Chapter 4

Spectrum of Infectious Diseases and Causative Organisms

Diseases caused by bacteria, viruses, fungi, and other parasites are major causes of

death, disability and eventually lead to social and economic disruption for millions

of people. Though safe and effective measures to cure these infections are available

today, these preventive cares remain inaccessible to large section of people who are

economically weak. This leads to huge losses to the families and communities in

productivity.

*Children are particularly vulnerable to infectious diseases. In children below age

group of five, pneumonia, diarrhea, and malaria are considered as leading causes of

death.

Infectious diseases are also of great concern to the health of adults since it may cause

disability, bad quality of life and reduces productivity or sometimes even cause

death.

As a person gets infected with one infectious disease becomes more susceptible to

other diseases as well.

Classical examples are HIV/AIDS coinfection with tuberculosis or malaria

coinfection with other neglected diseases. Timely interventions can cure and save
patients from suffering since most of the infectious diseases are preventable and

treatable.

*By definition, a disease is an illness that is characterized usually by two of the

criteria—recognizing the etiologic agent, typical signs, and symptoms of a disease.

Most diseases follow a characteristic pattern as shown in Fig. 1.1. As the disease sets

in due to an exposure to an infectious agent, pathological changes are noticed and

progression toward clinical manifestation occurs till medical interventions are done.

Because not all infections result in disease, therefore conducting an outbreak

investigation requires familiarity with a natural history of a disease in order to

identify who are infected people.

*The infectious disease spectrum can be divided into three classes of infection:

(1) infection not very frequent,

(2) infection results in clinical disease that is rarely fatal, and

(3) infection results in severe disease that is usually fatal.

• Neglected diseases can be prevented and treated through effective interventions.

• Often these diseases leave children and adults weak and malnourished. For

example, intestinal worms are a major cause of malnutrition, stunting, and impaired

development among children.

Lymphatic filariasis (LF)—or elephantiasis—is a crippling, mosquito-borne

infection characterized by swollen limbs and breasts, genital damage and thickened,

hardened skin.

Globally, it is the second-leading cause of permanent disability. Antiparasitic drugs

administered annually for at least five years can break the cycle of transmission.
Trachoma, a bacterial infection of the eye, can result in blindness after multiple

infections. It is transmissible from person to person by direct contact or contact with

contaminated clothing; flies also help to spread trachoma.

Trachoma has become the leading cause of preventable blindness due to its ease of

transmission. Repeated infections slowly cause scarring of the upper eyelid that can

lead to total blindness during adulthood.

Leprosy is a bacterial disease that in 2008 affected 212,802 people in sub-Saharan

Africa, India, Nepal, and Brazil.

The disease is transmitted through contact with droplets from the nose and mouth of

an infected person who is not receiving treatment. Leprosy affects the nervous
system, skin, limbs, and eyes. It can be treated using multidrug therapy, though

disability or disfigurement may be permanent.

Buruli ulcer is an ulcer on the skin, often on the hands and feet, that occurs most

commonly in children under 15 inhabiting wet, tropical regions. The disease causes

disfiguring skin ulcers that may limit joint motion and cause disability. The

infectious agent is Mycobacterium ulcerans.

The bacteria typically enter the host through cuts, wounds, or bites of insects that

thrive in infected waters. Infection may cause permanent scarring of tissue.

Outbreaks of buruli ulcer are most common after flooding, which may be the result

of deforestation or construction of dams and irrigation systems.

Recognition of an Infectious Disease in a Population

The terms “infection” and “disease” are not synonymous. An infection results when

a pathogen invades and begins to grow within a host. Disease results when tissue

function is impaired as a consequence of the invasion and growth of a pathogen.

Human body has defense mechanisms to prevent infection and when this mechanism

fails to prevent onset of the disease, infection sets in.

