MOUNTAINS OF THE MOON UNIVERSITY

SCHOOL OF HEALTH SCIENCES

DEPARTMENT OF PUBLIC HEALTH
P.O.BOX, 837 FORTPORTAL, UGANDA
TEL: +256 483 425 766

Distance Education Program

BSC. Public Health

INTRODUCTION TO PUBLI HEALTH

Module — PH 111

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 INTRODUCTION
COURSE DESCRIPTION

This course covers the introduction to public health a subject that deals with the art and
science of preventing diseases, promoting health and prolonging life among groups and
communities. The course covers the dynamics of disease transmission, disease causation
and prevention among human populations.

COURSE OBJECTIVES:
Learning Objectives: At the end of the course students should be able to:
1. Explain the epidemiological triad of diseases (interaction between the host
(person), the agent (disease causative organism) and the environment.
2. Explain the levels of prevention of communicable diseases.
3. Identify the environmental factors affecting health
4. Discuss, giving examples, local environmental health hazards
5. Discuss the impact of global environmental changes on population health
6. Describe, giving examples, the biological factors determining health
7. Discuss at least three major lifestyle factors determining health
8. Explain the inter-relationship between lifestyle factors and other
determinants of health
9. Outline differing views on the contribution of healthcare to population health
10. Give examples of commonly used indicators employed to examine the impact
of healthcare on population health
11. Describe how health services can promote health
12. Classify communicable diseases according to causative organisms.
13. Explain the body’s immune response to disease causing microorganism.

COURSE OUTLINE
 Definition and scope of public health:
Explanation of the concepts of disease causation, transmission, disease prevention
and control:
Disease causation: Students to read about interactions of the host, agent and disease
(epidemiological triad) in causing disease. Determinants of health and introduction to
micro organisms as pathogens.
Disease transmission: Disease transmission will include discussion on the mechanism of
communicable disease transmission (direct and indirect disease transmission) and the role
of vectors in disease transmission.
Disease Prevention: Disease prevention will include discussion on principles of
communicable disease control (primary, secondary, tertiary prevention and
environmental control). Students will widely read about vaccine preventable disease
transmission under primary disease prevention.
 History of public health and the new public health
 Theories of diseases (miasmatic, germ theory, etc)
 Current challenges in public
 Concepts of disease causation, transmission, prevention and control.

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 Health determinants
 Introduction to microorganisms and pathogens,
 Natural history of disease,
Natural history of the disease is the progress of the disease right from the time of
infection to disease without treatment. The direction the disease takes ranges from an
acute to a chronic disease with or without recovery and/ or death.
 Introduction to microbiology
i. Taxonomy and classification of microorganisms: bacteria, viruses, protozoa and
fungi.
ii. Classification of organisms: kingdom, phylum, class, order, general species.
iii. The basic characteristics of bacteria, viruses, protozoa and fungi.
iv. The life cycles of parasites of public health importance.
v. Basic laboratory investigations for disease causing microorganisms.
 Immunology
i. Discuss types of immunity (innate, passive and active immunity).
ii. Explain the bodies immune response to disease causing microorganisms
(pathogens).
iii. To discuss concepts of vaccine trials.

COURSE CONTENT
LECTURE 1: DEFINITION AND SCOPE OF PUBLIC HEALTH

Defining Health

Health is a state of complete physical, mental and social well being, and not merely the
absence of disease or infirmity.
World Health Organisation (WHO) 1948

This definition has been heavily criticised…….

……health is, therefore, seen as a resource for everyday life, not an object of living; it is
a positive concept emphasising social and personal resources, as well as physical
capacities.
WHO 1984

Population health

Population health refers to the health of a population as measured by health status

indicators and as influenced by social, economic and physical environments, personal
health practices, individual capacity and coping skills, human biology, early childhood
development, and health services. (FPTACPH Canada, 1997). A population health
approach addresses the entire range of individual and collective factors that determine
health.

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What is Public Health?

Public health is "the science and art of preventing disease, prolonging life and promoting
health through the organized efforts and informed choices of society, organizations,
public and private, communities and individuals." (1920, C.E.A. Winslow). It is
concerned with threats to the overall health of a community, based on population health
analysis. The population in question can be as small as a handful of people or as large as
all the inhabitants of several continents (for instance, in the case of a pandemic). Public
health is typically divided into epidemiology, biostatistics and health services.
Environmental, social, behavioral, and occupational health are also important subfields.

What is the Difference between Public Health and Clinical Medicine?

There are 2 distinct characteristics of public health:

 It deals with preventive rather than curative aspects of health

 It deals with population-level, rather than individual-level health issues

The focus of public health intervention is to prevent rather than treat a disease through
surveillance of cases and the promotion of healthy behaviors. In addition to these
activities, in many cases treating a disease may be vital to preventing, such as during an
outbreak of an infectious disease or in the case of HIV and AIDS, where clients on ART
are less infectious to their partners.

Examples of Public Health Interventions

 Hand washing
 Vaccination (Immunization) programs
 Distribution of condoms.
 Construction of latrines.
 Building of sewers.
 Regular collection of garbage followed by incineration or
 Disposal in a landfill
 Providing clean water
 Draining standing water to prevent the breeding of mosquitoes.

Goals of Public Health

The goal of public health is to improve lives through the prevention and treatment of
disease.

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How is Pubic Health Knowledge and Skills Used to Improve the Health of A
Community?

Describe the Assess the Establish causes

Step 1 population health needs of disease
affected Assess
effectiveness of
the
health care
system

Step 2 Promoting health by

risk reduction,
treatment etc.

Step 3 Monitor activities implemented

Evaluate the impact of interventions

What is the difference Between Public Health and Community Health?

Community health is a field within public health. It is a discipline that concerns itself
with the study and betterment of the health characteristics of biological communities.
While the term community can be broadly defined, community health tends to focus on
geographic areas rather than people with shared characteristics. Medical interventions
aimed at improving the health of a community range from improving access to medical
care to public health communications campaigns.

Success of community health programmes rely on the transfer of information from health
professionals to the general public using one-to-one or one to many communication
(Mass communication). The latest shift is toward Health marketing.

Health Promotion:

Health Promotion is the process of enabling people to increase control over, and to
improve, their health. (WHO 1984): It comprises three components:

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  Health Education
 Prevention
 Health Protection

Assignment 1(a):

1) Explain the meaning of the term ‘public health’?

2) Explain the difference between the work of a public health practioner
implementing a malaria control programme, and a clinician working in a
hospital in Uganda?
3) List the public health measures which would be used to prevent outbreak
of diarrhoeal diseases in Fort Portal Municipality?
4) Mention 4 ways in which public health knowledge you acquire from this
course can be applied at your workplace to improve health of the people
you serve?

What Does ‘Being Healthy’ Mean to You: For each indicate whether true, false or if
you do not know.

For me, being healthy involves: True False Don’t know

1. Enjoying being with my family and friends   

2. Living to a ripe old age   

3. Feeling happy most of the time   

4. Having a job   

5. Hardly ever taking tablets or medicines   

6. Being the ideal weight for my height   

7. Taking regular exercise   

8. Feeling at peace with myself   

9. Never smoking   

10. Never suffering from anything more serious   

than a mild cold, flu or stomach upset

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 11. Not getting things confused or out of proportion   
– assessing situations realistically

12. Being able to adapt easily to big changes in my life   

such as moving house or a new job

13. Drinking only moderate amounts of alcohol or   

none at all

14. Enjoying my work without too much stress   

15. Having all the parts of my body in good   

working condition

16. Getting on well with other people most of the time   

17. Eating the ‘right’ foods   

18. Enjoying some form of relaxation or recreation   

Adapted from Ewles L & Simnet t I. Promoting Health: a practical guide. Elesevier Science Ltd, 2003. Pg4.

LECTURE 2: HISTORY OF PUBLIC HEALTH AND THE NEW PUBLIC

HEALTH

History Of Public Health

In some ways, public health is a modern concept, although it has roots in antiquity. From
the beginnings of human civilization, it was recognized that polluted water and lack of
proper waste disposal spread communicable diseases (theory of miasma). Early religions
attempted to regulate behavior that specifically related to health, from types of food
eaten, to regulating certain indulgent behaviors, such as drinking alcohol or sexual
relations. The establishment of governments placed responsibility on leaders to develop
public health policies and programs in order to gain some understanding of the causes of
disease and thus ensure social stability prosperity, and maintain order.

Early Public Health Interventions

Human Excreta Disposal: By Roman times, it was well understood that proper
diversion of human waste was a necessary tenet of public health in urban areas.

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Variolation: The Chinese developed the practice of variolation following a smallpox
epidemic around 1000 BC. Variolation involved inhaling the dried crusts that formed
around lesions of infected individuals. An individual without the disease could gain some
measure of immunity against it this practice. Also, children were protected by inoculating
a scratch on their forearms with the pus from a lesion. The practice of vaccination did not
become prevalent until the 1820s, following the work of Edward Jenner to treat smallpox.

Disposal of human dead bodies: During the 14th century Black Death in Europe, it was
believed that removing bodies of the dead would further prevent the spread of the
bacterial infection. This did little to stem the plague, however, which was most likely
spread by rodent-borne fleas.

Burning parties of Cities: Burning parts of cities resulted in much greater benefit, since
it destroyed the rodent infestations

Quarantine: The development of quarantine in the medieval period helped mitigate the
effects of other infectious diseases. However, according to Michel Foucault, the plague
model was later controverted by the cholera model. A Cholera pandemic devastated
Europe between 1829 and 1851, and was first fought by the use of what Foucault called
"social medicine", which focused on flux, circulation of air, location of cemeteries, etc.

The science of epidemiology was founded by John Snow's identification of polluted

public water well as the source of an 1854 cholera outbreak in London. Dr. Snow
believed in the germ theory of disease as opposed to the prevailing miasma theory.

Snow’s work heralded the rise of numerical approaches to the measurement of health,
pursued with vigour and political courage by Edwin Chadwick. Indeed, accounting in
relation to epidemics and other diseases and the process of enumerating deaths attributed
to them became major drivers of civic quantification and census activity more generally,
especially in Britain.

What does the field of Epidemiology involve?

The numerical discipline of epidemiology seeks through quantitative processes to

measure the distribution of illness in society and, by careful analysis, seek associations
and correlations between personal and environmental factors that could account for the
distribution of illness. Often, effective public health action is needed to change the
environment to promote health through policies and laws, and this started with
epidemiology.

