DISEASE AND DISEASE

TRANSMISSION

By Okello Innocent
 Introduction to transmission of disease
• A variety of organisms exist, including some which can survive and
even develop in the body of people or animals.
• If the organism can cause infection, it is an infectious agent.
• Infectious agents which cause infection and illness are called
pathogens.
• Diseases caused by pathogens, or the toxins they produce, are
communicable or infectious diseases.
• To be able to persist or live on, pathogens must be able to leave an
infected host, survive transmission in the environment, enter a
susceptible person or animal, and develop and/or multiply in the
newly infected host.
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• The transmission of pathogens from current to future
host follows a repeating cycle.
• This cycle can be simple, with a direct transmission
from current to future host, or complex, where
transmission occurs through (multiple) intermediate
hosts or vectors.
• This cycle is called the transmission cycle of disease,
or transmission cycle.
The transmission cycle has different elements:

• The pathogen: the organism causing the infection

• The host: the infected person or animal ‘carrying’ the pathogen
• The exit: the method the pathogen uses to leave the body of the host
• Transmission: how the pathogen is transferred from host to susceptible
person or animal, which can include developmental stages in the
environment, in intermediate hosts, or in vectors
• The environment: the environment in which transmission of the pathogen
takes place.
• The entry: the method the pathogen uses to enter the body of the
susceptible person or animal
• The susceptible person or animal: the potential future host who is
receptive to the pathogen
 1. The pathogen
• The pathogen is the organism that causes the infection.
Specific pathogens cause specific infections.
• E.g Cholera is caused by the bacterium Vibrio cholerae, and
Leishmaniasis is caused by different species (spp.) of the
protozoa Leishmania.
• Specific infections also have specific transmission cycles.
• To be able to react appropriately to health problems in a
population, the specific infection causing the problems must
be known. Identification of the infection will usually be done
by medical personnel.
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• Different categories of pathogens can infect humans. These pathogens
include viruses, bacteria, rickettsiae, fungi, protozoa, and helminths
(worms).
• All pathogens go through a lifecycle, which takes the organism from
reproducing adult to reproducing adult.
• This cycle includes phases of growth, consolidation, change of structure,
multiplication/reproduction, spread, and infection of a new host.
• The combination of these phases is called the development of the
pathogen.
• Two terms are commonly used to describe pathogens leaving the host
through faeces or urine: latency and persistence.
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• After excretion, a latent pathogen must develop in the environment
or intermediate host before a susceptible person or animal can be
infected. During the latent period the pathogen is not infectious.
• A non-latent pathogen does not need to go through a
development, and can cause infection directly after being excreted.
• Persistency describes how long a pathogen can survive in the
environment.
• A persistent pathogen remains viable for a long period outside the
host (perhaps months), while a non-persistent pathogen remains
viable for only a limited period (days, or weeks).
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• Active immunity is the resistance the person or animal develops
against the pathogen after overcoming infection or through
immunisation (vaccination).
• Depending on the pathogen, the effectiveness of active immunity
often decreases over time.
• Usually immunity only develops against the specific pathogen that
caused the infection.
• If there are different types (serotypes or strains) of the same
pathogen (e.g. in dengue fever and scrub typhus), immunity will often
only develop against the particular type which caused the infection.
• The person or animal can still develop the illness when infected with
another serotype or strain of the pathogen.
 2.The host:
• The host is the person or animal infected by the pathogen.
• The importance of the host in the transmission cycle is its
roles as both reservoir and source of pathogens.
• There are two types of host: definitive and intermediate
host.
• The definitive host is the person or animal infected with the
adult, or sexual, form of the pathogen.
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• In most infections, people are usually the definitive host.
• The intermediate host is an animal or person infected by
a larval, or asexual, form of the pathogen.
• Cysticercosis and hydatid disease are the only infections
for which people are the intermediate host.
• Only helminths have both definitive and intermediate
hosts.
• All other pathogens only have definitive hosts, although
vectors function technically as intermediate hosts for
protozoa.
 Zoonosis: transmission from animal to person
• Some pathogens are specific to humans, others to animals.
• Many pathogens are less specific and can infect both people and
animals. Infections that can naturally be transmitted from animal
to person are called zoonoses.
• Many of these infections normally occur in an animal cycle, with
people being infected by chance.
• The problem with zoonoses is that a continuous reservoir of
pathogens exists outside humans.
• Even if all human infections were cured and transmission to
people stopped, the presence of an animal reservoir would
remain a continuous risk to people.
 Table. Categories of pathogenic organisms and their characteristics
Pathogen Description Latency Persistence Additional
information
Virus Particles invade living cells. The pathogens are Viruses can survive Where vectorborne,
The pathogen needs non-latent. for months in transmission to
structures in these cells to tropical offspring is possible
reproduce. temperatures. .
The immunity is
often longlasting.

