Wolaita Sodo University

College of Health Sciences and Medicine

school of public health

Communicable disease control

BY: Shimelash Bitew

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 Course outline for CDC
Program Bachelor of science in Public Health
Module category Core
Module name Public Health Intervention
Module Code PubHM2081
Module Credit 13 ECTS

Course: Communicable Course code: ECTS: 3

diseases Control PubH2082

Mode of delivery Block

Instructor’s Name:Shimelash B. email

information
address: sbitew0@gmail.com
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Course objectives
 At the end of the course students will be able to
 Define infectious diseases and differentiate them
 Summarize methods of disease transmission and apply
principles of infection control.
 Describe the epidemiology and scope of communicable
diseases in Ethiopia,
 Identify infection prevention and control strategies to limit
the secondary spread of infections
 Describe pharmacological interventions for preventing,
treating, and controlling infectious diseases
 Identify the preventive and control principles of each
communicable diseases.
 Participate in teaching subordinates and significant others
on managing patients with communicable diseases.

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Table of contents
1. Introduction
2. Oro fecal transmitted disease
3. Air born disease
4. Vector born disease
5. Sexually transmitted disease
6. Zoonotic disease
7. Other diseases(Leprosy, meningitis, scabies,
NTD, and food poison)

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Academic policies of class
 Attendance: If you are going to miss more than 25% of
the classes, you should not take the final evaluation of
this course.
 Assignments: No late assignment will be accepted.
 Tests/Quizzes: you will have short quizzes and tests.
If you miss the class or, are late to class, you will miss
the quiz or test. No makeup tests or quizzes will be
given.
 Cheating: you must do your own work and not copy
and get answers from someone else. Also, please do not
chew gum, eat, listen to recorders or CD players, or talk
about personal problems.
 Please be sure to turn off pagers and cell phones
before class and exam sessions.
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 Assessment Arrangement
No Assessment methods Marks in % Assessment time

1 Group assignment 1 15
2 Quiz 1 10 Determined by
lecturer
4 Attendance, class participation 5

6 Mid exam 30

7 Final 40 Monday 10:00

  Total 100%  

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References
 Dr Sofonias Getachew , 2006, CDC lecture note for health
officer
 Epidemiology lecture notes for health sciences
 Internal medicine lecture notes
 Abrham S. Benenson,1995, control of communicable
diseases manual, 16th edition, an official report of the
American public Health Association, The united Book press,
Inc, Baltimore.
 Davidson's, 1999, principles and practice of medicine, 18th
edition, Harcourt, Edinburg, London.
 Harrison's, 1998, principles of internal medicine, 18th edition,
McGraw - Hill companies, U.S.A
 Madeleine Fletcher, 1992, principles and practice of
Epidemiology, Addis Ababa     University, Ethiopia.

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Chapter one- Introduction
 Learning objectives
 Define communicable disease.
 Define epidemiology and epidemiological
terminologies.
 Describe the burden of communicable
diseases in Ethiopia.
 Describe the factors involved in the chain
of communicable disease transmission.
 Identify the different levels of disease
prevention.
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Introduction…
 Brain storming
 What is Health?
 What is disease?
 What are the major classification of disease?

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Introduction….
Health:
 Traditionally, health is equated with survival, absence of disease.
However, health is more than the absence of disease.
 WHO (1948): A state of complete social, physical and mental
wellbeing and not merely the absence of disease or infirmity.
 NB. Words disease, illness and sickness should not be used
interchangeably or regarded as synonyms. 
 Disease: Is a physiological / psychological dysfunction, which is
diagnosed by physician or any medical expert.
 Illness: is a subjective state of the person who feels aware of not
being well.
 Sickness: is state of social dysfunction, i.e., a role that the
individual assumes when sick. 10
Introduction…
 Disease broadly classified as
 Non communicable disease
Eg, hypertension, diabetes mellitus, cancer
 Communicable disease
Eg, malaria, TB, HIV

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Introduction –definition
Communicable disease - are illnesses due to specific
infectious agents or its toxic products, which arise
through transmission of that agent, or its toxic
products from an infected person, animal or inanimate
reservoir to a susceptible host, either directly or
indirectly, through an intermediate plant or animal
host, vector or inanimate environment.
Infectious agent- identifies the specific agent or
agents causing the disease; classifies the
agent(s); and may indicate its (or their) important
characteristics.

