cholera ==> Sanitation
 Smallpox ==>Immunization
For example, over the 20th century, life expectancy for
Americans has increased by 30 years.
 25 of those years is due to achievements in public health
 Less than 4 of those years is due to medical advances.
Cont..
Core Public Health Disciplines;-

Public Health is composed of other
The core ones include:
disciplines.
Epidemiology
Biostatistics
Behavior Science/Health Education
Environmental Health

Cont..
Public Health is also concerned with:
Global Health
Nutrition
Maternal and Child Health
Public Health laboratory policy
Public Health policy
Public Health practices
 EPI DEMO LOGOS

 Upon, on, befall People, population, man the Study of
The study of anything that happens to people

“That which befalls man”

Definition of Epidemiology
 Many definitions have been proposed over time by different
scholars.
Oxford English Dictionary
 The branch of medical science which treats of epidemics- old
 The scientific study of the spread and control of diseases – new
 Kuller LH: Am J Epid 1991;134:1051
 Epidemiology is the study of "epidemics" and their prevention
 The study of the distribution and determinants of health-related

states or events in specified human populations and its
application to the control of health problems.
-Dictionary of Epidemiology Porta M, ed. Dictionary of
Epidemiology, 5th ed. New York: Oxford U. Press, 2008

“The Study of…”
Basic science of public health
Approaches problems systematically and

quantitatively
Uses rigorous techniques and methods to produce

valid (accurate) and reliable (precise) findings
Compares observed vs. expected

Distribution and Determinants...
What* Who Where
Why / and How

When
How Many

The Five W’s of Journalism / Epidemiology
 What* = Diagnosis
 Who = Person
 Where = Place
 When = Time
 Why / How = Cause, Risk factors, modes of transmission
* and How Many

…Distribution…
What = Clinical
Who = Person Descriptive Epidemiology(Distribution)
Where = Place or
When = Time
___________________________________________
Why / How = Cause,
Risk factors,
modes of transmission Analytic Epidemiology (Determinants)

….Determinants....
Hallmark = Comparison group

• Example: 30 of 100 people became ill. What made these 30
individuals ill?
• All 30 breathed the air.
• All 30 drank the water.
• All 30 ate fish.
• Of 70 non-ill people, all breathed the air.
• What if almost all drank water but none ate fish?
• What if none drank water but almost all ate fish?

…Health-Related States or Events…
original focus
• epidemics of infectious diseases
Current domain much broader
• acute and chronic diseases

• events (e.g., injuries)
• conditions (e.g., disabilities)
• behaviors
• social
• genetics
• other

Case Definition
 Set of uniformly applied criteria for determining whether a person
should be identified as having a particular disease, injury, or other
health-related condition
 Use simple and objective criteria
 Develop a case definition using:
 Symptoms or laboratory results
 Affected population (person)
 Location (place)
 Time frame
…Populations…
 Unit of observation is groups rather than individuals

 The epidemiologist‘s “patient “is the population
 Clinician vs. epidemiologist

Clinician Vs Epidemiologist (Patient with Diarrhea)
.
Clinician Epidemiologist
Main Goal Treatment Determine cause,

(± Diagnosis) prevent other cases
What is wrong with Exposure/sources?
Questions patient?
What treatment is Who else exposed?
appropriate? Potential for spread
Action Treatment Intervention

(control & prevention)
CDC principles of Epidemiology, 3rd ed 25

…Application…
 Not just the study of…

 It is an applied science with direct practical applications.
 Practice of epidemiology is both science and art
– Provides data for decision-makers
– Tool for public health action

History of epidemiology
S. No Year Event
1 400 Hippocrates suggested that the development of human disease
B.C. might be related to lifestyle factors and the external environment
2 1662 Graunt analyzed births and deaths in London and quantified
disease in a population
3 1839 William Farr(the father of modern vital statistics and surveillance)
Farr set up a system for routine summaries of causes of death
4 1747 Lind used an "experimental" approach to prove the cause of
scurvy by showing it could be treated effectively with fresh fruit.
5 1854 John Snow (considered father of modern epidemiology)formed
and tested a hypothesis on the origins of cholera in London: one
of the first studies in analytic epidemiology
6 1920 Goldberger published a descriptive field study showing the dietary

origins of pellagra
7 1937 Austin Bradford Hill mainly Suggested criteria for establishing
causation
.

