Professional Documents
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(EC08)
Module: EPM301 Epidemiology of Communicable Diseases
Course: PG Diploma/ MSc Epidemiology
This document contains a copy of the study material located within the computer
assisted learning (CAL) session. The first three columns designate which page,
card and screen position the text refers to.
If you have any questions regarding this document or your course, please
contact DLsupport via DLsupport@lshtm.ac.uk.
Important note: this document does not replace the CAL material found on your
module CDROM. When studying this session, please ensure you work through
the CDROM material first. This document can then be used for revision purposes
to refer back to specific sessions.
These study materials have been prepared by the London School of Hygiene & Tropical Medicine as part of
the PG Diploma/MSc Epidemiology distance learning course. This material is not licensed either for resale
or further copying.
London School of Hygiene & Tropical Medicine September 2013 v1.0
Objectives
By the end of this session, you should be able to:
Section 2: Introduction
During this study module, you have been introduced to some of the unique
characteristics of infectious disease epidemiology.
While many of the basic epidemiological skills you have been learning apply equally
to infectious and non-infectious disease epidemiology, there are specific issues that
need to be considered when dealing with infectious diseases.
The ability of an infectious agent to be transmitted between individuals, and the
characteristic of acquired immunity, require special methods of measurement and
analysis.
In this session you will review the topics covered during the unit. You will be directed
to references in your reader that combine some of these topics, to consider the
issues more comprehensively.
Section 4: Transmissibility
4.1: Transmissibility
The ability of infectious agents to be transmitted between individuals results in an
exponential increase of cases within a relatively short time period in a susceptible
population.
If one person transmits to 3 others, and each of these transmits to three others,
and so on (see diagram opposite), the number of cases can rapidly escalate.
4.2: Transmissibility
As you saw in session EC03, by quantifying the transmissibility of an infection,
epidemiologists are able to identify the potential scale of the problem.
The measurement of transmissibility, using the attack rate measure in different
age, social or behavioural groups, can be used to identify the individuals at
greatest risk of infection.
This can also identify the relative effectiveness of different modes of transmission,
and may help to determine appropriate public health interventions.
The secondary attack rate measure is generally used for infections that are
transmitted to household or other close contacts (e.g. tuberculosis) where the
contacts constitute an easily identifiable group of individuals that can be
investigated.
By contrast, the basic reproduction number is used to measure transmissibility
at a population level. This is difficult to measure directly, but can be inferred from
seroprevalence surveys or the average age at first infection for a disease that
confers life-long immunity.
4.3: Transmissibility
The transmissibility of infectious agents implicates them as an important cause of
disease increasingly so as the world's population grows, travels and congregates
in urban centres.
In a susceptible population, this characteristic can lead to outbreaks of infection in
which the disease burden is focused rather than being distributed throughout a
population over time. The detection, investigation and control of outbreaks are a
major focus of public health activities, increasingly so in countries where more and
more diseases are being brought under control.
In session EC04 you learned about the tools used to define an outbreak, to identify
the cause and routes of transmission, and to control the spread of infection.
This involves establishing the existence of the outbreak, collecting data and
describing the epidemiological characteristics of the disease. Subsequently,
hypotheses about the mode and source of transmission need to be tested, after
which an appropriate intervention must be recommended.
In the simulated outbreak investigation (session EC05), the exercise tried to
capture the urgency of problem. The transmissibility of infectious agents
dictates that the most important aspect of an outbreak investigation is rapid action.
4.4: Transmissibility
For outbreaks and endemic infections, blocking the transmission of infections is the
main target of public health activities. By studying the characteristics of the
infectious agent (EC01 & EC02) and its transmissibility (EC03), we can better
inform public health activities.
The dynamic spread of an infection through a population (completely or partially
susceptible) can help to identify whether or not an infection will be a problem in a
particular setting.
In session EC06 you were introduced to the methods of mathematical modelling of
infectious diseases. These allow quantification of the rate at which an infection will
be transmitted through a population, and can be used to indicate whether the
infection will die out, persist endemically, persist with regular epidemic peaks, etc.
Such methods can be used, with caution, to predict the future course of an
epidemic or the likely outcome of introducing a particular intervention.
Section 5: Immunity
Infectious agents may induce an immune response from the host in an attempt to
control the infection and reduce any harmful effects. The initial response is nonspecific, followed by a specific response involving the production of antibodies.
Some infectious agents are able to evade the immune response and can co-exist
with the host (as in the case of many macroparasites), or kill the host (as in the
case of HIV).
When an effective immune response has been produced, the presence of specific
antibodies or the body's ability to produce these antibodies can be used as an
immunological marker in epidemiological studies.
This is known as seroepidemiology, and the immunological markers are used to
indicate previous infection or in some cases protection from subsequent infection.
5.1: Immunity
The body's ability to defend itself from attack has been exploited by scientists in
the development of vaccines. Vaccines induce a specific immune response that
protects (partially or completely) against subsequent infection and/or disease due
to a specific infectious agent.
This is one of the most important approaches to the control of infectious diseases, as
it protects individuals and, if used on a large-scale, can benefit whole populations.
Interaction: Tabs: Vaccine efficacy:
However, vaccines are rarely completely protective to all individuals. The concept of
measuring the efficacy and effectiveness of a vaccine was discussed in session
EC07.
You saw that there are different methods of assessing vaccine efficacy, related to
study design. The relative benefits of these designs can vary according to the
mechanism of protection of the vaccine.
Section 6: Summary
This is the end of EC08. When you are happy with the material covered here please
move on to session EC09.
The main points of this session will appear below as you click on the relevant title.
In this unit we have focused on the study and measurement of characteristics of
infectious diseases. Such epidemiological studies are used to identify appropriate
methods of control and to assess the benefit of various interventions.
You should now have the basic tools necessary to identify pertinent questions in
infectious disease epidemiology and appropriate methodologies to answer such
questions.
To integrate some of the issues that have been raised in this unit, read the following
papers in your reader:
Interaction: Tabs: Guyer/McBean:
In the paper by Guyer and McBean (1981), the authors review the epidemiology and
control of measles in Cameroon during and after the introduction of mass
immunisation.
Consider the epidemiological characteristics (age and time patterns) of the disease
before and after the introduction of vaccination. Both surveillance data and
serological studies were used to assess the epidemiology of the disease.
Note that the age profile of the disease shifted towards the older age groups after
the introduction of vaccination.
Interaction: Tabs: Mossong/Muller:
Mossong and Muller (2000) have used a measles outbreak to estimate the local
vaccine efficacy and the transmissibility of the infection, drawing together concepts
from sessions EC03 C07. The paper includes some mathematics but do not worry
if you don't understand the formulae.
Note that mathematical modelling is used to estimate the vaccination coverage
necessary to minimise outbreaks in these partially vaccinated populations. However
the estimates are locally specific, and might not have a wider application due to
differences in vaccine coverage and vaccine efficacy.