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King Faisal University – College of Medicine Department of Family and Community Medicine Third Year Course Introduction to Comprehensive

Health II (MDFM 336)

Epidemiology Reading Materials Definitions and Terminology
Infection:
The entry and development or multiplication of a disease-producing agent in the body. The body responds to defend itself against the infectious agent or introduction of a harmful organism producing illness

Contamination:
This is applied to inanimate objects like water, food. articles used by the patient which carry diseases - producing germs, bacteria and/or parasites and/or chemical poisons.

Pollution:
Mainly for water, which suffers from bad physical qualities (bad odor, or taste, turbidity, color, etc.)

Infestation:
Presence of Parasites on the surface of a body ( e.g. louse infestation or the invasion of tissues by animal parasites (e.g. round worm infestation).

Communicable Disease (Infectious Disease):
A disease resulting from infection or infestation, capable of being directly or indirectly transmitted from man to man, animal to animal, animal to man or from the environment (through air, dust or soil, water, food etc. to man or animal.

Endemic:
(En = in, demos = people). The constant presence of a disease in a geographic area, without importation from outside or (presence of illness in certain area all over the year)

Epidemic:
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(Epi = upon, demos = people). The occurrence in a community or specific geographic area of cases of an illness clearly in excess of normal expectation for that population based on past experience . This definition covers not only the classical epidemic diseases such as cholera and typhoid but also the modern scourges of man-kind such as cancer coronary heart disease or (sudden appearance of illness in certain area and in specific time).

Pandemic:
(Pan = all, demos = people). A disease is said to be pandemic when it spreads from one country to another in a short time or occurs at the same time in different countries, viz. influenza, cholera (epidemic in more than one country)

Epidemio-Endemic:
It is an epidemic upon an endemic disease

Sporadic:
The word sporadic means scattered about cases are separated from each other. There is no recognizable common source of infection, viz, polio herpes zoster,

Exotic disease:
Disease which are imported into a country

Zoonoses:
Diseases and infections which are naturally transmitted between vertebrate animals and man, e.g., rabies, bovine tuberculosis, brucellosis, anthrax

Enzootic:
An endemic occurring among animals, e.g., bovine tuberculosis

Primary case:
It is a first case arising within a given area and which is the source of infection to other persons.

Secondary case:
It arises as a result of infection from a pre-existing known primary case.

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Communicable Disease Cycle
Agent in Reservoir Mode of Transmission Susceptible Host

Characteristics of an Infectious Agent
1. Infectivity:
The ability of an agent to enter and establish itself in a host. It can occur in three forms: 1. 2. 3. Colonization Inapparent infection Infectious disease Agents of high infectivity: Measles, chickenpox, Agents of low infectivity: Hepatitis A & B, leprosy

2. Pathogenecity:
The ability of an agent to cause disease in an infected host. Case of disease Pathogenecity = ----------------------Total No. infected Agents of high pathogenecity: rabies, measles, chicken pox Agents of low pathogenecity: Poliomyelitis, cholera, leprosy

3. Virulence:
The ability of an agent to produce serious and sometimes fatal disease. Severe & fatal disease -----------------------------------All cases of disease

Virulence =

Agents of high virulence: rabies, plague, yellow fever Agents of low virulence: Chicken pox, common cold, tonsillitis

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4. Immunogenecity:
The ability of an infection to produce a specific immunity. Immunity can be: Humoral, Cellular, or Both e. g.: Infections with high immunity: Measles, chicken pox, mumps Infections with low immunity: Influenza, malaria, gonorrhea

Host Immunity Susceptible host: a person or animal presumably not possessing resistance against a
particular pathogenic agent exposed to such agent. and for that reason is liable to contract the disease, when

Immunity: Resistance of the total body mechanisms to invasion and/or multiplication of
the infectious agent.

Classification of immunity: 1. Innate (Inherent): the ability to resist disease independent of specific antibodies
development, i.e., it is not related to prior infection or immunization. This depends on the natural defence mechanisms of the body (e.g. body surface, skin, mucous membrane, blood, phagocytic cells, histiocytes, monocytes, Polymorphonuclear leucocytes)

2. Acquired resistance/immunity: the ability to resist disease due to development of
specific antibodies against the infectious agent. It may be:

(A) Natural:
Active: subclinical or active disease Passive: Transplacental or by breastmilk

(B) Artificial:
Active: by vaccination Passive: administration of hyperimmune sera, immunoglobulins, or antitoxins.

