CHAPTER 1: PUBLIC AND

ENVIRONMENTAL HEALTH

FOR ECH4102

BY N. ABDULLAH

LEARNING OBJECTIVE
1. To explain environmental engineering aspect in public health.

2. To identify and describe dissemination of infectious disease

related to water and other route of transmission.

PUBLIC HEALTH CONCEPT

Important major areas of public health:
1.
2.
3.
4.

Health Services
Epidemiology
Social/Behavioral Science
Environmental Health
Deals with all environmental aspects (physical,
chemical & biological) that impact human
health.
Involve assessment & control of these
environmental factors to prevent disease &
improve health
5. Biostatistics

Health Services
Deals with diagnose & treatment of diseases
Epidemiology
Study the causes of illness and distribution of disease in
populations.
The science behind public health study disease control
& prevention.
Social/Behavioral Science
Deals with human psychology, economics, history, and
anthropology. Focus to describe, understand, predict,
and change the public's health
Biostatistics
Application of statistic in area of biology via data
collection, analysis and interpretation.
applied in public health including epidemiology, health
services research, nutrition, and environmental health

PUBLIC HEALTH POLICE

POWERS
1. Inspections & closures
2. Licensing & discipline of health professionals & facilities
3. Quarantine & isolation
4. Vaccination, testing and treatment requirement

5. Seizure, embargo and impounding of unsafe substances

Public Health vs. medical care:
1. Skills are very often different

2. Public Health deals with populations, prevention and policy, and

includes research on all of these.
3. Treatment of individual patients is NOT its focus, but rather
populations at risk

MAJOR TYPES OF PUBLIC

HEALTH ACTIVITIES
1.

Surveillance

2.

Outbreak investigation

3.

Reference diagnosis and consultation

4.

Research (bench-to-field-to-prevention)

5.

Technical assistance & training (lab &

epidemiology)

6.

Initiate & support implementation

projects

7.

Health policy and Health

communication

[Philosophically founded on Epidemiology]

1. SURVEILLANCE
Definition:

Ongoing systematic collection,

analysis, interpretation and
dissemination of health data =
information for action.

Types of Surveillance:
1. Active
2. Passive

3. Enhances passive
4. Sentinel

6 core activities of public health

surveillance:
1. detection,
2. registration,
3. confirmation,
4. reporting,
5. analysis and
6. feedback

1. Active surveillance: health department

visit or call a location to collect data
2. Passive surveillance: report is sent to
health department based on known rules
and regulations
3. Enhanced passive : Health Department
distribute information on a particular
disease and ask for data/report
4. Sentinel surveillance: a pre-selected
sample of potential data sources submit
information.

1. SURVEILLANCE SYSTEM
Hospital syndromic
surveillance
Syndromes
Diagnostic tests
Bed and ventilator
availability
Prescription
pharmaceutical
stocks/usage
School surveillance
Absenteeism
Syndromes
Reportable disease
surveillance

Environmental surveillance
24/7 phone duty
Death surveillance
Pneumonia and influenza
Unusual deaths
Death certificates
OTC pharmaceutical
surveillance
EMS surveillance
ELCIDS food-borne disease
surveillance

EMS = Environmental Management System/

emergency medical service
OTC = over the counter

ELCIDS = epidemiological and Laboratory

Capacity for Infectious Disease Surveillance

GLOBAL PUBLIC SURVEILLANCE:

COMPONENT & PROCESS

Ref: WHO

GLOBAL PUBLIC SURVEILLANCE:

DECISION INSTRUMENT

2. OUTBREAK INVESTIGATION
Definition of Outbreak:

The occurrence of more cases than is expected in a given area

over a period of time.

Types of Outbreak:

1. Common source: everyone is exposed to same thing

2. Propagated: spread gradually from a person to another
3. Mixed: common source+propagation
4. Others: zoonotic or vector-borne

2. OUTBREAK INVESTIGATION
Work flow:
1. Prepare for field work

2. Establish the existence of an outbreak

3. Verify the diagnosis
4. Define and identify cases
1. Establish a case definition

2. Identify and count cases

5. Perform descriptive epidemiology
6. Develop hypotheses
7. Evaluate hypotheses

8. Reconsider/refine hypotheses and

conduct additional studies
9. Implement control and prevention
measures
10. Communicate findings

Objectives:
1. Describe the outbreak: person,
place, & time
2. Determine disease characteristics
Specific agent
Pathogenicity
Incubation period
Communicability
3. Identify modes of transmission
Person-to-person/ Airborne/
Common source (food or
water)/Zoonotic/Vector-borne
4. Identify additional cases and
contacts
5. Identify the source of infection
6. Interrupt disease transmission
present and future.

2. HOW TO CONTROL EPIDEMIC?

1.

Insect or animal reservoir- effective control by eliminate

them.

2.

Control transmission of pathogen

3.

Food or water: water purification, pasteurised milk,

food protection law

Air-borne: difficult to control, wear mask

Vaccination-tetanus, small pox, diphtheria, whooping
cough, polio myelitis

1.
2.
4.

MMR vaccine (mump, measles and rubella)

HPV vaccine-given to young girl (prevent cervical
cancer)
Quarantine- limit freedom of movement of infected
individual

6 quarantinable diseases (international agreement)

are: 1) smallpox, 2) cholera, 3) typhoid fever, 4)
plague, 5) yellow fever, 6) relapsing fever.

Signal flag called

YELLOW JACK
or LIMA
show ship is under
Quarantine.

Vaccination-tetanus, small pox, diphtheria, whooping cough,

polio myelitis have been eliminated.
Adult inadequately immunised against childhood disease- low
titre of Antibodies as immunity gradually disappear with age.,
so tetanus vaccine to be given every 10yr
Two vaccines (dead polivirus & oral live-attenuated virus)
have eradicated polio from most countries in the world,[3][4]
and reduced the worldwide incidence from an estimated
350,000 cases in 1988 to just 223 cases in 2012
Quarantine- involve limitation of freedom of movement of
individual with active infection to prevent spread of disease,
yellow

HOW VACCINE WORKS?

WHAT IS DISEASE?
Disease (due to an infectious agent) is what may
happen while your immune response tries to control
an infection;
Disease may be the final outcome if your immune
system either fails, or over reacts.
Infection does not necessarily equal disease
Infectious disease: disease caused by replicating
agent transmissible to human from other person,
animal or environment

STAGES OF DISEASE
In term of clinical symptom, typical course of disease can be divided into 6
stages:
1. Infection organism lodged in host
2. Incubation period- time of infection & appearance of symptoms. Length can
be short/long depends on inoculum size, virulence of pathogen, resistance of
host and distance from entrance site to the focus infection site

3. Prodromal period-a short period where 1st symptoms such as headache and
feeling of illness appear
4. Acute period- disease at its height, with overt (done or shown openly; plainly
apparent) symptoms such as fever and chills
5. Decline period- symptom is subsiding, temperature falls, followed by intense
sweating and feeling of well-being
6. Convalescent period- patient regains strength and return to normal.
During later stage of infection cycle, immune mechanism of the host becomes
increasingly important. Recovery is normally due to these immune mechanism.

TERMINOLOGY
RELATED TO DISEASE
Endemic low incidence of disease constantly present in
population
Outbreak cases number sudden increase in short time
Epidemic larger cases number spread to wider area
Pandemic disease spread cross the globe

Mortality death incidence

Morbidity fatal + nonfatal cases.
Statistically more precise to tell the health of a population
compare to mortality- as major cause of illness is quite
different than a major cause of death.

