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Epidemiology of communicable diseases
Global Burden of Infectious Diseases (WHO 1999) - Communicable of infectious diseases continue to remain a
leading cause of morbidity, disability and mortality worldwide.
Epidemiologic Triangle - A model for disease causation, invoked to the explanation occurrence
of infectious diseases.
Infectious Disease - These are usually categorized according to mode of transmission,
whether or not they are vaccine-preventable, etc.
Infection - The entry, development or multiplication of an infectious agent in the
body tissue of man or animals.
Infectious Disease - A clinically manifest disease of man/animal resulting from an infection.
Communicable Disease - An illness due to a specific infectious agent or its toxic products that
arises through transmission from a reservoir to a susceptible host either
directly or indirectly.
Tetanus, Botulism, Staphylococcal food poisoning - Communicable but not infectious diseases.
Communicable - All infectious diseases are this.
Incubation Period - Time interval between initial contact with an infectious agent and the first
appearance of symptoms associated with the infection.
Communicable Period - Time during an infectious agent may be transferred from an infected
host/reservoir to another susceptible host.

Gradient of Infection
Inapparent Infection - Infection in a host without recognizable clinical signs or symptoms.
Laboratory means -^ is identified only via this.
Severe Disease - High rate of several clinical manifestations, high case of fatality rate, high
proportion of surviving patients with sequelae, serious problem from a
public health standpoint where the disease causes excess mortality.
Effect of Inaparent Infection
On Control of Disease - Insufficient to direct control procedures solely to clinically apparent cases.
All Infections - Control procedures must be directed towards this.
On Disease Statistics
Number of infections diagnosed and reported – This will be understated.
Severity of the disease - This will be overstated.

Infectious Disease Process

Ethologic Agent  Reservoir  Portal of Exit  MOT  Portal of Entry  Susceptible Host

ENVIRONMENT - Domain that is external to the host and in which the agent may exist, survive
or originate. Sum total of influences not part of the host. Enhance or
diminish survival of agent.
Physical - Water, humidity, geologic formations, etc.
Social - Totality of the behavioral, personality, attitudinal and cultural characteristics
of a group of people.
Reservoir - The environment can act as this that fosters the survival of infectious disease agent. A
living organism or inanimate matter where the infectious agent
normally lives and multiplies.
Environment, Animal, Humans -^ examples
Zoonoses - Infectious diseases that have vertebrate animal reservoirs and the potentially
transmissible to human under natural conditions.
Carrier - Any person or animal that harbors a particular infectious agent without
discernible clinical disease and serves as potential source of infection.
Cases - Another type of main reservoir.
INFECTIOUS AGENTS - Causes the infection
Types of Infectious Agents
Bacteria - TB and Shigellosis
Viruses and Rickettsia - AIDS, hepatitis
Fungi - Candidiasis, Athlete’s food
Protozoans - Ameobiasis, Giardiasis
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Helminthes - Schistosomiasis, Ascariasis
Intrinsic Properties - Properties of infectious agents that do not need any interaction with host.
Essential to understanding an agent’s epidemiology, including its MOT.
Morphology, chemical composition, antigenic property - ^ is useful in classification and specific identification of the following.
Intrinsic Properties Relate to Perpetuation of species: Visibility, Host Range, Growth Requirements, Antibiotic Resistance, Antigenic Variation

Properties Relating to Host-Agent Interaction - Affected by environmental conditions, dose, route of infection, age, nutritional
status and race of the host.
Infectivity - Ability of an agent to enter and multiply in a susceptible host and produce infection.
Infective Dose -^’s basic measure
Infectiousness - The ease of spread in population, infectivity can only be inferred to as this.
Polio and Measles - Has High Infectivity
Secondary Attack Rate (SAR) - Measure of infectivity, proportion of close contacts who become infected.
Infection Rate (IR) - Measure of infectivity, determined via serologic surveys after epidemics.

¿ new cases∈group−initial cases ¿ persons with antibody response

SAR= IR=
¿ Suceptiblepersons∈group−initial cases Total no . exposed

Immunogenicity - Infection’s ability to produce specific immunity in the host.

Immunity - The resistance associated with the presence of antibodies or cells having a
specific action on the microorganism or on its toxin.
Serologic Surveys - ^ is measured on this
Immunogenicity depends on: Amount of antigen formed in host, site of multiplication, Agent’s ability to induce lifelong immunity.
Pathogenicity - Ability to produce illness in an infected population.
Measles - Example of a disease with high pathogenicity due to few subclinical cases.
Polio - Disease with low pathogenicity, being most cases are subclinical.

