Adama science and technology

university
ASOHS
COMMUNICABLE DISEASES AND ITS
CONTROL
For BSc Midwifery students
By: Dr. Kassim Ralick(MD, MSc in TRID)
AU,SOHS,ASELLA CAMPUS,2013 GC
 Course objectives
At the end of this course, the students will be able to:-

Define and differentiate communicable and non-

communicable diseases.

Diagnose and investigate the causative agents and mode

of transmission

Identify method of treatment and prevention

Explain the principles of communicable disease control

and undertake epidemic investigation

2
 INTRODUCTION
Disease

The term disease broadly refers to any condition that

impairs normal function, and is therefore associated
with dysfunction of normal homeostasis.

A disease is an abnormal condition that affects the

body of an organism. It is often construed as a medical
condition associated with specific symptoms and signs.
It may be caused by factors originally from an external
source, such as infectious disease, or it may be caused
by internal dysfunctions, such as autoimmune diseases
 Cont…
Illness and sickness are generally used as
synonyms for disease. However, this term is
occasionally used to refer specifically to the
patient's personal experience of their disease.
In this model, it is possible for a person have a
disease without being ill (to have an objectively
definable, but asymptomatic, medical condition).
ill without being diseased (such as when a person
perceives a normal experience as a medical
condition, or medicalizes a non-disease situation
their life)
 Signs and Symptoms
• Signs and symptoms are diagnostic "tools" which help
the assessor determine the condition of the patient.
• A medical sign is an objective indication of some
medical fact or characteristic that may be detected by a
physician during a physical examination or by a clinical
scientist by means of an in vivo examination of a patient
.
• Signs may have no meaning to the patient, and may
even go unnoticed, but may be meaningful and
significant to the healthcare provider in assisting the
diagnosis of medical condition(s) responsible for the
patient's symptoms.
 Cont…

• Symptom:- is subjective evidence of disease

or physical disturbance observed by the
patient.
• <headache is a symptom of many diseases.
• <visual disturbances may be a symptom of
retinal arteriosclerosis.
 Classification of disease
Diseases can be classified according to two major
dimensions

According to the time course, they are classified as

1. Acute disease:- is characterized by a rapid onset
and a short duration and

2. Chronic disease :- is characterized by prolonged

duration.
 Cont…
Based on the cause , it can categorized as:-

1. Infectious (communicable):- caused by living

parasitic organisms such as viruses, bacteria,
fungus parasites etc.

2. non-infectious(non communicable):- which

are caused by something other than a living
parasitic organism.
 Cont…
Most of the common diseases in Africa including
Ethiopia are infectious diseases due to infection
by living organisms.

These are called communicable diseases, because

they spread from person to person, or sometimes
from animals to people.

They occur at all ages but are most serious in

childhood and also they are to a great extent
preventable.
 Communicable diseases:
These are illnesses due to specific infectious agent
or its toxic products.

Arise through transmission of infectious agent or its

toxic products from an infected person, animal, or
inanimate reservoir to a susceptible host.

Transmission - either directly or indirectly, through

an intermediate plant or animal host, vector or
inanimate environment. 10
 Cont.…

• Communicable diseases can be conveniently

divided based on the mode of transmission
and the causative agent.

11
 cont.…

A. Based on mode of transmission

1. Airborne diseases:- those diseases need droplet nuclei or
dust for transmission. E.g. Tuberculosis
2. Vehicle borne diseases:- They need non-living substance or
object for transmission. E.g. Cholera
3. Vector Borne disease: They need vectors (living organisms,
usually insects) for transmission. E.g. Malaria
4. Other STI,and contact diseases, etc

12
 cont.…

B. Based on the Biologic agent (causative organism)

1.Bacterial diseases e.g. syphilis, gonorrhea, etc
2.Protozoal diseases e.g. Malaria
3.Viral diseases e.g. HIV/AIDS
4.Helminthes diseases e.g. Ascariasis
5.Fungal diseases e.g. Candidiasis

13
 Why CDC remain important in developing
countries Becouse:-

 Many of them are very common

• Some of them are serious and cause death and disability

• Some of them cause widespread out breaks of disease or

epidemics

• Most of them are preventable by fairly simple means.(by

improving Poor socio-economic status, low educational status

• Lack of access to modern health care service of the individuals

makes them vulnerable to a variety of diseases
 Epidemiology and Scope of
Communicable diseases in ethiopia
During the past years, there
e
has been a dramatic fall
in the incidence of infectious diseases, particularly in
developed countries. This is due to several factors
including:
.Immunization
. Anti-microbial chemotherapy
.Improved nutrition
.Better sanitation and housing
 Cont…
In less developed countries, however, especially
in the tropics, infectious diseases continue to be
one of the commonest causes of death,
particularly in children. Ethiopia, as part of the
developing world, has two big health problems.

1.Infectious diseases (communicable diseases) 80%

of these can be prevented by simple sanitary
measures.
2.Nutritional problems
 The top leading causes of outpatient
visits :
1. All types of malaria
2. Intestinal parastosis
3. Acute upper respiratory infection
4. Infections of skin and subcutaneous tissue
5. Diarrheal disease(dysentry)
6. Tuberculosis of respiratory system
7. Sexually transmitted infection
 The top leading causes of admission
• All types of malaria
• Pneumonia
• Tuberculosis of respiratory system
• Diarrheal diseases (dysentery)
• Gastroenteritis and colitis
• Meningitis
Top leading causes of deaths were
1.Tuberculosis of the respiratory system
2. Pneumonia
3. All types of malaria
4. Diarrheal diseases
5. Meningitis
6. Gastroenteritis and colitis
7. AIDS
8. Others, like acute febrile illnesses, trachoma
(commonest cause of blindness in Ethiopia) are the
major public health problems in our country.
 Terminology and Definitions
•Infection
•Contamination •Exotic
•Infestation •Sporadic
•Attack rate
•Contagious disease •Primary/secondary cases
•Incidence and prevalence •Zoonosis, epizootic and
of infectious diseases enzootic
•Epidemic •Nosocomial infection
•Endemic •Opportunistic infection
•Hyperendemic •Eradication
•holoendemic •Elimination
•Pandemic
 Terminology and Definitions
(cont.)
•Incubation period
•Virulence •Infectivity period
•Reproductive rate of •Serial interval
•Latent period
infection
•Transmission Probability
•Host ratio
•Vector (source)
•Reservoir
 Common terminologies
1. Incubation period: The time interval between infection of
the host and the first appearance of symptoms and signs
of the disease.

2. Prodromal period:- The time interval between the onset

of symptoms of an infectious disease and the
appearance of characteristic manifestations.
E.g. In measles from the onset of fever to the development
of characteristic skin lesions.

3. Prepatent period: The period in people between the time

of exposure to a parasite and the time when the parasite
can be detected in blood or in stool.
22
 Cont’d…
4. Extrinsic incubation period (Incubation period in
a vector): is the time between entrance of an
organism into the vector and the time when that
vector can transmit the infection

6. Illness: Individual or subjective feeling of

discomfort (uneasiness).