Some infectious agents are easily transmitted and they are referred as contagious,

but they are not very likely to cause disease that is, they are not so virulent. The

poliovirus is an example. Other infectious agents are highly virulent, but not terribly

contagious. The terror surrounding Ebola hemorrhagic fever is based on the

virulence of the virus which has recorded 50– 90% fatality rate among those

infected; however, the virus itself is not transmitted easily by casual contact but

through body fluids. The infectious agents both contagious and highly virulent are

difficult to control.

In order to cause disease, pathogens must meet the following criteria:

1. Able to enter the host body.

2. Adhere to specific host cells.

3. Invade and colonize host tissues.

4. Damage the host tissues.

5. Capable of multiplying inside the host.

Entrance to the host typically occurs through natural openings of the body such as

the mouth, eyes, or genital openings, or through wounds due to which the damaged

skin get exposed to pathogens.

Only some pathogens can grow at the initial entry site, mostly they must invade areas

of the body by attaching to specific host cells.

The pathogen may adopt different mechanism for multiplying inside the host:

Some pathogens multiply between host cells or within body fluids, while others such

as viruses and some bacterial species enter the host cells and grow there.

Although the growth of pathogens may be enough to cause tissue damage in some

cases, whereas in other cases, the pathogen is capable of producing toxins or

destructive enzymes.

For example, Corynebacterium diphtheriae, the bacterium that causes diphtheria,

grows only on nasal and throat surfaces. However, the toxin it produces is distributed

to other tissues by the circulatory system. This toxin is capable of damaging heart,

liver, and nerve tissues.

Streptococcus pyogenes is the infectious agent associated with several diseases

including strep throat and “flesh eating disease.“ The organism produces several

enzymes that work in a synergistic way to break down barriers between epithelial

cells and remove fibrin clots thus helping the bacteria to invade tissues.
Occurrence of Infectious Diseases

Epidemiology: Epidemiology is the study of the occurrence of disease in

populations. Epidemiologists are concerned not only with infectious diseases, but

also with noninfectious diseases such as cancer and atherosclerosis, and with

environmental diseases such as lead or arsenic poisoning.

These epidemiologists work to achieve the following targets:

1. To prevent or minimize the impact of diseases in the population.

2. To identify unusually high incidences of a particular disease.

3. To determine the effectiveness of a vaccine, and

4. Calculating the cost-effectiveness of various means of controlling disease

transmission.

5. To track down the cause of a “new” disease.

6. To determine its reservoir and mode of transmission, and

7. Help to organize and mobilize various healthcare workers to bring the disease

under control.

Acquisition of Disease

1. Sources of Infectious Disease

a. Sources through which one may acquire an infectious disease include: • Inanimate

reservoirs. • Sick individuals. • Asymptomatic carriers. • Other species.

2. Reservoir a. Source of Disease: • A reservoir is defined as the source of an

infecting microorganism. • An infectious disease spreads from a reservoir to

individual. • It includes in animates (such as animals), or humans.

3. Carrier a. Intraspecific Reservoir: In case of human disease, a carrier is defined as

a person who is infected and carries a communicable disease for transmission to

another uninfected person. This carrier serves as an "intraspecific" reservoir b.

Asymptomatic Carriers: An individual who is asymptomatic or carrying an

infection without showing any symptoms of the disease may also be a potential

carrier of the disease.

4. Zoonosis

a. Animal Reservoir: • A zoonosis is a communicable disease which is transmitted

from a non-human animal to a human. • Here the non-human animal is the reservoir.

b. Uni- or bi-directional: • Zoonotic reservoirs can be either unidirectional, e.g.,

transmitting only from nonhumans to humans; or bidirectional, i.e., back and forth

between non-human animals and humans.

• The kind of replication the microorganism does might differ between its multiple

hosts, e.g., Plasmodium spp. The passage of pathogens between populations can
range from rare to common (e.g., emerging infectious diseases vs. Lyme disease).

About 150 zoonotic human disease are known. Some of the important ones include:

anthrax, brucellosis, bubonic plague, cat-scratch fever, influenza, malaria,

salmonellosis, toxoplasmosis.

5. Endogenous Infection

• An endogenous infection is one which is caused by an opportunistic pathogen from

an individual’s own normal microbiota.

