INTRODUCTION TO CPH PH Activities

- Health situation monitoring and analysis

Health (WHO Definition) - Epidemiological surveillance/disease prevention and
- State of complete physical, mental and social well- control
being, not merely the absence of disease or infirmity. - Development of policies and planning in public health
- Strategic management of health systems and services
Health Determinants: for population health gain
 Income and social status - Regulation and enforcement to protect public health
 Education - Human resources development and planning in public
 Physical environment health
 Employment and working conditions - Health promotion, social participation and
empowerment
 Social support networks
- Ensuring the quality of personal and population based
 Culture
health services
 Genetics
- Research, development and implementation of
 Personal behavior and coping skills
innovative public health solutions
 Health services
 Gender CASE STUDIES
Epidemic of Milk Formula-Associated Infant Death – China
Public Health 2008
Acheson Report, London 1988 - Melamine in infant formula causes four deaths
- The science and art of preventing disease, prolonging - 40,000 children flood health care facilities
life and promoting health through the organized - 12,900 hospitalized with severe kidney damage
efforts of society. - Chinese milk products recalled in Japan, Hong Kong,
Dr. Winslow's Definition Singapore and Southeast Asia
Science and art of: Disability-Adjusted Life Years (DALYS)
- preventing disease - Burden of disease
- prolonging life - One DALY can be thought of as one lost year of
- promoting health and efficiency through organized "healthy" life.
community effort for the sanitation of the - Measurement of the gap between current health
environment status and an ideal health situation where the entire
- control of communicable diseases population lives to an advanced age, free of disease
- education of individuals in personal hygiene and disability
- organization of medical and nursing services for the - Calculated as the sum of the Years of Life Lost (YLL)
early diagnosis and preventive treatment of disease due to premature mortality in the population and the
- development of social machinery to ensure everyone Years Lost due to Disability (YLD) for incident cases of
a standard of living adequate for the maintenance of the health condition
health - YLL = number of deaths X standard life expectancy at
the age at which death occurs
WHO Definition
- Art of applying science in the context of politics so as Philippine Health Care Delivery System
to reduce inequalities in health while ensuring the DOH
best health for the greatest number.

Core Business
- Disease control
- Injury prevention
- Health protection
- Healthy public policy (e.g., environmental hazards)
- Promotion of health and equitable health gain

Functions (Modified from Yach’s Definition)