23
 Cont’d…
Cont’d
7. Disease:- A state of physiological and psychological
dysfunction.

8. Contamination:- Presence of living infectious agent on a

body surface, in cloths, bedding toys, surgical instruments
or dressings or other articles or substances including water
and food.

9. Infestation:- For persons or animals, the lodgment (entry),

development and reproduction of arthropods (insects) on
the surface of the body or in the clothing.
10. Infectious agent:- an agent capable of causing infection.24
 Cont’d…
Cont’d
11. Period of communicability (communicable period)
 It is the period during which an infectious agent is
transmitted from the infected person to the susceptible
host.

 E.g. In diphtheria and streptococcal infection, the period

of communicability is from the date of first exposure to a
source of infection until the infecting microorganism is no
longer disseminated from the involved mucus membrane.

 Some diseases are more communicable during the

incubation period than during the actual illness. e.g.
hepatitis A, measles.
25
 Cont’d…
Cont’d
• In diseases such as TB, leprosy, syphilis, gonorrhea and
some of the salmonelloses, the communicable state may
exist over a long period and sometimes intermittent period
when active chronic lesions permit the discharge of
infectious agent from the source of the skin or through any
of the body orifices.

• In diseases transmitted by arthropods, such as malaria and

yellow fever, the period of communicability is during
which the infectious agent occurs in the blood or other
tissues of the infected person in sufficient number to
permit infection of the vector.

26
 Cont’d…
Cont’d
12. Transmission cycle:- is a cycle which describes how an
organism grows, multiplies and spreads.
 In some cases man may be the only host in which case the
infection spreads directly from man to man. Eg.: measles.
 In some cases like malaria the transmission cycle involves
man and mosquito.
13. Exposure:- The contact between the agent and
susceptible host.
14. Infectivity:- The ability of an agent to invade and multiply
in a host.
15. Pathogenicity:- The ability of an agent to produce
clinically apparent disease, or the property of an infectious
agent that determines the extent to which overt disease is
produced. 27
 Cont’d…
Cont’d
16. Virulence:- The ability of infectious agent to produce
severe disease among clinically infected persons.
17. Immunogenicity:- The ability of an agent to produce
specific immunity.
18. Symptoms of a disease: Refers to malfunctions in which
the patient himself claims to feel. (E.g. fever, headache)
19. Signs of a disease: Manifestations of a disease that can
be examined by others.
20. Transmission: The travel or spread of an infectious agent
from its source to a susceptible host.
21. Source of infection: A person, animal or inanimate
environment from which the particular organism spreads
to its new host.
28
 Cont’d…
Cont’d
22. Viability: - Ability of an organism hard enough potentially
to live.
23. Survival or longevity: Ability of an organism to live for
long duration.
24. Infected individual: A person or animal that harbors an
infectious agent and who has either manifests disease or
unapparent infection.
25. An infectious person or animal is one from which an
infectious agent can be naturally acquired.
26. Unapparent infection: The presence of infection in a host
without recognizable clinical signs and symptoms. It can
be identified only by laboratory means (blood).
Asymptomatic, sub clinical and occult infections are
synonymous.
29
 Infection
Infection is the entry and development or
multiplication of an infectious agent in the body
of man or animals. An infection does not always
cause illness.
There are several levels of infection (Gradients of
infection):
◦ Colonization (S. aureus in skin and normal nasopharynx)
◦ Subclinical or inapparent infection (polio)
◦ Latent infection (virus of herpes simplex)
◦ Manifest or clinical infection
 Infestation
• It is the lodgment, development and
reproduction of arthropods on the surface of
the body or in the clothing, e.g. lice, itch mite.
This term could be also used to describe the
invasion of the gut by parasitic worms, e.g.
ascariasis.
 Contagious disease
• A contagious disease is the one that is
transmitted through contact. Examples
include scabies, trachoma, STD and leprosy.
 Host
• A person or an animal that affords subsistence
or lodgement to an infectious agent under
natural conditions. Types include: an obligate
host, definitive (primary) host, intermediate
host and a transport host.
 Vector of infection
• An insect or any living carrier that transports
an infectious agent from an infected individual
or its wastes to a susceptible individual or its
food or immediate surroundings. Both
biological and mechanical transmissions are
encountered.
 Reservoir
• Any person, animal, arthropod, plant, soil, or
substance, or a combination of these, in which
an infectious agent normally lives and
multiplies, on which it depends primarily for
survival, and where it reproduces itself in such
a manner that it can be transmitted to a
susceptible host. It is the natural habitat of
the infectious agent.
 Incidence and prevalence of
infectious diseases
Incidence of an infectious disease: number of
new cases in a given time period expressed
as percent infected per year (cumulative
incidence) or number per person time of
observation (incidence density).
Prevalence of an infectious disease: number of
cases at a given time expressed as a percent
at a given time. Prevalence is a product of
incidence x duration of disease, and is of little
interest if an infectious disease is of short
duration (i.e. measles), but may be of
interest if an infectious disease is of long
duration (i.e. chronic hepatitis B).
 Epidemic

• “The unusual occurrence in a community of

disease, specific health related behavior, or
other health related events clearly in excess
of expected occurrence”
• (epi= upon; demos= people)
• Epidemics can occur upon endemic states
too.
 Endemic
• It refers to the constant presence of a disease
or infectious agent within a given geographic
area or population group. It is the usual or
expected frequency of disease within a
population.
• (En = in; demos = people)
 Hyperendemic and holoendemic
The term “hyperendemic” expresses that the
disease is constantly present at high incidence
and/or prevalence rate and affects all age
groups equally.

The term “holoendemic” expresses a high level

of infection beginning early in life and affecting
most of the child population, leading to a state
of equilibrium such that the adult population
shows evidence of the disease much less
commonly than do the children (e.g. malaria)
 Pandemic and Exotic
An epidemic usually affecting a large proportion
of the population, occuring over a wide
geographic area such as a section of a nation,
the entire nation, a continent or the world,
e.g. Influenza pandemics.

Exotic diseases are those which are imported

into a country in which they do not otherwise
occur, as for example, rabies in the UK.
 Sporadic
The word sporadic means “scattered about”. The
cases occur irregularly, haphazardly from time to
time, and generally infrequently.
The cases are few and separated widely in time
and place that they show no or little connection
with each other, nor a recognizable common
source of infection
e.g. polio, meningococcal meningitis, tetanus….

However, a sporadic disease could be the starting

point of an epidemic when the conditions are
favorable for its spread.
 Attack rates and primary/secondary
cases
 Attack rate: proportion of non-immune exposed
individuals who become clinically ill.

 Primary (index) cases: The person who comes

into and infects a population is the primary case.
 secondary cases :-Those who subsequently
contract the infection are secondary cases.
Further spread is described as "waves" or
"generations".
 Zoonosis, epizootic and enzootic
Zoonosis is an infection that is transmissible
under natural conditions from vertebrate
animals to man, e.g. rabies, plague, bovine
tuberculosis…..
An epizootic is an outbreak (epidemic) of
disease in an animal population, e.g. rift valley
fever.
An Enzootic is an endemic occurring in animals,
e.g. bovine TB.
 Nosocomial infections
Nosocomial (hospital acquired) infection :- is
an infection originating in a patient while in a
hospital or another health care facility.