Endemic

Disease that is constantly present in a population, usually at low

incidence
Pathogen may no be highly virulent
Majority of people is immune

Though, few individual may suffer and remain reservoir for the
infection

CAUSE OF WORLDWIDE DEATH

TOP10 CAUSE OF DEATH WORLDWIDE

Low Income

Middle income

High Income

1.

1.

Heart attack

1.

Heart attack

2.

Stroke

2.

Stroke

3.

Pulmonary disease

3.

Lung Cancer

4.

Lower respiratory
infection

4.

Alzheimer

5.

Lower Respiratory
infection

6.

Pneumonia

Lower respiratory
infections

2.

Diarrhoeal diseases

3.

HIV/AIDS

4.

Heart disease

5.

Malaria

5.

Diarrhoeal diseases

6.

Stroke

6.

HIV/AIDS

7.

TB

7.

Road accidents

8.

Premature birth

8.

TB

7.

Colon cancer

9.

Birth asphyxia

9.

Diabetes

8.

Diabetes

9.

High blood

10. Neonatal infection

10. High blood

10. Breast cancer

TOP10 CAUSE OF DEATH IN

MALAYSIA (2008)-MEDICALLY CERTIFIED
1.

Heart attack

2.

Pneumonia

3.

Cerebrovascular disease

4.

Septicaemia

5.

Road accident

6.

Chronic respiratory disease

7.

Lung cancer

8.

Diabetes

9.

Condition originating in the

perinatal

10. Liver diseases

NATION HEALTH BURDEN-DALY

The WHO global burden of disease (GBD) measures
burden of disease using the disability-adjusted life year
(DALY).
This time-based measure combines years of life lost
due to premature mortality and years of life lost due to
time lived in states of less than full health.
DALY include assessment on the burden of disease
consistently across diseases, risk factors and regions.

EMERGING INFECTIOUS DISEASES

Newly identified & previously unknown infectious agents that cause public health
problems either locally or internationally

Re-emerging infectious disease

Infectious agents that have been known for some time,
had fallen to such low levels that they were no longer
considered public health problems & are now showing
upward trends in incidence or prevalence worldwide

EMERGING INFECTIOUS DISEASE

1.SARS

10. Antibiotic-resistant

2. West Nile disease

5. Ebola and Marburg viruses

Pneumococci
S.aureus (MRSA)
Gonococci
Salmonella
11. Cryptosporidium

6. Dengue

12. Anthrax

7. Influenza H5/N1 (?)

13.Spanish flu

8. Hanta virus

14. Dengue & DHF

3. Variant CJD disease

4. Monkey pox

9. E. Coli O157:H7
Factor contribute the emergence of EID: AGENT
1) Evolution of pathogenic infectious agents (microbial
adaptation & change)
2) Development of resistance to drugs
3) Resistance of vectors to pesticides

EMERGING INFECTIOUS DISEASE

(AIDS-RELATED)
1. Pneumocystis carinii
pneumonia
2. Tuberculosis

3. Mycobacterium-avium
complex
4. Kaposis sarcoma (HHV-8)
5. HSV-2

6. Cryptosporidium
7. Microsporidium

8. Cryptococcus neoformans
9. Penicillium marneffei
10. Disseminated salmonella
11. Bacillary angiomatosis
(Bartonella henselae)
12. HPV

ANIMAL-HUMAN EID
>2/3rd emerging infections originate from animals- wild &
domestic
Emerging Influenza infections in Humans associated with
Geese, Chickens & Pigs
Animal displacement in search of food after deforestation/
climate change (Lassa fever)
Humans themselves penetrate/ modify unpopulated regionscome closer to animal reservoirs/ vectors (Yellow fever,
Malaria)

FACTORS CONTRIBUTING TO
EMERGENCE
AGENT

Evolution of pathogenic infectious agents

(microbial adaptation & change)
Development of resistance to drugs
Resistance of vectors to pesticides
Note : Increasing virulence of microbes like Influenza A virus, which
exhibits frequent changes in its antigenic structure giving rise to new
strains with endemic and pandemic propensities.

FACTORS CONTRIBUTING TO
EMERGENCE
HOST

Human demographic change (inhabiting new areas)

Human behaviour (sexual & drug use)
Human susceptibility to infection (Immunosuppression)
Poverty & social inequality
Aging of population

HOST FACTORS CONTRIBUTING TO EMERGENCE

ARE:
1.Mass migration of people provoked by natural and man made
disaster with concomitant rehabilitation of displaced people in
temporary human settlements under unhygienic conditions.

2.Uninhibited and reckless industrialization leading to

migration of labor population from rural to urban areas in
unhygienic squatter settlements
3.International travel as a result of trade and tourism contributing
to global dispersion of disease agents, disease reservoirs and
vectors
4.Changes in lifestyle that promote unhealthy and risk prone
behavior patterns affecting food habits and sexual practices.
5.Declining immunity of as a result of HIV infection, which make
him vulnerable to a host of infections.

FACTORS CONTRIBUTING TO
EMERGENCE
ENVIRONMENT
Climate & changing ecosystems
Economic development & Land use (urbanization, deforestation)
Technology & industry (food processing & handling)
International travel & commerce
Breakdown of public health measure (war, unrest, overcrowding)
Deterioration in surveillance systems (lack of political will)

Environmental sanitation characterized by unsafe water supply ,

improper disposal of solid and liquid waste, poor hygienic practices
and congested living conditions all contribute to emergence of
infection.
Climatic changes resulting from global warming inducing increased
surface water evaporation , greater rainfall changes in the direction of
bird migration and changes in the habitat of disease vectors are also
contributory factors.

Deforestation forces animals into closer human contact- increased

possibility for agents to breach species barrier between animals &
humans
El Nino- Triggers natural disasters & related outbreaks of infectious
diseases (Malaria, Cholera)
Global warming- spread of Malaria, Dengue, Leishmaniasis, Filariasis

EXAMPLES OF RECENT EMERGING DISEASES

Source: NATURE; Vol 430; July 2004;

www.nature.com/nature

EXAMPLES OF EMERGING
INFECTIOUS DISEASES

Hepatitis C- First identified in 1989

Hepatitis B- Identified several decades earlier

In mid 1990s estimated global prevalence 3%

Upward trend in all countries

Prevalence >90% in high-risk population

Zoonoses- 1,415 microbes are infectious for human

Of these, 868 (61%) considered zoonotic

70% of newly recognized pathogens are zoonoses

Notes : Zoonoses process whereby an infectious disease is transmitted

between different species of animals

Dr. KANUPRIYA CHATURVEDI

EMERGING ZOONOSES: HUMAN-ANIMAL

INTERFACE

Avian influenza virus

Ebola virus

Bats: Nipah virus

Marburg virus

EMERGING ZOONOSES: HUMAN-ANIMAL

INTERFACE

Borrelia burgdorferi: Lyme

Deer tick (Ixodes scapularis)

Mostomys rodent: Lassa fever

Hantavirus Pulmonary Syndrome

DISEASE
CLINICAN VIEW

EPIDEMIOLOGIST VIEW

classified according to signs Mean of spread of

and symptoms
infectious diseases
1. Diarrheal diseases
2. Respiratory diseases
3. Cutaneous/soft tissue
infection
4. CNS diseases
5. Septicemic diseases
6. Fever of undetermined
origin

1. Contact

Direct
Indirect formites, body
secretions

2. Vector
3. Air-borne
4. Food-borne

CAUSATIVE AGENTS OF DISEASE

1. biological- bacteria , virus, protozoa, helminth (virus) and
fungi, prion
2. chemical- pesticide, petroleum product, cleansing agent

