CONCEPTS OF

MICROBIAL
DISEASE
EPIDEMIOLOGY
Maj Gen (Retd) Prof. Dr. ASM Matiur Rahman
MBBS(Dhaka), MCPS (BD), D. Bact (Manchester) MSc (Manchester UK)
FCPS(BD), FCPS (Pak),FRCP (Edin) FICS (USA) FRCP (Glasgow) FAS (BD)

 Definition of epidemiology
 The epidemiologic triad
 Definition of communicable diseases
 Importance of studying communicable
diseases epidemiology
 Terminology
 Dynamics of disease transmission (chain
of infection):
› Human reservoir or source
› Modes of transmission
› Susceptible host

 Changes of the pattern of infectious
diseases
 Discovery of new infections
 The possibility that some chronic diseases
have an infective origin.

 A condition of the body or some part or organ of the body in which its functions are deranged.  It is deviation from normal body-function.  It is a mal-adjustment of human organism to the environment. .

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editor. vector or the inanimate environment. either directly or indirectly through an intermediate plant or animal host. animal or inanimate reservoir to a susceptible host. (Source: Benensen AS. Sixteenth Edition. An illness due to a specific infectious agent or its toxic products that arises through transmission of that agent or its products from an infected person. 1995) . Control of Communicable Diseases Manual.

and the application of this study to control of health problems .  The study of the distribution and determinants of health-related states or events in specified population.

and person. and behavioral factors that influence health. cultural. hypothesis testing. and experiments. social. causes of death.  Distribution: analysis by time. reactions to preventive regimens. biological.  Determinants: physical. and provision and use of health services. Study: surveillance. place. observation. . analytic research. behavior.  Health-related states or events: diseases.

that is to assess the public health importance of diseases. Specified populations: those groups of people with identifiable characteristics  Application to control: refers to the goal of epidemiology. identify the population at risk. describe the natural history of disease. and evaluate the prevention and control of disease . identify the causes of disease.

3. To provide the data essential to the planning. Ultimate aim of epidemiology should be: To eliminate or reduce the health problem or it’s consequences and To promote the health and wellbeing of society as a whole .According to the International Epidemiological Association (IEA). To identify etiological factors (risk factors) in the pathogenesis of the disease. implementation and evaluation of services for the prevention control and treatment of disease and to the setting up of priorities among those services. To describe the distribution and magnitude of health and disease problems in Human populations. epidemiology has three main aims 1. 2.

Major Factors Contributing to the Emergence of Infectious Diseases • Human demographics and behavior • Technology and industry • Economic development and land use • International travel and commerce • Microbial adaptation and change • Breakdown of public health measures .

environment  Classification of human Infections by modes of transmission  Incubation Period  Spectrum of disease  Herd Immunity . Host. Agent.

Susceptible MODE OF TRANSMISSION RESERVOIR/ THROUGH SOME VEHICLE Host/Non – SOURCE OF OR VECTOR Immune/ AGENT Poor herd immunity .

Water Fingers Stool Food New Host Flies Soil .

Epidemiologic Triad Disease is the result of forces within a dynamic system consisting of: agent of infection host environment .

host. and environmental factors. H = host. A = agent. E = environment . H A A A = Agent H H = Host E = Environment E E Increase in the ability of an agent to The proportion of susceptible in the infect and cause disease in man human host population is increased A H H A A H E E At equilibrium E Environmental change Environmental change facilitates agent spread host susceptibility Interaction of agent.

Biological Chemical Physical Helminths Foods Heat Protozoans Poisons Light / radiation Fungi Drugs Noise Bacteria Allergens Humidity Rickettsia Pressure Viral .

AGENT The first link in CHAIN OF INFECTION is the microbial agent. or parasite. which may be a bacterium. fungus.leukocidin haemolysin proteinase > antegenic variation (antegenic drift and shift) > resistance-transfer plasmids . •INFECTIVITY PATHOGENICITY •VIRULENCE INVASIVENESS •DOSE SPECIFICITY •OTHER AGENT FACTORS > production of enzymes : streptococci -. virus.

sugar.Immunological factor.Stress. Housing. Physical exercise.Marital status.Sex b) Biological: Biochemical level of blood e.Occupation. c) Social & economic: Education. Cellular component of blood e.WBC. Use of drug.g:RBC. d) Life style: Nutrition.alchole. .Blood group & enzymes.a) Demographic factor: Age.g:Cholesterol.Platelets.

