Haramaya University

College of Health And Medical Sciences

School of Nursing and Midwifery
Department of Nursing

Course: Communicable Disease Control

Course Code: COMH 362
Cr. Hr: 4

By: Anteneh Eshetu

(MPhill,Bsc,Dip.)
1
 2

Overview of Communicable
Disease
UNIT ONE
Definition of the terms
1. HEALTH
3

 Derived from Old English hal

 Meaning whole, sound in

 WHO 1948, in the preamble to its constitution, as:

“A state of complete physical, mental, and

social well-being and not merely the absence
of disease or infirmity.”
 Definition Con…
 In 1984, a WHO health promotion initiative led to
4 expansion of the original WHO description, which can

be abbreviated to:
 “The extent to which an individual or a group is able
to realize aspirations and satisfy needs, and to change
or cope with the environment

 Health is a resource for everyday life, not the objective

of living
 It is a positive concept, emphasizing social and
personal resources as well as physical capabilities.”
 Definition Con…
 Health is a state characterized by
5
 Anatomical, physiological, &

psychological integrity
 Ability to perform personally valued
family, work, and community roles
 Ability to deal with physical, biological,
psychological, and social stress
 A feeling of well-being &
 Freedom from risk of disease & death
 Definition Con…
2. DISEASE
6
 Literally, dis-ease, the opposite of ease,
o When something is wrong with a bodily
function
 The words disease, illness, and sickness are
used as if they were interchangeable, but they
are better regarded as not synonymous
 Disease
 Is the biological dimension of non-health

Essentially physiological dysfunction

 Definition Con…
3. Illness
7 Is a subjective or psychological state of the
person who feels aware of not being well
 The experience of a person with a disease
 A social construct (idea or belief) made/shaped
from transactions between healers and patients
in the context of their common culture
4. Sickness
 Is a state of social dysfunction of a person with a disease
 the role that the individual assumes when ill;
 A result of being defined by others as unhealthy
 Definition Con…
 In the real world, lay concepts of illness and
8
medical concepts of disease interact and
shape each other
 Neither disease nor illness is infinitely malleable: both
are constrained by bio-logy and by culture

• Disease is the biological dimension of nonhealth,

an essentially physiological dysfunction
Communicable Disease
5. Communicable disease (CD) is


9
"illness due to a specific infectious agent or its toxic
products that arises through transmission of that
agent or its products from an infected person, animal,
or reservoir to a susceptible host, either directly or
indirectly through an intermediate plant or animal
host, vector, or the inanimate environment"

 CD pathogens include
 bacteria, viruses, fungi, parasites and prions
 CD Con…
 Surveillance and control of CD is an important part of

10 protecting the public's health

 B/C CD have so much impact on the population

 The CD is branch of the Division of Public Health
 The CD primarily deals with
 Infectious diseases that are reportable by law to
the state health department, and
 A few other CDs of public health significance
Like influenza & other infections
 CD Con…
 Other functions of the branch CD include:
1.11 Ongoing information and education for the PH care
providers and local health departments on CDs and how
to prevent them

2. Alerts and timely information about emerging or

seasonal CD events, or the occurrence of a new CD

3. Routine surveillance and quality assurance of disease

reporting by physicians, hospitals and laboratories to
detect trends and assess the public health impact of
disease
 CD Con…
4. Investigation of and intervention in response to
12 disease outbreaks, and the ongoing development of

strategies, policies, and practices to prevent the spread

of diseases

5. Training in disease surveillance, reporting criteria, data

quality, investigation and control for local health
departments

6. Management of veterinary public health issues, &

diseases of animal origin that can affect humans
7. Outpatient care and support services related to
HIV/AIDS, other STDs, and tuberculosis
 CD Con…
 CDs pose a major threat to public health
13
and are significant concern to nurses
 Their public health importance in terms of
human suffering, disability & death is
compounded by the considerable toll they
take on economic growth and development
CD Con…
The main reasons why CDs are becoming major public
14
health importance are:-

A. Microbial agents of CDs are :-

-Dynamic–use different methods to react and behave

-Resilient–able to feel better quickly after unpleasant

events

-Well adapted - to exploit opportunities for change &

spread
 CD Con…
B. Their importance on economical growth and
15 development due to human suffering, death and

disability

C. Difficulty of controlling many important diseases due

to
-Lack of vaccine & therapeutic drugs
-Reduced effectiveness of existing drugs
-Spread of drug resistant microbes
CD Con…
 In general, diseases can be classified
16 according to two major dimensions as to
the time course and cause
 According to the time course:
 Acute- characterized by a rapid onset & a short
duration
 Chronic disease- characterized by prolonged duration
 Based on the cause - diseases can be categorized as
 Infectious, caused by living parasitic organisms

( viruses, bacteria, parasitic worms, etc)

 Non-infectious which are caused by something other
CD Con…
 Most common diseases in Africa are environmental

17 diseases (infectious)

 These are called communicable diseases

 B/C they spread from person to person, or animals to people

 They occur at all ages but are serious in childhood and

they are to a great extent preventable
 In developed countries where they have been prevented,
other health conditions such as accidents and the
degenerative diseases become the common.
CD Con…
Epidemiological scope of CD in Ethiopia
18
 In the past 70 years there has been dramatic fall in
incidence of infectious diseases

 This is due to several factors including

 Immunization
 Anti microbial chemotherapy
 Improved nutrition and
 A better sanitation and housing

 In developing countries, especially in the tropics,

infectious diseases continue to be the commonest
 CD Con…
Ethiopia has two big health problems
1.
19 Infectious diseases (CD)
• 80% can be prevented by simple sanitary measure
2. Nutritional problems `
• CDs kill more than 14 million people each year
• 46% of these deaths occur in developing countries
• Among CDs attributable deaths in such developing
countries, 90% of deaths are mainly associated with
1. Acute diarrheal & respiratory tract infection in
children
2. HIV/AIDS 4. Malaria
3. Tuberculosis 5. Measles
 CD Con…
 In Ethiopia: Infectious and CDs account for about 60-
20 80% of the health problems in the country

 HIV/AIDS, TB & Malaria are the common CDs

 The national adult HIV prevalence in 2008 was 2.2%

 Females (2.6%) &
 Males (1.8%)
 CD Con…
 TB has been recognized as a major public health
21 problem in Ethiopia since the 1950s

 Ethiopia ranks 7th out of the world’s 22 high-burden

countries for TB
 Incidence ≈379/100 000 population for all forms of TB
 Prevalence of all forms of TB is 643/100 000 population
 TB morality rate of 84/100 000 population per year (WHO,
2008)

 Malaria is one of the leading causes of morbidity and

mortality in Ethiopia
 CD Con…
 Neglected Communicable Diseases
22
 Leprosy
 Onchocerciasis
 Leishmaniasis
 Schistosomiasis
 Soil-transmitted helminthiasis
 Lymphatic filariasis, and trachoma
 From these onchocerciasis, leishmaniasis, leprosy &
trachoma have a relatively better national control &
elimination programs
 CD Con…
 Currently it is believed that ≈ 60% of deaths causes by
23
CD can be attributed to
 HIV/AIDS
 Malaria
 Tuberculosis
 Measles
 Diarrheal disease &
 Acute respiratory infection
24
25
Top10 leading causes of inpatient deaths in most regions of
Ethiopia, September2008–August 2009
26
Definition of other terms
Public Health? Winslow
27 PH is the science & art of preventing disease prolonging
life promoting health & efficiency through organizing
community effort to promote active participation

Epidemiology
 Is the study of the frequency, distribution and
determinants of disease and other health related
conditions in human populations & the application of
this study to the promotion of health and prevention
and control of health problems
 Definition Con…
EPIDEMIC
28
 from the Greek epi (upon), d-emos (people)

 The occurrence in a community or region of cases of

an illness, specific health-related behavior, or other
health-related events clearly in excess of normal
expectancy
 The community or region and the period in which the cases
occur must be specified precisely
 The number of cases indicating the presence of an epidemic
varies according to
 The agent, size, and type of population exposed;
 Previous experience or lack of exposure to the disease; and
 Definition Con…
 Epidemicity
29
 Is thus relative to
 Usual frequency of the disease
 In the same area,
 Among the specified population,
 At the same season of the year

