Infection

Infection
Transmission
Transmission
Isolation
Isolation

Infectious Disease Epidemiology Section

Office of Public Health
Louisiana Dept of Health & Hospitals
504-219-4563
http://www.dhh.louisiana.gov/offices/?id=249

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 Spectrum: No Exposure - Exposure -
Colonization - Infection - Disease

Host + Infectious agent What is “Exposed” ?

→ No foothold: Exposed •Means of transmission:
→Foothold, no reaction Being in the same room as
Colonization an infectious tuberculous
Carrier patient or with a person
→Foothold: epithelial attachment with HIV
→Multiplication: Infection • Specific information:
→Direct cytotoxicity Eating a meal or eating the
→Toxins contaminated food item?
→Tissue disruption Exposure definition relies
→Tissue injury on information that may
→Dissemination not be all known
→Asymptomatic
→Symptomatic
 Flora at Colonization Sites
OROPHARYNX NASOPHARYNX CONJUNCTIVA
Streptococcus viridans group Staphylococci Staphylococci
Streptococcus pyogenes Streptococci Corynebacteria
Streptococcus pneumoniae Moraxella catarrhalis Haempphilus
Staphylococci Neisseria spp
Moraxella catarrhalis Haemophilus spp SKIN
Neisseria spp Staphylococci
Corynebacterium spp Corynebacteria
UPPER INTESTINE
Haemophilus spp Propionibacteria
Streptococci
Anaerobes: Bacteroides Candida
Lactobacillus spp
Candida albicans Malassezia furfur
Candida spp
GENITOURINARY TRACT
Staphylococci, Streptococci LOWER INTESTINE
Enterococci Aerobic G- bacilli: E.coli, Klebs
Lactobacillus spp, Corynebacterium Enterobacter, Proteus, Serratia
Neisseria spp, Anaerobes Providencia, Bacteroides, Anaerobic
Candida albicans Enterococci, Streptococci, Candida
Transmission
Chain of Infection
Missing Links
 Roles in Transmission

Foot & Mouth Disease

z Animal disease
z Indicator: Cattle Symptomatic
z Maintenance: Sheep, goat Asymptomatic, reservoir
z Amplifier: Pig High transmitter
1 Million virus /mL air breathed
 Mode of Transmission
Classification by Portal of Entry

ÎRespiratory
ÎGastrointestinal
ÎSkin
ÎGenital
ÎIntrauterine or
transplacental
ÎUrinary
ÎPersonal contact
ÎWater and food
ÎArthropod borne
 Transmission:
Source of Infectious Material

z Blood: splashed on medical

employee...
z Internal Body fluids Blood, internal
(cerebrospinal, pericardial, fluids and genital
pleural, peritoneal, synovial, fluids do contain
amniotic): medical setting blood borne
pathogens (HIV,
z Genital fluids (vaginal, HBV, HCV, CMV)
prostatic secretions, semen):
sexual contact
HBV, HSV to the newborn
occurs during delivery
 Transmission:
Source of Infectious Material

z Transplacental transfer of blood: syphilis

z Secretions: saliva, nasal discharge, sweat, tear,
breast milk
z Excretions: urine (schistosomiasis,
leptospirosis), feces (numerous enteropathogens)
z Mucosal membranes (nasal, oropharyngeal,
rectal, genital): sexual contact, delivery
z Skin, squames
z Tissue: Transplant, grafts, blood transfusion,
blood components
z Bites
 Gastro Intestinal / Fecal Oral Route
(Contact)

Transmission by the fecal-oral route is the second most

important mode of transmission after the respiratory tract

z excreted by the feces Viruses with envelopes do not survive

exposure to hydrochloric acid in the
z transmitted to the oral stomach, bile acids in the duodenum,
portal of entry through salts and enzymes of the gut. Small
ƒ contaminated food enterovirus without envelope
ƒ contaminated (Norwalk agent, rotavirus, polio and
water, milk, drinks coxsackie are able to resist. Hepatitis
ƒ hands A and E are also transmitted by the
fecal-oral route.
ƒ flies
 Gastro Intestinal / Fecal-Oral Route
(Contact)

z Site of entry:
- oropharynx for some microorganisms
- intestinal tract for most viruses

z Surviving through the upper GI tract

is essential
 Transmission by Gastrointestinal Route
Fecal-Oral Route

z Typhoid fever
z Shigella
z Cholera
z Polio
z Coxsackie, Echo, Reo
z Norwalk agent
z Rotavirus
z Hepatitis A, Hepatitis E
 Gastrointestinal Transmission /
Animal Host and Contaminated Food Product

