Infectious process

By Professor Nagwa Shokeir

IV. Mode of transmission:

Could be classified into: A) Contact transmission: i) Direct contact. ii) Indirect contact iii) Droplet contact. iv) Transplacental B) Common vehicle transmission, which can occur through : i) Ingestion. i) Inoculation. iii) Deposition

C) Vector transmission
i) Mechanical ii) Biological

D) Air-born transmission:
i) Droplet nuclei ii) Dust particles

A) Contact transmission:
Means transmission during an association between the infected man or animal and the new host .This may be in the form of : 1. Direct contact: association between the infected man or animal and the new host, without a third object

Direct contact may occur through - sexual intercourse, - kissing and - touch Examples - venereal diseases - scabies, - contact of saliva of a rabid animal with abraded skin

2. Indirect contact:
Through touching contaminated objects for instances, toys, handkerchiefs, soiled clothing towels Microorganisms will be transmitted from hands to mouth or from hands to abraded skin or mucous membranes Examples :conjunctivitis, trachoma, skin infections, and diphtheria , hospital infections particularly in transmitting infections to surgical wounds

3. Droplet transmission:
Droplets spray directly onto the mucous membrane of the nose, mouth during sneezing coughing, spitting or talking ( usually limited to a distance of one meter or less) Examples: Measles, streptococcal infections, influenza, diphtheria

4. Transplacental transmission:
The organism is carried from mothers to fetus through the placenta, e.g. Syphilis, AIDS and German measles

B) Common vehicle transmission

Vehicle can be water, milk or biological products as blood, agents via this vehicle are introduced to the susceptible host through: 1- ingestion of contaminated food and drink for instance typhoid, paratyphoid, food poisoning, dysentery and cholera

2. Infected blood and plasma

Inoculation of plasma, blood, serum or even vaccine, e.g. viral hepatitis, syphilis and malaria

3. Agents of diseases inoculated to the skin or mucous membrane :

This is important for the group of diseases that can be transmitted by the swimming pools, e.g. Conjunctivitis and sinusitis

The role played by common vehicles depends on the viability of infective agents outside the body, environmental influences as dryness, temperature and sunlight

C) Vector transmission:
Various insects are known to be vectors for disease transmission either: 1- Mechanical transmission: The vectors carry pathogenic organisms of different infections on the feet or mouth parts, or may be ingested and pass in the insect feces or vomited later on. It can be:

a) Direct:
If the insect as houseflies become contaminated from discharges of infected eyes and transmit it to a healthy eyes as in case of purulent conjunctivitis

b ) Indirect:
This occurs when insects as houseflies and cockroaches carrying pathogenic organisms settle on human food or drink, they will contaminate such food as occurs with typhoid, dysentery and cholera

2- Biological transmission:
The agents have to pass through some biological activity inside the vector which requires a certain period of time " extrinsic incubation period " After this period, the insect is then able to transmit infection to the new host. The infectious agent may be passed vertically to succeeding generations ( transovarian transmission )

The biological transmission can be:

1- Propagative biological transmission: Simple multiplication of the causative organism in the vector. Example is yersenia pestis agent of plague in flea and virus of yellow fever in the Aides Aegypti mosquito

2-Cyclo-propagative:
Organisms here multiply and undergo changes within the vector as in case of malaria

3-Cyclo-developmental :
Here the agent of disease have a cycle of developmental changes inside the vector, with no multiplication, example is filaria in mosquito

D) Air-born transmission:
The dissemination of suspended particles in the air consisting partially or wholly of microorganisms. They remain suspended for a long period of time (the reservoir and the host may not be in the same room). Some organisms retain their infectivity (as TB and hemolytic streptococci) and the others do not

Air-born transmission can be :

1-Droplet nuclei The small particles result from evaporation of the fluids from the droplets of infected person They contain pathogens and remain suspended in air for a long period of time. When they are inhaled by a susceptible host they cause infection

2- Dust nuclei:The large particles fall on the ground to mix with the dust and become part of the dust of the room The organisms resist drying for a long time ( TB and hemolytic streptococci ) The source of these particles is the discharge of infected persons contaminating bedding, clothes, floor, soil

V. Portal of entry ( Inlet )

With some exception, the portal of entry to a host corresponds the portal of exit from reservoir. Accordingly, we can classify the portals of entry into: A- Natural inlets including mouth, nose, rectum, vagina, urethra and conjunctiva B- Unnatural inlets for instance by inoculation through blood sucking insect or injection

Incubation period:
The time interval between exposure to an infectious agents and appearance of the first sign or symptom of the disease. There is an average period for every communicable disease. However, there is a range.

