Dynamics of Disease

Transmission
 Objectives
• At the end of lecture students will be able
to :
– Understand iceberg phenomenon of disease
– Know definitions of important terms i.e.
epidemic, endemic and pandemic
– Explain herd immunity
– Understand steps of outbreak investigation
 Spectrum of disease
• The idea that an exposure can lead to
varying signs, symptoms and severity of
the same disease in the population is the
spectrum of disease.
• Why do we have varying degrees of
severity?
• The outcome will depend on the
interactions of host, agent and
environmental factors.
 Factors Affecting Disease Transmission

VECTOR -- Susceptibility
-- Prevalence Host -- Immune response
-- Portal(s) of entry -- Resistance
--- Portal(s) of entry

Vector
Agent Environment

-- Balance of immune to
-- Virulence Toxigenicity susceptible individuals
-- Infectivity Resistance --- Opportunity for
-- Pathogenicity Antigenicity exposure (e.g. crowding)
Routes of transmission
 Timeline for Infection

Infection
Dynamics of Latent Infectious Non-infectious
infectiousness period period

Susceptible
Time
Infection

Dynamics of Incubation Symptomatic Non-diseased

disease period period

Susceptible
Time
 Transmission

Cases
• Index – the first case identified
• Primary – the case that brings the
infection into a population
• Secondary – infected by a primary case
• Tertiary – infected by a secondary case
Classification of diseases according to
spectrum

Examples: Tuberculosis, Polio, Hepatitis A, Meningitis, AIDS

(Low pathogenicity and low virulence)
 Examples: Measles, Chickenpox
(High pathogenicity & low virulence)

Examples: Rabies, Hemorrhagic fevers caused by Ebola and Murberg

viruses.

(High pathogenicity & high virulence)

 Iceberg Phenomenon
• Cases of illness correctly diagnosed by clinicians in the community
often represent only the “tip of the iceberg.”
• Many additional cases may be too early to diagnose or may remain
asymptomatic.
• Examples: Tuberculosis, meningitis, polio, hepatitis A, AIDS.
• The risk is that persons with in-apparent or undiagnosed infections
may be able to transmit infection to others.
Iceberg Phenomenon

Diagnosed
disease

Undiagnosed or
wrongly diagnosed disease
 Iceberg Phenomenon--application
• Persons with in-apparent or undiagnosed infections can
transmit infections to others.
• Control measures must not be directed solely for
clinically apparent cases.
• Control measures must be directed toward all infections
capable of being transmitted to others;
– both clinically apparent cases and
– those with in-apparent or undiagnosed infections.
 Important terms
Reservoir
• A host that carries a pathogen without injury to
itself and serves as a source of infection for
other host organisms (asymptomatic infective
carriers)
Endemic
• The constant presence of a disease or infectious
agent within a given geographic area or
population group; may also refer to the usual
prevalence of a given disease within such area
or group.

Epidemic
• The occurrence of more cases of a disease than
expected in a given area or among a specific
group of people over a particular period of time.
Pandemic
• An epidemic occurring over a very wide area
(several countries or continents) at the same
time and usually affecting a large proportion of
the population.
e.g. Influenza, cholera
Outbreak
• A more or less localized epidemic affecting
large number of a group, in the community
e.g. outbreak of food poisoning
Sporadic
• Cases occur irregularly, haphazardly from
time to time and generally infrequently.
• Cases are few and separated widely in
space and time showing no connection to
each other.
 Endemic-epidemic-pandemic
Cases

Time

 Endemic
 Transmission occur, but the number of cases remains constant
 Epidemic
 The number of cases increases
 Pandemic
 When epidemics occur at several continents – global epidemic
 esa Cf o
Epidemic vs Endemic

Epidemic
Endemic
esaesi D arfeob sNu
m

Time
 Herd effect (Herd immunity)
Immunised individuals provide indirect protection to
susceptible (unvaccinated, partially vaccinated)
individuals:

  
    
  
 Herd effect (Herd immunity)
• Most mass vaccination provides herd
immunity
• Protection occurs even when vaccination
coverage is less than 100% of the population
• The greater the infectivity (reproductive rate)
of a disease, the higher the immunisation
rate needed to achieve herd immunity
 What is an outbreak ?
• Occurrence of more cases of disease than
expected

