Chapter11Epidemiology and Public Health Revised

EPIDEMIOLOGY AND PUBLIC HEALTH
Chapter Outline
• Epidemiology
• Interactions Among Pathogens, Hosts and the
Environment
• Chain of Infection
• Reservoirs of Infection
• Modes of Transmission
• Public Health Agencies
• Bioterrorism and Biological Warfare Agents
• Water Supplies and Sewage Disposal
Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins
Epidemiology
• Introduction
– Epidemiology can be loosely defined
as the study of disease.
– Epidemiologists study the factors
that determine the frequency,
distribution, and determinants of
diseases in human populations.

The factors include the following:
1. characteristics of various pathogens;
2. susceptibility of different human populations
resulting from
a. . overcrowding,
b. lack of immunization,
c. nutritional status,
d. inadequate sanitation procedures, and
other factors;
3. locations (reservoirs) where pathogens are
lurking; and the
4. various ways in which infectious diseases are
transmitted.
It could be said that epidemiologists are
concerned with the who, what, where, when,
and why of infectious diseases:
▪ Who becomes infected?
▪ What pathogens are causing the infections?
▪ Where do the pathogens come from?
▪ When do certain diseases occur?
▪ Why do some diseases occur in certain
places but not in others?
▪ How are pathogens transmitted?
▪ Do some diseases occur only at certain
times of the year? If so, why?
Epidemiologists also develop ways to
prevent, control, or eradicate diseases in
populations.

Epidemiologic Terminology
• A communicable disease is an infectious disease that can

be transmitted from one person to another
• A contagious disease is a communicable disease that is
easily transmitted from person-to-person.
• Zoonotic diseases are diseases that humans acquire from
animal sources.
• The incidence of a particular disease is the number of
new cases of that disease in a defined population during
a specific time period.
• The morbidity rate is the number of new cases of a
particular disease that occurred during a specified time
period per a specifically defined population (usually per
1,000, 10,000 or 100,000 population).
Epidemiologic Terminology, cont.
• Prevalence
– Period prevalence is the number of cases of a disease
existing in a given population during a specific time
period (e.g., total number of cases of dengue in the
Phils. during the year 2009).
– Point Prevalence is the number of cases of a disease
existing in a given population at a particular moment
in time (e.g., the number of cases of malaria in the
Phil. Population at this moment).
• Mortality rate is the ratio of the number of people who
died of a particular disease during a specified time period
per a specified population; also referred to as death rate.
(e.g. the number of people who died of dengue in 2019
per 100,000 Phil. Population)
• A sporadic disease is one that occurs only

occasionally within the population of a
particular geographic area; example,
tetanus.
• An endemic disease is one that is always
present within the population of a particular
geographic area; example, gonorrhea.
• An epidemic disease is defined as a greater
than usual number of cases of a disease in a
particular region, usually within a short
period of time; example, the Legionnaire’s
disease epidemic of 1976.
• A pandemic is a disease that is occurring in epidemic
proportions in many countries simultaneously. Examples
include:
– Influenza
Examples:
1. the Spanish flu pandemic of 1918 during which
more than 20 million people were killed worldwide
(500,000 in the U.S.);
2. the H1N1 (“swine flu”) pandemic of 2009-2010.
3. the ongoing COVID-19 pandemic
– HIV/AIDS
– Tuberculosis
– Malaria
Interactions Among Pathogens, Hosts,
and the Environment
Whether an infectious disease occurs depends

on the following factors:
A. Factors pertaining to the pathogen which
are:
1. virulence of pathogen ( measure or degree
of pathogenicity)
2. mode of entry ( is there a portal of entry?)
3. number of organisms ( will there be a
sufficient number to cause infection? )

B. Factors pertaining to the host (the person
who may become infected) such as:
1. health status ( has the person been
hospitalized? Does he/she have any
underlying disease?)
2. nutritional status
3. hygiene
4. age*
5. travel*
6. lifestyle*
* May affect the susceptibility of the host

C. Factors pertaining to the environment
such as:
1. physical factors such as climate, season,
2. geographic location;
3. availability of appropriate reservoirs;
4. sanitary and housing conditions; and
5. availability of potable water

The Chain of Infection
There are 6 components in the infectious
disease process:
● a pathogen
● a source of the pathogen (a reservoir)
● a portal of exit
● a mode of transmission
● a portal of entry
● a susceptible host
The Chain of Infection, cont.