The length of incubation period depends on:

1- If the agent is an organism or toxin 2- The virulence of the organism 3- The dose of the inoculum 4- The host resistance

Long incubation periods are encountered in infectious and serum hepatitis, tuberculosis and AIDS Short incubation period is that of staphylocooal food poisoning, as the agent is the enterotoxin present in the ingested food rather than the organism

Knowledge of the incubation period is important to :1- It is used practically for surveillance of contacts of communicable diseases 2- To apply preventive measures in certain diseases - Measles vaccine if given to the contacts in the first three days after exposure it will prevent the disease

- If given in the second three days after exposure it will modify the attack ( subclinical manifestation and result in solid immunity ) 3- Identification of the source of infection, water borne epidemic of typhoid has longer incubation period than milk borne while shell fish borne typhoid has a shorter one

Extrinsic incubation period:This is the period taken by the infective agent outside the human body until it becomes infective again to a new individual, e.g. yellow fever takes (9 12) days in Aedes Aegypti to be infective after the blood meal

VI. The susceptible host

The host is a person or other living animal, including birds and arthropods, that affords subsistence or lodgment to an infectious agent under natural condition

Resistance:
It is the total body mechanisms which act as barriers to invasion or multiplication of infectious agents or their damaging effects of their toxins

Types of resistance:
A- Natural barriers ( inherent resistance, non specific ) B- Acquired resistance ( immunity, specific )

A) Natural barriers:
It is non-specific resistance of the body against the invading organisms which does not depend on the presence of specific antibodies or antitoxin for protection, but depends on the anatomical or physiological characteristics of the host

b) Acquired resistance:
This depends on antibodies production. Immunity may be :1- Passive immunity: a) Natural b) Artificial

2- Active immunity:
a) Natural b) Artificial

1. Passive immunity:
Passive immunity is the type of resistance in which ready made antibodies are gained a) Natural passive immunity ( infant immunity ): It is the resistance of infant due to the presence of antibodies passed from the mother to the foetus via the placenta

The mother should have acquired the infection and / or vaccine and developed specific antibodies against certain diseases

These passive acquired antibodies in the foetus are at their highest level at birth, then start to decline gradually until they are insignificant usually by the end of six months

Such natural passive immunity in the infant could be induced artificially by immunizing the mother during pregnancy, as in case of immunization by tetanus toxoid to protect the newly born infant against tetanus neonatorum
Breast milk, specially the colostrums, contains plenty of antibodies (immunoglobulin account for about 95% of the protein in colostrums). Antibodies are continually secreted in breast milk but in a lower level than that of colostrums

b) Artificial passive immunity (passive immunization):

It is the immunity induced by injecting immune serum or immunoglobulin. It is of short duration, remaining for about three weeks, during which the antibodies given are gradually eliminated.

Examples of materials used for passive artificial immunity:

1- Sera of artificially immunized animals, these are used either for prophylaxis or treatment as in case of antitetanic and antidiphtheretic sera. 2- Immunoglobulin: This is a plasma protein fraction that carries most of antibodies present in the body, used as prophylaxis, e.g. in measles and infectious hepatitis

2. Active immunity:
This is the type of immunity in which the person makes or develops his own antibodies. It may be : a) Natural actively acquired immunity or post infection immunity: It may be solid or for a long time as in case of mumps and measles or it may be of moderate duration (for years) as in case of meningitis or it may be for a short period as in common cold

b) Artificial actively acquired immunity:

This is produced artificially by active immunization using an immunizing agent which is a specific antigen when introduced in the body, provoke the formation of antibodies

The ideal immunizing agent should be:

1- Antigenically stable 2- Give durable immunity 3- Have minimal side effects 4- Easy in administration 5- Of reasonable cost as well as being available 6- Keeping quality is good

Types of immunizing agents ( vaccines ):

I- Live attenuated vaccines: a) Attenuated vaccine: In these vaccines, microorganisms lose their pathogenicity but retain their power of multiplication and antigenicity. Attenuation can be done by repeated subcultures or by cultivation under unfavorable condition, e.g. Sabin vaccine of polio, measles, German measles and mumps vaccines.

b) Variant forms of living organisms vaccine:

In these vaccines a milder species of the organisms closely related Antigenically to the human disease agents, are used, such as smallpox vaccine using cow pox virus and BCG vaccine using bovine tubercle bacilli

II- Non living vaccines:A- Killed or inactivated: Killed bacterial organisms ( using heat or chemicals as ether and Formalin ) examples typhoid, whooping cough vaccines. Inactivated virus as salk vaccine of polio virus.

B- Products of organisms ( Toxoid ): Toxoid is the toxins after loosing their toxicity but retaining their antigenicity e.g. Diphtheria, and tetanus toxoid

C- Part of organisms:
- The subunit of hepatitis B surface antigen ( HBsAg ) prepared from plasma of HBsAg positive carriers or by genetic engineering - Part of polysaccharide capsule of Nisseria meningitides used as a vaccine against meningococcal meningitis

Herd immunity:
It is the state of immunity within the community. Herd immunity is the factor that decides the epidemiological pattern of any infectious disease among that community. The incidence of diseases rises at times when the number of susceptible in the population is highest and the herd immunity is lowest.

The best example is measles epidemic in Fidjii in 1975 in which the attack rate approached 100% and fatality rate was excessively high. The spread of the disease among all age groups equally is characteristic of the absence of immunity

The well known rhythm of measles epidemic in urban communities is due to the variation in community susceptibility. Following an epidemic, immunity is at its highest level. The level of susceptibility increases as new infants are born, an epidemic will develop after accumulation of susceptible. The herd immunity could be produced artificially by immunization, or naturally after infection

Several factors play a role in community protection namely:

1- The extent of coverage of the immunization program 2- The degree of resistance to infection afforded by the vaccine 3- Duration and degree of infectivity of the organism 4- Past experience with different infections 5- Overcrowding and environmental sanitation

Thank you