Jens Martensson

Communicable
diseases
Epidemiology
Dr.Shimaa Saied (MD)

Jens Martensson
Public health

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 What is epidemiology?
• It is the study of the distribution and determinants of health-
related states or events in specified populations, and the application
of this study to the control of health problems.

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• Distribution is studied in relation to: the person, place and time:
Who? Where? When?
• Determinants of diseases are studied by the causation model:
Agent, Host, & Environment.

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Patterns of spread of communicable diseases:
• a. Sporadic: disease occurs in of scattered individual cases ―not
related.
• b. Endemic: constant presence of a particular disease in a locality.

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• c. Epidemic: occurrence of an unusually increased number ―in
excess of normal‖ of cases in a specific place & community, within a
limited time.The cases can be traced to a common source
• d. Outbreak: epidemic within a closed or confined community
such as a camp, hospital, school or institute
• e. Pandemic: epidemic spreads over some countries of the world.
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 Why School children are more liable to
communicable diseases ?
Children came from different areas to the school life
leading to continuous mixing of children.

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They are of vulnerable age and more prone to certain
diseases.

Unsound health habits of children and lack of personal

hygiene.

Overcrowding in an unsanitary environment.

 Measles (Morbilli, Rubeola)
• Acute highly infectious disease of childhood. Sporadic cases appear
all the year, and incidence increases in
• winter and spring
• Causative organism: Measles virus. It perishes within hours outside

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the body.
• Reservoir of infection: Cases, no carriers.
• Infectivity: The virus finds exit in nose and throat secretions
throughout the disease (about 9 days)
• during:
• Catarrhal stage (4 days): More infectivity.
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• Rash stage (5 days): Infectivity declines.

 Measles
Modes of transmission:
• Direct droplet infection.
• Airborne infection, by droplet nuclei, in confined places.
• Using articles freshly soiled by nose and throat secretions.

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• Through a third person who nurses the case, and spreads
infection to others.
• Neither rash nor branny scales of desquamation are infectious.

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 Measles
Susceptibility: (among un-immunized)
• Susceptibility begins after the age of 6 months, after maternally
acquired immunity fades.
• The highest incidence is found in preschool children of 3 – 5 years.

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• By the age of 10 years, most children would have been exposed to
infection and got the disease.
• Those who have escaped infection and disease in childhood remain
susceptible, and may get measles at any age.

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• Incubation period: About 10 days. Measles

• Clinical picture:
• 1. Catarrhal Stage: usually 4 days
• 2. Eruptive Stage: Skin rash appears 4 days after onset of disease,

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and lasts for about 5 days, to end in fine branny desquamation.
Once the rash develops, general condition of case improves with
drop of temperature and clearing up of respiratory catarrh.
• 3. Convalescence: begins when eruption and bran-like
desquamation resolves.

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 Measles
• Complications:
• - Secondary bacterial infection: May cause otitis media, sinusitis,
cervical adenitis, acute respiratory infections (bronchitis,
pneumonia, and bronchopneumonia), diarrheal disease in young
children, and purulent conjunctivitis.

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• - Tuberculosis: severe measles in debilitated children may cause
exacerbation of dormant or quiescent tuberculosis. Measles
may also be associated with temporary suppression of
tuberculin reaction in the infected.
• - Viral bronchopneumonia, and rarely encephalitis.

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 Measles

• Fatality: Measles by itself is usually benign. Fatality is due to

complications, especially acute respiratory infections (ARI),
diarrheal disease and encephalitis. Fatality is higher in young
(below two years) and debilitated children.

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• Diagnosis: By clinical picture. The two diagnostic signs are
Koplik’s spots in the catarrhal stage, and the characteristic rash.

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Prevention: Measles
• 1- Active immunization:
• By live attenuated measles vaccine in a single dose of 0.5 ml, SC.
Compulsory vaccination of infants at 12 months, in Egypt in the
form of MMR

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• Protective Value: gives solid lifelong protection, in more than 95% of
vaccinated susceptible.
• 2- Seroprophylaxis: human normal immunoglobulin is given to
susceptible contacts neither diseased nor vaccinated before), of any
age, for seroprevention or seroattenuation of disease.

