You are on page 1of 329

Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.

2004 4:56am page i

Communicable Disease Epidemiology and Control

A Global Perspective
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 4:56am page ii

This book is dedicated to Michael Colbourne (19191993), malariologist, teacher and

previously Dean at the Universities of Hong Kong and Singapore, who while at the
London School of Hygiene and Tropical Medicine gave me considerable help in its
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 4:56am page iii

Communicable Disease
Epidemiology and Control
A Global Perspective

2nd Edition


Formerly of
London School of Hygiene and Tropical Medicine, UK

CABI Publishing
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 4:56am page iv

CABI Publishing is a division of CAB International

CABI Publishing CABI Publishing

CAB International 875 Massachusetts Avenue
Wallingford 7th Floor
Oxfordshire OX10 8DE Cambridge, MA 02139
Tel: 44 (0)1491 832111 Tel: 1 617 395 4056
Fax: 44 (0)1491 833508 Fax: 1 617 354 6875
E-mail: E-mail:

R. Webber 2005. All rights reserved. No part of this publication may be reproduced in
any form or by any means, electronically, mechanically, by photocopying, recording or
otherwise, without the prior permission of the copyright owners. All queries to be
referred to the publisher.

A catalogue record for this book is available from the British Library, London, UK.

Library of Congress Cataloging-in-Publication Data

Webber, Roger.
Communicable disease epidemiology and control: a global perspective /Roger Webber. - -2nd ed.
p. cm.
Includes index.
ISBN 0-85199-902-6 (alk. paper)
1. Communicable diseases- -Epidemiology. 2. Communicable diseases- -Prevention. I.
RA643.W37 2005
614.5- -dc22

ISBN 0 85199 902 6

Typeset by Kolam Information Services Pvt. Ltd, Pondicherry, India

Printed and bound in the UK by Biddles Ltd, Kings Lynn
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 4:56am page v


Introduction x

1 Elements of Communicable Diseases 1

1.1 What are Communicable Diseases? 1
1.2 The Agent 2
1.3 Transmission 7
1.4 Host Factors 11
1.5 The Environment 12

2 Communicable Disease Theory 21

2.1 Force of Infection 21
2.2 Epidemic Theory 22
2.3 Endemicity 28
2.4 Quantitative Dynamics 30

3 Control Principles and Methods 32

3.1 Control Principles 32
3.2 Control Methods Vaccination 34
3.3 Environmental Control Methods 40
3.4 Vector Control 52
3.5 Treatment and Mass Drug Administration 61
3.6 Other Control Methods 61

4 Control Strategy and Organization 62

4.1 Investigation of an Outbreak 62
4.2 Surveillance 66

Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 4:56am page vi

vi Contents

4.3 Control and Eradication 68

4.4 Campaigns and General Programmes 69
4.5 Control Organization 69

5 Notification and Health Regulations 73

5.1 International Health Regulations 73

5.2 National Health Regulations 74
5.3 Special Surveillance 74
5.4 Vaccination Requirements 74

6 Classification of Communicable Diseases 77

7 Water-washed Diseases 80

7.1 Scabies 80
7.2 Lice 81
7.3 Superficial Fungal Infections (Dermatophytosis) 82
7.4 Tropical Ulcers 83
7.5 Trachoma 84
7.6 Epidemic Haemorrhagic Conjunctivitis 86
7.7 Ophthalmia Neonatorum 87
7.8 Other Infections 88

8 FaecalOral Diseases 89

8.1 Gastro-enteritis 89
8.2 Cryptosporidosis 92
8.3 Cholera 92
8.4 Bacillary Dysentery (Shigellosis) 97
8.5 Giardia 98
8.6 Amoebiasis 98
8.7 Typhoid 100
8.8 Hepatitis A (HAV) 103
8.9 Hepatitis E (HEV) 104
8.10 Poliomyelitis (Polio) 105
8.11 Enterobius (Pin Worm) 107

9 Food-borne Diseases 108

9.1 Food Poisoning 108

9.2 Campylobacter Enteritis 111
9.3 The Intestinal Fluke (Fasciolopsis) 112
9.4 The Sheep Liver Fluke (Fasciola hepatica) 115
9.5 The Fish-transmitted Liver Flukes 115
9.6 The Lung Fluke 117
9.7 The Fish Tapeworm 118
9.8 The Beef and Pork Tapeworms 119
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 4:56am page vii

Contents vii

9.9 Trichinosis 121

9.10 Other Infections Transmitted by Food 122

10 Diseases of Soil Contact 124

10.1 Trichuris (Whip Worm) 124

10.2 Ascaris 125
10.3 Hookworms 127
10.4 Strongyloides 130
10.5 Tetanus 132

11 Diseases of Water Contact 136

11.1 Schistosomiasis 136

11.2 Guinea Worm 142

12 Skin Infections 144

12.1 Chickenpox/Shingles (Varicella) 144

12.2 Measles 145
12.3 Rubella 149
12.4 Mumps 150
12.5 Streptococcal Skin Infections 151
12.6 Leprosy 152

13 Respiratory Diseases and Other Airborne Transmitted Infections 156

13.1 Tuberculosis 156

13.2 Acute Respiratory Infections (ARI) 164
13.3 Influenza 166
13.4 Whooping Cough (Pertussis) 167
13.5 Diphtheria 168
13.6 Meningococcal Meningitis 169
13.7 Haemophilus influenzae (Meningitis and Pneumonia) 172
13.8 Pneumococcal Disease 172
13.9 Otitis Media 175
13.10 Acute Rheumatic Fever 176

14 Diseases Transmitted Via Body Fluids 178

14.1 Yaws 178

14.2 Pinta 179
14.3 Endemic Syphilis 181
14.4 Venereal Syphilis 181
14.5 Gonorrhoea 183
14.6 Non-gonococcal Urethritis (NGU) 185
14.7 Lymphogranuloma Venereum 186
14.8 Granuloma Inguinale 187
14.9 Chancroid 187
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 4:56am page viii

viii Contents

14.10 Genital Herpes 188

14.11 Human Papilloma Virus (HPV) 188
14.12 Human Immunodeficiency Virus (HIV) 189
14.13 Hepatitis B (HBV) 193
14.14 Hepatitis C (HCV) 194
14.15 Hepatitis Delta (HDV) 195
14.16 Ebola Haemorrhagic Fever 196
14.17 Marburg Haemorrhagic Fever 196
14.18 Lassa and CrimeaCongo Haemorrhagic Fevers 197

15 Insect-borne Diseases 198

15.1 Mosquito-borne Diseases 198

15.2 Arboviruses 199
15.3 Japanese Encephalitis (JE) 203
15.4 Dengue 204
15.5 Yellow Fever 206
15.6 Malaria 208
15.7 Lymphatic Filariasis 219
15.8 Onchocerciasis 228
15.9 Loiasis 234
15.10 African Trypanosomiasis (Sleeping Sickness) 234
15.11 American Trypanosomiasis (Chagas Disease) 241
15.12 Leishmaniasis 244

16 Ectoparasite Zoonoses 249

16.1 Plague 249

16.2 Typhus 254
16.3 Louse-borne Relapsing Fever 260
16.4 Tick-borne Relapsing Fever 260
16.5 Diseases Transmitted by Hard Ticks 263
16.6 Tick Typhus/Fever 265
16.7 Rocky Mountain Spotted Fever 266
16.8 Lyme Disease 266
16.9 Arboviruses 267

17 Domestic and Synanthropic Zoonoses 269

17.1 Rabies 269

17.2 Hydatid Disease 272
17.3 Toxocariasis 275
17.4 Larva Migrans 275
17.5 Toxoplasmosis 276
17.6 Brucellosis 277
17.7 Anthrax 279
17.8 Leptospirosis 281
17.9 Lassa Fever 282
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 4:56am page ix

Contents ix

18 New and Potential Diseases 284

18.1 The Animal Connection 284

18.2 The Pox Diseases 287
18.3 Nipah and the Lyssa Viruses 287
18.4 Arboviruses 288
18.5 Bioterrorism 288

19 List of Communicable Diseases 290

Index 303
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 4:56am page x


Since the first edition of this book, commu- rest of the world. Guinea worm has been
nicable diseases have caught the attention of cleared from most of the endemic area by
the world with the appearance of the severe simple improvements in water supply,
acute respiratory syndrome (SARS), bovine a tribute to rudimentary health measures.
spongiform encephalopathy (BSE or mad Leprosy, the disease of antiquity, due to an
cow disease) and new variant Creutzfeld active search and find programme has de-
Jakob disease (CJD), as well as the relentless creased to such a degree that it is no longer
increase in HIV infection. The vulnerability a health problem in many countries. Chagas
of the human population to these new dis- disease, the awful debilitating condition
eases and the difficulty that the medical ser- that has troubled South and Central America
vices have had in controlling them has for such a long time, has been declared
revealed the seriousness of communicable eradicated from Uruguay, Chile and Brazil,
diseases. Also, the use of anthrax as a with Venezuela and Argentina soon to
weapon and the potential use of other micro- follow. This has been by simple control of
organisms in this way has generated the fear the vector and improvement in standards of
and dread that developed when the great housing, attention to detail rather than some
plagues forged their relentless passage new invention.
across the world. But communicable dis- The appearance of new diseases and the
eases have always been with us not a ser- persistence of infections that have always
ious problem in developed countries, but been with us mean that a knowledge of com-
the main cause of death and infirmity in municable diseases is still necessary. Many
the developing world. Lower respiratory in- developed countries felt that communicable
fections are still the major cause of death, diseases were no longer a health problem,
and malaria, despite all the efforts of control, but they are as important as they have ever
causes considerable mortality every year. been. This is no more so than in the develop-
The news is not all bad though. Since ing world where the burden of communic-
the first edition was published, poliomyel- able diseases has always been a major
itis has been eradicated from Europe, the concern.
Americas and the Western Pacific, and con- While individuals fall sick and require
tinued good progress is being made in the the expertise of the medical profession, it is

Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 4:56am page xi

Introduction xi

the overall assessment of the cause of dis- parasitology are often taught as separate dis-
eases and how to control them that will most ciplines, but since they form such an inte-
rapidly solve the problem in the commu- gral part of many communicable diseases,
nity. Indeed, communicable diseases are the essentials have been included.
community problems and need to be looked The range of communicable diseases
at in this way. Epidemiology is the science occurring throughout the world is consider-
of communities, looking at many individ- able. A comprehensive list is given in Chap-
uals to try and discover common features ter 19, but only those of importance are
in them. From this analysis, the cause and covered in detail in the main part of the
characteristics of a disease can be worked book. Emphasis is placed on the developing
out. The emphasis in this book is, therefore, countries, as this is where most communic-
epidemiological. able diseases are found. It is hoped this
Learning about these diseases one by selection of diseases provides a more repre-
one is a long and complicated process that sentative perspective of the world situation
the doctor needs to undertake in order to (Table 1.1).
understand how to treat the individual. Whilst communicable diseases mainly
However, it is the method of transmission affect the developing world, new and emer-
that is the key to control and several diseases gent diseases, such as new variant CJD and
often share the same method of transmis- SARS have re-awakened the developed
sion. This allows diseases to be grouped to- countries to the importance of these infec-
gether so that knowing the characteristics of tions. This has now become a major issue, so
one means that any of the diseases in the a new chapter has been added to this second
group can probably be controlled in a simi- edition. Also, although most diseases arise
lar way. While there are always exceptions, within the same country, there is an inter-
grouping them should make it easier to learn national importance as more people travel to
about all the many diseases that afflict us, different countries and exotic diseases are
and this is one of the intentions of this book. imported. Concern has been raised that cli-
This seems to have been borne out, as the mate change due to global warming could
first edition has been used as a course book provide conditions for diseases to increase
for several teaching programmes and it is their range and affect countries where they
hoped that changes made in this second edi- have not normally been a problem, so a new
tion will make it even more suitable. section has been added to this edition.
Communicable diseases tend to behave While the emphasis of this book is on
in a similar pattern. Such generalizations diseases found in tropical and developing
determine the first chapters, which look at countries, it does seem to have found a
communicable disease theory, formulating useful place in the teaching programmes of
common principles in both epidemiology developed countries and, therefore, a few
and control. Classifying communicable dis- more diseases, more common in developed
ease can be by organism, clinical presenta- countries, have been added. A balance has
tion or system of the body attacked, but the to be achieved though between attempting
epidemiologist is interested in causation, to cover everything superficially or concen-
which is the approach taken here. trating on certain diseases in more depth,
Trying to find similarities can often be and within the constraints of trying to keep
useful, well shown by grouping respiratory this book to a manageable size, it is hoped
diseases into acute respiratory infections the right balance has been achieved.
(ARI), which has produced an important ad- Many of the examples are taken from
vancement in the control of this familiar my personal experience of working in the
problem. Every effort has, therefore, been Solomon Islands and Tanzania, with shorter
made to find common themes to make the periods in South America and various Asian
understanding and learning of communic- countries. Much of what I have learnt has
able diseases easier and as a consequence come from the large number of people who
their management. Also, entomology and have helped and worked with me in these
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 4:56am page xii

xii Introduction

countries. I owe them a considerable debt for the World Health Organization (WHO) and
their wisdom and assistance, help that I by the publishers, CAB International, who
hope I pass on in the following pages. have been my main source. The Internet has
Experience is invaluable, but organiz- changed the whole way of researching for a
ing ones thoughts and developing a critical book and I am most grateful to the many
judgement comes from working in an aca- unknown writers who have contributed to
demic environment and many people in the the various sites I have used. But, the old-
London School of Hygiene and Tropical fashioned way of using books is still neces-
Medicine (LSHTM) have helped me in the sary and I wish to acknowledge the use of
various drafts of this manuscript. I wish to the library in LSHTM and, in particular,
particularly thank John Ackers, David Brad- Brian Furner and John Eyers for all their
ley, Sandy Cairncross, Michael Colbourne assistance.
(who sadly died before the first edition was Many organizations assisted me and
published), Janette Costello, Felicity Cutts, I am especially grateful to WHO for supply-
Paul Fine and Peter Smith. Andrew Tom- ing print quality copies of their many fig-
kins of the Institute of Child Health and Wil- ures. The Department for International
liam Cutting of the University of Edinburgh, Development (DFID) has been my employer
kindly read through sections on the child- in the Solomon Islands, Tanzania, and as a
hood infections. Maurice King gave me con- member of the Tropical Diseases Control
siderable help in the layout of the book and Programme at LSHTM. They have given me
encouragement to persevere with it. Sameen considerable assistance in this entire en-
Sidiqi from the Pakistan Institute of Medical deavour and I would particularly like to
Sciences reviewed the text for use in Asia thank the Health and Population Division
and wrote the section on rheumatic fever. Dr Low Cost Book Programme for a generous
Julie Cliff, who has spent most of her grant towards publishing costs of the first
working life in Africa and teaches at the edition.
University of Maputo, Mozambique, gave In these days of rising prices and com-
me much valuable advice as the manuscript mercial competition, it is becoming increas-
was getting ready for publication. But, one ingly difficult to produce books that are
person to whom I owe special thanks is affordable in developing countries. Every
Brian Southgate, who has been my mentor effort has been made to produce this volume
and friend for many years. He introduced me as cheaply as possible, without sacrificing
to many original concepts and has been a quality, but even so the copy price is higher
kindly guide to being more scientific. than I wished it to be. This is mainly to allow
In this edition, I particularly wish to production at a lower cost for developing
thank Chris Curtis, Peter Godfrey-Faussett, countries, so every copy bought is helping
Richard Hayes and David Warhurst from more copies to be made available where they
LSHTM for helping me update on material are most needed.
I could not find on the helpful websites of

Roger Webber
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 25.10.2004 12:34pm page 1

Elements of Communicable Diseases

1.1 What are Communicable Diseases? tries and non-communicable in the

developed world.
A communicable disease is an illness that is Epidemic diseases devastate whole
transmitted from a person, animal or inani- populations, as when measles ravaged Fiji,
mate source to another person either dir- killing adults as well as children. Popula-
ectly, with the assistance of a vector or by tions then have to start again from the sur-
other means. Communicable diseases cover vivors to recover their former strength.
a wider range than the person-to-person These are essentially young and growing
transmission of infectious diseases; they populations. With endemic diseases, it is
include the parasitic diseases in which a children who are particularly vulnerable,
vector is used, the zoonoses and all the so there is a high birth rate to compensate.
transmissible diseases. It is this element of With so many young people in the popula-
transmission that distinguishes these dis- tion, chronic non-communicable diseases
eases from the non-communicable. are uncommon, but as people live longer,
If diseases are communicable, then they such diseases become more frequent.
present in an epidemic or endemic form, Chronic non-communicable diseases, there-
while if non-communicable as acute or fore, are a problem of older aged populations
chronic, as follows: as seen in the Western world.
This division between the developed
Communicable: and developing world is purely artificial as
far as diseases are concerned. When the
. epidemic (e.g. measles); plague, or black death as it was known,
. endemic (e.g. malaria). spread across Europe, it caused as much dev-
astation as when communicable diseases
Non-communicable: were introduced to newly discovered nations
by Western explorers. The population started
. acute (e.g. accidents); again from the survivors as it has had to do in
. chronic (e.g. coronary heart disease). the developing countries. Just over a 100
years ago, measles was as serious a cause
All these can occur at the same time and of childhood death in large European cities
in the same place, but communicable dis- as it is in countries today without well-organ-
eases are more common in developing coun- ized vaccination programmes. A tropical

Q R. Webber 2005. Communicable Disease Epidemiology and Control, 2nd edition (Roger Webber)

Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 25.10.2004 12:34pm page 2

2 Chapter 1

environment is more favourable to many dis- probably a causative factor in gastric cancer.
eases than the cooler temperate regions, but The commonest cancer with a communic-
even here, tropical diseases like malaria were able cause is cancer of the cervix, which is
once common in Europe. There is nothing due to infection with the human papilloma
new or different about these artificially virus (Section 14.11). Prevention of this in-
divided parts of the world except for the re- fection by vaccination, now under trial,
sources that each is able to devote to the im- offers the greatest hope of reducing this im-
provement of its populations health. portant cause of female mortality.
Communicable diseases could be reduced Equally intriguing is the possibility that
to manageable proportions if sufficient re- atheroma has an infective cause or associ-
sources, both in financial and educational ation. With arteriosclerosis being largely re-
terms, could be spent on them and much of sponsible for coronary heart disease (CHD)
the reason why certain diseases (as illus- and a major killer in Western countries, the
trated in Table 1.1) are more common than possibility of preventing an infective causal
others is due to poverty. agent is attractive. Chlamydia pneumoniae
The difference between communicable has been found within atheroma lesions, but
and non-communicable diseases was quite not normal arteries, while cytomegalovirus
clear-cut. When it was an organism that was is able to infect the smooth muscle cells of
transmitted, the disease was communicable; arterial walls. The association of H. pylori
otherwise the disease was classified as non- and CHD now seems unlikely, but herpes
communicable. However, this strict bound- virus 1 could induce an endothelial cell re-
ary is becoming less well-defined as new sponse. The cause will probably be found to
suspect organisms are discovered or dis- be multi-factorial, but perhaps in the course
eases, by their very nature, suggest a commu- of time, nearly all diseases will be shown to
nicable origin. Various cancers are good have a transmissible factor in their caus-
examples; the link between hepatitis B ation. Even road accidents, for which there
virus (Section 14.13) and hepatocellular does not seem to be a necessity to look for a
cancer is well established and is now being predisposing cause as in a communicable
prevented by routine vaccination. Epstein disease, might be made more likely to
Barr virus (EBV) seems to be a pathogenic occur due to infection with toxoplasmosis
factor in Burkitts lymphoma, but there is (Section 17.5).
also a causal relationship with malaria; so The key to any communicable disease is
controlling malaria (Section 15.6) in Africa to think of it in terms of agent, transmission,
and Papua New Guinea, where this tumour host and environment. These components are
is found, could have a double benefit. The illustrated in Fig. 1.1, which will be used as a
EBV might also have a causal effect in non- framework in the description of this section.
Hodgkins lymphoma and nasopharyngeal There needs to be a causative agent, which
cancer. Kaposis sarcoma may well be trans- requires a means of transmission from one
mitted by the sexual route as shown by the host to another, but the outcome of infection
number of people with it who acquire human will be influenced by the environment in
immunodeficiency virus (HIV) infection via which the disease is transmitted.
sexual transmission, compared with those
becoming infected from blood transmission,
in which case the tumour occurs only rarely.
The trematode worms Schistosoma haema- 1.2 The Agent
tobium (Chapter 11) and Opisthorcerchis
sinensis (Section 9.5) are causative factors The agent can be an organism (virus, bac-
in bladder cancer and cholangiocarcinoma, teria, rickettsia, protozoan, helminth,
respectively. As a result, their control as fungus or arthropod), a physical or a chem-
communicable diseases will also reduce ical agent (toxin or poison). If the agent is an
cancer incidence. Helicobacter pylori, an or- organism, it needs to multiply and find a
ganism that thrives in gastric secretions, is means of transmission and survival.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 25.10.2004 12:34pm page 3

Elements of Communicable Diseases 3

Table 1.1. The burden of communicable diseases in the world. Data from The World Health Report
2002, World Health Organization, Geneva.

DALYsa (000s) Mortality (000s)

Disease Total Females Total Females

Lower respiratory infections 90,748 42,846 3,871 1,856

HIV/acquired 88,429 42,973 2,866 1,338
syndrome (AIDS)
Diarrhoeal disease 62,451 30,818 2,001 966
Malaria 42,280 22,256 1,124 592
Tuberculosis 36,040 13,411 1,644 569
Measles 26,495 13,260 745 372
Pertussis 12,464 6,240 285 142
Tetanus 8,960 4,497 282 141
Meningitis 6,420 2,961 173 77
Lymphatic filariasis 5,644 1,327 0 0
Syphilis 5,400 2,416 167 70
Trachoma 3,997 2,915 0 0
Chlamydia (STI) 3,494 3,199 8 8
Gonorrhoea 3,320 1,883 2 2
Leishmaniasis 2,357 946 59 24
Hookworm 1,825 893 4 2
Upper respiratory infections 1,815 881 70 35
Schistosomiasis 1,760 678 15 5
Hepatitis B 1,684 605 81 28
Trichuriasis 1,649 800 2 1
Trypanosomiasis (African) 1,598 568 50 18
Otitis media 1,474 719 6 3
Ascariasis 1,181 577 4 2
Onchocerciasis 987 416 0 0
Hepatitis C 844 313 46 17
Japanese encephalitis 767 400 15 8
Dengue 653 366 21 11
Chagas disease 649 316 13 6
Diphtheria 185 89 5 3
Leprosy 177 79 4 2
Poliomyelitis 164 80 1 0
Total 415,911 199,728 13,594 6,298
DALY, disability-adjusted life year.
The DALY is a calculation of the morbidity and mortality of the particular disease averaged out over the
expected life of a person. It reflects the prevalence of the disease and the disability it produces. For example,
a common disease such as lymphatic filariasis will have a high DALY because of the large number infected
and the disability caused, although nobody dies from the disease.

exact replicas are produced, so that any nat-

1.2.1 Multiplication ural selection will act on batches or strains,
rather than on individuals. By contrast,
Two methods of multiplication occur, sexual reproduction offers great scope for
sexual and asexual reproduction, which variety, both within the cells of the single
have different advantages. In asexual repro- organism and from one organism to another.
duction, a succession of exact or almost This means that natural selection acts on

Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof


Transmission Environment

I Age Sex
Intermediate Susceptibility
Multiplication host F Genetic Pregnancy
Asexual Sexual E
Vector Inherent defence mechanisms
C Physical Inflammatory PHYSICAL

Chapter 1
Survival Climate
Animal Resistance
Persistence Latency I Seasonality
Nutrition Multiple infections
Plant Trauma and debilitating
Effect E conditions

Virulence Toxicity Carriers Immunity


25.10.2004 12:34pm page 4

O Innate
Dose response Cyclical sub-clinical Acquired

Fig. 1.1. Agent, transmission, host and environment.

Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 25.10.2004 12:34pm page 5

Elements of Communicable Diseases 5

individuals and variations of vigour and voirs are, therefore, the final host if several
adaptability occur. intermediaries are used.
There are different consequences of The relationship between the parasite
these methods of reproduction. With asex- and the host is one of continual challenge,
ual organisms, the strain of the organism is or what has been termed a biological arms
either successful or unsuccessful in invad- race. When the parasite first attacks a new
ing the host, whereas in sexual organisms, species, the host attempts to eliminate
certain individuals may succeed while it, resulting in a severe reaction. In the
others may not. In continuing its existence, course of time, adaptation can occur so that
only one organism of the asexual parasite the reaction of the host diminishes and
requires to be transmitted, whereas in the the adaptability of the parasite increases.
case of the sexual parasite, both male and The parasite is able to live in the host with
female adults must meet before reproduc- few ill effects (e.g. Trichuris trichiura),
tion can take place. Some parasites seem to forming an established population, continu-
be at a tremendous disadvantage, e.g. the ing with minimal reaction from the host.
filarial worm Wuchereria bancrofti, where The host then acts as a reservoir from
both male and female individuals go which parasites attack new hosts of the
through long migrations in the body to find same species or attempt to colonize different
an individual of the opposite sex, but des- species. Reservoirs can be humans, animals,
pite all these problems, they are one of the vectors or the inanimate environment (e.g.
most successful of all parasites. soil, water). However, it is always in the
Whether the organism reproduces sexu- parasites interest to improve its reproduct-
ally or asexually is relevant in treatment and ive capability. If a new mutation arises,
control. If a treatment is successful in des- which is beneficial to this end, then the mu-
troying an asexually reproducing organism, tation will be selected, generally to the
then it will also be successful against all the hosts disadvantage so that virulence can
other individuals, unless a mutation occurs, increase as well as decrease.
which will also confer resistance to the treat- The adaptability of parasites to their
ment for all others of that strain. In contrast, human hosts might even have advantages
sexual reproduction produces individuals for us. Ascaris, Trichuris and the hook-
of different vigour meaning that some indi- worms secrete substances to reduce the
viduals will succumb to treatment, while host immune response, which inadvertently
others will not. However, having two sexes are absorbed by the gut lining and help
can be a disadvantage for the organism in reduce allergy such as that due to hay
that methods of control can be devised to fever. Our more hygienic surroundings,
attack only one of the sexes or prevent by decreasing these parasites, may be re-
them from meeting. sponsible for the increase in allergic dis-
eases such as asthma in the developed
countries. It is a strange irony to actually
introduce these parasites to combat allergic
1.2.2 Survival
Agents survive by finding a suitable host
within a certain period of time. They have Persistence Another mechanism used by
been able to improve their chances of find- parasites to survive is the development of
ing a new host or prolonging this period by a special stages that resist destruction in an
number of different methods. adverse environment. Examples are the
cysts of protozoa, e.g. Entamoeba histolytica
Reservoirs and parasite adaptability A reser- and the eggs of nematodes, e.g. Ascaris. Bac-
voir is a storage place for water, but serves as teria can persist in the environment by the
an appropriate term to describe a suitable development of spores as with anthrax and
place for storing agents of infection. Reser- tetanus bacilli (Fig. 1.2).
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 25.10.2004 12:34pm page 6

6 Chapter 1

Latency A developmental stage in the develop before changing into the infective
environment that is not infective to a new form. Ascaris, the hookworms and Strongy-
host is called latency. This allows the loides exhibit latency.
parasite time for suitable conditions to

70 70

Enteric 65


55 55

50 50
Temperature (C)

45 Vibrio cholerae 45

Ascaris 40

35 35

30 30

25 Entamoeba 25

20 20
0.1 1 10 100 1000 10,000

1 day 1 week 1 month 1 year

Time (hours)

Fig. 1.2. Persistence of pathogens in excreta. The lines represent conservative upper boundaries for
pathogen death that is, estimates of the time temperature combinations required for pathogen inactivation.
Organisms can survive for long periods at low temperatures, so a composting process must be maintained at a
temperature above 438C for at least a month to effectively kill all pathogens likely to be found in human excreta.
From Feachem, R.G., Bradley, D.J., Garelick, H. and Mara D.D. (1983) Sanitation and Disease: Health Aspects
of Excreta and Wastewater Management. World Bank, Washington, DC, p. 79. Reprinted by permission of John
Wiley & Sons Ltd.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 25.10.2004 12:34pm page 7

Elements of Communicable Diseases 7

1.2.3 The effect of the agent the adult exhibiting severe manifestations
may be almost non-infectious. In the other-
If enough agents survive to infect a new host, wise harmless typhoid carrier, a bout of diar-
they will produce illness, the severity of rhoea can cause the passage of a sufficient
which is determined by its toxicity and number of organisms to initiate an epi-
virulence. demic.
Infectious agents produce a toxic reac- For each infectious agent, a minimum
tion due to the foreign proteins they consist number of organisms the infective dose is
of or produce in their respiratory or repro- required to overcome the defences of the
ductive process (e.g. malaria). Sometimes host and cause the disease. A large dose of
the organism produces very little toxicity or organisms may be required, such as with
it can be out of all proportions to the insig- Vibrio cholerae or very few, as with E. histo-
nificant primary infection (e.g. tetanus). lytica. In most infections, once this number
Some organisms produce toxins when is surpassed, the severity of the disease is
they grow in food, causing illness at a dis- the same whether a few or large number of
tance (e.g. Clostridium botulinum). Toxic organisms are introduced, while in others,
chemicals can also contaminate food (e.g. there is a correlation between dose and se-
adulterated cooking oil) producing an ill- verity of illness. Estimates of doses have
ness that has all the appearances of an epi- been attempted in cholera and typhoid
demic produced by a living organism. using healthy volunteers, but variables
Some agents have a very marked effect such as host susceptibility prevent any
on their host, while others a mild one. degree of precision. An example is food
A good example is influenza. In the so- poisoning where the severity of the illness
called Spanish flu of 1918, it is estimated is determined by the quantity of the infected
that 50 million people were killed world- food item that is consumed. On the benefi-
wide, while subsequent epidemics of influ- cial side, a low dose of organisms may pro-
enza have caused mainly mild infections, duce no symptoms of disease, but may be
with mortality only in the young or the sufficient to induce immunity. Poliomyel-
aged. As an infection progresses in a com- itis is one of the many examples.
munity, virulence can increase or decrease Infections with a low infective dose (e.g.
due to its passage through several individ- enteric viruses and E. histolytica) can spread
uals. Generally, virulence decreases, pas- by person-to-person contact. This means
sage through many experimental animals that the provision of a safe water supply or
being a method used in developing vac- sanitation will have little or no effect. At the
cines. other extreme are organisms like typhoid
and cholera, when a high infective dose (of
the order of 106 organisms/ml of water) is
required to produce the disease. Improving
1.2.4 Excreted load and infective dose water quality and the reduction of patho-
gens in the sewage will be beneficial to the
The number of organisms excreted can vary community.
considerably due to the type of infection or
the stage of the disease. In diseases such as
cholera, there may be vast numbers of organ-
isms excreted (106 ---1012 vibrios/g of faeces), 1.3 Transmission
whereas in hookworm infection, the number
of eggs may be comparatively few. In Schis- Communicable diseases fall into a number
tosoma mansoni, asymptomatic children of transmission patterns as illustrated in
excrete the largest number of eggs, whereas Fig. 1.3.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 25.10.2004 12:34pm page 8

8 Chapter 1


Environment Environment

Human Human Human

Fish Mollusc
Mollusc Mollusc host(s)
Mollusc Fish

Human Human
Animal Vector
human Human Human human
reservoir reservoir

Animal Animal Arthropod Arthropod

Human Human
Animal Animal animal
reservoir Human Human reservoir

Animal Animal Arthropod Arthropod

reservoir to
human reservoir Animal

Animal Insect

Insect Insect Human Human

Animal Insect

Fig. 1.3. Transmission cycles.

Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 25.10.2004 12:34pm page 9

Elements of Communicable Diseases 9

1.3.1 Direct occur due to the feeding of the arthropod or

as a result of its habits. The cycles of trans-
Direct transmission includes person- mission are:
to-person contact as from dirty fingers or
via food and water in the diarrhoeal . direct insect to human as in malaria;
diseases. Direct transmission also occurs . insect to animal with humans entering the
through droplet infection in the respiratory cycle as an abnormal host (e.g. bubonic
diseases. Autoinfection can occur where plague);
humans contaminate themselves directly . insect to animal including humans, from
from their external orifices. Examples are whom it is transmitted to other humans by
transmission of Enterobius from anal the same or another insect vector (e.g.
scratching or infection of skin abrasions yellow fever and East African sleeping
with bacteria from nose-picking. sickness).

(Snails, especially in descriptions of schis-

1.3.2 Human reservoir with intermediate host tosomiasis, are often called vectors, but they
do not carry the infection from one host to
The adults of schistosomiasis live in another and act only as intermediate hosts.)
humans, but for transmission to another
human, the parasite must undergo develop-
mental stages in a snail as intermediate 1.3.5 Zoonosis
host. In Opisthorchis, Paragonimus and
Diphyllobothrium, more than one kind of In the classification by transmission cycle,
intermediate host is required. diseases fall into two main groups: the dis-
eases where only humans are involved and
those in which there is an animal reservoir
1.3.3 Animal as intermediate host or reservoir or intermediate host. These are zoonoses,
which are infections that are naturally trans-
Animals can either be intermediate hosts as mitted between vertebrate animals and
with Taenia saginata and Taenia solium humans. They can be grouped according to
where cysticerci must develop in the animal the intimacy of the animal to the human
muscle before they infect humans or they being:
can be reservoirs such as in Chagas disease.
The infection is maintained in a wild rodent . domestic, animals that live in close prox-
reservoir, where the foraging dog becomes imity to man (e.g. pets and farm animals);
infected, bringing infection into the home . synanthropic, animals that live in close
of a vulnerable human. association with man, but are not invited
(e.g. rats);
. exoanthropic, animals that are not in close
1.3.4 Vector association with man (e.g. monkeys).

A vector carries the infection from one host The importance of this type of classification
to another either as part of the transmission is that it indicates the focality of the disease.
process, such as a mosquito, or it can be As domestic animals are universally distrib-
mechanical, for example, through the uted, domestic zoonotic diseases are cosmo-
housefly, which inadvertently transmits or- politan, whereas at the other extreme, in an
ganisms to the host on its feet and mouth exanthropic zoonosis, such as scrub typhus
parts. All vectors of importance are either or jungle yellow fever, it is quite possible for
insects, mosquitoes, flies, fleas, lice, etc. or humans to live in the same locality, but sep-
arachnids, ticks and mites. Infection may arately from the disease area. Humans have
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 25.10.2004 12:34pm page 10

10 Chapter 1

no part in the disease cycle, but come into The carrier state can either be transient or
contact with it only when they accidentally chronic.
enter the affected place (focus). The important features of carriers are as
In zoonoses, the animal is all-important follows:
in control. In some diseases, such as the beef
and pork tapeworms, good hygienic practice 1. The number of carriers may be far
and inspection of the animal carcass may be greater than the number of those who are
all that is required to interrupt transmission. sick.
At the other extreme, a disease such as 2. Carriers are not manifest so they and
yellow fever can never be eradicated from others are unaware that they can transmit
the population even if every man, woman the disease.
and child were immunized because the res- 3. As carriers are not sick, they are not re-
ervoir of disease remains in the monkey stricted and, therefore, disseminate the dis-
population. In a zoonosis, the animal reser- ease widely.
voir is of prime importance and only by 4. Chronic carriers may produce repeated
studying the ecology of the animal popula- outbreaks over a considerable period of
tion can any rational attempt be made to time.
control it.
Identification of carriers is a singularly diffi-
cult and generally unsuccessful exercise. If
1.3.6 Plants the carrier is asymptomatic, the organism is
often in such reduced numbers or excreted
Vegetable material that is eaten by the host at such infrequent intervals that routine cul-
can serve as a method of transmission. This ture techniques will not detect them. The
can either be a specific plant, such as water investigation has to be repeated many
calthrop on which the cercariae of Fascio- times and is probably only successful at spe-
lopsis buski encyst, or non-specific, such as cific instances, for example, during a minor
any salad vegetable that might be carrying diarrhoeal episode in a suspected typhoid
cysts of E. histolytica. carrier. A further difficulty is that clinically
unaffected people object to having investi-
gations performed on them, making the
coverage incomplete. Examples of diseases
1.3.7 Carriers and sub-clinical transmission
in which the carrier state is important are
typhoid, amoebiasis, poliomyelitis, menin-
Diseases in which there is an animal reser- gococcal meningitis, diphtheria and
voir, intermediate host or vector are com- hepatitis B. Cholera can produce more car-
plex and difficult to control, but even in riers than those that are sick. More on
the simplified transmission cycle of direct carriers will be found in the sections dealing
spread from human-to-human, complica- with each of these diseases.
tions occur with the carrier state. A carrier In some diseases, the carrier state
is a person who can transmit the infective appears to be prolonged or is perpetuated
agent, but is not manifesting the disease. when there are, in fact, no carriers. This
There are several types of carriers: may be due to cyclical sub-clinical transmis-
sion when infection is transmitted within a
. asymptomatic carriers who remain well family or throughout a community, without
throughout the infection; the subjects being aware of any particular
. incubating or prodromal carriers who are symptoms. One member of a family passes
infectious, but unaware that they are in on the disease to another and becomes free
the early stages of the disease; of it him/herself. It is then passed on to other
. convalescent carriers who continue to be family members and eventually back again
infectious after the clinical disease has so that it is maintained in a sub-clinical
passed. cycle. When someone who is susceptible to
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 25.10.2004 12:34pm page 11

Elements of Communicable Diseases 11

the disease accidentally enters this cycle or as poliomyelitis and goitre, which are more
the organism is more widely disseminated, commonly found in females than males. Oc-
then a clinical outbreak occurs. This is a cupation can determine which sex is more
mechanism by which poliomyelitis is main- likely to be involved, such as in East Africa
tained in the community. where males, who hunt and collect honey
in tsetse fly infested forest, are more likely
to contract sleeping sickness. Social habits
may also be a determinant, such as the
1.4 Host Factors custom of the Fore people in Papua New
Guinea, where the women eat the brains
If the agent is transmitted to a new host, its of the recently dead, making kuru predom-
successful invasion and persistence will inantly a disease of women.
depend upon a number of host factors.

Pregnancy When a woman is pregnant, her

physiological mechanisms are altered and
1.4.1 Susceptibility she becomes more susceptible to infections.
Chickenpox is a severe disease in preg-
Genetic Certain diseases can only affect nancy and malaria attacks the pregnant
animals and when they are transmitted to woman as though she had little acquired
man, they are not able to establish them- immunity. The pregnant woman contract-
selves. An example is Plasmodium berghei, ing Lassa fever is more likely to die from
the rodent malaria parasite, which cannot the illness.
produce disease in man although closely
related to the human malaria parasite. How-
ever, some newly emergent diseases have
1.4.2 Inherent defence mechanisms
succeeded in crossing this genetic barrier,
such as HIV and severe acute respiratory
syndrome (SARS). Any infecting organism must be able to over-
Genetic disposition also determines come the bodys inherent defence mechan-
the hosts response to infecting organisms. isms. These can either be:
Mycobacteria are common in the environ-
ment, but only certain people develop tuber- . physical, such as the skin, mucus-
culosis or leprosy. The type of disease (e.g. secreting membranes or acidity of the
tuberculoid or lepromatous leprosy), is also stomach; or
determined by the genetic make-up. . inflammatory, the localized reaction,
which includes increased blood flow, the
attraction of phagocytes and isolation of
Age During the course of life, different dis-
the site of inoculation.
eases affect particular age groups. The child-
hood diseases of measles, chickenpox and
diphtheria are found at one end of the life-
span, with the degenerative diseases and 1.4.3 Resistance
neoplasms predominating at the other.
The persons susceptibility and defence
Sex The same advantages that parasites mechanisms may be altered by the resistance
derive from having two sexes, producing of the individual. This may be lowered by
many individuals of different vigour, also the following:
benefit humans, and it is thought that
evading parasites might be one of the main 1. Nutrition. Where the nutritional status is
reasons why mammals evolved with two decreased, the susceptibility to a disease is
sexes. However, one or other sex might increased, or the clinical illness is more
more commonly succumb to illness, such severe.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 25.10.2004 12:34pm page 12

12 Chapter 1

2. Trauma and debilitating conditions. factors are subtle, diffuse and wide-ranging.
Poliomyelitis may be a mild or inapparent A few of the more important ones are men-
infection, but if associated with trauma, tioned in this section. These will be divided
such as an intramuscular injection, then into the social environment and the physical
paralytic disease can result. The appearance environment.
of shingles or fungal infections in debili-
tated people is often seen.
3. Multiple infections. The presence of one
1.5.1 The social environment
disease may make it easier for other
infecting organisms. Secondary respiratory
infections commonly occur in measles. Education Sufficient knowledge is available
Yaws has been noticed to increase and about most of the communicable diseases
spread more rapidly following an outbreak for them to be prevented, if only people
of chickenpox. were taught how. Education is a complex
process; it is not just teaching people, but
they must understand to such an extent that
1.4.4 Immunity they are able to modify their lives. This is
not a sudden process; changes made by one
generation are used as the starting point for
Experience of previous infection by a host
improvements or modifications in the
can lead to the development of immunity.
following. Change is always opposed and
This can either be cellular, conferred by
steps that seem easy to the educated may
T-lymphocyte sensitization or humoral,
be insurmountable for the uneducated.
from B-lymphocyte response. Immunity
Also, education is not just the adding of
can either be acquired or passive.
new knowledge, but the rational appraisal
of traditional beliefs and customs.
Acquired (both cellular and humoral) im-
An improvement in the level of educa-
munity follows an infection or vaccination
tion and understanding was probably the
of attenuated (live or dead) organisms. This
most important reason why endemic com-
will induce the body to develop an immune
municable diseases largely disappeared
response in a number of diseases. Immunity
from the developed world. As education
is most completely developed against the
improved, there was a demand for better
viral infections and may be permanent.
living standards. Good water and proper
With protozoal infections (e.g. malaria), it
sewage disposal were provided, personal
is only maintained by repeated attacks of
hygiene became a normal rather than an ab-
the organism.
normal practice and cleanliness was sanc-
tioned as a desirable attribute. All these
Passive (humoral only) immunity is the changes occurred before the advent of anti-
transfer of antibodies from a mother to her biotics. The decline of tuberculosis in Eng-
child via the placenta. Passive immunity is land and Wales (Fig. 13.3) is a classic
short lived, as in the protection of the young example of how the incidence of a major
infant against measles for the first 6 months communicable disease decreased as living
of life. Passive immunity can also be intro- standards rose.
duced (e.g. in rabies immune serum).

Resources and economics The lack of re-

sources leads to poverty, which reduces the
1.5 The Environment ability to combat disease. The term re-
sources relates to everything that people
The transmission cycle used by the agent to need to carry on their livelihood. Perhaps
reach the host takes place within an environ- the most important resource is land, which
ment that determines the success and is used by the family for living on
severity of the infection. Environmental and growing crops. Alternatively, this land
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 25.10.2004 12:34pm page 13

Elements of Communicable Diseases 13

can be used to produce commodities that measuring the benefit of a health interven-
can be sold as part of a manufacturing pro- tion is difficult to do.
cess. As the society develops, education or A development of these methods in-
the ability to perform a service becomes a volves the concept of marginal costs, which
resource. is best illustrated using the three different
Resources are required to enact the strategies of a vaccination programme:
preventive methods or raise standards that (i) fixed units; (ii) mobile clinics; and
have come to be demanded by education. In (iii) outreach programmes. Using fixed
the simplest terms, food is required to build units (clinics and hospitals), the largest
up body processes and prevent malnutri- number of children will be reached for the
tion. But with a little extra money, a water least cost, but to obtain higher coverage it
supply can be built or a better house con- will cost more per child by this method
structed. (building more clinics) than by adding an
Resources, education and disease are outreach programme to the existing clinics.
inextricably linked. Diseases are best pre- To contact the remaining children (at the
vented by educating people to overcome margin of an outreach programme), it will
them, but resources are required by the edu- be cheaper to use mobile clinics. So each
cated to achieve this. Greater resources strategy has its value and it is more cost-
allow increased education and improved effective to use them in this stratified fash-
education leads to better utilization of re- ion. Another example of the economics of
sources. Both these factors help in reducing vaccination will be found in Section 3.2.8.
the incidence of communicable diseases.
Making the optimum use of resources
and balancing what is needed with what is Communities and movements People gather
available is the province of health econom- to form communities, constructing some
ics. The sick need treatment, but there may form of habitation in which to live. The
be several alternatives available and the type of structure they live in can play an
cheapest one producing the desired effect important role in the diseases they succumb
will be the most appropriate for the health to. In South America, the Reduviidae bugs
service of the country. The World that transmit Chagas disease live in the mud
Health Organization (WHO) essential drugs walls of houses, so replacing these with
programme has helped to limit unnecessary more permanent materials can prevent the
expenditure. Health economics involves as- disease. Conversely, if a fire is lit within the
sessing the actual needs of the community, house for cooking and heating, the smoke-
which are expressed as felt needs and trans- filled interior leads to an increase in acute
lated into demands, but financial restric- respiratory infections, one of the most
tions will limit what can be supplied. common of all health problems.
Health services will need to make choices The attraction of cities has resulted in one
between implementation of one scheme of the largest demographic changes in recent
and another, such as a mass drug adminis- times. For the majority of the population that
tration (MDA) programme or improved lived in rural areas, urban areas now have
curative services, basing their choices on become the commonest place of residence in
cost-effectiveness and costbenefit analysis. tropical countries. Slums have developed
In cost-effectiveness, programmes that yield in which the diseases of poverty thrive and
the greatest health improvement for the the imbalance of the sexes has led to an in-
available resources such as a vaccination crease in sexually transmitted infections
programme are chosen, whereas in cost (STIs). At the other extreme is the nomad con-
benefit analysis, the outputs of different pro- tinually moving from place to place, making it
jects are measured and emphasis given to difficult to provide maternal and child health
the one producing the greatest benefit per (MCH) services, with the result that children
unit of cost. Although costbenefit analysis are not vaccinated, making them vulnerable to
is the more desirable for long-term planning, many childhood infections.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 25.10.2004 12:34pm page 14

14 Chapter 1

People have to move to get to their place many troubles that these unfortunate people
of work, attend school, visit the clinic or for suffer from.
many other reasons, but all such movements As with refugee health, a new speciality
incur a health risk. The woman collecting has developed around the health of travel-
water may make herself more vulnerable lers. The phenomenal increase in air travel
to contracting a diarrhoeal disease, by drink- has brought the risk of contracting a commu-
ing water from a polluted source, while the nicable disease in a foreign country to all
tsetse fly vectors of Gambiense sleeping kinds of people. Over 2000 cases of malaria
sickness favour biting people at water- are imported to England and Wales every
gathering places. The mother carrying her year, making it more important than many
baby to market with her makes it more liable of the indigenous health problems. HIV in-
to contact measles and whooping cough fection in European countries has changed
at a younger and more vulnerable age. from being predominantly in the homosex-
Fishermen, with their greater contact with ual community to an increasing problem in
water, are more likely to contract schisto- the heterosexual, mainly due to infections
somiasis. contracted overseas. Problems also travel in
Local migrations from one country to a the other direction when students from mal-
neighbouring country for trade or visiting aria-infected areas come to temperate coun-
relatives can pose a risk to the health of tries to study, losing their acquired immunity
individuals or families. In much of South- and rendering them liable to contract serious
east Asia, malaria is more intense along the malaria when they return home.
borders between countries, so that crossing
to the next country and staying for a few
days has been found to increase the chance
of contracting malaria by as much as sixfold. 1.5.2 The physical environment
Following trading routes was the way by
which classical cholera was taken to East Topography The nature of the physical sur-
Africa in the 19th century and repeated roundings can influence the diseases that
with El Tor cholera in the 20th century. are found there. In much of Asia, a complex
Schistosomiasis was carried to the Americas interaction termed forest fringe malaria de-
and Arabia along with the slaves who were scribes the greater likelihood of developing
forcibly taken to these parts of the world; a malaria at the forest margin. The man enters
continuing vengeance for the evils inflicted the forest to fell timber, often illegally, while
on them. the woman goes there to collect firewood,
Travel to another country permanently bringing them into range of mosquitoes that
to seek employment or escape from civil live within the forest cover. A similar cycle
conflict is a particularly vulnerable time for of transmission occurs with yellow fever
the individual and the family. Refugees, in as illustrated in Fig. 16.3. Destruction of
particular, need extra help, but sometimes primary forest, to be replaced by secondary
this can be misplaced and the situation growth, makes ideal conditions for the de-
made worse. During the Cambodian crisis, velopment of mite islands, which are
water containers were provided to house- important in scrub typhus (Section 16.2).
holds in refugee camps along the Thai Human activity not only destroys the
border, but these proved to be excellent natural balance of nature, but also often
breeding places for Aedes mosquitoes, with changes the landscape to make it more suit-
the result that there were large outbreaks of able for the transmission of communicable
dengue. In Tanzania, refugees were settled diseases. The growing of rice in paddy fields
in a large uninhabited forest area, which was provides suitable conditions for Culex mos-
infested with tsetse flies, so soon cases of quitoes that transmit Japanese encephalitis
sleeping sickness began to appear. Refugee and Anopheles sinensis, the vector of mal-
health has become a subject in its own right aria in much of China. The construction of
and communicable diseases are one of the dams and irrigation canals has encouraged
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 25.10.2004 12:34pm page 15

Elements of Communicable Diseases 15

the proliferation of intermediate host snails breeding sites for Anopheles mosquitoes,
of schistosomiasis. However, the Simulium but excessive rain can wash out larvae and
fly that transmits onchocerciasis breeds in cause a reduction in the number of mosqui-
fast-flowing oxygenated streams that are toes. Some diseases, such as trachoma,
often destroyed when dams are built, de- favour dry arid regions.
priving them of their breeding place. All
major construction projects should, there- Wind produces local alterations to the
fore, have a health evaluation to determine weather. A major wind system is the mon-
how the health risk can be minimized. soon, which brings rainfall to the Indian
sub-continent and Southeast Asia. In West
Climate can be divided into different Africa, the hot dry Harmattan blows down
components of temperature, rainfall from the Sahara, reducing humidity and in-
(humidity) and less importantly, wind. creasing dust. It is these secondary effects on
These attributes of the climate have a rainfall and temperature that determine the
marked influence on where diseases are disease patterns.
found and the ways in which they are to be The winds are appreciated by man to
controlled. improve his living conditions in the warm
moist areas of the world and avoided in the
Temperature varies by distance from the hot dry zones. However, excess wind in hur-
equator, altitude, prevailing winds and the ricane areas or the localized tornado cause
size of land masses. A number of diseases destruction and loss of life (Fig. 1.5). Natural
are found only in the tropics, which is the disasters disrupt the normal pattern of life,
main area for communicable diseases. Tem- destroy water supplies and provide ideal
perature decreases with altitude so that mal- conditions for epidemics to occur.
aria will be found at the lower hot altitudes,
while respiratory diseases are common in Seasonality Temperature and rainfall to-
the colder hills. At the fringe of the mosqui- gether determine the best time to grow
toes range, exceptional conditions of tem- crops and the seasonal patterns of a number
perature and humidity can produce of diseases. In areas of almost constant rain,
epidemic malaria. there is very little seasonal variation, but in
Temperature not only affects the pres- the drier regions, seasonality can be quite
ence or absence of disease, but also often marked. These areas are illustrated in Fig.
regulates the extent. The malaria parasite 1.4.
has a shorter developmental cycle as the The pattern of life determined by sea-
temperature rises, thereby permitting an in- sonality can be generalized as follows:
creased rate of transmission. Many insect
vectors have a more rapid development in . Food stores are low or absent during the
the tropics, making them difficult to control. rains as it is the longest time since the
The life cycle of a number of parasites are harvest.
directly related to temperature. . During the rains, people are required to
work their hardest when they have the
Rainfall is perhaps the most essential elem- least amount of food.
ent in human livelihood. Rainfall must be . The rains bring seasonal illnesses, espe-
sufficient and regular (Fig. 1.4) allowing cially diarrhoea and malaria, which debili-
people to plant crops and ensure that they tate just when complete fitness is required.
come to fruition. An irregular rainfall can be . The time of the rains often coincides with
as disastrous as a low rainfall, leading to late pregnancy for the woman, conception
failed crops, malnutrition and a reduction having taken place during harvest. Since
of resistance to infection. all members of the family are required to
Rainfall also has a direct effect on cer- work in the fields and much of the burden
tain diseases. Moderate rainfall creates fresh of cultivating falls on the woman, the

Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 25.10.2004 12:34pm page 16
Chapter 1
Fig. 1.4. The tropics rainfall and seasonality. - - - -,The tropics, Cancer to Capricorn; , developing country zone. Seasonality within the tropical region: , rainfall in
every season; , heavy seasonal rainfall; , variable seasonal rainfall; &, arid.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 25.10.2004 12:34pm page 17
Elements of Communicable Diseases 17
, revolving tropical storms (tornadoes, hurricanes, cyclones).
, earthquake areas; *, active volcanoes;
Fig. 1.5. Natural disaster zones.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 25.10.2004 12:34pm page 18

18 Chapter 1

increased strain threatens her pregnancy, lutants from the many dry months, makes
while her physical reserves are stretched this a period of diarrhoeal diseases. The sea-
even further. sonality of cholera, allows a warning system
. Once harvest comes, then body weight is to be implemented and prevention initiated
restored, excess crops are stored or sold (see Section 8.6).
and some respite taken before the cycle 4. A different pattern of seasonal diseases
repeats itself. occurs with the viral infections, where
measles (see Fig. 1.7) serves as a good
This pattern leads to the following observa- example. As measles confers life-long im-
tions: munity, the only way that sufficient suscep-
tibles can accumulate for another epidemic
1. Attendance for treatment at medical to occur is by immigration or reproduction.
institutions and admission to hospital often If the birth rate is high, a critical number of
follow a cyclical pattern. This is illustrated susceptibles will soon be produced and
in Fig. 1.6 where it will be seen that annual epidemics will occur. If the birth
the reporting of ill health is least during rate is low, then the interval may be every
the dry months and increases with the 23 years.
rains. 5. Knowledge of the seasonality of a disease
2. Knowledge of the seasonality of a disease allows planned preventive services. If a
can be used in health planning, the deploy- mobile or mass vaccination campaign is
ment of manpower, the ordering of supplies, used to combat measles, then timing it in
the best time to take preventive action, etc. the few months before an expected epidemic
3. Many illnesses show a marked seasonal is the most cost-effective. In Tanzania,
pattern. Mosquitoes require water to breed, measles outbreaks often occur in the rainy
so rainfall will determine a seasonal pattern season (Fig. 1.7), a time of shortages, malnu-
for many of the vector-borne diseases. The trition and difficult communications the
massive contamination of rivers caused by worst possible time to have to do emergency
the first rains washing in accumulated pol- vaccination to contain the epidemic. Just a


Rain Rain
No. of admissions (thousands)





Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec


Fig. 1.6. Seasonality of admissions to Mbeya hospital, Tanzania, 19801983.

Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 25.10.2004 12:34pm page 19

Elements of Communicable Diseases 19

few months before, there was little ill health, there has been an increase in the frequency
nutritional status was high, road conditions and severity of storms in many parts of the
good and medical staff were at their slackest. world.
This would have been the best time to Increase in temperature has the poten-
ensure that every child was vaccinated. tial to expand the range of infections that
are normally constrained by temperature,
for example, malaria. This has led to specu-
1.5.3 Climate change due to global warming lation that malaria could become a problem
in the developed countries of Europe and
The increase in carbon dioxide and other North America where it occurred in former
pollutants in the atmosphere due to the times. However, this is unlikely as good pre-
burning of fossil fuels (coal, petrol, etc.) ventive measures are able to keep the dis-
has led to an increase in global temperature. ease from spreading even if the malarial
Although the temperature increase is com- mosquito re-establishes itself. A good
paratively small, it has begun to have a major example is Australia where much of the
effect on the climate, with a disruption of country lies within the tropical region,
weather systems and a raising of the sea the main malaria vector Anopheles farauti
level. This has been most marked on a (the same as Papua New Guinea and
system of currents off the west coast of Solomon Islands) is present, yet control
South America known as the El Nino south- methods have eradicated the parasite and
ern oscillation. Climatic systems are re- continued surveillance has prevented it
versed or severely disrupted, with heavy from being re-introduced.
rains and flooding when no rain is normally A more serious problem is in areas of
expected and drought conditions when highlands within tropical countries such as
there should normally be rain. Countries in East Africa and South America. At a certain
South America, Southeast Asia and Oceania altitude where the lower temperature pre-
are the most affected, but its effects are felt vents the mosquito and parasite from de-
all over the world. Even without El Nino, veloping, malaria is not found, but


No. of measles




Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec


Fig. 1.7. Mean monthly measles cases, 19771981, Mbeya region, Tanzania.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 25.10.2004 12:34pm page 20

20 Chapter 1

evidence from Ethiopia and Kenya has likely that most of the effects will be concen-
shown that this level is already rising. Mal- trated in the poorer regions of the world,
aria is now found at higher altitudes with with an increase in vector-borne and diar-
the rate of ascent linked to the rise in tem- rhoeal diseases, malnutrition and natural
perature. There is also a greater risk of epi- disasters.
demic malaria with the wider fluctuations of
temperature that have resulted and the
number of people who have no immunity.
Other diseases transmitted by mosquitoes 1.5.4 Medical geography
like dengue and Japanese encephalitis, and
other arboviruses, such as Rift Valley fever, Features such as topography, climate and
are likely to increase. altitude are more commonly the province
Effects will be most felt at the extremes of geography than medicine, but their value
of the world, i.e. the tropics and the Arctic is appreciated and epidemiologists are
and Antarctic regions. If ocean levels rise, making more use of geographical tools to
then small island nations will be threatened help them understand the distribution and
by a reduction in land area on which to live spread of disease. The classic tool is the map
and grow their crops and salinity will in- and many examples will be found in several
trude into freshwater aquifers. Thirteen of sections of this book where maps are used.
the 20 major conurbations are at sea level A development of mapping is Geographical
and the population at risk from storm surges Information Systems (GIS) using the wealth
could rise from 45 to 90 million people. of data collected by orbiting satellites. These
Countries at greatest risk are Bangladesh, map the surface of the world at frequent
China, Egypt and the small island nations intervals so that comparisons can be made
of the Pacific, Caribbean and Indian Oceans. over time. Features known to be important
At the other extreme, a rise in temperature in disease transmission, such as the distri-
could damage the permafrost, upsetting the bution of populations or the breeding places
balance of nature and the livelihood of the of disease vectors can be identified from sat-
indigenous people who live in these parts of ellite images and predictions made without
the world. The increase in carbon dioxide having to laboriously follow-up these fea-
will result in preferential conditions for tree tures on the ground. Examples are the move-
growth and the development of forests, ment of people into the Amazon jungle
which would be beneficial in the long run, where yellow fever is endemic and detailed
but the animals that live in these lands study of a small area for mosquito-related
might not be able to adjust to the rate of features, such as rice-paddy, which can
change and become extinct. then be looked for in satellite images for
While most of the concern of increase in the whole country. GIS is at the forefront of
disease due to global warming has been ex- monitoring changes that are resulting from
pressed in the Western world, it is more global climatic change.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 25.10.2004 6:50am page 21

Communicable Disease Theory

The previous chapter attempted to unify such as proximity (density) of populations,

communicable diseases into basic units, carriers, reservoirs, climate and seasonality,
the agent, a route of transmission to a host will have separate effects. To single these
and the way the environment influences the out and ascribe values to them will involve
outcome. Generalizations have been made considerable, and generally unnecessary,
in attempting to limit and clarify all the al- complexity. In some disease patterns, cer-
ternatives and variations that are possible. tain factors have sufficient influence that
Developing principles, not discovering ex- they require to be given values, but for the
ceptions, has been the objective. A stage is time being, it is best to consider these al-
now reached where interactions between together as a force of infection. This can be
these various elements can be suggested summarized as:
and tried. The approach can either be intui-
tive, a method used with reasonable success The force of infection
in earlier attempts at explaining disease dy- Number of infectious individuals
namics, or analytical, where the precision,  Transmission rate
ease of modification and extrapolation are
considerably greater.