 A single case of CD long absent from a population or

first invasion by a disease not previously recognized in
that area requires immediate reporting and full field
investigation
 Two cases of such a disease associated in time and
place may be sufficient evidence to be considered an
epidemic
Definition Con…
ENDEMIC DISEASE
30 Constant presence of a disease or infectious agent

within a given geographic area or population group

 Usual prevalence of disease in such an area or group

HOLOENDEMIC
 Disease for which a high prevalent level of infection
begins early in life and affects 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
 Malaria in many communities is a holoendemic
 Definition Con…
HYPERENDEMIC
 Disease that is constantly present at a high incidence
31

and/or prevalence and affects most or all age groups

equally
SPORADIC
 Occurring irregularly, haphazardly, from time to time,
and generally infrequently
 (e.g., cases of certain infectious diseases)

PANDEMIC
 An epidemic occurring worldwide or over a very wide
area, crossing international boundaries, and usually
affecting a large number of people
 Definition Con…
INFECTION (Syn: colonization)
32
 The entry and development or multiplication of
infectious agent in the body of man or animals
 Infection is not synonymous with infectious
disease; the result may be inapparent or manifest
Infestation
 Is presence of living infectious agents on exterior
surfaces of the body (e.g pedic-ulosis, scabies)
Contamination
 The presence of living infectious agents upon articles of
clothing or soiled articles is represents contamination of
articles
 Definition Con…
Infectious agent-
33
 An agent which is capable of causing infection

GRADIENT OF INFECTION
 Range of manifestations of illness in the host

reflecting response to infectious agent

 It extends from death at one extreme to inap-parent

infection at the other.

 The manifestations varies with the specific infectious
disease
 Human infection with virus rabies is almost invariably

fatal, whereas high proportion of childhood with the

virus of polio experience a subclinical or mild clinical
 Definition Con…
DISEASE CONTROL
 Control means ongoing operations or programs aimed
34

at reducing incidence and/or prevalence, or

eliminating such conditions.

 Applied to many CDs & some noncommunicable

conditions
 35

UNIT-II
DISEASE TRANSMISSION DYNAMICS
Chain of disease transmission
 Infection
36
 implies that the agent has achieved entry and
begun to develop or multiply, whether or not
the process leads to disease
 Transmission of infectious agents
 Any mechanism by which an infectious agent is spread
from a source or reservoir to another person.

 A model used to understand the infection process is

called the chain of infection
37
 Chain of disease Con…
 Each link must be present in sequential order for an
38 infection to occur

 The links are:

 infectious agent, reservoir, portal of exit from
the reservoir, mode of transmission, and portal
of entry into a susceptible host
 Understanding the characteristics of each link
provides with methods to prevent the spread of
infection
 Sometimes the chain of infection is referred as the
transmission cycle
39
 Chain of disease Con…
 Chain of disease transmission

40  Refers to a logical sequence of factors or links of

a chain, which are essential to the development

of the infectious agent & propagation of disease
 Components of Chain of Infection
1. Causative Agent
2. Reservoir host
3. Portal of exit
4. Mode of transmission
5. Portal of entry
6. Susceptible host
41
 Chain of disease Con…
 Etiology of disease includes all factors that
42
contribute to the occurrence of a disease

 These factors are related to

 Agent
 Host &
 Environment
 I. The agent
A. Nutritive element
eg. Excessive------Cholesterol
Deficiency----Vitamin, Protein
B. Chemical Agents
eg. Poison---------Carbon monoxide (CO)
C. Physical Agents
eg. Radiation
D. Infectious agents, for example:
Metazoa ---Hookworm, schistosomiasis
Protozoa ---Amoeba
Bacteria--- M.Tb
Fungus----Candidiasis
43
Virus-----Measles
 Chain of disease Con…
I. The agent
44
A. Nutritive element, C. Physical Agents,
Excessive-----Cholesterol Example:---- Radiation
Deficiency----Vitamin, ----Heat
----Protein D. Infectious agents
Metazoa ---Hookworm,
B. Chemical Agents,
Poison------Carbon schistosomiasis
Protozoa ---Amoeba
monoxide(CO) Bacteria--- M.Tb
Fungus----Candidiasis
 Chain of disease Con…
 The agents of infection:-
45  The agents range from viral particles to
complex multi-cellular organisms

 These can be characterized through their:

 Size
 Chemical character
 Antigenic makeup
 Ability to survive outside the host
 Ability to produce toxin etc.
 Chain of disease Con…
 The different mechanisms employed by infectious
46 pathogens are:

 Direct tissue invasion

 Production of toxins
 Immunologic enhancement or allergic
reaction
 Persistent or latent infection
 Enhancement of host susceptibility to
drugs
 Immune suppression
 Chain of disease Con…
 Host agent interaction is characterized by
47
1. Infectivity,
2. Pathogencity
3. Virulence or
4. Immunogenicity

1. Infectivity:
 Is ability of an agent to invade & multiply in a host
 i.e. the ability to produce infection
 Chain of disease Con…
 It can be measured by infection rate
48
 Infection rate
 The incidence rate of manifest plus inapparent

infections
(the latter determined by
seroepidemiology)

Infection rate = total number of infected people x100

 Chain of disease Con…
2. PATHOGENICITY :
49  The ability of micro-organism to induce or
produce clinically apparent infection
 Pathogenecity
 The property of an organism that determines
 the extent to which overt disease is produced in an infected
population,
 or the power of an organism to produce disease
 Also used to describe comparable properties of toxic
chemicals
 Chain of disease Con…
 Pathogenicity of infectious agents is measured by the
50 ratio of the number of persons developing clinical

illness to the number exposed to infection

 It is measured by determining the proportion of

infections that result in clinical apparent diseases

Pathogenecity = Total number of clinical cases

Total number of subclinical cases
 Chain of disease Con…
3. VIRULENCE :
 The proportion of clinical cases resulting in severe
51
outcome or clinical disease

 Virulence
 The degree of pathogenicity;
 The disease-evoking power of a microorganism 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
52
 Chain of disease Con…
Factors which can change the above properties for
53
infectious agents are:
 Environmental conditions:
 May be favorable or unfavorable to the specific agent

 Dose of the agent:

 Severity of disease may be related to the amount entering the
host body

 Route of infection:
 The same agent may cause different levels of severity
according to the route of entry

 Host factors (age, race, nutritional status)

 Chain of disease Con…
II. Reservoir of infection
54  Any person, animal, arthropod, plant, soil,
substance, or 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
 The place where the infectious agent is normally
present before infecting a new human is called a
reservoir
 The natural habitat of the infectious agent.
 Chain of disease Con…
 Types of reservoirs
55 1. Human
2. Animals
3. Non-living things as reservoir

1. Human
 There are a number of important pathogens, which
are specifically adapted to man.
 E.g Measles, Smallpox, Syphilis, Meningococcal
meningitis, Typhoid, Gonorrhea
 The cycle of transmission is from man to man
Human  Human  Human
 Chain of disease Con…
 Human reservoir are classified as cases and carries
56
 Cases – individuals identified as having the disease,
health disorder or condition under investigation
 Carries – is an infected person or animal who does not
have apparent clinical infection but is potential source of
disease to other
 Carriers can be classified as follows:-
a. Healthy/ asymptomatic carries
- In such carriers infection remains unapparent
E.g. poliovirus, Hepatitis virus, Meningococcal
 Chain of disease Con…
b. Incubatory or precocious carries
57
– Those excrete pathogen during incubation period
e.g. measles, mumps ,chickenpox

c. Convalescent carriers
- Those continue to harbor the agent after recovery
from the illness
e.g. Diphtheria, HBV

d. Chronic carriers
-is carrier state that persist for a long period of
time
 Chain of disease Con…
 In general carrier state occurs due to either of the
58
following conditions;
 In adequate treatment
 Inadequate immune response
 Disease agent not completely eliminated
 Chain of disease Con…
2. Animals
59
The term zoonosis is applied to disease transmission
from animals to man under natural condition

E.g. - Bovine tuberculosis--- - Cow to man

- Brucellosis ---- Cows, pigs and goats to man
- Anthrax----- Cattle, sheep, goats, horses to man
-Rabies ---Dogs, foxes and other wild animals to man
Animal …….. Animal…………Animal


Human
 Zoonoses/zoonosis are diseases where infectious
agents can be transmitted from animal hosts to
 Chain of disease Con…
3. Non-living things as reservoir
60
 Many of the agents are basically saprophytes living in soil
and fully adapted to live freely in nature.