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 Measles
• Seroprevention: Measles is prevented by giving adequate
dose of immunoglobulin (0.25 ml / kg
• body weight), intramuscularly, within 6 days of exposure to
infection. It is protective for at least

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• 6 weeks.
• Seroattenuation: When the susceptible is given smaller
dose of immunoglobulin within six days,
• or the same dose of sero-prevention 6- 8 days after exposure,
measles will not be prevented, but
• attenuated, and followed by solid immunity.
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 Measles
• 3- Control of measles in school:
• Cases are isolated at home, and released as given before. Exposed
susceptible children are segregated for two weeks from last
exposure. Before returning to school, they are examined for rash

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(isolated). But if respiratory catarrh is present, they are segregated
for 4 days more, to confirm whether the case is measles (rash
appears) or not.

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• General control measures: Measles
• control measures for cases and contacts:
• A- Measures for cases
• 1. Case finding:

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• Early case finding and appropriate diagnosis will facilitate tracing the
reservoir and source of infection
• 2. Notification:
• According to type of disease, it may be to Local Health office or
Ministry of Health & Population (MOHP) or even to WHO

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 Measles
3. Isolation: complete separation of the case from contact with
anyone except those responsible for the treatment until no more
risk of transmitting infection. It is carried out in:
- Fever hospitals in case of cholera, meningococcal meningitis and
pneumonic plague.

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- Home for other diseases, provided that sanitary measures are taken to
prevent the occurrence of secondary infections.
4. Disinfection: It means destruction of the pathogenic
microorganisms finding exit from patient's body it may be:
a. Concurrent: applied during patient isolation by treating excreta,
discharges, soiled articles or fomites of the patient.
b. Terminal: conducted after death or removal of the patient from
hospital. It is applied to place and belongings of the patient by 17
 Measles
5. Treatment: It includes symptomatic treatment of general
constitutional manifestations and the
use of drugs (e.g. antimicrobial, anti-toxins, immunoglobulins and
others).

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6. Release: It depends upon the period of infectivity and the
presence or absence of carrier status.
Release is based on clinical cure and after becoming
bacteriologically free in 3 successive
investigations, especially for diseases with convalescent carriers.

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 Measles
B- Measures for contacts
Contacts are listed to control them through the following
measures:
1. Observation to detect any sign or symptom of the disease.

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2. Segregation: excluded from work to prevent further spread
of the disease.
3. Isolation: this is only considered in disease that is highly
infectious and fatal (e.g. cholera, pneumonic plague and pneumonic
anthrax).
Period of isolation is for the maximum incubation period
counted from date of last exposure. 19
 Mumps (Epidemic Parotitis)
• Mumps is an acute infectious disease characterized by:
• - Generalized infection (viraemia).
• - Localization of infection in the salivary glands (commonly the
parotids), CNS and some glands of the

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• body.
• Causative organism: Mumps virus, a mixovirus which is relatively
resistant outside the body.
• Reservoir of infection: Man (cases and incubatory carriers).The
virus finds exit in saliva.
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 Mumps
• Modes of transmission:
• Direct droplet infection:The main method of spread.
• Saliva-contaminated articles and fomites.
• In utero infection: Potential risk.

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• Incubation period: 18 days on the average.
• Period of infectivity: From the last days of incubation period,
throughout the disease, until swelling
• of salivary glands subsides completely.

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Clinical picture: Mumps
• Prodromal period: mild constitutional manifestations; fever,
malaise, headache, and body
• aches for 1-2 days, before swelling of salivary glands.
• Enlargement of salivary glands: the characteristic feature.