• An individual faces this consequence when the immune system is weak when an

opportunist is deposited in a location .

6. Portals of entry

a. Pathogen route of entry: A portal of entry is the route a pathogen takes to enter

a host. Typical routes include: • Mucous membranes. • Skin. • Parenteral.

b. Typical Portals of Entry: • Each pathogen takes a specific and preferred portal of

entry and exit. • Many pathogens are not able to cause disease if their usual portal of

entry is artificially bypassed.

7. Mucous Membrane Portal of Entry

a. Mucous membranes line or cover: • Respiratory tract. • Gastrointestinal tract. •

Genitourinary tract. • Eyes.

b. The gastrointestinal and respiratory tracts are particularly common mucous

membrane portals of entry.

c. Microbes gain access to these mucous membranes during the following activities:

• During inspiration. • Upon ingestion. • Touching the eyes. • Touching the

genitourinary tract.

8. Skin Portal of Entry • Normally very impenetrable to most microorganisms, the

skin can serve as an efficient portal of entry for many pathogens only when broken.

• Some pathogens are capable of entering through otherwise intact skin either via

natural pores or by actually boring through, however.

• Examples of pathogens which can enter through intact skin include the hookworm

larvae of Necator americanus and some fungi.

9. Parenteral Portal of Entry

• A parenteral portal of entry is defined as a means of entry where direct deposit of

pathogens takes place into body cavities or wounds.

• portal of entry through a break in skin is often considered as a parenteral portal of

entry.

10. Portals of exit • Respiratory infections mostly utilize the mouth and nose as

portals of exit.
• Gastrointestinal infections tend to exit in feces or in saliva.

Mode of Transmission of Pathogens

Epidemiologists follow transmission of a disease by correlating geographical,

seasonal, and age group incidence of a disease with possible modes of transmission.

A disease limited to a restricted geographical location may suggest a particular

vector; malaria, for example, is transmitted by a mosquito found mainly in tropical

regions. Different pathogens have different modes of transmission, which are usually

related to the habitats of the organisms in the body.

For instance, respiratory pathogens are generally airborne, whereas intestinal

pathogens are spread by food and water.

If the pathogen has to survive, it must undergo transmission from one host to another.

Even environmental factors may play a role in the survival of pathogen, and such

variables as weather patterns may influence exposure to pathogen.

*For example, California encephalitis, caused by a group of Bunyaviruses occurs

primarily during the summer and fall months and disappears every winter, in a

predictable cyclic pattern.

The virus is transmitted from mosquitoes which, of course, are prevalent only during

summer months. Disappearance of the insect vector causes the disease to disappear
until the vector reappears and retransmits the virus in the summer months. The

process of transmission involves the following steps:

Movement between environments: Transmission is the transfer of a disease-

causing microorganism from one environment to another, particularly from an

external environment to a susceptible individual. Technically it is explained as a

process where the pathogen is transferred from a portal of exit to a portal of entry.

1. Contact Transmission

• Direct contact (person to person).

• Indirect contact.

• Droplets.

Person-to-person transmission: Direct contact transmission is a physical form

of transmission.

2. Airborne Transmission

Transmission of pathogens occurs via aerosol.

Airborne transmission is a form of vehicle transmission. This type of

transmission occurs via droplets for example mucous droplets which remain

airborne and may be associated with dust particles. It has been observed that

airborne transmission is a problem within airliners due to reduced turnover of

cabin air and therefore air recycling is increased. Therefore, the potential

pathogenic organisms get an opportunity to remain viable and circulate

repeatedly thus may infect passengers.

3. Foodborne Transmission Foodborne transmission is a form of vehicle

transmission. Any number of pathogens that are found in food and not killed

during processing may be transmitted via food. Generally, pathogens that

undergo foodborne transmission are either being transmitted from the: • Food

handlers. • Flora that are originally associated with the food product; e.g.

Salmonella spp. tends to be part of the normal flora of chickens and consequently

associated with chicken products.