 Biologically, they are usually equipped to withstand

marked environmental changes in temperature and
humidity
 E.g. - Clostridium botulinum agent of Botulism -
Clostridium tetani agent of Tetanus
- Clostridium welchi agent of gas gangrene
 Chain of disease Con…
III. Portal of exit (mode of escape from reservoir)
61  This is the site through which the agent escapes
from the reservoir.
 The site on the infected host through which the
infectious agent gets out
 E.g.
 GIT: typhoid fever, bacillary dysentery, amoebic
dysentery, cholera, Ascariasis,
 Respiratory: TB, common cold
 Skin and mucus membranes: Syphilis.
 GUT, blood, body tissue and other fluids
 Chain of disease Con…
IV. Mechanism of transmission (MoT)
62
 Refers to the mechanisms by which an infectious
agent is transferred from one person to another or
from a reservoir to a new host
 Transmission may be direct or indirect
1. Direct transmission:
 Direct & essentially immediate transfer of infectious

agents to a receptive portal of entry through which human

or animal infection may take place
 This could be
 Chain of disease Con…
 Direct Vertical
63  E.g. Trans placental transmission of syphilis, HIV, etc.
 Direct horizontal:-
 Direct contact:-
 Via direct touching, biting, kissing, sexual contact
 Direct projection:-
• Droplet spread on to the conjunctiva or on to
mucus membrane of eye, nose or mouth during
sneezing coughing, spitting or talking
• Usually limited to a distance of 1m or less
• May be by direct exposure of tissue to an agent in soil,
 Chain of disease Con…
2. Indirect transmission
64  Could be Vehicle borne transmission Vector
borne transmission Air borne transmission
a. Vehicle borne transmission:
Indirect contact through contaminated inanimate objects
(fomites) like:
 Bedding, toys, handkerchiefs, soiled clothes, cooking or
eating utensils, surgical instruments
 Contaminated food and water
 Biological products like blood, serum, plasma or IV-fluids
or any substance serving as intermediate means
 Chain of disease Con…
NB. The agent may or may not multiply or develop in
65 the vehicle before it is introduced in to man.

b. Vector borne transmission:

Occurs when the infectious agent is conveyed by an
arthropod (insect) to susceptible host
1. Mechanical transmission: When the
 Arthropod transports the agent by soiling its feet or

proboscis in which case

 Multiplication of agents in the vector does not occur

E.g common house fly

2. Biological transmission:
 When the agent multiplies in the arthropod before it is
 Chain of disease Con…
C. Air borne transmission:
66 Transition of MOs by air to a suitable portal of entry,

usually the respiratory tract

 Types of particles implicated are dusts & droplet nuclei

 Dust:

 Small infectious particles of varying size may arise

from soil, clothes, bedding and resuspended by air

currents
 Droplet nuclei:

 Small residues resulting from evaporation of fluid

(droplets emitted by an infected host)

 They usually remain in the air for long period of time
 Chain of disease Con…

67
Summary of different modes of transmission
 Chain of disease Con…
V. Portal of entry
68
 The site through which an infectious agent

enters the host is called the route of entry

 The site in which the infectious agent enters
to the susceptible host. Such as;
 Mucus membrane
 Skin
 Respiratory tract
 GIT
 GUT
 Chain of disease Con…
VI. Susceptible host and risk factors
69 After infectious agent gets to the body it has to
multiply to cause disease
 Infection may or may not leads to disease
 Susceptible hosts are individuals who are likely to
develop a CDs after exposure to infectious agents


 A person or animal lacking sufficient resistance to a

pathogenic agent to prevent disease when exposed
 Occurrence of infection and its outcome are in part
determined by host factors
 Chain of disease Con…
 Host factors:-
70  Influence exposure, susceptibility or response to
agents
 It includes
 Genetic factors, such as:
 Age
 Sex
 Physiologic states, such as:
 Pregnancy
 Puberty
 Stress
 Chain of disease Con…
 Immunologic condition such as:
71  Active immunity: Prior infections, such as immunization
 Passive immunity: Gamma globulin

 Immunity is the ability of the host to resist infection

 Human behavior, such as
 Hygiene - Sexual
 Diet handling.
 Host factors result from interaction of genetic
endowment with the environment
 Chain of disease Con…
 Resistance to infection is determined by non-specific and
72 specific factors

 Non-specific factors
 Skin and mucus membrane
 Mucus, tears, gastric secretion
 Reflex responses such as coughing and sneezing
 Specific factors
 Genetic-hemoglobin resistant to Plasmodium falciparum
 Naturally acquired or artificially induced immunity.
 Acquired immunity (may be active or passive)
 Chain of disease Con…
 Active immunity-
73  acquired following actual infection or immunization.
 Passive immunity-
 preformed antibodies given to the host

 At the community level:

 Herd immunity host resistance at the community
(population) level
 Chain of disease Con…
 Herd immunity can be defined as
74
 Resistance of a community (group) to invasion
and spread of an infectious agent, based on the
immunity of a high proportion of individuals in
the community.

 The high proportion of immunes prevents

transmission by highly decreasing the probability of
contact between reservoirs and susceptible hosts
 Chain of disease Con…
 Conditions in which herd immunity best functions
75
1. Single reservoir (the human host)
 If there is another source of infection it can transmit the
infection to susceptible hosts.
2. Direct transmission (direct contact /direct projection)
 Herd immunity is less effective for diseases with efficient
airborne transmission
3. Total immunity
 Partially immune hosts may continue to shed the agent,
and hence increase the likelihood of bringing the infection
to susceptible hosts
 Chain of disease Con…
4. No shedding of agents by immune hosts (no carrier
76 state)

5. Uniform distribution of immunes

 Unfortunately susceptibles usually happen to live in
clusters or pockets because of socioeconomic, religious, or
geographic factors
6. No overcrowding
 Overcrowding also increases the likelihood of contact
between reservoirs and susceptible hosts
 However, these conditions for the operation of herd
immunity are seldom fulfilled
Time Course of a Disease in Relation to Its
Clinical Expression and Communicability
77
 Chain of disease Con…
Time Course of a Disease in Relation to Its Clinical
78 Expression and Communicability
 There are different period encountered in the

course of infectious disease

 Pre- patent period:
 The time interval b/n biological onset & the time first
shedding of the agent
 This is time interval b/n infection and the point at which
the infection can first be detected in blood, stool, urine
…
 it is measured by first shading of the agent in these
biological products.
 Chain of disease Con…
 Incubation period
79
 Time interval b/n infection and the first appearance of
sign and symptom.
 It is time interval b/n biological and clinical onset

 Communicable period
 Period during which an infected host can transmit
the infection to susceptible host.

 Latent period
 Time interval b/n recovery & relapse or recrudescence in
clinical disease
80
 81

DETERMINANTS OF
DISEASES
DETERMINANTS OF 82

DISEASES

1. Principles of Disease Causation

2. Disease models
3. Natural History Of Diseases
4. Course of diseases
5. Level of Disease Prevention
6. Disease Control
Principles of Disease Causation & Models
1. Disease causation
83 A cause of a disease is
 A factor (event, condition or characteristics)
 That precedes the disease event &
 Without which the disease event
 Either would have not occurred at all
 Or would have not occurred until some later time

 A factor is something that influence the occurrence

 Each cause is seen as necessary & sufficient in itself to
cause a disease
 Not all associations between exposure & disease are
causal
 Disease causation Con…
 A cause of a disease can be
84
1. Necessary cause
2. Sufficient cause
 Necessary cause
 Is that type of factor without which the disease does not
occurred at all
 Sufficient cause
 A set of conditions, factors, or events sufficient to produce
a given outcome
• A complete causal mechanism that does not require the
presence of any other determinant in order for an outcome
such as disease, to occur
• If the disease always result from the factor, then the factor
 Disease causation Con…
 There are two principles in disease causation
85 1. Single Germ Theory
2. The Ecological approach

 AGENT OF DISEASE
 A factor whose presence, excessive presence, or relative
absence is essential to cause a disease
 A disease may have a single agent, a number of
independent alternative agents or a complex of two or
more factors whose combined presence is essential
 II Disease models Con…

86
1. EPIDEMIOLOGIC TRIANGLE ANDTRIAD (BALANCE BEAM)
 Disease models Con…
 Was widely used for several years
87
 Is still referred frequently
 Considers the importance of three components

