CONCEPTS OF

MICROBIAL
DISEASE
EPIDEMIOLOGY
Maj Gen (Retd) Prof. Dr. ASM Matiur Rahman
MBBS(Dhaka), MCPS (BD), D. Bact (Manchester) MSc (Manchester UK)
FCPS(BD), FCPS (Pak),FRCP (Edin) FICS (USA) FRCP (Glasgow) FAS (BD)
 Definition of epidemiology
The epidemiologic triad
Definition of communicable diseases
Importance of studying communicable
diseases epidemiology
Terminology
Dynamics of disease transmission (chain
of infection):
Human reservoir or source
Modes of transmission
Susceptible host
 Changes of the pattern of infectious
diseases
Discovery of new infections
The possibility that some chronic diseases
have an infective origin.
 A condition of the body or some part or
organ of the body in which its functions
are deranged.
It is a mal-adjustment of human organism
to the environment.
It is deviation from normal body-function.
 An illness due to a specific infectious agent or
its toxic products that arises through
transmission of that agent or its products
from an infected person, animal or inanimate
reservoir to a susceptible host; either directly
or indirectly through an intermediate plant or
animal host, vector or the inanimate
environment.
(Source: Benensen AS, editor. Control of Communicable Diseases
Manual. Sixteenth Edition, 1995)
 The study of the distribution and
determinants of health-related states or
events in specified population, and the
application of this study to control of health
problems
 Study: surveillance, observation, hypothesis testing, analytic
research, and experiments.
Distribution: analysis by time, place, and person.
Determinants: physical, biological, social, cultural, and
behavioral factors that influence health.
Health-related states or events: diseases, causes of death,
behavior, reactions to preventive regimens, and provision and
use of health services.
 Specified populations: those groups of people
with identifiable characteristics
Application to control: refers to the goal of
epidemiology, that is to assess the public health
importance of diseases, identify the population at risk,
identify the causes of disease, describe the natural
history of disease, and evaluate the prevention and
control of disease
According to the International Epidemiological Association (IEA),
epidemiology has three main aims
1. To describe the distribution and magnitude of health and disease
problems in Human populations.
2. To identify etiological factors (risk factors) in the pathogenesis of the
disease.
3. To provide the data essential to the planning, implementation and
evaluation of services for the prevention control and treatment of
disease and to the setting up of priorities among those services.
Ultimate aim of epidemiology should be:
To eliminate or reduce the health problem or its consequences and
To promote the health and wellbeing of society as a whole
Major Factors Contributing to the Emergence of
Infectious Diseases

Human demographics and behavior

Technology and industry
Economic development and land use
International travel and commerce
Microbial adaptation and change
Breakdown of public health measures
 Agent, Host, environment
Classification of human Infections by
modes of transmission
Incubation Period
Spectrum of disease
Herd Immunity
 Susceptible
MODE OF TRANSMISSION
RESERVOIR/ THROUGH SOME VEHICLE Host/Non
SOURCE OF OR VECTOR Immune/
AGENT Poor herd
immunity
 Water

Fingers

Stool Food New Host

Flies

Soil
 Epidemiologic Triad

Disease is the result of

forces within a dynamic
system consisting of:
agent of infection
host
environment
 H A
A A = Agent H
H = Host
E = Environment
E E

Increase in the ability of an agent to The proportion of susceptible in the

infect and cause disease in man human host population is increased

A H

H A
A H
E
E At equilibrium E
Environmental change Environmental change
facilitates agent spread host susceptibility

Interaction of agent, host, and environmental factors.

A = agent, H = host, E = environment
Biological Chemical Physical
Helminths Foods Heat
Protozoans Poisons Light / radiation
Fungi Drugs Noise
Bacteria Allergens Humidity
Rickettsia Pressure
Viral
AGENT
The first link in CHAIN OF INFECTION is the microbial agent, which may be a
bacterium, virus, fungus, or parasite.