Reservoirs of Infection
• The sources of microorganisms that cause infectious diseases are
many and varied; they are known as reservoirs of infection or simply
reservoirs.
Living reservoirs – humans, pets, farm animals, insects, arachnids
Human carriers( any person who is colonized with a particular
pathogen, but the pathogen is not currently causing disease in the
person )
• Passive carriers – carry the pathogen without ever having
had the disease.
• Incubatory carriers – are capable of transmitting a pathogen
during the incubation period of a particular infectious
disease.
• Convalescent carriers – harbor and can transmit a particular
pathogen while recovering from an infectious disease
• Active carriers – have completely recovered from the disease,
but continue to harbor the pathogen indefinitely.(e.g.
Typhoid Mary)
Reservoirs of Infection, cont.
• Animals
– Infectious diseases that humans acquire
from animal sources are called zoonotic
diseases or zoonoses.
– Zoonoses may be acquired by
a. direct contact with an animal,
b. inhalation or ingestion of the pathogen,
or
c. injection of the pathogen by an
arthropod.

Category Disease Pathogen Animal Mode of
reservoir Transmission
Viral Avian An Birds Direct or
diseases influenza influenza indirect
virus contact with
infected
birds
Rabies Rabies virus Rabid Animal bite
dogs, cats, or inhalation
bats
Yellow fever Yellow fever Monkeys Aedes
virus aegypti
mosquito
bite
West Nile West Nile Birds Mosquito
virus virus bite
encephalitis
Bacterial Anthrax Bacillus Cattle, Inhalation,

diseases anthracis sheep,goats ingestion, entry
diseases through
cuts, contact with
mucous
membranes
Brucellosis Brucella spp. Cattle, swine, Inhalation,
goats ingestion of
contaminated
milk, entry
through cuts,
contact with
mucous
membranes
Leptospirosis Leptospira spp. Cattle, rodents, Contact with
dogs contaminated
animal urine
Plague Yersinia pestis Rodents Flea bite

Fungal Tinea(ringworm) Various Various Contact with
infections dermatophytes animals, infected animals
including dogs
Protozoal African Subspecies of Cattle, wild Tsetse fly bite
diseases trypanosomiasis Trypanosoma game animals
bruceii
Toxoplasmosis Toxoplasma Cats, pigs, Ingestion of
gondoii sheep, rarely oocysts in cat
cattle feces, or cysts in
raw or
undercooked
meat
Helminth Rat tapeworm Hymenolepsis Rodents Ingestion of
disease infection diminuta beetle containing
the larval stage

Reservoirs of Infection, cont.
• Nonliving Reservoirs
– Air, soil, dust,
contaminated water and
foods, and fomites
– Fomites - inanimate
objects capable of
transmitting pathogens
(e.g., bedding, towels,
eating and drinking
utensils, hospital
equipment, telephones,
computer keyboards,
etc.)

Inanimate Vectors of Infection (Fomites)

Most Common Modes of Transmission
of Infectious Diseases
• Direct skin-to-skin contact
• Direct mucous membrane-to-mucous membrane
contact by kissing or sexual intercourse
• Indirect contact via airborne droplets of respiratory
secretions, usually produced by sneezing or
coughing
• Indirect contact via food and water contaminated by
fecal matter
• Indirect contact via arthropod vectors
• Indirect contact via fomites
• Indirect contact via transfusion of contaminated
blood or blood products or by parenteral injection
using nonsterile syringes or needles
Common Route of Transmission of Infectious Diseases
ROUTE OF EXIT ROUTE OF TRANSMISSION OR DISEASES
ENTRY
Skin Skin discharge → air → respiratory Chickenpox, colds, influenza,
tract measles, staph and strep infections
Skin to skin Impetigo, eczema, boils, warts,
syphilis
Respiratory Aerosol droplet inhalation Colds, influenza, pneumonia,
Nose or mouth → hand or object → mumps, measles, chickenpox,
nose tuberculosis
Gastrointestinal Feces → hand → mouth Gastroenteritis, hepatitis,
Stool → soil, food, or water → salmonellosis, shigellosis, typhoid
mouth fever, cholera, giardiasis, amebiasis
Salivary Direct salivary transfer Herpes cold sore, infectious
mononucleosis, strep throat
Genital secretions Urethral or cervical secretions Gonorrhea, herpes, Chlamydia
Semen infection Cytomegalovirus infection,
AIDS, syphilis, warts
Blood Transfusion or needlestick injury Hepatitis B, cytomegalovirus
Insect bite infection, malaria, AIDS
Malaria relapsing fever
Zoonotic Animal bite Rabies
Contact with animal carcass Tularemia, Anthrax
Arthropod Rocky Mountain spotted fever, Lyme
disease, typhus, viral encephalitis,
Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & yellow
Wilkins fever, malaria, plague
Modes of Disease Transmission