 These factors are

1. Agent
2. Host &
3. Environment
 Disease causation Con…

 Environmental factor
88 Influence the 1 Existence of the agent
2 Exposure of the host to the agent
3 Susceptibility to the agent
 Environmental factor includes
 Biological environmental
Infectious agent Reservoir Vectors
 Social environmental
1. Socioeconomic 2. Political organization
( Affect the level of medical care)
 Physical environmental
Heat, Light, Water, Air, Industrial wastes Indoor pollution
 Disease causation Con…
 Host factor
89
 Results from interaction of genetic endowment
with environment
 Host factor includes
 Genetic inheritance------Age Sex Ethnicity
Weight Height
 Physiological status-----Pregnancy Puberty Stress
 Immunologic condition-----Active & Passive immunity
 Human behavior---------- Hygiene Diet handling
 Previous disability preexisting disease (Intercurrent)
 Disease models Con…
 Each components must be analyzed & understood for

90 prediction of patterns of diseases

 This model highlights the agent of a disease as separate

component
 Considers agent as it is not part of the environment
 Model is important to describe diseases which has one
agent (infectious diseases)
 A change in any of the components will alter the existing
equilibrium to increase or decrease disease frequency
 III. Natural History Of Diseases
 Natural history of disease refers to
91
 the progression of a disease process
 in an individual over time,
 in the absence of intervention

 Each disease has it’s own natural history

 Any general formulation of this process is arbitrary

 Natural history Con…
 It is useful to have a picture of natural history
92
 To understand to plan intervention measures
including prevention and control

 The process begins with exposure to causative agent

 Without medical intervention, the process ends with

recovery, disability, or death
 Natural history Con…

93
Most diseases have a characteristic natural history
 The time frame and manifestations of disease
may vary from individual to individual
 The usual course of a disease may be halted at any
point in the progression by
 Preventive and therapeutic measures,
 Host factors, and other influences.
 Natural history Con…
 There are four stages in natural history
94
1. The stage of susceptibility

2. The stage of pre- clinical (sub-clinical) disease

3. The stage of clinical disease

4. The stage of death or disability

 Disability is the limitation of a persons activity including

his/her role as parent, wage earner
 Natural history Con…
 The major purpose of investigating epidemiology of

95 diseases is to learn how to control & prevent

 Disease prevention means to interrupt or slow the

progression of diseases
 The aim of disease prevention
 To push back the level of detection & intervention to the
precursors & risk factors of diseases

 Epidemiology plays central role disease prevention by

identifying those modifiable factors (causes) of diseases
96
Course of diseases
I. Stage of susceptibility
97 In this stage disease has not yet developed but the

ground work for the disease has been laid by the presence
of factors that favor its occurrence.
 Example:
- Unvaccinated child is susceptible to measles.
- A person practicing casual and unprotected sex
has a high risk of getting HIV infection
- High cholesterol level increases the risk of
coronary heart disease
Course of diseases Con…
II. Stage of per symptomatic (sub-clinical disease)
98 In this stage there is no manifestation of disease but
pathogenic changes have started to occur
 There are no detectable signs or symptoms and the disease
can only be detected through special tests
– Detection of antibodies against HIV in an apparently healthy
person.
– Ova of intestinal parasite in the stool of apparently healthy
children.

– This stage may lead to the clinical stage, or may

sometimes end in recovery
Course of diseases Con…
III. The clinical stage
99 The person has developed signs and symptoms of the
disease
 The clinical stage of different disease differ in duration,
severity and outcome
 Outcome may be recovery, disability or death
 Common cold has short and mild clinical stage
 Polio has severe clinical stage and patients may develop
paralyses
 HIV/AIDS has longer clinical stage and results in death
Course of diseases Con…
IV. Stage of disability or death
 Diseases run their course & then resolve completely either
100

spontaneously or by treatment but may result in a residual

defect, leaving the person disabled for a short or longer
duration end in death
 Disability is limitation of a person's activities
 Disease has occurred and left over damage (disability) or
may end with the death of the victim
e.g. Trachoma may cause blindness
101
TIME COURSE OF INFECTIOUS DEASES
 There are different period encountered in the

course of infectious disease

102

 Pre- patent period-

 The time interval b/n biological onset & the time
first shedding of the agent
 Is the interval b/n infection & the point at which
the infection can first be detected in blood,
stool, urine …and
 It is measured by first shading of the agent in
these biological products
Time Course con…
 Incubation period
103
 Time interval between infection and the first
appearance of sign and symptom. It is time
interval between biological and clinical onset.
 Communicable period
 Period during which an infected host can
transmit the infection to susceptible host.
 Latent period
 Time interval between recovery & relapse in
clinical disease or recrudescence in clinical
disease.
104
V Level of Disease Prevention
1. Primordial Level of Disease Prevention
105
 Stage of disease
 Existence of underlying condition leading to causation
 The aim is
 to avoid the emergence and establishment of the social,
economic, and cultural patterns of living that are known to
contribute to an elevated risk of disease
 Target
 Total population and selected groups
 Example: smoking, environmental pollution
 Levels of prevention con…
2. Primary Level of Disease Prevention
106
 Stage of disease
 No disease but specific causal factors exist
 The causative agent exists
 The aim is
 To prevent development of disease
 To prevent healthy people from becoming diseased/sick

 Target
 Total population and selected groups

 Example: immunization, Measles, polio

 Levels of prevention con…
 The main purpose of primary prevention is
107
 Promoting health
 Prevention of exposure
 Prevention of diseases through

Active & Passive immunization

 Levels of prevention con…
3. Secondary Level of Disease Prevention
108
 Stage of disease
 Early stage of disease.
 The aim is to
 Cure patients and
 Prevent the development of advanced disease
 Target
 Patients
 It involves detecting diseased people as early as
possible to
 Stopor slow the progression and
 Prevent or limit permanent damage
 Levels of prevention con…
4. Tertiary Level of Disease Prevention
109

 Stage of disease
 Late stage of disease.
 The aim is to
 Prevent development of severe disease and
disability
 Target
 Patients
 Especially patients with chronic illnesses & disabilities that
can not be cured
 Levels of prevention con…
 Tertiary Level prevention has two objectives
110
1. Treatment
 To prevent further disability or death

2. Rehabilitation
 To limit the physical, psychological, social &
financial impacts of the disease

 Example: Leprosy
Disease Control
Disease control
111
 Is ongoing operations or programs aimed at reducing
incidence and/or prevalence of CD & conditions to a
level where it can not be a major public health
problem
 Disease control is ongoing operations to reduce:
I. The incidence of disease
II. The duration of disease, and consequently the risk
of transmission
III. The effects of infection; and
IV. The financial burden to the community
 Disease Control Con…
 Control activities may focus on primary prevention or
112 secondary prevention

 Most control programs combine the two

 Tertiary prevention is comparatively less relevant to

control efforts

 In disease control, the ‘’ agent’’ is permitted to present

in the community at a level where it ceases to be a
public health problem according to the tolerance of
the population
Disease Control Con…
Methods of Controlling Communicable Disease
113
 There are three main methods of CDC based on the
targets of the actions to be taken.
1. Protection of the susceptible host
2. Interruption of transmission
3. Actions on the reservoir
Disease Control Con…
I. Protection of the susceptible host
114
 This can be achieved through:-
 Immunization
 Chemoprophylaxis
 Better nutrition
 Personal protection
e.g. Wearing shoes, using mosquito bed net,
insect repellants etc.
 Disease Control Con…
II. Interruption of transmission
115
 This involves action taken on different ways of
transmission so as to control disease transmission from
infected host to susceptible host
 It can take place through:-
 Improvement of environmental sanitation and
personal hygiene
 Control of vectors
 Sterilization and disinfection of materials
 Use of protective materials such as glove, mask
 Disease Control Con…
III. Actions on the reservoir
116
A. Man as reservoir
 Early detection and treatment

 Isolation-

 separation of infected persons for a period of

communicability
 is indicated for infectious disease with high morbidity,

mortality and infectivity

 Quarantine–

 limitation of the movement of persons or animals

who are apparently well but have been exposed to

the infectious disease for duration of the maximum
Disease Control Con…
 The word quarantine comes from the Italian quaranta,

117
meaning forty, and refers to the 40 days arbitrarily (or
empirically) believed to be an adequate isolation period,
 perhaps based on the biblical 40 days

 The clinical distinction between isolation and

quarantine is that
 Isolation is procedure for persons already sick
 Quarantine is often applied to (apparently)
healthy contacts
 Disease Control Con…
B. Animals as reservoir
118
 Action will be determined depending on
 The usefulness of the animals
 Their intimacy with man
 Feasibility of protecting susceptible animals
 The action can be destroying the infected animal
considering the above mentioned conditions
e.g. destroy rat to control plague
 Disease Control Con…
C. Non - living things reservoir
119
 The measurement can be limiting exposure of
human being to the affected area
E.g. Soil, water, forest etc…
 Disease Control Con…
Disease elimination