INFECTIVITY PATHOGENICITY
VIRULENCE INVASIVENESS
DOSE SPECIFICITY
OTHER AGENT FACTORS
> production of enzymes : streptococci -- leukocidin
haemolysin
proteinase
> antegenic variation (antegenic drift and shift)
> resistance-transfer plasmids
a) Demographic factor: Age,Sex
b) Biological: Biochemical level of blood
e.g:Cholesterol,sugar,Blood group & enzymes, Cellular
component of blood
e.g:RBC,WBC,Platelets,Immunological factor.
c) Social & economic: Education,Occupation,Stress,Marital
status, Housing.
d) Life style: Nutrition, Physical exercise, Use of
drug,alchole.
HOST SPECIFITY : (AGENT)
Micro-organisms may be specific to their range of host.

St. Louis encephalitis virus -- has a broad range of host, including many
avian species, mammals, and mosquitoes.
Rickettsia prowazekii, the species that causes TYPHUS FEVER has a very
narrow host range, involving body lice and man.
Brucella abortus is highly communicable in cattle but not in man.

Salmonella species -- Salmonella typhimurium common to both animals

and humans.
Salmonella dubin primarily infects bovine.

Salmonella typhosa is known to infect only humans.

 Physical:Heat,cold,light,noise,
radiation,
Social, political, economic
Population density
Biological:Viral,Microbial
agent,Insects,Rodents,Animals
Psychological:Habit,belief,attitudesocial
imbalance etc.
THE DISEASE IS INITITED
AT THE CELLULAR LEVEL
WHEN THE
NECESSARY CAUSE (AGENT)
BECOMES SUFFICIENT I.E.
COMPLIMENTED BY ITS
CAUSAL PARTNERS
 1.Diseases due to biological agents:Protozoa,bacteria,virus,fungi,
spirochetes.
2.Diseases due to Physical
agents:Heat,cold,pressure,sound,radiation,eletricity etc.
3.Diseases due to Chemical agents: acid &
alkali,gases,dusts,allergens,metals etc.
4.Diseases due to Mechanical agents:Chronic friction, Automobile force.
5.Diseases due to Nutrient agents: Excess or deficiency of
protein,fat,carbohydrate,minerals,vitamins etc.
6.Diseases due to Psychological
factors:Anxiety,stress,tension,depression etc.
7.Diseases due to Genetic factors: Chromosomal anomalies.
8.Diseases due to Metabolic & hormonal disorders: Lack of secretion of
Insulin hormone.
 IT IS THE WAY IN WHICH A
DISEASE EVOLVES OVER TIME
FROM THE EARLIEST STAGE OF
ITS PREPATHOGENESIS PHASE
TO ITS TERMINATION AS
RECOVERY, DISABILITY OR
DEATH, IN THE ABSENCE OF
TREATMENT OR PREVENTION
 Exposure to Agent
Symptom
Development
Pre-exposure
Stage: Preclinical
Stage:
Factors
present Exposure to Clinical Resolution
leading to causative Stage: Stage:
problem agent: no
development symptoms Symptoms Problem resolved.
present present Returned to health
or chronic state or
death

Primary Prevention Secondary Tertiary

Prevention Prevention
Progression of disease in individual over time
Incubation Period

The interval between the time of contact and/or entry of the

agent and onset of illness (latency period)

The time required for the multiplication of microorganisms

within the host up to a threshold where the parasitic
population is large enough to produce symptoms
Incubation Period

The interval between the time of contact and/or entry of the

agent and onset of illness (latency period)

The time required for the multiplication of microorganisms

within the host up to a threshold where the parasitic
population is large enough to produce symptoms
Latent period

The period from infection until the infectious period

starts.
 The relationships of some important time periods. The patient at the
bottom is infected first, and transmits the infection to a second
patient

etc.