Public Health Agencies
• World Health Organization (WHO)
– A specialized agency of the United Nations
founded in 1948; www.who.org
– Missions: to promote technical cooperation for
health among nations; to carry out programs to
control and eradicate diseases; to improve the
quality of human life
• Investigates outbreaks of Ebola virus, and
presently, the Covid19 virus.
• Eradicated smallpox
• Attempting to eradicate polio and
dracunculiasis

Other WHO Initiatives:
1. The Access to COVID-19 Tools (ACT) Accelerator

2. Decade of Healthy Ageing (2020-2030)
3. Defeating meningitis by 2030
4. Eliminate yellow fever epidemics (EYE) 2017-2026
5. Global Action Plan for Healthy Lives and Well-Being
for All
6. WHO collaborative multi-centre research project on
Severe Acute Respiratory Syndrome (SARS)
diagnosis

Public Health Agencies, cont.
Department of Health(DOH)
The Department of Health (DOH) is the principal health
agency in the Philippines. It is responsible for ensuring
access to basic public health services to all Filipinos
through the provision of quality health care and regulation
of providers of health goods and services.
VISION
Filipinos are among the healthiest people in Southeast
Asia by 2022, and Asia by 2040
MISSION
To lead the country in the development of a productive,
resilient, equitable and people-centered health system
Public Health Agencies, cont.
Health Programs of DOH
1. Adolescent Health and Development Program
2. Blood Donation Program
3. Barangay Nutrition Scholar (BNS) Program
4. Dengue Prevention and Control Program
5. Emerging and Re-emerging Infectious Disease
Program
6. Malaria Control Program
7. Measles Elimination Campaign ( Ligtas Tigdas )
8. Women and Children Protection Program
The prevention and control of epidemics is a never-ending community goal. To
be effective, it must include measures to:
1. Increase host resistance through the development and administration of

vaccines that induce active immunity and maintain it in susceptible persons
2. Ensure that persons who have been exposed to a pathogen are protected
against the disease (e.g., through injections of gamma globulin or antisera)
3. Segregate, isolate, and treat those who have contracted a contagious

infection to prevent the spread of pathogens to others
4. Identify and control potential reservoirs and vectors of infectious diseases;

this control may be accomplished by prohibiting healthy carriers from working
in restaurants, hospitals, nursing homes, and other institutions where they may
transfer pathogens to susceptible people and by instituting effective sanitation
measures to control diseases transmitted through water supplies, sewage, and
food (including milk)

Bioterrorism and Biological
Warfare Agents
• Microbes purposely used to harm others in

wartime are called biological warfare (bw)
agents.
• Pathogens used to create fear, chaos, illness,
and death in situations other than war are
called bioterrorism agents. Examples:
– Bacillus anthracis (the cause of anthrax)
– Clostridium botulinum (the cause of
botulism)
– Smallpox virus (Variola major)
– Yersinia pestis (the cause of plague)
▪ Anthrax is caused by B. anthracis, a spore-forming, Gram
positive bacillus.
▪ People can develop anthrax in several ways resulting in three
forms of the disease:
a. cutaneous anthrax,
b. inhalation anthrax, and
c. gastrointestinal anthrax.
▪ Anthrax infections involve marked hemorrhaging and serous
effusions (fluid that has escaped from blood or lymphatic
vessels) in various organs and body cavities and are
frequently fatal.
▪ Of the three forms of anthrax, inhalation anthrax is the most
severe, followed by gastrointestinal anthrax and then
cutaneous anthrax. Patients with cutaneous anthrax develop
lesions
▪ Bioterrorists could disseminate B. anthracis spores via
aerosols or contamination of food supplies.
▪ Botulism is a potentially fatal microbial intoxication, caused by
botulinal toxin, a neurotoxin produced by C. botulinum.
▪ C. botulinum is a spore-forming anaerobic Gram-positive

