Chapter 15.

Epidemiology and
Nosocomial Infections
Epidemiology

• Epidemiology: the study of when and where diseases occur and how they are
transmitted in populations. CDC (Centers for Disease Control and Prevention) is
the epidemiological center of the Untied States that compiles an annual national
list of "notifiable diseases", i.e. infectious disease cases physicians are required to
report. (Epidemiological studies include non-infectious diseases as well, e.g.
cancer, heart diseases, mental health and smoking-related diseases.)
• Epidemiological measures of disease: Incidence (number of new cases per
100,000 people in a period of time, measuring if the disease is still spreading or is
disappearing); Prevalence (total number of people having the disease, measuring
how widespread a disease is in a population at a time point); Mobidity (number
of disease cases in a population per year); Mortality (number of death due to a
disease in a population per year)
• Pioneers of epidemiology: John Snow (made the first epidemiological map that
identified the source of the 1849 London cholera outbreak); Ignaz Semmelweis
(prevented childbirth death by instituting hand-washing); Florence Nightingale
(wrote the first statistical study that lowered war-time soldier death from
infection).
• Classifying infectious diseases: epidemic diseases (diseases that occur in a short
period of time, e.g. West Nile virus outbreak in NYC); endemic diseases (diseases
that constantly present in a local population, e.g. Lyme disease); pandemic
diseases (worldwide occurrence, e.g. flu).
• Methods of epidemiological studies
o Descriptive studies: Careful collection of geographic, demographic, and
temporal information of a disease
o Analytical studies: Statistical analysis of association and correlation
between disease factors and disease cases, in order to identify the disease
cause(s). For example, do a case group-control group comparison
o Experimental studies: Comparison of a treatment group with a control
(untreated, with placebo) group
• Modes of disease transmission
o Direct contact: person-to-person. e.g., AIDS
o Indirect contact: transmission through a fomite (non-living objects, e.g.,
shared utensils in hospital).
o Droplet: coughing, sneezing, etc. Droplets contain "droplet nuclei", which
are dried mucus embedded with microbes.
o Vehicle transmission: waterborne (e.g., cholera), airborne (e.g., TB;
Aerosols, e.g, dusts, contain live bacteria, endospores, fungal spores and
naked viruses), and foodborne (e.g., botulinum toxin)
 o Vector-borne: mechanical or biological transmission by arthropods and
rodents (e.g., malaria, Lyme disease)
• Disease reservoir: the primary source and maintenance host of a pathogen
o Human reservoirs: e.g, AIDS, polio, HBV, all human-specific pathogens
o Animal reservoirs: e.g., Rabies, Lyme disease (Borrelia burgdorferi).
Diseases occur primarily in the wild animals or pets are called zoonoses.
Humans are accidental (non-maintenance) hosts of zoonoses.
o Non-living reservoirs: soil and water, e.g., Bacillus anthracis (anthrax),
Clostridium tetani (tetanus)
• Portals of entry: broken or intact skins; mucous membranes in respiratory,
digestive, and urogenital tracts; body openings (e.g., mouth, ear, urethra); placenta
(e.g., mother-fetus transmission of HIV-1). Yersinia pestis causes bubonic plague
with 50% mortality rate through flea bites, and causes pneumonic plague with a
100% mortality when inhaled.
• Portals of exit: Respiratory discharges (saliva and droplets from coughing,
sneezing); Gastrointestinal tract discharges (feces through diarrhea); Urogenital
tract exits (urine and semen); Blood (e.g., malaria); Milk (known to transmit HIV-
1)
• Disease control: Isolate (of patients of communicable diseases); Quarantine (of
affected population, including non-symptomatic disease carriers from the general
public); Large-scale immunization (to achieve herd immunity - i.e., group
immunity, where most people are immune to an infectious disease so that the
disease can only affect a small number of individual, and will not cause an
epidemic); Vector control (of arthropods and rodents)

Nosocomial (hospital-acquired) infections

• Hospitals are major reservoir of opportunistic pathogens (e.g. Staphylococcus

aureus, E.coli, Clostridium difficile, Candida albicans, causing surgical wound
infections, diarrhea and yeast infections) and antibiotic-resistant pathogens (e.g.
resistant strains of Pseudomonas aeruginosa).
• Compromised (weakened) status of host, resulting from invasive procedures
(surgery, anesthesia, etc.) and suppressed immune systems (caused by drugs,
radiations, etc)
• Hospital chains of transmission: person-to-person route of transmission; fomite
route of transmission (through non-living objects, e.g. needles, catheters,
respiratory aids, endoscopes, dental drills).
• Control and prevention of hospital infections:
o Vigorous hand-washing
o Strictly follow aseptic techniques for handling biological samples and
hospital equipments and tools
o Selective antibiotic use (preventive use only for surgery and immune-
compromised patients)
o Follow the Universal Precautions (CDC guidelines for safe-handling of
ALL body fluids)
Molecular Epidemiology (Case Study: the 2003 SARS
outbreak)

• Molecular epidemiology: the use of DNA sequences to trace the source and routes
of disease outbreaks. It's a modern, highly effective method of monitoring the
spread of an infectious disease.
• Procedures: (1) Isolation of SARS viruses (a coronavirus) from index cases in
multiple regions; (2) DNA-sequencing of pathogen genes; (3) Reconstruction a
phylogenetic tree to show the relationships between viral samples
• Study conclusions: (1) high viral diversity in Guangdong, China, indicating it's
the source of the SARS virus; (2) at least three viral strains were introduced into
Hong Kong independently; (3) the worldwide outbreak is caused by a single
strain.