Infectious Disease Epidemiology

Berhe B. (Email: berhebeyene2005@gmail.com)

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Session objectives
By the end of this session, students will be expected to:
 Define infectious disease epidemiology
 List the components in the infectious disease process
 Describe natural history and time course of an infectious
disease
 Identify factors that affect person-to-person infectious
disease transmission
 Describe the type of carriers and roles in the infectious
disease transmission

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 Infectious Disease Epidemiology

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 Introduction
 Despite the great scientific advances that have reduced
morbidity and mortality from communicable diseases over
the past decades, communicable diseases continue to
account for a major proportion of acute illnesses, even
in technologically advanced countries, though the types of
diseases may vary from place to place.

• Communicable diseases are characterized by the presence of

the infectious agent , the susceptible human population and
transmission mode from one host to another.

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 Infectious diseases (Communicable diseases)

Are diseases caused by pathogens that are

transmitted either directly between persons
or indirectly via a vector or the environment

 a disease caused by an infectious agent or its

toxic products

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Why are infections important?

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 Communicable diseases con’t…
Because
Cause outbreaks
High numbers
Mortality, morbidity
High costs
Treatment can become difficult (resistance)

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Which are the most important infections in Ethiopia?

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 Special features of infectious disease Epidemiology

 A case may also be a risk factor

- Person with infection can also be source of infection
 People may be immune
- Having had an infection or disease could result to resistance to an
infection (immunity)
 A case may be a source without being recognized
- Asymptomatic/sub-clinical infections
 There is sometimes a need for urgency
- Epidemics may spread fast and require control measures
 Preventive measures (usually) have a good scientific
evidence

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 Case
 Primary case
– Person who brings the disease/infection into a population
 Secondary cases
– Persons who are infected by primary case
 Index case
– First case discovered during an outbreak

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 Infectious disease epidemiology cont’d

A case is a risk factor …

 Infection in one person can be transmitted to others

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 Infectious disease epidemiology Cont’d
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, SARS
 Surveillence of infectious disease
 Identification of source of outbreaks
 Studies of routes of transmission and natural history of
infections
 Identification of new interventions

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 Natural history of disease ?

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The “natural history of disease” refers to the
progression of disease process in an individual
over time, in the absence of intervention.

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Natural History of diseases cont’d
There are four stages in the natural history of disease.
1. Stage of susceptibility
2. Stage of subclinical disease
3. Stage of clinical disease
4. Stage of disability or death

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 Levels of disease prevention
1. Primary
health promotion(wide range of social and
environmental interventions)
Prevention of exposure
Prevention of disease
2. Secondary prevention
Screening
Early detection and treatment
3. Tertiary prevention
Rehabilitation

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Chain of disease transmission (Components of
infectious process)
 Definition: Logical sequence of factors or links
of a chain that is essential to the development
of infectious agent and to propagation of
disease.

 The infectious process (components of

infectious disease process) includes the
following 6 components:

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 Chain of Transmission

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 1. Agent
• An organism that causes the infection or
infectious process range from viral particles to
complex multi-cellular organisms
N.B –host agent interaction is characterized by
infectivity, Pathogenicity, virulence or
immunogenicity.

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 2. Reservoir
 It is an organism or habitat, in which an infectious
agent normally lives, transforms, develops and/or
multiplies. Depending upon the agent, the reservoir
may be: humans, animals, and/or environment
Humans reservoirs
 two types of human reservoirs(acute clinical cases and
carriers)
 Acute clinical cases are people who are infected with the disease agent
and become ill. Because they are ill, their contacts and activities may be
limited. They are also more likely to be diagnosed and treated than
carriers are.
Carriers, on the other hand, are people who harbor
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infectious agents but are
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not ill. 20
 Reservoir cont’d
Carriers can be:
Asymptomatic carriers: Transmitting infection without
ever showing signs of the disease
Incubatory carriers: are people who are going to become
ill, but begin transmitting their infection before their
symptoms start. Examples:
 measles: a person infected with measles begins to shed the
virus in nasal and throat secretions a day or two before any
cold symptoms or rash are noticeable.
HIV infection may be present for years before the
person develops any symptoms.
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 Reservoir cont’d
Convalescent carriers : Are people who continue to be
infectious during and even after their recovery from
illness. This happens with many diseases. Example:

 Salmonella patients may excrete the bacteria in feces

for several weeks, and rarely even for a year or
more. This is most common in infants and young
children. Treatment with inappropriate antibiotics
may prolong the convalescent carrier phase.

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 Reservoir cont’d

Chronic carriers: are people who continue to harbor

infections for a year or longer after their recovery.
Example:
 The chronic carrier state is not uncommon following
hepatitis B infection, whether or not the person became ill,
and may be lifelong. The risk of developing chronic hepatitis
B depends on the person’s age at infection. About 90% of
infants infected at birth become chronic carriers of the
disease, compared with only 1-10% infected after age 5.
That is why it is so important to give hepatitis B vaccine to
newborns.

