Infectious Disease

Epidemiology

Outline
1. What is Infectious disease
epidemiology
2. Selected definitions specifically used in
infectious disease epidemiology
3. Dynamics of disease transmission
Source or reservoir
Modes of transmission
Susceptible host

What is infectious disease

epidemiology?
Epidemiology
Deals with one population
Risk case
Identifies causes

Infectious disease epidemiology

Two or more populations
A case is a risk factor
The cause often known

What is infectious disease

epidemiology?
1. Two or more populations
Humans
Infectious agents
Helminths, bacteria, fungi, protozoa, viruses, prions

Vectors
Mosquito (protozoa-malaria), snails (helminths-schistosomiasis)
Blackfly (microfilaria-onchocerciasis)

Animals
Dogs and sheep/goats Echinococcus
Mice and ticks Borrelia

What is infectious disease

epidemiology?
2. A case is a risk factor
Infection in one person can be transmitted to others

What is infectious disease

epidemiology?

3. The cause often known

An infectious agent is a necessary cause

Outline
1. What is Infectious disease
epidemiology
2. Selected definitions specifically used
in infectious disease epidemiology
3. Dynamics of disease transmission
Source or reservoir
Modes of transmission
Susceptible host

INFECTION:
The entry and development or multiplication
of an infectious agent in the body of man or
animals.
Different levels of infection

Colonization: (e.g. S. aureus in skin & nasopharynx

Sub-clinical/ inapparent infection: (e.g. Polio)
Latent infection: (e.g. virus of Herpes Simplex)
Manifest/ clinical infection

CONTAMINATION:
Presence of an infectious agent on a
body surface, or clothes, beddings, toys,
surgical instruments, dressings, or other
inanimate articles or substances including
water, milk, and food.
Pollution implies the presence of
offensive, but not necessarily
infectious matter in the environment.

INFESTATION:
The lodgment, development, and
reproduction of arthropods on the surface
of the body (of human being or animal) or
in the clothing : e.g. lice, itch mite
Also invasion of gut by parasitic worms

HOST:
A person or animal, including birds and
arthropods that affords subsistence or
lodgment to an infectious agent under
natural conditions (opposed to
experimental conditions)
DEFINITIVE HOST: in which parasite attains
maturity or passes its sexual phase
INTERMEDIATE HOST: parasite is in larval or
asexual stage

INFECTIOUS DISEASE:
A clinically manifest disease of man or
animals resulting from an infection

CONTAGIOUS DISEASE:
A disease that is transmitted through
contact. E.g. scabies, trachoma, STD

COMMUNICABLE DISEASE:
An illness due to a specific infectious
agent or its toxic products capable of
being directly or indirectly transmitted from
man to man, animal to animal, or from the
environment (through air, dust, soil, water,
food, etc.) to man or animal

Infectious Disease

Definitions
Infectious diseases

Tetanus

Measles

vCJD

Caused by an infectious agent

Communicable diseases
Transmission directly or indirectly from an infected person

Transmissible diseases
Transmission through unnatural routes from an infected person

Note
Infections are often subclinical infections vs infectious diseases!
Antonyms not well-defined
Non-communicable diseases virus involved in pathogenesis of ca cervix?
Chronic diseases HIV?

EPIDEMIC:
(Epi=upon; Demos=people)
Unusual occurrence in a community or a
region of disease, specific health related
behavior, or other health-related events
clearly in excess of expected
occurrence.
What constitutes significant excess???
OUTBREAK: small or localised epidemic
Modern/ slow epidemics: CHD, cancer

ENDEMIC:
en= in, demos= people
Constant presence of a disease or infectious
agent within a given geographic area or a
population group, without importation from
outside
Refers to usual/expected frequency
Hyperendemic: The disease present in a
constant high incidence/ prevalence rate
Holoendemic: high level of infection beginning
early in life & affecting most of child population
(e.g. malaria)

SPORADIC:
Sporadic =scattered about
The cases occur irregularly, haphazardly
from time to time, & generally infrequently
Cases show little or no connection with
each other
E.g. polio, tetanus, herpes zoster, and
meningococcal meningitis
A sporadic case may start an epidemic

PANDEMIC:
An epidemic usually affecting a large
proportion of the population, occurring
over a wide geographic area such as a
section of a nation, entire nation, a
continent or the world.
E.g. inflenza pandemic 1918 & 1957,
acute haemorrhagic conjunctivitis in 1971
& 1981

Endemic - Epidemic - Pandemic

Cases

R>1

R=1
R<1

Time

Endemic
Transmission occur, but the number of cases remains
constant

Epidemic
The number of cases increases

Pandemic

When epidemics occur at several continents global

epidemic

Number of Cases of a Disease

Endemic vs Epidemic

Endemic
Time

Epidemic

EXOTIC:
Diseases which are imported into a
country in which they do not otherwise
occur, e.g. rabies in UK