LECTURE 3: THEORIES OF DISEASES (MIASMATIC, GERM THEORY, ETC)

Rationalistic Explanations of Disease

In ancient Greece and Rome numerous scholars (from Hippocrates to Galen) developed
rationalistic explanations of how disease developed and, in epidemics, how it spread

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through the population: Below are some of these theories which persisted in medicine
and in the general public's thinking until recent times:

A. Humoral Theory

The humoral theory was the dominant concept among medical scholars and practitioners
of the ancient world and it was still a major explanation of disease in the western world in
the eighteenth century. It was based on the assumption that there were not different
diseases but, rather, diverse imbalances in the sick individual. The primary factors were
considered to be four basic substances or humors: Blood, Phlegm, Yellow Bile, and
Black Bile. In turn, each of these humors was associated with a major organ of the body,
as follows: Blood - from the heart, Phlegm - from the brain (Anatomy was not well
understood!), Yellow Bile - from the liver and Black Bile - from the spleen.

Under the humoral concept, treatment consisted of methods presumed to restore humoral
balance. On the assumption that fever was related to too much blood, the most commonly
used of these "treatments" was phlebotomy or bleeding. On the assumption that humoral
imbalance was often related to too much of a poison or poisons, weird concoctions were
used as purgatives and/or emetics. At times treatment was based on the objective of
neutralizing such poisons by medication with another poison.

B. Miasmatic Theory

Humoral theory was inadequate when it came to explaining epidemics. How do we

account for large numbers of people who are sick or dead from a similar illness in a short
period of time and in a specific geographical area? Theologically, divine wrath for real or
imagined national sins was usually invoked. Rationalistic explanations for such dramatic
involvement of large segments of a population tended to center around two major and
often overlapping ideas of miasms (bad air).

Miasmatic Theory

The miasmatic theory of disease held that diseases such as cholera, the Black Death, were
caused by a miasma (Greek language: "pollution"), a noxious form of "bad air". In
general, this concept has been overtaken by the more scientifically founded germ theory
of disease. "

Miasma is considered to be a poisonous vapor or mist that is filled with particles from
decomposed matter (miasmata) that could cause illnesses and is identifiable by its nasty,
foul smell (which, of course, came from the decomposed material).

The miasmatic theory of disease began in the Middle Ages and continued to the mid
1800s, when it was used to explain the spread of cholera in London and in Paris, partly
explaining Haussmann's latter renovation of the French capital. The disease was said to
be preventable by cleansing of the body and items. Dr. William Farr, the assistant
commissioner for the 1851 London census, was an important supporter of the miasma

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theory. He believed that cholera was transmitted by air, and that there was a deadly
concentration of miasmata near the River Thames' banks.

The wide acceptance of Miasma theory during the cholera outbreaks overshadowed the
theory brought forth by John Snow that cholera was spread through water. This slowed
the response to the major outbreaks in the Soho district of London and other areas.

Another proponent of the miasmatic theory was Crimean War nurse, Florence
Nightingale (1820-1910), who was made famous for her work in making hospitals
sanitary, and fresh-smelling. Other expressions of miasmatic theory focused on
objectionable odors from swamps or rotting garbage or other human wastes. Hence,
during epidemics, such as yellow fever or cholera, there would be measures to clean up
the foul air, water or earth or to neutralize the bad miasms. One way in which the
vocabulary of miasma theory has come down to us today is in the name of two important
diseases influenza (the influence) and malaria (bad air).

C. Contagia Theory

Somewhat intertwined with miasmatic concepts were various hypotheses that postulated
the "bad seeds" as contagia. Such entities could be passed from one person to another
through the air, water, soil, or fomites such as clothing, bedding, utensils, or other
belongings of the sick. Hence the development of such measures as quarantine and the
burning of the possessions of the dead during outbreaks of plague as well as other
epidemics. Even in times when the medical scholars were theorizing and practicing
humoral explanations of disease the general public seemed more inclined toward contagia
principles, whether it is the isolation of lepers or deserting the sick in time of plague.

Contagia could be passed from one person to another through the air, water, soil, or
fomites such as clothing, bedding, utensils, or other belongings
of the sick.

From the time of the great plagues of the fourteenth to seventeenth centuries there were
numerous suggestions of particulate contagia that had some of the characteristics of
living creatures - such as reproduction. Acceptance of this concept by the medical and
scientific world of the time was made difficult by preconceived notions. Before the
advent of the microscope and other technologies, such "living things" could not be
demonstrated. Their possible existence was, therefore, often ridiculed.

Furthermore, even when such creatures could be seen, as in the case of parasitic worm
infections, the general acceptance of the concept of spontaneous generation led many to
the conclusion that these things were the result of the disease and not the cause.

D. Germ Theory

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After numerous tantalizing suggestions that living organisms could be responsible for
disease, the germ theory became firmly established during the last quarter of the
nineteenth century.

“By the middle of the nineteenth century John Snow, in his classic studies on the
epidemiology of cholera, concluded that this disease was caused by a specific poison, that
the poison particles were dispersed in the water with sewage, and caused cholera by
multiplying in the next victim after ingestion in contaminated water.

By these hypotheses and the development of microscopic and cultural techniques by

Louis Pasteur, Robert Koch, and others, the Germ Theory of Disease became the
major thinking in the medical world and in the thinking of the general population.

Hence about a century ago, we arrived to a conclusion about the origin of disease, i.e. that
sickness and disease in plants, animals, and humans could be attributed to various
infectious organisms or "germs": bacteria, viruses, fungi, and parasites, Just as "natural
selection," at this same time, seemed to be answering questions regarding the origin of
species.

The Germ Theory of Disease has provided a rationalistic explanation for many diseases,
both individual and epidemic. Hence In the nineteenth century a search that had been
going on for more than 150 centuries ended. The spirits which primitive man had thought
responsible for pestilential disease were finally seen and identified as bacteria.

 Treatment of individual sickness and even epidemics should be done on a purely

rationalistic, than religious basis. There is hence need to avoid the harsh
condemnation of the sick people such as AIDS patients on religious grounds.

Assignment 2: Case Study

In 1992 Uganda reported in Rakai District the first case of a strange disease
characterized by severe loss of weight, which later came to be known as AIDS. Since
then the disease has spread throughout the country, killing approximately 1 million
Ugandans, leaving over 1 million orphans Currently 6.1 % (About 1.7 million) of
Ugandans are living with the disease.

 List the commonest misconceptions about the cause of AIDS among

communities in Uganda particularly in the early years of the epidemic?
 What effect did these misconceptions have on:

i) Spread of the disease.

ii) Society acceptance and care of people living with the disease

iii) Why did the discovery that AIDS is caused by the HIV virus, contribute
significantly to control of spread of the epidemic?

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 LECTURE 4: THE CONCEPT OF ‘NEW PUBLIC HEALTH’

What is meant by the concept of new public health?

Epidemiology has its own limitations: Not all attributes relevant to health are currently
capable of being quantified by epidemiology techniques. This has given rise to a new
branch of public health labeled known as the new public health. The new public health
deals with the sociological and anthropological determinants of health. It engages with
human behaviour, political activity, ethics and human rights, in pursuit of better health.

Modern Public Health

Recent Public Health Achievements

During the 20th century, the dramatic increase in average life span is widely credited to
public health achievements, such as vaccination programs and control of infectious
diseases, effective safety policies such as motor-vehicle and occupational safety,
improved family planning, fluoridation of drinking water, anti-smoking measures, and
programs designed to decrease chronic disease. As the prevalence of infectious diseases
in the developed world decreased through the 20th century, public health began to put
more focus on chronic diseases such as cancer and heart disease. An emphasis on
physical exercise has also been reintroduced.

Modern Public Health Challenges

Meanwhile, the developing world remained plagued by largely preventable infectious

diseases, exacerbated by malnutrition and poverty. Front-page headlines continue to
present society with public health issues on a daily basis: emerging infectious diseases
such as SARS, Swine Flu (currently at pandemic levels), increase of HIV-AIDS among
young heterosexual women and its spread in Sub saharan Africa; the increase of obesity,
diabetes, the impact of adolescent pregnancy; and the ongoing social, economic and
health disasters related to disasters. These are all ongoing modern public health
challenges.

Modern public health is often concerned with addressing determinants of health across a
population, rather than advocating for individual behaviour change. There is recognition
that our health is affected by many factors including where we live, genetics, our income,
our educational status and our social relationships - these are known as "social
determinants of health."

A social gradient in health runs through society, with those that are poorest generally
suffering the worst health. However even those in the middle classes will generally have
worse health outcomes than those of a higher social stratum. The new public health seeks
to address these health inequalities by advocating for population-based policies that
improve the health of the whole population in an equitable fashion.

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Epidemiologic Transition and Health

Today, it is widely assumed that with increasing economic growth, the developing
countries will follow the same path as Europe and North America and experience what
has become known as the "epidemiologic transition." This term describes the changing
patterns of disease that accompanied overall improvements in health in the late 19th and
early 20th Century. As mortality rates declined and life expectancy rose, these
populations experienced a shift in the pattern of disease, from one dominated by
infectious diseases to one dominated by chronic disorders such as heart disease and
cancer. The shift to chronic diseases can be partly explained by the fact that many more
people were living to the age when chronic diseases strike. Even so, this transition
represented not just a simple substitution of one set of problems for another but an overall
improvement in health. Elements of this epidemiologic transition are in fact occurring
now, to varying degrees, throughout much of the developing world. In some of the
middle-income countries of Latin America and Asia, for instance, chronic diseases now
take as great or an even greater toll than infectious diseases [1]. But this transition is by
no means complete. Many countries, especially the poorest, still have a huge burden of
infectious diseases along with a growing problem of chronic diseases. These populations
have not traded one set of problems for another; instead, they are suffering from both, in
what is known as the "double burden" of disease. Nor is the transition inevitable. As the
history of the Sanitary Revolution illustrates, concerted policies and investments are
necessary to improve both environmental quality and public health.

Future Challenges to Public Health

 Infectious diseases: Public health today and in the future continues to face
serious challenges from continuing infectious diseases. These include HIV,
malaria and tuberculosis, especially in countries where poverty is rife such as sub-
Saharan Africa and parts of Asia (including several hundred million people in
India). Antibiotic resistance is another major concern, leading to the
reemergence of diseases such as Tuberculosis.