Use/applications of Epidemiology (Purposes Of Epidemiology)
 Elucidate the natural history of disease.
 Describe the health status of the population.
 Establish causation of disease.
 Provide an understanding of what causes or sustains disease in
populations.
 Define standards and ranges for normal values of biological and
social measures.
 Guide health and healthcare policy and planning.
 Assist in the management and care of health and disease in
individuals.
Scope of epidemiology

Fundamental Assumptions In Epidemiology
A. “Disease human population does not occur at random”
B. “Human disease has causal and preventive factors
 That can be identified through systematic investigation of

different populations or sub-groups of individuals within a
population at different places or times”.
 Allows for the study of causal and preventive factors

Major categories of epidemiology
 Descriptive Epidemiology – Defines the amount and

distribution of health problems. It answers the questions: Who,
what, and where.
 Analytic Epidemiology – Analyses the causes or determinants

of health and disease. Answers the questions of why and how.

Descriptive Epidemiology is an antecedent of
Analytic Epidemiology.
BY Wakgari Mosisa . (BSc, MPHE) Jul 8, 2024

33
Theories/ principles of diseases causation
Disease causation
 The cause of a disease is an event, condition, or characteristics
that precede the disease event and without which the disease
event either would not have occurred at all or would not have
occurred at some latter time.
 Not all associations between exposure and diseases are causal.

 If disease does not develop without the factor being present,
then we term the causative factor “necessary factor” if the
disease always result from the factor then we term the causative
factor “sufficient factor “
 Example- Tubercle bacilli is a necessary factor for tuberculosis
-Rabies virus is sufficient for developing clinical rabies

Necessary Causes vs. Sufficient Causes
 If A is necessary for B (necessary cause) that means you will never have
B if you don't have A.
 In other words, if one thing is a necessary cause of another, then that
means that the outcome can never happen without the cause. However,
sometimes the cause occurs without the outcome.
 If A is sufficient for B (sufficient cause), that means that if you have A,
you will ALWAYS have B. In other words, if something is
a sufficient cause, then every time it happens the outcome will follow.
The outcome always follows the cause. However, the outcome may
occur without the cause.
BY Wakgari Mosisa . (BSc, MPHE)
36 Jul 8, 2024
What does cause Disease?
There are different theories :

 Supernatural
 Hippocratic
 Single germ
 Classic epidemiologic
 Ecological
 Multi-factorial causation

Causal Relationships
A causal pathway may be direct or indirect:
 Direct causation, A causes B without intermediate effects
 Indirect causation, A causes B, but with intermediate effects
 In human biology, intermediate steps are virtually always

present in any causal process

Epidemiological models in disease causation
 Models are purposely simplified representations
 Facilitates the understanding of nature (complex)
 The following are the widely used ones:
1. Epidemiologic triangle/triad
2. Web of causation model
3. The Wheel model
4. Causal pie model

1. The epidemiologic triangle/ triad (balance
beam):
.
HOST
AGENT ENVIRONMENT

46
Malaria
.
Agent
Vector
Host Environment

47
The epidemiologic triad Model
.
Host:
Intrinsic factors, genetic, physiologic factors, psychological factors,
immunity
Health
or
Illness
?
Agent:
Amount, infectivity, pathogenicity, virulence, Environment:
chemical composition, cell reproduction
Physical, biological, social

48
Epidemiological models ….
2. The web of causation model
 especially developed to enhance understanding of chronic
diseases
 de-emphasizes the role of the agent and highlights other
factors that encourage the onset of disease
49
2. Web of Causation
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Web of Causation for the Major Cardiovascular Diseases

51
Example of a Web of Causation
.
Overcrowding Malnutrition
Exposure to
Mycobacterium
Susceptible Host Infection Tuberculosis
Tissue Invasion and

Reaction
Vaccination Genetic

52
3-The Wheel
 depict human – environment relations
 The wheel consists of a hub (the host or human), which has genetic
makeup as its core.
 Surrounding the host is the environment, schematically divided into
biological, social, and physical
 For hereditary diseases, the genetic core would be relatively large.
 For conditions like measles the genetic core would be of lesser
importance;
3-The Wheel …
.
The Wheel of Causation
Biological Social Environment

