ARBA MINCH UNIVERSITY

DEPARTMENT OF PUBLIC HEALTH

EPIDEMIOLOGY AND BIOSTATISTICS UNIT

COMMUNICABLE DISEASE EPIDEMIOLOGY

BY MATHEWOS A. (MPH/EPIDEMIOLOGY AND BIOSTATISTICS)

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 Learning Objectives
At the end of this unit the student is expected to:
Define the natural history of disease and its different stages.

Describe the components of infectious disease process

Discus causal concepts of disease

 Discus the models of diseases causation

Describe components of chain of infection

Describe levels of disease prevention

Describe levels of disease occurrence

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 COMMUNICABLE DISEASE
EPIDEMIOLOGY

• The natural history of disease:

It refers to the progression of a disease process

in an individual over time, in the absence of
intervention.
It is the course and outcome of the diseases.

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 The natural history of disease…

 The process begins with exposure to the causative

agent capable of causing disease.
 Without medical intervention, the process ends with
recovery, disability, or death.
 The usual course of a disease may be halted at any
point in the progression by preventive and therapeutic
measures.
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Stages in the natural history of a disease

There are four stages in the natural history of a

disease. These are:

1. Stage of susceptibility

2. Stage of pre-symptomatic (sub-clinical) disease

3. Stage of clinical disease

4. Stage of recovery, disability and death

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Stages in the natural history of a disease…

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 Stages…..
1. Stage of Susceptibility:

In this stage disease not developed yet, but the ground work has

been laid by the presence of factors that favor its occurrence.

Example: Unvaccinated child is susceptible to measles.

Exposure to factors which could be modifiable or non- modifiable,

e.g. smoking, unprotected sex, age etc

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 Stages…

2. Stage of pre symptomatic (sub-clinical) disease:

• In this stage, no manifestations of disease but pathologic
changes (damages) have started to occur.
• Disease can only be detected by special tests

• Signs and symptoms of the disease are not present.

• May lead to clinical stage or may sometimes end in recovery

without development of any signs or symptoms.

• Examples:
– Detection of antibodies against HIV in an apparently healthy person.
– Ova of intestinal parasite in the stool of apparently healthy children.
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 Stages..

3. The clinical stage:

 At this stage, the person has developed signs and symptom of the
disease.
 The outcomes of this stage may be recovery, disability or death.
 The clinical stages of different diseases vary in duration, severity and
out come,
• Examples:
– Common cold has a short and mild clinical stage and almost everyone recovers quickly.
– ƒ Polio has a severe clinical stage and many patients develop paralysis becoming
disabled for the rest of their lives. ƒ
– Rabies has a relatively short but severe clinical stage and almost always results in death.
ƒ
– Diabetes Mellitus has a relatively longer clinical stage and eventually results in death if
the patient is not properly treated.
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 Stages…
4. Stage of recovery, disability or death:
 In this stage the residual defect of short or long duration happens leaving
the person disabled to a great or lesser extent
– Disability – any limitation of a person’s activity including his/her role as
parent, wage earner and member of community.

Examples:
Trachoma may cause blindness

Meningitis may result in blindness or deafness.

Meningitis may also result in death.
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 Stages…

• Detection and treatment at any stage can alter

the natural history of a disease,
• But the effects of treatment can only be
determined if the natural history of the disease
in the absence of treatment is known.

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 Infectious disease epidemiology

Definition:

The study of circumstances under which both

infection and disease occur in a population and
the factors which influence their frequency,
spread and distribution of infectious diseases.

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 Infectious disease epidemiology used for?

• Surveillance 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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 Communicable disease

Definition:
Communicable disease (infectious disease) – is 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, animal, or reservoir to a susceptible
host, either directly or indirectly through an intermediate
plant or animal host, vector, or the inanimate environment.
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Components of Infectious Disease Process

• Infectious diseases result from the interaction

of infectious agent, susceptible host/reservoir
and environment that brings the host and
the agent together.

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 Cont…
Agent: Agent is an infectious micro organism- virus,
bacteria, parasite, or other microbe.