It has to be a new disorder unrelated to the

patient’s primary condition.

 Examples include infection of surgical wounds, hepatitis B and

urinary tract infetions.
 Opportunistic infection
• This is infection by organisms that take the
opportunity provided by a defect in host
defense (e.g. immunity) to infect the host and
thus cause disease.

– For example, opportunistic infections

are very common in AIDS. Organisms
include Herpes simplex,
cytomegalovirus, M. tuberculosis….
 Eradication and Elimination
Termination of all transmission of infection by the
extermination of the infectious agent through
surveillance and containment.
Eradication is an absolute process, an “all or none”
phenomenon, restricted to termination of
infection from the whole world.

The term elimination is sometimes used to

describe eradication of a disease from a large
geographic region. Disease which are amenable
to elimination in the meantime are polio, measles
and diphtheria.
 Reproductive rate of infection:
infection
Reproductive rate of infection: potential for
an infectious disease to spread.
Influential factors include:-
 the probability of transmission between an infected and a
susceptible individual
 frequency of population contact;
 duration of infection;
 virulence of the organism and population immune proportion .
Dynamics of disease Transmission (Chain of Infection)

I II III

Source or Reservoir Modes of transmission

Susceptible host
 (I): Source or Reservoir
• The starting point for the occurrence of a communicable
disease is the existence of a reservoir or source of infection.

• The source of infection is defined as “the person, animal,

object or substance from which an infectious agent passes or
is disseminated to the host (immediate source). The reservoir
is “any person, animal, arthropod, plant, soil, or substance, or
a combination of these, in which an infectious agent normally
lives and multiplies, on which it depends primarily for survival,
and where it reproduces itself in such a manner that it can be
transmitted to a susceptible host. It is the natural habitat of
the infectious agent.”
Types of reservoirs

Reservoir

Human Animal Non-living

reservoir reservoir reservoir
 Human reservoir

Human reservoir

Type:
•Incubatory
•Primary case •Convalescent carriers
cases •Index case •healthy
•Secondary cases

According to spectrum of disease: Duration: Portal of exit:

•Clinical cases •Temporar •Urinary
(mild/severe-typical/atypical) y •Intestinal
•Sub-clinical cases •Chronic •Respiratory
•Latent infection cases •others
 Cases
• A case is defined as “a person in the
population or study group identified as having
the particular disease, health disorder, or
condition under investigation”
 Carriers
• It occurs either due to inadequate treatment or immune
response, the disease agent is not completely eliminated,
leading to a carrier state.

• It is “an infected person or animal that harbors a specific

infectious agent in the absence of discernible (visible)
clinical disease and serves as a potential source of infection
to others.
• Three elements have to occur to form a carrier state:
1. The presence in the body of the disease agent.
2. The absence of recognizable symptoms and signs of disease.
3. The shedding of disease agent in the discharge or excretions.
 Animal reservoirs
• Zoonosis is an infection that is transmissible
under natural conditions from vertebrate
animals to man, e.g. rabies, plague, bovine
tuberculosis…..
• There are over a 100 zoonotic diseases that
can be conveyed from animal to man.
 Reservoir in non-living things
• Soil and inanimate matter can also act as
reservoir of infection.

• For example, soil may harbor agents that

causes tetanus, anthrax and
coccidiodomycosis.
 (II): Modes of transmission
Mode of transmission

Direct Indirect
transmission transmission

Direct Vehicle-borne
contact •Vector-borne:
Droplet infection •Mechanical propagative
•biological
Cyclo-prop.
Contact with soil
Air-borne Cyclo-develop.

Inoculation into skin or mucosa

Fomite-born
Trans-placental (vertical) Unclean hands
and fingers
 (III): Susceptible host
An infectious agent seeks a susceptible host
aiming “successful parasitism”.

Four stages are required for successful parasitism:

1. Portal of entry
2. Site of election inside the body
3. Portal of exit
4. Survival in external environment
 Virulence and Case Fatality Rate
Virulence: is the degree of pathogenicity; the disease
evoking power of a micro-organism in a given host.
Numerically expressed as the ratio of the number of
cases of overt infection to the total number
infected, as determined by immunoassay. When
death is the only criterion of severity, this is the case
fatality rate.

Case fatality rate for infectious diseases: is the

proportion of infected individuals who die of the
infection. This is a function of the severity of the
infection and is heavily influenced by how many
mild cases are not diagnosed.
 Serial interval and Infectious period
Serial interval: (the gap in time between the
onset of the primary and the secondary cases)
the interval between receipt of infection and
maximal infectivity of the host (also called
generation time).

Infectious (communicable) period: length of

time a person can transmit disease (sheds the
infectious agent).
 Incubation and Latent periods
Incubation period: time from exposure to
development of disease. In other words, the
time interval between invasion by an
infectious agent and the appearance of the
first sign or symptom of the disease in
question.

Latent period: the period between exposure and

the onset of infectiousness (this may be
shorter or longer than the incubation period).
Transmission Probability Ratio (TPR)

TPR is a measure of risk transmission

from infected to susceptible individuals during
a contact.

TPR of differing types of contacts,

infectious agents, infection routes and strains
can be calculated.

There are 4 types of transmission

probabilities.
 TPR (cont.)
Transmission probabilities:
p00: tp from unvaccinated infective to
unvaccinated susceptible
p01: tp from vaccinated infective to
unvaccinated susceptible
p10: tp from unvaccinated infective to
vaccinated susceptible
p11: tp from vaccinated infective to vaccinated
susceptible
 TPR (cont.)
• To estimate the effect of a vaccine in reducing
susceptibility, compare the ratio of p10 to
p00.
• To estimate the effect of a vaccine in reducing
infectiousness, compare the ratio of p01 to
p00.
• To estimate the combined effect of a vaccine,
compare the ratio of p11 to p00.
CHAIN OF DISEASE TRANSMISSION

64
 Chain of disease transmission
Refers to a logical sequence of factors or links of a
chain that are essential to the development of the
infectious agent and progression of disease.

It has six components:

 The infectious agent
 Its reservoirs
 Its portal of exits
 Its mode of transmission
 Its portal of entry, and
 The susceptible host 65
 Chain …
The traditional model (epi triad) illustrates that
infectious diseases result from the interaction of
agent, host, and environment.

More specifically, transmission occurs when the

agent leaves its reservoir or host through a portal
of exit, and is conveyed by some mode of
transmission, and enters through an appropriate
portal of entry to infect a susceptible host. This is
sometimes called the chain of infection and is
illustrated in the next Figure.