Second patient
Latent period Infectious period
Incubation Clinical disease

First patient
Latent period Infectious period
Incubation Clinical disease

Serial interval
Infection
Time
 Schematic diagram of stages of infection in
host
Disease in host

Agent being shed

Total period of infection (agent present)

Time
Incubation
period

Latent
period Period of communicability

Infection patent
Infection Infection terminated,
latent becomes latent, or
intermittently patent
 PRE-PATHOGENIC PHASE OR
SUSCEPTIBILITY STAGE
PATHOGENIC PHASE
1. INCUBATION PERIOD
2. PRODROMAL STAGE
3. STAGE OF OVERT DISEASE
4. STAGE OF DEFERVESCENCE
5. STAGE OF CONVALESCENCE
 DEATH

CLINICAL
DISEASE SEVERE
DISEASE

SUB CLINICAL MILD ILLNESS

DISEASE

INFECTION WITHOUT
CLINICAL ILLNESS

EXPOSURE WITHOUT INFECTION

34
 clinical
Spectrum of illness most
diseases demonstrate a
range of manifestations and
severities
Example: Polio
95%: subclinical subclinical
4%: flu-like
1%: paralysis
 An etiological agent responsible for the disease
should be present
There should be a reservoir or carrier for the
etiological agent to survive
The infecting agent should be able to escape
from the reservoir of infection through the
portal of exit
There should be a possible source of entry to
transmit the agent to a new susceptible host
The agent should be able to invade the new host
The host should be susceptible
GRADIENT OF INFECTION

Refers to variety of host responses to infections :

INAPPARENT
MILD
MODERATE
SEVERE
FATAL ILLNESS
The relation of severity of illness to disease statistics.

INFECTION
DISEASE
Inapparent Mild Moderate Severe Fatal

Likely to be seen by a
doctor ; may be
recorded
Likely to be
hospitalized
and recorded
Distribution of clinical severity for three classes of infections (not
drawn to scale)

Class A - INAPPARENT INFECTION FREQUENT

Example : Tubercle bacillus

0 Percentage of Infection 100

Class B - CLINICAL DISEASE FREQUENT ; FEW DEATHS
Example : Measles virus

0 Percentage of Infection 100

Class C - INFECTIONS USUALLY FATAL
Example : Rabies virus

0 Percentage of Infection 100

Inapparent Mild Moderate Severe Fatal

GRADIENT OF INFECTION (cont.)

Epidemiologic importance of inapparent infection :

many inf. Agents produce far more cases of inapparent infection than of
overt disease

individuals with inapparent infections may be as infectious as clinical cases

Ex : MENINGOCOCCAL MENINGITIS POLIO

 Infectivity
Pathogenicity
Virulence
Antigenicity
 Latent infection
Sub-clinical infection or
inapparent or occult
Atypical infection
Severe clinical infection
 Infection Exotic
Contamination Sporadic
Infestation Attack rate
Contagious disease Primary/secondary
Incidence and cases
prevalence of infectious Zoonosis, epizootic and
diseases enzootic
Epidemic Nosocomial infection
Endemic Opportunistic infection
Hyper endemic Eradication
holoendemic Elimination
Pandemic
 Virulence Incubation period
Reproductive rate of Infectivity period
infection Serial interval
Host Latent period
Vector (source) Transmission Probability
Reservoir ratio
 Infection is the entry and development or
multiplication of an infectious agent in the
body of man or animals. An infection does not
always cause illness.
There are several levels of infection
(Gradients of infection):
Colonization (S. aureus in skin and normal nasopharynx)
Subclinical or inapparent infection (polio)
Latent infection (virus of herpes simplex)
Manifest or clinical infection
 The presence of an infectious agent on a
body surface, on or in clothes, beddings,
toys, surgical instruments or dressings, or
other articles or substances including
water and food
 It is the development and reproduction of
arthropods on the surface of the body or in
the clothing, e.g. lice, itch mite. This term
could be also used to describe the invasion
of the gut by parasitic worms, e.g.
ascariasis.
 A contagious disease is the one that is
transmitted through contact. Examples
include scabies, trachoma, STD and
leprosy.
 A person or an animal that affords
subsistence to an infectious agent under
natural conditions. Types include: an
obligate host, definitive (primary) host,
intermediate host and a transport host.
 An insect or any living carrier that
transports an infectious agent from an
infected individual or its wastes to a
susceptible individual or its food or
immediate surroundings. Both biological
and mechanical transmissions are
encountered.
 Any person, animal, arthropod, plant, soil,
or substance, or a combination of these, in
which an infectious agent normally lives
and multiplies, on which it depends
primarily for survival, and where it
reproduces itself in such a manner that it
can be transmitted to a susceptible host. It
is the natural habitat of the infectious
agent.
 Incidence of an infectious disease: number of new
cases in a given time period expressed as percent
infected per year (cumulative incidence) or number
per person time of observation (incidence density).