Number of newly infected individuals

2.1 Force of Infection Force of infection
 Number of susceptible individuals in
In a communicable disease, the number of the population
new cases occurring in a period of time is
dependent on the number of infectious per- If the susceptible population is sufficiently
sons within a susceptible population and large to maintain a permanent pool of sus-
the degree of contact between them. Per- ceptibles (as would happen in a disease
sons, whether infectious or susceptible, where there is little or no immunity) and
and a period of time are all quantifiable the force of infection is constant, then
factors, but the degree of contact can depend newly infected individuals will continue
upon very many variables (some of which to be produced, while infectious individuals
have been covered above). The factors, remain in the population. One healthy

Q R. Webber 2005. Communicable Disease Epidemiology and Control, 2nd edition (Roger Webber)

Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 25.10.2004 6:50am page 22

22 Chapter 2

carrier might continue to infect a large an unusual disease, a few cases could be an
number of individuals over a long period epidemic, whereas with a common disease
of time, or a brief devastating epidemic, (e.g. gastroenteritis), an epidemic occurs
with a short period of infectiousness, may when the usual rate of the disease is substan-
infect a large number of people over a short tially exceeded. Criteria can be set so that
period of time. Parasitic infections, such as when the number of cases exceeds this
hookworm, would be an example of the level the epidemic threshold is crossed.
former and measles, an example of the latter. The epidemic threshold can either be the
Of course, measles produces immunity, upper limit of cases expected at that particu-
which will alter the size of the susceptible lar time, an excess mortality, or a combin-
population. ation of both the number of cases and the
The proportion of susceptible individ- mortality.
uals can be reduced by mortality, immunity Characteristics of an epidemic (Fig. 2.1)
or emigration, or increased by birth or immi- are as follows:
gration. After a certain period of time, a suf-
ficient number of non-immune persons 1. Latent period, the time interval from ini-
would have entered the population for a tial infection until start of infectiousness.
new epidemic of the disease to occur. 2. Incubation period, the time interval from
initial infection until the onset of clinical
disease. The incubation period varies from
2.2 Epidemic Theory disease to disease and for a particular dis-
ease has a range. This range extends from a
Epidemics can occur unexpectedly, as when minimum incubation period to a maximum
a new disease enters a community, or can incubation period (see Chapter 19).
occur regularly at certain times of the year, 3. Period of communicability, the period
as in epidemics of measles. Epidemic con- during which an individual is infectious.
trasts with endemic, which means the The infectious period can start before the
continuous presence of an infection in the disease process commences (e.g. hepatitis)
community and is described by incidence or after (e.g. sleeping sickness). In some dis-
and prevalence measurements. This section eases, such as diphtheria and streptococcal
will cover epidemics and how they are infections, infectiousness starts from the
measured. date of first exposure.
Epidemic means an excess of cases in
the community from that normally Various factors modify the incubation
expected, or the appearance of a new infec- period so that if it is plotted on a time-
tion. The point at which an endemic disease based graph, it is found to rise rapidly to a
becomes epidemic depends on the usual peak and then tail off over a longer period
presence of the disease and its rate. With (Fig. 2.2). The infecting dose, the portal of

Infection Infectious

Incubation period Disease


Latent period Period of communicability

Fig. 2.1. Parameters of an infection (see text for definitions).

Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 25.10.2004 6:50am page 23

Communicable Disease Theory 23


Minimum Time
Maximum incubation period

Fig. 2.2. Distribution curve of incubation times (the epidemic curve).

entry, immune response of the host and a . Common source epidemics can further be
number of other factors modify the normal divided into a point source epidemic
distribution to extend the tail of the graph. resulting from a single exposure, such as
By using a log-time scale, this skewed curve a food poisoning episode, or an extended
can be converted to a normal distribution epidemic resulting from repeated mul-
and the mean incubation period measured. tiple exposures over a period of time (e.g.
An epidemic can either be a common a contaminated well).
source epidemic or propagated source epi- . In a propagated source epidemic, the
demic (Fig. 2.3). agent is spread through serial transfer

Common source epidemics

Point source Extended source



Time Time

Propagated source epidemic



Fig. 2.3. Epidemic types.

Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 25.10.2004 6:50am page 24

24 Chapter 2

from host to host. With a disease having In a point source epidemic, the number of
a reasonably long incubation period, the cases of the disease occurring each day are
initial peaks will be separated by the plotted on a graph to produce an epidemic
median incubation periods. Chickenpox curve. The earliest cases will be those with
(varicella) can start as an epidemic in one the minimum incubation period and the last
school; then mingling children will lead of the cases are those with the maximum
to transfer to another school, leading to a incubation period if all were infected at a
series of propagated epidemics. single point in time, as illustrated in Fig. 2.4.
Three factors describe a point source
2.2.1 Investigation of a common source
. the epidemic curve;
. the incubation period of the disease;
. the time of infection.
In the investigation of any outbreak of a
disease, the basic approach is to gather infor- If only two of these factors are known, then
mation on the following: the third can be deduced. From the epi-
demic curve, the median (or geometric
1. Persons: age, sex, occupation, ethnic mean) of the incubation periods is deter-
group, etc. comparing the number infected mined. If the disease is known from its clin-
with the population at risk. ical features, then the incubation period will
2. Place: country, district, town, village, also be known (Chapter 19). Therefore, by
household and relationship to geographical measuring this known incubation period
features such as roads, rivers, forests, etc. back in time from the median incubation
conveniently marked on a map. period on the curve or the minimum incuba-
3. Time: annual, monthly (seasonal), daily tion period from the beginning of the curve,
and hourly (nocturnal/diurnal). The the time of infection can be calculated. The
number of cases occurring within each source now localized to a restricted period
time-period is plotted on a graph. These of time can be more easily investigated.
aspects will be covered in greater detail If the disease is unknown, but there
later. is evidence of the time of infection (e.g.

Median or geometric
mean incubation period
Number of cases

Curve of specific disease x

Time onset of disease

Maximum times

Fig. 2.4. Investigation of a point source epidemic.

Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 25.10.2004 6:50am page 25

Communicable Disease Theory 25

a particular event in time that brought all the In a new infection, everyone will be at risk
cases together or linked them by a common (e.g. with the SARS virus), but as the infec-
phenomenon), then the incubation period tion spreads, persons will become immune
can be calculated and a disease (or aetio- and are therefore no longer at risk. Where an
logical agent producing a disease) with this epidemic occurs at regular intervals (e.g.
incubation period can be suspected. This measles), only those people who have not
method was used to work out the incubation met the infection before or have not been
period for the first epidemic of Ebola haem- vaccinated will be at risk.
orrhagic fever, as there were a large number
of fatal cases that occurred in one hospital at
the same time. 2.2.2 Investigation of propagated source
In an extended source epidemic, the epidemics
time of infection can be deduced by
measuring back in time from the first case With a propagated source epidemic, phases
on the rising epidemic curve to the max- of infection occur at regular intervals. The
imum and minimum incubation periods of time-period between these phases is called
the diagnosed disease. Search within this the serial interval (Fig. 2.5). Features of the
defined period of time can elucidate the epidemic are measured in the same way as a
source. common source epidemic, while an esti-
Epidemics are suitably described by ex- mate of time of recurrence is given by the
pressing them in attack rates. In a common serial interval. After several propagated epi-
source epidemic, the overall attack rate is demics, cases remaining from the previous
used: epidemic will merge with the next so that
the regular serial pattern will be lost.
Overall attack rate Contagiousness or the probability that
Number of individuals affected during an epidemic an exposure will lead to a transmission is

Number (of susceptibles) exposed to the risk measured by:

Serial interval

Secondary Tertiary cases

Primary case cases
One minimum
incubation period

One maximum incubation period

Fig. 2.5. Investigation of a propagated source epidemic.

Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 25.10.2004 6:50am page 26

26 Chapter 2

Secondary attack rate

from a single case in an unlimited, wholly
Number of cases within the period of susceptible population. For example, if one
one minimum and one maximum case gave rise to two and these two to four,
incubation period (secondary cases) etc., as illustrated in Fig. 2.6, the basic repro-
from the primary case ductive rate would be 2. This is the most
Number (of susceptibles) exposed to the risk extreme situation. In reality, the epidemic
is modified by immunity or the population
An example is smallpox, which had a high limited by people having already become
secondary attack rate and was therefore very infected; therefore, such a rapid increase
contagious. Since smallpox was eradicated does not occur. If the basic reproductive
and people are no longer vaccinated, the rate is less than 1, as illustrated in Fig. 2.7,
level of immunity has waned and there is the epidemic will not take off. The import-
the fear that a very similar disease, monkey- ance of this concept is in control, whereby if
pox, could now increase and be a threat. the basic reproductive rate can be reduced
However, it has a lower secondary attack below 1, then the disease will die out.
rate; so we can rest assured that this is un- The basic reproductive rate has been
likely to happen (see also Section 18.2). used in mathematical models of disease,
particularly for malaria and filariasis.

2.2.3 Dynamics of epidemics

2.2.4 Population size
The increase in cases in an epidemic has
given rise to a measure called the basic re- As mentioned above, the continuation of an
productive rate. This measures the average epidemic is determined by the number of
number of subsequent cases of an infection susceptibles remaining in the population.

1 2 4 8 16 32
Case reproductive rate = 2

Fig. 2.6. Basic reproductive rate increasing i.e. >1. Maximal transmission: every infection produces a new
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 25.10.2004 6:50am page 27

Communicable Disease Theory 27

4.5 3 2 1.3

Basic reproductive rate = 0.66

Fig. 2.7. Basic reproductive rate decreasing i.e. <1. Unsustained transmission: each transmission gives rise
to less than one new case and the infection dies out.

Once an individual has experienced an epi- structure and the conditions (hygiene, etc.)
sode of the disease (whether manifest or of the host population. In third world coun-
not), he or she may develop immunity tries with their high birth rates the critical
(either temporary or permanent) or die. population is less than that in developed
When a certain number of individuals have countries. Examples of the critical human
developed immunity then there are insuffi- population size are for measles 500,000 and
cient susceptibles and the infection dies out. for varicella 10,000.
This collective permanent immunity (as If the population is less than the critical
occuring in viral infections) is called the size, then regular epidemics will occur at
herd immunity. After a period of time, intervals related to the population size. An
depending on the size of the population, example is given in Fig. 12.2 of a measles
this herd immunity becomes diluted by epidemic, which occurred regularly every 3
new individuals born (or by immigration) years in a well-defined community. These
and a new epidemic can take place. This is regular epidemics can be analysed in the
called the critical population (the theoret- same way as a propagated source epidemic,
ical minimum host population size required from which it has been shown that the
to maintain an infecting agent). It depends smaller the community, the longer is the
upon the infectious agent, the demographic interval between epidemics.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 25.10.2004 6:51am page 28

28 Chapter 2

An extension of the concept of herd

immunity shows that not everyone in a
Suspected cause Cases Controls
population needs to be vaccinated to pre-
vent an epidemic. On the same principle Present a b
as calculating the critical population, the Absent c d
critical rate of vaccination coverage can
also be worked out. In other words, the
population that will need to be successfully In the example above, the relative risk of
vaccinated to reduce the population at risk contracting cholera after eating raw fish is
below the epidemic threshold. It can be
similarly shown that even if this target is 31  60
not reached, then the epidemic will be put 38
off until a future date when the susceptible
unvaccinated children will have grown
older and therefore be able to cope with Cohort studies A cohort is a group of people
the infection better. This is illustrated in all exposed to the same aetiological agent.
Fig. 12.2. By following this group over time, the risk of
developing disease can be measured. A
modification of the technique can be used
2.2.5 Investigating food- and water-borne in outbreak investigation, particularly food
epidemics poisoning. This compares the attack rate in
the persons exposed to the factor with the
attack rate in those not exposed to the factor.
Other epidemiological techniques are useful
In a food poisoning outbreak, where various
for investigating food- and water-borne epi-
foods are suspected, then the attack rates in
demics, particularly casecontrol and
those eating and not eating the range of
cohort study methods.
foods can be compared. This is best illus-
trated by using an example as shown in
Casecontrol studies An example of the use Table 2.1. The relative risk for each food
of a casecontrol study in a cholera investi- item is calculated as above and the results
gation is given where fish were suspected to set down in a table. Most of the relative risk
contain the aetiological agent. In this com- values are about 1, but there is over four
munity, people preferred to eat fish marin- times the risk of becoming ill if you ate
ated, but uncooked. Cases were interviewed fish, so the investigator would suspect fish
as to whether they ate raw fish and com- as being the most likely cause.
pared with a similar group who had not
had the disease. The results are set out in a
two-by-two table: there was a significant
finding w2 50.47; P <0:001. 2.3 Endemicity

An endemic disease implies that there is a

Cases Controls Total constant rate of infection occurring in the
community. As new individuals are born,
Ate raw fish 31 8 39
they become infected, are cured (including
Did not eat raw 3 60 63
fish self-cure), retain the infection for life or
Total 34 68 102 become immune. Prevalence rates will
measure the level of endemicity as it applies
to the community. Incidence rates will
A reasonable estimate of the relative measure change in the level of infection
risk can be arrived at (as the incidence rates over a period of time.
are not known) from the two-by-two table, While it is useful to compare prevalence
using the odds ratio, ad/cb: from one community to another, on more
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 25.10.2004 6:51am page 29

Communicable Disease Theory 29

Table 2.1. Food-specific attack rates and the relative risks of eating different foods (meal eaten by 152

Ate Did not eat

Food item Sick Well Attack rate (%) Sick Well Attack rate (%) Relative risk

Rice 115 28 80.4 45 4 55.5 1.4

Potatoes 111 31 78.2 9 1 90.0 0.9
Fish 93 22 80.9 17 30 18.9 4.3
Beans 101 29 77.7 16 6 72.7 1.1
Coconut 86 22 79.6 24 20 54.5 1.5
Bananas 109 32 77.3 10 1 90.9 0.8

careful investigation, it will be found that equally to a community, then the overall
within a community, prevalence rates can decrease in disease will leave the foci to
also vary. These areas of increased preva- maintain infection. However, if the foci are
lence within a community are called foci. identified and treated, then the infectious
Two types of foci occur: source is contained (Fig. 2.8).
Incidence rates show change in the en-
. host focality, where some individuals
demicity either upwards, downwards or
have more severe infection than others,
remaining the same. A decreasing incidence
e.g. worm load in schistosomiasis;
will indicate that the disease may be dying
. geographical focality, where certain
out, especially if control measures have
localities have a higher prevalence rate
been used. Incidence rates often show a sea-
than others. Malaria exhibits geographical
sonal pattern (Fig. 1.7) and threshold levels
that take into account this seasonal variation
These concepts are important in control can be set to give early warning of the dis-
strategy. When a control method is applied ease becoming epidemic.

Fig. 2.8. The focality of endemic disease. (a) A universally homogenous prevalence rate is measured in an
area. (b) Once control measures have been implemented, foci of persistent transmission are revealed.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 25.10.2004 6:51am page 30

30 Chapter 2

2.4 Quantitative Dynamics means that the potential for infecting the
rest of the family has hardly altered. (This
Estimates of the magnitude of the infectious is a simplistic example implying that the
process, or the degree of control likely to be eggs will still be concentrated where infec-
achieved, can be calculated. As an introduc- tion is most likely to occur.)
tion to quantitative dynamics, examples of
helminth infections are used.
2.4.2 Schistosomiasis

2.4.1 Hookworm An idealized situation is illustrated in

Fig. 2.9. Ten people with schistosomiasis
Consider a family of five people with four are all potential polluters of a body of water.
out of the five infected with hookworms, Each gram of faeces might contain 80 eggs,
producing on average some 4000 eggs/g of but if only half of them reach the water, then
faeces. Approximately 200 g of faeces are there are still 40  200 (an average stool spe-
voided by the average person each day, so cimen is 200 g) 8  103 eggs per person or
the four people are excreting 4  4000 8  104 eggs from all ten people, reaching the
200 3:2  106 eggs=day. If each of these water every day. The miracidium that
eggs results in a viable larva, then the poten- hatches from the egg needs to find a host
tial for infection would be astronomical. snail to complete its development. Snails
If the head of the household is now per- can reproduce rapidly so that one snail can
suaded to install a latrine and he encourages produce a colony in 40 days and be infective
his family to use it, then hopefully there in 60 days. The numbers of cercariae liber-
should be no further contamination of the ated from a snail are immense, but because
surroundings and infection will decrease as they need to find a human host within 24 h
the worms die off. Unfortunately, his (generally less), few are successful. The ten
youngest child does not understand how to people entering the water at the other side
use a latrine and despite being taken to it by of the picture could all become infected,
his mother, half of the stools are still de- but in reality, only a proportion are likely to
posited indiscriminately around the neigh- be so.
bourhood. This results in 100(g)  4000 When control is considered, there is
(eggs) 4  105 eggs deposited, which the choice of preventing pollution of the
Faecal pollution

Specific snails

Final host

Prevent all Kill nearly Prevent water

faecal contamination all snails contact

Very difficult Difficult Most feasible

Fig. 2.9. Theoretical environmental control of schistosomiasis.

Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 25.10.2004 6:51am page 31

Communicable Disease Theory 31

water, destroying the snails or preventing Of course, the situation is never as clear-
water contact. (There is also mass treatment cut as this, but the illustration is made to
of the population which will reduce the show that a sanitation or molluscicide pro-
total egg load, but for the present argument, gramme needs to be virtually perfect,
it will not be discussed here.) If latrines whereas prevention from water contact can
were provided and nine out of the ten provide complete protection to the individ-
people used them, there would still be ual. This is a simplified example, but a more
8  103 eggs from the tenth person going realistic situation can be simulated by the
into the water, sufficient to maintain almost use of mathematical models.
the same level of snail infections. If all the Mathematical models will not be
snails were destroyed except a few, then covered in any more detail here, but
within 60 days, the situation would return examples will be found in measles (Fig.
to what it was before. However, if any one of 12.1), malaria (Section 15.6 and Fig. 15.7)
the ten people could be prevented from and lymphatic filariasis (Fig. 15.10). They
making contact with the water, then his/ are especially useful in determining control
her freedom from infection would be strategy, which is the subject of the next few
absolute. chapters.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:40am page 32

Control Principles and Methods

3.1 Control Principles ation can be used for animals as well as

humans. The former is more effective be-
Control can be directed either at the agent, cause animals can be forcibly restrained.
the route of transmission, the host or the Because it is difficult to quarantine humans,
environment. Sometimes it is necessary to it is not widely practised as a method of
use several control strategies. The general control, except where the disease is very
methods of control are summarized in infectious or the patient can be restrained
Fig. 3.1. easily (e.g. in hospital, Lassa fever).

Contacts People who might have become

3.1.1 The agent infected because of their close proximity to
a case are called contacts. They can be isol-
ated, given prophylactic treatment or kept
Destruction of the agent can be by specific
under surveillance.
treatment, using drugs that kill the agent
in vivo, or if it is outside the body, by the
Environmental health Methods of personal
use of antiseptics, sterilization, incineration
hygiene, water supplies and sanitation are
or radiation.
particularly effective against all agents
transmitted by the faecaloral route whether
by direct transmission or complex parasitic
3.1.2 Transmission cycles involving intermediate hosts.

When the agent is attempting to travel to Animals Whether they act as reservoirs
a host, it is at its most vulnerable position; or intermediate host animals can be con-
therefore, many methods of control have trolled by destruction or vaccination (e.g.
been developed to interrupt transmission. against rabies). If animals are to be eaten,
their carcasses can be inspected to make
Quarantine or isolation Keeping the agent at sure that they are free of parasitic stages.
a sufficient distance and for a sufficient The excretions or tissues of an animal can
length of time away from the host until it be infectious; so protective clothing and
dies or becomes inactive can be effective in gloves should be worn when handling
preventing transmission. Quarantine or isol- animals.

Q R. Webber 2005. Communicable Disease Epidemiology and Control, 2nd edition (Roger Webber)

Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:40am
Personal hygiene
Water supplies Physical protection
Sanitation Vaccination

Contacts Transmission

Quarantine Direct E Education

cyclical sub clinica n
Carriers and l
Intermediate i

Control Principles and Methods

host r
Plants Assistance
Agent Host n
Cooking e
Diagnosis and specific Communications

Destruction Vector control

(Larvae) (Adults)
Larvicides Adulticides
Biological Biological

page 33
Notification and surveillance

Fig. 3.1. Control principles.

Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:40am page 34

34 Chapter 3

Cooking Proper cooking renders plant own from natural or artificial infections
and animal produce safe for consumption, that it acquires.
although some toxins are heat-resistant. Artificial infection is given by vaccin-
Food should be prepared hygienically ation, or rather the objective is to administer
before cooking and stored properly after- the antigenic substances produced by the
wards. disease organisms in a vaccine without the
host developing the disease. Vaccine can be
given, but immunity does not always result
Vector control is one of the most highly due to poor administration, the vaccine no
developed methods of interrupting trans- longer being potent, or the host not develop-
mission because the parasite utilizes a ing an immune response. Therefore, the term
vulnerable stage for development and trans- vaccination is mostly used in this book to
port. Attack on vectors can either be on their indicate the administration of vaccine rather
larval stage by using larvicides and methods than immunization, which can be misunder-
of biological control, or while they are adults stood as immunity has been given.
with adulticides. The immune system of the full-term
newborn is capable of producing antibodies
and mobilizing cellular defenses. Bacillus
Calmette-Guerin (BCG) and polio can be
3.1.3 Host
given shortly after birth and killed antigen
vaccines are also effective from the first
The host can be protected by physical month of life. Some live vaccines like
methods (mosquito nets, clothing, housing, measles do not provide protection if given
etc.), by vaccination against specific dis- early because of circulating maternal anti-
eases or by taking regular prophylaxis. bodies.
Vaccines can be of four different kinds:

3.1.4 Environment 1. Live attenuated organisms give the body

an actual infection, inducing antibody pro-
duction. This is the best kind of vaccine as it
The environment of the host can be im-
generates maximal response from a single
proved by education, assistance (agricul-
dose and as a consequence, immunity is
tural advice, house building, subsidies,
long-lasting. The danger with live attenuated
loans, etc.), and improvement of communi-
vaccines is that the organisms could revert
cations (to market his produce, reach health
to the virulent strain. Examples are measles
facilities, attend school, etc.). In the course
and oral polio, which are attenuated virus
of time, these will be the most effective
infections, and BCG, which is an attenuated
methods of preventing continuation of the
transmission cycle.
2. Killed organisms are used when it is
not possible to produce a live attenuated
strain. Immunity does not develop so well
and the vaccine has to be repeated to induce
3.2 Control Methods Vaccination the body defence mechanisms to increase
their response. An example is pertussis
3.2.1 Vaccines (whooping cough).
3. Active components can be separated
The newborn baby carries antibodies trans- from organisms and vaccines made from
mitted from its mother across the placenta these organisms. Good immunity is pro-
and from early breast-feeding, protecting it duced, but they are expensive to manufac-
at a very vulnerable stage in life. The effects ture. An example is hepatitis B vaccine,
of these antibodies wear off after 6 weeks to 6 which is a recombinant DNA or plasma-
months so that the baby starts making its derived vaccine.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:40am page 35

Control Principles and Methods 35

4. Toxoids are detoxified bacterial exo- early. Diphtheria, pertussis and tetanus are
toxins and are an important way of produ- normally combined in a triple vaccine (DTP)
cing antibodies to bacterial toxins. They do given at monthly intervals in early child-
not prevent the infection, but counteract the hood after the first month of age. If resources
dangerous effects of the toxin. Like killed permit, a booster dose should be given at 18
organisms, several doses have to be given months to 4 years of age. Adults should have
to induce a sufficient antibody response booster doses of adult vaccine (Td) every 10
and booster doses repeated from time to years.
time to maintain the level. Diphtheria and
tetanus toxoid are two vaccines in this Poliomyelitis infection is induced by three
category. different strains of virus. The oral polio vac-
cine (OPV) contains all three attenuated
strains of the virus, but the gut may not
3.2.2 Vaccine schedules be infected by three strains at the same
time and so three doses are required to
The type of vaccine and the age of risk ensure protection. In developing countries
of developing the target disease determine where wild poliovirus is circulating, a
the optimum time and schedule for adminis- first dose is given as soon after birth as
tering each vaccine. The characteristics of possible, followed by three other doses at
the principal vaccine-preventable diseases the same time as DTP. In the WHO global
(included in the Expanded Programme of eradication programme mass vaccination,
Immunization (EPI) programme in most regardless of previous vaccination, all chil-
developing countries) are as follows: dren under 5 years (two doses at an interval
of 4 weeks) are vaccinated, followed by
mopping up in areas of low coverage or
Tetanus can enter the neonate through an
where continuing transmission is identi-
infected umbilical cord, producing a high
fied. Endemic polio is now only found in
mortality. Protection is by immunizing
Africa and Southeast Asia. Inactivated
pregnant women with tetanus toxoid. This
polio vaccine (IPV) is favoured in many de-
protection is short lived and the child
veloped countries, but is more expensive
should be given tetanus toxoid early in
and produces less herd immunity. As the
infancy as the combined vaccine diphtheria,
reservoir of wild virus is being eliminated,
tetanus and pertussis (DTP). Toxoid is
IPV is the preferred vaccine as there is no
also given to adults as a course of three
risk of reversion of the vaccine to a patho-
vaccinations to prevent tetanus, or if not
genic form.
so protected, when there is a wound,
which could possibly be infected with
Haemophilus influenzae type b is an import-
Clostridium tetani. The World Health
ant cause of meningitis and pneumonia in
Organization (WHO) policy is to vaccinate
children under 6 years of age, particularly
all women of childbearing age with a
those 418 months and a vaccine given
lifetime total of five doses of tetanus
before this age gives a high degree of protec-
tion. The vaccine is a conjugate known as
Hib and has the advantage of inducing anti-
Whooping cough (pertussis) is a serious body response and immunological memory
disease of young children, often with in infants as well as reducing nasopharyn-
a fatal outcome in infants less than 6 months geal carriage of the organism, thereby redu-
old. Vaccination must start before this cing transmission. It is given at the same
time, preferably at 1 month or soon after, to time as DTP.
produce a sufficient level of antibodies.
Measles is one of the most important causes
Diphtheria is a dangerous disease at any of childhood death and disability in the
age, so it is preferable to start protection tropics. It reaches maximal prevalence
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:40am page 36

36 Chapter 3

by the end of the first year of life, but high-risk countries. BCG should not be
many children already would have been given to pregnant women or those with
infected by 612 months. Maternal anti- symptomatic HIV infection. However, even
bodies do not diminish sufficiently until in countries where there is a high level of
6 months for the attenuated virus to be ef- HIV and tuberculosis, BCG should be given
fective, so the optimal time for vaccination to all infants at birth, as it is unlikely that
is 9 months in developing countries. Pro- they would have developed symptoms of
longed immunity is obtained if vaccine is HIV infection by this time.
given later (at 1215 months) so this is a
preferable time in developed countries or Hepatitis B leads to chronic liver disease,
those in which there is a low prevalence. especially cirrhosis, which is a predisposing
A second measles vaccination should be cause of primary liver cell cancer. The
given at 45 years or on school entry (see prevalence of hepatitis B is as high as 8%
Section 12.2). in many parts of the world, but if the vaccine
is administered before infection, the disease
Rubella The objective of giving rubella vac- and carrier state are prevented. WHO recom-
cination is to reduce congenital rubella syn- mends that hepatitis B vaccine be included
drome (CRS), which occurs if a woman in the routine childhood vaccination sched-
becomes infected just before or in the first ule. It is most conveniently administered
20 weeks of pregnancy. If the vaccination in three doses at the same time as DTP,
programme is efficient, then a strategy to but in countries with a high carrier state,
eliminate rubella by giving a combined an additional dose at birth is recommended.
measles and rubella (MR) or measles, This will probably only be necessary for
mumps and rubella (MMR) vaccination to a comparatively short period of time be-
all children 912 months old can be started. cause once hepatitis B vaccine becomes
If the objective is to reduce CRS, then widely used, the carrier state will rapidly
all adolescent girls and women of childbear- decline. In developed countries where the
ing age should be vaccinated (see Section incidence is much lower, the vaccine
12.3). is given in adolescence or to those at risk,
but will probably be incorporated into the
Mumps An infection of the salivary glands, routine vaccination programme at some
mumps can cause orchitis and meningitis stage.
and more rarely encephalitis. Vaccination
is conveniently combined with MR vaccines Combinations and schedules Different vac-
and given at 912 months of age in develop- cines can be combined (e.g. DTP), or can be
ing countries or 1215 months in developed given together (e.g. DTP and polio). A suffi-
countries, with a second dose at 45 years or cient interval must be left between doses to
at school entry (see Section 12.4). allow time for the antibody response to take
place, 1 month normally being sufficient.
Tuberculosis The maximum age risk of tu- All these factors and the national character-
berculosis depends on the prevalence of istics of a country will determine the vaccin-
active infection in the community. Where ation schedule to be followed. A suggested
there are many open cases, even small chil- regime is as follows:
dren are at risk, but in a society where most
cases are in older people and individuals do
Before birth Tetanus toxoid to all women of
not contact many others until they start
childbearing age with at least
work in young adulthood, the period of two doses in the first
greatest risk is adolescence. In developing pregnancy and one in the
countries, vaccination is given at birth, second.
whereas in developed countries, BCG is Birth BCG. OPV in endemic areas
given when the child starts school or select- and hepatitis B vaccine in
ively to risk groups such as immigrants from areas of high prevalence
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:40am page 37

Control Principles and Methods 37

12 months DTP plus OPV plus hepatitis B 4. A primary course need never be repeated,
plus Hib even if the booster dose is long delayed.
23 months DTP plus OPV plus hepatitis B 5. An interrupted course can be resumed
plus Hib whenever feasible without starting from the
36 months DTP plus OPV plus hepatitis B
beginning again.
plus Hib
915 months MMR (see Sections 12.2, 12.3
6. If the interval between doses ends up
and 12.4); OPV if not given at as being longer than planned, the immuno-
birth logical effect will not be reduced. The
45 years or MMR only disadvantage of long drawn out sched-
school entry ules is that the individual is not rapidly

DTP and OPV can be given even if the child

has a mild illness. Measles vaccine can also 3.2.4 The cold chain
be given if the child is having a mild illness
as it does not have any effect for several
The cold chain is a descriptive term for the
days, by which time the minor illness
whole sequence of links that must be main-
would have been cured. Vaccination should
tained in transporting the vaccine in a viable
always be given to the malnourished child,
condition from the manufacturer to the
who is at particular risk from infection. Pro-
person to be vaccinated. Vaccines will only
tective response is good except in cases of
survive when they are maintained at the
severe kwashiorkor. (Further information
correct temperature. There are certain limits
can be found on individual vaccines under
when the vaccine can be allowed to depart
the various diseases.)
from the optimal temperature, but the range
and time are very short and vaccines rapidly
lose their potency. To vaccinate with non-
3.2.3 Operational factors potent vaccine is not only a waste of time
and money, but also brings discredit to the
In planning vaccination programmes, cul- vaccination programme.
tural, logistic and other operational factors Some vaccines are stored at freezing
largely determine the coverage. Some of temperature (poliomyelitis, BCG and
these are: measles), while others are at the standard
refrigerator temperature of 488C (DTP
1. The strongest motivation to attend MCH and tetanus). If stored at the wrong tempera-
clinics is immediately after the child has ture, the vaccine will be destroyed. The two
been born; the shorter the interval between elements of the cold chain are speed of
birth and vaccination, the more likely they transport and maintenance of a steady tem-
are to be brought by their mothers. perature; hence the fastest means of getting a
2. A range of ages, days and combinations vaccine from one place to another is used.
should be available so that the time of A temperature-sensitive strip that changes
attendance is always the right time for vac- colour if the batch becomes too warm during
cination. If a mother is told to bring her the period of transport accompanies most
child back at a set time or at a particular vaccines. The viability of the vaccine can
age of the child, then she probably will not then be checked and the problem link in
bother. the cold chain detected.
3. Admission to hospital is an ideal oppor- Cold boxes are very well insulated con-
tunity to check whether the vaccination tainers lined with freezer packs in which
schedule is up to date. Measles vaccination vaccines can be transported or stored for
is particularly important as many children up to 7 days. They are valuable for mobile
contract serious measles when admitted to vaccination teams, but for the individual
hospital for another complaint. vaccinator, a hand-held vacuum flask will
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:40am page 38

38 Chapter 3

store vaccines for 12 days, depending on economics of static and mobile vaccination
the outside temperature. clinics, see Section 1.5.1.
Certain vaccines, such as measles and Mobile clinics are easier to organize
BCG, are sensitive to light and need to be where only one dose of vaccine is required
protected while they are being diluted, (e.g. measles) and have a special place in
stored and administered to a person. Special mass campaigns.
dark glass syringes can be obtained, but
covering with a cloth is just as efficient.
Many potent vaccines are destroyed by 3.2.6 Seasonality and vaccination campaigns
being drawn up into syringes that are still
warm from the sterilizing process, a sad end Many infections follow a seasonal pattern
to a long cold chain. with sufficient regularity that peaks of
incidence can be forecast. If the pattern is
known, the epidemic can be prevented by
3.2.5 Mobile and static clinics carrying out mass vaccination before it is
expected (see Fig. 1.7).
Vaccination can be from static and/or
mobile clinics. Their various advantages
and disadvantages are given in the following 3.2.7 Ring vaccination
If an epidemic is spreading, it can be con-
tained by vaccinating everyone in a ring
Static Mobile
around the site of the epidemic. Villages
should be chosen where cases have not
Coverage Limited to 10 km Large areas
radius yet been reported and an attempt made to
Availability Always Occasional vaccinate as many people as possible. If the
Transport Not required Required ring is too close to the epidemic, then the
Costs High capital, low Moderate disease might have already affected some
recurrent costs capital, high people outside the defensive ring and then
recurrent costs another will need to be started even further
Vaccine Often erratic Good away.

A static clinic responsible for providing 3.2.8 Economies of vaccination

primary care services (including delivery)
for both the mother and the child is the most Vaccination coverage is often poor because
effective. A child stands a greater chance of of constraints put on staff by the cost of
receiving all its vaccines from a static health vaccines. Vaccines should be supplied in
unit. However, as distance from the clinic small dose quantities so that a vial can be
increases, the probability of a mother bring- opened even if there is only one child to
ing her child to the clinic decreases for every be vaccinated. Spare vaccine can often be
kilometer to be walked. Coverage is best used up on other children attending the
closest to the clinic and decreases further health centre for other reasons. The cost of
away, with often large gaps between clinics vaccination is not just the price of the actual
as shown in Fig. 3.2. It is in the inadequately vial of vaccine, but includes the whole cold
covered areas between the static clinics that chain and the salary of the vaccinator. To
an epidemic is likely to occur. Outreach ser- have a vaccinator sitting around not vaccin-
vices or mobile clinics then become valuable ating because there are not enough children
in vaccinating the in-between areas. For the to warrant opening a vial is a false economy.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:40am page 39

Control Principles and Methods 39

Fig. 3.2. Unequal vaccination coverage from static clinics. , vaccinated child; , non-vaccinated child;
Hosp., hospital; H.C., health centre; Disp., dispensary.

Proportional costs have been calculated as where AR is the attack rate (discussed in
follows: Section 2.2.1). The VE indicates the max-
imum achievable level, but poor vaccination
technique or storage can reduce this. Also,
Capital 1215% Transport 20%
the more people who are vaccinated, the
Salaries 45% Vaccine 5%
Training 23% Others 1216%
greater the number of apparent vaccine fail-
ures. If the above equation is rewritten to
express the percentage of cases vaccinated
3.2.9 Vaccine efficacy (PCV) in terms of the percentage of the popu-
lation vaccinated (PPV) and VE, then:
Vaccine efficacy (VE) is calculated by:
(AR in unvaccinated  AR in vaccinated) PPV  (PPV  VE)
VE  100% PCV
AR in unvaccinated 1  (PPV  VE)
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:40am page 40

40 Chapter 3

By knowing two of these variables, the third 3.3 Environmental Control Methods
can be calculated. Figure 3.3 shows three
curves generated from the equation, each Many diseases result from contamination of
for a different VE. These curves predict the the environment by faecal matter with trans-
theoretical proportion of cases with a vac- mission by the direct route (e.g. by fingers),
cine history. For example, if a measles epi- or via food and water. The mechanisms are
demic is observed in a population with schematically illustrated in Fig. 3.4. The
homogeneous measles exposure where various control methods available are as
90% of the individuals are vaccinated follows:
(PPV90%) with a 90% effective vaccine
(VE90%), the expected percentage of . personal and domestic hygiene;
measles cases with a history of being vaccin- . proper preparation, cooking and storage
ated would be 47% (PCV47%: Example A). of food;
However, if only 50% were vaccinated, then . use of water supplies;
9% of the cases would have been found to be . proper disposal of excreta and waste;
vaccinated (Example B). This is not to say . miscellaneous methods including meat
that there is anything wrong with the vaccin- inspection and hygiene.
ation programme, but explains why there
may appear to be an unexpected number of Classifying the water- and sanitation-related
vaccinated population amongst the cases. diseases into well-defined categories allows

Fig. 3.3. Percentage of cases vaccinated (PCV) per percentage of population vaccinated (PPV), for three
values of vaccine efficacy (VE). Reproduced by permission from Weekly Epidemiological Record 7, 20
February 1981. World Health Organization, Geneva.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:40am page 41

Control Principles and Methods 41

rational control methods to be applied and 3 diseases are reduced by rigorous

(Table 3.1). The potential impact of control hand-washing after defecation and before
methods is seen in Table 3.2. eating.
Personal hygiene is closely related to
the availability of water in sufficient quan-
3.3.1 Personal hygiene tity. Water quality is of less importance.
Washing is improved by using warm water
Personal hygiene is the understanding by and soap. Soap reduces surface tension and
the individuals of how infections can be emulsifies oils, allowing bacteria to be more
transmitted to them or others by unclean easily removed. However, large quantities of
habits, and using appropriate methods to water can still be effective in the absence of
avoid them. Infection can be avoided by pre- soap.
venting bad habits (e.g. promiscuous defeca-
tion) or introducing good habits (e.g. hand-
washing before eating). Infections that can 3.3.2 Protection of foods
be reduced by personal hygiene are shown
in Table 3.3. Food-transmitted infections can spread
Category 1 diseases are reduced by either through contamination or by a
washing of the body and clothing with specific intermediate host. Flies indirectly
water, which is best heated and with the contaminate food. Protection of the food we
addition of soap if available. Categories 2 eat can be by the following:

Contaminated or
Faecaloral infected food and
auto-infection water
person to person

in soil before
oral infection
Land-based Contaminating
intermediate host insect

Penetrating Urine breeding

Penetrating intermediate Contaminated
skin host water

Fig. 3.4. Routes of transmission of the water- and sanitation-related diseases.

Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:40am page 42

42 Chapter 3

Table 3.1. A classification of water- and excreta-related diseases.

Category Characteristics Examples Transmission Control measures

1. Water- Diseases of poor Skin diseases, eye Person-to-person Personal hygiene

washed hygiene diseases, louse- (and Increase water
disease borne typhus autoinfection) quantity
2. Faecaloral (a) Low infective Enterobius, Person-to-person Personal hygiene
diseases dose amoebiasis, (and Increase water
enteric viruses autoinfection) quantity
(b) High infective Diarrhoeal diseases, Contamination of Excreta disposal
dose. Able to cholera, typhoid, food or water Cook food
multiply hepatitis A Improve water
outside host quality
3. Soil-mediated (a) Development Ascaris, hookworm, Larvae penetrate Personal hygiene
diseases in soil Strongyloides skin or swallowed Excreta disposal
(b) Development Taenia spp. Cysts in meat Meat inspection
in animal Cook food
(cow or pig)
4. Water-based Helminths
diseases requiring
(a) Copepods Guinea worm Ingested in water Improve water
(b) Snails only Schistosomiasis Penetrates skin Reduce water
(c) Two Fasciolopsis, Eating uncooked Excreta disposal
intermediate Opisthorchis, specific foods Cook food
hosts Paragonimus,
5. Water- and (a) Breeding in Malaria, filariasis, Mosquitoes Drain breeding sites
excreta- water or arboviruses Maintain water
related insect sewage supplies and
vectors sanitation
(b) Breeding or Onchocerciasis, Simulium Water supply at site
biting near trypanosomiasis Tsetse fly of use
(c) Breeding in Diarrhoeal diseases Housefly Excreta disposal

Modified from Bradley, D.J. (1978) In: Feachem, R.G. et al. (eds) Water, Wastes and Health in Hot Climates. Reproduced by
permission of John Wiley & Sons Ltd, Chichester.

. inspection of raw produce; . preventing contamination of cooked

. packaging and avoiding contamination; foods;
. suitable storage conditions and time- . eating cooked foods immediately.
. washing and correct preparation; Infections that can be reduced by the proper
. adequate and even cooking; protection of food are shown in Table 3.4.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:40am page 43

Control Principles and Methods 43

Table 3.2. The potential impact of environmental control methods (compare with Table 3.1).

Personal Cooking Water

Disease category hygiene of foods supplies Sanitation Miscellaneous

1. Water-washed diseases  
2. Faecaloral diseases 
3. Soil-mediated diseases  Meat inspection
4. Water-based diseases  Reduce water contact
5. Water- and excreta-     Protection from insects
related insect vectors

, Very effective; , moderately effective; , effective; , not effective; , can be either effective or not effective.

Table 3.3. Infections that can be reduced by personal hygiene.

Category Infection

1 Skin sepsis and ulcers

1 Conjunctivitis
1 Trachoma
1 Scabies
1 Yaws
1 Leprosy
1 Tinea
1 Louse-borne fevers
1 Flea-borne infections (including plague)
2 Enteric viruses (including hepatitis A and polio)
2 Enterobius
2 Amoebiasis
2 Trichuris
2 Giardia
2 Shigella
2 Typhoid
2 Other Salmonellae
2 Campylobacter
2 Non-specific diarrhoeal diseases
2 Cholera
2 Leptospirosis
3a Ascaris

Category 2 infections contaminate food off the intermediate stages and procedures,
before or after cooking. Flies are often in- such as roasting on a spit or cooking meat
volved. Even if contamination has occurred, under done, do not provide high enough
correct storage and the disposal of cooked temperatures inside the meat. Meat inspec-
foods after a limited time can prevent suffi- tion can be effective in Taenia infection (3b).
cient multiplication of bacteria to reach an
infective dose.
Categories 3b and 4c (Table 3.4) require 3.3.3 Water supplies
specific intermediate hosts in their transmis-
sion, so their destruction or proper cooking is Contaminated water can be the vehicle
an effective means of control. Cooking needs of transmission of a number of disease-
to be at a sufficiently high temperature to kill producing organisms. Water is also important
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:40am page 44

44 Chapter 3

in diseases of poor hygiene as a medium for water-borne etc. However, water supplies
intermediate hosts and as a breeding place need to be maintained and when they break
for vectors of disease. down, the disease can be expected to return.
The infections and possible improve- In rural water supplies where chlorine
ments that may occur as a result of installing treatment of the water is costly, difficult
a water supply are shown in Table 3.5. to maintain or inappropriate, then a differ-
ent standard to that in large centralized sup-
The provision of water There are four aspects plies may be acceptable. This should not be
of water supply, which can help to control considered unsatisfactory as the provision
disease transmission: of a properly constructed water supply is
an improvement on what was used before.
. improve water quantity; Also quality is closely related to quantity. By
. improve water quality; providing a greater volume of water at a
. reduce water contact by bringing water more accessible site, quality will usually be
to site of use; improved.
. prevent spillage by proper maintenance of Health aspects are the concern of the
supplies and drainage. medical worker, whereas the villager looks
upon water as a basic necessity. His, or
It will be noticed how this is the normal rather her (as women are nearly always the
process in the supply of water. The first carriers of water), major concerns will be
objective is to provide water in sufficient quite different. These are the following:
quantity, which is followed by improving
its quality and finally a piped system is con- . availability of water at a more convenient
structed. If this is the pattern followed, then place (preferably in the village);
similarly it can be anticipated that the first . a continuous and reliable supply;
group of diseases to be reduced will be the . additional water for crops and domestic
water-washed and faecaloral, then the animals.

Table 3.4. Reduction of infection by food protection.

Category Infection Type of food Possible reduction

2 Enteric viruses (including hepatitis All

A and polio)
2 Hymenolepis All
2 Amoebiasis All
2 Trichuris All
2 Giardia All
2 Shigella All, especially dairy produce
2 Typhoid All, especially dairy produce
2 Salmonellae All, especially dairy produce
2 Campylobacter All, especially dairy produce
2 Non-specific diarrhoeal diseases All, plus fly contamination
2 Cholera Marine animals, salad
2 Leptospirosis Rat-contaminated foods
2 Brucellosis Milk produce
3a Ascaris All
3b Taenia Cow or pig meat
4b Trichinella Pig
4c Fasciolopsis Salad
4c Opisthorchis Fish (fresh water)
4c Paragonimus Crustacea (fresh water)
4c Diphyllobothrium Fish (fresh water)

Refer to footnote of Table 3.2 for the description of +++, ++ and +.

Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:40am page 45

Control Principles and Methods 45

Table 3.5. Expected improvements when installing a water supply.

Category Infection Water improvement required Possible reduction (%)

1 Skin sepsis and ulcers Increase water quantity 50

1 Conjunctivitis Increase water quantity 70
1 Trachoma Increase water quantity 60
1 Scabies Increase water quantity 80
1 Yaws Increase water quantity 70
1 Leprosy Increase water quantity 50
1 Tinea Increase water quantity 50
1 Louse-borne fevers Increase water quantity 40
1 Flea-borne diseases (including Increase water quantity 40
2 Enteric viruses (including Increase water quantity 10?
hepatitis A and polio)
2 Enterobius Increase water quantity 20
2 Hymenolepis Increase water quantity 20
2 Amoebiasis Increase water quantity 50
2 Trichuris Increase water quantity 20
2 Giardia Increase water quantity 30
2 Shigella Improve water quality 50
2 Typhoid Improve water quality 80
2 Other Salmonellae Improve water quality 50
2 Campylobacter Improve water quality 50
2 Non-specific diarrhoeal diseases Improve water quality 50
2 Cholera Improve water quality 90
2 Leptospirosis Improve water quality 80
3a Ascaris Increase water quantity 40
3a Hydatid Increase water quantity 40
3a Toxocara Increase water quantity 40
3a Toxoplasmosis Increase water quantity 40
4a Guinea worm Reduce water contact 100
4b Schistosomiasis
9 Reduce water contact 60
5a Malaria = Water piped to site of use and 10
5a Filariasis ; maintenance of water 10
5a Arboviruses  supplies 10?
5b Onchocerciasis Water piped to site of use 20?
5b Gambian trypanosomiasis 80

From Bradley, D.J. (1978) In: Feachem, R.G. et al. (eds) Water, Wastes and Health in Hot Climates. Reproduced by
permission of John Wiley & Sons. Ltd, Chichester.

It is a combination of these health and social munity should be served, when they
factors that needs to be used in deciding should receive their supply and the level of
the appropriateness and benefits of water availability. There are many alternative
supplies. strategies that may be, or inadvertently
will be, used. They might include the
Economic and planning criteria Everybody following:
wants the best possible water supply they
can get, but resources are limited so it . priority of an area on health grounds;
will be many years before everyone has . priority to an area of water scarcity;
the supply they desire. Decisions have . encouragement of development to an area
to be made as to which sections of the com- of high potential;
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:40am page 46

46 Chapter 3

. priority to communities that can contrib- is 650 mm, then 10  5  650  0:8 26,000
ute in money and labour; l/year or 71 l/day, on average.
. first come, first served; The demand for water will be deter-
. political favouritism. mined by the availability, the number
of people and the use to which it is
Other alternatives in the nature of the put. Availability is the most crucial factor
supply can also be considered: as water that has to be carried some distance
will be used much more sparingly than
. supplying a large number of people with when there is a tap inside the house. Aver-
the simplest of supplies; age figures taken from a number of studies
. restricting supplies to certain demonstra- are as follows:
tion areas with a high standard;
. start with the most available natural water
sources; Rural supply 20 l/person/day
. plan a major project, such as a dam, Standpipe 40 l/person/day
followed by extension of supply in subse- Single tap in the home 80 l/person/day
quent years. Multiple taps with bath,
W.C., etc. 200300 l/person/day
This will depend on how much the country,
region, district or village is prepared to
At least 50% extra capacity is allowed for
pay for the price of water. Savings can be
future growth of the community and expan-
made by the following: (i) economies of
sion of the supply. A water source is chosen
scale; (ii) standardizing the equipment; and
where the expected demand on the supply
(iii) self-help labour.
will never be exceeded, even in the driest
The initial water master plan is best
time of the year. If this is not possible, then
formulated by skilled engineers, but its exe-
some form of storage will be required. Water
cution can be by a purpose-trained techni-
use during the night is far less than during
cian, utilizing community effort. The plan
the day, so a poor supply can be boosted by
needs to take account of health, engineering,
providing a storage tank that fills at night. In
political and community demands.
areas of wide seasonal variation, more ex-
tensive storage facilities may be required,
Water capacity and use In selecting a suit- such as a dam, to save the rainfall in the
able source, the amount of water it produces few wet months.
and its regularity need to be known. If a
spring or stream does not flow all the year Choice of water supply Choosing a water
round, then it is not suitable unless a dam is source will depend upon the following:
also built. Measurements of water flow
should be made at the end of the dry season . proximity to user;
and the people asked if the source has ever . reliability;
dried up. A temporary dam can be con- . quantity of water;
structed and the rate of filling a measured . quality of water;
bucket estimates the flow. Wells can be . technical feasibility;
mechanically pumped out and the fall . resources available;
noted for a given flow of water. Rainwater . social desirability or taboo;
catchment is derived from the simple for- . maintenance.
The alternative choices are illustrated in
1 mm of rainfall on 1 m2 of the roof in plan
Figs 3.5 and 3.6. Rainwater naturally seeps
will give 0.8 l of water.
through the earth until it finds an impervi-
As an example, if the roof plan area is ous layer (such as clay) on which it collects.
10 m  5 m and the average annual rainfall When this impervious layer comes to the
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:40am page 47
Control Principles and Methods 47
Fig. 3.5. Sources of water.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:40am page 48
48 Chapter 3
Fig. 3.6. Water catchment and the fresh water lens of coral islands.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:40am page 49

Control Principles and Methods 49

surface, water runs out of the ground as a ent, but poor quality water. Other sources
spring. It can also form the bed of a river or in should be used if possible, but if there is no
an enclosed area, a lake. This groundwater alternative, then some form of water treat-
can be tapped by a shallow well. At a much ment, such as filtration and storage, should
deeper level, a second impervious layer can be incorporated. A constant spring that
trap a large quantity of water. A deep well or never dries up is a very suitable source, as
bore hole is required to reach this source of it is comparatively free from contamination
water. Island populations (Fig. 3.6) have and can normally be led to an outlet without
particular problems in obtaining water and requiring pumping. Maintenance costs will,
are generally left with only two alternatives. therefore, be low, so greater capital expend-
Provided they have suitable roofing material iture can be allowed for protecting the
(e.g. corrugated iron), rainwater can be col- spring and piping its water to the village.
lected and stored in a tank. The other alter- Rainwater catchment is an under-
native is to sink a well to tap the freshwater utilized source of pure water, either as a
lens. Due to a fortunate quality of coral rock, main method or as subsidiary (for drinking
it acts like a large sponge, holding fresh water). So much good water runs to waste off
water that has percolated through, floating large expanses of roof that have already been
on the denser sea water. Provided the well is paid for in the construction of the building.
sunk just far enough and not pumped out too This water can be tapped for good use. With
hard, freshwater can be obtained. The differ- the additional cost of guttering and a tank, a
ent water sources are summarized in Table family can have a good, safe source of water
3.6. inside or very close to their house. Storage
Wells are often a good supply, as long as tanks can either be close to the roof or large
contamination can be prevented and have concrete structures built underground.
the advantage that they can be sited close Their main danger is that if water is allowed
to houses. This can be achieved by sealing to collect in poorly maintained gutters or
them and having a pump fitted, but this will uncovered tanks, then mosquitoes can
require maintenance. Deep wells and bore breed there.
holes need special equipment for their con- The ideal is to find a source that has
struction and complex pumps to lift water both constant quantity and good quality,
from these depths. They are mainly applic- but where the latter is not available, then it
able in areas of severe water shortage such as can be improved by simple methods, such as
deserts. Lakes and rivers provide conveni- the three-pot system (Fig. 3.7).

Table 3.6. Sources of water, their advantages and disadvantages.

Spring Shallow well Bore hole River Lake Catchment

Proximity Distant Near Intermediate Near Near Near

Reliability Good Variable Good Unreliable Good Unreliable
Quantity Good Moderate Good Variable Good Poor
Quality Good Moderate Good Poor Poor Good
Technology Easy Moderate Difficult Easya Easya Moderate
Cost Low Moderate High Lowa Lowa Moderate to high
Community High Moderate Moderate Low Low Moderate
Maintenance Low Moderate High Low Low Moderate
These assessments are for taking water by hand from the river or lake. If a pump and supply system are used, then the
technology is difficult and the cost high.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:40am page 50

50 Chapter 3

Only the top clear water that has

been standing all night is poured
off for drinking

Drinking water (clean the pot

before refilling)

The first large pot is cleaned out

and filled with freshwater. This is
left to settle until the next day

Fig. 3.7. The three-pot system a simple means of improving water quality.

3.3.4 Sanitation
supply, but nobody wants to change his or
her defecation practice. This is quite simple
With food and water supplies, the emphasis to explain in that substances taken into
is on the prevention of contamination, but the body can be understood as a direct
with sanitation, it is reducing the source of cause of illness, whereas excreting some-
the contamination. Social habits concerned thing from the body cannot. Defecation is a
with excreta disposal are often strongly held necessary, but private business and is not
and unless these are approached in a sens- a matter for discussion. There are also social
ible manner, any new system will fail. Sani- reasons that are set by religious, racial
tation is not just the provision of latrines, or cultural practice. These may dictate
but a complex and inter-related subject in- where and where not to defecate, will prob-
volving people, water supplies and all other ably separate the sexes and define particular
aspects of environmental health. anal-cleansing practices. With all these
patterns and customs that have been taught
Health factors As shown in Table 3.1, the since childhood, any change becomes a
main impact of sanitation is on groups 2, long and difficult process. If a family can
3a, 4c and 5c. The installation of sanitation see the benefits of a latrine, then they
may produce a reduction in the infections will install and look after it; the health
shown in Table 3.7. authority can then assist in technical speci-
fications and subsidize costs. Any attempt
The provision of sanitation When providing to impose systems or even build them
sanitation, there is a sharp contrast with free of charge will cause resentment or
water supplies. Everybody wants a water non-use.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:40am page 51

Control Principles and Methods 51

Like water, sanitation has to be paid that the former is outside the house, while
for, but here costs are even less accepted by the latter carries excreta from within
the population. People are only prepared to the house. The cost of this convenience is
pay for the minimum possible in getting rid typically ten times that of a pit latrine.
of their excreta. Only in urban areas will it In choosing the most appropriate ex-
be considered necessary to pay for the re- creta disposal system, the emphasis should
moval of excrement; in rural areas, there is be on simplicity. Only when a simpler
sufficient space. A subsidizing scheme then method becomes outmoded because of
becomes the main way in which sanitation rising standards and expectations will a
can be improved. For instance, in pit latrine more sophisticated system become appro-
construction, villagers will need to dig their priate. A simple incremental process, as
own hole, but might be sold a bag of cement illustrated in Fig. 3.8, can be planned.
at a reduced price or be provided with a The first stage is to bury excreta, which
squatting slab free of charge. will lead on to using a pit latrine. If pit
Cost is related to convenience, which latrines are already accepted by the commu-
is why people are prepared to pay for nity, then demonstrating the advantages of
improved systems, their willingness to pay improved pit latrines will be the next step.
usually having nothing to do with health. The type of facility will also be determined
A good pit latrine can be as effective in dis- by the availability of water. As mentioned in
ease control as a conventional water-carried Section 3.3.3, the provision of water should
sewage system, the only difference being precede any sanitation programme as

Table 3.7. The expected improvements from the installation of sanitation.