ZOONOSIS:
An infection or infectious disease transmissible
under natural conditions from vertebrate animals
to man. Enzootic/ epizootic
E.g. rabies, plague, bovine TB, anthrax,
brucellosis, salmonellosis, endemic typhus,
hydatidosis, etc
EPIZOOTIC: an outbreak of disease in an
animal population
EPORNITHIC: outbreak of disease in bird
population

NOSOCOMIAL INFECTION:
(Hospital acquired) is an infection
originating in a patient while in a hospital/
health care facility. It denotes a new
disorder (unrelated to the patients primary
condition) associated with being in a
hospital
E.g. infection of surgical wounds, hepatitis
B, and UTI

IATROGENIC DISEASE:
(Physician induced) any untoward or adverse
consequence of a preventive, diagnostic, or
therapeutic regimen or procedure, that causes
impairment, handicap, disability or death
resulting from a physicians professional activity
or from the professional activity of other health
professionals
E.g. reaction to penicillin and immunizing
agents, aplastic anaemia following
chloramphenicol use, childhood leukemia
due to prenatal X-ray, hepatitis B following
blood transfusion etc.

OPPORTUNISTIC INFECTION:
Infection by an organism(s) that takes the
opportunity provided by a defect in host
defense to infect the host and hence
cause disease.
The organism normally not pathogenic
E.g. Herpes simplex, CMV, Toxoplasma,
MTB, M avium intracellularae, etc

SURVEILLANCE:
The continuous scrutiny of the factors that
determine the occurrence and distribution
of disease and other conditions of ill health
(to detect changes in trend)

ERADICATION:
Termination of all transmission of infection
by extermination of the infectious agent
through surveillance & containment.
(Small pox, Guinea worm, polio, measles,
diphtheria)

Outline
1. What is Infectious disease
epidemiology
2. Selected definitions specifically used
in infectious disease epidemiology
3. Dynamics of disease transmission
Source / reservoir
Modes of transmission
Susceptible host

Chain of Infection

Horton & Parker: Informed Infection Control Practice

Chain of Transmission

Reservoir
Portal of exit

Person to person
transmission

Susceptible Host

Portal of entry

Agent

Mode of transmission

Dynamics of
infectiousness
Susceptible

Infection

Dynamics of transmission: time line

Latent
period

Infectious
period

Non-infectious

Dynamics of
disease
Susceptible

Infection

Time

Incubation
period

Symptomatic
period

Non-diseased

Time

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
T

S
Susceptible
Immune
Sub-clinical
Clinical

P
S

S
T

1. Reservoir of infection:
any person, animal, arthropod, plant, soil
or substance (or combination of these) in
which an infectious agent lives and
multiplies, on which it depends primarily
for survival and where it reproduces itself
in such manner that it can be transmitted
to a susceptible host

Reservoir
1. Human
Cases (Person with symptomatic illness)
Carriers:
Asymptomatic/ Healthy
Incubating

Temporary vs chronic

Convalescent
2. Animal: zoonosis
3. Environmental (non-living): soil, plant, water

Two types of reservoir

Homologous reservoir: when another
member of the same species is the victim.
E.g. man is the principal reservoir of vibrio
cholerae
Heterologous reservoir: when the
infection is derived from a reservoir other
than man. E.g. birds and animals infected
with salmonella

Source of infection:
person, animal, object or substance
from which an infectious agent passes or
disseminated to the host
Reservoir and source may be different

Examples

in hookworm infection, reservoir is man, but

source of infection is the soil contaminated
with infective larvae
in tetanus, reservoir and the source are the
same, i.e. soil
in typhoid fever, the reservoir of infection may
be a case or carrier, but the source of infection
may be faeces or urine of patients or
contaminated food, milk or water

Infection Cycle of Schistosomiasis

Peters: Tropical Medicine and Parasitology, 2001 (www)

Infection Cycle of Leishmaniasis

Lipoldova & Demand, 2006 (www)

Arthropod Vectors
Pathogen - Vector
Viruses (Arbovirus) - Mosquitoes
Bacteria (Yersinia) - Fleas
Bacteria (Borrelia) - Ticks
Rickettsias (R. prowazeki) - Lice, ticks
Protozoa (Plasmodium) - Mosquitoes
Protozoa (Trypanozoma) -Tsetse flies
Helminths (Onchocerca) - Simulium flies

2. Mode of Transmission
Direct

Direct contact
Droplet spread
Contact with soil
Inoculation into skin
or mucous (through
Secretions, Blood,
Faeces/urine)
Transplacental
(vertical)

Indirect
Vehicle borne (Food/
water)
Vector borne
(mechanical/
biological)
Air borne (Dust/
droplet nuclei)
Fomite-borne
Unclean hands and
fingers

Portal of exit
Human/animal
Respiratory tract
Genito-Urinary tract
G.I. tract: Faeces, Saliva
Skin (exanthema, cuts, needles, blood-sucking
arthropods)
Conjunctival secretions
Placenta
Environmental
Cooling towers