- A set of fundamental activities that address the
determinants of health, protect a population’s health
and treat disease.
Levels of Health care - Regulation of health professionals is carried out by
- Primary the Professional Regulation Commission.
- Secondary
- Tertiary PhilHealth
Local Health System/ Inter-local Health System - Regulates health providers that are in compliance
- Inter local health zone: cluster of municipalities with its quality guidelines, standards and procedures
- Characteristics and components: through accreditation.
 Definite population and geographical area
 Central referral hospital and primary level Food and Drug Administration (FDA)
facilities (i.e., RHU and BHS) - Regulates pharmaceuticals along with food, vaccines,
cosmetics and health devices and equipment
PHILIPPINE HEALTH SYSTEM
Organization and Governance COMMUNITY ASSESSMENT
• Decentralized setting Basic Definitions & Functions
- Department of Health (DOH) serving as the governing  Needs
agency - Help focus solution
- Both local government units (LGUs) and the private - Try to base needs in outcome is strongest
sector providing services to communities and - Summarizes what need & who has need
individuals - One need per statement
• Department of Health - Do not confuse need with solution, e.g.,
- Provides national policy direction need is for more therapy
- Develops national plans, technical standards and  Capacities
guidelines on health - Helps design a solution
1) Developing health policies and programmes - Cover individuals
2) Enhancing partners’ capacity through technical assistance experience/knowledge/skills, associations,
3) Leveraging performance for priority health programmes and organizations
among these partners  Barriers
4) Developing and enforcing regulatory policies and standards - Identify roadblocks during solutions
5) Providing specific programmes that affect large segments of
the population Steps in an Assessment
6) Providing specialized and tertiary level care. 1. Identify the condition of concern
2. Developing a vision and principles to guide action
LGUs 3. Identify and mobilize stakeholders into guiding
• Local Government Code of 1991: coalition
- Granted autonomy and responsibility for their own 4. Explore condition, why problem, history, causes,
health services politics
- But were to receive guidance from the DOH through 5. Develop baseline measure to measure future impact
the Centres for Health Development (CHDs) 6. Best practices, intervention models, guidelines
• Provincial Governments 7. Profile community (client)
- Provide secondary hospital care 8. Document existing solutions/service system
• City and municipal administrations 9. Develop list of capacities/resources to build on
- Provide primary care, including maternal and child 10. Develop list of needs (gaps in services, felt need, etc.)
care, nutrition services, and direct service functions. 11. Identify barriers to solutions
12. Make report understandable/politically acceptable
Rural Health Units (RHUs)
- Created for every municipality in the country in the Goals of an Assessment
1950s to improve access to health care - Unite, educate, coordinate, mobilize
people/institutions
Private Health Sector - Understand a condition/problem
- Larger than the public sector in terms of human, - Collect information on a condition/problem
financial and technological resources - Provide information to design a solution, e.g.,
- Composed of for-profit and non-profit providers capacities, model programs, research
- Caters to 30% of the population - Provide baseline data to measure progress
- Regulated by the DOH and the Philippine Health - Provide data to see if vision impacted
Insurance Corporation
- Regulation of health science schools and universities Relevant Definitions
is under the Commission on Higher Education. - Incidence = number during a time period
Example: 5000 people were homeless in 1999
 - Prevalence = number at any one time - Hard to control
Example: on 1 Dec 99, 500 were homeless - Can be dominated by a few
- Valid = measures concept under study, nothing else - Hard to summarize results
- Reliable = consistent over time - May not be reliable (hard to replicate)
- Baseline data = starting point from which to measure 3. Interviews
results - Easy to conduct
- Can discover political realities
Logic of Needs/Capacities - Can get ‘off the record’ information
 Clients - High validity/reliability
 Living in condition - Can explore answers
 Have needs - Can get capacities via stories & histories
- That are caused by xxx - Hidden agendas
- And not solved due to xxx - Hard to summarize
- And related to other problems - Can be biased by who is interviewed
- Others addressed these needs by xxx with 4. Document Analysis
xxx results - -Readily available information
- So given strengths xxx - Inexpensive
- The most promising approach is xxx - High reliability
Need Types - Analysis tools exist
- Normative = compared to standards (poverty rate) - Can get at capacities via histories
- Perceived = What people say, e.g., expert opinion - Hard to analyze
- Expressed = squeaky wheel, e.g., waiting lists, - Hard to summarize
unemployment rate, public forums, surveys - Moderate validity because you cannot always find
- Relative = compared to similar situations, concern is documents on topic
equity, (infant mortality rate) 5. Observation
- Inexpensive
Types of Capacities - High validity
 Local Institutions - Gives information on the context
 Citizens Groups and Associations - Hard to analyze
 Individual Contributions - Hard to summarize
- May be biased due to values of the designer/
Sources of Data observer
 Primary (you collect for current purpose) - Moderate/low reliable (hard to replicate)
- Experts 6. Group Process (Focus Groups)
- Key informants - Detailed analysis
- Citizens/consumers - Quick
 Secondary (others collected for other purposes) - Can use techniques as brainstorming & Nominal
- Census bureau group
- Research studies - Online techniques are available, e.g., chat rooms
- Agency reports - Requires experience
- Requires planning
Methods of Primary Data Collection - Hard to get diversity
1. Surveys - Difficult to summarize
- Targeted
- High validity/reliability Data Analysis
- Many analysis tools (stats) When using statistics for the general public, remember the
- Cost effective (sampling) following principles:
- Online options are possible - Minimum data collection, maximum analysis
- Experience required - Keep it simple
- Time consuming - Distinguish between data and interpretation of data
- Requires a pretest - Use totals and average, percents, etc.
- Return or missing rate
- Sample size vs. accuracy Data Presentation Techniques
2. Public Forums  Know your audience (research vs. program grant)
- Easy to set up  Executive summaries (assume multiple readers)
- Gives all the opportunity to participate  One picture worth 1000 words
- High validity  Use indicators and graphics
- CYA  Geographic Information Systems (GIS) help
  Use tables and figures  Protozoa:
 Put data in appendices unless needed to understand - Amoebiasis and malaria
text  Viruses:
- Dengue, rabies, HIV/AIDS and SARS
Conclusion
 Data is best for identifying need Benefits from Microbes
 Stories, histories, etc. best for identifying capacities  As indigenous microflora
 People know needs but need help with solutions - Non-specific immune response
 Data presentation should be logical - Digestion process (e.g., Vit. K and B1 production
 Minimum data collection, maximum use by Escherichia coli)
 Assessment should present a picture/tell a story  Oxygen production
- Photosynthetic cyanobacteria