bacillus.
▪ Botulinal toxin may cause nerve damage, visual difficulty,

respiratory failure, flaccid paralysis of voluntary muscles, brain
damage, coma, and death within a week if untreated.
Respiratory failure is the usual cause of death.
▪ Bioterrorists could add botulinal toxin to water supplies or

food. Botulinal toxin is odorless and tasteless, and only a tiny
quantity of the toxin need be ingested to cause a potentially
fatal case of botulism.
▪ Botulism can also result from entry of C. botulinum spores into

open wounds.
▪ Smallpox is a serious, contagious, and sometimes fatal viral
disease.
▪ Patients experience fever, malaise, headache, prostration,
severe backache, a characteristic skin rash and occasional
abdominal pain and vomiting.
▪ Smallpox can become severe, with bleeding into the skin and
mucous membranes, followed by death.
▪ The last naturally occurring case in the world was in Somalia in
1977. Since 1980, when the WHO announced that smallpox
had been eradicated, most people no longer receive smallpox
vaccinations. Thus, throughout the world, huge numbers of
people are highly susceptible to the virus.
▪ Although there are no reservoirs for smallpox virus in nature,
preserved samples of the virus exist in a few medical research
laboratories worldwide. There is always the danger that
smallpox virus, or any of the other pathogens mentioned here,
could fall into the wrong hands.
▪ Plague is caused by Y. pestis, a Gram-negative coccobacillus.
It is predominantly a zoonosis and is usually transmitted to
humans by flea bite and can manifest itself in several ways:
a. bubonic plague – named for the swollen, inflamed and
tender lymph nodes that develop.
b. septicemic plague – may cause septic shock, meninigitis,
or death
c. pneumonic plague – highly communicable and involves
the lungs; can result in localized outbreaks or devastating
epidemics
d. plague meningitis.
▪ Bioterrorists could disseminate Y. pestis via aerosols,

resulting in numerous severe and potentially fatal pulmonary
infections. Pneumonic plague can be transmitted from
person to person.
The Black Death – A Historical Note
▪ During the Middle Ages, plague was referred to as the
black death because of the darkened, bruised appearance
of the corpses. The blackened skin and foul smell were the
result of cell necrosis and hemorrhaging into the skin.
▪ Plague probably dates back from 1000 or more years BC.
In the past 2,000 years, the disease has killed millions of
people—perhaps hundreds of millions.
▪ Huge plague epidemics occurred in Asia and Europe,
including the European plague epidemic of 1348–1350,
which killed about 44% of the population (40 million of 90
million people). The last major plague epidemic in Europe
occurred in 1721.
▪ Plague still occurs, but the availability of insecticides and
antibiotics has greatly reduced the incidence of this
dreadful disease.
Lesion of
cutaneous anthrax
Smallpox
▪ The etiologic agents of anthrax, botulism,
smallpox, and plague have been classified
as category A bioterrorism agents.
▪ Category A agents are those that:
1. Pose the greatest possible threat for a
bad effect on public health
2. May spread across a large area or need
public awareness
3. Need a great deal of planning to protect
the public’s health.
Water Supplies and Sewage Disposal
• Water is the most essential resource

necessary for the survival of humanity!
• The 2 general types of water pollution:
– Chemical pollution – from

factories and mining companies
▪ Biological pollution (e.g., fecal

material and garbage)
▪ Waterborne epidemics today are

the result of failure to make use
of available existing knowledge
and technology. In those
countries that have established
safe sanitary procedures for water
purification and sewage disposal,
outbreaks of typhoid fever,
cholera, and dysentery occur only
rarely

