Introduction (EC01)

Module: EPM301 Epidemiology of Communicable Diseases

Course: PG Diploma/ MSc Epidemiology

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assisted learning (CAL) session. The first three columns designate which page,
card and screen position the text refers to.
If you have any questions regarding this document or your course, please
contact DLsupport via DLsupport@lshtm.ac.uk.
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module CDROM. When studying this session, please ensure you work through
the CDROM material first. This document can then be used for revision purposes
to refer back to specific sessions.
These study materials have been prepared by the London School of Hygiene & Tropical Medicine as part of
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London School of Hygiene & Tropical Medicine September 2013 v1.0

Section 1: EC01 Introduction

Aims

To introduce the important concepts of infectious disease epidemiology.

Objectives
By the end of this session, you should be able to:

explain what infectious diseases are and why they are important.
describe the characteristics of infectious agents that influence transmission.
describe the characteristics of host populations that influence transmission.

This session should take you between 2 and 2.5 hours to complete.

Section 2: Why study infectious diseases?

An infectious disease can be defined as:
"An illness due to a specific infectious
agent (or its toxic products) that
arises through transmission of that
agent (or product) from an infected
person, animal or reservoir to a
susceptible host."
This transmission can occur directly,
or indirectly through an intermediate
host, vector or the environment.
You have already considered some of the concepts and measures of infectious
disease epidemiology in session FE07 and you may wish to review this.
Interaction: Hyperlink:specific infectious agent: output (appears on RHS)

Interaction: Hyperlink: person, animal or reservoir: output (appears on RHS)

Interaction: Hyperlink: susceptible host: output (appears on RHS)

Interaction: Hyperlink: susceptible host: output (appears on RHS)

2.1: Why study infectious diseases?

Infectious diseases have always existed and have had a major impact on human
development. It is widely believed that our immune systems and genetic makeup
have evolved over many years under the selective pressure of potentially fatal
diseases, such as malaria (Haldane 1948; Weatherall 1996).
In addition, epidemics of infectious diseases have decimated entire communities, and
have sometimes changed the course of history.
Examples
In Europe in the 14th Century, there
were about 25 million deaths from
bubonic plague out of a population of
approximately 100 million.
In 1520 the Aztecs lost about half of
their population of 3.5 million from
smallpox, introduced by the more
immune invading Spaniards. This has
been proposed as an important feature
in the defeat of the Aztecs by the

Spanish invaders.
In 1919, after the First World War, the
global epidemics of influenza killed an
estimated 20 million people during one
year - more than died as a result of the
war.

2.2: Why study infectious diseases?

During the 20th century, important advances in the prevention and control of many
infectious diseases were achieved with the development of vaccines and antibiotic
drugs. This has sometimes created the impression that infectious diseases are no
longer a major threat to public health. However, this is far from being the case.
The following is a quote from Dr Gro Harlem Brundtland, the Director-General of
the World Health Organization:
"Illness and death from infectious diseases can be, in most cases,
avoided at an affordable cost. It is in everyone's interest that these
obstacles to development be removed. Because of drug resistance,
increased travel and the emergence of new diseases, we may only have a
limited time in which to make rapid progress."
In the following cards, you will see some of the reasons why infectious diseases are
still an important challenge to public health at the beginning of the 21st century.

2.3: Why study infectious diseases?

Mortality
Infectious diseases are a leading cause of global mortality, causing more than 13
million deaths a year.
They are still the main cause of death among children under 5 and the main
single cause of premature death in persons under the age of 45.
Click below to see pie charts of the main causes of death in each of these groups.
You can use the 'swap' button in the graph viewer to switch between the two
charts.

Note:
On this plot, and others in the study module, you can click on the small symbol
in the corner of the diagram to see information about the source of the image.

2.4: Why study infectious diseases?

Morbidity
Infectious diseases are also a major cause of global morbidity. They are
responsible for a huge amount of disability and suffering in the world as
measured in DALYs. Click below for an example.
Interaction: Hyperlink: DALYs: output (appears in new window)

DALY
Disability Adjusted Life Years, a measure of disease burden.
It includes years of life lost due to premature death, and years of healthy life lost
due disability or illness.
Recurring episodes of illness and long-term disability have a major economic
impact on the developing countries most affected by infectious diseases.

2.5: Why study infectious diseases?

Role in chronic disease
Infectious diseases are increasingly being implicated in the pathogenesis of many
important diseases that were previously thought to have a non-infectious origin.
Interaction: Tabs:
Example 1 : output
Cervical cancer is now known to be associated with human papillomavirus infection.
Cervical cancer is the sixth most common cancer worldwide and the most common
cancer in women in many developing countries.
Interaction: Tabs:
Example 2 : output
In the past two decades, evidence has grown on the role of Helicobacter pylori
infection in gastritis, duodenal ulcer, gastric ulcer, gastric cancer and gastricmucosa-associated lymphoid tissue (MALT) lymphoma.

Interaction: Tabs:
Example 3 : output
Chronic infection with hepatitis B or C can cause primary hepatocellular carcinoma
(HCC). HCC is among the most common cancers in many parts of Africa and Asia.

2.6: Why study infectious diseases?

Potential for epidemic spread
A specific feature of infectious diseases is their ability to be transmitted between
individuals. This can result in the occurrence of large outbreaks.
Between 19972000 there were more than 600 outbreaks of disease considered by
the WHO to be of 'international importance'. Click below to see a world map of
some of these _on the map you can click the location of each outbreak for details.
Interaction: Hyperlink: outbreaks: output (appears in new window)
Outbreak
The term used to describe a localised epidemic, e.g. in a village, town or city.
The term 'large outbreak' is increasingly being used instead of 'epidemic', as it is
less emotive.
Interaction: Button: Show: output

2.7: Why study infectious diseases?

Potential for epidemic spread
(continued)
With increasing urbanisation and international travel, the world is becoming a
smaller place, and the routes for transmission of infection are increasing. Aeroplane
journeys enable individuals to travel within the incubation period of most infectious
diseases.
This allows infections to spread to distant places within very short periods of time.
An example of this is the annual global dispersal of meningococcal meningitis by
pilgrims returning from the Haj Muslim religious festival (Saudi Arabia).
Click below for an illustration of this.

2.8: Why study infectious diseases?