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Terminologies
 Epidemics- the occurrence of any health related condition in a given
population in excess of the usual frequency in that population.
 Endemic- a disease that is usually present in a population or in an
area at a more or less stable level.
 Sporadic- a disease that does not occur in that population, except at
occasional and irregular intervals.
 Pandemic- an epidemic disease which occurs world- wide
 Disease - a state of physiological or psychological dysfunction.
 Infection - the entry and development or multiplication of an
infectious agent in the body of man or animal
 Contamination – presence of living infectious agent upon articles
 Infestation – presence of living infectious agent on the exterior
surface of the body
 Infectious- caused by microbes and can be transmitted to other
persons.
 Infectious agent- an agent capable of causing infection
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Introduction….
 Burden of disease in Ethiopia
 In Ethiopia about 60-80% are due to nutritional
problems and communicable disease
Some important indicators of health in Ethiopia in2005
EC.
 Potential health service coverage in 2006- 100.00%
 EPI- fully immunized 77.7%
 Under five mortality 88 per 1000 live births
 Infant mortality 59 per 1000 live births
 maternal mortality ratio 676 per 100,000 live births

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Introduction..
 In 2005 53.3 % from all were communicable
Ra Top 10 morbidity in 2005 Case %
nk Diagnosis
1 Acute upper respiratory infections 2,128,657 7.5%

2 Malaria (confirmed with P. falciparum) 2,116,047 7.4%

3 Acute Febrile Illness (AFI) 2,084,211 7.3%

4 Pneumonia 1,776,470 6%

5 Diarrhea (non-bloody) 1,598,188 5.6%

6 Malaria (confirmed with species other than 1,215,552 4.3%
P. falciparum)
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Introduction
Ra Top 10 mortality cause in Ethiopia cases %
nk in 2005 diagnosis
1 Pneumonia 1,410 7.5%
2 AIDS 1,112 5.9%
3 Tuberculosis all forms 813 4.3%
4 Cerebro-vascular accident (stroke) 790 4.2%
5 Trauma (injury, fracture etc.) 706 3.7%
6 Malaria (confirmed with P. falciparum) 644 3.4%
7 HIV disease 616 3.3%
8 Neonatal sepsis 613 3.2%
9 Other or unspecified diseases of the 563 3.0%
circulatory system
10 Glaucoma 515 2.7%
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Introduction …
Generally communicable disease in
Ethiopia
 Are commonest cause of morbidity and
mortality
 Are relatively easy to prevent and
control
 Are epidemic prone
 Put most of the population at risk

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Introduction…
 Special feature of communicable disease
 A case may be a risk factor
 Each disease has its own incubation period
 People may be immune
 An individual may be a source without being
recognized as a case
 There is sometimes need of urgency
 preventive measures have good scientific
background

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Classification of communicable disease

1. Based on clinical manifestation

 Diarrhea disease Eg: AWD, amoeba,
 Febrile disease Eg: malaria
 Respiratory disease Eg: common cold,
 Central nervous system infection Eg:
meningitis
 Cardiovascular infection Eg: mayocarditis
 Urinary tract infection Eg: UTI,
pylonephritis

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Classification of communicable disease

2. Based on time course

 Acute infection: abrupt onset, short duration (<2
weeks), rapid progressive
 Chronic infection: >2 weeks , slow progressive
3. Based on taxonomy of infectious agent
 Metazoan- helminthiasis
 Protozoal- malaria
 Bacterial – TB, meningitis
 Fungal-candidiasis
 Viral – HIV, polio

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Classification of communicable disease

4. Based on mode of transmission

 Oro fecal disease – typhoid fever
 Air born disease- TB
 Vector born disease – malaria
 Zoonotic disease- rabies
 Direct contact – HIV,

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Course of infection over time
 Natural history of disease-is the course of
disease over time without/unaffected by
treatment or intervention
 They have four phases
1. Stage of susceptibility- period of exposure
2. Stage of subclinical disease(pre symptomatic
stage)
3. Stage of clinical disease
4. Stage of disability or death or cure
NB: recovery will be at any stage in the course of
infection
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 Course of infection over time
 It begins with an exposure of a susceptible
host to a causative agent.
 Each disease has its own natural history
Recovery is possible

Pathological Onset of Symptoms Usual time of Diagnosis

Changes
Exposure

Stage of Stage of Stage of Clinical Stage of outcome: Time

Susceptibility Subclinical Disease Disease Disease or
(Pre-symptomatic disease) (Symptomatic Stage)| Recovery or
Death
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Course of infection over time
Helps in understanding the intervention measures that could
be undertaken in order to prevent or control the disease
Four main stages are identifiable in the course of a disease:
1.  Stage of Susceptibility
 Disease has not yet developed but risk factors are present
Eg; unvaccinated child is susceptible to measles.
2. Stage of Pre-symptomatic Disease (Sub-clinical stage)
 The disease process has already begun but not manifested
i.e. no signs and symptoms of disease are detectable
 The disease can only be detected through special tests.

