OF

EPIDEMIOLOGY INFECTIOUS DISEASES

OUTLINE
Chain of infection Factors Affecting Communicability Herd Immunity Iceberg Concept of Infection

CHAIN OF INFECTION
Disease transmission involves a sequence of events that involves conveyance of the disease agent from its reservoir or source through a portal of exit, its spread by one of several modes of transmission, to a susceptible host through an appropriate portal of entry (Fig. 1).

Causative agent

The Chain Model of Infectious Diseases

Mode of transmission

Fig. 1. Chain of infection. Disease or infection occurs when the 6 key components in the chain are linked. Epidemiologic Methods for the Study of Infectious Diseases, Oxford University Press
2001

We shall illustrate this using AI as an example (Fig.2.

Enters the susceptible host (chickens) 5 AIV leaves its reservoir or 4 source through the portal of exit
pathogen 1 The is Avian Influenza virus.

AIV is transmitted through direct contact with Reservoir is infected materials 3 wild migratory 2 waterfowl. or through droplet nuclei. AIV exits the wild waterfowl through the feces. Fig. 1. Chain of Infection for AIV

Components of the Chain

INFECTIOUS AGENT bacteria, virus, parasite, fungus, prion or any organism that can cause infection/disease. RESERVOIR - The medium or habitat in which infectious agents thrive, propagate and multiply. SOURCE - Often the place where the agent originates where it lives, grows, and multiplies. PORTAL OF EXIT- pathway by which a pathogen leaves its host. MODE OF TRANSMISSION method by which the pathogen gets from the reservoir to the new host PORTAL OF ENTRY- pathway through which the pathogen enters its new host SUSCEPTIBLE HOST- animal that is at risk for developing an infection from the disease.

RESERVOIRS AND SOURCES OF INFECTION

Reservoirs
Animate or inanimate

>1 species
Unidentified Varies with the locale

Important in control

Endemic / Natural Cycle Bird-mosquito cycle RESERVOIRS

Ardeola grayii (pond heron) Bubulcus ibis (cattle egret),

Amplification cycle

JAPANESE ENCEPHALITIS

Rice fields

Farms

Dead-end hosts Rural infections Rural & peri-urban infections

Pig/ducklingmosquitopig/duckling cycle exist in nature. Amplifying hosts

Reintroduction of infected mosquitoes or vertebrates

Bird mosquito cycle is important in maintaining and amplifying JEV in the environment.

Vertical transmission Infected Vertebrate Reservoirs

Japanese encephalitis Life Cycle

Taeniasis
Leakage of raw sewage onto pasture following Cysticercosis floods Muncipal sewage sludge application on the farm Defecation of in feed/water Infection of cattle prior to arrival

Taeniasis

Ingestion of infected meat

Definitive Host

Intermediate Host

Definitive Host

Fig. Taeniasis saginata and cysticercosis transmission cycle

Carriers
Silent infection Not essential for perpetuation Caution - some: vaccinated Important in Incubatory control

Convalescent

Inanimate objects

Fomites - some examples

ROUTES AND MODES OF TRANSMISSION

Skin, Hair
Anus Placenta Semen Urogenital Respiratory tract tract Gastrointestinal Conjunctiva Mouth, nose

Mammary

Circulatory system

Fig. Portals (routes) of Entry and Exit in Vertebrate Animals

Some examples of ports of entry and exit are described in the next slides.

Oral Route
Rotavirus

B. abortus

Feeds, water

Respiratory route
Dusts Droplets Droplet nuclei
>5 nm < 5 nm

Poor ventilation High population density

Cornea

Mucous membrane
urogenital tract

localized M. bovis
generalized - NDV

Labile agents:

Trypanosoma equiperdum

Skin route
Intact Cuts or abrasions Bites by animals and vectors Direct contact w/ organisms e.g. ringworm Penetration e.g., hookworms

Localized - e.g. B. anthracis

Generalized - leptospires

Veterinary Procedures

Mass vaccination without changing needles

Catheterization/endoscopy with contaminated equipment

Transfusion with contaminated fluids

Rectal palpation withou changing sleeves

There can be more than one route of entry/exit What is the primary route?

