Yanet-Liyana college of Health sciences

Infectious Disease Epidemiology

Tsegaye A(PhD)
October, 2021
Hawassa
1
 Learning objectives
At the end of the session, the student we will able to:
• Describe the theory of disease causation
• Describe Infectious disease concept
• Explain the Concept of Natural disease history
• Describe the concept of epidemiologic triangle
• Mention the Disease causation models
• List the Component of chain of infection
• Describe the Principle of infectious disease control
 Theory of disease causation
1. Hippocrates theory
Environmental factors have effect on personal
wellbeing
2. Supernatural theory
• Stated that all disease causing by supernatural
forces
• i.e. either the cause of God or due to evil forces of
demons
• Disease prevention was based on religious
practice
 Cont……
3. The Miasma theory
• Attributed disease to bad odor or air
• This model had been used to explain epidemics of disease like
cholera, malaria
4. Contagion theory
Assumes that all disease are contagious(communicable) in nature
Isolation of people, avoiding contact with cases were the main
preventive measure
5. The epidemiological triad theory
• This theory states that causation of disease is
the function of environment, causative agent
and host factor

• Still an important model for infectious disease

6.Multi-causal theory
• The most recent model of disease causation
• Has different variants including the causal pie and
web-causal theory
• Web-causal theory states that disease are caused
by function of different factors like scio-cultural,
political, environment etc
• What is communicable disease?

• How do it transmit in human?

 Communicable disease
• A communicable (or infectious) disease is one
caused by transmission of a specific pathogenic
agent to a susceptible host.
Infectious agents may be transmitted to humans
either:
• directly, from other infected humans or animals,
or
• indirectly, through vectors, airborne particles or
vehicles.
 Communicable disease cont….
• Vectors: are insects or other animals that carry the
infectious agent from person to person.
• Vehicles: are contaminated objects or elements of the
environment (such as clothes, water, milk, food, blood,,
parenteral solutions or surgical instruments).
• Contagious diseases: are those that can be spread
(contagious literally means “by touch”) between humans
without an intervening vector or vehicle
 Natural History of Disease
• Natural history of disease refers to the progression of a
disease process in an individual over time, in the
absence of treatment.

• The process begins with exposure to the causative

agent capable of causing disease.

• Without medical intervention, the process ends with

recovery, disability, or death.
Figure 1: Natural History of Disease Timeline

Usual time
of diagnosis

NB. Knowing the natural history of disease is important

for prevention of disease.
 Stage of natural history
• Stage at w/c the host start to be exposed
1. Stage of
• For infectious disease the exposure is usually a
susceptibility micro-organisum.

• The stage of pre-symptomatic disease

2.Stage of sub- • Pathogenic change started to occur but the disease is
clinical yet to manifest

• Sign and symptoms of the disease have become

3.Stage of apparent
Clinical disease

4.Stage of Recovery, disability and death

Disease may have progressed to the point of causing a
residual effect
 Why do you think that scientfic process of
studying natural history of disease is difficult?
1. The scientific objectives of observing the natural
history of a disease is not ethically acceptable

2. Long term follow up studies might be needed to

clearly describe the natural history of chronic disease
 Spectrum of infectious disease
• If a huge number of individuals are equally exposed to an
infectious agent; they do not all respond in the same
manner:
 Some do not become infected all
 Some infected but develop no or mild or moderate
symptoms
 Some become infected and developed severe symptoms
 Some die as result of their infection( see figure 3)
 The spectrum of illness for communicable
disease

Inapparent Mild
infection disease Sever Death

No sign or
Clinical illness sign and
symptom
symptom
What is epidemiological triad?
 Epidemiological triangle
• The epidemiologic triad or triangle, the traditional
model for infectious disease.
• The triad consists of an external agent, a susceptible
host, and an environment that brings the host and
agent together.
• Disease causation based on the complex interaction
between the agent and the susceptible host in an
environment that supports transmission of the agent
from a source to that host
Figure2: Epidemiologic triangle and triad (balance beam)
Table 1: Examples of causes of disease by host, agent
and environmental factors

Host factors Agent factors Environmental factors

Age Virulence of organisms Home overcrowding

sex Serotype of organisms Air pollution

Previous disability Antibiotic resistance Workplace hygiene

Behaviour Weather

Genetic inheritance Water composition

Height Food contamination

Weight
 Epidemiological triad cont…
• Agent: originally referred to an infectious
microorganism or pathogen: a virus, bacterium,
parasite, or other microbe.
• Generally, the agent must be present for disease to
occur; however, presence of that agent alone is not
always sufficient to cause disease.
• A variety of factors influence whether exposure to an
organism will result in disease
 Characteristics of Infectious Disease Agents
• Infectivity: refers to the capacity of the agent to enter and
multiply in a susceptible host and thus produce infection
or disease(Infection Rate).
• Pathogenicity: refers to the capacity of the agent to cause
overt disease in the infected host( ability to produce the
signs & symptoms of a disease (Clinical to sub-clinical
ratio)
 The ratio of the number of individuals with clinically
apparent disease to the number exposed to an infection.
 Cont…..
• Virulence : refers to an agent’s capacity to induce
disease in the host( i.e. the ability to produce sever
clinical disease)
 If the disease is fatal, virulence can be measured by
the case fatality rate (CFR).

Toxigenicity: refers to the capacity of the agent to

produce a toxin or poison.

Eg. botulism and shellfish poisoning result from

the toxin produced by the microorganism
Figure 3:
Exposure Infection Disease Disease outcome

Infectiousness Pathogenicity Virulence

(Infection rate) (Clinical: Sub-clinical) (CFR; Hospitalization rate)

1) Infectivity= No. of subjects infected X 100

Total No. of subjects exposed
2) Pathogenicity = No. of subjects manifesting the disease X 100
Total No. of subjects infected
3)Case Fatality Rate =
No. of subjects with serious disease(including fatal cases) X 100
Total No. of subjects with cases(disease)

• Hospitalization Rate = No. of hospitalized cases X 100

Total No. of cases 24
• Host :refers to the human who can get the disease.
• A variety of factors intrinsic to the host, sometimes called
risk factors, can influence an individual’s exposure,
susceptibility, or response to a causative agent.
• Opportunities for exposure are often influenced by
behaviors such as sexual practices, hygiene, and other
personal choices as well as by age and sex.
• Susceptibility and response to an agent are influenced by
factors such as genetic composition, nutritional and
immunologic status, anatomic structure, presence of
disease or medications, and psychological makeup.
• Environment: refers to extrinsic factors that affect the
agent and the opportunity for exposure.

 physical factors such as geology and climate, biologic

factors such as insects that transmit the agent,

 Socioeconomic factors such as crowding, sanitation, and

the availability of health services.
 Disease Factor( casual pie)
• A cause of a disease can be defined as a factor that
influences the occurrence of disease.
 Any conditions , directly or indirectly contribute for development
of a specific disease.

Necessary Vs Sufficient Factors

 Necessary F.: the disease will not occur without the

presence of that factor.
 E.g.: Mycobacterium TB for TB

 Sufficient F.: the presence of the factors always result

in disease
Figure 3:Rothman’s Causal Pies

1. From the above component causes:- A, B, C, D, E, F, G, H, I,J,

2. All factors (component causes) together form sufficient cause.
3. Only cause “A” constitutes the necessary cause: since it appears
as a members of each sufficient cause
 Chain of Infection
• Infection implies that the agent has achieved entry and
begun to develop or multiply, whether or not the process
leads to disease.
• The infection process is called the chain of infection
• Each link must be present and in sequential order for an
infection to occur
• There are six components of the infectious disease process
constituting chain of disease transmission
 Components of Chain of Infection
1. Causative Agent

2. Reservoir host

3. Portal of exit

4. Mode of transmission

5. Portal of entry

6. Susceptible host
Figure 4: Chain of Infection
 Reservoir
• The starting point of the occurrence of communicable
disease is the existence of reservoir or source of infection

• The reservoir of an infectious agent is the habitat in

which the agent normally lives, grows, and multiplies.