¿ Infected persons withdisease

Pathogenicity =
Total Number Infected
Virulence - Extent to which severe disease is produced in a population with clinically
manifest disease.
Rabies - Example of a very virulent disease.
Case Fatality Ratio (CFR) - ^ is measured by this and the proportion of severe cases.
Toxigenecity - Capacity of the agent to produce a toxin or poison. Disease results from the
toxin produced by the agent rather than from the agent itself.
Resistance - Ability of the agent to survive adverse environment conditions.
Coccidomycoses and Hepatitis - Agents of these diseases are highly resistant.
Gonococci and Influenza - Agents of these diseases are fragile

Disease According to Host-Related Properties

RELATIVE DEGREE INFECTIVITY PATHOGENICITY VIRULENCE
High Measles Rabies Rabies
Chickenpox Measles TB
Poliomyelitis Chickenpox Leprosy
Smallpox Smallpox Smallpox
Commoncolds
Intermediate Mumps Rubella Poliomyelitis
Rubella Mumps
Common colds
Low TB Poliomyelitis Measles
Very Low Leprosy (?) Leprosy (?) Chickenpox
Rubella
Common colds

Pathogenic Mechanisms and Examples

Direct Tissue Invation - Salmonella, Shigella
Production of a Toxin - Staph, Clostridium
Immunologic Enhancement or Allergic Reaction - M. Tb
Persistent or talent Infection - Varicella-Zoster
Enhancement of host susceptibility to drugs - Varicella, Influenza B
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Immune Suppression - HIV

THE HOST - After exposure to the agent, may progress through a chain of events from
subclinical (inapparent) infection to a clinical case.
Defense Mechanism (Immunity) - The degree of infection and disease severity depends on this.
Immunity - Resistance of the host to a disease agent.

Non-specific Defense Mechanisms of the Host:

Skin, Mucosal Surface, Tears, Saliva, High pH of Gastric Juice, Immune System, Age, Nutritional Status, Genetic Factors
Disease-Specific Defense Mechanism
Natural Active - Infection includes an immunologic response (host produces antibody against
the agent)
Artificial Active - Vaccination simulates antibody production against the agent.
Natural Passive - Maternal antibodies are acquired by the fetus transplacentally that confers
short-term immunity to the newborn.
Artificial Passive - Performed antibodies against a specific disease are administered to an exposed
individual as means of prophylaxis against the disease.

Mechanism of Transmission - Various mechanisms by which agents are transported from the reservoir to the
susceptible host.
Direct - Immediate and direct contact, person to person, droplet spray
Indirect - No contact from person to person
Vector-borne - Mechanical or biological transmission by an arthropod
Vehicle-borne - Infected blood on used needle, fomites
Airborne - Droplet nuclei, dusts
Portals of Exit and Entry with Examples
Respiratory Tract - Diphtheria, influenza
Gastrointestinal Tract - Typhoid Fever
Gastro-Urinary Tract - Gonorrhea
Skin - Leptospirosis, Hep B
Conjunctiva - Trachoma
Other examples: Insect Bites, drawing of blood, surgical procedures, accidents

Aspects of Person to Person Spread

Generation Time - Period between receipt of infection by host and maximal communicability of
that host. Time of maximal communicability may precede/follow the
end of the incubation period.
Incubation Period -^ is roughly equivalent to this
Herd Immunity - Immunity of a group/community. Resistance of a group to invasion and spread
of an infectious agent based on the immunity of a high proportion of
individual members of the group.
Propagated Epidemics -^ is an important factory underlying of this.

Community Reactions to Agent - Sum total of the reactions of individuals comprising the group
Sporadic - Intermittent presence of a disease, occurrence of a few cases every now and
then often without relationship to each other.
Endemic - Constant presence of a disease within a geographical area.
Hyperendemic - Indicates persistent and intense transmission
Epidemic - Occurrence in a community of cases of an illness clearly in excess of normal
expectancy
Pandemic - An outbreak of exceptional proportion spreading quickly from one area to
another. Epidemic of worldwide proportion.

Herd Immunity, Exposure/contact rate - Community reactions depend on this.

Opportunities for progressive transmission of agent to new hosts are affected by:
 Size of the reservoir (determines frequency of contact)
 Readiness of transmission
 Environmental sanitation
 Density of vectors
 Infectivity of the agents
 Density of population
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Element of Chance - The probability of contact between the susceptible host and source of infection.
Site, Number of cases + location and immunes - ^ depends on this.

Epidemiology of non-communicable disease

NOTES:
 Communicable disease can be chronic and non-communicable diseases can be acute

Non-Communicable Diseases - Includes all traditionally defined diseases such as cancer, chronic respiratory
diseases, mental health and injuries and violence.
Tobacco Addiction - Single largest cause of preventable morbidity and mortality.
Tobacco Cancers - On the 15th place in the list of top NCDs.