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The parotid glands are the commonly
• affected, while the submaxillary and sublingual are occasionally
involved, either together with or
• rarely without the parotids.
• Bilateral non-suppurative parotitis: with tender painful
swelling which lasts for 3 – 5 days, then resolves over one or
two weeks. 22
 Mumps
• Clinical picture:
• Involvement of other parts of the body: e.g. CNS and some
glands around one week after onset, and are considered as
―complications of disease―, or occasionally occurs without

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• involvement of salivary glands,

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 Mumps
• Complications: May affect adults (commonly) or children
(occasionally).
• Orchitis: The testis may undergo atrophy, usually unilateral,
but may be bilateral causing sterility.
• Oophoritis: Of fewer incidences than orchitis.

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• Mastitis: in females and males.
• Pancreatitis: may be followed by diabetes mellitus later in
life.
• Meningoencephalitis: usually benign.
• Congenital anomalies: when infection occurs during the first
trimester of pregnancy. 24

• Fatality: Rare, if any.

 Mumps
• Prevention: Active immunization and seroprophylaxis.
• 1- Active immunization: By mumps vaccine, or MMR
vaccine.
• Mumps vaccine: live attenuated given to adolescents and young

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adults who had not mumps before specially at–risk groups of
military camps and confined institutes, in a single dose of 0.5 ml
subcutaneously.
• MMR Vaccine: Triple live attenuated vaccine of mumps, measles
and rubella. It is given to susceptible adolescents and young
adults, especially females before marriage, in a single dose of 0.5
ml SC. 25
 Mumps
• Prevention: Active immunization and seroprophylaxis.
• 2- Seroprophylaxis: specific immunoglobulin, in adequate
dosage, is given to:
• Susceptible adolescents and young adults when exposed to

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infection.
• Adolescents and young adult cases of mumps immediately
when parotitis appears, to prevent involvement of other parts
of the body causing complications.
• Control: follows the general control measures
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 Mumps
• Prevention: Active immunization and seroprophylaxis.
• 2- Seroprophylaxis: specific immunoglobulin, in adequate
dosage, is given to:
• Susceptible adolescents and young adults when exposed to

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infection.
• Adolescents and young adult cases of mumps immediately
when parotitis appears, to prevent involvement of other parts
of the body causing complications.
• Control: follows the general control measures
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 Varicella (Chickenpox)
• An acute highly infectious disease most cases occur in childhood.
• Causative organism:
• Varicella – Zoster virus (V–Z virus) which causes two clinical forms
of the disease, varicella and

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• herpes zoster.
• Reservoirs of infection: cases of varicella and herpes zoster (no
carriers).
• Cases of varicella:The virus finds exit through:
• - Upper respiratory secretion.
• - Fluid of ruptured vesicles of skin eruption. 28
 Chickenpox
• Infectivity:
• Cases of varicella: Through clinical course of disease, about one
day before up to 7 days after
• appearance of rash]

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• Cases of herpes zoster, occasionally: The virus is found in
vesicles of skin eruption.

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 Chickenpox
• Modes of transmission:
• 1. From cases of varicella:
• - Direct droplet infection and airborne infection.
• - Contact infection: Contact with fluid of vesicles.

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• - Articles and fomites freshly soiled with fluid of vesicles, or upper
respiratory discharges.
• 2. Exposure to a case of herpes zoster:
- Direct exposure to fluid of vesicles.
- Using objects soiled with fluid of vesicles.
• Incubation period: 2 – 3 weeks. 30
 Chickenpox
• Clinical picture:
• Varicella:
• Short prodromal period for 24 hours, followed by appearance
of skin eruption.

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• Rash: maculopapules, rapidly progress to superficial vesicles in
few hours, which rupture and
• dry up in few days, forming crusts and scabs that fall off in around
one week, without leaving
• any pitting of skin. Secondary infection and pustulation of vesicles
may sometimes occur.
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 Chickenpox
• Clinical picture:
• Characteristics of varicella eruption:
• Centripetal: More rash on trunk and head, than neck and
limbs.

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• Pleomorphic: Rash appears in successive crops, and so all
stages (papules, vesicles, crusts) are found on the body at the same
time.

