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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:
explain what infectious diseases are and why they are important.
describe the characteristics of infectious agents that influence transmission.
describe the characteristics of host populations that influence transmission.
This session should take you between 2 and 2.5 hours to complete.
Spanish invaders.
In 1919, after the First World War, the
global epidemics of influenza killed an
estimated 20 million people during one
year - more than died as a result of the
war.
Note:
On this plot, and others in the study module, you can click on the small symbol
in the corner of the diagram to see information about the source of the image.
DALY
Disability Adjusted Life Years, a measure of disease burden.
It includes years of life lost due to premature death, and years of healthy life lost
due disability or illness.
Recurring episodes of illness and long-term disability have a major economic
impact on the developing countries most affected by infectious diseases.
Interaction: Tabs:
Example 3 : output
Chronic infection with hepatitis B or C can cause primary hepatocellular carcinoma
(HCC). HCC is among the most common cancers in many parts of Africa and Asia.
Show: output
example: output
Since the mid-1980s there has been a major resurgence of diphtheria in several
countries of Eastern Europe, which had previously been progressing towards
elimination of the disease. In 1993, 15,211 diphtheria cases were reported in
Russia and 2,987 cases in Ukraine. The main reason for the return of diphtheria in
these countries was a decreased immunisation coverage due to an irregular supply
of vaccines and large-scale population movements
(Galazka et al 1995).
Interaction: Hyperlink:
Example
example: output
The mechanisms involved in many infectious diseases are well understood, from
the molecular aspects of the infectious agent to the demographic characteristics
of host populations. This level of understanding has enabled potentially very
effective prevention and control measures to be developed for some infectious
diseases.
With efficient intervention strategies and the advent of national public health
agencies, elimination of specific infectious diseases has become feasible. In some
cases, there has even been the possibility (or reality) of global eradication.
Following the successful WHO programme for the global eradication of smallpox
through vaccination, the last naturally acquired case of this disease occurred in
October 1977 in Somalia.
The countries of the Western Hemisphere have set a target for the elimination of
measles by the end of the year 2005.
The Global Polio Eradication Initiative was established in 1988 following a
resolution of the World Assembly to eradicate poliomyelitis. Strategies to
immunise millions of children on the same day have resulted in few countries now
reporting cases due to wild poliovirus.
Dracunculiasis (guineaworm) is now also on the verge of eradication. After
intensive, globally co-ordinated programmes, the number of reported cases has
dropped from almost 3.5 millions in 1986 to less than 2000 in 2010, and the
disease remains endemic only in 4 countries (Ethiopia, Ghana, Mali and Sudan).
Click below for an illustration of this.
The time in the infection process between becoming infected and being able to
transmit the infection.
Interaction: Hyperlink: infectious: output (appears in new window)
Infectious
An infectious individual is one that is able to transmit an infectious agent to another
individual.
The infectious period, also known as the period of communicability, is the period of
the infection process during which the infected individual is infectious.
Interaction: Hyperlink: non-infectious: output (appears in new window)
Non-infectious period
The final stage in the infection process when an individual is no longer able to
transmit the infectious agent, either because they have cleared the infection through
an effective immune response or intervention treatment, or because they have died.
Interaction: Hyperlink: incubation: output (appears in new window)
Incubation period
The time from initial infection to the onset of symptoms and/or signs of clinical
illness.
Interaction: Hyperlink: incubation: output (appears in new window)
Symptomatic period
The time during which symptoms and/or signs of the disease are evident.
Symptoms refer to characteristics associated with feeling unwell, such as fever,
coughing, etc., while signs refer to measurable characteristics of being unwell, such
as body temperature, mean haemoglobin level, etc.
That's correct. The immune state is that which occurs after the individual
has cleared the infection, is no longer infectious and no longer susceptible
to future infection with the same infectious agent.
Incorrect response (drag to all other boxes)
Incorrect
Interaction: Drag and Drop: Suscept. (years)
Correct response (drag to bottom LHS box):
That's correct. An individual is susceptible prior to becoming infected.