66
Chain …

67
 Chain …
1. The infectious agent / Etiology /causative organism
It is an agent capable of causing infection or
infectious disease.
• They range from viral particles to complex
multicellular organisms.
Infectious agents may bring about pathologic effect
through different mechanisms. The mechanisms
include:
- Direct tissue invasion
- Production of a toxin
- Allergic reaction
- Immune suppression 68
 Chain …
Classification of infectious agent by size and type

a. Metazoa (multicellular organisms e.g. helminthes):

 The largest, like tape worms or the filariae, are visible
to the naked eye.
 They are made up of many cells and are called
metazoan.
b. Protozoa (unicellular organisms e.g. amoeba):
 Complicated but single-cell organisms, like malaria
parasite and amoeba are called protozoa.
 They are smaller and can only be seen when
magnified by a microscope.
69
 Chain …

c. Bacteria (e.g. T.pallidum, M.tuberculosis):

- Smaller than protozoa simple, single cells best
seen under a microscope after they have
been stained with dyes.
d. Rickettsiae and Chlamydiae are smaller and
can only multiply with in cells.
e. Viruses: Smallest of all which can’t even be
seen with an ordinary microscope.
f. Fungus e.g.C.albicans
70
 Chain …
2. Reservoir
Any person, animal, arthropod, plant, soil or
substance (or a combination of these) in which an
infectious agent:
Normally lives and multiplies,
On which it depends primarily for survival and
Where it reproduces itself in such a manner that it can be
transmitted to a susceptible host.

• Is the habitat in which an infectious agent normally

lives, grows, and multiplies.
71
 Chain …

Reservoirs include humans, animals, and the environment.

The reservoir may or may not be the source from which an
agent is transferred to a host. For example, the reservoir of
Clostridium botulinum is soil, but the source of most
botulism infections is improperly canned food containing C.
botulinum spores.
Types of Reservoirs
a. Man: There are a number of important pathogens that are
especially adapted to man such as measles, small pox,
typhoid, M. meningitis, gonorrhea and syphilis.
- The cycle of transmission is from man to man.
72
 Chain …
Many of the common infectious diseases have human
reservoirs.
Diseases which are transmitted from person to person
without intermediaries include the sexually transmitted
diseases, measles, mumps, streptococcal infection, most
respiratory pathogens, and many others.
Smallpox was eradicated after the last human case was
identified and isolated because humans were the only
reservoir for the smallpox virus.
Two types of human reservoir exist:
– Persons with symptomatic illness
– Carriers
73
 Chain …
Carrier
 For the public health worker, the challenge is that persons
with unapparent or undiagnosed infections may
nonetheless be able to transmit them to others. Such
persons who are infectious but have subclinical disease are
called carriers.

 It is an infected person or animal who does not have

apparent clinical disease but is a potential source of a
disease.

 Frequently, carriers are persons with incubating disease or

unapparent infection.
74
 Chain …
Types of Carriers
A. Healthy or Asymptomatic Carriers: These are
persons whose infection remains unapparent
throughout its course.
E.g. In polio virus, meningococcal meningitis
and hepatitis virus infections, there is a high
carrier rate.

75
 Chain …

B. Incubatory or Precocious Carriers: These are

individuals or persons who excrete the pathogens
during the incubation period (before the onset of
symptoms or before the characteristic features of
the disease are manifested).

- Who are capable of transmission before they are

clinically ill
E.g. Measles, mumps, chicken pox and hepatitis
76
 Chain …
C. Convalescent Carriers:-These
Carriers: are those who continue to
harbor (re-infect with) the infective agent after recovering
from the illness.
- Who are capable of transmission after they are clinically
ill.
• E.g. Diphtheria, Hepatitis B virus

D. Chronic carriers: - is one who continues to harbor an

agent (such as hepatitis B virus or Salmonella typhi—the
agent of typhoid fever) for a extended time (months or
years) following the initial infection.
• E.g. Typhoid fever, HB & HIV virus infection.
77
 Chain …

• Carriers commonly transmit disease because they

do not recognize themselves as infected and
consequently take no special precautions to
prevent transmission.

• Symptomatic persons,
persons on the other hand, are
usually less likely to transmit infection widely
because their symptoms increase their likelihood of
being diagnosed and treated, thereby reducing their
opportunity for contact with others.
78
 Chain …
b. Animals:
Animals Some infective agents that affect man
have their reservoir in animal.

Zoonosis: transmission of disease from animals

to man under normal conditions. E.g.:
 Bovine TB is from cow to man;
 Brucellosis is from cow, pigs and goats to man;
 Anthrax is from cattle, sheep, goats, horses to man
 Rabies is from dogs, foxes etc to man

79
 Chain …
N.B. Man is not an essential part (usual
reservoir) of the life cycle of the agent.
Animal …….. Animal…………Animal
↓
Human

80
 Chain …
c. Environmental reservoirs
• Plants, soil, and water in the environment are also reservoirs for
some infectious agents. Many fungal agents, such as those
causing histoplasmosis, live and multiply in the soil.

• Biologically, they are usually equipped to with stand marked

environmental changes in temperature and humidity.

• E.g. Clostridium botulinum, etiology of botulism; Clostridium

tetani, etiology of tetanus; Clostridium welchi etiology of gas
gangrene.

81
 Chain …
3. Portal of exit(mode of escape from the reservoir)
Is the path by which an agent leaves the source host.
Possible portal of exit include all body secretions &
discharges: mucus, saliva, tears, breast milk, vaginal
discharges, excretions (feaces & urine), blood, etc.
E.g.
 Gastrointestinal tract: typhoid fever, bacillary dysentery,
amoebic dysentery, cholera, Ascariasis etc.
 Respiratory: TB, common cold etc.
 Skin and mucus membrane: syphilis
82
 Chain …
4. Mode of Transmission/mechanism of
transmission
This refers to the mechanism by which an
infectious agent is transferred from a reservoir to a
new host.
Transmission may be direct or indirect

I. Direct transmission: Consists of essentially

immediate transfer of infectious agents from an
infected host or reservoir to an appropriate portal
of entry.

83
 Chain …
This direct transmission is of two types:
A. Direct vertical: such as transplacental transmission of
TORCHS- (Toxoplasmosis, Rubella, Cytomegalovirus
infection, Herpes simplex infection, syphilis, others)

B. Direct horizontal: This may be by direct contact such as

touching (Feaces – hand - mouth e.g. shigellosis), biting
(Rabies), kissing (e.g. mononucleosis), sexual intercourse, or
by direct projection (droplet spread) on to the conjunctiva
or on to mucus membrane of eyes, nose or mouth during
sneezing, coughing, spiting, or talking;
• Usually limited to a distance of about one meter or
less.
84
 Chain …
II. Indirect transmission

a. Vehicle borne transmission:

A vehicle is defined as any non-living substance or
object by which an infectious agent can be
transported and introduced in to a host.
E.g. food, water, milk, fomites, towels, clothes, etc.
This is indirect contact through contaminated
inanimate objects or any substance serving as
intermediate means by which an infectious agent is
transported and introduced in to a susceptible host
through a suitable portal of entry. 85
 Chain …
b) Vector borne transmission:
transmission A vector is an organism
(usually an arthropod such as an insect, tick, or louse),
which transports an infectious agent to a susceptible
host or to a susceptible vehicle.

Mechanical transmission:
transmission the agent does not multiply
or undergo physiologic changes in the vector. The
arthropod transports the agent by soiling its feet or
proboscis.
• It is simple mechanical carriage by a crawling or flying
insect through soiling of its feet or proboscis, or by
passage organism through its GIT. E.g. Common house
fly. 86
 Chain …
Biological transmission:
transmission When the agent undergoes
changes within the vector, the vector is serving as
both an intermediate host and a mode of
transmission. This type of indirect transmission is a
biologic transmission
• Guinea worm disease and many other vector borne
diseases(malaria) have complex life cycles which require
an intermediate host.
• Since the agent undergoes part of its life cycle in the
intermediate host, the agent cannot be transmitted by the
intermediate host until the agent has completed that part
of its life cycle.
87
 Chain …
 Sal Varian transmission: In which case infective
saliva is injected in to the host. E.g. Female
anopheles mosquito causes malaria.

