Infectious Disease Epidemiology

Prof dr Bhisma Murti, MPH, MSc, PhD

Department of Public Health,

Faculty of Medicine, Universitas Sebelas Maret
 Infectious Disease
Definitions
 Infectious diseases
– Caused by an infectious agent
 Communicable diseases Tetanus Measles Hepatitis B
– Transmission – directly or indirectly –
from an infected person
 Transmissible diseases
– Transmission – through unnatural
routes – from an infected person
 Contagious disease
– An old English word for communicable
disease, now is still used for a very
communicable disease
 Definition
• Infectious diseases
– Diseases involving an agent (bacterial, viral,
parasitic) which is transmitted from infected to
non-infected hosts

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 Infectious and Non-Infectious
Diseases
• Infectious (and parasitic) diseases
– Bacterial
• salmonellosis, tuberculosis, cholera
– Viral
• polio, HIV, influenza
– Parasitic
• malaria, lymphatic filariasis, helminth
– Protozoa
– Fungi
• Non-infectious diseases Vibrio cholerae
– cancers, heart disease, diabetes
mellitus

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 Infectious Disease Epidemiology:
Major Differences
1. A case can also be an exposure (or a risk factor)
2. Subclinical infections influence epidemiology
3. Contact patterns play major role
4. Immunity
5. There is sometimes a need for urgency
6. Causal (infectious) agent is often known
 Major Differences
• Unlike non-infectious diseases, the occurrence of
infectious disease events in a given host depends
on
– occurrence of the disease in other members of the
host population
– length of time that infected hosts remain infectious

• Infectious disease epidemiology

– centres around understanding the relationship
between the host and infectious agent (or parasite)
and the transmission of the infectious agent between
hosts
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 Components of Infectious Process
1. Agent
2. Reservoir
3. Portals of entry
and exit
• Giardia lamblia is an example of infectious
4. Transmission agent (see the above Figure). It is a
microscopic parasite that causes a
5. Immunity gastrointestinal illness called giardiasis. The
main symptom of giardiasis is diarrhea
• Giardia lamblia is often transmitted
to children who drink untreated water from
creeks and rivers contaminated with the
droppings of an infected animal.
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Factors Involved in the Disease
Transmission
 Infectious Agent
– Infectious = biologic
organism living and
replicating within a host
– Infectious disease =
infection + illness
– Contamination = agent on
exterior surface near host

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 Types of Agents
– Helminths (parasitic worms)
Ascaris
– Fungi and yeasts (lower plants, worm
lack chlorophyll)
– Protozoa (eucaryotes; complex life Plasmodium
cycles) falciparum
– Bacteria (capable of independent causes malaria
reproduction) Vibrio cholera
causes cholera
– Rickettsia (intracellular
reproduction; require Ixodes tick HIV
carrier) causes
– Viruses (submicroscopic; have AIDS
genetic material but incapable of
multiplication outside of host)
– Prions (‘infectious proteins’)
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 Reservoirs
– Where the agent multiplies
– Without the reservoir, the agent can’t perpetuate
– Agent ‘factory’
– Types of reservoirs
• symptomatic cases
• carriers
• animals
• inanimate objects

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 Case Reservoirs
• Symptomatic case reservoirs
– examples
• influenza
• measles
• smallpox
– for many other agents, cases represent biological
dead ends

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 Carrier Reservoirs
• Carrier reservoirs
– carrier = contagious person without discernable
signs of disease
– types of carriers
• inapparent throughout (e.g. polio)
• incubatory (e.g. Hepatitis B, HIV)
• convalescent (e.g. Salmonella typhi)

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 Animal Reservoirs
• Animal reservoirs
– direct zoonoses
• non-human vertebrate  human
• e.g. rabies, brucellosis
Rabies is a zoonosis, which
can be transmitted from
– cyclozoonoses (e.g. dogs to humans.
echinococcus)
– metazoonoses (e.g. Yellow Fever)
– saprozoonoses (e.g.
coccidiomycosis)

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 Inanimate Reservoirs
• Inanimate reservoirs
– water
– food
– soil

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 Portal of Entry and Exit
– Respiratory
– Conjunctiva
– Urogenital
– Gastrointestinal
– Skin
– Placenta