Environment
Host
(human)
Genetic Core
Physical Environment

54
4. The causal pie model
 Because the agent-host-environment model does not work well
for some noninfectious diseases, several other models have
been proposed
 One of the newer models; is based on the multi-factorial
nature of causation in many diseases
 Factors as pieces of a pie, the whole pie making up the
sufficient cause for a disease.
 Disease may have more than one sufficient cause
BY Wakgari Mosisa . (BSc, MPHE) Jul 8, 2024 55
Necessary Vs Sufficient Cause
 NECESSARY CAUSE: A causal factor whose presence is
required for the occurrence of the disease.
 SUFFICIENT CAUSE. A causal factor or collection of

factors whose presence is always followed by the occurrence
of the disease.
 component causes- The factors represented by the pieces of the

pie in this model

 The Rothman’s causal Pie model illustrates the factors that act to
cause disease as pieces of a pie, the whole pie making up the
sufficient causes for a disease.
 A cause presented in all pies representing the sufficient causes for a

particular disease is considered a necessary cause for the disease.
 Control of the disease could be achieved by removing one of the

components in each "pie" and if there was a factor common to all
"pies“ (necessary cause), the disease would be eliminated by
removing that alone.
BY Wakgari Mosisa . (BSc, MPHE) Jul 8, 2024 58

Exercise
 Some of the risk factors for heart disease are smoking,
hypertension, obesity, diabetes, high cholesterol, inactivity,
stress, and type A personality.
 Are these risk factors necessary causes, sufficient causes?

59
Natural History of Diseases
 The natural history of disease refers to the progression of a
disease process in an individual over time, in the absence of
intervention.
 The process begins with exposure to the causative agent
capable of causing disease & the process ends with recovery,
disability, or death.
 The Course of a disease may be halted at any point in the
progression by preventive and therapeutic measures, host
factors, and other influences.

Stages of Natural History of Disease
.

Stages of Natural . . .
1. Stage of susceptibility
 Disease has not yet developed, but the groundwork has been
laid by the presence of factors that favor its occurrence.
Example: unvaccinated child is susceptible to measles.
2. Stage of Pre-symptomatic (sub-clinical) disease
 There
are no manifestations of the disease but pathologic
changes (damages) have started to occur in the body.
 The disease can only be detected through special tests.
 The stage may lead to the clinical stage, end in recovery.

 Examples:Detection of antibodies against HIV in an
apparently healthy person.
 Ova of intestinal parasite in the stool of apparently
healthy children.
3. The Clinical stage
 Theperson has developed signs and symptoms of the disease.
The clinical stage of different diseases differs in duration,
severity and outcome.
 The outcomes of this stage may be recovery, disability or death.

4. Stage of disability or death
 Some diseases run their course and then resolve completely
either spontaneously or by treatment.
 In others the disease may result in a residual defect, leaving the
person disabled for a short or longer duration.
 Still, other diseases will end in death.
 Disability is limitation of a person's activities including his role
as a parent, wage earner, etc
 Examples:
 Trachoma may cause blindness
 Meningitis may result in blindness or deafness. Meningitis may also result
in death.

Possible outcomes after exposure to an infectious
agent
.
Exposure
No Clinical Subclinical Carriage

infection infection infection
Death Immunity Carriage Non-immunity

Dynamics of Disease and Infectiousness
.
Period Between Exposure to

Infectiousness
Latent period Infectious period Non-infectious period
Incubation period Clinical disease Recovery
Infection Onset of Resolution of

symptoms symptoms
Time

Cont…
 Begins by exposure to a 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 and other influences.

Cont…
 Eventually the host becomes noninfectious by,
 Clearing the infection, possibly by developing

immunity
 Therapeutic intervention, or
 Death.
 The host may become non-clinically ill while still harboring

the microbe (also called carrier).