Rickettsiae Organisms resemble n/a n/a Transmission of the

bacteria. pathogen to the
However, similar to viruses, offspring of the
the pathogen needs to vector occurs. The
develop inside the cells of immunity is usually
the host. longlasting.
Bacteria Bacteria are single cell The pathogens are Persists up to The immunity
organisms. They are non-latent. several weeks. developed is often
considered more primitive Can multiply incomplete or
than animal or plant cells. outside the host. short-lived.

Fungi A group of organisms which n/a n/a The duration of the

include yeast, moulds, and immunity is
mushrooms. variable.

Protozoa Protozoa area single cell The pathogens are Forms a The immunity is
organisms. non-latent. resistant cyst which only maintained by
can survive for repeated infections
months. or vaccinations.

Helminths Helminths are worms The pathogen is The pathogen is Usually no immunity
(worms) latent. It often has a persistent and some is built up against
(roundworms, flukes or
complex lifecycle may the pathogen.
tapeworms). Often male and survive for years in
female must meet in host to with a development
in the environment the environment.
reproduce, and sometimes
they multiply in intermediate or intermediate
hosts. hosts.
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• Prevention of zoonoses often includes control of
animal hosts.
• This is possible by reducing the number of hosts (e.g.
controlling rats), immunising domestic animals, or
avoiding unnecessary contact with host animals.
 Carriers: hosts without obvious illness
• A person or animal who develops an illness is an obvious example of a host.
• It is very common, however, for infections to occur without the disease
developing. The person or animal infected can potentially spread the
pathogen, but does not show clear symptoms.
• The symptoms may be mild, or may be completely absent.
• These hosts are called carriers, or asymptomatic carriers.
• The host can be infectious for a short period in transient carriers, or over a
prolonged period in a chronic carrier.
• Incubating carriers have been infected and can spread the pathogen, but do
not yet show the symptoms of the illness.
• Convalescent carriers continue to spread the pathogen even though they
have recovered from illness.
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• In many infections carriers play an important role in
transmitting the pathogen.
• It is usually not possible to identify asymptomatic
carriers, and unless the family and other close
contacts of the sick person or even the whole
population can be treated, carriers will remain a
threat to the health of those surrounding them.
 3. Transmission of disease
• To survive as a species, pathogens must infect new people or animals.
• To do this, they must leave the body of the host, find their way to a
new susceptible person or animal, and enter the body of that person
or animal
• Interventions that aim to improve the health of a population usually
try to reduce the risk of transmission of infection.
• To do this appropriately, the public Health specialist needs to be
familiar with the pathogens’ transmission route(s).
• It is this understanding that enables the specialist to determine which
control measures will be most effective in a particular situation.
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• The most useful categorisation is based on the transmission
cycles of the infections.
• Diseases with similar transmission cycles can be controlled
by similar preventive measures, and will occur in similar
environments.
• Some terms relating to the transmission or classification of
infections are defined below:
• Food-borne infections: infections which can be transmitted
through eating food containing the pathogen.
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• Vector-borne infections: infections transmitted through vectors.
Vectorborne infections are only for infections with a biological vector, that is a
vector in which the pathogen goes through a development before further
transmission is possible (e.g. mosquitoes, tsetse fly, body louse).
• In those infections which are transmitted by mechanical vectors, the animal
is only a vehicle for transporting the pathogen (e.g. domestic flies,
cockroaches).
• Water-borne infections: infections which can be transmitted through
drinking water which contains the pathogen.
• Water-washed infections: infections caused by pathogens whose
transmission can be prevented by improving personal hygiene.
• Infections can have either direct or indirect transmission routes.
 Infections with direct transmission
• A pathogen with a direct transmission route can infect a
susceptible person or animal immediately after leaving the
host.
• The pathogen does not need to develop in the
environment, in an intermediate host, or in a vector.
• In faecal pathogens these are the non-latent infectious
agents.
• This group contains three disease-groups: faecal-oral
infections, leptospirosis, and infections spread through
direct contact.
 Faecal-oral infections
• These pathogens leave the host through faeces, and enter the susceptible
person or animal through ingestion.
• Transmission occurs mainly through direct contact with contaminated
fingers; food contaminated directly with excreta, contaminated hands,
domestic flies, soil, or water; contaminated drinking-water; or contaminated
soil.
• Faecal-oral infections are food-borne, water-borne, and water-washed.
• As faecal-oral infections are transmitted directly, any route that will take
matter polluted with faeces directly or indirectly to somebody’s mouth could
potentially transmit the pathogen.
• Faecal-oral infections include diarrhoeal diseases such as cholera and
bacillary dysentery, typhoid, hepatitis A, and poliomyelitis.
 Infections of direct contact
• All the diseases covered in this category are infections which
affect the skin or eyes. Pathogens are present on the skin or in
the discharges of affected body parts or eyes.
• The pathogens are transmitted directly through
contaminated hands, clothes, domestic flies, or any other
contaminated material.
• The pathogen enters the body through skin or mucous
membranes such as the eyes.
• These infections are associated with poor personal hygiene
and are water washed.
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• Few of these infections have animal hosts. The diseases in this
category include conjunctivitis, trachoma, yaws, and scabies.
Infections with indirect transmission
• A pathogen with an indirect transmission route must go through a
development phase outside the host before it can infect a new
susceptible person or animal.
• This development will take place in a specific intermediate host,
vector, or type of environment.
• This need to go through a particular organism or environment gives
the transmission route a focus, which preventive measures can
target, for example by vector control or improved food preparation.
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• The disease-groups with indirect transmission are soil-

