Chapter 2

The Dynamics of Disease

Disease as an epidemiologic triad - disease is the product of an interaction

between the human host, an infectious or other type of agent and the
environment that promotes the exposure
o Vector (such as a mosquito or deer tick) is often involved
o Human susceptibility is determined by a variety of factors including
genetic background and nutritional and immunologic characteristics
o Immune status of an individual determined by many factors
including prior experience both with natural infection and
immunization
Host characteristics: age, sex, race, religion, customs, occupation, genetic
profile, marital status, family, background, previous diseases, immune
status
Agents: biologic (bacteria, viruses), chemical (poison, alcohol, smoke),
physical (trauma, radiation, fire), nutritional (lack, excess)
Environmental factors: temperature, humidity, altitude, crowding, housing,
neighbourhood, water, milk, food, radiation, air pollution, noise)

Modes of Transmission
Direct
o Person-to-person contact
Indirect
o Common vehicle
Single exposure
Multiple exposures
Continuous exposure
o Vector
Clinical and Subclinical Disease
Iceberg concept of disease - only clinical illness is readily apparent, but
infections without clinical illness are important to the web of disease
transmission though they are not visible clinically
o In the host: from subclinical (exposure without infection; infection
without clinical illness) to clinical disease (moderate severity mild
illness; classical and severe disease)
o In the cell: from below visual change (exposure without attachment
and/or cell entry; viral multiplication without visible change or
incomplete viral maturation) to discernible effect (inclusion body
formation; cell transformation; cell dysfunction)
Clinical Disease
Characteristed by signs and symptoms

Nonclinical Disease
Preclinical disease: not yet clinically apparent but destined to progress to
clinical disease
Subclinical disease: not clinically apparent and not destined to become
clinically apparent (often diagnosed by serologic [antibody] response or
culture of the organism
Persistent (chronic) disease: person fails to shake off the infection and it
persists for years, at times for life
Latent disease: infection with no active multiplication of the agent, as
when viral nucleic acid is incorporated into the nucleus of a cell as a
provirus; in contrast to persistent infection, only the genetic message is
present in the host, not the viable organism
Carrier Status
Carrier: person to harbors the organism but is not infected as measured
by serologic studies (no evidence of an antibody response) or by evidence
of clinical illness
o Person can still infect others, though infectivity is often lower
o May be of limited duration or may be chronic lasting years of
months
o Ex. Typhoid Mary cause 10 typhoid fever outbreaks
Endemic
Habitual presence of a disease within a given geographic area (fewer
cases over short time period)
Epidemic
Occurrence, in a community of region, of a group of illnesses of similar
nature, clearly in excess of normal expectancy and devices from a
common or propagated source (more cases over a longer time period)
Pandemic
Worldwide epidemic
Disease Outbreaks
Common-vehicle exposure - outbreak occurs in the group of people who
have eaten a food contaminated with a microorganism
o If food only served once: it is a single exposure
o If food served multiple times: multiple exposures to people who eat
it more than once
When water is contaminated with sewage the contamination can be either:
o Periodic - multiple exposures as a result of changing pressures in
the water supply system that may cause intermittent contamination
o Continuous - constant leak leads to persistent contamination

Single-exposure, common-vehicle outbreak very common, characterized

by:
o Outbreaks are explosive: sudden and rapid increase in number of
cases of a disease in a population
o Cases limited to people who share a common exposure
o In a food-borne outbreak, cases rarely occur in persons who
acquire the disease from a primary case (i.e. relative rarity of
secondary cases in these outbreaks - not well understood)
o Contamination from norovirus is the leading cause of food-borne
illness

Immunity and Susceptibility

Disease in a population depends on a balance between those who are
susceptible for the disease and those who are immune to the disease
o Observed in formerly isolated populations who have been exposed
to a disease, ex. 19th century, measles occurred in Faroe Islands in
an epidemic form when infected individuals entered the isolated
and susceptible population
Herd Immunity
Resistance of a group of people to an attack by a disease to which a large
proportion of the members of the group are immune (if a large percentage
of the population is immune, the entire population is likely to be protected,
not just those that are immune)
Reduces the likelihood of encounters between those infected and those
susceptible to infection
Not necessary to achieve 100% immunization rates to successfully
immunize a population (for measles it is 94% of the population)
Conditions to achieve herd immunity:
o Disease agent must be restricted to a single host species within
which transmission occurs
o Transmission must be relatively direct from one member of the host
species to another
o Infections must induce solid immunity
Incubation Period
The interval from receipt of infection to the time of onset of clinical illness
(time required for organism to replicate sufficiently until it reaches the
critical mass needed for clinical disease to result)
1374, Black Death in Europe: Venetian Republic appointed three officials
to inspect all ships entering the port to look for sick people
in 1377, the Italian seaport Raguso isolated travelers for 30 days after
arrival to see if infection developed, this was later expended to 40 days
(quarante giorni), and this is the origin of the word quarantine

different diseases have different incubation periods, and within a disease

there is often a range of incubation periods rather than a set time frame
o influenza has short incubation period
o rabies has long incubation period
epidemic curve: distribution of the times of onset of the disease

Three Critical Variables:

1. When did the exposure take place?
2. When did the disease begin?
3. What was the incubation period for the disease?
If we know any two of these, we can calculate the third.
Attack Rate
Number of people at risk in whom a certain illness develops / total number
of people at risk
Useful for comparing the risk of disease in groups with different exposures
Primary case: person who acquires the disease from the exposure (ex.
contaminated food sources)
Secondary case: person who acquires the disease from exposure to a primary
case.
Secondary attack rate: the attack rate in susceptible people who have been
exposed to a primary case
Exploring Occurrence of Disease
Three questions:
1. Who was attacked by the disease?
Characteristics of the human host are related to disease risk,
factors include sex, age, and race
2. When did the disease occur?
Certain diseases occur with a certain periodicity, which can
include specific seasons, public health campaigns, etc.
3. Where did the cases arise?
Geographic clustering of diseases can be caused by vector,
environmental factors, etc.
Steps in Investigating an Acute Outbreak
1. Define the outbreak and validate the existence of an outbreak
a. Define the numerator (cases)
i. Clinical features: is the disease known?
ii. What are its serologic or cultural aspects?
iii. Are the causes partially understood?

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b. Define the denominator: What is the population at risk of

developing the disease? (i.e. susceptible)
c. Determine whether the observed number of cases clearly
exceeds the expected number
d. Calculate the attack rates
Examine the distribution of cases by the following:
a. Time: look for time-place interactions
b. Pace
Look for combinations (interactions) of relevant variables
Develop hypothesis based on the following:
a. Existing knowledge (if any) of the disease
b. Analogy to diseases of known etiology
c. Findings from investigation of the outbreak
Test hypotheses
a. Further analyze existing data (case-control studies)
b. Refine hypotheses and collect additional data that may be
needed
Recommend control measures
a. Control of current outbreak
b. Prevention of future similar outbreaks
Prepare a written report of the investigation and the findings
Communicate findings to those involved in policy development and
implementation and to the public

Cross-Tabulation
Helpful in determining which of the possible agents is likely the cause, as
is often the case in a food-borne disease outbreak
Compare the attack rate for each exposure against each other
Conclusion: