LEARNING OBJECTIVES

At the end of the session, the student must be able to:

1. Define
a. infection
b. infectious disease and communicable disease
c. incubation period and communicable period
2. Discuss
a. the variations in the severity of illness (gradient of
infection)
b. the effect of the gradient of infection on the control of
diseases
c. the effect of the gradient of infection in disease
statistics
LEARNING OBJECTIVES:
3. Enumerate and discuss:
a. the intrinsic properties of infectious agents
b. the different host-agent interactions
c. the different pathogenic mechanisms
d. the carrier state and its implications in the
control of diseases
e. the different mechanisms of transmission
f. the basic aspects of person-to-person spread
g. the different community reactions to an agent
GLOBAL BURDEN OF INFECTIOUS
DISEASES (WHO 1999a)
Communicable or infectious diseases
continue to remain a leading cause of
morbidity, disability and morality
worldwide
13.3 million deaths out of a total of 53.9
million deaths (25%) in 1998 were due
to infectious diseases
Most of these deaths occurred in the
economically developing countries,
contributing 1 in 2 deaths
EPIDEMIOLOGY OF
INFECTIOUS DISEASES
Epidemiologic triangle as a model for
disease causation is usually invoked to the
explanation occurrence of infectious
diseases
This session will discuss how agent, host
and environment relate to key topics of
infectious disease epidemiology
Infectious disease are usually categorized
according to mode of transmission,
whether or not they are vaccine-
preventable, etc
DEFINITIONS
INFECTION
- The entry, development or multiplication of an
infectious agent in the body tissues of man or
animals
INFECTIOUS DISEASE
- A clinically manifest disease of man/animal
resulting from an infection
COMMUNICABLE DISEASE
- An illness due to a specific infectious agent OR
its toxic products that arises through
transmission from a reservoir to a susceptible
to a susceptible host either directly or indirectly
 Some communicable diseases may not be infectious BUT
all infectious diseases are communicable.
communicable but not infectious:
-tetanus
- botulism
- staphylococcal food poisoning
INCUBATION PERIOD
- time interval between initial contact with an infectious
agent and the first appearance of symptoms associated
with the infection
COMMUNICABLE PERIOD
- time during an infectious agent may be transferred from
an infected host/reservoir to another susceptible host
GRADIENT OF INFECTION
Ranges from inapparent infection to serve clinical
disease or even death
Inapparent infection
- infection in a host without recognizable clinical
signs or symptoms
- identifiable only by laboratory means
Severe disease
- High rate of severe clinical manifestations
- High case of fatality rate
- High proportion of surviving patients with sequelae
- Serious problem from a public health standpoint
where the disease causes excess mortality
EFFECT OF INAPARENT
INFECTION
On Control of Disease
> Insufficient to direct control procedures
solely to clinically apparent cases
>Control procedures must be directed toward
all infections capable of being transmitted
to others
On Disease Statistics
> the number of infections diagnosed and
reported will be understated
> the severity of the disease will be
overstated
INFECTIOUS DISEASE PROCESS
ETHIOLOGIC
AGENT

Reservoir Portal of exit

Portal of entry Mode of

Transmission

SUSCEPTIBLE
HOST
A. The ENVIRONMENT
- Domain that is external to the host and in
which the agent may exist, survive, or
originate
- Sum total of influences that are not part of
the host and comprises physical,
climatologic, biologic, social and economic
components
- Physical: water, humidity, geologic
formations, etc
- Social: totality of the behavioral,
personality, attitudinal, and cultural
characteristics of a group of people
Role of environmental in
infectious transmission:
- May enhance or diminish the survival of
the agent and may serve to bring agent
and host into contact
- May act as a reservoir that fosters the
survival of infectious disease agent
Reservoir
- Living organism or inanimate matter in which
an infectious agent normally lives and
multiplies on which the agent depends
primarily for survival and reproduces itself in
such manner that it can be transmitted to a
susceptible host
- The reservoir may be:
- Part of the physical environment (e.g.,
contaminated water supply of food for cholera
& typhoid)
- Animals or insects (vector)
- Other human beings
Reservoir
- Zoonoses: infectious diseases that have
vertebrate animal reservoirs and the
potentially transmissible to human under
natural conditions (rabies and plague)
- Main reservoir: cases and carriers
- CARRIER any person or animal that
harbors a particular infectious agent
without discernible clinical disease and
serves as potential source of infection
Humans As Peservoir
Type of carrierExample
Inapparent
Polio, meningitis,
throughout
hepatitis