transmitted helminths, water-based helminths, beef/pork
tapeworm infection, Guinea-worm infection, and vector-
borne infections.
• Soil-transmitted helminths
• These worms leave the body through faeces as eggs or larvae.
After excretion they have to develop in soil.
• They can be further divided based on how the pathogen
enters the human body.
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• Entrance by penetration of the skin: the pathogen enters
the body through skin which is in direct contact with
contaminated soil.
• This is the method used by hookworms and threadworms.
• Entrance by ingestion: if either contaminated soil, or food or
hands contaminated with polluted soil come into contact
with the mouth, the pathogen can be transmitted.
• These infections can be food-borne and water-washed.
• This method is used by roundworms and whipworms.
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• Water-based helminths
• These pathogens leave the body through excreta. The
infectious agents must develop in intermediate hosts living
in freshwater.
• The transmission of these infections is therefore only
possible if excreta containing the pathogens reaches fresh
surface water in which there are suitable intermediate
host(s).
• Based on transmission cycle, this category can be sub-
divided in two groups:
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• Schistosomiasis. After excretion, the pathogen infects a freshwater snail, in which it
develops and multiplies.
• The snail releases the pathogens into the water, and people are infected when these
pathogens penetrate skin which is in direct contact with infected freshwater.
• Only one type of schistosomiasis (which occurs only in Asia) has an important reservoir
in an animal host; all other types have people as the only host of importance.
• Water-based helminths with two water-based intermediate hosts.
• The first intermediate host is a freshwater snail or copepod. The second intermediate
host is a freshwater plant, fish, or crabs/crayfish.
• The intermediate hosts are specific to the pathogen. These infections are food-borne
and people become infected when they eat the second intermediate host without
properly cooking it.
• All these infections affect both animals and people. These diseases include
opisthorchiasis, clonorchiasis, and lung fluke disease.
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Guinea-worm
• In this infection the pathogen, a large worm, creates a
blister on the person’s skin, which erupts when it comes
into contact with water, releasing the worm’s larvae.
• These larvae then infect a copepod (Cyclops), in which it
develops. The disease is water-borne.
• People become infected by drinking water containing
Cyclops, and are the only host to this infection. Figure 2.5
shows the transmission route of Guinea-worm.
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Vector-borne diseases
• These infections are transmitted by vectors. Vectors are arthropods (insects,
ticks, or mites) which can transmit infections from host to future host.
• The pathogen exists in the blood or skin of the host. The vector becomes
infected when it feeds on a host. The pathogen develops and multiplies
inside the vector, which then becomes infectious.
• People are usually infected through the bite of an infectious vector, though
other ways of entry are possible.
• With several vector-borne diseases animal hosts are important reservoirs.
Vector-borne diseases include yellow fever, malaria, sleeping sickness,
plague, epidemic louse-borne typhus fever, and louse-borne relapsing fever.
 The environment
• The environment is everything that surrounds the pathogen in
its transmission from host to susceptible person or animal.
• The environmental factors include climate, landscape, human
surroundings, and human behaviour.
• Environmental factors are often associated, for example
higher altitudes result in lower temperatures, landscapes are
formed by the climate.
• The climate
• The climate and its seasonal changes play an important role in
disease transmission. The presence of vectors and
intermediate hosts often depends on rain and temperature.
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• In general, direct sunlight, a dry environment, and high temperatures will
reduce the survival times of pathogens in the environment.
• The climate influences human behaviour. In cold climates people will crowd
together and wear more clothing.
• If this is combined with poor personal hygiene the body-louse, vector of
louse-borne typhus fever and louse-borne relapsing fever, can thrive.
The landscape
• The landscape consists of the larger physical structures in the environment.
These structures are usually natural, but can be man-made.
• They include mountains, deserts, rivers, jungle, artificial water reservoirs, and
deforested areas. Aspects of the landscape that would influence disease
transmission most are the microclimate, the presence of water, and types of
vegetation.
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• Man-made modifications of the landscape often increase the risk of disease
transmission by creating a habitat favourable to vectors or intermediate hosts.
• The human surroundings
• Landscape and human surroundings are closely linked, and it is difficult to
divide the two clearly. The difference is one of scale; while the landscape
normally cannot be modified or improved by individual people, individuals can
modify the human surroundings.
• Although the landscape will normally be similar for all people living in an area,