Time Course of Disease& Communicability
.
16

Cont…
The natural history of infectiousness includes:
 Prepatent period: the time interval from infection to
becoming infectious (shedding of the agent).
 Infectious period: the time during which an infected host
could infect another host or vector.
 Incubation period: the time interval from infection to
symptomatic disease.
 Latent period: the time interval from infection to
development of infectiousness

Cont…
 Non-infectious period: either by recover from the infection
or by death.
 The symptomatic period.
 The probability of developing symptoms or disease after
becoming infected is referred as pathogenicity (time of
pathogenicity).
 Asymptomatic period: The host eventually becomes
asymptomatic either by recovering from the symptoms or by
death.
 Carrier state develops when the person become
asymptomatic but remains infectious
Infectious Disease process…
Carriers may be
Asymptomatic carriers: Transmitting the disease without ever

showing manifestations of the disease. Example: Polio,
amoebiasis
Incubatory carriers: Transmitting the disease during incubation

period, i.e. from first shedding of the agent until the clinical
onset. Example: Measles, mumps

Infectious Disease process…
Convalescent carriers: Transmitting the disease during
convalescence period i.e. from the time of recovery to when
shedding stops. Example: Typhoid fever
Chronic carriers: Transmitting the disease for a long period /

indefinite transmission. E.g.: Hepatitis B

Infectious disease process
 Infectious diseases result from the interaction of infectious
agent, susceptible host/reservoir and environment that
brings the host and the agent together.
 Infection implies that the agent has achieved entry and begun to
develop or multiply, whether or not the process leads to disease.
A model used to understand the infection process is called the
chain of infection

Components of infectious Disease Process…
 The infectious process of a specific disease can be described by
the following components (factors).
1. Causative agent
2. Reservoir host
3. Portal of exit
4. Mode of transmission
5. Portal of entry and
6. Susceptible host.
Components of . …
Jul 8, 2024
77 BY Wakgari Mosisa . (BSc, MPHE)
Chain of Disease Transmission/the Infectious disease cycle…

The Infectious disease cycle…
1. Infectious agent/etiology
 Is an organism that is capable of producing infection or
infectious disease
 Necessary cause to produce a disease
 The biological properties of the agent may play a major role in
its epidemiology
 In order to survive the agent must be able to:
 Multiply
 Emerge from the host
 Reach the new host
 Infect the new host
The Infectious disease cycle…
 These can generally be grouped into the following five major
taxonomic groups
1. Virus: e.g. HIV; measles; Polio Herpes, etc.
2. Bacteria: e.g. M. tuberculosis; N. meningitidis; N. gonorrhea
3. Protozoa: e.g. Plasmodia species; E. histolytica; Giardia lamblia,
Leishmania species, etc.
4. Fungi: e.g. Candida albicans; Cryptococcus neoformans; Histoplasma
capsulatum
5. Metazoa: e.g. Helminths

Intrinsic properties of Microorganisms
Infectivity: the ability of an agent to invade and multiply
(produce infection) in an exposed host
Infectivity is a measure of the progression of an infectious
agent from exposure to infection
 It is the ability to cause infection in an exposed susceptible
host and is measured by the infection rate (infectiousness).
 It is the proportion of exposed persons who become infected
𝑇𝑜𝑡𝑎𝑙 𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝐼𝑛𝑓𝑒𝑐𝑡𝑒𝑑 𝑃𝑒𝑜𝑝𝑙𝑒

𝐼𝑛𝑓𝑒𝑐𝑡𝑖𝑜𝑛 𝑅𝑎𝑡𝑒= ×100%
𝑇𝑜𝑡𝑎𝑙 𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑆𝑢𝑐𝑒𝑝𝑡𝑖𝑏𝑙𝑒 𝑃𝑒𝑜𝑝𝑙𝑒 𝐸𝑥𝑝𝑜𝑠𝑒𝑑

Intrinsic properties of
Microorganisms…
 Factors influence the infectivity of an agent.
 Host and environmental factors
 The dose,
 The route of entry,
 source of infection, and
 the strain of the agent

Intrinsic properties of Microorganisms…
Pathogenicity: is the ability of an agent to produce a clinically
manifest disease in susceptible host.
 It is measured by determining the proportion of infections that

result in clinically apparent disease
𝑇𝑜𝑡𝑎𝑙 𝑁𝑢𝑚𝑏𝑒𝑟𝑜𝑓 𝐶𝐿𝐼𝑁𝐼𝐶𝐴𝐿𝐶𝑎𝑠𝑒𝑠

𝑷𝒂𝒕𝒉𝒐𝒈𝒆𝒏𝒊𝒄𝒊𝒕𝒚= ×100%
𝑇𝑜𝑡𝑎𝑙 𝑁𝑢𝑚𝑏𝑒𝑟𝑜𝑓 𝑆𝑈𝐵𝐶𝐿𝐼𝑁𝐼𝐶𝐴𝐿𝐶𝑎𝑠𝑒𝑠

 Virulence: this is the ability of an agent to produce severe
disease.
 It is measured by determining the proportion of clinical
cases resulting in severe clinical manifestations.
 Some of measures of virulence as it applies to humans are
the case fatality rate (CFR)