Agents exhibits portal

preferences
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 Transmission
– Contact
– direct (host  host)
– indirect (host  exudate or secretion  host)
– droplet (airborne short distance)
– nuclei (airborne suspended)
– intermediary
– vector (animate)
– vehicles (inanimate)

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 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
Components of the infectious process
4. Transmission
– common vehicle
• point source
• e.g. Legionellosis
– serial
• host to host (propagative)
• e.g. smallpox
 Immunity
– All factors that alter likelihood and severity of
infection after host is exposed
– Types of immunity
• innate = inborn
• acquired = ‘learned’ response needed
Immunity
 Innate Immunity
– Physical barriers
• e.g. skin, cilia, mucosal, sheaths
– Chemical barriers
• e.g. acidity, enzymatic, bioactive
– Non-specific cellular and physiologic responses
• e.g. phages, polymorphs, inflammation

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 Acquired Immunity
– Cellular
• lymphocytes
• stem cells (bone marrow)
– Non-cellular (‘humoral’)
• antibodies
• cytokines

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 Exposure to Infectious Agents

No infection Clinical Sub-clinical Carrier

Death Carrier Immunity No immunity

Outcome
 Natural History of Disease (with
Timeline for Infection)
Dynamics of Latent Infectious Non-infectious
infectiousness period period

Susceptible
Time

Dynamics of Incubation Sympto Non-diseased

disease period matic
period
Susceptible
Time
 Epidemiological Characteristics
• Latent period
– the time interval from infection to development of
infectiousness

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 Epidemiological Characteristics
• Incubation period
– the time interval from infection to development of
signs of disease
– not always a fixed period of time, shows some
variation due to
• route of inculation
• virulence of agent
• host factors (age, immune status)
– follows a log normal distribution

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 Epidemiological Characteristics
• Infectious period
– the time during which time the host can infect
another susceptible host

• Non-infectious period
– the time interval between infection to
development of clinical disease

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 Epidemiological Characteristics
• The carrier state
– asymptomatic carriers of infection
– play an important role in spreading disease

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 Acute and Chronic Diseases
• Depending on the time course of a disease and
how long the clinical manifestations persist,
communicable diseases can be classified as
acute or chronic.
• Acute diseases - rapid onset and short duration
of illness. E.g., diarrhea that starts suddenly
and lasts less than 14 days is
an acute diarrheal disease.
• Chronic diseases - prolonged duration of
illness. E.g. a chronic diarrheal disease lasts
more than 14 days.
 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

 Epidemiological characteristics
• Infectivity
– the ability of an agent to cause infection in a
susceptible host

– in theory, depends on the minimum number of

infectious particles required to establish infection

– in diseases spread from person to person, the

proportion of susceptible individuals who develop
infection after exposure
– the secondary attack rate is a measure of infectivity

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 Epidemiological characteristics
• Pathogenicity
– the ability of the infectious agent to induce disease
– agents with high pathogenicity
• viruses causing rabies, smallpox, measles, chicken pox
– agents with low pathogenicity
• polio virus, arboviruses (mosquito borne)
• Virulence
– describes the severity of disease, after infection has
occurred
– measured using the case fatality rate

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 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
 Epidemiological characteristics
• Secondary attack rate

10 people in a room 1 infected individual enters 3 infections result

Prevalence: 4 cases out of 11

Secondary attack rate: 3 cases out of 10

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 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
 Epidemiological characteristics
TIME

Death

Infection Clinical disease

Susceptible
host Recovery

No infection

Incubation period

Latent Infectious Non-infectious

Exposure Onset

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 Epidemiological
characteristics
• Chicken pox
– an infectious disease caused by the varicella-zoster
virus
– signs: a blister-like rash, itching, tiredness and fever
– the latent period for chicken pox is shorter than the
incubation period, so a child with chicken pox
becomes infectious to others before developing
symptoms
– in the event of an outbreak, does it make sense to
keep children with chicken pox away from school?
No. Children with symptoms of chicken pox are no longer
infectious to others

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 Epidemiological
characteristics
TIME

Death

Infection Clinical disease

Susceptible
host Recovery

No infection

Incubation period

Latent Infectious Non-infectious

Exposure Onset

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 Epidemiological characteristics
– HIV (AIDS)
• latent period relatively short
• infectious period occurs (many years) before the onset
of symptoms