Top 5 Positions Reasons for the Prominence of NCD

1. Ischemic Heart Disease 1. Aging of the Population
2. Depression 2. Impact of automobiles
3. Road Traffic Injuries 3. Lifestyle Changes
4. Cerebrovascular Disease 4. Tobacco Addiction
5. Chronic Obstructive Pulmonary Disease (COPD) 5. Physical Activity
Group of NCDs 6. Social and Behavioral Factors
 Cancers
 Lifestyle related (CVD, diabetes)
 Injury (unintentional, intentional)
 Genetic disorders
 Disabling disorders
 Occupational disorders
 Nutritional disorders
 Endocrine disorders
 Substance abuse

NATURAL HISTORY
Characteristics of the Agent - Absence of a single necessary agent. Most NCDs are classified via
manifestations rather than etiology.
Risk Factors - Known causes of NCDs.
Time Frame - Takes years before illness is apparent. No multiplication of causative agent is
involved. Multiple low doses exposures.
Nature of the Disease - Chronic in nature, permanent, leave residual disability, requires special
training for patient rehabilitation, requires long periods of supervision.
Chronicity - Function of the long latency period.
Slow disease process - This leads to adaptive response to stress, determined over the long term.
Presence of Synergism - This leads to decreased latency, produce illness in the prime of live even with
low level exposures.

Infectious Disease Non-infectious disease

Single necessary agent
Agent-disease specificity
Causes are known
Short incubation period
Single exposure usually sufficient
Usually produce acute disease
Acquired immunity disease
Diagnosis based on tests specific to disease agent
No single necessary agent
Seldom agent-disease specificity
Causes are unknown
Intervention often based on risk factors
Long Latency period
May require multiple exposure to same or multiple agents
Most often produce chronic disease
Acquired immunity unlikely
Diagnosis often dependent on non-specific symptoms or tests
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Methodological Issues in the Study of NCD

A. NATURAL HISTORY
a. Lack of a single necessary agent causing the disease makes it moredifficult to isolate the effect of any individual
factor
b. Synergistic effects of other agents and effects of known causes must be controlled
c. Long latency period → recall problems
d. Chronic nature and low frequency of occurrence → prevalent cases studied rather than incident cases → difficult
interpretation of causality
B. CASE IDENTIFICATION
a. Presence or absence of a cluster of symptoms
b. Criteria for diagnosis may vary by institution or by physician → research using medical records problematic
C. MEASURING EXPOSURE
a. Quantification is important but problematic
b. Acuteness or chronicity/high dose or low dose
c. Is dose a function of a metabolite, enzymatic alteration, level of the original agent?
d. Environmental levels or body levels?
e. Plasma levels, brain concentration, kidney, or some other organ tissue?
f. Precise quantification identifies levels hazardous to health → important for planning control measures.
g. Demonstration of dose effect helps establish casual role for the agent
h. Constancy or intermittence of the exposure
i. Relevant time or period of exposure

Conflicting Findings and Casualty

 Publication bias
 Criteria for casualty
o strength of association
o temporal correctness
o dose - effect relationship
o biological plausibility
o consistency of findings
o specificity of relationships

Problems in Investigating Disease Etiology

1) Absence of a known agent
- Especially a problem for chronic diseases, makes diagnosis difficult, may take distinction between diseased and non-
diseased people difficult.
2) Difficulty of measuring and characterizing exposure
- Problematic in environmental exposures, technology to accurately detect/measure exposures may not be available.
3) Multi-factorial nature of etiology
- Relevant factors may be both environmental and constitutional and may also interact with other factors.
4) Long Latent Period -
-Presence during which host and environmental factors interact before the disease manifests. Makes it difficult to link
antecedent events with the outcomes.
5) Indefinite Onset
-Most chronic diseases are characterized by this, the problem of identifying the time of onset of the disease makes collection
of incidence data difficult.
6) Differential effect of factors on incidence and course of disease
-the nature of the exposure disease relationship may be different during the initial development of the disease and the later
course of the disease (i.e., factors may act differently at various stages of the disease

Major Categories of Etiological Agents

Occupational - Chemical, metals and naturally occurring minerals
To be considered
 size and shape of particles
 route of exposure
 free or compound form
 organic vs inorganic form
 liquid or vapor form
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General Environmental - Conditions in the work environment that will influence the likelihood that
workers will come in contact with an agent. Cleanliness and ventilation.
Host Factors -Lifestyle behaviors may increase the risk of disease from occupational exposure
to an agent.
Sources of Exposure - Contamination of air, water and soil by industrial activities.