Factors that influence the degree of infectivity, pathogenicity,
and virulence include:
 Strain of agent
 Dose of agent
 Route of infection
 Hostfactors like host age, host nutritional status; host
immune response;
 Treatment, especially on virulence; and
 Season, through influencing exposure to the agent and other
factors that enhance the entry of the agent into the body and
its transmission.
Infectious Disease process…components
2. Reservoirs:
an organism or habitat, in which an infectious agent normally
lives, transforms, develops and/or multiplies.
Reservoirs for infectious agents may be humans, animals,
plants or other inanimate objects.
Agents with a human reservoir include measles, mumps, and
most respiratory pathogens.
 Animals as a reservoir of infection- brucellosis (cows and
pigs), anthrax (sheep), plague (rodents), trichinosis (swine),
and rabies (bats, raccoons, dogs, and other mammals).
A person who does not have apparent clinical disease, but is a
potential source of infection to other people is called a Carrier
3. Portal of Exit
 is the way the infectious agent leaves the reservoir
 Possible portals of exit include all body secretions and discharges:
Nose — secretions
Mouth — saliva, sputum
Skin, intact — pustules, lesions
Skin, broken — blood
Breast (females) — milk, secretions
Vagina (females) — secretions
Penis (males) — ejaculate
Anus — feces
35

This is the site on the reservoir of infection through which the
infectious agent escapes from the reservoir. This includes:
Gastrointestinal Tract(GIT) e.g. Typhoid fever, amoebiasis,
etc.,
Respiratory Tract e.g. Tuberculosis, common cold
Skin and Mucous membrane e.g. STDS, Scabies, ringworm

4. Mode of Transmission of Infectious Agents
 It is the mechanism by which an infective agent are conveyed

to a susceptible host
 There are two major modes
 Direct Transmission
 In-direct Transmission

A. Direct Transmission
 immediate transfer of the agent from a reservoir to a susceptible

host by direct contact or droplet spread.
i. Direct contact: The contact of skin, mucosa, or conjunctiva

with infectious agents directly from person or vertebrate animal,
 Mechanism: via touching, kissing, biting, passage through the

birth canal, or during sexual intercourse.
 Example: HIV, rabies, gonorrhea

ii. Direct projection: projection of saliva droplets by coughing,
sneezing, singing, spitting or talking.
 Example: common cold
iii. Trans-placental: Transmission from mother to fetus.
 Example: syphilis

Vertical Transmission
• Transplacental
– TORCH Complex
• Toxoplasma • During Birth
• Other (syphilis, VZV) – Group B
• Rubella Streptococcus
• Cytomegalovirus – Herpes
– Gonorrhea
• Herpes
– Listeria
• Breastfeeding
– Parvovirus B-19
– HIV
– HIV
– HTLV-1, HTLV-2
– Others?
92
The Infectious Disease… components
B. Indirect Transmission
 an agent is carried from reservoir to a susceptible host by
 suspended air particles or
 animate (vector-mosquitoes, fleas, ticks...) or
 inanimate (vehicle-food, water, biologic products,

fomites) intermediaries.

 Vehicle-borne:
 Transmission occurs through indirect contact with inanimate

objects (fomites): by
 bedding, toys, or surgical instruments; as well as
 through contaminated food, water, IV fluids etc.
 Vehicle-borne
 food or water – Salmonella, hepatitis A
 fomites, biologic products – coxsackievirus

Some Causes of Food-borne, Waterborne Diseases
 Food-borne  Waterborne
– Bacillus cereus – Entamoeba histolytica
– Campylobacter jejuni – Cryptosporidium parvum
– Clostridium botulinum – Giardia lamblia

– Clostridium perfringens – Hepatitis A
– Legionella pneumophila
– Cyclospora cayetanensis
– E. coli O157:H7 – Vibrio cholera
– Hepatitis A – Parasitic
– Schistosoma
– Listeria monocytogenes
– Dracunculus
– Norovirus
– Salmonella species – Taenia solium
– Staphylococcus aureus – et al.
– Yersinia enterocolitica
95
 Vector-borne: The infectious agent is conveyed by an
arthropod to a host.
 Vectors may be biological or mechanical.
 Biological vector: If the agent multiplies in the vector
before transmission.
 Salivarian E.g. Malaria by the anopheles mosquito
 Stercorarian E.g. Typhus by ticks or lice
 Mechanical vector: If the agent is carried by the leg or

proboscis. E.g. Trachoma by flies
Vectors and Vector-borne Diseases
.
Pathogen Vector Disease
West Nile virus mosquito WNV
Encephalitis
flea Plague
Yersinia pestis
Borrelia burgdorferi tick Lyme disease

Rickettsia prowazekii louse, tick Epidemic typhus
Plasmodium falciparum mosquito Malaria
Trypanosoma cruzi tsetse fly Chagas‘ disease
Onchocerca volvulus Simulium fly River blindness
97
 Non vector intermediate host:
 Hosts not playing an active role in transporting the agent to

humans.
 A host in which the agent undergoes an asexual phase of its

development.
Example: Aquatic snails in the transmission of

schistosomiasis.

5. Portals of Entry
 Eye (conjunctivitis)
 Mouth – food-borne, water-borne, fecal-oral
Susceptible Host (via
e.g. Typhoid fever, amoebiasis, etc. portal of entry)
 Nose/mouth – airborne, droplet (tuberculosis)

e.g. Tuberculosis, common cold
 Skin e.g. Scabies, ringworm
 Genital tract, anus (STIs)
 Bloodstream (hepatitis B, HIV) 44
 injury site (tetanus),

 urethral (chlamydial infection),
6. Susceptible host
 This is a person who is highly likely to acquire infection when exposed
to the agent
 Host- a person or animal that harbors an infectious agent under natural
conditions
 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 in the
interaction of genetic endowment with the environment over the entire
life span.
E. g: Genetic factors: sex, blood type, etc.
 Environmental factors: immunity acquired as a result of past infection
 At the community level: Host resistance at the community
(population) level is called herd immunity
 Herd immunity can be defined as the resistance of a
community (group) to invasion and spread of an infectious
agent, based on the immunity of a high proportion of
individuals in the community
 The high proportion of immunes prevents transmission by
highly decreasing the probability of contact between
reservoirs and susceptible hosts.

 Herd immunity best operates when

 Single reservoir is involved
 Mode of transmission is direct
 There is total immunity
 No shedding of agent by immune host
 Uniform distribution of immunes
 No overcrowding

Levels of Disease Prevention
 It is important to the levels in details for implementing
interventions that prevent or ameliorate infections.
 It involves the interruption or slowing of disease
progression through appropriate intervention.
 Epidemiology plays a central role in disease prevention by
identifying modifiable causes of disease and their risk
factors.

Cont…
There are several stages during the course of a disease where

we can intervene to control the disease.
 Three levels, (Primary, Secondary, and Tertiary)
I. Primary Prevention
The objectives here are to promote health, prevent
exposure, and prevent the occurrence of disease.

Cont…
A. Health Promotion (Primordial):
• This consists of general non-specific interventions that
enhance health and the body‘s ability to resist disease.
• The improvement of socio-economic status through the
provision of adequate:
– education,
– affordable and adequate housing and clothing, etc.

Cont…
B. Prevention of exposure:
• Specific to individual diseases compared to primordial
prevention
Example
– Provision of safe and adequate water, proper excreta
disposal
– Vector control;
– Provision of a safe environment at home
– Use of bed nets
– Consistent use of condom

Cont…
C. Prevention of Disease:
 This is when the intervention aims to prevent the initiation of
disease, in persons who may already be exposed to the agent
 A n example of intervention, which acts at this stage is
immunization.
 Sometimes it may be difficult to differentiate interventions in what
form of prevention they involved.

Cont…
II. Secondary Prevention:
• Interventions that act after the biological onset of a disease, but
before permanent damage sets in.
• The objective here is to stop or slow the progression of disease and
to prevent or limit permanent damage.
• Strategy at this stage is through early detection and treatment of
disease.

Cont…
III. Tertiary Prevention
 Intervention that acts after permanent damage has set in, and
the objective of tertiary prevention is to limit the impact of
the damage.
 The impact can be physical, psychological social (social
stigma or avoidance by others), and financial.
 Strategy at this stage in general is rehabilitative.

