EPIDEMIOLOGY OF

COMMUNICABLE DISEASES
 Communicable diseases
• A communicable disease is a disease due to a specific infectious
(biological) agent or its toxic products capable of being directly or
indirectly transmitted from man to man, from animal to man, from
animal to animal, or from the environment (through air, water, food, etc..)
to man.
 • Is a disease which is not infectious. Such
diseases may result from genetic, life style
or other factors other than a pathogen.
Non-
communicable • Most non-communicable diseases are
chronic diseases. Such as:-
disease: • Cardiovascular diseases
• Cancers
• Diabetes
• Chronic lung diseases
 Terminology and Definitions
• Infection
• Contamination
• Contagious disease
• Nosocomial infection
• Opportunistic infection
• Zoonosis
• Endemic
• Sporadic
• Pandemic
Infection:
• It is the entry, development and multiplication of an
infectious agent in the body of man or animal.
• Outcome of infection varies.
Infectious disease:
• A clinically manifest disease of man or animal resulting
from infection.

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 • The presence of an
infectious agent on a body
surface, on or in clothes,
contamination toys, surgical instruments ,
or other articles or
substances including water
and food
 • A contagious disease is the one
that is transmitted through
Contagious contact or close proximity.
disease
• Examples include scabies,
trachoma, STD and leprosy.
 • Nosocomial (hospital acquired)
infection is an infection
originating in a patient while in a
Nosocomial hospital or another health care
infections facility.
• It has to be a new disorder
unrelated to the patient’s
primary condition.
• Examples include infection of
surgical wounds, hepatitis B and
urinary tract infections.
 • This is infection by
organisms that take the
opportunity provided by a
Opportunistic defect in host defense
infection ( immunity) to infect the
host and thus cause disease.

• For example, opportunistic

infections are very common
in AIDS. Organisms include
Herpes simplex,
cytomegalovirus.
 • Zoonosis is an infection that
Zoonosis is transmissible under
natural conditions from
vertebrate animals to man,
e.g. rabies, plague, bovine
tuberculosis.
 • “The unusual occurrence in a
community of disease, specific
Epidemic health related behavior, or other
health related events clearly in
excess of expected occurrence”
 • It refers to the constant presence
of a disease or infectious agent
Endemic within a given geographic area or
population group. It is the usual
or expected frequency of disease
within a population.
Pandemic • An epidemic usually
affecting a large proportion
of the population, occurring
over a wide geographic area
e.g. Influenza pandemics.
 • The word sporadic means “scattered about”.
• The cases occur irregularly, haphazardly from
Sporadic time to time, and generally infrequently.
• The cases are few and separated widely in
time and place that they show no or little
connection with each other, nor a recognizable
common source of infection
• e.g. polio, meningococcal meningitis, tetanus.
 Concept of Disease causation

Epidemiologic Triad
Disease is the result of
forces within a
dynamic system
consisting of:

Agent Host
Agent

Host disease

Environment Environment
 Epidemiologic Lever
(at equilibrium)

HOST AGENT

ENVIRONMENT

Changes in characteristics of Agent, Host or Environment Disease

Changes in characteristics of Agent, Host or
Environment

 Disease In The Host

 Epidemiological triad

Agent
• entity necessary to cause disease in a susceptible host

Examples
– Biological (bacteria, virus, parasites, etc)
– physical (heat, cold, sound, radiation etc))
– chemical (Endogenous e.g. urea, ketones, etc)
(Exogenous e.g. insecticide gases, drugs, etc)
– nutrients (proteins,fats,carbohydrates,vitamines and
minerals. Any excess or deficiency may lead to
disorders)
 Epidemiologic Triad - Agent

Infectious agents factors:-

• Infectivity – ability of the infectious agents to
invade and multiply in a host (produce
infection).
• Pathogenicity – ability to induce clinically
apparent illness( cause disease).
• Virulence – ability to cause sever clinical
manifestation and death)
 Epidemiological triad
•Host
Definition: person that is susceptible to effect of agent