Newly emerging diseases
Over the past three decades, over 30 new infectious diseases and pathogens have
been identified for the first time in humans.
These include diseases with a very high case-fatality rate, such as new variant
Creutzfeldt-Jacob disease (nvCJD) and Ebola haemorrhagic fever. Some of these
new infections are highly prevalent, for example Hepatitis C and rotavirus. Other
infections, such as HIV, have rapidly spread around the world.
(Click on each of the terms above to view details about each one opposite.)
Interaction: Hyperlink: nvCJD: output (appears on RHS)

New variant Creutzfeldt-Jacob disease (nvCJD)

A new variant of Creutzfeldt-Jakob disease was described in the United Kingdom in
1996. The agent is considered to be the same as that causing bovine spongiform
encephalopathy, a disease that emerged in the 1980s and affected thousands of
cattle in the United Kingdom and other, mainly European countries.
http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/CreutzfeldtJakobDise
ase/ for more information.
Interaction: Hyperlink: Ebola: output (appears on RHS)
Ebola
The first outbreaks of Ebola haemorrhagic fever occurred in 1976 and the
discovery of the virus was reported in 1977. Cases reported to WHO up to June
1997 indicated a case-fatality rate of over 70%. A major outbreak in Uganda in
2000 was thought to be associated with spread of the virus by soldiers moving
across the country. http://www.who.int/csr/disease/ebola/en/index.html for
more information.
Interaction: Hyperlink: Hepatitis C: output (appears on RHS)
Hepatitis C
This virus was identified in 1989, and is now known to be the most common cause of
post-transfusion hepatitis worldwide. So far, up to 3% of the world population are
estimated to be infected, among whom 170 million are chronic carriers at risk of
developing liver cirrhosis and/or liver cancer.
http://www.who.int/vaccine_research/diseases/viral_cancers/en/index2.htm for
more information.
Interaction: Hyperlink: rotavirus: output (appears on RHS)
Rotavirus
First recognised in 1973, rotavirus is the most common cause of childhood diarrhoea
worldwide. 20% of all diarrhoeal deaths and 5% of all deaths in under-5 year olds
are due to rotavirus. http://www.cdc.gov/vaccines/pubs/pinkbook/rota.htm for more
information.
Interaction: Hyperlink: HIV: output (appears on RHS)
HIV
Although the Acquired Immune Deficiency Syndrome (AIDS) was recognised in
1981, the causal virus, HIV, was first isolated in 1983. It is estimated that, since
the start of the epidemic, 30.6 million people worldwide have become HIV-infected
and nearly 12 million have died from AIDS or AIDS-related diseases. UNAIDS
Global Report http://www.unaids.org/globalreport/Global_report.htm for more
information.
Click below to see the global distribution of HIV/AIDS.
Interaction: Button:

Show: output

2.9: Why study infectious diseases?

Re-emerging diseases
In addition to the emergence of new infectious diseases, many old diseases that had
previously been under control are starting to appear in increased numbers or in
previously unaffected populations.
Resurgence of infectious diseases can occur because of any of the following
reasons:
changes in social or environmental
conditions,
failure to maintain immunisation
programmes (click for an example),
increased drug resistance (click for an
example.
Drug resistance is currently an increasing problem for a number of diseases
worldwide, and we are often in a race to develop new treatments faster than the
pathogens can develop resistance. Click below to see some examples.
Interaction: Hyperlink:
Example

example: output

Since the mid-1980s there has been a major resurgence of diphtheria in several
countries of Eastern Europe, which had previously been progressing towards
elimination of the disease. In 1993, 15,211 diphtheria cases were reported in

Russia and 2,987 cases in Ukraine. The main reason for the return of diphtheria in
these countries was a decreased immunisation coverage due to an irregular supply
of vaccines and large-scale population movements
(Galazka et al 1995).
Interaction: Hyperlink:
Example

example: output

Mortality and morbidity rates from tuberculosis (TB) in industrialised countries

declined during most of the 20th century. However, from the mid-1980s onwards,
many of these countries have seen an important increase in the incidence of TB.
This is mainly due to a decline in TB control programmes, the increased incidence
of multi-drug resistance TB and the effect of the HIV epidemic (Grange 1998).
Interaction: Button: Show: output (appears in new window)

2.10: Why study infectious diseases?

Potential for prevention and control

The mechanisms involved in many infectious diseases are well understood, from
the molecular aspects of the infectious agent to the demographic characteristics
of host populations. This level of understanding has enabled potentially very
effective prevention and control measures to be developed for some infectious
diseases.
With efficient intervention strategies and the advent of national public health
agencies, elimination of specific infectious diseases has become feasible. In some
cases, there has even been the possibility (or reality) of global eradication.
Following the successful WHO programme for the global eradication of smallpox
through vaccination, the last naturally acquired case of this disease occurred in
October 1977 in Somalia.
The countries of the Western Hemisphere have set a target for the elimination of
measles by the end of the year 2005.
The Global Polio Eradication Initiative was established in 1988 following a
resolution of the World Assembly to eradicate poliomyelitis. Strategies to
immunise millions of children on the same day have resulted in few countries now
reporting cases due to wild poliovirus.
Dracunculiasis (guineaworm) is now also on the verge of eradication. After
intensive, globally co-ordinated programmes, the number of reported cases has
dropped from almost 3.5 millions in 1986 to less than 2000 in 2010, and the
disease remains endemic only in 4 countries (Ethiopia, Ghana, Mali and Sudan).
Click below for an illustration of this.

2.11: Why study infectious diseases?

Infectious disease epidemiology
In epidemiology, we are interested in describing and explaining the distribution of
diseases in populations. The distribution of an infectious disease depends on
the transmission of the infectious agent within the host population.
This is a dynamic process, which is influenced by characteristics of the specific
infectious agent, characteristics of the host population and characteristics of the
relationship between the infectious agent and the host.
In the next few pages we will look at how these different factors act together to
influence the transmission of infectious diseases in populations.