INTRODUCTION TO MICROBIOLOGY  Decomposition
- Saprophytes
AND INFECTIOUS DISEASE PROCESS
 Microbial ecology and elemental cycles
- Extensive role of certain bacteria in nitrogen
Microbiology
cycle
 Study of microbes (microscopic organisms)
 Food chain
 Microbe categories:
- Phytoplankton and zooplankton
- Cellular and acellular (infectious particles)
 Commercial uses
- Pathogen, non-pathogen and opportunistic
- Foods, chemicals, and alcoholic beverages
 Antibiotics
Microbe Categories
- Penicillin, streptomycin and amphotericin B
 CELLULAR
 Biotechnology
Prokaryotes
- Bacteria
Minimum Competency
- Archaeans
- Infectious diseases and the pathogens that cause
Eukaryotes
them
- Certain algae
- Sources of these pathogens and how they are
- Certain fungi
transmitted
- Protozoa
- Diagnostic procedures for infectious diseases and
 ACELLULAR
appropriate chemotherapy
- Viruses
- Protective measures against diseases for oneself
- Prions
and patient
Microbe Categories
History of Infectious Diseases
 Pathogen or disease-causing microbes
Earliest Known Infectious Diseases:
 Non-pathogen
 Bacterial diseases
- Indigenous microflora
- Tuberculosis, syphilis, anthrax, bacillary
- 500 to 1,000 different species of microbes
dysentery, botulism, typhoid fever, typhus fever
 Opportunistic microbes
and diptheria
- Potential to cause disease in
 Fungal
immunocompromised host or when introduced
- Ergotism caused by Claviceps purpurea
to anatomical locations they don’t belong in (e.g.,
 Parasitic
intestinal microflora in the blood)
- Amoebic dysentery, schistosomiasis,
dracunculiasis and tapeworm infections
MICROBIAL DISEASE
 Viral diseases
Disease Causation
- Rabies, smallpox and measles
 Infectious disease
- Pathogen colonizes a person’s body resulting in
Microbiology Pioneers
disease
 Anton van Leeuwenhoek (1632 -1723)
 Microbial intoxication
- Father of microbiology
- Ingestion of toxin produced by a microbe
- Inventor of single-lens (simple) microscope
Examples of Diseases Caused by Pathogens
- First to see bacteria and protozoa
 Bacteria:
- Tuberculosis, leptospirosis and typhoid fever
 Fungi:
- Ringworm infections
  Leeuwenhoek’s Microscope and Illustrations Bacterial Characteristics
 Louis Pasteur (1822 -1895)  Morphology
- Fermentation and different fermentation - Cellular morphology
products (i.e. yeast: glucose – ethanol, - Colonial morphology
Acetobacter: glucose – vinegar)  Motility
- Disproval of abiogenesis  Atmospheric requirements
- Aerobe and anaerobe concept  Nutritional requirements
- Pasteurization of liquids (63 to 65°C for 30  Metabolism
minutes or 73 to 75°C for 15 seconds).  Pathogenicity
- Precautionary measures against silkworm  Genetics
disease
- Contributions to germ theory of disease Morphology
- Hospital protocol reforms that prevent  Basic shapes and arrangement:
transmission of infectious diseases - Coccus (pl. cocci)
- Vaccines against chicken cholera, anthrax, swine  Singly, diplococci, streptococci,
erysipelas and rabies staphylococci, tetrads and octads
 Robert Koch (1843-1910) - Bacillus (pl. bacilli)
- Discovery of:  Singly, diplobacilli, streptobacilli and
Bacillus anthracis palisades
Mycobacterium tuberculosis  Coccobacilli
Vibrio cholerae - Spirillum (pl. spirilla)
- Bacterial fixation, staining and photographing - Pleomorphic
methods Colonial Morphology
- Developed bacterial cultivation methods with R.  Bacterial colony
J. Petri and Frau Hesse, and were the first to - Mound or pile of bacteria
obtain pure cultures - Millions of cells
- Koch’s postulates  Size, color, shape, elevation and appearance of the
Prove that a specific microbe is the cause of margin
a specific infectious disease  Generation time
- Exceptions to Koch’s Postulates: Motility
 Organisms that are impossible or  Flagella or axial filaments
difficult to grow in cultures such as
 Gram negative bacteria
obligate intracellular parasites (e.g.,
 Determined by:
viruses, rickettsias and chlamydias) and
- Turbidity in semisolid medium
fastidious organisms (e.g., M. leprae and
- Hanging-drop preparation
T. pallidum).
Atmospheric Requirements
 Human-specific infectious diseases
 Oxygen requirements
 Synergistic infections such as acute
- Obligate aerobes (20 to 21% O2)
necrotizing ulcerative gingivitis and
- Microaerophiles (5% O2)
bacterial vaginosis
- Anaerobes
 Attenuation of pathogens grown in vitro
 Obligate
 Aerotolerant – grow better anaerobically but
BASIC COMPARISON OF MICROBES survive in the presence of O2
BACTERIA  Facultative – grow regardless of atmospheric
Taxonomy and Classification O2 conditions
 Traditional  Carbon dioxide requirements
- 23 phyla - Capnophiles: 5 to 10% CO2
- 32 classes - Capnophilic anaerobes
- 5 subclasses  Bacteroides and Fusobacterium species
- 77 orders - Capnophilic aerobes
- 14 suborders  Neisseria, Campylobacter and Haemophilus
- 182 families species
- 871 genera Nutritional Requirements
- 5,007 species  Basic elements
 Cell wall characteristics - Carbon, hydrogen, oxygen, sulfur, phosphorus
- Gram positive and nitrogen
- Gram negative
- Cell-wall less
  Special elements - Moulds
- Potassium, calcium, iron, manganese, - Fleshy
magnesium, cobalt, copper, zinc and uranium Fungal Structures
 Vitamins  Unicellular (e.g., yeasts)
 Fastidious – microbes having special nutritional needs  Filaments (e.g., moulds and fleshy fungi):
 Examples: - Hypha (pl., hyphae)
- Neisseria spp.  Septate – cytoplasm divided into cells by
- Haemophilus spp. cross-walls
Metabolism  Aseptate
 Specific enzymes  Coenocytic – aseptate hypha having
- Catalase multinucleated cytoplasm
- Urease - Mycelium (pl., mycelia) or thallus
Pathogenicity
 Ability to cause disease PROTOZOA
 Factors: Taxonomy and Classification
- Capsules, pili, or endotoxins, exotoxins and  Classified under kingdom Protista
enzymes  Classified into phyla based on method of locomotion
Atypical Bacteria - Ciliates
 AKA “unique” or “rudimentary” bacteria - Amoeba
- Rickettsias, chlamydias and closely related - Flagellates
bacteria - Sporozoa
 Gram negative, obligate intracellular Characteristics
pathogens  Life stages:
 In vitro culture requires embryonated - Trophozoite – motile, feeding, dividing
chicken eggs. - Cyst – non-motile, dormant , survival
- Mycoplasmas  Additional organelles
 Cell-wall less - Pellicles – cell wall-like; for protection
- Cytostomes – food ingestion
ARCHAEA - Contractile vacuoles – pump water out of
Taxonomy and Classification cell
 Traditional - Pseudopodia
- 2 phyla
- 8 classes VIRUSES
- 12 orders Virus Components
- 21 families  Very small (measured in nanometers)
- 69 genera  Components
- 217 species - Nucleic acid core, capsid and envelope
 Previously referred to as archaeobacteria or ancient Classification
bacteria  Genetic material (either DNA or RNA)
 Cocci, bacilli or long filaments  Shape of the capsid
 Majority are extremophiles  Number of capsomeres
 Live at ocean bottom, geysers and hot springs  Size of capsid
Characteristics  Presence or absence of envelope
 Ph  Type of host infected
- Acidophiles and alkaliphiles  Type of disease produced
 Temperature  Target cell
- Thermophiles and psychrophiles  Immunologic properties
 Salinity
- Halophiles EPIDEMIOLOGY AND PUBLIC HEALTH
 Atmospheric pressure Introduction
- Piezophiles (formerly barophiles)  Pathology
Structural and functional disease manifestations
FUNGI Diagnosis
General Characteristics  Epidemiology
 Non-photosynthetic - Who, what, where, when and why
 Chitin in cell walls - Frequency, distribution and determinants of
 Classification disease in a population
- Yeast
 - Factors: pathogen characteristics, mode of Epidemiologic Triangle
transmission and host susceptibility