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 Meningococcal Meningitis
• (Epidemic Cerebrospinal Meningitis, "Cerebrospinal Fever")
• . A contagious bacterial disease caused by the meningococcus
(Neisseria meningitides).
• Causative organism:

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• - It is delicate and perishes rapidly outside the body. It is natural
inhabitant of nasopharynx, but potentially pathogenic.
• - A Gram-ve aerobic diplococcic and 13 serogroups of N.
meningitides have been identified according to the polysaccharides
of the capsule. Six of which (A, B, C, W135, X and Y) can cause
epidemics or outbreaks. Group A is the agent of most epidemics in
Africa and outbreaks
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 Meningococcal Meningitis
Magnitude of the problem:
• It can cause severe brain damage and is fatal in 50% of cases if
untreated. Even when the disease is diagnosed early and
adequate treatment is started, 5% to 10% of patients die,

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typically within 24 to 48 hours after the onset of symptoms. In
as many as 10-15% up to 20% of survivors, there are
persistent neurological defects, including hearing loss, speech
disorders, and loss of limbs, mental retardation and paralysis.
Group A meningococcus accounts for an estimated 80–85% of
all cases in the meningitis belt, with epidemics occurring at
intervals of 7–14 years.
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Reservoir of infection: Meningococcal Meningitis
• - Man (cases and carriers).
• Carriers: The chief sources of spread. The Meningococcus is a
commensal of the nasopharynx, where during non-epidemic
periods around 5 – 10% of the population are carriers. Carrier
rate, especially of group A, sharply increases before epidemics

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and outbreaks, to reach 20-80% or more especially in closed
communities as camps. Increase in carrier rate to exceed
20% is a significant sign of threatening outbreak.
• Communicability period
• Until live Neisseria meningitides no longer present in nose &
mouth. Meningococci usually disappear from nasopharynx
within 24h after antimicrobial treatment to which organism 35
 Meningococcal Meningitis
• Exit of Infection: Nasopharyngeal discharge.
• Modes of transmission:
• - Direct droplet infection, on contact with carriers (usually)
and may be cases (little role).

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• - Indirect transmission, by airborne infection or contaminated
articles and fomites is insignificant, as
• the organism is delicate and perishes rapidly outside the body.
• Incubation period:
• - Sporadic cases (in non-epidemic time): 2 - 10 days with
average 4 days.
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 Meningococcal Meningitis
Clinical picture:
• Untreated cases pass through the following stages:
• Sudden onset, with high fever, severe headache, body aches,
chills, nausea and vomiting.

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• Nasopharyngitis: with catarrhal manifestations : The disease
is either self-limited in many
• cases, which thus pass unnoticed and acquire immunity,
or the organisms invade blood
• causing septicemia and meningitis, in some cases.
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• Meningococcemia: Nasopharyngitis is followed by acute
meningococcal septicemia which either recovers or the
organisms localize in the meninges causing meningitis, or
occasionally passes into chronic septicemia, without localizing
in the meninges.

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• Meningitis: Follows localization of the organisms of
septicemia in the meninges, showing :
• - Meningeal irritation, with nuchal rigidity and head retraction
(stiff neck and back, due to reflex spasm of muscles): positive
Kernig and Brudzinski signs, and opisthotonus.
• - Increased pressure of cerebrospinal fluid.
• - Mental irritability and nervous manifestations. 38
• Complications:
• Hydrocephalus.
• Involvement of cranial nerves (optic neuritis, ocular nerve
palsies, and perceptive deafness.
• Temporary arthritis, myocarditis, intravascular coagulation

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(peripheral thrombophlebitis),
• nephritis and others.

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• Diagnosis:
• Clinical: Usually.
• Laboratory: microscopic examinations of the spinal fluid
(gram –ve aerobic diplococci).
• Laboratory confirmed by:

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• - Growing (culture) the bacteria from specimens of spinal fluid
or - Blood agglutination tests (latex) or - Polymerase chain
reaction (PCR).
• Treatment: Appropriate antibiotic treatment must be
started as soon as possible, ideally after the
• lumbar puncture has been carried out if such a puncture can
be performed immediately.
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Preventive measures :
• 1. Sanitary environment: Adequate ventilation and spacing
(no crowdedness) of any confined place, especially public
places, schools, institutes, barracks and camps.
• 2. Health education.