Incorrect response (drag to all other boxes)
Incorrect
Interaction: Drag and Drop: Infectious (days)
Correct response (drag to bottom centre RHS box):
That's correct. The infectious period occurs after the individual has become
infected and the infectious agent has had some time to develop and
reproduce. It partially overlaps with the appearance of clinical illness.
Incorrect response (drag to all other boxes)
Incorrect
Interaction: Drag and Drop: Latent (days)
Correct response (drag to bottom centre LHS box):
That's correct. The latent period is the interval between getting infected and
becoming infectious.
Incorrect response (drag to all other boxes)
Incorrect
Interaction: Drag and Drop: Incubation (days)
Correct response (drag to top centre box):
That's correct. The incubation period is the interval between the point of
infection and the onset of symptoms (illness).
Incorrect response (drag to all other boxes)
Incorrect
As you can see, for an acute infection the average duration of the latent and
infectious stages is short when compared with the susceptible and immune stages.
For chronic infections, such as Hepatitis B and HIV and most helminth infections, the
infectious period can last for many years. You will see later in this session, how
patterns of infection vary between infections.
Interaction: Tabs:
The abundance of the infectious agent is relatively low at the time of infection, but
increases with time. This is only the case for microparasites, which multiply within
the host.
Often, the onset of illness (symptoms) is associated with the occurrence of large
numbers of the infectious agent. This is because the symptoms are due to toxins
produced by the infectious agent, or due to the immune response to the infection
(e.g. fever), both of which will be proportional to the abundance of the infectious
agent._
Interaction: Tabs:
Note that the latent period overlaps with the incubation period, but they are not
identical. An individual may be infectious before displaying any symptoms of disease,
and may remain infectious after the symptoms have gone. In fact, for some
infections, the individual may remain asymptomatic throughout the infection, but
still be infectious. This inability to identify all sources of infection makes it more
difficult to measure the transmissibility of infectious diseases (as you will see in
session EC03), and to target appropriate control measures.
Interaction: Hyperlink: asymptomatic: output (appears in new window)
Asymptomatic
An asymptomatic individual is one that is infected and potentially infectious, but does
not exhibit any symptoms of the disease. In fact the individual may not suffer any
obvious adverse effects from the infection, and can be quite healthy.
(back to tabs)
Interaction: Tabs:
Finally, you can see that the end of the symptomatic period is associated with a
decline in abundance of the infectious agent and with the build-up of specific
antibody. This represents the development of an effective specific immune
response, which eliminates the infection and therefore the disease.
For some infectious agents, this immune response is associated with subsequent
protection from infection with the same agent and this is known as the immune
state.
Interaction: Hyperlink: immune: output (appears in new window)
Immune
An immune individual is one that is resistant to infection with a particular infectious
agent due to a biological mechanism of defence.
Source
The specific immune response can have a memory component that enables the
immune system to recognise an infectious agent that has caused infection
previously. This
immunological memory is stimulated by recognition of the specific antigens
involved, by circulating antibodies, and may result in the immune system
preventing re-infection with the same infectious agent.
Measurement of these antibodies can sometimes indicate whether an individual is
protected from re-infection, if the specific antibodies are known to be correlated with
protection against infection.
Interaction: Hyperlink:immunological memory: output (appears in new
window):
Immunological memory
The enhanced immune response that occurs following re-infection with the same
infectious agent.
Acute, self-limited infections are generally viruses and bacteria that induce
lasting immunity to re-infection.
Can you think of some examples of infections that show this pattern?
The duration of infection can usually be measured in days, and protective immunity
is often lifelong.
Interaction: Hyperlink: source: output (appears in new window)
Source:
Mims CA, Playfair JHL, Roitt IM, Wakelin D and Williams R. Medical Microbiology.
London, St Louis: Mosby; 1993.
Interaction: Tabs: 2 : output
Latent infections induce an initial acute infection with subsequent recovery and
persistence in a non-infectious latent form that 'hides' from the immune system for
years. This latent form can then be reactivated at a later stage, when it multiplies
causing disease and producing infectious material. The causes of reactivation are
unclear, but have been associated with immunosuppression
(e.g. stress-induced, HIV infection).