Exercise
1. How do we prevent malaria?
 Primary
 Secondary
 Tertiary
2. How do we prevent STIs?

 Primary
 Secondary
 Tertiary

Disease control
 Vaccination
 Shifts individuals from susceptible to recovered state.
 For some diseases this shift is not permanent.
 Therapy increases the rate of flow out of the infected states
 Permanent cure moves the individual from the infected
to the recovered state.
 Temporary cure moves the individual from the infected
to the susceptible state.
 Education through behavioral change, reduces shifting
from susceptible to infected.

Cont…
.
Education
Susceptible Infected
Therapy
Vaccination Recovered Education

Estimating Transmission
 Transmission probability is the probability, given that there
is contact between an infective source and susceptible host,
successful transfer of infective agent will occur so that the
susceptible host becomes infected.
 There are different ways of estimating transmission
probability; including secondary attack rate, reproductive
number, and the like.

Secondary Attack Rate (SAR)
 Measures the spread of disease among contacts of an
index case.
 The index cases are excluded from the numerator and
denominator
 Index case: The case that brings a people (household) to the
attention of the public health personnel.

Time Periods for Estimating Household
Secondary Attack Rate
.
Onset of
Primary
Case
Maximum Maximum
Definition of Infectious Period Incubation Period
Time Interval
Minimum Time
Secondary Cases
Incubation Period
Primary Co-Primary Secondary Secondary Tertiary

Case Case Case Case Case
1 2 3 4 5
Onset of Cases in
Households
Time

Example on SAR
 Consider an outbreak of shigellosis in which 18 persons in 18
different households all became ill. If the population of the
community is 1,000, then the overall attack rate is 18 /1,000 x
100% = 1.8%. One incubation period later, 17 persons in the
same households as these ―primary cases developed
shigellosis. If the 18 households included 86 persons, calculate
the secondary attack rate.

Example Cont…
.

Basic Reproductive Number
• Basic reproductive number, denoted by R0, is:
– the expected number of new infected hosts that one infectious
host will produce during his (or her) period of infectiousness in a
large, susceptible population.
– Example: if R0 = 9 for measles in a population, then one

person with measles introduced into that population can be
expected to produce 9 (nine) secondary infections before
recovering.

Cont…
• Basic reproductive number, R0
 Does not include the new cases produced by the secondary cases
or further down the chain.
 Does not include secondary cases who do not become infectious.

Cont…
• Basic reproductive number, R0
– for an epidemic to occur, R0 must be > 1
– if R0 < 1, the disease will not be reproduced, so an
epidemic will not occur
– R0 is a composite of three important aspects of infectious
diseases:
• the proportion of susceptible contacts, C
• transmission probability, β
• duration of infectiousness, d.
 R0= C x β x d

Effective Reproductive Number
• R0 usually assumes all contacts are susceptible.
• In reality, there are some people immune of the disease

under study.
• In these circumstances, the number of new cases infected
persons (R) are below the R0.
• This reproductive number is called effective reproductive

number and is denoted by R.

Cont…
 Effectivereproductive number then will be the product of R0
and the proportion of susceptible people in the community.
R = R0 x S (S = proportion of susceptible)
Example:
• Let R0 of measles is 9, and half the population is not
immunized, then R = 9 x ½= 4.5.
• A case of measles will infect about 4.5 new cases before
getting recovery.

Cont…
 If the proportion of susceptible is very low, the probability
of contact with an index case will be low (transmission may
not occur).
 If immunization gives complete/lifelong immunity among
all the immunized, and if “ f” is the proportion of
immunized individuals, the proportion of susceptible will be
(1- f)
 R = R0 x (1-f)
 To eliminate the disease, R should be below 1
 R = R0 x (1-f) <1; f = 1 - 1/R0

Cont…
• Example
 Let R0 for measles is 9.0, proportion of immunization that is
needed to stop transmission of the disease in the community
will be:
 If we immunize 89% of the population we can stop transmission

of measles in a community, which is called herd immunity.

