1. Introduction to Environmentally Transmitted Pathogens: Some Basic Concepts of Epidemiology, Infection, Disease, Environmental Transmission and Waterborne-Exposure Lecture 3 ENVR 421 Mark D. Sobsey

2. Epidemiology - Definition The logic of observation and the methods to quantify these observations in populations (groups) of individuals. The study of the distribution of health-related states or events in specified populations and the application of this study to the control of health problems. Epidemiology includes: – 1) methods for measuring the health of groups and for determining the attributes and exposures that influence health; – 2) study of the occurrence of disease in its natural habitat rather than the controlled environment of the laboratory (exception: clinical trials); and – 3) methods for the quantitative study of the distribution, variation, an determinants of health-related outcomes in specific groups (populations) of individuals, and the application of this study to the diagnosis, treatment, and prevention of these states or events.

3. Infectious Disease Epidemiology: Classical Epidemiology the study of epidemics the study of the dynamic factors involved in the transmission of infectious agents in populations the natural history of infectious disease –how a disease spreads through groups or a population –how a case of that disease develops in an individual

4. Basic Epidemiological Concepts and Terms Incidence: # of new cases of disease/total # at risk. Incidence rate: Incidence/unit of time. Prevalence: # cases (or # with defined condition) existing at one time. Prevalence rate: # of such cases/total # at risk. Epidemic: – # cases in excess of expected # for population – the uncontrolled spread of a disease (or condition) in a community. Immunity: Inherited, acquired, or induced resistance to infection by a specific pathogen – Acquired r esistance due to previous infection is from protective cellular and antibody responses in the host Herd immunity: cumulative # of immune persons in population or % of population immune.

5. Outbreaks or Epidemics A disease or condition at involves many or an excessive number of people at the same time and the same place The occurrence of a disease or condition at a frequency that is unusual or unexpected – increase above background or endemic level Requirements for an outbreak or epidemic: (i) presence of an infected host or other source of infection. (ii) adequate number of susceptibles (iii) an effective method of contact for transmission to occur.

6. Transmission/Exposure Routes of Infectious Agents: Entry to and/or Exit From the Body Sites or Portals of Exit or Entry: Respiratory Enteric or Gastrointestinal Skin: especially if skin barrier is penetrated Genitourinary Eye

7. Routes or Methods of Entry Direct Personal Contact: Person (animal)-to- Person Indirect Personal Contact: Droplet, Fomites, Other Vehicles Water and Food (Gastrointestinal Tract) Vector-borne: often insects Intrauterine or Transplacental Organ Transplants, Blood and Blood Products

8. Transmission Routes of Infectious Agents

9. Infectious Diseases and the Process of Infection Infection: the growth/multiplication of a microbe in a host Infection does not always result in injury of the host (disease) Two main classes of infection by site: – localized – generalized (disseminated; systemic) Some infections are usually localized but can sometimes spread to another site – Example: Amoebic dysentery occurs in the intestines (colon); sometimes it spreads to the liver causing liver abscess

10. Localized Infections Organism enters the body and reaches target site of infection Organism adheres to or enters host cells and multiplies at site of infection Infection spreads within the site (e.g., respiratory tract; intestines) Symptoms of illness appear Organism does not spread through the lymphatic system or reach the bloodstream Infection subsides due to host defenses (e.g., immunity) Agent eliminated from the body; infected cells replaced; "cure "

11. Generalized Infections Organism enters the body and reaches target site of initial infection Organism adheres to or enters host cells and multiplies at initial site of infection Infection spreads within site and to other sites via tissues, lymphatic system, bloodstream (bacteremia, viremia, etc.) and possibly other routes Symptoms of illness may appear Organisms infect other organs, tissues and cells; more spread via bloodstream Symptoms of illness become severe Host defenses eliminate organisms leading to cure or disease continues, possibly leading to irreversible damage or death

13. Factors Influencing Exposure and Infection: Agent (Microbe) Factors Sources, Reservoirs, Transport and Persistence (in the Environment) Ability to Enter a Portal in the Human or Other Host Ability to Reach and Proliferate at Site(s) of Infection in the Host Excretion of the Agent from the Host Quantity and "Quality" (including virulence) of the Infectious

14. Factors Influencing Exposure and Infection: Environmental Factors Reservoirs: where organisms can live, accumulate or persist outside of the host of interest; could be another organism or the inanimate environment. Vehicles: inanimate objects/materials by which organisms get from one host to another; includes water, food, objects (called fomites) and biological products (e.g., blood). Amplifiers: Types of reservoirs where organisms proliferate; often applied to organisms transmitted by the airborne route. Vectors: Living organisms bringing infectious organisms to a host. – Mechanical vectors: Microbes do not multiply in the vector ex: biting insects infected with the infectious organism – Biological vectors: Microbes must propagate in the vector before they can be transmitted to a host.

