Summary of study module

(EC08)
Module: EPM301 Epidemiology of Communicable Diseases
Course: PG Diploma/ MSc Epidemiology

This document contains a copy of the study material located within the computer
assisted learning (CAL) session. The first three columns designate which page,
card and screen position the text refers to.
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contact DLsupport via DLsupport@lshtm.ac.uk.
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module CDROM. When studying this session, please ensure you work through
the CDROM material first. This document can then be used for revision purposes
to refer back to specific sessions.
These study materials have been prepared by the London School of Hygiene & Tropical Medicine as part of
the PG Diploma/MSc Epidemiology distance learning course. This material is not licensed either for resale
or further copying.
London School of Hygiene & Tropical Medicine September 2013 v1.0

Section 1: EC08 Summary of study module

Aim

To review the topics covered in this unit.

Objectives
By the end of this session, you should be able to:

Summarise the topics in this unit

Recall the basic concepts of infectious disease epidemiology

This session should take you between 30 and 45 minutes to complete.

Section 2: Introduction
During this study module, you have been introduced to some of the unique
characteristics of infectious disease epidemiology.
While many of the basic epidemiological skills you have been learning apply equally
to infectious and non-infectious disease epidemiology, there are specific issues that
need to be considered when dealing with infectious diseases.
The ability of an infectious agent to be transmitted between individuals, and the
characteristic of acquired immunity, require special methods of measurement and
analysis.
In this session you will review the topics covered during the unit. You will be directed
to references in your reader that combine some of these topics, to consider the
issues more comprehensively.

Section 3: Characteristics of infectious diseases

In session EC01 you were introduced to some of the characteristics of infectious
diseases that influence their epidemiology.
You learned that epidemiologists approach the quantification of microparasites and
macroparasites differently. While prevalence of infection is used to measure the
burden of infection in a population, intensity of infection can also be used to
distinguish between the relative burden among individuals of macroparasites and
some protozoan microparasites.
The variety of patterns of infection showed how infectious agents can differ in their
persistence within a host, and how this might relate to the burden of disease they
impose on their host. Some infections are acute, others are chronic, and others are
latent, being able to relapse and cause disease after years of no apparent infection.

Section 4: Transmissibility

Infections can be transmitted in different ways, either directly or indirectly. The

mode of transmission defines the effective contact necessary between a susceptible
and infectious individual. This in turn influences the duration of infectiousness.
Many infections can be transmitted in more than one way - better ensuring their
persistence in different settings.
The mode of transmission determines who gets infected and when and where the
infection occurs. These epidemiological characteristics were described in session
EC02, as indicators that a disease has an infectious cause.
In addition, determining the people, places and times at greatest risk of disease,
can help to identify the cause of the disease and the mode of transmission. This
information can also be used to target control measures appropriately to those at
greatest risk of disease and at times of greatest need.

4.1: Transmissibility
The ability of infectious agents to be transmitted between individuals results in an
exponential increase of cases within a relatively short time period in a susceptible
population.
If one person transmits to 3 others, and each of these transmits to three others,
and so on (see diagram opposite), the number of cases can rapidly escalate.

4.2: Transmissibility
As you saw in session EC03, by quantifying the transmissibility of an infection,
epidemiologists are able to identify the potential scale of the problem.
The measurement of transmissibility, using the attack rate measure in different
age, social or behavioural groups, can be used to identify the individuals at
greatest risk of infection.
This can also identify the relative effectiveness of different modes of transmission,
and may help to determine appropriate public health interventions.
The secondary attack rate measure is generally used for infections that are
transmitted to household or other close contacts (e.g. tuberculosis) where the
contacts constitute an easily identifiable group of individuals that can be
investigated.
By contrast, the basic reproduction number is used to measure transmissibility
at a population level. This is difficult to measure directly, but can be inferred from
seroprevalence surveys or the average age at first infection for a disease that
confers life-long immunity.

4.3: Transmissibility
The transmissibility of infectious agents implicates them as an important cause of
disease increasingly so as the world's population grows, travels and congregates
in urban centres.
In a susceptible population, this characteristic can lead to outbreaks of infection in
which the disease burden is focused rather than being distributed throughout a
population over time. The detection, investigation and control of outbreaks are a
major focus of public health activities, increasingly so in countries where more and
more diseases are being brought under control.
In session EC04 you learned about the tools used to define an outbreak, to identify
the cause and routes of transmission, and to control the spread of infection.
This involves establishing the existence of the outbreak, collecting data and
describing the epidemiological characteristics of the disease. Subsequently,
hypotheses about the mode and source of transmission need to be tested, after
which an appropriate intervention must be recommended.
In the simulated outbreak investigation (session EC05), the exercise tried to
capture the urgency of problem. The transmissibility of infectious agents
dictates that the most important aspect of an outbreak investigation is rapid action.