Host: Host factors influence individual's exposure,

susceptibility or response to a causative agent.
For example- age, sex, race, socioeconomic status, and
behaviors (smoking, drug abuse, lifestyle, sexual
practices and contraception, eating habits) affect
exposure.
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 Cont…
Environment: Environmental factors are extrinsic
factors which affect the agent and the opportunity
for exposure.
– Physical factors such as geology, climate, and physical
surrounding (e.g., maternal waiting home, hospital);
– Biologic factors such as insects that transmit the agent;
and
– Socioeconomic factors such as crowding, sanitation,
and the availability of health services.
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 Causal Concepts of Disease

 A cause of a disease can be defined as a factor (characteristic,

behavior, event, etc.) that influences the occurrence of disease.
 Is an event, condition, characteristic or a combination of
these factors which plays an important role in producing the
the health outcome.
 Logically, a cause must precede an outcome
 Not all associations between exposure and disease are causal.

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 Cont…
 If disease does not develop without the factor
being present, then we term the causative
factor "necessary".
 If the disease always results from the factor, then
we term the causative factor "sufficient".
 Factors which inevitably produce or initiate the
disease are termed as ‘’sufficient cause’’
 Usually sufficient cause is not a single factor -comprises
several compartment causes.
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 Cont…
 A necessary cause is a component of each of
the sufficient causes
– Example, exposure to mycobacterium tuberculosis
is necessary for tuberculosis to develop, but it is
not sufficient as not everyone exposed develops
the disease
– On the other hand, exposure to rabies virus by
itself is sufficient to initiate clinical rabies.

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 Factors in disease causation

1. Etiological factors:
– Nutritional elements –
• excessive- cholesterol, obesity
• Deficiency- vitamins, proteins, mineral  goiter,
Kwashiorkor etc…
– Chemical agents – Poisons- carbon monoxide, etc
– Physical agents – Ionizing radiation, burn, etc
– Infectious agents :
• Protozoa - malaria, amoeba, giardiasis
• Bacteria - typhoid fever, tuberculosis, pneumonia
• Virus - measles, poliomyelitis, rabies, yellow
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fever, AIDS 21
 Factors…
2. Host (Intrinsic) factors: are factors which influence
susceptibility, exposure, or response to agents.

– Age, sex, socioeconomic status, and behaviors

(smoking, sexual practice, eating habits), genetic,
nutrition/immunologic status, concurrent infection, and
physiologic state.

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 Factors…

3. Environmental (extrinsic) factors: are factors which influence existence of

the agent and the opportunity for exposure
– physical environment – physical factors- heat, light, air, radiation,
chemicals

– Biological environment – human population density, Flora- as sources of

food, as source of agents, and Fauna- as food source, as host, as vectors

– social environment – economic level- availability of facility, occupation

- exposure to chemical agents, urbanization- urban crowding, war,
floods, etc
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 Theories of disease causation/Models

• There are a number of disease causation

models:
– Models are purposely simplified representations to
facilitate the understanding of nature which is
complex.
– The purpose of the models is to simplify reality
and make easier to grasp the essence of the
issue.

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 Models…
1.The epidemiologic triad or triangle

Is the traditional model of infectious disease

causation.

• It has three components:

 An external agent,
 A susceptible host, and
 An environment that brings the host and agent
together.
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 Models…

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 Examples of causes of disease by host, agent
and environmental factors.

 Host factors: Age, Sex, Behavior, Genetic

inheritance, Weight...
 Agent factors: Virulence of organisms, Antibiotic
resistance...
 Environmental factors: Home overcrowding, Air
pollution, Workplace hygiene, Water composition,
Food contamination, Animal contact

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 Cont…

• From the perspective of epidemiologic triangle, the

host, agent, and environment can coexist harmoniously.

• Disease and injury occur only when there is altered

equilibrium between them.

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 Component causal model :

The agent-host-environment model does not work for some non-

infectious diseases, several other models have been proposed based
on multi-factorial nature of causation in many diseases.

 Causal pie is one of the models that take into account multiple factors
which are important in causation of disease.

 In the causal pie model, the factors are represented by pieces of the
pie called component causes, the whole pie making up the sufficient
cause for a disease.
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Causal model concepts …
Sufficient Sufficient Sufficient
cause I cause II cause III

A B
B F A H

C D I
A G C

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 Cont…
 A disease may have more than one sufficient cause, each
sufficient cause composed of several factors.
 The factors represented by the pieces of the pie in the above
model are called component causes
 All factors (component causes) together form the sufficient
cause while component cause A constitutes the necessary cause.
 A single component cause is rarely a sufficient cause by itself
 Thus, the model deemphasizes the role of the agent and
highlights other factors.
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 Cont…

• It is not necessary to identify all the components

of a sufficient cause before effective prevention
can take place,
• Since the removal of one component may
interfere with the action of the others and thus
prevent the disease or injury.
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 Example
Causes of tuberculosis (TB)
Genetic factors
Malnutrition
Crowded housing
Poverty
Exposure to bacteria (m.tuberculosis)