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• 3. Specific prevention:
• a) Active Immunization:Vaccines are available,
• Non conjugate: polysaccharide vaccines— available in
either bivalent (groups A and C), trivalent (groups A, C and
W135), tetravalent (groups A, C,W135 and Y) forms.
• Conjugate: available for groupA, group C, tetravalent
vaccines (groups A, C,W135 &Y).
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Preventive measures :
• Dose, administration & indications: Vaccination is given 0.5 ml
IM to at – risk groups, including
• the military groups, hajj pilgrims, individuals with immune
dysfunction and schoolchildren.

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• Advantages of conjugate vaccines are:
• - It induces a higher and more sustainable immune response.
• - It is expected to confer long-term protection (5-7
years)&decrease carrier rate.

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Preventive measures :
• b- Chemoprophylaxis (for contacts): It is the reliable
preventive measure, especially for confined
• groups, as it eliminates the organisms in the nasopharynx.
• For children:

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• • Rifampicin for children: less than1month (5 mg/Kg twice daily
/2 days) and for more than1month
• (10 mg/Kg twice daily /2 days)
• • Ceftriaxone: single dose 125 mg i.m (less than 15years).
• • Suphadiazine: 125-150mg/kg/day divided into 4 equal doses
on each of 2 consecutive days 43

• (resistance 50%).So not commonly used.

Control measures :
• 1- General control measures …..
• N.B:Release: Chemotherapy eliminates infection in 24 hours,
and so the case can be released once clinically free, and
general condition is satisfactory.

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• 2. Control of contacts :
• - Enlistment and surveillance for 7 days.
• - Chemoprophylaxis, (as mentioned before).
• - No segregation from school or work, nor swabbing of
nasopharynx, as chemoprophylaxis readily eliminates infection.
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• Epidemic measures: In case of outbreak major emphasis on:
• - Surveillance, early diagnosis and immediate treatment of
suspected cases.
• - Reduce overcrowding and ventilate living and sleeping
quarters.

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• International measures: WHO collaborating centers provide
support as required and some
• countries need vaccination for the disease e.g., KSA for Hajj
pilgrims.

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 Seasonal influenza
• Influenza is an acute highly infectious disease showing
endemic, epidemic and pandemic spread.
• Each year, seasonal epidemics of influenza cause serious illness
and death throughout the world.

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• Influenza occurs globally with an annual attack rate
estimated at 5%–10% in adults and 20%–30% in children.
• The World Health Organization estimates that the global
disease burden from influenza up to 1 billion infections, 3
million to 5 million cases of severe disease, and between
300,000 and 500,000 deaths annually.
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 Seasonal influenza
• Causative agent:
• Three types of seasonal Influenza virus (RNA virus) are
recognized according to the two relatively stable
ribonucleoprotein and matrix protein:

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• Type A: responsible for epidemics and pandemics.
• Type B: may cause outbreaks in confined groups, less liable
to mutation & only affects humans.
• Type C: causes sporadic cases, mild or unapparent disease &
affects humans and pigs.

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 Seasonal influenza
• Influenza A viruses are further subdivided into many
different subtypes according to the antigens based on two viral
surfaces glycoproteins: the haemagglutinin (H) and
neuraminidase (N) projections on their surfaces. There are
16 haemagglutinin subtypes and 9 neuraminidase

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• subtypes of influenza A viruses e.g. (H1N1, H2N1, H5N1….).
• There are multiple strains due to mutation through:
• Antigenic drifts –minor antigenic change.
• Antigenic shifts –major antigenic change.