Characteristics
– Demographic characteristics:-
• age
• sex
• ethnicity
• Occupation
social class

– Social and economic characteristics

– Genetic
– Immunity
 environment

Definition : Conditions / external surroundings that

influence interaction between agent & host
Three components:-
– Biological environment
– physical environment
– social environment
 ENVIRONMENT

• Environmental conditions  major influence on health status of individuals in

the population

Famines Pathogen’s ability to

War survive
Poor housing & outside host?
Poor Sanitation
Poverty Transmission from
Floods affects
Host to Host
Earthquakes
Adverse climate
 Factors Influencing Disease Occurrence

•Demographic characteristics
•Biological characteristics
•Socioeconomic characteristics
Host

Agent Environment
•Biological agents •Physical environment
•Physical agents •Biological environment
•Chemical agents •Social environment
•Nutrient agents
DYNAMICS OF DISEASE
TRANSMISSION
(IN INFECTIOUS DISEASES)
Chain of transmission of
Transmission

• Agent (e.g. mico-organism)

• Reservoir of infection
• Portal of Exit
• Suitable mode of transmission
• Portal of entry into susceptible host
• Susceptible host
Chain of transmission of Transmission

Portal of Portal of
Exit Entry

Micro- Transmission
Organism
(Agent)
Reservoir Host
 A Reservoir:
• Any person, animal, arthropod, plant, soil or
Chain of substance (or combination of these) in which

Infection an infectious agent lives and multiplies and

can be transmitted to the susceptible host
(Natural Habitat).
Chain of Infection

• Source and Reservoir may be the

Same:
Example: Tetanus (the soil)
• May be different
Example: hookworm infection( man
and contaminated soil)
 Types of reservoir:

Source and • Human reservoir

Reservoir: • Animal reservoir
• Reservoir in Non-living.
 • Is the most important source or
reservoir of infection.
• Either cases or carriers.

• Cases:
Human Reservoir (a case is a person in the population
identified as having the particular
disease, health disorder or condition
under investigation).
• Cases may be:
1. Clinical cases:- in which there are signs and symptoms of the disease (mild or
severe).
1. Subclinical cases:-
• The disease agents may multiply in the host but does not manifest
itself by signs and symptoms.
• The disease agent is eliminated and contaminates the environment in
the same way as clinical cases.
• Can be detected only by laboratory test.
• Example:- measles.
Cases
 Primary cases– the case that brings the
infection into a population

Index cases – the first case identified

 Secondary cases– infected by a primary case

 Tertiary cases – infected by a secondary case

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 • Carriers

Human Reservoir A carrier is an infected person or animal

that hides a specific infectious agent in
the absence of apparent clinical disease
and serves as a potential source of
infection to others.
• In carrier state the disease agent is not completely eliminated either
due to inadequate treatment or immune response.

• Carriers are less infectious than cases, but they are more dangerous
than cases.
Elements in • Presence of disease agent in the body
carrier state • Absence of recognizable symptoms and
signs of disease.
 Carriers
Carriers may be classified according to:
1. Type
– Incubatory – can transmit the disease during the incubation period
– Convalescent – can transmit the disease during the convalescent period
– Healthy- can transmit the disease while healthy
 2. Duration
– Temporary
– Chronic
3-Portal of exit:-
Carriers • Urinary
• Intestinal
• Respiratory
• others
 Exposure to Infectious Agents

No infection Clinical Sub-clinical Carrier

Death Carrier Immunity No immunity

Outcome

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Chain of Infection
Modes of Transmission

Source or Susceptible
Modes of
Reservoir Host
Transmission
 Modes of transmission

After an agent exits its natural reservoir, it may be transmitted to a susceptible

host in many different ways.

