Infectious Disease Epidemiology

Principles of Epidemiology Lecture 7

Dona Schneider, PhD, MPH, FACE

Concepts in Infectious Epidemiology

Agent, host, environment
Classification of human infections by modes of transportation Incubation period Spectrum of disease

Herd immunity

Epidemiology (Schneider)

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
Epidemiology (Schneider)

Epidemiologic Triad Concepts

Infectivity ability to invade a host

(# infected / # susceptible) X 100

Pathogenicity ability to cause disease

(# with clinical disease / # of infected) X 100

Virulence ability to cause death

(# of deaths / # with disease (cases)) X 100

All are dependent upon the condition of the host

-

Immunity (active, passive)

Nutrition Sleep

Hygiene

Mode of Transmission
Person-to-person (respiratory, orogenital, skin)
Examples: HIV, measles

Vector (animals, insects)

Examples: rabies, yellow fever

Common vehicle (food, water)

Examples: salmonellosis

Mechanical vectors (personal effects) such as doorknobs, or toothbrushes are called FOMITES
Epidemiology (Schneider)

Classification by Mode of Transmission

Dynamics of Spread through Human Populations

Spread by a common vehicle

Ingestion

Salmonellosis

Inhalation
Inoculation

Legionellosis
Hepatitis

Propagation by serial transfer from host to host

Respiratory
Anal-oral Genital

Measles
Shigellosis Syphilis

Epidemiology (Schneider)

Principle Reservoir of Infection Man Infectious hepatitis Other vertebrates (zoonoses) Tularemia Agent free-living Histoplasmosis Portal of Entry/Exit in Human Host Upper respiratory tract Diphtheria Lower respiratory tract Tuberculosis Gastrointestinal tract Typhoid fever Genitourinary tract Gonorrhea Conjunctiva Trachoma Percutaneous Leptospirosis Percutaneous (bite of arthropod) Yellow fever
Epidemiology (Schneider)

Cycles of Infectious Agent in Nature

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

Complex Cycles
Helminth infections River blindness

Epidemiology (Schneider)

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

Epidemiology (Schneider)

Each infectious disease has a characteristic incubation period, dependent upon the rate of growth of the organism in the host and Dosage of the infectious agent Portal of entry Immune response of the host Because of the interplay of these factors, incubation period will vary among individuals For groups of cases, the distribution will be a
curve with cases with longer incubation periods creating a right skew

Epidemiology (Schneider)

Spectrum of Disease

Exposure

Subclinical manifestations
Pathological changes

Symptoms

Clinical illness
Time of diagnosis

Death
Whether a person passes through all these stages will depend upon infection and prevention, detection and therapeutic measures

Epidemiology (Schneider)

Iceberg Concept of Infection

CELL RESPONSE HOST RESPONSE
Lysis of cell
Discernable Cell transformation effect or Cell dysfunction

Fatal
Clinical and severe disease Moderate severity Mild Illness Clinical Disease

Incomplete viral Below visual maturation change Exposure without cell entry

Infection without clinical illness Subclinical

Disease
Exposure without infection

Spectrum of Disease (cont.)

Example

90% of measles cases exhibit clinical symptoms

66% of mumps cases exhibit clinical symptoms <10% of poliomyelitis cases exhibit clinical symptoms

Inapparent infections play a role in transmission. These are distinguished from latent infections where the agent is not shed
Epidemiology (Schneider)

Subclinical/Clinical Ratio for Viral Infections

Virus
Clinical feature Age at infection Estimated ratio Clinical cases 0.1% to 1.0% 1% 1% to 10% 50% to 75% 5% 10% 14% 80% to 95% 50% 60% >99% >>>>99%

+ 1000:1 Paralysis Child Polio Epstein-Barr Mononucleosis 1 to 5 years > 100:1 6 to 15 years 10:1 to 100:1 16 to 25 years 2:1 to 3:1 Hepatitis A Icterus < 5 years 20:1 5 to 9 years 11:1 10 to 15 years 7:1 Adult 1.5:1 Rubella Rash 5 to 20 years 2:1 Influenza Fever, cough Young adult 1.5:1 Measles Rash, fever 5 to 20 years 1:99 CNS symptoms Any age <1:10,000 Rabies

Herd Immunity

The decreased probability that a group will develop an epidemic because the 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

Epidemiology (Schneider)

Investigating an Epidemic
Determine whether there is an
outbreak an excess number of cases from what would be expected
There

must be clarity in case definition and diagnostic verification for each case

Investigating an Epidemic (cont.)

Plot an epidemic curve (cases against
time)

Calculate attack rates

If there is no obvious commonality for the outbreak, calculate attack rates based on demographic variables (hepatitis in a community) If there is an obvious commonality for the outbreak, calculate attack rates based on exposure status (a church supper)
Epidemiology (Schneider)

Investigating an Epidemic (cont.)

Determine the source of the epidemic
If there is no obvious commonality for the outbreak, plot the geographic distribution of cases by residence/work/school/location to reduce common exposures If there is an obvious commonality for the outbreak, identify the most likely cause and investigate the source to prevent future outbreaks
Epidemiology (Schneider)

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

Epidemiology (Schneider)

Calculation of Attack Rate for Food X

Ate the food (exposed) Did not eat the food (not exposed) Ill Well Total Attack Ill Well Total Attack Rate Rate

10

13

76%

11

64%

Attack Rate = Ill / (Ill + Well) x 100 during a time period

Attack rate = (10/13) x 100 = 76% ( 7/11) x 100 = 64% RR = 75/64 = 1.2
Epidemiology (Schneider)

Secondary Attack Rate

Secondary Total number of cases initial case(s) x 100 attack rate = Number of susceptible persons (%) in the group initial case(s)

Used to estimate to the spread of disease in a family, household, dorm or other group environment. Measures the infectivity of the agent and the effects of prophylactic agents (e.g. vaccine)

Epidemiology (Schneider)

Mumps experience of 390 families exposed to a primary case within the family
Population
Age in years

Cases

Total
300 450 152

No. susceptible before Primary primary cases occurred

Secondary
50 87 15

2-4 5-9 10-19

250 420 84

100 204 25

Secondary attack rate 2-4 years old = (150-100)/(250-100) x 100 = 33%

Epidemiology (Schneider)

Case Fatality Rate

Case fatality = Number of cases of disease X rate (%)
Number of deaths due to disease X

x 100

Reflects the fatal outcome (deadliness) of a disease, which is affected by efficacy of treatment

Epidemiology (Schneider)

Assume a population of 1000 people. In one year, 20 are sick with cholera and 6 die from the disease.
The cause-specific mortality rate in that year from cholera =

6 1000

= 0.006 = 0.6%

The case-fatality rate from cholera =

6 = 0.3 = 30% 20
Epidemiology (Schneider)