 Non Communicable Diseases in Developed Countries: With increasing

urbanization virtually world wide and ageing of all populations such that average
life expectancy worldwide is now 65, diseases that relate to the way in which we
live and the cities we build, especially cardiovascular disease, diabetes, heart
disease and stroke account for a huge amount of misery. The WHO estimates that
heart disease and stroke account for 10% and 5% of the global burden of disease,
with a further 4% attributable to chronic respiratory diseases and 1% to diabetes.
Cancer is close behind. Other chronic diseases make up a further 28% of the
global burden of disease.

 Non communicable diseases in developing countries such as Uganda: such as

cardiovascular disease are also increasingly becoming important in developing
countries. Many of these disorders, such as diabetes and heart disease, occur
because the risk factors that are very strongly associated with them – obesity, lack

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 of exercise, elevated blood pressure, lipids and smoking – derive from the way
people live, eating habits, especially the amount eaten. Diabetes is a major public
health concern: In 2006, according to the World Health Organization, at least 171
million people worldwide suffered from diabetes. Its incidence is increasing
rapidly, and it is estimated that by the year 2030, this number will double. A
controversial aspect of public health is the control of smoking. Many nations
have implemented major initiatives to cut smoking, such as increased taxation and
bans on smoking in some or all public places.

How Can The Future Public Health Challenges Be Addressed?

 Among the many challenges that face us, questions of ecological and resource
Sustainability and the pressures of economic development look set to gain
strength in the next fifty years. To address them there is need for a continued
reduction in poverty and destitution.
 A number of unresolved problems remain: global warming, ocean acidification,
depletion of the oceans, loss of species, and the continuing rise of illnesses that
derive from the animal world as the human population expands and the
temperature rises.
 Although forces that we cannot predict may modulate these challenges, but in
addition to them we face the necessity to act to combat the rising tide of Non
Communicable Diseases including mental illness. Fortunately, the things we need
to do are largely known. They depend upon open access, social action, political
commitment, leadership and patience. The challenge to all with an interest in
public health is to make sure that history records that, having perceived this
problem, our generation moved to deal with it.

Assignment 3:

1) Explain the meaning of the concept ‘new public health’?

2) List 3 infectious diseases and 3 non communicable diseases which present a
future challenge to public health?
3) Which public health measures would you recommend for addressing each of
the above diseases?
4) Explain why the problem of global warming is a major concern to public health
now and in the future?

LECTURE 5: DETERMINANTS OF HEALTH

These are environmental, social and personal characteristics and behaviours which affect
people’s health They are the things that make people healthy or not.

The context of people’s lives determines their health, and so blaming individuals for
having poor health or crediting them for good health is inappropriate. Individuals are
unlikely to be able to directly control many of the determinants of health. Income and

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social status - higher income and social status are linked to better health. The greater the
gap between the richest and poorest people, the greater the differences in health.

Examples of Determinants of Health

 Education: Low education levels are linked with poor health, more stress and
lower self-confidence. Education also has implications on access to health
services.
 Physical environment: Safe water and clean air, healthy workplaces, safe houses,
communities and roads all contribute to good health. Employment and working
conditions – people in employment are healthier, particularly those who have
more control over their working conditions. On the other hand poor sanitation,
pollution, radiation, poor housing and humidity all predispose to ill health e.g.
pneumonia and other airway obstructive diseases, cancer etc. Other determinants
include altitude and temperature e.g. highland areas such as Kigezi highlands, less
prone to malaria
 Social support networks – Greater support from families, friends and
communities is linked to better health. Culture - customs and traditions, and the
beliefs of the family and community all affect health.
 Genetics - Inheritance plays a part in determining lifespan, healthiness and the
likelihood of developing certain illnesses. Personal behaviour and coping skills –
balanced eating, keeping active, smoking, drinking, and how we deal with life’s
stresses and challenges all affect health.
 Health services -Access and use of services that prevent and treat disease
influences health.
 Gender: - Men and women suffer from different types of diseases at different
ages.
 Personal factors: Lifestyle e.g. smoking, drinking, sexual behaviour, occupation

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The figures below summarize the determinants of health:

Dalhgren and Whitehead, 1991

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Public Health asks:

What must we do to keep people healthy?

Health Promotion asks:

How do we improve the health of the population?

Medicine asks:

How do we diagnose and treat people?

Lecture 6: EXAMPLES OF HOW VARIOUS FACTORS IMPACT ON HEALTH:

Determinants of Health 1: Biological & lifestyle factors

1.0 Biological factors determining health

Biological factors determine an individual’s predisposition to ill health:

 Sex (male or female).

For example….the obvious: women can get ovarian cancer, but not prostate cancer!

For example….the less clear cut: men are more likely to suffer from heart attacks…but
women get a lot of them too!

 Age

For example….as we get older we become more susceptible to degenerative conditions

such as cancer and ischaemic heart disease

The biological factors are considered the ‘stable’ factors determining health. Certainly it
is, as yet, difficult to halt the march of time and consequently our age. However,
technological advances are increasingly impacting on other biological factors particularly
the hereditary ones.

2.0 Hereditary factors

Research to identify the individual genes involved in the causation of diseases has
become both popular and contentious in recent times:

• 1950s methods for studying chromosomes developed

• 1970s study of genetic material began

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• 1994 <3000 genes had been mapped

• March 2001 approximately 7000 genes mapped

• Some conditions are directly inherited e.g. haemophillia
• Some conditions result from alterations or mutations e.g. Down’s Syndrome
• Many conditions are multi-factorial in origin, with hereditary and environmental
factors interacting e.g. heart disease

3.0 Lifestyle Factors

“Genes load the gun. Lifestyle pulls the trigger” Dr. Elliot Joslin

In the first half of the last century people were too busy trying to survive to worry
about health as much we do today, much less about how we might practice healthier
habits in order to prevent disease. Progress that did occur was brought about through
the organization of unions in the workplace, legislatures, and public health
ordinances. Toward the end of the century, in 1990, the Healthy People 2000 report
made a call to work toward a culture that actively promotes responsible behavior and
the "adoption of life-styles that are maximally conducive to good health■ (USDHHS,
1990). Since that time, there is more and more concrete evidence indicating that
practicing healthy habits can significantly decrease our chances of developing chronic
disease. Therefore, of all the health determinants that we have discussed, lifestyle
factors are among the most controllable and influential factors influencing our health.

Author: Diane Wilson, USA; From “Lifestyle Factors and the Prevention Movement”
www.pitt.edu/~super1/lecture/lec4231/006.htm

Lifestyles can be thought of as:-

...habits that promote health (for example regular exercise) or compromise health (for
example smoking). {Naidoo & Wills}

• Lifestyles are not simply ‘individual choices’, but are complex interactions
between behaviour and environment.

• Lifestyles are influenced by factors such as: family, culture and income

A) Smoking: Some Impacts on Health & Environment

Smoking was listed as a behavioural risk factor for five out of the ten leading
causes of death in the USA in 1997. {Oxf Txt PH p 115}

• 20 fatal illnesses
• 50 non fatal illnesses
• Widespread addiction
• Deforestation
• Indoor air pollution

19
• Waste and litter

B) Physical Activity

Physical inactivity was listed as a behavioural risk factor for three out of the ten
leading causes of death in the USA in 1997. {Oxf Txt PH p 115}

 Over 65% of the world population is not physically active.

 There are lots of benefits of regular physical activity

 Around the world, physical inactivity is more prevalent in urban areas - mainly in
poorer communities.

Benefits of physical activity include:

• Prevention of ill-health e.g. cardiovascular, osteoporosis, obesity...

• Prevention of disability e.g. arthritis, sleep disturbance…
• Improved well-being, self efficiency and quality of life…
• Reduced health care costs

C) Alcohol Consumption

Alcohol abuse was listed as a behavioural risk factor for four out of the ten leading
causes of death in the USA in 1997. {Oxf Txt PH p 115}.

WHO defines excessive drinking as 6 or more standard drinks on a single

occasion. A standard drink is equal to a half pint of beer or a single measure of spirits
or 1 glass of wine.

Physical effects of excess alcohol consumption

Physical Health

• Liver disease
• Cancers of the Mouth, Liver, Breast, Colon
• High Blood Pressure
• Stroke
• Epilepsy, neuropathies, myopathies
• Delirium tremens

Alcohol Related Psychological & Social Problems

Psychological Health

• Depression

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 • Anxiety, pathological jealousy
• Memory disturbances
• Personality change
• Suicide
• Alcohol psychoses

Social Problems

• Marital difficulties
• Family problems
• Child abuse
• Unemployment
• Financial stress
• Accidents (RTAs)
• Crime
• Homelessness

Determinants of Health 2: Physical environment

What is environment?

Environment: that which environs or surrounds; surrounding conditions, influences, or

forces, by which living forms are influenced or modified in their growth and
development.

Consider the scope of the term ‘environment’….

- Social, physical, cultural…...

- From personal to global…...

21
Environmental factors that may effect health

i) Water

‘Inherent dangers’ in relation to water refer to such factors as risk of accidents or

inclement weather conditions leading to morbidity and mortality from drowning etc.
Water presents a danger to those who work (e.g. merchant sea men) AND play (e.g.
leisure craft, swimmers etc.).

What can be the problem with water?

– Unsafe for drinking

– Unsafe for washing
– Unsafe for recreation

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 Why?

– Bacteria, viruses, amoebae

– Parasites e.g. schistosomiasis, trachoma
– Chemicals e.g. nitrates
– Inherent dangers…….

The results: for example………Diarrhoeal diseases alone made up 4.2% of the global
burden of disease in 2002 (WHO). 88% of that burden was due to unsafe water.

ii) AIR

Air pollution is a risk factor for acute and chronic respiratory disease, as well as other
hazards such as lead exposure.

Outdoor air pollution

Mainly due to burning fossil fuels:

– for transport
– for power
– for industry

• Urban air pollution is a serious problem - particularly in the so called “mega

cities”.

• Worldwide it is estimated that 7 million premature deaths could be avoided by

2020 if the Kyoto Protocol recommendations were implemented…….

23
Pope et al., 1995

INDOOR AIR POLLUTION

.occurs when burning biomass fuels (wood, dung etc) and/or fossil fuels (coal etc) for
cooking, heating or lighting.