Infections transmitted:
z Salmonella
z Campylobacter
z Yersinia
z Listeria

Salmonellas infect a wide variety of domestic animals,

birds and other wildlife.
Food derived from salmonella infected animal (eggs,
dairy product, meat) are the major source of infection
if improperly prepared.
Salmonella is less often transmitted by water or direct
contact.
 Food Poisoning

Food poisoning overlaps both classes

of gastrointestinal transmission
z food from infected animal & improperly
prepared: eggs, chicken with
salmonella, listeria in unpasteurized
milk

z food contaminated in environment:

Vibrio vulnificus or Vibrio cholerae in
raw oysters

z food contaminated during preparation

from an infected food item: potato
salad contaminated by Salmonella from
raw chicken

z food contaminated by human source:

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:

z Needle injection, cut during a surgical
procedure, accidental cut, crushing injury…
z Bite: rabies
z Arthropod bite for vector borne infections:
malaria, filariasis…

Some parasites are able to penetrate directly

through the intact skin: larvae of hookworm,
cercariae of schistosoma
 BBP & Skin Penetration

z Blood borne pathogens ( HBV, Risk of

HCB, HIV) does not penetrate if infection after
percutaneous
blood was splashed exclusively on exposure to
intact skin blood from
infected
patients:
z Need injury to the skin: with a •HBV 30%
hollow bore needle or other sharp •HCV 3%
object (lancet, glass, scalpel) •HIV 0.3%
contaminated with blood to cause
an infection
 BBP & Skin Penetration

z Solid needle does not carry sufficient

quantities of blood to cause an infection ( ± )

z Viral titer is best predictor of risk of

infection

z Mucosal membranes allow BBP penetration.

Data from 21 studies worldwide on mucosal
membrane exposure of 1107 HCW showed
only one conversion: risk of 0.09%, 95%CI =
0.006% to 0.5%.
 Sexual Transmission
(Mucous Membrane Transmission)
Neisseria gonorrheae, Chlamydia
z Bacteria and viruses trachomatis
present in the Treponema pallidum
genital fluids and Hemophilus ducreyi
on the mucosal Mycoplasma hominis, Ureaplasma
membranes urealyticum
Calymnatobacterium granulomatis
z Transmitted to the ± Shigella spp, Campylobacter spp
mucosal membranes ± Group B streptococci
of the partner ±Bacterial vaginosis associated bacteria
during sexual acts: HSV Herpes simplex virus 1 and 2
membranes CMV Cyto megalo virus or herpes virus 5
Hepatitis B virus
involved Human papilloma virus
- vagina Molluscum contagiosum virus
- penis HIV Human immunodeficiency virus 1 and 2
- anus and rectum Trichomonas vaginalis
- oropharynx ± Entamoeba histolytica, Giardia lamblia
Phtirius pubis
Sarcoptes scabei
 Perinatal Transmission
(Mucous Membrane Transmission)

Infections occur when the

newborn goes through
the birth canal, from the Neisseria gonorrheae
cervix or vagina to the
newborn. Chlamydia trachomatis
HBV
HSV
 Transplacental Transmission
or Vertical Transmission

Microorganisms
present in the blood of the
Syphilis
mother go through the Toxoplasma
placenta to infect the CMV, HBV
fetus. HIV
In some cases it is difficult HSV
to differentiate between Rubella
perinatal or transplacental
transmission, since both
Varicella
modes of transmission are
known to occur.
 Arthropod Borne Transmission

may transmit infections by two Mosquitoes,

mechanisms: flies, fleas, true
bugs, ticks, lice
z Passive transmission:
-the insect acts as a live syringe
- no incubation time
- no multiplication while carried by
the arthropod
- not specific, wide variety of
microorganisms
- not very inefficient
 Arthropod Borne Transmission

z Active transmission:
- multiplication of microorganisms in
arthropods
- may be very effective: multiplied 1000 to
million
- requires a period of multiplication in the
arthropod
- very specific: some microorganisms &
arthropods
 Main Modes of Transmission