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Sources of infection (Reservoirs)
Reservoir:
A living material in which the infective agent lives and multiplies so that it can be transmitted to a susceptible host. OR: Any person, animal, arthropod, plant, soil or substance, in which an infectious agent normally lives and multiplies, on which it depends primarily for survival, and where it reproduces itself in such a manner that it can be transmitted to a susceptible host.

(1) Human Reservoirs: 1. Infected persons:
i. Inapparent infection (covert or subclinical infection) the organisms multiply and cause some reaction but is not clinically detectable. ii. A case of infectious disease (or overt disease) with clinical symptoms and signs of disease. The milder the disease or the higher percentage of its occurrence in a subclinical form, the greater will be the risk of spreading the infection. iii. Colonization: presence and multiplication of the agent on the surface of the body without producing evidence of any reaction in the host e.g. staphylococcus aureus in nasal mucosa.

2. Carriers:
A carrier is an infected person that harbors a specific infectious agent without showing signs and symptoms of the clinical disease and serves as a potential source of infection to man. The carrier state may occur in individual with an infection which is inapparent throughout its course (asymptomatic carrier) or during the incubation period, convalescence, post-convalescence of an individual with a clinically recognizable disease. Carriers are dangerous reservoirs of infection because: a) b) c) A carrier does not show any clinical manifestations. The carrier and his contacts are unaware of the fact that he can infect them and It is not always easy to discover carriers since laboratory examinations which may not

consequently they do not take any precautions. always be easy or practical are usually required.

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Carriers are classified in several ways: I. Chronological classification:
a) Contact carriers: These are persons who are in contact with infective cases e.g. doctors, nurses, parents, or servants. The main characteristic of this type is that the period of carriage ends as soon as the patient is cured. b) Inapparent carriers: throughout without showing any symptoms and signs, such as polio virus, meningococcus, hepatitis B virus. c) Incubating (incubatory) carriers: These are persons who discharge the microorganisms during the incubation period e.g. measles, mumps, infective hepatitis and poliomyelitis. d) Convalescent carriers: These are persons who discharge the microorganisms during the convalescence period. They are the commonest type of carriers in certain diseases e.g. typhoid fever. Some of the carriers may remain so after the convalescence period i.e. post-convalescent carriers. Thus before releasing patients suffering from diseases in which a carrier state known to develop, as in typhoid fever, release samples are required after clinical cure and as a rule the patient is not discharged until it is proved by the laboratory methods that on three consecutive bacteriological examination the samples are free from the infectious agent.

ii. Classification of carriers according to the duration of carriage:
a) Temporary carriers: These are persons who harbor the micro-organism for a period of time less than three months, except in typhoid, where the period is less than one year. b) Chronic carriers: These are carriers that harbor and excrete the infecting organisms for many months or years. Carriers may discharge the organisms continuously without intermission or the micro-organism may not be demonstrated in the carrier’s excreta for a period of time to be recovered. again and hence named intermittent carriers. That is why one has to examine suspected persons three times consecutively before excluding the carrier state, e.g.: salmonella typhi causing typhoid fever, hepatitis B & C.

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III. Classification of carriers according to habitat of organisms in body:
a) Upper respiratory tract carriers: As in streptococci and staphylococci and diphtheria. b) Fecal carrier: As in cases of typhoid and paratyphoid bacilli, virus hepatitis and amoebic cysts. Fecal carrier could be divided accordingly into: i. Billiary carrier: When the organism lives in the biliary tract and liberated with the bile to reach the intestine and excreted with faces e.g. typhoid bacilli. ii. Intestinal carrier: when the organism lives in the intestinal wall e.g. amoebic cyst c) Genito-urinary carrier: e.g. gonorrhea, typhoid and paratyphoid bacilli d) Skin carrier: e.g. staphylococci.

(2) Animal Reservoirs:
Dogs as reservoirs of rabies virus. Cattle meat as reservoirs of taenia worms. Fleas as reservoirs of plague bacillus.

(3) Reservoirs in non-living things:
Soil can act as reservoirs for C. tetani, C. welchii (gas gangrene bacilli).

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Modes of Transmission
Once a pathogen escapes from the reservoir, it either passes directly to another host or finds a way through which it can be transmitted to a host. Studying the mode of transmission in any communicable disease is of great importance from the control point of view. Indeed, one may not be able to know the causative agent, but if the mode of transmission of that agent to the host is known the spread of infection from the reservoir could be controlled or prevented. The mode of transmission is that mechanism by which an infectious agent is transported from the reservoir and source of infection to the new host. The modes of transmission could be classified into: 1. Direct transmission. 2. Indirect transmission.