Section 3: Infection and disease

What are infectious agents?
An infectious agent is an organism that is capable of producing infection or
infectious disease in a larger host organism. These organisms are also known as
parasites because they derive their nourishment from the organism that they live
in or on. Those that cause disease are known as pathogens.
There are two main classes of parasite:
microparasites
macroparasites
Click on each of these for details.
Interaction: Hyperlink: microparasites: output (appears on RHS)
Microparasites include prions, viruses, bacteria, protozoa and fungi.
Microparasites are able to multiply within the host organism, although some
protozoa also undergo some of their development outside the definitive host.
Microparasites are so small that they are invisible to the naked eye. They are usually
present in the host in such large quantities that epidemiologists usually count the
number of infected hosts (prevalence of infection) rather than the number of
parasites (intensity of infection). However, intensity can be measured for protozoans,
which lie at the boundary of microparasites and macroparasites.
Interaction: Hyperlink (from above): prions: output (appears in new window)
Prion
An infectious agent that is believed to have no genetic material. It is an abnormal
form of a normally occurring protein of the central nervous system. It is thought to
spread by inducing a change in the shape of the normal protein.
Interaction: Hyperlink: microparasites: output (appears on RHS)

Macroparasites include helminths and arthropods (the latter are usually

ectoparasites).
Macroparasites are not able to directly multiply within the host, and often need to
leave the host to complete their life cycle.
Macroparasites can usually be seen by the naked eye. This means that the
number of parasites can be counted, and this has revealed that macroparasites
are usually unevenly distributed within the host population. Often, many hosts
are infected by a few parasites, and a few hosts are infected by many parasites.
The effect on the host and the reproductive potential of the macroparasite often
depends on the intensity of the infection.
Interaction: Hyperlink: helminths: output (appears in new window)
Helminth
A helminth is any parasitic worm, though it usually refers to one living in the
intestines of a vertebrate animal.
Interaction: Hyperlink: arthropods: output (appears in new window)
Arthropod
The largest phylum of the animal kingdom, containing several million species.
Arthropods are characterised by a rigid external skeleton, paired and jointed legs
and a fluid-filled cavity in which most of the major organs are found.
Interaction: Hyperlink: arthropods: output (appears in new window)
Ectoparasite
A parasite that lives on the skin of the host and obtains nourishment by sucking
blood. Included in this category are ticks, lice, fleas and mites.
The term 'infestation' is used to refer to an infection with ectoparasites.

3.1: Infection and disease

Exercise
Classify each of the following according to the category in which the causative
infectious agent belongs, by dragging the white boxes into the blue bays opposite.
If you are unfamiliar with these examples, look-up the disease in on the CDC website
http://www.cdc.gov/DiseasesConditions/az/m.html
.

Interaction: Drag and Drop:

Correct response: Drag to Microparasite box

That's correct, the infectious agent of malaria is a protozoan parasite and is
classified as a microparasite.
Incorrect response: Drag to Macroparasite box
In fact the infectious agent of malaria is a protozoan parasite and is
classified as a microparasite

Interaction: Drag and Drop:

Correct response: Drag to Macroparasite box
That's correct, tapeworms are intestinal helminths, and are classified as
macroparasites. The adult worms live within the host, but the eggs are shed
with faeces, so multiplication does not occur within the host.
Incorrect response: Drag to Microparasite box
In fact tape worms are intestinal helminths, and are classified as
macroparasites. The adult worms live within the host, but the eggs are shed
with faeces, so multiplication does not occur within the host.

Interaction: Drag and Drop:

Correct response: Drag to Microparasite box
That's correct, hepatitis C is caused by a virus, which is a microparasite. The
virus multiplies within the host in numbers that cannot be quantified.
Incorrect response: Drag to Macroparasite box
In fact hepatitis C is caused by a virus, which is a microparasitic infectious
agent. The virus multiplies within the host in numbers that cannot be
quantified.

Interaction: Drag and Drop:

Correct response: Drag to Microparasite box
That's correct, the infectious agent of cholera is a bacterium, and is
therefore a microparasite.

Incorrect response: Drag to Macroparasite box

In fact, the infectious agent of cholera is a bacterium, and is therefore a
microparasite.

3.2: Infection and disease

Course of infection
You have previously been introduced to the concept that an individual passes
through different stages of infection and different stages of disease (session
FE07).
In this section you will review these stages and consider their implications for the
spread of infection.
You may remember that the stages of infection pass from susceptible to
latent to infectious and finally to non-infectious.
Similarly, the stages of disease pass from being well to incubation of the
infection to being symptomatic and usually to being well again.
Interaction: Hyperlink: susceptible: output (appears in new window)
Susceptible
adj. Able to be infected.
In the infection process, the susceptible period is the period prior to infection.
n. A susceptible individual, i.e. an individual that is not protected by any genetic
or immune mechanism.
Interaction: Hyperlink: latent: output (appears in new window)
Latent period

The time in the infection process between becoming infected and being able to
transmit the infection.
Interaction: Hyperlink: infectious: output (appears in new window)
Infectious
An infectious individual is one that is able to transmit an infectious agent to another
individual.
The infectious period, also known as the period of communicability, is the period of
the infection process during which the infected individual is infectious.
Interaction: Hyperlink: non-infectious: output (appears in new window)
Non-infectious period
The final stage in the infection process when an individual is no longer able to
transmit the infectious agent, either because they have cleared the infection through
an effective immune response or intervention treatment, or because they have died.
Interaction: Hyperlink: incubation: output (appears in new window)
Incubation period
The time from initial infection to the onset of symptoms and/or signs of clinical
illness.
Interaction: Hyperlink: incubation: output (appears in new window)
Symptomatic period
The time during which symptoms and/or signs of the disease are evident.
Symptoms refer to characteristics associated with feeling unwell, such as fever,
coughing, etc., while signs refer to measurable characteristics of being unwell, such
as body temperature, mean haemoglobin level, etc.

3.3: Infection and disease

The diagram opposite represents the typical time course of an acute viral or
bacterial infection in an individual. It shows the progression through the different
stages of infection and disease.
Drag and drop the appropriate stages (on the right) into the spaces on the
diagram.
'Suscept.' means 'susceptible'.
Interaction: Drag and Drop: Immune (decades)
Correct response (drag to bottom RHS box):

That's correct. The immune state is that which occurs after the individual
has cleared the infection, is no longer infectious and no longer susceptible
to future infection with the same infectious agent.
Incorrect response (drag to all other boxes)
Incorrect
Interaction: Drag and Drop: Suscept. (years)
Correct response (drag to bottom LHS box):
That's correct. An individual is susceptible prior to becoming infected.
Incorrect response (drag to all other boxes)
Incorrect
Interaction: Drag and Drop: Infectious (days)
Correct response (drag to bottom centre RHS box):
That's correct. The infectious period occurs after the individual has become
infected and the infectious agent has had some time to develop and
reproduce. It partially overlaps with the appearance of clinical illness.
Incorrect response (drag to all other boxes)
Incorrect
Interaction: Drag and Drop: Latent (days)
Correct response (drag to bottom centre LHS box):
That's correct. The latent period is the interval between getting infected and
becoming infectious.
Incorrect response (drag to all other boxes)
Incorrect
Interaction: Drag and Drop: Incubation (days)
Correct response (drag to top centre box):
That's correct. The incubation period is the interval between the point of
infection and the onset of symptoms (illness).
Incorrect response (drag to all other boxes)
Incorrect

3.4: Infection and disease

Interaction: Tabs:

As you can see, for an acute infection the average duration of the latent and
infectious stages is short when compared with the susceptible and immune stages.
For chronic infections, such as Hepatitis B and HIV and most helminth infections, the
infectious period can last for many years. You will see later in this session, how
patterns of infection vary between infections.