1. Necessary cause ?
2. Sufficient cause ?
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 The wheel model
 This model considers all factors involved in
disease causation:
– A hub (the human host) with genetic make up as its
core and
– Surrounding the host is the environment divided in to
Biological
Social and
Physical environment

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 The wheel model …
Physical environment

Host Social environment

Genetic core

Biological environment

The relative size of the different components of a wheel depend upon the role played by
the factor/s in that specific component in the development of the disease state.
For hereditary disease – genetic core would be relatively large, for measles – host and
biologic factors contribute more.

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 Summary of causal concepts:

 The agent of a disease can be any factor (a living or nonliving

thing) depending up on the nature of the disease being considered

 The agent can be contained into a component of the environment.

 Thus description of disease causation can broadly be grouped in to

host factors and environmental factors

 The interaction of host and environmental factors and the state of

the equilibrium of such interactions determine whether disease
develops or not
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 Summary of causal concepts …
 The share of the role played by any of the factors in causing
a disease is variable for different conditions.

 In infectious (communicable) disease, the infectious agent is

the necessary causal factor.

 Diseases are not the result of operation of any single factor

rather a result of multiple causation or multi factorial
etiology. This is the basic principle of disease causation
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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

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 Transmission Probability

• The transmission probability is the probability

that, given that there is contact between an
infective source and a susceptible host,
successful transfer of the infective agent will
occur so that susceptible host become infected.

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 Disease Transmission

Infectious Susceptible
Host Host

Contact

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 Cont…

Transmission depends on:

– Infectious host

– Susceptible host
– Contact definition
– Infectious agent

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 Transmission Probability

Two common ways of estimating transmission

probability are:
A: Secondary attack rate
B: Binomial Model

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 Secondary Attack Rate

• A secondary attack rate is a measure of the frequency of

new cases of a disease among the contacts of known cases.

• It requires identifying infectious persons and susceptible

people who make contact with them by some definition of
contact.

• SAR is a proportion, not a rate.

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 Cont…

SAR = Numbers of person exposed(have contact with a

known case)who develop disease ÷ Total number of
susceptible exposed person X 10n

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 Chain of Infection

• Infection implies that the agent has achieved

entry and begun to develop or multiply,
whether or not the process leads to disease.
• A model used to understand the infection
process is called the chain of infection (fig. 3)

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 Cont…

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 Components of Chain of Infection

1. Causative Agent

2. Reservoir host

3. Portal of exit

4. Mode of transmission

5. Portal of entry

6. Susceptible host.
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 The infectious disease process …
1. The agent: range from viral to complex multi-cellular organism
– Host-agent interaction and the resulting outcome of infection depend on:
 Infectivity – ability of an agent to invade and multiply in host -
Ability to produce infection.
 Pathogenicity - ability to produce clinically apparent infection

 Virulence - the proportion of clinical cases resulting in severe

clinical disease
 Immunogenicity - the infection’s ability to produce specific
immunity

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 Cont …

• Some factors can change these properties of the infectious agents:

– Environmental conditions - may favor or not

– Does of the agent (the amount entering may be related to severity of

the disease)
– Host factors (age, sex, presence of concurrent infection, etc)
– Pathogenic mechanisms - different mechanisms (direct tissue invasion,
production of toxin, immunologic enhancement or allergic reaction,
immune suppression, enhancement of host susceptibility to drugs
*Some agents may use more than one mechanism)

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 Chain if Infection …
2. Reservoirs: is the habitat in which an infectious agent
normally lives, grows and multiplies.
– May be humans, animals, plants or other inanimate objects.

• Agents with a human reservoir include measles, mumps, and

most respiratory pathogens.
• Human reservoirs may be persons with symptomatic illness, or
carriers.

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 Chain of infection …
•A carrier is a person without apparent disease who is nonetheless capable of
transmitting the agent to others.

•Or A person who does not have clinical disease, but is a potential source of
infection to other people.

•The importance of carriers in the transmission of disease depends on their:

1) Number,

2) Detect-ability,

3) Mobility, and

4) Chronicity.
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 Carriers may be:
 Asymptomatic carriers: (transmitting infection without ever
showing signs of the disease),

 Incubatory carriers: (transmitting infection by shedding the agent

before the onset of clinical manifestations), or

 Convalescent carriers: (transmitting infection after the time of

recovery from the disease).