3. physical- sun UV, X-ray equipment,

4. too little of something- lack of Vit. D cause rickets, lack of
niacin cause kwashiorkor
5. too much of something- excessive food or water can be fatal,
excess CO2 in respiratory can cause fatal
6. hereditary- haemophilia, baldness, poor eyesight
7. stress-emotional disorder, stroke, heart attack
8. disease of unknown cause- many die due to environmental
pollutant working synergistically with other factors. Eg.
cancer

CAUSATIVE AGENTS OF DISEASE

Biological, Chemical and Physical cause of disease
are spread through air, water, food, insect, fomites
(fork, doorknob etc) and animal.
In Environmental health, many programmes
address the need to control the causative agent
while it is in the environment before it get into the
public and cause disease

SOME IMPORTANT DISEASES

1. Spread by Contact

2. Vector-borne

STD

Malaria, dengue, yellow fever

Staphylococcus infections

Viral encephalitis

Streptococcal infections

Schistosomiasis

Nosocomial

Leishmaniasis

Rhinovirus colds

Trypanosomiasis

Brucellosis (slaughter house

contact)

Tularemia

Hepatitis B

SOME IMPORTANT DISEASES

3. Air-borne

4. Food- & Waterborne

Tuberculosis

Cholera

Influenza

Giardiasis

Childhood infections
(measles, mumps, rubella,
pertussis)

Listeriosis

Legionella

Staphylococcal enterotoxin
food poisoing
Shigellosis
Campylobacter
Salmonellosis
Clostridium perfringens food
poisoning

1. TYPES OF TRANSMISSIONS BY
CONTACT
1)

Direct Host-to-host

2) Indirect host-to-host

infected host transmit

disease to a
susceptible host

occur by living/ inanimate means

living agent transmit disease is called vectorusually anthropods (insect, mites or fleas) or
vertebrates (dog, cats)

Anthropods only carrier of agent from 1 host to

another , not a host for the disease- via biting

Some pathogen replicate inside anthropods (this

consider an alternate host) and build up
inoculum

Inanimate agent (fomites)- bedding, toys, books,

surgical equipment- which come in contact with
people can also transmit disease.

Food and water are referred to as disease

vehicles.

route can be
respiratory (cold, flu),
direct contact
(syphilis, gonorrhea),
skin direct contact
(staphyloccus causes
boil, pimples) or fungi
(ringworm)

ASSESSING INFECTIOUS DISEASE

TRANSMISSION
Epidemiologist follows the incidence of disease by correlate
geographical, seasonal and age-group distribution of a disease with
possible modes of transmission.
If disease is limited to a restricted geographical location- it may
suggest vector, eg. Tropical region, malaria via mosquito vector
If disease is limited by seasonal- often indicate mode of transmission
eg. Measles, chickenpox for school children and close contact
Age distribution- important for statistic to eliminate particular routes of
transmission
Different pathogen, have different mode of transmission- usually
related to the habitat of the organism in the body
Eg. Respiratory pathogen is usually airborne, intestinal pathogen
usually, waterborne/ food borne

PARASITOLOGY VOCABULARY
Host: The animal the parasite lives on/in

There can be more than one host during a life cycle

Often life cycle include larval stages and adult stages in
different hosts
Vector: an animal that carries a parasite to the host
Reservoir: Non-human host where the parasite can live
This term is only applied when the parasite can infect
humans

DISEASE RESERVOIR
1) Human

2) Animal (zoonoses)

AIDS

Anthrax

Syphilis

Listeriosis

Gonorrhea

Viral encephalitis

Shigellosis

Rabies

Typhoid fever

Plaque

Hepatitis B

Brucellosis

Herpes Simplex virus

Non-typhoidal salmonellosis

DISEASE RESERVOIR
3) Soil

4) Water

Botulism

Legionnaires disease

Tetanus

Meliodosis

Blastomycosis

Pseudomonas infectionssepsis, UTI, hot tub folliculitis

Coccidioidomycosis
Histoplasmosis

CARRIERS
infected individual not showing obvious sign of clinical disease.

Potential cause of infection to others

Acute carrier- individual in the incubation period of disease,
then follow by development of the infection
Chronic carrier-individual who had a clinical disease and
recovered, or may have subclinical infection that remained in
apparent throughout.
Identify carrier by X-ray, immune test, cultural
2 diseases with significant carrier- typhoid fever and TB
(usually food handler) eg. Typhoid Mary in early 1990s

EPIDEMIOLOGICAL PROPERTIES
OF INFECTIOUS AGENTS
1. Infectivity

The propensity for transmission

Measured by 2o attack rate in household, school, etc
2. Pathogenicity

The propensity for an agent to cause disease or clinical

symptoms
Measured by the ratio of apparent: inapparent
3. Virulence

The propensity for an agent to cause severe disease

Measured by the case:fatality ratio

EPIDEMIOLOGICAL TERMINOLOGY
OF INFECTIONS
Incubation Period

Secondary attack rate

Persistent infection
Latent infection
Inapparent (subclinical infection)
Immunity
Herd immunity

 Incubation period - The period between exposure to the agent

and onset of infection (with symptoms or signs of infection)
Secondary attack rates - The rates of infection among exposed
susceptibles after exposure to an index case, such as in a
household or school
Persistent infection - A chronic infection with continued low-grade
survival and multiplication of the agent
Latent infection - An infection with no active multiplication of the
agent, as when viral nucleic acid is integrated into the nucleus of a
cell as a provirus. In contrast to a persistent infection, only the
genetic message is present in the host, not viable organisms.

 Inapparent (or subclinical infection) An infection with no

clinical symptoms, usually diagnosed by serological
(antibody) response or culture
Immunity The capacity of a person when exposed to an
infectious agent to remain free of infection or clinical illness
Herd immunity
The immunity of a group or community. The resistance of
a group to invasion and spread of an infectious agent, based
upon the resistance to infection of a high proportion of
individual members of the group.
The resistance is a product of the number of susceptible
and the probability that those who are susceptible will come
into contact with an infected person.

PORTAL OF ENTRY
1. Skin- epidermis provide defence vs. pathogen
entry, if cut occur, pathogen may allow in
2. reproductive organ- penis, uterus and ovaries
require body contact, STD- prevention by
prophylactics or abstention from sex
3. respiratory tract (nose, bronchi, aveoli)- TB,
pneumonia, strep, human nose has hair to
filter pathogen, cilia, mucus to prevent it
4. Digestive tract- mouth, aesophagus,
stomach, small intestine and large intestineHCL secreted in stomach kill some germ, bile
has an antiseptic power because eof its high
pH

HUMAN DEFENCE AGAINST DISEASE

1st line of defence (ENVIRONMENTAL MANAGEMENT)- prevention. Apply
technology and art of science to control causative agent of disease in environment
before it gets to human. This use the environmental health element
2nd line of defence (PUBLIC HEALTH & PREVENTIVE MEDICINE)-based on
human body adaptation to prevent agent of disease. This include skin, mucous
membrane, cilia, tears- so, proper nutrition, good personal health practise, routine
check up
3rd line of defence (PUBLIC HEALTH &PREVENTION MEDICINE)-if the 2nd
defence are not sufficient to prevent the entrance of pathogens, then use immunity
(active and passive) and phagocytosis (natural- leukocytes destroy pathogen in
blood).
4th line of defence (CURATIVE MEDICINE)- when sick, need surgery-medication.

THE 1ST LINE OF DEFENCE VS.