(www)

Portal of Entry
Respiratory tract
Mouth (faecal-oral transmission)
Skin
Mucous membranes
Blood

Factors influencing disease

transmission
Agent

Environment

Host

Factors influencing disease

transmission
Agent

Environment

Infectivity

Weather

Pathogenicity

Housing

Virulence

Geography

Immunogenicity

Occupational setting

Antigenic stability

Air quality

Survival

Food

Age
Sex

Host

Genotype
Behaviour
Nutritional status
Health status

3. Susceptible host
A. susceptible parasitism (4 stages)
Portal of entry
Site of election & multiplication
Portal of exit
Survival in environment

Predisposition to Infections
(Host Factors)

Gender
Genetics
Climate and Weather
Nutrition, Stress, Sleep
Smoking
Stomach Acidity
Hygiene

Susceptible host (contd..)

B. Incubation period: the time interval between
invasion by an infectious agent and appearance of
the first sign or symptom of the disease in question
Latent period: in non-infectious diseases
Importance of IP

Tracing the source

Period of surveillance
Immunization
Identification of point source
Prognosis

Susceptible host (contd..)

C. Serial interval
the gap in time between the onset of the
primary case and the secondary case

Susceptible host (contd..)

D. Generation time
the interval of time between receipt of
infection by a host and maximal infectivity of
that host
Roughly equals to I.P.
Exceptions: Mumps: maxim communicability
48 hrs before swelling of salivary glands
GT refers to transmission of infection whether
clinical or subclinical

Susceptible host (contd..)

E. Communicable period
the time during which an infectious agent
may be transferred directly or indirectly
from an infected person to another
person, from an infected animal to man or
from an infected person to an animal,
including arthropods
Measure of communicability: SAR

Susceptible host (contd..)

F. Secondary attack rate
the number of exposed persons
developing the disease within the range of
the incubation period, following exposure
to the primary case
SAR=
No. of exposed persons developing the disease within the range of IP
total number of exposed/ susceptible contacts

Ecological Factors in Infections

Altered environment
{Air conditioning}

Changes in food production & handling

{intensive husbandry with antibiotic protection; deepfreeze; fast food industry}

Climate changes
{Global warming}

Deforestation
Ownership of (exotic) pets
Air travel & Exotic journeys / Global movements
Increased use of immunosuppressives/ antibiotics
American Museum of Natural History Exhibition:
Epidemic! The World of Infectious Disease

What is infectious disease

epidemiology then used for?
Identification of causes of new, emerging
infections, e.g. HIV, vCJD, SARS
Surveillence of infectious disease
Identification of source of outbreaks
Studies of routes of transmission and
natural history of infections
Identification of new interventions

Types of Screening
Mass:
Screening whole population or subgroups.
Very popular in the past.
Now, they feel it is useless unless followed by
treatment.

High Risk:
More returns can be expected if applied to high risk
groups (based on Epidemiological Studies).
Now, screening for risk factors- as these precede
onset of diseases

Multi phasic:
combination of many tests for many conditions in
large no. of people.
It can be a combination of questionnaire, clinical exam
and investigations.
There is a lot of doubt about the practice and its
benefits.

Test
Results
Positive
Negative
Total

Diagnosis
Diseased

(a) TP
(c) FN
a+c

Total

Not diseased

(b) FP
(d) TN
b+d

a+b
c+d
a + b+c
+d

Sensitivity:
Ability of the test to identify correctly those
who have the disease. a/ a+c x100.
Specificity:
Ability of the test to identify correctly those
who do not have the disease d/b+d x100.
An ideal Screening test should be 100% sens. &
100% speci.

Predictive accuracy:
Predictive value reflects the diagnostic power of a
screening test.
The predictive value of a positive test indicates the
probability that a person with positive result has the
disease in question a/a+b X100.
As the prevalence of disease declines, the PvPT
becomes low.

False Negative:
Means the result is negative in those who

actually have the disease in question c/a+c X100.

False Positive:
Means the result is positive in those who actually

do not have the disease in question b/b+d X100.

Yield:
The amount of previously undiagnosed cases
that are diagnosed as a result of screening
test.
This depends on many factors like sensitivity,
specificity, prevalence & participation.

Screening
Test

Lung cancer
Diseased

Total

Not diseased

results
Positive

a [40]

b [20]

a+b[60]

Negative

c [100]

d [9840]

c+d[9940]

a+c[140]

b+d [ 9860]

a+b+c+d

Total

[10000]

 Sensitivity

= ( 40/ 140) x 100=28.57%

Specificity

= ( 9840 / 9860) x 100=99.79%

Predictive value of a positive test

= [ 40/ 60]x100=66.66%
Predictive value of a negative test
= [ 9840/ 9940]x100=98.9%
Percentage of false negatives
= [ 100 / 140] x100=71.4%
Percentage of false positives
= [ 20 / 9860] x 100 =0.20%