Prevalence of an infectious disease: number of cases

at a given time expressed as a percent at a given
time. Prevalence is a product of incidence x duration
of disease, and is of little interest if an infectious
disease is of short duration (i.e. measles), but may be
of interest if an infectious disease is of long duration
(i.e. chronic hepatitis B).
 The unusual occurrence in a community of
disease, specific health related behavior,
or other health related events clearly in
excess of expected occurrence
(epi= upon; demos= people)
Epidemics can occur upon endemic states
too.
 It refers to the constant presence of a
disease or infectious agent within a given
geographic area or population group. It is
the usual or expected frequency of disease
within a population.
(En = in; demos = people)
 Endemic vs. Epidemic

No. of cases of a disease

Endemic Epidemic

Time

Dr. G.U Ahsan, PhD Infectious Disease Epidemiology / Page 56

 The term hyper endemic expresses that the
disease is constantly present at high
incidence and/or prevalence rate and affects
all age groups equally.

The term holoendemic expresses a high

level of infection beginning early in life and
affecting most of the child population, leading
to a state of equilibrium such that the adult
population shows evidence of the disease
much less commonly than do the children
(e.g. malaria)
 An epidemic usually affecting a large
proportion of the population, occuring over a
wide geographic area such as a section of a
nation, the entire nation, a continent or the
world, e.g. Influenza pandemics.

Exotic diseases are those which are imported

into a country in which they do not otherwise
occur, as for example, rabies in the UK.
 The word sporadic means scattered about.
The cases occur irregularly, haphazardly from
time to time, and generally infrequently. The
cases are few and separated widely in time
and place that they show no or little
connection with each other, nor a
recognizable common source of infection e.g.
polio, meningococcal meningitis, tetanus.
However, a sporadic disease could be the
starting point of an epidemic when the
conditions are favorable for its spread.
 Attack rate: proportion of non-immune
exposed individuals who become clinically ill.

Primary (index)/secondary cases: The person

who comes into and infects a population is
the primary case. Those who subsequently
contract the infection are secondary cases.
Further spread is described as "waves" or
"generations".
 INFECTIVITY :

Ability of an agent to invade and multiply (produce infection) in a host.

Assessed by Secondary Attack Rate*

Example : high in measle

low in leprosy

S.A.R.* = No. of New Cases Among Contacts

Total No. of Susceptible

Infectious Disease Epidemiology / Page 61

SECONDARY ATTACK RATE*

is the number of cases among contacts occurring

(within the accepted incubation period) due to exposure
to a primary case, in relation to the total exposed
contacts. (susceptible contacts)
 Index Case
- Person that comes to the attention of public
health authorities