DISEASE

Water quality management

Water pollution control

Human waste disposal

Solid and hazardous waste management

Environment safety & accident

prevention

Rodent control

Noise control

Insect control

Housing hygiene

Milk sanitation

Radiological health control

Food quality management

Recreational sanitation

Occupational health practice assure

healthy and safety of worker

Institutional environmental
management- prevent nosocomial
infection

International travel sanitation

Land use management

Air pollution control

Product safety & consumer protection

Environmental planning

2nd LINE of DEFENCE vs.

DISEASE:
Host defenses: physical, chemical, anatomical barriers:

3rd LINE OF DEFENCE:

Host immunity: the ability of higher organisms to resist infection
nonspecific defenses (passive defenses; innate immunity) respond to any invader
natural barriers, antimicrobial compounds
phagocytes (neutrophils or polymorphonuclear leukocytes, PMNs)
complement
natural killer cells (NK cells)

cytokines, chemokines small proteins; coordinate, modulate

specific defenses (adaptive immunity) respond to a specific invader

cell-mediated cytotoxic T cells, activated macrophages
humoral - antibodies

blood and lymph systems

extravascation:

extravascation:

phagocytosis:
phagosome
nucleus

bacteria

fusion of
phagosome
and lysosome

lysosome

PMN

bacteria are engulfed

in phagosome of PMN

several pattern recognition molecules (PRMs) on PMN

membrane (aka Toll-like receptors (TLRs))
recognize a pathogen-associated molecular pattern
(PAMP)
e.g., TLR-4 recognizes bacterial LPS

release of bacterial
fragments to external
environment

degradation of
bacteria within
phagolysosome

3rd LINE OF DEFENCE (continue)

Innate host defenses:
natural host resistance some organisms more sensitive to infection by given
pathogen than others
age very young, very old individuals are most susceptible

stress fatigue, exercise, dehydration, large climate changes, stress-related hormone

release, suppression of inflammation; predispose to infection
diet alteration may influence normal microbiota, decrease resistance, alter
susceptibility
physical, chemical, anatomical barriers may prevent successful infection when
integrity is intact
tissue specificity pathogen must contact environment suited to its needs, for
successful infection

compromised host: one or more resistance mechanisms inactive;

susceptibility increased
suppressed e.g., drug therapy-induced versus compromised e.g., AIDS

ZOONOSES
disease that occur primarily in animal, but occasionally transmitted to
human.
Since public health for animal is less, infection rate for these disease in
animal is very high.
to control zoonosis in human is not good approach to eradicate it from
animal reservoir.
Success case for zoonosis control are bovine TB and brucellosis via
pasteurization of milk.
Some have more complex life cycle. Eg. Protozoa (malaria) and
metazoans(tapeworms). So, control in human or in the alternative
animal host.

NOSOCOMIAL INFECTION

Hospital acquired infections

Cross infection from patient or hospital personnel and vice versa

present a constant hazard

Hospital are hazardous because

1.
2.
3.
4.
5.

6.
7.
8.
9.

many patients are weakened resistance to disease

reservoir for highly virulent pathogen
Crowding of wards
much movement of hospital personnel from patient to patient
hospital procedure such as catheterisation, hypodermic injection,
spinal puncture, removal of tissue/fluid/biopsy carry risk of
introducing pathogen to patient
In maternity ward, infant immune system usually susceptible to
infection
surgical procedure is major hazard, body exposed to source of
contamination
drug for immunosuppressant (organ transplant patient) increase
susceptibility to infection
use antibiotic to control infection carry risk of resistant strain (MRSA)

HOSPITAL PATHOGEN
E.coli as most causes for Urinary tract infection, others are
yeast Candida albican, Psedomonas aeruginosa,
enterococcus
Staphylococcus aureus - associated with skin, surgical, and
lower respiratory tract- problem for newborn baby
S.aureus habitat is in nasal passage as normal flora. So, in
healthy personnel show no disease, but once infected the
susceptible patients may cause serious infection
Pseudomonas aeruginosa- causing infection of lower
respiratory and urinary tract. Also cause infection in burn
patients (where patient loss barrier to skin infection) It is drug
resistant, so difficult to treat.

WHAT ARE THE

SCARIEST INFECTIOUS THREATS?

Bioterrorism (anthrax; smpox; etc.
Pandemics (influenza; plague;..)

Can you say: BIRD FLU ???

Ebola; SARS;
Lyme; Hanta;
Cryptosp;
Cyclospora;
E. coli 0157/H7

Nosocomial
Infections

Mass Casualty =
Bioterrorism; Pandemics
New Infectious Agents =
Nipah virus; Pulmonary Hantavirus
Syndrome; Cyclospora;
Antimicrobial Resistance =
Bacterial, Fungal, Viral, Parasitic

POSSIBLE AGENTS OF BIOTERRORISM

POSSIBLE AGENTS OF BIOTERRORISM

Category A: (anthrax, botulism, plague, smallpox, tularemia,
VHFs)
can be easily disseminated or transmitted from person to person;
result in high mortality rates and have the potential for major
public health impact;
might cause public panic and social disruption; and
require special action for public health preparedness

POTENTIAL BIOTERRORISM AGENTS

Category B: (ricin, food/water threats, brucellosis, Q fever, etc.)
are moderately easy to disseminate;
result in moderate morbidity rates and low mortality rates; and
require specific enhancements of CDC's diagnostic capacity
and enhanced disease surveillance.

POTENTIAL BIOTERRORISM AGENTS

Category C: (emerging infections like Nipah virus and hantavirus)
availability;
ease of production and dissemination; and
potential for high morbidity and mortality rates and major health
impact.

CHARACTERISTICS OF
BIOTERRORISM
Presentation of a rare and serious disease
Presentation of rare and serious symptoms
Large number of people seeking care for nonspecific
symptoms
Unexpected rapidly increasing disease incidence
Disease clusters w/a common source of infection
Endemic disease rapidly emerging at an uncharacteristic
time or in an unusual pattern
Low attack rates for people who stay indoors
Sudden increase in mortality

BIOLOGICAL AND CHEMICAL

WARFARE
threat to human population,

An emerging challenge for public health

Silent, invisible and deadly
Use to injure, kill and incapicitate
Chemical warfare: gas or liquid form
Biological warfare: living bacteria (B.anthracis-anthrax) or
viruses (variolae- small pox)
Use in terrorism act
Chemical warfare: will be discussed in Chapter 7 (sub-section).

CHALLENGE ON DECISION MAKING

Infectious diseases: Some are global, Some are geographically
focal, Some are economically important & Some are socially
important
Whether to Eradicate or Eliminate or control? Depends on:
Ability of available tools (vaccines, drugs, etc.)

Epidemiologic vulnerability: ability to implement available tools

in a cost-effective manner. Based on the LIFE CYCLE

Availability of sustained funding.

Political will:
Burden of disease
Perception and promotion of outcome
Impact on over all health services sector
Impact on over all development
Luck

CHALLENGES TO UNDERSTAND &

CONTROL PARASITIC DISEASE
BROAD SCIENTIFIC CHALLENGES
Vaccine development
Vector manipulation
Drug development
Drug resistance
Host genetic contribution
Rapid surveillance/diagnostic tools
Few new scientists entering the field
BROADER SOCIETAL CHALLENGES

Universal Sanitation/Public Health

Adequate Housing
Adequate Food - nutrition
Available Health Care
Sustainability (Public/Private/Political Commitment)
Few new public health officials entering the field

SOME OF THE REAL CHALLENGES OF

PARASITIC HELMINTH E/E/C CAMPAIGNS
Implementation i.e, Just Doing It

Donor fatigue it takes a long, sustained effort

Drug resistance the threat of any drug- based anti-infectious
disease program - especially with a single drug
Monitoring ??