– in a given area
– among a specific group of people
– over a particular period of time
 Food-or waterborne outbreak
(WHO definition)
• two or more persons
• similar illness
• after ingestion of the same type of food or
water
• from the same source
• epidemiological evidence - the food or the
water - the source of the illness
 Why investigate outbreaks?
• Stop the outbreak
– Find and neutralise the source (cause)
– Prevent additional cases
• Prevent future outbreaks
• Improve surveillance and outbreak detection
• Improve our knowledge
• Keep the public’s confidence
• Training
 Steps of an outbreak
investigation
• Confirm outbreak and diagnosis
• Define a case

Control measures
• Identify cases & obtain information
• Describe data collected and analyse
• Develop hypothesis
• Test hypothesis: analytical studies
• Special studies
• Communicate results,
– including outbreak report
• Implement control measure
 Routine surveillance
Clinical / Laboratory
Detection General public
Media
 Confirm outbreak and diagnosis
Is this an outbreak?
• More cases than expected?
• Surveillance data
• Surveys: hospitals, labs, physicians

Caution!
• Seasonal variations
• Notification artefacts
• Diagnostic bias (new technique)
• Diagnostic errors (pseudo-outbreaks)
 Cases of legionellosis by week of notification
France, January 1996 - August 1997

0
1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 3

1996 Week of notification 1997

 Cases of legionellosis by week of notification
France, January 1996 - August 1997

8 National meeting:
legionellosis diagnosis and
7 reporting
6

0
1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52
 Confirm outbreak and diagnosis
• Laboratory confirmation
• Contact (visit) the laboratories
• Meet attending physicians
• Examine some cases

Not always necessary to confirm all the

cases
but confirm a proportion
throughout the outbreak
 Outbreak confirmed 

Immediate control Further

measures? investigation?
- prophylaxis - aetiological agent
- exclusion / isolation - mode of transmission
- public warning - vehicle of transmission
- hygienic measures - source of contamination
- others - population at risk
- exposure causing illness
 Outbreak confirmed,
further investigations warranted

Epidemiologist
Microbiologist
Form Outbreak Clinician
Control Team? Environmentali
st
Engineers
Veterinarians
Others

Team coordinates
field investigation
 Descriptive epidemiology

- Who are the cases? (person)

- Where do they live? (place)

- When did they become ill? (time)

 Case definition
• Simple, practical, objective
• Sensitive?
• Specific?
• Multiple case definitions
– confirmed
– probable
– possible
 notifications
laboratories
Identify & hospitals, GPs
count cases schools
workplace,
cases,
media, etc
 Identify &
count cases

Obtain
information

Identifying information
Demographic information
Clinical details
Exposures and known
risk factors
 Identify &
count cases

Obtain
information

Describe in
Analysis of - time
descriptive data - place
- person
 Place
• Place of residence
• Place of possible exposure
– work
– meals
– travel routes
– day-care
– leisure activities

• Maps
– identify an area at risk
 Person
• Distribution of cases by age, sex, occupation,etc (numerator)
– 60 female
– 50 male

• Distribution of these variables in population (denominator)

– 600 females
– 350 males

• Attack rates
– female: 60/600
– Males: 50/350
 Develop hypotheses

- Who is at risk of becoming ill?

- What is the disease?

- What is the source and the vehicle?

-What is the mode of transmission?

 Compare hypotheses
with facts

Test specific hypotheses

Analytical studies
- cohort studies
- case-control studies
 Testing hypothesis
• Cohort
– attack rate exposed group
– attack rate unexposed group

• Case control
– % of cases exposed
– % of controls exposed
 Verify hypothesis
Special investigations/studies

• Microbiological investigation
• Environmental investigation
• Veterinarian investigation
• Trace back investigations (origin of foods)
• Entomological investigations
 Implement control measures

May (must) occur at any At first, general measures

time during the outbreak!! According to findings,
more specific measures

1) Control the source of pathogen

2) Interrupt transmission
3) Modify host response
 Outbreak report
• Regular updates during the
investigation
• Detailed report at the end
– communicate public health messages
– influence public health policy
– evaluate performance
– training tool
– legal proceedings
 References
• http://www.dorak.info
• Tayal,S. Assistant professor King Saud
University
• Leon Gordis. Epidemiology (3rd ed.)