Interaction: Tabs:

The abundance of the infectious agent is relatively low at the time of infection, but
increases with time. This is only the case for microparasites, which multiply within
the host.
Often, the onset of illness (symptoms) is associated with the occurrence of large
numbers of the infectious agent. This is because the symptoms are due to toxins
produced by the infectious agent, or due to the immune response to the infection
(e.g. fever), both of which will be proportional to the abundance of the infectious
agent._
Interaction: Tabs:

Note that the latent period overlaps with the incubation period, but they are not
identical. An individual may be infectious before displaying any symptoms of disease,
and may remain infectious after the symptoms have gone. In fact, for some

infections, the individual may remain asymptomatic throughout the infection, but
still be infectious. This inability to identify all sources of infection makes it more
difficult to measure the transmissibility of infectious diseases (as you will see in
session EC03), and to target appropriate control measures.
Interaction: Hyperlink: asymptomatic: output (appears in new window)
Asymptomatic
An asymptomatic individual is one that is infected and potentially infectious, but does
not exhibit any symptoms of the disease. In fact the individual may not suffer any
obvious adverse effects from the infection, and can be quite healthy.
(back to tabs)

Interaction: Tabs:
Finally, you can see that the end of the symptomatic period is associated with a
decline in abundance of the infectious agent and with the build-up of specific
antibody. This represents the development of an effective specific immune
response, which eliminates the infection and therefore the disease.
For some infectious agents, this immune response is associated with subsequent
protection from infection with the same agent and this is known as the immune
state.
Interaction: Hyperlink: immune: output (appears in new window)
Immune
An immune individual is one that is resistant to infection with a particular infectious
agent due to a biological mechanism of defence.

3.5: Infection and disease

Immune response to infection
When an infectious agent enters its host, it has the potential to cause a lot of harm
and potentially to kill. Because of this the body has evolved a defence mechanism
called the immune system.
The immune system is made up of many organs and cells, which defend the body
against infection, disease and foreign substances. The immune system is able to
recognise that the infectious agent is foreign, and will initially mount a non-specific
immune response to control the infection and limit the amount of damage caused.
Interaction: Hyperlink: non-specific immune response: output (appears in new
window)
Non-specific immunity
Refers to the body's natural immunity, which provides an immediate defence
against infection. This is mostly a cell-mediated response.
Also known as innate immunity.
This is followed by a
specific immune response, which is responsible for clearance of the infection.
The specific response involves the development of antibodies that recognise
specific antigens.
For example, by reacting with surface antigens, antibodies can:
prevent viruses from entering cells
neutralise the effects of bacterial
toxins
coat bacteria to make them more
recognisable to cellular responses
(such as phagocytosis and lysis).

Interaction: Hyperlink: specific immune response: output (appears in new

window)
Specific immunity
This involves the gradual development of an immune response to a specific
recognised part of the infectious agent during the infection.
Also known as acquired or adaptive immunity.

Interaction: Hyperlink: antibodies: output (appears in new window)

Antibody

A soluble protein that is able to react specifically with foreign material.

Interaction: Hyperlink: antigens: output (appears in new window)
Antigen
A molecule that induces a specific antibody or cell-mediated immune response.

Interaction: Hyperlink: phagocytosis: output (appears in new window)

Phagocytosis
When material, such as a bacterial cell, is engulfed by white blood cells called
phagocytes, and the material is digested within the phagocytes to render it harmless.
Interaction: Hyperlink: lysis: output (appears in new window)
Lysis
The rupture of the cell membrane, causing the cell contents to be expelled.

3.6: Infection and disease

Immune response to infection (continued)
Because antibodies develop in response to infection, they are good markers of
previous infection with a specific infectious agent. Measurement of the presence of
specific antibodies is known as seroprevalence, and this allows epidemiologists to
develop a profile of infection experience.
The graph opposite shows what an age-seroprevalence profile might look like for a
typical childhood viral or bacterial infection. The vertical axis represents the
proportion of individuals that are seropositive.
Interaction: Hyperlink: seroprevalence: output (appears in new window)
Seroprevalence
The percentage of the population that are seropositive (produce antibodies in
response to a specific antigen).
Interaction: Hyperlink: seropositive: output (appears in new window)
Seropositive
Seropositive means that the individual or sample tested did have specific antibodies
to the antigens tested.

Source

Immune response to infection (continued)

Because antibodies develop in response to infection, they are good markers of
previous infection with a specific infectious agent. Measurement of the presence
of specific antibodies is known as seroprevalence, and this allows
epidemiologists to develop a profile of infection experience.
The graph opposite shows what an age-seroprevalence profile might look like for a
typical childhood viral or bacterial infection. The vertical axis represents the
proportion of individuals that are seropositive.
Interaction: Hyperlink: Source: output (appears in new window)
Source:
Modified from figure 8a in:
Nokes DJ and Anderson RM. The use of mathematical models in the epidemiological
study of infectious diseases and in the design of mass immunization programmes.
Epidemiology and Infection 1988; 101(1): 1-20.

3.7: Infection and disease

Immune response to infection (continued)
Measurement of antibodies can also be used to indicate whether an individual has
produced a specific immune response to a vaccine, and how strong that response
has been. However, this is not necessarily an indication of protection.

The specific immune response can have a memory component that enables the
immune system to recognise an infectious agent that has caused infection
previously. This
immunological memory is stimulated by recognition of the specific antigens
involved, by circulating antibodies, and may result in the immune system
preventing re-infection with the same infectious agent.
Measurement of these antibodies can sometimes indicate whether an individual is
protected from re-infection, if the specific antibodies are known to be correlated with
protection against infection.
Interaction: Hyperlink:immunological memory: output (appears in new
window):
Immunological memory
The enhanced immune response that occurs following re-infection with the same
infectious agent.