Modes of transmission are classified as:

1-Direct Transmission

2-Indirect Transmission
 Direct Transmission:-
immediate transfer of the
agent from a reservoir to a
susceptible host without an
intermediate agency.
Modes of
transmission Indirect Transmission:-
The agent transfer from a
reservoir to a susceptible
host with an intermediate
agency.
 Direct
Transmission (1)Direct contact
– Droplet infection
– Transplacental
(Vertical)
– Inoculation into the
skin or mucosa
 (1)Direct contact
Transmission occurs through direct contact
Direct from skin-to-skin contact, mucosa to
mucosa or skin to mucosa.
Transmission Examples:-
• STD,AIDS and leprosy
• Hookworm is spread by direct contact
with contaminated soil
 Direct transmission

– Droplet spread
refers to direct projection of a spray of droplets of saliva and naso-
pharyngeal secretions during coughing, sneezing or speaking to the
surrounding atmosphere then to respiratory mucosa or skin of the close
contact.

Droplet spread is classified as direct because transmission is by direct spray

over a few feet, before the droplets fall to the ground.
Example:-
Common cold, whooping cough and meningococcal
meningitis .
 – Transplacental transmission:-
Transmission of infectious agent
vertical from the mother to the
Direct fetus
transmission Example:-
TORCH agents(Toxoplasma gondii,
rubella virus, cytomegalovirus and
herpes virus)
 Direct Transmission

- Contact with soil:-

Example :- Tetanus , hookworm

- Inoculation into skin or mucosa:

Example:-
• Hepatitis B virus through contaminated syringes or needles
 Indirect Transmission

Indirect transmission:-

(1)Air-borne
(2)Vehicle-borne
(3)Vector-borne
• Mechanical
• Biologic
 Indirect Transmission

(1) Air-borne:-
Droplet nuclei:-
• They are tiny, dry residue of droplets
• May remain airborne for long time and
then drawn into the alveoli of the lungs
• Example:-
TB, influenza, chickenpox and measles.
 Indirect Transmission

Dust:-
Droplets which are expelled during sneezing, coughing and talking into the
immediate environment and become part of the dust.
Example:-
Streptococci
 Indirect Transmission

(2) Vehicle-borne:-
Transmission of infectious agent through an inanimate intermediate such as
water, food and blood.
Example:-
Transmitted by water and food: Hepatitis A, Cholera, Polio and Typhoid
fever.
Transmitted by blood: Hepatitis B
 Indirect Transmission

Vector –borne:-
Transmission by animate intermediate .
Most vectors are arthropods such as mosquitoes, fleas, and ticks.
Transmission by vector may be mechanical or biological
 Indirect Transmission

• In mechanical transmission, the agent does not multiply or undergo

physiologic changes in the vector.

• For example:- flies carry Shigella on appendages.

 Indirect Transmission

Biological transmission :-
When the agent passes through a developmental multiplication in the vector, the
vector is serving as both an intermediate host and a mode of transmission.
Example :-
Malaria parasite in the mosquito
Chain of Host:

Infection is a person or animal that affords

subsistence or lodgment to an
infectious agent

Source or Susceptible
Modes of
Reservoir Host
Transmission
Strategies The chain of infection:-
• Agent (e.g. mico-organism)
to break • Reservoir of infection
the chain • Portal of Exit
of • Suitable mode of transmission

infection • Portal of entry into susceptible host

• Susceptible host
 Strategies to break the chain of
infection
Control measures directed to reservoir of infection
1. Active case finding & prompt Rx
2. Detection & Rx of subclinical cases & contacts
3. Detection of carriers & eliminate carrier state e.g.
typhoid
4. Health education (public)
5. Eliminate animal reservoir & vector e.g. rabies
6. Environmental sanitation (proper excreta &
waste disposal, safe water supply, proper
& adequate housing, food quality control,
vector control)
 Strategies to break the chain of
infection
Control measures directed to micro-organisms such as:

• Reduce or destroy microbes (hand washing, disinfection, sterilization)