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 Seasonal influenza
• Influenza A viruses are further subdivided into many
different subtypes according to the antigens based on two viral
surfaces glycoproteins: the haemagglutinin (H) and
neuraminidase (N) projections on their surfaces. There are
16 haemagglutinin subtypes and 9 neuraminidase

Jens Martensson
• subtypes of influenza A viruses e.g. (H1N1, H2N1, H5N1….).
• There are multiple strains due to mutation through:
• Antigenic drifts –minor antigenic change.
• Antigenic shifts –major antigenic change.

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 Seasonal influenza
• Clinical picture: Manifestations and severity vary from
unapparent, mild, typical case up to severe fatal disease.
Uncomplicated disease is self-limited within 2-7 days.
• Typical case: abrupt onset, high fever, chills, headache,

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prostration, myalgia, and respiratory catarrh (sore throat and
cough).
• Period of communicability:
• In adult in first 3-5 days of illness, in young children 7-10 days
and may be longer in immune-compromised persons.

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 Seasonal influenza
• Complications:
• Secondary bacterial infection of respiratory tract, usually
streptococcal or pneumococcal, causing acute sinusitis, otitis
media, bronchitis and Pneumonia.

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• Viral pneumonia: by influenza virus (rare).
• Pericarditis, myocarditis, and thrombophlebitis
(uncommon).

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 Seasonal influenza
• Prevention and control measures:
• A- Preventive measures:
• General measures :
• o Adequate ventilation and spacing in confined and public

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places are generally required, yet they are not significantly
effective to prevent spread of influenza outbreaks and
epidemics.
• o Educate the public and health care personnel in basic
personal hygiene, including hand hygiene, and cough etiquette
and specially transmission via unprotected coughs and sneezes
and from hand to mucus membranes. 52
 Seasonal influenza
• Specific measures:
• o Active immunization: It is the only effective preventive
measure.
• Types of vaccines:

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• 1. Inactivated whole virus vaccine & Split virus vaccine:
• Polyvalent contain commonly prevalent strains (changed
every year)
• It is 70 – 80 % effective, decrease complications by about
50 -60% and mortality by 80%.
• It is given annually in a dose of 0.5 ml IM.
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• Specific measures: Seasonal influenza
• 2. The live attenuated influenza vaccine(LAIV): It is
used in the form of nasal spray stimulating local respiratory
immunity. It is more protective, and so preferred than the
inactivated vaccine given parenterally. LAIV should not be
administered to patients who are severely

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• o Chemoprophylaxis: a nuramidase inhibitor drugs are
used:
• 1. Oseltamivir (Tamiflu) is used as 75mg once daily for 7-10
days orally for adult persons and doses calculated for younger
age according to weight.
• 2. Zanamivir (relenza) is approved for prophylaxis for persons
above 5 years old by inhalation once daily (2 puffs). 54
Control measures:
Seasonal influenza
• Control of cases:
• Notification to local health office.
• Isolation at home, though not practical especially for mild
and unapparent cases.

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• Concurrent disinfection of respiratory discharges, articles
and fomites.
• Treatment: rest in bed, with symptomatic treatment.
Antibiotics may be given, when
• necessary for prevention and control of secondary bacterial
infection.
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 Seasonal influenza
• Specific treatment: oseltamivir is used for treatment 75mg
twice daily for 5 days orally for adult persons and doses
calculated for younger age according to weight.. Also zanamivir is
approved for treatment for persons above 7years old twice daily
by inhalation.

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• Control of contact: avoid direct contact with the patient and
avoid using his articles and fomites, and supervision for case
finding for maximum incubation period.

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 Seasonal influenza
• C- Epidemic measures
• Health planning and education and Vaccination for high risk.
• Community surveillance and adherence for infection control
recommendation.

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• Health care system should anticipate increased health
demand during epidemic period and health
• care personnel vaccination.
• Maintain adequate supply of antiviral.

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 Seasonal influenza
• C- Epidemic measures
• Health planning and education and Vaccination for high risk.
• Community surveillance and adherence for infection control
recommendation.

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• Health care system should anticipate increased health
demand during epidemic period and health
• care personnel vaccination.
• Maintain adequate supply of antiviral.

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Thank
You Dr.shimaasaied@gmail.com