Category Infection Through reduced contamination of reduction

1 Trachoma The environment; flies (group 5c)

2 Enteric viruses (including hepatitis A) Vegetables
2 Hymenolepis Food and water
2 Amoebiasis Vegetables
2 Trichuris Food and water
2 Giardia Food and water
2 Shigella Food and water
2 Typhoid Food and water
2 Other Salmonellae Food and water
2 Campylobacter Food and water
2 Non-specific diarrhoeal diseases Food and water
2 Cholera Food and water
3a Ascaris Soil
3a Hookworm Soil
3a Strongyloides Soil
3b Taenia Soil
4b Schistosomiasis Water
4c Fasciolopsis Water
4c Opisthorchis Water
4c Paragonimus Water
4c Diphyllobothrium Water
5 Housefly-transmitted diseases The environment; flies a
5 Filariasis Water and Culex quinquefasciatus
Sanitation, if not properly built or maintained, can be as responsible for increasing the fly nuisance as well as decreasing it.
Refer to footnote of Table 3.2 for the description of +++, ++, + and .
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:40am page 52

52 Chapter 3

personal hygiene can only be taught if there practice and poses considerable threat of
is water at hand to wash with. The quantity infection. The easiest solution is to lead it
and proximity of this water will then deter- into a soakaway, but precautions similar to a
mine the type of sanitary system that can latrine need to be taken.
be used. In the second part of Fig. 3.8, the
incremental progression of a water-utilizing
sanitary system is shown. A pourflush 3.4 Vector Control
latrine can be installed where water is
obtained from a village standpipe, but Parasites are transmitted from one host to
with a septic tank or sewerage, a water- another by vectors, often utilizing the stage
flushing system requires in-house water in the vector to undergo multiplication or
connections. development. In some parasites (e.g. mal-
aria) the vector is the definitive host,
Siting and contamination The unit must be whereas in others such as Wuchereria ban-
sited so that it does not contaminate the crofti, it is the intermediate host. Whichever
environment in such a way as to threaten part the vector plays, it is a vital one for the
the health of others. With a pit latrine, bac- parasite and it cannot continue if the vector
terial pollution can travel downwards for is destroyed or reduced to sufficiently low
a distance of up to 2 m. If the contamination numbers. The time of changing from one
reaches the water table, it will flow horizon- host to another is a precarious time for the
tally for up to 10 m. This means that any parasite and considerable loss may occur.
latrine should be sited at least this distance Malaria gametocyte development must coin-
away from a water supply, such as a well. cide with a mosquito taking a blood meal
The latrine should also be placed downhill and both male and female gametocytes are
to the well, although excessive pumping required for fertilization and maturation
will draw water into the well from all direc- to take place in the insects stomach.
tions, including possibly from a latrine. If W. bancrofti suffers considerable parasite
a latrine is built less than 10 m from a river loss during the vector stage. The vector,
or stream, it can pollute it, as the water table therefore, does not have to be completely
will be flowing towards the stream. Latrines destroyed, but must be kept at levels too
in this situation can be potent sources of low for transmission to take place. So vector
pollution if the river is used for drinking control means vector reduction and not
water. Pollution of the soil is a complex vector eradication.
subject and the rough rule of 10 m distance
between a latrine and source of drinking
water is given as a guide. Contamination is
3.4.1 Mosquito control
dependent upon the following:

. the velocity of groundwater flow (should The various ways in which mosquitoes can
be less than 10 m in 10 days); be controlled are as follows:
. the composition of the soil (not fissured,
e.g. as in limestone). . adulticides;
. repellents;
Expert advice should be obtained before . personal protection;
embarking on a latrine programme. . larvicides;
In a sealed system such as a septic tank . biological control;
or an aquaprivy, contamination of the soil . environmental modification.
will not take place unless there is a crack in
the structure. However, the effluent is These are all illustrated in Fig. 3.9.
highly charged with pathogens and must be
disposed of properly. Running it into a Adulticides Killing the adult mosquito can
storm drain, as often happens, is a bad either be done while it is flying using a
Surface Hole and Simple pit Improved pit or Composting
defecation bury latrine latrine latrine

Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:40am

Control Principles and Methods

Pourflush Pourflush to
latrine soakaway Flush toilet to Flush toilet connected to
septic tank sewerage system


page 53

Fig. 3.8. Types of excreta disposal systems incremental sanitation.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:40am page 54

54 Chapter 3


Knock-down insecticide



Pupa Larva

Biological control Environmental modification

Fig. 3.9. Mosquito control methods.

knock-down spray or when it is resting with fecting aircraft. Knock-down sprays com-
a residual insecticide. Knock-down insecti- monly contain pyrethrum, derived from
cides will kill adult mosquitoes at the time a species of chrysanthemum grown in high-
of application only, whereas residual in- land areas of East Africa. They can be
secticides continue to have a lethal effect dispersed in aerosols, smoke generators
for a considerable period of time. (fogging) or ultra-low volume (ULV) aerial
trol epidemics of vector-transmitted disease RESIDUAL INSECTICIDES Residual spraying is
where an explosive increase in the number the main method for control of mosquito-
of flying adults is responsible. They have transmitted disease because the insecticide
been used in malaria epidemics, but have continues to remain active for 6 months or
perhaps their greatest value in dengue and more. By careful organization, repeated ap-
the control of arbovirus infections. They are plications made at regular intervals can
used as space sprays (aerosols) in the house, maintain a continuing killing effect. Ideally
for mosquito survey counts and for disin- they should be sprayed just before the start
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:40am page 55

Control Principles and Methods 55

of the main transmission season, especially allowed back into the houses. This takes a
in areas where malaria is seasonal. considerable amount of organization with
Residual insecticides act on the resting a strict schedule of notification, followed
mosquito. Mosquitoes need to rest after they by spraying. The supervisor answers any
have taken a blood meal and generally questions, ensures that the work is done
choose the nearest place, which is the wall and arranges logistic support. If residual
of the victims house. If the wall has been spraying is not adequately explained to
sprayed with residual insecticide, then people, then organizational resistance will
the mosquito will absorb a lethal dose develop. The target is to spray every dwell-
through its legs while it is resting. The ing house whether permanently or tempor-
insecticide can either be sprayed as an emul- arily occupied.
sion or wettable powder, as few of the in-
secticides commonly used go into solution Deterrents and repellents can be either
with a cheap and easily obtainable medium smokes or applications to the body in the
such as water. Emulsions are best on non- form of creams and solutions. They do not
absorbent surfaces, while wettable powders kill the insect, but deter it from biting.
are suitable for mud, leaf or other poor qual- Mosquito coils or heated pads have a
ity walls. The wettable medium (generally combined deterrent and repellent action.
water) soaks into the wall and leaves the They are made with small quantities of
powder on the surface. Some of the insecti- pyrethroids in a slow burning base, but
cide is taken into the porous surface, but this other insecticides can be added to enhance
gradually comes out, maintaining a steady the activity. Used in a still atmosphere,
concentration. Once residual insecticide they can be most effective. If they do not
has been sprayed on a wall, then it must prevent all the bites, they reduce the
not be washed or painted. number, which is important in filariasis
Residual insecticide sprayed on a sur- transmission. They reduce the probability
face depends upon a number of factors: of being bitten by an infective mosquito
carrying any disease.
. the proportion of active insecticide in the The most commonly used repellent is
preparation; diethyltoluamide (DEET), which can be
. the amount of insecticide mixed with the applied to the person, clothing, tents and
fluid medium; mosquito nets. The solutions can either
. mixing, before and during application; be dissolved in methylated spirit or emulsi-
. the distance from the surface that is fied with water and applied to the surface.
sprayed; It is not absorbed by synthetic fabrics and
. the speed of application. a cotton or wool base is essential if it is
to remain for some time. Four weeks of
These are all specified for a particular activity is given if continuously exposed,
insecticide and sprayers must be trained to but if the garments (such as a shawl or leg
ensure that the right concentration is bands) are kept in a polythene bag, then
delivered. A measured area of plaster can repellent action can continue for 3
be scraped and the insecticide content 6 months. Precaution should be taken
analysed. while applying DEET to the skin as some
Residual spraying is carried out by a individuals are sensitive, while neuro-
team of sprayers with manually operated logical toxicity can be produced in children.
spray apparatus covering a village at a time. Natural repellents made from eucalyptus
Houses are emptied and pets and domestic oil are preferable for application to the
animals restrained at a suitable place some person.
distance away (as they are sensitive to in-
secticides). Any insects, beetles and lizards Mosquito nets and personal protection Perso-
that are killed should be swept up and dis- nal protection is a valuable precaution in
posed of before the domestic animals are reducing the number of mosquito bites.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:40am page 56

56 Chapter 3

Clothing that covers the arms and legs every year) as this decreases the effective-
especially if combined with a repellent can ness of the insecticide.
protect an individual most effectively. With Some people suffer from nasal conges-
the appearance of widespread insecticide tion when sleeping under a net that has
resistance, greater reliance must now be recently been treated with deltamethrin or
placed on personal protection. lambda-cyhalothrin and it is probably better
The use of mosquito nets is a well-tried to put it to one side for the first 2 days if
method of personal protection. Mosquito either of these insecticides has been used.
nets are fitted to the bed and the edges Otherwise they are perfectly safe and no
tucked under the mattress. A knock-down long-term effects have been recorded.
spray applied prior to retiring will prevent One of the problems of treating mos-
any mosquitoes entering the net when the quito nets is that they need to be retreated
occupant goes to bed. Young children at annual or 6-monthly intervals, so a recent
should be placed under nets before it gets innovation has been long-lasting insecti-
dark. If the custom is to sleep on a mat on the cidal nets (LLIN) where the insecticide is
floor rather than a bed, then mosquito nets impregnated into the fibre of the net before
can still be used. The sale of subsidized it is woven. Such nets are effective for
mosquito nets can be an effective method 4 years or more and, therefore, are being
of malaria control, if they are subsequently actively promoted for malaria control.
treated with an insecticide. A less satisfactory alternative is to
Mosquito nets are treated with screen the whole house, but this is expen-
synthetic pyrethroids, such as permethrin, sive and a torn area will destroy the whole
deltamethrin, lambda-cyhalothrin or alpha- effect. Air conditioning, by providing
cypermethrin. They deter mosquitoes from a sealed room, generally prevents mosqui-
entering should the net be torn or kill it if it toes from entering. Even so, it is preferable
touches the net. Nylon nets are better than to use a knock-down spray in the evening
cotton because they absorb less solution and to prevent any mosquitoes that may have
are stronger, but this has to be offset by their entered. The cost of these methods is con-
greater cost. Additional advantages of siderably higher than using treated
treated nets are that they provide some pro- mosquito nets.
tection to other people sleeping in the same
room. They also kill fleas, lice, bed bugs and Larvicides Substances that block the
cockroaches and even if rolled up will still breathing apparatus of mosquito larvae and
provide some protection. A modification of destroy the surface tension (so they sink to
this method is to treat curtains that are used the bottom) or poison them are known as
to cover doors, windows or any opening. larvicides. Kerosene spread on water covers
These methods are used in community mal- the siphon of the larvae so that it dies from
aria control programmes. asphyxiation. High-spreading oils have
Nets are treated by soaking them in a been developed, which inactivate the force
solution of the insecticide when new or of surface tension that larvae use to float on
after they have been washed. The amount the surface. Insecticides sprayed on collec-
of insecticide is 200 mg/m2 permethrin, tions of water will kill larvae as well as many
25 mg/m2 deltamethrin or 10 mg/m2 other organisms (including fish), are expen-
lambda-cyhalothrin, calculated by measur- sive and generally objected to by the public
ing the area of the net. Some treated net and hence are rarely used as larvicides.
programmes are using standard sized nets, Such preparations as temephos (Abate),
all of which are made of the same material, with its very low toxicity, are a notable ex-
to avoid having to measure each one, but a ception.
rough approximation can be made by Larvicides are not efficient methods of
weighing each net. Once nets have been mosquito control, their main use being in
treated, they should not be washed again urban and periurban areas, especially
until just before re-treatment (normally against culicine vectors. Drains and gutters
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:40am page 57

Control Principles and Methods 57

can be sprayed and temephos added to water ment to make it unsuitable for the vector.
containers and septic tanks. Surface sprays This can include simple methods such as
must be renewed at regular intervals. burying tin cans or cutting holes in old
To control Culex quinquefasciatus, the tyres to drain water, to clearing vast tracks
main vector of urban filariasis, which breeds of forest for tsetse fly control. Any method of
in latrines or soakaways, expanded poly- environmental modification on a large scale
styrene beads can be placed in the pit. The must carefully consider other systems that
beads float on the surface of the water so may be damaged. Clearing large areas of
larvae are dislodged and prevented from forest can affect the water retention of the
breathing, while the function of the latrine soil and deforesting river banks can lead to
or soakaway is not disrupted. The polystyr- severe erosion. On the other hand, filling-in
ene is manufactured as fine granules and or draining a swamp can provide extra land.
when placed in boiling water, it expands Eucalyptus trees, which absorb large
into beads. amounts of water from the soil, can be
planted and at a later time, their wood can
Biological control The term biological con- be used.
trol is used to describe the natural method of Specific methods of environmental
reducing vectors. Various natural agents modification, such as for trypanosomiasis,
that have been tried include predators such will be found under the particular disease,
as larvivorous fish, microbial organisms while the emphasis here will be on mosquito
(e.g. Bacillus thuringiensis and B. sphaeri- control. One of the most successful methods
cus) or modification of the insect itself. Male for reducing surface water and preventing
insects can be sterilized by radiation or with breeding places is the construction of sub-
chemosterilants and then released into the surface drains. This should be within the
environment. If these sterile males compete ability of most health personnel. The system
successfully with the unsterilized males, of drains should follow the contours
then the females will not be fertilized. Un- (Fig. 3.10) and be at least 1.5 m below the
fortunately, this technique requires the surface. The gradient needs to be between
preparation and release of a sufficient 1 in 400 and 1 in 30. Various materials
number of males to outnumber those in the can be used for constructing the drains,
natural habitat, which is generally imprac- such as stones, bamboo or poles laid
tical. An alternative technique is to breed length-wise in the bottom of the drain. An-
mosquitoes that are refractory to the target other method of environmental control is to
disease. This can either be through genetic use a siphon, which flushes out mosquito
manipulation or by introduction of a closely larvae, or a simple dam as shown in
related natural species. Species replace- Fig. 3.11.
ment, as the method is called, offers some
promise because similar, but competitive
species can be obtained from different parts
3.4.2 Insecticides
of the world.
The problem with any biological
method is that nature requires a balance. If Insecticides for vector control include the
a predator destroys all its food supply, then following:
it will die. As a result, an equilibrium is
reached where the number of predators and 1. Poisons (e.g. Paris Green, which was used
those they prey on remain in sufficient extensively as a larvicide). Anopheles
numbers for both to exist. Biological control gambiae was eradicated from Upper Egypt
is, therefore, more an aid rather than a by this preparation. In view of the resistance
definitive method. to insecticides that has developed, it could
be reconsidered.
Environmental modification In some situ- 2. Fumigants (e.g. hydrogen cyanide,
ations, it is possible to modify the environ- methyl bromide and ethyl formate) can

Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:40am
Chapter 3

page 58
Fig. 3.10. Contour drains in a (A) narrow ravine and (B) wide ravine. (From Davey, T.H. and Lightbody, W.P.H. (1987) The Control of Diseases in the Tropics.)
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:40am page 59

Control Principles and Methods 59

Fig. 3.11. A locally constructed dam for the control of Anopheles fluviatilis in Nepal. Every 3 days, the bung is
removed and the head of water rushing down the stream is sufficient to dislodge developing mosquitoes.

be used on grain or clothing to destroy temephos (Abate) are low-toxic compounds

infestations. widely used as larvicides.
3. Knock-down (e.g. pyrethrum, bioresme-
thrin and bioallethrin). Carbamates Carbamates act in a similar
4. Residual, which are sub-divided into manner to the organophosphates except
organophosphates, carbamates and pyreth- that they compete with acetylcholinesterase
roids. (Organochlorines, 4,4-dichlorodiphe- rather than combining with it, making their
nyl-1,1,1-trichloroethane (DDT), benzene effects more easily reversed and thereby
hexachloride (BHC) and dieldrin, which conferring an advantage to humans.
were widely used originally, are no longer Examples are propoxur and carbaryl.
available due to their toxic and long-lasting
effects on the environment.) Pyrethroids Pyrethrum is a naturally occur-
ring insecticide, obtained from a species of
Organophosphates Organophosphates, such chrysanthemum, that has been synthesized
as malathion and fenthion, are volatile sub- to produce a range of more active forms with
stances that require frequent application. good residual ability. These are stable sub-
They act by inhibiting cholinesterase at the stances with low mammalian toxicity and
nerve junctions and, therefore, can produce are widely used both for agricultural and
temporary paralysis (and respiratory failure) medical control. Examples are permethrin,
in humans as well as insects. They do not deltamethrin and lambda-cyhalothrin,
have a long residual action or persist in the which are particularly valuable for treating
environment. Chlorpyrifos (Dursban) and mosquito nets.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:40am page 60

60 Chapter 3

3.4.3 Resistance . regular and effective washing of clothes

and bedding;
When an insecticide is being chosen for a . repellents;
control programme, the vector must be . improved house construction;
tested against various strengths of the in- . insecticides.
secticide to determine the discriminatory
dose (this is when 99.9% mortality of Ectoparasites favour dirty dark places,
the sample occurs). These tests need to be whether they are searching for a suitable
repeated from time to time during the course habitat on a person or a vantage place in the
of the programme to determine whether the house from which to mount an attack. Fleas
vector remains sensitive. If there are tech- and lice are not removed by washing, but the
nical reasons why this cannot be done, continued use of warm water and soap con-
then resistance will probably only be no- siderably deters them. If this is combined
ticed by an increase in number of insects or with washing of clothes, then fleas can rap-
cases of the disease. This might, however, idly be controlled. Where possible, clothes
indicate deficiencies in the spraying pro- and bedding should be boiled or at least sub-
gramme and these should first be ruled out. jected to very hot water as fleas are not
Correct application of insecticide can be affected by cold water. Some communities
measured as mentioned above, while a practice head shaving to control lice, while
simple field test for suspected resistance short hair makes them easier to control.
can be performed by placing a few of the Fleas and lice favour overcrowded con-
insects in a glass jar held against the sprayed ditions, such as those occuring during wars,
surface for a minute. If they are not all killed, famines or refugee camps. Efforts should be
then resistance should be suspected and en- instituted to reduce overcrowding, but
tomological assistance obtained. where this is impossible, washing and
Resistance may be partial or complete. laundry facilities should at least be pro-
If partial, then increasing the concentration vided. Wearing of other peoples clothes or
of insecticide may be sufficient to control sharing combs are common methods of
the vector. Unfortunately, complete resist- transferring ectoparasites in tropical areas.
ance is soon likely to develop. Resistance is Repellents have been used successfully
a genetic character and resistant strains are in areas where infection is likely. Impreg-
selected out under pressure of insecticides. nated socks and trousers can be effective
Initially resistance to one insecticide oc- when passing through micro-habitats of
curred, but subsequently cross-resistance scrub typhus or wild rodent plague. Ticks,
has developed making several insecticides bedbugs and reduviids are repulsed by repel-
ineffective. Some species now have mul- lents.
tiple resistance. Biological control or trying Bedbugs, ticks and reduviid bugs live in
a completely different strategy may be cracks in the walls of poorly constructed
effective. houses, coming out at night to attack sleep-
ing persons. Improving house construction
or applying a layer of unbroken plaster to a
3.4.4 Ectoparasite control wall discourages these arthropods perman-
ently. Bed nets can protect the individual
Ectoparasites live on the outside of the body, from being bitten.
such as fleas, lice, bedbugs, mites and ticks. Insecticides are especially useful in epi-
They are responsible for transmitting a demic conditions. Dusting clothing, using a
number of diseases covered in Chapter 16. puffer to supply the insecticide up trouser
There are various control methods: legs and skirts and down collars and sleeves,
can quickly reduce the number of ectopara-
. personal hygiene; sites in concentrations of people. Insecticide
. reduction of interpersonal contact from solutions can be applied to the hair to kill off
overcrowding and clothes sharing; head lice or to clothing if repellents are not
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:40am page 61

Control Principles and Methods 61

available. Rat burrows and runs should be 15.7 and 15.8). However, an MDA needs to
dusted with insecticides to kill off plague- cover the entire population in the infected
carrying fleas before rat catching. Benzyl area and the full dose of treatment seen to be
benzoate or BHC is effective against scabies swallowed. This becomes an administrative
mites. exercise requiring a large number of assist-
ants to ensure that the drug has been properly
taken. One of the most successful campaigns,
3.5 Treatment and Mass Drug in the Pacific Island of Samoa, used womens
Administration groups who are a very well-organized
segment of society, with the result that the
Treatment of the sick is not only a humani- coverage was over 90%. Generally, such
tarian action, but reduces the length of organizations are not available resulting in a
illness and, therefore, the period of commu- lower coverage rate.
nicability, thereby aiding control. However, Mass treatment is also used in the con-
where treatment is incomplete, it can actu- trol of trachoma (Section 7.5). Treatments
ally prolong the period of communicability, and MDA regimes will be found under the
encourage the development of carriers or relevant diseases in Chapters 718.
worst of all, resistant organisms. Case find-
ing and treatment is the main method of
control for leprosy (Section 12.6) and tuber-
culosis (Section 13.1), but careful follow-up
is essential to ensure that treatment is taken 3.6 Other Control Methods
for the whole period. Rapid diagnosis and
treatment is particularly important in acute The zoonoses often require specific control
respiratory infections (Section 13.2) and methods to reduce or eliminate the animal
meningitis (Sections 13.6 and 13.7). The reservoir. Dogs are the major animal source
development of effective single dose therapy of human disease (Table 17.1) so only those
for the treatment of the sexually transmitted animals which are useful in the society,
infections (STIs, Chapter 14) has been one of should be kept, and strays and unwanted
the great challenges of chemotherapy, dogs should be destroyed. Laws to reduce
but the power of the needle has also been dog-fouling are reasonably effective in
the means of transmission of several com- developed countries and could perhaps be
municable diseases. In many societies, applicable to urban areas of some developing
having an injection (irrespective of what is countries.
given) is seen as the panacea of all ills, but Rats are a serious transmitter of disease,
unfortunately improperly sterilized needles especially plague (Section 16.1), leptospir-
(including intravenous infusions) have been osis (Section 17.8) and Lassa fever (Section
responsible for much of the transmission of 17.9). Methods of controlling rats will be
HIV infection and hepatitis B. found in Box 16.1. Other methods of disease
Mass drug administration (MDA) is used control and prevention will be found under
as a method of control of filariasis (Sections the specific diseases.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 25.10.2004 7:00am page 62

Control Strategy and Organization

The first two chapters covered the elements several events can be carried out at the
and theory of communicable diseases and same time.
the previous chapter discussed how to inter- Excess cases, unusual deaths, exceed-
rupt transmission with the various methods ing the epidemic threshold or an unex-
of control available. This chapter considers pected clustering of cases will be indicators
how to put all this information into action that an outbreak of a new or known epi-
when faced by an outbreak, or the applica- demic disease is taking place. The cause
tion of control methods in an established will need to be identified and an estimate
endemic disease. made of the magnitude and distribution of
cases. Field investigations are organized
and active surveillance set up to find any
new cases. The disease can be confirmed
4.1 Investigation of an Outbreak by using an agreed case definition, specific
laboratory test or sero-epidemiological
In any communicable disease outbreak, the technique. The disease must be notified
following sequence of events will need to as soon as possible, both nationally and pos-
take place: sibly internationally (see Chapter 6). Judge-
ment needs to be used in spending time
. outbreak detection; on making an accurate diagnosis, or starting
. investigation; treatment with the information that is avail-
. confirmation; able. There will be great pressure to treat
. notification; cases, which is a necessary humanitarian
. analysis; action, but until transmission is interrupted
. treatment of cases; more cases will occur. Once the disease
. interruption of transmission; is under control, methods must be imple-
. prevention of recurrence; mented to prevent recurrence. Finally,
. analysis and writing of a report; the outbreak is analysed and written up.
. surveillance. A surveillance system is on the look-out for
the first indications of the communicable
These are not mutually exclusive stages, disease starting again. These stages will be
and although they are in order of action, considered in more detail.

Q R. Webber 2005. Communicable Disease Epidemiology and Control, 2nd edition (Roger Webber)

Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 25.10.2004 7:00am page 63

Control Strategy and Organization 63

4.1.1 Identification pillars of epidemiology persons, place

and time. Information should be collected
The start of an epidemic can be dramatic from as many angles and from as wide a
with a large number of cases being reported field as possible. The more pointers there
or many people dying. However, the cause are to a method of transmission, the stronger
may well be anticipated, as the agents of will be the case.
most communicable diseases are now It will generally not be possible to com-
known. The person reporting the outbreak plete a detailed epidemiological investiga-
will probably have made a provisional diag- tion before starting some control methods,
nosis or it might be anticipated, having been for example, if it is diarrhoeal disease, then
reported in a neighbouring region. It will emergency boiling of drinking water can be
need to be confirmed by laboratory methods started. However, a full investigation must
or by careful clinical judgement (e.g. be made and completed, as quite often dif-
measles). A case definition is a useful tool ferent factors come to light. A full investi-
for ensuring that everybody understands gation will help prevent a recurrence.
what they are looking for. This can either The method used in an epidemiological
be very general, such as fever with no obvi- search is as follows:
ous cause as in a suspected malaria epi-
demic, or a more detailed description, such 1. Look for a common event that is shared
as with the rash and symptoms of measles. by all the cases.
In the general case definition, this will indi- 2. Study exceptions to see if there are
cate that laboratory confirmation is re- rational explanations.
quired, as in the example of malaria with a 3. Base these findings on the population at
blood slide being taken. risk.
Normally, the confirmation of diagnosis 4. Elucidate changes that have occurred in
is relatively easy, but several laboratory the environment, which may have favoured
specimens may be required and restraint the outbreak.
exercised in rushing to a diagnosis (e.g. in 5. Make a hypothesis of cause, route of
typhoid). Alternatively, it may be a unique transmission and method of control.
and rare disease in which the aetiology and
transmission have not been worked out. If Ideally, information should be collected on
this is the case, expert assistance is sought, every case, but this might be scant or absent
while general principles of control are in the first few cases. However, it is import-
carried out. ant to investigate these first cases thor-
Enquiry and search is made to deter- oughly so that the start of the epidemic can
mine the extent of the outbreak, whether be accurately fixed and an epidemic curve
there are many more cases, especially in drawn (see Chapter 2). If it is a very large
areas where there are no medical facilities. epidemic, then it might be preferable to take
Cases may be hidden or exaggerated to avoid a sample of cases and study these in detail,
or attract medical attention. Is this the first but some record of the total number of cases
case or have there been several cases over a will always be required.
period of time? Have the cases come from Information on persons should be avail-
another administrative area or country, and able, and sex and age classification can read-
is there a risk that they might infect other ily give an indication as to the cause of the
areas? Was notification received and should epidemic. If it is just children who are in-
notification be given? volved, then it is a common disease in
which adults have obtained immunity such
as measles. If there are more cases in one sex
4.1.2 The epidemiological investigation than another, then this might indicate a div-
ision of duties such as women (who are the
Collecting information on the cause and main collectors of water) succumbing to
method of transmission utilizes the three cholera in larger numbers than men.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 25.10.2004 7:00am page 64

64 Chapter 4

The address of each case should be plot- person and place data. Laboratory confirm-
ted on a map and a note made of the most ation of cases might give a different pattern
affected areas and whether there is any clus- from clinical assessment, especially where
tering. Look for associations, such as rivers, several medical staff are involved. If avail-
breeding places of vectors, forests that might able, samples might need to be taken from a
harbour reservoir animals, or any other fea- suspect cause, such as a food item, or from
ture that the nature of the disease indicates the environment, such as a river used for
to be important. If maps are not available, drinking water, which will all take time to
then constructing a simple sketch map be analysed. However, a negative result will
might be necessary, especially if it is a very not necessarily alter the hypothesis; the spe-
well-defined epidemic. Typhoid cases often cimen may have been collected too late or
occur in communities, so the houses of indi- from the wrong place. It is the strength of
vidual victims will need to be identified on a association of all the different pieces of evi-
sketch map of the village or town. Any clus- dence that should be used to decide on the
tering or association of cases might lead to cause.
the carrier from which the epidemic started.
Exceptional cases can often provide defini-
tive evidence of an association such as the 4.1.3 Treatment of cases
visit by a person resident in a different area,
which subsequently becomes infected.
The priority is to organize the treatment of
All calculations, such as the morbidity
cases rather than become involved in the
and mortality rates, must be done on the
clinical management, and concentrating
population at risk. Normally, this is the
time on investigating the outbreak and insti-
population of the entire area, district, region
gating control. This should be by:
or country, but in a very localized epidemic,
the population of the village, town or group
of villages might give a better estimate. . setting up emergency treatment centres or
Population figures are available from census arranging transport of cases to hospital;
data, malaria control programmes and often . mobilization of staff, medicines and equip-
collected by the village authorities. Other- ment according to need;
wise, a sample needs to be taken of the . formulation of a standard treatment
number of occupants in a random number schedule;
of houses, followed by counting of all the . making rules on period of quarantine,
houses in the area and multiplied by management of contacts, prevention of
the average house occupancy. carriers and disposal of the dead.
There is normally a reason why an epi-
demic has occurred at a particular period in As the epidemic means a large number of
time. Diarrhoeal diseases often start at the cases of a single disease, once the diagnosis
beginning of the rainy season and influenza has been made, the treatment of all the cases
is more common during winter months. Reli- will be the same. There may be a compli-
gious gatherings or other large collections of cated case that requires special attention,
people provide ideal conditions for the trans- but the priority of the investigating doctor
mission of disease. If there are strong indica- is to interrupt transmission and bring the
tors, then these can be used in future epidemic to an end. A standard treatment
surveillance and to initiate preventive action. schedule should be devised and all available
A working hypothesis is established as staff at every level made available to help
soon as possible so that emergency control with treating the cases. Instead of trying
action can be commenced, but a detailed to bring all the cases to a hospital, it may
investigation must be completed. Search be better to set up emergency treatment
back within the maximum and minimum centres in the proximity of the outbreak.
incubation period from the first case or Schools, community centres, religious
cases using other indicators gained from buildings and warehouses can be utilized
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 25.10.2004 7:00am page 65

Control Strategy and Organization 65

for this purpose. Not only does this avoid deaths are items of information that author-
the problem of transporting cases, but frees ities are particularly interested in. The func-
the hospital from fresh contamination or dis- tions of a report are to:
. inform planning and organizing author-
ities of what has happened;
. notify other workers who are or might
4.1.4 Interruption of transmission
soon be participating in a similar out-
Once a hypothesis of causation is made from . make a record to be referred to in future
the epidemiological investigation, a method outbreaks;
of control is commenced. This can be done . evaluate actions taken and improvements
in three different phases: that should be made;
. provide information for the general
. emergency; public;
. specific; . elicit funds for more permanent prevent-
. long-term prevention. ive measures;
. illustrate for teaching purposes;
If the communicable disease is in epidemic . be used for the advancement of science if
form and threatening a large number of of an original nature.
people, then emergency methods must be
implemented as soon as possible. These are
often non-specific and should commence 4.1.6 Outbreak organization and community
before the detailed investigation has been participation
finished. As an illustration of these three
different strategies, an epidemic of dengue
Outbreaks occur suddenly and often with
can be used. The emergency method would
little warning so there is no time to wait
be a knock-down spray, such as fogging
for help to arrive; the doctor, nurse or
which kills all adult mosquitoes indiscrim-
other health worker must take control.
inately. This will control the immediate
Generally, the temptation is to become so
problem, but once the number of adult
involved in patient management and treat-
mosquitoes builds up again, the epidemic
ment that no investigation is done. But until
might recommence. The specific method
the cause of the outbreak is investigated,
would be a programme selectively against
cases will continue and generally increase
the Aedes mosquito vector by destroying
in number.
all temporary breeding places and using
Help in patient care can be obtained
larvicides in water containers. Long-term
from many sources, such as other health
prevention would be by permanently
workers, public health inspectors, hospital
altering breeding places, placing mosquito
porters, even cleaning staff, but probably the
netting over water tanks, repairing broken
main resource will be relatives. In most soc-
guttering and all the techniques that are
ieties, relatives will come with the patient
available for removing the mosquito per-
and remain with them until they are cured.
Care needs to be taken that they do not
become patients themselves if it is a highly
infectious disease, so instructions on pre-
4.1.5 Analysis and report ventive methods will need to be given and
A communicable disease outbreak should In many communities, there is a
be analysed in detail and written down as a local organization that should be involved
report. This will be based on the investiga- at an early stage. This may be official, a vil-
tions made, the control methods used and lage chief or headman; religious, the village
their outcome. The number of cases and priest; or just a respected member of the
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 25.10.2004 7:00am page 66

66 Chapter 4

community such as a school teacher. In not bother to collect the information or even
some countries, the local organization will worse, to falsify the data. Even the routine
have a person responsible for the health of data already collected should be looked at in
the community or a village health commit- detail; for example, staff may record the
tee. They will be of value in identifying number of patients reporting headaches,
cases, but even more useful in seeing that which will not be a valuable criterion.
control measures, such as boiling drinking Recording fever rather than headache (and
water, are enforced. They will also have a taking a blood slide) is far more useful.
role in preventing the epidemic from Accuracy of data collection can be im-
starting up again in the future, such as en- proved by training, with regular refresher
suring that all children are vaccinated. courses so that all staff are taught the same
method at the same time. Regular feedback
of an analysis of the data will encourage staff
to be vigilant in their returns. Comparing
4.2 Surveillance
one area with another will show up weak-
nesses, which can then be strengthened.
Surveillance of communicable diseases Formulating case definitions encourages a
is the continuous watching for any changes more consistent diagnosis.
in known diseases and the monitoring of Where facilities are available, labora-
the environment for any new diseases that tory confirmation is always desirable. Every
may appear. fever case in a tropical area should routinely
The key to surveillance is reporting, de- have a blood slide taken, and sputum smears
veloped in such a way that a continuous always made from persons with a chronic
record is kept, not the desperate call of cough. In special circumstances, having a
an established epidemic. Surveillance screening programme can enhance routine
methods are of several kinds and are dis- investigations. Examples are antibiotic re-
cussed below. sistance patterns of STIs, Aedes aegypti
index in dengue-susceptible areas, vaccine
coverage in under-fives clinics and rainfall
4.2.1 Routine or passive surveillance records to measure seasonality.
All data collected must be analysed or
All health facilities collect data in their there is no point in collecting it in the first
record keeping, at its simplest being the place. The well-established criteria of per-
name, age and sex of the individual and the sons, place and time will be the basic model,
symptoms or diagnosis of their illness. but special techniques may also be required.
Considerable use can be made of well-kept Data from one level are sent to the next
records and it is worth doing an analysis of higher level where they are analysed, and a
the type of information collected to deter- copy of the analysis sent both to the level
mine the best system to use with the above and to those collecting the data in the
resources available. Hospital records, while first place. Special reporting may be re-
more detailed than in small clinics, will not quired for notifiable diseases. Evaluations
be representative of the population. need to be made at regular intervals to
Additional categories can be added to modify and improve the system.
the basic data collected, but care must be
taken not to overload the health staff so
that an unreasonable amount of their time 4.2.2 Active surveillance
is taken up with filling in forms. Every add-
itional entry must be tested by a small pilot Active surveillance is the deliberate search
study to ensure that it is collecting the infor- for target data. This has been used particu-
mation required and is within the means of larly in malaria control programmes, where
the staff to collect it. If it is too onerous a contacts of malaria cases are visited and
task, then there will be a tendency to either blood slides taken, as illustrated in Fig. 4.1.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 25.10.2004 7:00am page 67

Control Strategy and Organization 67

Fig. 4.1. An active case detection (ACD) technician taking a blood slide from a woman suffering from fever in
a malaria eradication programme (St Isabel, Solomon Islands)

Another example is a leprosy field worker as contacts and bacteria counts, among
who visits all the villages in his/her area and others. Suspect cases or contacts should be
examines the population for any signs of kept under observation. Monitoring of treat-
early disease. Suspect cases are then sent to ment can detect the appearance of resistant
clinic or hospital for further tests. organisms or an imbalance in the treatment
regime. Utilization of staff and equipment
can also be built into an emergency surveil-
4.2.3 Sentinel health service surveillance lance system.

Special health problems involving detailed

or laboratory investigation are often best col- 4.2.5 Serological and virological surveillance
lected by using sentinel health services.
These are given extra staff or facilities to Where laboratory facilities permit, a record
enable them to identify the disease. Influ- of certain diseases can be obtained from
enza information is often collected in this serological or virological studies. An
way, as it is notoriously difficult to distin- example is the use of anonymous testing of
guish influenza from the common cold and blood samples collected at antenatal clinics
other causes of a respiratory infection. Sev- for HIV and hepatitis B infections. Care must
eral sentinel health centres will then give a be taken to ensure that the data are represen-
reasonable estimate of the problem in the tative of the population and are measured
entire area. continuously.
As the incidence of a parasitic disease
declines, it becomes increasingly difficult to
4.2.4 Emergency surveillance detect the parasite and serological surveil-
lance can be of more value. This method has
Emergency surveillance is set up during an been used in malaria programmes nearing
outbreak to monitor special risk areas, such eradication.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 25.10.2004 7:00am page 68

68 Chapter 4

4.2.6 Other forms of surveillance

Control Eradication
Where all information reaches a single cen-
tral authority, it is reasonable to assume that Objective Minimal Complete
it is representative of the entire area from incidence elimination
which it is collected. An example would be Duration Indefinite Time-limited
a public health laboratory, where more com- Coverage Areas of high Entire area
plex and standardized results are available. incidence
Other allied disciplines may collect Method Effective Faultless
data that is relevant to health, such as veter- Reservoir Animal or Human only
inary and entomology services. Sleeping
Organization Good Perfect
sickness is a more widespread and devastat- Costs Moderate for a High for limited
ing disease in cattle than humans, so out- long time period
breaks in cattle are indicators to take Complications Acceptable Extremely
precautions in associated human commu- serious
nities. Anthrax and bovine spongiform en- Imported cases Not important Very important
cephalopathy (BSE) are other examples. Surveillance Reasonable Very good
Epidemics may first be reported by
persons in authority, such as village leaders,
school teachers, priests, etc. Indeed, they healths greatest triumphs against disease.
can often be relied upon to give continued This was only possible because the vaccine
and reasonably accurate information for was extremely effective, there was no other
the community they serve. It is often one reservoir but humans and the organization
of the functions of a village leader to was very good. Recently, an entirely differ-
collect data on births and deaths, which ent kind of disease, Guinea worm, has been
can be valuable in estimating the popula- eradicated from all countries except one
tion. (where there is a civil war) by a programme
More information on surveillance can of protected-well construction. Poliomyel-
be found in Section 5.3 and under each itis has been eliminated from WHO regions
disease in Chapters 717. of the Americas, Europe and Western Pacific
and in 2001 only 600 cases were reported
from the rest of the world. The global yaws
campaign eradicated yaws from large areas
4.3 Control and Eradication of the world, but it is still endemic in some
places and on the increase in others. The
A communicable disease can be controlled tremendous progress of the malaria eradica-
or eradicated. By controlling a disease, it is tion campaign, followed by an equally im-
kept at such a minimum level that it no pressive resurgence of the disease, has been
longer poses a health problem. Eradication a devastating setback to the doctrine of
on the other hand sets out to eliminate the eradication. (There have been other local-
disease completely. The difference between ized eradication programmes such as
control and eradication can be summarized Anopheles gambiae from South America.)
in the following table. With eradication, it is an all-or-none pro-
The attraction of putting the entire cess if eradication is not complete, then the
health effort, funded by international sup- disease can return to its former levels and all
port into the eradication of a disease requires effort has been wasted. In these circum-
organization of the very highest order. There stances, it is preferable to choose the alterna-
have been five global eradication efforts, out tive target of control, which will be the
of which two were successful, the other two method used in the majority of infections.
almost successful and the remaining one A new terminology has been introduced
was not successful. The eradication of small- by WHO elimination. This uses a special
pox worldwide has been one of public programme and enhanced resources similar
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 25.10.2004 7:00am page 69

Control Strategy and Organization 69

to an eradication programme, but accepts vices for a brief special effort, which can
that eradication will not necessarily be continue to be maintained in their routine
achieved. Lymphatic filariasis, Chagas dis- services. An example is a mobilization of the
ease, trachoma, maternal and neonatal tet- general health services to do a mass vaccin-
anus have been designated as suitable for ation campaign before the start of the rainy
elimination programmes. season (Section 3.2.6). For the rest of the
year, they can continue with the routine
vaccination programme.
4.4 Campaigns and General Programmes

Communicable diseases can be controlled 4.5 Control Organization

by campaigns (called special programmes
by WHO) or made a function of the general During the malaria eradication campaigns, a
health services. Special campaigns have the high level of organizational methodology
attraction of putting all the effort into one was developed, which is a useful model for
particular disease, often with considerable any communicable disease control pro-
initial success, but over the long term, break- gramme. The four stages are as follows:
ing down again. Integrating the control
method with the general health services . preparatory;
often gives a more consistent result. The ad- . attack phase;
vantages and disadvantages are as follows: . consolidation;
. maintenance.

General health
Campaigns services 4.5.1 Preparatory
Effectiveness Initially very Only moderate
good The preparatory stage is perhaps the most
Continuation Poor Moderate important, and time spent on collecting
Duration Short Long baseline data, trying to forecast problems
Staff Special General health and assessing the feasibility of the proposal
required workers is always time well spent.
Salary Inflated Average Surveys are made of the disease to
Staff problems No career Addition to measure its prevalence over as wide an area
structure routine duties as possible. A good sample survey might be
Cost High Low
sufficient to measure the endemicity, but
Integration Low High
this will not reveal the foci of infection,
which normally cause the most problems.
It is the integration of the campaign into the In addition, a surveillance system needs to
general health services that destroys the be established, if there is not one already, to
good progress made. There are difficulties continually collect data on cases as the pro-
of emphasis, staff absorption and resent- gramme proceeds.
ment by the multi-purpose worker. Cam- The population will need to be enumer-
paign workers are often specially recruited ated and it might be justified to spend
for the task, probably from non-medical money on carrying out a census if one has
backgrounds and are paid inflated salaries not been done recently. Maps are essential
to offset the time-limited nature of the oper- and if suitable ones are not available, then
ation. The general health services are not they need to be drawn. They must contain
used to dealing with the special disease up-to-date village locations, preferably with
and feel they are being given extra work, the population marked on them. Figure 4.2
while still being paid the same. An alterna- is an example of a map prepared in this
tive might be to use the general health ser- way.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 25.10.2004 7:00am page 70

70 Chapter 4

1081 llopa
Masebe Mbaka
Ndola 2657
Kasala 1498 1965 Lugombo
Tenende (Mwaya)

Itope M Lake
Kikusya si
1292 Nyasa
(Itungi Port)
1799 Kilasilo (D) Nkuyu
1743 Itunge
Ibungu Kajunjumele
Ndandalo 4906
(D) 2220
2135 Isaki 1971 Kyela 1982
Kilwa (D)
Kingila 1902 2560

Itope Lubaga
ng 1183
we 1727 Njikula Isanga
1163 Ndwanga (Mungano)
Ngonga (D)

1996 Ikolo (D)

1759 Lugombo
N Mpunguti


0 5


All weather roads 1965 Village with census
Tenende population
Other roads
(D) Dispensary
International boundary
District boundary


Fig. 4.2. Part of a village location map prepared for a disease control programme.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 25.10.2004 7:00am page 71

Control Strategy and Organization 71

Every level of society must be commit- 4.5.2 Attack

ted from the senior administrative head,
through divisional chiefs and influential In the attack phase, the method that was
people, to the established health worker. found to be effective in the pilot programme
This will require regular meetings, with the is extended to the whole area. Alternatively,
establishment of key contacts. Without the area can be covered in sequence, but if
the complete and continued cooperation of this is done, then measures may need to be
the people, any special effort is doomed to instituted to prevent re-infection. Time
failure. tables and procedures are required to ensure
Planning of the persons, money and ma- that separate teams cover the area in a regu-
terials (logistics) to be used in the pro- lar manner. Realistic targets are set and or-
gramme is often the easiest part to initiate, ganization developed to make sure they are
but one of the most difficult to maintain. kept. The delay in one part will cause the
Utilizing existing staff who retain all their delay of everything else.
usual functions and continue in an estab- During the attack phase, the number of
lished pattern of service is preferable to re- cases found by the passive surveillance ser-
cruiting special staff, but this should not be vices will rapidly diminish, so progress is
at the expense of existing services. If special assessed by making serial surveys. Inci-
staff need to be recruited, then conditions of dence is more useful than prevalence data;
service must be carefully worked out so that therefore, surveys are conducted at regular
no conflict arises with existing staff. intervals in sample areas. However, this can
Adequate funding is required, as no dis- pose a strain on relations with the popula-
ease control programme has remained tion that is being sampled and areas of
within estimates; they nearly always cost higher prevalence may be missed, so new
more than expected. Additions arise that sample areas may need to be used after a
were not foreseen, inflation increases faster time.
than allowed for and the programme takes To ensure that all the remaining cases
longer than planned. If adequate finances are found, an active surveillance system
cannot be secured and the programme has can be established. This involves special
to be abandoned, then the net result is worse workers, each with an assigned area
than doing nothing in the first place. More which is visited on a regular basis. Active
serious is the damage done to the existing surveillance is no substitute for passive sur-
health services by diverting funds from veillance, the two should work closely
them. together.
Included in the preparatory stage is a
pilot programme to try out the techniques
and organization in a limited area. The
pilot programme is a scaled down version 4.5.3 Consolidation
of the full programme, not a special effort to
show what can be done. The area chosen In the consolidation phase, the full appar-
should be fully representative of the larger atus of disease reduction is disbanded and
area to be covered. If there are marked vari- reliance placed on small specialist teams
ations, then several pilot studies of differing that can rapidly respond to the active sur-
criteria may be required. veillance system. If a focus of malaria is
The pilot programme can be for a set found, then focal spraying and radical treat-
period of time, or continued into the full ment of cases is implemented. If a yaws or
programme after it has been assessed. If polio case is suspected, then mass treatment
there are major difficulties, then the pro- or vaccination is given in the surrounding
gramme should proceed no further, but the area. The essence of the consolidation phase
whole strategy reworked. If there are minor is speed and efficiency. If rapid remedial
problems, then these are indicators of major action cannot be carried out, then the dis-
problems in the future. ease is liable to return.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 25.10.2004 7:00am page 72

72 Chapter 4

4.5.4 Maintenance or a continuing level

of control amount of funds and staff availability per-
mits, then this might need to be continued
If the target of the programme is to eradicate indefinitely. A limited control programme
the disease, then the maintenance phase may be sufficient to reduce the burden of
will be an efficient monitoring system disease to allow a rise in the standard
to ensure that any introduced cases are rap- of living, which in the long term will have
idly detected and treated. If it was to reduce the most sustained effect on controlling the
the disease to an acceptable level that the disease.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 25.10.2004 3:25pm page 73

Notification and Health Regulations

Due to the serious nature of a disease . paralytic poliomyelitis;

or the ease by which it is transmitted, . malaria;
some diseases are notifiable. Individual . influenza;
countries will have their own priorities as . human immune deficiency virus (HIV);
to which diseases these should be, whereas . smallpox;
international agreement specifies certain . severe acute respiratory syndrome
diseases which must be notified to other (SARS).
countries, generally via the WHO.
The initial case is notified by e-mail to and subse-
5.1 International Health Regulations quent summaries of the number of cases sus-
pected and confirmed are sent at weekly
International health regulations require intervals.
that certain diseases be notified. The The regulations are being revised and
purpose is to warn other countries and instead of the current list of three diseases,
intended travellers to the country of the this will be replaced by a requirement for all
health risks involved. Assistance can also countries to notify WHO of all diseases or
be requested, once the disease has been events of international public health import-
notified. ance. This will mean that such events, as
Diseases subject to the International the first cases of a new infection, such as
Health Regulations (1969, 1974 and 1992) SARS, must be reported.
are as follows: In addition, a region (e.g. the South
Pacific Commission or Association of
. plague; Caribbean States), may initiate its own regu-
. cholera; lations, for example, for the following
. yellow fever. disease:

Diseases under surveillance by WHO are as . dengue;

follows: . diphtheria;
. typhoid;
. louse-borne typhus; . whooping cough;
. relapsing fever; . scrub typhus.

Q R. Webber 2005. Communicable Disease Epidemiology and Control, 2nd edition (Roger Webber)

Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 25.10.2004 3:25pm page 74

74 Chapter 5

5.2 National Health Regulations . any person or persons dying from diar-
Countries have their own system of national . any person dying of jaundice in the yellow
notification of some diseases, including the fever zone (see Fig. 5.1);
following: . Aedes aegypti index;
. severe case of chicken pox or other un-
. tuberculosis; usual pox rashes;
. leprosy; . any case of acute flaccid paralysis
. sleeping sickness. following a feverish illness;
. severe pneumonia with difficulty in

5.2.1 Notifiable diseases for England and

Wales Any case coming within one of these cat-
egories is reported immediately to the re-
sponsible Medical Officer or doctor in
Very rare Common
charge, who is required to investigate the
infections Rare infections infections
Anthrax Leptospirosis Food poisoning WHO has set up an international sur-
Leprosy Yellow fever Viral hepatitis veillance team to investigate any case of sus-
Typhus Cholera Whooping cough pected smallpox reported. The suspected
Relapsing fever Diphtheria Tuberculosis case must be isolated and WHO informed
Plague Poliomyelitis Malaria immediately. There is also concern about
Smallpox Typhoid fever Meningitis emergent diseases and the strengthening of
Viral Paratyphoid Meningococcal surveillance systems, so the linking of one
haemorrhagic fever septicaemia countrys reporting with another will assist
fever Rabies Ophthalmia
in detecting new diseases before they
Tetanus neonatorum
Encephalitis Measles
become a serious problem.
(bacillary and
Rubella 5.4 Vaccination Requirements
Scarlet fever
The only vaccination now required for inter-
national travel is yellow fever for persons
who come from or pass through a yellow
5.3 Special Surveillance fever zone (Fig. 5.1).
Cholera vaccination is no longer
The principles of surveillance were men- required by international regulations.
tioned in Section 4.2. A country at particular A yellow fever vaccination must be recorded
risk may be advised to set up a surveillance on the prescribed form with the signature
system of international or national import- of the doctor; the batch number and official
ance. Some suggestions are: stamp of the vaccination centre. The
vaccination is valid for 10 years, 10 days
. in plague areas, any case of fever, glandu- after the date of the vaccination or revaccin-
lar enlargement and death; ation.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 25.10.2004 3:25pm page 75

Notification and Health Regulations 75

(Map 1)
























Yellow fever
endemic zone SOUTH
WHO 93636

Fig. 5.1. The yellow fever endemic zones in Africa (Map 1) and Central and South America (Map 2, see next
page). Yellow fever endemic zones are areas where there is a potential risk of infection on account of the
presence of vectors and animal reservoirs. Some countries consider these zones as infected areas and require
an international certificate of vaccination against yellow fever from travellers arriving from these areas.
(Reproduced, by permission, from WHO (2004) International Travel and Health, Vaccination Requirements
and Health Advice, World Health Organization, Geneva.)
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 25.10.2004 3:25pm page 76

76 Chapter 5

(Map 2)







Yellow fever
WHO 93637

endemic zone

Fig. 5.1. Map 2.

Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 25.10.2004 7:04am page 77

Classification of Communicable Diseases

No biological system is perfect and commu- provisos, all the communicable diseases
nicable diseases in particular are not readily are listed in Chapter 19, at the end of the
classified; however, any grouping makes it book, rather than here, so quick reference
easier to understand and remember, so the can be made to them.
objective of this short chapter is to look at There are 340 diseases listed in Chapter
the different ways this can be done. 19, of which the commonest causative organ-
A disease is a morbid condition of the ism is a virus, being responsible for 185
body (e.g. measles or plague). As the cause of diseases, with arboviruses causing 118
diseases were discovered, they became infections. Bacteria and chlamydia account
identified by the causative organism, such for 66 and the larger parasites for 54 infec-
as trypanosomiasis or pneumococcal men- tions, of which the nematodes cause 21 dis-
ingitis, but confusion arose because there eases, protozoa 17 and helminths 16. The
are two forms of African trypanosomiasis commonest method of transmission is, there-
and one of American, while the pneumococ- fore, the vector, with the mosquito being
cus is an important cause of pneumonia incriminated in a staggering 76 infections,
as well as meningitis. This confusion con- ticks in 31, and other or unknown biting
tinues. Instead of settling on one system insects in 42 of the infections. In methods of
or another, I have tried to list all the commu- control, with vectors being so frequent,
nicable diseases by either the disease state vector control is the commonest, which
or the organism by which they are best iden- proved useful in 134 of the disease condi-
tified. For example, in the case of gastro- tions, but simple methods, such as using re-
enteritis, one of the commonest causes of pellents and sleeping under mosquito nets,
diarrhoea in developing countries, it is pref- are all that are required most of the time. Next
erable to separately list the various organ- comes personal hygiene, invaluable for pre-
isms that can cause it. Where these are venting 90 infections just washing your
particularly distinct, such as rotavirus infec- hands, not spitting and making an effort to
tion, then they are put into the list. On be clean can be remarkably effective. Allied
the other hand, the streptococcus is respon- to personal cleanliness is food hygiene, en-
sible for such an array of diseases that just to suring that food is prepared properly, ad-
put down streptococcal infection would equately cooked and stored under safe
fail to reveal important diseases such as conditions, accounting for 57 of the prevent-
rheumatic fever or otitis media. With these ive methods. Allied to the proper cooking of

Q R. Webber 2005. Communicable Disease Epidemiology and Control, 2nd edition (Roger Webber)

Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 25.10.2004 7:04am page 78

78 Chapter 6

food is the control of animals either in their diseases can be classified into 11 groups as
farming, slaughter, and the control of do- follows:
mestic pets, this group being responsible
for 41 disease preventive actions. Chemo-
therapy as a method of control is valuable
in 40 diseases and vaccination in 35, but Water washed diseases 7
several of these are major disease problems, Faecaloral diseases 8
such as tuberculosis, measles and the STIs. Food-borne diseases 9
The provision of a good water supply will Diseases of soil contact 10
reduce 39 conditions and sanitation another Diseases of water contact 11
23, while the control of rats is important in Skin infections 12
17 conditions. The social and educational Respiratory diseases and other airborne 13
methods appropriate to controlling STIs transmitted infections
will be valuable in 20 conditions, while the Diseases transmitted via body fluids 14
Insect-borne diseases 15
screening of blood donors will avoid 14 dis-
Ectoparasite zoonoses 16
eases and the proper sterilization of needles, Domestic and synanthropic zoonoses 17
instruments and giving sets could prevent
nine diseases.
No attempt is made in the next few Water-washed diseases could be called
chapters to cover all 340 of the diseases person-to-person diseases, but many dis-
listed, but to select only those of worldwide eases including skin infections and respira-
importance, which are major problems in tory diseases are also transmitted from one
certain parts of the world, or to illustrate a person to another, so a preferable descrip-
particular disease pattern. Readers might tion is to include the main method of con-
find it useful to refer to the list in Chapter trol, which is washing. They could also be
19 first, before turning to the fuller descrip- called diseases of poor hygiene, but since
tion in the following pages. hygiene is involved in the control of very
Diseases are normally classified by many diseases, to call them this would
the causative organism, which has much make this category far too large. Faecaloral
to recommend it for the clinician and the is a very large group and could quite easily
pathologist, but different organisms can incorporate many of the diseases in the
cause similar diseases, such as Escherichia chapter on food-borne diseases, but it is
coli, a bacteria and Giardia intestinalis, a easier to consider control methods if a sep-
protozoa, both producing diarrhoea in the arate chapter is made. There are important
individual. Control methods are similar; as diseases that are acquired by contact with
a result, an epidemiologist will find it pref- either soil or water, which means that
erable to include them in the same group. methods of control are very specific. Skin
On the other hand, the closely linked group infections are obvious in their presentation
of viruses that cause hepatitis are very and most of them are transmitted directly by
different in their means of transmission skin contact but also use other modes of
hepatitis A is transmitted by the faecaloral transmission, so it is more convenient to
route and hepatitis B by blood and other classify them by their most common method
body fluids, so it is preferable to separate of presentation. Instead of putting leprosy in
these two diseases into different categories. a separate chapter as in the previous edition,
Transmission is the key to the epidemiology because its means of transmission has not
of communicable diseases. Once the means been fully worked out, it is included in
of transmission is known, it leads to the the chapter on skin infections. The respira-
best method of control, so it is preferable to tory infections are transmitted by the air-
use this as the method of classification. borne route, which is also a method of
Based on these criteria, all communicable transmission of several other infections
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 25.10.2004 7:04am page 79

Classification of Communicable Diseases 79

that present in different ways. The chapter complexities of the many communicable
on diseases transmitted via body fluids is an diseases.
attempt to bring together common themes in The fewer groups there are, the easier it
the transmission and control of diseases is to remember all of them, sparing the oner-
transmitted via blood, seminal fluid, cer- ous task of learning about each disease in
vical secretions, saliva and other less detail. However, if each group is too broad,
common methods of transmission. It in- much of the essential information is also
cludes the STIs, which would warrant a lost, thereby defeating its purpose. For
chapter of their own, but other diseases example, Vietnam had classified all its com-
that share many common features, such as municable diseases into just four groups, but
hepatitis B and non-venereal syphilis, are this was found to lack the precision to work
better included with them. Insect-borne dis- out the best control strategy for each group,
eases not only include a large number of so this was replaced by an abbreviated clas-
health problems, but also some of the most sification, as follows:
important diseases in the world such as mal-
aria. It is already the largest chapter and 1. Person-to-person (skin and eye diseases).
could be even bigger, but the combination 2. Faecaloral transmission.
of ectoparasite transmission (by fleas, lice, 3. Soil-contact.
etc.) and zoonosis is a very specific one, so a 4. Airborne (respiratory infections).
separate chapter has been included for this 5. Diseases transmitted via body fluids
category. The rest of the zoonoses, where a (includes STIs).
vector is not included, form the last chapter 6. Vector-borne diseases.
in the classification. 7. Zoonoses.
No classification system is perfect and
not every disease fits neatly into the 11 cat- This simplification was due to the absence
egories. For many diseases, there is more of such diseases as schistosomiasis and
than one means of transmission and these Guinea worm, which are the only members
can also be important in developing control of the diseases of water contact in the clas-
methods. However, the categories are suffi- sification above, and several others, which
ciently broad to encompass minor differ- allowed amalgamations. Any country might
ences. Bringing them together into such a similarly like to draw up its own classifica-
system demonstrates similarities and asso- tion system based on the important diseases
ciations, making it easier to understand the found there.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 19.10.2004 9:54am page 80

Water-washed Diseases

The simplest disease transmission is by 7.1 Scabies

person-to-person contact (see Fig. 1.3). The
diseases of poor hygiene arise from direct Organism Infection of the skin is by a mite
contact of the skin, conjunctiva or mucous Sarcoptes scabiei.
membrane. Alternatively, organisms from
the skin or in conjunctival secretions can
Clinical features There is a skin rash and
be transported by an intermediate vehicle.
intense itching where the mite burrows
The essential mechanism is contamination
into the superficial layers of the skin. It
due to lack of hygiene.
favours the wrists and hands, although in
There are two groups of diseases in this
heavy infections, it may be found in almost
category skin diseases and eye diseases
any area of the body, but not the head or face.
and it is convenient to describe them in this
Due to scratching, the affected skin can
order. The skin diseases include infections
become thickened and discoloured leading
of scabies and lice and the superficial fungal
to a mistaken diagnosis of eczema. Second-
diseases. Tropical ulcers, for which a means
ary infection is common and glomerulo-
of transmission has still not been defined,
nephritis can occur.
are conveniently included here. The eye dis-
eases of significance in public health are
trachoma, epidemic haemorrhagic conjunc- Diagnosis is made from clinical presenta-
tivitis, epidemic keratoconjunctivitis and tion, but skin scrapings can be made and
ophthalmia neonatorum. the mite viewed microscopically.
The main method of control of the dis-
eases of poor hygiene is to increase water Transmission of scabies is due to close per-
quantity. They are the first category in sonal contact, permitting the mite to pass
Table 3.1 called the water-washed dis- from one person to another. It can be trans-
eases. Providing an adequate volume of mitted by shared clothing and is potentiated
water for washing encourages personal by poor hygiene. Where possible, infected
hygiene. individuals should be prevented from

Q R. Webber 2005. Communicable Disease Epidemiology and Control, 2nd edition (Roger Webber)

Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 19.10.2004 9:54am page 81

Water-washed Diseases 81

infecting others, for example by keeping used in the control of malaria (Section
children away from school until they are 16.5.10) or the naturally occurring Chrysan-
cured of the infections. Careful search themum from which it is derived, is also
should be made for unreported or unrecog- effective. Reduction in scabies can be an
nized cases in the community. Scabies can additional benefit of insecticide-treated
be spread amongst adults as a STI. Intract- mosquito nets, otherwise permethrin can
able scabies in adults, not responding to be administered as a 5% cream or 1% lotion.
treatment, can indicate HIV infection. Ivermectin, used in the treatment of filaria-
sis and onchocerciasis (Sections 15.7 and
Incubation period 26 weeks. 15.8), can be given systemically as a mass
treatment on its own or is a side-benefit of
Period of communicability As long as there one of these control programmes. If none of
are viable mites on the individual, up until the special preparations are available, then
1 week after the first course of treatment. repeated applications of oil to the skin
can be effective. Any oil usually used by
people to rub on the skin, such as coconut
Occurrence and distribution Scabies is
oil, can be effective. As the mite lives in a
found worldwide, but favours the hot,
small burrow through which it breathes, to
moist tropics and flourishes in conditions
seal-off the opening with a film of oil as-
of poverty. It mainly occurs in children,
phyxiates it. This requires careful and
but anyone who comes in contact with
repeated application to the whole body
infected individuals (e.g. mothers and
after washing.
school teachers) can become infected with
scabies. Surveillance School teachers should be
encouraged to regularly examine school
Control and prevention Scabies is a commu- children or do spot checks on any child
nity problem and treatment of an individual found to be scratching.
is insufficient unless the whole family,
school or village is similarly treated. In com-
munities with poor hygiene, the provision of 7.2 Lice
adequate water is the most effective method
of controlling the disease. People should be Body lice are potential vectors of typhus
encouraged to wash themselves with soap (Section 16.2) and relapsing fever (Section
and water and wash their clothes and bed- 16.3), but the main worry of people is per-
ding. Improving the water supply to provide sonal infestation.
an adequate quantity of water is the main
method of prevention. Organism Pediculus humanus corporis, the
body louse, P. h. capitis, the head louse and
Treatment Specific treatment is by benzyl P. thirus pubis, the crab louse. Lice glue
benzoate, but this may need to be accompan- their eggs to body hairs (nits) in which they
ied by an antibiotic if there is secondary are resistant to treatment until the nymphs
infection. A 10% emulsion of benzyl benzo- hatch.
ate is liberally applied to the whole body
and left for 24 h before being washed off. Clinical features and diagnosis Intense, local-
Treatment is repeated after 7 days to kill off ized itching at the site of bite will indicate
larvae that have hatched from eggs. The lice, which can be found and identified with
whole family is treated at the same time, a hand lens. If P. h. corporis is not on the
ensuring that only clean clothes and bed- skin, they will be amongst body hair or in
ding are used. Alternatively crotamiton the clothes.
10% or sulphur 6% in petrolatum is applied
to the entire body for 23 days before being Transmission is by close contact between
washed off. The insecticide permethrin, people, the sharing of clothes, hats and
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 19.10.2004 9:54am page 82

82 Chapter 7

combs. Crab lice are generally transmitted be scratching his/her head. In situations
during sexual contact. such as refugee camps, people should be
encouraged to examine their clothes and
Occurrence and distribution Body lice are those of their children at regular intervals.
found worldwide in conditions of poverty
or where people are forcibly driven together,
such as in refugee camps. They are more 7.3 Superficial Fungal Infections
common in colder regions of the world or (Dermatophytosis)
in mountainous parts of the tropics where
people huddle together to keep warm. Head Organism Fungi of the genus Trichophyton,
lice are found both in the tropics and the Microsporum, Epidermophyton and Scytali-
colder regions, especially amongst school dium.
Clinical features Also called tinea, the
Incubation period Eggs hatch in 1014 days. fungi attack specific sites on the body,
the moist skin in the feet or groin, the nails,
the scalp or the body. Tinea corporis (often
Period of communicability is as long as there
called ring worm) produces well-defined,
are viable lice on the individual, up until 2
circular lesions that spread out from the
weeks after the first course of treatment.
centre causing slight depigmentation as
Body and head lice remain alive for up to
they proceed. Tinea capitis causes areas
1 week on clothing not being worn, and nits
of baldness, hairs becoming brittle so that
for 1 month.
they break off. Tinea versicolor produces
a blotchy hypopigmentation that can
Control and prevention Washing with warm sometimes be misdiagnosed as leprosy.
water and soap at frequent intervals is the Tinea imbricata is particularly common in
main method of prevention. Clothes of an Western Pacific Islands, producing serpigin-
infected person should be boiled or insuf- ous scaly designs that can cover the whole
flated with insecticide powder. The practice body.
of pressing clothes with a hot iron might
have originated as a method of controlling Diagnosis is clinical, but infected hairs
lice. Combs should be washed regularly and fluoresce in ultraviolet light.
only used by one person.
Transmission is by close bodily contact, the
Treatment is with 1% permethrin cream sharing of clothes, towels, etc. Dogs, cats
rinse, naturally occurring pyrethrins (from and other animals also carry the fungus.
Chrysanthemum) and oral ivermectin. The
treatment should be repeated after 1014 Incubation period 414 days.
days to kill any young lice recently hatched
from nits. Shaving of heads is a rigorous and Period of communicability Fungal material
effective method of control of head lice, but can persist on articles, such as towels
not of body lice. In epidemic situations, and clothing, for considerable periods of
whole communities should be treated irre- time.
spective of whether lice have been found or
not (Section 16.2). Clothes and bedding can Occurrence and distribution Superficial
be treated with 1% malathion, 0.5% per- fungal infections are widely distributed
methrin, 2% temefos (Abate), 5% iodofen- throughout the world, being found in
phos, 1% propoxur or 5% carbaryl. developed as well as developing countries.
Children are most commonly affected.
Surveillance Parents or older siblings
should carefully search through childrens Control and prevention Prevention is by
hair, looking for nits, if the child is found to washing the body with soap and water, and
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 19.10.2004 9:54am page 83

Water-washed Diseases 83

not sharing clothes, towels, combs, etc. fever. An ulcer that refuses to heal then de-
Towels should be boiled. velops at the initial point of infection, pro-
ducing increasing tissue loss.
Treatment Local applications, such as
tolnaftate, miconazole, ketoconazole, clotri- Incubation period Uncertain but probably
mazole, econazole, naftifine, terbinafine or between 1 and 5 days.
ciclopirox, can be used. Acetylsalicylic acid
ointment or benzoic acid compound (Whit- Period of communicability Unknown, but
fieldss ointment) are effective if applied probably as long as there are moist lesions.
regularly for nearly 3 weeks. In resistant
cases, griseofulvin, itraconazole or oral ter- Occurrence and distribution Tropical ulcers
binafine can be given by mouth for a suffi- are found in the warm, moist areas of the
ciently long period to clear all the fungal world, where the temperature and humidity
residue. are fairly constant. All ages and both sexes
are susceptible.
Surveillance School children should be
examined regularly, especially the head, Control and prevention Tropical ulcers can
feet and groins. be prevented by taking scrupulous care over
minor cuts and abrasions. As soon as any
break in the skin surface occurs, it should
7.4 Tropical Ulcers be cleaned, an antiseptic applied and
covered with a dressing. Where dressings
Tropical ulcers are a common debilitating are in short supply, certain kinds of leaves
condition. They cause tissue loss and pain, can be used. Flies should be controlled by
which temporarily invalids the person, the provision of sanitation (Section 3.3.4)
making daily work an agonizing burden. and the disposal of garbage.
The condition can last for several months
and even when it heals, the victim is left Treatment During the invasive stage, antibi-
with a scar that may lead to contracture. otics should be given both systemically and
There are two types of tropical ulcers: non- locally, and the limb rested. Once the ulcer
specific or due to a Mycobacterium, often has formed, antibiotics have no effect and a
called Buruli ulcer. These should both be cleaning solution, such as Eusol, should be
differentiated from yaws (Section 14.1). applied. In coastal areas, soaking the
affected limb in seawater is a cost-free
method of cleaning out the ulcer. Skin
7.4.1 Non-specific tropical ulcers grafting may be necessary.

