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Epidemiology of Infectious

M. Tevfik DORAK
Infectious Disease Epidemiology:
Major Differences

• A case can also be an exposure

• Subclinical infections influence epidemiology
• Contact patterns play major role
• Immunity
• There is sometimes a need for urgency

What is infectious disease

• Epidemiology Infectious disease

• Deals with one epidemiology
 Two or more populations
• Risk ➨ case
 A case is a risk factor
• Identifies causes
 The cause often known

What is infectious disease

Two or more populations

Infectious agents
Helminths, bacteria, fungi, protozoa, viruses, prions
Mosquito (protozoa-malaria), snails (helminths-schistosomiasis)
Blackfly (microfilaria-onchocerciasis) – bacteria?
Dogs and sheep/goats – Echinococcus
Mice and ticks – Borrelia

What is infectious disease

A case is a risk factor …

Infection in one person can be
transmitted to others

What is infectious disease

The cause often known

 An infectious agent is a necessary cause

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
 Identification of new interventions

Concepts Specific to Infectious Disease

Attack rate, immunity, vector,

transmission, carrier, subclinical
disease, serial interval, index case,
source, exposure, reservoir,
incubation period, colonization,
generations, susceptible, non-specific
immunity, clone, resistance, repeat
episodes …
Infectious Disease

 Infectious diseases
TetanusMeasles 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

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

Routes of transmission
Direct Indirect
 Skin-skin  Food-borne
 Herpes type 1  Salmonella
 Mucous-mucous  Water-borne
 STI  Hepatitis A
 Across placenta  Vector-borne
 toxoplasmosis  Malaria
 Through breast milk  Air-borne
 HIV  Chickenpox
 Sneeze-cough  Ting-borne
 Influenza  Scarlatina

 A relevant contact – depends on the agent
Skin, sexual intercourse, water contact, etc

Some Pathogens that Cross the Placenta
Modes of Disease Transmission
Exposure to Infectious Agents

No infection Clinical Sub-clinical Carrier

Death Carrier Immunity No immunity


Timeline for Infection

Dynamics of Latent Infectious Non-infectious
infectiousness period period


Dynamics of Incubation Symptomatic Non-diseased

disease period period


 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

Susceptible P


Person-to-Person Transmission

Data from Dr. Simpson’s studies in England (1952)

Measles Chickenpox Rubella
Children exposed 251 238 218
Children ill 201 172 82

attack rate 0.80 0.72 0.38

Attack rate = ill


Epidemiologic Triad

Disease is the result of

forces within a
dynamic system
agent ofof:
Factors Influencing Disease

Agent Environment
• Weather
• Infectivity
• Housing
• Pathogenicity
• Geography
• Virulence
• Occupational setting
• Immunogenicity
• Air quality
• Antigenic stability
• Food
• Survival

• Age
• Sex
• Genotype
• Behaviour
• Nutritional status
• Health status
Epidemiologic Triad-Related Concepts

Infectivity (ability to infect)

(number infected / number susceptible) x 100

Pathogenicity (ability to cause disease)

(number with clinical disease / number infected) x 100

Virulence (ability to cause death)

(number of deaths / number with disease) x 100

All are dependent on host factors

Predisposition to Infections
(Host Factors)

Climate and Weather
Nutrition, Stress, Sleep
Stomach Acidity
Chain of Infection

Horton & Parker: Informed Infection Control Practice (www)

Infection Cycle of Schistosomiasis

Peters: Tropical Medicine and Parasitology, 2001 (www)

Infection Cycle of Leishmaniasis

Lipoldova & Demand, 2006 (www)

Iceberg Concept of Infection
Infectious Agents

Protoctists / Protozoa
Phylogenetic Classification of Bacteria

Oxford Textbook of Medicine

Phylogenetic Classification of Viruses

Oxford Textbook of Medicine


Mabbott & MacPherson, Nat Rev Microbiol 2006 (www)


A host that carries a pathogen

without injury to itself and serves
as a source of infection for other
host organisms
(asymptomatic infective carriers)


Other Vertebrates

Birds & Bats


NOT vectors

A host that carries a pathogen without

injury to itself and spreads the
pathogen to susceptible organisms

(asymptomatic carriers of pathogens)


Other parasites have life cycles that involve

intermediate organisms, or vectors, which carry
disease-causing microorganisms from one host to
another. The protozoan blood parasite that causes
sleeping sickness, or trypanosomiasis, infects humans,
cattle, and other animals. It uses the tsetse fly as a
vector to carry it from one host to the next. When a
tsetse fly bites an infected animal, it picks up the
parasite when it sucks blood. When an infected fly bites
another animal, the parasite enters the bloodstream and
begins to reproduce in the new host.
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

Koch’s Postulates

The same organism is present in every case

It is isolated or grown in pure culture
The disease can be reproduced in healthy
animals after infection with pure culture
The identical pathogen is reisolated from the
experimental animals
Koch’s Postulates
Ecological Factors in Infections

Altered environment
{Air conditioning}

Changes in food production & handling

{intensive husbandry with antibiotic protection; deep-
freeze; fast food industry}

Climate changes
{Global warming}

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 (www)
Infectious Disease Process

Direct tissue invasion

Persistent or latent infection
Altered susceptibility to drugs
Immune suppression
Immune activation (cytokine storm)
Mathematical Modelling
in Infectious Disease
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

duration of infectiousness
R0 = p • c • d
contacts per unit time

Infection will ….. disappear, if R<1

become endemic, if R=1
become epidemic, if R>1
Reproductive Number, R0

• Useful summary statistic

• Definition: the average number of
secondary cases a typical infectious
individual will cause in a completely
susceptible population
• Measure of the intrinsic potential for an
infectious agent to spread

Reproductive Number, R0

• If R0 < 1 then infection cannot invade a population

– implications: infection control mechanisms
unnecessary (therefore not cost-effective)

• If R0 > 1 then (on average) the pathogen will invade

that population
– implications: control measure necessary to
prevent (delay) an epidemic
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

What determines R0 ?
p, transmission probability per exposure – depends on the infection
 HIV, p(hand shake)=0, p(transfusion)=1, p(sex)=0.001
 interventions often aim at reducing p
 use gloves, screene blood, condoms

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

 same room, within sneezing distance, skin contact,
 interventions often aim at reducing c
 Isolation, sexual abstinence

d, duration of infectious period

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

Immunity – herd immunity
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)

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

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

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

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

p > 1-1/15 = 0.94

The higher R0, the higher proportion of immune required for herd immunity
Endemic - Epidemic - Pandemic


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

Endemic vs Epidemic
Number of Cases of a Disease

Endemic Epidemic

Levels of Disease Occurrence

Sporadic level: occasional cases occurring at

irregular intervals
Endemic level: persistent occurrence with a low to
moderate level
Hyperendemic level: persistently high level of
Epidemic or outbreak: occurrence clearly in
excess of the expected level for a given time period
Pandemic: epidemic spread over several countries
or continents, affecting a large number of people