3.8: Infection and disease

Exercise 1
To help you check that you have understood what each of these terms mean,
complete the following exercises.
Match three of the terms on the left to the definitions on the right
Interaction: Drag and Drop: Specific
Correct response: (drag to drop 4 on RHS)
That's right.
Incorrect response:
Sorry, that's not correct. Check the definitions on the previous cards and try
again.
Interaction: Drag and Drop: Non-specific
Correct response: (drag to drop 1 on RHS)
That's right.
Incorrect response:
Sorry, that's not correct. Check the definitions on the previous cards and try
again.
Interaction: Drag and Drop: Antibodies
Correct response: (drag to drop 3 on RHS)
That's right.
Incorrect response:
Sorry, that's not correct. Check the definitions on the previous cards and try
again.

Interaction: Drag and Drop: Antigens

Correct response: (drag to drop 2 on RHS)
That's right.
Incorrect response:
Sorry, that's not correct. Check the definitions on the previous cards and try
again.
When you first become infected with an infectious agent your body has never
seen before, your immune system will mount a
drop 1 immune
response to bring the infection under initial control. Then in response to
drop
2 that can be recognised on the infectious agent, the immune system will
produce
drop 3 that will mediate a drop 4 immune response.

3.9: Infection and disease

Exercise 2
Match three of the definitions on the left to the terms on the right, by clicking on
the term and dragging an arrow across to the corresponding definition.
Feedback will appear below:
drop 1

An individual who produces antibodies in response to a specific antigen

drop 2

The proportion of individuals in a sample that do not produce antibodies to a specific

antigen.
drop 3

An individual who does not produce antibodies in response to a specific antigen.

drop 4

The proportion of individuals in a sample that produce antibodies to a specific

antigen.
drop 5

An individual who produces a non-specific reaction in response to a specific antigen.

Interaction: Drag and Drop: Seroprevalance
Correct response: (drag to drop 4)
That's right, the "sero-" refers to antibodies, and this is a type of
prevalence.
Incorrect response
Incorrect
Interaction: Drag and Drop: Seropositive
Correct response: (drag to drop 1)
That's right, the "sero-" refers to antibodies, and positive means that they
are produced.
Incorrect response
Incorrect
Interaction: Drag and Drop: Seronegative
Correct response: (drag to drop 3)
That's right, the "sero-" refers to antibodies, and negative means that
they are not produced.
Incorrect response
Incorrect

3.10: Infection and disease

Patterns of infection
Because of the different types of immune response elicited by different infectious
agents, the course of infection may differ.
Click below to view a diagram showing five different patterns of infection, as
listed below:
1. Acute, self-limited infection
2. Persistent infection with shedding
(production of infectious material)
3. Latent infection
4. Persistent slow infection following an
acute infection
5. Persistent slow infection (no acute
stage)
Interaction: Button: Show: output (appears in new window)
Interaction: Tabs: 1 : output

Acute, self-limited infections are generally viruses and bacteria that induce
lasting immunity to re-infection.
Can you think of some examples of infections that show this pattern?
The duration of infection can usually be measured in days, and protective immunity
is often lifelong.
Interaction: Hyperlink: source: output (appears in new window)
Source:

Mims CA, Playfair JHL, Roitt IM, Wakelin D and Williams R. Medical Microbiology.
London, St Louis: Mosby; 1993.
Interaction: Tabs: 2 : output

Persistent infections are those that produce a chronic asymptomatic 'carrier'

state, which is a source of infection for others.
More button
Think of at least one macroparasite and one microparasite that induce this type of
infection pattern.
Cloud button
Interaction: Hyperlink: source: output (appears in new window)
Source:
Mims CA, Playfair JHL, Roitt IM, Wakelin D and Williams R. Medical Microbiology.
London, St Louis: Mosby; 1993.
Interaction: Button: More: output (appears in new window)
After an initial acute infection, which may or may not be associated with detectable
symptoms, the infectious agent is 'controlled' by the immune system, but is not
eliminated. The agent is able to persist at low levels that do not cause disease, but
continues to multiply and release infectious material (e.g. virus particles, eggs).
However, immune control can subsequently fail, resulting in severe symptoms.
Interaction: Button: Cloud: output (appears in new window)
This category includes helminth infections, such as tapeworms and schistosomes,
and the Hepatitis B virus.
Interaction: Tabs: 3 : output

Latent infections induce an initial acute infection with subsequent recovery and
persistence in a non-infectious latent form that 'hides' from the immune system for
years. This latent form can then be reactivated at a later stage, when it multiplies
causing disease and producing infectious material. The causes of reactivation are
unclear, but have been associated with immunosuppression
(e.g. stress-induced, HIV infection).
Examples button
Interaction: Hyperlink: source: output (appears in new window)
Source:
Mims CA, Playfair JHL, Roitt IM, Wakelin D and Williams R. Medical Microbiology.
London, St Louis: Mosby; 1993.

Interaction: Button: Examples: output

Examples
Examples of latent infections are herpes simplex virus, causing cold sores on
reactivation, and varicella-zoster virus, causing chicken pox initially and shingles on
reactivation. Tuberculosis and vivax malaria can also produce latent infections.

Inter
output

action: Tabs: 4 :

Persistent slow infection following an acute infection refers to infections that

are initially suppressed by the immune system, but are then able to slowly build-up
again to levels that cause disease. These infections persist for long-periods and
gradually 'over-power' the immune system.
Can you name a well-known example of this type of persistent infection?
Cloud button
Interaction: Hyperlink: source: output (appears in new window)
Source:
Mims CA, Playfair JHL, Roitt IM, Wakelin D and Williams R. Medical Microbiology.
London, St Louis: Mosby; 1993.
Interaction: Button: Cloud: output
The most common example in this category is the HIV virus, which can be infectious
without causing symptoms for many years. Another example is the HTLV1 virus that
causes leukaemia. Infection is thought to occur early in life, primarily through breast
milk, but the tumour develops in late adulthood.
Interaction: Tabs: 5 : output

Persistent slow infections with no acute stage are rare, and refer to long-term
infections that multiply and build-up over many years.
The best example of this is the spongiform encephalopathy, Creutzfeld-Jakob
disease, which is thought to be caused by a prion infection of the central nervous
system. The disease only becomes apparent after many years, and is often confused
with other forms of dementia.
Interaction: Hyperlink: source: output (appears in new window)
Source:
Mims CA, Playfair JHL, Roitt IM, Wakelin D and Williams R. Medical Microbiology.
London, St Louis: Mosby; 1993.