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Course of infection over time
Example
 Detection of antibodies against HIV in an apparently healthy
person
 Ova of intestinal parasite in the stool of apparently healthy
children
3. The Clinical Stage
 Signs and symptoms of the disease are manifested in this
stage
 The severity of the disease is variable depending on the
interaction of certain factors like nutritional status,
immunity of individuals and virulence of the disease
causing agent
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Course of infection over time
 Clinical stage of different diseases differs in duration,
severity, disability and death.
4. Stage of Outcome
 In this stage the clinical disease results in one of the
following: Recovery, Disability(disability, impairment,
handicap), Death
 Impairment: symptoms at organ level ,e.g. broken leg
 Disability: objective alteration of behavior or
performance at individual level e.g. can’t work
 Handicap: changed interaction with others at social or
environmental level. e.g cannot work.

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Causal concepts of disease
 A cause of a disease or injury is an event, condition,
characteristic or a combination of these factors which
plays an important role in producing the health outcome.
  Logically, a cause must precede an outcome
 Almost no one cause acts alone , different factors act
 The causes of disease can be classified in to two:
1. Sufficient- If the disease always results from the factor or
set of factors , Eg: rabies
2. Necessary - If disease does not develop without the factor
being present, Eg; TB- tubercle bacillus
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Course of infectious disease over time
 Different periods are encountered in the course of
development infectious disease. Those periods are
described below:
1. Prepatent Period: is the time interval between infection and
the point at which the infection can first be detected
 Measured by the first shedding of the infectious agent by
the host.
 Sometimes infection cannot be detected when the agent is
first shed, only later when antibodies to the agent appear, as
in HIV

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Course of infectious disease over time
2.Incubation Period: the time interval between
infection and the first clinical manifestation of disease
 It is the time between biological and clinical onset
 Useful to identify the source of infection and the
infectious agent especially in the investigation of
epidemics

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Course of infectious disease over time
3. Prodromal period: -The time interval between
the onset of symptoms of an infectious disease and
the appearance of characteristic manifestations.

E.g. In measles from the onset of fever and coryza

to the development of characteristic signs like kop
lick spots and characteristic skin lesions

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Course of infectious disease over time
4. Communicable Period: the period during which an
infected host can transmit the infection to others
 Measured by the length of the time in which the
agent is shed by the host
 Degree of transmissibility does not remain constant
throughout the period of communicability, as the
amount of infectious agent that is shed by the
infected host is variable at different points time

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Course of infectious disease over time
5. Generation time: is the period between the onset of
infection in a host and the maximal communicability
of that host
Maximal communicability may be during or after
the incubation period.
6. Latent Period: the time interval between recovery
and the occurrence of a relapse or recrudescence of
infectious disease

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 Fig 2. Time course of a disease in relation to
its clinical expression and communicability

Clinical case
Symptomatic
Incubatory Convalescent
transmission transmission
Clinical

Co
Threshold

nv
a
l es
er

ce
r ri
Chronic

nt
Asymptomatic carrier
ca

Asymptomatic carrier

ca
ry

rri
ato

er
ub
c
In

TIME
Time of infection Agent starts 1 manifestation of
st
Recovery Agent stops Relapse
(biological onset) being shed disease (clinical onset) being shed

Latent period
Incubation period

Prepatent Communication period

period 33

Generation
INFECTIOUS DISEASE PROCESS
(CHAIN OF DISEASE TRANSMISSION)

It is the linkage of factors involved in the

transmission of communicable disease in the form of
chain of successive events.

It is a continuous process.

Conventionally divided into six components for the
purpose of understanding and to learn where to act in
order to halt disease transmission.

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CHAIN OF DISEASE TRANSMISSION
 The chain of disease of transmission involves
six components:
1. Infectious Agent
2. Reservoir
3. Portal of exit
4. Mode of transmission
5. Route of entry
6. Susceptible host
 Understanding those links helps to develop
appropriate prevention and control methods.

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CHAIN OF DISEASE TRANSMISSION
1. Infectious Agent:
It is an organism capable of causing infection such as bacteria,
viruses, protozoa, helmets etc.
Development of infectious disease is dependent on the host –
parasite interactions.
Characteristics of the agent that affect the course of infectious
disease
 Infectivity: is the ability of the agent to produce infection in an
exposed host.

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CHAIN OF DISEASE TRANSMISSION
 Pathogenicity: the ability of an agent to produce a
clinically manifest disease in susceptible host.