4.4: Transmissibility
For outbreaks and endemic infections, blocking the transmission of infections is the
main target of public health activities. By studying the characteristics of the

infectious agent (EC01 & EC02) and its transmissibility (EC03), we can better
inform public health activities.
The dynamic spread of an infection through a population (completely or partially
susceptible) can help to identify whether or not an infection will be a problem in a
particular setting.
In session EC06 you were introduced to the methods of mathematical modelling of
infectious diseases. These allow quantification of the rate at which an infection will
be transmitted through a population, and can be used to indicate whether the
infection will die out, persist endemically, persist with regular epidemic peaks, etc.
Such methods can be used, with caution, to predict the future course of an
epidemic or the likely outcome of introducing a particular intervention.

Section 5: Immunity
Infectious agents may induce an immune response from the host in an attempt to
control the infection and reduce any harmful effects. The initial response is nonspecific, followed by a specific response involving the production of antibodies.
Some infectious agents are able to evade the immune response and can co-exist
with the host (as in the case of many macroparasites), or kill the host (as in the
case of HIV).
When an effective immune response has been produced, the presence of specific
antibodies or the body's ability to produce these antibodies can be used as an
immunological marker in epidemiological studies.
This is known as seroepidemiology, and the immunological markers are used to
indicate previous infection or in some cases protection from subsequent infection.

5.1: Immunity
The body's ability to defend itself from attack has been exploited by scientists in
the development of vaccines. Vaccines induce a specific immune response that
protects (partially or completely) against subsequent infection and/or disease due
to a specific infectious agent.
This is one of the most important approaches to the control of infectious diseases, as
it protects individuals and, if used on a large-scale, can benefit whole populations.
Interaction: Tabs: Vaccine efficacy:
However, vaccines are rarely completely protective to all individuals. The concept of
measuring the efficacy and effectiveness of a vaccine was discussed in session
EC07.
You saw that there are different methods of assessing vaccine efficacy, related to
study design. The relative benefits of these designs can vary according to the
mechanism of protection of the vaccine.

Interaction: Tabs: Herd immunity:

The public health benefit of a vaccine will vary according to the amount of the
population covered and according to the vaccine efficacy because of the concept of
herd immunity.
The idea that an individual can be protected from infection because of the immunity
of the surrounding individuals is the driving force in the use of immunisation to
eliminate infections locally or to eradicate infections globally.

Section 6: Summary
This is the end of EC08. When you are happy with the material covered here please
move on to session EC09.
The main points of this session will appear below as you click on the relevant title.
In this unit we have focused on the study and measurement of characteristics of
infectious diseases. Such epidemiological studies are used to identify appropriate
methods of control and to assess the benefit of various interventions.
You should now have the basic tools necessary to identify pertinent questions in
infectious disease epidemiology and appropriate methodologies to answer such
questions.
To integrate some of the issues that have been raised in this unit, read the following
papers in your reader:
Interaction: Tabs: Guyer/McBean:
In the paper by Guyer and McBean (1981), the authors review the epidemiology and
control of measles in Cameroon during and after the introduction of mass
immunisation.
Consider the epidemiological characteristics (age and time patterns) of the disease
before and after the introduction of vaccination. Both surveillance data and
serological studies were used to assess the epidemiology of the disease.
Note that the age profile of the disease shifted towards the older age groups after
the introduction of vaccination.
Interaction: Tabs: Mossong/Muller:
Mossong and Muller (2000) have used a measles outbreak to estimate the local
vaccine efficacy and the transmissibility of the infection, drawing together concepts
from sessions EC03 C07. The paper includes some mathematics but do not worry
if you don't understand the formulae.
Note that mathematical modelling is used to estimate the vaccination coverage
necessary to minimise outbreaks in these partially vaccinated populations. However
the estimates are locally specific, and might not have a wider application due to
differences in vaccine coverage and vaccine efficacy.

Interaction: Tabs: Prevots et al:

The paper by Prevots et al. (1997) describes an investigation of a polio outbreak in
Albania.
Think about the epidemiological characteristics of poliovirus see
http://www.cdc.gov/polio/ for more information on this. Look at the age-profile of
the disease.
Review the methods used to investigate the outbreak. Pay close attention to the
identification of different risk groups and the estimation of separate attack rates for
these different groups.
Consider how, even for a highly efficacious vaccine, effectiveness can be reduced by
logistic limitations.
The epidemiology of infectious diseases requires a different approach to that for
non-infectious diseases. Try to consider what you have learned about this when
reading studies and reports about infectious diseases, and be aware of the
complexities of this topic.
This is a very dynamic subject, with new discoveries being made all the time, and
new methodologies being developed everyday; especially in the fields of
immunology, molecular biology, genomics and bioinformatics. Apart from the
development of new vaccines, these new tools may help to improve our study and
understanding of the epidemiology of infectious diseases and methods to control
them.
This unit has aimed to introduce you to some of the main concepts of the
epidemiology of infectious diseases.
We hope that you continue to read about this subject and learn more about the
subtleties of the different diseases.