Incubatory

Chickenpox, measles,

hepatitis
Convalescent

Diphtheria, hep B,

Salmonella, cholera
Chronic
Thypoid fever, hep B
B. THE INFECTIOUS AGENTS
1. THE TYPES OF INFECTIOUS
AGENTS
- Bacteria TB, shigellosis
- Viruses and rickettsia: AIDS, hepatitis
- Fungi: candidiasis, athletes foot
-Protozoans: ameobiasis, giardiasis
- Helminthes: schistosomiasis,
ascariasis
B. THE INFECTIOUS AGENTS
2. INTRINSIC PROPERTIES
- properties of infectious agents
that do not need any interaction with host
- understanding a particular
intrinsic property may be essential to
understanding an agents epidemiology,
including its mode of transmission
- strains or isolates of a particular
agent from different outbreaks, different
geographic areas at different times may
vary significantly in these intrinsic
properties
INTRINSIC PROPERTIES
Useful in classification and specific identification:
Morphology
Chemical composition
Antigenic property

Relate to perpetuation of species:

Visibility
Host range
Growth requirements
Antibiotic resistance
Antigenic variation
3. PROPERTIES RELATING TO
HOST-AGENT INTERACTIONS
a) Infectivity
b) Immunogenicity
c) Pathogenicity
d) Virulence
e) Toxigenecity
f) Resistance

- Affected by envtal conditions, dose, route of

infection as well as age, nutritional status,
race of the host
INFECTIVITY
- Ability of an agent to enter and multiply in a
susceptible host and produce infection
- Basic measure is infective dose
- Can only be inferred via: ease of spread in
population (infectiousness)
- High infectivity: polio and measles
>Measured by:
Secondary attack rate (SAR): proportion of close
contacts who become infected
Serologic surveys after epidemics to determine the
infection rate (IR)
INFECTIVITY Cont.

SAR = # new cases in group initial cases

#susceptible persons in group initial cases

IR = # persons with antibody response

total no. exposed
IMMUNOGENICITY
Infections ability to produce specific
immunity in the host e.g., measles
Immunity the resistance associated with the
presence of antibodies or cells having a
specific action on the microorganism or on
its toxin
Measured by serologic surveys
Depends on:
amount of antigen formed in the host
site of multiplication
Agents ability to induce lifelong immunity
PATHOGENICITY
- Ability to produce illness in an infected population
- Measles has high pathogenecity (few subclinical cases)
- Polio has low pathogenecity (most cases are subclinical
- Measured by the proportion of infection which results in disease
Pathogenicity = # infected persons with disease
total
number infected persons
VIRULENCE
- Extent to which severe disease is produced in a population with
clinically manifest disease
- Rabies is very virulent
- Measured by:
> case fatality ratio (CFR)
>proportion of severe cases
 Toxigenicity
Capacity of the agent to produce a toxin or
poison
Disease results from the toxin produced by
the agent rather than from the agent itself

Resistance
Ability of the agent to survive adverse
environment conditions
Agents of coccidomycoses and hepatitis are
highly resistant
Gonococci and influenza virus are fragile
Disease according to
host-related properties
RELATIVE INFECTIVITY PATHOGENICIT VIRULENCE
DEGREE Y

High Measles Rabies Rabies

Chickenpox Measles TB
Poliomyelitis Chickenpox Leprosy
Smallpox Smallpox Smallpox
Common colds
Intermediate Mumps Rubella Poliomyelitis
Rubella Mumps
Common colds
Low TB Poliomyelitis Measles