Examples button
Interaction: Hyperlink: source: output (appears in new window)
Source:
Mims CA, Playfair JHL, Roitt IM, Wakelin D and Williams R. Medical Microbiology.
London, St Louis: Mosby; 1993.
Inter
output
action: Tabs: 4 :
Persistent slow infections with no acute stage are rare, and refer to long-term
infections that multiply and build-up over many years.
The best example of this is the spongiform encephalopathy, Creutzfeld-Jakob
disease, which is thought to be caused by a prion infection of the central nervous
system. The disease only becomes apparent after many years, and is often confused
with other forms of dementia.
Interaction: Hyperlink: source: output (appears in new window)
Source:
Mims CA, Playfair JHL, Roitt IM, Wakelin D and Williams R. Medical Microbiology.
London, St Louis: Mosby; 1993.
Example
Houseflies can act as mechanical vectors of Entoamoeba histolytica, which causes
the intestinal illness amoebiasis. The fly lands on a contaminated surface where it
picks up infected material on its legs. It can then transport this infective matter to
food.
A biological vector is one in which the infectious agent undergoes multiplication or a
necessary stage of development.
Interaction: Button: Example: output (appears in new window)
Example
The female Anopheles mosquito is a biological vector of Plasmodium falciparum, the
protozoan parasite that causes malaria. The mosquito ingests the sexual stages of
the parasite when she feeds on an infectious person. The parasite then undergoes
sexual reproduction and a period of development and multiplication, before the
infectious sporozoites are injected into the person on whom the mosquito next
feeds.
For an infection that is directly transmitted, there will be many opportunities for
effective contact, while for a sexually transmitted infection the opportunities will be
fewer. Because of this, the duration of infectiousness is likely to differ between
infections according to the mode of transmission.
Interaction: Button: Example: output (appears in new window)
Example
Individuals with influenza will only be infectious for a number of days, while those
with HIV will be infectious for many years. This is necessary to ensure that there are
sufficient opportunities of effective contact so that the infection can be transmitted.
Section 7: Summary
This is the end of EC01. When you are happy with the material covered here please
move on to session EC02.
The main points of this session will appear below as you click on the relevant title.
Importance of infectious diseases 1
Infectious diseases are responsible for a large amount of the disease, suffering and
mortality worldwide, and this is recognised by the World Health Organisation.
Infectious disease epidemiology is a growing field. In recent years infectious agents
have been shown to be responsible for chronic diseases such as many cancers. A
number of new infections and diseases have been identified. Diseases previously
thought to be under control are re-emerging due to failing control programmes or
drug resistance.
Importance of infectious diseases 2
(link takes you to relevant page)
Due to their particular characteristics, infectious diseases can lead to large
outbreaks of disease, and this is especially evident in urban settings. With the
increasing urbanisation and globalisation of recent and coming years, infectious
diseases will be causing problems on a world-scale for many years to come.
Because infectious agents do not recognise political boundaries, global alliances to
combat infectious diseases are on the increase in the form of collaborative research
and global eradication programmes.
Infectious agents
(link takes you to relevant page)
Infectious agents can be categorised as microparasites (prions, viruses, bacteria,
protozoa and fungi) and macroparasites (helminths and arthropods).
These categories have implications for modes of transmission, duration of infection,
and measurement of infection in epidemiological studies.
Course of infection
(link takes you to relevant page)
During the course of an infection, an individual passes through recognisable
stages:
Susceptible able to be infected
Reservoirs
(link takes you to relevant page)
A reservoir is the natural environment of an infectious agent. Reservoirs can be
inanimate, animal or human. Reservoirs are important when aiming to control or
eradicate an infectious disease.
The distribution of a reservoir may determine the geographical distribution of an
infectious agent.
Characteristics of the host population
(link takes you to relevant page)
In addition to characteristics of the infectious agent, characteristics of the host
population can also determine transmission. Because hosts can develop protective
immunity against an infectious agent, the effect of herd immunity may enable
susceptible individuals in a highly immune population to be protected from infection.
If insufficient susceptible individuals are available, the infection will die out.
In addition to population size, host behaviour will also determine the probability and
frequency of effective contact, and therefore transmission.