Section 4: Transmission of the infectious agent

Infectivity and infectiousness

The infectivity of an infectious agent is its ability to enter, survive and multiply in
the host once a potentially infective contact has occurred.
The infectiousness of an infectious agent is the ease with which it is transmitted to
another host and this is closely associated with the mode of transmission.
However, there is a lot of overlap between the usage of these two terms, as the
infectiousness of an agent is usually dependent to some extent on its ability to
multiply and to survive.
Interaction: Tabs: Infective dose : output
Enough infectious material must be produced to provide a sufficient infective dose
for subsequent transmission. It is often difficult to quantify this, and the infective
dose is likely to vary according to the immune status of the host.
All parasites tend to multiply in very large numbers to increase the likelihood that
the infection will be transmitted.
Interaction: Hyperlink: infective dose: output (appears in new window)
Infective dose
The amount of infective material that is necessary to establish an infection in a
susceptible host.
(back to main card)
Interaction: Tabs: Duration of infection : output
An individual can be infected without being infectious, and therefore the duration of
infectiousness is an important determinant of transmissibility, as you will see in
session EC06.
Example button
The duration of infectiousness is therefore a characteristic of the infectious agent
that determines whether there is sufficient opportunity for transmission to occur.
Interaction: Button: Example: output (appears in new window)
Example
The malaria parasite has an asexual phase of multiplication that is responsible for
the disease. However it is the sexual stages that are infectious to a biting mosquito
and these are not easily detectable in the circulating blood throughout an infection.

4.1: Transmission of the infectious agent

Virulence and transmissibility

Virulence is the amount of pathogenicity that an infectious agent causes, that is,
the severity of the disease that may result from an infection.
Biologists previously believed that parasites should evolve towards being less
virulent, because more virulent parasites are more likely to drive their hosts, and
themselves, to extinction. On an individual scale, a parasite that rapidly kills its host
has less chance of being successfully transmitted to the next host, than one that coexists with its host for many years.
This theory was also initially supported by the introduction of a highly virulent strain
of viral myxomatosis into Australia in 1950 to control the rabbit population.
Successively less virulent strains of the virus rapidly appeared over the following
years. However, the predominant strain was eventually found to be of an
intermediate virulence.
Subsequent mathematical models of this idea have indicated that parasites do not
necessarily need to evolve to be less and less virulent. Their evolution will depend on
the relationship between virulence and transmissibility of the parasite (May &
Anderson 1983).

4.2: Transmission of the infectious agent

(Centre top remains static)
If virulence increases the parasite's probability of being transmitted to another
host, then this characteristic will be selected for. That is, parasites with this
characteristic will be more likely to become widespread, than parasites without this
characteristic.
For example, the virulence of the rabies virus may cause rabid dogs to bite,
therefore increasing transmission of the virus. Such an influence on the behaviour of
an infected host is beneficial to the transmission of the infectious agent.
In recent years, molecular techniques have identified a number of 'virulence
genes'. It is thought that these genes are linked to improved survival in the host.
For example, the adherence of malaria infected red blood cells to blood vessels is
involved in the development of cerebral malaria, which can be fatal, but also allows
the parasites to evade the spleen where they would be removed.

4.3: Transmission of the infectious agent

Modes of transmission
The mode of transmission of an infectious agent is the mechanism by which it is
transmitted from a source or reservoir to a host.
There are two main modes of transmission of an infectious agent (shown opposite).
However, a specific infectious agent may have more than one mode of transmission.

1. Direct transmission this is the

direct and essentially immediate
transfer of the infective agent and can
occur by direct contact or droplet
spread.
2. Indirect transmission this involves
an intermediate means of transfer of
the infective agent between an
infectious and susceptible host, and
can occur by vehicle-borne,vector-borne
or airborne transmission.
These will be considered in more detail on the following cards.

4.4: Transmission of the infectious agent

Direct transmission
Direct transmission can occur by means of direct contact, such as touching,
biting, kissing or sexual intercourse.
Click below for examples.
Interaction: Button: Example: output (appears in new window)
Examples
Neisseria gonorrhoeae, the bacteria that causes gonorrhoea, are transmitted from
one person to another by secretions from the mucus membranes during sexual
intercourse.
The rabies virus is transmitted to a human host when saliva from a rabid animal is
introduced in the peripheral nervous system by a bite or scratch.
Another form of direct transmission is droplet spread, in which the infectious
agent is transferred by direct projection (over a distance of less than 1 metre) of a
droplet spray onto the mucous membranes of the host. This can occur by sneezing,
coughing or talking - words containing the letter 'F' are perfect for such
transmission!
Interaction: Button: Example: output (appears in new window)
Example
The influenza virus is transmitted from one person to another either by droplet
spread or by direct physical contact.

4.5: Transmission of the infectious agent

Indirect transmission

Airborne transmission includes the dissemination of microbial aerosols that may

remain suspended in the air for long periods of time. Depending on the time, some
infections will retain their infectivity and others will lose it. These are distinct from
the droplets mentioned previously, which are too large to remain suspended in the
air.
Interaction: Hyperlink: microbial aerosols: output
Microbial aerosols
Suspensions in the air of particles consisting partially or wholly of micro-organisms.
Back to main card
Interaction: Button: Example: output (appears in new window)
Example
The herpes zoster virus, which causes chickenpox, can be transmitted from person to
person by airborne spread.

4.6: Transmission of the infectious agent

Vehicle-borne transmission refers to the involvement of a contaminated,
inanimate material or object (sometimes called a fomite) such as food, water, a
surgical instrument or eating utensil.
Examples
i Vibrio cholera is transmitted from one
person to another via contaminated
water or food.
The infective stages of the
schistosome parasite, which causes
bilharziasis, are acquired from water
after having undergone development in
freshwater snails. The infective stages
penetrate through human skin when the
person is swimming or wading in water.
Sharing of contaminated needles
transmits HIV between intravenous
drug users.