 Stercorarian transmission: In which case infective

fecal or regurgitated material will be deposited
near the bite wound, and then the agent enters
the host through autoinoculation. E.g. Body louse
causes relapsing fever.

88
 Chain …
c). Air-borne transmission: Dissemination of microbial
organisms by air to a suitable portal of entry, usually the
respiratory tract.
Two types of particles are implicated in this kind of spread:

• i) Dusts: - Airborne dust includes infectious particles blown

from the soil by the wind as well as material that has
settled on surfaces and become suspended by air currents.

89
 Chain …
• ii) Droplet nuclei: are the residue of dried droplets. The
nuclei are less than 5 μ (microns) in size and may
remain suspended in the air for long periods, may be
blown over great distances, and are easily inhaled into
the lungs and exhaled. This makes them an important
means of transmission for some diseases.
• Tuberculosis, for example, is believed to be transmitted
more often indirectly, through droplet nuclei, than
directly, through droplet spread.
• Microbial aerosols are suspensions of particles in the
air consisting partially or whole of microorganisms.

90
 Chain …
5. Portal of entry: The site via which the infectious
agent enters to the susceptible host.

 The portal of entry must provide access to tissues in

which the agent can multiply or a toxin can act.

 Often, organisms use the same portal to enter a new

host that they use to exit the source host.
 For example, influenza virus must exit the
respiratory tract of the source host and enter the
respiratory tract of the new host.
91
 Chain …
The route of transmission of many enteric
(intestinal) pathogenic agents is described as
“fecaloral” because the organisms are shed in
feces, carried on inadequately washed hands, and
then transferred through a vehicle (such as food,
water, or cooking utensil) to the mouth of a new
host.

Other portals of entry include the skin (hookworm),

mucous membranes (syphilis, trachoma), and
blood (hepatitis B).

92
 Chain …
6. Susceptible Host - The final link in the chain of
infection is a susceptible host.
Susceptibility of a host depends on genetic factors,
specified acquired immunity, and other general
factors which alter an individual’s ability to resist
infection or to limit pathogenicity.
An individual’s genetic makeup may either increase or
decrease susceptibility.
General factors which defend against infection include
the skin, mucous membranes, gastric acidity, cilia in
the respiratory tract, the cough reflex, and
nonspecific immune response.
93
 Chain …
General factors that may increase susceptibility are
malnutrition, alcoholism, and disease or therapy
which impairs the nonspecific immune response.
Specific acquired immunity refers to protective
antibodies that are directed against a specific agent.
Individuals gain protective antibodies in two ways:
1)They develop antibodies in response to infection,
vaccine, or toxoid; immunity developed in these ways
is called active immunity.
2)They acquire their mothers’ antibodies before birth
through the placenta or they receive injections of
antitoxins or immune globulin; immunity that is
acquired in these ways is called passive immunity. 94
 Chain …

• Note that the chain of infection may be

interrupted when an agent does not find a
susceptible host. This may occur if a high
proportion of individuals in a population is
resistant to an agent. These persons limit spread
to the relatively few who are susceptible by
reducing the probability of contact between
infected and susceptible persons. This concept is
called herd immunity.

95
NATURAL HISTORY OF DISEASE

96
 Natural History of a disease

• Defn; It is the progression of disease process in

an individual overtime, in the absence of
intervention.
• Each disease has its own life history, and thus any
general formulation of this process is arbitrary.
•
• However it is important to develop a schematic
picture of the natural history of the disease as a
framework within which to understand and plan
intervention measures including prevention and
control of diseases.
97
 Cont…
• Every disease in a host follows a potentially predictable life
cycle from onset to final outcome, which is known as its
natural history.
• Understanding the natural history of disease is important
to:
- Clinicians in establishing appropriate treatment and
accurate prognosis, and
- It is vital to public health professionals in developing
effective disease prevention and control strategies.
• The natural history of a communicable disease refers to the
sequence of events that happen one after another, over a
period of time, in a person who is not receiving treatment.
98
 Natural……

• Recognizing these events helps you understand how

particular interventions at different stages could
prevent or control the disease.

• Events that occur in the natural history of a

communicable disease are grouped into four stages:
1. Exposure/Stage of susceptibility
2. Infection/ Stage of subclinical disease
3. Infectious disease/ Stage of clinical disease and
4. Outcome/ Stage of recovery, disability or death
99
Natural……

100
Natural……

101
 Natural……
1. Stage of susceptibility/ Exposure -
Precedes the onset of disease. The disease has not
yet developed, but the host is susceptible due to
the presence of risk factors.
Individuals with high serum cholesterol,
hypertension, a sedentary lifestyle, and diabetes,
for example, have an increased risk of developing
coronary heart disease.
Likewise lack of sleep, excessive stress, and poor
eating habits may predispose one to the common
cold.
102
 Natural……
2. Stage of subclinical /infection-
• The disease process has begun, but no overt signs
or symptoms are evident to the host.

• After the disease process has been triggered,

pathological changes then occur without the
individual being aware of them.
• This stage of subclinical disease, extending from the
time of exposure to onset of disease symptoms, is
usually called the incubation period for infectious
diseases, and the latency period for chronic
diseases.
103
 Natural……
• This period may be as brief as seconds for
hypersensitivity and toxic reactions to as long as
decades for certain chronic diseases.
• For example, the typical incubation period for
hepatitis A is as long as 7 weeks. The latency period
for leukemia to become evident among survivors of
the atomic bomb blast in Hiroshima ranged from 2
to 12 years, peaking at 6–7 years.
• Most screening programs attempt to identify the
disease process during this phase of its natural
history, since intervention at this early stage is likely
to be more effective than treatment given after the
disease has progressed and become symptomatic. 104
 Natural……
3. Stage of clinical disease-

• The onset of symptoms marks the transition

from subclinical to clinical disease. Most
diagnoses are made during the stage of clinical
disease.

• The disease process may result in illness that

ranges from mild to severe or fatal. This range is
called the spectrum of disease.
105
 4. Stage of Recovery, disability or
death:
• Some diseases run their course and then
resolve completely either spontaneously or by
treatment.
• In others the disease may result in a residual
defect, leaving the person disabled for a short
or longer duration.
• Still other diseases will end in death.
• Disability: A limitation of a person’s activities
including his role as a parent, wage earner, etc.

106
THANK YOU
107
EPIDEMIOLOGY OF COMMUNICABLE
DISEASE

108
 Introduction to Epidemiology
• Epidemiology is considered as the basic science of public
health.

• It provides useful tools and methods to describe variations

in disease occurrence and identify factors that influence the
occurrence of disease among population groups.

• The occurrence of disease is dependent on variations in

exposure of individuals in the population to the causes of
the disease that are commonly behavioural and
environmental.

