Epidemiology of Infectious

Diseases
Prof. Bhisma Murti

Department of Public Health,

Faculty of Medicine,
Universitas Sebelas Maret
Infectious Disease Epidemiology:
Major Differences

 A case can also be an exposure

 Subclinical infections influence epidemiology
 Contact patterns play major role
 Immunity
 There is sometimes a need for urgency
 What is infectious disease epidemiology?

 Epidemiology Infectious disease epidemiology

 Deals with one population  Two or more populations
 Risk  case  A case is a risk factor
 Identifies causes  The cause often known
What is infectious disease epidemiology?

Two or more populations

 Humans
 Infectious agents
 Helminths, bacteria, fungi, protozoa, viruses, prions
 Vectors
 Mosquito (protozoa-malaria), snails (helminths-schistosomiasis)
 Blackfly (microfilaria-onchocerciasis) – bacteria?
 Animals
 Dogs and sheep/goats – Echinococcus
 Mice and ticks – Borrelia

(www)
What is infectious disease epidemiology?

A case is a risk factor …

 Infection in one person can be transmitted to others

(www)
 What is infectious disease epidemiology?

The cause often known

 An infectious agent is a necessary cause

What is infectious disease epidemiology then used for?

 Identification of causes of new, emerging infections, e.g. HIV, vCJD, SARS
 Surveillence of infectious disease
 Identification of source of outbreaks
 Studies of routes of transmission and natural history of infections
 Identification of new interventions
Concepts Specific to Infectious Disease
Epidemiology

Attack rate, immunity, vector,

transmission, carrier, subclinical
disease, serial interval, index case,
source, exposure, reservoir,
incubation period, colonization,
generations, susceptible, non-specific
immunity, clone, resistance, repeat
episodes …
 Infectious Disease

Definitions Tetanus Measles Hepatitis B

 Infectious diseases
 Caused by an infectious agent
 Communicable diseases
 Transmission – directly or indirectly – from an infected person
 Transmissible diseases
 Transmission – through unnatural routes – from an infected person

Note
 Infections are often subclinical – infections vs infectious diseases!
 Antonyms not well-defined
 Non-communicable diseases – virus involved in pathogenesis of diabetes?
 Chronic diseases – HIV?
Routes of transmission

Direct Indirect
 Skin-skin  Food-borne
 Herpes type 1  Salmonella
 Mucous-mucous  Water-borne
 STI  Hepatitis A
 Across placenta  Vector-borne
 toxoplasmosis  Malaria
 Through breast milk  Air-borne
 HIV  Chickenpox
 Sneeze-cough  Ting-borne
 Influenza  Scarlatina

Exposure
 A relevant contact – depends on the agent
Skin, sexual intercourse, water contact, etc
Some Pathogens that Cross the Placenta
Modes of Disease Transmission
 Exposure to Infectious Agents

No infection Clinical Sub-clinical Carrier

Death Carrier Immunity No immunity

Outcome
 Timeline for Infection

Dynamics of Latent Infectious Non-infectious

infectiousness period period

Susceptible
Time

Dynamics of Incubation Symptomatic Non-diseased

disease period period

Susceptible
Time
 Transmission
Cases
 Index – the first case identified
 Primary – the case that brings the infection into a population
 Secondary – infected by a primary case
 Tertiary – infected by a secondary case

T
S
Susceptible P
S
Immune
S
T
Sub-clinical

Clinical
 Person-to-Person Transmission

Hypothetical Data
Measles Chickenpox Rubella
Children exposed 251 238 218
Children ill 201 172 82

attack rate 0.80 0.72 0.38

Attack rate = ill

exposed
 Epidemiologic Triad

Disease is the result of

forces within a dynamic
system consisting of:
agent of infection
host
environment
 Factors Influencing Disease
Transmission

Agent Environment
• Weather
• Infectivity
• Housing
• Pathogenicity
• Geography
• Virulence
• Occupational setting
• Immunogenicity
• Air quality
• Antigenic stability
• Food
• Survival

• Age
• Sex
• Genotype
Host
• Behaviour
• Nutritional status
• Health status
 Epidemiologic Triad-Related Concepts

•Infectivity (ability to infect)

(number infected / number susceptible) x 100
•Pathogenicity (ability to cause disease)
(number with clinical disease / number infected) x
100
•Virulence (ability to cause death)
(number of deaths / number with disease) x 100

•All are dependent on host factors

Predisposition to Infections
(Host Factors)

Gender
Genetics
Climate and Weather
Nutrition, Stress, Sleep
Smoking
Stomach Acidity
Hygiene
Chain of Infection
Iceberg Concept of Infection

