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15/08/24

LECTURE 5
CHAPTER 35: EPIDEMIOLOGY AND PUBLIC HEALTH
MICROBIOLOGY

35.1 Epidemiology Is an Evidence-Based Science


EPIDEMINOLOGY
 By definition, epidemiology, is the science that evaluates
the occurrence, determinants, distribution, and control of
health and disease in a defined human population
 Study of the occurrence, distribution, & control of diseases
(infectious & non infectious)
 Epidemiology: an Evidence-Based Science
 Determines:
o causative agent
o source and/or reservoir of disease agent
o mechanism of transmission
o host and environmental factors that facilitate
development of disease within a defined population
Epidemiology Terminology
 sporadic disease is When a disease occurs occasionally
and/or at irregular intervals in a human population
 Endemic: disease constantly present, usually in low
numbers (common cold)
 Disease: impairment of the normal, healthy state of an
organism/ any of its components as a result of
environmental factors, infective agents, defects of the
body
 Hyperendemic diseases gradually increase in frequency
beyond the endemic level but not to the epidemic level
 Incidence: reflects the no. of new cases of a disease in a
population at risk during a specified time period.
 An outbreak is the sudden, unexpected occurrence of a
disease, usually in a limited segment of a population
 The attack rate is the proportional number of cases that
develop in a population exposed to an infectious agent.
 Epidemic: occurrence of disease in unusually high
numbers in a localized region (Ebola)
o – Outbreak affecting many people at once.
 Reservoir host—organism remains healthy while virus
thrives.
 Index case—first person identified in an epidemic.
 Pandemic: spread of disease across continents (Covid-19,
H1N1 swine flu, HIV)

35.2 Epidemiology Is Rooted in Well-Tested Methods


Epidemiology methods
Public Health Surveillance
 Public health surveillance involves the proactive
evaluation of genetic background, environmental
conditions, human behaviors and lifestyle choices,
emerging infectious agents, and microbial responses
to chemotherapeutic agents to monitor the health of
a population.
 public health practitioners look for cause-and-effect
relationships to determine risk.

Remote Sensing and Geographic Information Systems: Charting


Infectious Disease Data
 Remote sensing and geographic information systems
are map based tools that can be used to study the
distribution, dynamics, and environmental correlates of
microbial diseases.
 Remote sensing (RS) gathers digital images of the
Earth’s surface from satellites and output from
biological sensors, and transforms the data into maps.
 A geographic information system (GIS) is a data
management system that organizes and displays digital
map data from RS and facilitates the analysis of
relationships between mapped features.
 Examples:
o Location of the habitats of the malaria parasite &
mosquito vectors in Mexico, Asia & South Africa
o If a microbial disease is associated with certain
vegetation types/ physical characteristics
(elevation, precipitation), RS & GIS can identify
regions of high risk
Measuring Infectious Disease Epidemiology
 Statistics: collection, organization & interpretation of
numerical data.
 Morbidity rate: the no. of people that become ill because
of a specific disease within a susceptible population during
a specific period
 Prevalence rate: total no. of individuals infected in a
population at any one-time, dependent incidence &
duration of disease
 The mortality rate is the relationship between the
number of deaths from a given disease and the total
number of cases of the disease

35.3 Infectious Disease Is Revealed Through Patterns Within a


Population
Patterns of infectious disease in a population
 A communicable disease is an infectious disease that
can be transmitted from person to person.
 Not all infectious diseases are communicable; for example,
Lyme disease is acquired through a tick bite but cannot be
transmitted person-to-person
 Two major types of epidemics are recognized: common
source
(noncommunicable) and propagated (communicable)
o Common-source epidemic: rapid increase up to a
peak in the no. of individuals infected & then rapid
but more gradual decline. Cases reported over one
incubation period
o Propagated epidemic: slow & gradual rise & gradual
decline in no. of individuals infected. One infected
individual placed into a susceptible population.
 Cases reported over several incubation periods of the
disease. (Strep throat
 epidemiologists recognize an infectious disease in a
population by using various surveillance methods.
 Surveillance is a dynamic activity that includes gathering
information on the development and occurrence of a
disease, collating and analyzing the
data, summarizing the findings, and using the information
to select control methods
Herd immunity
 herd immunity: a threshold percentage of the population
having immunity so that even when isolated cases of a
disease reemerge, there is no escalation of the disease
throughout the population.
 Group resistance
 Immunization: high level of herd immunity.
 New susceptible individuals enter the population by
migration & birth
 Level can be altered by changes in the pathogen
 • Antigenic drift: small antigenic changes by a
mutation, ability to evade host immune system
 Antigenic shift: a major change in the antigenic
character of an organism that alters it to an antigenic
strain unrecognized by host immune mechanisms eg.
influenza virus, hybridization between animal & human
strain of virus