120 Reduction of case transmission to a predetermined very
low level
 WHO (1991) defined elimination of TB as a
public health problem as reduction of prevalence
to a level below 1 case per 1,000,000 population
 An intermediate goal b/n control and eradication
 Elimination is interruption of transmission of disease,
from large geographic regions or areas
 e.g. elimination of measles, polio
 Regional elimination is seen as an important precursor of
eradication
 Disease Control Con…
Eradication of Disease
 Termination of all transmission of infection by
121

extermination of the infectious agent through

surveillance & containment
 In 1992, the WHO defined it as

“Achievement of a status whereby no further cases

of a disease occur anywhere & control measures are
unnecessary”
 Smallpox was eradicated in 1977, based on
joint control and surveillance activities
 Regional eradication has been successful with
poliomyelitis
122

SOURCES OF DATA
FOR
COMMUNITY HEALTH
SOURCES OF DATA FOR COMMUNITY HEALTH
 There are different sources of data for community
123
health
 Each source has advantages & disadvantages
 Information from these sources are used for
 Health planning
 Health programming
 Evaluation of health services
 Sources of data Con…

124
Major sources are
1. Census
2. Vital statistics
3. Health services records
4. Health survey
 Sources of data Con…
A. Census
125
Is a periodic count (enumeration) of a
population
 Census data are necessary for
1. Accurate description of health status of a
population
2. Are principal sources of denominator for
rates of diseases and death
 Sources of data Con…

126
Census data provides us information on
1. Size and composition of population
2. The forces that determine these variables
Birth Death Fertility etc
3. The trends anticipated in the future
General trends or direction
 Sources of data Con…
 There are two types of census counts
127

De facto
Dejure

 De facto
 Counting persons according to their
location at the time of enumeration
 But excluding those who are temporarily
away
 Sources of data Con…
 Dejure
128
 Counting persons according to their usual
place of residence

 But excluding temporary visitors

 Sources of data Con…

129
Ethiopia counting (De facto)
 We had three enumerations
1976 1986 1996/8
 Data was collected on
 Age sex size of population
 Mortality Fertility
 Language Ethnicity
 Housing condition
 Sources of data Con…
 From census data we can calculate
130
CBR, CDR, ASMR, SSMR

Limitation of census data

1. It is very expensive
2. Difficulty to compile and analyze (Is time consuming)
3. Carried every 10 years hence it can not assess yearly
changes (impacts of events)
 Sources of data Con…
B. Vital statistics
131
 Is a system by which all birth & death occurring

nationwide are registered and compiled centrally

 Certificate is issued for each birth & death
 It is the source of information for calculation of birth rates
& death rates
 Cause specific mortality can be calculated
 But denominator is obtained from census
 Sources of data Con…
 Main characteristics of vital statistics
132
1. Comprehensiveness
 All birth and death are registered
 All marriage & divorces are registered

2. Compulsory by law
 (Should be enforced by law)

3. Compiled centrally
 To serve as source of information

4. Continuous

 Sources of data Con…
 Limitation of Vital statistics
133

 Un availability of nation wide registration of

birth and death
 Data is not complete
 Home delivery
 Death certification
 Traditional marriage
 Sources of data Con…
C. Health services records
134

 Data generated from all health institution are

reported centrally to MOH (FMOH) and
compiled analyzed and published on health
service directory

 In Ethiopia this is the major source of health

information
 Sources of data Con…
 Advantages of health services records
135

1. Easy to obtain
2. Low cost
3. Continuous system of reporting
4. Causes of illness and deaths are available
 Sources of data Con…

 Limitation of health services records

136
1. Not comprehensive (Coverage)

2. Not representative
 Only few can go to health facilities

3. Lack of denominator

4. Lack of uniformity in quality

5. Diagnosis varies across levels of health facilities

6. Lack of compliance with reporting

7. Irregularity and incompleteness of published

 Sources of data Con…
 Notification of infectious diseases
137
 Notification is at different level
 Internationally
1. Plague
2. Cholera
3. Yellow fever

 Every country has notifiable diseases

 Sources of data Con…
 In Ethiopia (some 19 diseases including)
138 Some immediately some quarterly


 Measles
 Polio myelitis
 Neonatal tetanus
 Diarrhea
 Diarrhea with severe DHN
 Bloody diarrhea
 Meningococcal meningitis
 Typhoid fever
 Malaria
 Sources of data Con…
 Major problem with sources of notification is
139

1. Low compliance
2. Delay in reporting
 Sources of data Con…
D. Health survey /Research/
140
 Are studies conducted on representative sample
population to obtain more comprehensive data for
monitoring health status of a population

 There are two types of health survey

1. Survey of specific diseases
2. Survey of general health status
 Sources of data Con…
1. Survey of specific diseases
141

 Studies conducted on each specific diseases

1. EPI

2. Control of Communicable Diseases (CDD)

3. Prevention and control of HIV/AIDS

 Sentinel survey
 BSS (Behavioral Surveillance Survey)

4. TB/Leprosy control
 Sources of data Con…
2. Survey of general health status
142
 Are studies on general health status of population
 They are based on interview, physical examination &
laboratory tests
 They are more reliable than survey of specific
diseases
 But they are more expensive
 Sources of data Con…
 Advantages of survey based on interview
143

1. They are more representative of health

condition of community
2. Denominator is known
3. Data are more uniform in quality
 Sources of data Con…
 Limitation
144

 Data accuracy is dependent on

Memory of interviewee &
Cooperation of interviewee

 Expensiveness
DISEASE SURVEILLANCE

Define surveillance
Differentiate types of surveillance
Describe purpose of surveillance
Discuss integrated disease surveillance & response
Evaluate the guiding principles of surveillance
 Surveillance
 Surveillance is
146

Systematic and continuous

collection, analysis, and interpretation of data
integrated with the timely and coherent
dissemination of the results
to those who have the right to know to take
action
 Surveillance con…
Continuous
147
analysis, interpretation, and feedback of
systematically collected data
using methods distinguished by their
practicality, uniformity, and rapidity
rather than by accuracy or completeness

 Is an essential feature of epidemiological and

public health practice
 Surveillance con…
 It provides information
148
 used to investigate, prevent, & control disease
 Its purpose is to provide a factual basis for
 setting priorities, planning programs & taking action
 to promote and protect community health

 Its final phase is the application of information to

 Health promotion
 Disease prevention & control

 A surveillance system includes a functional capacity

 for data collection, analysis, &
 dissemination linked to public health programs
 Surveillance con…
 By observing trends in time, place, & persons, changes
149
can be observed or anticipated and action, including
investigative or control measures, can be taken
 Sources of data may relate directly to disease or to
factors influencing disease
 Data may include mortality/morbidity reports based on
-Death certificates -Hospital records -Notifications
-Laboratory diagnoses -Outbreak reports
-Vaccine uptake & side effect -Disease absence
records -Serological surveillance via serum banks
-Changes in disease agents, vectors, or reservoirs
 Surveillance con…
 It is distinguished from monitoring by
150  Surveillance is continuous and ongoing, whereas
 Monitoring tends to be more intermittent or
episodic

 Surveillance can be conducted

 Globally (eg. AIDS surveillance system managed by WHO)
 Regional (eg. polio surveillance in Latin America)
 National, or
 Institutional (eg. surveillance for nosocomial infections or
potential causes of epidemics in refugee camps)
Surveillance con…
Information for Action
151

Although surveillance is meant to guide a larger

action it also provides the basis for identifying
individuals who need treatment and preventive
services
 Surveillance con…
 We do not limit surveillance to diseases for
152
which we have effective control measures
Surveillance can be justified for two additional purposes:
1) To learn more about the natural history, clinical
spectrum, and epidemiology of a disease, and
2) To obtain baseline data which we can use to assess the
effectiveness of prevention and control measures when
they are developed and implemented

 Surveillance is a system of close observation of all aspects

of the occurrence and distribution of a given disease
 Goals of Surveillance is to
1. Detect cases or clusters of cases thereby enabling
153 interventions to be implemented

2. Assess the public health impact of a health event or

determinant and measure trends

3. Demonstrate the need for PH intervention programmers

and resources

4. Monitor the effectiveness of disease prevention and

control measures and intervention strategies

5. Identify high-risk populations or geographic areas

6. Develop hypotheses leading to analytic studies

 Surveillance con…

The purposes of monitoring health events are :