• Rx cases (antimicrobials)
 Strategies to break the chain of
infection
Control measures directed to reservoir of infection
portal of exit ) such as:

• Cover mouth & nose when coughing

• Use gloves
• Screen blood donors
Strategies • Disrupt direct contact –
gloves, handwashing,
to break disifection
Chain of • Interrupt indirect contact –
proper disposal of
Transmissi contaminated materials
on • Prevent contamination of food
& water
• Eliminate vectors thru public
health measures
• Proper housing; good
ventilation; avoid
overcrowding
• Proper disposal of excreta &
waste
Strategies Control measures
directed to portal of
to break entry such as:
the chain
of infection • Use masks, gloves
• Isolate cases
• Disposable needles
Strategies Control measures directed to
susceptible host such as:
to break
the chain • Vaccinate hi risk gp (e.g. Hepatitis B
of infection vaccination for health workers,
soldiers)
• Screen health care workers
• Health intervention – vector control,
clean & safe water supply
CONTROL • 1. Isolation of cases
• 2. Health education
MEASURE • 3. Environmental Sanitation (+
S TO STOP proper sewage & waste
disposal)
TRANSMIS • 4. Screening of blood donors
SION • 5. Vector Control
• 6. Legislation
• 7. Disease Notification
• 8. Legislation (Local &
International)
• 9. Increase host resistance (e.g.
immunization,
chemoprophylaxis, mechanical
protection etc.)
 Natural History of Disease

Natural History of Disease:

The way in which a disease evolves over time from earliest stage of its
prepathogenesis phase to its termination as recovery, disability or
death, in absence of treatment or prevention.
 The Natural History of Disease
Event that take place in the natural history of
disease(infectious disease):-

1- prepathogenesis phase:- Stage of susceptibility

– before onset of disease

- Risk Factors: factors which are associated with increased

probability of developing the disease
- Such as: age, sex, race, occupation, family history, social
economic status, education
 The Natural History of Disease

2- Pathogenesis phase:-
Begins with the entry of the disease agent in the susceptible human
host.
 Natural History of Disease

Death

Subclinical Clinical
Good health
changes disease

Recovery

•Peptic ulcer disease •Cholera

•Myocardial infarction •Dengue fever
 The Natural History of Disease
Exposure Onset of Symptoms & Signs

Incubation Period

Pathologic Time of Diagnosis

Changes

Susceptibility Subclinical Disease Clinical Disease Recovery,

Disability
or Death
 • Incubation period:
• The time from exposure to
development of disease.

Incubation • In other words, the time

periods interval between invasion by
an infectious agent and the
appearance of the first sign
or symptom of the disease
Iceberg Phenomena
 ICEBERG PHENOMENA

VARIATION OF SEVERITY OF A DISEASE PROBLEM

DEAD
VISIBLE
“TIP OF THE ICEBERG”
SEVERE CASES
CASES (CLINICAL ILLNESS)

INVISIBLE CASES
(ASYMPTOMATIC INFECTION) INVISIBLE

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Iceberg Concept of Infection
HOST RESPONSE

Fatal

Clinical and Clinical

severe disease Disease

Moderate severity
Mild Illness

Infection without
clinical illness
Subclinical
Disease

Exposure
without infection
 The pyramid and iceberg of disease

1 Diseased, diagnosed & controlled

Diagnosed
disease
2 Diagnosed, uncontrolled

3 Undiagnosed or wrongly
diagnosed disease
Undiagnosed or
wrongly diagnosed disease

4 Risk factors for disease

5 Free of risk factors

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 ‘Iceberg’ disease concept

• Study ONLY symptomatic cases or individuals – may produce a misleading picture

of a disease

Public Health Implications of Iceberg Phenomena:-

• Difficult to control disease transmission in community

• Inaccurate data for public health programs
 • EXAMPLES:
ICEBERG • Hepatitis B carriers
PHENOMENA • Cholera carriers
• HIV/AIDS
Thank You