1.

3 Epidemiology and control of infectious

Disease Epidemiology
Science that evaluates occurrence, determining factor, distribution, and control of health and disease in a defined human population Disease is the result of forces within a dynamic system consisting of:  Agent of infection  Host  environment

Types of Epidemiological Investigation/ Study

 Descriptive Epidemiology: Retrospective studies that collect data on diseases occurrence.  Examples: Initial studies on toxic shock syndrome outbreaks.  Analytical Epidemiology: Analyzes a disease to determine its probable cause.  Case control method: Look for factors that precede disease. Compare sick individuals to healthy individuals.  Cohort method: Study two populations, one that has been exposed to a certain risk factor (e.g.: blood transfusion or sexual contact) . Control group is not exposed to risk factor.  Experimental Epidemiology: Test drugs or vaccines on susceptible populations.

Classifying Infectious Diseases

Communicable Diseases: disease transmitted from one host to another, directly or indirectly. Example: Tuberculosis, herpes, flu, AIDS, chickenpox, mumps, polio, and hepatitis. Contagious Diseases: communicable disease that easily spread from one person to another. Example: Chickenpox and measles. Noncommunicable Diseases: Disease caused by microbes that live outside the body or by opportunistic pathogens that live inside the body. It does not spread from one host to another. Example: Tetanus, botulism, and yeast infections.

Classifying Infectious Diseases

Systemic infection: widespread infection in many systems of the body; often travels in the blood or lymph Focal infection: infection that serves as a source of pathogen for infections at other sites in the body Primary infection: initial infection within a given patient Secondary infection: infection that follow a primary infection; often by opportunistic pathogens

Disease Duration
Acute Disease: disease in which symptom develops rapidly, but lasts a short time. E.g:Flu and common cold. Chronic Disease: disease with usually mild symptom that develop slowly and last a long time. E.g: Tuberculosis, hepatitis B, and infectious mononucleosis. Subacute Disease: disease with time course and symptom between acute and chronic.E.g: Subacute bacterial endocarditis (streptococci). Latent Disease: disease that appear long time after infection. Causative agent remains inactive for a time, but then becomes active and produces disease symptoms .E.g: Shingles, genital and oral herpes, AIDS.

SOURCES OF INFECTION
WHERE DO PATIENTS GET THEIR INFECTIONS FROM...? IN THE COMMUNITY Humans (host)
clinical case , e.g. measles tuberculosis convalscent carrier e.g. typhoid diphtheria hepatitis B symptomless carrier e.g. typhoid, hepatitis

Animals (agent)
(zoonoses) clinical case e.g. rabies psittacosis carrier e.g. salmonella leptospirosis vector-borne e.g. malaria Lyme disease plague

Environment
auto-infection e.g. UTI candidiasis food salmonellosis, campylobacter soil e.g. tetanus

water cryptosporidiosis, giardia, cholera airborne e.g. legionellosis

SOURCES OF INFECTION
WHERE DO PATIENTS GET THEIR INFECTIONS FROM...? IN THE HOSPITAL

Cross-infection

Humans

e.g. chickenpox streptococcal pharyngitis wound infection

clinical case

Humans

auto-infection
symptomless carrier
e.g. MRSA gent-resistant GNRs

e.g. some
Staph aureus wound infections

food

salmonellosis

Environment
ventilator e.g.Pseudomonas endoscopes
e.g. mycobacteria H. pylori

IVI

e.g. Staph aureus, diphtheroids, staph epidermidis air/dust Staph aureus legionella ,

disinfectants, solutions etc

eg. Pseudomonas

TRANSMISSION OF INFECTION
DEFINITIONS OF TERMS BY EXAMPLE

Salmonella gastro-enteritis Reservoir y more commonly animal gut flora y less commonly human cases & carriers Source or Vehicle y food from affected animals y contaminated food

TRANSMISSION OF INFECTION
DEFINITIONS OF TERMS BY EXAMPLE

S. aureus wound infection Reservoir y Human nose & skin Source or Vehicle y Hands of health care workers

insert here

PATTERNS OF INFECTION DEFINITIONS

Disease Incidence y Percentage of population that contracts a disease in a given time period. o Disease Prevalence y Percentage of population that has the disease during given time period. Sporadic y rare infections, occurring now and then, without any particular pattern e.g. gas gangrene, or Strep. pyogenes wound infections Outbreak y commonly used to mean a limited epidemic, e.g. in a hospital ward
o