ASTU, SOHS, Epidemiology for Clinical Nurse

24/11/23 Students, By Getu Teshome(MPH) 109
 Cont....

• Epidemiology studies the nature of diseases,

and their causes, and it uses systematic
methods of measurement to test ideas,
questions and hypotheses, and hence it is a
science (bio-science), serving medicine and
public health.

ASTU, SOHS, Epidemiology for Clinical Nurse

24/11/23 Students, By Getu Teshome(MPH) 110
 Definition of Epidemiology

• The word epidemiology comes from Greek words

epi meaning “on or up on”, demos meaning
“people” and logos, means “the study of or
Science.”

• Epidemiology is the study of the frequency,

distribution, and determinants of disease and
other health-related states or events in specified
populations, and the application of this study to
the promotion of health and to the prevention
and control of health problems.
ASTU, SOHS, Epidemiology for Clinical Nurse
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 Defn...
• The unique contribution of epidemiology to
health sciences is the fact that epidemiological
studies are conducted in human populations.

• Thus, due to ethical and practical reasons

epidemiological studies are largely
observational

ASTU, SOHS, Epidemiology for Clinical Nurse

24/11/23 Students, By Getu Teshome(MPH) 112
 Scope of epidemiology

• The scope of epidemiology at the beginning (originally)

was limited to understanding epidemics of
communicable disease and epidemic investigations.

• Lately, epidemiology was extended to endemic

communicable diseases and non-communicable
diseases.

• Now it is the basis of advancing our understanding of

all kinds of diseases whether they belong to
communicable, non-communicable or injury category.
ASTU, SOHS, Epidemiology for Clinical Nurse
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 Scope...
• It is used in laboratory sciences, clinical medicine and
public health.

• Its scope in public health ranges from routine

surveillance to research strategies for
the testing of hypotheses about causes

measurement of health and disease risks

and evaluations of preventive, diagnostic and

therapeutic programs and technologies.

ASTU, SOHS, Epidemiology for Clinical Nurse

24/11/23 Students, By Getu Teshome(MPH) 114
 Scope...
At present epidemiologic methods are being applied to
(scope):
• Infectious and non infectious diseases,
• Injuries and accidents
• Nutritional deficiencies, Mental disorders
• Maternal and child health, Congenital anomalies
• Cancer, Occupational health
• Environmental health
• Health behaviors, Violence etc
Hence, epidemiology can be applied to all disease
condition and other health related events.
ASTU, SOHS, Epidemiology for Clinical Nurse
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 Use or purposes of epidemiology

• The ultimate purpose of epidemiology is

prevention and control of disease, in an effort to
improve the health status of population.

• Epidemiology has been used in several ways in

the planning and evaluation of health
intervention in an effort to improve the health
status of the population.

• Some of the uses of epidemiology in public health

practice are mentioned below:
ASTU, SOHS, Epidemiology for Clinical Nurse
24/11/23 Students, By Getu Teshome(MPH) 116
 1. Diagnostic purposes or the health
status assessment of the population:

• Just as the doctor caring for an individual patient

requires diagnosis so does the community health
worker needs community diagnosis or group
diagnoses.

• Community wide health interventions are costy

in terms of resource and should always be based
as much as possible on sound community
diagnosis.
ASTU, SOHS, Epidemiology for Clinical Nurse
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 Dx purpose...

• Epidemiological studies provide data for

community diagnosis which encompasses the
identification and detail analyses of the health
needs, demands, priorities and resources of a
defined community.

• This would serve as bases for the planning and

implementation of health intervention measures.
ASTU, SOHS, Epidemiology for Clinical Nurse
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 2. Identification of determinants
(causation) of a disease.
• Identification of determinants leads to prevention and control of
diseases.
3. Evaluation of methods of disease control:
• It is important in measurement of effectiveness in reducing the
frequency of the disease.

• If not effective method, then necessary alterations are made

accordingly.

• E.g. effectiveness of residual DDT spraying is measured by the

reduction in the incidence of malaria.

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4. Observation of the natural history of
disease
• Essential to make prognosis or the likely outcome of a patient’s
illness.
•
• This prognosis is the basis for rational decision about Rx.

5. Classification of a disease:
The epidemiological diagnoses of a disease are an integral part of
its basic description by means of which it is defined and recognized.

• E.g. Gonorrhoea classified as STIs based on its mode of transmission.

• Malaria is classified as protozoal infection based on its mode of
transmission.
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6. Define standards and ranges for normal
values of biological and social measures.

7.Guide health and healthcare policy and

planning.

8. Assist in the management and care of health

and disease in individuals
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EPIDEMIC DISEASE OCCURANCE

122
 Definition of Epidemics
• It may include any kind of dx or injury, including non –
infectious conditions (dx)

• There is no general rule about the number of cases

that must exist for a dx to be considered an epidemic.
• Epidemics means;
• If the number of cases exceeds the expected level on
the basis of the past experience of the particular pop.
then it is an epidemic. This level varies for different
disease and different circumstances.
 Definition Cont...
• There is no specification of geographic extent; an
epidemic may cover a small area within city or an
entire nation, or may have a worldwide distribution.

• An epidemic may encompass any time period: Few

hours (chemical intoxication or bacterial food
poisoning), A few weeks (influenza and hepatitis), and
several years (addiction and AIDS).

• A dx that remains epidemic over many years eventually

may be considered as endemic.
• E.g. Hypertension in the USA.
Causes of epidemic :when do epidemic
arise?
• Any communicable dx in an individual or in a
community results from a dynamic interaction
between the agent, the host and the environment
(Ecological concept).

• Agent and host are always engaged in a constant

struggle for survival.

• The winner depends on the environment of

interaction.
 More specifically the causes may be
• The recent increase in amount or virulence of agent
• The recent introduction of the agent into a setting
where it has not been before.

• An enhanced mode of transmission so that more

susceptible are exposed.

• Some change in the susceptibility of the host response

to the agent
• Factors that increase host exposure or involve
introduction through new portal of entry.
 Types of epidemics

• Epidemics can be classified according to the method of

spread or propagation, nature and length of exposure
to the infections agent, and duration.
There are two principal types of epidemics.
1. Common source epidemic:
epidemic disease occurs as a result
of exposure of a group of susceptible persons to a
common source of a pathogen, often at the same time
or within a brief time period.
• A. a point source epidemic (PSE):
(PSE) when the exposure is
simultaneous, the resulting cases develop within one
incubation period
 Types cont...
• In PSE the epidemic curve will commonly show a sharp
rise and fall. e.g. A food borne epidemic following an
event where the food was served to many people

• B. a continuous common source epidemic (CSE): If the

exposure to a common source continues over time. E.g.
A water born outbreak that is spread through a
contaminated community water supply.
• The epidemic curve may have a wide peak because of
the range of exposures and incubation periods.
 Types cont...
2. Propagated (progressive) or contact epidemics: the
infectious agent is transferred (propagated) from one
host to another.
It can occur through direct person to person
transmission (by mode of transmissions) or it can
involve more complex cycles in which the agent must
pass through a vector as in yellow fever and malaria.

• Initial rise in the number of cases is usually gradual.

