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The Chain of Infection

Infectious diseases are transmitted from one person to another through a series of stepsa chain of infection
(see Figure 9.1). New infections can be prevented by interfering with any step in this process.

Click here for a description of Figure 9.1 The Chain of Infection.

FIGURE 9.1
FIGURE 9.1 The Chain of InfectionAny break in the chain of infection can prevent disease.
Links in the Chain

The chain of infection has six major links: the pathogen, its reservoir, a portal of exit, a means of transmission, a
portal of entry, and a new host.

Pathogen

The infectious disease cycle begins with a pathogen, a microorganism that causes disease. HIV (the virus that
causes acquired immune deficiency syndrome, commonly known as AIDS) and the tuberculosis bacterium are
examples of pathogens. Many pathogens cause illness because they produce toxins that harm human tissue;
others do so by directly invading body cells.

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Reservoir

The pathogen has a natural environmentcalled a reservoirin which it typically lives. This reservoir can be
a person, an animal, or an environmental component, such as soil or water. A person who is the reservoir for a
pathogen may be ill or may be an asymptomatic carrier who, although having no symptoms, can spread
infection.

Portal of Exit

To transmit infection, the pathogen must leave the reservoir through some portal of exit. In the case of a human
reservoir, portals of exit include saliva (for mumps, for example), the mucous membranes (for many sexually
transmitted infections), blood (for HIV and hepatitis), feces (for intestinal infections), and nose and throat
discharges (for colds and influenza).

Means of Transmission

Transmission can occur directly or indirectly. In direct transmission, the pathogen is passed from one person to
another without an intermediary. Direct transmission usually requires fairly close association with an infected
host, but not necessarily physical contact. For example, sneezing and coughing can discharge infectious particles
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into the air, where they can be inhaled by someone nearby. Most common respiratory infections and many
intestinal infections are passed directlyfor example, when a person with an infectious agent on his or her
hands touches someone else. In addition to coughing and sneezing into the crook of the arm, proper
handwashing is also key. See Figure 9.2 for proper handwashing techniques to help reduce transmission
opportunities. Other means of direct transmission include sexual contact and contact with blood.

Click here for a description of Figure 9.2 Proper Handwashing Techniques.

FIGURE 9.2
FIGURE 9.2 Proper Handwashing Techniques

Source: Ontario Ministry of Health and Long-Term Care. 2007. Handwashing,


http://www.southwesthealthline.ca/healthlibrary_docs/C.5.Handwashing.pdf (retrieved June 10, 2015).
Catalogue No. CIB-4446797 March 2007. Queen's Printer for Ontario, 2007. Reproduced with permission.

Transmission can also occur indirectly. Animals and insects, such as rats, ticks, and mosquitoes, can serve as
vectors, carrying the pathogen from one host to another. Pathogens can also be transmitted via contaminated
soil, food, or water or from inanimate objects, such as eating utensils, doorknobs, and handkerchiefs. Some
pathogens float in the air for long periods, suspended on tiny particles of dust or droplets that can travel long
distances before they are inhaled and cause infection.

Portal of Entry

To infect a new host, a pathogen must have a portal of entry into the body. Pathogens can enter in one of three
general ways:
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1. Direct contact with or penetration of the skin

2. Inhalation through the mouth or nose

3. Ingestion of contaminated food or water

Pathogens that enter the skin or mucous membranes can cause a local infection of the tissue, or they may
penetrate into the bloodstream or lymphatic system, thereby causing a more extensive systemic infection.
Agents that cause sexually transmitted infections (STIs) usually enter the body through the mucous membranes
lining the urethra (in males) or the cervix (in females). Organisms that are transmitted via respiratory secretions
may cause upper respiratory infections or pneumonia, or they may enter the bloodstream and cause systemic
infection. Food-borne and water-borne organisms enter the mouth and travel to the location that will best support
their reproduction. They may attack the cells of the small intestine or the colon, causing diarrhea, or they may
enter the bloodstream via the digestive system and travel to other parts of the body.

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The New Host

Once in the new host, a variety of factors determine whether the pathogen will be able to establish itself and
cause infection. People with a strong immune system or resistance to a particular pathogen are less likely to
become ill than people with poor immunity (the concept of immunity will be discussed later in the chapter). The
number of pathogens that enter the new host is also important; the body's defences may be able to overcome a
few bacteria, for example, but may be overwhelmed by thousands. If conditions are right, the pathogen will
multiply and produce disease in the new host. In such a case, the new host may become a reservoir from which a
new chain of infection can be started.

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QUICK STATS

250 000 Canadians get infections in hospitals each year; 800012 000 of them die as a result.

Canadian Institutes of Health Research, 2009; Ontario Council of Hospital Unions, 2011

Breaking the Chain

Interrupting the chain of infection at any point can prevent disease. Strategies for breaking the chain include a
mix of public health measures and individual action. For example, a pathogen's reservoir can be isolated or
destroyed, as when a sick individual is placed under quarantine or when insects or animals carrying pathogens
are killed. Public sanitation practices, such as sewage treatment and the chlorination of drinking water, can also
kill pathogens. Transmission can be disrupted through various strategies, such as handwashing and the use of
facemasks. Immunization and the treatment of infected hosts can stop the pathogen from multiplying, producing
a serious disease, and being passed on to a new host. Some methods of breaking the chain of infection are listed
in Figure 9.1.

QUESTIONS FOR CRITICAL THINKING AND REFLECTION

Think about the last time you were sick with a cold, the flu, or an intestinal infection. Can you identify the
reservoir from which the infection came? What vector, if any, transmitted the illness to you? Did you pass the
infection to anyone else? If so, how? What could you do differently to avoid infecting others?

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