 Virulence: the ability of an agent to produce severe

disease.

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CHAIN OF DISEASE TRANSMISSION
 Immunogenicity: refers to the ability of the agent to
induce immune response & thus an immune state in the
host.
 Toxigenecity: refers to the capacity of the agent to produce
a toxin, or poison.
 Resistance: refers to the ability of the agent to survive
adverse environmental conditions during transmission.
 The effect of characteristics of an agent depends on several
factors like: strain of agent, dose of agent, route of infection,
host factors, environmental condition (favorable or unfavorable
to the agent).
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CHAIN OF DISEASE TRANSMISSION
2. Reservoir is :Living or non-living thing
 In which an infectious agent normally lives and multiplies
i.e. on which it depends primarily for survival.
 Where it reproduces itself in such a way that it can be
transmitted to a susceptible host
 Types: Man, animals and non-living things
 Human being as Reservoir 
The human being serves as a sole reservoir of infectious
agents for certain diseases, like measles, typhoid fever,
gonorrhea

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 CHAIN OF DISEASE TRANSMISSION
The human being acts as a reservoir of infection by acting in two
ways:
 As active case of a disease - having signs and symptoms of a
disease
 As carrier of the infectious agent - does not have signs and
symptoms of the disease
Types of carriers:
 Incubatory/Precocious – excrete infectious agent before onset
of signs and symptoms or during incubation period, i.e. from first
shedding of the agent until the clinical onset E.g. – measles,
hepatitis…
 Convalescent – continue to excrete the infectious agent after
recovery E.g. – Typhoid, HBV infection 40
CHAIN OF DISEASE TRANSMISSION
 Healthy/asymptomatic –transmitting the disease without
ever showing manifestations of the disease. E.g., polio,
 Chronic carriers – transmitting the disease for a long
period/indefinite transmission. E.g., viral hepatitis, typhoid
fever
Importance of carriers in transmission:
 May serve as significant source of infection E.g. – HIV/AIDS,
Meningitis, Poliomyelitis
 Act as hidden source of infection hence not easy to take preventive
measures.
 Greater potential to move from place to place as they are not
debilitated.
 Can be chronic carriers and repeatedly introduce the disease.
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CHAIN OF DISEASE TRANSMISSION
 Animals as Reservoirs: for zoonotic diseases
 Some of the common infectious diseases where animals serve
as primary reservoir of infection include:
 Bovine tuberculosis – raw milk of Cattle,
 Tania saginita - raw meat
 Anthrax - Cattle
 Rabies - Dogs
 Non-Living Things as Reservoirs 
 Non-living things, which serve as reservoirs of infection,
include soil for Clostridium tetani and Tania solium, food
for Salmonella typhi, water for V. cholera, etc.
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CHAIN OF DISEASE TRANSMISSION
3. Portal of Exit: The site on the reservoir of infection through
which the infectious agent escapes from the reservoir. It
include all body secretions of infections and discharges; mucus,
saliva, tears, breast milk, vaginal and cervical secretions,
excretions (feaces and urine), blood, and tissues.
Example  
 Gastrointestinal Tract (GIT) e.g. Typhoid fever, amoebiasis
etc.
 Respiratory Tract e.g. Tuberculosis, common cold
 Skin and Mucous membrane e.g. STDs, Scabies

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CHAIN OF DISEASE TRANSMISSION
4. Mode of transmission
The mechanism by which an infectious agent is transferred
from a reservoir of infection to a new host
a. Direct transmission
Refers to the immediate transfer of infectious agents from an
infected host or reservoir to an appropriate portal of entry on
the susceptible host.
Direct contact: contact of the skin, mucosa, or conjunctiva
with infectious agents directly transferred from another
reservoir. It can occur through Touching breaks in skin
,Biting ,Kissing especially deep ,Passage through the birth
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canal and During sexual intercourse
CHAIN OF DISEASE TRANSMISSION
Direct projection: refers to projection of droplets of saliva
created by expiratory activities of coughing, sneezing, spitting,
talking, and singing.  
Trans placental: refers to transmission of an infectious agent
from mother to her fetus in through the placenta
b. Indirect transmission:
This takes the following forms.  
Airborne transmission - transmission to a suitable portal of
entry, usually the respiratory tract, through particles, dust, and
droplet nuclei.
Droplet nuclei are dried residues of droplets of respiratory 45
secretions emitted from infected host
CHAIN OF DISEASE TRANSMISSION
Vehicle Borne Transmission – transmission via a vehicle.
A vehicle is any non-living substance or object by which an
infectious agent can be transported and introduced into a host
through a suitable portal of entry  
Vehicles include food, milk, water, soil, fomites or contaminated
objects such as towels, clothes, bedding, and handkerchiefs, cooking
and eating utensils, toys, syringes and needles, surgical instruments
and dressings;
biological products obtained from one person for medical use
another person, like blood and its products for transfusion, tissues
and organs for transplants, semen used in artificial insemination
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CHAIN OF DISEASE TRANSMISSION
Vector-Borne Transmission - the infectious agent is carried
from the reservoir of infection to the susceptible host by a
vector
 A vector is an organism, which transports an infectious agent
to a susceptible host or to a suitable vehicle
Vector may be
Biological vector – if the agent multiplies in the vector
before transmission
e.g. mosquito vector for malaria
Mechanical vector – if the agent is carried by the leg or
proboscis, e.g. common house fly. 47
CHAIN OF DISEASE TRANSMISSION
5. Portal of entry
The site on the susceptible host through which
an infectious agent gets into the susceptible host
It usually parallels with portal of exit.
It can be:  
 Gastrointestinal tract e.g. typhoid fever
 Respiratory tract e.g. tuberculosis
 Skin and mucus membrane e.g. STD, scabies