Very Low Leprosy (?) Leprosy (?) Chickenpox

Rubella
Common colds
3. PATHOGENIC MECHANISMS
a) Direct tissue invasion (e.g. Salmonella,
Shigella)
b) Production of a toxin (e.g. Staph,Clostridium)
c) Immunologic enhancement or allergic reaction
(e.g., M. Tb)
d) Persistent or talent infection (e.g. Varicella-
zoster)
e) Enhancement of host susceptibility to drugs of
otherwise minimal toxicity (e.g. Varicella,
Influenza B)
f) Immune suppression (e.g. HIV)
C. THE HOST
The host after exposure of the agent may
progress through a chain of events leading
from subclinical (inapparent) infection to a
clinical case
The end result may be complete recovery,
permanent disability, disfigurement of
death
Degree of infection & disease severity
depends on the defense mechanisms
(immunity) of the host
Immunity refers to the resistance of the
host to a disease agent
Non-specific Defense
Mechanisms of the Host
Skin
Mucosal surface
Tears
Saliva
High pH of gastric juice
The immune system ( cellular immunity;
phagocytes & macrophages)
Age, nutritional status, genetic factors
Disease Specific Defense
Mechanisms
- Humoral immunity may :
Natural, active: an infection includes an
immunologic response (host produces antibody
against the agent)
Artificial active: vaccination simulates antibody
production against the agent
Natural, passive: maternal antibodies are acquired
by the fetus transplacentally that confers short-
term immunity to the newborn
Artificial, passive: performed antibodies against a
specific disease are administered to an exposed
individuals as a means of prophylaxis against the
disease
MECHANISMS OF
TRANSMISSION
- Various mechanisms by which agents are
transported from the reservoir to the susceptible host
1. DIRECT
a. immediate and direct contact (person to person)
b. droplet spray
2. INDIRECT
a. vector-borne mechanical or biological
transmission by an athropod
b. vehicle-borne infected blood on used needle,
fomites
c. airborne droplet nuclei, dusts
Portals of exit (and entry)
1. Respiratory tract (e.g. diphtheria,
influenza)
2. Gastrointestinal tract (e.g. typhoid fever)
3. Gastro-urinary tract (e.g. gonorrhea)
4. Skin (e.g. Leptospirosis, hep B)
5. Conjunctiva (e.g. trachoma)
6. Trasplacental (e.g. rubella, hepatitis B,
syphilis)
7. Others made available through insect
bites, drawing of blood, surgical
procedures, accidents
ASPECTS OF PERSON-TO-
PERSON SPREAD
A. Generation Time
Period between receipt of infection by host
and maximal communicability of that host
Roughly equivalent to incubation period
Time of maximal communicability may
precede or follow the end of the incubation
period
e.g. for mumps, the period of
maximum communicability precedes
swelling of salivary gland by 48 hrs
ASPECTS OF PERSON-TO-
PERSON SPREAD
B. Herd Immunity
Immunity of a group or a community
resistance of a group to invasion and spread
of an infectious agent based on the immunity
of a high proportion of individual members of
this group
Important factor underlying the dynamics of
propagated epidemics
COMMUNITY REACTIONS
TO AGENT
- Sum total of the reactions of individuals comprising the group
a. Sporadic
- intermittent presence of a disease
- occurrence of a few cases every now and then often without
relationship to each other
b. Endemic
- constant presence of a disease within a geographical area
- hyperendemic indicates persistent and intense transmission
c. Epidemic
- occurrence in a community of cases of an illness clearly in
excess of normal expectancy
d. Pandemic
- an outbreak of exceptional proportion spreading quickly from
one area to another
-an epidemic of worldwide proportion
Community reactions
depend on:
- Herd immunity
- Exposure or contact rate

- Opportunities for progressive transmission of

agent to new hosts
- Affected by:
I. Size of the reservoir (determines frequency of
contact)
II. Readiness of transmission
Envtal sanitation
Density of vectors
Infectivity of the agents
Density of population
Element of Chance
- The probability of contact between the
susceptible host and source of infection