154

1. To detect sudden changes in disease

occurrence and distribution

2. To follow secular (long-term) trends and

patterns of disease
3. To identify changes in agents and host factors

4. To detect changes in health care practices

 Surveillance con…
 Interpretation of surveillance data may provide the basis
155for generating hypotheses & stimulating health research

 Archival surveillance data have also been used to develop

statistical models of diseases
 Eg. Predicting feasibility of programs to eradicate measles & polio

 Key sources of surveillance data includes

 Census data
 Mortality reports (birth and death certificates, autopsy reports)
 Morbidity reports (notifiable disease reports)
 Hospital data (discharge dx/surgical logs/hospital infection rep

 Not all sources are available in every country

Sources of surveillance data
1. Absenteeism record
156 school/workplace/compensation claims
2. Epidemic reports
3. Laboratory test utilization and result reports
4. Drug utilization records
5. Adverse drug reaction reports
6. Special survey
e.g. research data, serologic surveys
7. Police records (for injury, alcohol-related crime)
8. Information on animal reservoirs & vectors
e.g. for rabies, plague
 Surveillance con…

9. Environmental data (hazard/water/food testing)

157

10. Special surveillance systems

e.g. injury & occupational illness

Types of surveillance systems

 Public health surveillance systems classified as
1. Passive
2. Active
3. Sentinel

 All are utilized in the surveillance of CDs

 Surveillance con…
I. Passive surveillance
158
 Refers to monitoring of data supplied to
authorities by professionals as a requirement
under law

 It is one in which health care providers send

reports based on a known set of rules and
regulations
 CD surveillance is reliant on passive
surveillance, using both clinical & laboratory
 Surveillance con…
 But Passive surveillances are likely to
159
underestimate the true burden of illness
 It could be b/c
 Many people with notifiable diseases may
 Have mild illness
 Not seek care
 Incorrectly diagnosed
 Not receive laboratory testing
 Surveillance con…
II. Active surveillance

160
Is a more vigorous surveillance system which is used to
make under reporting impossible
 Especially for serious conditions
 Active surveillance is one in which public health
officials contact providers to solicit reports of events or
diseases
 This supplementary surveillance can be in response to a
large outbreak
 It is useful to determine prevalence rate of cases if
 There is lack of data or
 Cases occur sporadically
 Surveillance con…
 Active surveillance is usually limited to specific diseases over
161 a limited period of time
 In passive surveillance incomplete reporting, is common
 The process of case ascertainment in outbreak
investigation can be example of active surveillance
 Active systems can
 validate the representativeness of passive systems,
 enable more complete reporting of conditions or
 be used in conjunction with or part of specific
epidemiological or outbreak investigations
 Surveillance con…

III. Sentinel surveillance systems

162
 Are surveillance established for the purpose of
enabling simple & early detection of disease

 It uses a pre-arranged sample of reporting

sources to report all cases of one or more
conditions
 Animals are often used to provide early warning
 Sentinel healthcare providers & clinicians collect data on
selected indicators to assist in estimating size of problem
among the general population
 Surveillance con…
 Sentinel surveillance
163  Usually sample sources are selected to be those
most likely to see cases
 In developing countries, it provides a practical
alternative to population-based surveillance
 In this strategy, officials define
Homogenous population subgroups and
The regions to be sampled

 They then identify institutions that serve the

population subgroups of interest, and that can and
will obtain data regarding the condition of interest
 Surveillance con…
 Surveillance based on secondary data analysis can

164
make productive use of data sets collected for other
purposes
 Data from marketing surveys, patient records, police
records, and other sources can be used as sources of
data
 Such data may be of lesser quality and timeliness than
data collected through systems designed specifically
for surveillance
 Surveillance data is first analyzed in terms of time,
place, and person
 Surveillance con…
 Data are analyzed as rates rather than the numbers of
165
cases reported
 If delays occur b/n diagnosis & reporting, we analyze
data by date of onset, rather than the date of report

 We should determine denominator to calculate rates

 Techniques that can be used to display data includes
 Tabular & graphic
 Cluster & time series analysis &
 Computer mapping may also be used
 Surveillance con…
 Surveillance data may be assessed for changes over time
166
 Secular trends, are usually analyzed by graphing the
occurrence of disease by year

 Any key events, like initiation or cessation of a control

program should be noted on the graph

 Changes in surveillance system which may influence the

appearance of long-term trends should be indicated on
the graph
 Surveillance con…
 Surveillance data should be analyzed by place
167  Even when secular trend reveal no increases in overall incidence

 Analysis by place may reveal a geographic cluster of

cases, which deserves investigation

 Analyzing surveillance data by the characteristics

person variables may reveals patterns or clues
 (age, sex, and behavioral risk factors)

 There is no single “threshold” above which disease

patterns are different enough from the expected to
warrant further investigation
 Surveillance con…
 The excess necessary to trigger action depend on the
168
 Priority assigned to the disease &
 Interest, capability & resource of ministry or agency

 Public, political, or media attention and pressure, can

sometimes make it necessary to investigate minor
variations in disease occurrence, which might no
otherwise be pursued

 Apparent increases should be treated as real until proven

otherwise
 Surveillance con…
 However other causes of apparent increases should also
169
be considered, including
 Increase in the denominator population
 Improved detection,
 “batch” reporting, or
 other changes in the system itself
 Surveillance data should be disseminated to those
 Who provide reports, and
 Who need to know for administrative, program-planning, and
decision-making purposes
 Surveillance con…


170
Newsletters and other reports of surveillance data can
also help to maintain the quality of a surveillance system
by providing motivation for continued reporting by health
care providers

 Surveillance data should be “information for action”,

collected only if it is functionally linked with community
health programs
 Surveillance con…
Evaluation of Surveillance system
171 Five aspects of the surveillance system should


be assessed in justifying, designing or evaluating

1. Importance of the event under surveillance to PH
 Incidence and prevalence
 Severity (case-fatality or death-to-case ratio)
 Mortality (CDR,ASMR, years of potential life lost
 Health care costs
 Potential for spread
 Preventability
 Surveillance con…
2. The objectives and operation of the system
172
 The case definition of the health event and the
population under surveillance

 The time period for data collection

 (weekly/monthly, annually)
 What information is collected (is it relevant?)
 The reporting sources
 How data are handled (transfers/delays/confidentiality)
 How data are analyzed (who? Frequency/thoroughness
 How data are disseminated
 Surveillance con…
3. The system’s usefulness

173
Action taken as a result of the information
 Future or potential uses
4. Attributes or qualities of the surveillance system
 Simplicity & Timeliness
 Flexibility
 with changes in case definition or funding,
to add new diseases
 Acceptability
 Judged by proportion who report, completeness
 Surveillance con…
 Sensitivity
 Ability to detect events intended to detect
174

 Predictive value positive

 Proportion of reported cases which truly are
cases or
 Proportion of epidemics which are actual
epidemics
 Representativeness
 extent to which one can generalize or draw
conclusions from surveillance data
 Surveillance con…
5. Cost(resource) requirement for system operation
175
Surveillance systems are never perfect
Understanding the limitations of surveillance data is
important to ensure correct interpretation

Most common limitations of surveillance systems:

A. Under reporting
B. Lack of representativeness of reported cases
C. Lack of timeliness
D. Inconsistency of case-definitions
 These limitations suggest specific steps, which may be
taken to improve a surveillance system
 Surveillance con…
 Surveillance systems are strengthened by improving
176
 Awareness of practitioners
 Simplification of the process of reporting
 Frequent feedback to those reporting
 Widening “net”
Eg. obtain reports from Lab or schools than relying on physicians
 Using active (rather than passive) surveillance

 Remember to “share the data, the responsibility, &

the credit”
 Surveillance con…

Factors determining selection of disease for surveillance:

177

1. Magnitude of the disease

2. Feasibility of control measures

3. Need for monitoring & evaluating performance of a

control program

4. Resource availability
 Surveillance con…
Activities in surveillance:
178

1. Data collection and recording

2. Reporting and notification
3. Compilation, analysis, & interpretation
4. Dissemination of findings for action
 Surveillance con…
Conditions where active surveillance is appropriate (8)
179
1. For periodic evaluation of ongoing programs
e.g. HIV/AIDS, EPI..