Early History
 John Snow
- Father of epidemiology
- Broad street water pump
- Cholera transmission
 1884 London Cholera Outbreak Investigation

Infectious Disease
 Caused by pathogen
 Classification according to:
- Source
- Occurrence Chain of Infection
- Mode of transmission  Pathogen
According to Source
 Reservoir
 Zoonotic disease
 Portal of exit
- Animal to human
 Mode of transmission
 Communicable disease
 Portal of entry
- Human to human
 Susceptible host
 Contagious disease
- Easily transmitted
Reservoirs
According to Occurence
A. Living
 Sporadic: occasional
 Human carriers
 Endemic: always
- Passive
 Epidemic: > usual - Incubatory
 Pandemic: simultaneous - Convalescent
- AIDS, malaria and tuberculosis - Active
 Animals
1. AIDS
 Arthropod vectors
 Caused by Human Immunodeficiency Virus (HIV) first B. Non-living
isolated in 1983
 Fomites
 First detected in 1981 but believed to have existed as
early as 1959 Human Carriers
2. MALARIA
 Passive carriers
 Caused by Plasmodium spp. - Carry the pathogen without ever having had the
 Transmitted by Anopheles spp. in tropical and disease
subtropical countries
 Incubatory carriers
3. TUBERCULOSIS - Transmit the pathogen during the incubation
 Caused by Mycobacterium tuberculosis period of the disease
 Increasing number of MDR-TB cases  Convalescent carriers
- Transmit the pathogen during recovery
Health Indicators  Active carriers
 Incidence/Morbidity Rate - Continue to carry the pathogen even after
- New cases recovery (e.g., Typhoid bacillus in gall bladder).
 Prevalence Zoonoses
- Existing cases  Rabies: dogs, cats, bats, skunks and other animals
- Types: point and period
 Toxoplasmosis: cats and raw meat
 Point: at a certain point or moment
 Salmonellosis: turtle, reptiles and poultry
in time (e.g., at present).
 BSE: cows
 Period: specified time period (e.g.,
 Tularemia: rabbits
year 2009).
 Psittacosis: birds
 Death/Mortality Rate
- Died of a particular disease
Vector-borne Infections SAMPLING METHODS
 Mosquito: dengue, malaria and elephantiasis The Sampling Design Process
 Tick: lyme disease
 Flea: plague
Modes of Transmission
 Contact
 Air borne
 Droplet
 Vehicular
 Vectors
Biological Warfare Agents
 Potential threats:
- Bacillus anthracis
- Clostridium botulinum
- Variola major Define the Target Population
- Yersinia pestis  The target population is the collection of elements or
 For complete list, see Burton Table 11-8 objects that possess the information sought by the
researcher and about which inferences are to be
1. Anthrax made.
 Caused by Bacillus anthracis  The target population should be defined in terms of
 Forms: elements, sampling units, extent, and time.
- Cutaneous, inhalation and gastrointestinal  An element is the object about which or from which
2. Botulism the information is desired, e.g., the respondent.
 Caused by Clostridium botulinum  A sampling unit is an element, or a unit containing the
 Botulinal toxin element, that is available for selection at some stage
- Nerve damage of the sampling process.
- Visual difficulty  Extent refers to the geographical boundaries.
- Respiratory failure  Time is the time period under consideration.
- Flaccid paralysis of voluntary muscles  Important qualitative factors in determining the
- Brain damage or coma sample size
- Death - the importance of the decision
3. Smallpox - the nature of the research
 Caused by Variola major - the number of variables
 Severe symptoms and characteristic skin rash - the nature of the analysis
 Last naturally occurring case: Somalia, 1977 - sample sizes used in similar studies
4. Plague - incidence rates
 Caused by Yersinia pestis - completion rates
 Forms: - resource constraints
- Bubonic, septicemic, pneumonic and Classification of Sampling Techniques
meningitis

Water Treatment
 Prevent water-borne diseases
 Processes:
- Filtration
- Sedimentation
- Coagulation
 Aluminum potassium sulfate
- Chlorination

Coliform Count
 Indicators of fecal contamination Convenience Sampling
 Family Enterobacteriaceae  Convenience sampling attempts to obtain a sample of
- E. coli convenient elements. Often, respondents are
- Enterobacter spp. selected because they happen to be in the right place
- Klebsiella spp. at the right time.
 - use of students, and members of social
organizations
- mall intercept interviews without qualifying the Stratified Sampling
respondents  A two-step process in which the population is
- department stores using charge account lists partitioned into subpopulations, or strata.
- “people on the street” interviews  The strata should be mutually exclusive and
Judgmental Sampling collectively exhaustive in that every population
 Judgmental sampling is a form of convenience element should be assigned to one and only one
sampling in which the population elements are stratum and no population elements should be
selected based on the judgment of the researcher. omitted.
- test markets  Next, elements are selected from each stratum by a
- purchase engineers selected in industrial random procedure, usually SRS.
marketing research  A major objective of stratified sampling is to increase
- bellwether precincts selected in voting behavior precision without increasing cost.
research  The elements within a stratum should be as
- expert witnesses used in court homogeneous as possible, but the elements in
Quota Sampling different strata should be as heterogeneous as
 Quota sampling may be viewed as two-stage possible.
restricted judgmental sampling.  The stratification variables should also be closely
- The first stage consists of developing control related to the characteristic of interest.
categories, or quotas, of population elements.  Finally, the variables should decrease the cost of the
- In the second stage, sample elements are stratification process by being easy to measure and
selected based on convenience or judgment. apply.
Snowball Sampling  In proportionate stratified sampling, the size of the
 In snowball sampling, an initial group of respondents sample drawn from each stratum is proportionate to
is selected, usually at random. the relative size of that stratum in the total
- After being interviewed, these respondents are population.
asked to identify others who belong to the target  In disproportionate stratified sampling, the size of the
population of interest. sample from each stratum is proportionate to the
- Subsequent respondents are selected based on relative size of that stratum and to the standard
the referrals. deviation of the distribution of the characteristic of
Simple Random Sampling interest among all the elements in that stratum.
 Each element in the population has a known and Cluster Sampling
equal probability of selection.  The target population is first divided into mutually
 Each possible sample of a given size (n) has a known exclusive and collectively exhaustive subpopulations,
and equal probability of being the sample actually or clusters.
selected.  Then a random sample of clusters is selected, based
 This implies that every element is selected on a probability sampling technique such as SRS.
independently of every other element.  For each selected cluster, either all the elements are
Systematic Sampling included in the sample (one-stage) or a sample of
 The sample is chosen by selecting a random starting elements is drawn probabilistically (two-stage).
point and then picking every ith element in succession  Elements within a cluster should be as heterogeneous
from the sampling frame. as possible, but clusters themselves should be as
 The sampling interval, i, is determined by dividing the homogeneous as possible. Ideally, each cluster
population size N by the sample size n and rounding should be a small-scale representation of the
to the nearest integer. population.
 When the ordering of the elements is related to the  In probability proportionate to size sampling, the
characteristic of interest, systematic sampling clusters are sampled with probability proportional to
increases the representativeness of the sample. size. In the second stage, the probability of selecting
 If the ordering of the elements produces a cyclical a sampling unit in a selected cluster varies inversely
pattern, systematic sampling may decrease the with the size of the cluster.
representativeness of the sample.
 For example, there are 100,000 elements in the
population and a sample of 1,000 is desired. In this
case the sampling interval, i, is 100. A random
number between 1 and 100 is selected. If, for
example, this number is 23, the sample consists of
elements 23, 123, 223, 323, 423, 523, and so on.
Types of Cluster Sampling  Any systematic bias that occurs during data
collection, analysis or interpretation
- Respondent error (e.g., lying, forgetting, etc.)
- Interviewer bias
- Recording errors
- Poorly designed questionnaires