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CHAIN OF DISEASE TRANSMISSION
6. Susceptible host
A host who is highly likely to acquire infection when
exposed to the infectious agent
Can be seen at:
Individual level:
The degree of acquiring infection depends on the following
factors, which in general are referred to as host factors:
 Immunity status
 Nutritional status
 Age, Gender, Race
 Hygienic practices
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Levels of Disease prevention
Definition of terms: 
 Prevention: Actions aimed at eradicating, eliminating, or
minimizing the impact of disease and disability.
 Control: Applied to many communicable and some non-
communicable conditions. It is an ongoing operations or
programs aimed at reducing incidence and/or prevalence
Or it is a mix of operations or programs aimed at
reducing the health problem of a defined population.

50
Levels of Disease prevention
Eradication: is termination of all transmission of infection
by extinction 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.
Elimination: is sometimes used to describe eradication of a
disease from a large geographic region. Disease which is
amenable to elimination in the meantime is polio, measles and
diphtheria.
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Levels of Disease prevention
Disease prevention is important for implementing
interventions that prevents occurrence of disease.
 It involves the interruption or slowing of disease progression
through appropriate intervention.
Levels of prevention is related with natural history of a
disease
There are three levels disease prevention and control.

52
Levels of Disease prevention
There are three levels disease prevention and control.
1. Primary Prevention
Aimed at preventing healthy people from becoming sick
Main objectives include:
 Promoting health
 Preventing exposure
 Preventing disease
Keeps the disease process from being established by
eliminating causes of disease or increasing resistance to disease

53
Levels of Disease prevention
A. Health promotion
 General non-specific interventions that enhance health and the body’s
ability to resist disease
 Examples
 Improvement of socio-economic status
 Provision of adequate food, housing, clothing
 Education
B. Prevention of exposure
 Avoidance of factors which may cause disease if an individual is
exposed to them
Example
 Provision of safe and adequate water
 Environmental modification like Vector control
 Proper waste disposal
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Levels of Disease prevention
C. Prevention of disease
 The prevention of disease development after the individual
has become exposed to the disease causing factors.
 Between exposure and biological onset
Example- Immunization
 2. Secondary prevention
 Involves detecting people who already have the
disease as early as possible and treat them
 Carried out after the biological onset of the disease,
but before permanent damage sets in.
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Levels of Disease prevention
 Objective
 To stop or slow the progression of disease and to prevent or
limit permanent damage
Example
 Prevention of blindness from trachoma
 Early detection and treatment of breast cancer to prevent its
progression to the invasive stage
With secondary prevention it is possible to
 Cure or slow its progression
 Prevent complication
 Limit disabilities
 Reverse communicability, of infectious disease
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Levels of Disease prevention
 3. Tertiary prevention
Targeted towards people with chronic diseases and
disabilities that cannot be cured
Needed in some diseases because primary and
secondary prevention have failed, and in others
primary and secondary prevention are not effective.

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Levels of Disease prevention
Objectives
 Treatment to prevent further disability or death and
 To limit the physical, psychological, social and financial
impact of disability, thereby improving the quality of life.
This can be done through rehabilitation, which is the
retraining of the remaining functions for maximal
effectiveness.
Example
 Physiotherapy to an affected limb to restore motion and
prevent contraction

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Summary of introduction
 What is communicable disease?
 Chain of infectious disease?
 Natural history of disease
 Time course of infection
 Level of prevention

59