Isolation guidelines in Institutions are based on these

AIRBORNE

DROPLET
AND Vector borne,
Common source: CONTACT
Water, Food,
Direct Indirect
Equipment, Rx
 Droplet Transmission

A droplet of will fall in Droplets above

h it 10 μ m are
c t trapped in the
100 μm
ire ft. 10 seconds
D 3 nose and
40 μm 1 minute usually do not
make it to the
20 μm 4 minutes bronchi

10 μm 20 minutes

5-10 μm 30-45 minutes

May be inhaled
to alveoli
≤ 5 μm Droplet nuclei
 Transmitted by Droplets

z Hemophilus influenzae
z Meningococci
z Pneumococcal infections (invasive, resistant)
z BACTERIAL RESPIRATORY Infections
- Diphtheria, Pertussis, pneumonic plague,
Mycoplasma pneumoniae
- Strepto pharyngitis, pneumonia, scarlet fever
z VIRAL RESPIRATORY Infections
- Adenovirus, Influenza, Mumps, Parvovirus,
Rubella
z ANY PAROXYSMAL COUGH (Pertussis?)
 Transmitted Airborne
z Droplet nuclei = droplets less than 5 µ in
diameter
- from evaporation of larger droplets
- or from direct formation during coughing,
speaking, singing
z Transmission may occur over long distance

Transmitted by D.N.
z Tuberculosis (Infectious)
z Suspects of TB: request
sputum smear
z Measles
z Varicella
 Transmitted by Contact

• Gastrointestinal, respiratory, skin, wound

infections
• Colonization with multidrug resistant bacteria
• Enteric infections, enteroviral infections in infants
• RSV, Para influenza
• Infectious skin infections: HSV, impetigo, cellulitis,
scabies, staphylococcal furunculosis
• Viral hemorrhagic conjunctivitis, viral fevers
• Some respiratory infections, bronchiolitis in infants,
children
• Abscess, draining wound
 Skin Hand Flora a ns s h ed
Hu m
0, 0 00 4 to
,0 0 a y (
300 mes/ d
RESIDENT FLORA qua
s
z Survives on the skin more than 24 hours 5 mm)
z Not easily removed, hours of scrubbing 2 rr y
c a
z Complete sterilization impossible l e to
a b
z Low virulence c te ria
ba
z Staphylococci, diphteroides
z mostly Gram +
z very few Gram – TRANSIENT FLORA
- Survive on skin less than 24 hours
- Easily removed with soap and water
- Acquired during contacts with
contaminated areas mouth, nose, perineal
area, genitals, anal area
- Catheter, bedpan, urinal, patient care
casual contact
- May have high virulence Enterobacteria,
Gram - bacilli, Pseudomonas...
Isolation
Precaution System CDC 1996

IS AN EXPANSION OF
UNIVERSAL PRECAUTIONS
 Standard Precautions
Same concept as UNIVERSAL PRECAUTIONS
z Precautions should be taken for any contact with Blood and
Body Fluid (UP)
z AND for any contact with
- secretions and excretions
- mucous membranes
- damaged skin
- contaminated environment and equipment

If it is wet, red or dirty

Take Precautions
 Hand Washing

z Wash hands
5 s
-1
z Alcohol based hand rubs 10
Gloves

ES
LO V
A CE
G E PL
O TR ING
O N A SH
D D W
N
HA
 Surgical Masks, Eye Protection
Face Shields

z For Personnel
- protect from splashes
/sprays of BBF/ S E
- to prevent large droplets
(<5μ) on/from patient

z For patients
- to prevent emission of
droplet (large and droplet
nuclei)
 Airborne Precautions
Small droplets (<5m) emitted when coughing &
performance of procedures

z ROOM WITH
VENTILATION CONTROL
- Negative air pressure
- >6 air exchange /hour
- HEPA filtered or
exhaust out

z PERSONAL RESPIRATOR

z PATIENT wears surgical

mask if coughing & when
transported
Airborne Precautions
Personal Respirator

z For Personnel
z In AIRBORNE
ISOLATION ONLY
z To prevent
inhalation of
droplet nuclei
z Main leak comes
from poor fit
around face