PATHOGENESIS OF INFECTIOUS DISEASE

Introduction
Strengths and Weaknesses of  The prefix “path-”
Basic Sampling Techniques - Pathogen: disease-causing microbe
- Pathology: study of disease
- Pathologist: physician who studies disease
- Pathogenesis: steps or mechanisms involved in
the development of a disease
Infection vs. Infectious Disease
 Infection
- Colonization of a body part by a pathogen

 Infectious disease
- Disease resulting from infection
Reasons Why Infection Does Not Occur
 Inappropriate anatomic location
 Absence of receptors
 Microbial antagonism/Competitive inhibition
Nonprobability vs. Probability Sampling  Non-specific and specific immunity
Infectious Disease Process Phases
 Incubation period
 Prodromal period
 Period of illness
 Convalescence/Disability/Death
Localized vs. Systemic
 Localized
- Confined at original site of infection
Boils, pimple and abscesses
 Systemic
- Generalized
- Miliary tuberculosis
Onset and Duration of Disease
 Acute:
Random Sampling Error - Measles, mumps and influenza
 Random error - the sample selected is not  Subacute:
representative of the population due to chance - Bacterial endocarditis
 The level of it is controlled by sample size  Chronic:
 A larger sample size leads to a smaller sampling error. - Tuberculosis, leprosy and syphilis
Non-sampling Error Latent Infections
 Systematic error  Symptomatic to asymptomatic then back to being
 The level of it is NOT controlled by sample size. symptomatic
 The basic types of non-sampling error  Examples: herpes, shingles and syphilis
- Non-response error Primary and Secondary Infections
- Response or data error  Primary: Respiratory viruses
Non-Response Error  Secondary: Bacterial infections (e.g., S. pneumoniae
 Occurs when units selected as part of the sampling and H. influenzae)
procedure do not respond in whole or in part Virulence:
 If non-respondents are not different from those that  Virulent strains:
did respond, there is no non-response error - Toxigenic strain of C. diptheriae
Response or Data Error
 - Flesh-eating and erythrogenic toxin-producing S. Virulence Factors: Enzymes
pyogenes  Endotoxin:
- TSST-1 producing S. aureus - Lipopolysaccharide in gram negative bacterial
cell walls
 Shigella spp. - Chills, fever, prostration and septicemia
- More virulent than Salmonella spp. because of - Gram negative sepsis
lower infective dose  Exotoxins:
- Neurotoxins:
 Tetanospasmin and botulinal toxin
Virulence Factors (Table 14-2): - Enterotoxins
 Structures:  C. difficile toxin B - pseudomembranous
- Structures for attachment: pili, receptors and colitis
ligands - TSST-1
- Capsule - Epidermolytic toxin
- Flagella - Erythrogenic toxin
 Intracellular survival - Leukocidin
 Exoenzymes - Diphtheria toxin
 Toxins Pathogen Escape Routes
Virulence Factors: Structures for Attachment  Antigenic variation:
 Pili: N. gonnorhoeae, N. meningitidis, P. aeruginosa, - Influenza viruses, HIV, B. recurrentis, N.
Salmonella, Shigella, V. cholerae, E. coli and S. gonnorhoeae and African trypanosomes
pyogenes.
 Receptors and adhesins (a.k.a. integrins and ligands):  Camouflage and molecular mimicry:
- Protein F of S. pyogenes and fibronectin on host - Schistosomes, streptococcal capsule and
cell surfaces Mycoplasma
- Gp120 of HIV and CD4+ of T helper lymphocytes
Virulence Factors: Flagella and Capsule MAJOR BACTERIAL DISEASES
 Flagella Introduction and Generalizations
 Phagocyte evasion Introduction
 Capsule  Caused by bacteria
 Anti-phagocytic  Laboratory confirmation necessary
 Phagocytes lack cellular receptors for capsular - Same bacterial disease  different
material manifestations
Virulence Factors: Intracellular Survival - Different bacterial diseases  same
 Obligate: manifestation
- Rickettsia: endothelial and vascular smooth  Organ system affected
muscle - Mode of transmission
- Chlamydia: conjunctival epithelia, respiratory - Sign and symptoms
and genital tracts  Groups:
- Ehrlichia: monocytes - Shape
o phagocytophilum: granulocytes - Gram staining
- Malaria and Babesia: red cells - Acid fast staining
 Facultative: - Spore formation
- Mycobacterium tuberculosis - Intracellular survival
- Brucella abortus
- Francisella tularensis Gram Negative Cocci
- Legionella pneumophila  Neisseria
- Listeria monocytogenes  Branhamella
- Salmonella spp.  Veilonella
- Yersinia pestis  Acidaminococcus
Virulence Factors: Enzymes  Megasphaera
 Necrotizing enzymes Gram Positive Bacilli
 Coagulase  Bacillus
 Kinases  Bifidobacterium
 Hyaluronidase (Spreading factor)  Nocardia
 Collagenase  Erysipelothrix
 Hemolysin  Listeria
 Lecithinase
  Streptomyces  Clinical manifestation
 Actinomyces - Black eschar
 Mycobacterium  Causative agent
 Corynebacterium - Bacillus anthracis
 Clostridium  Reservoir
 Arcanobacterium - Animals and soil
 Propionibacterium  Mode of transmission
 Lactobacillus - Through wounds
 Eubacterium - Inhalation
Acid Fast Bacilli - Ingestion
 Mycobacterium
 Nocardia Gas Gangrene/Myonecrosis
Spore Formers  Clinical manifestation
 Bacillus - Necrosis from ischemia
 Clostridium  Causative agent
Intracellular Bacteria - Clostridium perfringens
 Chlamydia  Reservoir
 Rickettsia - Soil
 Coxiella  Mode of transmission
 Ehrlichia - Deep puncture wounds
 Anaplasma
Leprosy/Hansen’s Disease
Laboratory Identification  Lepromatous
- Numerous skin nodules, involvement of the eyes
 Direct staining
and nasal mucosa
 Inoculation on primary plates
 Tuberculoid
- 16 to 24 hours
- Few skin lesions
 If positive for growth:
- Peripheral nerve involvement may lead to loss of
- Staining
sensation
- Biochemical testing
 Causative agent
 Sensitivity testing
- Mycobacterium leprae
- 16 to 24 hours
 Reservoir
 Results
- Armadillos
 Mode of transmission
Minimum Competency
- Inhalation or broken skin
 Disease
- Tuberculoid form is non-contagious
 Organ system affected
 Clinical manifestation
Staphylococcal Skin Infections
 Causative agent
 Clinical manifestation
 Reservoir - Folliculitis
 Mode of transmission - Furuncles/ Carbuncles
- Impetigo
I. Bacterial Diseases of the Skin - SSSS
Acne  Causative agent
 Clinical manifestation - Staphylococcus aureus
- Inflamed, infected abscesses  Mode of transmission
- Direct contact with purulent lesions or
 Causative agent asymptomatic carriers
- Propionibacterium acnes
Streptococcal Skin Infections
 Mode of transmission  Impetigo
- Non-communicable - Vesicular, pustular and encrusted stages
 Scarlet fever
Anthrax/Wool Sorter’s Disease - Pink red rash on abdomen, sides of the chest and
 Forms skin folds
- Cutaneous - High fever, nausea and vomiting
- Pulmonary
- Gastrointestinal
  Erysipelas - Other bacteria
- “St. Anthony’s Fire:” Hot and tender red  Mode of transmission
eruptions, fever and cellulitis - Highly contagious
 Necrotizing fasciitis - Contact with eye or respiratory discharges
- Inflammation of the fascia - Indirect contact
 Causative agent
- Streptococcus pyogenes Chlamydial Conjunctivitis/Inclusion
 Mode of transmission Conjunctivitis/Paratrachoma
- Direct contact  Clinical manifestation
- Respiratory droplets - Mucopurulent discharge
- Indirect contact - Mild scarring of the cornea or the conjunctiva
 Causative agent
II. Bacterial Diseases of the Ears - Chlamydia trachomatis
Otitis Externa/Swimmer’s Ear  Mode of transmission
 Clinical manifestation - Contact with genital discharges:
- Itching - Finger to eye
- Malodorous discharge - Passage through birth canal
- Impaired hearing  Non-chlorinated swimming pools
 Causative agents
- Proteus vulgaris Chlamydial Keratoconjunctivitis/Trachoma
- Escherichia coli  Clinical manifestation
- Pseudomonas aeruginosa - May be concurrent with chlamydial
- Staphylococcus aureus nasopharyngitis or non-gonococcal urethritis/
 Reservoir cervicitis
- Fomites  Causative agent
 Mode of transmission - Chlamydia trachomatis
- Swimming in contaminated pools  Mode of transmission
- Indigenous microflora - Direct contact with infectious ocular or nasal
- Contaminated ear cleaning materials secretions