2. For programs which have time limit of operation

e.g Small pox

3. With the occurrence of unusual situations

4. When a new disease/event is discovered

5. When investigating a new mode of transmission

 Surveillance con…
 Active surveillance is appropriate
180

6. When a high-risk period is recognized

7. When a disease appears in a new geographic

area or affect a new subgroup of population

8. When previously eradicated disease reappear

or low incidence disease occur at a higher
level of endemicity
 Surveillance con…
Features of good surveillance system
181
 A good surveillance system
 Uses combination of passive & active mechanisms
to collect data
 Emphasize the collection of minimum data in
simplest possible way
 Assure quality and enhance compliance
 Make sure that the data collected is useful for the
workers who collect the data
 Surveillance con…
 good surveillance system con…
182
 Timely reporting
 Timely and comprehensive action
 Action must be targeted towards both
Case detection & treatment and
Control of the disease

 Strong laboratory services for accurate diagnosis.

 183

INVESTIGATION AND
MANAGEMENT OF EPIDEMICS
(OUT BREAK)
184
 Outbreak investigation
Uncovering Outbreaks

185 Outbreaks may be detected when routine & timely
analysis of surveillance data reveals
 An increase in reported cases or
 An unusual clustering of cases
 In health departments we may detect increases or
unusual patterns of disease from
 Weekly tabulation of case report by time & place
 Examination of exposure information on the case
reports
 Outbreak investigation
Importance of Investing Possible
186 Outbreaks
 Health departments investigate outbreaks b/c of

1. The need to start control & prevention measures

2. They provide opportunity for research & training

3. Program considerations; and

4. Public, political, or legal concerns

 Outbreak investigation
 The 1° PH reason to investigate outbreak is
187 to control & prevent further disease
 Before developing any control strategies we must identify
where the outbreak is in its natural course:
 Are cases occurring in increasing numbers? or
 Is the outbreak just about to be over?
 If cases are continuing to occur our goal
may be to prevent additional cases
 If an outbreak is to be over, our goal may be
to prevent outbreaks in the future
 Outbreak investigation
 The balance between control measures versus further
188
investigation depends on how much is known about
 The cause
 The source, and
 The mode of transmission

 Relative priority of investigative & control

efforts during an outbreak, based on level of
knowledge of
 The source,
 Mode of transmission, and
 Causative agent
Relative priority of investigative & control efforts
during outbreak
189
Definition
Outbreak is
-Occurrence
190 of a specific disease more than expected
number in a given area or among a specific group of
people over a specified period of time
 Outbreak investigation
CLUSTER
 Aggregation of cases in a given area over a particular
191

period without regard to whether the number of cases is

more than expected

Disease Clustering
 Commonly clustering is due to an aggregation of
relatively rare events or diseases in time and/or place
 It should not be used in context of common diseases
 It could be mini-epidemic of a rare event in which
occurrence of disease is clearly in excess of expected
 Cluster provide useful clues to PH action but often they
are difficult to handle b/c of small number
Level of disease Occurrence
 In a community diseases can occur at different levels
192 at a particular point in time
• Some diseases usually present at a predictable level
• This is called the expected level

• But sometimes they occur in excess of expectation

• Disease occurring at unexpected levels may be
described as:
 Epidemic
 Occurrence of health related condition (disease) in excess of
the usual frequency in an area or among a specific group of
people over a particular period of time
 Disease Occurrence …

 Outbreak
193
 An epidemic of shorter duration covering a more limited area
 Endemic
 A disease that is usually present in a population or in an area at a
more or less stable level
 Sporadic
 A disease that does not occur in that population, except at
occasional and irregular intervals
 Pandemic
 An epidemic disease which occurs world wide
 Cluster:
 Is an aggregation of cases in a given area over
particular period without regard to whether the
 Outbreak investigation
Types of epidemic (outbreak)
194
 Epidemic can be classified according to
 Methods of spread or propagation
 Nature & length of exposure to infectious agent
 Duration

 Patterns of Epidemics
1. Common source epidemics
2. Propagated or progressive epidemics
3. Mixed Epidemics
 Outbreak investigation
1. Common source epidemics
195 Disease occurs when susceptible group are exposed
to common source of pathogen, at the same time or
within a brief time period
 Are outbreakes caused by exposure of a group of
people to a common infectious agent or a toxin
 They are of three types
A. Point source
B. Continuous common source
C. Intermittent common source
A. Point source epidemic/outbreak
If the exposure is brief & simultaneous all exposed
develop the disease within one incubation period
196
 Point source
 A rapid rise and fall of an epidemic curve suggests a
197 point source epidemic

 An epidemic curve with no clear peak & prolonged

duration of outbreak shows
 Source of outbreak remains for a longer time,
days, wks
 Longer continuously or intermittently and
 Multiple exposures with variable incubation
period
 B. Continuous common source
198
 Makes wide peak in the epidemic curve, because of the
range of exposures & incubation periods

C. Intermittent common source

 Results in an irregular pattern of the epidemic curve that
reflects the intermittent nature of the exposure
Types of epidemics cont.
 Common source epidemic with continuous or
199
intermittent exposure
 Exposure continues over a period of time
 Lasts for more than one incubation period
 E.g. Outbreak of hepatitis A from exposure to
food contaminated by infected food handler
intermittently or continuously
 Epidemic curve-extended and irregular
 E.g. of a common source epidemic

200 A waterborne 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 the range of incubation periods
 Common source epidemics
Number of
201 cases

Continuous Common Source

Time
 Common source epidemics
Number of
202 cases

Continuous Common Source

Time
 Intermittent Common Source
Number of
203 cases

Time
 2. Propagated or progressive epidemics
This type of outbreak occurs through
204 1. Direct person-to-person transmission or
.
2. Transmission through a vector
Epidemic curve would have successive series of peaks
reflecting increasing numbers of cases in each generation
 Types of epidemics cont.
 Propagated/Progressive epidemics

205 Infectious agents is transferred from one host to
another either directly or indirectly
 Lasts for more than one incubation period
 E.g. – Measles, Malaria, Shigellosis
 Epidemic curve-initial slow rise, succession of several peaks
and usually sharp fall
Propagated/progressive epidemics
Propagated/progressive epidemics

206 caused by direct person to person transmission of
disease or
 transmission by vector
 It is characterized by epidemic curve of successive series of
peaks
 Typical Propagated Epidemic Curve

207
 Type…

3. Mixed epidemics
 Epidemics having the features of both
208

common source and propagated epidemics

E.g. a common source outbreak may be followed by
secondary person-to-person spread
 Epidemic begins with a single common source of
infectious agent with subsequent propagative spread
e.g. in case of food borne pathogens
 Outbreak investigation
Outbreaks are detected in one of the following ways
209 (Uncovering Outbreaks)
1. Outbreaks may be detected when routine, timely analysis
of surveillance data reveals
 An increase in reported cases or
 An unusual clustering of cases
2. In a health department, we may detect increases in or
unusual patterns of disease from
 Weekly tabulation of case reports by time & place or
 Examination of exposure information on the case reports
themselves.
 Outbreak investigation

Questions that should be answered when

investigating epidemic are
210

 What is the etiological agent responsible for the

epidemic?
 What is/are the predominant modes of
transmission?
 What specific source/s of disease can be identified
 e.g human carriers, breeding sites for vectors, etc.?
 Outbreak investigation

Importance of investigation out break are

211

1. To determine the specific cause(s) of out break early

2. To take appropriate measure directed at controlling the

epidemic

3. To prevent future occurrence of the out break

 Outbreak investigation

Rationales to investigate possible outbreaks

212

1. Need to institute control and prevention measures

2. Research opportunities

3. Training

4. Public, political or legal concerns

5. Program considerations
 Outbreak investigation
Basic principles of epidemic investigation
1.213 Conduct multiple activities are simultaneously; run a
dynamic process

2. Maintain communication with officials, stake

holders, public

3. Apply epidemiologic and statistics principles

4. Record all steps taken in investigation process

5. Careful and critical review of literatures

6. Maintain open but critical mind to uncover new

pathogens/transmission means
Outbreak investigation
Objective of outbreak investigation & mgmt
•214 Anticipation or prediction
 epidemics can be prevented

• Preparedness or readiness to respond

• Early detection - to know when there is problem

• Rapid investigation -to describe the event for

intervention
• Effective response -act appropriate control measures
• Evaluation -identify what went right and wrong
Outbreak investigation

What should be the priority action in an outbreak?