4.7: Transmission of the infectious agent

Indirect transmission
Vector-borne infections are transferred to the host by an invertebrate vector (e.g.
insects, lice, fleas, ticks).
A mechanical vector is one that simply carries the infectious agent on or in its body.
Interaction: Button: Example: output (appears in new window)

Example
Houseflies can act as mechanical vectors of Entoamoeba histolytica, which causes
the intestinal illness amoebiasis. The fly lands on a contaminated surface where it
picks up infected material on its legs. It can then transport this infective matter to
food.
A biological vector is one in which the infectious agent undergoes multiplication or a
necessary stage of development.
Interaction: Button: Example: output (appears in new window)
Example
The female Anopheles mosquito is a biological vector of Plasmodium falciparum, the
protozoan parasite that causes malaria. The mosquito ingests the sexual stages of
the parasite when she feeds on an infectious person. The parasite then undergoes
sexual reproduction and a period of development and multiplication, before the
infectious sporozoites are injected into the person on whom the mosquito next
feeds.

4.8: Transmission of the infectious agent

Exercise
Click and drag on each of the infections below to connect it with its mode of
transmission from the list opposite. Remember that some infections have more than
one mode of transmission. If you are unfamiliar with any of these infections, refer to
the CDC website http://www.cdc.gov/DiseasesConditions/az/m.html for more
information.
Interaction: Drag and Drop: Hepatitis B virus
Correct response: (drag to direct contact button on RHS)
That's correct, hepatitis B can be transmitted by direct contact, for example
by sexual intercourse and from mother-to-child at birth. Note that there are
two possible modes of transmission.
Incorrect response: (drag to all other buttons on RHS)
Incorrect
Interaction: Drag and Drop: Dengue virus
Correct response: (drag to biological vector borne button on RHS)
That's correct, dengue viruses are transmitted only through the bite of the
Aedes spp. mosquito. As the virus multiplies within the mosquito, this is a
biological vector.
Incorrect response: (drag to all other buttons on RHS)
Incorrect
Interaction: Drag and Drop: Polio virus

Correct response: (drag to droplet spread button on RHS)

That's correct. Poliovirus can be transmitted by droplet spread. Throat
secretions are infectious, and in areas of high sanitation, this droplet spread
becomes relatively more important than faecal-oral spread. Note that there
are two possible modes of transmission.
Incorrect response: (drag to all other buttons on RHS)
Incorrect

4.9: Transmission of the infectious agent

Effective contact
The mode of transmission of the infectious agent dictates the type of exposure that
could result in transmission of infection. It therefore determines what constitutes
an effective contact between an infective person and a susceptible person, which
is contact that will enable transmission.
The quantification of potentially infectious contacts between infective persons and
susceptible persons is important in infectious disease epidemiology. You will look at
this concept in more detail in session EC03.
Interaction: Button: Example: output (appears in new window)
Neisseria gonorrhoea is transmitted from one person to another by secretions from
the mucus membranes during sexual intercourse. This means that only sexual
contact between an infective person and a susceptible person constitutes a
potentially infectious exposure. Other forms of direct contact (such as touching
hands) and indirect contact (such as sharing eating utensils) do not constitute a
potentially infectious exposure.
Duration

For an infection that is directly transmitted, there will be many opportunities for
effective contact, while for a sexually transmitted infection the opportunities will be
fewer. Because of this, the duration of infectiousness is likely to differ between
infections according to the mode of transmission.
Interaction: Button: Example: output (appears in new window)
Example
Individuals with influenza will only be infectious for a number of days, while those
with HIV will be infectious for many years. This is necessary to ensure that there are
sufficient opportunities of effective contact so that the infection can be transmitted.

4.10: Transmission of the infectious agent

Reservoirs
Like all living organisms, each infectious agent has a natural habitat, or reservoir. A
reservoir is the habitat in which an infectious agent normally lives, on which it
depends for survival and in which it reproduces. There are 3 main types of reservoir,
and some infectious agents require more than one type of reservoir to complete
their life cycle.
Inanimate reservoir
Animal reservoir
Human reservoir
Interaction: Hyperlink: Inanimate reservoir: output (appears on RHS)
Inanimate reservoir
Some infectious agents live and multiply in inanimate reservoirs such as water or
soil.
Click below for an example:
Interaction: Button: Example: output (appears in new window)
Example
Clostridium botulinum is a spore-forming bacillus that causes food borne botulism.
C. botulinum spores live and multiply in the soil from where they can be transmitted
to a susceptible host.
Back to LHS
Interaction: Hyperlink: Inanimate reservoir: output (appears on RHS)
Animal reservoir
Arthropods, reptiles, amphibians, birds and mammals all act as reservoirs for a
number of different infectious agents of humans.

Click below for some examples:

Interaction: Button: Example 1: output (appears in new window)
Example
The rabies virus normally lives and reproduces in a number of biting mammal
species, such as dogs, foxes, skunks and bats. The virus can be transmitted from
any of these reservoirs to a susceptible host.
Interaction: Button: Example 2: output (appears in new window)
Example
The leishmania parasite can be maintained in a number of mammals including wild
rodents and domestic dogs. The parasites are transmitted to humans from this
reservoir host through the bite of an infective sandfly vector.
Back to LHS
Interaction: Hyperlink: Human reservoir: output (appears on RHS)
Human reservoir
Many infectious agents have humans as their reservoir.
Click below for an example:
Interaction: Button: Example: output (appears in new window)
Example
Humans are the natural reservoir of the hepatitis B virus. Many individuals have
chronic asymptomatic infections that act as a source of infection to susceptible
individuals.

4.11: Transmission of the infectious agent

Reservoirs
The distribution of the reservoir(s) of an infectious agent will influence the
distribution of the infectious disease caused by the agent.
For example, monkeypox virus is a sporadic infection that clinically resembles
smallpox. Most cases have occurred either singly or in small clusters in remote
villages bordering the tropical rainforest, where the population has frequent contact
with wild animals.
Studies have indicated that wild squirrels may be a significant reservoir host.
Human-to-human transmission usually dies out quickly, therefore frequent contact
with the reservoir host is necessary to maintain the disease among humans.
The disease has only been reported from Central and West African rainforest
countries.

Section 5: Host population characteristics

For an infectious agent to be transmitted within a human population, susceptible
individuals must be exposed to a source of infection.
The continued transmission of an infectious agent in a population is dependent on
the number of infective and susceptible individuals present, and on the
effective contact between these individuals.
You have seen that the susceptible status of the host is dependent on the likelihood
of previous infection, and on whether a protective immune response is produced.
However, for an infectious agent to persist in a host population there must be an
adequate number of susceptible hosts in the population. This is because the
probability of making effective contact will be dependent on the abundance of
susceptible individuals. You will learn in session EC06 that there is a critical
number of susceptible individuals required for the continuous transmission of
an infectious agent in a population.
If sufficient individuals are immune to a particular infectious agent, the remaining
susceptible individuals may be protected by this population characteristic, known
as herd immunity.