Organism No specific organism is normally

detected, but initial infection is often ac- 7.4.2 Buruli ulcer
companied by cellulitis, probably caused
by a Streptococcus. Organism Mycobacterium ulcerans is found
in the exudate of the ulcer.
Transmission Flies are responsible for con-
taminating small wounds and scratches or Clinical features There is at first just a small
occasionally biting insects transmit papule surrounded by shiny skin, but this
infecting organisms directly. Scratching of soon breaks down to reveal a large necrotic
the wound by the host can be a potent ulcer with undermined edges. Tissue
method of instilling organisms into the skin. damage may be extensive involving bone
and other structures.
Clinical features The initial wound becomes
red and indurated, with cellulitis spreading Diagnosis is made on clinical grounds and a
to the regional lymph nodes, and systemic stained smear of the exudate.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 19.10.2004 9:54am page 84

84 Chapter 7

Transmission The method of transmission Clinical features Commencing as a kerato-

has not been elucidated, but there are conjunctivitis, the first sign is red eye.
presumed to be environmental factors due There may be irritation and discharge, but
to the relationship with rivers and wetlands. it is passed off as a self-limiting infection. A
The role of aquatic insects has recently been follicular infiltration of the conjunctiva then
suggested as M. ulcerans has been found in takes place particularly in the upper lid.
the salivary glands of insects. Focal out- Blood vessels grow into the periphery of
breaks have followed migrations and move- the eye, forming pannus. Trachoma is often
ments of people, for example due to floods or complicated by secondary infection. It is at
dam construction. In Australia, koalas and the late stages of the disease, when it is non-
opossums are found naturally infected. infectious that scarring, particularly of the
upper eyelid, turns the eyelashes inwards to
Incubation period Unknown. rub on the eye, a condition called trichiasis.
This constant rubbing of the eyeball, aided
by the dryness of the conjunctiva, damages
Occurrence and distribution Central Africa, the cornea, leading to scarring and finally
Central and South America, Southeast Asia, blindness.
Australia and New Guinea. Children and
women living near rivers or wetlands in a
Diagnosis is usually made on clinical
rural region are predominantly affected.
grounds, but can be confirmed by finding
There has been a progressive increase in
the characteristic inclusion bodies in
cases and more attention is being paid to
scrapings taken from the conjunctiva.
working out the transmission and how to
control the infection.
Transmission Trachoma is a disease of poor
sanitary conditions where a combination of
Control and prevention Several trials have
close contact and dirty conditions encour-
been made with BCG vaccination
ages transmission. Within the family unit,
and although these showed some early
transmission is from child-to-child or by
protection, it was not sustained. Health
flies that are attracted to the discharges
education in areas of high endemicity, with
around the eyes. These are mainly Musca
the provision of facilities for treating lesions
sorbens. Cycles of reinfection and recrudes-
as soon as they occur, has reduced the
cence continue to damage the eye and lead
period of debility and the severity of the
to blindness at school age. The usual
method of wiping away secretions with
hands, towels or clothing, which is then
Treatment Anti-mycobacterial drugs, such used by the adult on other children or
as streptomycin, dapsone, rifampicin or themselves, is a typical pattern of transmis-
thiambutosine, have been found to be help- sion.
ful, especially in the early stage, but essen-
tially treatment is surgical with excision of
Incubation period. 512 days.
the ulcer and skin grafting.

Period of communicability continues as long

as active lesions are still present. Once treat-
7.5 Trachoma ment commences, infectivity ceases within
23 days although the clinical disease per-
A common infectious disease, trachoma is sists.
the major cause of blindness in the world.
Occurrence and distribution Trachoma is
Organism Chlamydia trachomatis, a micro- found mainly in the dry regions of the
organism that has features both of bacteria world (Fig. 7.1), especially Africa, South
and viruses. America and the extensive semi-desert
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 19.10.2004 9:54am page 85
Water-washed Diseases 85
Fig. 7.1. The distribution of trachoma.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 19.10.2004 9:54am page 86

86 Chapter 7

regions of Asia. A disease of antiquity, it was Treatment Mass treatment is preferable, as

first described by the ancient Egyptians. the majority of the population in an infected
In endemic areas, 8090% of children area will have trachoma. This is given easily
are infected by the age of 3 years. In condi- in schools, but is better done at home, where
tions of improved sanitation, there is a nat- the main transmission takes place. A single
ural cycle lasting until the age of 11 years, dose of azithromycin (20 mg/kg) is better
with little residual damage. Females de- than topical tetracycline and one dose a
velop trachoma and blindness as adults year may be sufficient to eliminate the
more commonly than males because they blinding propensity of trachoma. Mothers
are directly concerned with looking after can be taught to regularly treat all children
children. The chance of acquiring infection in the household.
is increased by large families with short Preventing blindness, once scarring and
birth intervals, as there are more children trichiasis have developed, is very easily
of a young age living in close proximity. done by a simple operation that a Medical
Assistant can be trained to do. This involves
Control and prevention The use of water to cutting through the scarred conjunctiva of
wash away secretions, clean clothes and the the upper lid and everting it so that the eye-
surroundings is perhaps the single most ef- lashes no longer rub on the cornea.
fective method. Washing the face often has
been shown to reduce the risk of developing Surveillance After the initial survey, follow-
trachoma so regular daily face washing up surveys should be conducted at regular
should be encouraged. Long-term prevent- intervals. This is most easily done in pri-
ive measures include improved sanitation mary schools.
and the provision of water supplies.
Flies proliferate in rubbish and excre-
ment, reaching their maximum numbers 7.6 Epidemic Haemorrhagic
during the dry, sunny period of the year.
The damp, moist conditions in open pit
latrines may be more important in encour-
aging fly breeding than non-use of latrines. First recognized in Ghana in 1969, epidemic
Any flushing mechanism or improved acute haemorrhagic conjunctivitis has
latrine will discourage flies. caused epidemics in a number of parts of
A strategy for a control programme is as the world, which have given their name to
follows: the disease (e.g. Nairobi eye).

. conduct a survey to find the worst- Organism Enterovirus 70 is the most import-
affected areas; ant aetiological agent and has been respon-
. give mass treatment; sible for tens of millions of cases.
. conduct health education through Coxsackievirus A24 has also been respon-
schools, stressing regular face washing; sible for large outbreaks.
. provide back-up services.
Clinical features The infection starts sud-
WHO has launched a programme for the denly, with pain and sub-conjunctival
global elimination of trachoma by 2020 and haemorrhages. There is often much swelling
given it the acronym of SAFE. This stands and discomfort in the eye; however, it is a
for: self-limiting condition, terminating within
12 weeks. In a few cases, there are systemic
. Surgery for trichiasis; effects involving the upper respiratory tract
. Antibiotics; or central nervous system (CNS). CNS
. Facial cleanliness; effects are identical to those of poliomyelitis
. Environmental improvement. and residual paralysis can occur.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 19.10.2004 9:54am page 87

Water-washed Diseases 87

Diagnosis is clinical once the first few cases ring. Upper respiratory symptoms and fever
of an epidemic have been identified. Labora- often accompany the eye disease.
tory confirmation can be made by isolating
the virus from a conjunctival swab. Transmission Similar to epidemic haemor-
rhagic conjunctivitis.
Transmission is from one person to another
from the discharges of infected eyes. Where Incubation period 412 days.
there are systemic infections, transmission
may be by the respiratory route. As with Period of communicability 14 days from
trachoma, intra-familial transmission is onset of disease.
common and in situations of poor hygiene
and overcrowding, large epidemics can Occurrence and distribution Epidemics have
occur. occurred in Asia, North America and
Incubation period 13 days.
Control and prevention are similar to epi-
Period of communicability 4 days from the
demic haemorrhagic conjunctivitis.
start of symptoms.

Occurrence and distribution It occurs in epi- Treatment and surveillance As with haemor-
demic form infecting a large number of rhagic conjunctivitis.
people in the immediate vicinity. Epidemics
have been mainly in tropical cities in Africa,
Asia, South America, the Caribbean and Pa- 7.7 Ophthalmia Neonatorum
cific Islands.
Infection of the eye of the newborn infant
Control and prevention Careful hand-wash- can lead to blindness.
ing, use of separate towels and sterilization
of ophthalmologic instruments are import- Organism Neisseria gonorrhoea or C.
ant in preventing transmission. Methods to trachomatis.
improve hygiene and reduce overcrowding
will prevent major epidemics.
Clinical features and transmission If the
mother has gonorrhoea or non-gonococcal
Treatment There is no treatment, so
urethritis (NGU) caused by C. trachomatis
mass administration of eye ointment is not
(see Sections 14.5 and 14.6), the infants
eyes can become contaminated with infec-
tious discharges as it passes through the
Surveillance The first cases of an epidemic
birth canal. This leads to conjunctivitis and
should be notified centrally and neighbour-
in gonococcal infection, an important cause
ing countries warned.
of blindness, especially in developing
7.6.1 Epidemic keratoconjunctivitis
Diagnosis is made by microscopic examin-
Organism Adenovirus 5, 8 and 19. ation of maternal vaginal discharges.

Clinical features Epidemic keratoconjuncti- Incubation period is 15 days in gonococcal

vitis is similar to epidemic haemorrhagic infection and 512 days with Chlamydia
conjunctivitis, but a keratitis also develops infection.
in some 50% of cases, 7 days after onset.
This normally resolves in about 2 weeks, Period of communicability As long as genital
but a minority is left with conjunctival scar- or ocular infection persists.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 19.10.2004 9:54am page 88

88 Chapter 7

Occurrence and distribution Infection is Surveillance. All vaginal discharges during

found more commonly in sex trade workers the antenatal period should be examined
and the sexually promiscuous. It is more and cultured. Where an infant is born with
common in developing countries, where ophthalmia neonatorum (sticky eye), the
routine testing of expectant mothers is not parents and any sexual contacts should be
performed. fully investigated (Section 14.5).

Control and prevention Detection and treat-

ment of the initial infection in the mother
(see Sections 14.5 and 14.6) is the best strat-
egy. Any vaginal discharge occurring during 7.8 Other Infections
pregnancy should be examined, cultured
and treated. Many of the faecaloral diseases covered in
Chapter 8 and those due to soil contact
Treatment At delivery, all babies eyes in Chapter 10 are due to poor personal hy-
should be routinely wiped and a 1% aque- giene. Streptococcal and staphylococcal
ous solution of silver nitrate instilled. infections of the skin (Section 12.6) are also
Wiping both eyes at delivery alone can prevented by good personal hygiene. Yaws
reduce the incidence of infection if silver (14.1), pinta (14.2) and endemic syphilis
nitrate is not available and should always (14.3) are readily cured by penicillin, but
be practised. A 2.5% solution of povidone- in the long-term, personal hygiene is the
iodine, tetracycline 1% or erythromycin best preventive strategy. A full list of dis-
0.5% eye ointment, can be used as alterna- eases prevented by good personal hygiene
tives to silver nitrate. can be found in Section 3.3.1.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:41am page 89

FaecalOral Diseases

The faecaloral group of diseases is trans- Clinical features Profuse, watery diarrhoea
mitted by person-to-person contact, through with occasional vomiting, but despite the
water, food or directly to the mouth. The fluid nature of the stools, faecal material is
absence of a proper water supply, rubbish always present. There is never the rice-water
and dirty surroundings with an abundance stool characteristic of cholera. Water and
of flies are the typical situations in which electrolytes are lost, which in the young
these diseases thrive. The incidence of these child may be sufficient to cause dehydration
diseases can be controlled by: (i) breaking and ionic imbalance, leading to death. Nor-
the faecaloral cycle with personal hygiene; mally, a self-limiting condition, but in un-
(ii) increase in water quantity; (iii) improve- hygienic surroundings, or where babies
ment in water quality; (iv) food hygiene; and bottles are used, repeated infections occur
(v) the provision of sanitation. The disposal leading to chronic loss of nutrients and sub-
of garbage and the control of flies are also sequent malnutrition. A serious infection in
important. neonates, mortality decreases with age until
Many of the diseases in this group cause in adults, it is just a passing inconvenience
diarrhoea (Table 8.1). (travellers diarrhoea).

Diagnosis is made on clinical criteria unless

8.1 Gastroenteritis laboratory facilities sufficient to identify
viral infections are available. Specific DNA
Gastroenteritis is a common form of diar- probes are likely to be the most appropriate
rhoea that predominantly attacks children. method of identifying causative organisms
It is endemic in developing countries, but in developing countries if they can be made
seasonal epidemics occur. Attempts to find cheap enough.
a specific organism as a cause are often un-
successful and not essential, as management Transmission Epidemics occur in families or
and control are the same. Strains of entero- groups of children sharing similar surround-
toxigenic, enteropathogenic and enteroag- ings. Infection is often seasonal, for
gregative Escherichia coli as well as enteric example, the beginning of the rains
viruses, particularly rotavirus, are the main heralding an outbreak. This would suggest
organisms. Campylobacter (Section 9.2) is transmission by water and simple control
now a major cause. measures, such as boiling of water, can

Q R. Webber 2005. Communicable Disease Epidemiology and Control, 2nd edition (Roger Webber)

Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:41am page 90

90 Chapter 8

Table 8.1. Diarrhoeas.

Presentation Disease Organism Characteristics

Acute watery Salmonellosis, food Salmonella, Staphylococci, Sudden onset with vomiting in
diarrhoea poisoning B. cereus, C. perfringens, group of people associated by
V. parahaemolyticus food
Gastroenteritis E. coli or non-specific Common, mainly in children,
(bacterial) epidemic
Gastroenteritis Rotavirus and other Occurs in children, often in
(viral) enteroviruses institutions (hospitals, schools,
Cryptosporidiosis Cryptosporidium etc.)
Cholera V. cholerae Severe, dehydration, rice-water
stools, epidemic
Acute diarrhoea with Bacillary dysentery, Shigella sp., C. jejuni Severe, seasonal, all ages
blood Campylobacter Sporadic, from
contaminated food, animal
Chronic diarrhoea Giardiasis G. intestinalis Mainly children and travellers
(Sprue or malabsorption syndromes) Adults, mostly males; nutritional
deficiencies especially of folic
Chronic diarrhoea Amoebiasis E. histolytica Cooler climates, mainly adults
with blood
Balantidiasis B. coli Similar to amoebiasis;
associated with pigs
Schistosomiasis S. mansoni Endemic areas, characteristic
eggs in stools

B. (cereus), Bacillus; C. (perfringens), Clostridium; V. (parahaemolyticus), V. (cholerae) Vibrio; E. (coli), Escherichia;

C. (jejuni), Campylobacter; G. (lamblia), Giardia; E. (histolytica), Entamoeba; B. (coli), Balantidium; S. (mansoni),
Schistosoma. Many other diseases cause diarrhoea (e.g. measles, malaria, tonsillitis).

stop the epidemic. Improperly sterilized Control and prevention is by the following
babies bottles or their contents are a methods:
common method of infecting the neonate.
. promotion of breast-feeding;
Incubation period 1272 h (generally . use of oral rehydration solution (ORS) in
48 h). the community;
. improvement in water supply and sanita-
Period of communicability 810 days. . promoting personal and domestic hy-
Occurrence and distribution Gastro- . vaccination (rotavirus and other vaccines,
enteritis is found throughout the world, e.g. measles).
especially in developing countries and in
conditions of poor hygiene. It is particularly Breast-feeding not only provides a sterile
common where bottle-feeding has been re- milk formula in the correct proportions (in
cently introduced, such as by unscrupulous contrast to the often-contaminated bottle),
infant-feed companies. A seasonal distribu- but also promotes lactobacilli and contains
tion suggests contamination of the water lactoferrins and lysozymes. Promoting
supply. breast-feeding and the administration of
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:41am page 91

FaecalOral Diseases 91

ORS solution in the community are the main

control strategies. Improvement in water
supplies and sanitation, with the promotion
of personal hygiene, are long-term meas- One litre clean water
ures. +
The oral cholera vaccine WC/rBS has
been shown to be about 60% effective
against enterotoxigenic E. coli so might One level teaspoon salt
have some place in control although its pro- +
tective effect in infants is considerably less.
Rotavirus vaccine (RRV-TV) has so far been
shown to be less effective in developing
countries than the developed and several
cases of intussusception has resulted in its
withdrawal from use in the latter. Prevent-
ing other childhood infections by vaccin-
ation, especially those associated with
gastro-intestinal disease, such as polio and
measles, can reduce the severity of gastro-

Treatment is by replacement of fluid and 8 level teaspoons sugar

electrolytes using ORS in the moderately +
dehydrated and intravenous replacement
in the severely dehydrated.

A suitable ORS is made by dissolving the following

constituents in 1 l of water:
The juice of one orange (for potassium)
Sodium chloride 3.5 g (Na 90 mmol)
Fig. 8.1. Preparing a simple oral rehydration
Trisodium citrate 2.9 g (citrate 10 mmol)
Potassium chloride 1.5 g (K 20 mmol, Cl tering it to her child. If it tastes salty, then
88 mmol)
more water should be added.
Glucose anhydrous 20.0 g (glucose 111 mmol)
A naturally available rehydration solu-
tion is the fluid from a green coconut. A
7-month coconut has been found to be the
These ingredients can be obtained sep- most suitable. Rice-water made from a hand-
arately or in packets of readily prepared ful of rice boiled in a saucepan of water until
mixtures. In the absence of prepared it disappears, plus the appropriate amount
packets, a simpler formulation can be made of salt for the volume of water, makes a
as shown in Fig. 8.1, which consists of simple rehydration solution. Carrot water
mixing salt and sugar in 1 l of clean water. can also be used.
Potassium is not an essential constituent, If mothers are taught how to make up
but addition of the juice of one orange is these solutions, then they can treat their
useful. Tea leaves also contain potassium, children as soon as they start to get diar-
so the mixture can be prepared as tea with rhoea. The mother should use a cup and a
the addition of salt and sugar. Teaspoons spoon and sit with her child giving it small
vary in size and it is dangerous to give too quantities of fluid at frequent intervals.
much salt; hence a useful check is for the Severe dehydration can usually be pre-
mother to taste the solution before adminis- vented by primary care from the mother.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:42am page 92

92 Chapter 8

There is no need to use an antibiotic or Occurrence and distribution. Cryptospori-

an antispasmodic, both of which are contra- diosis has a worldwide distribution, found
indicated. Lactobacilli, which inhibit E. particularly in conditions of poor hygiene. It
coli, colonize the gut in the breast-fed infant. is endemic in many developing countries
In some countries, lactobacilli are adminis- where infection is acquired at an early age.
tered in yoghurt (curd). Massive epidemics have occurred in de-
veloped countries when the water purifica-
Surveillance In countries with a seasonal tion system had failed (such as the 1993
rainfall pattern, gastro-enteritis outbreaks Milwaukee epidemic where there were
often start with the beginning of the rains, 500,000 cases). In other areas, it is a disease
so monitoring the weather can provide early of animal handlers, homosexuals and insti-
warning of an impending outbreak. tutions. There is a marked seasonality in the
northern hemisphere with peaks of disease
in spring and autumn.
8.2 Cryptosporidiosis
Control and prevention is by personal hy-
Organism Cryptosporidium parvum is a giene, the provision of sanitation and safe
protozoan parasite found in poultry, fish, water supplies. Domestic animals and pets
reptiles and mammals, especially cattle, can be important sources of infection and
pigs, sheep, dogs and cats, from which the therefore precautions should be taken
infection can be acquired. when handling them.

Clinical features Cryptosporidiosis pre- Treatment is with oral rehydration to re-

sents as an acute watery diarrhoea associ- place fluid loss (Section 8.1).
ated with abdominal pain. Fever, anorexia,
nausea and vomiting can also occur, espe- Surveillance Animals, particularly cattle
cially in children. There may be repeat and pigs, can be examined for Cryptosporid-
attacks, but these do not normally continue ium infection.
for more than a month. In the immunodefi-
cient, especially those with HIV infection,
the disease enters a chronic and progressive 8.3 Cholera
Organism. Vibrio cholerae. Classical chol-
Diagnosis is by finding the oocyst in faecal era is caused by V. cholerae 01, while most
samples. Alternatively, the intestinal stages of the recent epidemics have been due to the
can be looked for in intestinal biopsy speci- El Tor biotype. V. cholerae 0139, which
mens. appeared in 1992, is a more virulent ser-
ogroup variant of the El Tor biotype.
Transmission is from person-to-person
via the faecaloral route, from animals or Clinical features A profound diarrhoea of
faecal-contaminated water. The oocyst rapid onset that leads to dehydration and
can survive in nature for a considerable death should be considered as a case of chol-
period of time. The infecting dose is very era until proved otherwise. The diarrhoea
low. contains no faecal particles, but is watery
and flecked with mucus (not cells), the so-
Incubation period. 112 days. Mean of called rice-water stools. The passage of large
7 days. quantities of fluid leads to rapid and ex-
treme dehydration, which can be fatal.
Period of communicability Up to 6 months in Vomiting can also be present in the early
faecal material. stages.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:42am page 93

FaecalOral Diseases 93

Diagnosis V. cholerae can be identified from epidemiological investigations show this

the diarrhoeal discharge, vomitus or by source of infection to be important, but
rectal swab. Its characteristic mobility (it bacteriologists have not isolated organisms
vibrates, hence being called a vibrio) can be in sufficient numbers. One possible explan-
seen by dark ground or phase-contrast mi- ation is the presence of non-agglutinable
croscopy and is inhibited by specific anti- vibrios (alternatively known as non-cholera
serum. Confirmation of the diagnosis is vibrios), which are closely related to V.
made by culture on TCBS sucrose agar. cholerae except that they do not agglutinate
A suitable transport medium is Carey Blair, antisera. These are known to be mutations
or alternatively 1% alkaline (pH 8.5) pep- so that shifts between typical vibrios and
tone water, which can also be used for non-agglutinable forms may occur. If this
water samples. is a regular feature in nature, then it could
help to explain where cholera goes to
Transmission Classical cholera is a disease (especially the classical form) during inter-
of water transmission, whereas El Tor is by epidemic periods. The appearance of
both water and food. Generally, epidemic non-01 cholera (vibrio 0139) supports this
cholera is transmitted by water and endemic view.
cholera by food. It may appear in a seasonal V. cholerae has been found to remain
pattern, often in association with other viable in crude sewage for over a month
causes of diarrhoea (Fig. 8.2). It is the en- and in sewage-contaminated soil for up
demic nature of El Tor and its persistence to 10 days, a possible source of infection
in the environment that has been respon- carried over to rivers or wells. It has
sible for its prodigious spread. been isolated from a number of foodstuffs
For every clinical case of El Tor cholera, especially those with a pH between 6 and
there can be as many as 100 asymptomatic 8, such as milk produce (e.g. ice cream),
cases, explaining how epidemics spread sugar solutions, meat extracts or articles
from one region to another, but not how of food preserved by salt. Uncooked fish
infection persists in the environment. Vib- and vegetables, which have been washed
rios may be able to persist in an aquatic or irrigated by sewage effluent, have been
environment, such as in the mucilaginous responsible for outbreaks.
covering of water plants or fish, in associ- Direct person-to-person spread or via
ation with copepods or other zooplankton. fomites, such as utensils or drinking straws
An alternative method may be due to con- (in home-brewed alcohol parties), do not
tinuous person-to-person transmission in appear to be as important as expected.
a sub-clinical asymptomatic cycle. When a Even for persons attending the death of a
susceptible person enters the cycle or there cholera victim, it is more likely that infec-
is an environmental or climatic change, a tion will result from drinking water or con-
fresh epidemic starts. suming food that has been prepared for the
V. cholerae in water are easily des- mourning ceremony, rather than from the
troyed by sunlight, chemical action or com- dead person or their shrouds.
peting bacteria. However, where these A case of cholera can excrete between
elements are not present, it can survive in 107 and 109 V. cholerae per millilitre
fresh water for some time and in saline water of diarrhoeal discharge and since the
for at least a week. The level of salinity volume of this discharge may be in
needs to be between 0.01% and 0.1% as is excess of 20 l/day, the potential for contam-
found in estuarine or lagoon water. V. cho- ination of the environment is enormous.
lerae in these saline environments can be Clearly, though the severe case is unlikely
taken up by shellfish or fish, which then to be anything but a transitory source,
form an alternative method of infection it is the asymptomatic case passing from
when eaten uncooked. 102 to 105 organisms/g of stool in a spas-
The isolation of V. cholerae from modic manner that poses the greatest
river water has been perplexing because hazard.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:42am page 94

94 Chapter 8






1973 1974 1975




1976 1977 1978

Fig. 8.2. Similar pattern of gastroenteritis and cholera in Calcutta, India (19731978). (Reproduced with
permission from the Indian Council of Medical Research (1978) National Institute of Cholera and Enteric
Diseases, Annual Report, Indian Council of Medical Research, Calcutta.)

A high dose of V. cholerae is required press gastric acidity. Blood group O is

to infect the healthy subject. Some 106108 associated with an increased severity of
organisms are needed, but if the person has a cholera.
decreased gastric acidity, then 103 organ-
isms may be sufficient. Lowered gastric
acidity is found more commonly than Carriers are of short duration; 70% of
expected and may be related to malnutrition cholera cases are free of vibrios at the end
or diet. Cannabis smoking is known to de- of the first week and 98% by the end of the
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:42am page 95

FaecalOral Diseases 95

third. Long-term carriers are rare and of no ized by super-chlorination (adding two to
epidemiological importance. three times the calculated amount of chlor-
ine required for the volume of water) or
Incubation period 15 days. people should be advised to boil the water
they use for drinking. Boiling water is un-
popular as it uses vital firewood, monopol-
Period of communicability is until about
izes scarce cooking pots and the water has a
5 days after recovery, but prolonged excre-
flat taste. However, there is no reason why
tion of organisms can continue in some in-
water cannot be boiled at the same time as
dividuals. Antibiotics reduce the period of
the meal is cooked and simple clay pots
used instead of metal ones. Boiled water
can be re-aerated by shaking it up. A not so
Occurrence and distribution Humans are the safe, but easier method is to leave water to
only known reservoir, but the persistence of stand and then decant off the supernatant.
the organism in the environment, in pos- A simple way of doing this is the three-pot
sibly a changing form, as discussed above, system (Fig. 3.7). Chlorine can be added to a
may be another source. In endemic areas, well or community water supply, but any
cholera is a disease of children (adults vegetable matter in the water will inactivate
having developed immunity in childhood), chlorine and several times the amount cal-
whereas in its epidemic form, adults are the culated may be required.
more usual victims. The disease is associ- The banning or restriction of food
ated with poverty and poor hygienic prac- should only be made on good epidemi-
tices. ological evidence. If fish are properly
Classical cholera is restricted to South cooked before being eaten, then they are un-
Asia and caused by V. cholerae 01. The El likely to be a source. Disruption of a fish-
Tor biotype has infected Asia, Africa, eating practice may have dire consequences
Europe, Pacific Islands and South America; on other aspects of peoples health. It is
the majority of cases are now found in Africa. more often the fisherman rather than the
First isolated from pilgrims to Mecca in the fish, or the farmers, rather than their pro-
quarantine station of El Tor in West Sinai duce that are the purveyors of cholera.
(now Egypt) in 1906, it differs from the clas- Quarantine is rarely effective, as bribery
sical variety by producing a soluble haemo- or evasion of the barricades by the few who
lysin. It is classified as either Ogawa, Inaba or might be carrying the infection negates the
Hikojima of the classical serotypes. The im- hardships borne by the many who are not.
portance of the El Tor biotype is that it can Giving tetracycline to immediate contacts of
survive longer in water, is more infectious, cases will reduce the number of asymptom-
can cause mild infections and more fre- atic carriers, but the widespread distribu-
quently produces the carrier state. All these tion of the drug will encourage tetracycline
characteristics have assisted in the extensive resistance.
spread of this organism. The new and more The original inactivated V. cholerae
virulent V. cholerae 0139 has spread to many vaccination gives about 50% protection
parts of Asia and been responsible for epi- and only lasts for 6 months. It does not pre-
demics in India, Bangladesh, Myanmar, vent the asymptomatic disease state and can
Thailand and Malaysia. actively encourage the spread of infection
and, therefore, is not recommended as a
Control and prevention Control is aimed at method of control. A new oral vaccine
the cause. All too often a panic situation (WC/rBS) consisting of killed whole V. cho-
develops, foods are banned, vaccination lerae 01 in combination with a recombinant
given and quarantine instigated. If cholera B subunit of cholera toxin confers protection
is epidemic and preliminary investigations of up to 90% for 6 months and has been
indicate that water is the vehicle of trans- found to be effective in preventing cholera
mission, then the supply should be steril- in high-risk areas, such as refugee camps
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:42am page 96

96 Chapter 8

and urban slums. Protection was found to of normal saline and one unit of sodium
last for 3 years in 50% of those vaccinated bicarbonate can be used. The patient should
at the age of 5 years or above. Another oral be rehydrated intravenously as rapidly
vaccine (CVD 103-HgR) conferred good pro- as possible, the rehydration substituted
tection and was also effective in infants as by ORS once the patient can swallow. This
young as 3 months of age. Either of these allows the body mechanisms to regulate
vaccines can be used pre-emptively in electrolytes, as ionic imbalance can rapidly
high-risk areas, epidemic situations and occur with intravenous infusion to which
to protect travellers entering areas of high many patients succumb. The body fluid
endemicity. deficit should be restored, followed by
Persons dying from cholera should maintenance of one and a half times the
be buried quickly and the ceremony kept equivalent amount of bowel loss. Fluid loss
to a minimum. Disinfectants and hand- can be measured by directing fluid into a
washing facilities should be provided at bucket placed under the bed. A bed
treatment centres and when bodies are pre- or cholera cot is not essential though and
pared for burial. Flies should be controlled the patient can be nursed on a plastic sheet
by disposing or covering all faecal dis- laid on the ground with the earth hollowed
charges, although they have not been out under the pelvis to take a receptacle
shown to play a significant role in transmis- to collect the outpouring fluid.
sion. Tetracycline is not essential in treat-
ment, but shortens the duration of the ill-
Treatment The vibrio binds to the cells and ness and quantity of fluid replacement
produces an enterotoxin, which activates required. Tetracycline is given in a dose of
adenyl cyclase, an intracellular enzyme 500 mg 6-hourly for 3 days or Doxycycline in
that initiates a system of fluid and ion trans- a single dose of 300 mg. Sensitivity must be
port from the plasma to the intestinal lumen. monitored as the development of tetracyc-
There is no mucosal damage and increased line resistance will necessitate changing to
permeability is unlikely, which explains another antibiotic.
why glucose and electrolytes can still be The management of a cholera epidemic
absorbed by the mucosa. This allows large requires speed and good organization. Es-
quantities of low-protein fluid, bicarbonate sentially treatment is taken to the people by
and potassium to escape through an essen- setting up treatment centres at strategic
tially undamaged intestine. Management is places in the vicinity of the epidemic.
to correct dehydration in this otherwise self- These can be dispensaries, schools, church
limiting disease. halls or even tents, supplied with staff and
Fluid replacement must be rapid and fluids. Cholera patients do not need to be
adequate, the most easily available being treated in hospital.
the first choice. If rehydration can be started
as soon as cholera symptoms begin, then
oral rehydration will be all that is required. Surveillance for cholera is both national and
ORSs can either be prepared from ready international. An outbreak of cholera must
mixed packets of salts (Section 8.1) or by be reported to WHO, providing an advance
making a sugarsalt solution (Fig. 8.1). Un- warning system to neighbouring countries.
fortunately, most cases have already lost Nationally, a warning system can be imple-
a considerable quantity of body fluid on mented for diarrhoeal diseases where an in-
presentation, which means that they will crease in numbers or persons dying from
require intravenous infusion. If available, diarrhoea may indicate an underlying out-
Ringer lactate solution (Hartmanns) con- break of cholera (Fig. 8.2). Where cholera
tains the nearest approximation of electro- exhibits a seasonal pattern, the population
lytes to that lost in the diarrhoeal fluid. As and health staff can be placed on the alert
a second best option, a mixture of two units when the next season starts.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:42am page 97

FaecalOral Diseases 97

8.4 Bacillary Dysentery (Shigellosis) sive fly breeding takes place. Only 10100
organisms are required to produce the dis-
Organism Bacillary dysentery is due to Shi- ease.
gella invading the bowel. The species and Carriers can be important and
strains of Shigella are numerous. There are sporadic epidemics in institutions might in-
four main groups: dicate a food handler with unsanitary
. S. dysenteriae with 12 serotypes;
. S. flexneri with 14 serotypes; Incubation period 17 days.
. S. boydi with 18 serotypes;
. S. sonnei with one serotype. Period of communicability 4 weeks, but may
persist for longer in the carrier.
The most severe are S. dysenteriae and
the least severe S. sonnei, with S. flexneri Occurrence and distribution Any outbreak
being the most common in endemic areas. of an acute diarrhoeal disease with blood
Another form of bloody diarrhoea is due to should be considered to be bacillary dysen-
enteroinvasive and enterohaemorrhagic tery until proved otherwise. Distribution is
E. coli, particularly serotype 0157. worldwide with sporadic outbreaks occur-
ring in both the developed and the develop-
Clinical features Bacillary dysentery pre- ing world. Infection is often carried from one
sents as an acute diarrhoeal illness with area to another or across international
blood in the stools, more acute and severe boundaries by carriers.
than amoebic dysentery. In mild infections,
blood may be absent with a similar presen- Control and prevention Bacillary dysentery
tation to gastroenteritis. In severe cases, the is likely to present as an outbreak;
stools are a mixture of pus and blood, and so control will need to be implemented in
tenesmus is common. Fever accompanies the manner described in Section 4.1. Gener-
the illness and nausea or frank vomiting ally, it is better to bring treatment to the
can occur. Severity is determined by the site of the outbreak, setting up temporary
strain of organism and age of the person, treatment centres, unless the outbreak is a
with a moderate mortality in the very small one and the hospital has sufficient
young and very old. facilities to isolate cases. A seasonal out-
break will suggest that water supplies need
Diagnosis If bacteriological facilities per- to be improved. Search for carriers is gener-
mit, the organism should be identified, ally unsatisfactory and investigation should
typed and sensitivity determined. A suitable be restricted to food handlers.
transport medium is Carey Blair. Where Breast-feeding is protective for babies
this is not possible, a simple epidemi- and infants and should be continued even
ological investigation may provide suffi- by the sick mother. Washing hands with
cient information to indicate the mode of soap and water is the most effective method
transmission. of interrupting transmission.
With widespread antibiotic resistance,
Transmission is by the faecaloral route with Shigella infections could be controlled by
either food or water as the main vehicle vaccinating susceptible groups, especially
carrying the infection. Bacillary dysentery if there is an outbreak in the vicinity. A live
can occur in small outbreaks amongst fam- oral vaccine of S. flexneri (SC602) is cur-
ilies, suggesting food as the mode of transfer. rently under trial, while others are in the
Seasonal epidemics coinciding with the ar- developmental stage.
rival of the rains indicate water-borne
spread. Flies can be important in hot dry Treatment Management is the same as
months when garbage accumulates and mas- with other diarrhoeas to replace fluid and
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:42am page 98

98 Chapter 8

electrolytes lost. ORS is adequate and effect- for infecting people in restaurants, while a
ive in all cases, but the severely dehydrated poorly maintained water supply dissemin-
will require intravenous rehydration. There ates infection more widely. The cysts can
is a place for antibiotics in the treatment survive for several weeks in fresh water
of bacillary dysentery although sensitivity and are not killed by normal levels of chlor-
must be determined, as resistance is ine. An animal reservoir might also be re-
common. Ampicillin, nalidixic acid, sponsible.
TMPXSMX, ciprofloxacin or ofloxocin
can be given as a 5-day course. Antibiotic Incubation period 325 days; mean 7
treatment should not be relied upon as resist- 10 days.
ance makes control more difficult and the
disease can relentlessly spread though a Period of communicability The organism can
country. persist in the bowel for many months and
during all of this time the infection can be
Surveillance is similar to cholera (Section transmitted.
8.3) with notification of any outbreaks
and monitoring of the weather for seasonal Occurrence and distribution The infection is
occurrences. found worldwide, but is more common in
There are many similarities between the tropics and where conditions of hygiene
cholera and bacillary dysentery, especially are poor, ensnaring the unsuspecting travel-
in the management and control so further ler with chronic diarrhoea. Heavy infections
help can be found in Section 8.3. occur in children, especially those in insti-
tutions or debilitated by other conditions.

8.5 Giardia Control and prevention Individuals who are

rigorous with their personal hygiene can
Organism The small flagellate Giardia intes- largely avoid infection. Drinking water can
tinalis (lamblia) is a common commensal of be boiled or treated with five to ten drops of
the human small intestine, but heavy infec- iodine per litre of water. Proper food hand-
tions can cause diarrhoea. ling and preparation, especially the washing
of hands is essential, while long-term pre-
Clinical features Faeces are loose and greasy vention is through proper sewage disposal
with an unpleasant odour. Bloating and and the protection of water supplies.
abdominal distension can occur. Chronic
infections can produce partial villous atro- Treatment is with tinidazole either as a
phy with a resulting malabsorption syn- single dose of 2 g or 300 mg a day for 7 days.
drome. Giardia is one of the causes of Metronidazole can also be used.
travellers diarrhoea.
Surveillance Giardia is a common infection
Diagnosis The characteristic face-shaped in travellers and a routine stool examination
flagellate is occasionally seen in the faeces, after travelling to a less-developed area is
easily detected by its high motility, but the advisable.
cysts are more commonly found (Fig. 9.1).
Jejunal biopsy or the duodenal string test
may be performed in the differential diagno- 8.6 Amoebiasis
sis of the malabsorption syndrome.
Organism Amoebiasis is caused by the
Transmission is by person-to-person transfer protozoan Entamoeba histolytica, which
of cysts from the faeces of an infected indi- exists in an amoeboid form in the human
vidual or by contamination of food or water. large intestine and as a cyst in the environ-
Infected food handlers are often responsible ment.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:42am page 99

FaecalOral Diseases 99

The pathogenic amoeba enters a muco- sound. The abscess is usually not
sal fold and feeds on red blood cells tapped, unless in differential diagnosis
(RBCs). Penetrating through the muscularis from a bacterial abscess or is about to
mucosae, an abscess is formed with vascular burst.
necrosis taking place at its base. This leads
to tissue disintegration and the develop- Transmission Cysts of E. histolytica are
ment of an ulcer (the so-called flask-shaped formed in the large intestines and passed
ulcer). Active amoebae can be found in the into the environment in the faeces. They
base of an ulcer. survive in faeces for only a few days, but if
they enter water, they remain viable for con-
Clinical features Illness presents as acute siderably longer periods. Infection occurs
diarrhoea with frank blood, chronic diar- through drinking contaminated water or
rhoea or as an abscess with no apparent eating irrigated salad vegetables. Flies can
transitional period of diarrhoea. If the carry cysts for some 5 h. In circumstances
amoebic ulcer penetrates a blood vessel, of poor hygiene, direct faecaloral transfer
fresh blood is passed in the stool, which is via food, or by utensils, can take place.
a characteristic feature. Amoebae from the Cysts can survive in the cold for consid-
breached circulatory system are carried to erable periods, but they are killed by a tem-
various parts of the body, the liver being perature over 438C, which must be obtained
the commonest. In the liver, an abscess is in any composting system where human
formed, with the right lobe being the pre- faeces are used. Non-survival of amoebic
dominant site. Liver damage is a predispos- cysts is a useful indicator of effective decom-
ing cause with liver abscess more common position (see Fig. 1.2).
in males than females. The expanding ab-
scess can track outwards through the peri- Incubation period 24 weeks.
toneum, abdominal wall and on to the skin
or upwards to form a sub-phrenic abscess or Period of communicability Cyst passing can
enter the pleural cavity. The most serious continue for many years.
site of amoebic abscess development is in
the brain. All these features are illustrated
Occurrence and distribution Amoebiasis is
on Fig. 8.3.
a disease of poor hygiene, more commonly
Symptoms of an abscess are fever,
found in cooler environments than hot
weight loss and localized tenderness.
ones. In the tropics, it predominantly occurs
Amoebic pus is characteristically a pale red-
in highland areas or where there is a
dish brown colour (without odour) and
large temperature fluctuation. It is an infec-
can be discharged on to the skin from a
tion of adult life and if the period
penetrating ulcer, or coughed up from the
of residence in an endemic area is long,
lung. In a chronic infection, an amoeboma
there is greater chance of becoming
can be formed, which may be confused with

Diagnosis is made by examining fresh Control and prevention is by personal

stool specimens within half an hour of hygiene, food hygiene and the proper provi-
their production for motile amoebae with sion of water and sanitation. Sand filtration,
ingested RBCs. Amoebae are occasionally especially if it is combined with alum floc-
found in amoebic pus, which similarly culation, removes cysts from water supplies.
must be examined as soon as possible as A high concentration of chlorine is required
the active forms rapidly die off. The finding to kill cysts (3.5 ppm residual) although they
of cysts indicates infection, but search are more sensitive to iodine.
must be made of fresh stool or pus for motile
amoebae. Liver abscess is diagnosed Treatment of all stages of the disease is by
by X-ray (raised diaphragm) or by ultra- metronidazole 2.4 g single dose for 3 days or
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:42am page 100

100 Chapter 8


Swallowed cyst
Lung develops into

with engulfed red
blood cells

Amoebae in base of
ulcer entering
blood vessel

Non-pathogenic cysts in human intestine

Cyst passed
in stools

710 m 912 m 1520 m 1215 m

Endolimax lodamoeba Entamoeba coli E. histolytica
E. nana buetschlii
E. hartmani

Fig. 8.3. Amoebiasis.

2 g daily for 5 days or by other derivatives of

the 5-nitroimidazole group of compounds 8.7 Typhoid
(tinidazole, ornidazole and nimorazole).
Cyst passers can be given diloxanide furoate Organism Salmonella enterica serovar
(Furomate), 500 mg 8-hourly for 10 days. Typhi.

Surveillance Routine stool specimens Clinical features Although transmitted by

should be examined for amoebic cysts. the faecaloral route, typhoid manifests
Cysts of E. histolytica can be differentiated mainly as a systemic infection, generally
from other cysts by size and number of presenting as a fever. The fever starts grad-
nuclei (Fig. 8.3). ually, increasing in a stepwise fashion
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:42am page 101

FaecalOral Diseases 101

over the first 12 weeks, with a progressive Transmission The main method of transmis-
malaise, disorientation and drowsiness. At sion is water, contaminated by faecal mater-
the end of the first week, a rash of character- ial from a carrier. These water-borne
istic rose spots may appear (not seen in black outbreaks may not always be explosive and
skins). where low-grade infection of the water
The stools are normally constipated at source is taking place, groups of cases,
first, but may later change to diarrhoea. If the spread over time, may occur.
organism localizes in the Peyers patches of S. enterica has been found to survive
the small intestine, ulceration, haemorrhage periods of 4 weeks in fresh water, but if
and perforation may occur. the water is stored in bright sunlight (as in
a reservoir), then the number of organisms
Diagnosis is difficult and depends upon rapidly dies off. It can survive in aerobic
finding the organism in blood, stool or conditions with organic nutrient present,
urine. A blood culture (35 ml) taken in the as found in contaminated streams. If
first week is the most satisfactory. Culture the stream is polluted with raw sewage,
from the stools can be obtained if repeated then the organism can survive over 5 weeks
examinations are made from the start of the and within solid faecal material for consid-
illness, with a greater likelihood of becom- erable periods of time. Seawater is bacteri-
ing positive as the illness progresses, pro- cidal, but where a sewage outfall is near
vided antibiotics have not been used. a shellfish bed, then the organism is
Finding the organism from urine, in which filtered and concentrated providing a potent
it is excreted spasmodically, is more diffi- source of infection if the shellfish are eaten
cult. Where the diagnosis has still not been raw.
made and further investigation considered Milk and dairy products provide ideal
necessary, S. enterica can be cultured from culture media and can become infected
the bone marrow or bile (by duodenal string during handling by a carrier, or rinsing of
test). Bone marrow culture has the advan- containers with polluted water. Contamin-
tage of occasionally being positive even if ated ice cream has been responsible for sev-
the patient has received antibiotics. Sewage eral outbreaks. Pasteurization of milk at
culture can be used in the investigation of 608C is effective in killing S. enterica. Infec-
epidemics. tion of meat products and canned foods is
The Widal test on the patients serum less common, but can occur in the cooling
can indicate infection, but a search for process (if carried out in polluted water).
S. enterica must also be made to confirm Flies can transmit the organism from
the diagnosis. The Widal test has three com- faeces to food, whereas person-to-person in-
ponents, the H (flagella) the O (somatic) and fection is uncommon. Secondary cases form
Vi antigens. The H antibody titre can be a very small proportion of an epidemic; so
raised by any Salmonella infection and serial transmission in an unhygienic envir-
remain raised (giving an estimate of previ- onment is not a feature.
ous exposure), whereas the O antibody indi-
cates recent infection. However, both H and Carriers The carrier state is the most
O levels will be raised by a recent typhoid important epidemiological feature, with
immunization, negating any value of the persistence of the organism in some individ-
test. A titre of 1/40 or higher is required. uals for periods in excess of 50 years. Three
Added weight is given to the diagnosis by per cent of typhoid cases are found to still be
making a series of tests and demonstrating a excreting organisms after 1 year. People
rising titre. The Vi antibody is produced become more prone to act as carriers if they
during the acute stage of the disease and have a chronic irritational process, such
persists while the organism is present as cholecystitis, and especially the presence
and, therefore, has a value in detecting the of gallstones (in which S. enterica are able
carrier state. to survive). Opisthorchis sinensis has
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:42am page 102

102 Chapter 8

also been associated with the development which outbreaks occur. Drinking water
of faecal carriers. Urinary carriers often taken from polluted streams can be boiled,
suffer from an abnormality of the urinary chlorinated or left to stand (the three-pot
tract such as calculus and Schistosoma hae- system in Fig. 3.7). Reservoirs and settling
matobium is a predisposing cause. tanks can reduce the level of organisms
below the infecting dose.
Incubation period is 330 days, with a mean Where the outbreak can be traced to
of 814 days. The length of the incubation a food source, a search for carriers can
period is inversely proportional to the be made. Stool specimens should be
infecting dose. obtained from persons involved in the prep-
aration of the food. If a carrier is discovered,
Period of communicability From 1 week after they should be prohibited from preparing
the start of illness for a period of 3 months, food. This cannot always be applied to do-
except in the chronic carrier where it con- mestic catering, so careful instruction in
tinues for years. personal hygiene should be tried. The organ-
ism can persist under the nails, so these
Occurrence and distribution In most tropical should be kept short. Food must be pro-
areas, the disease is endemic with seasonal tected from flies and stored only for limited
outbreaks. Water is probably the main periods. All shellfish must be properly
vehicle of transmission, but may be more cooked.
related to the gathering of people at scarce An infecting dose of at least 103 organ-
water sources (as occurs in the dry season), isms is required (except in persons suffering
rather than epidemics occurring with the from achlorhydria), but may need to be as
early rains. Endemic typhoid is maintained high as 109. The main effect of vaccination
by sub-clinical infections, especially in un- appears to be to offer protection against
diagnosed children, who obtain a degree of lower dose infecting inocula (less than 105
immunity. It has been suggested that these organisms).
sub-clinical infections result from persons Typhoid vaccine has a variable effect,
swallowing lower bacterial doses than the offering protection to persons who receive
critical threshold. In endemic areas, the a low infecting dose, but none to those who
peak of infection is in children between 5 ingest a high dose of organisms. It may,
and 12 years of age. therefore, be useful for individual protec-
Typhoid is a worldwide disease and tion, but is limited on a mass immunization
serious outbreaks, generally epidemic in basis, except to selected groups such as
nature, have occurred in developed coun- school children. The live oral vaccine (Ty
tries from contamination of the water supply 21a) gives protection for at least 3 years and
or food produce. Repair work on water sup- may also give cross-immunity against S.
plies or an accidental interruption of chlor- enterica Paratyphi B. It is administered in
ination has led to epidemics. Typhoid three capsules taken orally on days 1, 3 and
organisms have persisted in canned meat 5. A vaccine containing the polysaccharide
cooled in infected water thousands of miles Vi antigen is administered parenterally by a
away from the outbreak. Many well-known single injection. Both of these methods pro-
outbreaks have been due to ice cream. The duce less reaction than the whole-bacteria
movement of carriers can be followed from vaccine. A booster dose is required every
the outbreaks they produce as they travel 3 years in travellers or persons from non-
around. endemic areas living in countries where
typhoid is common. The oral vaccine is
Control and prevention Control relies on the probably more effective in young children
protection of water supplies and the sanitary and in mass programmes, given as a liquid
disposal of faeces. Placing latrines too close formulation rather than in capsules, but pro-
to wells, fractures in water mains and acci- guanil, mefloquine and antibiotics should
dental contamination by sewage are ways in be stopped 3 days before administration.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:42am page 103

FaecalOral Diseases 103

Treatment is with ampicillin or co-tri- and epidemic in developed, but is less com-
moxazole, but multiple resistant organisms monly detected.
have meant that more expensive antibiotics,
such as the quinalones (e.g. ciprofloxocin Control and prevention See typhoid.
and ofloxacin) and third-generation cepha-
losporins, are now required. Prolonged
Treatment See typhoid.
treatment of the carrier with ampicillin, 1 g
three times a day for 11 weeks has been suc-
cessful, or if available, one of the quinalones Surveillance See typhoid.
can be used. Relapse occurs in about 5% of
treated acute cases.
8.8 Hepatitis A (HAV)
Surveillance Once a carrier has been identi-
fied they should be warned of the danger Organism Infectious hepatitis is a viral in-
they pose to others and told to report their fection caused by a member of the Picorna-
condition to any medical people they come viridae, which includes both enteroviruses
in contact with. Carriers are sometimes and rhinoviruses.
registered by health authorities.
Clinical features The main pathology is in-
flammation, infiltration and necrosis of the
8.7.1 Paratyphoid liver, resulting in biliary stasis and jaundice.
The infection generally starts insidiously,
Organism Salmonella enterica Paratyphi A, the person feels lethargic, anorexic and
B and C. Paratyphi B is the commonest. depressed. Fever, vomiting, diarrhoea and
abdominal discomfort ensue before the ap-
Clinical features Paratyphoid is similar to pearance of jaundice reveals the diagnosis.
typhoid, but with less systemic effects and Once jaundice appears, the person generally
diarrhoea a more important feature. A rash is starts to feel better. Hepatitis A is a mild
less commonly seen, but when it does occur, disease leading to spontaneous cure in the
it is more extensive involving the limbs and large majority, with only a few cases de-
face as well as the body. Ulceration of the veloping acute fulminant hepatitis and
gut can occur, but less commonly than in even rarely severe chronic liver damage.
typhoid. There is an increase in symptomatic and
severe cases with increasing age.
Transmission Infection originates from a car-
rier or a person with the illness, more com- Diagnosis is made on clinical grounds and
monly food-borne than by other means (see by the demonstration of IgM antibodies to
under food poisoning, Section 9.1). HAV (IgM anti-HAV) in serum.