 Chronic carriers: shed the agent for a long period of time, or even
indefinitely.

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 Chain of infection …
3. Portal of exit: the way by which an agent leaves the
reservoir.
– Usually corresponds to the site at which the agent is localized

– Possible portals of exit include:

• all body secretions & discharges; mucus, saliva, tears

• breast milk, vaginal and cervical secretions
• excretions (feces and urine, blood and tissues)

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 Modes of Transmission of Infectious Agents

4. Transmission:
The mechanism by which an infective agent exists from a reservoir
host and enters into a susceptible host is referred as mode of
transmission.

– There are two major modes:

1. Direct Transmission
2. Indirect Transmission

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 Direct Transmission

1. Direct Transmission- immediate transfer of the agent

from a reservoir to a susceptible host by direct
contact or droplet spread/projection.

1.1 Direct contact – the contact of skin, mucosa or

conjunctiva with infectious agents via: touching,
kissing, sexual intercourse, blood transfusion, biting

Examples: HIV/AIDS/STIs, rabies

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 Direct …
1.2 Direct projection – refers to projection of saliva,
droplets by coughing, sneezing, spitting or talking
Example: common cold
1.3 Trans placental: is transmission from mother to fetus
through the placenta.
• Example: syphilis, HIV/AIDS

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 Direct…

Direct Vertical- e.g. Trans-placental transmission-

transmission from mother to fetus.
Direct Horizontal-by direct touching, biting, kissing,
sexual intercourse, droplet spread on to the
conjunctiva, nose, mouth during sneezing, coughing,
talking. It is usually limited to a distance of a meter or
less
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 Indirect Transmission:
2. Indirect Transmission

An agent is carried from reservoir to a susceptible host by suspended

air particles or by animate (vector mosquitoes, fleas, ticks...) or
inanimate (vehicle-food, water, biologic products) intermediaries.

• Example:
– Vehicle-born: food, water, towels, ...
– Vector-borne: insect, animals, ...
– Airborne: dust, droplets
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 Indirect Transmission …
2.1 Vehicle borne – occurs through indirect contact with
food, water, and fomites (inanimate objects such as
bedding, toys, surgical instruments, handkerchiefs).

2.2 Vector borne – the agent is conveyed by an

arthropod to a host.. The vector may be biological or
mechanical.

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 Indirect…
• Biological vector - if the agent undergoes changes within
the vector before transmission. The vector serves as both an
intermediate host and a mode of transmission. Example:
Anopheles mosquito is a biological vector for malaria.
• Mechanical vector - if the agent doesn’t multiply or
undergo physiological changes in the vector; just carried by
the leg or proboscis of the vector.
Example: Flies are mechanical vectors for the transmission of
trachoma.
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 Indirect…
2.3 Air borne – by particles that are suspended in air:
dust or droplet nuclei (dried residue of aerosols).
• Air borne dust – includes infectious particles blown
from the soil by the wind
• Droplet nuclei – are the residue of dried droplets,
less than 5µ in size and may remain in the air
suspended for long periods and blown over long
distances. Example: TB (Tuberculosis)

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 Chain of infection …

5. Portal of entry: the site where an infectious agent enters

susceptible host. Examples:

-Nasal mucosa is portal of entry for common cold

-Conjunctiva is the portal of entry for trachoma
-Injury site is portal of entry for tetanus

6. Host: The susceptible human host is the final link in the

infectious
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 Chain of Infection …

• Host susceptibility can be seen at:

– Individual level

 The interaction of genetic endowment with the environment over the entire
life span
 Genetic factors (sex, blood type…)

 Environmental factors (immunity as a result of past infections)

– Community level – host resistance at the community (population) level is herd

immunity
• The presence of high proportion of immunes prevents transmission by
highly decreasing the probability of contact between reservoirs and
susceptible hosts.
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 Herd immunity

• Herd immunity: defined as the resistance of a

population to the introduction and spread of an
infectious agent, based on the immunity of a high
proportion of individual members of the population,
thereby lessening the likelihood of a person with a
disease coming into contact with susceptible.