Investigating environmental exposures

-dose
-data on levels of exposure
-mobility of subjects
-confounders
-Wide rage of ages
- Length of exposure
- Meteorological conditions
- Seasonal effects
Lifestyle and Illness - Poverty, stress, exercise, drug and alcohol use, nutrition.

Descriptive epidemiology
Epidemiology - The study of the distribution and determinants of health-related states or events
in human populations. For prevention and control of health-related problems.
Core Activities: Public Health Surveillance, Disease Investigation, Communication
Descriptive Epidemiology - Concerned with the distribution of disease, including what populations do or
do not develop a disease, in what geographical locations it is most or
least common and how frequency of occurrence varies per time.
Time, Place, Person -^ is the study of occurrence and distribution of disease in terms of?
Disease - the what
Person - Who, Organizing epidemiologic data according to the characteristics of the
people involved.
Place - Where, geographic area in which contact between the susceptible host and
etiologic agent potentially occurred.
Time - When
Secular - Long time trend of disease occurrence
Seasonal - Variations based on climatic factors
Day of week and time of day - Analysis at shorter time periods.

Types of Descriptive Studies

Case Report and Case Series - Describe the experience of a single case or a group of patients with similar
diagnosis. Document unusual medical occurrences.
4 kinds of cases
o Case that represent a previously undescribed syndrome/disease
o Case with unexpected association of 2 or more diseases
o Case representing a new and important variation of an unexpected pattern
o Case with an unexpected evolution that suggests a therapeutic or adverse drug effect
Correlational Study (Ecologic) - Uses data from entire pop to compare disease frequency between different
group during the same time or in the same population at diff points in
time. Comparison of D and E between groups.
Group/unit -^’s unit of observation.
Exploratory - Rates of disease/mortality or condition from several communities are compared.
Ecologic Comparison - Comparison of frequency measures among several groups.
Ecologic Trend (Time Series) - Assessment of trends over time (line graph) . Frequency of the exposure and/or
disease at different points are determined per group before and/or after
the application of intervention
Ecologic Fallacy - When conclusions about a relationship between E and D are made at the
individual level based on ecologic data.
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Analytic Study Design
Cross Sectional Study - To determine co-existence between factor and outcome in a defined population
One group - Study population
Descriptive, observational, concurrent - Classification
Case Control Study - To show that the probability of exposure is greater in those with D than those in D.
Cohort Study - To show that the probability of disease is greater in exposed than in unexposed.
Experimental Study - To show that the probability of outcome of interest is greater in exposed than
the unexposed.
True Experiment - Manipulation and randomization is present.
Quasi- experiment - Manipulation is present but no randomization

Odds - Number of individuals with a characteristic which is expressed relative to the

number without the characteristic.
METHODOLOGIC ISSUES
Confounding - Effect of an extraneous variable that distorts the relationship of two variables;
under/over estimation of effect.
Difference between study groups -^ source
Bias - Systematic deviation from the truth, consequence of study design, occur at any
stage of the research process.
Systematic Error - Systematic deviation from the truth.

Introduction to epidemiology
Epidemiology - The study of the nature, cause, control and the determinants of the frequency
and distribution of disease, disability and death in human populations.
Epidemics -^’s literal translation “That which befalls man”
Epi - From this greek word meaning upon, on befall
Demos - Meaning people, population, man
Logy - Meany study off
Prevention of Disease/ Maintenance of Health- The ultimate goals of epidemiology
Epidemic - Attacking many people at the same time, occurrence in a community or region
of cases of illness clearly in excess of normal expectancy.

Factors leading to the success of eradication

 Universal political commitment
 Clear and specific goal with precise timetable
 Well-trained and committed staff
 Flexible strategy
 Features of the disease that made its elimination possible
 Availability of an effective and stable vaccine

BASIC CONCEPTS
Cause - Event, condition, characteristic that plays a role in producing occurrence of a disease.
Association - Identifiable relationship between an exposure and disease, does not always
indicate that there is a cause-effect relationship.
Causation - Presence of a mechanism that leads from exposure to disease.
Statistical Association - Statistical dependence between two variables, degree to which the rate of
disease in person with a specific exposure is either higher or lower than
the rate of disease among those without that exposure.
Cause - Epidemiology does not determine this.
Association - Epidemiology determines this between a given exposure and frequency of
disease in population.
Infer - This is done to causation based upon the association and several other factors.
Causal - Association between categories of events/ characteristics in which an alteration
in the frequency or quality of one category is followed by a change in
the other.
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Non-Causal - Association of both categories of events with a third category.
Direct Cause - There is an immediate reaction/association
Indirect Cause - There is an intermediate stage, aka predisposing cause.