Research ??
See example: Dracunculiasis

TASK TO DEAL WITH EMERGING

DISEASES
Surveillance at national, regional, global level
epidemiological,
laboratory
ecological
anthropological
Investigation and early control measures
Implement prevention measures
behavioural, political, environmental
Monitoring, evaluation

CURRENT SCENARIO OF
SURVEILLANCE SYSTEM
Independent vertical control programmes
Surveillance gaps for important diseases
Limited capacity in field epidemiology, laboratory diagnostic
testing, rapid field investigations
Inappropriate case definitions
Delays in reporting, poor analysis of data and information at all
levels
No feedback to periphery
Insufficient preparedness to control epidemics
No evaluation

SOLUTIONS

Public health surveillance & response systems

Rapidly detect unusual, unexpected, unexplained disease patterns

Track & exchange information in real time

Response effort that can quickly become global

Contain transmission swiftly & decisively

Dr. KANUPRIYA CHATURVEDI

SOLUTION: GOARN PROGRAMME

Global Outbreak Alert & Response Network
Coordinated by WHO
Mechanism for combating international disease outbreaks
Ensure rapid deployment of technical assistance, contribute to
long-term epidemic preparedness & capacity building

Dr. KANUPRIYA CHATURVEDI

SOLUTION: GOARN PROGRAMME

The Global Outbreak Alert and Response Network (GOARN) is a
technical collaboration of existing institutions and networks who pool
human and technical resources for the rapid identification,
confirmation and response to outbreaks of international importance.
The Network provides an operational framework to link this expertise
and skill to keep the international community constantly alert to the
threat of outbreaks and ready to respond.
The Global Outbreak Alert and Response Network contributes towards
global health security by:
combating the international spread of outbreaks
ensuring that appropriate technical assistance reaches affected states
rapidly

contributing to long-term epidemic preparedness and capacity

building.

Dr. KANUPRIYA CHATURVEDI

SOLUTIONS

Internet-based information technologies

Improve disease reporting

Facilitate emergency communications &
Dissemination of information
Human Genome Project

Role of human genetics in disease susceptibility, progression &

host response
Microbial genetics

Methods for disease detection, control & prevention

Improved diagnostic techniques & new vaccines
Geographic Imaging Systems
Monitor environmental changes that influence disease emergence
& transmission

KEY TASKS - CARRIED OUT BY WHOM?

Global
Regional

Synergy

National

WHAT SKILLS ARE NEEDED?

Public Health
Infectious
diseases

Epidemiology

Telecom. &
Informatics

International
field experience

Laboratory
Information
management

Multiple expertise needed !

GLOBAL DISEASE INTELLIGENCE:

A WORLD ON THE ALERT

Collection

Verification

Distribution

Response

THE BEST DEFENSE

(MULTI-FACTORIAL)
Coordinated, well-prepared, well-equipped PH systems
Partnerships- clinicians, laboratories & PH agencies
Improved methods for detection & surveillance
Effective preventive & therapeutic technologies
Strengthened response capacity
Political commitment & adequate resources to address
underlying socio-economic factors
International collaboration & communication

END PART 1

PARASITIC DISEASES

PATHOGENS CATEGORY CAUSING

DISEASE
1. Virus

2. Bacteria
3. Fungi
4. Parasites

PATHOGENS CATEGORY CAUSING DISEASE

Dissemination of fungi in the body indicates a breach or deficiency of host
defenses.
Superficial fungal infection: on cutaneous skin, hair, no discomfort to patient,
eg tinea vigra, tinea visicolor

Cutaneous fungal infection: dermatophyte, ringworms-most fungal infection

in human
Subcutaneous mycoses: deeper layer of epidermis
Systemic mycoses: eg in lung, can be life threatening
Biphasic or dimorphic: can exist as mold/hyphal/filamentous form[1] or as
yeast.
Prion: is PrP is an infectious agent composed of protein in a misfolded form
Some fungi, eg yeast Candida spp. can be found on skin rich in subaceous
gland (eg: mouth, vagina). Found in healthy tissue, but sometimes under
certain condition can cause disease

MAJOR GROUPS OF PARASITES

1.

Protozoans

Single-cell eukaryotes
Eg: Malaria, Giardia, Trichomonas vaginalis
Can invade:

2.

Helminths (The Worms)

3.

Tissues- Trypanosomes, Toxoplasma, Plasmodium

Intestinal lumen- Entamoeba histolytica, cryptosporidium

Multicellular animals
Flukes, Tapeworms, Roundworms

Ectoparasites

Multicellular animals
Live outside the host
Ticks, Lice, Flea

PROTOZOA: TRYPANOSOMA CRUZI

Causing Chagas disease

Epidemiology:

Mexico to S. America
16-18 million people infected (45,000 die/yr)

Vector: Reduviid bug (aka. kissing bug)

Reservoir: rodents, dogs, cats, armadillos,

Pathologies:

Inflammation at bite
Swelling of the eyes
Fever, malaise
Enlarged Heart
Heart Failure

PROTOZOA: MALARIA
See example for challenge to control and eradicate section.

PROTOZOA: ENTAMOEBA HISTOLYTICA

Epidemiology:

Worldwide distribution- Mexico, India,

West and South Africa, South America
10% of the worlds population is
infected (50 million)
Most are asymptomatic (carriers)
50-100,000 deaths per year
Vector: Flies carry cysts from human
feces to human food or water or humans
self-infect after touching fecally
contaminated items, can be sexually
transmitted

PROTOZOA: ENTAMOEBA HISTOLYTICA

Reservoir: Humans are the only hosts

Pathologies:

Mild to severe intestinal discomfort

Dysentary (bloody diarrhea)
Can invade and destroy the liver (abscess)
Treated with Metronidazole (flagyl)

HELMINTHS (THE WORMS)

Three main groups:
1. Flukes- Liver flukes, Lung flukes, Intestinal flukes, Schistosoma
species (blood flukes)

2. Roundworms Intestinal (Pinworm, Whipworm, Ascarids, hookworms)

Tissue (Trichinella, Anisakis, Baylisascaris)
3. Tapeworms Intestinal (Teania solium-beef tapeworm)
Tissue (Echinichoccus granulosus)

HELMINTHS : PIN WORM

Enterobius vermicularis (Pin
Worm)
Epidemiology:
Worldwide
Most common helminth in
North America
No vector
No reservoir
Treatment: Mebendazole

HELMINTHS : ASCARIS LUMBRICOIDES

Giant Roundworm of Humans
Epidemiology:
Temperate/tropical regions with poor hygiene
2 billion (~1/3 of world pop.)
Fecal-oral transmission (eggs)
No vector, No reservoir
Night-soil
Pathologies:

Adults (12-20cm) in intestine can cause mechanical obstruction

Abdominal pain
Bowel perforation
Cough & wheezing from juveniles in lungs
Treated with Mebendazole

HELMINTHS : ASCARIS LUMBRICOIDES

HELMINTHS : FASCIOLOPSIS BUSKI

(INTESTINAL FLUKE)
Epidemiology: Southeast Asia

Females (2-7cm) produce

about 25,000 eggs/day.
no vector, but has 3 hosts
Abdominal pain, diarrhea,
malabsorption, toxemia

Attaches to mucosa

Reservoir: Pigs
Treatment: Praziquantel

HELMINTHS : FASCIOLOPSIS BUSKI (INTESTINAL FLUKE)

HELMINTHS: ECHINOCHOCCUS
GRANULOSUS

(Hydatid Cyst Disease)

Epidemiology: S. America, Australia,

Kenya, Europe,

Russia- (where dogs are used for

herding sheep)
Canine tapeworm (dogs, wolves,
coyotes)

No vector

Reservoirs: Sheep, elk, caribou

Pathologies: cysts can infect liver,

lungs or spleen.