Cont…
 Summary …
 an epidemic is unlikely to occur if the initial proportion
of the population susceptible, (1-f), is less than 1/R0
 if (1-f) are susceptible, f is immune; thus, the critical
proportion of individuals to be vaccinated to achieve herd
immunity is:

Values of R0 for Well-known Infectious Diseases
Disease Transmission R0
HIV/AIDS Sexual 2-5
Diphteria Saliva 6-7
Influenza Air-born Droplet 2-3
Measles Air-born 12-18
Mumps Air-born Droplet 4-7
Pertussis Air-born Droplet 12-17
Polio Feco-Oral Route 5-7
Rubella Air-born Droplet 5-7
SARS Air-born Droplet 2-5
Smallpox Social Contact
6-7

Cont…
 So knowing the R0 for an infectious disease outbreak can be

helpful if we are implementing control measures:
 vaccination for meningococcal disease
 contingency planning for an influenza epidemic

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Introductions to Epidemiology (2) (1)ggfddssdfgygssrtyyyytrdsertyyfdedfghj

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Epidemiology

BY: Wakgari Mosisa (BSc , MPH in Epidemiology)

Basic Concepts in Community Health

2 BY Wakgari Mosisa . (BSc, MPHE) Jul 8, 2024

The problem here is to evaluate the health of a

These approach requires techniques and skills in

6 BY Wakgari Mosisa . (BSc, MPHE) Jul 8, 2024

In community medicine, the community replaces the

Community diagnosis- is the process of identification and

7 BY Wakgari Mosisa . (BSc, MPHE) Jul 8, 2024

9 BY Wakgari Mosisa . (BSc, MPHE) Jul 8, 2024

11 BY Wakgari Mosisa . (BSc, MPHE) Jul 8, 2024

Among the greatest global achievements:

Core Public Health Disciplines;-

13 BY Wakgari Mosisa . (BSc, MPHE) Jul 8, 2024

Public Health is also concerned with:

 EPI DEMO LOGOS

The study of anything that happens to people

15 BY Wakgari Mosisa . (BSc, MPHE) Jul 8, 2024

 The study of the distribution and determinants of health-related

16 BY Wakgari Mosisa . (BSc, MPHE) Jul 8, 2024

Approaches problems systematically and

Uses rigorous techniques and methods to produce

Compares observed vs. expected

17 BY Wakgari Mosisa . (BSc, MPHE) Jul 8, 2024

What* Who Where

Why / and How

18 BY Wakgari Mosisa . (BSc, MPHE) Jul 8, 2024

 Why / How = Cause, Risk factors, modes of transmission

* and How Many

19 BY Wakgari Mosisa . (BSc, MPHE) Jul 8, 2024

20 BY Wakgari Mosisa . (BSc, MPHE) Jul 8, 2024

Hallmark = Comparison group

21 BY Wakgari Mosisa . (BSc, MPHE) Jul 8, 2024

• epidemics of infectious diseases

Current domain much broader

• acute and chronic diseases

22 BY Wakgari Mosisa . (BSc, MPHE) Jul 8, 2024

 Unit of observation is groups rather than individuals

24 BY Wakgari Mosisa . (BSc, MPHE) Jul 8, 2024

Main Goal Treatment Determine cause,

Action Treatment Intervention

25 BY Wakgari Mosisa . (BSc, MPHE) Jul 8, 2024

 Not just the study of…

26 BY Wakgari Mosisa . (BSc, MPHE) Jul 8, 2024

6 1920 Goldberger published a descriptive field study showing the dietary

28 BY Wakgari Mosisa . (BSc, MPHE) Jul 8, 2024

30 BY Wakgari Mosisa . (BSc, MPHE) Jul 8, 2024

A. “Disease human population does not occur at random”

B. “Human disease has causal and preventive factors

 That can be identified through systematic investigation of

 Allows for the study of causal and preventive factors

31 BY Wakgari Mosisa . (BSc, MPHE) Jul 8, 2024

 Descriptive Epidemiology – Defines the amount and

 Analytic Epidemiology – Analyses the causes or determinants

32 BY Wakgari Mosisa . (BSc, MPHE) Jul 8, 2024

BY Wakgari Mosisa . (BSc, MPHE) Jul 8, 2024

34 BY Wakgari Mosisa . (BSc, MPHE) Jul 8, 2024

-Rabies virus is sufficient for developing clinical rabies

35 BY Wakgari Mosisa . (BSc, MPHE) Jul 8, 2024

There are different theories :

37 BY Wakgari Mosisa . (BSc, MPHE) Jul 8, 2024

A causal pathway may be direct or indirect:

 Direct causation, A causes B without intermediate effects