- Depends on:
I. Site of source
II. Number of cases and their location
relative to susceptibles
III. Number of Immunes
LEARNING OBJECTIVES
1. Differentiate non-communicable from
communicable diseases
2. Explain some important methodological
issues in studying the etiology of NCD
3. Give examples of major categories of
etiologic agents
EPIDEMIOLOGY OF NCD
I. Comparison of communicable and non-
communicable diseases
II. Methodological issues in the study of
non-communicable diseases
III. Major categories of etiologic agents
BURDEN OF NCDs
Rising trends in non-communicable diseases
as a result of demographic and
epidemiological changes, as well as economic
globalization
Increase in life expectancy combined with
changes in lifestyles are leading to epidemics
of non-communicable diseases (NCD), mainly
cardiovascular diseases, cancer and diabetes
In 1998, NCD accounts for 63% of global
deaths
43% of all DALY globally were attributed to
NCD
Non-Communicable Diseases
Includes all traditionally defined NCDs
such as CVD, cancer, chronic
respiratory diseases, mental health as
well as injuries and violence

In all WHO regions (except sub-Saharan

Africa), NCDs today constitute the
largest contributor to burden.
 NCDs accounted for 60% of all deaths in
1999 and 43% of DALYs with injuries
adding 9% of all deaths and 14% of all
DALYs
By 2020, 10 out of the top 15 causes of
DALYs lost will be attributable to NCDs,
mental health and injuries/violence
 The top five positions will be occupied
by Ischemic Heart Disease, depression,
road traffic injuries, cerebrovascular
disease and Chronic Obstructive
Pulmonary Disease (COPD)
15 place: trachea, bronchus and lung
cancers (better known as tobacco
cancers)
GROUP OF NCDs
Cancers
Lifestyle-related (CVD, diabetes)
Injury (unintentional, intentional)
Genetic disorders
Disabling disorders
Occupational disorders
Nutritional disorders
Endocrine disorders
Substance abuse
REASONS FOR THE
PROMINENCE OF NCD
1. Aging of the population
2. Impact of automobiles
3. Lifestyle changes
4. Tobacco addiction
-single larges cause of preventable
morbidity and mortality
5. Physical activity
6.Social and behavioral factors
I. NATURAL HISTORY
A. CHARACTERISTICS OF THE AGENT
-Absence of a single necessary agent

-most NCDs are classified on the basis of

manifestations rather than on etiology
(e.g., CVD, renal disease, neoplasm)

-known causes are risk factors

e.g. obesity, elevated cholesterol levels,
hypertension
B. TIME FRAME
- Take years or decades before illness is
apparent
- No multiplication of causative agent is
involved
- Multiple low-dose exposures ( some
chemicals)
- Some conditions seem to evolve
subsequent to chronic conditions or high
risk stakes such as obesity, smoking,
diabetes and high blood cholesterol
C. NATURE OF THE DISEASE
- Chronic in nature
- chronic disease
(1957 Commission on Chronic Disease)
- Permanent
- leave residual disability
- Caused by nonreversible pathological
alterations
- Requires special training of the patient
for rehabilitation
- Requires long periods of supervision,
observation or care
- Chronicity
Function of the long latency period
Slow disease process adaptive
responses to stress ( may be determined
over the long term)

CD can be chronic (e.g. rheumatic heart

disease)
NCD can be acute (e.g. chemical poisoning)
D. Synergism in Disease Causation

> Asbestos and lung cancer (RR=B)

> Smoking + asbestos and lung cancer (RR=90)

- Presence of synergism decreased latency

(produce illness in the prime of life even with
low lever exposures)
- Role of initiators and promoters
Summary of Differences:
Infectious Disease Non-infectious disease

Single necessary agent No single necessary agent

Agent-disease specificity Seldom agent-disease specificity

Causes are known Causes are unknown

Intervention often based on risk factors
Short incubation period Long Latency period

Single exposure usually sufficient May require multiple exposure to same

or multiple agents
Usually produce acute disease Most often produce chronic disease

