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Epidemiology of Infectious

Diseases
M. Tevfik DORAK
http://www.dorak.info
(www)
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

(www)
What is infectious disease
epidemiology?

• Epidemiology Infectious disease


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

(www)
What is infectious disease
epidemiology?

Two or more populations


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

(www)
What is infectious disease
epidemiology?

A case is a risk factor …


Infection in one person can be
transmitted to others

(www)
What is infectious disease
epidemiology?

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
infections
 Identification of new interventions

(www)
Concepts Specific to Infectious Disease
Epidemiology

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

Definitions
 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

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

(www)
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

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

(www)
(www)
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

Outcome

(www)
Timeline for Infection

Infection
Dynamics of Latent Infectious Non-infectious
infectiousness period period

Susceptible
Time
Infection

Dynamics of Incubation Symptomatic Non-diseased


disease period period

Susceptible
Time

(www)
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 P
S
Immune
S
T
Sub-clinical

Clinical

(www)
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


exposed

(www)
Epidemiologic Triad

Disease is the result of


forces within a
dynamic system
consisting
agent ofof:
infection
host
environment
Factors Influencing Disease
Transmission

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

• Age
• Sex
• Genotype
Host
• Behaviour
• Nutritional status
• Health status
(www)
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)

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

Bacteria
Viruses
Fungi
Protoctists / Protozoa
Helminths
Phylogenetic Classification of Bacteria

Oxford Textbook of Medicine


Phylogenetic Classification of Viruses

Oxford Textbook of Medicine


Prions

Mabbott & MacPherson, Nat Rev Microbiol 2006 (www)


Reservoirs

A host that carries a pathogen


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

Humans
{hepatitis}

Other Vertebrates
{zoonoses}

Birds & Bats


{histoplasmosis}

NOT vectors
Vectors

A host that carries a pathogen without


injury to itself and spreads the
pathogen to susceptible organisms

(asymptomatic carriers of pathogens)


Vectors

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}

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 (www)
Infectious Disease Process

Direct tissue invasion


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

(www)
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

(www)
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)

(www)
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
(www)
Endemic - Epidemic - Pandemic
R>1
Cases

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

(www)
Endemic vs Epidemic
Number of Cases of a Disease

Endemic Epidemic

Time
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
occurrence
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

(www)
http://www.dorak.info