• Reservoirs include humans, animals, and the

environment.
 Reservoir……

• Human reservoirs may be persons with symptomatic

illness, or carriers.
• A carrier is an infected person without apparent disease
who is nonetheless capable of transmitting the agent to
others
3 elements have to occurs the carriers:
 The presence of the body of disease agent
 The absence of recognizable symptom and sign of
disease
 The shedding of agent in the discharge or excretions
 Type of carriers

• Asymptomatic carriers (transmitting infection without ever

showing signs of the disease).Ex. Hepatitis A, Poliomyelitis
• Incubatory carriers (transmitting infection by shedding the agent
before the onset of clinical manifestations).Eg. Measles, mumps
• Convalescent carriers (transmitting infection after the time of
recovery from the disease).Eg. Typhoid fever
• Chronic carriers :shed the agent for a long period of time, or
even indefinitely. Eg. Hepatitis B virus
• Animal reservoirs. Humans are also subject to diseases that
have animal reservoirs.
• Many of these diseases are transmitted from animal to animal,
with humans as incidental hosts.
• The term zoonosis refers to an infectious disease that is
transmissible under natural conditions from vertebrate animals
to humans.
• Long recognized zoonotic diseases include brucellosis (cows
and pigs), anthrax (sheep), plague (rodents),
trichinellosis/trichinosis (swine),
 Res……..
• Environmental reservoirs. Plants, soil, and water
in the environment are also reservoirs for some
infectious agents.
• Many fungal agents, such as those that cause
histoplasmosis, live and multiply in the soil.
 Portal of exit

• Portal of exit is the path by which a pathogen leaves its host.

• The portal of exit usually corresponds to the site where the pathogen
is localized.

For example,

 influenza viruses and Mycobacterium tuberculosis exit the respiratory

tract,

 schistosomiasis through urine,

 cholera vibrio in feces, skin, alimentary……

 Modes of Transmission of Infectious
Agents
• The mechanism by which an infective agent exists from a reservoir

host and enters into a susceptible host is referred as mode of

transmission. There are two major modes:
Direct Transmission- immediate transfer of the agent from a reservoir to a susceptible
host by direct contact or droplet spread.
Example:
⎯ Touching
⎯ Kissing
⎯ Sexual intercourse
⎯ Blood transfusion
⎯ Trans-placental
 MOT cont…..
• Indirect Transmission- an agent is carried from reservoir
to a susceptible host by suspended air particles or by
animate (vector-mosquitoes, fleas, ticks...) or inanimate
(vehicle-food, water, biologic products, fomites)
intermediaries.
Example:
⎯ Vehicle-born: food, water, towels, ...
⎯ Vector-borne: insect animals, ...
⎯ Airborne: dust, droplets
⎯ Parenteral injections
 Factors which influence the development of
disease
Strain of the agent
Dose of the agent
Route of infection, and…
 Host’s(Age,Nutritional status,Immune status,
Influence of treatment &Influence of season
 Group Exercise
1. Describe chain of cholera transmission?(G1)

2. Describe the identification the character and the chain of infection of

hepatitis A disease, and suggest your prevention and control
mechanisms?(G2)
3. Use the Agent-Host-Environment model to describe the role of the
human immuno deficiencyvirus (HIV) in AIDS(G3).
4. Some of the risk factors for heart disease are smoking, hypertension,
obesity, diabetes, high cholesterol, inactivity, and stress. Are these risk
factors necessary causes, sufficient causes, or component causes?why?(G4)
5. Describe the common infectious disease prevention and control
principles? (G5)

6. What are the health professional role in CD control?(G6)

What is infectious disease epidemiology
Infectious disease epidemiology
Levels of Disease Occurrence

• Diseases occur in a community at different levels

at a particular point in time.