Rickettsia prowazekii. including many avian species. mammals. the species that causes TYPHUS FEVER has a very narrow host range.HOST SPECIFITY : (AGENT) Micro-organisms may be specific to their range of host. . Salmonella dubin primarily infects bovine. and mosquitoes. St.Salmonella typhimurium common to both animals and humans. Salmonella species -. Salmonella typhosa is known to infect only humans. Louis encephalitis virus -. involving body lice and man. Brucella abortus is highly communicable in cattle but not in man.has a broad range of host.

economic  Population density  Biological:Viral.  Social. radiation.Animals  Psychological:Habit.belief.attitudesocial imbalance etc.cold.Rodents.light.Insects.noise.Microbial agent. political. Physical:Heat. .

COMPLIMENTED BY ITS CAUSAL PARTNERS .E.THE DISEASE IS INITITED AT THE CELLULAR LEVEL WHEN THE NECESSARY CAUSE (AGENT) BECOMES SUFFICIENT I.

 5.minerals.  6.carbohydrate.Diseases due to Nutrient agents: Excess or deficiency of protein.tension.cold.metals etc.  4.  2.Diseases due to biological agents:Protozoa.stress.Diseases due to Mechanical agents:Chronic friction.  8.vitamins etc. 1.dusts.eletricity etc. Automobile force.radiation.pressure.fungi.  3.fat.  7.allergens.Diseases due to Physical agents:Heat.Diseases due to Metabolic & hormonal disorders: Lack of secretion of Insulin hormone.depression etc.virus. spirochetes.bacteria.Diseases due to Psychological factors:Anxiety.gases. .Diseases due to Chemical agents: acid & alkali.sound.Diseases due to Genetic factors: Chromosomal anomalies.

IN THE ABSENCE OF TREATMENT OR PREVENTION . DISABILITY OR DEATH. IT IS THE WAY IN WHICH A DISEASE EVOLVES OVER TIME FROM THE EARLIEST STAGE OF ITS PREPATHOGENESIS PHASE TO ITS TERMINATION AS RECOVERY.

Exposure to Agent Symptom Development Pre-exposure Stage: Preclinical Stage: Factors present Exposure to Clinical Resolution leading to causative Stage: Stage: problem agent: no development symptoms Symptoms Problem resolved. present present Returned to health or chronic state or death Primary Prevention Secondary Tertiary Prevention Prevention .

Progression of disease in individual over time .

Incubation Period • The interval between the time of contact and/or entry of the agent and onset of illness (latency period) • The time required for the multiplication of microorganisms within the host up to a threshold where the parasitic population is large enough to produce symptoms .

Incubation Period • The interval between the time of contact and/or entry of the agent and onset of illness (latency period) • The time required for the multiplication of microorganisms within the host up to a threshold where the parasitic population is large enough to produce symptoms .

Latent period The period from infection until the infectious period starts. .

The patient at the bottom is infected first. Second patient Latent period Infectious period Incubation Clinical disease First patient Latent period Infectious period Incubation Clinical disease Serial interval Infection Time . The relationships of some important time periods. and transmits the infection to a second patient etc.

Schematic diagram of stages of infection in host Disease in host Agent being shed Total period of infection (agent present) Time Incubation period Latent period Period of communicability Infection patent Infection Infection terminated. latent becomes latent. or intermittently patent .

INCUBATION PERIOD 2. PRODROMAL STAGE 3. PRE-PATHOGENIC PHASE OR SUSCEPTIBILITY STAGE  PATHOGENIC PHASE 1. STAGE OF DEFERVESCENCE 5. STAGE OF CONVALESCENCE . STAGE OF OVERT DISEASE 4.

DEATH CLINICAL DISEASE SEVERE DISEASE SUB CLINICAL MILD ILLNESS DISEASE INFECTION WITHOUT CLINICAL ILLNESS EXPOSURE WITHOUT INFECTION 34 .

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clinical  Spectrum of illness ≡ most diseases demonstrate a range of manifestations and severities  Example: Polio › 95%: subclinical subclinical › 4%: flu-like › 1%: paralysis .

 An etiological agent responsible for the disease should be present  There should be a reservoir or carrier for the etiological agent to survive  The infecting agent should be able to escape from the reservoir of infection through the portal of exit  There should be a possible source of entry to transmit the agent to a new susceptible host  The agent should be able to invade the new host  The host should be susceptible .

GRADIENT OF INFECTION Refers to variety of host responses to infections : INAPPARENT MILD MODERATE SEVERE FATAL ILLNESS .

The relation of severity of illness to disease statistics. may be recorded Likely to be hospitalized and recorded . INFECTION DISEASE Inapparent Mild Moderate Severe Fatal Likely to be seen by a doctor .