4. Waterborne Transmission Waterborne transmission is a form of vehicle

transmission. Generally, this is via sewage (i.e., fecal) contaminated water

supplies. Gastrointestinal pathogens that are present in feces may get transmitted

through contaminated water if it enters drinking water supply for some reason.

Transmission of waterborne diseases mainly takes place through fecal– oral

route.
Herd immunity can be defined as a method to reduce the number of infected

individuals in a segment of unimmunized population by immunizing a proportion

of population instead of the whole population.

The effect of herd immunity can be measured by testing a sample of the

population for the presence of a chosen disease against which the population has

been vaccinated.
Herd effect will also lead to measurable decline in incidence of the disease in the

unimmunized segment of the population where the program has been started.

The induced herd immunity of a given vaccine exhibits geographic variation and

therefore it depends upon coverage and efficacy of the vaccine. Herd effect is

determined by herd immunity as well as the force of transmission of the

corresponding infection. It is important to understand this phenomenon in order

to design immunization programs more effectively. This will further help at

control, elimination or eradication of vaccine preventable infectious diseases.

Fungal Infections Superficial fungal infections are found on the top layers of the

skin and mucous membranes, the hair, and the nails.

Examples of fungal infections encountered on the skin and other external surfaces

include athlete’s foot, jock itch, ringworm, and candida.

Infections of the Hair Follicles—Cause Folliculitis, Furuncles, and Carbuncles

Pathogenesis Most furuncles, carbuncles as well as many cases of folliculitis, are

caused by Staphylococcus aureus, a facultative anaerobic, Gram-positive coccus.

The infection induces an inflammatory response with swelling and redness.

If the infection continues, the follicle becomes a plug of inflammatory cells and

necrotic tissue. Once the organism enters the bloodstream, the infection can be

disseminated to other parts of the body, such as heart, bones, or brain.

• Host -microbe interactions

• Example of symbiosis, or “living together”

• Mutualism: both partners benefit – E.g., in large intestine, some bacteria

synthesize vitamin K and B vitamins, which host can absorb; bacteria are supplied

with warmth, energy sources

• Commensalism: one partner benefits, other is unharmed – Many microbes living

on skin neither harmful nor helpful, but obtain food and necessities from host

• Parasitism: one organism benefits at expense of other – All pathogens are

parasites, but medical microbiologists often reserve for eukaryotic pathogens (e.g.,

protozoa, helminths).
The Normal Microbiota

The Protective Role of the Normal Microbiota

• Significant contribution is protection against pathogens

• Covering of binding sites prevents attachment

• Consumption of available nutrients

• Production of compounds toxic to other bacteria

• When killed or suppressed (e.g., during antibiotic treatment), pathogens may

colonize, cause disease

• Some antibiotics inhibit Lactobacillus (predominate vagina of mature females,

suppress growth of Candida albicans); results in vulvovaginal candidiasis

• Oral antibiotics can inhibit intestinal microbiota, allow overgrowth of toxin-

producing Clostridium difficile

• Stimulation of adaptive immune system

• Changes occur in response to physiological variations within host

Principles of Infectious Disease

Colonization refers to microbe establishing itself on body surface

• Infectious disease yields noticeable impairment – Symptoms are subjective effects

experienced by patient (e.g., pain and nausea) – Signs are objective evidence (e.g.,

rash, pus formation, swelling)

• Initial infection is primary infection – Damage can predispose individual to

developing a secondary infection (e.g., respiratory illness impairing mucociliary

escalator).

Pathogenicity

• Opportunistic pathogen (opportunist) causes disease only when body’s innate or

adaptive defenses are compromised or when introduced into unusual location

• Can be members of normal microbiota or common in environment (e.g.,

Pseudomonas)

• Virulence refers to degree of pathogenicity

• Virulence factors are traits that allow microorganism to cause disease

Characteristics of Infectious Disease

• Communicable or contagious diseases easily spread

• Infectious dose is number of microbes necessary to establish infection

• ID50 is number of cells that infects 50% of population

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