• Some diseases are usually present in a

community at a certain predictable level, this is
called the expected level, but at times disease
may occur in excess of what is expected
1. Expected levels

A. Endemic: a persistent level of low to moderate

occurrence
B. Hyper-endemic: a persistently high level of
occurrence
C. Sporadic: occasional cases occurring at
irregular intervals
Levels of disease occurrence : Expected levels
Excess of what is expected
A. Epidemic: occurrence of disease in excess of
what is expected in a limited period.
B. Outbreak: same as epidemic, often used by
public health officials because it is less
provocative to the public.
C. Pandemic: an epidemic spread over several
countries or continents, affecting a large
number of people.
 Principles of communicable disease control

 3-main methods of controlling ‘Communicable Ds’

1. Elimination of the reservoir

2. Interruption of transmission

3. Protection of the susceptible host

 1. Elimination of the reservoir
• The use of this method depends on the nature of the reservoir.
For e.g.:-

A. Man as a reservoir: this method is not a viable option.

Therefore, related control measures include:
• Detection & Rx. of cases
• Isolation, and
• Quarantine

B. Animal as a reservoir: In here, the use of the method also

depends on the usefulness of the animals.
e.g. for rabies: pet-dogs are protected by vaccine.
Stray/homeless dogs are destroyed
 Methods of controlling communicable disease
cont…….
2. Interruption of transmission:
 Prevent the transmission by controlling the mode of transmission
• Improve environmental sanitation & personal hygiene.
• Control of vectors
• Disinfection & sterilization, use of condom, wearning of face
mask,

3. Protection of susceptible host:

 Protect the new host before infected.
• Active and passive immunization
• Chemoprophylaxis, e.g. for malaria, meningitis etc.
 Quarantine
• Restriction of the activities of well persons or
animals who have been exposed to a case of
communicable disease during its period of
communicability (i.e., contacts) to prevent
disease transmission during the incubation
period if infection should occur.
 Isolation
• Separation, for the period of communicability,
of infected persons or animals from others
under such conditions as to prevent or limit the
transmission of the infectious agent from those
infected to those who are susceptible or who
may spread the agent to others.
 Role of the health professional

 Establish surveillance for unusual diseases and

drug resistant agents
 Assure laboratory capacity to investigate new
agents.
 Develop plans for handling outbreaks of
unknown agents.
 Summary of disease prevent level
Level of Stage of disease Target
Preventio
n
Primordia Existence of underlying condition leading to causation Total
l The aim is to avoid the emergence and establishment of the social, population
economic, and cultural patterns of living that are known to contribute and
to an elevated risk of disease. selected
Example: smoking, environmental groups
pollution

Primary Specific causal factors exist. The causative agent exists but the aim is Total
to prevent the development of disease. population,
Example: immunization, Measles, polio selected

Secondar Early stage of disease . The aim is to cure patients and prevent the Patients
y development of advanced disease. Example: Early detection &
treatment of cases of tuberculosis & STD
Tertiary Late stage of disease(treatment & rehabilitation). Patients
The aim is to prevent severe disability and death. Example: Leprosy
Yanet –Liyana College of Health Sciences address for
remote text book and journal access
ylc.edu.et
Pass word
yanet@2013
• Join telegram page
YLCHS 1st year MPH in HSM/ YLCHS 1st year MPH in
RH
 Response: Role of HIV in AIDS:
Agent

human immunodeficiency virus

Host

• Behavioral factors which increase likelihood of exposure, such as intravenous

drug use, men who have sex with men, etc.

• Biologic factors which determine whether an exposed person becomes infected,

such as presence of genital ulcers

Environment
• biologic factors, such as infected persons to transmit the
infection
• physical factors, such as inconvenient bedside position
and needle design which contribute to needle stick injuries
among health care workers
• socioeconomic and societal factors, such as those that
contribute to drug use
 Response: Risk factor of HD

• Classification of risk factors for heart disease

All are component causes.
 Exercises 2
Match each term with the correct example.

A. endemic B. pandemic C. epidemic

1. Malaria is present in Ethiopia at all times

because of the presence of infected
mosquitoes. Malaria is _____ in Ethiopia.
2. The measles case in SNNPR is an excess
of what is expected for this region. This
infectious disease is a/an ______
3. COVID-19 is one of the worst global
diseases in history. It is a/an _________.
60
4. Write the all chain of infection diseases?

5. What are the prevention and control principle

of infectious disease?
Thank you