Pathologies depend on location of the

cyst Jaundice, coughing etc

If ruptured, the cyst fluid will typically

kill the host

HELMINTHS: ECHINOCHOCCUS GRANULOSUS

3) ECTOPARASITES
Insect, mites (scabies), lice, pubic louse
(crab), head louse.
Epidemiology: Worldwide
Usually no vector
Usually temporary
Reservoirs: variable
Pathologies: Itching, scabs at the site of
the bite, rashes, redness etc.
Often carriers of bacterial infections

PUBLIC HEALTH CONCERN:

EXAMPLES OF PARASITIC CASES
1) Drancunculiasis

2) Malaria

1) Dracunculiasis

Guinea worm being removed in Zabzugu-Tatale, Ghana; 2000

Dracunculus medinensis (Guinea worm)

PROGRESS IN THE ERADICATION OF

DRACUNCULIASIS
1981 -- > 4,000,000 cases
1986 --

3,500,000 cases

1989 --

890,000 cases

1992 --

374,000 cases

1995 --

129,000 cases

1998 --

79,000 cases (61%, Sudan)

1999

80,000 cases (70%, Sudan)

2000 --

70,000 cases (73%, Sudan)

2001 --

60,000 cases (78%, Sudan)

2002 --

50,000 cases (74%, Sudan)

2003 --

31,000 cases (62%, Sudan; 27%, Ghana)

2004 --

16,026 cases (45%, Sudan; 45%, Ghana)

2005 -Ghana)

10,715 cases vs. 14,418 in 2004 (Jan-Oct)(61%, Sudan; 29%,

[Down from 20 to 4 countries; Chad, Ethopia, Mali & South Sudan, 2012 only
542 cases]

DRACUNCULIASIS ERADICATION
Coordinating Programs:
WHO; UNICEF; Peace Corps; World Bank; NGOs;NHDI
Global 2000/Carter Center; B&M Gates Fdn ($28.5M)
WHO Collaborating Center (CDC)
Industrial partners
Critical Elements:
Safe water: Borehole or scoop wells; Rx source water (temephos);
Filter water (nylon nets; PVC pipe filters)
Community-level health education
Case Containment, plus rewards
Regional/Country/Local (village level) commitment
Monthly reporting and feedback
Coordination and financing

WHAT ARE THE MAJOR CHALLENGES

TO GUINEA WORM ERADICATION?
It requires behaviour change !!!
People need to stay out of the water when they have lesions
People need to filter their water through nylon nets
In part this depends on knowledge and alternatives, but not
entirely
Other aspects are organizational, financial, technical and political

CHALLENGE OF ANTIMICROBIAL
RESISTANCE
Example: Malaria

~2.5 Billion (40% Worlds Population) At Risk

400-900 million febrile infections/year

0.7-2.7 million deaths/year, >75% African children

~4 die per minute
~5000 die per day
~35,000 die per week
< 20% come to attention of the health system

Pregnant women at high risk of dying, low birth weight children

Children suffer cognitive damage and anemia

Families spend up to 25% of income on treatment

Major Impediment to Economic Growth and Development, as well as
health

2) MALARIA

Is malaria an emerging disease?

[At least drug-resistant malaria is an emerging disaster]

YES !!!

DEVELOPMENT OF RESISTANCE TO
ANTIMALARIAL DRUGS
Chloroquine
16 years
Fansidar
6 years
Mefloquine
4 years
Atovaquone
6 months

1940

1950

1960

1970

1980

1990

CHALLENGE OF ANTIMICROBIAL
RESISTANCE
SOLUTIONS..

Reduce infections (hand washing, vaccines, etc.)

Judicious (done with good judgement or sense) use
of antibiotics (not every ear ache)
Limit human antibiotic use in animals
Combination therapy
Target virulence factors
Competitive exclusion

Malaria Prevention
Mosquito Avoidance
- Evening and night behaviour
- Mosquito Nets
- Air conditioning
- Screens
- Repellant
- Pyrethrin coils
Mosquito Killing
- Destroy breeding sites
- Fog spraying
- Residual spraying
Plasmodium killing - Chemoprophylaxis

WATER-RELATED INFECTIONS

WATER RELATED
INFECTIONS
Related to water or impurities in water
Transmission by 4 mechanism :
1)
2)
3)
4)

Water- borne
Water-washed
Water-based
Insect vector

1. WATER-BORNED MECHANISM
Pathogen in water taken by human/animal
Disease eg. Cholera, typhoid, diarrhoeas and dysenteries
These disease also can be transmitted by any route which allow faecalmouth contact
Preventive strategy- improve drink water quality, prevent casual used of
unimproved sources

cholera patient showing evidence of extensive fluid loss (hand, cheeks)

(CDC Public Health Image Library)

2.WATER-WASHED
MECHANISM
Infections of intestinal tract and skin

Poor hygiene and limited availability of water

3 types:
Infection of intestinal tract diarrhoeal, cholera,
dysentery
Infection of skin and eyes-skin sepsis, scabies and
fungal infection due to poor hygiene
Infection due to lice and mites
Prevention-increase water quality, improve
accessibility and reliability of domestic water supply,
improve hygiene

3.WATER BASED
MECHANISM
Pathogen spends a part of its life cycle in a water
snail or other aquatic animal
Infection of parasitic worms (helmiths)
Eg: Guinea worm, larvae escape man through
blister and into small aquatic animal, then man drink
water containing these larvae
Acquire by eating insufficiently cooked fish
Prevention: reduce contact with infected water,
control snail population

4. INSECT VECTOR MECHANISM

Spread by insect which either
breed in water or bite near water
Eg. Malaria, yellow fever,
dengue, river blindness and
sleeping sickness

Prevention-improve surface
water management, destroy
breeding sites, decrease visit to
breeding sites, use mosquito
netting

EXCRETA-RELATED
INFECTIONS
All disease in the faecal-oral route, most water-based diseases are
caused by pathogen transmitted in human excreta (normally in
faeces)
This can be controlled by improvement of water supply and hygiene,
excreta disposal, toilet, final disposal or re-use

A). FAECAL-ORAL DISEASE (NONBACTERIAL)

Cause by virus, protozoa and helmiths

Spread easily from person due to bad hygiene

Improve excreta disposal unlikely to reduce their incidence. Health
education

b). Faecal-oral disease (Bacterial)

Person-to-person transmitted,
Also contaminated food crops, water source with faecal material
Eg. Salmonella passed in the faces of bird

C). SOIL-TRANSMITTED
HELMITHS
Parasitic worms whose eggs are
passed in faeces

This route require period of

development in favourable of
their growth- usually moist soil
Reach to human via ingestion
Latrine help to avoid faecal
contamination of the floor hep to
limit transmission
Eggs survive for months
between host

Eliminate eggs by sedimentation

in stabilisation ponds, heat or
prolonged storage

D). BEEF AND PORK TAPEWORMS

(TAENIA)
Require period in body of host
before infecting human
When meat eaten without
sufficient cooking
Prevent untreated excreta
eaten by pig/cattle help
prevent transmission of
parasite

E). WATER-BASED HELMINTHS

Passed in excreta and then to
snail (aquatic host)
Re-infect man through skin or
eating uncooked fish
One egg can multiply in snail
to produce thousand larvae

F). EXCRETA-RELATED
INSECT VECTORS
2 kinds:
1.Culex pipens group of mosquitoes, breed in highly polluted water and
transmits filariasis
2. Flies and cockroaches, breed where faeces exposed, they carry
pathogen on their bodies and intestinal tract.