• > 2 billion people depend on biomass fuels or coal for energy

• responsible for 2.7% of global disease burden (WHO 2002)
• indoor smoke contains various pollutants e.g. particles, CO, carcinogens etc
• exposure depends on concentration of pollutants and time spent in polluted
environment

24
Broader implications

• Poverty cycle
• Gender issues
• Environmental impact: deforestation, methane….

iii) CHEMICALS

Increased economic prosperity has seen a dramatic rise in the use of chemicals for sectors
such as: industry e.g. benzene derivatives, Agriculture e.g. pesticides and transport e.g.
lead, diesel

Exposure to a number of industrial chemicals listed below is known to cause cancer, lung
and skin diseases.

 Asbestos and man made fibers

 Basic chemicals
 Cement, glass and ceramics
 Electronics
 Iron and steel
 Manufacture of rubber and plastic products
 Metal products
 Mining
 Pesticides, paints and pharmaceuticals
 Petroleum products
 Pulp industries
 Service industries
 Textiles and leather

 Wood and furniture.

People are exposed to both natural and man made chemicals everywhere: at home, at
school, at leisure, at work, traveling. Chemicals can have immediate and/or chronic
effects, with a variety of adverse outcomes:

– nervous +/or immune system

– reproductive system
– cancer

iv) Waste Disposal

• Increasing prosperity and technology has lead to an increase both in quantity

and quality of waste products in everyday life e.g. plastic, chemical effluent etc.

25
Some of the health effects of waste in general are:

• the transmission of agents of infectious disease from human and animal excreta
(sanitation, hygiene and water-related);
• exposure to toxic chemicals in human and animal excreta; and in industrial wastes
discharged into the environment;
• environmental degradation, direct and indirect impacts on health;
• exposure to radioactive wastes;
• exposure to health-care wastes;
• exposure to solid wastes and involvement in informal waste recycling; and
• Breeding of disease vectors.

Landfill Sites

• some evidence of small risk of congenital abnormalities

• little evidence of excess cancer risk
• self-reported symptoms of respiratory illness ?causal

Incineration

• self-reported symptoms of respiratory illness ?causal

• inconclusive evidence on reproductive health effects
• inconclusive evidence on cancer

b) Transport Systems

Health effects

 Accidents between motor vehicles, bicycles and pedestrians (particularly children

and young people).
 Pollution from burning fossil fuels such as particulates and ozone.
 Noise from transportation.
 Psychosocial effects such as severance of communities by large roads and the
restriction of children’s movement.
 Climate change due to CO2 emission
 Loss of land
 Improved physical activity from cycling or walking
 Increased access to employment, shops and support services
 Recreational uses of road spaces
 Contributes to economic development

• Vector borne diseases

• exhaust emissions  local & global impact on respiratory morbidity
• RTAs  global annual total deaths approaching one million. Death rates higher
in middle and low income countries.
• Disruption of neighborhoods  social isolation, reduction in physical activity…...

26
 • Disruption of livelihoods (!)  economic strain, social upheaval…...
• Increase noise level  sleep disturbance, tension….

Can you think of examples for each health effect?

27
28
d) THE GLOBAL ENVIRONMENT

Global Climate Change

• average global temperature has increased by 0.6 +/- 0.2 deg C since the mid 1800s
 extremes of temperature, weather distortions (el Nino) etc

The balance of evidence suggests a discernible human influence on global climate.

(IPCC 2001)

• The impact on health can be due to the:

– direct consequences of flooding, drought, storms etc
– changes in pattern of diseases e.g. malaria
– social displacement
– economic hardship

29
THE GLOBAL ENVIRONMENT

Other global environment changes

• Ozone depletion  increase UV irradiation  skin cancer

• Changes in flora & fauna

as humans demand more space,

raw materials, food……

• Impairment/destruction of food producing ecosystems e.g. agricultural land,

fisheries etc

the erosion of life support systems at a global level has become a serious and pressing
public health issue…..(Gro Harlem Bruntland)

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e) Food and Agriculture

i) Food production

 Tobacco farming and its impact on heart disease, stroke, certain cancers and
chronic respiratory disease. Including passive smoking and impact of foetal
development. Pesticide policies on tobacco crops require consideration.
 Changes in land use, soil quality, choice of crop, use of agricultural labour and
occupational health.
 Mechanization of work previously done by hand, and plantation agriculture.
 Fisheries – biotoxins, pollution, chemical use, wastewater, processing, and
occupational health
 Forestry – vector borne diseases, occupational health, and food security.
 Livestock use – vector borne diseases, drug residues, animal feed, waste, and food
security.
 Sustainable farming including chemical and energy use, biodiversity, organic
production methods, and diversity of foods produced.
 Fertilizer use – nitrate levels in food, pollution of waterways, re-use of
agricultural waste.
 Water – irrigation use and its impact on river/water-table levels and production
outputs.
 Pesticide usage and veterinary drugs– legal requirements, best practice, consumer
issues.

ii) Access to, and distribution of food

 Household food security – appropriate food being available, with adequate access
and being affordable (location of markets, supermarkets and closure of small
suppliers creating food deserts in cities).
 Food supplies, including national and regional food security, and regional
production.
 National food security – able to provide adequate nutrition within a country
without relying heavily on imported products
 Cold-chain reliability – the safety of transporting products that deteriorate
microbiologically in the heat.

iii) Dietary patterns, diversity of food available and home production, particularly:

 Fruit and vegetable consumption on reduced stroke, heart disease and risk of
certain cancers,
 Total, saturated and polyunsaturated fat, carbohydrates and sugars consumption
on obesity, heart disease, stroke and other vascular diseases.
 Alcohol consumption and impact on social effects related to behaviour (traffic
accidents, work/home accidents, violence, social relations, unwanted pregnancy
and STDs), and toxic effects (all-cause mortality, alcoholism, certain cancers,

31
 liver cirrhosis, psychosis, poisoning, gastritis, stroke, foetal alcohol syndrome and
others).
 Micronutrients such as iron, vitamin A, zinc and iodine and their impact on
deficiency syndromes.

iv) Food safety and food borne illness hazards

Food and water are the major sources of exposure to both chemical and biological
hazards. They impose a substantial health risk to consumers and economic burdens on
individuals, communities and nations.

 Microorganisms such as salmonella, campylobacter, E. coli O157, listeria,

cholera.
 Viruses such as hepatitis A, and parasites such as trichomonosis in pigs and cattle.
 Naturally occurring toxins such as mycotoxins, marine biotoxins and glycosides.
 Unconventional agents such as the agent causing bovine spongiform
encephalopathy (BSE, or "mad cow disease"),
 Persistent organic pollutants such as dioxins and PCBs. Metals such as lead and
mercury.
 New foods developed from biotechnology such as crops modified to resist pests,
changes in animal husbandry, antibiotic use and new food additives.
 Food packaging, preservation and safety, and avoidance of long storage

v) Housing:

 Improvements in housing and improved mental health and general health

 The possibility of improved housing leading to rent rises, impacting negatively on
health.
 Movement of original tenants after housing improvement and therefore not
benefiting from the improvements.
 Housing tenure, outdoor temperature, indoor air quality, dampness, housing
design, rent subsidies, relocation, allergens and dust mites, home accident
prevention, and fire prevention.
 Homelessness

vi) Energy: Various energy sources have a number of health effects.

 Fossil fuels: Pollution from vehicle exhaust fumes may result in respiratory
disease.
 Hydropower and their impact on vector borne diseases, and pollution
 Nuclear power
 Other energy sources
 Occupational health effects of energy workers
 Impacts on ecosystems, agriculture, forests, fisheries and building materials
 Noise

32
  Global warming resulting in drought, famine, and spread of malaria to highland
areas.

vii) Urbanization

Urbanization has far reaching health effects:

 Urban housing problems: slum areas resulting in hygiene related diseases e.g.
cholera and diarrhoeal diseases. Overcrowding resulting in TB and other
respiratory diseases.
 City environment and non-communicable diseases e.g. obesity due to lack of
exercise and dietary habits.
 Communicable diseases e.g. cholera, diarrhoeal diseases, respiratory diseases,
STIs including HIV and AIDS.
 Road trauma
 Psychosocial disorders: stress, depression and other forms of mental illness
 Urban wastes
 Health services

Determinants of Health 3: Healthcare – determining health?

33
 • Inadequate healthcare accounts for just 10% of premature deaths
• Healthcare receives the greatest share of resources in the USA, compared to other
determinants. What do you think is the situation in Uganda’s health system?
• Healthcare affects health status through quality & access - the USA is comparable
to other European Union countries in terms of quality, but trails nearly all for
access.
• Inverse law is true in access to health care in developing countries such as
Uganda: i.e the rich who have less burden of ill health, access health care more,
than the poorest who bear the biggest burden of ill health.

The role of healthcare…the early years

• Before the 20th century the notion that health services could contribute to
improved population health would have been untenable! Going to hospital was
often viewed as a route to death rather than recovery!
• By the beginning of the 20th century with a greater understanding of hygiene &
aseptic technique, as well as the advent of safe anesthesia and new drugs, things
had changed.

• During the 20th century scientific knowledge and healthcare advances grew. By
the 1960s there was real optimism that health care would be able to ‘cure’ all
infection and cancer, for example. This enthusiasm was accompanied, in
industrialized nations, by the appearance of new hospitals & health centres to
deliver such care.

Impact of Healthcare Services

It is relatively easy to see how the impact of personal medical services are apparent at an
individual level where modern technology and treatment saves lives and permits patients
to recover from infection, injury, illness which would have been fatal in previous times.

On the other hand, the impact of medical advances on population health is not always
easy to demonstrate.

The role of healthcare…dissenting voices

From the mid 1960s differing opinions on the ‘optimistic’ role of healthcare were voiced:

Thomas McKeown argued that the decline in mortality over the previous 100 years had
largely been because of improvement in living conditions and societal change in general.
His best known example to illustrate his point was in plotting TB mortality against
specific ‘healthcare’ interventions (see the 2 figure below):.

In 1975 Ivan Illich wrote his now famous book

34
Limits to Medicine: Medical Nemesis in which he argued (strongly) that medicine was
not just useless,but harmful. He identified two main ways in which people could be
harmed:

• Clinical iatrogenesis: the use of advanced technologies and treatments, carrying

the conventional ‘risk’ that 1 in 20 patients may in fact be ‘normal’ (Remember
95% confidence intervals!!), would expose patients to unnecessary and
unacceptable harm
• Social iatrogenesis: where a dependency on medicine is created and is essentially
disempowering (this idea empathised with the growing movement which
challenged institutionalisation of patients with mental health problems.)