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 3. Portal of Exit
 The portals most commonly associated with human and
animal diseases are:
 Respiratory
 Genitourinary
 Alimentary
 Skin
 Transplacental

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 4. Portals of Entry
 The portal of entry into the host is usually the same as
the portal of exit from the reservoir. In some diseases,
however, the exit and entry portals may differ.
Example:

 Staphylococcal bacteria may escape from one person’s

respiratory tract to infect another person’s skin lesion.
If that person is a food handler, the staphylococcal
bacteria may escape from the infected skin lesion,
contaminate food where it can incubate, and cause
“food poisoning” in people eating the food.
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 Portals of Exit and entry

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 5. Transmission routes
Direct transmission Indirect transmission

Mucous to mucous membrane Waterborne

Across placenta Airborne

Transplants, blood Foodborne

Skin to skin Vectorborne

Sneezes, cough Objects/Fomites

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 Examples of transmission routes and diseases
• Mucous to mucous - STI, feacal-oral (shigella)
• Placental - toxoplasmosis
• Transplants, blood - HBV
• Skin to skin -Herpes Type 1
• Sneezes, cough-influenza
• Waterborne - cryptosporidium, giardia
• Airborne - varicella
• Foodborne- salmon
• Vector -malaria,
• Objects - scarlet fever, norovirus
• Most pathogens for indirect transmission also can be directly
transmitted

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 Possible outcomes after exposure to an infectious agent

Exposure

No infection Clinical infection Subclinical infection Carriage

Death Immunity Carriage Non-immunity

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Possible outcomes after exposure to an infectious agent cont’d

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 6. The susceptible human host
 A person lacking sufficient resistance to a
particular pathogenic agent to prevent
disease if exposed.

 The concept of host susceptibility or

resistance can be seen at two levels,
individual and that of the population.
 Susceptibility is affected by

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 susceptible human host cont’d
1. Genetic factors: The role of genetic factors in susceptibility to
infectious diseases is not yet well understood. Genes do seem
to play a role in the progression of HIV disease, and perhaps in
individuals’ susceptibility to meningococcal meningitis.

2. General resistance factors include many body functions that we

take for granted. Intact skin and mucous membranes help us
resist disease. So do the gastric acid in our stomachs, the cilia
in our respiratory tracts, and the cough reflex.

3. Specific acquired immunity is the greatest influence on host

susceptibility. This immunity is specific to a particular disease
agent, and it may be acquired naturally or artificially.
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 Factors influencing disease transmission
Climate change
Megacities
Pollution Vector proliferation
Vector resistance

Food production Infectivity

Intensive farming Pathogenicity
Antibiotics Virulence
Immunogenicity
Antigenic stability
Population growth
Migration
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 Time course of an infectious disease
Pre-patent Period: between biological onset and
the time of first shedding of the agent.
Incubation Period: between infection ( biological
onset) and the first clinical manifestations of
disease (clinical onset).
Communicable Period: The time interval during
which the agent is shed by the host.
Latent Period: The interval between recovery
and the occurrence of relapse or recrudescence
in clinical disease.
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 Reproductive rate
 Potential of an infectious disease to spread
in a population
 Dependent on 4 factors:

– Probability of transmission in a contact between an

infected individual and a susceptible one
– Frequency of contacts in the population -
contact patterns in a society
– Duration of infectiousness
– Proportion of the population/contacts that are
already immune, not susceptible

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 Basic reproductive rate (R0)
Basic formula for the actual value: R0 = β * κ * D
• β - risk of transmission per contact (i.e. attack rate)
– Condoms, face masks, hand washing  β ↓
• κ - average number of contacts per time unit
– Isolation, closing schools, public campaigns  κ ↓
• D - duration of infectiousness measured by the same
time units as κ
– Specific for an infectious disease
– Early diagnosis and treatment, screening, contact
tracing  D ↓
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 Basic reproductive rate (R0)
• Average number of individuals directly infected by an infectious
case (secondary cases) during her or his entire infectious period,
when she or he enters a totally susceptible population
• (1+2+0+1+3+2+1+2+1+2)/10 = 1.5
– R0 < 1 - the disease will disappear
– R0 = 1 - the disease will become endemic
– R0 > 1 - there will be an epidemic

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 800
700
600

number of cases
500
400
300
200
100
0
1 2 3 4 5 6 7
generation

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 800
700
600

number of cases
500
400
300
200
100
0
1 2 3 4 5 6 7
generation

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 Effective reproduction number R
If the population is not fully susceptible, the
average number of secondary cases is less than
Ro. This is the effective reproduction number.
 If ‘x’ is the proportion of susceptible
population, R is the product of the basic
reproductive number and the proportion of
susceptible contacts. I.e. R= R0 X

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 Effective reproduction number R
Initial phase R = R0
• Epidemic in susceptible
population
• Number of susceptible
starts to decline
• Eventually, insufficient
Peak of epidemic R = 1
susceptible to maintain
transmission. When
each infectious person
infects <1 persons,
epidemic dies out
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 Changes to R(t) over an epidemic
1200

1000

800 Susceptible
number

Incident cases
600 R=1
Im m une
400 R>1 R<1

R=R0
200

0
0 0.05 0.1 0.15 0.2
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 R, threshold for invasion
• If R < 1
– infection cannot invade a population
– implications: infection control mechanisms
unnecessary (therefore not cost-effective)

• If R > 1
– on average the pathogen will invade that
population
– implications: control measure necessary to
prevent (delay) an epidemic

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 Principles of communicable disease control

1. Attacking the source (reservoir) of infection

 Treatment of cases and carriers
 Isolation
 Quarantine
 Reservoir control
 Active surveillance of contacts
 Effective reporting system

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 Principles of CDC cont’d
2. Interrupting the chain of transmission
 Environnemental satiation
 Personal hygiene
 Vector control
 Disinfection and sterilization

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 Principles of CDC cont’d
3. Reducing host susceptibility
 Immunization
 Better and improved nutrition
 Health education
 Chemoprophylaxis
 Person protection

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 Questions/discussion

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