Diagnosis See typhoid. Transmission The early case is highly infec-

tious contaminating food and water.
Infection can also be transmitted directly
Incubation period 110 days.
from poor personal hygiene such as by
hand-shaking. Intra-familial transmission
Period of communicability 12 weeks. is the commonest pattern generally due to
contamination of food and utensils by a food
Occurrence and distribution Paratyphoid handler, but large epidemics can occur
has a similar distribution to typhoid with where a person in the early stages of the
an endemic pattern in developing countries illness prepares community food. Because
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:42am page 104

104 Chapter 8

of its insidious nature, the disease is not of preparing food. In an epidemic situation,
generally recognized until jaundice appears, search should be made for the origin of the
by which time infection may have been outbreak and preventive measures taken. In
widely transmitted. the long term, water supplies and sanitation
Hepatitis is mainly a disease of poor should be upgraded.
sanitation, with water and food as the prin- HAV vaccine protects the individual at
cipal vehicles of transmission, but can also risk and should be mandatory for those going
occur when sanitation is good. Salads, cold from an area of good sanitation to one of
meats and raw sea food are common poor sanitation, such as tourists and expatri-
vehicles of transmission. ates. Two doses are required to be given
The carrier state is not important, but a 618 months apart, although one dose still
large number of asymptomatic cases are gives high levels of immunity. Immunity
produced. Epidemics occur when sewage from a two-dose regime may be lifelong, but
contaminates water supplies producing in- a booster at 10 years is currently recom-
fection in people who have previously mended. As most of the population in an
acquired some immunity, suggesting that endemic area would have met the infection
the disease may be dose-dependent. Where as children and either had no symptoms or
there is a large infecting inoculum, infection just a mild infection, there is no case for mass
can occur despite previous experience of the vaccination, except for high-risk groups.
disease. Chimpanzees and other animals
have been found infected, but probably Treatment There is no specific treatment
have no epidemiological significance. and supportive measures should be under-
taken. Fatty foods should be avoided and a
Incubation period is 1550 days, generally good fluid intake maintained.
about 28 days.
Surveillance Once hepatitis has been
Period of communicability is the later half of detected, health authorities should notify
the incubation period until about 1 week central authorities and surrounding areas.
after jaundice appears, so that most cases
have already transmitted the virus to family
and contacts before they report for medical 8.9 Hepatitis E (HEV)
Organism An enteric (E) virus provisionally
Occurrence and distribution Hepatitis is en- classified as a calicivirus.
demic in most tropical countries, with chil-
dren coming into contact early in life and Clinical features Hepatitis E is very similar
developing a degree of immunity. Non- to hepatitis A except that it nearly always
immune persons, such as from an area of occurs in large epidemics. The main differ-
good sanitation coming into this environ- ence is that hepatitis E results in a high
ment, are likely to develop the disease. Epi- mortality in pregnant women (up to 20%).
demics occur in developed countries,
especially in institutions, such as schools Transmission Similar to hepatitis A, al-
and prisons, due to poor food hygiene. though the main means of transmission is
via water. A reservoir has been found in
Control and prevention During an outbreak wild and domestic pigs, suggesting a zoono-
of hepatitis A, extra effort should be made to tic pattern of transmission.
encourage scrupulous personal hygiene
with hand-washing. Anybody who starts to Diagnosis is by the detection of IgM and IgG
feel unwell should be temporarily relieved anti-hepatitis E virus (anti-HEV) in serum.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:42am page 105

FaecalOral Diseases 105

Incubation period 39 weeks. be a history of normal birth with commence-

ment of walking, followed by a feverish
Period of communicability From 14 days illness and the development of flaccid par-
after the appearance of jaundice for a further alysis. The paralysis is limited to well-
2 weeks. demarcated muscle groups and there is no
sensory loss. A similar history may be given
Occurrence and distribution Hepatitis E has for meningitis, but the damage will be
been responsible for large epidemics in central with accompanying mental defi-
South and Southeast Asia, especially Myan- ciency.
mar and Vietnam, where it appears to be
endemic. Epidemics have also occurred in Transmission is generally via the faecaloral
North Africa, Ethiopia, China and Mexico. route, although the virus initially multiplies
in the oro-pharynx; hence airborne trans-
Control and prevention The same as hepa- mission can also occur. The virus then in-
titis A, but extra precautions should be vades the gastro-intestinal tract, where it is
taken to protect pregnant women. There is excreted for several weeks.
no specific vaccine. A disease of low hygiene, young chil-
dren (45 months) meet the virus with only a
small proportion showing overt disease. Of
these, 8090% have an inapparent sub-
8.10 Poliomyelitis (Polio)
clinical disease, 510% suffer from fever,
headache and minor clinical signs, with
Organism Poliovirus (Enterovirus) types 1, 2 only 1% going on to paralysis. Paralysis is
and 3. more common with older age. Therefore, a
non-immune person going into an endemic
Clinical features Infection commences with environment is at far greater danger of de-
fever, general malaise and headache, the ma- veloping paralytic poliomyelitis. Raising
jority of cases resolving after these mild standards of hygiene will also have the
symptoms, but approximately 1% proceed same effect because it spares people from
to paralytic disease. The virus has a predi- meeting the virus as young children and
lection for nerve cells, especially those with allows a pool of susceptibles to develop. In
a motor function (the anterior horn cells of the course of time, the number of non-
the spinal cord and the motor nuclei of the immunes will be sufficient for an epidemic
cranial nerves). These cells are destroyed to take place. There will also be a higher
and a flaccid paralysis results. proportion of paralysed cases (peak age
As a generalization, paralysis is more 59 years) and many deaths. Sadly, the rais-
common in the lower part of the body, be- ing of living standards will change polio
coming less common the higher up it from an endemic disease with a few para-
affects. Unilateral lameness is more lysed cases to an epidemic disease of in-
common than bilateral lameness. The severe creased severity. In epidemic poliomyelitis
form of bulbar poliomyelitis is generally where sanitation is good, pharyngeal spread
fatal in poor countries where respirators becomes a more important method of trans-
and intensive nursing care are not available. mission.
Site of paralysis is associated with injections Poliovirus strains vary in their neuro-
or operations and such procedures should virulence with the more virulent strains
be avoided if there is any suggestion of having a greater tendency to spread. This
poliomyelitis. could be due to a lower infective dose of
the virulent virus being required to produce
Diagnosis of the disabled case is made on disease.
clinical grounds, differentiating from the
spastic paralysis of birth injury with which Incubation period is from 5 to 30 days with a
it is commonly confused. In polio, there will mean of 10 days.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:42am page 106

106 Chapter 8

Period of communicability From 2 days after There is a slight risk of a live attenuated
exposure up until 6 weeks. virus becoming more virulent, so it is prefer-
able to vaccinate the majority of the popula-
Occurrence and distribution Poliomyelitis tion all at one time. Also, in a situation of
formerly occurred throughout the world, en- raising sanitary standards, epidemic polio-
demic in the poorer regions and epidemic in myelitis will only be prevented if there are
those with good sanitation, but this has sufficient people immunized to produce
changed considerably with the WHO pro- herd immunity. For these reasons, mass
gramme of eradicating polio from the campaigns can be effective. These should
world. The Americas, Europe and Western always be followed up by static clinics vac-
Pacific are now free of infection, while there cinating newborns and missed persons. The
are very few cases remaining in the rest of WHO, in its bid to eradicate polio from the
the world. The end of 2005 has been set world, recommends National Immunization
as the target date for global eradication of Days (NID) on which all children under the
polio. age of 5 years are vaccinated, irrespective of
previous immunization status. Two doses
Control and prevention The main method of are given at a months interval followed by
prevention and control is with polio vac- mop-up operations in areas of low coverage
cine. Two types of vaccine are available, or where continuing transmission has been
the killed (Salk) and the attenuated living identified.
(Sabin). The Salk vaccine is given by intra- School children and adults, who have
muscular injection, inducing a high level of received a full course of childhood vaccin-
immunity not antagonized by inhibitory ations, should have booster doses every
factors in the gut, but is expensive to pro- 10 years. Maintenance of vaccination cover-
duce because it contains many organisms. age should continue even in countries now
The Sabin vaccine is administered orally free of infection and is essential for travel to
making it easier and cheaper as well as pro- parts of the world where polio has not yet
ducing intestinal immunity, which can been eradicated.
block infection with wild strains of polio- The long-term aim of prevention should
virus. Multiplication of the virus in the be to raise standards of hygiene with the
intestine makes it very useful in preventing provision of water supplies and sanitation,
epidemics and allows it to spread to non- but as mentioned above, this must proceed
vaccinated persons in conditions of poor at the same time as an adequate vaccination
hygiene, thereby protecting them as well. programme.
Unfortunately, the inhibiting action of anti-
bodies in breast milk and colonization of the Treatment There is no specific treatment for
gut by other entero viruses can reduce its the acute stage, but rest and the avoidance of
effectiveness. Increasing the dosage and tell- physical activity are beneficial. Specific
ing mothers not to breast-feed for at least an supportive measures can be given to those
hour after administration can help. with disabilities.
Because there are three strains of the
poliovirus, the vaccine should be given on Surveillance developed for poliomyelitis
three separate occasions, separated by eradication looks for cases of acute flaccid
periods of at least 1 month to ensure that paralysis (AFP) in children under 15 years
immunity develops to each of the strains. of age. These are investigated by stool exam-
Polio vaccine is conveniently administered ination, inquiry and search for other cases
at the same time as DTP. A preliminary dose in the area. Remedial measures are carried
can be given soon after birth in areas where out around the case, vaccinating all con-
wild poliovirus is circulating. tacts.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:42am page 107

FaecalOral Diseases 107

8.11 Enterobius (Pin Worm) Period of communicability As long as adult

female worms discharge eggs until 2 weeks
Organism A nematode worm Enterobius after treatment.
Occurrence and distribution This very
Clinical features The main symptom is in- common infection is more prevalent in the
tense pruritis ani. Heavy infections can temperate than tropical regions of the world,
rarely cause appendicitis or salpingitis in favouring conditions where poor hygiene
the female. prevails.

Transmission The gravid female migrates out Control and prevention Good personal hy-
of the anus at night to lay her eggs on the giene, particularly cutting of finger nails
perianal skin before dying. This activity of and washing hands, is the means of control.
the female causes the patient to scratch so Bedding and underclothes need to be
that eggs are transferred to the fingers where washed frequently at the same time as treat-
they are swallowed or passed on to someone ment is given.
else. Eggs are thrown into the air such as
during bed making or sweeping and so are
often inhaled. Masses of eggs are liberated Treatment is with piperazine 65 mg/kg for
on each occasion so that infection of family 7 days, pyrantel pamoate in a single dose of
groups, dormitories of school children, etc. 10 mg/kg (maximum 1 g), repeated after
occur at the same time. 2 weeks, or albendazole or mebendazole
100 mg single dose repeated after 2 weeks.
Diagnosis Eggs can be collected from It is preferable to treat everyone in the
the perianal skin by using an adhesive tape group at the same time to break the transmis-
slide. This is examined directly by micro- sion cycle.
scope, the characteristic oval egg with flat-
tened side measuring 5060 mm by 20 Surveillance Regular checks in an institu-
30 mm (Fig. 9.1) being seen. tional situation, especially on individuals
with repeat infections will prevent spread
Incubation period 26 weeks. throughout the establishment.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 7:27pm page 108

Food-borne Diseases

The faecaloral mechanism for transfer of group of persons who have shared the same
infection often includes food as a mechan- meal. Sometimes, a sub-normal temperature
ism of infection, but in addition, there are or lowered blood pressure is the presenting
other diseases that are only transmitted by symptom. The incubation period is very
food. These can infect foods in general, such short and sufficiently precise for the type of
as with food poisoning, or be very specific in food poisoning to be suspected by the length
a particular food, such as certain helminth of time since the food item was eaten.
infections. As the method of infection is very
specific so are its methods of control, which Incubation period With staphylococcal food
include food hygiene, the proper cooking of poisoning, it is between 1 and 6 h; Salmon-
foods and sanitary methods to prevent the ella over 6 h, usually 1236 h, and for Clos-
food from being contaminated. tridia, 1224 h or several days. Less
commonly, food poisoning can be due to
Bacillus cereus (112 h) and Vibrio parahae-
9.1 Food Poisoning molyticus (1248 h).

9.1.1 Food poisoning due to bacteria Transmission is through the consumption of

food contaminated with the bacteria or its
Organism Food poisoning can either be due toxins. Infection can sometimes result from
to bacteria, viruses, organic or inorganic a contaminated water supply and via milk
poisons (Table 9.1). The most common that has not been pasteurized. Salmonella
poisoning is that produced by bacteria. The generally infects the food in the living
main types of bacterial food poisoning are state, such as cattle, poultry or eggs, but
due to Salmonella, Staphylococcus or Clos- unhygienic practice in the slaughtering of
tridia. animals or preparation of foodstuffs can
also be responsible. The bacteria are killed
Clinical features Due to the similarity of pre- by proper cooking and no toxins are pro-
sentation, it is more convenient to consider duced; so examination of the meal should
them as a group, rather than individually. reveal an improperly cooked source.
Onset is sudden with fever, generally Staphylococcal food poisoning results
vomiting and/or diarrhoea in a family or from toxin produced by the bacteria so the

Q R. Webber 2005. Communicable Disease Epidemiology and Control, 2nd edition (Roger Webber)

Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 7:27pm page 109

Food-borne Diseases 109

Table 9.1. Food poisoning.

Agent Period of onset (h) Symptoms Types of food

Bacterial food poisoning

Staphylococcal 16 Sudden, vomiting more Stored food
B. cereus 112 than diarrhoea
Salmonella 1236 Vomiting, diarrhoea and Improperly cooked meat,
fever eggs and milk produce
C. perfringens 924 Abdominal cramps, Cooked meat, especially
diarrhoea, shock pig
C. botulinum 924 Ptosis, dry mouth, paralysis Preserved foods
V. parahaemolyticus 1248 Abdominal pain, diarrhoea Undercooked or raw fish
and fever
Fish poisoning
Ciguatera 130 Parathesiae, malaise, Barracudas, snappers, sea
sweating, diarrhoea and bass, groupers
Scombroid 112 Burning sensation, nausea, Tuna, mackerel, salmon or
vomiting cheeses
Tetraodontoxins 0.53 Hypersalivation, vomiting, Puffer fish
parasthesiae, vertigo,
Shellfish, paralytic 0.53 Parasthesiae and paralysis Clams and mussels
Shellfish, diarrhetic 0.53 Diarrhoea and vomiting Clams, scallops, etc.
Plant foods
Akee (Blighia sapida) 23 Vomiting, convulsions, Unripe fruit
Cassava (Cyanide) Hours Vomiting, diarrhoea, Improperly processed root
abdominal pain,
headache, coma
Triorthocresyl- Days Neuropathy Cooking oil

food may be adequately cooked and no bac- ease of short duration, but in New Guinea
teria isolated from the suspected food and the Western Pacific Islands, it is respon-
source. It is commonly transmitted by food sible for enteritis necroticans or pigbel, in
handlers with an infected lesion or un- which there is an acute necrosis of the
hygienic habits, such as transferring bacteria small and large intestines with a high fatal-
from the nose. V. parahaemolyticus is par- ity rate. This is associated with feasting,
ticularly associated with seafood or food generally of pig meat, but also from other
that has been washed with contaminated animals such as cattle. Children, particu-
seawater. larly boys, are mainly affected. The disease
Clostridia food poisoning can be caused is probably accentuated by a protease inhibi-
by several types of organisms. C. botulinum tor contained in sweet potato, preventing
infection results in a severe disease, botu- breakdown of the toxin.
lism, which is characteristic of home-pre- Clostridia have resistant spores, which
served foods (see further Section 18.5). C. can remain in the soil for long periods, and
perfringens generally produces a mild dis- their contamination of partly cooked and
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 7:27pm page 110

110 Chapter 9

re-heated food allows multiplication and amongst food handlers. Anyone with a
production of the toxin. septic or discharging sore should be banned
There is often a seasonality of food from handling and preparing food.
poisoning, Salmonella in the summer Food must be stored, prepared and
months and C. jejuni in spring and autumn. cooked properly (Section 3.3.2). Establish-
C. perfringens occurs throughout the year. ments that prepare food, such as restaurants
and hotels, should be regularly inspected
Diagnosis and investigation of the and certified.
outbreak The epidemiologist is concerned
with diagnosing the cause of the outbreak Treatment The treatment of cases of food
and, therefore, a search is made to discover poisoning is supportive with fluids and
a common food that has been eaten by all electrolytes (either orally or intravenous).
the persons who have succumbed to the
illness. The foodstuff is likely to be one par- Surveillance Food handlers should be
ticular ingredient of the meal, rather than checked by supervisors and food establish-
the whole meal and samples should be ments visited on a regular basis by health
taken for culture. If nothing is grown, this inspectors.
does not rule out a Staphylococcal or
Clostridia food poisoning cause and finer
questioning on foodstuffs consumed might 9.1.2 Fish poisoning
be the only way to discover the offending
item. (See Section 2.2.5 on how to analyse
Organism Fish poisoning is a specific form
the relative importance of different foods
of food poisoning caused by toxins present
in the fish or shellfish when they are caught
or which develop due to partial decompos-
Period of communicability In Salmonella in- ition taking place if they are not eaten
fection, organisms can be excreted for up to straight away or refrigerated. Ciguatera
1 year although it is generally just for a toxin is produced by the dinoflagellate Gam-
period of weeks. bierdiscus toxicus, which is present in
algal blooms, often called red tides, while
Occurrence and distribution Food poisoning shellfish poisoning can de due to the dino-
is found worldwide with large outbreaks as- flagellates Gonyaulux, Gymnodinium,
sociated with gatherings of people, such as Dinophysis or Alexandrium.
celebrations and weddings. Many small out-
breaks and those occurring in the home go Clinical features Symptoms are normally
unreported unless individuals are ill mild with paraesthesia (tingling and burn-
enough to be hospitalized. Sometimes a ing sensations or pain and weakness), mal-
batch of food is infected and distributed to aise, sweating, diarrhoea and vomiting, but
several outlets, so as soon as the food- in the young or those who have consumed a
poisoned item is discovered, all of it must large quantity of poison, the condition is
be traced and destroyed. more serious. Respiratory and motor paraly-
sis can occur, often resulting in fatalities.
Control and prevention All suspect food Neurological symptoms can persist for
must be destroyed and if it is part of a some time after the original illness.
common foodstuff, then all must be traced
and disposed of. The source of contamin- Transmission is through eating fish that has
ation, such as an abattoir, must be looked not been refrigerated or already contains the
for and control measures implemented. Pre- toxin. At certain times of the year and when
vention is by proper cooking of food and hurricanes, seismic shocks or similar dis-
personal hygiene. Where repeated attacks turbances of the coral reef occur, an
occur, a search for a carrier should be made algal growth containing the dinoflagellate
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 7:27pm page 111

Food-borne Diseases 111

develops. Fish feed on the algal bloom, or it bizarre symptoms, such as paralysis, may
is inadvertently filtered by shellfish, and be caused by an organic or inorganic poison
their flesh becomes poisoned. Fish that are contaminating the food. Examples are cyan-
normally quite edible, such as barracuda, ide poisoning from poorly processed bitter
snappers, sea bass and groupers, become cassava, eating unripe akees (a fruit popular
poisonous at these periods. The commonest in the Caribbean) or contaminants in
poison is ciguatoxin, which is not destroyed cooking oil.
by cooking. Although very localized, such out-
breaks can be serious with considerable
Incubation period 0.53 h after eating fish or morbidity and sometimes mortality, neces-
shellfish. sitating the identification of the source as a
matter of urgency and banning them from
human consumption.
Period of communicability Not transmitted
from person-to-person.
9.2 Campylobacter Enteritis
Occurrence and distribution Fish poisoning
is commonly found amongst island commu- Organism Campylobacter jejuni.
nities or coastal people in which fish is a
major item of diet. It is an important problem
Clinical features An acute diarrhoeal disease
in Pacific Islands, the Caribbean, Southeast
with abdominal pain, malaise, fever and
Asia and Australia.
vomiting. It is often self-limiting within 4
7 days, but in severe cases, pus and blood are
Control and prevention All freshly caught found in the stools, with a presentation
fish should be gutted and refrigerated as similar to bacillary dysentery. With its asso-
soon as caught, unless cooked and eaten ciation with a food source, it is often thought
straight away. Red tides (algal blooms) to be a case of food poisoning until the or-
occur as a result of some disturbance ganism is identified. Campylobacter enter-
of coral reefs, such as hurricanes, earth- itis is an important cause of travellers
quakes and El Nino climatic disturbances. diarrhoea.
Algal blooms and hence fish poisoning
are related to the surface temperature. As Diagnosis The organism can be isolated
a result, where this is abnormally increased from the stools using selective media. A pre-
during an El Nino event, there is an in- liminary diagnosis can be made by examin-
crease in fish poisoning and the converse ing a specimen of stool with phase-contrast
when the temperature is less than (dark-ground) microscopy, where an organ-
expected. ism similar to a cholera vibrio will be seen.
The presence of faecal material and absence
Treatment There is no specific treatment; of cholera-like symptoms will differentiate
supportive therapy being given. it from cholera.

Surveillance When red tides are reported, Transmission Domestic animals including
eating reef fish should be avoided. poultry, pigs, cattle, sheep, cats and dogs
are reservoirs of the organism and their
consumption or humans close association
9.1.3 Food poisoning due to organic or with them is responsible for much
inorganic toxins of the transmission. Most infections are
due to faecal contamination by animals or
More generalized outbreaks involving large birds, especially of unpasteurized milk
numbers of people not necessarily associ- and unchlorinated water. Water can be con-
ated with each other and presenting with taminated by bird droppings in which the
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 7:27pm page 112

112 Chapter 9

organism is able to survive for several ment. This sometimes leads to abscess and
months at a temperature below 158C. Many haemorrhage, but as well as these local
infections are transmitted by pets, espe- effects, the parasite produces toxins. These
cially puppies and person-to-person trans- can lead to oedema, weakness and prostra-
mission can occur in a similar way. tion, ending fatally in the debilitated child.

Incubation period 110 days. The larger the Diagnosis is made by finding the egg in
dose of organisms ingested, the shorter the faeces, a giant among parasites (Fig. 9.1).
incubation period. The egg is indistinguishable from Fasciola
hepatica (see Section 9.4).
Period of communicability 27 weeks, but
person-to-person transmission is uncom- Transmission The eggs are passed in faeces
mon. either directly into water or are washed
there following rains, where they hatch and
Occurrence and distribution Children under liberate a miracidium, which must find a
2 years of age are most commonly infected snail of the genus Segmentina. Developing
in developing countries, immunity develop- first into a sporocyst, then a redia, numerous
ing to further infection in those over this cercaria are produced. On leaving the snail,
age. There is a worldwide distribution with the cercaria encyst on water plants that are
many of the cases in developing countries subsequently eaten raw by humans (Fig.
not being identified. There has been a 9.2). These plants include the water calthrop
progressive increase in Campylobacter (Trapa sp.), the water chestnut (Eliocharis
for no explainable reason. It is one of the tuberosa) and the water bamboo (Zizania
commonest causes of gastroenteritis aquatica). Beds of these water plants are
(Section 8.1). often grown in ponds fertilized by human
sewage, providing considerable opportunity
for transmission. Even if the foods are sub-
Control and prevention Proper cooking of sequently cooked, they are often first peeled
foodstuffs and control of pets are the main with the teeth so that cercariae are still
preventive methods. Wherever possible, swallowed.
water should be chlorinated and milk pas- A reservoir of infection is maintained in
teurized. pigs, sheep, cattle and other domestic herbi-
vores. Infection is particularly high in pig-
Treatment Oral rehydration. rearing areas. Humans also act as reservoirs.

Surveillance and investigation An outbreak of Incubation period 23 months.

Campylobacter should be investigated in
the same way as a food-poisoning outbreak Period of communicability is 12 months, but
and remedial measures taken around the animals act as a permanent reservoir.
Occurrence and distribution East Asia, espe-
cially China, Taiwan, Thailand, Borneo and
9.3 The Intestinal Fluke (Fasciolopsis) Malaysia, in some 15 million people.

Organism The large human fluke Fasciolop- Control and prevention is by the proper
sis buski. preparation and cooking of water plants.
Much can be done to reduce transmission
Clinical features The adult worm lives in the by regulating the use of human faeces as a
small intestines and produces damage by fertilizer. Domestic animals should be kept
inflammatory reaction at the site of attach- away from water plant cultivation ponds.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 7:27pm page 113

Food-borne Diseases 113

Ascaris Hookworm Trichuris Enterobius

Taenia H. nana
H. diminuta Balantidium

Sputum or faeces


Heterophyes Diphyllobothrium Paragonimus

F. hepatica & F. buski


cyst S. japonicum

S. mansoni S. haematobium
E. coil E. histolytica E. nana

0 10 30 50 100 m

Fig. 9.1. Parasite eggs found in faeces, urine and sputum. E. (nana), Endolimax; E. (coli), E. (histolytica),
Entamoeba; F. (hepatica), Fasciola; F. (buski), Fasciolopsis; H. (diminuta), H. (nana), Hymenolepis; S.
(haematobium), S. (japonicum), S. (mansoni), Schistosoma.

Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 7:27pm
Fasciola hapatica

Fasciolopsis buski

Chapter 9
(F. buski)
Redia in snail

Egg of Water calthrop Grasses
F. hepatica or Water chestnut
F. buski Water bamboo
(F. hepatica)

page 114
Fig. 9.2. The intestinal (Fasciolopsis) and sheep liver (Fasciola) flukes.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 7:27pm page 115

Food-borne Diseases 115

Treatment is with praziquantel 25 mg/kg found in Africa and the Western Pacific;
three times a day for 12 days. 2.5 million are probably infected in the
world, with up to 60% of the population in
Surveillance When a case is diagnosed, highly endemic areas.
other members of the family should be in-
vestigated and a common food source Control and prevention In known endemic
looked for. areas, careful control is required in the grow-
ing and consumption of water plants such as
cress. Animal faeces should not be used to
9.4 The Sheep Liver Fluke (Fasciola fertilize water plants. The close association
hepatica) of humans and sheep or other domestic
animals greatly increases the opportunity
Organism The sheep liver fluke Fasciola for infection.
hepatica. Less commonly F. gigantica.
Treatment Triclabendazole at 10 mg/kg
Clinical features The parasite has a single dose, which can be repeated after 12 h.
predilection for the liver, piercing the gut
wall and migrating through the liver sub- Surveillance Sheep should be examined at
stance to lie in the biliary passages. This regular intervals and treated.
migration and residence in the liver causes
extensive damage, leading to fibrosis and
cirrhosis. 9.5 The Fish-transmitted Liver Flukes

Diagnosis is made by finding the very large Organism The trematode fluke Opisthorchis
egg in the stool, which is almost identical to sinensis (previously called Clonorchis).
that of Fasciolopsis (Fig. 9.1).
Clinical features The adult fluke lives in the
Transmission The life cycle is similar to Fas- branches of the bile duct resulting in trauma
ciolopsis in that eggs passed in the faeces and inflammation. Dilation of the biliary
liberate a miracidium on contact with system causes a distortion of the liver archi-
water. The miracidium searches for and in- tecture, which can lead to biliary stasis, hep-
vades snails of the genus Lymnaea. After atic engorgement, fatty infiltration and
passing through sporocyst and redia stages, finally cirrhosis. O. sinensis is a risk factor
the cercaria encyst on grass or water plants for cholangiocarcinoma. Migration of the
(e.g. water cress). The normal life cycle is in flukes up the pancreatic duct can damage
sheep, humans becoming incidentally the pancreas leading to recurrent pancrea-
infected when contaminated water plants titis.
are eaten (Fig. 9.2). Cattle and goats also act
as reservoirs. Diagnosis The small operculated egg is
found on faecal examination (Fig. 9.1).
Incubation period Probably 23 months.
Transmission Humans are infected by eating
Period of communicability Not transmitted raw fish, which includes pickled, smoked or
from person-to-person. undercooked fish. Eggs passed in the faeces
develop into miracidia, which are swal-
Occurrence and distribution Worldwide lowed by snails of the genus Bulimus, Bi-
distribution in sheep-rearing areas, espe- thynia or Parafossarulus. These pass
cially the Andean highlands of Bolivia, through the sporocyst and redia stages in
Ecuador and Peru, the Nile delta region of the snail and produce free-swimming cer-
Egypt and northern Iran. F. gigantica is caria. Seeking out a suitable fish, cercaria
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 7:27pm page 116

116 Chapter 9

penetrate between the scales and encyst in Period of communicability Eggs may be
the flesh. The parasite also attacks dogs, passed for as long as 30 years, but reservoir
cats, rats and pigs, which form reservoirs of animals are also an important source of
infection (Fig. 9.3). human infection.

Occurrence and distribution Distribution is

very similar to Fasciolopsis, being found in
Incubation period Approximately 4 weeks. China, Japan, Korea, Taiwan, Thailand,

Eggs ingested
by snail

Bulimus or

Redia Cercariae encyst

under fish scales

Fig. 9.3. The fish-transmitted liver flukes, Opisthorchis sinensis, O. felineus, O. viverrini, H. heterophyes and
M. yokogawai.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 7:27pm page 117

Food-borne Diseases 117

Laos, Cambodia and Vietnam (lower include cough and chest pain. If the parasite
Mekong valley). Some 30 million people migrates to a site other than the lung, it can
suffer from the disease. cause CNS, liver, intestinal, genitourinary or
subcutaneous disease.
Control and prevention Control is by the
proper cooking of fish. Members of the
Diagnosis is by finding eggs in the sputum,
carp family (Cyprinidae), the so-called
or if swallowed, in the faeces (Fig. 9.1). Any
milk fish, are eaten raw as a delicacy.
case of haemoptysis without other signs of
They are grown in fish farms as part of
tuberculosis should have a sputum examin-
a system of aquaculture, fertilized by
ation, on which an acid-fast bacilli (AFB)
human faeces. Regulation of this practice
stain has not been used, as this destroys the
is required to reduce this unpleasant
infection. Other foods, such as fish paste
often added to food after it has been
cooked to improve the taste, are made Transmission The egg on reaching water
from raw fish and are a potent source of softens and a miracidium frees itself from
infection. the egg capsule and searches for a snail of
the genus Semisulcospira. Passing through
Treatment Treatment is with praziquantel the sporocyst and redia stages, the cercaria
25 mg/kg three times a day for 12 days. encysts in the gills and muscles of fresh-
water crabs and crayfish. Humans are
Surveillance When a case is identified, infected by eating uncooked, salted or
search should be made for the culprit food pickled freshwater crab (Eriocheir and Pota-
source. mon) or crayfish (Cambaroides), while an
There are a number of less common animal reservoir (mainly cats and dogs)
trematodes that have the same life cycle as helps to maintain the disease. The liberated
O. sinensis (Fig. 9.3). O. viverrini is found in metacercaria pass through the intestinal
Thailand and Laos where raw fish paste is a wall and penetrate the diaphragm to enter
favourite food additive. O. felineus occurs in the lung. Adults develop in the lungs to
Central and Eastern Europe, similarly caus- produce eggs, which are liberated into the
ing disease of the liver. As suggested by its sputum. Occasionally they find their way to
name, it is mainly a disease of cats, but unusual sites, the brain being particularly
humans can become infected. Heterophyes serious (Fig. 9.4).
heterophyes and Metagonimus yokogawai,
found in Asia and the Far East, do not attack
Incubation period 610 weeks.
the liver, but remain in the intestines. The
eggs of all of these flukes are very similar
(Fig. 9.1). Period of communicability Up to 20 years.

Occurrence and distribution P. westermani

9.6 The Lung Fluke disease is found mainly in China, other
parts of Asia, Africa and the Americas.
Organism Unique amongst all the hel- Closely related species are P. africanus
minths, the trematode Paragonimus wester- and P. uterobilateralis in West Africa, P.
mani selectively inhabits the lung. pulmonalis in Japan, Korea and Taiwan,
P. philippinensis in the Philippines, P. het-
Clinical features Foreign body reaction erotremus in Thailand and Laos, P. kellicotti,
to the parasite in the lung results in fibrosis, P. caliensis and P. mexicanus in Central
compensatory dilation and abscess forma- and South America. In all, it has been
tion. Haemoptysis is often an important calculated that some 30 million people
feature, mimicking tuberculosis. Symptoms suffer from the lung fluke.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 7:27pm page 118

118 Chapter 9

in sputum
or faeces Redia
in crab gills


Fig. 9.4. The lung fluke Paragonimus westermani.

Control and prevention Control is most Diagnosis is made by finding the egg in the
effectively achieved by ensuring that all faeces (Fig. 9.1). Sometimes, worm segments
crab and crayfish meat is properly cooked. (proglotids) are also passed.
Much can be achieved by teaching people
about the life cycle of this and other trema- Transmission The adult worm is found in
tode infections, stressing that all food must the intestines of humans, dogs, cats, foxes
be cooked and faeces disposed of properly. and bears, and a number of other mamma-
Spitting should be outlawed. lian hosts. Eggs are passed in the faeces,
which on contact with water liberate a cor-
Treatment is by praziquantel 25 mg/kg three acidium, which is ingested by a copepod
times a day for 2 consecutive days. Alterna- (Cyclops and Diaptomus). The coracidium
tively, triclabendazole 10 mg/kg, repeated in develops in the copepod to a larval form, a
12 h, can be used. procercoid, which when eaten by a fresh-
water fish finds its way into the muscles
Surveillance It is a focal disease so that iden- and develops into a plerocercoid. When the
tifying a case will often lead to a foci of raw or improperly cooked fish is eaten,
infection and preventive action can then be the liberated plerocercoid attaches itself
instituted. to the intestinal wall and develops into an
adult tapeworm (Fig. 9.5).

9.7 The Fish Tapeworm Incubation period 36 weeks.

Organism The large tapeworm Diphyllobo- Period of communicability Humans can con-
thrium latum. tinue to liberate eggs into the environment
for many years, but most of the infective
Clinical features The presence of such a source is from the animal reservoir.
large worm (10 m or more) in the intestines
can consume a considerable quantity of Occurrence and distribution The parasite is
nutrients, but the main pathology is due to found in the cooler parts of the world,
its selective absorption of vitamin B12, around lakes of Europe, America, China
resulting in a megaloblastic anaemia in the and Japan. It is also found in indigenous
host. tribes living in the Arctic and sub-Arctic
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 7:27pm page 119

Food-borne Diseases 119

Gravid segment

Eggs passed
in faeces

Plerocercoid in fish

hatched in

Procercoid in

Fig. 9.5. The fish tape worm Diphyllobothrium latum.

regions. It is a disease of some 13 million Treatment Niclosamide as a single dose of

people. 2 g or praziquantel as a single dose of
510 mg/kg.
Control and prevention Control is by
ensuring that fish are properly cooked.
Deep-freezing fish will also kill the parasite. 9.8 The Beef and Pork Tapeworms
Sanitation will decrease the human cycle
and animal faeces should be prevented Organism Taenia saginata, the beef tape-
from entering water sources. worm and T. solium the pork tapeworm.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 7:27pm page 120

120 Chapter 9

Clinical features The adult worm of both also been found that birds feeding on sewage
species can live in the intestines producing can carry eggs for long distances and then
little pathology, being diagnosed often by deposit them on pasture land. Flies might
accident. It does, however, share the food have a place in transmission. The eggs de-
supply of its host so that when intake is velop into cysticerci in the muscles,
inadequate, debility can occur. The serious favouring the jaw, heart, diaphragm, shoul-
problems are due to the Cysticercus cellulo- der and oesophagus. Humans acquire the
sae (from T. solium). The cysts die and cal- disease by eating improperly cooked beef
cify, those in the brain being a common or pork containing the cysticercus.
cause of epilepsy or mental disorder. Both the beef tapeworm (T. saginata)
and the pork tapeworm (T. solium) have
Diagnosis is made by finding the proglottids the same life cycle except that the intermedi-
(worm segments) in the faeces, the patients ate stage, the cysticercus of T. solium, can
often making their own diagnosis. It is very also occur in humans. This happens by
important to distinguish between T. sagi- swallowing eggs directly, either by auto-
nata and T. solium in view of the danger of infection, from eggs in food or water or
inducing cysticercosis. T. saginata has 18 through sewage contamination. Also any
30 compound branches of the uterus on each gastric disturbance that might cause the re-
side whereas T. solium has only 812 (Fig. gurgitation of proglottids into the stomach
9.6). (including improper treatment) can lead to
the liberation of vast quantities of eggs, with
Transmission The adult worm lives in the the result that cysticerci are produced any-
small intestine of man and as it matures, where in the body including the brain, orbit
gravid segments break off and are passed in and muscle.
the faeces. Cattle or pigs inadvertently eat
the proglottids (mature segments) or the dis- Incubation period 814 weeks.
charged eggs contaminate the pasture. Alter-
natively, the animal can become infected by Period of communicability Adult worms
drinking water polluted by sewage. It has can live for as long as 30 years, their eggs

T. saginata

T. solium

in muscle


Fig. 9.6. The tape worms Taenia solium and T. saginata.

Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 7:27pm page 121

Food-borne Diseases 121

contaminating the environment and in ing in official abattoirs, with meat inspec-
T. solium a direct threat to any other person. tion, can prevent the dissemination of
infected meat. Condemned carcasses must
Occurrence and distribution These are the be burnt.
commonest and most cosmopolitan of all
the tapeworms, with a worldwide distribu- Treatment for both worms is with niclosa-
tion in beef- and pork-eating areas, espe- mide 2 g as a single dose. Alternatively, pra-
cially in the tropical belt and Eastern ziquantel as a single dose of 510 mg/kg can
Europe. Over 60 million people are thought be given. Praziquantel at a dose of 50 mg/kg
to be infected. for 15 days can be used for cerebral cysticer-
These two worms are found in areas of cosis in conjunction with corticosteroids, as
beef and pork eating where there is a ready an in-patient.
transmission cycle in operation. Finding the
worm in humans means that it is probably Surveillance Where a localized cycle of in-
reasonably common in that area, whereas fection is occurring, investigation may
other places where beef and pork eating are reveal a sewage leak or other source of con-
just as much part of the usual diet, they are tamination that could easily be rectified.
not found. T. saginata is increasing in
Europe probably because of human sewage
contamination of animal drinking water. T. 9.9 Trichinosis
solium is common in Mexico, Chile, Africa,
India, Indonesia and Russia. Organism Trichinella spiralis (Fig. 9.7),
T. nelsoni, T. nativa, T. britovi and T. pseu-
Control and prevention The main means dospiralis, nematode worms.
of control is the proper cooking of meat.
The underdone steak or joint of meat where Clinical features The severity of the disease
internal temperatures are not high enough depends upon the dose of larvae that
to kill the cysticercus are common ways have encysted in the tissues. During the
in which transmission can still take place second week of infection, there is headache,
despite cooking. Proper control of slaughter- insomnia, pain, dyspnoea and pyrexia with

Human eats
uncooked meat Lion

Encysted larva

Fig. 9.7. Trichinella spiralis.

Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 7:27pm page 122

122 Chapter 9

oedema of the orbit and eosinophilia. If the animals are infectious, probably for the rest
symptoms are sufficiently severe, death can of their life due to repeated doses of
result; otherwise, once the attack is over, the infecting nematodes.
cysts cause no further trouble, gradually die
and calcify. Occurrence and distribution Approximately
40 million people of the worlds population
Diagnosis is made by muscle biopsy of the are affected although trichinosis commonly
deltoid or thigh muscles where the encysted occurs as a localized outbreak with a group of
larvae are found. people all contracting the disease at the same
time. A classic example is for a wild pig to be
Transmission The life cycle is a simple one, killed and cooked over a fire by turning it on a
encysted larvae in the muscles are eaten by spit. By this means, only the outside meat is
another animal and the liberated larva de- well cooked and inside, the temperature has
velops into an adult to produce numerous not been sufficient to kill the larvae. Out-
new larvae, which are then carried to all breaks in the industrialized countries and in
parts of the body in the circulation. Only the urban areas of developing countries are
the larvae that reach striated muscle survive, commonly caused by eating sausages, espe-
the diaphragm, tongue, throat, eye and cially of the salami type.
thorax being the favoured sites.
In the different climatic zones of the Control and prevention All meat for human
world where different groups of animals consumption should be inspected. The cal-
live off each other, several transmission cified cysts can be detected with the naked
cycles have evolved. In Africa, the warthog eye and by cutting into the muscle. Where
and the bushpig form the vital link in the an outbreak occurs, such as with eating
cycle. Being the favoured prey of lions and sausages, the source should be investigated
leopards, these carnivores, with the hyenas and food hygiene practices enforced.
and jackals that finish off the remains, All meat must be properly cooked until
become infected. The general scavenging there is no redness in any part of the joint.
nature of the warthog and pig inadvertently Cooking slowly for a long time is preferable
eating the remains of dead animals allows to cooking quickly or on an open fire where
the cycle to be completed. Humans come in the outside gets overcooked while the inside
as intruders, a dead end to the cycle when remains almost raw. Deep freezing of meat
they feast on a recently killed bushpig. for 20 days or irradiation can kill the cysts.
In Europe and Asia, the rat is the reser-
voir of infection, but by its scavenging Treatment is symptomatic with steroids.
nature, the pig acquires infection and when Mebendazole or albendazole should also be
cooked on a spit or otherwise eaten in an given for 4 days.
improperly cooked way, humans become
infected. Sausages made from food scraps or
hamburgers contaminated with bits of pork Surveillance Where an outbreak occurs, the
can be potent sources. In the Arctic, the seal participants at the feast will all start having
and polar bear are involved in the transmis- symptoms at much the same time. By
sion cycle; the latter acquires very high levels counting back 2 weeks from these cases, the
of infection. The death of some Arctic ex- source of infection can be localized.
plorers has been attributed to killing and
eating polar bears infected with trichinosis.
9.10 Other Infections Transmitted
Incubation period 815 days. by Food

Period of communicability Not transmitted A number of other infections are also trans-
from person-to-person, but once infected mitted by food although their principal
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 7:27pm page 123

Food-borne Diseases 123

method of transmission is by other means. also be transmitted by food, especially that

Any of the faecaloral diseases covered in grown in soil such as root crops and vege-
Chapter 8 can be transmitted this way ba- tables. Hydatid disease (Section 17.2) and
cillary dysentery, typhoid, hepatitis A, Giar- Toxoplasma (Section 17.5) can be acquired
dia and El Tor type cholera being spread by through food. Brucellosis (Section 17.6) is
eating salad vegetables, raw fish or other often transmitted in goats milk or cheese
food. The parasitic worms transmitted by made from it, while anthrax (Section 17.7)
soil contact, Trichuris, Ascaris, Strongy- can rarely be caught by eating the meat of a
loides and the hookworms (Chapter 10) can cow that has died from the disease.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 25.10.2004 7:15am page 124

Diseases of Soil Contact

The soil can be a source of infection for 10.1 Trichuris (Whip Worm)
several diseases particularly those caused
by nematodes and the bacterial infection, Organism The nematode Trichuris tri-
tetanus. Transmission can either be direct chiura, which has a characteristic egg
from contamination with the soil as with (elongated and with a knob at each end)
tetanus bacilli, by swallowing nematode when seen in faecal specimens (see Fig. 9.1).
eggs, or the larvae can penetrate the skin
when it comes into contact with the soil.
Developmental stages often take place in Clinical features A large number of people
the soil, which becomes a necessary envir- carry this infection quite asymptomatically,
onment for the life cycle. The promotion of but it has been realized that the debilitating
personal hygiene and preventing contamin- effect of this infection, especially in children
ation of soil through sanitation are the main in developing countries, can be quite consid-
methods of control for the nematode infec- erable. This is especially the case when tri-
tions and vaccination for tetanus. churiasis is associated with other common
Since there is a common mode of trans- infections, the combined effect leading to
mission for the three main nematode much ill health. When there are over 16,000
infections (Trichuris, Ascaris and the hook- eggs/g of faeces, a chronic bloody diarrhoea,
worms), they nearly always go together. As a anaemia, rectal prolapse and occasionally,
result, if the person is infected with one appendicitis can result. These infections
nematode, he or she is likely to have all tend to occur when the child eats earth
three infections. It is this combined effect (pica), which can be a result of iron defi-
that causes considerable morbidity in chil- ciency. Heavy infections are probably po-
dren in developing countries and if one tentiated by nutritional deficiencies,
looks again at Table 1.1, it will be noticed especially of zinc.
that having all three infections bring their
importance in terms of DALYs to the 12th Diagnosis The characteristic egg is easily
position. seen in a fresh faecal specimen (Fig. 9.1).

Q R. Webber 2005. Communicable Disease Epidemiology and Control, 2nd edition (Roger Webber)

Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 25.10.2004 7:15am page 125

Diseases of Soil Contact 125

Transmission The egg develops in the soil 10.2 Ascaris

and when swallowed directly or as a con-
taminant of food, it changes into an adult in Organism The nematode worm Ascaris lum-
the caecum. Eggs are most commonly carried bricoides.
on the fingers or swallowed when the fingers
are licked. The soil is readily contaminated
Clinical features The fertile egg, when
from indiscriminate defecation, especially
swallowed, hatches in the stomach and the
where the faeces are not buried or a latrine
larva penetrates the intestinal mucosa to
used. Villages often have traditional places
enter the blood stream, passing through the
for defecation, thereby increasing the poten-
venous and pulmonary circulations to
tial for infection than when such customary
the lungs where it breaks through the
places are not the rule.
alveolar wall to emerge in the bronchioles.
Migrating up to a main bronchus, it ascends
Incubation period It takes 23 months for the trachea and is swallowed back into
eggs to be found in the faeces after eggs are the gastro-intestinal tract. By the time it
first swallowed, with symptoms occurring reaches the intestines, it has developed
about 1 month after ingestion. into an adult, the fertilized female laying
eggs into the excrement (Fig. 10.1). This
Period of communicability Persons can common intestinal parasite can occur in
remain infected for several years if not considerable numbers without causing
treated, continually contaminating the en- any symptoms and is often found when a
vironment if they have poor defecating routine stool examination is performed.
practices. When the larvae pass through the lungs,
pneumonitis and possible haemoptysis
can occur, otherwise the sheer number
Occurrence and distribution It is a very of worms can cause intestinal obstruction
common parasite (perhaps 540 million or blocking of vital structures, such as the
people are infected) and causes far more common bile duct. Where nutrition is mar-
disability than previously thought to be the ginal, the loss of nutrient can be sufficient
case (see Table 1.1). Most of the infection to tip a child into malnutrition. It has
with debilitating consequences occurs in been calculated that 25 worms can produce
developing countries, but the parasite is a loss of 4 g protein daily from a diet contain-
found worldwide. ing 4050 g protein. Deficiency of vitamins
A and C can also occur. Academic perform-
Control and prevention Washing hands ance in school decreases with heavy Ascaris
before having food and the careful prepar- infections.
ation of food are the main methods of con-
trol. Vegetables and root crops, in particular, Diagnosis Direct smear examination of the
must be washed carefully to remove all stool is sufficient for diagnosis (Fig. 9.1).
earth. Parents should discourage their chil- The egg has a strong outer coat, which is
dren from eating earth and have anaemia stained brown from bile pigments, thus dif-
treated with iron supplementation. Proper ferentiating it from hookworm eggs, which
sanitation should be installed to prevent are of a similar size.
soil contamination.
Transmission The eggs are not infective until
Treatment is with mebendazole or albenda- they have undergone development in the
zole. (See under hookworm for dosage.) soil for 12 weeks. They require warmth
and moisture to develop and will remain
Surveillance Routine stool investigation of viable in the soil for a considerable period
children admitted to hospital will show a of time awaiting the right conditions.
number of nematode infections. The infective larva goes through stages of
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 25.10.2004 7:15am page 126

126 Chapter 10

Eggs swallowed
in water or
contaminated food

Eggs passed
in faeces

Development in soil
12 weeks

Fig. 10.1. Ascaris lumbricoides life cycle.

development within the egg casing and if Incubation period 1020 days
swallowed, infection occurs. Eggs are
normally swallowed in polluted water, on Period of communicability From 2 months
vegetables that have been washed with pol- after infection up until about 1 year.
luted water or by swallowing earth directly.
Eggs are passed during indiscriminate Occurrence and distribution Ascaris is a
defecation. very common nematode infection found in
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 25.10.2004 7:15am page 127

Diseases of Soil Contact 127

all parts of the world and in all strata of the suggest a diagnosis of tuberculosis. The
society (1000 million people are estimated main effect results from the adult worms
to be infected). Children aged 37 years have attaching to the intestinal wall where they
the highest prevalence. invaginate a piece of mucosa, extracting
blood and nutrients. Anaemia results from
Control and prevention is with personal hy- frank blood loss and depletion of iron re-
giene, food hygiene and proper sanitary fa- serves. The degree of anaemia produced
cilities. The egg is extremely resistant, being depends upon the worm load and one esti-
unaffected by cold, drying and disinfect- mate calculates that 60120 worms (meas-
ants. A temperature of 438C or higher is re- ured by 30 worms excreting 1000 eggs/g
quired to kill them; therefore, any faeces) will result in slight anaemia,
composting process using human excreta whereas over 300 worms (10,000 eggs/g
must maintain this temperature for at least faeces) will cause severe anaemia. The
1 month (Fig. 1.2). newly established worm may produce sev-
eral bleeding points and if the sexes are un-
Treatment is with pyrantel pamoate or balanced, the search for a mate can result in
mebendazole. (See under hookworms for increased activity. These effects will natur-
dosage.) ally be most profound in the growing child
and the pregnant woman. It is the combin-
ation of malaria, malnutrition and other
Surveillance As with Trichuris infection, it
intercurrent infections, in combination
is worth doing routine stool examination on
with hookworms, that accentuate the ser-
children admitted to hospital as any
iousness of this infection.
lessening of the worm burden will improve
Diagnosis Eggs are found in faecal examin-
ation. They are oval and have colourless thin
walls differentiating them from Ascaris,
10.3 Hookworms which has a thick brown exterior (Fig. 9.1).
The eggs of the two species are identical and
Organism Ancylostoma duodenale and only the adults can be differentiated, mainly
Necator americanus cause the two common from their characteristic mouthparts (Fig.
hookworm infections of humans. 10.2).

Clinical features The infective (filariform) Transmission The eggs are passed in the
larvae directly penetrate the skin and mi- faeces and hatch within 2448 h to liberate
grate to a blood vessel or lymphatic vessel an intermediate (rhabditiform) larva. After
from where they are carried in the circula- some days, it moults to produce the infective
tion to the lungs. In the lungs, they break out filariform larva. In suitable conditions of
of the alveoli, find their way up the trachea moist, warm but shaded soil (308C for N.
and enter the gastro-intestinal tract. The americanus and 258C for A. duodenale),
adult stage is finally reached in the duode- this stage of the larva can live for several
num or jejunum, where the male and female months awaiting the opportunity to pene-
worms mate and produce eggs (Fig. 10.2). trate through the skin of a new host. (The
Despite its extensive journey through ingested third stage larvae of Ancylostoma
the human body, like Ascaris, the hook- can also produce infection.) The larva com-
worms are very well adapted to their host monly penetrates the foot of the unshod
and only produce symptoms when heavy person and intense infection can occur
infections occur. The passage through the where areas of beach or bush are demarcated
skin can result in a transient urticaria for defecation purposes. Non-human hook-
(ground itch), while that through the lungs worms can also penetrate the skin and pro-
pneumonitis and haemoptysis. Occasion- duce cutaneous larva migrans (see Section
ally, the haemoptysis can be sufficient to 17.4).
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 25.10.2004 7:15am page 128

128 Chapter 10

Necator americanus Ancylostoma


Larvae pierce skin


Rhabditiform larva

Filariform larva
810 days

Fig. 10.2. The hookworm life cycle and identification.

Incubation period 810 weeks. distributed, being found extensively

throughout the tropical belt and well north
Period of communicability From about of the Tropic of Cancer in America and the
2 months after infection to up to 5 years; gen- Far East. A. duodenale is found in the Far
erally 1 year. East, the Mediterranean and the Andean
part of South America (Fig. 10.3). It has
Occurrence and distribution N. ameri- been suggested that N. americanus was
canus, despite its name, is the more widely carried from Africa to the Americas as a
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 25.10.2004 7:15am page 129
Diseases of Soil Contact 129
, Ancylostoma duodenale.
, Necator americanus,
Fig. 10.3. Distribution of the hookworms.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 25.10.2004 7:15am page 130

130 Chapter 10

result of the slave trade. Altogether, some and degree of pathological change and
720 million of the world population have hence the clinical features.
hookworms. An infective filariform larva develops
in warm moist soil, penetrates the skin,
Control and prevention is by use of pit and follows the same internal route as the
latrines or other methods of sanitation. The hookworms to the final resting site in the
wearing of footwear effectively prevents small intestine. However, no eggs are passed
penetration by the larvae. The open sandal to the outside, only rhabditiform larvae are
type of footwear often worn (thongs, flip- found in the faeces. If environmental condi-
flops) is not effective and infection can read- tions are favourable, a free-living cycle takes
ily occur. Mass treatment can be given to place, with the rhabditiform larvae develop-
reduce the parasite load, but without health ing into adults in the soil. This cycle can be
education and the proper use of latrines, it repeated and the number of potential para-
will only produce a temporary improve- sites increases with each completed cycle. If
ment. conditions change, filariform larvae are pro-
duced or if unsuitable for the free-living
Treatment A number of drugs are effective cycle, then the rhabditiform larvae passed
in treatment. Albendazole 400 mg single in the faeces change directly into filariform
dose, mebendazole 500 mg single dose or larvae. Direct autoinfection can also occur,
100 mg twice a day for 3 days, levamisole with the rhabditiform larvae penetrating the
2.5 mg/kg daily for 3 days, oxantel 10 mg/kg intestinal mucosa to enter the blood stream
daily for 3 days or pyrantel pamoate 10 mg/ without ever leaving the body. Swallowed
kg daily for 3 days. The treatment should be larvae can as well complete their develop-
repeated 12 weeks after the previous treat- ment by entering the body through the intes-
ment. There is concern that resistance tinal mucosa (Fig. 10.4). Achlorhydria, as
could develop as in veterinary practice; occurring in malnutrition, makes infection
therefore, combinations, such as mebenda- easier by the oral route.
zolelevamisole or pyranteloxantel, have It is the abnormal cycle of autoinfection
been advocated. In the debilitated child, that can lead to wandering larvae producing
supporting therapy will need to accompany linear urticaria (larva currens) or eosinophi-
deworming. Iron supplementation, or in the lic lung. Larva currens can persist for
severe case blood transfusion, will be re- periods in excess of 40 years. Immunocom-
quired to treat anaemia. promised persons, such as those with HIV
infection or malignant disease, can get wide-
spread dissemination of worms with serious
Surveillance When mass treatment is
planned, an initial survey will delineate
the size of the problem. Follow-up spot
checks of individual stool specimens can Diagnosis is made by finding the rhabditi-
be made to assess progress. form larvae in the faeces or in the aspirate
of the duodenal string test. Serological tests
can be of value, but where positive, repeat
10.4 Strongyloides stool examinations should be made.

Organism The nematode Strongyloides ster- Transmission is from direct penetration

coralis, which is morphologically similar to of the skin by infective stage (filariform)
the hookworms. Far less common is larvae or being swallowed from contamin-
S. fulleborni. ated food, water or fingers. Soil is cont-
aminated by faeces deposited directly on
Clinical features There are several alterna- the ground or inadequately buried.
tive cycles of development and it is the
type of cycle which determines the nature Incubation period 24 weeks.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 25.10.2004 7:15am page 131

Diseases of Soil Contact 131

Infective filariform
larva pierces skin

larva passed
in faeces

adults in soil

Fig. 10.4. Strongyloides stercoralis life cycles.