35
36
Dissenting voices challenged...

Understandably McKeown and Illich’s views have been challenged. For example:

• Johan Mackenbach demonstrated that the introduction of antibiotics and other

healthcare advances in the Netherlands accelerated the rate of declining mortality
and calculated the percentage contribution that could be attributed to healthcare

• Illich’s arguments were challenged on the basis that interventions were much
more likely to have been evaluated and found effective

The role of healthcare…another voice

Archie Cochrane argued in his 1971 publication Effectiveness & efficiency: random
reflections on health services that healthcare was not sufficiently evaluated and that
much more appraisal was required. He promoted the use of the RCT as the means to
measure interventions and their outcomes. The present day Cochrane Collaboration,
which was set up to undertake systematic reviews of the evidence pertaining to all aspects
of healthcare, is named after him.

But how do we know if healthcare is contributing to health?

There are many ‘indicators’ employed to demonstrate the ‘results’ of healthcare.

Somewhat ironically mortality indicators are often used to look at historical trends in
disease and its management - but health is more than “the avoidance of death”.

Furthermore, mortality statistics are not without their problems to interpret:

• Data can be subject to artifact e.g. changes in coding of diseases over time
• The significance of improved living standards can act as a confounder in trying to
establish the reason for a health improvement at population level

37
Health care performance

Mortality indicators provide a broad overview of how things are changing. To examine
why change might be occurring, it is necessary to examine the process in more detail.

There are essentially two types of health performance indicator:

1 Those examining things that should not happen with adequate care e.g. vaccine
preventable deaths; deaths after routine surgery? Can you think of any recent
examples in Uganda?

2 Those including diseases where both incidence and mortality can be measured. ?
Can you think of examples?

These indicators can be used to look at different aspects of the health system e.g. rates of
measles infection reflects the function of the public health & primary care services;
diabetic registers can reveal information about primary & secondary care services

Healthcare can play an important part in improving population health, but it will
have to be relevant to the health needs of the population and founded on evidence of
effectiveness….. before we can truly rely on our healthcare services….

To assist us to come safely into this world and comfortably out of it, and during life to
protect the well and care for the sick and disabled.

(McKeown 1979).

How can health services promote health?

• Designing facilities appropriately - patients care about surroundings!

• Developing health services that meet the needs of marginalized groups -
introducing ‘hand held records’ for the Traveling Community?
• Deliver consistent messages - emphasizing ‘centres of excellence’ for cancer
treatment with still no nationwide screening for breast and cervical cancer
screening?
• Concern for staff as well as patients - within the EU work-related injuries 34%
higher in health care sector

Assignment 4:

1) What do you understand by the term ‘health’?

2) Explain the effect of the following on the health status of communities in
Uganda?

a) Agriculture
b) Water and sanitation

38
 c) Education
d) Gender disparity
e) Health services

3) Uganda has a high infant mortality rate of 76 per 1000 live births In case were
the Assistant District Health Officer in charge of child health, explain the strategy
you would employ to improve the health status of the children.

LECTURE 6: CONCEPTS OF DISEASE CAUSATION, TRANSMISSION,

PREVENTION AND CONTROL.

Dynamics of Disease Transmission

 Human disease does not occur at random. It results from interaction of the host (a
person), the agent (infectious type or other type) and the environment (e.g.
contaminated water supply).
 For such interaction to occur the host must be susceptible
 Human susceptibility to disease is determined by a variety of factors including
genetic background, nutritional and immunological characteristics
 The factors that cause human disease include biologic, physical and chemical
factors.

Triad of disease/Epidemiological triad: The epidemiological triad is the interaction

between agent, environment, and host to produce disease in the latter

Agent

Host Environment

For infection to occur, all the links in the chain must connect:

39
  First, there must be a susceptible host.
 Next, there must be a causative agent. In its natural settings, the agent resides
ands replicates in a reservoir (for example, cattle are the reservoir for E
coli O157:H7—a cause of bloody diarrhea and kidney failure in humans).

The source: is where the agent is prior to infecting the host (for example, beef
contaminated with E coli O157:H7).

Reservoir: Sometimes the source is the reservoir (humans getting E coli O157:H7 by
visiting a cattle ranch).
The portal of exit: When it exists, is how the agent exits the source/reservoir (cattle
fecally excrete E coli O157:H7).

The mode of transmission: is the mechanism by which the agent is transmitted from
the source/reservoir to the host (contact, droplet, airborne, etc.).

The portal of entry: is how the agent enters the host (respiratory, gastrointestinal,
mucous membranes, etc.).

40
LECTURE 7: PREVENTION; DEFINITION AND CONCEPT

Definition of Prevention:

“Actions aimed at eradicating, eliminating, or minimizing the impact of disease and

disability. The concept of prevention is best defined in the context of levels, traditionally
called primary, secondary, and tertiary prevention” A Dictionary of Epidemiology,
Fourth Edition, Edited by John M. Last

Prevention refers to actions aimed at eradicating, eliminating or minimizing the impact of

disease and disability, or if none of these are feasible, retarding the progress of the
disease and disability.

The concept of prevention is best defined in the context of levels, traditionally called
primary, secondary and tertiary prevention. A fourth level, called primordial prevention,
was later added:

 Primary prevention: - Early intervention to avoid initial exposure to agent of

disease preventing the process from starting.
 Secondary prevention:- During the latent stage (when the disease has just
begun), process of screening and instituting treatment may prevent progression to
symptomatic disease.
 Tertiary prevention - During the symptomatic stage (when the patient shows
symptoms), intervention may arrest, slow, or reverse the progression of disease.

Levels of Prevention, Represented Diagrammatically

Stage of disease Level of prevention Type of response

DisesDisediseas
e Pre- Primary Health promotion and
disease Prevention Specific protection

Latent Secondary Pre-symptomatic

Disease prevention Diagnosis and
treatment

Symptomatic Tertiary 1) Disability limitation for

Disease prevention early symptomatic
disease.
2) Rehabilitation for late
symptomatic disease

41
Primordial Prevention

Primordial prevention consists of actions and measures that inhibit the emergence of risk
factors in the form of environmental, economic, social, and behavioral conditions and
cultural patterns of living etc.

It is the prevention of the emergence or development of risk factors in countries or

population groups in which they have not yet appeared

For example, many adult health problems (e.g., obesity, hypertension) have their early
origins in childhood, because this is the time when lifestyles are formed (for example,
smoking, eating patterns, physical exercise).

In primordial prevention, efforts are directed towards discouraging children from

adopting harmful lifestyles

The main intervention in primordial prevention is through individual and mass education

Primary Prevention

 Primary prevention can be defined as the action taken prior to the onset of
disease, which removes the possibility that the disease will ever occur.
 It signifies intervention in the pre-pathogenesis phase of a disease or health
problem.
 Primary prevention may be accomplished by measures of “Health promotion” and
“specific protection”
 It includes the concept of "positive health", a concept that encourages
achievement and maintenance of "an acceptable level of health that will enable
every individual to lead a socially and economically productive life".
 Primary prevention may be accomplished by measures designed to promote
general health and well-being, and quality of life of people or by specific
protective measures.

42
 Primary prevention

Achieved by

Health Specific
promotion protection

Immunization and seroprophylaxis

Health education
chemoprophylaxis
Environmental modifications Use of specific nutrients or supplementations
Protection against occupational hazards
Nutritional interventions Safety of drugs and foods
Life style and behavioral changes Control of environmental hazards,
e.g. air pollution

Health Promotion

Health promotion is “the process of enabling people to increase control over the
determinants of health and thereby improve their health”.

Approaches for Primary Prevention

The WHO has recommended the following approaches for the primary prevention of
chronic diseases where the risk factors are established:

a. Population (mass) strategy

b. High -risk strategy

Population (mass) strategy

 “Population strategy" is directed at the whole population irrespective of

individual risk levels.
 For example, studies have shown that even a small reduction in the average
blood pressure or serum cholesterol of a population would produce a large
reduction in the incidence of cardiovascular disease
 The population approach is directed towards socio-economic, behavioral and
lifestyle changes

High -risk strategy

 The high -risk strategy aims to bring preventive care to individuals at special risk.

43
  This requires detection of individuals at high risk by the optimum use of clinical
methods.

Determinants of Prevention

Successful prevention depends upon:

o A knowledge of causation,
o Dynamics of transmission,
o Identification of risk factors and risk groups,
o Availability of prophylactic or early detection and treatment measures,
o An organization for applying these measures to appropriate persons or
groups, and
o Continuous evaluation of and development of procedures applied

Preventable Causes of Disease

 Biological factors and Behavioral Factors

 Environmental factors
 Immunologic factors
 Nutritional factors
 Genetic factors
 Services, Social factors, and Spiritual factors

Secondary Prevention

 It is defined as “action which halts the progress of a disease at its incipient stage
and prevents complications.”
 The specific interventions are: early diagnosis (e.g. screening tests, and case
finding programs) and adequate treatment.
 Secondary prevention attempts to arrest the disease process, restore health by
seeking out unrecognized disease and treating it before irreversible pathological
changes take place, and reverse communicability of infectious diseases
 It thus protects others from in the community from acquiring the infection and
thus provides at once secondary prevention for the infected ones and primary
prevention for their potential contacts.
 Secondary prevention attempts to arrest the disease process, restore health by
seeking out unrecognized disease and treating it before irreversible pathological
changes take place, and reverse communicability of infectious diseases.
 It thus protects others from in the community from acquiring the infection and
thus provide at once secondary prevention for the infected ones and primary
prevention for their potential contacts.

44
Early diagnosis and treatment

 WHO Expert Committee in 1973 defined early detection of health disorders as

“the detection of disturbances of homoeostatic and compensatory mechanism
while biochemical, morphological and functional changes are still reversible.”
 The earlier the disease is diagnosed and treated the better it is for prognosis of
the case and in the prevention of the occurrence of other secondary cases.

Screening: is the early detection of disease, precursors to disease, or

susceptibility to disease in individuals who do not show any signs of disease.

