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INFECTIOUS DISEASE
CONTROL
Riris Andono Ahmad

Infectios diseases and history

Mummy in ancient Egypt (3500 SM) with TB.

Lepra was known in India and Cina 1400 SM
Black death during medieval Europe
Flu pandemy in 18 – 20 century
HIV pandemy 90’
Re emerging Malaria and TB

SARS
Avian flu
Anthrax
Ebola
Bioterorisme?

present Future?
past

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Leading cause of death in High income countries

Leading cause of death in middle income countries

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Leading cause of death Globally

Agent
Host

Environment

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Perjalanan alamiah penyakit

Waktu

Gejala klinis
Mati

Infeksi

Pejamu rentan

Sembuh

Tanpa infeksi

Cacat

Kronis/carrier

Periode inkubasi

Laten
Infeksius
Non-infeksius

Paparan
Onset

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Perjalanan alamiah penyakit

•  Periode laten
Interval waktu antara terjadinya infeksi sampai saat
penyakit menjadi infeksius
•  Periode infeksius
Periode saat seseorang bisa menginfeksi individu
rentan lainnya
•  Periode non infeksius
Periode setelah orang sakit tidak mampu menularkan
penyakit
•  Periode inkubasi
Interval waktu sejak infeksi hingga munculnya gejala
klinis penyakit

Perjalanan alamiah penyakit

•  Cacar air
•  Agen virus varicella-zoster
•  Periode laten lebih pendek daripada periode inkubasi, anak
dengan cacar air menjadi infeksius sebelum timbul gejala
•  Pertanyaan: ketika terjadi KLB, tindakan pencegahan apa yang
terbaik?

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Perjalanan alamiah penyakit

Waktu

Mati

Infeksi
Gejala klinis

Pejamu rentan
Sembuh

Tanpa infeksi
Cacat

Kronis/carrier

Periode inkubasi

Laten
Infeksius
Non-infeksius

Paparan
Onset

PAP Malaria
TIME

Gejala klinis
Mati

Infeksi

Pejamu rentan

Sembuh

Tanpa infeksi

Cacat?

Kronis

Periode inkubasi

Laten
Infeksius

Paparan
Onset

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Reproductive Number, R0
A measure of the potential for transmission



The basic reproductive number, R0, the mean number of individuals directly
infected by an infectious case through the total infectious period, when
introduced to a susceptible population



probability of transmission per contact




R0 = p • c • d
duration of infectiousness

contacts per unit time

Infection will ….. disappear, if

R < 1



become endemic, if
R = 1



become epidemic, if
R > 1

(www)

Basic reproduction number

R0! = 3!

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Reproductive Number, R0
Use in STI Control

R0 = p • c • d

p
condoms, acyclovir, zidovudine

c
health education, negotiating skills

D
case ascertainment (screening,


partner notification), treatment,


compliance, health seeking
behaviour,
accessibility of services

(www)

What determines R0 ?
p, transmission probability per exposure – depends on the infection

v  HIV, p(hand shake)=0, p(transfusion)=1, p(sex)=0.001

v  interventions often aim at reducing p

v  use gloves, screene blood, condoms

c, number of contacts per time unit – relevant contact depends on infection

v  same room, within sneezing distance, skin contact,

v  interventions often aim at reducing c

v  Isolation, sexual abstinence

d, duration of infectious period

v  may be reduced by medical interventions (TB, but not salmonella)

(www)

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Endemic - Epidemic - Pandemic

R > 1

Cases

R = 1

R < 1

Time

v Endemic
v Transmission occur, but the number of cases remains
constant
v Epidemic
v The number of cases increases
v Pandemic
v When epidemics occur at several continents – global
epidemic

(www)

Immunity and R0

(www)

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Immunity – herd immunity

v If R0 is the mean number of secondary cases in a susceptible population, then
R is the mean number of secondary cases in a population where a proportion, p,
are immune
R = R0 – (p • R0)

v What proportion needs to be immune to prevent epidemics?

If R0 is 2, then R < 1 if the proportion of immune, p, is > 0.50
If R0 is 4, then R < 1 if the proportion of immune, p, is > 0.75

v If the mean number of secondary cases should be < 1, then

R0 – (p • R0) < 1
p > (R0 – 1)/ R0 = 1 – 1/ R0

v  If R0 =15, how large will p need to be to avoid an epidemic?

p > 1-1/15 = 0.94

v The higher R0, the higher proportion of immune required for herd immunity

Herd immunity
•  a type of immunity that occurs when the
vaccination of a portion of the population (or herd)
provides protection to unvaccinated individuals."
•  If a large percent of the population is immune, the
entire population is likely to be protected, not just
those who are immune.

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Populations are heterogeneous ...

Why do we have to think about

heterogeneity?

Measles outbreak (almost 3000 cases) despite coverage of 96%

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Host heterogeneity
•  Disease independent (can be measured also for non-
infected individuals):
•  Age, sex, other demographic variables
•  Behaviour (e.g. number of contacts, compliance with vaccination)
•  Disease dependent (only for infected individuals):
•  Transmission route
•  Disease stage; primary versus secondary infection
•  Clininal symptoms or asymptomatic

Pathogen heterogeneity
•  Heterogeneity between strains:
•  Virulence (defined as host mortality or severity of disease)
•  Vulnarability to host immune response
•  Competition via cross-immunity
•  Within host heterogeneity:
•  Immunogenic variability (HIV)
•  Different location within host leads to different effects (invasive
infection versus carrier)

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Predicted Change in Risk of Malaria Transmission

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450 ft.

~2•F warming

1970-1990

Diaz & Graham, Science: 19967

Communicable  disease  control  

Morbidity control Infection control Transmission control

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Intervention methods
•  Immunizations
•  Case management
•  Environmental & hygiene
•  Vector control
•  Behaviour change
•  Regulatory measures
•  Socio-economic development

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