215
 Steps of an outbreak investigation
1. Prepare for field work
216
2. Establish the existence of an outbreak
3. Verify the diagnosis
4. Describe the epidemic with respect to time,
place, person
5. Formulate and Test Hypotheses
6. Search for additional cases
7.Analyzing the data
8. Make a decision on the hypotheses tested
9. Implement control and prevention measures
10. Communicate findings
Steps in outbreak investigation
Step 1: Preparing for Field Work
 Before leaving for field one should be well prepared
217

 Preparations can be grouped into three

categories:
A. Investigation B. Administration & C. Consultation
a. Investigation
 1st one has to have scientific knowledge, supplies,&
equipment for the investigation
 Discuss with someone knowledgeable about disease, field
investigations, review applicable literature
 Assemble references /journal articles & questionnaires/
 Consult lab. staff to ensure that you take lab. material
 Arrange for portable computer, Dictaphone, camera etc
Steps in outbreak investigation
b) Administration:
 2nd you must pay attention to administrative procedure
218

 Make travel & other arrangements & get them approved

 Take care of personal matters

c) Consultation:
 3rd you must know your expected role in the field

 All parties should agree on your role

 You should know who your local contacts will be

 You should know when and where you are to meet with

local officials & contacts

Steps in outbreak investigation
Step 2: Establishing the Existence of an Outbreak
 Verify if a reported outbreak is indeed an outbreak
219
 Determine expected number of cases before deciding

observed number exceeds expected

 Compare the observed with the expected

 Usually we compare the current number with previous

few wks or mths, or a comparable previous few years

 For notifiable disease use health department records

 Other diseases find existing data locally

 If local data are not available apply rates from

neighboring states or national data etc
 Finally, conduct a survey of the community to establish
the background of disease
Steps in outbreak investigation

Step 3: Verifying the Diagnosis


220
You can verify outbreak existence & diagnosis together

 Your goals in verifying the diagnosis are to

1. Ensure problem has been properly diagnosed &

2. Rule out lab. error as basis for increase Dxed cases

 To verify Dx review clinical findings & lab. result

 It is not possible to confirm every case with lab. evidence
 Establish criteria for labeling persons as cases
 Classify cases based on symptoms lab. results or both
 The investigator should use case definitions
Steps in outbreak investigation
 Review the clinical and laboratory findings of the cases to

establish the diagnosis

221
 To ensure the problem has been properly diagnosed and
to rule out laboratory error as the basis for the
increase in diagnosis
 If you have any doubt about the laboratory findings
review the laboratory techniques
 Send specimen for confirmation to reference laboratory
 Summarize the clinical findings with frequency
distribution
 Depending on the type of the problem under investigation
establish criteria for labeling persons as "cases"
Steps in outbreak investigation
Case definition

222 Is a standard set of criteria to differentiate b/n cases
and non cases
 Cases can be one of the following:

1. Confirmed/definite:
 A case with laboratory verification
2. Probable:
 A case with typical clinical features but without
laboratory confirmation
3. Possible:
Steps in outbreak investigation
 Cases can be identified using
1. stimulated passive surveillance
223

 i,e. sending out letters of health institutions

and asking for reports, alerting the public
through media and asking cases for others;
2. Active surveillance
 i.e. visiting health facilities for collecting

information and conducting a survey can also

be used to identify the cases.
Steps in outbreak investigation
Step 4. Describe epidemic with respect to time, place,
person /Perform Descriptive Epidemiology/
224
 Collect relevant information related to the investigation

 Information could be obtained from the

 Already existing records or you can obtain

 Using a case investigation form specifically
designed for a particular situation under
investigation
 Information must be collected carefully, so that, at the end
they will enable investigator to characterize the outbreak
with respect to time, place and person
Steps in outbreak investigation
 Outbreak can be Xized by time, place & person by using

well established descriptive epidemiological tools

225
 Tools such as epidemic curve and spot mapping
 Epidemic curve
 Plots the cases by the time of onset & provide a time frame
for the outbreak investigation
 Spot map
 Plots cases by location & shows geographic spread of cases
 Attack rates-
 Calculate rates of illness in population at risk by

exposure to specific suspected items & other relevant

attributes
 Identification of "relevant" attributes may be a
226
Steps in outbreak investigation

227
228
229
230
231
Steps in outbreak investigation

Performing Descriptive Epidemiology


232
Each case must be defined according to standard
epidemiologic parameters:
 The date of onset of the illness,
 The place where the person lives or became ill, &
 The socio-demographic characteristics
(age, sex, education level, occupation)
 Tools to be used when characterizing the epidemic are
epidemic curve, spot map and attack rates
Steps in outbreak investigation

 Epidemic curve is an important tool for the investigation

233
of disease outbreaks
 In epidemic curve the distribution of cases is plotted over
time, usually in the form of histogram
 the date of onset of each case on the horizontal axis, &
 the number of cases corresponding to each date of onset on the
vertical axis
 Spot map is a map of locality where the outbreak has
occurred, on which the location of cases is plotted
Steps in outbreak investigation
 The spot map is often helpful in detecting the source of an
234
outbreak
 Mapping disease can be done at all levels, on a local,
district, regional, countrywide, or international basis,
depending on the purpose


Mapping can be used

1. to investigate epidemics or disease etiology,
2. to plan the allocation of resources on geographic
basis
Steps in outbreak investigation
 One limitation of a spot map is that it does not take into

account underlying geographic differences in population

235

density.
 Thus the spot map needs to be supplemented by a
calculation of place-specific attack rates.

 Attack rates are a tool that is important for the analysis

of disease outbreaks by personal characteristics attack
rates i.e. attack rates by age, sex, occupation, income,
religion etc.
Steps in outbreak investigation
5. Formulating and testing hypothesis

236
Involve assessment of the data collected to date and the
generation of hypotheses that may explain the outbreak
 The goal is to explain the specific exposure(s) that caused
the outbreak
 Formulate the hypotheses based on your characterization of
the epidemic by time, place, and person
 The hypotheses should address source of the agent, mode of
transmission, and exposures that caused the disease
 Determine the type of epidemic-
 Common source Vs propagated
Steps in outbreak investigation
 Based on characteristics of the epidemic
237
 Define the population at the highest risk and
 Consider the possible source(s) of the disease (infection)
 The hypotheses should be testable
 In an outbreak investigation, evaluation of hypotheses can
be done in two ways:
1. By comparing the hypotheses with the established fact,
2. By using analytic epidemiology to quantify relationships
and explore the role of chance
 The analytic technique utilizes the cohort and the case-
control approach to identify possible source of an
outbreak
Steps in outbreak investigation
 The cohort approach identifies the comparison group
238
based on exposure status
 The case-control method identifies the comparison
groups on the basis of their disease status
 Calculate/Compute
1. Odds ratio to determine the relation b/n cases and controls
with regard to exposure to the suspected cause - case-
control
2. Relative risk to determine risk difference b/n exposed and
non-exposed
3. Statistical tests to determine the role of chance
Steps in outbreak investigation
 In both analytic approaches, a test of
239
significance has to be worked out to determine
 Statistically significant difference only
provides supportive evidence on the possible
source of an outbreak.
 Causation can only be established after careful
assessment of the whole situation and requires
laboratory proof, which is not always easy.
Steps in outbreak investigation
6. Searching for additional cases

240 Involves locating unrecognized or unreported cases
 This may be done:
 Passive: By inquire physicians or hospitals or both if
they have seen similar cases
 Active: By doing intensive investigation in the
community on asymptomatic persons or contacts of
the cases
 Eg. Doing liver function test in an investigation of
hepatitis A outbreak
Steps in outbreak investigation

241 7. Analyzing the data

 This involves assembling all the results and

then interpreting the findings

8. Make decision on the hypotheses tested

 This is made on the hypothesis tested

involves ensuring the findings are consistent

with the hypothesis.
Steps in outbreak investigation
9. Intervention and follow-up

242 Although it is discussed late, intervention must start as
soon as possible depending on the specific circumstances
 Appropriate and Adequate interventions
 The investigator should aim control measures at the weak
link or links in the chain of infection
 Make sure the epidemics is controlled
 Control measures may targe at agent, source, or reservoir
 Eg. Controlled may be by destroying contaminated foods,
making contaminated water safe and clean, or destroying
mosquito breeding sites, or an infectious food handler
could be removed from the job and treated
Steps in outbreak investigation
10. Report of the investigation
 At the end prepare a comprehensive report and submit to
243
the appropriate/concerned agency (or agencies).
 The report should follow the usual scientific format:

 introduction, background, methods, results, discussion, and

recommendations
 The report should discuss in detail:
 Factors leading to the epidemic
 Effectiveness of the measures used for the control of the
epidemic
 Recommendations for the prevention of similar episodes in the
future
 Managing outbreak/epidemics