REFUSE-RELATED
INFECTION
Poor refuse disposal encourage fly breeding
Promote disease associated with rats, such as plague,
salmonellosis, endemic typhus
Uncollected refuse can obstruct streets and drainage channel
Refuse is potential source for composting, food source of animal

HOUSE-RELATED
INFECTION
Interaction between housing and human health are numerous
Location affect the health of inhabitant

In manner promote airborne disease- overcrowding, ventilation, air,

temp, humidity
In manner promote population of rats, fleas, mites, lice- share with
animals, poultry, pets.

WATER RELATED
DISEASES-EXAMPLES

EXAMPLE 1 : CHOLERA
transmitted almost exclusively via contaminated water (fecal-oral route); also raw
shellfish, vegetables (Americas)
7 or 8 world-wide pandemics since 1817
endemic in Africa, parts of Asia, Indian subcontinent, Central & South America
controlled by applying appropriate water treatment, sanitation measures
V. cholerae: gram negative, curved rod; free-living in coastal waters, adhering to
normal microbiota
disease: initiated when ingested bacteria attach to epithelial cells of small
intestine, begin to grow and release enterotoxin (toxin affecting GI tract)
characterized by copious watery diarrhea rice water stools
fluid losses may exceed 20 L per day
untreated, mortality rate can reach 60%
treatment: intravenous or oral liquid and electrolyte replacement therapy
(20 g glucose, 4.2 g NaCl, 4.0 g NaHCO3, 1.8 g KCl in 1 L H2O)

EXAMPLE 2: Typhoid (Salmonella typhi)

most common route of transmission is via water; may also be foodborne, by
direct contact with infected individuals
virtually eliminated in developed countries as a result of water treatment
practices
carrier state can be important (carrier: individual that harbours organism
but shows no disease symptoms)
story of Typhoid Mary see p. 823 (11th ed) or p. 853 (10th ed) of Madigan
S. typhi: gram negative rod, one of the Enterobacteriaceae
disease: systemic infection with sustained bacteremia (bacteria in blood),
characterized by high fever (several weeks)
also initial headache, often constipation, then diarrhea
complications may include perforation of intestinal wall
mortality may approach 15% in untreated typhoid; reduced to less than 1%
with antibiotic therapy (e.g., chloramphenicol, ampicillin, cephalosporins)

Example 3: Legionellosis (Legionella pneumophila)

severity of infection varies:
may be asymptomatic
Pontiac fever: mild cough, mild sore throat, mild headache, self-limiting
Legionellosis: a type of pneumonia, more likely to affect elderly, immuneimpaired, associated with certain L. pneumophila serotypes
intestinal disorder. then high fever, chills, muscle aches, followed by dry
cough, chest and abdominal pain
Legionella: discovered in late 1970s, probably a recent human pathogen
present in small numbers in natural waters and soil, may live inside free-living
protozoa, heat- and chlorine-resistant
lives happily in cooling towers, air conditioning systems, hot water tanks,
whirlpool spas, etc.
bacteria disseminated in humidified aerosols, human infection is via airborne
droplets (showering, water-dependent heating/cooling systems)
no person-person transmission
entirely different than other pathogens involved in respiratory infections
a newly emergent disease resulting from changing human behaviour

Example 4: Cryptosporidiosis and Giardiasis

common waterborne diseases in areas with regulated water supplies
cysts or oocysts of these parasitic protozoa found in most surface waters
chlorine-resistant; dose rates can be low
cryptosporidiosis in Milwaukee, WI affected over 400,000 people (spring 1993)
outbreak attributed to overburdened water supply system + spring rains and runoff
from surrounding farmland into L. Michigan (source for supply system)

Giardia lamblia: flagellate; infects animals (e.g., beaver), humans

environmentally resistant cyst (~10 m dia) is infective agent
ingested cysts germinate in intestine, resultant trophozoites grow on intestinal wall
explosive, foul-smelling, watery diarrhea, cramps, flatulence, nausea, weight loss
Cryptosporidium parvum: infects variety of warm-blooded animals
resistant oocysts transmitted to new host via feces-contaminated water
oocysts (~2-5 m) smaller than Giardia, more chlorine-resistant
ingested oocysts germinate, trophozoites growth within epithelial cells of stomach,
intestine
mild, self-limiting diarrhea in healthy individuals
chronic diarrhea in individuals with impaired immunity (+ possible
complications)

trophozoites

cyst stained
with iodine

Giardia lamblia life cycle (US CDC)

Giardia lamblia life cycle (US CDC)

E.COLI 0157:H7
Illness through food & water, undercooked, contaminated food

Enterohemorraghic, diarrhea, kidney failure

Highly virulence. 10-100 cfu can cause illness
Outbreak: 1982 in USA due to consumption of hamburger

SHIGELLOSIS
infectious disease caused by bacteria Shigella

Symptoms: diarrhea, fever, stomach cramps, bloody stool

after 1-2days expose to bacteria. Last 5-7days.

WATERBORNE VIRAL
DISEASES
Waterborne viral diseases:
many cause gastroenteritis (e.g., rotaviruses, Norwalk-like)
may cause eye throat infections (e.g., adenoviruses)
hepatitis (liver disease): hepatitis A, hepatitis E viruses
polio: wild poliovirus been eliminated from western hemisphere
most are neutralized by chlorination

ENTEROTOXIGENICITY OF E.COLI INFECTION

ROTAVIRUS INFECTION

SHIGELLA INFECTION

PART OF CHAPTER 8 OF THIS COURSE

AIR-BORNE INFECTIOUS
DISEASES

WHATS THE
PROBLEM TO HUMAN?

RESPIRATORY SYSTEM

Respiratory
System

OBJECTIVES
To describe transmission, prevention and control of respiratory
diseases caused by microbial agent (air pollutant) due to poor
environmental health.

Other types of air pollutants (PM, chemicals, Sox, Nox, Pb, VOC,
O3, DPM, smog, etc will discuss in separate chapter; Air
pollution)

RESPIRATORY
DISEASES
Air inside building contains 500-1000
microbes/cubic meter of air,

humans breathe 6 liters/min at rest. So up to

10,000 microbes per day enter lungs.
Air contains fungal spores, some bacteria.
But most infections occur by coming in contact
with fluids from sneezes, coughs, hands of other
infected people.
Respiratory infection l-develop colds just from
inhaling droplets via sneezing or coughing. Hand
contact is much more frequent, and rubbing
eyes after contact is an especially effective way
of getting virus into body.

Best defenses: Frequent hand washing and

avoidance of close contact with infected people

SUMMARY OF EPIDEMIOLOGY FOR

TYPICAL RESPIRATORY DISEASE

EXAMPLES OF RESPIRATORY TRACT

PATHOGENS: COMMON COLD
The most common of all infectious diseases. Average
American gets 2/year.
Over 200 different viruses may cause cold. Most are RNA
viruses in rhinovirus or adenovirus family
Reproduce best at temperatures cooler than body temp.
(33C rather than 37C), which is nasal pathway temp., so
most infections occur in epithelial lining of nasal passageway.
Infection usually last a week or so, until antibodies to virus are
made.