CAUTION Do not overlook other routes Veterinary procedures

Portal of exit

MODE OF TRANSMISSION
Direct Indirect HORIZONTAL
Vehicle
Vectorborne

Portal of entry

Agent(s) in source VERTICAL

Airborne

Contact Droplet spread Propagative Developmental Cyclopropagative Mechanical Biological Droplet nuclei Dust

Susceptible hosts

In utero Transovarial Colostral

Fig. Ways in which infectious agent are transmitted from affected to susceptible animals Source: AVET Manual.

FAO.

VERTICAL TRANSMISSION Transmission of disease agents from one generation to another through sperm, placenta, milk, egg or vaginal fluids. HORIZONTAL TRANSMISSION Transmission of disease agents from an infected individual to a susceptible contemporary.

Two general modes of horizontal transmission

1. Direct transmission
The direct and immediate transfer of an agent from a host/reservoir to a susceptible host. Can occur through direct physical contact such as exposure to an animal or its waste products.

EXAMPLES Anthrax from direct contact with an infected animal, across placenta (toxoplasmosis), fecal-oral and ingestion of infected food (trichinosis)

Horizontal Transmission
2. Indirect transmission Transfer or carriage of an agent by some intermediate item, organism, means or process to a susceptible host, resulting in disease.
MEANS OF INDIRECT DISEASE TRANSMISSION Fomites, vectors, air currents, dust particles, water, food, oral-fecal contact and other mechanisms that effectively transfer disease-causing organisms

MODE OF TRANSMISSION
Direct Transmission Direct Contact: bites, licks, touch, sexual intercourse, droplet spread Droplets sneezing, coughing, sniffing or bellowing
Indirect Transmission Airborne: droplet nuclei dust: particles from soil, clothes, bedding, contaminated floors Vehicle inanimate objects Vector invertebrate animals Mechanical: flies, roaches, Biological : lice, mites, mosquitoes, ticks VERTICAL TRANSMISSION Transovarial via the egg In utero within uterus Colostral via colostrum or milk

Disease examples
Rabies, cutaneous anthrax Mycoplasmosis

Histoplasmosis

Salmonellosis, Paratuberculosis, FMD Schistosomiasis, Filariasis, Dengue Tick infestation Salmonellosis in chickens

Airborne transmission A form of indirect transmission Conveyance of droplets or dust particles containing the pathogen to the host to cause infection.
MEANS OF AIRBORNE TRANSMISSION Sneezing, coughing, bellowing, barking, spraying microscopic pathogen carrying droplets into the air that can be breathed in a nearby susceptible hosts. Through conveyance of droplets through a buildings heating or airconditioning ducts spread by fans

Vector-borne transmission Conveyance of the infectious agent through a vector such as lice, mice, ticks, mosquitoes. a) Mechanical vector-borne transmission The pathogen, in order to spread, uses a host (e.g., fly, flea, louse) as a mechanism for a ride, for nourishment, or as part of a physical transfer process.
b) Biological transmission The pathogen undergoes changes as part of its life cycle while within the host/vector and before being transmitted to the new host

BOX 1. Direct contact as a mode of transmission forToxocara canis infection Contaminated soil is considered the traditional means of transmission. Contaminated hair ?

Types of Vectors

Flying

Non-flying

Swimming

May have >1 vector Important in control, prediction

Mosquitoes as Vectors
Flight range Biting patterns - indoor/outdoor - nocturnal/diurnal Biting frequency Host preference Habitat

Vehicle Transmission
CYCLOPROPAGATIVE PROPAGATIVE PROPAGATIVE Multiplication staphylococci in milk
Multiplication & development of Strongyloides in soil

DEVELOPMENTAL
Development of nematode eggs in soil

Increasing hosts defenses Recognition of Susceptible Host

Protecting portals of entry Prevent a route of transmission Interrupt transmission

Control portals of exit

Control of agent Pathogen identification Controlling or eliminating agent at source of transmission Reservoir /Source identification & control

The choice of methods depends on.