Water Supplies and Sewage Disposal, cont.
• Water must be properly treated to make it safe for human consumption. There are
several steps involved in such treatment.
1. The water first is filtered to remove large pieces of debris such as twigs and
leaves.
2. Next, the water remains in a holding tank, where additional debris settles to the
bottom of the tank; this phase of the process is known as sedimentation or
settling.
3. Alum (aluminum potassium sulfate) is then added to coagulate smaller pieces of
debris, which then settle to the bottom; this phase is known as coagulation or
flocculation.
4. The water is then filtered through sand or diatomaceous earth filters to remove the
remaining bacteria, protozoan cysts and oocysts, and other small particles. In some
water treatment facilities, charcoal filters or membrane filtration systems are also
used. Membrane filtration will remove tiny Giardia lamblia cysts and C. parvum
oocysts.
5. Finally, chlorine gas or sodium hypochlorite is added to a final concentration of 0.2
to 1.0 ppm; this kills most remaining bacteria. In some water treatment facilities,
ozone (O3) treatment or ultraviolet (UV) light may be used in place of chlorination.

Steps in Water Treatment

▪ In the laboratory, water is tested for fecal
contamination by checking for the presence of
coliform bacteria (coliforms), such as E. coli and other
members of the family Enterobacteriaceae.
▪ These bacteria normally live in the intestinal tracts of
animals and humans; thus, their presence in drinking
water is an indication that the water was fecally
contaminated.
▪ With respect to the presence of coliforms, water is
considered potable (safe to drink) if it contains 1
coliform or less per 100 mL of water.

• Sewage Treatment
– Raw sewage consists mainly of water, fecal material, garbage, and
bacteria
– Includes primary, secondary, and tertiary sewage treatments
A. Primary Sewage Treatment

- In the sewage disposal plant, large debris is first filtered out (called screening),
skimmers remove floating grease and oil, and floating debris is shredded or ground.
- Then, solid material settles out in a primary sedimentation tank. Flocculating
substances can be added to cause other solids to settle out. The material that
accumulates at the bottom of the tank is called primary sludge.
B. Secondary Sewage Treatment
- The liquid (called primary effluent) undergoes secondary treatment, which includes
aeration or trickling filtration.
- aeration encourages the growth of aerobic microbes, which oxidize the dissolved
organic matter to CO2 and H2O. Trickling filters accomplish the same thing but in a
different manner.
- After either aeration or trickling filtration, the activated sludge is transferred to a
settling tank, where any remaining solid material settles out. The remaining liquid
(called secondary effluent) is filtered and disinfected (usually by chlorination), so that
the effluent water can be returned to rivers or oceans.
C. Tertiary Sewage Treatment
- In some desert cities, where water is in short supply, the
effluent water from the sewage disposal plant is further
treated so that it can be returned directly to the drinking
water system; this is a very expensive process.
- Tertiary sewage treatment involves the addition of chemicals,

filtration (using fine sand or charcoal), chlorination, and
sometimes distillation.
- In other cities, effluent water is used to irrigate lawns;

however, it is expensive to install a separate water system
for this purpose.
- In some communities, the sludge is heated to kill bacteria,

then dried and used as fertilizer.

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EPIDEMIOLOGY AND PUBLIC HEALTH

Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

• A communicable disease is an infectious disease that can

• A sporadic disease is one that occurs only

Whether an infectious disease occurs depends

Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Bacterial Anthrax Bacillus Cattle, Inhalation,

Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

1. The Access to COVID-19 Tools (ACT) Accelerator

Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

1. Increase host resistance through the development and administration of

3. Segregate, isolate, and treat those who have contracted a contagious

4. Identify and control potential reservoirs and vectors of infectious diseases;

Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

• Microbes purposely used to harm others in

▪ C. botulinum is a spore-forming anaerobic Gram-positive

▪ Botulinal toxin may cause nerve damage, visual difficulty,

▪ Bioterrorists could add botulinal toxin to water supplies or

▪ Botulism can also result from entry of C. botulinum spores into

▪ Bioterrorists could disseminate Y. pestis via aerosols,

• Water is the most essential resource

• The 2 general types of water pollution:

– Chemical pollution – from

▪ Biological pollution (e.g., fecal

▪ Waterborne epidemics today are

Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

A. Primary Sewage Treatment

- Tertiary sewage treatment involves the addition of chemicals,

- In other cities, effluent water is used to irrigate lawns;

- In some communities, the sludge is heated to kill bacteria,

Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

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