Henle-Koch’s Postulates - Postulates for determining than an infectious agent is the cause of a disease.
Postulates:
 Organism must be present in every case of the disease
 Organism must be able to be isolated and grown in pure culture
 Organism must, when inoculated into a susceptible animal, cause the specific disease.
 Organism must be recovered from the animal and identified.
Assumption:
 A particular disease has one cause
 A particular cause results in one disease
o But not true for many diseases
 Causes cannot be established by means of Koch’s postulates since many factors act together to cause diseases.
Determination of Cause
Biomedical Scientists - Elucidate pathogenic causes/mechanisms (cellular/subcellular processes)
Epidemiologists - Investigate other less specific factors, risk factors that are associated with an
increased risk of becoming diseased.
Risk Factor - Increases the chance of a disease
Preventive Factor - Lessens the chance of a disease.

Necessary Cause - A disease cannot develop in its absence.

Sufficient Cause (Satisfying condition) - It inevitably produces or initiates a disease, this guarantees a disease but the
disease does not ensure the presence of the cause. Set of minimum
conditions that produce diseases.
Component Cause - Cause of any effect consists of a constellation of components that act in
concert to produce a disease. (One disease occurs in different
situations.)
Judging Causality
1. Determine presence of validity, remove chance, bias and confounding
2. Determine causality

Chance - A random variability, determined by sample size.

Epidemiologic Assumption - Draw an inference about the experience of an entire population based on study
of only a sample.
Bias - Two types are selection and misclassification.
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Statistical Approaches - Is done in the presence of bias.
Confounding - Effect of extraneous variable that distorts the relationship between the effect
and disease.
Confounder - Extraneous variable, non- comparable study groups. Associated with exposure
but not the consequence of the exposure.
Stratified/Regression analysis - Is done in the presence of confounders.
Plausibility - Lack of this may simply reflect lack of medical knowledge.
Association - There must not be any bias, chance, and confounding. Relation must be very
high or low.

Multiple Causation - More than one factor should be present for disease to develop.
Host factors (intrinsic) - Affect susceptibility to disease.
Environmental Factors (Extrinsic) - Influence exposure and sometimes indirectly affect susceptibility as well.

Ecologic Models
Ecology - The study of relationship of organisms to each other as well as other aspects of
the environment.
Web of Causation - There is no single cause, causes are interacting, illustrated interconnectedness
Multiple Causation - Possible to interrupt the causation of disease by cutting the chains.

 THE WEB

Natural History of Disease - Course of disease over time unaffected by treatment or prevention.
1. Stage of susceptibility - Disease has not developed, interaction of agent, host and envi. Groundwork for
disease due to the presence of factors.
Risk Factors - Factors whose presence is associated with an increased probability that the
disease will develop later. Not all risk factors will develop the disease.
Agent - Factor whose presence/absence causes a disease.
Host - Human in whom an agent produces a disease
Intrinsic Factors - Examples are genetic, past envi. Exposures, personality, social class
Environment - Provides reservoirs of agents to live/multiple. MOT
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2. Stage of presymtomatic (sublclinical) - No manifestation or signs/symptoms, pathologic changes have started to occur.
3. Stages of Clinical Disease - Changes in the organs, shows signs and symptoms.
Classification of disease - This is important in this stage for better management.
4. Stage of recovery, disability or death - final stage
Disability - Any temporary or long-term reduction of a person’s activity as a result of an
acute or chronic condition.
Induction Period - Causal action to disease initiation. (cause-effect)
Latent Period - Disease occurrence to detection (effect- detection)

Levels of Prevention - Objective is to halt/reverse the disease process.

Natural History of Disease - The basis of the 4 levels
a) Primordial - Avoid the emergence and establishment of the patterns of living that are
known to contribute to elevated risk of disease. Change in lifestyle
b) Primary - General health promotion, specific protective measures (Education and prevention)
c) Secondary - Early diagnosis and prompt treatment. May cure of slow progression of disease
Screening surveys - Are designed to uncover asymptomatic diseases and to alter the natural history
of the condition detected.
d) Tertiary - Limitation of disability and rehabilitation, residual stage. PT.

Development of Disease Phase of Prevention Target Population

Underlying conditions leading to
Primordial Total population/selected groups
causation
Total population/selected
Specific “causal” factors Primary
groups/individuals
Early stage of disease Secondary Patients
Late stage of disease Tertiary Patients

International Classification of Disease - Is an international standard diagnostic classification. Health problems are
categorized into disease entities. Serves as common language.