CLINICAL DISEASE FREQUENT .INFECTIONS USUALLY FATAL Example : Rabies virus 0 Percentage of Infection 100 Inapparent Mild Moderate Severe Fatal .INAPPARENT INFECTION FREQUENT Example : Tubercle bacillus 0 Percentage of Infection 100 Class B . FEW DEATHS Example : Measles virus 0 Percentage of Infection 100 Class C .Distribution of clinical severity for three classes of infections (not drawn to scale) Class A .

Agents produce far more cases of inapparent infection than of overt disease • individuals with inapparent infections may be as infectious as clinical cases Ex : MENINGOCOCCAL MENINGITIS POLIO .) Epidemiologic importance of inapparent infection : • many inf.GRADIENT OF INFECTION (cont.

 Infectivity  Pathogenicity  Virulence  Antigenicity .

 Latent infection  Sub-clinical infection or inapparent or occult  Atypical infection  Severe clinical infection .

epizootic and diseases enzootic  Epidemic  Nosocomial infection  Endemic  Opportunistic infection  Hyper endemic  Eradication  holoendemic  Elimination  Pandemic . Infection  Exotic  Contamination  Sporadic  Infestation  Attack rate  Contagious disease  Primary/secondary  Incidence and cases prevalence of infectious  Zoonosis.

 Virulence  Incubation period  Reproductive rate of  Infectivity period infection  Serial interval  Host  Latent period  Vector (source)  Transmission Probability  Reservoir ratio .

 Infection is the entry and development or multiplication of an infectious agent in the body of man or animals. aureus in skin and normal nasopharynx) › Subclinical or inapparent infection (polio) › Latent infection (virus of herpes simplex) › Manifest or clinical infection . An infection does not always cause illness.  There are several levels of infection (Gradients of infection): › Colonization (S.

or other articles or substances including water and food . toys. surgical instruments or dressings. on or in clothes. beddings. The presence of an infectious agent on a body surface.

e.g. ascariasis. . It is the development and reproduction of arthropods on the surface of the body or in the clothing. e. itch mite.g. This term could be also used to describe the invasion of the gut by parasitic worms. lice.

trachoma. Examples include scabies. A contagious disease is the one that is transmitted through contact. STD and leprosy. .

 A person or an animal that affords subsistence to an infectious agent under natural conditions. . Types include: an obligate host. intermediate host and a transport host. definitive (primary) host.

Both biological and mechanical transmissions are encountered. . An insect or any living carrier that transports an infectious agent from an infected individual or its wastes to a susceptible individual or its food or immediate surroundings.

 Any person, animal, arthropod, plant, soil,
or substance, or a combination of these, 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. It
is the natural habitat of the infectious
agent.

 Incidence of an infectious disease: number of new
cases in a given time period expressed as percent
infected per year (cumulative incidence) or number
per person time of observation (incidence density).

 Prevalence of an infectious disease: number of cases
at a given time expressed as a percent at a given
time. Prevalence is a product of incidence x duration
of disease, and is of little interest if an infectious
disease is of short duration (i.e. measles), but may be
of interest if an infectious disease is of long duration
(i.e. chronic hepatitis B).

 “The unusual occurrence in a community of
disease, specific health related behavior,
or other health related events clearly in
excess of expected occurrence”
 (epi= upon; demos= people)
 Epidemics can occur upon endemic states
too.

 It refers to the constant presence of a disease or infectious agent within a given geographic area or population group.  (En = in. It is the usual or expected frequency of disease within a population. demos = people) .

G. Epidemic No.U Ahsan. Endemic vs. of cases of a disease Endemic Epidemic Time Dr. PhD Infectious Disease Epidemiology / Page 56 .

malaria) . The term “hyper endemic” expresses that the disease is constantly present at high incidence and/or prevalence rate and affects all age groups equally.g.  The term “holoendemic” expresses a high level of infection beginning early in life and affecting most of the child population. leading to a state of equilibrium such that the adult population shows evidence of the disease much less commonly than do the children (e.

e.g. the entire nation. occuring over a wide geographic area such as a section of a nation. . as for example. rabies in the UK.  Exotic diseases are those which are imported into a country in which they do not otherwise occur. Influenza pandemics. An epidemic usually affecting a large proportion of the population. a continent or the world.

nor a recognizable common source of infection e. a sporadic disease could be the starting point of an epidemic when the conditions are favorable for its spread. polio.  However. tetanus…. The cases occur irregularly. meningococcal meningitis. .g. The cases are few and separated widely in time and place that they show no or little connection with each other. and generally infrequently. The word sporadic means “scattered about”. haphazardly from time to time.