15. Environmental Factors Influencing Survival or Proliferation of Infectious Agents Physical: temperature, relative humidity, sunlight, moisture content or water activity, climate and weather, etc. Chemical and Nutritional: Antimicrobial chemicals, nutrients for microbial proliferation. Biological: Antagonistic activity by other organisms: antimicrobial agents, parasitism, etc.; presence and state of a vector

16. Factors Influencing Exposure and Infection: Host Factors and Host Susceptibility Opportunities for host exposure –transmission routes – host availability Susceptibility factors –Dosage (quantity) and "quality" of infectious organisms, including their "virulence"; –age –immunity – nutritional status –immunocompetence and health status, –genetics –behavior (personal habits) of host.

17. Infectivity of Pathogenic Microorganisms and Risk of Infection, Illness and Death Infection  Illness  Sequelae Death Secondary Spread

18. Dose-Response and Infectious Dose (ID) Probability of infection is dose-dependent – Higher dose → higher probability of infection/illness; dose-response relationship Microbes differ in infectivity Enteric and respiratory viruses: infectious at very low doses – 1 cell culture ID has high probability of infecting an exposed human. – May still need exposure to many virions Most enteric bacteria: infective at moderate (10s-100s cells) to high (1,000 cells) doses. Protozoa: can be infective at low doses – ID 50 at 1-10 cysts of Giardia lamblia ) or oocysts of Cryptosporidium parvum

19. Outcomes of Infection Microbes differ in their ability to produce the different outcomes of infection: (i) infection without illness; (ii) infection with illness; (with or without long-term sequelae) and (iii) infection, illness and then death

20. The Iceberg Concept: As Applied to Virus Infections

21. Transmission Dynamics of Infectious Diseases: Host States in Relation to Pathogen Transmission Susceptible InfectedResistant λ1λ1 λ2λ2 λ3λ3 Pathogen Exposure λ = the rate or probability of movement from one state to another

22. Mortality Rates for Different Viruses in Healthy, Immunocompetent Humans (Rates Higher in the Immunocompromised) VIRUSES:% Mortality Adenovirus0.01% Enteroviruses0.001 (average) –Coxsackievirus B0.59-0.94 –Echoviruses0.28 Hepatitis A virus0.3 Norwalk virus0.0001 Rotavirus0.01

23. Mortality Rates for Different Pathogens in Healthy, Immunocompetent Humans (Rates Higher in the Immunocompromised) BACTERIA:% Mortality Campylobacter jejuni0.1 E. coli0.2 Salmonella spp.0.1 Shigella spp.0.2 PARASITES: Giardia lamblia0.0001 Entamoeba histolytica0.3

24. Transmission Categories of Water- Related Diseases Water-borne Water-washed Water-based Water-related/Insect vector- borne

25. Waterborne Caused by ingestion of water contaminated by human or animal feces or urine containing pathogenic bacteria or viruses Mostly enteric diseases transmitted by the fecal-oral route – Bacterial: cholera, typhoid, amoebic and bacillary dysentery diseases – Viral: Infectious hepatitis – Protozoan parasitic: amoebic dysentery Some are due to organisms NOT fecally associated that proliferate in water – example: Legionellosis ( Legionella bacteria) via aerosols and droplets

26. Water-washed or Water Hygiene Diseases Caused by poor personal hygiene and skin or eye contact with contaminated water Diseases whose exposure is reduced by the use of water for personal and domestic hygiene: –washing: clothes, floors, other household chores –bathing and other personal hygiene –cleaning of cooking and eating utensils Includes: –many enteric organisms –diseases of the skin and eyes (ex: trachoma) –insect infestations Scabies caused by mites Pediculosis caused by lice Tick-borne diseases

27. Water-based Caused by parasites found in intermediate organisms living in contaminated water Exposure by skin contact with infested water –Schistosomiasis free ‑ living larvae released from aquatic snails (the intermediate host) invade the skin –Dracunculiasis (Guinea Worm disease) –Other helminths

28. Water-related, Insect Vector-borne Caused by insect vectors, especially mosquitoes, that breed in water; water habitat "insect vector" diseases –Insect vectors breed in or near water Examples: –Dengue (virus) –Filariasis (nematode worms) –Malaria (protozoan) –Onchocerciasis; river blindness (filarial worm) –Trypanosomiasis (parasite) –Yellow Fever (virus)