Screening finds people that are likely to have a disease or it looks for factors that
are precursors to disease. Mammography, a special X-ray of the breasts, can
detect breast cancers early in their development, when they can be easier to treat.
Pap smears detect changes in the cervix that can be precursors to cancer.
Screening tests can also be used to identify people that are at greater risk of
having a disease, for example, cholesterol tests can identify people who are more
likely to develop heart disease. In recent years, advances in molecular genetics
have resulted in the ability to identify people who are susceptible to developing
certain diseases, this will lead to the development of many new kinds of screening
tests.

Tertiary prevention

 It is used when the disease process has advanced beyond its early stages.
 It is defined as “all the measures available to reduce or limit impairments and
disabilities, and to promote the patients’ adjustment to irremediable
conditions.”
 Intervention that should be accomplished in the stage of tertiary prevention
are disability limitation, and rehabilitation.

45
Disability limitation

Disease

Impairment

Disability

Handicap

Impairment

Impairment is “any loss or abnormality of psychological, physiological or anatomical

structure or function.”

Disability

Disability is “any restriction or lack of ability to perform an activity in the manner or

within the range considered normal for the human being.”

Handicap

Handicap is termed as “a disadvantage for a given individual, resulting from an

impairment or disability, which limits or prevents the fulfillment of a role in the
community that is normal (depending on age, sex, and social and cultural factors), for
that individual.”

46
Disease and Disease Transmission

Chain of Infection

The agent leaves reservoir through portal of exit, and is conveyed by some mode of
transmission, and enters the appropriate portal of entry to infect a susceptible host.

Diagram illustrating the chain of infection

 Agent: A microbial organism with the ability to cause disease.

 Reservoir: A place where agents can thrive and reproduce.
 Portal of Exit: A place of exit providing a way for an agent to leave the reservoir.
 Mode of Transmission: Method of transfer by which the organism moves or is
carried from one place to another.
 Portal of Entry: An opening allowing the microorganism to enter the host.
 Susceptible Host: A person who cannot resist a microorganism invading the
body, multiplying, and resulting in infection.

Characteristics of Agents

1. Infectivity - capacity to cause infection in a susceptible host

2. Pathogenicity - capacity to cause disease in a host
3. Virulence - severity of disease that the agent causes to host

Modes of Disease Transmission

 Direct transmission: Immediate transfer of agent from a reservoir to a

susceptible host by direct contact or droplet spread.

47
 o Direct contact: occurs through kissing, skin-to-skin contact, and sexual
activity.
o Droplet spread: - direct transmission by direct spray over a few feet,
before droplets fall to ground.
 Indirect transmission: - agent is carried from reservoir to a susceptible host by
suspended air particles, vectors, or vehicles.
o Vectors – These are animate intermediaries (such as fleas, flies, and
mosquitoes) which carry the agent through mechanical means.
o Vehicles/Fomites –These are inanimate intermediaries (objects) that
carry agent

 Mechanical transmission:–In this mode of transmission there is no

multiplication or change of the agent within the vector
 Biological transmission: In this mode of transmission, the agent undergoes
changes within the vector, and the vector serves as both an intermediate host and
a mode of transmission

Natural history of disease.

The natural history of disease refers to a description of the uninterrupted progression of

the disease in an individual from the moment of exposure to the causal agents until
recovery or death. Bhopal (2002) argues that knowledge of the natural history of disease
ranks alongside causal understanding in importance, for the prevention and control of
disease. Natural history of disease is one of the major elements of descriptive
epidemiology.

For every health problem the number of known cases of a disease is a tip of an iceberg.
That is the number of known cases of disease is outweighed by those that remain
undiscovered. In practice there is usually a ‘clinician’s fallacy’ in which an inaccurate
view of the nature and causes of a disease results from studying the minority of cases of
the disease that are seen in clinical treatment (Morris, 1975; Duncan, 1988). Hence the
need for selection of representative cases for study.

48
The figures below illustrate the natural history of HIV and AIDS:

The Natural History of HIV infection

Stage 1 (asymptomatic) Stage II Stage III Stage IV Death

Up to 15 years or more 2 years 5 years 9 months

Assignment 5:

1) Explain the 3 conditions that must be present for an infection to take place?
2) Explain what is meant by the term ‘disease prevention’? Illustrate the 4 levels
of prevention using HIV and AIDS, and lung cancer, as specific examples.
3) Read about the life cycle of malaria parasites and explain the meaning of the
following terms in the context of malaria transmission: a) agent b) host c)
reservoir d) portal of entry e) portal of exit.
4) Read about the following diseases and briefly describe their natural history:

49
 i. Measles
ii. Malaria
iii. Tuberculosis
iv. Swine influenza

Lecture 8: Immunology

DEFINITIONS:

Antigen (Ag): A molecule which elicits a specific immune response when introduced
into an animal. More specifically, antigenic (immunogenic) substances are:

1. Generally large molecules (>10,000 daltons in molecular weight),

2. Structurally complex (proteins are usually very antigenic),
3. Accessible (the immune system must be able to contact the molecule), and
4. Foreign (not recognizable as "self").

Antibody (Ab): A glycoprotein produced in response to an antigen that is specific for the
antigen and binds to it via non-covalent interactions. The term "immunoglobulin" is often
used interchangeably with "antibody". We will use the term "immunoglobulin" to
describe any antibody, regardless of specificity, and the term "antibody" to describe an
antigen-specific "immunoglobulin". Immunoglobulins (Igs) come in different forms (IgA,
IgD, IgE, IgG, IgM) that reflect their structure.

How antibodies are produced

 Animals contain numerous cells called lymphocytes

 Each lymphocyte is responsive to a particular antigen by virtue of specific surface
receptor molecules,
 Upon contacting its appropriate antigen, the lymphocyte is stimulated to
proliferate (clonal expansion) and differentiate.
 The expanded clone is responsible for the secondary response (more cells to
respond) while the differentiated ("effector") cells secrete antibody,

CELLS OF THE IMMUNE RESPONSE

Immune responsive cells can be divided into five groups based on i) the presence of
specific surface components and ii) function: B-cells (B lymphocytes), T-cells (T
lymphocytes), Accessory cells (Macrophages and other antigen-presenting cells), Killer
cells (NK and K cells), and Mast cells. Some of the properties of each group are listed
below.

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Cell group Surface components Function
 Direct antigen recognition
 Differentiation into antibody-
producing plasma cells
B-lymphocytes  Antibodies recognize specific
antigens and destroy them

 CD3 molecule
 Involved in both humoral and
 T-cell receptor (TCR, Ag
T-lymphocytes cell-mediated responses
recognition)

 Recognizes antigen
 Promotes differentiation of B-
cells and cytotoxic T-cells
Helper T-cells  CD4 molecule
 Activates macrophages
(TH)
 ‘Hence work as ‘Manager of the
Immune System’

 Down regulates the activities of

Suppressor T-cells  CD8 molecule
other cells
(TS)
 Recognizes appropriate antigen
Cytotoxic T-cells  CD8 molecule  Kills cells expressing appropriate
(CTL) antigen

 Variable  Phagocytosis and cell killing

Accessory cells
 Immunoglobulin Fc receptor  Main function is phagocytosis of
 Complement component C3b foreign antigens
Macrophages receptor  Can be "activated" by T-cell
 Class II MHC molecule lymphokines.

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LYMPHOID TISSUES

Primary Secondary
Responsible for maturation
Sites for Antigen contact and response
of Antigen-reactive cells.

Thymus
Bone
(T-cell Lymph nodes Spleen
marrow
maturation)
Expansion of lymphatic system,
separate from blood circulation. Similar to lymph nodes but part
T-cell B-cell
Deep cortex harbors mostly T- of blood circulation. Collects
maturation maturation
cells, superficial cortex harbors blood-borne antigens.
mostly B-cells

TYPES OF IMMUNITY

Innate or Inborn Immunity: The type of immunity inherited by the organism from the
parents and protects it from birth throughout life is known as innate immunity.
Example: Human beings have innate immunity against distemper a fatal disease of dogs.

Acquired or Adaptive Immunity: This is an immunity developed by an animal in

response to a disease caused by infection of pathogens. It is very specific and prevents
further attacks. It lasts for the whole life of the organism in certain cases and for a few
years in others.

Acquired immunity is further of two types - natural or active and artificial or passive
Active Immunity

Active Immunity:
Immunity is said to be active when an organisms’ own cells produce antibodies. It
develops as a result of contact with pathogenic organisms or their products. It may be
acquired naturally or artificially. Active immunity is produced naturally by the attack of
the disease like measles or produced artificially by vaccinations (immunization).

Passive Immunity

Immunity is said to be passive when antibodies produced in another organism are

injected into a person to induce protection against diseases. Passive immunity is
developed for rabies, tetanus toxin, or salmonella infection. It has the advantage of
providing immediate relief

Disadvantages of passive immunity: But it has some problems. It is not long lasting

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and antibodies may cause reactions.

An antibody is a protein produced by the body in response to the presence of an antigen.

Anti bodies belong to a group of proteins called globulins and they are also known as
Immunoglobulin (Ig).

Adaptive (Specific) Immunity and Non Specific Immunity

Adaptive (Specific) Immunity has the following features:

1) Specificity: It is the ability to distinguish differences among various foreign

molecules.
2) Diversity: It can recognize a vast variety of foreign molecules.
3) Discrimination between self and non-self: It can recognize and respond to molecules
that are foreign or 'non-self'. It can also avoid response to molecules that are part of the
body or 'self' of the animal
4) Memory: When the immune system encounters a specific foreign body namely a
microbe, for the first time, it generates immune responses and eliminates the invading
organism. The system retains the memory. When a second encounter with the same group
of microbe occurs, the memory helps in producing greater and quicker immune response.

Adaptive/ Specific immunity uses 2 groups of cells (1) Lymphocytes (2) Antigen
presenting cells.

A healthy man has about one trillion lymphocytes. Lymphocytes may be distinguished
into 2 kinds, namely T-cells or T-lymphocytes and B-cells or B lymphocytes. T cells are
responsible for cellular immunity. B cells provide humoral immunity. Both the types are
produced in bone marrow. The process of their production is called Haematopoiesis.
Some immature lymphocytes first migrate to the thymus gland, where they mature to
become T-Cells. As their maturation occurs in Thymus gland, they are called T cells. The
rest of the lymphocytes, which mature in the bone marrow itself are called B cells.