PATTERNS OF INFECTION DEFINITIONS

Epidemic y A sudden unexpected rise in number of infections caused by a particular pathogen y Can range from the small scale e.g. a few individuals y up to nationwide, e.g. the BSE epidemic in UK Pandemic y a world-wide epidemic y e.g. HIV or influenza Endemic implies a constant significant number of infections indefinitely y e.g. methicillin-resistant S. aureus is endemic to many hospitals

Patterns of Infection
Examples

Epidemic infection or outbreak e.g. an outbreak of salmonella gastro-enteritis

Introduction of pathogen followed by point source outbreak with abrupt start

No. of new cases

outbreak sputters on due to limited human-tohuman spread Day Days

PATTERNS

OF

INFECTION

EXAMPLES

Endemic

infection

continuous level of infection

e.g. S. aureus wound infections in a hospital

predominantly due to human-to-human spread (cross-infection)

Chain of Infection

Horton & Parker: Informed Infection Control Practice (www)

Infectious Agents
An agent capable of producing infection infective agent. E.g: Bacteria Viruses Fungi Protozoa Helminths

PRODUCING CHARACTERISTICS OF INFECTIOUS AGENTS

Invasiveness Pathogenicity Virulence Infectious dose Viability in the free state Host specificity Antigenic variation Ability to develop resistance to

DISEASE

antimicrobial agents

Reservoirs
A host that carries a pathogen without injury to itself and serves as a source of infection for other host organisms
(asymptomatic infective carriers)

E.g:Humans {hepatitis}

Other Vertebrates
{zoonoses}

Birds & Bats

{histoplasmosis}

SUSCEPTIBLE HOST
A person lacking effective resistance to a particular pathogenic organism

CHARACTERISTICS THAT INFLUENCE SUSCEPTIBILITY TO AND SEVERITY OF DISEASE:

     

HOST

Age Socioeconomic status Disease history Lifestyle Heredity Nutritional status

 

  

Immunization status Diagnostic/therapeutic procedures Medications Pregnancy Trauma

THE MOVEMENT OF MICROBES HOSTS: INFECTION

INTO

[INSERT FIGURE 14.3]

THE MOVEMENT OF MICROBES INTO HOSTS: INFECTION

[INSERT TABLE 14.4]

MODES OF INFECTIOUS DISEASE TRANSMISSION

Transmission

is either from a reservoir or a portal of exit to another hosts portal of entry Three groups of transmission y Contact transmission Direct, indirect, or droplet y Vehicle transmission Airborne, waterborne, or foodborne y Vector transmission Biological or mechanical

MODES OF INFECTIOUS DISEASE TRANSMISSION

[INSERT TABLE 14.11]

Vectors
A host that carries a pathogen without injury to itself and spreads the pathogen to susceptible organisms
(asymptomatic carriers of pathogens)

MODES OF INFECTIOUS DISEASE TRANSMISSION

[INSERT TABLE 14.10]

THE MOVEMENT OF PATHOGENS OUT HOSTS: PORTALS OF EXIT

OF

[INSERT FIGURE 14.11]

INFECTION CONTROL GENERAL PRINCIPLES

Remove reservoir or source of infection Interrupt transmission of infection Increase host resistance to infection

Remove reservoirs & sources

y

Human-to-human

Case finding & treatment

e.g. TB STDs, diphtheria, TB, meningitis

Contact tracing

Animals

Culling of infected animals

E.g. TB, Brucella

Environment

Clean water, good housing

Interrupt transmission
y

Human-to-human
avoid overcrowding changes in behaviour (e.g. safe sex) isolation of infectious cases (e.g. from school, work)

Animals & Environment

Food hygiene, vector control, animal vaccination & treatment, poopscooping

Increase host resistance

Improved diet y Vaccination (Hepatitis B) y Chemoprophylaxis
y

Meningitis, diphtheria, TB

HOSPITAL-ACQUIRED INFECTION
WHY WORRY?