Acquired immunity disease Acquired immunity unlikely

Diagnosis based on tests specific to Diagnosis often dependent on non-

disease agent specific symptoms or tests
II. Methodological Issues in the
Study of NCD
A. NATURAL HISTORY
- Lack of a single necessary agent causing the
disease makes it more difficult to isolate the
effect of any individual factor
- Synergistic effects of other agents and effects
of known causes must be controlled
- Long latency period recall problems
- Chronic nature and low frequency of
occurrence prevalent cases studied rather
than incident cases difficult interpretation of
causality
B. CASE IDENTIFICATION
- presence or absence of a cluster of
symptoms
- criteria for diagnosis may vary by institution or
by physician research using medical
records problematic
C. MEASURING EXPOSURE
- quantification is important but problematic
- acuteness or chronicity/high dose or low dose
- Is dose a function of a metabolite, enzymatic
alteration, level of the original agent?
-environmental levels or body levels?
-plasma levels, brain concentration, kidney, or
some other organ tissue?
- Precise quantification identifies levels
hazardous to health important for planning
control measures.
- Demonstration of dose effect helps establish
casual role for the agent
- Constancy or intermittence of the exposure
- Relevant time or period of exposure
B. CONFLICTING FINDINGS AND
CASUALTY
- Publication bias

- Criteria for casualty:

strength of association
temporal correctness
dose-effect relationship
biological plausibility
consistency of findings
specificity of relationships
Problems in investigating
disease etiology
1. Absence of a known agent
- especially a problem for chronic
diseases;

-makes diagnosis difficult

-absence of good tests may take

distinction between diseased and non-
diseased persons very difficult
Problems in investigating
disease etiology (cont)
2. Difficulty of measuring and
characterizing exposure
- quite problematic in environmental
exposures;
-technology to accurately
detect/measure exposures may not be
available.
Problems in investigating
disease etiology (cont)
3. Multi-factorial nature of etiology
- relevant factors may be both
environmental and constitutional
- relevant factors may also interact with
other factors
Problems in investigating
disease etiology (cont)
4. Long latent period
- presence of a long latent period during
which host and environmental factors
interact before the disease becomes
manifest;
- the long latent period makes it difficult
to link antecedent events with the
outcomes
Problems in investigating
disease etiology (cont)
5. Indefinite onset
- most chronic diseases, for example,
are characterized by indefinite onset;
- the problem of identifying the time of
onset of the disease makes collection of
incidence data difficult;
Problems in investigating
disease etiology (cont)
6. Differential effect of factors on
incidence and course of disease
- the nature of the exposure-disease
relationship may be different during the
initial development of the disease and
the later course of the disease (i.e.,
factors may act differently at various
stages of the disease
Problems in investigating
disease etiology (cont)
Example cancer of the breast and SES
incidence of breast cancer is generally higher
among women with high SES than women with
low SES;
Studies from the California Tumor Registry have
shown that, within stage, survival of patients
with breast cancer was better for more
advantaged women ( e.g., those treated in
private rather than country hospitals). Lower
incidence among low SES but better prognosis
among those with high SES.
Major Categories of
Etiological Agents
A. Occupational

A. General environmental

B. Lifestyle and Illness

OCCUPATIONAL
- chemical
- metals and naturally occurring minerals

(graph)
Considerations in investigating
occupational exposures

Agent factors to be considered

- size and shape of particles
- route of exposure
- free or compound form
- organic vs inorganic form
- liquid or vapor form
 Environmental factors
Conditions in the work environment that will
influence the likelihood that workers will come in
contact with an agent
General cleanliness and ventilation
Lighting, temperature

Host factors
- Lifestyle behaviors that may increase the risk of
disease from occupational exposure to an agent
- Genetic consultation
ENVIRONMENTAL FACTORS
Sources of exposure
- contamination of air, water and soil by
industrial activities or inadequate waste
disposal
- lower dose of exposure than in
occupational environments
Pesticides
Housing materials
Automobile exhausts
radiation
 Investigating environmental exposures
- dose
- data on levels of exposure
- mobility of subjects
- confounders

Additional considerations
Wide rage of ages
Length of exposure
Meteorological conditions
Seasonal effects
LIFESTYLE
- poverty, stress, exercise, drug and alcohol
use, nutrition