EXAMPLES OF RESPIRATORY
TRACT PATHOGENS: PNEUMONIA
One disease (inflammation in alveoli of lungs) -- many
possible causes.
Normally occurs as secondary infection following viral
infection or other ilness.

One of top 10 cause of death

Most frequent pathogen in many cases = Streptococcus
pneumoniae.
Bacterium grows rapidly in alveoli, protected from
phagocytosis by capsule. Lung spaces fill with blood,
bacteria, phagocytes fluid buildup lung inflammation.

EXAMPLE OF RESPIRATORY TRACT

PATHOGENS: PNEUMOCYSTIS PNEUMONIA
a fungal disease, caused by Pneumocystis carinii, a yeast.

Used to be rare, but since AIDS, disease has exploded into

prominence. In early days of AIDS, 80% of patients developed this
type of pneumonia.
In lung, Pneumocystis carinii elicits intense inflammatory response,
produces foamy exudate of fluid. As infected cells die, leaves
honeycomb appearance.
Can be treated with certain antifungal antibiotics.

OTHER CAUSES OF
PNEUMONIA
Staph. aureus, often after influenza infection.

Legionella pneumoniae, first isolated in 1976 at a Legionnaire's

convention. Bacteria can grow in water-cooling towers used for
air conditioners, was spread as fine aerosol in closed
buildings.
Mycoplasma pneumoniae, often spread by people living in
close quarters (schools, military barracks)

Diphtheria
Caused by bacterium Corynebacterium diphtheriae.
Infection can lead to a "pseudomembrane" covering the
posterior pharynx (back of the throat to you non-clinical types).
Diphtheria toxin: Toxins released by the organism create an
inflammation on the pharyngeal mucosal surfaces. The
pseudomembrane may obstruct breathing to the point of
asphyxation and death. The toxin may travel to the heart and
lead to heart failure

STREPTOCOCCAL
DISEASES
Streptococcus pyogenes-microbiota of 5-15% of humans,
usually in respiratory tract, usually not producing obvious
disease.
Streptococcal infections can produce a family of diseases examples:

suppurative (pus-forming) infections

pharyngitis (sore throat)
scarlet fever (extensive skin rash)
impetigo (infection of superficial skin layers

cellulitis (infection of deep skin layers)

necrotizing fasciitis (bacteria attack and destroy muscle tissue)
streptococcal toxic shock syndrome

TUBERCULOSIS
M. tuberculosis is a strictly aerobic bacterium, with a very slow
doubling time (12-18 hours)
long latent period; antibody response are 8-12 weeks after infection.
TB is usually asymptomatic; only 10-20% of infected persons become
diseased.
How does M. tuberculosis cause disease? any, but lung is common
focus of infection, so consider sequence of infectious TB in lung:
Bacterium is taken up inside phagosome by macrophage (first stage of
phagocytosis), grows and replicates & form tubercule which may spread
through respiratory system and other tissues
Patients with pulmonary TB have respiratory problems, cough up mucus
secretions frequently. TB can attack many other sites in body as well as
lungs.
TB is one of the most common diseases world-wide.
Worldwide annual deaths from TB: 3 million (98% in developing
countries)
Worldwide annual reported disease cases: 8 million
Worldwide incidence of infection: somewhere between 1 in 10 to 1 in 3
people

LEPROSY

Mycobacterium leprae

Bacterium cannot be grown in culture, only in footpads of

armadillos (lower body temperatures).

One of the most dreaded (and joked about) of diseases.

Still a major problem, 14 million people worldwide,

Transmission is still a mystery. Most people who come in

contact with lepers do not get infected. Lepers have high
bacterial counts in nasal discharges, but disease does
not spread in epidemic fashion.

Disease manifestation: 2 types

Lepromatous leprosy. The worst form of the disease,
bacteria spread to every organ and part of body. Can
lead to loss of fingers, toes, nasal deformation,
eventually death.
Tuberculoid leprosy. Mild disease, symptoms due to
delayed hypersensitivity to proteins. Full recovery often
occurs.

INFLUENZA
infectious disease of birds and mammals
fever, sore throat, muscle pains, severe headache,
coughing, and weakness and fatigue
Pneumonia
Can be confused with common cold. Flu is much
more severe!!!

INFLUENZA VIRUS
RNA, enveloped

Highly contagious

Viral family
orthomyxoviridae

Incubation 2days (1-4days)

Mode of transmission

Size80-200nm in diameter
Three types

A, B, C
Surface antigens
H (haemaglutinin)
N (neuraminidase)

Droplet (conjunctiva, nasal

and nasal mucosa)
Airborne
Contact
Viral Survival

Humidity (35-40%), 28oC

1-2days on nonporous
surface
Can undergo antigenic shift
and drift

NATURAL HOST OF INFLUENZA VIRUS

PANDEMIC FLU

Bird Flu
Human Flu
Swine Flu
Horse Flu
Dog Flu

ANTIGENIC SHIFT: RE-ASSORTMENT

In human

ANTIGENIC SHIFT: RE-ASSORTMENT

in pigs

ANTIGENIC DRIFT: MUTATION

In human

EXAMPLE 1: SARS- BIRDS TO HUMAN

Hong Kong, SAR China, 1997, H5N1-Hundreds of infections
with H5N1 bird flu (over a short timeframe)
18 hospitalizations
6 deaths
Hong Kong, SAR
China, 1999, H9N2
The Netherlands,
2003, H7N7
Hong Kong, SAR
China, 2003, H5N1

BIRD FLU -WORLD-WIDE THREATS

Wash. Post, Dec. 16, 1997

EXAMPLE 2: H1N1 INFLUENZA

Spanish flu-1918
Global death total: 50 million to 100 million
In 6 months 20 million deaths
The greatest medical holocaust in history" and may
have killed as many people as the Black Death
was misdiagnosed as dengue, cholera, or typhoid
category 5 influenza CDC pandemic severity index
(ie: projected death in USA 2 Million)

H1N1 PANDEMIC- 2009

Refer to swine flu

Over 182166 reported cases, 1799 death, in 177

countries
rates of influenza illness continue to decline in the
temperate regions
Tropical Asia -increasing rates of illness as they
enter their monsoon season
India, Thailand, Malaysia, and Hong Kong-have
active surveillance programs

H1N1PANDEMIC- 2009

MALAYSIA
Nipah virus outbreak in 1999,

Severe Acute Respiratory Syndrome (SARS) not

affected
(H5N1 (bird flu) outbreak in 2004.- not affected

National Influenza Pandemic Preparedness Plan

(NIPPP) which serves as a time bound guide for
preparedness and response plan for influenza
pandemic.
HINI in 2009

STRATEGY TO SLOWDOWN
H1N1 ANTIVIRAL DRUG &
VACCINE
Oseltamivir (trade name Tamiflu)
Zanamivir (trade name Relenza)

PUBLIC RESPONSE
Social distance

Respiratory hygiene
Mask (N95 mask for health-care worker)
Hygiene
Risk communication

PANDEMIC PROBLEMS
Not enough vaccine

Not enough antivirals (oseltamvir)

Classical epidemic control

Physical restriction of people

Isolation of the sick
Quarantine of the exposed
Ban all public gatherings: work, school, shopping malls,
theaters, churches, and yes, bars and clubs

BENEFIT OF PANDEMIC
INFLUENZA PLANNING AND
FEARS
Silver lining factor

Improved surveillance
Planning for vaccine strategies, vaccine supply
Attention of media, governments, markets
May break the vicious cycle of neglect, followed by
no effort or investment

END OF CHAPTER