35.4 Infectious Diseases and Pathogens Are Emerging and


Reemerging
GLOBAL PANDEMICS
 New, reemerging, or drug resistant infections that have
increased within the past three decades.
 COVID-19, HIV/AIDS, tuberculosis, H1N1 influenza virus,
Zika virus, hepatitis C and E viruses and Ebola virus.
 Category A pathogen—highest threat to public health.
 High mortality rate.
 Category B pathogen—second-highest priority.
 Moderate morbidity and low mortality rates.
 Category C pathogen—third-highest priority.
 Emerging pathogens with potential for high morbidity.

EMERGING AND REEMERGING INFECTIOUS DISEASE


 Hanta virus pulmonary syndrome
 Ebola virus (West Africa, 2014, 2017)
 Lyme disease (England)
 SARS
 SARS-CoV-2
 H1N1 swine flu pandemic Klebsiella pneumoniae (KZN,
2005, 2007, 2016, PE Neonatal ICU)
 Cryptosporidiosis
 Creutzfeldt-Jakob disease
 Vancomycin/ methicillin resistant Staphylococcus
aureus
 Vancomycin resistant Enterococci (current)
 Carbapenem resistant Enterobacteriaceae (current)
 Foodborne outbreaks: Listeria •
 MDR/ X-DR tuberculosis (current)
 • Marburg virus – Angola
 Measles
 Zika virus
 M-pox

Systematic Epidemiology
 Continued surveillance of emerging and reemerging
infectious diseases has stimulated the establishment of
a field called systematic epidemiology, which
focuses on the ecological and social factors that
influence the development of these diseases.
 Numerous factors have been identified

Reasons for Increases in Emerging and Reemerging


Infectious Diseases Include
 World population growth and urbanization.
 Increases exposure to microbes.
 Crowded workplaces and public transportation.
 Increased international travel.
 Mass migrations of people.
 Climate change

Health care associated (nosocomial infections)


 Pathogens acquired while in a hospital/ clinical care
facility
 Why are patients in hospital more susceptible to
infection?
o Compromised hosts
o Breaks in skin: lesions, wounds/ surgery, bed sores
o Breaks in mucous membranes (digestive,
respiratory, urinary systems)
 Healthcare-acquired infections (HAI)
o Infections acquired by patients while in a hospital
or other clinical care facility.
o 5 to 10% of all hospital patients acquire a HAI.
 Often caused by non-invasive bacteria from normal
microbiota.
 Many hospital strains are antibiotic-resistant.

Sources of Healthcare-Associated Infections


 Endogenous sources & Exogenous sources
o Catheter-associated urinary tract infections
o Surgical site infections
o Central line-associated bloodstream infections
o Ventilator-associated pneumonias
o Animate sources—hospital staff, patients, and
visitors.
o Inanimate sources—flowers, food, and computers.

Control, Prevention, and Surveillance

 Nosocomial infections
o prolong hospital stays by 4–14 days
o result in additional R377 to R445 billion per year
to direct health-care costs – result in approximately
99,000 deaths annually
 Proper training of personnel in basic infection control
measures
o e.g. handling of surgical wounds and hand
washing
 Monitoring of patient for signs and symptoms of
nosocomial infection

Control, Prevention & Surveillance

Hospitals have programs that include:


1. Surveillance of nosocomial infections (patients & staff)
2. Microbiology laboratory
3. Isolation procedures
4. Procedures: use of catheters & other instruments
5. Nosocomial disease education program for staff on
disinfection, sterilization procedures
6. Infection control specialist to manage program
7. Evaluation of disinfectants, rapid test systems & other
products
8. Monitoring trends in the antimicrobial drug resistance of
infectious agents 9. Techniques to prevent spread of
nosocomial infections
Control of epidemics
1. Reduce/ eliminate source/ reservoir of infection
– Quarantine & isolation of cases & carriers
– Destruction of an animal reservoir of infection
– Treatment of sewage to reduce water contamination
– Therapy that reduces/ eliminates infectivity of the
individual
2. Break the connection between source & susceptible host
– Chlorinate water
– Pasteurization of milk/ beverages
– Food handling regulations
– Destruction of vectors
3. Increase herd immunity by immunization
– Passive immunization (temporary immunity)
– Active immunization
– Prophylactic treatment of infection
Vaccines & Immunization
Vaccine
• Killed, live/ weakened microbes (attenuated vaccine)
• Inactivated bacterial toxins (toxoids)
• Purified cellular subunits (eg. Capsule polysaccharides),
• Recombinant vectors/ DNA, mRNA
• Immunization: delivery of vaccines to induce
antibodies & activate T-cells
• Vaccinomics: application of genomics & bioinformatics
to vaccine development
• Adjuvant: enhances immune response, assists antigen
presenting cells (APC). (oil in water emulsions, bees wax,
alum)
Comparison of Different Vaccine Types
COVID-19 vaccines
• COVID-19 vaccines use a harmless version of a spike-
like structure on the surface of the COVID-19 virus - S
protein.
• Messenger RNA (mRNA) vaccine: PfizerBioNTech and the
Moderna COVID-19 vaccines use mRNA.
• Vector vaccine: Janssen/Johnson & Johnson COVID-19
vaccine, AstraZeneca & University of Oxford
• Protein subunit vaccine: Novavax, PfizerBioNTech
(Comirnaty), Moderna vaccine (Spikevax)
Immunized Hosts – Who Needs Vaccines, and When?
• Vaccination of children should begin at birth
• Further vaccination depends on relative risk
– living in close communities
– reduced immunity
– international travelers
– health-care workers
Role Of Public Health System: Epidemiological Guardian
• Immunizations, inspect restaurants, food stores, water
& sewage treatment
• Local organizations: Provincial department of Health
• National organizations: National Health Laboratory
Services (NHLS), Medical Research Council (MRC), National
Institute of Communicable Diseases (NICD)
International organizations:
• Centers for disease control & prevention (CDC)
• World Health Organization (WHO) Bioterrorism
Preparedness •Bioterrorism
– “intentional or threatened use of viruses, bacteria, fungi,
or toxins from living organisms to produce death or
disease in humans, animals, and plants”
Bioterrorism
• Biological weapons: viruses, bacteria, toxins & parasites
• More destructive than chemical weapons
• A small quantity (few kg) can kill millions
• If acquired & properly disseminated, could become a
difficult public health challenge
• High costs of vaccinating large populations
• Biological agents in terrorism results in fear, panic, and
chaos.

Key Indicators of a Bioterrorism Event


• Sudden increased numbers of sick people, especially
with unusual diseases for that place and/or time of year
• Sudden increased numbers of zoonoses, diseased
animals, or vehicle-borne illnesses
ANTIBIOTIC STEWARDSHIP
o Antibiotic stewardship: preventing the indiscriminate
use of antibiotics
o Restrict resistance development & preserve the
antibiotics we currently have
o Reducing adverse effects
o Improving both patient outcomes & the cost
effectiveness of antibiotic treatment
Stewardship programmes
o Improve patient outcomes (minimising the duration of
treatment/ stay in hospital)
o Clinical guidelines/ treatment guidelines
o Reduce risk of adverse effects (dosing accounts for
patient characteristics such as age, weight, renal &
immune function)
o Eliminating prescriptions for antibiotics to which
patients have reported allergies or adverse events.
Stewardship team (multidisciplinary)
o Infectious disease physician
o Clinical pharmacist with infectious disease training
o Medical microbiologist
o Infection controls professional
o Hospital epidemiologist
o Information technology specialist
Design an audit to review antimicrobial prescribing

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