10-15% of patients will get infected during a stay in hospital Costs >1 billion per year in UK A single large outbreak can cost 10-100K Effects of nosocomial infection

y y y y y y

Increased mortality & morbidity Prolonged hospital stay Increased drugs bill Increased staffing costs Demoralising for staff & patients Decreased public confidence in hospitals & doctors

WHY IS HOSPITAL-ACQUIRED INFECTION DIFFERENT FROM COMMUNITY-ACQUIRED INFECTION?

Many patients have impaired immunity

y y y

After anti-cancer chemotherapy After transplants Extremes of age

Many patients have impaired normal physiological defences

y y y

Breaches in skin Implanted foreign bodies (biofilms) Impaired phsyiology (Peristalsis, mucociliary escalator)

Many vulnerable patients in close proximity to each other for prolonged periods of time

WHY IS HOSPITAL-ACQUIRED INFECTION DIFFERENT FROM COMMUNITY-ACQUIRED INFECTION?

There is a distinct hospital flora

y

"ordinary" pathogens

e.g pnemococci, E. coli, S. aureus, can all cause disease both inside and outside hospital only cause infection in patients with impaired immunity e.g Serratia marsecens, Xanthomonas maltophilia, S. epidermidis, Corynebacterium jeikeium overlap with previous groups selected for in a darwinian fashion by antibiotic usage in hospitals include opportunists which are inherently multi-resistant (e.g. Xanthomonas maltophilia) and multi-resistant varieties of common organisms, e.g. MRSA, gent-resistant E. coli

opportunists

multi-resistant bacteria

HOSPITAL-ACQUIRED INFECTION
SYNDROMES

Nosocomial UTI
~30% of hospital infections y Usually catheter associated
y

Asymptomatic colonisation common

Treatment of clinical infection often requires catheter removal

BUT only under antibiotic cover!

Chest infection
y y y

~20% of nosocomial infections Gram-negative pneumonia

Problem in critically ill & immunocompromised patients

Legionellosis
Vigilance is necessary for early detection of outbreaks Control by

raising the hot water temp regular cleaning & inspection of water & air-cooling systems

Wound Infections
~20% of nosocomial infections y Rates vary depending on whether clean or dirty surgery
y

Blood-stream Infections
~30% of nosocomial infections y Especially device-associated infection y Treatment: remove the foreign body
y

HOSPITAL-ACQUIRED INFECTION
ROGUES GALLERY

Methcillin-resistant Staphylococcus aureus

y y y

MRSA Infection Requires vancomycin treatment Colonisation requires isolation, decontamination with mupirocin and betadine VRE, includes E, faecalis and E. faecium Low grade pathogens If also multi-drug resistant treatment can be difficult

Vancomycin-resistant enterococci
y y y

E. faecium but not E. faecalis treatable with quinupristin & dalfopristin (Synercid)

Clostridium difficile
y y y

Causes Antibiotic-associated colitis Can cause outbreaks in hospitals Patients should be isolated Require treatment with expensive drugs such as amikacin and imipenem Patients should be isolated Can cause outbreaks e.g. on oncology wards or in ITU Aspergillus fumigatus and Candida albicans can cause nosocomial outbreaks

Gentamicin-resistant GNRs
y y y

Fungal infection
y

CONTROL OF CROSS-INFECTION

Handwashing is paramount!
y y

even for Consultants! wash your hands before & after examining patients, especially if you look at undressed wounds Alcoholic hand rubs may provide a convenient alternative to soap and water, especially where sinks are in short supply or during an outbreak

Isolation of infectious patients

y y

whenever you admit or assess a patient think:

does this patient need to be isolated? Side-room isolation (or cohort nursing or isolation ward) Hand-washing on entry & exit Use of aprons and gloves microbiologist or infection control nurse for advice infection control manual for isolation protocols

general precautions

consult

contains advice on meningitis, D&V, open TB, MRSA, hepatitis, HIV, and lots more besides - everything from Lassa to lice!!

Prophylaxis
y

e.g. of contacts of chickenpox, diphtheria, meningitis

SUMMARY

[INSERT FIGURE 14.20]

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