Primary Case
- Person who acquires the disease from an
exposure
- Attack rate

Secondary Case
- Person who acquires the disease from an
exposure to the primary case
- Secondary attack rate
 Zoonosis is an infection that is transmissible
under natural conditions from vertebrate
animals to man, e.g. rabies, plague, bovine
tuberculosis..
An epizotic is an outbreak (epidemic) of
disease in an animal population, e.g. rift
valley fever.
An Enzotic is an endemic occurring in
animals, e.g. bovine TB.
 Nosocomial (hospital acquired) infection is
an infection originating in a patient while
in a hospital or another health care facility.
It has to be a new disorder unrelated to
the patients primary condition. Examples
include infection of surgical wounds,
hepatitis B and urinary tract infetions.
 This is infection by organisms that take the
opportunity provided by a defect in host
defense (e.g. immunity) to infect the host
and thus cause disease. For example,
opportunistic infections are very common
in AIDS. Organisms include Herpes
simplex, cytomegalovirus,
M. tuberculosis.
 Termination of all transmission of infection by the
extermination of the infectious agent through
surveillance and containment. Eradication is an
absolute process, an all or none phenomenon,
restricted to termination of infection from the whole
world.

The term elimination is sometimes used to describe

eradication of a disease from a large geographic
region. Disease which are amenable to elimination in
the meantime are polio, measles and diphtheria.
 DIRECT INDIRECT
TRANSMISSION
TRANSMISSION VECHICLE BORNE
DIRECT CONTACT VECTOR BORNE
DROPLET INFECTION A) mechanical
CONTACT WITH SOIL B) biological
INOCULATION INTO AIR-BORNE
SKIN OR MUCOSA FOMITE BORNE
UNCLEAN HANDS
TRANSPLACENTAL AND FINGERS
Classification by mode of transmission

Cycles of Infectious Agent in Nature

- Man-man Influenza
- Man-arthropod-man Malaria
- Vertebrate-vertebrate-man Psittacosis
- Vertebrate-arthropod-vertebrate-man Viral encephalitis

Complex Cycles
- Helminth infections River blindness
 It is defined as the person,
animal, object or
substance from which an
infectious agent passes or
is disseminated to the
host
 It is defined as any person, animal,
arthropod, plant, soil, or substance
(or combination of these in which
an infectious agent lives and
multiplies, on which it depends
primarily for survival, and where it
reproduces itself in such manner
that it can be transmitted to a
susceptible host
 For example, in hookworm infection, the
reservoir is man, but the source of infection is
the soil contaminated with infective larvae.
In tetanus the reservoir and source are the
same (Soil)
In typhoid favor the reservoir infection may
be a case or carrier, but the source of the
infection may be stool or urine of a patient or
contaminated food or water.
Thus the term source refers to the
immediate source of infection and may or
may not be a part of reservoir.
 Classification of Reservoir:

Human Reservoir
Animal Reservoir
Reservoir in nonliving things
 It occurs either due to inadequate treatment or immune response, the
disease agent is not completely eliminated, leading to a carrier state.

It is an infected person or animal that harbors a specific infectious

agent in the absence of discernible (visible) clinical disease and
serves as a potential source of infection to others.
Three elements have to occur to form a carrier state:
1. The presence in the body of the disease agent.
2. The absence of recognizable symptoms and signs of disease.
3. The shedding of disease agent in the discharge or excretions.
 TYPE PORTAL OF EXIT
A) Urinary
A) Incubatory
B) Intestinal
B) Convalescent
C) Respiratory
C) Healthy
DURATION
A)Temporary
B)Chronic
1. Presence of specific microbes in
the body
2. Absence of apparent symptoms
and signs
3. Shedding of micro-organisms in
the discharges or excretions
4. As a source of infection to others
 Carriers are less infectious but are
more dangerous than cases,
because they escape recognition
and continuing as they do to live a
normal life among the population
They can readily infect the
susceptible individuals over a wider
area and longer period of time,
under favourable conditions.
 DOSE OF INOCULUM
SITE OF MULTIFICATION
RATE OF MULTIFICATION
HOST DEFENCE MECHANISM
 GENERATION TIME
INFECTIVE DOSE
PORTAL OF ENTRY
INDIVIDUAL SUCEPTIBILITY
 Tracing the source of infection
and contact
Period of surveillance
Immunization
Identification of point source or
propagated epidemics
Prognosis
 IT IS DEFINED AS THE TIME
REQUIRED FOR 50% OF
THE CASES TO OCCUR
FOLLOWING EXPOSURE
Infectious period