Period of communicability Due to autoinfec- Occurrence and distribution Mostly found in

tion and long-living adult worms, once the warm wet tropics, the parasite also
infected, a person can continue to produce occurs in temperate areas. S. fulleborni has
larvae for 3040 years. only been reported from Africa and Papua
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 25.10.2004 7:15am page 132

132 Chapter 10

New Guinea. Adults, rather than children, Transmission The organism is introduced
manifest the clinical symptoms, either ac- into a wound from soil, dust or animal
quiring the parasite when they were chil- faeces. Cutting the umbilical cord with an
dren or in adult life. unsterile instrument, such as a bamboo
knife, or traditional practice of treating the
Control and prevention All the methods ap- umbilical stump are potent methods of caus-
plicable to the other soil-based nematode ing neonatal tetanus. These can involve
infections are applicable, such as personal covering the stump with an unsterile dress-
hygiene, careful washing and preparation of ing or customary practice of using a cow
vegetables and the wearing of adequate foot- dung or earth poultice.
wear. Soil contamination can be prevented The bacillus is found naturally in the
by good sanitation. soil where it survives in anaerobic condi-
tions. Many types of soils have been found
Treatment is the same as for hookworm in- to harbour C. tetani, but it is more common
fection or any of these treatments can in cultivated soils, especially those
be combined with ivermectin or diethylcar- manured with animal faeces. The organism
bamazine (DEC, see under filariasis, Section is found in horse and cattle dung and less
15.7). commonly in pig, sheep and dog faeces. It is
occasionally found in human excreta, par-
ticularly in people associated with animals.
The vegetative form of the organism is
10.5 Tetanus
sensitive to antibiotics, disinfectants and
heat, but as a spore, it is resistant to all but
Organism The bacillus Clostridium tetani, the super-heated steam of an autoclave.
which is a Gram-positive rod with spherical, Indeed, the spores of C. tetani are used to
terminal spores, giving it a characteristic test the effectiveness of the sterilizing pro-
drum-stick appearance. cess because if it cannot survive, then no
other organism can (apart from anthrax).
Clinical features Infection results from the Spores can survive for considerable
organism entering an abraded surface, such periods of time, but when they enter a
as a cut or scratch. It favours anaerobic con- wound or umbilical stump in which there
ditions, liberating toxin, which produces is a low oxygen reduction potential, they
severe muscle spasms. It is a serious condi- release the vegetative form, which grows
tion in the neonate due to infection of the anaerobically and infection takes place. It
umbilical cord stump. is the moist, contaminated umbilical stump
The adult presents with muscle spasm or the traumatized wound that provides
and rigidity. There may be trismus, in which suitable conditions.
the muscles of the jaw and later the back The replication of the organism is not
become rigid leading to lock jaw and important, but toxin is produced that can
opisthotonos. Muscle spasms can produce have a profound effect out of all proportion
the characteristic half smile, half snarl of to the initial infection. The exotoxin has a
risus sardonicus or generalized opisthoto- high affinity for nervous tissue and as little
nos. These spasms are initiated by external as 0.1 mg is sufficient to kill a person. Toxin
stimuli, such as touch or attempts at intub- is absorbed along the nerves, reaching the
ation, and every care must be taken to pro- spinal cord where the generalized features
tect the patient from such stimuli. Neonatal of the disease are produced.
tetanus generally presents as a difficulty in
sucking; then the rigidity of muscles and Incubation period is from 421 days, but
generalized convulsions develop. It usually most cases occur within 14 days. There is a
commences within 510 days of birth. relationship between incubation period and
severity, with an incubation period of less
Diagnosis is on the clinical presentation. than 9 days having a mortality of 60% and
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 25.10.2004 7:15am page 133

Diseases of Soil Contact 133

more than 9 days 25% mortality. This is due children or adults who have not been vac-
to the dose of the toxin. cinated before should be given two doses of
adsorbed tetanus toxoid (0.5 ml), separated
Period of communicability Not transmitted by 4 weeks and a third dose of 1 ml 6 months
from person-to-person directly or indirectly. later. Booster doses every 10 years will
maintain a high level of immunity.
Occurrence and distribution Tetanus occurs In the event of a person being injured
worldwide, with higher rates in Africa, Asia and presenting with a contaminated wound
(especially Southeast) and the Western Pa- that could produce tetanus, the following
cific. Neonatal tetanus is a serious problem action should be taken clean out the
in Africa, especially where birth practices wound, give penicillin, then the following:
are rudimentary. There is an association
with agricultural areas where animal excreta . If the person has been fully vaccinated in
is commonly used for fertilizing the soil, as a the past, a booster dose of toxoid is re-
fuel or as a plaster on the walls of houses. quired only if this is more than 10 years
Domestic animals either share the same ago.
house as their owners or live in such close . If there is no record of tetanus vaccination
proximity that their faeces contaminate the or protection is in doubt, then give the first
surrounding soil. dose of tetanus toxoid plus 250 units of
human tetanus immune globulin or 1500
Control and prevention The aim should units of equine tetanus antitoxin,
always be to prevent tetanus with vaccin- following a test dose. Instruct the person
ation and good hygiene practices, especially to return at 4 weeks and then 6 months to
with the newborn. complete the course of vaccination.
The most effective way of preventing
neonatal tetanus is the vaccination of all Good birth practices are important in pre-
women of childbearing age. The policy is to venting neonatal tetanus and several coun-
give all women a lifetime total of five doses of tries have developed systems for contacting
tetanus toxoid. This is preferable to waiting traditional birth attendants (TBAs) and
until the woman becomes pregnant because giving them courses of instruction. Pre-
many women do not attend antenatal clinic, packed sterilized blades for cutting the cord
especially those who are likely to use trad- can be given and iodine, spirit or similar
itional applications to the umbilical cord antiseptic provided to apply to the cord
stump. The effectiveness of various strat- stump. Where there is no system of TBAs
egies is shown in Fig. 10.5. Women should, but delivery takes place at home with the
therefore, be given their first dose of tetanus assistance of mother or other female
toxoid at first contact or as early as possible relative, then an instruction sheet in the
during pregnancy. The second is given local language can be given to the pregnant
4 weeks later and the third 612 months woman when she attends the antenatal
after the previous dose or during the clinic or at any other contact with the health
next pregnancy. Doses four and five are services. Figure 10.6 illustrates several strat-
given at yearly intervals. Where a woman egies for reducing neonatal tetanus as tried
has a certificate to say that she has received out in rural Haiti.
vaccination as a child, then she only needs to
have two doses during the first pregnancy Treatment Tetanus is a self-limiting disease
and one more before or during the second and if the patient can be kept alive for
pregnancy. 3 weeks, then complete recovery should
Infants are given tetanus toxoid as part take place, but keeping the patient alive
of their childhood vaccination programme for this period of time is the problem. It is
as DTP at 6, 10 and 14 weeks of age. An the toxin that is causing the symptoms
additional booster dose of DTP can be and once this is fixed in the nerves, only
given at 18 months to 4 years of age. School support can be given to the patient to
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 25.10.2004 7:15am page 134

134 Chapter 10


A 3 DPT in infancy

B 3 DPT in infancy and

1 DPT in 2nd year

C As in B plus 1 DT
at school entry

D As in C plus 1 DT
at school leaving

E 2 DT at school

F 3 DT at school

G 5 TT as recommended
by EPI

0 2 4 6 8 10 20 30 40

Age (years)

Fig. 10.5. Expected duration of tetanus immunity after different vaccination schedules. DPT, diphtheria,
pertussis and tetanus; DT, diphtheria and tetanus; TT, tetanus toxoid; EPI, Expanded Programme of
Immunization. (Reproduced by permission of the World Health Organization, Geneva.)

1940 1948 262.21

1949 1955 220.52

1956 1962 136.63

1963 1966 78.54

1967 1968 355

1969 1970 56

1971 1972 07

0 50 100 150 200 250 300

Mortality rates per 1000 live births

Fig. 10.6. Neonatal mortality per 1000 live births in rural Haiti, 19401972, from a retrospective study of
2574 mothers. 1, before national programme for training TBAs; 2, national programme for training TBAs; 3,
hospital treatment for tetanus, training of TBAs by hospital nurse; 4, immunization of pregnant women in
hospital clinics; 5, immunization of women in market places by hospital team; 6, immunization after door-
to-door invitation by community workers. (Reproduced by permission of the World Health Organization,
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 25.10.2004 7:15am page 135

Diseases of Soil Contact 135

maintain respiration, urinary output and be eradicated because C. tetani will always
nutrient intake. The patient is sedated to remain in the environment) as a health
reduce spasms and in all ways, expertly problem by 2005, by intensified vaccination,
nursed. The contaminated wound must be the promotion of clean delivery practices
cleaned and excised, antitoxin or immuno- and a programme of school vaccination.
globulin administered and penicillin given High-risk areas need to be identified from
to kill any remaining organisms. Sadly, the a knowledge of the birth practices, lack
mortality from tetanus is high 40% in of health facilities or preponderance of
adults and 90% in neonates, so the objective cases. All children at school entry should
should always be to try and prevent it. be required to bring their vaccination
certificates with them and if these are
Surveillance WHO has set out to eliminate not adequate, receive a course of tetanus
maternal and neonatal tetanus (it can never toxoid.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:47am page 136

Diseases of Water Contact

Water is an important medium for the trans- the disease until adulthood. Passing blood
mission of disease processes. Normally it is in the urine is one of the first signs of S.
through drinking water, which has become haematobium disease, but because it is so
polluted by faecal material, that infection is common in the local area, it is generally
transmitted, or through water used to wash ignored, with boys assuming it quite normal
food and the food subsequently consumed. that they should have period bleeding like
It also serves as a medium for fish or other girls do. Infection and egg output increases
organisms to live, which may carry a para- up to about 15 years of age and then de-
sitic stage that is transmitted when they are clines. Individuals vary in their response,
eaten (as covered in Chapters 8 and 9). In with some persons acquiring heavy infec-
this chapter, we look at one important dis- tions and developing severe pathological
ease and one almost eradicated that are changes, while others have only minor
transmitted by contact with water, in symptoms. The more serious manifestations
which the intermediate stages are free are liver fibrosis, portal hypertension and
living. Minimizing water contact is, there- obstructive urinary problems, with the path-
fore, the best method of control if it can be ology depending upon the species of para-
applied. site and the number of eggs deposited in the
tissues. Infections with S. mansoni and S.
japonicum lead to intestinal and liver
11.1 Schistosomiasis damage, while that with S. haematobium
results in bladder complications, including
Organism The main parasites are Schisto- bladder cancer.
soma haematobium, S. mansoni and S.
japonicum. Other species, such as Diagnosis is made by finding the charac-
S. intercalatum and S. mekongi do occur, teristic eggs (Fig. 9.1) of S. haematobium in
but they are only important in well- the urine and those of S. mansoni and S.
defined areas and their epidemiology and japonicum in the faeces or from a rectal
control are similar to one of the three main snip. Urine samples are best collected bet-
types. ween 1100 and 1500 h when egg output is at
a maximum. Leaving the urine to stand, cen-
Clinical features Infection normally starts trifuging it, or passing it through a filter in-
in childhood, with often very little signs of creases the chance of finding eggs. While the

Q R. Webber 2005. Communicable Disease Epidemiology and Control, 2nd edition (Roger Webber)

Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:47am page 137

Diseases of Water Contact 137

qualitative diagnosis is required in the indi- snail using geotactic and phototactic behav-
vidual case, quantitative estimates are more iour, homing-in on a chemical substance
valuable in epidemiological investigations. miraxone inadvertently liberated by the
In S. haematobium, the simplest method is snail. The miracidium must penetrate a
to pass 10 ml of urine through a filter in a snail within 812 h, but their chance of suc-
Millipore holder. The paper or membrane is cess decreases with age. Some 40% of snails
taken out, dried and stained with ninhydrin are infected at a distance of 5 m in still water,
and the eggs counted directly. Immuno- but where the water is flowing, similar infec-
logical methods, indirect fluorescent anti- tion rates can occur at a far greater distance.
body test (IFAT) and enzyme-linked Normally, infection occurs in water flowing
immunosorbent assay (ELISA) test have at 10 cm/s or less. Even after the rigours of the
also been developed for schistosomiasis, journey when miracidia have entered the
but they only indicate recent or past infec- correct species of snail, many are inactivated
tion, so eggs must be looked for to confirm and only a small proportion develop into
the diagnosis. They are useful in epidemi- sporocysts. This is determined by the part
ological surveys for rapidly defining the of the snail entered and immunity to re-
extent of the infected area. infection developed by the snail (Fig. 11.1).
Pathology is related to the number of Cercariae are stimulated by light to
worms, which can be measured by the emerge from the snail when the ambient
number of eggs produced. In S. haemato- temperature is between 108C and 308C. Cer-
bium, the production of 50 eggs/ml of urine carial emergence increases as daylight pene-
or above is regarded as the level of severe trates the watery environment producing a
pathology and much of present day control peak for S. mansoni at 1200 noon and for S.
strategy is aimed at reducing the egg count haematobium, mid-to-late afternoon. With
below this level. S. japonicum, the stimulus produced by
light is delayed and maximal cercarial liber-
Transmission Infection results from cer- ation occurs at 2300 h. The number of cer-
cariae directly piercing the skin of a person cariae issuing from a snail can be immense,
when they go into the water. On penetrating in the order of 10003000/day, but this
the subcutaneous layer of the host, the cer- depends upon the species and relative size
caria becomes a schistosomule, migrates to of the snail. Where more than one miracid-
the lungs and finally develops into an adult ium has penetrated a snail, there is depres-
in the portal vessels of the liver. Both male sion of cercarial production; this may also
and female worms are required so that occur if the snail is host to other trematode
pairing can take place prior to migration to infections. Cercarial output is greatest in S.
the final destination in the mesenteric or mansoni, less in S. haematobium and least
vesical plexus. Adult worms can live for of all in S. japonicum. Cercariae survive for
2030 years, but are active egg producers 24 h, but their greatest chance of penetrating
for 38 years, although some have produced the host is when they are young. When cer-
viable eggs for over 30 years. The egg output cariae enter within 2 h of release, only 30%
per day in S. haematobium is some 20250, die, but this rises to 50% at 8 h and 85%
in S. mansoni 100300 and in S. japonicum at 24 h.
15003500. It is this massive output of eggs The snail intermediate hosts are species
in S. japonicum that leads to the more rap- specific, Bulinus spp. in S. haematobium,
idly developing and severe pathology. Biomphalaria spp. in S. mansoni and Onco-
Less than 50% of eggs manage to pass melania spp. in S. japonicum. They are il-
through the bladder or intestinal wall to de- lustrated in Fig. 11.1. They can adapt to a
velop further, the remainder being trapped wide range of habitats from natural water-
in the tissue. On reaching water, a tempera- ways to temporary ponds and cultivated rice
ture of 10308C and the presence of light fields. Whenever there is sufficient organic
induce hatching, resulting in miracidia matter on which to feed, snails will be
swimming out. They actively search out a found. Within a body of water, distribution

Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof

Chapter 11
S. mansoni Bulinus

18.11.2004 5:47am page 138

S. haematobium Biomphalaria
S. japonicum

Fig. 11.1. Schistosomiasis species and life cycles.

Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:47am page 139

Diseases of Water Contact 139

may be quite irregular with dense colonies dividuals and their age, with a few individ-
in some places and complete absence in uals having heavy infections and egg
others. Various factors, which may influ- outputs, while the majority have light infec-
ence snail colonization, are: tions. In areas of high endemicity, children
between 5 and 14 years are responsible for
. Electrolyte concentration. Snails demand over 50% of the contamination. As the infec-
a minimum calcium concentration, tion rate declines, older age groups become
cannot tolerate high salt content or a low more important.
pH. People are infected by collecting water,
. Light is not required by the snail, and they washing (both clothes and the person), in
can often survive in near total darkness. their occupation (such as fishing) or during
. Rainfall may herald the end of the dry recreation. Children are most commonly
season and provide water in which snail infected when they play in water, while in
populations can increase, but if the rain- adults, it is when they carry out their domes-
fall is too heavy, it may flush out the tic duties or occupation. Infection is gener-
snails, resulting in a subsequent decrease. ally due to repeated water contact over
Snail populations, therefore, may follow a a long period of time, but can occur from a
seasonal pattern. single immersion if it coincides with a large
. Temperature rise encourages expansion number of cercariae in the water.
of the population up to a maximum of Animals, such as water buffalo, cattle,
approximately 308C. pigs, dogs, cats and horses, can also serve as
. Density is a limiting factor and results in reservoirs of S. japonicum, but they are
reduced growth. less important than humans as sources of
. Aestivation or the ability of snails to sur- infection.
vive out of the water for weeks or months
allows populations of snails to continue Incubation period 26 weeks.
from one season to another, possibly also
transferring immature infections of S.
haematobium and S. mansoni. The snail Period of communicability 1020 years.
host of S. japonicum can survive condi-
tions of desiccation best of all. Occurrence and distribution S. haemato-
bium and S. mansoni were originally dis-
Snails are capable of self-fertilization, al- eases of Africa, where they are widely
though cross-fertilization is more common. distributed, but with the massive exodus of
Their reproductive capacity is phenomenal slaves that took place in the 17th and 18th
and a single snail can produce a colony centuries, this legacy was carried with
within 40 days and be infective in 60 days. them. The East African slave trade carried
When conditions are optimal, many species S. mansoni to the Arabian peninsula and
of snails will double their population in 23 S. haematobium to the Yemen and Iraq.
weeks. In measuring the age of snail popula- The Western trade was solely in S. mansoni,
tions, size of snails is a useful indicator. A which found a suitable snail host in South
large number of small samples from many America and the Caribbean. S. japonicum
different areas are preferable to a few large probably originated in China, where it has
samples in estimating the numbers and dens- been found in mummified bodies, but is also
ity in water courses. Infection rates in snails found in the Philippines, Taiwan and Sula-
are generally low, with only some 12% of wesi in Indonesia (Fig. 11.2). No cases have
the colony being infective, but even so this been found in Japan since 1978. A separate
level is sufficient to account for high preva- species S. intercalatum, pathogenically
lence rates in the human population. similar to S. mansoni, is found in Congo,
Humans contaminate water either by Cameroon, Central African Republic, Chad,
urinating or defecating into or near water Gabon and Sao Tome. S. mekongi is re-
courses. Egg output is variable between in- stricted to the Mekong River basin in Laos,
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:47am page 140
140 Chapter 11
S. japonicum.
S. haematobium,
S. mansoni,
Fig. 11.2. Distribution of schistosomiasis.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:47am page 141

Diseases of Water Contact 141

Thailand and Cambodia. Other localized male technique, but since many snails are
species are S. malayensis in peninsular Ma- hermaphrodite, it is only suitable with
laysia and S. mattheei found in southern Oncomelania.
Africa. Where small and temporary ponds are
foci of infection, they can be drained or
Control and prevention There are two filled (by controlled tipping of household
approaches to the control of schistosomia- refuse). Where canals and irrigation systems
sis: are responsible, concrete lining, increasing
rate of flow and any method to reduce
. reduce the transmission of the parasite; vegetation can discourage snail habitation.
. reduce the level of infection in individ- Unfortunately, these methods are rarely
uals. effective on their own and need to be com-
bined with molluscicides (e.g. niclosamide,
The first attempts to control the parasite, Bayluscide), which can be administered as
while the second aims at minimizing the a liquid, suitable for treating moving water,
pathological effects. The various methods or as granules in lakes and ponds. Continu-
of control are as follows. ous application is required to make a
sustained effect on the snail population. It
has the disadvantage of killing fish and
Humans pollute the environment by urinat- is expensive. Cheaper preparations, such
ing or defecating into bodies of water. This as copper sulphate, are still in limited use
can be minimized by encouraging the use of and naturally occurring plant preparations,
latrines. Unfortunately, it is very difficult to such as Endod (Phytolacca dodecandra),
get everybody in a family or community have shown promise. However, the remark-
to always use a latrine and the few non- able recovery of snail populations once con-
users will be sufficient to maintain a level trol methods are removed and the cost
of pollution (see Section 2.4.2). There is also of molluscicides make snail reduction a
the longevity of the adult worms, meaning less effective approach in schistosomiasis
that prevalence rates will remain static in the control.
community for a considerable period of time.
REDUCTION OF THE SNAIL INTERMEDIATE HOST The water contact can be highly effective in the
snail is a vulnerable link in the life cycle of individual. Various ways of encouraging
the parasite and can be attacked in an effort this are:
to break transmission. The various methods
that can be used are: . health education, especially to school
children, but this is often ineffective
. predators; unless an alternative (e.g. swimming
. biological control; pool), is provided;
. water management and engineering; . providing places to wash have been disap-
. molluscicides. pointingly ineffective for the cost
Various kinds of fish (particularly Tilapia . where areas of absent or minimal trans-
and Gambusia) are natural predators, but mission occurs in occupational or recre-
they will only reduce snails to a certain ational bodies of water, people can be
level unless they have an alternative source encouraged to use these, rather than the
of food. Snails, especially of the Marisa and heavily infected parts;
Helisoma genera, compete for food supplies . wear rubber boots when wading through
and Marisa will even prey on eggs and water, or if accidental exposure occurs,
juveniles of Biomphalaria. Another ap- then rub vigorously with a towel and
proach to biological control is the sterile apply 70% alcohol;
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:47am page 142

142 Chapter 11

. drinking water can be treated with iodine somiasis have been tried depending on the
or chlorine or if left to stand for at least resources and nature of the disease as
48 h, cercarial die-off will be complete. follows:

REDUCTION OF HUMAN INFECTION BY MASS CHE- . Raising of economic standards by the pro-
MOTHERAPY With the discovery of effective vision of water supplies and sanitation,
preparations, such as praziquantel, single- environmental engineering and water
dose MDA is now a good method of control. management has been shown to be effect-
A suitable target population is school chil- ive on a long-term basis in countries such
dren between 5 and 15 years of age where as Japan and China.
mass therapy is used. Alternatively, only the . In well-controlled irrigation schemes,
positive cases, or those with heavy infec- mollusciciding on its own may be effect-
tions, are treated following a simple diag- ive. Where discipline and motivation of
nostic procedure. Individual treatment, the population are less certain, a double
based on worm load estimation, aims at dis- approach of mass chemotherapy and re-
ease control by reducing morbidity. It per- duction of water contact is more effective.
mits limited resources to be more widely . When resources are scarce and greatest
spread and attempts the less ambitious benefit for limited finance is required,
target of disease rather than transmission treatment of high worm load cases is the
reduction. method of choice.
The anti-malarial drug artemethur is
also valuable in the control of schistosomia- Surveillance Effectiveness of control strat-
sis and could be used in areas where there is egies can be measured by:
no malaria, such as China, southern Brazil
and Southwest Asia. It can be used in com- . change in incidence rate;
bination with praziquantel. . a shift in peak prevalence to an older age
REDUCTION OF THE ANIMAL RESERVOIR Animal . reduction in geometric mean egg output;
reservoirs are responsible for maintaining . greater awareness of socio-economic
S. japonicum. In order of importance they values (e.g. the use of water supplies and
are dogs, cows, pigs, rats and water buffa- sanitation facilities).
loes. As most of these are domestic animals,
proper animal management can reduce con-
tamination of the environment. Vaccination
of domestic animals could be done. Baboons 11.2 Guinea Worm
and monkeys have been shown to be reser-
voirs of S. mansoni and could play a part Dracunculus medinensis, the largest of the
in maintaining infection. There is little pro- nematode worms to attack humans, used to
spect of controlling these animals. be a serious problem in India, Pakistan,
southern Iran, most of West Africa, South-
VACCINATION There are difficulties in pre- west Asia and Sudan, infecting some 80 mil-
paring a vaccine because the schistosome is lion people. It is spread by spilt-water
able to absorb host antigen and mask its washing larvae back into an unprotected
presence, but three vaccines are currently well or by infected people using walk-in
under trial for S. mansoni. wells. WHO launched an eradication pro-
gramme to make all wells safe with a sur-
STRATEGIES FOR SCHISTOSOMIASIS CONTROL Var- rounding wall and concrete apron so as to
ious approaches for the control of schisto- prevent all spilt-water from washing back
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:47am page 143

Diseases of Water Contact 143

into the well. Walk-in wells were converted Sudan, where control was hampered by
into lift-wells or alternative water supplies the continuing war, while most of the rest
provided. By these simple strategies, were in Ghana, Nigeria and Mali.
Dracunculus infection has been eradicated This has been the most successful eradica-
from most of the area. In 2003, there were tion programme to use such a simple
32,193 cases; 63% of these cases were in strategy.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 19.10.2004 10:09am page 144

Skin Infections

The skin is a common site for several children. Illness commences with fever
communicable diseases, presenting with followed by a characteristic skin rash of
rashes of various kinds. Infection is often macules, papules, vesicles, pustules and
transmitted from one person to another dried crusts. The lesions occur in groups,
directly by skin contact or by other means, appearing over several days, so pox of differ-
especially the airborne route. Control is by ent stages will be seen at the same time. In
the avoidance of contact with infected chickenpox, the rash is distributed cen-
individuals and where available the use of trally, appearing on the chest and abdomen
vaccines. and sparsely on the feet and hands.
Some skin infections, tropical ulcers The majority of people contract the
and those due to scabies and lice have been disease in childhood when it is an incon-
covered in Chapter 7 as they share common venience rather than a life-threatening con-
methods of control. Typhoid often has an dition, but if this has not occurred and if
accompanying skin rash, but is more appro- they subsequently develop the illness as
priately covered with other faecaloral adults, it can be very serious. This is a par-
diseases in Chapter 8. Meningococcal men- ticular problem in island and isolated com-
ingitis often presents with a petechial rash munities where varicella can be a fatal
and is covered in Chapter 13. Many of the disease in the elderly. Pregnant women,
arbovirus diseases present with skin rashes, who contract the disease in late pregnancy
but as their method of transmission is by or shortly after delivery, are at risk of severe
vectors, they are covered in Chapters 15 generalized chickenpox with a 30% mortal-
and 16. ity. Neonates who develop chickenpox
within 10 days of birth are liable to a serious
generalized infection. Chickenpox in early
pregnancy may result in congenital malfor-
12.1 Chickenpox/Shingles (Varicella) mations. Death results from generalized
viraemia, pneumonia, haemorrhagic com-
Organism Herpesvirus varicella-zoster virus plications, encephalitis or cardiomyopathy.
(VZV). The virus remains latent in the body,
lodged in nerve bundles, and in later life,
Clinical features A generally mild disease, especially during a debilitating disease
chickenpox is a common infection of (such as HIV infection), the identical virus

Q R. Webber 2005. Communicable Disease Epidemiology and Control, 2nd edition (Roger Webber)

Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 19.10.2004 10:09am page 145

Skin Infections 145

(VZV) causes shingles. This presents as age, who have not had chickenpox as a
a vesicular rash with erythema in a well- child, and the immunocompromised. There
defined area of skin supplied by the affected is a risk in using vaccination by shifting
dorsal root ganglia. Pain and paraesthesia the age of developing naturally acquired
occur along the course of the affected nerve. chickenpox to older age groups where the
disease is more serious, making it unlikely
Diagnosis is on clinical criteria, especially to become part of the routine childhood
the central distribution of the rash and the vaccination programme.
presence of lesions at different stages, differ-
entiating it from smallpox. Any case of a pox Treatment Acyclovir and vidarabine can be
rash that dies or has an unusual distribution used to treat adults, children with serious
should be a smallpox suspect (see Section disease and older persons with shingles.
18.2). Human varicella-zoster immunoglobulin
(VZIG) is available in some centres and can
Transmission The infection is transmitted by be used within 10 days of exposure for con-
fluid from the vesicles. This can occur in the tacts liable to develop severe disease, such
pharynx before the main rash, when trans- as pregnant women, neonates and the
mission is by droplets; otherwise, the spread immunosuppressed.
occurs by direct skin contact, airborne dis-
persion of vesicle fluid or through articles Surveillance Outbreaks should be reported
soiled by discharges. so that susceptible individuals can be pro-
tected and given vaccination if available.
Incubation period varies from 2 to 3 Any suspect case of smallpox must be
weeks. reported to WHO.

Period of communicability is from 3 days

before the onset of the rash to 6 days after 12.2 Measles
its first appearance.
Organism Measles is a member of the Para-
Occurrence and distribution Chickenpox myxoviridae family of viruses.
occurs worldwide in an epidemic form
often spreading serially (Section 2.2) from Clinical features Measles normally com-
one place to another. It is a disease of chil- mences with a prodromal fever, cough, con-
dren in the temperate regions, but is more junctivitis and small spots (Kopliks spots)
commonly found in adults in the tropics. most easily seen inside the mouth. The char-
acteristic blotchy rash begins on the third to
Control and prevention One attack of seventh day of the illness, generally on the
chickenpox confers life-long immunity; so face, but soon spreads to the whole body.
it is preferable for children to have the dis- In developing countries, it is a serious
ease rather than be protected and run the disease and accounts for a considerable
risk of developing it as adults. Special amount of mortality and morbidity in the
groups, such as neonates, pregnant women childhood population. It particularly has a
and the sick, should be protected by pre- severe effect on the nutritional status of the
venting cases of chickenpox from coming child, resulting in the healthy child losing
into contact with them. In hospital, cases of weight and the malnourished child becom-
chickenpox should be isolated from other ing critically ill. The peak of infection is
patients. between 1 and 2 years of age, at the very
A live, attenuated varicella virus vac- time when breast milk alone is an inad-
cine has been developed, but is not widely equate source of food supply and weaning
available. It is useful for vaccinating high- foods may not yet have been introduced.
risk groups, such as women of childbearing The association of nutritional change and
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 19.10.2004 10:09am page 146

146 Chapter 12

measles can be, and often is, a lethal com- Diagnosis is on clinical criteria, but measles
bination. IgM can be found in the saliva with im-
There are a number of reasons for the munological tests.
nutritional depletion produced by measles.
Any disease process puts extra demands on Transmission Although the main feature of
the body, increasing catabolism. Fever and measles is the skin rash, it is transmitted by
the desquamation of all epithelial surfaces the airborne route from nasal and pharyn-
demands protein replacement, which is geal secretions. This can be by articles con-
handicapped by a sore mouth, often second- taminated with secretions such as cloth or
arily infected by Candida, thus preventing clothing used to wipe a running nose as well
the child from sucking properly so that even as by respiratory droplets produced in a
breast milk is not taken. Then from the other coughing bout.
end, diarrhoea, which is such a common Measles is the most contagious of all
feature of measles in developing countries, infectious diseases and no age is spared. In
discharges the body reserves further. Per- the Fijian outbreak in the 1870s, adults
haps the greatest weight loss is due to im- as well as children succumbed, affecting
munosuppression, much of which takes families as a whole at the same time, causing
place after the child has recovered from the deprivation and starvation that resulted in a
acute attack. high death rate. Now adults have experi-
The disease process attacks all epithe- enced measles as children, with the age
lial surfaces, producing most of its compli- of infection getting younger. This is ex-
cations in the respiratory tract. Pneumonia plained by greater contact of communities
is the commonest complication, while lar- due to improvement of communication,
yngo-tracheo-bronchitis is serious, with a while the intense social contact at a very
high mortality. Acute respiratory infections young age (babies carried on their mothers
(see Section 13.1) are one of the leading back) gives maximum opportunity for early
causes of childhood ill health and the seque- transmissions.
lae of measles are responsible for a large
component of this problem. If the acute
Incubation period 1014 days.
pneumonia does not kill, the damage done
makes the child more susceptible to further
attacks of respiratory infection when the Period of communicability From 1 day before
measles has long gone. the first signs of infection until 4 days after
The effects on the eye can cause blind- the rash starts (or 4 days before to 4 days
ness. Corneal lesions result from epithelial after the rash begins).
damage, which can lead to ulceration, sec-
ondary infection and scarring. In severe Occurrence and distribution Measles has
cases, perforation or total disorganization been a severe infection in Western countries
of the eye can occur. These severe effects for a considerable period of time, producing
only result if there is concomitant vitamin mortality in poor and slum populations
A deficiency, so giving vitamin A to all similar to what is seen in developing coun-
measles cases is effective. Measles by its tries. Introduced with European explor-
nutritional and direct effects has been ation, it caused devastating epidemics,
regarded as the most important cause of particularly in island communities, some
blindness in a number of tropical countries. of which never recovered their former popu-
Measles is an important cause of otitis lation numbers. However, in many develop-
media. It can also result in encephalitis, ing countries in which it is a major problem,
either in the acute form or a late slow-onset there is evidence that measles has been
sclerosing panencephalitis, which is always present for several hundred years, with the
fatal. pattern having changed from sporadic
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 19.10.2004 10:09am page 147

Skin Infections 147

epidemics with all ages involved to one of tions of high infectivity, such as during
endemicity in which the under-5-year-olds an epidemic, admission to hospital or refu-
are predominantly affected. gee camp or if the infant has HIV infec-
tion, then reducing the age of vaccination
Control and prevention of measles is by to 6 months is justified. In this case, another
vaccination. As measles is such an infec- vaccination should be given at 1215
tious disease, it can be reckoned that every months.
child will develop it. Some 10% will either In developed countries, vaccination
have such a mild infection or be partially is given at 1215 months so that the time
protected by maternal antibodies as to taken to reduce the incidence in the popula-
appear not to have been infected. A further tion will be less, as shown in Fig. 12.1. The
1020% will not have measles until the greater the coverage the more rapidly this
following year due to the epidemic effect; is achieved. For example, 60% coverage
therefore, the expected number of cases of will theoretically take 12 years to reduce
measles can be calculated from the birth rate the incidence to zero if vaccination is given
minus 25%. If the birth rate in a developing at 12 months, but never be achieved at 9
country is 50,000, then 75% of this means months. However, 70% coverage will
that 37.5 cases of measles per 1000 can be achieve zero incidence with vaccination
expected each year, which represents given at 9 months, which is being achieved
37,500 cases in an administrative unit of a by an increasing number of developing
million people. Calculations like these can countries.
be used to estimate the number of children Effective measles vaccination coverage
to be vaccinated and hence the vaccine re- will not only reduce the number of children
quirements. developing the disease in an epidemic, but
Eighty per cent of susceptibles will will have the secondary benefit of raising the
need to be vaccinated to produce control of age of developing the disease, as can be seen
the disease, but a lower target may be accept- in Fig. 12.2. Epidemics had occurred in
able in more isolated communities. This Namanyere, Tanzania, regularly every
target will need to be achieved every year second year until 1978 when there was
in rural areas, but as much as every 6 months only a minor increase, the main epidemic
in urban areas. Measles vaccine is 90% ef- being delayed until 1979. This meant that
fective if the cold chain is not broken. children born in 1977, who could have
Maternal antibodies protect the new- expected to become infected in their second
born infant for the first 6 months of life, but year of life (1978), had their measles put off
thereafter the child becomes readily suscep- until 1979 when they were beyond the age of
tible to infection with a peak around 1 year. maximum mortality.
The seroconversion rate is some 76% at The chances of a susceptible child de-
the age of 6 months, 88% at 9 months and veloping measles when admitted to hospital
100% at 12 months. Giving measles vaccin- is very high as it is already sick with another
ation at 1 year would produce the best con- complaint. It is fortunate that measles vac-
version, but, by this time in developing cine can produce protective immunity
countries some 50% of the population quicker than the wild virus (about 8 days
would have already had the disease. Giving for the vaccine and 10 days for the disease),
it at 6 months will be before all but a so as long as the child is vaccinated within
few have had the disease, however the ser- 48 h of admission, it will be protected.
oconversion rate is so poor at this time that Because of the severity of disease in the
not many will be protected. The best com- debilitated child, there are very few contra-
promise is a first vaccination at 9 months, indications and the malnourished and those
with the possibility of a second opportunity with minor infection should all be vaccin-
through periodic mass campaigns. In condi- ated. HIV infection is not a contraindication
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 19.10.2004 10:09am page 148

148 Chapter 12


(a) Vaccination at 9 months

Percentage of initial incidence level




0 5 10 15 20 25 30


(b) Vaccination at 12 months

Percentage of initial incidence level





0 5 10 15 20 25 30


Fig. 12.1. The relative impact of immunization programmes on measles incidence in the age group 019
years, according to age at vaccination and population coverage. (Reproduced by permission from Cvetanovic,
B., Grab, B. and Dixon, H. (1982) Bulletin of the World Health Organization, 60(3), 405422.)

as the child is more likely to die from in South and Central America, give a
measles than from complications of receiv- second measles vaccination using vaccin-
ing a live vaccine. ation days or special campaigns. Countries
The policy in many countries is to give a of the western hemisphere have set a target
second measles vaccination at 45 years or for the cessation of measles transmission by
on school entry. Other countries, especially 2007.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 19.10.2004 10:09am page 149

Skin Infections 149


Vaccinations started
No. measles epidemics 60






1972 1973 1974 1975 1976 1977 1978 1979 1980

Fig. 12.2. Prolongation of the time interval between measles epidemics due to vaccination in Namanyere,

As vaccination coverage is increasing, a needs to be determined to work out the best

potential problem could arise because less time to supplement routine vaccination pro-
maternal antibody is produced by mothers grammes. If measles cases are focal, then this
who have acquired their immunity from may indicate gaps in vaccination coverage
vaccination rather than by having measles. (Fig. 3.2). Since all children should be vac-
This means that infants of a younger age will cinated, an estimate of vaccine coverage can
become susceptible, so vaccination may be made by comparing the number of new
need to be given earlier if coverage is not vaccinations with the number of children
complete. born.
Measles vaccine is conveniently com-
bined with rubella (MR) or both with rubella
and mumps (MMR). Despite adverse publi- 12.3 Rubella
city given to the MMR vaccine, no compli-
cations have been confirmed and the Organism Rubella virus, a member of the
vaccine should continue to be used. Togaviridae family of viruses.

Treatment There is no specific treatment, Clinical features Infection in the adult

but supportive therapy with fluids and is generally mild, presenting with a maculo-
easily digested foods needs to be given. Vita- papular rash of short duration, fever, con-
min A supplementation should be given to junctivitis and cervical lymphadenopathy.
all children with measles. Complications Some 2050% of the infections are sub-
may require additional treatment, such as clinical. However, if the woman is pregnant,
antibiotics for bacterial chest infections. especially in the first 10 weeks of pregnancy,
her developing fetus will suffer from
Surveillance All cases of measles should be congenital rubella syndrome (CRS). The
recorded and monthly totals charted to indi- congenital defects are more severe if the
cate epidemics and estimate when new epi- infection is acquired earlier in pregnancy,
demics will occur (Fig. 12.2). Measles has a resulting in stillbirth in the first few weeks.
seasonal pattern, which can vary markedly Otherwise a range of congenital defects
from country to country (Fig. 1.7); so this can result, including cataracts, glaucoma,
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 19.10.2004 10:09am page 150

150 Chapter 12

deafness, heart defects and microcephaly. rubella or to vaccinate all children aged
Milder defects will develop between the 915 months as part of the routine child-
11th and the 16th weeks and after the hood vaccination programme. If the vaccin-
20th week of pregnancy, there is no further ation programme is considered sufficiently
risk. efficient to embark on the latter strategy,
then an extra campaign to target all women
Diagnosis is by detecting IgM from serum or and girls over 12 years of age should be run
saliva and is important if infection in a preg- at the same time for the first few years of
nant woman is suspected. introducing rubella vaccination.
If a policy of childhood vaccination is
Transmission The virus is transmitted adopted, then rubella vaccine is best admin-
in droplets from the nasopharynx by the istered with measles vaccine as MR or in
airborne route or direct contact. Most infec- combination with measles and mumps as
tions are acquired from children and adults MMR (see Sections 12.2 and 12.4).
during an outbreak, but infants with CRS
can produce virus from pharyngeal secre- Surveillance An estimate of the level of CRS
tions and urine for up to 1 year so are a can be obtained from hospital records and
potent source of infection. MCH records of deaf and blind infants.
Measles vaccination records and numbers
Incubation period 1520 days. of cases of measles are good indicators of
the efficiency of the childhood vaccination
programme in deciding which strategy of
Period of communicability From 7 days
rubella vaccination to introduce.
before the onset of the rash to 4 days after.
CRS infants continue to shed virus for up to
12 months.
12.4 Mumps
Occurrence and distribution Worldwide dis-
tribution, but the importance of rubella in Organism Mumps virus is a member of the
developing countries has not been appreci- Paramyxoviridae family of viruses.
ated until comparatively recently. It occurs
in an epidemic form probably due to the Clinical features Mumps is not a true skin
number of susceptibles in the population, infection, but is included here as it shares
with children becoming infected when common means of control with measles and
they are 28 years of age in urban areas and rubella. It is an infection of the salivary
612 years in rural areas. glands producing enlargement and pain in
the parotid gland, but can lead to orchitis,
Control and prevention The objective is to mastitis, meningitis, pancreatitis and acute
prevent CRS by vaccination of children and respiratory symptoms (see Section 13.1).
adults. Although adolescent girls and Commonly an infection of children 25
women of childbearing age are the target years of age, the more serious manifestations
population, just vaccination of this group are more likely in adults, especially males.
will never eliminate rubella; therefore, all
children of both sexes should ideally be vac- Diagnosis is made on clinical grounds, but
cinated. However, if the vaccination pro- serological confirmation can be made with
gramme is far from complete, the effect will mumps-specific IgM, a rise in IgG or culture
be to postpone the age of infection to older of saliva or urine.
and more dangerous ages in women likely to
become pregnant. Developing countries, Transmission The virus is transmitted via
therefore, need to decide between protecting direct contact or by droplets spread by the
adolescent girls and women of childbearing airborne route. Any contact of saliva, such as
age only, with no attempt to eliminate sharing of cutlery, wiping the mouth with a
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 19.10.2004 10:09am page 151

Skin Infections 151

common cloth, or kissing, can result in erysipelas or scarlet fever. Pyoderma and
transmission. impetigo are superficial skin infections
with vesicles, pustules and crusts. Erysip-
Incubation period 1424 days. elas is a red, tender, oedematous cellulitis
of the infected part of the body, originating
Period of communicability 6 days before to 6 from the point of infection. Scarlet fever
days after the start of parotitis. presents as a generalized rash that blanches
on pressure with high fever, strawberry
Occurrence and distribution Mumps is prob- tongue and flushing of the cheeks. In some
ably more common than assumed to be with cases, there is an appreciable mortality
up to 85% of the population found to have or else it can result in otitis media, glomer-
been infected in adult life, although few ulonephritis or acute rheumatic fever
would have manifested the disease. With (ARF, Section 13.10). Although not a skin
such a high proportion of the population infection, streptococci can also cause puer-
meeting the virus, there is a relatively high peral fever due to post-delivery infection of
risk of complications and costbenefit stud- the female genital tract.
ies have shown that vaccination produces
substantial economic savings. Diagnosis Culture of the organism from
the point of infection or pharynx on blood
Control and prevention The reason for in- agar.
cluding mumps in the routine childhood
vaccination programme is similar to that Transmission is mainly by the respiratory
for rubella (Section 12.3). Where there is an route or direct contact with the lesion or
efficient programme with the majority of skin (in impetigo). Flies can transfer the or-
children being vaccinated, it is advanta- ganism and are a major means of infecting
geous to include it with measles and rubella scratches and wounds in tropical countries.
as the MMR vaccine. However, if less than The organism can be carried in the nose,
75% of children are vaccinated, then this pharynx, anus and vagina or in chronic
could result in an epidemiological shift to skin lesions, and is an important cause of
older age groups, increasing the likelihood hospital infections.
of complications. If mumps vaccination is
included, then a second opportunity, either Incubation period 13 days.
by the routine programme or by catch-up
campaigns, should be given unless coverage Period of communicability 1021 days or
is over 90%. until a chronic infection has been treated.

Surveillance Comparing the number of chil- Occurrence and distribution Worldwide,

dren born with those who complete their predominantly in children, but scarlet
childhood vaccinations or are vaccinated fever is more common in temperate regions.
against measles will give an estimate of the Infected skin lesions either due to strepto-
efficiency of the vaccination programme cocci or staphylococci are very common in
and whether mumps vaccination should be tropical regions.
Control and prevention Treat all cases
promptly and dress infected lesions in a
12.5 Streptococcal Skin Infections sterile manner. Any person with an infected
lesion should not be involved in operations
Organism Streptococcus pyogenes, group A. or hospital duties until healed. Personal hy-
giene, especially the washing of hands after
Clinical features Streptococcal infections of defecation, and the discouragement of nose-
the skin can present as pyoderma, impetigo, picking should be advocated. Use of proper
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 19.10.2004 10:09am page 152

152 Chapter 12

latrines and the control of flies are long-term disease respond in different ways to the
preventive measures. challenge.
The generation time from inoculation to
Treatment Benzathine penicillin G intra- multiplication of a stable number of M.
muscular, or penicillin G or V orally. leprae is only 1824 days, but the develop-
ment of the disease will take anything from 7
Surveillance Scarlet fever and puerperal months to in excess of 7 years (mean 36
fever are notifiable diseases in some coun- years). The first lesion is described as inde-
tries. terminate (Fig. 12.3) because at this early
stage, it is impossible to decide to which
place in the spectrum of disease it will
develop. There is either a single ill-defined,
12.6 Leprosy slightly hypopigmented macule, commonly
seen on the face, trunk or exterior surfaces,
Organism Mycobacterium leprae. or there may be a small anaesthetic patch.
The lesion will then develop into a leproma-
Clinical features Leprosy illustrates the tous or tuberculoid type or oscillate in the
conflict between the infecting organism transitional state of borderline leprosy
and the host more dramatically than any between these two extremes.
other disease. M. leprae is widespread in Lepromatous leprosy (LL) reflects the
the environment, yet only a small propor- complete breakdown of the hosts immune
tion of people ever show clinical symptoms responses and the maximum infection
of the disease and those few who do get the with M. leprae. In the early stages, the signs

Bacillary index Cell-mediated immunity

Level of


Lepromatous Borderline Tuberculoid



Fig. 12.3. The spectrum of leprosy illustrating the proportion of bacilli, the cell-mediated immune response
and the level of instability, in the different forms of the disease.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 19.10.2004 10:09am page 153

Skin Infections 153

of the disease may be very few, but a skin light touch. A skin smear in TT is nearly
smear will reveal large numbers of mycobac- always free of bacilli (pauci-bacillary), so
teria (multi-bacillary). Early signs that the diagnosis depends upon the detection
have been described, but rarely observed, of nerve damage.
are oedema of the legs and nasal symptoms Borderline leprosy, as its name sug-
of stuffiness, crust formation and blood- gests, is on the border between the two ex-
stained discharge. These are unlikely to tremes of LL and TT. True borderline (BB) is
be recognized as leprosy and it is generally uncommon, with the disease tending to pro-
not until the more obvious skin lesions gress to either the lepromatous (BL) or tuber-
become apparent that the diagnosis is culoid (BT) part of the spectrum. Signs,
made. therefore, vary between the two extremes
Leprosy lesions favour the cooler parts with features of each, but predominating in
of the body, so the buttocks, trunk, exposed one or the other. Borderline leprosy is
limbs and face are the more likely sites. common, but its instability leads to reaction
Lesions may be macules, papules or and nerve damage, which can often be
nodules, with or without a colour change severe.
and often show lack of sweating when the Where the host response is adequate
patient becomes hot. The signs of nerve and cell-mediated immunity high, the dis-
damage do not appear until much later in ease tends towards the tuberculoid end of
LL, with a concurrent thickening of the the spectrum, where it is low to LL. Simul-
skin of the forehead, loss of eyebrows and taneous HIV infection will shift the host re-
damage to the cartilage of the nose. The eyes sponse from the tuberculoid towards the
are also attacked with an infiltrative kera- lepromatous. Otherwise the host response
titis, iritis and eventually leads to blindness. can vary over the course of the illness pro-
Tuberculoid leprosy (TT) is at the op- ducing reactions, which can either be up-
posite end of the spectrum, showing the full grading (towards TT) or downgrading
response of cell-mediated immunity to the (towards LL). These are type 1 reactions.
attacking organism (Fig. 12.3). M. leprae has The nearer the case is to the centre of the
a predilection for nervous tissue and it spectrum, the more severe is the reaction.
is within this nervous tissue that the cell- Type 1 reactions may affect all tissues, skin
mediated response takes place, causing and nerves only or produce a generalized
early damage to the nerves. The tuberculoid systemic reaction.
patient, therefore, tends to present early A different type of reaction (type 2) is
with signs of weakness or loss of sensation. found in lepromatous and borderline lepro-
Palpation of the nerves will often demon- matous cases and is associated with massive
strate a thickening with loss of sensation or destruction of bacilli. Immune complexes
motor power in the distribution of the are formed in the tissues and these lead to
affected nerve. The ulna nerve, as it bends an increased reaction in existing lesions.
over the medial epicondyle at the elbow, or The characteristic finding is erythema nodo-
the lateral popliteal nerve, where it curves sum leprosum, which appears on the skin as
round the neck of the fibula, are good places painful red nodules commonly on the face
to palpate nerves for thickening. Dermal and exterior surfaces.
lesions are not raised, often appearing as
apparently normal areas of the skin, lacking Diagnosis A skin smear is made from
sensation or sweating when the patient every suspected case of leprosy, collecting
exercises. Occasionally though, they are dermal tissue without drawing blood.
well-defined and scaly with raised edges, A negative smear does not mean that a case
but quite different from the succulent is not leprosy as tuberculoid cases rarely
macules and papules of LL. Loss of sensa- have mycobacteria. Smears are stained
tion should be elicited with a pin as well as with ZiehlNeelsen stain and the number
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 19.10.2004 10:09am page 154

154 Chapter 12

of mycobacteria counted, giving the bacter- over 80% of school children in Uganda, but
ial index: only 40% of children under 5 years of age in
6 Over 1000 bacilli in an average field
Leprosy can occur in an epidemic as
5 1001000 bacilli in an average field well as an endemic pattern, but due to the
4 10100 bacilli in an average field incredibly protracted life history of the dis-
3 110 bacilli in an average field ease, the epidemic form is rarely seen.
2 110 bacilli in 10 fields Between 1921 and 1925, there was an epi-
1 110 bacilli in 100 fields demic in the Pacific island of Nauru, with
30% of the population becoming infected
and the disease was notably non-focal. All
Mycobacteria can also be obtained from
ages were susceptible and most people de-
nasal scrapings of the inferior turbinate.
veloped tuberculoid (BTTT) leprosy,
A skin biopsy is taken from tuberculoid
which healed spontaneously.
and borderline patients or a nerve biopsy
It has been estimated that as much as
where there is no skin lesion.
5% of people are susceptible to LL and con-
tact with a lepromatous case increases the
Transmission The method of transmission
risk of infection. Children and young adults
has not been conclusively demonstrated,
are more commonly affected, but the chil-
but several factors, such as prolonged close
dren of leprosy patients do not develop LL
contact, the finding of large numbers of ba-
any more frequently than the general popu-
cilli in the nasal discharges of lepromatous
lation. It would seem that leprosy is very
cases and in the skin, suggest that both
similar to tuberculosis in that the organism
airborne and direct skin contact are import-
is more common than assumed to be, asymp-
ant. M. leprae have been found to survive
tomatic infections may occur, but only
from 2 to 7 days outside the body in nasal
those who are susceptible will develop the
secretions. Individuals vary in their suscep-
tibility and it is possible that repeated doses
Due to active control measures and
of bacilli or a large infective dose are re-
multiple drug therapy, there has been a
quired to produce the disease.
marked reduction of leprosy in the world,
with a global prevalence of one case in a
Incubation period 120 years. population of 10,000 in 2001. Among 122
countries considered endemic in 1985,
Period of communicability Possibly 1 month 107 have achieved elimination and leprosy
to 2030 years. Treatment with rifampicin remains a public health problem only
renders the patient non-infectious after 3 in Angola, Brazil, Central African Republic,
days. Congo, Cote dIvoire, Guinea, India, Liberia,
Niger, Madagascar, Mozambique, Myanmar,
Occurrence and distribution Leprosy is Nepal, Paraguay and Tanzania. It is dimin-
found mainly in the tropical regions of ishing as a disease burden in India,
the world, with poor socio-economic condi- Brazil, Myanmar, Madagascar, Nepal and
tions probably being a major factor. LL Mozambique.
is more common in Asia and TT more
common in Africa. This differing suscepti- Control and prevention The immediate
bility might help to explain the response of control is a reduction of the leprosy reser-
the peoples of these two continents to BCG. voir by case finding, treatment and follow-
BCG, given at birth, can produce a hypersen- up, especially those with the lepromatous
sitivity and change the cell-mediated im- form of the disease. A small proportion of
munity from negative to positive, but some cases will present themselves, but active
people appear to have no natural immunity search must be made for others concentrat-
and remain always susceptible to the lepro- ing on selective groups. School children
matous form of the disease. BCG protected should receive priority, as they are likely to
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 19.10.2004 10:09am page 155

Skin Infections 155

contain a quarter of all cases and a higher mine has the advantage of being anti-
proportion of new ones. Also contacts of inflammatory as well as bacteriostatic, and,
any case should be examined at frequent therefore, can be used in the treatment of
intervals, as leprosy is more common in reactions at a dose of 100 mg three times a
those people who have prolonged contact week. Steroids and thalidomide are also
with a leprosy case. All new cases are useful in the treatment of reactions.
treated by multiple drug therapy (see Part of any leprosy programme is the
below). development of a rehabilitation service.
BCG vaccination induces hypersensi- This not only encourages leprosy patients
tivity and increased resistance to develop- to present themselves for treatment, but
ing leprosy in some ethnic groups and helps them to return as participating
is valuable in the prevention of leprosy members of the community. Much can be
as well as tuberculosis (Section 13.1). done from limited resources, such as making
M. leprae-based vaccines are under trial in sandals out of old tyres and pieces of wood.
several countries with promising results. The elements of rehabilitation are to protect
The long-term reduction of disease will re- anaesthetic limbs, actively treat sores and
quire an improvement in general hygiene, ulcers and provide support (including sur-
better housing and less overcrowding. gery) to restore function. The eyes are also
damaged in leprosy and, supportive treat-
Treatment is determined by the bacterial ment can do much to prevent blindness
index of the case. from developing.