Epidemic extends over a number of incubation periods.
 Types cont...
• The epidemic curve is relatively gentle upslope and
somewhat sleeper tail. E.g. Out breaks of malaria.

• When it is difficult to differentiate the two types of

epidemics by the curve use spot map (studying the
geographic distribution): in propagated one there will
be successive generations of cases.

3. Mixed epidemics: The epidemic begins with single,

common source of an infectious agent with the
subsequent propagate spread. E.g. many food borne
pathogens
Levels of epidemic Disease occurrence
• Disease occurs in community at different level
at particular point in time.
• Some diseases are usually occur at predicted
level.
• This is called expected level of disease, and
sometimes they occur in excess of what is
expected.
 Diseases occurring at expected level
• Endemic – the presence of disease at more or less
stable level.
• Habitual presence of disease in a given geographic
area.
• Occurring in a community at roughly constant level.
• The prevalence and incidence of the disease fairly
constant over time.
• It is the persistent level of occurrence with a low to
moderate disease level.
• Example – TB in Ethiopia, malaria in low land area
 .....expected level
• Hyper endemic – a persistently high level of
disease occurrence
• Sporadic –occasional or irregular occurrence
of disease in an interval.
• Those which are not present in population
normally but give rise irregularly to epidemic.
• Example – plague
 Endemic disease can rapidly become
epidemic due to

• Accumulation of susceptible individual by birth or

immigration from non-endemic area. E.g. new
comers from highland or non-malarias area to a
lowland malarias area
• Ecological change e.g. . Favour breeding of insect
vectors
• Increase of organism on carriers or animal before
it occurs in human population
• E.g. Plague epidemics in rat and yellow fever in
monkey before it attack the man
Diseases occurring at unexpected level
• Epidemic – disease occurring in excess of what is
expected.
• Occurrences of disease or health related condition in
excess of usual occurrence in a given area or among
specific group of people over specified period of time.
• The number of cases showing epidemics depends on:
• infectious agent
• Size and type of the population exposed
• Previous experience or lack of exposure to disease
• Time and place of occurrence
 ....unexpected level
• A single case of a communicable disease long
absent from a population or the first invasion
by a disease not previously recognized in that
area requires immediate reporting and
epidemiological investigation.
• Two cases of such a disease associated in time
and place are sufficient evidence of
transmission to be considered as epidemics.
 ...unexpected level
• Outbreak: this is an epidemic of shorter
duration covering a more limited area
• Cluster: an aggregate of cases in a given area
over a particular period without regard to
whether the number of cases is more than
expected.
• Pandemic: epidemic involving several
countries or continents affecting a large
number of people. E.g. HIV/AIDS.
 Epidemic Disease Occurrence

Level of disease
• The amount of a particular disease that is usually
present in a community is referred to as the
baseline level of the disease. This level is not
necessarily the preferred level, which should in
fact be zero; rather it is the observed level.

• Theoretically, if no intervention occurred and if

the level is low enough not to deplete the pool of
susceptible persons, the disease occurrence
should continue at the baseline level definitely.
138
 Epidemic Disease Occurrence
• Thus, the baseline level is often considered the
expected level of the disease.

• For example, over the past 30 years the number of

reported cases of small pox in Ethiopia is 0. Therefore,
assuming there is no change in population, we would
expect to see approximately no reported cases next
year.
• While some diseases are so rare in a given population
that a single case warrants an epidemiologic
investigation (e.g., rabies, plague, polio), other diseases
occur more commonly so that only deviations from the
normal warrant investigation.
139
 Epidemic Disease Occurrence
Different diseases, in different communities, show
different patterns of expected occurrence.

A persistent level of occurrence with a low to moderate

disease level is referred to as an endemic level.

A persistently high level of occurrence is called a hyper

endemic level.

Sporadic refers to a disease that occurs infrequently and

irregularly.

140
 Epidemic Disease Occurrence
• Occasionally, the level of disease rises above the
expected level.

• When the occurrence of a disease within an area is

clearly in excess of the expected level for a given time
period, it is called an epidemic. Public health officials
often use the term outbreak, which means the same
thing, because it is less provocative to the public, but is
often used for a more limited geographic area.

• When an epidemic spreads over several countries or

continents, affecting a large number of people, it is
called a pandemic.
141
 Cont….
• Epidemics can be classified according to their
manner of spread through a population:
1. Common-source
 Point
 Continuous
 Intermittent
2. Propagated
3. Mixed
142
 Cont…
A common-source outbreak
Is one in which a group of persons are all exposed to
an infectious agent or a toxin from the same source.
a. Point source outbreak - If the group is exposed over a relatively
brief period, so that everyone who becomes ill does so within one incubation
period.
E.g. The epidemic of leukemia cases in Hiroshima following the atomic bomb
blast.
b. Continuous common-source outbreak - case-patients
may have been exposed over a period of days, weeks, or longer. The range of
exposures and range of incubation periods tend to flatten and widen the peaks
of the epidemic curve.
c. Intermittent common-source outbreak -The epidemic
curve often has a pattern reflecting the intermittent nature of the exposure.
143
 Propagated outbreak
Results from transmission from one person to another.
Usually, transmission is by direct person-to-person contact, as with syphilis.
Transmission may also be vehicle borne (e.g., transmission of hepatitis B or
HIV by sharing needles) or vector borne (e.g., transmission of yellow fever by
mosquitoes).
In propagated outbreaks, cases occur over more than one incubation period.

Mixed epidemics
The pattern of a common-source outbreak followed by secondary person-to-
person spread.
For example, a common-source epidemic of shigellosis occurred among a group
of 3,000 women attending a national music festival. Many developed
symptoms after returning home. Over the next few weeks, several state
health departments detected subsequent generations of Shigella cases
propagated by person-to-person transmission from festival attendees.

144
 Epidemic Disease Occurrence
• Epidemics occur when an agent and susceptible hosts are
present in adequate numbers, and the agent can
effectively be conveyed from a source to the susceptible
hosts.
More specifically, an epidemic may result from the following:
1. A recent increase in amount or virulence of the agent.
2. The recent introduction of the agent into a setting where
it has not been before.
3. An enhanced mode of transmission so that more
susceptible are exposed.
4. Some change in the susceptibility of the host response to
the agent.
5. Factors that increase host exposure or involve
introduction through new portal of entry.

145
THANK YOU

146
Exercise 1
For each of the following situations, identify whether it reflects:
A. Sporadic disease
B. Endemic disease
C. Hyper endemic disease
D. Pandemic disease
E. Epidemic disease
____ 22 cases of legionellosis occurred within 3 weeks among residents of a
particular neighborhood (usually 0 or 1 per year).
____ Average annual incidence was 364 cases of pulmonary tuberculosis per
100,000 population in one area, compared with national average of 134
cases per 100,000 population.
____ Over 20 million people worldwide died from influenza in 1918–1919.
____ Single case of histoplasmosis was diagnosed in a community.
____ About 60 cases of gonorrhea are usually reported in this region per week,
slightly less than the national average.

147
EPIDEMIOLOGIC -TRIAD

148
 Epi-Triad
Illustrates that infectious diseases result from the interaction
of agent, host, and environment.

Pathogen is an infectious agent that can cause clinically

apparent infection.