The length of the time period during which a person

can transmit a disease.
 TIME

Susceptible Subclinical Death

Disease
Host
Clinical
Disease
No
infection
Recovery

Incubation
period

Exposure Onset
GENERATION TIME :

Interval between receipt of infection and maximal infectivity of the host

Applies
pplies to
to both
both clinical
clinical and
and inapparent
inapparent infections
infections

MUMPS : virus recovered from the mouth 5 days before onset to 4 days after
BUT significant infectiousness begins only on the day before onset
and lasts for a short time
GENERATION TIME : (cont.)

MEASLES : terminates before clinical recovery

DIPHTERIA : may continue for sometime after full recovery

STREP. INFECTION : infectiousness decreases during convalescence inspite

of the presence of organisms for a long time
Number of exposed persons developing the SAR

= disease within the range of the incubation period 100

Total number of exposed /susceptible
 IT IS THE LEVEL OF RESISTENCE
OF A COMMUNITY OR GROUP OF
PEOPLE TO A PARTICULAR
DISEASE
ROLE OF HERD IMMUNITY ON TRANSMISSION

A B

Susceptible individual Immune individual

 ROLE OF HERD IMMUNITY ON TRANSM (cont.)

Situation A : herd immunity 40% , transmission epidemic type, 1 primary case, 3

secondary case, 9 tertiary cases

Situation B : herd immunity 80% , transmission epidemic type

Herd Immunity

The decreased probability that a group will developed an

epidemic because the high proportion of immune individuals
reduces the chance of contact between infected and
susceptible persons

The entire population does not have to be immunized to

prevent the occurrence of an epidemic

Example : smallpox, measles

1. PRIMORDIAL PREVENTION--
INTERVENTIONS TAKEN BEFORE THE
DEVELOPMENT OF RISK FACTOR
2. PRIMARY PREVENTION -- INTERVENTIONS
TAKEN BEFORE THE DISEASE IS
ESTABLISHED
3. SECONDARY PREVENTION-- INTERVENTIONS
TAKEN AFTER THE DISEASE IS ESTABLISHED-
4. TERTIARY PREVENTION --
INTERVENTIONS TAKEN TO PREVENT
COMPLICATIONS
 WATCHING THE DISEASE WITH
SUSPICION, ATTENTION AND
AUTHORITY
1. SUSPECT UNLESS AND UNTIL IT IS
DISPROVED
2. BE ATTENTIVE AND CAUTIOUS
3. TRY TO GRASP THE ENTIRE NATURAL
HISTORY OF THE DISEASE
 DISEASE WILL BE A PUBLIC HEALTH
PROBLEM WHEN IT CAUSES HIGH
MORBIDITY AND MORTASLITY
DEMANDS URGENT HEALTH ACTION
EITHER IN THE FORM OF
1. CONTROL
2. ELIMINATION
3. ERADICATION
 CONTROL STRATEGY = REDUCING THE
MORBIDITY AND MORTALITY
A CONTINGENCY TEMPORARY
MEASURE IN CASE OF EMERGENCY
 NEAR ERADICATION STAGE

INTERMEDIARY BETWEEN CONTROL

AND ERADICATION STATUS

LESS PUBLIC HEALTH PROBLEM

BASED MAINLY ON SURVEILLANCE

ACTIVITIES
 RADICLE MEANS MAIN ROOT OF
A PLANT
ERADICATION MEANS
REMOVING ALONG WITH THE
MAIN ROOT i.e. IN ENTIRETY
ALL OR NONE FORMULA
 AGEENT IN
MODE OF TRANSMISSION
RESERVOIROR SUSCEPTIBLEP
SOURCE OPULATION

TO ERADICATE THE DISEASE ONE MUST:

- ELIMINATE THE RESERVOIR/SOURCE

OF THE AGENT
- CUT OFF THE TRANSMISSION
- MAKE THE PEOPLE IMMUNE TO THAT
DISEASE