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 Epidemiological
characteristics
TIME

Death

Infection Clinical disease

Susceptible
host Recovery

No infection

Incubation period

Latent Infectious

Exposure Onset

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 Epidemiological characteristics
• Malaria
– caused by protozoan parasites of the genus
Plasmodium
– human to human transmission via
mosquitoes
– signs: haemolytic anaemia
– the stages of the parasite that are infective
to mosquitoes occur about 10 days after
the development of symptoms
– latent period is around 10 days longer than
the incubation period, so early treatment
of symptoms could have an important
effect on transmission

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 Epidemiological
characteristics
TIME

Death

Infection Clinical disease

Susceptible
host Recovery

No infection

Incubation period

Latent Infectious

Exposure Onset

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 Endemic vs Epidemic
Number of Cases of a Disease

Endemic Epidemic

Time
Level 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
 Temporal trends
• Seasonal variation
– vector-transmitted diseases (malaria, dengue
fever) depend on exposure to infected mosquito
vectors
– disease transmission only occurs during the
warmer months of the year

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 Temporal trends
• Annual variation
– many infectious diseases exhibit marked and
repetitive cyclical trends
– due to infection exhausting the susceptible
population and then infecting the birth cohort
replenishing it
– examples
• measles, pertussis, polio

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 Temporal trends
• Herd immunity
– low population immunity
• infected individual enters population
• probability of transfer of infection to a susceptible individual
high
• probability of epidemic high
– high population immunity
• infected individual enters population
• probability of transfer of infection to a susceptible individual
low
• probability of epidemic low

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 Temporal trends
• Long-term trends
– useful for detecting emerging problems
– useful for assessing response to interventions

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 Temporal trends
• Temporal patterns of onset can provide
insight into the nature of the disease we’re
dealing with (even when we don’t know the
cause)
• Type of epidemics
1. Common source
2. Propagated

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 Temporal trends
1. Common source epidemics
– subjects are exposed to a common noxious influence
– common point source epidemics
• group is exposed over a relatively short period then disease
cases will emerge over one incubation period
• curve rises rapidly and contains a definite peak at the top,
followed by a gradual decline
– common continuous source epidemics
• group is exposed continuously and cases emerge over more
than one incubation period
• curve rises rapidly, no definite peak

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 Temporal trends
• Examples of common point source epidemics
– batch of contaminated feed causing an outbreak of
salmonellosis in feedlot cattle
– foodborne disease outbreaks
– epidemic of leukaemia in Hiroshima following the atomic
bomb blast
• Examples of common continuous source epidemics
– anthrax in cattle
– hepatitis in humans
– milk vacuum problem causing an outbreak of clinical
mastitis in a herd of dairy cows

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 Temporal trends
2. Propagated epidemics
– occur when the agent is transmitted through the
population from host to host (typically infectious
conditions)
– propagated epidemics, in theory, show a series of
progressively taller peaks one incubation period apart
– nature of epidemic depends on
• characteristics of agent (virulence) and host (susceptibility)
• contact rate
• population density

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 Temporal trends
• Estimating the time of exposure using an
epidemic curve
– Method 1
• identify last case and count back maximum incubation
period
• identify first case and count back minimum incubation
period
– Method 2
• count back the median incubation period from the peak of
the epidemic
• difficult to do if there is no distinct peak to epidemic curve

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 Temporal trends
• Stratified epidemic curves
– can be helpful to divide a population into
subgroups to identify factors that are influencing
the observed pattern of disease
– provides the investigator with a different
perspective on key variables

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 Temporal trends
• Shape of epidemic curves
– depends on the type of epidemic you are dealing
with (common source versus propagated)
– depends on the period of time over which
susceptible individuals are exposed
– depends on the minimum, average, and maximum
incubation periods for the disease

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 Temporal trends
• Cases that stand apart
– an early case may represent a background or
unrelated case, a source of the epidemic, or a
subject who was exposed earlier than most of the
cases
– late cases may represent unrelated cases, long-
incubation-period cases, secondary cases, or
persons exposed later than most of the cases
– outliers may sometimes represent miscoded or
erroneous data

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