Otitis Media Gonococcal Conjunctivitis/ Gonorrheal Opthalmia

 Clinical manifestations Neonatorum
- Persistent and severe headache  Clinical manifestation
- Temporary to permanent hearing loss - Acute redness and swelling of conjunctiva with
- Rupture of the eardrum purulent discharge
- Nausea, vomiting, diarrhea and fever - Corneal ulcers, perforation and blindness
- Bloody discharge and pus  Causative agent
- Bone infection and meningitis - Neisseria gonorrhoeae
 Causative agent  Mode of transmission
- Streptococcus pneumoniae - Contact with genital discharges:
- Streptococcus pyogenes  Finger to eye
- Staphylococcus aureus  Passage through birth canal
- Haemophilus influenzae
- Moraxella catarrhalis IV. Bacterial Diseases of the Respiratory Tract
 Mode of transmission Diptheria
- Introduction of indigenous nasopharynx  Clinical manifestation
microflora to the middle ear - Tonsils, pharynx, larynx and nose are
involved
III. Bacterial Diseases of the Eyes - Cytotoxin causes formation of a tough
Conjunctivitis/Pink eye adherent, grayish-white membrane
 Clinical manifestation - Difficulty in breathing, sore throat, swollen
- Irritation and reddening of the conjunctiva and tender cervical lymph nodes, tonsillitis
- Edema of the eyelids and swollen neck
- Mucopurulent discharge  Causative agent
- Sensitivity to light - Corynebacterium diptheriae
 Causative agents  Mode of transmission
- Haemophilus influenzae - Airborne droplets
- Streptococcus pneumoniae - Direct contact
 - Fomites and raw milk  Causative agent
- Legionella pneumophila
Streptococcal Pharyngitis/Strep Throat  Reservoir
 Clinical manifestation - Environmental water sources
- Sore throat, chills, fever, headache  Mode of transmission
- Beefy red throat with white patches of pus - Airborne transmission from water and
on pharyngeal epithelium perhaps dust
 Possible complications
- Otitis media Mycoplasmal Pneumonia/Primary Atypical Pneumonia
- Scarlet fever  Clinical manifestation
- Rheumatic fever - Gradual onset
- Glomerulonephritis - Headache, malaise, dry cough, sore throat
 Causative agent and chest discomfort
- Streptococcus pyogenes - Scant sputum which increases as disease
 Mode of transmission progresses
- Direct contact - Common in people 5 to 35 yrs. old
- Aerosol droplets and nasal secretions  Causative agent
- Contaminated fomites and milk products - Mycoplasma pneumoniae
 Mode of transmission
Pneumonia - Droplet inhalation
 Clinical manifestation - Direct contact with contaminated fomites
- Acute non-specific infection of the alveoli
and lung tissues Chlamydial Pneumonia
- Fever, productive cough, acute chest pain,  Clinical manifestation
chills and shortness of breath - Pneumonia or bronchitis
- Abnormal chest sounds and radiographs - Gradual onset of cough with little or no fever
 Community Acquired - Pharyngitis, laryngitis and sinusitis
- Streptococcus pneumoniae  Causative agent
- Haemophilus influenzae - Chlamydophila pneumoniae
- Staphylococcus aureus  Mode of transmission
- Klebsiella pneumoniae - Person-to-person transmission by
 Nosocomially Acquired respiratory secretions
- Staphylococcus aureus
- Pseudomonas aeruginosa Psittacosis
- Klebsiella  Clinical manifestation
- Enterobacter - Fever, chills, headache, muscle aches and a
- Serratia dry cough
- Acinetobacter  Causative agent
- Other GNB - Chlamydophila psitacii
 Mode of transmission  Reservoir
- Droplet inhalation - Birds
- Direct oral contact  Mode of transmission
- Contaminated fomites - Inhaling dried secretions from infected birds