.  Primary (index)/secondary cases: The person who comes into and infects a population is the primary case. Attack rate: proportion of non-immune exposed individuals who become clinically ill. Further spread is described as "waves" or "generations". Those who subsequently contract the infection are secondary cases.

of Susceptible Infectious Disease Epidemiology / Page 61 .* = No.R.A. INFECTIVITY : Ability of an agent to invade and multiply (produce infection) in a host. of New Cases Among Contacts Total No. Assessed by Secondary Attack Rate* Example :  high in measle  low in leprosy S.

in relation to the total exposed contacts. (susceptible contacts) .SECONDARY ATTACK RATE* is the number of cases among contacts occurring (within the accepted incubation period) due to exposure to a primary case.

Attack rate • Secondary Case .• Index Case .Person that comes to the attention of public health authorities • Primary Case .Person who acquires the disease from an exposure .Secondary attack rate .Person who acquires the disease from an exposure to the primary case .

.g.. e. bovine tuberculosis…. e. plague. Zoonosis is an infection that is transmissible under natural conditions from vertebrate animals to man.g. rift valley fever.g.  An epizotic is an outbreak (epidemic) of disease in an animal population. e. rabies. bovine TB.  An Enzotic is an endemic occurring in animals.

. Nosocomial (hospital acquired) infection is an infection originating in a patient while in a hospital or another health care facility. Examples include infection of surgical wounds. It has to be a new disorder unrelated to the patient’s primary condition. hepatitis B and urinary tract infetions.

 This is infection by organisms that take the
opportunity provided by a defect in host
defense (e.g. immunity) to infect the host
and thus cause disease. For example,
opportunistic infections are very common
in AIDS. Organisms include Herpes
simplex, cytomegalovirus,
 M. tuberculosis….

 Termination of all transmission of infection by the
extermination of the infectious agent through
surveillance and containment. Eradication is an
absolute process, an “all or none” phenomenon,
restricted to termination of infection from the whole
world.

 The term elimination is sometimes used to describe
eradication of a disease from a large geographic
region. Disease which are amenable to elimination in
the meantime are polio, measles and diphtheria.

 DIRECT  INDIRECT
TRANSMISSION
TRANSMISSION  VECHICLE BORNE
 DIRECT CONTACT  VECTOR BORNE
 DROPLET INFECTION  A) mechanical
 CONTACT WITH SOIL  B) biological
 INOCULATION INTO  AIR-BORNE
SKIN OR MUCOSA  FOMITE BORNE
 UNCLEAN HANDS
 TRANSPLACENTAL AND FINGERS

Vertebrate-vertebrate-man Psittacosis .Vertebrate-arthropod-vertebrate-man Viral encephalitis • Complex Cycles .Helminth infections River blindness .Man-arthropod-man Malaria .Man-man Influenza .Classification by mode of transmission • Cycles of Infectious Agent in Nature .

animal. object or substance from which an infectious agent passes or is disseminated to the host . It is defined as the person.

 It is defined as “any person. animal. or substance “(or combination of these in which an infectious agent lives and multiplies. on which it depends primarily for survival. plant. and where it reproduces itself in such manner that it can be transmitted to a susceptible host” . soil. arthropod.

 “Thus the term source” refers to the immediate source of infection and may or may not be a part of reservoir. in hookworm infection. For example. . but the source of infection is the soil contaminated with infective larvae.  In tetanus the reservoir and source are the same (Soil)  In typhoid favor the reservoir infection may be a case or carrier. but the source of the infection may be stool or urine of a patient or contaminated food or water. the reservoir is man.

Classification of Reservoir: •Human Reservoir •Animal Reservoir •Reservoir in nonliving things .

the disease agent is not completely eliminated. The absence of recognizable symptoms and signs of disease.  It is “an infected person or animal that harbors a specific infectious agent in the absence of discernible (visible) clinical disease and serves as a potential source of infection to others.  Three elements have to occur to form a carrier state: 1. 3. leading to a carrier state. The presence in the body of the disease agent. 2. . It occurs either due to inadequate treatment or immune response. The shedding of disease agent in the discharge or excretions.

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 TYPE PORTAL OF EXIT A) Urinary A) Incubatory B) Intestinal B) Convalescent C) Respiratory C) Healthy  DURATION A)Temporary B)Chronic .

Shedding of micro-organisms in the discharges or excretions 4. Presence of specific microbes in the body 2. Absence of apparent symptoms and signs 3. As a source of infection to others .1.