1. Direct mode of transmission: This mode of transmission comprises: a) Contact transmission. b) Droplet transmission. c) Transplacental transmission (Or Vertical Transmission) a) Contact transmission: This means close association between the infected person or animal and the new host, without intervening of a third party. It requires the presence of the reservoir and, the new host at the same time and at the same place when contracting infection, as in kissing & sexual intercourse. Examples: the group of venereal diseases, scabies, diphtheria and infectious mononucleosis. Another example is rabies in which there is actual contact between the saliva of the rabid animal and abraded skin or mucous membrane.
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b) Droplet transmission: It is the transmission of the spray emerging from an infected person during talking, sneezing or coughing directly to the mouth, nose or the conjunctiva of the new host. Such droplets travel not more than 3 feet from the reservoir. Transmission by droplet is considered a direct mode of transmission since it involves reasonably close association between two or more persons. Examples: Most of the diseases of the respiratory tract and those systemic diseases in which the organism present in the upper respiratory tract as measles are transmitted by droplet. Droplets have their importance also in surgical sepsis and in puerperal fever and here masks are of great value if used properly. It is to be noted that droplet transmission prevails more in winter when people tend to aggregate in crowded places. c) Transplacental transmission (Or Vertical Transmission): In some diseases of the mother, the causative agent may reach the fetus transplacentally from the blood of the pregnant mother e.g. syphilis and German measles (rubella). It has been observed that if mother contracts rubella infection (German measles) in the first three months of pregnancy, this may give rise to congenital abnormalities in the infant, such as congenital cataract, deafness or congenital heart disease. 2. Indirect transmission: This mode of transmission comprises: 1) Indirect contact transmission. 2) Common vehicle transmission through: a) Ingestion. b) Inoculation. c) Deposition.
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3) Insect-borne transmission (vector-borne transmission). 4) Air borne transmission. 1) Indirect contact transmission: Here transmission occurs through touching contaminated objects such as toys, handkerchiefs, soiled clothing or bedding. The infectious agent is then subsequently transmitted to the hand and mouth or passes through abraded skin or mucous membrane. Surgical instruments and dressing if contaminated play a role in the transmission of infection to surgical wounds. Skin infection could also be transmitted through the use of contaminated clothes as for example, fungus infection of the skin. 2) Common vehicle transmission: A vehicle of infection is: water, food, milk, biological products (serum and plasma) or any substance serving as an intermediate means by which an infectious agent is transported from a reservoir and introduced into a susceptible host through ingestion, inoculation or by deposition on skin or mucous membranes. A) Ingestion: As food and drinks. Many diseases are transmitted by this method e.g. typhoid, dysenteries, food poisoning and cholera. Water-borne infection: Water usually becomes contaminated from excreta as feces and urine, hence transmits pathogens causing intestinal infections such as cholera, typhoid & paratyphoid fever, bacillary and amoebic dysentery, infectious viral hepatitis A, etc.. Contamination of water from excreta of patients or carriers may happen at rivers, streams, wells, Water plant or pipes. Milk-borne infection: Milk is a very important mode of transmitting pathogenic organisms, because it is a good media for growth of many organisms. The presence
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of pathogenic organisms in milk may be due to: a) Pathogens being excreted in milk coming from infected animal, such as brucella melitensis and abortus (Malta Fever). b) Milk coming from animals with infected udders as in bovine T.B. and staphylococcal infection. c) Milk coming from healthy animal but becomes contaminated from a case or a carrier during milking. e.g.: discharges from skin lesions or nasal passages, as in case of staphylococcal food poisoning. d) Soiled utensils used for collecting milk or using contaminated water in washing utensils used for milk or for adulteration of milk. e) The milk may be contaminated through flies. B) Inoculation: As in the inoculation of plasma, blood, serum or vaccines, hence the importance of sterile techniques in inoculation to prevent sepsis and diseases as viral hepatitis B and C, HIV or AIDS, and syphilis. C) Deposition: Pathogenic micro-organisms or the infective stage of a parasite (bilharzia) if deposited on the skin or the mucous membrane of the ear, nasal sinuses or the conjunctiva e.g. during swimming may lead to the development of otitis media, sinusitis or conjunctivitis. 3) Insect borne transmission (vector-borne transmission): Various insects are known to transmit agents of diseases either mechanically or after some biological activities of the agents inside the insect vectors. A) Mechanical transmission: The insect only functions as a passive carrier of the etiologic agent of the disease picking the germs from the excreta or discharges of man or animals and depositing them on food or tissues. The best example being the role played by flies, in the
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transmission of enteric diseases, ophthalmias and wound infection. B) Biological transmission: Here for the agent to be able to infect other persons, the pathogens have to pass through some biological activity inside the insect vector, which in order to be completed, requires a certain period of time. This period is called “extrinsic incubation period" which is the period after the insect becomes infected until it becomes infective, e.g.: malaria, leishmaniasis, Rift Valley fever, 4) Air borne transmission: Transmission is through inhalation of the small residues of droplets that remain suspended in the air of enclosed spaces and thus transmission of infection to the susceptible may occur while the reservoir is not there e.g. pulmonary T.B. Another example is surgical sepsis. Coarse mucous particles and large droplets carrying the micro-organisms usually settle around cases or carriers on clothes, beddings, other articles or on the floor in the vicinity. The mucous particles or droplets dry off and the dried residues containing organisms, could be scuffed or whisked from these articles into the air during such activities as making beds, or cleaning the floor, or even by simple movements of human beings and then could be inhaled by the new hosts or may settle on open wounds. The best example for this method is in the transmission of staphylococci, tubercle bacilli, small box virus and rickettsia burnetti (Q fever).