Origin and differentiation of T cells and B cells

Both B-cells and T-cells are responsible for 2 types of specific immunity:

(a) Cell - mediated Immunity and (b) Anti-body mediated Immunity.

The human immune system can recognize a large variety of antigens. The sites on
antigens that are recognized by the antibodies are called Antigenic determinants. The
receptors of T and B-cells also recognize these sites.

Specific immunity involves the production of a specific type of cell or specific molecule
(antibody) to destroy a particular antigen. It is capable of recognizing and selectively
eliminating specific micro organisms. If antigen 1 invades the body, antibody 1 is
produced against it. If antigen 2 invades the body, antibody 2 is produced against it and

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so on. Acquired immunity is found only in vertebrates. Whenever the non-specific
defense mechanisms fail, specific defense mechanisms get activated. It requires several
days to be activated. Thus acquired immunity supplements the protection provided by
innate immunity. It gets activated in response to the presence of microbes in the system.

Non Specific Immunity

Non-specific immunity is not specifically directed against a particular microbe e.g.

protection offered by the skin, mucous membranes, saliva (lysozyme), gastric juice
(hydrochloric acid) and the inflammatory response produced by macrophages and
leucocytes.

Clonal Selection

B and T lymphocytes have specific receptors on their surface. When this receptor
interacts with the antigenic determinant specific to it, the B lymphocyte becomes
activated and divides to form a clone of cells. These cells also get transformed into
antigen producing B-cells and T cytotoxic cells. This phenomenon is called clonal
selection, because all the cells in a given T or B cells clone are derived from a single
parental cell. They exhibit the same specificity for antigenic determinant. But some
activated lymphocytes develop into memory cells instead and do not produce antibodies
immediately. They have a long life.

Principles of Vaccination/Immunization

The principle of vaccination or immunization is based on the property of 'memory' of the

immune system. A vaccine is always given before the occurrence of the disease.

A vaccine is defined as an inoculation containing germs in dead, weakened or virulent

form or modified toxins which when injected inside the body, stimulates the defensive
system of the body to produce antibodies. This creates immunity inside the body of an
organism against that particular disease. The process of inoculation of a vaccine into the
body of an organism is called Vaccination or Immunization

Vaccines are available against the diseases like typhoid, tuberculosis, tetanus, cholera,
small pox, diphtheria, polio, measles, whooping cough etc. However, no vaccines are yet
available for diseases like malaria, trypanosomiasis, AIDs etc.

History of Vaccination

The process of vaccination was first developed by Dr. Edward Jenner in 1796 A.D. The
word 'Vaccine' who derived by him from the Latin word 'Vacca' meaning cow. He found
out that the cow once attacked by a milder disease, namely cow pox, was immune to the
disease small pox. This English physician, in his land mark experiment in 1796, scratched
the skin of a boy to introduce into his body, the fluid from a sore of a milk maid who was
suffering from cow pox. When the boy was later exposed to small pox, he showed

54
resistance to the disease. The concept of vaccination thus evolved.

How vaccines work?

In vaccination, a vaccine, containing an antigen, is inoculated inside the body of an
organism. Antigens, once inside the body, stimulate the body's defensive mechanism to
produce anti bodies. This is primary immune response and the memory B and T cells are
generated. When the vaccinated person is attacked by the same pathogen, the memory
cells recognize the antigen quickly and control the invaders by producing a large number
of lymphocytes and antibodies. These fight against the antigen, thus protecting the
organism against that disease. The body becomes immune to that disease.

Duration of Immunity:

The immunity developed by the body against a disease (after vaccination), may be for a
short period of time, when it is said to be temporary, or may last throughout life, when it
is said to be permanent.

Example:
Temporary immunity e.g. Cholera Vaccine: where immunity lasts for about 6 months.
Permanent immunity e.g. small pox vaccine, where immunity lasts throughout life.

Primary and Secondary Immune Responses

Primary Response

The immune response due to first encounter with an antigen takes a longer time, feeble
and declines rapidly. After the initial contact with an antigen, there is a period of several
days during which no antibody is present, then there is a slow rise in the antibodies,
followed by a gradual decline. Such a response of the body to the first contact with an
antigen is called the Primary response.

Secondary Response

But when the antigen is contacted again, there is an immediate proliferation of

lymphocytes and the antibodies are produced in far greater numbers. This accelerated and
more intense response is called the Secondary response. This is due to the memory cells
that were produced during the primary response, which lasts for a long time, sometimes
even for a life-time. This is the reason why a person who had once suffered from chicken
pox or measles becomes immune to subsequent attacks of the same disease.

Lymphoid organs

These are organs where maturation and proliferation of lymphocytes takes place.

Primary Lymphoid Organs: Lymphoid organs where T and B lymphocytes mature and
acquire their antigen - specific receptors are called Primary Lymphoid organs. These

55
include: bone marrow (site of B cell maturation) and Thymus gland (site of T-cell
maturation)

Secondary Lymphoid Organs: After maturation, B and T cells travel through

circulatory system to organs called secondary lymphoid organs. They are lymph nodes,
spleen and tonsils. These organs are the sites for proliferation and differentiation of
lymphocytes, in response to specific antigens.

Host defense is present in many forms. Overall, the Immune Response (IR) can be
divided into two major classifications; humoral (antibody mediated) and cell-mediated
(mediated by T cells).. While these responses are not mutually exclusive, they provide
distinctly different avenues for dealing with pathogenic organisms or altered host cells.
These different responses will be discussed in more detail later.
Some of these responses are specific, others are non-specific.

Assignment 6:

1) Describe the difference between the following terms

a) Passive and active immunity.
b) Humoral and cell mediated immunity
2) Explain the importance of helper T cells (CD 4 cells) in the human
immune system?
3) Explain why a child, who has suffered from an attack of measles, will
never suffer from the disease again for life, while in the case of malaria
children get repeated episodes throughout life?

Lecture 9: Introduction to Microorganisms and Pathogens

Interventions to control infectious diseases

1. Alter risk factors (e.g., behavior)

2. Post-exposure prophylaxis
3. Diagnosis, treatment
4. Vaccination, immune globulin
5. Infection control practices
6. Case finding and isolation
7. Contact tracing and quarantine
8. Environmental disinfection
9. Identify and control infectious sources

Microorganisms and Pathogens

 The term "microorganism" refers to any of the microscopic forms of life found in
nature.

56
  Microorganisms are bacteria, viruses, yeasts, molds, fungi, protozoa, algae, and
prions.
 Harmful microorganisms are called "germs".
 Microbes are complex, reproducing microorganisms such as viruses, bacteria,
parasites, and fungi.
 Prions are transmissible, self-propagating proteins that can cause disease (usually
neurodegenerative diseases called spongiform encephalopathies).
 Communicable diseases can be caused by transmission of non-microbial agents;
for example, chemical toxicants or prions.
 Pathogenecity describes the probability of clinical disease given infection.
 Virulence describes the probability of severe disease or complication given
disease
 Microbes both cause and prevent disease.
 Microbes produce antibiotics used to treat disease.
 Pathogen
o A microorganism is considered to be a pathogen or pathogenic if it is
capable of producing disease.
o Though only a minority of microorganisms are pathogenic, practical
knowledge of microbes is necessary for their treatment so is highly
relevant to medicine and related health sciences.


Chain model of infectious Diseases: Reservoir

Human
 Symptomatic illness
 Carriers
 Asymptomatic (no illness during infection)
 Incubatory (pre-illness)
 Convalescent (post-illness recovery)
 Chronic (persistent infection)

For controlling the transmission of microbial agents, we must know the primary
reservoir. Reservoirs for microbes are human, animal, or environmental.
Examples of diseases where humans are the reservoir for the microbial agent include:
polio, hepatitis A, B, & C, measles, mumps, rubella, varicella and smallpox (before
eradication), malaria, etc.

Examples of diseases where animals are the reservoir for the microbial agent include:
West Nile virus disease (migratory birds), Lyme disease (rodents), E coli O157:H7
(cattle), cryptosporidiosis (cattle), avian influenza (wild and domestic waterfowl)

Examples of diseases where the environment is the reservoir for the microbial agent
include: legionellosis (water), leptospirosis (water), mycobacterium avium complex (soil,
water), coccidioidomycosis (soil dust).

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Modes of transmission for an exogenous agent

● Contact
–Direct contact (touch, kissing, and sex)
–Indirect contact (intermediate objects, fomites)
–Vertical transmission (before, during, and after birth)
●Respiratory droplets/secretions (cough, sneeze)
●Airborne (droplet nuclei, dust)
●Vehicle-borne (ingestion, instrumentation,
injection, infusion)
● Vector-borne (mechanical, biologic)

Prevention and Control of Infections

To prevent and control infectious disease we must know the mode of transmission. If the
mode of transmission is unknown; it becomes a primary focus of an investigation and
research.
 Direct contact: e.g., sexually transmitted diseases
 Indirect contact: e.g., contaminated surfaces and fomites
(Respiratory viral infections such as influenza)
 Respiratory droplets**: SARS, smallpox, pneumonic plague;
[Droplet precaution emphasizes barrier protection (face mask,
goggles), hand and respiratory hygiene, and cough etiquette.)]
 Airborne**: TB, measles, varicella [Airborne precaution
emphasizes breathing filtered air (respirators; e.g., N-95) and
 dilution (increasing air exchange by ventilation and negative
pressure rooms).]
 Vehicle-borne: Ingested food or water; intravenous infusions, urinary catheters,
injection drug use
 Vector-borne: mosquitos transmitting West Nile virus, malaria

Microbiology

Microbiology is the science that deals with the study of all kinds of microorganisms
including bacteria, viruses, molds, yeast, fungi, protozoa, algae and prions. The term
"microorganism" refers to any of the microscopic forms of life found in nature.

Medical microbiology

Medical microbiology is the study of the physiology of microbes and their role in disease.

Types of Microorganisms Very small organisms:

i. Living things which individually are too small to be seen with the
naked eye.

58
 ii. Something studied using characteristic techniques including:
1. aseptic technique
2. pure culture technique
3. microscopic observation of whole organisms
b. All of the following may be considered microorganisms:
i. bacteria
ii. fungi (yeasts, molds)
iii. protozoa
iv. microscopic algae
v. viruses
vi. various parasitic worms

Classification Types of Microorganisms

Considering the various types of approaches to taxonomy of microorganisms, we would

like to consider the characters that are used by the microbiologists for this purpose. The
following are the types of characters used in classification:

1. Morphological characters - These concern cell shape and size, staining reactions.
presence or absence of spores or reproductive forms, type of motility etc.