Infectious agent is an agent that is capable of causing

infection or infectious disease.

Pattern of communicable disease: different diseases are

common in different places and at different times.
Why? To understand this, we need to consider the agent,
the host and the environment. 149
 Epi-Triad
• The agents need a suitable environment in which to
grow and multiply and thus be able to spread and
infect another host.

• If they are not successful in doing this they die out.

• There is therefore a balance between the agent, the

host and the environment which can be shown as:
the host, agent, environment triad.
150
 Epi-Triad

Host

Agent Environment

151
 Epi-Triad
Hosts are affected by their environment.
 E.g. they may live in a hot and wet climate in which there
are many mosquitoes.
 But people can also change this environment by draining
swamps.
Similarly the environment can affect the agent.
 E.g. the altitude and temperature for malaria.

 When the balance between these three is constant, there

will be a fairly steady number of people getting sick all the
time.
 When this happens, a disease is said to be endemic.
152
 Epi-Triad
• When the balance is shifted in favor of the organism, for
example when many non-immune children have been born
in an area since the last measles epidemic, a large number
of cases of measles occur in a short time.

• This is called an epidemic. When all the non-immune have

had the disease it will go down again.

• If the balance can be shifted against the agent, the disease

will be controlled and the number of cases will go down.

153
 PREVENTION AND
CONTROL OF
COMMUNICABLE DISEASES

154
 PREVENTION AND CONTROL OF
COMMUNICABLE DISEASES

Disease prevention:
Inhibiting the development of a disease before
it occurs or if it occurs interrupting or slowing
down the progression of diseases.
There are three levels of prevention.

155
 PREVENTION…….
Primary prevention:
Primary prevention seeks to reduce the
frequency of new cases of disease occurring in
a population and, thus is most applicable to
persons who are in the stage of susceptibility.

It focuses on promoting health, preventing

exposure, and disease.

156
 PREVENTION…….

Health promotion: any intervention that promotes a

healthier and happier life.
Interventions that enhance health and the body's
ability to resist diseases.
Improvement of socioeconomic status; education
and vocational training; affordable and adequate
housing, clothing and food; old age pension
benefits; emotional and social support, relief of
stress etc.

157
 PREVENTION…….
Prevention of exposure: any intervention which
prevents the coming in contact between an
infectious agent and a susceptible host.
Eg. Provision of safe and adequate water; proper
excreta disposal; vector control; safe environment
at home (proper storage of insecticides and
medicines), at school and at work (proper
ventilation, monitoring of harmful substances in
factories), on the streets (driver licensing laws)
Prevention of disease: This occurs during the latency
period between exposure and the biological onset
of the disease. Eg. Immunization.
158
 PREVENTION…….
Remember breast feeding is:
Health promotion: by providing optimal nutrition
for a young child, either as the sole diet up to six
months of age, or as a supplement in later age.
Prevention of exposure: by reducing exposure of the
child to contaminated milk.
Prevention of disease after exposure: by the
provision of ant-infective factors, including
antibodies, WBCs and others.
159
 PREVENTION…….

Secondary prevention:
Secondary prevention attempts to reduce the number of
existing cases in a population and, therefore, is most
appropriately aimed those in the stage of pre
symptomatic disease or the early stage of clinical
disease.
Acted after the biological onset of the disease, but before
permanent damage sets in.
The objective here is to stop or slow the progression of
disease so as to prevent or limit permanent damage,
through the early detection and treatment of diseases.
160
 PREVENTION…….
Tertiary prevention:
Tries to limit disability and improve functioning following
disease or its complications, often through rehabilitation.
Therefore, it is most applicable during the late clinical stage
or the stage of outcome.
After permanent damage sets in, the objective of tertiary
prevention is to limit the impact of that damage. The
impact can be physical (physical disability), psychological,
social (social stigma), and financial.
Rehabilitation : is to the retraining of remaining functions
for maximum effectiveness, and should be seen in a very
broad sense, not simply limited to the physical aspect. 161
 PREVENTION…….

The natural history of disease and the levels of

prevention are closely linked.
As illustrated in next figure, appropriate levels of
prevention may be applied at each stage of the
natural history of disease.

162
PREVENTION…….

163
 Principles of communicable disease
control
Disease control: Involves all the measures designed
to reduce or prevent the incidence, prevalence
and consequence of a disease to a level where it
cannot be a major public health problem.

The actions may be effected through:

- Attacking the source
- Interrupting the mode of transmission and
- Protecting the host (susceptibility)

164
 Control…
1. Attacking the source
Domestic animals as reservoirs
• Immunization e.g. Brucellosis
• Destruction of infected animals e.g. Rabies
Wild animals as reservoirs
Post exposure prophylaxis e.g. Rabies

165
 Control…
Human as a reservoirs
Isolation of infected persons & separation of
infected persons from others for the period of
communicability.
Not suitable when:
• Large proportion are apparently infected, or
• In which maximal infectivity precedes over illness.
Treatment
• Of cases (clinical) and carriers
• Mass treatment: where large proportion are known to have
a disease, it is sometimes advisable to treat everybody,
without checking whether individuals have disease or not.
166
 Control…
Quarantine:
The limitation of freedom of movement of
apparently healthy persons or animals who
have been exposed to a case or infectious
disease.
• Cholera, plaque, and yellow fever are the 3
internationally quarantinable diseases by international
agreement. These diseases are very infectious, so
cases shouldn’t be referred but seniors must be
requested to visit the health center.
167
 Control…
2. Interrupting transmission
For Transmission by ingestion:
• Purification of water
• Pasteurization of milk
• Inspection procedures designed to ensure safe food
supply.
Improve housing conditions
For Transmission by inhalation
• Chemical disinfections of air
• Improving ventilation
168
 Control…
For transmission by vector or intermediate hosts
- Vector control measures
- Environmental manipulation (sanitation)
3. Measures that reduce host susceptibility
Immunization
• Active immunization: when either the altered organism or its
products is given to a person to induce production of
antibodies
E.g. BCG
• Passive immunization: provision of ready-made antibodies
E.g. TAT 169
 Control…
Chemoprophylaxis: use of antibiotics for known
contacts to a case.
E.g. Ciprofloxacin for contacts to a case of M.
meningitis

Better nutrition: Malnourished children get

infections more easily & suffer more severe
complications.
170
 BACKGROUND OF COMMUNICABLE
DISEASES PREVENTION AND
CONTROL IN ETHIOPIA

171
Public health importance of communicable
diseases prevention and control
• The burden of disease in Ethiopia is largely due to
potentially preventable communicable diseases.

• The national health policy gives emphasis for the

control and prevention of communicable disease.

• In the last decades alone severe and repeated

outbreaks of malaria, meningococcal meningitis,
relapsing fever and diarrhoeal disease have killed
thousands of lives and disabled many more
thousands.
172
Major communicable disease in Ethiopia.

• The country’s most important hearth problems are

communicable diseases such as:
– Diarrheal diseases
– Malaria
– HIV/ AIDS
– Tuberculosis
– STI/Sexually transmitted infections
– Meningococcal meningitis
– Cholera
– Measles and
– Bacillary dysentery
173
•Thank you

Thank you