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Types of Epidemics
1. COMMON SOURCE EPIDEMIC:
an outbreak due to the exposure of persons to common agent(infectious or non-infectious). It can result from: 1. Single exposure where the exposure is brief and simultaneous. Also the cases develop within one incubation period of the disease; e.g. :food poisoning outbreak. 2. Repeated multiple exposure, where the outbreak will be of longer duration; e.g. many persons drinking from a contaminated well. 3. Common exposure to a non-infectious agent, such as chemical poisons, polluted air or explosion of a nuclear plant; e.g. : London Fog of 1952 which led to a large number of deaths from respiratory diseases.

Characteristics of a common source epidemic:
• • • All cases develop within one incubation period of the disease. Epidemic curve shows rapid rise and fall within one incubation period. Chain of events is relatively simple and the times of onset vary over the range of the incubation period for the particular disease.

2. PROPAGATED (OR PROGRESSIVE) EPIDEMIC:

It results from transmission either direct or indirect of an infectious (or noninfectious) agent from one susceptible host to another. It can occur through direct person to persons transmission (e.g. Influenza) or it might need a vector (e.g. malaria).

Characteristics of a propagated epidemic:
• • • Epidemic extends over a number of incubation periods. The epidemic curve shows that new cases continue to develop beyond one incubation period. Chain of events are more complex. The rate of infection from one person to another depends on a number of factors, especially the proportion of susceptibles and immune persons in the population (Herd Immunity).
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Investigation and control of an epidemic (outbreak) of a communicable disease
 Verify (Confirm) the diagnosis  Verify the existence of an epidemic  Establish a case definition  Interview cases, search for additional cases, & identify pop. At risk  Describe the epidemic by: Person, Place & Time

Calculate the Attack Rates (A.R.): For the exposed group & compare them with the A. Rs. For the unexposed group

 Formulate & test hypotheses as to the cause of the epidemic (source, mode of transmission)  Apply control measures  Write a report  Conduct disease surveillance

Epidemics & epidemic investigation
In investigating an epidemic : The main objective Identify the source of infection

Median I.P. Time of Exposure Example:

----------------------------------- Time of onset of disease

Calculate the attack rates and compare the different ARs ------ to detect the source of infection AR for those with exposure (those who ate the food) – (minus) AR for those without exposure (those who did not eat the food)

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The food with the highest difference in the ARs will be the food responsible for the outbreak

Food-borne Outbreaks: Factors that contribute to food-borne disease outbreaks:
1. 2. 3. 4. 5. 6. 7. 8. 9. Inadequate refrigeration Preparing food far in advance of planned service Infected persons practicing poor personal hygiene Inadequate cooking or heat processing Holding food in warming devices at bacteria-incubating temperatures Contaminated raw ingredients in uncooked foods Inadequate re-heating Cross-contamination Inadequate cleaning of equipment 10. Obtaining foods from unsafe sources 11. Using leftovers 12. Storing acid foods in toxic containers 13. Intentional additives 14. Incidental additives

Reporting (Notification) of Communicable Diseases
Reporting system functions at four levels: 1. 2. 3. 4. Local level: community & PHC Centers Regional, District or Provincial level National level International level (WHO)

Classification of diseases according to level of reporting:
1. 2. Diseases subject to the International health Regulations (Updated 1992): Plague, Cholera, Y F. Diseases under surveillance by WHO: Louse-borne typhus fever, Relapsing fever, Paralytic poliomyelitis, Malaria, Influenza

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3.

Countries should notify WHO of all diseases of “Urgent international public health importance” Other diseases are classified according to specific policies of each country

4.

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