. High-risk (multi-bacillary) LL and BL Surveillance Dedicated leprosy field workers

cases: A three-drug regime consisting of have been found to be of considerable value
rifampicin 600 mg once a month super- in detecting new cases and following up
vised, dapsone 100 mg daily self-adminis- cases under treatment, otherwise a system
tered, clofazamine 300 mg once a month within the existing health service should
supervised, then 50 mg daily self-admin- be developed. Combining leprosy and
istered. Treatment should be continued tuberculosis surveillance is economically
for a minimum of 12 months. useful.
. Non-bacillary cases BT or TT: Rifampicin Initially whole populations should
600 mg once a month supervised, plus be screened in areas of high endemicity,
dapsone 100 mg daily self-administered, then concentration made on examining
for 6 months or six monthly doses within school children and all contacts of cases.
a 9-month period. All cases should be registered, often
managed as a combined programme with
All patients with positive skin smears at tuberculosis. Section 13.1 on follow-up
the start of treatment should have repeat and registration is equally applicable to
skin smears at 6 and 12 months. Clofaza- both diseases.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:48am page 156

Respiratory Diseases and Other Airborne
Transmitted Infections

The vulnerable respiratory apparatus is between human beings is a necessary part of

easily invaded by microorganisms. Breath- life, control becomes more difficult and
ing is continuous and as respiratory gases non-specific. Even so, the respiratory dis-
are wafted in and out, infecting organisms eases are an enigma, the voluminous quan-
find free passage deep inside the body. The tities of expelled organisms are sufficient to
site of entry is commonly the nasopharynx, infect the entire population, yet only some
but entry can also occur through the oro- individuals manifest disease. It is the infect-
pharynx and the conjunctiva. The lachrymal ive dose and the host response, which deter-
glands drain into the nasopharynx and ex- mines whether infection will occur.
perimental studies have shown that this is Environmental factors that increase the in-
often a more certain method of infection fective dose (e.g. overcrowding) or reduce
than directly through the nose. The respira- the host resistance (e.g. malnutrition or con-
tory system also includes connections to the comitant infections) can have a marked
middle ear, the sinuses and the gastro-intes- effect.
tinal tract. This chapter includes airborne trans-
The ciliated lining and mucus-secreting mitted infections that present as diseases of
cells of the respiratory tract can act as non- the respiratory system and also includes dis-
specific host defence mechanisms entrap- eases of other systems of the body that are
ping microorganisms and passing them to transmitted by the airborne route. Most of
the exterior. In attempting to expel these the skin infections, covered in Chapter 12,
secretions from the body by coughing or are also transmitted mainly by the airborne
spitting, organisms may be transmitted to route.
another host. The lymphoid tissues, espe-
cially the tonsils and adenoids, guard the
respiratory apparatus, but sometimes may 13.1 Tuberculosis
themselves become foci of infection.
Respiratory infections are usually trans- One of the major diseases in the world, tu-
mitted by direct contact between individ- berculosis poses considerable challenge in
uals and generally the closer the contact, developing countries. Not only are a pro-
the greater the chance of spread. As contact portion of the population infected with this

Q R. Webber 2005. Communicable Disease Epidemiology and Control, 2nd edition (Roger Webber)

Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:48am page 157

Respiratory Diseases and Other Airborne Transmitted Infections 157

debilitating and often fatal disease, but the ment, pleural effusion or cavity formation.
period of infectiousness is prolonged (ap- The third phase of the disease results from
proximately 5 years in an untreated case), complications of the regional nodes. These
permitting transmission to many other per- may be obstructive, leading to collapse and
sons. Indeed, in a number of countries, an consolidation, cause erosion and bronchial
endemic balance has been achieved destruction or spread locally. The final stage
whereby the number of cases that resolve is one of blood stream spread, disseminating
spontaneously, are cured by medical treat- bacilli to all parts of the body where they
ment or die, are replaced by an equal may produce tuberculous meningitis or mil-
number of new cases entering the pool of iary infection. Long-term complications are
tuberculosis. HIV infection has added to those of bones, joints, renal tract, skin and
the likelihood of people developing tuber- many other rare sites. These features are il-
culosis so that it is increasing in sub- lustrated in Fig. 13.1.
Saharan Africa. In the world, 8 million The risk of developing local and dis-
people develop tuberculosis every year and seminated lesions decreases over a period
2 million die from it. of 2 years. If the majority of cases are going
to progress, they will do so within 12
Organism Mycobacterium tuberculosis, but months of infection or 6 months from the
infection can also be caused by M. bovis development of the primary complex. By
(from cattle) or M. africanum. There are the end of 2 years, 90% of the complications
many mycobacteria occurring naturally, would have occurred. Bone and other late
including M. avium, M. intracellulare complications are a very small proportion
and M. scrofulaceum, that can sensitize beyond this time.
the individual and interfere with BCG
vaccination. In endemic countries, M. tuber- Diagnosis Tuberculosis is spread by droplet
culosis is widespread, with 13% of infection, so sputum-positive cases transmit
the population per year being at risk of the disease much more efficiently than those
infection. whose sputum is negative on microscopy.
The risk to the community is, therefore,
Clinical features A productive cough with from pulmonary tuberculosis and the em-
weight loss, fever and anaemia are the phasis should be on finding these cases by
most important signs of tuberculosis. Any taking a sputum smear, ideally confirmed
chronic cough persisting for 3 weeks or by culture. The comparative costs of diag-
more, especially if there is also weight loss nostic techniques are:
and anaemia, should be regarded as a pos-
sible case of tuberculosis and sputum smears
taken. Haemoptysis is an important diagnos- Smear 0.02
Culture 0.20
tic sign and may be streaking of the sputum
Sensitivity 0.40
with blood or frank coughing-up of fresh Full plate X-ray 1.00
Tuberculosis infects people in a spec-
trum of severity depending on the host re- Fifty sputum smears can be made for the
sponse, the dose of organisms and the length equivalent cost of one X-ray and this econ-
of time. The first sign of infection is the omy can be used for diagnosing cases in the
primary complex in which the organism is community. Anybody presenting to the
localized to an area of the lung with a corres- health services with a cough for 3 weeks or
ponding enlargement of the hilar lymph more should be asked to produce some
nodes. In the majority of people, this heals sputum and a smear made. This is dried and
completely or with a residual scar, and the stained with ZiehlNeelsen for acid-fast ba-
person develops immunity to further chal- cilli. X-ray examination has a high sensitiv-
lenge. If healing does not occur, then the ity and, therefore, is of more value in
focus extends to cause glandular enlarge- countries with a low incidence and plentiful

Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof


Bloodstream dissemination
Meningitis or miliary
Complications of regional
Extension of the focus Bronchial erosion
Pleural effusion or (incidence decreases with Late complications
Infection cavitation increasing age) renal and skin
(25% of cases (most after 5 years)
Primary complex occur within 9 months,
(majority of cases heal) 75% within 12)

Chapter 13
Bone and joint (most
Fever of onset
within 3 years)

1 early infection, especially in first year of life

Resistance (reduced by 2 malnutrition
Acquired 3 intercurrent infections, e.g. measles, pertussis

18.11.2004 5:48am page 158

48 weeks 3 months 6 months 12 months 24 months

Tuberculin- Risk of local and disseminated lesions Decreasing risk 90% within first 2 years

Fig. 13.1. The evolution of untreated primary tuberculosis (modified). (Reproduced by permission from Miller, F.J.W. (1982) Tuberculosis in Children, Churchill
Livingstone, Edinburgh.)
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:48am page 159

Respiratory Diseases and Other Airborne Transmitted Infections 159

resources, but sputum microbiology is still . malnutrition;

necessary to confirm the diagnosis and pro- . intercurrent infections, such as measles,
vide cultures for drug susceptibility testing. whooping cough and streptococcal infec-
A simpler form of search is made in the tion;
village of a newly diagnosed case. The con- . HIV infection;
tacts are examined to see if there is anybody . occupations or environments that damage
with a productive cough or clinical signs, the lung (mining, dust, smoke).
and a smear made. Contacts should be
given BCG. Chemoprophylaxis is given to As well as variation amongst individuals,
children under 6 years and to contacts posi- there are also considerable differences in
tive for HIV, and followed up at regular the susceptibility of populations. This can
intervals. This can all be included in the be measured by the annual tuberculosis in-
national registration system. fection rate, which compares the tuberculin
reaction of non-vaccinated subjects of the
Transmission is by the airborne route, with same age every 5 years. With BCG vaccin-
coughing and spitting being the main modes ation at birth, this cannot be done any
of disseminating the organism. Many people longer, but data obtained before this became
meet the tubercle bacillus in early life, ac- a universal policy is still valid. Another
quire resistance and are quite unaware of method of estimating incidence is from tu-
ever having come into contact with it. A berculosis notifications as seen in Fig. 13.2.
proportion, approximately 5%, will mani- There are also environmental factors
fest the disease in varying levels of severity. and density is as important as susceptibility
It might be nothing more than an enlarge- of the population. The dose of bacilli that
ment of the primary focus with a few sys- the individual will meet is increased by con-
temic effects, only to resolve spontaneously, tinued contact over a period of time. This
while others may have respiratory symp- dose/time factor is more likely to be found
toms or progress rapidly to blood stream in conditions of poverty and overcrowding.
spread presenting as a case of miliary or If the dose is sufficiently large and main-
tuberculous meningitis. The type and sever- tained for long enough, even the defences
ity of the disease is determined by the host of the immunologically competent individ-
response, but why one person should de- ual may be broken down.
velop tuberculosis, and another should not, The risk of infection is greatest in
cannot generally be determined. There is the young and rises again in the old, so over-
some evidence that susceptibility may be crowding increases the opportunity for
genetically determined as people who have infection to be acquired at a younger age.
suffered from tuberculosis, even if ad- Since the young mix extensively, they
equately cured, are more likely to develop a will have a greater opportunity for passing
new infection a second time. Some families on infection. At the other end of life, the
are particularly susceptible, as with the elderly often form persistent foci in a com-
famous literary family the Bronte sisters, munity, a potent source of infection to the
where first the mother died from tubercu- young.
losis, followed by nearly all the children, HIV infection has changed the epidemi-
yet the father never succumbed to the dis- ology and presentation of tuberculosis,
ease. The dose of bacilli might also be im- especially in Africa, leading to more lower
portant because young children in close lobe and extrapulmonary disease. (There
contact with an active case more commonly are estimated to be more than 20 million per-
develop severe tuberculosis (miliary or men- sons worldwide with dual tuberculosis and
ingitis). Factors that are known to reduce HIV, with the majority of these cases in
resistance are: Africa.) Reduced host response has in-
creased susceptibility and allowed reactiva-
. young age, especially the first year of life; tion or reinfection to take place as well as
. pregnancy; increasing the likelihood of new infection

Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof

Chapter 13

18.11.2004 5:48am page 160

The designations employed and the presentation of material on this map do not imply the expression of any opinion whatsoever on the part of the
World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers
or boundaries, Dashed lines represent approximate border lines for which there may not yet be full agreement.
Fig. 13.2. Tuberculosis notification rates, 2002. Reproduced by permission of the World Health Organization, Geneva.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:48am page 161

Respiratory Diseases and Other Airborne Transmitted Infections 161

from a contact or case; however, there is lence are defined as those where less than
evidence to suggest that HIV/tuberculosis 10% of children under 15 years have a posi-
patients are less infectious. Conversely, tu- tive tuberculin test. These are largely the
berculosis patients are more likely to rapidly countries of Western Europe and North
progress to full-blown acquired immuno- America. Tuberculosis, however, is increas-
deficiency syndrome (AIDS) when infected ing in Eastern Europe and the former USSR.
with the HIV virus. Initially HIV-infected Nearly the whole of the tropical world has a
tuberculosis patients commonly present high prevalence rate with some countries
with pulmonary infection similar to the HIV experiencing over 50% of the under 15-
negative case, but as the disease progresses, year-olds being tuberculin-positive. In add-
extrapulmonary tuberculosis predominates ition, urban areas have higher prevalence
and other manifestations of HIV disease, rates than rural areas. The rates are high in
such as chronic diarrhoea, generalized Africa and parts of South America. Asia,
lymphadenopathy, oral thrush and Kaposis India, Myanmar, Thailand and Indonesia
sarcoma, are more common. All HIV-positive all have high tuberculin-positive rates. In
cases should, therefore, be investigated the Americas, the indigenous peoples have
for tuberculosis and all tuberculosis cases a much higher rate than the non-indigenous.
tested for HIV. Despite the increase in extra- There is a high susceptibility in Pacific
pulmonary tuberculosis, it is still the Islands in which tuberculosis was an un-
sputum-positive case that is responsible for known disease until the arrival of explorers,
transmission of infection and this must who introduced the disease.
remain the priority in searching for cases.
Consumption of unpasteurized milk Control and prevention There are four main
may result in bovine tuberculosis in humans strategies for the control and prevention of
where the disease is present in the animal tuberculosis in the following order of prior-
population. This presents with enlargement ity:
and suppuration of the cervical lymph
nodes rather than pulmonary disease. It is . search and contact tracing for new cases;
now less common than before with the . adequate treatment of all cases, especially
testing of cattle and pasteurization of milk, the sputum-positive;
but in developing countries where cattle and . improvement of social and living condi-
their produce are an important part of the tions;
diet, such as in Central and South America, . BCG vaccination.
bovine tuberculosis is found.
Vaccination by BCG induces cell-mediated
Incubation period The period between infec- immunity to the mycobacteria and does not
tion and development of the primary com- generate humoral immunity, as do other
plex is 412 weeks. vaccines. BCG vaccination, therefore, alerts
the bodys defences rather than inducing
Period of communicability A new, untreated antibody formation. After a BCG vaccination
case of tuberculosis will normally produce a primary infection will still take place, but
organisms for 1218 months, but in those the progressive or disseminated infection
that develop a low-grade infection with will be reduced.
chronic cough, infection can continue Effectiveness of BCG varies consider-
for a considerable period of time (about ably in different countries in Europe,
5 years). Once treatment has started, the there is a good response, while in India, it
person becomes non-infectious in about is marginal. This is thought to be due to
2 weeks. atypical mycobacteria circulating in the en-
vironment and, therefore, BCG should be
Occurrence and distribution Tuberculosis is given at birth in developing countries or as
found worldwide (Fig. 13.2) in various soon after as possible. School entry or 1014
levels of severity. Countries of low preva- years is the main age for giving BCG in
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:48am page 162

162 Chapter 13

developed countries, while it is likely that Tuberculosis is particularly a disease of

some developed countries will move to a poor social conditions and overcrowding as
selective vaccination policy giving BCG shown by the remarkable decline of the in-
only to high-risk groups, such as immi- fection from industrialized countries prior
grants. BCG should be administered to all to the advent of chemotherapy. The disease
infants, including those born to mothers was as bad, if not worse in Europe, at the
with HIV infection. It should not, however, turn of the century than in many developing
be given to those with symptomatic HIV or countries now, but showed a progressive
pregnant women. and continuous reduction of cases as living
BCG is a freeze-dried vaccine given conditions improved. As standards in-
intra-dermally. Other methods, such as creased, there was a demand for improved
multiple puncture, jet injection or scarifica- housing with less people sharing the same
tion, have been found to be not so satisfac- room so that overcrowding declined. Per-
tory. The vaccine is sensitive to heat sonal hygiene improved and such practices
and light and, therefore, must be carefully as spitting disappeared almost completely
protected. (see Fig. 13.3).
Sputum smear examination is a very
simple technique for screening populations,
Treatment and prophylaxis The functions of
especially where there has recently been a
chemotherapy can be summarized as
case of tuberculosis. All contacts of a case
should have several sputum smears taken,
concentrating on the young and elderly. If a
contact has not been vaccinated, then they . treatment of individual cases to reduce
should be given BCG. Close contacts under 6 morbidity and mortality;
years of age and HIV-positive persons should . reduce the number and period of infec-
be given prophylaxis, unless they are sus- tious cases;
pected of having disease in which case they . provide a method of disease reduc-
should be given treatment. tion in developing countries where the



Specific chemotheraphy became available





10,000 Total
1915 1920 1925 1930 1935 1940 1945 1950 1955 1960 1965 1970 1975 1980

Fig. 13.3. The decline of tuberculosis in England and Wales 19121975. (From DHSS (1977) Annual Report of
the Chief Medical Officer, Department of Health and Social Security for 1976, Her Majestys Stationary Office,
London. Crown copyright, reproduced with the permission of the Controller of HMSO.)
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:48am page 163

Respiratory Diseases and Other Airborne Transmitted Infections 163

raising of social standards would take patient is cured, the Central Registry is noti-
some time to achieve; fied. Reminders and double checks can be
. prevent the emergence of resistant strains. built into the system, such as the central
registry sending out quarterly checks on
All treatment should be directly observed each patient.
therapy (DOT) to ensure compliance. A
newly diagnosed case of tuberculosis The sophistication of the system depends
should be treated with a four-drug regimen upon the resources of the country, but lack
for 2 months consisting of the following: of resources is never an excuse not to have a
system at all. To not follow-up a partially
treated patient is a waste of expensive hos-
Isoniazid 300 mg daily pital treatment, encourages the develop-
Rifampicin 10 mg/kg up to 600 mg daily ment of resistant organisms and increases
Pyrazinamide 35 mg/kg up to 2 g daily the risk to the community. Follow-up is
Ethambutol 25 mg/kg daily or streptomycin always cheaper than re-diagnosis and treat-
15 mg/kg daily ment.
Evaluation of the tuberculosis control
programmes is primarily by cohort analysis
This is followed by isoniazid and rifampicin in which the proportion of new smear-posi-
taken daily or three times weekly, for a fur- tive cases that are cured or are certified to
ther 4 months. If the taking of treatment have completed the treatment, but no smear
cannot be directly observed, then isoniazid done, is measured. The WHO target is 85%.
plus ethambutol taken daily should be used Other useful indicators are:
instead and given for a period of 6 months.
Treatment should continue for 912 months . annual rate of new tuberculosis cases
in those cases of miliary, tuberculosis men- diagnosed;
ingitis or bone/joint disease. . rate of sputum-positive cases diagnosed;
Prophylaxis with isoniazid can be given . proportion of children under 5 years of
to close contacts under 35 years of age and to age diagnosed;
babies (5 mg/kg) born to mothers, who de- . proportion of miliary and meningeal tu-
velop tuberculosis shortly before or after berculosis;
delivery. . rate of sputum smears examined;
. rate of BCG scars, on survey;
Surveillance A system to follow-up all diag- . relapse rate;
nosed cases of tuberculosis discharged from . rate lost to follow-up.
hospital or health centre is required on the
following lines: A decrease in the proportion of children
under 5 years of age diagnosed and those
1. Register the case with a central registry with miliary and meningeal tuberculosis
on diagnosis. will indicate improvement. However, this
2. When the patient is discharged, inform will need to be confirmed by a sputum
the registry, the nearest clinic to the persons smear survey. Nursing staff should be taught
home and the supervising doctor. to always give the BCG vaccination in the
3. The clinic ensures the patient receives same place, normally the deltoid area or lat-
regular follow-up treatment or goes and eral forearm below the elbow of the left arm,
finds them if they default. so that touring staff, school teachers, etc. can
4. The supervising doctor visits on a regular rapidly examine a group of children.
basis to check the clinical records and make The WHO DOTs strategy is summar-
sure that the registered patients are receiv- ized as:
ing treatment.
5. When the full course of treatment is com- . political commitment;
pleted and the doctor is satisfied that the . secure drug supply;
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:48am page 164

164 Chapter 13

. diagnosis by smear microscopy of passive because no prior contact with the new vari-
case-finding; ant has been made.
. treatment with rifampicin containing
DOT for 68 months; Clinical features ARIs are divided into upper
. cohort analysis. and lower ARIs, the former producing a run-
ning nose, sneezing and headache, while the
main symptoms of lower respiratory tract
13.2 Acute Respiratory Infections (ARI) infection are cough, shortness of breath and
inward drawing of the bony structure of the
lower chest wall during inspiration, which
The acute respiratory infections (ARI) are
is called chest indrawing. Both are generally
the commonest causes of ill health in
accompanied by fever. The main patho-
the world. WHO have estimated that there
logical feature is pneumonia, which can
are 1415 million deaths a year in children
either be lobar or bronchial. In lobar pneu-
under 5 years of age and one-third of these
monia, one or more well-defined lobes of the
are due to ARI, yet despite their importance,
lung are involved, whereas in bronchial
they are a poorly defined group of diseases.
pneumonia the condition is widespread.
They include the common cold, influenza,
The causes of pneumonia are listed in
pneumonia, bronchitis and a number of
Table 13.1.
other infections. They can be separated by
clinical criteria, but it is the differing re-
sponse of the individual to the organism Diagnosis Identifying the organism by cul-
that determines the clinical severity and ture of the sputum can be attempted where
management. A mild infection from an facilities permit, but in most developing
upper respiratory tract infection in one countries, ARI will be diagnosed on
person may develop in another to a life- clinical criteria.
threatening attack of pneumonia. It is, there-
fore, not only the organism that determines Transmission is by coughing out a large
the disease, but also the patients response number of organisms in a fine aerosol of
to the organism. droplets, which are either breathed in,
enter via the conjunctiva or are swallowed
Organisms A number of different organisms from fingers or utensils. Susceptibility and
have been implicated including Streptococ- response are determined by host factors,
cus pneumoniae, Haemophilus influenzae, some of which are listed below:
Mycoplasma pneumoniae, influenza, rhino-
viruses, adenoviruses, metapneumovirus 1. Age. Young children develop obstructive
and respiratory syncytial virus (RSV). diseases, such as croup (laryngo-tracheo-
Viruses are of a wide range, with each bronchitis) and bronchiolitis. Tonsillitis is
species having a number of serotypes, commonest in school age, whereas influ-
with new ones appearing from time to time. enza and pneumonia are important causes
However, the most important cause is of death in the elderly. In young children,
S. pneumoniae or the pneumococcus or mortality is inversely related to age.
H. influenzae. The host defends him or her- 2. Portal of entry. Volunteers have been
self by producing an appropriate immune more easily infected by some organisms ap-
response, but because of the large number plied to the conjunctiva than through the
of serotypes, it is a continuous process. In- nasopharynx.
fection will cause illness in some people, 3. Nutrition. Low birth weight and mal-
but not in others who have developed an nourished children have a higher morbidity
immune response to the specific organism and mortality. Certain nutritional deficien-
or an antigenically similar serotype. New cies, such as deficiencies of vitamin A and
antigenic mutations, as occur in influenza, zinc, contribute to the development of a
can cause epidemic or pandemic spread more severe disease and higher death rate.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:48am page 165

Respiratory Diseases and Other Airborne Transmitted Infections 165

Breast-feeding appears to have a protective tions and the active administration of anti-
effect. biotics to the severe case. The mild infection
4. Socio-economic. ARI is a disease of pov- is best treated at home and kept away from
erty with higher incidence in lower socio- sources of other infection, which may cause
economic groups and those that live in more serious disease, while the severe case
urban slums. Higher rates of lower respira- requires early treatment to prevent compli-
tory disease have been found with increas- cations and death. In children, the respira-
ing family size. Much of the reason for this tory rate and chest indrawing are used to
increase appears to be due to increased con- decide management:
tact and agglomeration as shown by children
attending day care facilities or school where . Mild cases, with a respiratory rate of less
infection occurs irrespective of social class. than 40 breaths/min in children of age
5. Air pollution. A correlation with domes- 212 months and 50 breaths/min in the
tic air pollution has been shown in South children of age 15 years, are treated at
Africa and Nepal. Passive smoking may home with supportive therapy. The
affect pulmonary function and make the mother should be encouraged to nurse
child more susceptible to infection as well her child, giving it plenty of fluids
as influence the child to become a smoker. (breast-feeding or from a cup), regular
6. Climate. More respiratory infections are feeding, cleaning the nose, maintaining it
found in the cooler parts of the world or in at a comfortable temperature and avoiding
the higher altitude regions of the tropics. contact with others.
There is a distinct seasonal effect in many . Moderate cases, with a respiratory rate of
countries, with more respiratory infections over 40 breaths/min in under-1-year-olds
in the winter. However, cold alone is not a and 50 breaths/min in children 15 years
causative factor. Cold derives its name old, but with no chest indrawing, should
from the belief that becoming chilled or be given antibiotics (oral cotrimoxazole
standing in a draught is responsible, but (4 mg/kg twice daily), oral amoxycillin
when volunteers are subjected to these (15 mg/kg three times a day) or intramus-
stresses and inoculated with rhinoviruses, cular penicillin G) and nursed at home.
they develop no more colds than controls. . Severe cases, with chest indrawing, cyan-
7. Other infections. Any infection, which osis or too sick to feed, must be admitted
causes damage to the respiratory mucosa, as in-patients and given active support as
will allow a mild infecting organism to pro- well as treatment with antibiotics.
gress to more serious consequences. The
most important of these diseases is measles, Control and prevention The first step in
with post-measles pneumonia being par- management of a child with ARI is to separ-
ticularly common. ate the mild from the moderate and to treat
the moderate and severe. The essence is
Incubation period This varies with the or- speed and active treatment. This can easily
ganism, but in most cases is 13 days. be taught at the primary health care level.
The mother can be educated on the manage-
ment of her child with a mild infection and
Period of communicability Variable; for the
when to refer. It is the delay in referral and
entire period of any respiratory symptoms.
treatment that will allow a moderate case to
become severe and the severe to die.
Occurrence and distribution Worldwide, the The village health worker can identify
most important cause of death in children in and treat the mild or moderate case of ARI
developing countries. using simple diagnostic criteria and a stand-
ard treatment protocol. Measuring the res-
Treatment The first line of action is to assess piratory rate and knowing which action
the severity of illness and give treatment. to take are the most important aspects.
This is supportive therapy for mild infec- Training and supervision of primary health
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:48am page 166

166 Chapter 13

care workers is a priority in the management nectomized children and the immuno-
of ARI. deficient. However, the new conjugate
Preventive actions that can be under- pneumococcal vaccine shows promise in
taken are listed below: children under 2 years of age and is likely
to be included in childhood vaccination
. Reduce contact. ARIs are just as common programmes if sufficient supplies can be
in industrialized countries as they are in made available. Vaccines against RSV,
developing countries, but infant deaths parainfluenza and the adenoviruses are
from respiratory infections in the former in preparation.
have declined. The reason would appear
to be due to smaller families and greater Surveillance Measles generally occurs as
birth intervals, permitting increased indi- seasonal epidemics, which can be fore-
vidual care of children and better nutri- casted and top-up vaccination given
tion. The child is reared at home and does (Section 12.2). Influenza is normally pan-
not need to be carried round where it is demic with warning given of strain of organ-
exposed at a very young age to infecting ism and vaccine composition, allowing
organisms. sufficient time for persons at risk to be
. Good nutrition. Well-nourished children protected.
are in a stronger position to defend them-
selves against any infection. Encourage
breast-feeding, especially during early
13.3 Influenza
stages of illness. Providing additional nu-
tritional support to children with measles
can prevent them developing post- Organism There are three types of influenza
measles pneumonia. viruses A, B and C with H antigen (15 sub-
. Health education. Teach people to cough types) and N antigen (9 subtypes), so that
away from others, cover the mouth when the virus is designated as H1N1, H1N2, . . . ,
coughing, not to spit or smoke and pro- H3N2. In addition, the site of isolation,
vide proper ventilation for smoke and culture number and year of isolation are
fumes. used (e.g. A/Beijing/262/95) (H1N1). So
. Vaccination of childhood infections. The far a major antigenic shift to H4 or N3 in
danger of developing pneumonia after human infection has not yet occurred. Anti-
measles is a serious problem, so preven- genic drift in both A and B viruses, produ-
tion of measles will reduce the severe cing new strains occurs at infrequent
forms of ARI. Indeed, measles vaccination intervals and is responsible for most epi-
is perhaps the single most effective demics.
preventive method (Section 12.2). Vaccin-
ation for H. influenzae is now recom- Clinical features Influenza presents with
mended by WHO in routine childhood fever, malaise, muscle aches and upper res-
immunization programmes. Pertussis, piratory symptoms of sudden onset. There is
diphtheria and BCG vaccination should initially a dry cough, which can sometimes
also be encouraged. be severe and often leads to secondary infec-
. Other vaccines. Influenza vaccine is pre- tion, with the production of sputum. It is a
pared annually according to the expected serious infection in the elderly with high
strain of influenza and should be given to death rates. When a major antigenic shift
those at risk (e.g. immunocompromised occurs as it did in 1918, all ages are suscep-
and those with chronic respiratory infec- tible and the number of deaths can be enor-
tions) if facilities allow. The polysacchar- mous (an estimated 50 million).
ide pneumococcal vaccine is not
recommended in routine childhood vac- Diagnosis is on clinical grounds taking care
cination programmes, but could be used to differentiate influenza (occurring season-
in special circumstances, such as for sple- ally or in epidemics) from other causes of
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:48am page 167

Respiratory Diseases and Other Airborne Transmitted Infections 167

respiratory infections, especially the Influenza vaccine is available for pro-

common cold. Direct immunofluorescence tecting at-risk persons, such as people over
(DIF) or virus isolation from throat or nasal 65 years of age, those with chronic chest or
swabs can be made in specialist centres. kidney disease and the immunocomprom-
ised. The difficulty of producing a vaccine
Transmission is via the airborne route is that a new one has to be produced each
through sneezing or coughing, but can also year, containing the expected composition of
be by direct contact with mucus. Influenza is antigenic sub-units. The WHO collaboration
highly infectious and spreads throughout centres, with reference laboratories through-
whole communities, potentiated by over- out the world, provide advance warning to
crowding and frequent social contact, such assist countries in producing vaccine, but
as at the work place. new techniques, such as virus manipulation
Influenza also occurs in birds and pigs to anticipate natural change in the virus,
and these may well be the reservoir from could allow banks of virus to be kept in store.
which human infection originates. The
close association of humans with domestic Surveillance Sentinel reporting centres with
birds and animals, particularly in South an agreed case definition probably provide a
China, is thought to be how new variants better idea of the influenza situation than
arise. collecting data of variable quality from
every clinic and hospital. This can be com-
Incubation period 15 days with a mean of 2 pared with laboratory-confirmed cases
days. where facilities permit. WHO reports on
the global situation in the Weekly Epidemi-
Period of communicability 2 days before ological Record (WER) from a worldwide
onset of symptoms to 5 days after. network of reporting centres.

Occurrence and distribution Influenza A is

responsible for pandemics and regular sea-
13.4 Whooping Cough (Pertussis)
sonal outbreaks, B for smaller localized out-
breaks and C produces mild infections. In
the tropics, epidemics tend to occur in the Organism Bordetella pertussis. B. paraper-
rainy season, while in temperate climates, tussis produces a milder disease.
influenza is nearly always a disease of the
winter months. Pandemics have occurred in Clinical features Illness commences with
1889, 1918, 1957, 1968 and 1977. upper respiratory symptoms, fever and
cough, which becomes paroxysmal with
Control and prevention As influenza is the characteristic whoop, or sometimes
highly infectious, the majority of the popu- ends in vomiting. The classic whooping
lation becomes infected during an epidemic, disease is not seen in children under 3
but any reduction of social contact, particu- months of age, when instead, they have
larly in crowded places, can reduce this like- attacks of cyanosis and stop breathing.
lihood. Spitting should be outlawed and Whooping cough is a serious disease if it
people encouraged not to cough directly at occurs at a young age, the severity being
people. The wearing of masks, as practised inversely proportional to age. A mild infec-
in China and Japan, is probably more effect- tion in the older child, it becomes an import-
ive in preventing spread from an infected ant cause of death in the very young.
person wearing a mask than in protecting
the non-infected. Once the cloth mask be- Diagnosis is mainly on clinical criteria,
comes damp through exhaled breath, it but culture of the organism from a nose or
ceases to be effective, but tight-fitting throat swab can be attempted, although the
masks with changeable filters should offer organism is difficult to grow. Serology is
reasonable protection. useful.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:48am page 168

168 Chapter 13

Transmission is via airborne spread of drop- Fluid loss is an important cause of mortality
lets particularly during the early stage of so mothers should be encouraged to give
illness. Older children and adults may extra fluids and breast-feed immediately
have such a mild infection that their import- after a coughing bout.
ance as a source of infection is not realized.
Vaccinated individuals can have sub- Surveillance In many countries, whooping
clinical infection in which organisms are cough is a notifiable disease.

Incubation period 710 days.

13.5 Diphtheria
Period of communicability 4 weeks from the
first symptoms, being most infectious in the Organism Corynebacterium diphtheriae and
first week, before the paroxysms start. rarely C. ulcerans.

Occurrence and distribution Whooping Clinical features Diphtheria produces both

cough is a serious disease in tropical coun- local and systemic effects. The organism
tries contributing to high rates of infant can infect the tonsils, pharynx, larynx,
mortality. Vaccination programmes have nose or skin, forming a pale grey membrane
markedly reduced the disease in the temper- and local inflammation. Symptoms are
ate regions of the world, but where the vac- fever, sore throat and enlarged cervical
cination programme has decreased or been lymph nodes in the pharyngeal form,
abandoned, it has rapidly returned as a blood-stained discharge in the nasal form
major health problem. and skin ulcers in the cutaneous form. The
Where the young infant is always inflammatory reaction produced in the re-
carried around by its mother, there is an spiratory tract can lead to swelling of the
increased opportunity for exposure, coming neck and respiratory obstruction. From the
into close contact with other children who primary site, exotoxin is produced, which
might be infectious. can cause myocarditis or neuropathy, espe-
cially cranial nerve palsies.
Control and prevention Isolation of cases, es-
pecially of young children and infants, Diagnosis Throat, nose or skin swab of the
should be instituted. Infective children exudate. A culture of the organism should be
should be kept away from school, markets sent to a reference laboratory if possible.
and any place where young children are
likely to congregate. Known contacts of a Transmission Diphtheria can be transmitted
case of whooping cough (e.g. in the by:
extended family of a case) should be given
a booster vaccination if they have been vac- . airborne transmission of droplets;
cinated before, otherwise they should re- . direct contact with lesions and exudates;
ceive prophylactic erythromycin and . indirect through articles soiled with dis-
vaccine. charges;
The median age for the disease is 2 . ingestion of contaminated milk.
years, but because of its severity, vaccin-
ation should be started at 12 months. In an unimmunized population, there is a
Three doses of vaccine are given, normally high incidence of carriers and a low inci-
combined with tetanus and diphtheria as dence of cases in a ratio of approximately
triple vaccine. 19:1. Between 6% and 40% of children are
infected every year so that by 5 years, some
Treatment Erythromycin is only effective 75% have been infected and by 15 years,
when given in the first week of the disease. nearly all the children are infected. This
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:48am page 169

Respiratory Diseases and Other Airborne Transmitted Infections 169

means that by 15 years of age, the majority of test dose for hypersensitivity. Erythromycin
children have developed immunity either or procaine penicillin G should be used for
by a sub-clinical infection or one in which specific treatment.
clinical symptoms were revealed.
Surveillance Diphtheria is a notifiable dis-
Incubation period 25 days. ease in most countries.

Period of communicability About 2 weeks.

13.6 Meningococcal Meningitis
Occurrence and distribution Commonly a
disease of children, diphtheria can occur in Organism Neisseria meningitidis. Many ser-
non-immunized adults with serious results. ogroups and sub-groups have been identi-
Outbreaks of the disease are seen, but it is fied, but of these A, B, C and Y are the most
probably a much more frequent disease than important in producing disease, while A
realised, as sub-clinical transmission and C predominate in epidemics. W135 has
through skin and possibly nasal lesions, recently been responsible for some out-
maintains immunity. This was probably breaks.
the situation in many tropical countries,
but now universal childhood vaccination Clinical features Fever, headache, vomiting,
programmes are protecting young children. neck stiffness and progressive loss of con-
A breakdown of these programmes, or sciousness. A petechial rash, which does
remaining pockets of unvaccinated adults, not blanch, is an important sign. Infants
leads to serious disease. show floppiness and high-pitched crying,
while children may present with convul-
Control and prevention Diphtheria is pre- sions.
vented by vaccination of all children with
three doses of diphtheria toxoid. This is Diagnosis is by lumbar puncture, but should
normally combined with pertussis and tet- not delay early treatment, which can be
anus as triple vaccine commencing in the given straight away and lumbar puncture
first or second month of life. Ideally, a done afterwards if necessary. A Gram stain
booster dose should be given at 18 months is only reliable in some 50% of cases, so
to 4 years of age. As with polio and rubella culture should be attempted wherever pos-
vaccination, diphtheria immunization sible and sensitivity obtained. Blood should
shifts the likelihood of disease to an older also be taken for culture and polymerase
and more dangerous age so complete cover- chain reaction (PCR). Smears from petechiae
age of all children is imperative. Adults can also be examined by Gram stain.
visiting an endemic country from one in
which the vaccination status is good, should Transmission is by airborne spread of drop-
have an adult-type booster (adult Td) in lets and from direct contact with secretions
which the concentration of the toxoid is re- from the nose or throat. The organism is
duced. Ideally, adults, particularly travel- found commonly in the nasopharynx so
lers, should have booster doses of adult Td other factors must also be responsible for
every 10 years. meningitis to occur.
In the event of an outbreak, previously Epidemic meningitis was first studied
vaccinated contacts should be given tetanus in cooler climates and an association found
and diphtheria toxoids and those not vac- with overcrowding, especially in military
cinated the toxoid and an antibiotic (ery- institutions. The organism when introduced
thromycin or penicillin). into an overcrowded environment produced
both cases and carriers (nasal). As the
Treatment If diphtheria antitoxin is avail- number of carriers increased, the number
able, it should be given to cases following a of cases of meningitis did so likewise.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:48am page 170

170 Chapter 13

However, in the African (Sahel) epidemic native explanation is that transmission is

form, the heat makes people spend much of directly from the nose through the skull
their time out of doors and overcrowding is and any traumatic insult to the nasal
not a phenomenon at this time of year (Fig. mucosa, such as the intense drying out
13.4). Although overcrowding seems to in- during the Sahel hot season, or upper res-
crease the number of carriers and the poten- piratory tract infection in colder climates,
tial for more cases, it does not explain the potentiates a greater number of organisms
mechanism for causing meningitis. to pass along these minute channels and
The organism inhabits the nasal mucosa overcome the defences of the meninges.
within which it is anatomically very close to
the meninges, although separated by for- Incubation period 210 days.
midable barriers of bone and membrane.
The generally accepted theory is that the
Period of communicability Once effective
organism passes from this site into the
treatment has started, the patient ceases to
blood stream, crosses the bloodbrain bar-
be infective within 24 h, but any carrier will
rier and enters the cerebrospinal fluid (CSF).
continue to produce organisms for between
Experimental evidence does not substanti-
2 weeks and 10 months.
ate this route unless there has been some
trauma to the meninges. Difficult though
the direct route may seem, it has been Occurrence and distribution Meningococcal
shown that minute passages through the meningitis occurs in epidemics, especially
bone of the skull do occur and transmission in the Sahel part of Africa in a band stretch-
of organisms along this route is a possibility. ing from Senegal to Ethiopia. The epi-
Furthermore, if organisms are introduced demics are markedly seasonal occurring in
directly into the sub-arachnoid space, infec- the early part of the year when the tempera-
tion will only occur if a critical level is ture is hottest and relative humidity at its
exceeded (103 organisms in dogs), suggest- lowest. With the arrival of the rains, the epi-
ing that this route could frequently be in- demic abates (Fig. 13.4). The amount of rain-
vaded, but only when there is excessive fall (1100 mm) delineates the southern
infection does meningitis develop. An alter- boundary of the meningitis belt, whereas






Jan. Feb. Mar. Apr. May. June July Aug. Sept. Oct. Nov. Dec.

No. meningitis Relative humidity %

Fig. 13.4. The seasonal variation of meningococcal meningitis in relation to relative humidity in the Sahel
region of Africa.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:48am page 171

Respiratory Diseases and Other Airborne Transmitted Infections 171

the northern boundary is the desert. Within lating a vaccination programme. Vaccine
this area, major epidemics, mainly of group can be used to immunize those most at risk
A, occur at 714-year intervals, with lesser concentrating on the 220-year age group
ones in between. and household contacts of cases. When
In addition to the meningitis epidemic there is an epidemic, mass vaccination
belt in Africa, there have also been epidem- should be given to communities in the
ics of group A organisms in India and Nepal, affected area, including vaccinating chil-
and group B in the Americas, Europe and dren below 2 years of age. It has been sug-
Pacific Island Nations. gested that an incidence of 15 cases per
Epidemic meningitis is commonest in 100,000 in a well-defined population for 2
the age group of 515 years, with males consecutive weeks heralds the beginning of
more frequently affected than females. an epidemic and the need to start mass vac-
Only about one in 500 persons infected cination.
with the organism will develop meningitis. A conjugated C vaccine has been found
Large, poor families and other conditions to be effective in all age groups, especially
where there is overcrowding, such as reli- young children, and in countries where
gious and social gatherings, refugee camps group C meningococcal disease is an import-
and labour lines, make meningitis more ant health problem it could be included
likely. in the national childhood vaccination pro-
gramme. If an epidemic is found to be
Control and prevention Overcrowding en- due to group C, then this vaccine should
courages the transfer of the infecting organ- be used.
ism and the carrier state, as well as
increasing the dose of bacteria that may be Treatment may need to be organized on
transmitted. All efforts should be made to a massive scale when an epidemic occurs
reduce overcrowding. It may be necessary by using dispensers, school teachers or
to close schools and reduce congregation of other educated people to care for isolated
people, such as in markets and religious communities. Temporary treatment centres
gatherings. In the long term, improvement (schools, churches, warehouses, etc.)
of housing and family planning will have may need to be set up, rather than bring
an effect. people into hospital. Benzyl penicillin or
Chemoprophylaxis should be given to chloramphenicol should be used, but in
close contacts, such as all family members, many countries, resistance to these antibiot-
school friends and anyone sharing in a large ics will require the use of cephalosporins.
communal sleeping place (such as a dormi- If the organism is unknown, use chloram-
tory). Rifampicin 10 mg/kg twice daily for 2 phenicol. In epidemics, long-acting chlor-
days, or if still sensitive to sulphonamides, amphenicol in oil preparations, given as
sulphadiazine 150 mg/kg for 2 days can be a single injection, avoids the problem
used. Chemoprophylaxis is not recom- of repeat injections. Dehydration is common
mended in large epidemics. and intravenous fluids may be required
There are several vaccines containing initially, followed by frequent drinks
either A and C, or A, C, Y and W135. administered by an attending adult.
Unfortunately, the very young and those
with acute malaria develop reduced Surveillance The regular epidemics that
immunity. There is also a genetic variation occur in Africa can be forecast and a
with some ethnic groups having a poor state of preparedness put into action. When
response. Due to these different factors, there is a case of meningitis, all contacts
duration of immunity varies from 3 years should be examined with nasalpharyngeal
or less in young children and must be swabs. Subtyping of the organism can assist
measured for each community when formu- in mapping out epidemics.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:48am page 172

172 Chapter 13

13.7 Haemophilus influenzae countries H. influenzae infection occurs

(Meningitis and Pneumonia) before this age. Where vaccination pro-
grammes are starting or catch-up vaccin-
Organism Haemophilus influenzae, com- ation of adults and children over 18 months
monly serotype b (Hib). is to be done, a single dose of vaccine is
sufficient. Hib can safely be given at the
same time as meningococcal vaccine.
Clinical features Fever, vomiting, stiff neck
In the event of an outbreak of several
and rigid back in older children, bulging
cases of meningitis, vaccination should be
fontanelle in infants. A common cause of
given to all children under 5 years of age
secondary infection in measles and other
within the area. Contacts of all ages in
respiratory infections, resulting in pneumo-
households or close communities where
nia (see Section 13.2). H. influenzae can also
there are unvaccinated children should be
cause epiglottitis, cellulitis, septic arthritis,
given prophylaxis with rifampicin (see also
osteomyelitis, empyema and pericarditis.
Section 13.6).
Diagnosis The CSF is often purulent, but
this can occur in other causes of meningitis; Treatment is with ampicillin or chloram-
hence culture of CSF or blood should be phenicol.
made. Serological tests are also of value.
Surveillance All family and contacts of a
Transmission Airborne transmission of case of meningitis should be investigated
droplets and direct contact with nasal by nose swabs. Children under 5 years
pharyngeal secretions. The organism is of age, who have been in contact with a
carried asymptomatically in the nose of case, should be followed-up and treatment
carriers who are often the source of infection started if they develop early signs, such as
to infants. fever.

Incubation period 24 days.

13.8 Pneumococcal Disease
Period of communicability Chronic nasal in-
fection can remain for a prolonged period. The pneumococcus causes a variety of dis-
eases, including ARI (Section 13.2), pneu-
monia (Table 13.1), meningitis (Table 13.2)
Occurrence and distribution H. influenzae is
and otitis media (Section 13.9), which are
the commonest cause of meningitis in
more conveniently covered under the vari-
infants and young children under 5 years
ous diseases they cause, but in view of the
of age, mainly 418 months of age. At pre-
availability of a vaccine, its possible use in
sent, it is a serious problem in developing
preventing these diseases will be discussed
countries, but with the advent of universal
Hib vaccination, the incidence is likely to
decline considerably, as has been the case
in developed countries. Organism Streptococcus pneumoniae the
Control and prevention Routine vaccination
of all children with Hib vaccine is now Clinical features S. pneumoniae is the com-
recommended. Vaccine should be given at monest cause of ARI and pneumonia, pre-
the same time as DTP or as a combination senting with cough, fever and rusty
vaccine (DTP/Hib). National vaccination coloured sputum (from blood staining).
programmes may include a booster dose at Both bronchopneumonia and lobar pneumo-
1218 months, but in most developing nia result, leading to a high mortality in
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:48am page 173

Respiratory Diseases and Other Airborne Transmitted Infections 173

Table 13.1. The causes of pneumonia.

Organism Clinical indicators Occurrence

Streptococcus pneumoniae Fever, cough, rusty sputum Infants, elderly

Haemophilus influenzae Slow onset, purulent sputum Secondary infection
Influenza A and B Fever, muscle pains Epidemic
Morbillivirus Measles Seasonal epidemics
RSV Wheezing, croup Seasonal winter peak
Adenoviruses Sore throat, conjunctivitis Children, winter months
Metapneumovirus Asthma, bronchiolitis Children
Coronavirus SARS Respiratory distress Close contact, animals?
Parainfluenza Croup, wheezing Children, immunodeficient
Mycoplasma pneumoniae Slow onset, malaise Epidemic, young adults
Chlamydia pneumoniae Slow onset, malaise Young adults
Staphylococcus aureus, Abscess formation Secondary infection, particularly of
Streptococcus pyogenes, influenza
Klebsiella pneumoniae
Legionella pneumophila Increasing fever, anorexia Air conditioners, males
Chlamydia psittaci Fever, unproductive cough Associated with birds
Coxiella burnetti Fever, weight loss Associated with sheep
Pneumocystis carinii Progressive dyspnoea Immunosuppressed, HIV
Cryptoccus neoformans Mycosis, disseminated Immunosuppressed, HIV
Nocardia asteroides Chronic, disseminated Immunosuppressed, HIV

Table 13.2. The causes of meningitis.

Organism Clinical indicators Occurrence

Neisseria meningitidis Fever, headache, rash Epidemic, African meningitis belt,

children and adults
Haemophilus influenzae Fever, vomiting, lethargy Infants
Streptococcus pneumoniae Fever, purulent CSF Infants, elderly
Mycobacterium tuberculosis Fever, cough, haemoptysis Children, young adults
Staphylococci Secondary infection Unsterilized instruments
Escherichia coli Floppy infant, not feeding Following delivery
Group B streptococci Floppy infant, not feeding Following delivery
Listeria monocytogenes Neonates, following birth Infection in the mother from
domestic animals or cheese
Campylobacter jejuni Diarrhoeal illness All ages (Section 9.2)
Echoviruses Clear CSF, rash Epidemic and seasonal
Coxsackieviruses Clear CSF, rash Epidemic and seasonal
Arboviruses Clear CSF, encephalitis Epidemic (Section 15.2)
Influenza A or B Reye syndrome Children given salicylates
Herpes zoster Reye syndrome Children given salicylates
Mumps virus Parotid swelling, encephalitis (Section 12.4)
Rubella virus Rash, encephalitis Neonates (Section 12.3)
Polio virus Flaccid paralysis Children (Section 8.10)
Herpes simplex type 1 and 2 Primary sore or genital infection Neonates, children or adults
Treponema pallidum Secondary or latent syphilis Adults (Section 14.4)
Cryptococcus neoformans Fungal infection Tropics, males
Leptospira interrogans Fever, myalgia, rash Infection from rat urine
Lymphocytic choriomeningitis Influenza-like symptoms Associated with mice
Angiostrongylus cantonensis Nematode worm Eating snails and slugs
Borrelia burgdorfi Lyme disease Deer ticks (Section 16.8)
Negleria and Acanthamoeba Amoebic meningoencephalitis Swimming pools,
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:48am page 174

174 Chapter 13

infants and the elderly. S. pneumoniae is Section 13.2 and in the same way as for
also the commonest cause of otitis media, otitis media in Section 13.9. Family plan-
causing fever and pain in the ear. If un- ning and the reduction of overcrowding
treated, this can lead to bacteremia and ful- should be advocated; smoking and having
minant meningitis, with a high fatality rate. open fires in the main living part of the
There is a high fever, lethargy and the patient house should be discouraged. Hand-wash-
rapidly descends into coma. S. pneumoniae ing and the careful disposal of discharges
is also a common cause of conjunctivitis. from nose, throat and the infected eye
should be practised.
Diagnosis is by culture of sputum, blood, A polysaccharide vaccine provides ap-
eye discharges or CSF. Gram stain of the proximately 65% efficacy in adults and can
characteristic blue staining diplococci pro- be used in high-risk patients, such as
vides a rapid indication of the likely healthy elderly adults living in institutions,
infecting organism. patients with chronic organ failure, those
with immunodeficiencies, splenectomized
Transmission is normally airborne spread of children and those with sickle cell disease.
droplets during sneezing or coughing from Unfortunately, the vaccine has limited effi-
infected persons or healthy carriers. Some cacy in children under 2 years of age and,
25% of persons carry S. pneumoniae in therefore, cannot be included in the routine
their nasopharynx, although these might childhood vaccination programme, and is
not all be the disease-producing serotypes. not currently used in developing countries
Transmission can also be by direct contact where a suitable vaccine would be of most
or through articles soiled with secretions, value. However, a conjugate vaccine was
such as handkerchiefs or clothes used to introduced into general use in USA in June
wipe the eye in conjunctivitis. 2000 for all children 23 months old and
younger, and for children 2459 months of
Incubation period 13 days. age who are at high risk of serious pneumo-
coccal disease. The vaccine has been shown
to be highly efficacious against invasive
Period of communicability is as long as secre-
pneumococcal disease, but only moderately
tions are produced in the clinical case, but
efficacious against pneumonia and otitis
the importance of healthy carriers is un-
media. At present, demand is outstripping
clear, with some possibly responsible for
supply, but depending on the results experi-
producing infection in the young or elderly
enced in USA and supply problems, it is
over considerable periods of time. Adequate
likely that this vaccine will soon be in-
treatment should render the case or carrier
cluded in routine childhood vaccination
non-infectious within 2 days.
programmes in other countries, including
the developing world. An alternative strat-
Occurrence and distribution Worldwide dis- egy may be to vaccinate pregnant women so
tribution, especially in developing coun- that maternal antibodies are passed on to the
tries, with ARI being a major cause of newborn child.
mortality in children. It is one of the com-
monest causes of terminal pneumonia in the
elderly in the developed world. Overcrowd- Treatment Penicillin G or erythromycin
ing and deprived socio-economic condi- are effective in the majority of cases, but
tions favour the disease. Miners and people where resistant strains are found or the
living in smoke-filled huts, such as in Papua child is seriously ill, cotrimoxazole, amoxi-
New Guinea, have an increased incidence. cillin or ampicillin should be used.

Control and prevention Active management Surveillance for ARI will be found in
and treatment of cases of ARI and pneumo- Section 13.2 and for otitis media in Section
nia should be carried out as outlined in 13.9.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:48am page 175

Respiratory Diseases and Other Airborne Transmitted Infections 175

13.9 Otitis Media Where the drum has ruptured, deafness

will result, leading to problems at school,
Acute ear infections are a common problem so what started off as a seemingly insignifi-
in children and are responsible for consider- cant problem can lead to poor development
able morbidity (Table 1.1). Acute middle ear and disability throughout the life of the in-
infection or otitis media is the main disease, dividual. Otitis media and deafness occur-
but this can lead to chronic otitis media or ring in the first 23 years of life can interfere
mastoiditis (chronic infection of the bony air with spoken language acquisition, leading
cells below the ear) or meningitis. to difficulties in communication, under-
The ear is joined to the nasopharynx standing and a barrier to education.
by the eustachian tube through which There is a particularly high level of
infecting organisms pass, so ear infections otitis media in Australian aboriginals and
are generally associated with respiratory the Inuit people of the Arctic with Pacific
infections. Islanders and native North Americans next
in order of magnitude. This may be due to
these people having larger eustachian tubes,
Organism S. pneumoniae and H. influenzae
which offer lower resistance to the passage
are the most common causative organisms,
of organisms.
but various viruses may initiate infection
and Pseudomonas aeruginosa and
Staphylococcus aureus are common in the Control and prevention Upper respiratory
discharges of chronic otitis media. infections should be adequately treated and
the eardrum always examined for redness
and bulging. The same risk factors that
Clinical features Fever and pain in the ear
cause ARI (Section 13.2) predispose to otitis
are the main presenting symptoms, but in
media, so relevant preventive action can be
the young child, crying and irritability will
be more prominent. The eardrum is red and
The conjugate pneumococcal vaccine
bulges outwards, rapidly leading to perfor-
has been shown to be moderately efficacious
ation and the appearance of pus. There will
against otitis media and once it becomes
be deafness in the ear until the perforation
more universally available, it can be antici-
has healed, or permanent deafness if the
pated to contribute to a reduction of this
condition remains untreated.
The child with deafness should be
Diagnosis is on clinical grounds and the examined and if found to have a discharging
infecting organism can be cultured if the ear should be treated as below: if the ear-
eardrum has ruptured. drum does not heal, then corrective surgery
can be performed.
Transmission is secondary to an upper res-
piratory infection, such as a sore throat or
Treatment In acute otitis media, penicillin G
or erythromycin given systemically for 5
days may be sufficient, but if there is poor
Incubation period 14 days. response or perforation has occurred, then
cotrimoxazole twice a day or amoxicillin
Period of communicability Not normally three times a day for 5 days should be used.
transmitted from person to person, except In the chronically discharging ear, it is im-
as an upper respiratory infection. perative to dry the ear out with wicking,
which the mother can be taught to do.
Occurrence and distribution This is a very Clean tissue paper is twisted into a point
common condition throughout the world and placed in the ear, replacing it as soon
and many children develop ear infections as it becomes wet and repeating until the ear
during the course of their childhood. remains dry. The child should not swim or
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:48am page 176

176 Chapter 13

water allowed to enter the ear when wash- lower (<1%) following endemic or sporadic
ing. Boric acid in spirit ear drops can be streptococcal infections. Healthy primary
instilled to help in drying the ear. school children are commonly found to be
carriers of GAbHS. Cutaneous streptococcal
Surveillance Surveys of deaf and partially infection is a frequent precursor of acute
deaf children will give an indication of the nephritis, but has not been shown to cause
amount of otitis media leading to perfor- ARF. Scarlet fever, however, is associated
ation of the eardrum. Where finances with ARF.
permit, this is best done by typanometry, Why only a small percentage of the
but a simple test using the spoken voice youthful population develop ARF remains
can give a rough estimate: a mystery. ARF patients, as a group, show a
higher antibody level to group A streptococ-
. responds to a whisper no deafness; cal antigens suggesting that repeated expos-
. responds only to the normal voice mod- ure to GAbHS may precipitate illness.
erate hearing impairment; Susceptibility is due to the immunological
. responds only to a loud voice severe status of the host, including both humoral
deafness. and cell-mediated immunity, with a 2%
familial incidence of ARF. A larger propor-
tion of children born to rheumatic parents
13.10 Acute Rheumatic Fever contract the disease. The carditis of RHD
might be the result of an autoimmune mech-
anism developing between group A strepto-
Organism Group A b-haemolytic strepto-
coccal somatic components and myocardial
coccus (GAbHS). The M-protein in the wall
and valvular components.
of the streptococcus is responsible for its
virulence and certain predominant sero-
Incubation period of the initial streptococ-
types, 1, 3, 5, 6, 14, 18, 19, 24, 27 and 29,
cal infection is 13 days and 19 days for
have a much greater rheumatogenic poten-
Period of communicability 1021 days of an
Clinical features ARF is a delayed non-sup- acute, untreated streptococcal infection.
purative sequel of upper respiratory tract
infection or scarlet fever with GAbHS. ARF Occurrence and distribution ARF/RHD is the
is important because it can lead to rheumatic commonest form of heart disease in children
heart disease (RHD), the resulting cardiac and young adults in most tropical and
damage producing considerable morbidity developing countries. The peak incidence
and mortality. is 515 years, but both primary and recur-
rent cases can occur in adults. There is
Diagnosis of ARF is based on major and neither a sex predilection nor a racial predis-
minor clinical criteria and a rising serum position.
antibody titre of a recent streptococcal infec- ARF is a disease of lower socio-
tion by the antistreptolysin-O titre (ASOT), economic groups, particularly those massed
antihyaluronidase or anti-DNase B tests. in the densely populated areas of urban met-
ropolitan centres. It is widespread with a
Transmission ARF results from an inter- high incidence in South Asia, Pacific
action of the bacterial agent, human host Islands, North and South Africa and urban
and environment. GAbHS are transmitted Latin America. It has been estimated that
from person to person through relatively RHD causes 2540% of all cardiovascular
large droplets, up to a distance of 3 m. ARF diseases in the developing world.
develops at a fairly constant rate of 3%
following untreated epidemics of strepto- Control and prevention There is no per-
coccal pharyngitis. The attack rate is much manent cure for RHD and the cumulative
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:48am page 177

Respiratory Diseases and Other Airborne Transmitted Infections 177

expense of repeated hospitalization for sup- diazine may be used for oral prophylaxis.
portive medical care is a considerable drain Regular taking of prophylaxis is essential
on the meagre health resources of develop- and compliance is a major problem. Patients
ing countries. The only reasonable solution with no evidence of cardiac involvement
is the prevention of rheumatic fever. ARF is should receive prophylaxis for a minimum
now a rare condition in developed countries of 5 years after the last attack of ARF, while
due to improved housing, reduction of over- those with carditis should continue until
crowding and the provision of adequate they are 25 years old. Prophylaxis should
health services, so this should be the long- be continued with penicillin in the pregnant
term aim. woman.
Prevention of the first attack (primary The emphasis of a prevention pro-
prevention) is by proper identification and gramme should be on health education,
antibiotic treatment of streptococcal infec- early diagnosis and treatment of sore throats
tions. The individual, who has suffered an and the provision of treatment facilities at
attack of ARF, is inordinately susceptible to primary level.
recurrences following subsequent strepto-
coccal infection and needs protection
(secondary prevention). While primary pre- Surveillance In developing strategies,
vention is preferable, the incidence of ARF baseline data on streptococcal epidemiology
as a sequel of streptococcal sore throat is and ARF/RHD prevalence in high-risk
never greater than 3%, even in epidemics. groups should be collected. A fully estab-
A vast number of infections would need to lished programme centre would operate a
be treated in order to achieve any meaning- central register, coordinate case-finding
ful reduction of the total number of sore surveys, run a system of secondary prophy-
throats and streptococci are responsible for laxis (especially follow-up) and promote
only 1020% of them. health education. Community control of
Most cases of severe RHD would be pre- ARF and RHD is viable only if it is firmly
vented by adequate prevention of recur- based on existing health services, which are
rences of ARF. No matter how mild the first an integral part of the primary health care
attack of ARF, secondary prevention with activities in the country. It is especially rele-
intramuscular long-acting benzathine peni- vant to school health services, by screening
cillin G 1.2 million units should be given at children and supporting those on secondary
monthly intervals. Penicillin V or sulpha- prophylaxis.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 19.10.2004 10:18am page 178

Diseases Transmitted Via Body Fluids

This category includes infections transmit- rounded papules, scattered all over the
ted from one human to another by the physio- body. These lesions exude serum, which is
logical fluids of the body: blood, serum, highly infectious. There is also a mild peri-
saliva, seminal fluid, etc. Transmission is ostitis in focal bony sites, but these and the
normally direct, but indirect transmission skin lesions normally heal with little
via fomites or flies can occur in some cases. residual damage. It is the tertiary stage that
It includes the treponematoses, both the appears after an asymptomatic period and
sexually and non-sexually transmitted. some 5 years after initial infection that
Sexual transmission accounts for the largest results in gross damage to skin and bone,
number of persons affected by these leading to hideous deformities. The oppos-
diseases. ite ends of the body are affected with
These are the diseases of close personal destructive lesions of the nasal bones
contact, either thriving in conditions of poor (gangoza) and scarring, and deformity of
hygiene, or in the most intimate contact of the lower limbs (sabre tibia).
all by sexual intercourse. They are, there-
fore, social diseases, determined by the Diagnosis is by finding T. p. pertenue in the
habits and attitude of people and it is only exudates of lesions. In the motile state, the
by effecting change in these values that any spirochete can be seen by dark ground mi-
permanent improvement will occur. croscopy or stained by Giemsa or silver salts.
The serological tests for syphilis (Section
14.1 Yaws 14.4) are positive.

Organism Treponema pallidum subspecies Transmission Yaws is a disease of poor hy-

pertenue. giene, with close bodily contact being the
manner in which infection is commonly
Clinical features Yaws is a non-venereal transmitted. Flies may be involved in trans-
treponemal disease affecting both the skin mission from clothing and dressings that
and bone. It commences as a primary papule have become contaminated by fluid from
that starts to heal, but after a period, varying sores. The spirochete cannot penetrate un-
from a few weeks to several months, it is broken skin, but requires a minor skin abra-
followed by generalized lesions, multiple sion or cut by which to enter.

Q R. Webber 2005. Communicable Disease Epidemiology and Control, 2nd edition (Roger Webber)

Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 19.10.2004 10:18am page 179

Disease Transmitted Via Body Fluids 179

Incubation period 28 weeks. areas, but unfortunately, there is now a

resurgence. Newly trained health personnel
Period of communicability can be as long as are unaware of the disease and penicillin
moist lesions persist in the untreated case, has been replaced by other antibiotics in
which can be several years. the treatment of common infections.
In the long term, improvements in the
level of hygiene and socio-economic status
Occurrence and distribution Yaws is pre- will reduce the conditions in which yaws
dominantly an infection of children, with thrives.
the mother becoming infected if she did not
acquire her infection in childhood. The
large overcrowded family with a poor stand- Treatment is a single injection of benzathine
ard of hygiene is the characteristic environ- penicillin G (1.2 million units for an adult,
ment in which yaws so readily spreads. The 0.6 million units for a child). Response is
need to stay indoors and keep close together very satisfactory and lesions heal within
for warmth in the rainy season might be the 23 weeks.
reason why the disease is more common at
this time of year. Surveillance Due to the possible appearance
Yaws is restricted to the moist tropical of new cases, a continuing awareness of
areas of the world in a band that passes the disease needs to be kept, with the
through the Caribbean, South America, taking of smears from any suspicious
Africa, Southeast Asia and the Pacific lesions. It is likely that search will discover
Islands (Fig. 14.1). A resurgence of cases more cases, so treat cases and contacts
has occurred in West Africa, India, South- along the same lines as in the eradication
east Asia, Pacific Islands, South America campaigns.
and the Caribbean.

Control and prevention Yaws with its rapid 14.2 Pinta

response to a single injection of penicillin
has been the subject of successful mass Organism Treponema carateum.
treatment campaigns in the endemic parts
of the world. Treatment in a mass campaign Clinical features The disease has many simi-
is to: larities to yaws, commencing as a primary,
painless papule. Secondary lesions, which
. all those with clinical signs of yaws; develop in 312 months, are flat and erythe-
. household, school and other close con- matous, but cover large areas of the body.
tacts; Tertiary lesions result in pigmentary
. any person suspected of incubating the changes often with large patches of leuco-
disease. derma. Only the skin is involved in pinta
with lesions commonly on the face and
The campaign is preceded by health educa- extremities.
tion encouraging all people to come forward
with any suspicious lesions. Each village is
visited in turn, everyone examined and Diagnosis is made on clinical grounds with
treatment given to cases, contacts or sus- supporting evidence from positive sero-
pects. A follow-up surveillance service logical tests for syphilis. T. carateum can
treats missed cases or new infections. This be found in the serous exudates from lesions
can readily be done by an effective rural by dark ground microscopy.
health service.
The success of the WHO mass cam- Transmission Direct contact or carriage by
paigns against yaws resulted in the virtual flies has been suggested as the means of
disappearance of the disease from many transmission. Trauma, especially to the

Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 19.10.2004 10:18am page 180
Chapter 14
Fig. 14.1. Distribution of the endemic treponematoses. (Reproduced by permission from Weekly Epidemiological Record, World Health Organization, Geneva.)
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 19.10.2004 10:18am page 181

Disease Transmitted Via Body Fluids 181

lower limbs, might facilitate entry of shared drinking vessels and eating utensils
organisms. is considered the most likely route. Direct
contact with lesions is also a likely method
Incubation period 13 weeks. of spread. It resembles venereal syphilis in
many of its features except that it is not
spread venereally.
Period of communicability is probably sev-
eral years, while secondary lesions are pre-
sent. Incubation period 2 weeks to 3 months.

Occurrence and distribution Pinta is re- Period of communicability is for as long as

stricted to moist tropical areas of Central moist lesions are present, generally several
and South America (Fig. 14.1), occurring in months.
communities with poor hygiene, such as in
the Amazon and Orinoco basins. Adults and Occurrence and distribution The non-
adolescents are mostly involved. Recent venereal form of syphilis is found in local-
surveys found the disease to be naturally ized foci in Africa and the Arabian
dying out. peninsula (Fig. 14.1), where it is known
locally as Bejel or Njovera. Predominantly
Control and prevention Mass treatment with an infection of childhood, it thrives in con-
penicillin in the same manner as for yaws ditions of poverty, overcrowding and where
(see above). there is limited sanitation.