Atypical Pneumonia Tuberculosis

 Legionellosis/Legionnaire’s Disease/Pontiac Fever  Clinical manifestation
 Mycoplasmal Pneumonia/Primary Atypical - Malaise, fever, night sweats, weight loss,
Pneumonia productive cough, shortness of breath, chest
 Chlamydial Pneumonia pain and hemoptysis
 Psittacosis  Possible complications
- Systemic disease involving the kidneys,
Legionellosis/Legionnaire’s Disease/ Pontiac Fever urinary bladder and bones
 Clinical manifestation  Causative agent
- Acute pneumonia with malaise, myalgia, - Mycobacterium tuberculosis
anorexia, headache, high fever and chills - Mycobacterium avium complex
- Dry cough followed by a productive cough  Reservoir
- Shortness of breath, diarrhea, pleural and - Animals: primates, cattle and other
abdominal pain mammals
  Mode of transmission  Mode of transmission
- Airborne droplets - Ingestion of contaminated food, raw milk or
- Prolonged direct contact water
- For bovine Tb: - Contact with infected animals
 Exposure to cattle - Indirectly via contaminated fomites such as
 Ingestion of unpasteurized milk or cutting boards
dairy products
Cholera
Whooping Cough/Pertussis  Clinical manifestation
Stages: - Profuse watery stools, occasional vomiting and
 Prodromal/ Catarrhal rapid dehydration
- Mild, cold-like symptoms  Possible complications:
 Paroxysmal - Circulatory collapse
- Severe uncontrollable coughing fits - Renal failure
- Coughing ends in a prolonged, high pitched, - Death
deeply indrawn breath  Causative agent
 Causative agent - Vibrio cholerae serogroup 01
- Bordetella pertussis - Vibrio parahaemolyticus
- Bordetella parapertussis - Vibrio vulnificus
- Bordetella bronchiseptica  Aquatic reservoirs:
 Mode of transmission - Copepods
- Droplet inhalation - Zooplankton
 Mode of transmission
V. Bacterial Diseases of the Gastrointestinal - Fecal-oral
System - Mechanical vectors such as flies and cockroaches
Bacterial Gastritis and Peptic Ulcers
 Gastritis Salmonellosis
- Upper abdominal pain, nausea and heartburn  Clinical manifestation
 Duodenal Ulcers - Gastroenteritis with sudden onset of headache,
- Gnawing, burning, aching, mild to moderate pain abdominal pain , nausea and vomiting
right below the breast bone - Severe dehydration
- Empty feeling and hunger  Possible complications
- Pain occurs when stomach is empty - Septicemia
 Gastric Ulcers - Localized infection in any tissue of the body
- Pain, bloating, nausea or vomiting after eating  Causative agent
- Penetration, perforation, obstruction and - Salmonella typhimurium
bleeding of the GIT - Salmonella enteritidis (>2000 serotypes)
 Causative agent  Reservoir
- Helicobacter pylori - Domestic and wild animals
 Mode of transmission  Mode of transmission
- Ingestion: - Fecal-oral
 Oral-oral
 Fecal-oral Typhoid Fever/Enteric Fever
 Clinical manifestation
Campylobacter Enteritis - Systemic disease with fever, severe headache,
 Clinical manifestation malaise, anorexia, a rash on the trunk, non-
- Diarrhea, nausea, vomiting, fever, malaise, productive cough and constipation
abdominal pain  Possible complications:
- Usually self-limiting (lasts 2 to 5 days) - Bacteremia
- Stools may contain: - Pneumonia
 Gross or occult blood - Gallbladder, liver, bone infection
 Mucus - Endocarditis
 WBC’s - Meningitis
 Causative agent  Causative agent
- Campylobacter jejuni - Salmonella typhi
 Reservoir  Mode of transmission
- Animals: poultry, cattle, sheep, swine, rodents, - Fecal-oral
birds, kittens, puppies and other pets - Pathogen may also be shed in urine
Paratyphoid Fever Genital Chlamydial Infections/ Genital Chlamydiasis
 Clinical manifestation  Clinical manifestation
- Less severe than typhoid - Most frequent cause of NGU
 Causative agent - Mucopurulent urethral discharge, urethral
- Salmonella paratyph itching and burning on urination
 Reservoir  Causative agent
- Domestic animals - Chlamydia trachomatis