 Carriers are less infectious but are more dangerous than cases. because they escape recognition and continuing as they do to live a normal life among the population  They can readily infect the susceptible individuals over a wider area and longer period of time. . under favourable conditions.

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 DOSE OF INOCULUM  SITE OF MULTIFICATION  RATE OF MULTIFICATION  HOST DEFENCE MECHANISM .

 GENERATION TIME  INFECTIVE DOSE  PORTAL OF ENTRY  INDIVIDUAL SUCEPTIBILITY .

 Tracing the source of infection and contact  Period of surveillance  Immunization  Identification of point source or propagated epidemics  Prognosis .

 IT IS DEFINED AS THE TIME REQUIRED FOR 50% OF THE CASES TO OCCUR FOLLOWING EXPOSURE .

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.Infectious period The length of the time period during which a person can transmit a disease.

TIME Susceptible Subclinical Death Disease Host Clinical Disease No infection Recovery Incubation period Exposure Onset .

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GENERATION TIME : Interval between receipt of infection and maximal infectivity of the host Applies pplies to to both both clinical clinical and and inapparent inapparent infections infections MUMPS : virus recovered from the mouth 5 days before onset to 4 days after BUT significant infectiousness begins only on the day before onset and lasts for a short time .

) MEASLES : terminates before clinical recovery DIPHTERIA : may continue for sometime after full recovery STREP.GENERATION TIME : (cont. INFECTION : infectiousness decreases during convalescence inspite of the presence of organisms for a long time .

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Number of exposed persons developing the SAR = disease within the range of the incubation period  100 Total number of exposed /susceptible .

 IT IS THE LEVEL OF RESISTENCE OF A COMMUNITY OR GROUP OF PEOPLE TO A PARTICULAR DISEASE .

ROLE OF HERD IMMUNITY ON TRANSMISSION A B Susceptible individual Immune individual .

1 primary case.) Situation A : herd immunity 40% . transmission epidemic type. ROLE OF HERD IMMUNITY ON TRANSM (cont. transmission epidemic type . 9 tertiary cases Situation B : herd immunity 80% . 3 secondary case.

measles .Herd Immunity • The decreased probability that a group will developed an epidemic because the high proportion of immune individuals reduces the chance of contact between infected and susceptible persons • The entire population does not have to be immunized to prevent the occurrence of an epidemic Example : smallpox.

INTERVENTIONS TAKEN BEFORE THE DISEASE IS ESTABLISHED 3. SECONDARY PREVENTION-. PRIMARY PREVENTION -.1. PRIMORDIAL PREVENTION-- INTERVENTIONS TAKEN BEFORE THE DEVELOPMENT OF RISK FACTOR 2. TERTIARY PREVENTION -- INTERVENTIONS TAKEN TO PREVENT COMPLICATIONS .INTERVENTIONS TAKEN AFTER THE DISEASE IS ESTABLISHED- 4.

BE ATTENTIVE AND CAUTIOUS 3. WATCHING THE DISEASE WITH SUSPICION. TRY TO GRASP THE ENTIRE NATURAL HISTORY OF THE DISEASE . ATTENTION AND AUTHORITY 1. SUSPECT UNLESS AND UNTIL IT IS DISPROVED 2.

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 DISEASE WILL BE A PUBLIC HEALTH PROBLEM WHEN IT CAUSES HIGH MORBIDITY AND MORTASLITY  DEMANDS URGENT HEALTH ACTION EITHER IN THE FORM OF 1. ERADICATION . ELIMINATION 3. CONTROL 2.

 CONTROL STRATEGY = REDUCING THE MORBIDITY AND MORTALITY  A CONTINGENCY TEMPORARY MEASURE IN CASE OF EMERGENCY .

 NEAR ERADICATION STAGE  INTERMEDIARY BETWEEN CONTROL AND ERADICATION STATUS  LESS PUBLIC HEALTH PROBLEM  BASED MAINLY ON SURVEILLANCE ACTIVITIES .

 RADICLE MEANS MAIN ROOT OF A PLANT  ERADICATION MEANS REMOVING ALONG WITH THE MAIN ROOT i.e. IN ENTIRETY  ALL OR NONE FORMULA .

ELIMINATE THE RESERVOIR/SOURCE OF THE AGENT .CUT OFF THE TRANSMISSION . AGEENT IN MODE OF TRANSMISSION RESERVOIROR SUSCEPTIBLEP SOURCE OPULATION TO ERADICATE THE DISEASE ONE MUST: .MAKE THE PEOPLE IMMUNE TO THAT DISEASE .