Availability of proper tools and techniques Relative cost effectiveness, efficiency & acceptability Stakeholders participation or involvement eg., producers, community, industry Political support Intersectoral coordination

Knowledge of the chain of infection provides the basis for determining the appropriate control measures. Every disease has some weak points in the chain that are susceptible to attack.

Control measures can be delayed due to:

Incomplete knowledge of the disease agents; Reservoirs or sources of infection Routes of transmission The susceptible hosts

Implications to disease control Identifying the weak points break the weakest links in disease transmission. Weakest Links? Controlling the reservoirs Interruption of transmission Protect the susceptible host

FACTORS AFFECTING COMMUNICABILITY

The ease with which a disease agent is spread within a population

BASIC REPRODUCTIVE NUMBER Average no. of secondary infections generated by one primary case in a susceptible population R = Ro x (1 P) The average number R = effective reproductive no.of secondary infections Ro = Basic reproductive no. generated by that oneisprimary P = proportion immune case in a susceptible pop1ulation R=1 Conditions supporting endemic disease exist.
R>1 No. infected animals can increase (epidemic?) R<1 Disease frequency declines (eradication?)

BASIC REPRODUCTIVE NUMBER

Depends on: Duration of infectious period Probability that a contact between an infective and susceptible individual will lead to an infection No. of new susceptible animals contacted per unit of time.

Ease of transmission
FMD Ro=70 IBR Ro=7

Ave. no. susceptible animals infected by each infected animal.

Other Factors
ENVIRONMENT

AGENT
Life cycle Minimal infectious dose

HOST FACTORS
Heterogeneity Immunity

Extrinsic Incubation Period Time between infection of a biological vector and acquisition of the biological vector of the ability to transmit the agent to another susceptible vertebrate host.

A G E N T

Prepatent period- Agent in secretions, excretions, blood or tissues Communicable period- time during which a disease agent may be transferred directly or indirectly from one infected animal to another, including invertebrate vectors.

A G E N T

Minimal Infective Dose The lower the minimal infective dose, the more readily the agent is transmitted.

H O S T F A C T O R S

Heterogeneity Individual variation in disease susceptibility: some are particularly susceptible.

Immunity Vertebrates develop stronger immune response than do metazoans.

Sources

Dust Solid matter, fabrics, etc 10-100m Hovers in clouds

Droplet Fluids from nose, throat >100 m Immediate in space <1m Best by face mask

Particle diameter Flight range Removal from air Control

45

Droplet nuclei Solid residues of evaporated droplets 2-10 m Dispersed thru out confined atmospheres Electrostatic precipitation Ventilation (air change &equivalent air disinfection)

Filtration and electrostatic precipitation Air cleanliness, Spacing out moistening, oiling, etc.

Dust Vulnerability Resistant

Droplet

Droplet nuclei

Mode of infection

Endemic infection of nose and throat

Indeterminate Vulnerable to chemical and physical agents Contact Epidemic infection contagion

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HERD IMMUNITY

Herd Immunity
When proportion of immune animals in the population is above the threshold level, the infection will die out in that population.

ICEBERG CONCEPT OF INFECTION

ICEBERG CONCEPT OF INFECTION

PhP PhP PhP

Susceptible in the future or resistant as a consequence of past exposure

CELL RESPONSE
Lysis of cell
Discernible effect Cell transformation

HOST RESPONSE
Fatal Clinical & severe disease Moderate severity Mild illness
Clinical disease

or cell dysfunction

Below visual change

Incomplete viral maturation Exposure without cell entry

Infection without Sublclinical clinical illness disease Exposure without infection

Fig. Iceberg concept of infection (Friies & Sellers, 2009)

Iceberg concept
Clinical cases are seen - subclinical infections are not

If only clinical cases are given an intervention, - mistake: Recovery as due to intervention