Shigellosis/Bacillary Dysentery Gonorrhea

 Clinical manifestation  Clinical manifestation
- Diarrhea with blood, mucus and pus - Painful urination in males
- Nausea, vomiting, cramps, fever - Asymptomatic for weeks to months in females
- As many as 20 bowel movements a day  Causative agent
 Possible complications: - Neisseria gonorrhoeae
- Toxemia
- Convulsions (in children) Syphilis
- HUS  Primary
 Causative agent - Chancre
- Shigella dysenteriae  Secondary (4-6 weeks after 1°)
- Shigella flexneri - Skin rash, fever, mucus membrane lesions
- Shigella boydii  Tertiary syphilis (5 to 20 years after 2°)
- Shigella sonnei - Damage to the CNS, CVS, visceral organs, bones,
- (Low infective dose: 10 to 100) sense organs and other sites
 Mode of transmission  Causative agent
- Direct or indirect fecal-oral transmission from - Treponema pallidum
patients or carriers  Other modes of transmission
- Direct contact with lesions and discharges
Enterovirulent Escherichia coli - Blood transfusion
 EHEC Diarrhea - Transplacental
 ETEC Diarrhea/ Traveller’s Diarrhea
VI. Bacterial Diseases of the Cardiovascular System
EHEC Diarrhea Infectious Endocarditis
 Clinical manifestation  Clinical manifestation
- Haemorrhagic, watery diarrhea with abdominal - Presence of vegetations on or within the
cramping endocardium; commonly involves a heart valve
- Slight fever - Blockage of arterial blood flow leading to stroke,
- Children <5 years are at risk of developing HUS heart attack or death
with anemia, low platelet count and kidney  Acute
failure - Staphylococcus aureus
 Causative agent - Streptococcus pneumoniae
- O157:H7, O26:H11, O111:H8 and O104:H21 - Neisseria gonorrhoeae
 Reservoir - Streptococcus pyogenes
- Cattle - Enterococcus faecalis
 Mode of transmission  Subacute
- Fecal-oral - Viridans Streptococci
- Staphylococcus epidermidis
ETEC Diarrhea/ Traveller’s Diarrhea - Enterococcus species
 Clinical manifestation - Haemophilus species
- Profuse watery diarrhea with or without mucus  Mode of transmission
or blood - Unintentional introduction of normal microflora
- Vomiting, abdominal cramping, dehydration and into the bloodstream
low-grade fever
 Causative agent Rickettsial Diseases
- ETEC  Rocky Mountain Spotted Fever/Tickborne Typhus
 Bacterial STDs Fever
 Endemic Typhus Fever/Murine Typhus Fever/
Fleaborne Typhus
 Epidemic Typhus Fever/Louseborne Typhus
  Rocky Mountain Spotted Fever/Tickborne Typhus Plague/Black Death
Fever  Initial S/S
 Clinical manifestation - Fever, chills, malaise, myalgia, nausea,
- Sudden onset of moderate to high fever, prostration, sore throat and headache
prostration, muscle pain, severe headache, chills,  Forms
conjunctival infection - Bubonic Plague
- Maculopapular rash on extremities which - Pneumonic Plague
spreads to much of the body - Septicemic Plague
 Causative agent  Causative agent
- Rickettsia rickettsia - Yersinia pestis
 Reservoir
Endemic Typhus Fever/Murine Typhus Fever/Fleaborne - Wild rodents, rabbits, carnivores and
Typhus domestic cats
 Clinical manifestation  Mode of transmission
- Acute febrile disease with shaking, chills, - Flea bite
headache, fever and a faint pink rash - Handling of infected animals
 Causative agent - Droplet transmission for pneumonic plague
- Rickettsia typhi
Rabbit Fever/Tularemia
Epidemic Typhus Fever/Louseborne Typhus  Cutaneous
 Clinical manifestation - Skin ulcers and regional lymphadenitis
- Sudden onset of headache, chills,  Ingestion
prostration, fever and general pains - Pharyngitis, abdominal pain, diarrhea, vomiting
- Rash on the upper trunk followed by spread  Inhalation
to the entire body, but usually not the face, - Pneumonia and septicemia
palms or soles  Causative agent
 Causative agent - Francisella tularensis
- Rickettsia prowazekii  Reservoir
- Wild animals, rabbits and beavers
Ehrlichiosis  Mode of transmission
 Clinical manifestation - Tick bite
- Similar to “Rocky Mountain Spotted Fever” - Ingestion of contaminated food or water
minus the rash - Entry into wounds while handling infected
 Causative agent animals
- Ehrlichia chaffeensis - Inhalation of dust
- Anaplasma phagocytophilum
 Mode of transmission Leptospirosis
- Tick bite  Clinical manifestation
- Fever, headache, chills, muscle aches, vomiting
Lyme Disease/Borreliosis - Jaundice, anemia and rash
 Clinical manifestation  Causative agent
- Characteristic target-like, red skin lesions - Leptospira interrogans
expanding to a diameter of 6 inches with a  Reservoir
central clearing - Soil
 Causative agent - Mammals
- Borrelia burgdorferi  Mode of transmission
 Early Disseminated - Direct or indirect contact
- Fatigue, chills, fever, headache, stiff neck,
muscle pain, joint aches, w/ or w/out VII. Bacterial Diseases of the Central Nervous
lymphadenopathy System
 Late Systemic Meningitis
- Neurologic and cardiac abnormalities  Clinical manifestation
 Reservoir - Early symptoms: fever, headache, stiff neck, sore
- Rodents and other mammals throat and vomiting
 Mode of transmission - Neurologic symptoms: dizziness, paralysis,
- Tick bite convulsions and death
  Causative agents - Entry through puncture wounds or burns
- Streptococcus pneumoniae - Needlestick injury
- Haemophilus influenzae
- Escherichia coli
- Neisseria meningitidis
- Streptococcus agalactiae
 Mode of transmission
- Respiratory droplets
- Unintentional introduction into the bloodstream,
then to the CNS

Listeriosis
 Clinical manifestation
- Meningoencephalitis or septicemia in
immunocompromised patients
- Fever, intense headache, nausea, vomiting,
delirium, coma, shock and death
 Causative agent
- Listeria monocytogenes
 Reservoir
- Environmental sources: soil, water, mud, cheeses
and milk
- Humans and other mammals
 Mode of transmission
- Ingestion of contaminated food or drink
- Transplacental or passage through birth canal

Tetanus/Lockjaw
 Clinical manifestation
- Acute neuromuscular disease with painful
muscular contractions of the masseter and neck
muscles
 Possible complications
- Spasms, rigid paralysis, respiratory failure and
death
 Opisthotonos
 Causative agent
- Clostridium tetani
 Reservoir
- Soil
 Mode of transmission
- Entry through puncture wounds or burns
- Needlestick injury

Botulism
 Clinical manifestation
- Symmetric, descending flaccid paralysis of motor
and autonomic nerves, beginning with the cranial
nerves
 Possible complications
- Respiratory failure and death
 Causative agent
- Clostridium botulinum
 Reservoir
- Contaminated canned goods
- Contaminated soil
 Mode of transmission
- Ingestion