2. Cultural Characters - These include the cultural requirements for multiplication (e.g.
nutrients. oxygen, temperature, etc.) and the way growth occurs in liquid media, and
particularly on solid media (e.g. colony form)

3. Biochemical Characters - These include the more specific biochemical characteristics

such as metabolic end-products and the presence or absence of a particular enzyme or
pathway.

4. Serological characters - . These concern the nature of the surface antigens as revealed
by suitable specific antibodies.

5. Molecular Characters. These include the sequences of bases in the DNA.

Characteristics of Disease Causing Microorganisms

2. Bacteria
a. Procaryotes:
i. Bacteria are simple, cellular organisms lacking a nucleus as well
as other characteristics of prokaryotes which distinguish them from
organisms that have nucleated cells.
ii. That is, bacteria are prokaryotes.
3. Fungi [yeast, mold]
a. Fungi are eukaryotic organisms including yeasts (single celled) and molds
(multicelled).
b. Defining characteristics include:

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 i. cell walls, often composed of chitin
ii. obtaining of nourishment by the absorbing of extra cellular
digested solutions of organic material found in their environment
4. Protozoa
a. Unicellular engulfers:
i. Protozoa are unicellular, eukaryotic organisms that derive
nourishment from their liquid environment, often by engulfment.
5. Virus
a. Viruses are infectious agents, so small they pass through filters known to
stop bacteria.
b. Viruses are not cellular and therefore are classified as neither prokaryotes
nor eucaryotes.
c. Viruses are obligate, intracellular parasites of cellular organisms.

organism: types: description: Some diseases:

prokaryotes,
absorbers, wet tetanus, botulism, gonorrhea,
Gram-negative,
Bacteria: conditions, animal chlamydia, tuberculosis, etc.,
Gram-positive
decomposers, cell etc.,
walls, unicellular
eucaryotes,
yeasts
absorbers, dry
(unicellular
conditions, plant mycoses: candida, ringworm,
Fungi: fungi), molds
decomposers, cell athlete's foot, etc.
(multicellular
walls, ~100
fungi)
human pathogens
Flatworms
metazoan
(platyhelminths), tape worm, trichinosis, hook
Helminthes: (multicellular
roundworms worm, etc.
animal) parasites
(nematodes)
eucaryotes,
parasites,
Unicellular and
engulfers and
slime molds, malaria, giardiasis, amoebic
protozoa: absorbers, wet
flagellates, dysentery, etc.
conditions, no cell
ciliates
wall, ~30 human
pathogens
acellular, obligate common cold, flu, HIV,
Enveloped, non-
viruses: intracellular herpes, chicken pox, swine
enveloped
parasites flu etc.

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 6. Binomial nomenclature
a. Each "species" or organism is assigned two names corresponding the
genus and "specific epithet" (i.e., species).
b. When employing binomial nomenclature, the following conventions are
employed:
i. the genus name (e.g., Escherichia) is always capitalized
ii. the species name (e.g., coli) is never capitalized
iii. the species name is never used without the genus name (e.g., coli
standing alone)
iv. the genus name may be used without the species name (e.g.,
Escherichia may stand alone, though no longer actually describes a
species)
v. when both genus and species name are present, the genus name
always comes before the species name (e.g., "coli of Eschichia"
does not work)
vi. when both genus and species name are present, the species name is
always placed directly after the genus name (e.g., Escherichia coli,
not coli Escherichia)
vii. genus and species are always italicized (or underlined) (e.g.,
Escherichia coli is a no-no)
c. Abbreviating:
i. The first time a binomial is used, the genus name is spelled out.
There after it is abbreviated.
ii. It is a good idea to abbreviate non-ambiguously.
iii. For example, the first time you use Escherichia coli, you use both
names spelled out. From then on you use E. coli instead.
iv. The species name is never abbreviated.
v. If you are talking about another microorganism that has a genus
name beginning with, in this case, E (such as Enterococcus
faecalis), it may be a good idea to use a less simple genus
abbreviation (such as Es. for Escherichia and En. for
Enterococcus). In other words, avoid abbreviating ambiguously.
d. Informal use:
i. These rules ought to be followed when employing binomial
nomenclature even in your speech.
ii. It is proper to refer to Escherichia coli (for example) as E. coli or
even Escherichia, but it is not proper to call it coli or "E. C.

Pathogenic bacteria

Although the vast majority of bacteria are harmless or beneficial, a few pathogenic
bacteria can cause infectious diseases. The most common bacterial disease is
tuberculosis, caused by the bacterium Mycobacterium tuberculosis, which effect about 2
million people mostly in sub-Saharan Africa. Pathogenic bacteria contribute to other
globally important diseases, such as pneumonia, which can be caused by bacteria such as
Streptococcus and Pseudomonas, and food borne illnesses, which can be caused by

61
bacteria such as Shigella, Campylobacter and Salmonella. Pathogenic bacteria also cause
infections such as tetanus, typhoid fever, diphtheria, syphilis and leprosy. Bacteria can
often be killed by antibiotics. They typically range between 1-5 micrometers in length.

Fungal

Fungal microbes can cause diseases in humans, animals and crop plants. Fungi most
often infect immuno-compromised patients or vulnerable people with a weakened
immune system. Most antibiotics cannot be used to treat fungal infections due to the fact
that fungi and their hosts both have eukaryotic cells.

Prion

Prion is the only pathogens containing nucleic acids are known to occur in multiple
strains. The collected studies described here argue persuasively that the prion is an
entirely new class of infectious pathogen and that prion diseases result from aberrations
of protein conformation. Whether changes in protein shape are responsible for common
neurodegenerative diseases, such as Alzheimer's and Creutzfeldt–Jakob disease,
remains unknown, but it is a possibility that should not be ignored.

VIRUSES

It has been estimated that 60% of all human infections are caused by viruses. They are
the simplest, yet least understood of all the microbes. However, new and better
techniques to study viruses continue to evolve. Most viral infections are untreatable, and
what "antiviral" drugs or vaccines that are available, are limited. The control of viral
infections is difficult at best and more often than not, requires that prevention techniques
be employed to prevent the transmission and spread of disease.

Pathogenic viruses are mainly those of the families of: Adenoviridae, Picornaviridae,
Herpesviridae, Hepadnaviridae, Flaviviridae, Retroviridae, Orthomyxoviridae,
Paramyxoviridae, Papovaviridae, Rhabdoviridae, Togaviridae. Some notable pathogenic
viruses cause: smallpox, influenza, mumps, measles, chickenpox and rubella. Ebola is
another pathogenic virus.

What are viruses?

Viruses are particles composed of genetic material, (e.g. DNA/RNA), lipids, (fats), and a
protein wall which protects this material. Unlike bacteria, viruses lack the ability to grow
or replicate on their own. They require a living host, (like a person), or a cell to support
their replication. They are able to enter a cell and then take over that cell, directing it to
make more virus particles. Some viral infections result in the eventual death of the host as
in smallpox or rabies, while others allow the host to continue to live even after infection
(as with the common cold).

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Viruses are very, very small

They are about 1/100th the size of a bacteria or fungus. They are not even visible with a
standard microscope. In order to be seen, a powerful electron microscope at
magnifications of 10,000 to 100,000 xs must be used. Some virus particles are so small
they cannot be seen. Their presence can only be detected by inoculating them into a
susceptible host or tissue cell culture, and then looking for a characteristic effect, (e.g.
illness in a person or death of the cell culture).

Transmission of Viruses

Viruses are spread or transmitted 4 ways:

 via the air in the form of very small droplets expelled from a cough or sneeze,
 by direct contact with infectious material such as respiratory or fecal material, or
by person to person contact,
 by vectors, (bugs, mosquitoes, ticks, etc),
 by indirect contact such as touching surfaces that are contaminated.

Strict pathogens

Some (relatively few) microbes can infect essentially all human hosts who are exposed to
the particular microbe AND cause essentially the same sort of infection and disease
symptoms in every infected person. “Strict pathogens”

Examples: Treponema pallidum (syphilis); HIV (AIDS); Plasmodium vivax

Opportunistic pathogens

Most microbes are more efficient at infecting some people than others and many
microbes can cause several different types of disease depending on the type of infection
(for example, depending on the site of infection) and variations in host-microbe
interactions. “Opportunistic pathogens”

 example, Escherichia coli

o Discussion. Escherichia coli is a very common type of bacteria that
normally lives in close contact with humans. Under what special
circumstances can Escherichia coli cause human disease?

Human variability In Responding To Infection With Pathogens]

We often speak of "the human body" and "human-microbe interactions" but it is wrong to
think that all people have similar interactions with micro-organisms. It is important to
keep in mind the full spectrum of human variability.

Sources of variation in host susceptibility to microbes:

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  variation in nutritional status,
 variation in levels of stress and circulating stress hormones,
 variation in genes that confer resistance to microbes,
 variations in somatic cell mutations involved in immune system function,
 physical damage to tissues can open tissue barriers that normally limit microbial
infections.
 Behavioral differences. Some behaviors promote health and avoid pathogens,
other behaviors damage defenses and bring people into contact with pathogenic
microbes.

Example: intravenous drug use allows exposure to disease-causing microbes

Assignment 9:

1. Give examples of disease causing organisms and the diseases these organisms
cause.

2) Explain why old people (60 years and above) tend to be more susceptible to
pneumonia than young adults?

3) Read about the following virus diseases and explain how each is transmitted?

a) Measles

b) Swine influenza

c) Rubella

d) Polio

4) For each of the above diseases describe the preventive measures.

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REFERENCES:

1) Infectious disease epidemiology, theory and practice, Kenrad E Nelson, Carolyn

Masters Williams, Neil M.H Graham.
2) Communicable disease: Jan Eshuis and Peter Manschot.
3) Detels R, McEwan J, Beaglehole R & Tanaka H. Oxford Textbook of Public
Health. Oxford: Oxford University Press, 2002. (Chapters 2.7).
4) World Health Report 2002: www.who.int/whr/2002/en
5) www.pitt.edu/~super1: Epidemiology, the internet and global health. The
Golden Lecture of Prevention.

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