the human surroundings may be very different for people living in the same
region, village, or even household. Many infections are linked to specific
circumstances, and people with specific occupations, socio-economic status,
gender, or religion may be far more at risk than others.
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• The human surroundings are created by a combination of
natural elements and how people have modified these
elements.
• In public health, human surroundings are concerned with
water supply, proper handling of excreta, removal of
unwanted water, adequate management of solid waste, and
control of vectors or intermediate hosts through
modification of the environment or change in behaviour
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Human behaviour
• People behave in a certain way because they believe that
they are making the most of their lives.
• Human behaviour is complex. It is influenced by culture, for
example religion, attitudes, and traditional beliefs; by social
position, such as gender or age; by availability of means, for
example money, energy, time, or material; and by politics.
• Having access to a safe water supply, or technically adequate
sanitation, does not automatically mean people will use
them.
 The future host:
• The success of a pathogen in infecting a person will depend
on:
• the infectious dose of the pathogen, and the number of
infectious agents which manage to enter the potential new
host (this applies mainly to faecal-oral infections); and
• whether the pathogen can overcome the barriers of the host.
The infectious dose
• The infectious dose is the number of pathogens which have
to enter the body of a susceptible person to cause infection.
• Infections with a low infectious dose are more likely to
be spread by direct person to-person contact than
infections with a high infectious dose.
• 
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• The barriers of the body against pathogens
• The body has a range of mechanisms that prevent a pathogen from causing
infection.
• The skin and mucous membranes have anti-microbial substances, and the
stomach is acid to act as the first barriers against pathogens.
Low acidity in the stomach or an open wound (e.g. insect bite, cut, abrasion)
can make this barrier ineffective.
• The next barriers are mechanisms that react to the pathogen, and try to
counter its development.
• These barriers are not specific to the pathogen, and the body does not need
to have been in contact with the pathogen for them to be effective. These
mechanisms are the host’s resistance against pathogens.
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• An individual’s immune system may have experienced a pathogen
through an earlier infection or immunisation (vaccination) with
inactivated pathogens.
• When the pathogens enter the person’s body, their immune system
will recognise the pathogen and make antibodies which will attack
the pathogen. This is called active immunity.
• The effectiveness of active immunity depends on the pathogen, and
the length of time since the body has been in contact with the
pathogen.
• Active immunity is effective only against that particular pathogen.
The effectiveness against bacteria and viruses usually lasts for years .
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• Passive immunity is created by introducing foreign antibodies into the body. An
unborn baby receives antibodies from the mother through the placenta, which will
protect it for some time after birth.
• Vaccination with antibodies is another way of creating passive immunity. The
foreign antibodies will slowly disappear from the body, and passive immunity will
usually only last days or months.
• Two important practical points define the susceptibility of a population:
• A population that is weakened because of poor nutrition or a high occurrence of
disease, fatigue, or stress has an increased risk of disease.
• When a pathogen is very common in a population, or the population is immunised,
most people will have some form of immunity against it. In this case the disease
will attack mainly children.
If the same pathogen is introduced into a population which has low immunity, there
is a risk of an outbreak (an epidemic) which can attack all ages.
The infection over time
• When a pathogen is introduced in sufficient numbers,
and overcomes the resistance and immune system of
a person or animal, infection will follow.
• The time between entrance of pathogen and
appearance of the first signs of disease or symptoms
is called the incubation period.
• NB: Not all infections will result in disease, and for
many infections asymptomatic carriers are common.
 Initial infection Onset of disease Full recovery

Incubation period Period of disease Disease

Communicability
Latent period Period of communicability

Incubating carrier Convalescent carrier

Time
Figure 2.6. Communicability and disease over time in one person
( adapted from 73)
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• The period of communicability is the period in which the host is
infectious, or the period in which pathogens are shed in the
environment.
• The time between entrance of pathogen and the onset of
communicability is the latent period. This is shown on a timeline in
Figure 2.6.
• In some infections the period of communicability starts before illness
is apparent.
• Hosts who can transmit the pathogen before showing symptoms are
called incubating carriers.
• If the period of communicability extends beyond the end of the
illness, the hosts are called convalescent carriers.
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