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 Cont…

• Example - If 90 % of the children are vaccinated for

measles, the remaining 10 % of the children who are
not vaccinated might not become infected with
measles because most of the children (90 %) are
vaccinated.
• That means transmission from infected person to
other susceptible children will not be easier.
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• Conditions under which herd immunity best
functions:

– single reservoir (the human host)

– direct transmission (contact or projection)
– total immunity (non-shedding of agents by immune hosts)
– uniform distribution of immunes
– no over crowding

*These conditions are seldom fulfilled

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 Levels of Disease Prevention

 The major purpose in investigating the epidemiology of diseases

is to learn how to prevent and control them.
 Disease prevention means to interrupt or slow the progression of
disease.
 Fluctuation in patterns of morbidity and mortality over time in
countries indicate that causes of disease are preventable.
 Hence, epidemiology plays a central role in disease prevention
by identifying those modifiable causes.

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 Prevention…

• Disease, Illness and sickness

– Disease – not at ease - is a physiological dysfunction
– Illness – is a subjective state of a person who feels
aware of not being well
– Sickness – a state of social dysfunction i.e. a role the
individual assumes when ill.

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 Levels of prevention

There are three levels of prevention

1) Primary prevention
2) Secondary prevention
3) Tertiary prevention

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 Levels of prevention…

1. Primary prevention – keeps the disease process from becoming

established by eliminating causes of disease or increasing resistance to disease..

– It may focus on the whole population with the aim of reducing the average
risk of the population (the population strategy) or
– it may focus on those at higher risk (the high risk individual strategy)

• The 3 objectives of primary prevention are to:

– promote health
– prevent exposure and
– prevent disease
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 Levels of prevention…
 Health promotion-includes non specific interventions that
enhance health and the body’s ability to resist disease.
Examples: Improvement of socioeconomic status, Provision of
adequate food, Housing, clothing, and education
 Prevention of Exposure-is the avoidance of factors which may
cause disease. Examples: provision of safe and adequate water,
proper excreta disposal, vector control, safe environment at home,
at school, work area etc.
 Prevention of Diseases- is the prevention of disease development
after the individual has become exposed to the disease causing
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factors. Example: Immunization-Active, passive.
 Levels of Prevention …
2. Secondary prevention: involves early detection and prompt
treatment of disease as early as possible
The objective of secondary prevention is to stop or slow the
progression of disease so as to prevent or limit permanent
damage.
It can be achieved through detecting people who already have
the disease as early as possible and treat them.
It is carried out before the person is permanently damaged.
Example:
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 Levels of disease prevention…
3. Tertiary prevention – targeted towards people with chronic
diseases & disabilities that cannot be cured
– It is used because primary and secondary preventions have
failed and are not effective for some diseases
– It is a form of rehabilitation which is the retraining of the
remaining functions for maximal effectiveness
– The objectives are to limit the physical, psychological, social
and financial impact of disability, there by improving the
quality of life
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 Levels of disease prevention…
• Rehabilitation is the process of restoring a person’s social identity by
repossession of his/her normal roles and functions in society.
• It involves the restoration and maintenance of a patient’s physical,
psychological, social, emotional, and vocational abilities.
• Interventions are directed towards the consequences of disease and injury.

• The provision of high quality rehabilitation services in a community should

include the following:
– Conducting a full assessment of people with disabilities and suitable support systems;
– Establishing a clear care plan;
– Providing measures and services to deliver the care plan.

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 Table 1. Levels of prevention in relation to the
stage of the disease.
Levels of Natural history of Stages of disease Target
prevention diseases
Primary Healthy person Specific causal factors exist Total population,
selected groups,
healthy
individuals

Secondary Biological/sub-clinical pre- Early stage of disease A/symptomatic

symptomatic stage patients
Clinical stage

Tertiary Late stage of disease Patients

Permanent damage,
disability, Death

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 Levels of Disease Occurrence

Diseases occur in a community at different levels at a particular

point in time. Some diseases are usually present in a community at
a certain predictable level, this is called the expected level, but at
times disease may occur in excess of what is expected.

1. Expected levels
a) Endemic: a persistent level of low to moderate occurrence

b) Hyper-endemic: a persistently high level of occurrence

c) Sporadic: occasional cases occurring at irregular intervals

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 Expected Vs Excess Cases
Number of
cases

Epidemic/Outbreak

Hyper-endemic

Endemic

Time

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 Levels of Disease Occurrence …
2. Excess of what is expected
a) Epidemic: occurrence of disease in excess of what is
expected in a limited period.
b) Outbreak: same as epidemic, often used by public
health officials because it is less provocative to the public.

c) Cluster: is a mini-epidemic of a rare event in which

occurrence of the disease is clearly in excess of that
expected.
c) Pandemic: an epidemic spread over several countries or
continents, affecting a large number of people.

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THANK YOU
VERY MUCH

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