5.1: Host population characteristics

While the mode of transmission determines the probability of effective contact,
population size and behaviour determine the rate at which such potentially
infective contacts may occur.
If people in a population mix randomly, each person will have an equal chance of
making contact with any other and so every susceptible person will have an equal
chance of being exposed to infection. However, in most populations people do not
mix at random, but have complex contact patterns.
Interaction: Tabs:
Example 1 : output
In small rural communities, the frequency of effective contact for even directly
transmitted infections may be low, but once the population has been infected and is
immune, the infection will die out. In large urban communities, such infections will
spread rapidly through a population, and there will be sufficient influx of newborn
susceptible individuals to maintain transmission.
Persistent infections will be better able to circulate in small communities, as the
infection will remain long enough to infect subsequent generations of susceptible
individuals.
Interaction: Tabs:
Example 2 : output
What type of contacts people make, and with whom, has an important influence on
the transmission of an infectious agent in a population.

For a sexually transmitted infection, transmission may be maintained by small

groups of individuals with high rates of sexual partner change, such as commercial
sex workers. The majority of the population may make insufficient effective contact
to be involved in transmission.

Section 6: Overview of study module

In this session, you have been introduced to the concepts of infectious disease
agents, patterns of infection, modes of transmission, and characteristics of host
populations.
These are the basic characteristics of infectious diseases that you need to be aware
of when thinking about measuring, describing or controlling infectious diseases.

6.1: Overview of study module

In session EC02, you will see that infectious diseases often have particular
distributions in relation to whom they infect, and when and where they occur.
These can sometimes be used to identify whether or not a disease has an infectious
cause.
Session EC03 considers the different methods of measuring the transmissibility of
an infection. It introduces you to the methodology behind the secondary attack
rate for measuring transmissibility in the context of a household contact study.
You will also review the concept of the basic reproduction rate.

6.2: Overview of study module

Session EC04 describes the process and methodology necessary to investigate an
outbreak of disease. It describes how to identify an outbreak and how to collect and
analyse data for an outbreak investigation. You will use these skills in the assessed
work for this unit, which you can undertake after completing sessions 14.
Session EC05 contains information on the assessed work, which is a simulated
outbreak investigation. You will consider important issues relating to group work,
and will be introduced to the problem at hand. The timing of this session will depend
on the allocation of groups.

6.3: Overview of study module

In Session EC06 you will be introduced to mathematical modelling in epidemiology.
This is a field of growing importance and is increasingly being used to make
predictions that inform public health policy. This session includes some mathematics,
but stresses the importance of understanding the concepts, rather than the
mathematics underlying them.
Finally, Session EC07 considers the subject of estimating vaccine efficacy. Vaccines
are fairly unique to infectious diseases, as they use the body's immune system to
protect an individual from infection. However, measuring the benefit of this is a
complex topic and this session aims to identify the current issues of interest.

Section 7: Summary
This is the end of EC01. When you are happy with the material covered here please
move on to session EC02.
The main points of this session will appear below as you click on the relevant title.
Importance of infectious diseases 1
Infectious diseases are responsible for a large amount of the disease, suffering and
mortality worldwide, and this is recognised by the World Health Organisation.
Infectious disease epidemiology is a growing field. In recent years infectious agents
have been shown to be responsible for chronic diseases such as many cancers. A
number of new infections and diseases have been identified. Diseases previously
thought to be under control are re-emerging due to failing control programmes or
drug resistance.
Importance of infectious diseases 2
(link takes you to relevant page)
Due to their particular characteristics, infectious diseases can lead to large
outbreaks of disease, and this is especially evident in urban settings. With the
increasing urbanisation and globalisation of recent and coming years, infectious
diseases will be causing problems on a world-scale for many years to come.
Because infectious agents do not recognise political boundaries, global alliances to
combat infectious diseases are on the increase in the form of collaborative research
and global eradication programmes.
Infectious agents
(link takes you to relevant page)
Infectious agents can be categorised as microparasites (prions, viruses, bacteria,
protozoa and fungi) and macroparasites (helminths and arthropods).
These categories have implications for modes of transmission, duration of infection,
and measurement of infection in epidemiological studies.
Course of infection
(link takes you to relevant page)
During the course of an infection, an individual passes through recognisable
stages:
Susceptible able to be infected

 Infected and latent infected but not

able to transmit the infection
Infected and infectious infected and
able to transmit the infection
Uninfected clear of infection and
either immune or susceptible once more
Course of disease
(link takes you to relevant page)
During the course of disease, an individual passes through recognisable stages:
Well uninfected and well
Incubation infected but not
exhibiting symptoms or signs of
disease
Symptomatic infected and showing
symptoms and/or signs of the disease
Well not showing symptoms of
disease (either clear from infection or
asymptomatic)
Patterns of infection
(link takes you to relevant page)
Five different patterns of infection can be described according to the immune
response elicited and the characteristics of the infectious agent relating to
transmission:
Acute, self-limited infection
Persistent infection with shedding
(production of infectious material)
Latent infection
Persistent slow infection following an
acute infection
Persistent slow infection (no acute
stage)
Methods of transmission
(link takes you to relevant page)
Infectious agents can be transmitted either directly, by direct contact or droplet
spread, or indirectly, by vector-borne, vehicle-borne or airborne transmission.
The mode of transmission determines what constitutes effective contact between a
susceptible and infectious person. It may also determine the duration of
infectiousness for a specific infectious agent.

Reservoirs
(link takes you to relevant page)
A reservoir is the natural environment of an infectious agent. Reservoirs can be
inanimate, animal or human. Reservoirs are important when aiming to control or
eradicate an infectious disease.
The distribution of a reservoir may determine the geographical distribution of an
infectious agent.
Characteristics of the host population
(link takes you to relevant page)
In addition to characteristics of the infectious agent, characteristics of the host
population can also determine transmission. Because hosts can develop protective
immunity against an infectious agent, the effect of herd immunity may enable
susceptible individuals in a highly immune population to be protected from infection.
If insufficient susceptible individuals are available, the infection will die out.
In addition to population size, host behaviour will also determine the probability and
frequency of effective contact, and therefore transmission.