CELL RESPONSE HOST RESPONSE

Infectious Agents

Bacteria
Viruses
Fungi
Protoctists / Protozoa
Helminths
 Reservoirs

A host that carries a pathogen

without injury to itself and serves
as a source of infection for other
host organisms
(asymptomatic infective carriers)
 Reservoirs

Humans
{hepatitis}

Other Vertebrates
{zoonoses}

Birds & Bats

{histoplasmosis}

NOT vectors
 Vectors

A host that carries a pathogen without

injury to itself and spreads the
pathogen to susceptible organisms

(asymptomatic carriers of pathogens)

 Arthropod Vectors

Pathogen - Vector
Viruses (Arbovirus) - Mosquitoes

Bacteria (Yersinia) - Fleas

Bacteria (Borrelia) - Ticks

Rickettsias (R. prowazeki) - Lice, ticks

Protozoa (Plasmodium) - Mosquitoes

Protozoa (Trypanozoma) -Tsetse flies

Helminths (Onchocerca) - Simulium flies

 Koch’s Postulates

The same organism is present in every case

It is isolated or grown in pure culture
The disease can be reproduced in healthy
animals after infection with pure culture
The identical pathogen is reisolated from the
experimental animals
 Ecological Factors in Infections

Altered environment
{Air conditioning}
Changes in food production & handling
{intensive husbandry with antibiotic protection; deep-
freeze; fast food industry}
Climate changes
{Global warming}
Deforestation
Ownership of (exotic) pets
Air travel & Exotic journeys / Global movements
Increased use of immunosuppressives/ antibiotics
Infectious Disease Process

Direct tissue invasion

Toxins
Persistent or latent infection
Altered susceptibility to drugs
Immune suppression
Immune activation (cytokine storm)
Mathematical Modelling
in Infectious Disease
Epidemiology
 Reproductive Number, R0
A measure of the potential for transmission

The basic reproductive number, R0, the mean number of individuals

directly infected by an infectious case through the total infectious
period, when introduced to a susceptible population
probability of transmission per contact

R0 = p • c • d duration of infectiousness

contacts per unit time

Infection will ….. disappear, if R<1

become endemic, if R=1
become epidemic, if R>1
 Reproductive Number, R0

 Useful summary statistic

 Definition: the average number of
secondary cases a typical infectious
individual will cause in a completely
susceptible population
 Measure of the intrinsic potential for
an infectious agent to spread
Reproductive Number, R0

 If R0 < 1 then infection cannot invade a population

implications: infection control mechanisms
unnecessary (therefore not cost-effective)

 If R0 > 1 then (on average) the pathogen will invade

that population
 implications: control measure necessary to
prevent (delay) an epidemic
 Reproductive Number, R0
Use in STI Control

R0 = p • c • d

p condoms, acyclovir, zidovudine

c health education, negotiating skills

D case ascertainment (screening,

partner notification), treatment,
compliance, health seeking
behaviour, accessibility of services
 What determines R0 ?
p, transmission probability per exposure – depends on the infection
 HIV, p(hand shake)=0, p(transfusion)=1, p(sex)=0.001
 interventions often aim at reducing p
 use gloves, screen blood, condoms

c, number of contacts per time unit – relevant contact depends on infection

 same room, within sneezing distance, skin contact,
 interventions often aim at reducing c
 Isolation, sexual abstinence

d, duration of infectious period

 may be reduced by medical interventions (TB, but not salmonella)

(www)
 Immunity – herd immunity

If R0 is the mean number of secondary cases in a susceptible population, then

R is the mean number of secondary cases in a population where a proportion, p,
are immune
R = R0 – (p • R0)

What proportion needs to be immune to prevent epidemics?

If R0 is 2, then R < 1 if the proportion of immune, p, is > 0.50
If R0 is 4, then R < 1 if the proportion of immune, p, is > 0.75

If the mean number of secondary cases should be < 1, then

R0 – (p • R0) < 1
p > (R0 – 1)/ R0 = 1 – 1/ R0

 If R0 =15, how large will p need to be to avoid an epidemic?

p > 1-1/15 = 0.94

The higher R0, the higher proportion of immune required for herd immunity
Endemic - Epidemic - Pandemic

R>1

R=1
R<1
Time

 Endemic
 Transmission occur, but the number of cases remains
constant
 Epidemic
 The number of cases increases
 Pandemic
 When epidemics occur at several continents – global
epidemic
 Endemic vs Epidemic
Number of Cases of a Disease

Endemic Epidemic

Time
 Levels of Disease Occurrence

Sporadic level: occasional cases occurring at

irregular intervals
Endemic level: persistent occurrence with a low to
moderate level
Hyperendemic level: persistently high level of
occurrence
Epidemic or outbreak: occurrence clearly in
excess of the expected level for a given time period
Pandemic: epidemic spread over several countries
or continents, affecting a large number of people