Control and prevention It is a disease of low

14.3 Endemic Syphilis personal hygiene where crowding together
and contact with lesions readily occurs.
Cross-immunity is shared with venereal
Organism Treponema pallidum subspecies
syphilis, therefore, eradication of the dis-
endemicum, which is indistinguishable
ease by mass treatment generally means a
from the T. pallidum that causes venereal
replacement by the more serious and devas-
tating venereal syphilis. Family planning,
better housing, education and improving
Clinical features The primary lesion is com- the general standard of hygiene might be
monly found at the angle of the mouth, a preferable control strategy in such situ-
appearing as a raised mucous plaque. ations.
A more florid skin infection follows with
moist papules under the arms and between
the buttocks and a maculo-papular rash on Treatment is with penicillin in the same
the trunk and limbs, resembling venereal manner as yaws.
syphilis. Destructive tertiary signs in the
skin, nasopharynx and bones develop after
months or years, but the nervous and cardio- 14.4 Venereal Syphilis
vascular systems are rarely involved.
Organism Treponema pallidum subspecies
Diagnosis is made on clinical grounds in en- pallidum.
demic areas and by detecting the organism
with dark ground microscopy. Serological Clinical features. The primary lesion of
tests for syphilis are positive and remain so syphilis is the chancre (a painless ulcer
for many years. with a serous discharge) normally found on
the genitalia of males and females, but can
Transmission Because of the site of the pri- occur in the mouth, on the breast or in the
mary lesion on the mouth, transmission by ano-rectal region. A regional lymph node
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 19.10.2004 10:18am page 182

182 Chapter 14

often enlarges to form a bubo. The primary Because of the almost identical nature
lesion heals spontaneously after a few of the T. pallidum of endemic syphilis and
weeks, but 6 weeks to 6 months later, venereal syphilis, it has been considered
the signs of secondary syphilis appear. that venereal syphilis developed from this
This may take several forms, but the more benign form. Once a venereal method
commonest is a maculo-papular rash and of transmission had been developed, the dis-
mucocutaneous condylomata around the ease was able to extend its boundaries from
genitalia and anus. As the infection is sys- the tropics to the Arctic.
temic, a generalized lymphadenopathy and Infection with T. p. endemicum confers
splenomegaly can occur, often accompanied immunity to venereal syphilis and infection
by fever. Following the period of secondary with T. p. pallidum gives immunity to the
syphilis, there is a latent phase after which other treponem infections and from con-
the destructive cardiovascular (aortic aneur- tracting venereal syphilis again, but this is
ysm) and central nervous symptoms (men- reduced by HIV infection. There is also some
ingitis, paresis or tabes dorsalis) occur, often innate resistance or inadequacy of the trans-
many years later. Should a woman be preg- mission mechanism as only some 30% of
nant while she has syphilis, her fetus may be contacts of a known infected source become
seriously affected. If she is pregnant during infected.
early syphilis, then the child is likely to be
stillborn, while the later stages of the disease Incubation period 990 days (usually 3
are more likely to produce a live-born child weeks).
suffering from congenital defects (deafness,
sabre tibia, Hutchinson teeth and CNS
involvement). Period of communicability Up to 1 year after
the primary lesion first appears.
Diagnosis is confirmed by finding T. p. pal-
lidum in the serous exudate from a chancre Occurrence and distribution The venereal
or by gland puncture. This can be examined diseases are totally cosmopolitan, taking
by dark ground microscopy or immuno- no account of climate, ethnic group or social
fluorescent staining. Serological tests can class; wherever sexual contact occurs,
assist in the diagnosis or be used in epidemi- venereal diseases can occur also. It is
ological studies. The rapid plasma reagin estimated that there are some 12 million
(RPR) is a sensitive test, while specific cases in the world today, with a large pro-
tests, such as the fluorescent treponemal portion of these in the tropics. The highest
antibody absorbed (FTA-Abs) test or incidence is amongst the 2024-year
T. pallidum haemagglutination antibody age group, followed by those 2529 years
(TPHA), are more difficult and expensive old.
to perform. Cross-reaction between the Syphilis is predominantly a disease of
Treponema of yaws, pinta and endemic urban areas and in conditions of sexual
syphilis negate the differential diagnosis of imbalance, such as mines, military estab-
these diseases. All patients with syphilis lishments and amongst seamen. With the
should be encouraged to have an HIV rapid urbanization that has occurred in the
test because of the high frequency of dual developing world and large movements of
infection. migrant labour, syphilis has been on the in-
crease in the tropics. When the migrant
Transmission Syphilis is transmitted by workers return to their homes and families,
direct contact with an infectious lesion or they bring venereal disease back with them.
its discharge during sexual intercourse. The main reservoir of infection is generally
Transmission can also occur congenitally in commercial sex workers or deserted
or from blood transfusion if the donor is in women forced into prostitution to support
the early stages of syphilis. Kissing can more their children. Due to the prolonged incuba-
rarely transmit the spirochete. tion period, the hidden site of the primary
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 19.10.2004 10:18am page 183

Disease Transmitted Via Body Fluids 183

lesion within the vagina, and the latent Treatment is with benzathine penicillin 2.4
period of the disease, syphilis is either not million units as a single dose (but often
suspected or purposely hidden. A large given intramuscularly at two different
number of contacting males can be infected sites). Alternatively, tetracycline 500 mg
by a single female. four times a day or doxycycline 100 mg
twice daily, both for 14 days can be given,
Control and prevention Contact tracing and especially in the patient allergic to penicil-
the adequate treatment of all cases is the lin and not pregnant.
main method of control, but in developing
countries, it is largely an impossible task. In Surveillance Antenatal and family planning
restricted communities, such as mines or clinics provide an important opportunity to
plantations, it can be used to considerable examine a large number of women and also
value, but in the vast, sprawling urban prevent cases of congenital syphilis. Rou-
slums where people come and go and ad- tine RPRs should be performed and all posi-
dress is not known, it is a hopeless task. tive cases fully investigated and treated.
The prohibition of commercial sex workers
only drives the practice underground and
is generally not acceptable in developing 14.5 Gonorrhoea
countries where they form a recognized seg-
ment of society in many cultures. A prefer- Organism Gonorrhoea is a bacterial disease
able answer is to try and examine known caused by Neisseria gonorrhoeae (the gono-
commercial sex workers at regular intervals coccus).
and encourage them to bring in others for
check-ups. A commercial sex worker aware Clinical features In the male, infection com-
of the damage that can be caused by the mences as a mucoid urethral secretion,
disease, once converted, can be a greater which soon changes to a profuse, purulent
proponent of health education than any discharge (as opposed to NGU where it is
trained worker. scanty, white, mucoid or serous). The dis-
Health education should start at school, charge is best seen first thing in the morning
encouraging delay of first sexual experience (dew drop) and a smear should be made
and the benefits of a monogamous relation- from this before the patient urinates. The
ship. Programmes should also be targeted at main symptom is pain on micturition, but
high-risk groups, such as miners, truck the degree of discomfort is very variable. In
drivers and the commercial sex industry, the female, the infection generally passes
encouraging safe sex and the use of unnoticed, but may present with urethritis
condoms. The likelihood of contracting a or acute salpingitis. It is this latter presenta-
sexually transmitted infection (STI) is pro- tion of the disease that can lead, in an acute
portional to the number of sexual partners. or chronic form of pelvic inflammatory dis-
Diagnostic and treatment facilities need ease, to sterility in the female. This is a ser-
to be widely available on a walk-in basis. It ious problem in the unmarried woman and a
is preferable to provide special clinics as cause of divorce in the married. In the male,
well as the routine health services. Unfortu- untreated or improperly treated infection
nately, many private practitioners, often not can result in urethral stricture, while gener-
even medically qualified, offer inadequate alized symptoms of arthritis, dermatitis or
treatment, so encouraging resistant organ- meningitis can rarely occur in either sex. In
isms to develop as syphilis is often con- the pregnant woman, there is a danger of the
tracted at the same time as other STIs. newborn infant developing gonococcal con-
All pregnant women should be tested junctivitis at the time of delivery. The dis-
for syphilis, preferably both in early and covery of this infection in the newborn
late pregnancy. All blood donors should be infant may be the manner in which the
screened (see also Box 14.1). infection is found in the woman.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 19.10.2004 10:18am page 184

184 Chapter 14

Box 14.1 The control of sexually transmitted infections (STIs).

There has been a considerable increase in STI with new STIs appearing or their relative importance
changing. Some of the reasons for these changes are:

. increasing world population, especially of younger age groups;

. urbanization and migrant labour;
. increasing travel and mixing of populations;
. alteration of social values and increasing promiscuity;
. development of contraceptive practice;
. ignorance of STI and lack of sex education;
. vulnerability of women biologically, culturally and socio-economically;
. inadequate treatment and development of resistant organisms.

International travel has allowed a mixing of cultural groups that would otherwise have remained isolated,
potentiating the spread of different types and strains of STI. The development of resistant strains has posed a
problem of imported cases to the developed world, but has left the developing world with an intolerable
situation that they are economically unable to deal with.
STIs are more prevalent in young people, yet with an increasing world population, it is predominantly
these younger age groups that are expanding at a more rapid rate than others. This increase in the youth of
the world has thrown a greater strain on the education services so that health education, especially of STIs, is
Change has occurred in the social structure whereby traditional values and the monogamous married
couple are no longer regarded as the norm. The development of contraceptives has freed the woman from
the risk of unwanted pregnancy, but at the same time, increased the opportunity for developing an STI.
Married women are particularly vulnerable when they are abandoned or their husbands have to find work
away from the confines of the family. STIs are often asymptomatic in women so they do not seek treatment,
putting their lives and those of any future children at greater risk.
Generally, the risk of developing an STI is more recognized, rather than the shock that previously led to
concealment or recourse to treatment from a medical quack. Also contraceptive practice should not be
discouraged for it is the problem of the rapidly expanding young population that is a major contributory
factor. The key is health education with a combined approach of contraceptive advice and STI information.
If this is to succeed there must be a considerable increase in treatment facilities, especially in urban areas.
Standard treatment regimes should be decided by specialists and administered by primary healthcare
workers. Improved treatment facilities, contact tracing, training of health workers and more effective
drugs will not only reduce the prevalence and seriousness of STIs, but also of HIV infection.

Diagnosis Due to the similarity in presenta- ate. N. gonorrhoeae is unable to penetrate

tion of gonococcal and non-gonocococcal stratified epithelium, but has a predilection
urithritis, the emphasis is on making a diag- for mucous membranes where it produces
nosis syndromically of a urethral discharge. an accumulation of polymorphonuclear
A smear should be made and stained with leucocytes and outpouring of serum to give
Gram stain, the finding of Gram-negative the characteristic discharge.
intracellular diplococci indicating gonococ- Important factors in the transmission of
cal infection. Where facilities permit, the gonorrhoea are:
discharge should be cultured, but as the or-
ganism is very sensitive, it must be inocu- . the short incubation period;
lated on to a culture plate or placed in . the often asymptomatic disease in women
transport medium (less satisfactory) as (estimated to be 80%);
soon as possible. . promiscuous sexual intercourse;
. urbanization and changing social values;
Transmission is by sexual intercourse . use of contraceptives;
or with contact of the infected mucous exud- . inadequate treatment.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 19.10.2004 10:18am page 185

Disease Transmitted Via Body Fluids 185

The combination of a short incubation as a person presents at a clinic. Health edu-

period and promiscuous sexual activity cation concentrating on the dangers of STIs
means that a large number of people can is the main preventive action (see also under
become infected in rapid succession. Since syphilis above and Box 14.1). The eyes of
women are often largely unaware of their babies as they are being born should be
infection they serve as a continuous reser- wiped and a 1% aqueous solution of silver
voir of the disease. Urbanization changes nitrate instilled (Section 7.7).
the social balance that occurs in the village,
traditional values and taboos are lost Treatment which used to be a simple matter
and promiscuity develops. Contraceptives with penicillin, is now fraught with prob-
allow increased opportunity for sexual lems of resistance not only to this antibiotic,
intercourse although the condom provides but to many others that have subsequently
limited protection. The contraceptive pill by been tried. Any recommended treatment
reducing the acidity of genital secretions regime may be ineffective in certain parts of
removes some of the natural defences, the world and local expertise must be con-
while the intra-uterine contraceptive device sulted to develop routines that are compat-
encourages mechanical spread of infection ible with the resistance patterns and
to the uterus and tubes. Improper treatment available resources. Recommended regi-
both by doctors and quacks, usually with mens are:
grossly inadequate doses of antibiotics, has
led to chronic infections and the develop- . ciprofloxacin 500 mg as a single oral dose
ment of resistant organisms. (but not in pregnant women or children), or
. azithromycin 2 g orally as a single dose, or
Incubation period 27 days (average 3 days). . ceftriaxone 125 mg by single intramuscu-
lar injection, or
Period of communicability can be months in . cefixine 400 mg as a single oral dose, or
untreated cases, especially hidden infec- . spectinomycin 2 g by single intramuscular
tions in women. injection.

Occurrence and distribution The number of Patients diagnosed with gonorrhoea often
cases of gonorrhoea in the world today is have Chlamydia infection as well, so treat-
estimated to be some 62 million. Under- ment for this condition should be combined
reporting, illegal treatment and the protec- as a routine (see below).
tion of contacts make any standard methods
of case treatment and contact tracing quite Surveillance Strains of the gonococcus re-
inadequate in most developing countries. sistant to the standard treatment regime in
Gonorrhoea is not so much found as a reser- the country are likely to be imported from
voir in commercial sex workers as more time to time, so sensitivity should be regu-
widely distributed amongst the promiscu- larly tested and the treatment regime modi-
ous under-25-year-olds. fied accordingly.

Control and prevention Where possible,

cases presenting at STI clinics should 14.6 Non-gonococcal Urethritis (NGU)
be encouraged to bring their partners (or
provide information so that they can Organism A number of organisms have been
be traced) for counselling and treatment. found to be responsible for urethritis not
Alternatively, contact cards can be sent caused by the gonococcus, including
anonymously to all contacts of a case, rec- Chlamydia trachomatis, Ureaplasma urea-
ommending them to present at a clinic. lyticum, Trichomonas vaginalis and Myco-
Condoms can be given out at the same time plasma hominis.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 19.10.2004 10:18am page 186

186 Chapter 14

Clinical features A low-grade urethritis with avoided until both partners are free of
mucoid rather than purulent discharge in signs. While cases of gonorrhoea should
the male, in which intracellular diplococci always be treated for NGU, if gonorrhoea
are not found in the smear, suggests NGU. has been excluded, then cases of NGU do
Infection is a low-grade discharge in the not also need to be treated for gonorrhoea.
female or is often asymptomatic so that a If a low-grade offensive discharge with some
reservoir of infection can occur if simultan- staining persists in the female, or irritation
eous treatment to both sexual partners is not in the male, this is probably Trichomonas
given. Sterility in women can result if the infection, which is effectively treated with
infection is not treated. In areas where gono- metronidazole 2 g orally or tinidazole 2 g
coccal urethritis is common, the prevalence orally in a single dose.
of NGU is also high so treatment should be
given for both conditions. Surveillance Several STIs can occur to-
gether, hence NGU is an indicator of pos-
Diagnosis This differs markedly in differ- sible syphilis and gonorrhoea, which
ent parts of the world with developing should always be looked for.
countries adopting a syndromic approach
(see above under gonorrhoea), while de-
veloped countries specifically test for 14.7 Lymphogranuloma Venereum
Chlamydia. Where possible, diagnosis
should be made by smear and culture, the
Organism Chlamydia trachomatis.
absence of intracellular diplococci indicat-
ing NGU. The nucleic acid amplification
test (NAAT) or IF test with monoclonal anti- Clinical features Lymphogranuloma vener-
body can be used on urethral or cervical eum is a chronic infection presenting as a
swabs. small painless papule, vesicle or ulcer on
the genitalia that often goes unnoticed, lym-
phadenitis being the clinical sign. The
Transmission is by sexual intercourse.
lymph nodes become grossly enlarged and
C. trachomatis and T. vaginalis are risk
generally suppurate with fistulas and fibro-
factors for HIV infection in the female.
sis developing, especially in the rectal area if
treatment is delayed.
Incubation period 12 weeks.
Diagnosis is by finding the organism in
Period of communicability In the asymptom-
lymph node aspirate with immunofluores-
atic case, infection can continue for a con-
cence or DNA probe.
siderable period of time.

Transmission Although sexual intercourse is

Occurrence and distribution NGU is more
considered the main means of transmission,
common than gonorrhoea and is found all
infection can also happen by direct contact
over the world with high levels in the sexu-
with open lesions.
ally promiscuous.

Control and prevention is the same as for Incubation period 330 days.
gonorrhoea and syphilis (see above).
Period of communicability is for as long as
Treatment is with azithromycin 1 g orally in there are active lesions, which may be for
a single dose, doxycycline 100 mg orally several years.
twice daily for 7 days, erythromycin
500 mg orally four times a day for 7 days or Occurrence and distribution Although it
tetracycline 500 mg orally four times daily occurs worldwide, lymphogranuloma
for 7 days. Sexual intercourse must be venereum is commoner in the tropics, espe-
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 19.10.2004 10:18am page 187

Disease Transmitted Via Body Fluids 187

cially in sub-Saharan Africa and parts of Occurrence and distribution Mainly in

Asia. the tropical regions of the world, especially
in southern India and Irian Jaya/Papua New
Control and prevention Treatment should be Guinea and amongst the aboriginal people of
commenced as soon as the diagnosis has Australia. It is less commonly found in
been made, the patient being advised to Africa and people of African origin, such as
refrain from sexual intercourse and close in the Caribbean and the northern part of
contact with others until all lesions have South America. It is a disease of the sexually
healed. Other methods of control are the active 2040-year age group, in males more
same as for syphilis and gonorrhoea above. than females, but children under 5 years also
contract the disease (presumably from con-
Treatment is with doxycycline 100 mg daily tact with their parents).
for 14 days, erythromycin 500 mg four times
daily for 14 days or tetracycline 500 mg four Control and prevention Control is the same
times daily for 14 days. as for syphilis and gonorrhoea above. Care
should be taken to prevent transmission
from open lesions to others and other parts
of the body.
14.8 Granuloma Inguinale
Treatment is with azithromycin 1 g orally on
Organism Calymmatobacterium granulo- the first day followed by 500 mg daily for a
matis. maximum of 14 days, doxycycline 100 mg
twice daily for 14 days, erythromycin
Clinical features Granuloma inguinale is a 500 mg orally four times a day for 14 days
chronic, progressive, ulcerating disease of or tetracycline 500 mg four times daily for
the ano-genital area without regional lym- 14 days.
phadonopathy. An initial lesion on the geni-
talia becomes eroded and ulcerated with Surveillance As with all STIs, it is possible
new nodules forming at the margins as the that more than one STI is present.
lesion extends. The lesions readily bleed on
contact and ulceration can continue to pro-
duce extensive destruction. Carcinoma of 14.9 Chancroid
the vulva has been reported to be associated
with granuloma inguinale. Organism Haemophilus ducreyi.

Diagnosis is made from smears or scrapings Clinical features An acute venereal infection
of the lesions stained with Giemsa, in which characterized by a soft chancre on the exter-
intracellular rod-shaped organisms (Dona- nal genitalia and regional lymphadenop-
van bodies) are found. athy. The lesion has an indurated base of
the chancre, which differentiates it from
Transmission The disease is transmitted syphilis. Chancroid is a predisposing cause
by direct contact with lesions either via of HIV infection with which it is frequently
sexual intercourse or other methods. It is associated.
frequently associated with anal intercourse.
Diagnosis The organism can be identified
Incubation period 116 weeks. with Gram-stain from the exudate of lesions,
but this is often difficult due to secondary
Period of communicability is while open infection.
lesions are present, which can be for a con-
siderable period of time in the untreated Transmission is by sexual intercourse or
patient. direct contact with lesions.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 19.10.2004 10:18am page 188

188 Chapter 14

Incubation period 314 days. Incubation period 212 days.

Period of communicability is as long as Period of communicability 27 weeks during

lesions continue to discharge, which can be the initial clinical infection and 5 days
months in the untreated case. during a recurrence.

Occurrence and distribution Predominantly Occurrence and distribution A worldwide

found in the tropical regions of the world and increasing problem amongst the
where it is common in men who probably sexually active. As the infection is difficult
obtain their infection from a commercial sex to treat there is a recurrent reservoir of infec-
worker. tion with each clinical attack and if one of
these should occur during delivery, then
Control and prevention See syphilis neonatal death or disability will result.
Control and prevention The same as with
Treatment Chancroid can be treated with gonorrhoea and syphilis (see above).
one of the following regimes: Infected persons should be warned of the
increased risk of developing HIV infection.
. azithromycin 1 g orally as a single dose, or
. ceftriaxone 250 mg intramuscularly as a Treatment There is no cure, but acyclovir
single dose, or 200 mg orally five times daily for 7 days or
. ciprofloxacin 500 mg orally twice daily for acyclovir 400 mg orally three times a day
3 days, or for 7 days, or other analogues will reduce
. erythromycin 500 mg orally four times the formation of new lesions, pain and the
daily for 7 days. period of healing, but not recurrent attacks.

14.10 Genital Herpes

14.11 Human Papilloma Virus (HPV)
Organism Herpesvirus simplex type 2
Organism Human papilloma virus (HPV).
(HSV2); less commonly type 1 (HSV1).

Clinical features Painful vesicles develop on Clinical features The main clinical presen-
the genitalia or surrounding area, which can tation is genital warts on the external geni-
subsequently ulcerate. Healing occurs after talia or within the vagina, but a large
initial infection only to recur at frequent proportion of infected persons show no clin-
intervals, often precipitated by stress or ical signs. When cellular immunity is de-
menstruation. Infection of the neonate can pressed condylomata acuminata, large
occur during delivery resulting in encephal- fleshy growths in moist areas of the peri-
itis, liver damage or lesions in the eye, mouth neum develop. However, the most serious
or skin. Infection with HSV2 carries an consequence of HPV infection is the devel-
increased risk of developing HIV infection. opment of carcinoma, particularly of the
cervix, but the anus and penis can also be
Diagnosis is made on clinical presenta- involved.
tion and by scrapings of the lesions where
characteristic multi-nucleated giant cells Diagnosis Cervical smears stained by
with intranuclear bodies are seen on micro- the Papanicolau method can detect pre-
scopy. cancerous changes.

Transmission is by sexual intercourse or Transmission is by sexual intercourse,

direct contact, such as oralgenital, or to but direct contact, as with other warts, is
the infant during delivery. possible.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 19.10.2004 10:18am page 189

Disease Transmitted Via Body Fluids 189

Incubation period 23 months. 14.12 Human Immunodeficiency Virus

Period of communicability Probably for
a considerable period of time as cancer Organism Human immunodeficiency virus
of the cervix appears to be associated with (HIV) either type 1 (HIV-1) or type 2 (HIV-
the cumulative number of sexual encoun- 2), HIV-1 being more pathogenic.

Occurrence and distribution It has been esti- Clinical features HIV infection leads to a dis-
mated that between 9% and 13% of the ruption of the helper T4 cell-mediated
world population is infected with HPV, immune mechanisms, resulting in an
which is some 630 million people. Seventy increased susceptibility to opportunistic
percent of these infections are sub-clinical infections. This breakdown of the bodys de-
with only a proportion developing genital fence system and the range of symptoms pro-
warts and some 2840 million the pre- duced is called acquired immunodeficiency
malignant condition. The prevalence of syndrome (AIDS). Presentation is generally
chronic persistent infection is about 15% by the symptoms of the opportunistic infec-
in developing countries and 7% in tion, so can be many and varied.
developed. Eighty per cent of the worldwide Initially, there may be an acute retro-
incidence of cervical cancer is in developing viral infection with fever, sweating and my-
countries. algia, but after this subsides, there is a
dormant period for months or years, after
Control and prevention The usual methods which symptoms of an opportunistic infec-
of reducing STI, such as delaying the age of tion occur. The opportunistic infections are:
first intercourse, monogamous relationship
and the use of condoms will all assist in . oral, vulvovaginal candidiasis, or of the
decreasing the likelihood of developing oesophagus, trachea, bronchi or lung;
HPV infection. The promotion of cervical . pulmonary or extrapulmonary tubercu-
smear testing in developed countries has losis (Section 13.1);
allowed detection of pre- and early cervical . atypical disseminated mycobacteriosis;
cancer amenable to surgical treatment, but . severe bacterial infections, such as pneu-
few if any developing countries are able to monia (Table 13.1) or pyomyocitis;
afford such a service. . Pneumocystis carinii pneumonia (Table
Three HPV vaccines are currently under 13.1);
trial and offer considerable hope that either . non-typhoid Salmonella septicaemia;
the non-infected can be protected or that a . oral hairy leucoplakia;
therapeutic vaccine can be used in the . reactivated varicella (Section 12.1);
already infected. . cytomegalovirus of an organ other than
liver, spleen or lymph nodes;
Treatment of the warts is by cryotherapy, . herpes simplex, visceral or not resolving
podophyllin or with trichloroacetic acid, mucocutaneous;
but HPV infection will remain. . disseminated mycosis, such as histoplas-
mosis, coccidioidomycosis or penicilium;
Surveillance Cytological services for . cryptococcosis, extrapulmonary;
screening women at regular intervals have . cryptosporidiosis with diarrhoea (Section
been shown to be cost-effective in reducing 8.2);
cervical cancer and should be set up wher- . isosporiasis or microsporidiosis with
ever resources permit. diarrhoea;
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 19.10.2004 10:18am page 190

190 Chapter 14

. toxoplasmosis of the brain (Section 17.5); . oropharyngeal candidiasis;

. intractable scabies not responding to . chronic progressive or disseminated
treatment (Section 7.1); herpes simplex infection;
. disseminated Strongyloides (Section . generalized lymphadenopathy;
The presence of either generalized Kaposi
. florid Chagas disease with acute myocar-
sarcoma or cryptococcal meningitis is
ditis or meningoencephalitis (Section sufficient for the diagnosis of AIDS.
15.11); If a test for HIV antibody in an adult or
. reactivated leishmaniasis (Section 15.12); adolescent (>12 years old) is positive then
. lymphoma (Section 1.1); the person is considered to have AIDS if
. Kaposis sarcoma (Section 1.1); one or more of the following conditions are
. HIV encephalopathy; present:
. progressive multifocal leucoencephalopa- . >10% body weight loss or cachexia, with
thy. diarrhoea or fever, or both, intermittent or
constant, for at least 1 month, not known to
Any process that stresses the immune be due to a condition unrelated to HIV
mechanism, such as repeat infections, will infection;
accelerate progression to AIDS. Tubercu- . cryptococcal meningitis;
losis and leprosy are affected by the disrup- . pulmonary or extra pulmonary
tion of the immune process. Any person tuberculosis;
with tuberculosis who contracts HIV . Kaposi sarcoma;
infection will progress more rapidly, while . neurological impairment that is sufficient
to prevent independent daily activities,
tuberculoid leprosy cases can convert to
not known to be due to a condition
unrelated to HIV infection;
. candidiasis of the oesophagus;
Diagnosis and AIDS case definition With . clinically diagnosed life-threatening or
such a range of possible symptoms and recurrent episodes of pneumonia, with or
lack of resources in developing countries to without aetiological confirmation;
perform serological confirmation, various . invasive cervical cancer.
attempts have been made to formulate a
case definition for AIDS. The one most Where full diagnostic facilities are available,
widely followed is the 1985 Bangui defin- the Centres for Disease Control and Preven-
ition, updated in 1994 by WHO, which is as tion (CDC) definition of infection (2000) can
follows: be used:
In adults or adolescents ($18 months), a
An adult or adolescent (>12 years of age) reportable case of HIV infection must meet
is considered to have AIDS if at least two one of the following criteria:
of the following major signs are present in
combination with at least one of the minor 1. Positive result on a screening test for HIV
signs listed below, if these signs are not
antibody (e.g. repeatedly reactive enzyme
known to be due to a condition unrelated to
HIV infection. immunoassay), followed by a positive result
on a confirmatory test for HIV antibody
Major signs (e.g. Western blot or immunofluorescence
. weight loss $ 10% of body weight; antibody test)
. chronic diarrhoea for more than
1 month; or
. prolonged fever for more than 1 month
(intermittent or constant);
2. Positive result of a detectable quantity on
Minor signs any of the following HIV virologic tests:
. persistent cough for more than 1 month;
. generalized pruritis dermatitis; . HIV nucleic acid detection (e.g. DNA
. history of herpes zoster; polymerase chain reaction);
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 19.10.2004 10:18am page 191

Disease Transmitted Via Body Fluids 191

. HIV p24 antigen test, including neutral- infants blood at the time of delivery. HIV
ization assay; is found in breast milk with about a 25%
. HIV isolation (viral culture). chance of it being transmitted to the infant.
Serological tests may not become posi-
Transmission is by: tive for up to 3 months after the person
became infected, so it is possible for a person
. sexual contact with an infected person; to transmit infection before they are shown
. inoculation with infected blood or blood to be positive.
products (including unsterile needles and
syringes); Incubation period to full-blown AIDS ranges
. from an infected mother to child before, from 1 to 18 years with a mean of 10 years. In
during delivery or for up to 2 years after if perinatal infection, the incubation period is
breast-fed; often shorter than 12 months. With such a
. from tissue transplants (rare). long incubation period the epidemic will
last for about 100 years if an effective inter-
Sexual contact is the commonest method of vention is not found.
transmission, with both heterosexual and
homosexual practice. The important epi-
demiological factor is number of sexual con- Period of communicability Infectiousness is
tacts so that prostitutes or promiscuous highest during initial infection, probably
homosexuals with hundreds, if not thou- extending throughout the life of the individ-
sands of new contacts annually are at ual, increasing again as immunity becomes
greatest risk. However, one contact with an suppressed. With the extension of life of the
infected person is able to produce infection. treated individual the period of communic-
Anal intercourse carries a higher risk of ability is also increased, although virus
infection than vaginal. There is no evidence shedding is diminished.
of increased risk during menstruation
and circumcision is protective in the Occurrence and distribution HIV infection
male. There is an association with other has now spread to most parts of the world,
STIs, particularly genital herpes simplex but is particularly prevalent in Africa, the
virus type 2 and ulcerating conditions, Americas, Europe (including Russia),
such as chancroid. Other STIs may potenti- South and Southeast Asia and an increasing
ate infection. problem in China. Some 25 million people
Blood transfusion of infected blood will have so far died from AIDS and 40 million
almost always transmit HIV. Pooled blood, are infected, comprising 36.8 million adults,
such as for producing factor VIII for the treat- 18.3 million of which are women, and 3.1
ment of haemophilia, is particularly danger- million children under 15 years of age (at
ous because it contains donations from 2003). Sixty-four per cent of all cases of
many people, any of which could be AIDS are in Africa with southern Africa
infected. Syringes and needles, if they are being the worst affected part of the contin-
not properly cleaned and sterilized, can con- ent. Nearly 40% of women of age 1524
tain small quantities of blood sufficient to years attending ante-natal clinic in Swazi-
transmit infection. This method may be re- land were HIV-positive, with only slightly
sponsible for many infections in developing lower rates for Botswana and Zimbabwe.
countries and is an important way of trans- In contrast though there has been a reduc-
mitting infection amongst drug abusers. tion in prevalence in East Africa where the
Transmission by needle stick injury can epidemic first started.
occur, but is uncommon. Initial spread in East Africa was along
The infected mother can pass on infec- transport routes, where lorry drivers made
tion to her child. Infection can be transmit- use of local bar-girls at each of their stops. In
ted congenitally, but it is more likely to South Africa, HIV infection was introduced
occur from a mixing of the mothers and into the mining communities in which it
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 19.10.2004 10:18am page 192

192 Chapter 14

spread rapidly via prostitutes. Sadly many developed, other control measures are
infections in developing countries have required.
been due to the use of poorly sterilized To prevent sexual spread:
needles when people have attended at
clinics for other illnesses. . limit the number of sexual partners,
Parts of South America and some Carib- encouraging monogamous relationships;
bean islands have very high incidence rates . avoid sexual contact with persons at high
due to the general attitude towards promis- risk, such as commercial sex workers,
cuity. Prostitution and injecting drug use are bisexuals and homosexuals;
responsible for very high rates in parts of . encourage male and female condom
Thailand and India, from which spread is use;
being encouraged through illegal networks. . provide adequate facilities for the detec-
Girls from Yunnan in China sent to work in tion and treatment of STIs;
brothels in Thailand returned infected with . provide counselling and HIV testing;
HIV and disseminated it to other parts of . provide general education for girls and
the country. However, both Thailand and sex education to both boys and girls;
Cambodia have now shown sustained re- . provide lifestyle training (how to say
ductions in the past 45 years. no).
A worrying trend has been the un-
changed incidence in Western countries, To prevent blood spread:
with an increasing rate in Europe, despite
the availability of antiretroviral (ARV) ther- . screen all blood for transfusions;
apy. Indeed this suggests that treatment, by . test donors before they give blood;
prolonging the life of HIV-infected persons, . only use blood transfusions when essen-
is increasing transmission, or the availabil- tial;
ity of treatment is reducing the fear of infec- . discontinue paid blood donors;
tion and allowing more risky behaviour. It is . use disposable syringes, needles, giving
hoped that ARV therapy will reduce the sets, lancets, etc. or ensure they are prop-
stigma of AIDS and allow preventive pro- erly sterilized;
grammes to work in developing countries, . injecting drug users should be discour-
so both strategies must proceed at the same aged from sharing equipment, preferably
time. using needle exchange schemes;
HIV-1 is common in the Americas, . medical workers should wear gloves when
Europe, Asia, Central and East Africa, dealing with possible infected blood (e.g.
whereas HIV-2 is found in West Africa or at delivery and in the laboratory).
in people that acquired their infection there.
To prevent perinatal spread:

Control and prevention Methods of control . advise infected mothers about the pos-
and prevention are aimed at the three routes sible risk to their infant and themselves if
of transmission sexual, blood and peri- they become pregnant;
natal. Several vaccines are under trial in- . good obstetric practice, especially redu-
cluding a prime boost technique using a cing trauma in procedures, such as artifi-
DNA vaccine followed by HIV in a modified cial rupture of membranes and fetal scalp
vaccinia virus, but the problem with all the monitoring, and only cutting the cord
vaccine candidates so far developed is the when it has stopped pulsating;
rapid rate at which the HIV virus alters its . priority ARV therapy should be given to
antigenic makeup. A live, attenuated vac- HIV-positive pregnant women and to the
cine has been developed, which seems to newborn infant (nevirapine has been
be effective, but because of the ability of shown to be effective in Uganda, but
the retrovirus to alter itself so rapidly, it is zidovudine and lamivudine can also be
likely to be too dangerous. Until a vaccine is used);
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 19.10.2004 10:18am page 193

Disease Transmitted Via Body Fluids 193

. provide information on breast-feeding to made to rectify the situation. Individual

allow each mother to decide. treatment is a highly specialized subject,
but will probably consist of two nucleoside
Caesarean section should not be encouraged analogues, a non-nucleoside reverse
in developing countries as the risk to the transcriptase inhibitor and/or a protease in-
mother in subsequent pregnancies is consid- hibitor, a three- or four-drug regime being
erably increased, but might be the strategy found to be more effective than a two-drug
of choice in developed countries. WHO regime. A second-line regimen should be
recommends that no change should be available in case of toxicity or treatment fail-
made in vaccination programme to mothers ure. Any opportunistic infection must re-
and children even though they may be ceive specific treatment for the condition.
infected with HIV, except in the child
with clinical AIDS who should not be Surveillance The prevalence of HIV
given BCG. infection can be estimated by testing an-
HIV is not spread by: onymously blood that has been obtained
. mosquitoes; for other purposes, such as in ante-natal or
. casual contact such as shaking hands, or STI clinics. Population-based surveys have
lavatory seats; been conducted in Zambia, South Africa
. through food, water or the respiratory and some other countries. Numbers of
route. cases of AIDS are reported to WHO using
the case definitions outlined above.
CONTROL PROGRAMMES The main method of
control is health promotion and should
involve community leaders, religious organ- 14.13 Hepatitis B (HBV)
izations and NGOs. This can be to the gen-
eral public to supply them with the correct Organism Hepatitis B virus (HBV).
information or to specific groups. The most
cost-effective health education will be to Clinical features In many parts of the
high-risk groups, such as commercial sex developing world, HBV infection is common,
workers, homosexuals, single workers, etc. but only about 30% show any symptoms.
However, they are difficult to motivate and However, these symptomatic cases present
it is probably better to concentrate effort on as a more severe disease than hepatitis A,
school children. Girls should have equal with a persistent jaundice, often resulting in
opportunity for education, whereas sex edu- liver damage.
cation should be an integral part of the After an insidious onset with anorexia,
school curriculum. Counselling and testing nausea and abdominal discomfort, jaundice
facilities need to be readily available as well then develops, from which the patient either
as programmes on mother-to-child transmis- recovers or goes on to develop chronic active
sion. Improved diagnosis and treatment fa- disease. Low-grade infection continues
cilities for STIs need to be made available, with periods of jaundice alternating with
providing early and adequate treatment. remissions, but invariably cirrhosis de-
Condoms can be dispensed at clinics, velops. The disease is more serious in
markets or at any suitable social marketing those over 40 years of age, in pregnant
opportunity (see Box 14.1). women and newborn infants. Hepatocellu-
All persons with HIV infection, includ- lar carcinoma is associated with chronic
ing those under treatment, are at risk of pass- hepatitis B infection.
ing on infection to others and should be
counselled about preventive measures to be Diagnosis can be made by finding the sur-
taken. face antigens (HBs Ag). There are four sub-
types adw, ayw, adr and ayr, which vary in
Treatment is largely unavailable in most de- their geographical distribution providing
veloping countries, but efforts are being useful epidemiological markers. A further
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 19.10.2004 10:18am page 194

194 Chapter 14

antigen e (HBe Ag) is a marker of increased Control and prevention Hepatitis B vaccine
infectivity as well as indicating active viral can be given to those at risk and as part of the
replication in hepatocytes (which may EPI programme. If given before infection, it
result in liver damage). prevents the development of disease and the
carrier state. Ideally, Hepatitis B vaccine is
Transmission can occur from blood, serum, given at the same time as DTP, but in coun-
saliva and seminal fluid. It is a hazard of tries where perinatal transmission is
blood transfusions, renal dialysis, injections common, such as in Southeast Asia, a dose
and tattooing. It can be transmitted by sexual at birth is recommended. Immunity is
intercourse and during delivery. The virus thought to last for at least 15 years in the
has been found in some blood-sucking fully vaccinated. There is convincing evi-
insects (e.g. bed bugs), but transmission by dence that reduction of carriers can prevent
this means has not been shown to occur. the development of primary liver cell
Certain people are more infectious cancer.
than others resulting in a carrier state, with Preventive methods are strict aseptic
the period of communicability being consid- precautions in giving blood transfusions, in-
erable. The risk of an infant becoming jections and the handling of blood. All blood
infected from a carrier mother can be donors should be screened with contribu-
5070% in some ethnic groups. There is tions to pooled blood being particularly
a greater likelihood of the mother passing scrutinized. The control of STIs has been
on the infection if she has acute hepatitis covered above. Homosexual practice is par-
B in the second or third trimester or up to ticularly liable to lead to HBV infection. Per-
2 months after delivery. A high titre of sur- sons at risk should be vaccinated.
face e antigen or a history of transmission to
previous children increases the risk of a Treatment There is no specific treatment,
mother infecting her infant. The carrier but alpha-interferon and lamivudine have a
state is more common in males and in limited effect in some people, particularly in
those that acquired their infection in child- the early stage of infection. Long-term treat-
hood. ment may also be of value.

Incubation period 6 weeks to 6 months (usu- Surveillance As with HIV infection, blood
ally 912 weeks), a larger inoculum of virus obtained in antenatal clinics, STI clinics or
probably resulting in a shorter incubation for other purposes can be anonymously
period. tested for HbsAg. Surveys in developing
countries demonstrated the high levels of
carriers, so with the implementation of rou-
Period of communicability From several
tine vaccination, follow-up surveys will
weeks before the onset of symptoms, con-
monitor the effectiveness of the vaccination
tinuing until the end of clinical disease,
unless the person becomes a carrier in
which case it is life long.

Occurrence and distribution The carrier state 14.14 Hepatitis C (HCV)

has been estimated to be present in over 350
million people with varying rates in differ- Organism Hepatitis C virus (HCV).
ent parts of the world: Western Europe, 1%;
South and Central America 27%; and Clinical features Similar in many respects to
Africa, Asia and Western Pacific, >8%. In- hepatitis B, HCV produces a milder disease,
fection is thought to occur commonly in in- but as many as 1020% will progress
fancy or early childhood in the more to cirrhosis and 1% to liver cancer in later
endemic areas. life.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 19.10.2004 10:18am page 195

Disease Transmitted Via Body Fluids 195

Diagnosis is difficult, dependent upon normally a self-limiting infection with only

detecting antibodies to HCV and confirming about 5% continuing into the chronic
by a recombinant immunoblot assay (RIBA). form of HDV. However, with super-
PCR is now commonly used. infection (HDV infection of an already
HBV-infected person), there is a severe
Transmission is due to the use of poorly ster- acute hepatitis with 80% continuing to
ilized needles, giving-sets and other chronic active hepatitis, often progressing
methods of parental administration and so to cirrhosis. Hepatocellular carcinoma
is common in developing countries and in due to HDV occurs with about the same
those who abuse drugs in developed coun- frequency as with HBV. The mortality
tries. Sexual or perinatal transmission due to HDV is between 2% and 20% making
probably only occurs rarely. it some ten times greater than for HBV
Incubation period 2 weeks to 6 months (usu-
ally 69 weeks). Diagnosis is made by detecting antibody to
HDV using a serological assay.
Period of communicability Weeks before the
start of clinical symptoms to lifelong. Transmission is the same as for HBV with the
main route of transmission via infected
Occurrence and distribution Infection is blood and blood products. Super-infection
found worldwide in the general population produces the greatest amount of virus and
in developing countries and mainly in chance of HDV transmission.
drug users sharing equipment in developed
countries. However, there are probably Incubation period 28 weeks.
many more cases than present figures sug-
gest and WHO estimates that there are 200 Period of communicability It is probably
million people infected, which amounts to most infectious in the weeks prior to symp-
3% of the worlds population. This means toms, becoming negligible once disease is
that there are about 170 million chronic car- manifest.
riers who could go on to develop cirrhosis or
liver cancer. Occurrence and distribution Areas of high
prevalence are the Mediterranean, South-
Control and prevention There is no vaccine west and Central Asia, West Africa and
for HCV, so all precautions need to be taken certain Pacific Islands. In the Amazon
to prevent further spread by rigorous adher- Basin, there is a particularly fulminant
ence to sterilization of needles and instru- genotype (III), which carries a high mortality
ments. rate. In Western Europe and North America,
infection is endemic in the drug addict
Treatment and surveillance See hepatitis B community. Worldwide WHO estimates
above. that more than 10 million people are

14.15 Hepatitis Delta (HDV) Control and prevention Since HDV is de-
pendent on HBV infection, the main strategy
Organism Hepatitis delta virus (HDV) is de- of control is to reduce HBV by vaccination.
pendent on HBV infection of the person. However, once chronically infected with
Either both viruses can infect at the same HBV, vaccination offers no protection. This
time or HDV infects an already infected makes all the other methods for the control
HBV carrier. of HBV relevant.

Clinical features With coinfection (both vir- Treatment and surveillance See hepatitis B
uses infecting at the same time), there is above.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 19.10.2004 10:18am page 196

196 Chapter 14

14.16 Ebola Haemorrhagic Fever virus has been found in monkeys in the
Philippines exported for experimental pur-
Organism Virus of the Filoviridae group of poses. The focal nature suggests a zoonosis,
organisms. but despite extensive search, no reservoir
has been found. Bats have been infected ex-
Clinical features Illness presents with perimentally, but do not die, so might be
sudden onset of fever, headache, muscle responsible for maintaining the virus in the
pains, sore throat and profound weakness. wild.
This progresses to vomiting, diarrhoea and
signs of internal and external bleeding, gen- Control and prevention The strictest level of
erally with the occurrence of liver and barrier nursing is required taking particular
kidney damage. Mortality is 5090%. care to avoid contact with blood and all se-
cretions. Patients who die must be buried or
Diagnosis is by ELISA for specific IgG and cremated immediately using the same pre-
IgM antibody or by PCR, but should only be cautions, with relatives being forbidden to
carried out in laboratories with maximum take the body away for burial. Patients who
facilities for protecting staff. recover must be counselled about the
dangers of sexual intercourse and the infect-
Transmission is by person-to-person contact ive nature of semen.
via blood, secretions, semen or tissues All contacts of a case and accidental
of an infected person. Infected blood, espe- contacts by healthcare workers must be
cially via syringes, causes the most serious quarantined and the temperature checked
infections, while transmission has occurred twice a day. Surveillance should continue
via semen up to 7 weeks after clinical for 3 weeks from the date of contact.
Infection has also occurred through Treatment There is no specific therapy and
handling ill or dead chimpanzees, but it is hyper-immune serum does not offer any
thought that like humans, they are suscep- long-term protection.
tible to the infection rather than being a
reservoir. Surveillance Outbreaks should be reported
to WHO, neighbouring countries and those
Incubation period 221 days. with air connections so that surveillance can
be mounted on travellers.
Period of communicability From start of
symptoms and for up to 10 weeks for
seminal fluid. Healthcare workers are par- 14.17 Marburg Haemorrhagic Fever
ticularly liable to become infected, espe-
cially during the phase of vomiting and A closely related virus infection, first iden-
diarrhoea. Contact with blood is invariably tified from laboratory monkeys in Marburg,
fatal. Germany, produces a similar illness to Ebola
haemorrhagic fever, but with a mortality of
Occurrence and distribution The main focus about 25%. Cases have occurred in Uganda,
of infection is the rain forest of Central Kenya, Zimbabwe and Congo (Zaire). In all
Africa, outbreaks having occurred in other respects, it is similar to Ebola haemor-
Sudan, Congo (formerly Zaire), Gabon and rhagic fever to which reference should be
Uganda. Another focus of an Ebola-related made above.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 19.10.2004 10:18am page 197

Disease Transmitted Via Body Fluids 197

14.18 Lassa and CrimeaCongo and Marburg disease and are highly infec-
Haemorrhagic Fevers tious through blood, urine and other body
fluids, but as they are both primarily zoon-
Lassa and CrimeaCongo haemorrhagic oses, they are covered in Sections 17.9 and
fevers have similar presentations to Ebola 16.9.2, respectively.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:50am page 198

Insect-borne Diseases

By adopting a more specific means of trans- and the next chapter on ectoparasites, which
mission, some parasitic organisms have attach to the host, such as fleas and lice.
become dependent on vectors for carriage Since the vector is all-important in transmis-
to a new host. Several vectors may be used sion, the diseases transmitted by them are
by some infecting organisms, such as arbo- grouped according to the vector.
viruses, but often a parasite is restricted to
only one kind of vector. This may appear to
reduce the chance of infection, but com- 15.1 Mosquito-borne Diseases
pared with the haphazard method of scatter-
ing large numbers of organisms into the The mosquito is the most important vector
environment, in the hope that one of them of disease, because it is abundant, lives in
will find a new victim, using a vector can close proximity to humans and needs to feed
have a greater chance of success. The para- on blood (the female must have a blood meal
site is carried right to the new host and in for the development of its eggs). Incredibly it
many cases introduced directly into it. is a very delicate insect, being easily blown
Often, a development stage takes place in by the wind, is a weak and slow flier, and
the vector and the infective stage continues susceptible to climatic change. Its success
for the rest of the vectors life. However, lies in its opportunism and rapid develop-
transmission depends on the vector being mental cycle, allowing large numbers to be
able to find a new host, often within a produced in a short period of time. Once a
limited period of time, at a vulnerable stage suitable breeding place appears, be it a few
in the life cycle, where control methods are puddles after a rainstorm or a man-made
most likely to succeed. water storage tank, mosquitoes will quickly
Vector transmission is one of the com- lay their eggs. These develop within a short
monest methods of spreading disease and period of time into a large number of adults.
many of the infections transmitted this way Each may become a vector, and although
are of major importance, so large sections many will die, there will be a sufficient
need to be devoted to them. Such is the number left to seek out suitable blood
importance that vector-transmitted diseases meals and transmit infection.
are discussed in two chapters this chapter, Some parasites are specific to certain
which includes all the vectors that use types of mosquitoes (e.g. malaria and
flight, such as mosquitoes and tsetse flies, the anophelines), while others, like the

Q R. Webber 2005. Communicable Disease Epidemiology and Control, 2nd edition (Roger Webber)

Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:50am page 199

Insect-borne Diseases 199

arboviruses, are less selective and utilize 15.2 Arboviruses

many different species. Different kinds of
mosquitoes may be required in a complex Arthropod-borne virus (arbovirus) infec-
transmission cycle such as yellow fever. tions occur in an epidemic form in different
Development of the parasite within parts of the world. Many viruses have been
the mosquito may be morphological without identified (see Table 15.1 and Chapter 19)
multiplication (as with filaria), asexual and are grouped into three-symptom
(arbovirus) or sexual reproduction (malaria). complexes.
Each of these methods confer advantages
and disadvantages, such as the sheer
number of organisms produced by asexual
(a) Those producing mainly fever and/or
reproduction, or the opportunity to produce
strains of varying type with sexual repro-
duction, but if the mosquito does not
live long enough for these developmental 15.2.1 Chikungunya, Onyong-nyong, West
stages to take place, then all is lost. Nile, Orungo, Oropouche and Ross River
There are two main groups of mosqui-
toes the anophelines and the culicines This group of infections are summarized
(which includes Aedes), separated by in Table 15.1. They present as a dengue-
characteristics found in all of the develop- like disease (see below) with headache,
ment stages (Fig. 15.1). The adult Anopheles fever, malaise, arthralgia or myalgia, lasting
mosquito raises its hind legs away from for a week or less. Rashes are common
the surface, easily remembered by its stance in Chikungunya, Onyong-nyong and West
being like one side of a letter A, while Nile. Chikungunya may present as a haem-
the lava lies horizontal to the surface. The orrhagic fever in India and Southeast
eggs are laid singly and have little floats Asia (see below), and West Nile and Oro-
on each side. In contrast, culicine mosqui- pouche as encephalitides. Ross River pre-
toes rest horizontal to the surface, their dominantly presents as a polyarthritis
larvae hang down from a single siphon and rash. There are many other arbovirus
and their eggs have no floats and are often infections presenting as fever, listed in
laid in rafts. It is better to try and differen- Chapter 19.
tiate an adult male, with bushy antennae,
from a female before subsequently separat- Diagnosis of all the arbovirus infections is
ing anophelines from culicines by the generally made on clinical grounds, once
length of the palps. More precise species the initial cases have been identified by
identification is required to identify which virus isolation in a specialist laboratory.
mosquitoes are principal vectors, but this A rise in specific IgM in serum or CSF is
needs entomological help. useful, if available.
Mosquitoes differ in their habits, some
preferring to take blood meals on humans Incubation period 215 days.
(anthropophilic) or on animals (zoophilic)
or are non-specific depending on which is Period of communicability of all the arbo-
most readily available. They also have par- virus infections is as long as there are still
ticular biting times, either only indoors, infected mosquitoes remaining.
only outdoors or a mixture of the two. The Susceptibility is general, but infection
biting period can be mainly during the night leads to immunity, probably life-long. In
or predominantly in the daytime. All these endemic areas, they are diseases of children,
different parameters need to be measured in otherwise they are epidemic, affecting all
determining the importance of each type of age groups and both sexes. In 2002, there
mosquito as a vector. were epidemics of West Nile virus in Israel,
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:50am page 200

200 Chapter 15

Fig. 15.1. The main differences between anopheline and culicine mosquitoes.

Canada and the USA (resulting in 3231 cases (b) Those presenting as fever and
and 176 deaths in the USA), countries where encephalitis
this infection had not occurred before.
While most people suffered minor illness, 15.2.2 Western equine, Eastern equine, St
individuals with weakened immune Louis, Venezuelan, Japanese, Murray Valley
systems, such as people with chronic dis- and Rocio
eases, those on chemotherapy or the elderly
suffered more serious effects, including This group of diseases present with a high
meningitis and encephalitis. fever of acute onset, headache, meningeal
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:50am page 201

Insect-borne Diseases 201

Table 15.1. The important arbovirus infections of humans.

Virus Distribution Vectors Reservoir

Mainly fever or arthritis

Chikungunya Africa, South and Southeast Aedes aegypti, Ae. Baboons, bats,
Asia africanus, Ae. rodents, monkeys
Onyong-nyong E. Africa, Senegal Anopheles gambiae, A. Mosquito?
West Nile Africa, Asia, Europe, USA Culex pipens molestus, C. Birds?
modestus, C. univittatus
Oropuche Trinidad, South America Mosquitoes, possibly Monkeys, sloths, birds
Orungo W. Africa, Uganda Ae. dentatus, Anopheles
Ross River Australia, New Zealand, C. annulirostris, Ae. vigilax, Mosquito
Pacific Islands Ae. polynesiensis

Fever and encephalitis

Western Equine Americas C. tarsalis, Culista melanura Birds

Eastern Equine Americas, Caribbean C. melanura, Aedes and Birds, rodents
Coquillettidia spp.
St Louis Americas, Caribbean C. tarsalis, C. nigripalpus, C. Birds
Venezuelan Central/South C. tarsalis and other Culex, Rodents
Equine America, Caribbean, parts of Aedes, Mansonia,
USA Sabethes, Psorophora,
Anopheles, Haemagogus
Japanese East, South and Southeast C. tritaeniorhynchus, C. Birds, pigs
Asia gelidus, C. fuscocephala
Murray Valley New Guinea, Australia C. annulirostris Birds
Rocio Brazil Probably mosquitoes Birds? Rodents

Haemorrhagic fevers
Yellow fever South America and Africa Ae. aegypti, Ae. africanus, Monkeys, mosquitoes
Ae. simpsoni, Ae. furcifer/
taylori, Ae. luteocephalus,
Haemagogus spp.
Dengue 1, 2, 3 Asia, Pacific, Caribbean, Ae. aegypti, Ae. albopictus, Human/mosquito,
and 4 Africa, Americas Ae. scutellaris group, Ae. (Monkeys in jungle
niveus, Ochlerotatus cycle)
Rift Valley Africa, Southwest Asia Ae. caballus, C. theileri, C. Sheep, cattle, etc.
quinquefasciatus and Mosquito
other Culex and Aedes
Kyasanur forest South India Haemaphysalis (hard ticks) Rodents, monkeys
CrimeanCongo Europe, Africa, Asia Hyalomma spp. (hard ticks) Domestic animals
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:50am page 202

202 Chapter 15

irritation, stupor, disorientation, coma, Some arbovirus infections can also be

spasticity and tremors. Fatality rates are spread by non-mosquito arthropods, such
variable with up to 30% in Japanese, Eastern as KFD and CrimeaCongo fever (see
equine and Murray Valley. Their distribu- Section 16.9.2).
tion, vectors and reservoirs are summarized
in Table 15.1. Japanese encephalitis is Control and prevention of arbovirus
covered in more detail below. infections The main method of control is
From the reservoir bird or animal, the the destruction of vector mosquitoes and
organism is often first transmitted to another breeding places. The most important are
host, such as horses in the equine arbovirus Culex and Aedes mosquitoes, which live in
infections. Humans are then mainly infected collections of water close to the home.
from mosquitoes feeding on the horses. Search is made for larvae and all breeding
places destroyed. A simple method is to use
Incubation period is 515 days. Susceptibil- school children, making it a game or giving a
ity is highest in the very young and old, with reward for the number of breeding places
inapparent infection occurring at other age found. Water tanks, blocked drains, dis-
groups. carded tin cans or old tyres are favourite
breeding places. Large breeding areas (such
as water tanks) can be covered, screened,
treated with insecticides or natural preda-
(c) Haemorrhagic fevers tors introduced (e.g. fish or dragonfly
larvae). An improvement on covering water
15.2.3 Yellow fever, dengue, Rift Valley, pots and containers is to use an insecticide-
Kyasanur forest disease, CrimeanCongo and treated pot cover rather than place the
Chikungunya insecticide in the container.
Where there is an epidemic in a com-
Apart from yellow fever, which will be pact area such as a town, the quickest and
covered in more detail below, a group of simplest (although expensive) method of
generally mild viral fevers including bringing the epidemic to an end is to use
dengue, Rift Valley, Kyasanur forest disease fogging or ULV aerial spraying. Compared
(KFD) and Chikungunya, which at certain with working hours lost, this can be a cost-
places and occasions take on a severe form effective procedure.
resulting in vascular permeability, hypovo- Personal prevention with repellents
laemia and abnormal blood clotting. Infec- (see malaria) can protect the individual.
tion commences as an acute fever, malaise, The infected case should be nursed under a
headache, nausea or vomiting with petechial mosquito net so as not to infect other mos-
rashes, severe bruising, epistaxis and bleed- quitoes. A vaccine is available for Vene-
ing from various sites. After a few days, zuelan, Eastern and Western equine
sudden circulatory failure and shock may encephalitis, which can be used both for
occur producing a mortality of up to 40%. humans and horses.
Rift Valley Fever is normally a disease Where an animal reservoir is involved,
of cattle, sheep, camels and goats, in which some restriction of animals or reduction of
high mortality can cause considerable eco- rodents can help. In Rift Valley fever, special
nomic loss, but spread to humans also precautions should be taken in handling
occurs. A large number of unexplained abor- domestic animals and their products by
tions in livestock is often the first sign of an wearing gloves and protective clothing.
impending epidemic. The disease was nor- Blood and other body fluids of patients are
mally restricted to Africa, but in 2000, it also infectious, so barrier nursing should be
spread to Saudi Arabia and Yemen, raising instituted. All animals should be vaccin-
the fear that it could infect other parts of ated. A vaccine for use in humans is under
Asia and Europe. trial.
Webber/Communicable Disease Epidemiology and Control, 2nd Edition Final Proof 18.11.2004 5:50am page 203

Insect-borne Diseases 203

Treatment There is no specific treatment, in urban areas, where suitable stagnant

supportive therapy being given (Ribavirin water permits the breeding of vector
may be of value). mosquitoes.

Surveillance Regular checks should be made Incubation period 414 days.

on mosquito-breeding places and control
methods instituted where mosquitoes are Period of communicability As long as there
found. People can be taught to regularly are infected mosquitoes continuing to bite
search their home areas for mosquito breed- people. Mosquitoes can also become
ing. (See further under yellow fever below.) infected by feeding on a clinical case any
time during the illness.

15.3 Japanese Encephalitis (JE) Occurrence and distribution Serological

surveys indicate that most people living in
Organism The Japanese encephalitis virus endemic areas contract sub-clinical infec-
(JEV) is a member of the flavivirus family, tion before the age of 15 years. However,
the same group of viruses as West Nile and young children and adults, who have not
St Louis encephalitis. been infected as children (including visit-
ors), may get clinical